Neera Ahuja

All Publications

• Public Health Benefits of Applying Evidence-Based Best Practices in Managing Patients Hospitalized for COVID-19. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Kalil, A. C., Chandak, A., Moore, L. S., Ahuja, N., Kolditz, M., Casciano, R., Kadambi, A., Yaghoubi, M., Tsiodras, S., Malin, J. J., Mozaffari, E., Bartoletti, M. 2024

  Abstract

  As COVID-19-related mortality remains a concern, optimal management of patients hospitalized for COVID-19 continues to evolve. We developed a population model based on real-world evidence to quantify the clinical impact of increased utilization of remdesivir, the effectiveness of which has been well established in hospitalized patients with COVID-19.The PINC AI healthcare database records for patients hospitalized for COVID-19 from January to December 2023 were stratified by those treated with or without remdesivir ("RDV" and "No RDV") and by supplemental oxygen requirements: no supplemental oxygen charges (NSOc), low-flow oxygen (LFO), and high-flow oxygen/non-invasive ventilation (HFO/NIV). Key vulnerable subgroups such as elderly and immunocompromised patients were also evaluated. The model applied previously published hazard ratios (HRs) to 28-day in-hospital mortality incidence to determine the number of potential lives saved if additional "No RDV" patients had been treated with remdesivir upon hospital admission.Of 84,810 hospitalizations for COVID-19 in 2023, 13,233 "No RDV" patients were similar in terms of characteristics and clinical presentation to the "RDV" patients. The model predicted that initiation of remdesivir in these patients could have saved 231 lives. Projected nationally, this translates to >800 potential lives saved (95% CI: 469-1,126). Eighty-nine percent of potential lives saved were elderly and 19% were immunocompromised individuals. Seventy-one percent were among NSOc or LFO patients.This public health model underscores the value of initiating remdesivir upon admission in patients hospitalized for COVID-19, in accordance with evidence-based best practices, to minimize lives lost due to SARS-CoV-2 infection.

  View details for DOI 10.1093/cid/ciae517

  View details for PubMedID 39449663

• Management of vulnerable patients hospitalized for COVID-19 with remdesivir: a retrospective comparative effectiveness study of mortality in US hospitals. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Mozaffari, E., Chandak, A., Berry, M., Sax, P. E., Loubet, P., Doi, Y., Amin, A. N., Ahuja, N., Muller, V., Casciano, R., Kolditz, M. 2024

  Abstract

  BACKGROUND: COVID-19 remains a major public health concern, with continued resurgences of cases and substantial risk of mortality for hospitalized patients. Remdesivir has become standard-of-care for hospitalized COVID-19 patients. Given the continued evolution of the disease, clinical management relies on evidence from the current endemic period.METHODS: Using the PINC AI Healthcare database, effectiveness of remdesivir was evaluated among adults hospitalized with a primary diagnosis of COVID-19 between December 2021 and February 2024. Three cohorts were analysed: adults, elderly (≥65 years), and those with documented COVID-19 pneumonia. Analyses were stratified by oxygen requirements. Patients receiving remdesivir were matched to those not receiving remdesivir using propensity score matching. Cox proportional hazards models were used to examine in-hospital mortality.RESULTS: 169,965 adults hospitalized for COVID-19 were included, of which 94,129 (55.4%) initiated remdesivir in the first two days of hospitalization. Remdesivir was associated with a significantly lower mortality rate as compared to no remdesivir among patients with no supplemental oxygen charges (NSOc) (aHR [95% CI]: 14-day, 0.75 [0.69-0.82]; 28-day, 0.77 [0.72-0.83]) and among those with supplemental oxygen charges (SOc): 14-day, 0.76 [0.72-0.81]; 28-day, 0.79 [0.74-0.83]) (p<0.0001, for all). Similar findings were observed for elderly patients and those hospitalized with COVID-19 pneumonia.CONCLUSIONS: This evidence builds on learnings from randomized controlled trials from the pandemic era to inform clinical practices. Remdesivir was associated with significant reduction in mortality for hospitalized patients including the elderly and those with COVID-19 pneumonia.

  View details for DOI 10.1093/cid/ciae512

  View details for PubMedID 39423791

• Large Language Model Influence on Diagnostic Reasoning: A Randomized Clinical Trial. JAMA network open Goh, E., Gallo, R., Hom, J., Strong, E., Weng, Y., Kerman, H., Cool, J. A., Kanjee, Z., Parsons, A. S., Ahuja, N., Horvitz, E., Yang, D., Milstein, A., Olson, A. P., Rodman, A., Chen, J. H. 2024; 7 (10): e2440969

  Abstract

  Large language models (LLMs) have shown promise in their performance on both multiple-choice and open-ended medical reasoning examinations, but it remains unknown whether the use of such tools improves physician diagnostic reasoning.To assess the effect of an LLM on physicians' diagnostic reasoning compared with conventional resources.A single-blind randomized clinical trial was conducted from November 29 to December 29, 2023. Using remote video conferencing and in-person participation across multiple academic medical institutions, physicians with training in family medicine, internal medicine, or emergency medicine were recruited.Participants were randomized to either access the LLM in addition to conventional diagnostic resources or conventional resources only, stratified by career stage. Participants were allocated 60 minutes to review up to 6 clinical vignettes.The primary outcome was performance on a standardized rubric of diagnostic performance based on differential diagnosis accuracy, appropriateness of supporting and opposing factors, and next diagnostic evaluation steps, validated and graded via blinded expert consensus. Secondary outcomes included time spent per case (in seconds) and final diagnosis accuracy. All analyses followed the intention-to-treat principle. A secondary exploratory analysis evaluated the standalone performance of the LLM by comparing the primary outcomes between the LLM alone group and the conventional resource group.Fifty physicians (26 attendings, 24 residents; median years in practice, 3 [IQR, 2-8]) participated virtually as well as at 1 in-person site. The median diagnostic reasoning score per case was 76% (IQR, 66%-87%) for the LLM group and 74% (IQR, 63%-84%) for the conventional resources-only group, with an adjusted difference of 2 percentage points (95% CI, -4 to 8 percentage points; P = .60). The median time spent per case for the LLM group was 519 (IQR, 371-668) seconds, compared with 565 (IQR, 456-788) seconds for the conventional resources group, with a time difference of -82 (95% CI, -195 to 31; P = .20) seconds. The LLM alone scored 16 percentage points (95% CI, 2-30 percentage points; P = .03) higher than the conventional resources group.In this trial, the availability of an LLM to physicians as a diagnostic aid did not significantly improve clinical reasoning compared with conventional resources. The LLM alone demonstrated higher performance than both physician groups, indicating the need for technology and workforce development to realize the potential of physician-artificial intelligence collaboration in clinical practice.ClinicalTrials.gov Identifier: NCT06157944.

  View details for DOI 10.1001/jamanetworkopen.2024.40969

  View details for PubMedID 39466245

• Prevalence of Potential Drug Interactions With Direct-Acting Antivirals for COVID-19 Among Hospitalized Patients. Clinical therapeutics Mozaffari, E., Chandak, A., Ustianowski, A., Rivera, C. G., Ahuja, N., Jiang, H., Berry, M., Okulicz, J. F., Amin, A. N. 2024

  Abstract

  Clinicians consider polypharmacy, comorbidities, and other factors including the potential for drug-drug interactions (DDIs) when evaluating therapeutic options for specific clinical diagnoses. Contemporary treatment for coronavirus disease 2019 (COVID-19) includes direct-acting antivirals (DAAs). We sought to characterize patients' characteristics, comorbidities, and medications received during their hospitalization for COVID-19 and quantify potential DDIs that clinicians consider in selecting appropriate DAAs.Patients hospitalized with a primary diagnosis of COVID-19 between May 2020 and December 2022 from the PINC AI Healthcare Database were identified. Medications administered during the hospitalization with the potential to cause DDIs with nirmatrelvir/ritonavir, remdesivir, or molnupiravir (per the Emergency Use Authorization factsheet or package insert) were assessed. For DDIs with nirmatrelvir/ritonavir, medications are categorized as "Contraindicated," "Avoid Concomitant Use," or "Other DDIs" (includes recommendation for dose modification or clinical and laboratory monitoring). For remdesivir, coadministration with chloroquine phosphate and hydroxychloroquine sulfate was not recommended. For molnupiravir, no drugs are listed as having potential DDIs. In a subset of patients, a multivariable logistic regression model was used to examine the association between documented patient/hospital characteristics and the likelihood of being "Contraindicated" to receive nirmatrelvir/ritonavir.Of the 788,238 patients hospitalized for COVID-19 in 920 hospitals, 53% were ≥ 65 years old, and 31% had Charlson Comorbidity Index (CCI) ≥ 3. During the study period, about half of the patients received medications categorized as "Contraindicated" (11%) and/or "Avoid Concomitant Use" (41%) with nirmatrelvir/ritonavir. The frequency of administered drugs was higher in those aged ≥ 65 years (68%), CCI ≥ 3 (78%), with high-risk underlying conditions (55%). About 1% of patients received medications that were not recommended to be coadmistered with remdesivir. Among a subset of patients hospitalized for COVID-19 in 2022, those who were older, had higher CCI, high-risk underlying conditions, severe hepatic impairment, Medicare insurance, and hospitalized in larger hospitals were significantly more likely to be categorized as "Contraindicated" when considering nirmatrelvir/ritonavir as a therapeutic option to manage COVID-19.A significant proportion of patients hospitalized for COVID-19 receive medications for other conditions that have the potential to result in DDIs with DAAs; most predominantly with nirmatrelvir/ritonavir, a strong CYP3A enzyme inhibitor, fewer with remdesivir, and none with molnupiravir. Higher age and comorbidity burden were significantly associated with a higher likelihood of receiving medications that are "Contraindicated" with nirmatrelvir/ritonavir. In the evolving COVID-19 era, these findings provide insights into patients hospitalized for COVID-19, and the polypharmacy evaluations that clinicians may encounter when selecting among DAAs to manage COVID-19.

  View details for DOI 10.1016/j.clinthera.2024.08.004

  View details for PubMedID 39244489

• Large Language Model Influence on Management Reasoning: A Randomized Controlled Trial. medRxiv : the preprint server for health sciences Goh, E., Gallo, R., Strong, E., Weng, Y., Kerman, H., Freed, J., Cool, J. A., Kanjee, Z., Lane, K. P., Parsons, A. S., Ahuja, N., Horvitz, E., Yang, D., Milstein, A., Olson, A. P., Hom, J., Chen, J. H., Rodman, A. 2024

  Abstract

  Large language model (LLM) artificial intelligence (AI) systems have shown promise in diagnostic reasoning, but their utility in management reasoning with no clear right answers is unknown.To determine whether LLM assistance improves physician performance on open-ended management reasoning tasks compared to conventional resources.Prospective, randomized controlled trial conducted from 30 November 2023 to 21 April 2024.Multi-institutional study from Stanford University, Beth Israel Deaconess Medical Center, and the University of Virginia involving physicians from across the United States.92 practicing attending physicians and residents with training in internal medicine, family medicine, or emergency medicine.Five expert-developed clinical case vignettes were presented with multiple open-ended management questions and scoring rubrics created through a Delphi process. Physicians were randomized to use either GPT-4 via ChatGPT Plus in addition to conventional resources (e.g., UpToDate, Google), or conventional resources alone.The primary outcome was difference in total score between groups on expert-developed scoring rubrics. Secondary outcomes included domain-specific scores and time spent per case.Physicians using the LLM scored higher compared to those using conventional resources (mean difference 6.5 %, 95% CI 2.7-10.2, p<0.001). Significant improvements were seen in management decisions (6.1%, 95% CI 2.5-9.7, p=0.001), diagnostic decisions (12.1%, 95% CI 3.1-21.0, p=0.009), and case-specific (6.2%, 95% CI 2.4-9.9, p=0.002) domains. GPT-4 users spent more time per case (mean difference 119.3 seconds, 95% CI 17.4-221.2, p=0.02). There was no significant difference between GPT-4-augmented physicians and GPT-4 alone (-0.9%, 95% CI -9.0 to 7.2, p=0.8).LLM assistance improved physician management reasoning compared to conventional resources, with particular gains in contextual and patient-specific decision-making. These findings indicate that LLMs can augment management decision-making in complex cases.ClinicalTrials.gov Identifier: NCT06208423 ; https://classic.clinicaltrials.gov/ct2/show/NCT06208423.Question: Does large language model (LLM) assistance improve physician performance on complex management reasoning tasks compared to conventional resources?Findings: In this randomized controlled trial of 92 physicians, participants using GPT-4 achieved higher scores on management reasoning compared to those using conventional resources (e.g., UpToDate).Meaning: LLM assistance enhances physician management reasoning performance in complex cases with no clear right answers.

  View details for DOI 10.1101/2024.08.05.24311485

  View details for PubMedID 39148822

  View details for PubMedCentralID PMC11326321

• Merlin: A Vision Language Foundation Model for 3D Computed Tomography. Research square Blankemeier, L., Cohen, J. P., Kumar, A., Veen, D. V., Gardezi, S., Paschali, M., Chen, Z., Delbrouck, J. B., Reis, E., Truyts, C., Bluethgen, C., Jensen, M., Ostmeier, S., Varma, M., Valanarasu, J., Fang, Z., Huo, Z., Nabulsi, Z., Ardila, D., Weng, W. H., Junior, E. A., Ahuja, N., Fries, J., Shah, N., Johnston, A., Boutin, R., Wentland, A., Langlotz, C., Hom, J., Gatidis, S., Chaudhari, A. 2024

  Abstract

  Over 85 million computed tomography (CT) scans are performed annually in the US, of which approximately one quarter focus on the abdomen. Given the current shortage of both general and specialized radiologists, there is a large impetus to use artificial intelligence to alleviate the burden of interpreting these complex imaging studies while simultaneously using the images to extract novel physiological insights. Prior state-of-the-art approaches for automated medical image interpretation leverage vision language models (VLMs) that utilize both the image and the corresponding textual radiology reports. However, current medical VLMs are generally limited to 2D images and short reports. To overcome these shortcomings for abdominal CT interpretation, we introduce Merlin - a 3D VLM that leverages both structured electronic health records (EHR) and unstructured radiology reports for pretraining without requiring additional manual annotations. We train Merlin using a high-quality clinical dataset of paired CT scans (6+ million images from 15,331 CTs), EHR diagnosis codes (1.8+ million codes), and radiology reports (6+ million tokens) for training. We comprehensively evaluate Merlin on 6 task types and 752 individual tasks. The non-adapted (off-the-shelf) tasks include zero-shot findings classification (31 findings), phenotype classification (692 phenotypes), and zero-shot cross-modal retrieval (image to findings and image to impressions), while model adapted tasks include 5-year chronic disease prediction (6 diseases), radiology report generation, and 3D semantic segmentation (20 organs). We perform internal validation on a test set of 5,137 CTs, and external validation on 7,000 clinical CTs and on two public CT datasets (VerSe, TotalSegmentator). Beyond these clinically-relevant evaluations, we assess the efficacy of various network architectures and training strategies to depict that Merlin has favorable performance to existing task-specific baselines. We derive data scaling laws to empirically assess training data needs for requisite downstream task performance. Furthermore, unlike conventional VLMs that require hundreds of GPUs for training, we perform all training on a single GPU. This computationally efficient design can help democratize foundation model training, especially for health systems with compute constraints. We plan to release our trained models, code, and dataset, pending manual removal of all protected health information.

  View details for DOI 10.21203/rs.3.rs-4546309/v1

  View details for PubMedID 38978576

  View details for PubMedCentralID PMC11230513

• Comparing IM Residency Application Personal Statements Generated by GPT-4 and Authentic Applicants. Journal of general internal medicine Nair, V., Nayak, A., Ahuja, N., Weng, Y., Keet, K., Hosamani, P., Hom, J. 2024

  View details for DOI 10.1007/s11606-024-08784-w

  View details for PubMedID 38689120

  View details for PubMedCentralID 10589311

• Influence of a Large Language Model on Diagnostic Reasoning: A Randomized Clinical Vignette Study. medRxiv : the preprint server for health sciences Goh, E., Gallo, R., Hom, J., Strong, E., Weng, Y., Kerman, H., Cool, J., Kanjee, Z., Parsons, A. S., Ahuja, N., Horvitz, E., Yang, D., Milstein, A., Olson, A. P., Rodman, A., Chen, J. H. 2024

  Abstract

  Diagnostic errors are common and cause significant morbidity. Large language models (LLMs) have shown promise in their performance on both multiple-choice and open-ended medical reasoning examinations, but it remains unknown whether the use of such tools improves diagnostic reasoning.To assess the impact of the GPT-4 LLM on physicians' diagnostic reasoning compared to conventional resources.Multi-center, randomized clinical vignette study.The study was conducted using remote video conferencing with physicians across the country and in-person participation across multiple academic medical institutions.Resident and attending physicians with training in family medicine, internal medicine, or emergency medicine.Participants were randomized to access GPT-4 in addition to conventional diagnostic resources or to just conventional resources. They were allocated 60 minutes to review up to six clinical vignettes adapted from established diagnostic reasoning exams.The primary outcome was diagnostic performance based on differential diagnosis accuracy, appropriateness of supporting and opposing factors, and next diagnostic evaluation steps. Secondary outcomes included time spent per case and final diagnosis.50 physicians (26 attendings, 24 residents) participated, with an average of 5.2 cases completed per participant. The median diagnostic reasoning score per case was 76.3 percent (IQR 65.8 to 86.8) for the GPT-4 group and 73.7 percent (IQR 63.2 to 84.2) for the conventional resources group, with an adjusted difference of 1.6 percentage points (95% CI -4.4 to 7.6; p=0.60). The median time spent on cases for the GPT-4 group was 519 seconds (IQR 371 to 668 seconds), compared to 565 seconds (IQR 456 to 788 seconds) for the conventional resources group, with a time difference of -82 seconds (95% CI -195 to 31; p=0.20). GPT-4 alone scored 15.5 percentage points (95% CI 1.5 to 29, p=0.03) higher than the conventional resources group.In a clinical vignette-based study, the availability of GPT-4 to physicians as a diagnostic aid did not significantly improve clinical reasoning compared to conventional resources, although it may improve components of clinical reasoning such as efficiency. GPT-4 alone demonstrated higher performance than both physician groups, suggesting opportunities for further improvement in physician-AI collaboration in clinical practice.

  View details for DOI 10.1101/2024.03.12.24303785

  View details for PubMedID 38559045

  View details for PubMedCentralID PMC10980135

• Adapted large language models can outperform medical experts in clinical text summarization. Nature medicine Van Veen, D., Van Uden, C., Blankemeier, L., Delbrouck, J. B., Aali, A., Bluethgen, C., Pareek, A., Polacin, M., Reis, E. P., Seehofnerová, A., Rohatgi, N., Hosamani, P., Collins, W., Ahuja, N., Langlotz, C. P., Hom, J., Gatidis, S., Pauly, J., Chaudhari, A. S. 2024

  Abstract

  Analyzing vast textual data and summarizing key information from electronic health records imposes a substantial burden on how clinicians allocate their time. Although large language models (LLMs) have shown promise in natural language processing (NLP) tasks, their effectiveness on a diverse range of clinical summarization tasks remains unproven. Here we applied adaptation methods to eight LLMs, spanning four distinct clinical summarization tasks: radiology reports, patient questions, progress notes and doctor-patient dialogue. Quantitative assessments with syntactic, semantic and conceptual NLP metrics reveal trade-offs between models and adaptation methods. A clinical reader study with 10 physicians evaluated summary completeness, correctness and conciseness; in most cases, summaries from our best-adapted LLMs were deemed either equivalent (45%) or superior (36%) compared with summaries from medical experts. The ensuing safety analysis highlights challenges faced by both LLMs and medical experts, as we connect errors to potential medical harm and categorize types of fabricated information. Our research provides evidence of LLMs outperforming medical experts in clinical text summarization across multiple tasks. This suggests that integrating LLMs into clinical workflows could alleviate documentation burden, allowing clinicians to focus more on patient care.

  View details for DOI 10.1038/s41591-024-02855-5

  View details for PubMedID 38413730

  View details for PubMedCentralID 5593724

• IgM N-glycosylation correlates with COVID-19 severity and rate of complement deposition. Nature communications Haslund-Gourley, B. S., Woloszczuk, K., Hou, J., Connors, J., Cusimano, G., Bell, M., Taramangalam, B., Fourati, S., Mege, N., Bernui, M., Altman, M. C., Krammer, F., van Bakel, H., IMPACC Network, Maecker, H. T., Rouphael, N., Diray-Arce, J., Wigdahl, B., Kutzler, M. A., Cairns, C. B., Haddad, E. K., Comunale, M. A., Ozonoff, A., Ehrlich, L. I., Melamed, E., Sesma, A. F., Simon, V., Pulendran, B., Nadeau, K. C., Davis, M. M., McCoey, G. A., Sekaly, R., Baden, L. R., Levy, O., Schaenman, J., Reed, E. F., Shaw, A. C., Hafler, D. A., Montgomery, R. R., Kleinstein, S. H., Becker, P. M., Augustine, A. D., Calfee, C. S., Erle, D. J., DeBakey, M. E., Corry, D. B., Kheradmand, F., Atkinson, M. A., Brakenridge, S. C., Higuita, N. I., Metcalf, J. P., Hough, C. L., Messer, W. B., Kraft, M., Bime, C., Peters, B., Milliren, C. E., Syphurs, C., McEnaney, K., Barton, B., Lentucci, C., Saluvan, M., Chang, A. C., Hoch, A., Albert, M., Shaheen, T., Kho, A. T., Liu, S., Thomas, S., Chen, J., Murphy, M. D., Cooney, M., Hayati, A. N., Bryant, R., Abraham, J., Jayavelu, N. D., Presnell, S., Jancsyk, T., Maguire, C., Qi, J., Lee, B., Fourati, S., Esserman, D. A., Guan, L., Gygi, J., Pawar, S., Brito, A., Fragiadakis, G. K., Patel, R., Overton, J. A., Vita, R., Westendorf, K., Shannon, C. P., Tebbutt, S. J., Thyagarajan, R. V., Rousseau, J. F., Wylie, D., Triplett, T. A., Kojic, E., Chinthrajah, S., Ahuja, N., Rogers, A. J., Artandi, M., Geng, L., Yendewa, G., Powell, D. L., Kim, J. N., Simmons, B., Goonewardene, I. M., Smith, C. M., Martens, M., Sherman, A. C., Walsh, S. R., Issa, N. C., Salehi-Rad, R., Dela Cruz, C., Farhadian, S., Iwasaki, A., Ko, A. I., Anderson, E. J., Mehta, A. K., Sevransky, J. E., Seyfert-Margolis, V., Leligdowicz, A., Matthay, M. A., Singer, J. P., Kangelaris, K. N., Hendrickson, C. M., Krummel, M. F., Langelier, C. R., Woodruff, P. G., Corry, D. B., Kheradmand, F., Anderson, M. L., Guirgis, F. W., Drevets, D. A., Brown, B. R., Siegel, S. A., Lu, Z., Mosier, J., Kimura, H., Khor, B., van Bakel, H., Rahman, A., Stadlbauer, D., Dutta, J., Xie, H., Kim-Schulze, S., Gonzalez-Reiche, A. S., van de Guchte, A., Carreno, J. M., Singh, G., Raskin, A., Tcheou, J., Bielak, D., Kawabata, H., Kelly, G., Patel, M., Nie, K., Yellin, T., Fried, M., Sullivan, L., Morris, S., Sieg, S., Steen, H., van Zalm, P., Fatou, B., Mendez, K., Lasky-Su, J., Hutton, S. R., Michelotti, G., Wong, K., Jha, M., Viode, A., Kanarek, N., Petrova, B., Zhao, Y., Bosinger, S. E., Boddapati, A. K., Tharp, G. K., Pellegrini, K. L., Beagle, E., Cowan, D., Hamilton, S., Ribeiro, S. P., Hodder, T., Rosen, L. B., Lee, S., Wilson, M. R., Dandekar, R., Alvarenga, B., Rajan, J., Eckalbar, W., Schroeder, A. W., Tsitsiklis, A., Mick, E., Guerrero, Y. S., Love, C., Maliskova, L., Adkisson, M., Siles, N., Geltman, J., Hurley, K., Saksena, M., Altman, D., Srivastava, K., Eaker, L. Q., Bermudez-Gonzalez, M. C., Beach, K. F., Sominsky, L. A., Azad, A. R., Mulder, L. C., Kleiner, G., Lee, A. S., Do, E., Fernandes, A., Manohar, M., Hagan, T., Blish, C. A., Din, H. N., Roque, J., Yang, S., Sigal, N., Chang, I., Tribout, H., Harris, P., Consolo, M., Edwards, C., Lee, E., Lin, E., Croen, B., Semenza, N. C., Rogowski, B., Melnyk, N., Bell, M. R., Furukawa, S., McLin, R., Schearer, P., Sheidy, J., Tegos, G. P., Nagle, C., Smolen, K., Desjardins, M., van Haren, S., Mitre, X., Cauley, J., Li, X., Tong, A., Evans, B., Montesano, C., Licona, J. H., Krauss, J., Chang, J. B., Izaguirre, N., Rooks, R., Elashoff, D., Brook, J., Ramires-Sanchez, E., Llamas, M., Rivera, A., Perdomo, C., Ward, D. C., Magyar, C. E., Fulcher, J. A., Pickering, H. C., Sen, S., Chaudhary, O., Coppi, A., Fournier, J., Mohanty, S., Muenker, C., Nelson, A., Raddassi, K., Rainone, M., Ruff, W. E., Salahuddin, S., Schulz, W. L., Vijayakumar, P., Wang, H., Wunder, E. J., Young, H. P., Rothman, J., Konstorum, A., Chen, E., Cotsapas, C., Grubaugh, N. D., Wang, X., Xu, L., Asashima, H., Bristow, L., Hussaini, L., Hellmeister, K., Samaha, H., Wimalasena, S. T., Cheng, A., Spainhour, C., Scherer, E. M., Johnson, B., Bechnak, A., Ciric, C. R., Hewitt, L., Carter, E., Mcnair, N., Panganiban, B., Huerta, C., Usher, J., Vaysman, T., Holland, S. M., Abe-Jones, Y., Asthana, S., Beagle, A., Bhide, S., Carrillo, S. A., Chak, S., Ghale, R., Gonzalez, A., Jauregui, A., Jones, N., Lea, T., Lee, D., Lota, R., Milush, J., Nguyen, V., Pierce, L., Prasad, P. A., Rao, A., Samad, B., Shaw, C., Sigman, A., Sinha, P., Ward, A., Willmore, A., Zhan, J., Rashid, S., Rodriguez, N., Tang, K., Altamirano, L. T., Betancourt, L., Curiel, C., Sutter, N., Paz, M. T., Tietje-Ulrich, G., Leroux, C., Thakur, N., Vasquez, J. J., Santhosh, L., Song, L., Nelson, E., Moldawer, L. L., Borresen, B., Roth-Manning, B., Ungaro, R. F., Oberhaus, J., Booth, J. L., Sinko, L. A., Brunton, A., Sullivan, P. E., Strnad, M., Lyski, Z. L., Coulter, F. J., Micheleti, C., Conway, M., Francisco, D., Molzahn, A., Erickson, H., Wilson, C. C., Schunk, R., Sierra, B., Hughes, T. 2024; 15 (1): 404

  Abstract

  The glycosylation of IgG plays a critical role during human severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, activating immune cells and inducing cytokine production. However, the role of IgM N-glycosylation has not been studied during human acute viral infection. The analysis of IgM N-glycosylation from healthy controls and hospitalized coronavirus disease 2019 (COVID-19) patients reveals increased high-mannose and sialylation that correlates with COVID-19 severity. These trends are confirmed within SARS-CoV-2-specific immunoglobulin N-glycan profiles. Moreover, the degree of total IgM mannosylation and sialylation correlate significantly with markers of disease severity. We link the changes of IgM N-glycosylation with the expression of Golgi glycosyltransferases. Lastly, we observe antigen-specific IgM antibody-dependent complement deposition is elevated in severe COVID-19 patients and modulated by exoglycosidase digestion. Taken together, this work links the IgM N-glycosylation with COVID-19 severity and highlights the need to understand IgM glycosylation and downstream immune function during human disease.

  View details for DOI 10.1038/s41467-023-44211-0

  View details for PubMedID 38195739

• Features of acute COVID-19 associated with post-acute sequelae of SARS-CoV-2 phenotypes: results from the IMPACC study. Nature communications Ozonoff, A., Jayavelu, N. D., Liu, S., Melamed, E., Milliren, C. E., Qi, J., Geng, L. N., McComsey, G. A., Cairns, C. B., Baden, L. R., Schaenman, J., Shaw, A. C., Samaha, H., Seyfert-Margolis, V., Krammer, F., Rosen, L. B., Steen, H., Syphurs, C., Dandekar, R., Shannon, C. P., Sekaly, R. P., Ehrlich, L. I., Corry, D. B., Kheradmand, F., Atkinson, M. A., Brakenridge, S. C., Higuita, N. I., Metcalf, J. P., Hough, C. L., Messer, W. B., Pulendran, B., Nadeau, K. C., Davis, M. M., Sesma, A. F., Simon, V., van Bakel, H., Kim-Schulze, S., Hafler, D. A., Levy, O., Kraft, M., Bime, C., Haddad, E. K., Calfee, C. S., Erle, D. J., Langelier, C. R., Eckalbar, W., Bosinger, S. E., Peters, B., Kleinstein, S. H., Reed, E. F., Augustine, A. D., Diray-Arce, J., Maecker, H. T., Altman, M. C., Montgomery, R. R., Becker, P. M., Rouphael, N. 2024; 15 (1): 216

  Abstract

  Post-acute sequelae of SARS-CoV-2 (PASC) is a significant public health concern. We describe Patient Reported Outcomes (PROs) on 590 participants prospectively assessed from hospital admission for COVID-19 through one year after discharge. Modeling identified 4 PRO clusters based on reported deficits (minimal, physical, mental/cognitive, and multidomain), supporting heterogenous clinical presentations in PASC, with sub-phenotypes associated with female sex and distinctive comorbidities. During the acute phase of disease, a higher respiratory SARS-CoV-2 viral burden and lower Receptor Binding Domain and Spike antibody titers were associated with both the physical predominant and the multidomain deficit clusters. A lower frequency of circulating B lymphocytes by mass cytometry (CyTOF) was observed in the multidomain deficit cluster. Circulating fibroblast growth factor 21 (FGF21) was significantly elevated in the mental/cognitive predominant and the multidomain clusters. Future efforts to link PASC to acute anti-viral host responses may help to better target treatment and prevention of PASC.

  View details for DOI 10.1038/s41467-023-44090-5

  View details for PubMedID 38172101

  View details for PubMedCentralID PMC10764789

• Clinical Text Summarization: Adapting Large Language Models Can Outperform Human Experts. Research square Veen, D. V., Uden, C. V., Blankemeier, L., Delbrouck, J. B., Aali, A., Bluethgen, C., Pareek, A., Polacin, M., Reis, E. P., Seehofnerova, A., Rohatgi, N., Hosamani, P., Collins, W., Ahuja, N., Langlotz, C., Hom, J., Gatidis, S., Pauly, J., Chaudhari, A. 2023

  Abstract

  Sifting through vast textual data and summarizing key information from electronic health records (EHR) imposes a substantial burden on how clinicians allocate their time. Although large language models (LLMs) have shown immense promise in natural language processing (NLP) tasks, their efficacy on a diverse range of clinical summarization tasks has not yet been rigorously demonstrated. In this work, we apply domain adaptation methods to eight LLMs, spanning six datasets and four distinct clinical summarization tasks: radiology reports, patient questions, progress notes, and doctor-patient dialogue. Our thorough quantitative assessment reveals trade-offs between models and adaptation methods in addition to instances where recent advances in LLMs may not improve results. Further, in a clinical reader study with ten physicians, we show that summaries from our best-adapted LLMs are preferable to human summaries in terms of completeness and correctness. Our ensuing qualitative analysis highlights challenges faced by both LLMs and human experts. Lastly, we correlate traditional quantitative NLP metrics with reader study scores to enhance our understanding of how these metrics align with physician preferences. Our research marks the first evidence of LLMs outperforming human experts in clinical text summarization across multiple tasks. This implies that integrating LLMs into clinical workflows could alleviate documentation burden, empowering clinicians to focus more on personalized patient care and the inherently human aspects of medicine.

  View details for DOI 10.21203/rs.3.rs-3483777/v1

  View details for PubMedID 37961377

  View details for PubMedCentralID PMC10635391

• Baricitinib Treatment of Coronavirus Disease 2019 Is Associated With a Reduction in Secondary Infections. Open forum infectious diseases Sweeney, D. A., Tuyishimire, B., Ahuja, N., Beigel, J. H., Beresnev, T., Cantos, V. D., Castro, J. G., Cohen, S. H., Cross, K., Dodd, L. E., Erdmann, N., Fung, M., Ghazaryan, V., George, S. L., Grimes, K. A., Hynes, N. A., Julian, K. G., Kandiah, S., Kim, H. J., Levine, C. B., Lindholm, D. A., Lye, D. C., Maves, R. C., Oh, M. D., Paules, C., Rapaka, R. R., Short, W. R., Tomashek, K. M., Wolfe, C. R., Kalil, A. C. 2023; 10 (5): ofad205

  Abstract

  We performed a secondary analysis of the National Institutes of Health-sponsored Adaptive COVID-19 Treatment Trial (ACTT-2) randomized controlled trial and found that baricitinib was associated with a 50% reduction in secondary infections after controlling for baseline and postrandomization patient characteristics. This finding provides a novel mechanism of benefit for baricitinib and supports the safety profile of this immunomodulator for the treatment of coronavirus disease 2019.

  View details for DOI 10.1093/ofid/ofad205

  View details for PubMedID 37206623

  View details for PubMedCentralID PMC10191442

• Characteristics associated with diagnostic yield of imaging for deep venous thrombosis and pulmonary embolism in the emergency department, hospital, and office settings: An Optum Clinformatics claims database study (2015-2019). Thrombosis research Rohatgi, N., Dahlen, A., Berube, C., Weng, Y., Wintermark, M., Ahuja, N. 2023; 224: 4-12

  Abstract

  Different patient characteristics influence the decision to order diagnostic imaging for deep venous thrombosis (DVT) and pulmonary embolism (PE) in different settings (emergency department (ED), hospital, and office). Diagnostic yield is defined as the proportion of tests that report positive results. We hypothesize different patient characteristics are associated with higher or lower diagnostic yield of imaging for DVT and PE in different settings.We used Optum Clinformatics™ national claims database (2015-2019) to assess the diagnostic yield of imaging for DVT and PE in three settings: (a) ED discharge, (b) Hospitalized, and (c) Office. We studied the patient characteristics associated with diagnostic yield using logistic regression.Diagnostic imaging for DVT and PE was performed in 1,502,417 and 710,263 visits, respectively. Diagnostic yield for DVT and PE was 9.8 ± 0.1 % and 12.7 ± 0.1 %, respectively in the overall cohort. In the ED discharge, hospitalized, and office settings, diagnostic yield for DVT was 10.4 ± 0.1 %, 16.9 ± 0.1 %, and 6.5 ± 0.1 %, respectively, and that for PE 6.4 ± 0.1 %, 18.7 ± 0.1 %, and 8.8 ± 0.2 %, respectively. Of the patients who underwent imaging for DVT, higher diagnostic yield was more likely with thrombophilia, central venous access, and cancer. Of the patients who underwent imaging for PE, higher diagnostic yield was most likely with thrombophilia, respiratory failure, and heart failure or acute myocardial infarction.In each setting, different patient characteristics influence the diagnostic yield of imaging for DVT and PE and can inform clinical practice. Judicious use of imaging for DVT and PE could reduce costs and avoid exposure to radiation and contrast.

  View details for DOI 10.1016/j.thromres.2023.02.004

  View details for PubMedID 36774701

• Development of a Definition of Postacute Sequelae of SARS-CoV-2 Infection. JAMA Thaweethai, T., Jolley, S. E., Karlson, E. W., Levitan, E. B., Levy, B., McComsey, G. A., McCorkell, L., Nadkarni, G. N., Parthasarathy, S., Singh, U., Walker, T. A., Selvaggi, C. A., Shinnick, D. J., Schulte, C. C., Atchley-Challenner, R., Horwitz, L. I., Foulkes, A. S., RECOVER Consortium, Alba, G. A., Alicic, R., Altman, N., Anglin, K., Argueta, U., Ashktorab, H., Baslet, G., Bassett, I. V., Bateman, L., Bedi, B., Bhattacharyya, S., Bind, M., Blomkalns, A. L., Bonilla, H., Bush, P. A., Castro, M., Chan, J., Charney, A. W., Chen, P., Chibnik, L. B., Chu, H. Y., Clifton, R. G., Costantine, M. M., Cribbs, S. K., Davila Nieves, S. I., Deeks, S. G., Duven, A., Emery, I. F., Erdmann, N., Erlandson, K. M., Ernst, K. C., Farah-Abraham, R., Farner, C. E., Feuerriegel, E. M., Fleurimont, J., Fonseca, V., Franko, N., Gainer, V., Gander, J. C., Gardner, E. M., Geng, L. N., Gibson, K. S., Go, M., Goldman, J. D., Grebe, H., Greenway, F. L., Habli, M., Hafner, J., Han, J. E., Hanson, K. A., Heath, J., Hernandez, C., Hess, R., Hodder, S. L., Hoffman, M. K., Hoover, S. E., Huang, B., Hughes, B. L., Jagannathan, P., John, J., Jordan, M. R., Katz, S. D., Kaufman, E. S., Kelly, J. D., Kelly, S. W., Kemp, M. M., Kirwan, J. P., Klein, J. D., Knox, K. S., Krishnan, J. A., Kumar, A., Laiyemo, A. O., Lambert, A. A., Lanca, M., Lee-Iannotti, J. K., Logarbo, B. P., Longo, M. T., Luciano, C. A., Lutrick, K., Maley, J. H., Marathe, J. G., Marconi, V., Marshall, G. D., Martin, C. F., Matusov, Y., Mehari, A., Mendez-Figueroa, H., Mermelstein, R., Metz, T. D., Morse, R., Mosier, J., Mouchati, C., Mullington, J., Murphy, S. N., Neuman, R. B., Nikolich, J. Z., Ofotokun, I., Ojemakinde, E., Palatnik, A., Palomares, K., Parimon, T., Parry, S., Patterson, J. E., Patterson, T. F., Patzer, R. E., Peluso, M. J., Pemu, P., Pettker, C. M., Plunkett, B. A., Pogreba-Brown, K., Poppas, A., Quigley, J. G., Reddy, U., Reece, R., Reeder, H., Reeves, W. B., Reiman, E. M., Rischard, F., Rosand, J., Rouse, D. J., Ruff, A., Saade, G., Sandoval, G. J., Schlater, S. M., Shepherd, F., Sherif, Z. A., Simhan, H., Singer, N. G., Skupski, D. W., Sowles, A., Sparks, J. A., Sukhera, F. I., Taylor, B. S., Teunis, L., Thomas, R. J., Thorp, J. M., Thuluvath, P., Ticotsky, A., Tita, A. T., Tuttle, K. R., Urdaneta, A. E., Valdivieso, D., VanWagoner, T. M., Vasey, A., Verduzco-Gutierrez, M., Wallace, Z. S., Ward, H. D., Warren, D. E., Weiner, S. J., Welch, S., Whiteheart, S. W., Wiley, Z., Wisnivesky, J. P., Yee, L. M., Zisis, S. 2023

  Abstract

  Importance: SARS-CoV-2 infection is associated with persistent, relapsing, or new symptoms or other health effects occurring after acute infection, termed postacute sequelae of SARS-CoV-2 infection (PASC), also known as long COVID. Characterizing PASC requires analysis of prospectively and uniformly collected data from diverse uninfected and infected individuals.Objective: To develop a definition of PASC using self-reported symptoms and describe PASC frequencies across cohorts, vaccination status, and number of infections.Design, Setting, and Participants: Prospective observational cohort study of adults with and without SARS-CoV-2 infection at 85 enrolling sites (hospitals, health centers, community organizations) located in 33 states plus Washington, DC, and Puerto Rico. Participants who were enrolled in the RECOVER adult cohort before April 10, 2023, completed a symptom survey 6 months or more after acute symptom onset or test date. Selection included population-based, volunteer, and convenience sampling.Exposure: SARS-CoV-2 infection.Main Outcomes and Measures: PASC and 44 participant-reported symptoms (with severity thresholds).Results: A total of 9764 participants (89% SARS-CoV-2 infected; 71% female; 16% Hispanic/Latino; 15% non-Hispanic Black; median age, 47 years [IQR, 35-60]) met selection criteria. Adjusted odds ratios were 1.5 or greater (infected vs uninfected participants) for 37 symptoms. Symptoms contributing to PASC score included postexertional malaise, fatigue, brain fog, dizziness, gastrointestinal symptoms, palpitations, changes in sexual desire or capacity, loss of or change in smell or taste, thirst, chronic cough, chest pain, and abnormal movements. Among 2231 participants first infected on or after December 1, 2021, and enrolled within 30 days of infection, 224 (10% [95% CI, 8.8%-11%]) were PASC positive at 6 months.Conclusions and Relevance: A definition of PASC was developed based on symptoms in a prospective cohort study. As a first step to providing a framework for other investigations, iterative refinement that further incorporates other clinical features is needed to support actionable definitions of PASC.

  View details for DOI 10.1001/jama.2023.8823

  View details for PubMedID 37278994

• Temporal Improvements in COVID-19 Outcomes for Hospitalized Adults: A Post Hoc Observational Study of Remdesivir Group Participants in the Adaptive COVID-19 Treatment Trial. Annals of internal medicine Potter, G. E., Bonnett, T., Rubenstein, K., Lindholm, D. A., Rapaka, R. R., Doernberg, S. B., Lye, D. C., Mularski, R. A., Hynes, N. A., Kline, S., Paules, C. I., Wolfe, C. R., Frank, M. G., Rouphael, N. G., Deye, G. A., Sweeney, D. A., Colombo, R. E., Davey, R. T., Mehta, A. K., Whitaker, J. A., Castro, J. G., Amin, A. N., Colombo, C. J., Levine, C. B., Jain, M. K., Maves, R. C., Marconi, V. C., Grossberg, R., Hozayen, S., Burgess, T. H., Atmar, R. L., Ganesan, A., Gomez, C. A., Benson, C. A., Lopez de Castilla, D., Ahuja, N., George, S. L., Nayak, S. U., Cohen, S. H., Lalani, T., Short, W. R., Erdmann, N., Tomashek, K. M., Tebas, P. 2022

  Abstract

  The COVID-19 standard of care (SOC) evolved rapidly during 2020 and 2021, but its cumulative effect over time is unclear.To evaluate whether recovery and mortality improved as SOC evolved, using data from ACTT (Adaptive COVID-19 Treatment Trial).ACTT is a series of phase 3, randomized, double-blind, placebo-controlled trials that evaluated COVID-19 therapeutics from February 2020 through May 2021. ACTT-1 compared remdesivir plus SOC to placebo plus SOC, and in ACTT-2 and ACTT-3, remdesivir plus SOC was the control group. This post hoc analysis compared recovery and mortality between these comparable sequential cohorts of patients who received remdesivir plus SOC, adjusting for baseline characteristics with propensity score weighting. The analysis was repeated for participants in ACTT-3 and ACTT-4 who received remdesivir plus dexamethasone plus SOC. Trends in SOC that could explain outcome improvements were analyzed. (ClinicalTrials.gov: NCT04280705 [ACTT-1], NCT04401579 [ACTT-2], NCT04492475 [ACTT-3], and NCT04640168 [ACTT-4]).94 hospitals in 10 countries (86% U.S. participants).Adults hospitalized with COVID-19.SOC.28-day mortality and recovery.Although outcomes were better in ACTT-2 than in ACTT-1, adjusted hazard ratios (HRs) were close to 1 (HR for recovery, 1.04 [95% CI, 0.92 to 1.17]; HR for mortality, 0.90 [CI, 0.56 to 1.40]). Comparable patients were less likely to be intubated in ACTT-2 than in ACTT-1 (odds ratio, 0.75 [CI, 0.53 to 0.97]), and hydroxychloroquine use decreased. Outcomes improved from ACTT-2 to ACTT-3 (HR for recovery, 1.43 [CI, 1.24 to 1.64]; HR for mortality, 0.45 [CI, 0.21 to 0.97]). Potential explanatory factors (SOC trends, case surges, and variant trends) were similar between ACTT-2 and ACTT-3, except for increased dexamethasone use (11% to 77%). Outcomes were similar in ACTT-3 and ACTT-4. Antibiotic use decreased gradually across all stages.Unmeasured confounding.Changes in patient composition explained improved outcomes from ACTT-1 to ACTT-2 but not from ACTT-2 to ACTT-3, suggesting improved SOC. These results support excluding nonconcurrent controls from analysis of platform trials in rapidly changing therapeutic areas.National Institute of Allergy and Infectious Diseases.

  View details for DOI 10.7326/M22-2116

  View details for PubMedID 36442063

• Association between Obesity and Length of COVID-19 Hospitalization: Unexpected Insights from the American Heart Association National COVID-19 Registry. Journal of obesity & metabolic syndrome Collins, W. J., Chang, A. Y., Weng, Y., Dahlen, A., O'Brien, C. G., Hom, J., Ahuja, N., Rodriguez, F., Rohatgi, N. 2022

  Abstract

  Background: Observational analyses have noted an association between obesity and poor clinical outcome from Coronavirus Disease 2019 (COVID-19). The mechanism for this finding remains unclear.Methods: We analyzed data from 22,915 COVID-19 patients hospitalized in non-intensive care units using the American Heart Association National COVID Registry of adult COVID-19 admissions from March 2020 to April 2021. A multivariable Poisson model adjusted for age, sex, medical history, admission respiratory status, hospitalization characteristics, and select laboratory findings was used to calculate length of stay (LOS) as a function of body mass index (BMI) category. Additionally, 5,327 patients admitted to intensive care units were similarly analyzed for comparison.Results: Relative to normal BMI subjects, overweight, class I obese, and class II obese patients had approximately half-day reductions in LOS (-0.469 days, P<0.01; -0.480 days, P<0.01; -0.578 days, P<0.01, respectively).Conclusion: The model identified a dose-dependent, inverse relationship between BMI category and LOS for COVID-19, which was not seen when the model was applied to critically ill patients.

  View details for DOI 10.7570/jomes22042

  View details for PubMedID 36058896

• Phenotypes of disease severity in a cohort of hospitalized COVID-19 patients: Results from the IMPACC study. EBioMedicine Ozonoff, A., Schaenman, J., Jayavelu, N. D., Milliren, C. E., Calfee, C. S., Cairns, C. B., Kraft, M., Baden, L. R., Shaw, A. C., Krammer, F., van Bakel, H., Esserman, D. A., Liu, S., Sesma, A. F., Simon, V., Hafler, D. A., Montgomery, R. R., Kleinstein, S. H., Levy, O., Bime, C., Haddad, E. K., Erle, D. J., Pulendran, B., Nadeau, K. C., Davis, M. M., Hough, C. L., Messer, W. B., Higuita, N. I., Metcalf, J. P., Atkinson, M. A., Brakenridge, S. C., Corry, D., Kheradmand, F., Ehrlich, L. I., Melamed, E., McComsey, G. A., Sekaly, R., Diray-Arce, J., Peters, B., Augustine, A. D., Reed, E. F., Altman, M. C., Becker, P. M., Rouphael, N. 2022; 83: 104208

  Abstract

  Better understanding of the association between characteristics of patients hospitalized with coronavirus disease 2019 (COVID-19) and outcome is needed to further improve upon patient management.Immunophenotyping Assessment in a COVID-19 Cohort (IMPACC) is a prospective, observational study of 1164 patients from 20 hospitals across the United States. Disease severity was assessed using a 7-point ordinal scale based on degree of respiratory illness. Patients were prospectively surveyed for 1 year after discharge for post-acute sequalae of COVID-19 (PASC) through quarterly surveys. Demographics, comorbidities, radiographic findings, clinical laboratory values, SARS-CoV-2 PCR and serology were captured over a 28-day period. Multivariable logistic regression was performed.The median age was 59 years (interquartile range [IQR] 20); 711 (61%) were men; overall mortality was 14%, and 228 (20%) required invasive mechanical ventilation. Unsupervised clustering of ordinal score over time revealed distinct disease course trajectories. Risk factors associated with prolonged hospitalization or death by day 28 included age ≥ 65 years (odds ratio [OR], 2.01; 95% CI 1.28-3.17), Hispanic ethnicity (OR, 1.71; 95% CI 1.13-2.57), elevated baseline creatinine (OR 2.80; 95% CI 1.63- 4.80) or troponin (OR 1.89; 95% 1.03-3.47), baseline lymphopenia (OR 2.19; 95% CI 1.61-2.97), presence of infiltrate by chest imaging (OR 3.16; 95% CI 1.96-5.10), and high SARS-CoV2 viral load (OR 1.53; 95% CI 1.17-2.00). Fatal cases had the lowest ratio of SARS-CoV-2 antibody to viral load levels compared to other trajectories over time (p=0.001). 589 survivors (51%) completed at least one survey at follow-up with 305 (52%) having at least one symptom consistent with PASC, most commonly dyspnea (56% among symptomatic patients). Female sex was the only associated risk factor for PASC.Integration of PCR cycle threshold, and antibody values with demographics, comorbidities, and laboratory/radiographic findings identified risk factors for 28-day outcome severity, though only female sex was associated with PASC. Longitudinal clinical phenotyping offers important insights, and provides a framework for immunophenotyping for acute and long COVID-19.NIH.

  View details for DOI 10.1016/j.ebiom.2022.104208

  View details for PubMedID 35952496

• Anti-nucleocapsid antibody levels and pulmonary comorbid conditions are linked to post-COVID-19 syndrome. JCI insight Jia, X., Cao, S., Lee, A. S., Manohar, M., Sindher, S. B., Ahuja, N., Artandi, M., Blish, C. A., Blomkalns, A. L., Chang, I., Collins, W. J., Desai, M., Din, H. N., Do, E., Fernandes, A., Geng, L. N., Rosenberg-Hasson, Y., Mahoney, M. R., Glascock, A. L., Chan, L. Y., Fong, S. Y., Phelps, M., Raeber, O., Purington, N., Röltgen, K., Rogers, A. J., Snow, T., Wang, T. T., Solis, D., Vaughan, L., Verghese, M., Maecker, H., Wittman, R., Puri, R., Kistler, A., Yang, S., Boyd, S. D., Pinsky, B. A., Chinthrajah, S., Nadeau, K. C. 2022; 7 (13)

  Abstract

  BACKGROUNDProlonged symptoms after SARS-CoV-2 infection are well documented. However, which factors influence development of long-term symptoms, how symptoms vary across ethnic groups, and whether long-term symptoms correlate with biomarkers are points that remain elusive.METHODSAdult SARS-CoV-2 reverse transcription PCR-positive (RT-PCR-positive) patients were recruited at Stanford from March 2020 to February 2021. Study participants were seen for in-person visits at diagnosis and every 1-3 months for up to 1 year after diagnosis; they completed symptom surveys and underwent blood draws and nasal swab collections at each visit.RESULTSOur cohort (n = 617) ranged from asymptomatic to critical COVID-19 infections. In total, 40% of participants reported at least 1 symptom associated with COVID-19 six months after diagnosis. Median time from diagnosis to first resolution of all symptoms was 44 days; median time from diagnosis to sustained symptom resolution with no recurring symptoms for 1 month or longer was 214 days. Anti-nucleocapsid IgG level in the first week after positive RT-PCR test and history of lung disease were associated with time to sustained symptom resolution. COVID-19 disease severity, ethnicity, age, sex, and remdesivir use did not affect time to sustained symptom resolution.CONCLUSIONWe found that all disease severities had a similar risk of developing post-COVID-19 syndrome in an ethnically diverse population. Comorbid lung disease and lower levels of initial IgG response to SARS-CoV-2 nucleocapsid antigen were associated with longer symptom duration.TRIAL REGISTRATIONClinicalTrials.gov, NCT04373148.FUNDINGNIH UL1TR003142 CTSA grant, NIH U54CA260517 grant, NIEHS R21 ES03304901, Sean N Parker Center for Allergy and Asthma Research at Stanford University, Chan Zuckerberg Biohub, Chan Zuckerberg Initiative, Sunshine Foundation, Crown Foundation, and Parker Foundation.

  View details for DOI 10.1172/jci.insight.156713

  View details for PubMedID 35801588

• Detailed characterization of hospitalized patients infected with the Omicron variant of SARS-CoV-2. Journal of internal medicine Ozdalga, E., Ahuja, N., Sehgal, N., Hom, J., Weng, Y., Pinsky, B., Schulman, K. A., Collins, W. 2022

  View details for DOI 10.1111/joim.13501

  View details for PubMedID 35417053

• Cost-Effectiveness of Baricitinib Compared With Standard of Care: A Modeling Study in Hospitalized Patients With COVID-19 in the United States. Clinical therapeutics Ohsfeldt, R., Kelton, K., Klein, T., Belger, M., Mc Collam, P. L., Spiro, T., Burge, R., Ahuja, N. 2021

  Abstract

  PURPOSE: In the Phase III COV-BARRIER (Efficacy and Safety of Baricitinib for the Treatment of Hospitalised Adults With COVID-19) trial, treatment with baricitinib, an oral selective Janus kinase 1/2 inhibitor, in addition to standard of care (SOC), was associated with significantly reduced mortality over 28 days in hospitalized patients with coronavirus disease-2019 (COVID-19), with a safety profile similar to that of SOC alone. This study assessed the cost-effectiveness of baricitinib+SOC versus SOC alone (which included systemic corticosteroids and remdesivir) in hospitalized patients with COVID-19 in the United States.METHODS: An economic model was developed to simulate inpatients' stay, discharge to postacute care, and recovery. Costs modeled included payor costs, hospital costs, and indirect costs. Benefits modeled included life-years (LYs) gained, quality-adjusted life-years (QALYs) gained, deaths avoided, and use of mechanical ventilation avoided. The primary analysis was performed from a payor perspective over a lifetime horizon; a secondary analysis was performed from a hospital perspective. The base-case analysis modeled the numeric differences in treatment effectiveness observed in the COV-BARRIER trial. Scenario analyses were also performed in which the clinical benefit of baricitinib was limited to the statistically significant reduction in mortality demonstrated in the trial.FINDINGS: In the base-case payor perspective model, an incremental total cost of 17,276 US dollars (USD), total QALYs gained of 0.6703, and total LYs gained of 0.837 were found with baricitinib+SOC compared with SOC alone. With the addition of baricitinib, survival was increased by 5.1% and the use of mechanical ventilation was reduced by 1.6%. The base-case incremental cost-effectiveness ratios were 25,774 USD/QALY gained and 20,638 USD/LY gained; a "mortality-only" scenario analysis yielded similar results of 26,862 USD/QALY gained and 21,433 USD/LY gained. From the hospital perspective, combination treatment with baricitinib+SOC was more effective and less costly than was SOC alone in the base case, with an incremental cost of 38,964 USD per death avoided in the mortality-only scenario.IMPLICATIONS: In hospitalized patients with COVID-19 in the United States, the addition of baricitinib to SOC was cost-effective. Cost-effectiveness was demonstrated from both the payor and the hospital perspectives. These findings were robust to sensitivity analysis and to conservative assumptions limiting the clinical benefits of baricitinib to the statistically significant reduction in mortality demonstrated in the COV-BARRIER trial.

  View details for DOI 10.1016/j.clinthera.2021.09.016

  View details for PubMedID 34732289

• New-onset IgG autoantibodies in hospitalized patients with COVID-19. Nature communications Chang, S. E., Feng, A., Meng, W., Apostolidis, S. A., Mack, E., Artandi, M., Barman, L., Bennett, K., Chakraborty, S., Chang, I., Cheung, P., Chinthrajah, S., Dhingra, S., Do, E., Finck, A., Gaano, A., GeSSner, R., Giannini, H. M., Gonzalez, J., Greib, S., Gundisch, M., Hsu, A. R., Kuo, A., Manohar, M., Mao, R., Neeli, I., Neubauer, A., Oniyide, O., Powell, A. E., Puri, R., Renz, H., Schapiro, J., Weidenbacher, P. A., Wittman, R., Ahuja, N., Chung, H., Jagannathan, P., James, J. A., Kim, P. S., Meyer, N. J., Nadeau, K. C., Radic, M., Robinson, W. H., Singh, U., Wang, T. T., Wherry, E. J., Skevaki, C., Luning Prak, E. T., Utz, P. J. 2021; 12 (1): 5417

  Abstract

  COVID-19 is associated with a wide range of clinical manifestations, including autoimmune features and autoantibody production. Here we develop three protein arrays to measure IgG autoantibodies associated with connective tissue diseases, anti-cytokine antibodies, and anti-viral antibody responses in serum from 147 hospitalized COVID-19 patients. Autoantibodies are identified in approximately 50% of patients but in less than 15% of healthy controls. When present, autoantibodies largely target autoantigens associated with rare disorders such as myositis, systemic sclerosis and overlap syndromes. A subset of autoantibodies targeting traditional autoantigens or cytokines develop de novo following SARS-CoV-2 infection. Autoantibodies track with longitudinal development of IgG antibodies recognizing SARS-CoV-2 structural proteins and a subset of non-structural proteins, but not proteins from influenza, seasonal coronaviruses or other pathogenic viruses. We conclude that SARS-CoV-2 causes development of new-onset IgG autoantibodies in a significant proportion of hospitalized COVID-19 patients and are positively correlated with immune responses to SARS-CoV-2 proteins.

  View details for DOI 10.1038/s41467-021-25509-3

  View details for PubMedID 34521836

• New-Onset IgG Autoantibodies in Hospitalized Patients with COVID-19 Chang, S., Feng, A., Meng, W., Apostolidis, S., Mack, E., Artandi, M., Barman, L., Bennett, K., Chakraborty, S., Chang, I., Cheung, P., Chinthrajah, S., Dhingra, S., Do, E., Finck, A., Gaano, A., Gessner, R., Giannini, H., Gonzalez, J., Greib, S., Gundisch, M., Hsu, A., Kuo, A., Manohar, M., Mao, R., Neeli, I., Neubauer, A., Oniyide, O., Powell, A., Puri, R., Renz, H., Schapiro, J., Weidenbacher, P., Wittman, R., Ahuja, N., Chung, H., Jagannathan, P., James, J., Kim, P., Meyer, N., Nadeau, K., Radic, M., Robinson, W., Singh, U., Wang, T., Wherry, J., Skevaki, C., Prak, E., Utz, P. WILEY. 2021: 3202-3205

  View details for Web of Science ID 000744545206097

• Asthma phenotypes, associated comorbidities, and long-term symptoms in COVID-19. Allergy Eggert, L. E., He, Z., Collins, W., Lee, A. S., Dhondalay, G., Jiang, S. Y., Fitzpatrick, J., Snow, T. T., Pinsky, B. A., Artandi, M., Barman, L., Puri, R., Wittman, R., Ahuja, N., Blomkalns, A., O'Hara, R., Cao, S., Desai, M., Sindher, S. B., Nadeau, K., Chinthrajah, R. S. 2021

  Abstract

  BACKGROUND: It is unclear if asthma and its allergic phenotype are risk factors for hospitalization or severe disease from SARS-CoV-2.METHODS: All patients over 28 days oldtesting positive for SARS-CoV-2 between March 1 and September 30, 2020, were retrospectively identified and characterized through electronic analysis at Stanford. A sub-cohort was followed prospectively to evaluate long-term COVID-19 symptoms.RESULTS: 168,190 patients underwent SARS-CoV-2 testing, and 6,976 (4.15%) tested positive. In a multivariate analysis, asthma was not an independent risk factor for hospitalization (OR 1.12 [95% CI 0.86, 1.45], p=0.40). Among SARS-CoV-2 positive asthmatics, allergic asthma lowered the risk of hospitalization and had a protective effect compared to non-allergic asthma (OR 0.52 (0.28, 0.91), p=0.026); there was no association between baseline medication use as characterized by GINA and hospitalization risk. Patients with severe COVID-19 disease had lower eosinophil levels during hospitalization compared to patients with mild or asymptomatic disease, independent of asthma status (p=0.0014). In a patient sub-cohort followed longitudinally, asthmatics and non-asthmatics had similar time to resolution of COVID-19 symptoms, particularly lower respiratory symptoms.CONCLUSIONS: Asthma is not a risk factor for more severe COVID-19 disease. Allergic asthmatics were half as likely to be hospitalized with COVID-19 compared to non-allergic asthmatics. Lower levels of eosinophil counts (allergic biomarkers) were associated with a more severe COVID-19 disease trajectory. Recovery was similar among asthmatics and non-asthmatics with over 50% of patients reporting ongoing lower respiratory symptoms three months post-infection.

  View details for DOI 10.1111/all.14972

  View details for PubMedID 34080210

• Comparison of Adverse Events Among Home- vs Facility-Administered Biologic Infusions, 2007-2017. JAMA network open Baker, M. C., Weng, Y., Fairchild, R., Ahuja, N., Rohatgi, N. 2021; 4 (6): e2110268

  Abstract

  Importance: Infusion reactions occur in 7% to 20% of patients receiving biologics. Home infusions are convenient and incur lower costs but may be associated with more adverse events; the safety of receiving biologic infusions for immune-mediated diseases at home remains unclear.Objective: To assess whether patients receiving home biologic infusions have increased adverse events requiring emergency department (ED) or hospital admission compared with patients receiving facility infusions.Design, Setting, and Participants: This retrospective cohort study used administrative claims data from a large national insurer for adult patients who received biologic infusions for immune-mediated disease between January 2007 and December 2017. Patients with hematologic malignant neoplasms or bone marrow transplantation were excluded. Data were analyzed from August 2019 to October 2020.Main Outcomes and Measures: ED or hospital admission on the same or next day after administration of a biologic infusion at home vs at a facility; secondary outcomes included discontinuation of the biologic after an ED or hospital admission and postinfusion mortality.Results: Of a total of 57 220 patients (mean [SD] age, 50.1 [14.8] years; 512 314 [68.1%] women) who received 752 150 biologic infusions (34 078 home infusions [4.5%] to 3954 patients and 718 072 facility infusions [95.5%] to 54 770 patients), patients who received home infusions were younger (mean [SD] age, 43.2 [13.2] vs 51.3 [14.8] years), more likely to be men (14 031 [41.2%] vs 225 668 [31.4%]), and had a lower Charlson comorbidity score compared with patients who received facility infusions (mean [SD] score, 0.5 [1.0] vs 1.1 [1.3]). Home infusions were associated with 25% increased odds of ED or hospital admission on the same or next day after the infusion (odds ratio [OR], 1.25; 95% CI, 1.09-1.44; P=.002) and 28% increased odds of discontinuation of the biologic after the ED or hospital admission (OR, 1.28; 95% CI, 1.08-1.51; P=.005). There was no difference in postinfusion mortality between home or facility infusions. The rates of adverse events were highest with home infusions of tocilizumab (48 of 481 infusions [10.0%]), vedolizumab (150 of 2681 infusions [5.6%]), and infliximab (1085 of 20 653 infusions [5.3%]), although the number of tocilizumab and vedolizumab infusions was low.Conclusions and Relevance: In this study, biologic infusions administered at home, compared with those administered at a facility, were associated with increased adverse events requiring escalation of care. Because the number of home infusions has increased and is expected to continue to rise, the safety implications of administering biologic infusions at home needs to be further assessed.

  View details for DOI 10.1001/jamanetworkopen.2021.10268

  View details for PubMedID 34081140

• Merits of Surgical Comanagement of Patients With Hip Fracture by Dedicated Orthopaedic Hospitalists. Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews Rohatgi, N. n., Weng, Y. n., Kittle, J. n., Ahuja, N. n. 2021; 5 (3)

  Abstract

  Rotating medical consultants, hospitalists or geriatricians, are involved in the care of patients with hip fracture, often after medical complications have already occurred. In August 2012, we implemented a unique surgical comanagement (SCM) model in which the same Internal Medicine hospitalists are dedicated year-round to the orthopaedic surgery service. We examine whether this SCM model was associated with a decrease in medical complications, length of stay, and inpatient mortality in patients with hip fracture admitted at our institution, compared with the previous model.We included 2,252 admissions to the orthopaedic surgery service with a hip fracture between 2009 and 2018 (757 pre-SCM and 1495 post-SCM). We adjusted for age, Charlson comorbidity score, and operating time in all regression analyses.Mean Charlson comorbidity score (1.6 versus 1.2) and median case mix index (2.1 versus 1.9) were higher in the post-SCM group. A 32% decrease was observed in the odds of having ≥1 medical complication(s) (odds ratio, 0.68 [95% confidence interval, 0.50 to 0.91], P = 0.009) post-SCM. No change was observed in length of stay or inpatient mortality despite an increase in medical complexity post-SCM.Having dedicated orthopaedic hospitalists may contribute to fewer medical complications in patients with hip fracture.

  View details for DOI 10.5435/JAAOSGlobal-D-20-00231

  View details for PubMedID 33720101

• Effect of electronic clinical decision support on inappropriate prescriptions in older adults. Journal of the American Geriatrics Society Singhal, S., Krishnamurthy, A., Wang, B., Weng, Y., Sharp, C., Shah, N., Ahuja, N., Hosamani, P., Periyakoil, V. S., Hom, J. 2021

  View details for DOI 10.1111/jgs.17608

  View details for PubMedID 34877652

• SARS-CoV-2 RNAemia predicts clinical deterioration and extrapulmonary complications from COVID-19. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Ram-Mohan, N. n., Kim, D. n., Zudock, E. J., Hashemi, M. M., Tjandra, K. C., Rogers, A. J., Blish, C. A., Nadeau, K. C., Newberry, J. A., Quinn, J. V., O'Hara, R. n., Ashley, E. n., Nguyen, H. n., Jiang, L. n., Hung, P. n., Blomkalns, A. L., Yang, S. n. 2021

  Abstract

  The determinants of COVID-19 disease severity and extrapulmonary complications (EPCs) are poorly understood. We characterized relationships between SARS-CoV-2 RNAemia and disease severity, clinical deterioration, and specific EPCs.We used quantitative (qPCR) and digital (dPCR) PCR to quantify SARS-CoV-2 RNA from plasma in 191 patients presenting to the Emergency Department (ED) with COVID-19. We recorded patient symptoms, laboratory markers, and clinical outcomes, with a focus on oxygen requirements over time. We collected longitudinal plasma samples from a subset of patients. We characterized the role of RNAemia in predicting clinical severity and EPCs using elastic net regression.23.0% (44/191) of SARS-CoV-2 positive patients had viral RNA detected in plasma by dPCR, compared to 1.4% (2/147) by qPCR. Most patients with serial measurements had undetectable RNAemia within 10 days of symptom onset, reached maximum clinical severity within 16 days, and symptom resolution within 33 days. Initially RNAaemic patients were more likely to manifest severe disease (OR 6.72 [95% CI, 2.45 - 19.79]), worsening of disease severity (OR 2.43 [95% CI, 1.07 - 5.38]), and EPCs (OR 2.81 [95% CI, 1.26 - 6.36]). RNA load correlated with maximum severity (r = 0.47 [95% CI, 0.20 - 0.67]).dPCR is more sensitive than qPCR for the detection of SARS-CoV-2 RNAemia, which is a robust predictor of eventual COVID-19 severity and oxygen requirements, as well as EPCs. Since many COVID-19 therapies are initiated on the basis of oxygen requirements, RNAemia on presentation might serve to direct early initiation of appropriate therapies for the patients most likely to deteriorate.

  View details for DOI 10.1093/cid/ciab394

  View details for PubMedID 33949665

• Asthma phenotypes, associated comorbidities, and long-term symptoms in COVID-19 European Journal of Allergy and Clinical Immunology Eggert, L. E., He, Z., Collins, W., Lee, A. S., Nadeau, K., Chinthrajah, R. 2021

  View details for DOI 10.1111/all.14972

• Factors Associated with Hospital-Acquired Delirium in Patients 18–65 Years Old J GEN INTERN MED Rohatgi, N., Weng, Y., Ahuja, N., Lansberg, M. G. 2021

  View details for DOI 10.1007/s11606-020-06378-w

• Characteristics of Younger and Older Adults with Hospital-Acquired Delirium: a Claims Data Study Spanning 14 years J GEN INTERN MED Rohatgi, N., Weng, Y., Ahuja, N., Lansberg, M. G. 2021

  View details for DOI 10.1007/s11606-020-06379-9

• COVID-19 coagulopathy and thrombosis: Analysis of hospital protocols in response to the rapidly evolving pandemic THROMBOSIS RESEARCH Parks, A. L., Auerbach, A. D., Schnipper, J. L., Anstey, J. E., Sterken, D. G., Hecht, T. H., Fang, M. C., Vaughn, V. M., Dunn, A. S., Linker, A. S., Hunt, D. P., Choi, J. J., Brotman, D. J., Streiff, M. B., Mattison, M. P., Pappas, M. A., Greysen, S., Hemsey, D. F., Dapaah-Afriyie, K., Ahuja, N., Collins, W. J., Herzig, S. J., Bhandari, S., Schumacher, E. R., Duggirala, V. S., O'Leary, K. J., Menard, G. E., Lin, M. Y., Hosp Med Reengn Network HOMERuN 2020; 196: 355–58

  Abstract

  As the Coronavirus disease 2019 (COVID-19) pandemic spread to the US, so too did descriptions of an associated coagulopathy and thrombotic complications. Hospitals created institutional protocols for inpatient management of COVID-19 coagulopathy and thrombosis in response to this developing data. We collected and analyzed protocols from 21 US academic medical centers developed between January and May 2020. We found greatest consensus on recommendations for heparin-based pharmacologic venous thromboembolism (VTE) prophylaxis in COVID-19 patients without contraindications. Protocols differed regarding incorporation of D-dimer tests, dosing of VTE prophylaxis, indications for post-discharge pharmacologic VTE prophylaxis, how to evaluate for VTE, and the use of empiric therapeutic anticoagulation. These findings support ongoing efforts to establish international, evidence-based guidelines.

  View details for DOI 10.1016/j.thromres.2020.09.018

  View details for Web of Science ID 000592174300032

  View details for PubMedID 32977136

  View details for PubMedCentralID PMC7492800

• Portable Ultrasound Device Usage and Learning Outcomes Among Internal Medicine Trainees: A Parallel-Group Randomized Trial. Journal of hospital medicine Kumar, A., Weng, Y., Wang, L., Bentley, J., Almli, M., Hom, J., Witteles, R., Ahuja, N., Kugler, J. 2020; 15 (2): e1–e6

  Abstract

  BACKGROUND: Little is known about how to effectively train residents with point-of-care ultrasonography (POCUS) despite increasing usage.OBJECTIVE: This study aimed to assess whether handheld ultrasound devices (HUDs), alongside a year-long lecture series, improved trainee image interpretation skills with POCUS.METHODS: Internal medicine intern physicians (N = 149) at a single academic institution from 2016 to 2018 participated in the study. The 2017 interns (n = 47) were randomized 1:1 to receive personal HUDs (n = 24) for patient care vs no-HUDs (n = 23). All 2017 interns received a repeated lecture series regarding cardiac, thoracic, and abdominal POCUS. Interns were assessed on their ability to interpret POCUS images of normal/abnormal findings. The primary outcome was the difference in end-of-the-year assessment scores between interns randomized to receive HUDs vs not. Secondary outcomes included trainee scores after repeating lectures and confidence with POCUS. Intern scores were also compared with historical (2016, N = 50) and contemporaneous (2018, N = 52) controls who received no lectures.RESULTS: Interns randomized to HUDs did not have significantly higher image interpretation scores (median HUD score: 0.84 vs no-HUD score: 0.84; P = .86). However, HUD interns felt more confident in their abilities. The 2017 cohort had higher scores (median 0.84), compared with the 2016 historical control (median 0.71; P = .001) and 2018 contemporaneous control (median 0.48; P < .001). Assessment scores improved after first-time exposure to the lecture series, while repeated lectures did not improve scores.CONCLUSIONS: Despite feeling more confident, personalized HUDs did not improve interns' POCUS-related knowledge or interpretive ability. Repeated lecture exposure without further opportunities for deliberate practice may not be beneficial for mastering POCUS.

  View details for DOI 10.12788/jhm.3351

  View details for PubMedID 32118565

• Baricitinib plus Remdesivir for Hospitalized Adults with Covid-19. The New England journal of medicine Kalil, A. C., Patterson, T. F., Mehta, A. K., Tomashek, K. M., Wolfe, C. R., Ghazaryan, V. n., Marconi, V. C., Ruiz-Palacios, G. M., Hsieh, L. n., Kline, S. n., Tapson, V. n., Iovine, N. M., Jain, M. K., Sweeney, D. A., El Sahly, H. M., Branche, A. R., Regalado Pineda, J. n., Lye, D. C., Sandkovsky, U. n., Luetkemeyer, A. F., Cohen, S. H., Finberg, R. W., Jackson, P. E., Taiwo, B. n., Paules, C. I., Arguinchona, H. n., Goepfert, P. n., Ahuja, N. n., Frank, M. n., Oh, M. D., Kim, E. S., Tan, S. Y., Mularski, R. A., Nielsen, H. n., Ponce, P. O., Taylor, B. S., Larson, L. n., Rouphael, N. G., Saklawi, Y. n., Cantos, V. D., Ko, E. R., Engemann, J. J., Amin, A. N., Watanabe, M. n., Billings, J. n., Elie, M. C., Davey, R. T., Burgess, T. H., Ferreira, J. n., Green, M. n., Makowski, M. n., Cardoso, A. n., de Bono, S. n., Bonnett, T. n., Proschan, M. n., Deye, G. A., Dempsey, W. n., Nayak, S. U., Dodd, L. E., Beigel, J. H. 2020

  Abstract

  Severe coronavirus disease 2019 (Covid-19) is associated with dysregulated inflammation. The effects of combination treatment with baricitinib, a Janus kinase inhibitor, plus remdesivir are not known.We conducted a double-blind, randomized, placebo-controlled trial evaluating baricitinib plus remdesivir in hospitalized adults with Covid-19. All the patients received remdesivir (≤10 days) and either baricitinib (≤14 days) or placebo (control). The primary outcome was the time to recovery. The key secondary outcome was clinical status at day 15.A total of 1033 patients underwent randomization (with 515 assigned to combination treatment and 518 to control). Patients receiving baricitinib had a median time to recovery of 7 days (95% confidence interval [CI], 6 to 8), as compared with 8 days (95% CI, 7 to 9) with control (rate ratio for recovery, 1.16; 95% CI, 1.01 to 1.32; P = 0.03), and a 30% higher odds of improvement in clinical status at day 15 (odds ratio, 1.3; 95% CI, 1.0 to 1.6). Patients receiving high-flow oxygen or noninvasive ventilation at enrollment had a time to recovery of 10 days with combination treatment and 18 days with control (rate ratio for recovery, 1.51; 95% CI, 1.10 to 2.08). The 28-day mortality was 5.1% in the combination group and 7.8% in the control group (hazard ratio for death, 0.65; 95% CI, 0.39 to 1.09). Serious adverse events were less frequent in the combination group than in the control group (16.0% vs. 21.0%; difference, -5.0 percentage points; 95% CI, -9.8 to -0.3; P = 0.03), as were new infections (5.9% vs. 11.2%; difference, -5.3 percentage points; 95% CI, -8.7 to -1.9; P = 0.003).Baricitinib plus remdesivir was superior to remdesivir alone in reducing recovery time and accelerating improvement in clinical status among patients with Covid-19, notably among those receiving high-flow oxygen or noninvasive ventilation. The combination was associated with fewer serious adverse events. (Funded by the National Institute of Allergy and Infectious Diseases; ClinicalTrials.gov number, NCT04401579.).

  View details for DOI 10.1056/NEJMoa2031994

  View details for PubMedID 33306283

• Baricitinib plus Remdesivir for Hospitalized Adults with COVID-19 (Adaptive COVID-19 Treatment Trial (ACTT-2)) The New England Journal of Medicine Study Team, M. 2020

  View details for DOI 10.1056/NEJMoa2031994

• The genealogy of teaching clinical reasoning and diagnostic skill: the GEL Study. Diagnosis (Berlin, Germany) Russell, S. W., Desai, S. V., O'Rourke, P. n., Ahuja, N. n., Patel, A. n., Myers, C. G., Zulman, D. n., Sateia, H. F., Berkenblit, G. V., Johnson, E. N., Garibaldi, B. T. 2020

  Abstract

  The genealogy of graduate medical education in America begins at the bedside. However, today's graduate medical trainees work in a training environment that is vastly different from medical training a century ago. The goal of the Graduate Medical Education Laboratory (GEL) Study, supported by the American Medical Association's (AMA) "Reimagining Residency" initiative, is to determine the factors in the training environment that most contribute to resident well-being and developing diagnostic skills. We believe that increasing time at the bedside will improve clinical skill, increase professional fulfillment, and reduce workplace burnout. Our graduate medical education laboratory will test these ideas to understand which interventions can be shared among all training programs. Through the GEL Study, we aim to ensure resident readiness for practice as we understand, then optimize, the learning environment for trainees and staff.

  View details for DOI 10.1515/dx-2019-0107

  View details for PubMedID 32146439

• Osteoarthritis risk is reduced after treatment with ticagrelor compared to clopidogrel: a propensity score matching analysis. Arthritis & rheumatology (Hoboken, N.J.) Baker, M. C., Weng, Y. n., William, R. H., Ahuja, N. n., Rohatgi, N. n. 2020

  Abstract

  Osteoarthritis (OA) is a common cause of joint pain and disability, and effective treatments are lacking. Extracellular adenosine has anti-inflammatory effects and can prevent and treat OA in animal models. Ticagrelor and clopidogrel are both used in patients with coronary artery disease, but only ticagrelor increases extracellular adenosine. The aim of this study was to determine whether treatment with ticagrelor was associated with a lower risk of OA.We conducted a 1:2 propensity score matching analysis using the Optum Clinformatics™ Data Mart from 2011 to 2017. We included patients who received either ticagrelor or clopidogrel for at least 90 days and excluded those with a prior diagnosis of OA or inflammatory arthritis. OA was identified using International Classification of Diseases codes. The primary outcome was the time to diagnosis of OA after treatment with ticagrelor versus clopidogrel.Our propensity score matched cohort consisted of 7,007 ticagrelor-treated patients and 14,014 clopidogrel-treated patients, with a median number of days on treatment of 287 and 284 respectively. For both groups, the mean age was 64 years, and 73% of the patients were male. Multivariate Cox-regression analysis estimated a hazard ratio of 0.71 (95% CI 0.64-0.79, p<0.001) for developing OA after treatment with ticagrelor compared to clopidogrel.Treatment with ticagrelor was associated with a 29% lower risk of developing OA compared to clopidogrel over five years of follow-up. We hypothesize that the reduction in OA seen in patients who received ticagrelor may in part be due to increased extracellular adenosine.

  View details for DOI 10.1002/art.41412

  View details for PubMedID 32564514

• Surgical Comanagement by Hospitalists: Continued Improvement Over 5 Years Journal of Hospital Medicine Rohatgi, N., Weng, Y., Ahuja, N. 2020

  View details for DOI 10.12788/jhm.3363

• Co-Management by Hospitalists: Why it makes clinical and fiscal sense. The American journal of medicine Rohatgi, N., Schulman, K., Ahuja, N. 2019

  View details for DOI 10.1016/j.amjmed.2019.07.053

  View details for PubMedID 31449770

• Reducing Telemetry Use Is Safe: A Retrospective Analysis of Rapid Response Team and Code Events After a Successful Intervention to Reduce Telemetry Use AMERICAN JOURNAL OF MEDICAL QUALITY Xie, L., Garg, T., Svec, D., Hom, J., Kaimal, R., Ahuja, N., Barnes, J., Shieh, L. 2019; 34 (4): 398–401

  View details for DOI 10.1177/1062860618805189

  View details for Web of Science ID 000476540300012

• Initiative for prevention and early identification of delirium in medical-surgical units: Lessons learnt in the past five years. The American journal of medicine Rohatgi, N., Weng, Y., Bentley, J., Lansberg, M. G., Shepard, J., Mazur, D., Ahuja, N., Hopkins, J. 2019

  Abstract

  BACKGROUND: Delirium is an acute change in mental status affecting 10-64% of hospitalized patients, and may be preventable in 30-40% cases. In October 2013, a task force for delirium prevention and early identification in medical-surgical units was formed at our hospital. We studied if our standardized protocol prevented delirium among high-risk patients.METHODS: We studied 105,455 patient encounters between November 2013 and January 2018. Since November 2013, there has been ongoing education to decrease deliriogenic medications use. Since 2014, nurses screen all patients for presence or absence of delirium using confusion assessment method (CAM). Since 2015, nurses additionally screen all patients for risk of delirium. In 2015, a physician order set for delirium was created. Non-pharmacological measures are implemented for high-risk or CAM positive patients.RESULTS: 98.8% of patient encounters had CAM screening, and 99.6% had delirium risk screening. Since 2013, odds of opiate use decreased by 5.0% per year (P<0.001), and odds of benzodiazepines use decreased by 8.0% per year (P<0.001). There was no change in anticholinergics use. In the adjusted analysis, since 2015, odds of delirium decreased by 25.3% per year among high-risk patients (N=21,465; P<0.001). Among high-risk patients or those diagnosed with delirium (N=22,121), estimated LOS decreased by 0.13days per year (P<0.001), odds of inpatient mortality decreased by 16.0% per year (P=0.011), and odds of discharge to nursing home decreased by 17.1% per year (P<0.001).CONCLUSION: With high clinician engagement and simplified workflows, our delirium initiative has shown sustained results.

  View details for DOI 10.1016/j.amjmed.2019.05.035

  View details for PubMedID 31228413

• State of Research in Adult Hospital Medicine: Results of a National Survey JOURNAL OF HOSPITAL MEDICINE Chopra, V., Burden, M., Jones, C. D., Mueller, S., Gupta, V., Ahuja, N., Sigmund, A., Eid, S. M., Soc Hosp Med Res Comm 2019; 14 (4): 207–11

  View details for DOI 10.12788/jhm.3136

  View details for Web of Science ID 000462532700002

• ACUTE KIDNEY INJURY IN LOWER-EXTREMITY JOINT ARTHROPLASTY Clinical Epidemiology, Prevention, and Management JBJS REVIEWS Rudy, M. D., Ahuja, N. K. 2019; 7 (4)

  View details for DOI 10.2106/JBJS.RVW.18.00121

  View details for Web of Science ID 000480781500009

• State of Research in Adult Hospital Medicine: Results of a National Survey. Journal of hospital medicine Chopra, V., Burden, M., Jones, C. D., Mueller, S., Gupta, V., Ahuja, N., Sigmund, A., Eid, S. M., Society of Hospital Medicine Research Committee 2019; 14 (4): 207–11

  Abstract

  BACKGROUND: Little is known about the state of research in academic hospital medicine (HM) despite the substantial growth of this specialty.METHODS: We used the Society of Hospital Medicine (SHM) membership database to identify research programs and their leadership. In addition, the members of the SHM Research Committee identified individuals who lead research programs in HM. A convenience sample of programs and individuals was thus created. A survey instrument containing questions regarding institutional information, research activities, training opportunities, and funding sources was pilot tested and refined for electronic dissemination. Data were summarized using descriptive statistics.RESULTS: A total of 100 eligible programs and corresponding individuals were identified. Among these programs, 28 completed the survey in its entirety (response rate 28%). Among the 1,586 faculty members represented in the 28 programs, 192 (12%) were identified as engaging in or having obtained extramural funding for research, and 656 (41%) were identified as engaging in quality improvement efforts. Most programs (61%) indicated that they received $500,000 or less in research funding, whereas 29% indicated that they received >$1 million in funding. Major sources of grant support included the Agency for Healthcare Research and Quality, National Institutes of Health, and the Veterans Health Administration. Only five programs indicated that they currently have a research fellowship program in HM. These programs cited lack of funding as a major barrier to establishing fellowships. Almost half of respondents (48%) indicated that their faculty published between 11-50 peer-reviewed manuscripts each year.CONCLUSION: This survey provides the first national summary of research activities in HM. Future waves of the survey can help determine whether the research footprint of the field is growing.

  View details for PubMedID 30933670

• Acute Kidney Injury in Lower-Extremity Joint Arthroplasty: Clinical Epidemiology, Prevention, and Management. JBJS reviews Rudy, M. D., Ahuja, N. K. 2019; 7 (4): e9

  View details for PubMedID 31045689

• Comparison of Outcomes for Adult Inpatients With Sickle Cell Disease Cared for by Hospitalists Versus Hematologists. American journal of medical quality : the official journal of the American College of Medical Quality Slade, J. n., Rohatgi, N. n., Weng, Y. n., Hom, J. n., Ahuja, N. n. 2019: 1062860619892060

  View details for DOI 10.1177/1062860619892060

  View details for PubMedID 31856577

• Thrombophilia testing in the inpatient setting: impact of an educational intervention. BMC medical informatics and decision making Kwang, H. n., Mou, E. n., Richman, I. n., Kumar, A. n., Berube, C. n., Kaimal, R. n., Ahuja, N. n., Harman, S. n., Johnson, T. n., Shah, N. n., Witteles, R. n., Harrington, R. n., Shieh, L. n., Hom, J. n. 2019; 19 (1): 167

  Abstract

  Thrombophilia testing is frequently ordered in the inpatient setting despite its limited impact on clinical decision-making and unreliable results in the setting of acute thrombosis or ongoing anticoagulation. We sought to determine the effect of an educational intervention in reducing inappropriate thrombophilia testing for hospitalized patients.During the 2014 academic year, we implemented an educational intervention with a phase implementation design for Internal Medicine interns at Stanford University Hospital. The educational session covering epidemiology, appropriate thrombophilia evaluation and clinical rationale behind these recommendations. Their ordering behavior was compared with a contemporaneous control (non-medicine and private services) and a historical control (interns from prior academic year). From the analyzed data, we determined the proportion of inappropriate thrombophilia testing of each group. Logistic generalized estimating equations were used to estimate odds ratios for inappropriate thrombophilia testing associated with the intervention.Of 2151 orders included, 934 were deemed inappropriate (43.4%). The two intervention groups placed 147 orders. A pooled analysis of ordering practices by intervention groups revealed a trend toward reduction of inappropriate ordering (p = 0.053). By the end of the study, the intervention groups had significantly lower rates of inappropriate testing compared to historical or contemporaneous controls.A brief educational intervention was associated with a trend toward reduction in inappropriate thrombophilia testing. These findings suggest that focused education on thrombophilia testing can positively impact inpatient ordering practices.

  View details for DOI 10.1186/s12911-019-0889-6

  View details for PubMedID 31429747

• Genomics in medicine: a novel elective rotation for internal medicine residents. Postgraduate medical journal Geng, L. N., Kohler, J. N., Levonian, P. n., Bernstein, J. A., Ford, J. M., Ahuja, N. n., Witteles, R. n., Hom, J. n., Wheeler, M. n. 2019

  Abstract

  It is well recognised that medical training globally and at all levels lacks sufficient incorporation of genetics and genomics education to keep up with the rapid advances and growing application of genomics to clinical care. However, the best strategy to implement these desired changes into postgraduate medical training and engage learners is still unclear. We developed a novel elective rotation in 'Genomic Medicine and Undiagnosed Diseases' for categorical Internal Medicine Residents to address this educational gap and serve as an adaptable model for training that can be applied broadly across different specialties and at other institutions. Key curriculum goals achieved include increased understanding about genetic testing modalities and tools available for diagnosis and risk analysis, the role of genetics-trained allied health professionals, and indications and limitations of genetic and genomic testing in both rare and common conditions.

  View details for DOI 10.1136/postgradmedj-2018-136355

  View details for PubMedID 31439813

• Determinants of Cost Variation in Total Hip and Knee Arthroplasty: Implications for Alternative Payment Models. The Journal of the American Academy of Orthopaedic Surgeons Rudy, M. D., Bentley, J. n., Ahuja, N. n., Rohatgi, N. n. 2019

  Abstract

  Alternative payment models have been proposed to deliver high-quality, cost-effective care. Under these models, payments may be shared between the hospital and the post-acute care services. Post-acute care services may account for one-third of the episode costs for total hip or knee arthroplasty (THA/TKA). Because hospitals or episode initiators bear notable financial risks in these payment models with minimal risk adjustment for complexity, it has been suggested these models may lead to prospective selection of healthier and younger patients. Studies evaluating the effect of patient demographics, medical complexity, and surgical characteristics on the cost of index hospitalization have been limited. We aimed to (1) quantify the impact of patient demographics, medical complexity, and surgical characteristics (type of anesthesia and operating time) on variation in direct cost of index hospitalization and (2) examine the association of these characteristics with discharge with home health services or to rehabilitation facility.Retrospective study of 3,542 patients admitted to our hospital for elective THA/TKA between 2012 and 2017. Multivariable generalized estimating equations were used for analysis.Patient demographics and medical complexity accounted for 6.2% (THA) and 5.6% (TKA) of variation in direct cost of index hospitalization. Surgical characteristics accounted for 37.1% (THA) and 35.3% (TKA) of the cost variation. One thousand one hundred eighty-three (53.4%) patients were discharged with home health services, and 1,237 (29.4%) were discharged to rehabilitation facility. Patient demographics and higher medical complexity were markedly associated with discharge with home health services or to rehabilitation facility after THA/TKA.Patient demographics and medical complexity had minimal impact on variation in direct cost of index hospitalization for elective THA/TKA compared with surgical characteristics but were markedly associated with discharge with home health services or to rehabilitation facility. Having additional risk adjustment in these payment models could mitigate concerns about access to care for higher risk, higher cost patients.

  View details for DOI 10.5435/JAAOS-D-18-00718

  View details for PubMedID 31192883

• Assessing the Relationship Between American Heart Association Atherosclerotic Cardiovascular Disease Risk Score and Coronary Artery Imaging Findings JOURNAL OF COMPUTER ASSISTED TOMOGRAPHY Li, Y., Zhu, G., Ding, V., Jiang, B., Ball, R. L., Ahuja, N., Rodriguez, F., Fleischmann, D., Desai, M., Saloner, D., Saba, L., Wintermark, M., Hom, J. 2018; 42 (6): 898–905

  View details for DOI 10.1097/RCT.0000000000000823

  View details for Web of Science ID 000451395400012

• Reducing Telemetry Use Is Safe: A Retrospective Analysis of Rapid Response Team and Code Events After a Successful Intervention to Reduce Telemetry Use. American journal of medical quality : the official journal of the American College of Medical Quality Xie, L., Garg, T., Svec, D., Hom, J., Kaimal, R., Ahuja, N., Barnes, J., Shieh, L. 2018: 1062860618805189

  Abstract

  Interventions guiding appropriate telemetry utilization have successfully reduced use at many hospitals, but few studies have examined their possible adverse outcomes. The authors conducted a successful intervention to reduce telemetry use in 2013 on a hospitalist service using educational modules, routine review, and financial incentives. The association of reduced telemetry use with the incidence of rapid response team (RRT) and code activations was assessed in a retrospective cohort study of 210 patients who experienced a total of 233 RRT and code events on the inpatient internal medicine services from January 2012 through March 2015 at a tertiary care center. The incidence of adverse events for the hospitalist service was not significantly different during the intervention and postintervention period as compared to the preintervention period. Reducing inappropriate telemetry use was not associated with an increase in the incidence rates of RRT and code events.

  View details for PubMedID 30293436

• Surgical Comanagement by Hospitalists in Colorectal Surgery Rohatgi, N., Wei, P., Grujic, O., Ahuja, N. ELSEVIER SCIENCE INC. 2018: 404-+

  View details for DOI 10.1016/j.jamcollsurg.2018.06.011

  View details for Web of Science ID 000445400300002

• Surgical Comanagement by Hospitalists in Colorectal Surgery. Journal of the American College of Surgeons Rohatgi, N., Wei, P. H., Grujic, O., Ahuja, N. 2018

  Abstract

  BACKGROUND: Patients with increasing age and medical complexity are undergoing colorectal surgery. Medical complications are not uncommon, and may contribute to higher mortality. We implemented a surgical co-management (SCM) model in July 2014 at our institution where same two SCM hospitalists were dedicated to Colorectal surgery year round. Each patient was screened daily by a SCM hospitalist for prevention and management of medical complications. Prior to SCM, hospitalists were typically consulted after medical complications had occurred.STUDY DESIGN: Pre-post study at an academic medical center with 938 patients in the pre-SCM group (July 2012 to June 2014), and 1,062 patients in the post-SCM group (July 2014 to May 2016). We evaluated if SCM by hospitalists improved outcomes of patients in Colorectal surgery.RESULTS: There was no significant difference in medical complications, patient satisfaction, or 30-day readmission rate to our institution for medical cause with the SCM intervention. This intervention was associated with a significant decrease in the proportion of patients transferred to intensive care unit after rapid response team calls (RR, 0.25 [95% CI, 0.05 to 0.84], P = 0.039), proportion of patients with LOS ≥5 days (RR, 0.73 [95% CI, 0.64 to 0.83], P <0.001), use of medical consultants (RR, 0.75 [95% CI, 0.63 to 0.89], P = 0.001), and the median direct cost of care by 10.3% (P = 0.0002).CONCLUSIONS: SCM intervention was associated with a decrease in transfers to intensive care unit after rapid response team call, LOS, medical consultants, and the cost of care.

  View details for PubMedID 30030136

• Lean-Based Redesign of Multidisciplinary Rounds on General Medicine Service JOURNAL OF HOSPITAL MEDICINE Kane, M., Rohatgi, N., Heidenreich, P. A., Thakur, A., Winget, M., Shum, K., Hereford, J., Shieh, L., Lew, T., Hom, J., Chi, J., Weinacker, A., Seay-Morrison, T., Ahuja, N. 2018; 13 (7): 482–85

  View details for DOI 10.12788/jhm.2908

  View details for Web of Science ID 000437294500006

• Diabetes and Hyperglycemia in Lower-Extremity Total Joint Arthroplasty: Clinical Epidemiology, Outcomes, and Management. JBJS reviews Rudy, M. D., Ahuja, N. K., Aaronson, A. J. 2018; 6 (5): e10

  View details for PubMedID 29847443

• DIABETES AND HYPERGLYCEMIA IN LOWER-EXTREMITY TOTAL JOINT ARTHROPLASTY Clinical Epidemiology, Outcomes, and Management JBJS REVIEWS Rudy, M. D., Ahuja, N. K., Aaronson, A. J. 2018; 6 (5)

  View details for DOI 10.2106/JBJS.RVW.17.00146

  View details for Web of Science ID 000437213100010

• Lean-Based Redesign of Multidisciplinary Rounds on General Medicine Service. Journal of hospital medicine Kane, M. n., Rohatgi, N. n., Heidenreich, P. n., Thakur, A. n., Winget, M. n., Shum, K. n., Hereford, J. n., Shieh, L. n., Lew, T. n., Horn, J. n., Chi, J. n., Weinacker, A. n., Seay-Morrison, T. n., Ahuja, N. n. 2018

  Abstract

  Multidisciplinary rounds (MDR) facilitate timely communication amongst the care team and with patients. We used Lean techniques to redesign MDR on the teaching general medicine service.To examine if our Lean-based new model of MDR was associated with change in the primary outcome of length of stay (LOS) and secondary outcomes of discharges before noon, documentation of estimated discharge date (EDD), and patient satisfaction.This is a pre-post study. The preperiod (in which the old model of MDR was followed) comprised 4000 patients discharged between September 1, 2013, and October 22, 2014. The postperiod (in which the new model of MDR was followed) comprised 2085 patients between October 23, 2014, and April 30, 2015.Lean-based redesign of MDR.LOS, discharges before noon, EDD, and patient satisfaction.There was no change in the mean LOS. Discharges before noon increased from 6.9% to 10.7% (P < .001). Recording of EDD increased from 31.4% to 41.3% (P < .001). There was no change in patient satisfaction.Lean-based redesign of MDR was associated with an increase in discharges before noon and in recording of EDD.

  View details for PubMedID 29394300

• Assessing the Relationship Between American Heart Association Atherosclerotic Cardiovascular Disease Risk Score and Coronary Artery Imaging Findings. Journal of computer assisted tomography Li, Y. n., Zhu, G. n., Ding, V. n., Jiang, B. n., Ball, R. L., Ahuja, N. n., Rodriguez, F. n., Fleischmann, D. n., Desai, M. n., Saloner, D. n., Saba, L. n., Wintermark, M. n., Hom, J. n. 2018

  Abstract

  The aim of this study was to characterize the relationship between computed tomography angiography imaging characteristics of coronary artery and atherosclerotic cardiovascular disease (ASCVD) score.We retrospectively identified all patients who underwent a coronary computed tomography angiography at our institution from December 2013 to July 2016, then we calculated the 10-year ASCVD score. We characterized the relationship between coronary artery imaging findings and ASCVD risk score.One hundred fifty-one patients met our inclusion criteria. Patients with a 10-year ASCVD score of 7.5% or greater had significantly more arterial segments showing stenosis (46.4%, P = 0.008) and significantly higher maximal plaque thickness (1.25 vs 0.53, P = 0.001). However, among 56 patients with a 10-year ASCVD score of 7.5% or greater, 30 (53.6%) had no arterial stenosis. Furthermore, among the patients with a 10-year ASCVD score of less than 7.5%, 24 (25.3%) had some arterial stenosis.There is some concordance but not a perfect overlap between 10-year ASCVD risk scores and coronary artery imaging findings.

  View details for PubMedID 30407249

• Factors Associated With Delayed Discharge on General Medicine Service at an Academic Medical Center. Journal for healthcare quality : official publication of the National Association for Healthcare Quality Rohatgi, N. n., Kane, M. n., Winget, M. n., Haji-Sheikhi, F. n., Ahuja, N. n. 2018

  Abstract

  Lack of collaboration between care teams and patients/families has been associated with delayed discharge from the hospital. In this study, we determine whether patients' awareness of the estimated date of discharge (EDD) was associated with a decrease in delayed discharge, and determine the factors associated with a delayed discharge. A total of 221 patients admitted to the General Medicine service between July and September 2014 were included in the study. Estimated date of discharge was identified within 36 hours of admission. The bedside nurse communicated this EDD to the patient/family. Patients were interviewed to identify whether they were aware of their EDD. Bedside nurses were interviewed to identify barriers to discharge. In our study, 49.8% of the patients had a delayed discharge. Patients who were aware of their EDD were less likely to have a delayed discharge (odds ratio [OR], 0.3 [95% confidence interval (CI), 0.1-0.6], p < .001). Patients who were discharged on Saturday or Sunday (OR, 4.8 [95% CI, 1.7-14.6], p < .001) and patients who were waiting for physicians' consult (OR, 4.5 [95% CI, 1.6-14.4], p = .007) were more likely to have a delayed discharge. Early identification of the EDD and communicating it with the care team and the patient/family, mobilizing resources for safe weekend discharges, and creating efficient process for consultations might decrease delayed discharges.

  View details for DOI 10.1097/JHQ.0000000000000126

  View details for PubMedID 29315151

• A high value care curriculum for interns: a description of curricular design, implementation and housestaff feedback POSTGRADUATE MEDICAL JOURNAL Hom, J., Kumar, A., Evans, K. H., Svec, D., Richman, I., Fang, D., Smeraglio, A., Holubar, M., Johnson, T., Shah, N., Renault, C., Ahuja, N., Witteles, R., Harman, S., Shieh, L. 2017; 93 (1106): 725–29

  View details for DOI 10.1136/postgradmedj-2016-134617

  View details for Web of Science ID 000416160200005

• Ketamine-Induced Mania During Treatment for Complex Regional Pain Syndrome. Pain medicine (Malden, Mass.) Mandyam, M. C., Ahuja, N. K. 2017

  View details for DOI 10.1093/pm/pnx061

  View details for PubMedID 28379460

• Ketamine-Induced Mania During Treatment for Complex Regional Pain Syndrome. Pain medicine (Malden, Mass.) Mandyam, M. C., Ahuja, N. K. 2017

  View details for DOI 10.1093/pm/pnx061

  View details for PubMedID 28379460

• TRIAD VIII: Nationwide Multicenter Evaluation to Determine Whether Patient Video Testimonials Can Safely Help Ensure Appropriate Critical Versus End-of-Life Care. Journal of patient safety Mirarchi, F. L., Cooney, T. E., Venkat, A., Wang, D., Pope, T. M., Fant, A. L., Terman, S. A., Klauer, K. M., Williams-Murphy, M., Gisondi, M. A., Clemency, B., Doshi, A. A., Siegel, M., Kraemer, M. S., Aberger, K., Harman, S., Ahuja, N., Carlson, J. N., Milliron, M. L., Hart, K. K., Gilbertson, C. D., Wilson, J. W., Mueller, L., Brown, L., Gordon, B. D. 2017

  Abstract

  End-of-life interventions should be predicated on consensus understanding of patient wishes. Written documents are not always understood; adding a video testimonial/message (VM) might improve clarity. Goals of this study were to (1) determine baseline rates of consensus in assigning code status and resuscitation decisions in critically ill scenarios and (2) determine whether adding a VM increases consensus.We randomly assigned 2 web-based survey links to 1366 faculty and resident physicians at institutions with graduate medical education programs in emergency medicine, family practice, and internal medicine. Each survey asked for code status interpretation of stand-alone Physician Orders for Life-Sustaining Treatment (POLST) and living will (LW) documents in 9 scenarios. Respondents assigned code status and resuscitation decisions to each scenario. For 1 of 2 surveys, a VM was included to help clarify patient wishes.Response rate was 54%, and most were male emergency physicians who lacked formal advanced planning document interpretation training. Consensus was not achievable for stand-alone POLST or LW documents (68%-78% noted "DNR"). Two of 9 scenarios attained consensus for code status (97%-98% responses) and treatment decisions (96%-99%). Adding a VM significantly changed code status responses by 9% to 62% (P ≤ 0.026) in 7 of 9 scenarios with 4 achieving consensus. Resuscitation responses changed by 7% to 57% (P ≤ 0.005) with 4 of 9 achieving consensus with VMs.For most scenarios, consensus was not attained for code status and resuscitation decisions with stand-alone LW and POLST documents. Adding VMs produced significant impacts toward achieving interpretive consensus.

  View details for DOI 10.1097/PTS.0000000000000357

  View details for PubMedID 28198722

• A high value care curriculum for interns: a description of curricular design, implementation and housestaff feedback. Postgraduate medical journal Hom, J. n., Kumar, A. n., Evans, K. H., Svec, D. n., Richman, I. n., Fang, D. n., Smeraglio, A. n., Holubar, M. n., Johnson, T. n., Shah, N. n., Renault, C. n., Ahuja, N. n., Witteles, R. n., Harman, S. n., Shieh, L. n. 2017

  Abstract

  Most residency programmes do not have a formal high value care curriculum. Our goal was to design and implement a multidisciplinary high value care curriculum specifically targeted at interns.Our curriculum was designed with multidisciplinary input from attendings, fellows and residents at Stanford. Curricular topics were inspired by the American Board of Internal Medicine's Choosing Wisely campaign, Alliance for Academic Internal Medicine, American College of Physicians and Society of Hospital Medicine. Our topics were as follows: introduction to value-based care; telemetry utilisation; lab ordering; optimal approach to thrombophilia work-ups and fresh frozen plasma use; optimal approach to palliative care referrals; antibiotic stewardship; and optimal approach to imaging for low back pain. Our curriculum was implemented at the Stanford Internal Medicine residency programme over the course of two academic years (2014 and 2015), during which 100 interns participated in our high value care curriculum. After each high value care session, interns were offered the opportunity to complete surveys regarding feedback on the curriculum, self-reported improvements in knowledge, skills and attitudinal module objectives, and quiz-based knowledge assessments.The overall survey response rate was 67.1%. Overall, the material was rated as highly useful on a 5-point Likert scale (mean 4.4, SD 0.6). On average, interns reported a significant improvement in their self-rated knowledge, skills and attitudes after the six seminars (mean improvement 1.6 points, SD 0.4 (95% CI 1.5 to 1.7), p<0.001).We successfully implemented a novel high value care curriculum that specifically targets intern physicians.

  View details for PubMedID 28663352

• Integrating Mobile Fitness Trackers Into the Practice of Medicine AMERICAN JOURNAL OF LIFESTYLE MEDICINE Ahuja, N., Ozdalga, E., Aaronson, A. 2017; 11 (1): 77–79

  View details for DOI 10.1177/1559827615583643

  View details for Web of Science ID 000446759400012

• Integrating Mobile Fitness Trackers Into the Practice of Medicine. American journal of lifestyle medicine Ahuja, N., Ozdalga, E., Aaronson, A. 2017; 11 (1): 77–79

  Abstract

  Mobile fitness trackers are increasingly used by patients as a means to become more involved in their own self-care; however, these devices measure disparate outcomes that may have equivocal relevance to true health status. It is vital for physicians to interpret both the quality and accuracy of the information that these trackers provide, and it is important to delineate which role, if any, these devices may serve in promoting quality patient care in the future. Potential benefits of mobile fitness trackers include the ability to motivate patients toward a healthier lifestyle, to develop a community of like-minded individuals seeking to improve their health, as well as to create an environment of sustainability and accountability for long-term promotion of health maintenance. However, limitations include the fact that mobile fitness trackers are not regulated by the Food and Drug Administration, that the employed metrics are not necessarily the best surrogates for true health status, and that the accuracy of measured endpoints has not yet been proven. As mobile fitness trackers both continue to rise in popularity and become increasingly sophisticated, physicians must be equipped to interpret and use this technology to better serve patients within an ever-changing, more technology-reliant health care system.

  View details for PubMedID 30202316

• Prevalence and Financial Impact of Inappropriate Thrombophilia Testing in the Inpatient Hospital Setting: A Retrospective Analysis Mou, E., Kwang, H., Hom, J., Shieh, L., Ahuja, N., Harman, S., Johnson, T., Kumar, A., Shah, N., Witteles, R., Berube, C. AMER SOC HEMATOLOGY. 2016

  View details for Web of Science ID 000394452508066

• A Multidisciplinary Initiative to Increase Inpatient Discharges Before Noon JOURNAL OF NURSING ADMINISTRATION Kane, M., Weinacker, A., Arthofer, R., Seay-Morrison, T., Elfman, W., Ramirez, M., Ahuja, N., Pickham, D., Hereford, J., Welton, M. 2016; 46 (12): 630-635

  Abstract

  The aim of this study is to evaluate the effect of 2 hospital-wide interventions on achieving a discharge-before-noon rate of 40%.A multidisciplinary team led by administrative and physician leadership developed a plan to diminish capacity constraints by minimizing late afternoon hospital discharges using 2 patient flow management techniques.The study was a preintervention/postintervention retrospective analysis observing all inpatients discharged across 19 inpatient units in a 484-bed, academic teaching hospital measuring calendar month discharge-before-noon percentage, patient satisfaction, and readmission rates. Patient satisfaction and readmission rates were used as baseline metrics.The discharge-before-noon percentage increased from 14% in the 11-month preintervention period to an average of 24% over the 11-month postintervention period, whereas patient satisfaction scores and readmission rates remained stable.Implementation of the 2 interventions successfully increased the percentage of discharges before noon yet did not achieve the goal of 40%. Patient satisfaction and readmission rates were not negatively impacted by the program.

  View details for DOI 10.1097/NNA.0000000000000418

  View details for PubMedID 27851703

• R-SCAN: Imaging for Low Back Pain. Journal of the American College of Radiology Hom, J., Smith, C. D., Ahuja, N., Wintermark, M. 2016; 13 (11): 1385-1386 e1

  View details for DOI 10.1016/j.jacr.2016.06.043

  View details for PubMedID 27595195

• The State of Medical Student Performance Evaluations: Improved Transparency or Continued Obfuscation? ACADEMIC MEDICINE Hom, J., Richman, I., Hall, P., Ahuja, N., Harman, S., Harrington, R., Witteles, R. 2016; 91 (11): 1534–39

  View details for DOI 10.1097/ACM.0000000000001034

  View details for Web of Science ID 000387208300024

• The State of Medical Student Performance Evaluations: Improved Transparency or Continued Obfuscation? Academic medicine Hom, J., Richman, I., Hall, P., Ahuja, N., Harman, S., Harrington, R., Witteles, R. 2016; 91 (11): 1534-1539

  Abstract

  The medical student performance evaluation (MSPE), a letter summarizing academic performance, is included in each medical student's residency application. The extent to which medical schools follow Association of American Medical Colleges (AAMC) recommendations for comparative and transparent data is not known. This study's purpose was to describe the content, interpretability, and transparency of MSPEs.This cross-sectional study examined one randomly selected MSPE from every Liaison Committee on Medical Education-accredited U.S. medical school from which at least one student applied to the Stanford University internal medical residency program during the 2013-2014 application cycle. The authors described the number, distribution, and range of key words and clerkship grades used in the MSPEs and the proportions of schools with missing or incomplete data.The sample included MSPEs from 117 (89%) of 131 medical schools. Sixty schools (51%) provided complete information about clerkship grade and key word distributions. Ninety-six (82%) provided comparative data for clerkship grades, and 71 (61%) provided complete key word data. Key words describing overall performance were extremely heterogeneous, with a total of 72 used and great variation in the assignment of the top designation (median: 24% of students; range: 1%-60%). There was also great variation in the proportion of students awarded the top internal medicine clerkship grade (median: 29%; range: 2%-90%).The MSPE is a critical component of residency applications, yet data contained within MSPEs are incomplete and variable. Approximately half of U.S. medical schools do not follow AAMC guidelines for MSPEs.

  View details for PubMedID 26703411

• R-SCAN: Imaging for Uncomplicated Acute Rhinosinusitis. Journal of the American College of Radiology Kroll, H., Hom, J., Ahuja, N., Smith, C. D., Wintermark, M. 2016

  View details for DOI 10.1016/j.jacr.2016.08.018

  View details for PubMedID 27744010

• A resident-created hospitalist curriculum for internal medicine housestaff. Journal of hospital medicine Kumar, A., Smeraglio, A., Witteles, R., Harman, S., Nallamshetty, S., Rogers, A., Harrington, R., Ahuja, N. 2016; 11 (9): 646-649

  Abstract

  The growth of hospital medicine has led to new challenges, and recent graduates may feel unprepared to meet the expanding clinical duties expected of hospitalists. At our institution, we created a resident-inspired hospitalist curriculum to address the training needs for the next generation of hospitalists. Our program provided 3 tiers of training: (1) clinical excellence through improved training in underemphasized areas of hospital medicine, (2) academic development through required research, quality improvement, and medical student teaching, and (3) career mentorship. In this article, we describe the genesis of our program, our final product, and the challenges of creating a curriculum while being internal medicine residents. Journal of Hospital Medicine 2016. © 2016 Society of Hospital Medicine.

  View details for DOI 10.1002/jhm.2590

  View details for PubMedID 27079160

• Surgical Comanagement by Hospitalists Improves Patient Outcomes: A Propensity Score Analysis. Annals of surgery Rohatgi, N., Loftus, P., Grujic, O., Cullen, M., Hopkins, J., Ahuja, N. 2016; 264 (2): 275-282

  Abstract

  The aim of the study was to examine the impact of a surgical comanagement (SCM) hospitalist program on patient outcomes at an academic institution.Prior studies may have underestimated the impact of SCM due to methodological shortcomings.This is a retrospective study utilizing a propensity score-weighted intervention (n = 16,930) and control group (n = 3695). Patients were admitted between January 2009 to July 2012 (pre-SCM) and September 2012 to September 2013 (post-SCM) to Orthopedic or Neurosurgery at our institution. Using propensity score methods, linear regression, and a difference-in-difference approach, we estimated changes in outcomes between pre and post periods, while adjusting for confounding patient characteristics.The SCM intervention was associated with a significant differential decrease in the proportion of patients with at least 1 medical complication [odds ratio (OR) 0.86; 95% confidence interval (CI), 0.74-0.96; P = 0.008), the proportion of patients with length of stay at least 5 days (OR 0.75; 95% CI, 0.67-0.84; P < 0.001), 30-day readmission rate for medical cause (OR 0.67; 95% CI, 0.52-0.81; P < 0.001), and the proportion of patients with at least 2 medical consultants (OR 0.55; 95% CI, 0.49-0.63; P < 0.001). There was no significant change in patient satisfaction (OR 1.08; 95% CI, 0.87-1.33; P = 0.507). We estimated average savings of $2642 to $4303 per patient in the post-SCM group. The overall provider satisfaction with SCM was 88.3%.The SCM intervention reduces medical complications, length of stay, 30-day readmissions, number of consultants, and cost of care.

  View details for DOI 10.1097/SLA.0000000000001629

  View details for PubMedID 26764873

• LOS OUTLIERS: A CHALLENGING PROBLEM FOR BOTH THE TEACHING AND PRIVATE NON-TEACHING GENERAL MEDICINE SERVICES AT STANFORD HOSPITAL Ketchersid, J., Shieh, L., Ahuja, N. K., Chi, J., Hom, J. SPRINGER. 2016: S294

  View details for Web of Science ID 000392201600372

• The Medical Education of Generation Y. Academic psychiatry Evans, K. H., Ozdalga, E., Ahuja, N. 2016; 40 (2): 382-385

  View details for DOI 10.1007/s40596-015-0399-5

  View details for PubMedID 26283527

• R-SCAN: Imaging for Headache. Journal of the American College of Radiology : JACR Hom, J. n., Ahuja, N. n., Smith, C. D., Wintermark, M. n. 2016; 13 (12 Pt A): 1534–35.e1

  View details for PubMedID 28341311

• Hospitalist intervention for appropriate use of telemetry reduces length of stay and cost JOURNAL OF HOSPITAL MEDICINE Svec, D., Ahuja, N., Evans, K. H., Hom, J., Garg, T., Loftus, P., Shieh, L. 2015; 10 (9): 627-632

  View details for DOI 10.1002/jhm.2411

  View details for Web of Science ID 000360836000012

• Eculizumab Induces Sustained Remission in a Patient With Refractory Primary Catastrophic Antiphospholipid Syndrome JCR-JOURNAL OF CLINICAL RHEUMATOLOGY Zikos, T. A., Sokolove, J., Ahuja, N., Berube, C. 2015; 21 (6): 311-313

  View details for DOI 10.1097/RHU.0000000000000290

  View details for Web of Science ID 000360665100006

• Diffuse Alveolar Damage in a Patient Receiving Dronedarone CHEST Stack, S., Nguyen, D., Casto, A., Ahuja, N. 2015; 147 (4): E131-E133

  Abstract

  Dronedarone is an amiodarone-like antiarrhythmic with a modified structure. The addition of a methyl sulfonyl group theoretically reduces the toxicity of amiodarone, specifically, adverse thyroid and pulmonary effects. Although animal studies have implicated dronedarone as a cause of lung injury, to date controlled trials in humans have not demonstrated an association. A 68-year-old woman developed a dry cough and worsening respiratory distress after receiving dronedarone for 6 months. Discontinuation of dronedarone therapy and subsequent steroid therapy led to a dramatic improvement of symptoms. Dronedarone may be associated with interstitial lung disease. We believe that patients receiving dronedarone should have their diffusing capacity of lung for carbon monoxide and lung volumes monitored prior to initiation of therapy and frequently thereafter.

  View details for DOI 10.1378/chest.14-1849

  View details for Web of Science ID 000354606300001

  View details for PubMedID 25846536

• The Medical Education of Generation Y Academic Psychiatry Evans, K. H., Ozdalga, E., Ahuja, N. 2015

  View details for DOI 10.1007/s40596-015-0399-5

• Gastrointestinal Manifestations of Henoch-Schoenlein Purpura DIGESTIVE DISEASES AND SCIENCES Menon, P., Singh, S., Ahuja, N., Winter, T. A. 2013; 58 (1): 42-45

  View details for DOI 10.1007/s10620-012-2124-5

  View details for Web of Science ID 000314182900010

  View details for PubMedID 22451115

• The Smartphone in Medicine: A Review of Current and Potential Use Among Physicians and Students JOURNAL OF MEDICAL INTERNET RESEARCH Ozdalga, E., Ozdalga, A., Ahuja, N. 2012; 14 (5)

  Abstract

  Advancements in technology have always had major impacts in medicine. The smartphone is one of the most ubiquitous and dynamic trends in communication, in which one's mobile phone can also be used for communicating via email, performing Internet searches, and using specific applications. The smartphone is one of the fastest growing sectors in the technology industry, and its impact in medicine has already been significant.To provide a comprehensive and up-to-date summary of the role of the smartphone in medicine by highlighting the ways in which it can enhance continuing medical education, patient care, and communication. We also examine the evidence base for this technology.We conducted a review of all published uses of the smartphone that could be applicable to the field of medicine and medical education with the exclusion of only surgical-related uses.In the 60 studies that were identified, we found many uses for the smartphone in medicine; however, we also found that very few high-quality studies exist to help us understand how best to use this technology.While the smartphone's role in medicine and education appears promising and exciting, more high-quality studies are needed to better understand the role it will have in this field. We recommend popular smartphone applications for physicians that are lacking in evidence and discuss future studies to support their use.

  View details for DOI 10.2196/jmir.1994

  View details for Web of Science ID 000309405400005

  View details for PubMedID 23017375

  View details for PubMedCentralID PMC3510747

• Interrelated Endocrinopathies: Hypothyroidism and Hyperprolactinemia Today’s Hosptialist Khilnani, N., Kothari, T. 2007; April: 20-23
• Disseminated Candidiasis in IV Drug Abusers: A Distinctive Syndrome. Johns Hopkins Advanced Studies in Medicine Rondon-Berrios, H., Khilnani, N., Trevejo-Nunez, G., Rouan, G. 2006; 6: 82-85
• Advice to Medical Students Applying for Residency Alliance for Academic Internal Medicine Speer, A., Khilnani, N. 2005; 3 (4:10): 10
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• Brain bloodflow abnormalities associated with oral cocaine use International Journal of Psychological Medicine Johnson, B., Lamki, L., Barron, B., Spiga, R., Chen, R., Meisch, R., Khilnani, N. 1997; 12 (2): 72-73