Honorary doctor of the military medical academy professor V.V. Volkov (To the 100th anniversary of his birth)

The main milestones of the life path, creative, clinical, scientific and pedagogical activity of Hero of Socialist Labor, laureate of the State Prize of the Union of Soviet Socialist Republics, Honored Scientist of the Russian Soviet Federative Socialist Republic, Honorary Doctor of the Military Medical Academy named after S.M. Kirov Professor Major General Medical Service Veniamin Vasilyevich Volkov are presented. His fundamental research in such sections of ophthalmology as the organization of specialized assistance in the Armed Forces, ophthalmotraumatology, combined lesions and burns of the eyes, vitreoretinal pathology, glaucoma, ophthalmoncology, visual organ physiology, lacrimation pathology, development and introduction of lasers into ophthalmological practice, made him one of the most authoritative specialists in domestic and world ophthalmology. In 1967, V.V. Volkov headed the Department of Ophthalmology, which he led 22 years before his dismissal from the Armed Forces on September 20, 1989. His multifaceted educational, medical and scientific activities were awarded numerous awards and titles. Employees of the Department of Ophthalmology of the Military Medical Academy named after S.M. Kirov are proud that they are students of the school of Professor V.V. Volkov, and the teachers of the older generation were lucky to work together with a scientist who made a significant contribution to the development of Soviet and Russian ophthalmology, whose works received widespread world recognition. Professor V.V. Volkov is a scientist who formed the scientific school of the Department of Ophthalmology of the Military Medical Academy named after S.M. Kirov in its modern form. Therefore, in 2019, the department was named after him.

Factors associated with clinical severity in Emergency Department patients presenting with symptomatic SARS-CoV-2 infection

ABSTRACTObjectiveTo measure the association of race, ethnicity, comorbidities, and insurance status with need for hospitalization of symptomatic Emergency Department (ED) patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection.MethodsThis study is a retrospective case-series of symptomatic patients presenting to a single ED with laboratory-confirmed SARS-CoV-2 infection from March 12-August 9, 2020. We collected patient-level information regarding demographics, public insurance status (Medicare or Medicaid), comorbidities, level of care, and mortality using a structured chart review. We compared demographics and comorbidities of patients who were (1) able to convalesce at home, (2) required admission to general medical service, (3) required admission to intensive care unit (ICU), or (4) died within 30 days of the index visit. Multivariable logistic regression analyses were performed to report adjusted odds ratios (aOR) and the associated 95% confidence intervals (95% CI) with hospital admission versus ED discharge home.ResultsIn total, 993 patients who presented to the ED with symptoms were included in the analysis with 370 (37.3%) patients requiring hospital admission and 70 (7.1%) patients requiring ICU care. Patients requiring admission were more likely to be Black or African American, to be Hispanic or Latino, or to have public insurance (either Medicaid or Medicare.) On multivariable logistic regression analysis comparing which patients required hospital admission, African-American race (aOR 1.4, 95% CI 0.7-2.8) and Hispanic ethnicity (aOR 1.1, 95% CI 0.5-2.0) were not associated with need for admission but, public insurance (Medicaid: aOR 3.4, 95% CI 2.2-5.4; Medicare: aOR 2.6, 95% CI 1.2-5.3; Medicaid and Medicare: aOR 3.6 95% CI 2.1-6.2) and the presence of hypertension (aOR 1.8, 95% CI 1.2-2.7), diabetes (aOR 1.6, 95% CI 1.1-2.5), obesity (aOR 1.7, 95% CI 1.1-2.5), heart failure (aOR 3.9, 95% CI 1.4-11.2), and hyperlipidemia (aOR 1.8, 95% CI 1.2-2.9) were identified as independent predictors of hospital admission.ConclusionComorbidities and public insurance are predictors of more severe illness for patients with SARS-CoV-2. This study suggests that the disparities in severity seen in COVID-19 among African Americans and Hispanics are likely to be closely related to low socioeconomic status and chronic health conditions and do not reflect an independent predisposition to disease severity.

What information do patients want about their medicines? An exploration of the perspectives of general medicine inpatients

Background Medicines are one of the most common healthcare interventions, yet evidence shows patients often do not receive the information they want about their medicines. This affects their adherence and healthcare engagement. There is limited research exploring what information patients want about their medicines, from whom and in what format. The aim of this study was to determine the medicines information needs of patients admitted to the general medical service of a large New Zealand (NZ) hospital, and identify the barriers and enablers to meeting these needs. Methods A descriptive exploratory approach using semi-structured interviews was used to understand the needs and preferences of patients for information about their regular medicines and the barriers and facilitators to obtaining this information. Patients admitted to a general medical ward at a large NZ hospital, aged 18 years and over, prescribed one or more regular medicines, and self-managing their own medicines prior to hospitalisation were included. Semi-structured interviews were conducted with each participant (n = 30) and transcribed, then analysed using a general inductive thematic analysis approach. Results Five overarching themes captured the medicines information needs of patients: (1) autonomy; (2) fostering relationships; (3) access; (4) communication; and (5) minimal information needs. Patients desired information to facilitate their decision-making and self-management of their health. Support people, written information, and having good relationships with health providers enabled this. Having access to information at the right time, communicated in a clear and consistent way with opportunities for follow-up, was important. A significant portion of participants were satisfied with receiving minimal information and had no expectations of needing more medicines information. Conclusions Although patients’ medicines information needs varied between individuals, the importance of receiving information in an accessible, timely manner, and having good relationships with health providers, were common to most. Considering these needs is important to optimise information delivery in general medical patients.

Frailty: Tackling the crisis

The UK has an ageing population and this is reflected in increasingly higher rates of consultations with GPs; these consultations often relate to complex and interdependent needs. Older people are more likely to be frail, relative to the general population, and the General Medical Service contract aims for a proactive identification of older people with moderate or severe frailty, and then their risk stratification using an evidence-based tool: the electronic frailty index. This article reflects on best practice in the assessment of older people in primary care and what interventions are in place to improve their outcomes.

Republished: Prevention of Nosocomial Catheter-Associated Urinary Tract Infections Through Computerized Feedback to Physicians and a Nurse-Directed Protocol

Catheter-associated urinary tract infections (CAUTIs) represent the most common nosocomial infection. The authors’ baseline rate of CAUTI for general medical service was elevated at 36 per 1000 catheter-days. The medical literature has consistently linked inappropriate catheter use with the development of CAUTI. The baseline data also revealed a high rate of inappropriate use of indwelling urinary catheters. Using the dual modalities of technology through prompts in the computerized order/entry system and handheld bladder scanners, as well as in combination with staff education and nurse empowerment, the authors were successful in reducing the use and duration of urinary catheters as well as the incidence of CAUTI. In subsequent data collection cycles over the following 2 years, 81% reduction in device use and a 73% reduction in the clinical end point of nosocomial CAUTI (36/1000 catheter-days to 11/1000 catheter-days; P < .001) was demonstrated.

Diagnostic, Treatment, and System Challenges in the Management of Recurrent Neuroleptic Malignant Syndrome on a General Medical Service

Neuroleptic malignant syndrome (NMS), an iatrogenic form of malignant catatonia, carries high morbidity and mortality rates especially in the context of delayed recognition and standard intervention protocol of lorazepam trial. However, there is limited guidance available through literature for further management if benzodiazepine treatment is ineffective and electroconvulsive therapy (ECT) is not readily accessible. This case report describes a multimodal approach to address the diagnostic, treatment, and logistical system challenges in an acute medical hospital through the case of a 69-year-old man with schizophrenia who represented from a psychiatric ward with neuroleptic malignant syndrome. We educated our inpatient colleagues for timely recognition of hyperexcited subtype of catatonia to avoid iatrogenic progression to neuroleptic malignant syndrome and our medical colleagues on the clinical course of catatonic symptoms to avoid any further disagreements and delays in treatment. We advocated for timely electroconvulsive therapy in the setting of limited access and utilized creative pharmacologic strategies such as N-methyl-D-aspartate (NMDA) receptor antagonists and longer acting benzodiazepines while managing medical complications.

Abstract 088: Characteristics of Congestive Heart Failure Patients Included in The Centers for Medicare and Medicaid Services Hospital Readmissions Reduction Program

Background: The Centers for Medicare and Medicaid Services Hospital Readmissions Reduction Program (HRRP) has created financial penalties for hospitals with higher risk-standardized readmission rates after hospitalization for specific conditions, including congestive heart failure (CHF). Identification and risk-standardization is performed with administrative data. Both to evaluate the utility of this metric for improving quality and to inform efforts by providers to reduce readmissions, more granular clinical information about patients included in the penalty is needed. Methods: All patients who contributed to the CHF component of the HRRP penalty at our hospital between June, 2012 and December, 2013 were identified and medical records were reviewed by a physician (A.J.C.). Information extracted included index inpatient service, cause of readmission, medications, scheduled follow-up, whether echocardiogram was performed, NT pro-BNP as measured at admission and discharge, weight documented during index hospitalization, last known ejection fraction, and discharge disposition. Results: During this time period, 212 readmitted CHF patients contributed to the HRRP penalty. Of those, 31 (14.6%) were excluded due to readmission to an outside hospital. Of the remaining 181, 6 (2.8%) were excluded as the cause of index admission was not confirmed to be CHF. These patients were excluded from all analyses. Of the remaining 175 patients, 79 (45.1%) were readmitted for recurrent CHF exacerbation while 96 (54.8%) were readmitted for reasons other than CHF. Seventy (40%) patients were discharged home with visiting nurse services, 44 (25.1%) discharged home without services, and 61 (34.9%) discharged to a skilled nursing facility. Of the 114 patients discharged home, 44 (38.6%) had follow-up scheduled at the time of discharge. The median length of time between the index admission and readmission was 13 days. Among the 79 patients readmitted for CHF-related causes, 39 (49.4%) initially had been hospitalized on the cardiology service while 40 (50.6%) were hospitalized on a general medical service. Of those 79 patients, 32 (40.5%) had left ventricular systolic dysfunction (LVSD). At time of index discharge, 28 (87.5%) of patients with LVSD had been prescribed a beta blocker and 12 (37.5%) had been prescribed an ACE inhibitor or ARB. Conclusions: About half of patients who contributed to the CHF component of the HRRP penalty at our hospital were readmitted for recurrent CHF, the other half for different diagnoses. Of those who were readmitted with recurrent CHF, more than half did not have systolic dysfunction. Many of the patients with recurrent CHF due to systolic dysfunction were not initially discharged on ACE or ARB therapy, largely due to hypotension or renal dysfunction. These findings underscore the challenges of reducing preventable hospital readmission in this HRRP penalty population.

Delirium: the invisible syndrome

Delirium is a neuropsychiatric sindrome characterized by acute onset, a fluctuating course, an altered level of consciousness, disturbances in orientation, memory, attention, thinking, perception and behaviour. One third of patients aged 70 or older were admitted to the general medical service of an acute care hospital experience delirium. The development of delirium is associated with worse outcome increased a 10-fold risk for death and a 3- to 5-fold risk for nosocomial complications, prolonged length of stay, and greater need for nursing home placement after discharge. Therefore patients with delirium have higher morbidity and mortality rates, higher re-admission rates, and a greater risk of long term institutionalization care, thereby having a significant impact on both health and social care expenditure. The cost of delirium to the health-care system is then substantial. Despite its clinical importance and health-related costs, it often remains under-recognized and inadequately managed. Recent evidence suggests that a better understanding and knowledge of delirium among health care professionals can lead to early detection, the reduction of modifiable risk factors, and better management of the condition in the acute phase.

Thrombocytopenia in Hospitalized Non-ICU Patients

Thrombocytopenia is common in patients admitted to the intensive care unit, with a reported prevalence of 8-68% and incidence of 13-44% in published series. Those who develop thrombocytopenia in an ICU have a statistically increased risk of ICU mortality, duration of mechanical ventilation, and platelet, RBC, and FFP transfusions. Few studies have examined the occurrence and risk factors for thrombocytopenia in non-ICU hospitalized patients. The only systematic investigation of thrombocytopenia in the non-ICU hospitalized medical population dates to 1989, predating modern diagnostic assays for a variety of infectious and drug-induced causes of thrombocytopenia. We, therefore, undertook this study to characterize the incidence and causes of thrombocytopenia in the general medical, non-ICU patient population at a tertiary care hospital. For this study, we performed a single-institutional retrospective analysis of patients admitted to a general medical ward at a tertiary care medical center (Duke University Hospital). Inclusion criteria included all adult patients (>18 years) admitted from the emergency department to the general medicine floors during the calendar year defined as 01/2014-01/2015. Exclusion criteria included pre-existing thrombocytopenia, ICU admission, or patients undergoing chemotherapy. Primary endpoints included patients with incident thrombocytopenia, defined as a platelet count on admission greater than 150 x 10^9/L with subsequent platelet counts decreasing to < 150 x 10^9/L. Patients meeting these criteria were evaluated for admission diagnosis, pertinent past medical history, cause of thrombocytopenia (infection, splenic sequestration, drugs, surgery, liver disease), cost of admission, and prognosis. Preliminary evaluation of patients admitted to the general medical service in 2014 reveals ~711 patients who meet inclusion criteria. Of patients developing absolute thrombocytopenia, 56% experienced a platelet count fall of greater than 30%. Those with incident thrombocytopenia greater than 30% had a statistically significant increase in mortality (n=36/399) compared to those with milder thrombocytopenia (n=13/312), (9.0% versus 4.2%, p<0.05), and had an increased length of stay (12.6 days versus 6.8 days, p<0.01). In patients who developed absolute thrombocytopenia, review of diagnosis codes associated with thrombocytopenia reveal a predominance of infectious etiologies (43%; sepsis, severe sepsis, septic shock, bacteremia, urinary tract infection/pyelonephritis, pneumonia, Clostridium difficile colitis). These results are similar to prior published data which suggests infection as a leading cause of incident thrombocytopenia in non-ICU hospitalized patients. Additional studies are underway to delineate non-infectious causes of thrombocytopenia. Disclosures No relevant conflicts of interest to declare.