Joshua Gentges

Introduction Chest pain is a common, expensive cause of admission to the hospital from the Emergency Department (ED). The History, ECG, Age, Risk Factors, and Troponin (HEART) score is a risk stratification tool often used to determine the disposition of chest pain patients. This study evaluates the association of age, gender, HEART score, diabetes mellitus (DM), hypertension (HTN), hypercholesterolemia, family history (Fam Hx), and tobacco use with major adverse cardiovascular events (MACE) and hospital readmission. While low-risk HEART score patients are generally discharged and high-risk patients generally admitted, data is limited on the appropriate disposition strategy for moderate-risk patients. Our goal is to understand the risks of cardiovascular morbidity, the studies performed, and the factors associated with readmission in moderate HEART score patients. Methods A retrospective cohort study was conducted using ED records from March 1, 2018, to March 31, 2019. Patients with a moderate HEART score (4-6) were included. Data on additional testing and outcomes were collected. Statistical analyses included Pearson Chi-square tests and unadjusted and adjusted logistic regression to assess associations between explanatory variables and outcomes. Multicollinearity was assessed with all variance inflation factors below 1.3. To evaluate how well the logistic model performed an area under the curve (AUC) analysis was performed, with values of 0.68 (cardiovascular morbidity events) and 0.67 (readmission) respectively. No pre-existing AUC cutoff was used. Results The study included 959 patients with a moderate HEART score. The average age was 58.9 years, and 486 (50.7%) were male. Cardiovascular disease morbidity events occurred in 72 (7.5%) of patients, and 108 (11.3%) were readmitted within six weeks. Higher HEART scores, male gender, and diabetes were significantly associated with increased odds of cardiovascular morbidity. Male gender, tobacco use, and hypercholesterolemia were significantly associated with hospital readmission. The percutaneous intervention occurred in 60 (6.3%) patients, coronary bypass grafting in 10 (1.0%), and cerebrovascular accident in two (0.2%). Myocardial perfusion imaging was performed in 421 (43.9%) of patients and echocardiogram in 445 (46.4%), while computerized tomography coronary angiogram was performed in 99 (10.3%). No deaths were identified in our study. Discussion The findings suggest that higher HEART scores, male gender, and diabetes are significant predictors of cardiovascular morbidity, while male gender, tobacco use, and hypercholesterolemia predict hospital readmission. Reliance on ED records could limit study generalizability as we did not capture direct admissions. The retrospective design could introduce bias from confounding variables. Most of the testing and intervention during hospitalization could reasonably have been performed in an outpatient setting. Conclusion This study provides quantitative data on the utility of hospitalization for moderate-risk HEART score patients. The results support the potential for outpatient management in certain cases, especially those with HEART scores of 4. Future studies should include randomized controlled trials comparing the discharge of moderate HEART score patients with inpatient management.

Health disparities among people experiencing homelessness are likely exacerbated by limited access to healthy, fresh, and minimally processed foods. Soup kitchens and shelters serve as essential food safety nets for preventing hunger in this population, and community interest is growing in the potential of “food is medicine” interventions to improve the mental and physical wellbeing of people who receive meals from these providers. This study describes our two-phase approach to first identify and prioritize nutrition needs within an urban soup kitchen community and then test and implement new recipes and menu guidelines to help the standard soup kitchen menu better align with those priorities. We began by first conducting a nutrition needs assessment, including a collection of intercept surveys from a convenience sample of soup kitchen guests to better understand their nutrition-related health needs, dental issues, food preferences, and menu satisfaction (n = 112), as well as a nutrition analysis of the standard menu based on seven randomly selected meals. Most respondents reported at least one chronic health condition, with depressive disorders (50.9%) and cardiovascular diseases (49.1%) being the most common. Nearly all guests requested more fruits and vegetables at mealtimes, and results from the menu analysis revealed opportunities to lower meal contents of sodium, saturated fat, and added sugars and to raise micronutrient, fiber, and omega-3 content. We then applied these nutrition needs assessment findings to inform the second phase of the project. This phase included the identification of new food inventory items to help support cardiovascular and mental health-related nutrition needs, taste test sampling of new healthy menu items with soup kitchen guests, and hands-on culinary medicine training to kitchen staff on newly-developed “food is medicine” guidelines to support menu transformation. All taste tests of new menu items received over 75% approval, which exceeded satisfaction ratings of the standard menu collected during the phase 1 needs assessment. Findings from this community-based participatory research project confirm the great potential for hunger safety net providers to support critical nutrition needs within this vulnerable population through strategic menu changes. However, more research is needed on the longitudinal impacts of such changes on health indicators over time.

Introduction:According to the US Center for Disease Control and Prevention, 30%–50% of antibiotic use in hospitals is unnecessary or inappropriate. The coronavirus disease 2019 pandemic further complicates antibiotic use leading to greater initiation of empiric antibiotics. The result is antibiotic overuse and increased duration of unnecessary therapy. Vancomycin is a drug of last resort, primarily relegated to the treatment of Methicillin-Resistant Staphylococcus aureus (MRSA). De-escalating vancomycin can mean waiting on MRSA culture results, which may take up to 96 h. Nares screening for MRSA is shown to possess high negative predictive value for ruling out suspected MRSA pneumonia, intra-abdominal infections, and bacteremia.Methods:This before-and-after study examines the impact of vancomycin therapy de-escalation due to absence of MRSA colonization detected via PCR assay of nares swabs. An intervention with providers using SMART goals was designed to increase nasal swabbing for MRSA and ultimately decrease vancomycin use at a large, tertiary-care urban hospital.Results:There was a significant increase in use of vancomycin nares swabs (28/150 vs 48/100, p = 0.040) in the immediate pre/postintervention period, and significant decreases in vancomycin usage days/1,000 patient days of 2.34% per month (p = 0.039) over a two year period after the intervention.Conclusion:An intervention using PCR nares swabs to detect MRSA led to significant, lasting decreases in vancomycin usage at this hospital. Similar interventions should be planned at hospitals experiencing overuse of this antibiotic.

Introduction Medical cannabis has recently become legal in Oklahoma. Cannabinoid hyperemesis syndrome (CHS) is severe nausea, vomiting, and often abdominal pain typically seen in heavy users of cannabis. The aim of this study is to determine whether emergency department (ED) diagnoses of CHS have increased after medical legalization. Methods We performed a retrospective chart review study of equivalent time periods prior to and after the first legal sales of medical cannabis in Oklahoma. Data were gathered from a single urban ED of adult patients with diagnosed or suspected CHS. We analyzed data using a chi-square analysis of CHS cases as a proportion of total ED visits. Results Diagnosed and suspected CHS visits increased from 43 cases in the eight months preceding the first legal sale to 62 cases in the eight months after legalization. This represents a statistically significant increase in ED visits for CHS (p = 0.026). Total ED encounters were 30,437 and 28,362, respectively, during those time periods. The proportion of visits for CHS was much higher (220/100000 vs 13.3/100000) than previously reported in the literature. The pre-legalization and post-legalization groups did not differ by age, sex, history of GI illness and diabetes, pregnancy, or other drug use. Conclusion We observed a statistically significant increase in ED visits for CHS after the first legal sales of medical cannabis in Oklahoma. Our high proportion of ED visits for CHS could be related to study design, increased provider awareness, high THC levels in Oklahoma’s medical cannabis, or increased numbers of cannabis users after legalization. Increases in ED visits for CHS and other cannabinoid-related illnesses must be weighed against the positive effects for cannabis users by policymakers.