KUMC Faculty Research Day 2021 - Virtual Poster Session - October 12, 2021

Yanming Li

KUMC Department of Biostatistics and Data Science

Background: For ICH the Joint Commission CSTK-04 stroke measure encourages anticoagulant reversal when initial INR > 1.4. Other guidelines are less definitive: AHA guidelines suggest reversing INR elevated due to VKA antagonist, and NCS/SCCM guidelines allow discretion regarding reversal for INR <2, but strongly encourages reversal of VKA-associated INR >1.4.

While evidence supports reversal for INR≥2.0, little has been published on patients with INR 1.5-1.9. Given the lack of data, it is unclear whether this cohort of patients experiences benefit or harm from anticoagulant reversal.

Methods: We conducted a retrospective review of patients admitted to our institution from January 2015 through March 2021 to determine the rate of reversal and outcome for ICH with INR between 1.5-1.9. This date range was selected due to the completeness of the data.

Results: Thirty-nine patients presented with ICH and an INR of 1.5-1.9. These patients represented 5% of the 756 total ICH patients. Reversal was at the discretion of the physician team. 19 patients received reversal for mild elevation in INR, while twenty patients did not. • The patients who received reversal were older (70.1yrs vs 60.3yrs), had higher INR (1.7 vs 1.6), and had higher ICH score (1.83 vs 1.4). • Warfarin was a less common cause of moderately elevated INR than was either direct oral anticoagulant or liver dysfunction • Nonetheless reversal of elevated INR was successful in maintaining INR less than 1.5 at 24 to 48 hours. (p value 0.04) • Mortality was not statistically different between the treated and untreated groups. (p value 0.63) • For low ICH scores there was a trend toward improved discharge MRS.

Discussion: • INR was successfully reversed in 75% of patients who were given reversal whereas in patients without reversal, 42% had INR less than the INR 1.5 within 48hours. • There were no thrombotic complications in the 39 patients. This may be related to the small size of the sample, or it may be related to the short period of observation allowed in the sample, or it may be related to the way thrombotic complications were adjudicated. • Liver failure was present in 11 patients. Only 3 of whom received reversal. 8 did not receive reversal. • There were relatively few warfarin patients: Vitamin K antagonists:8 (20.5%), Direct oral anticoagulants: 13 (33.3%). • A disproportionate number of patients had ICH during lovenox bridge for warfarin—3 patients out of 39. (7.6%) • A disproportionate number of patients with moderately elevated INR had dural venous sinus thromboses— 3 patients out of 39. (7.6%)

Conclusion: The use of reversal successfully lowered INR in patients with elevations 1.5-1.9. This successful reversal was without thrombotic complications. The decision to reverse was likely influenced by patient characteristics such as ICH score. Receiving reversal lessened the correlation between ICH score and discharge mRS. Further studies are warranted to determine causality.

Aaron LacKamp

KUMC

Introduction: The goal of reducing hospital readmissions for patients with diabetes mellitus (DM) is multifaceted, with benefits to patient outcomes, provider burden, and health system costs. Current studies and data analysis have yet to elucidate a clear approach to accurately identify at-risk patients and implement effective interventions to reduce readmissions. We trialed a QI pilot program that utilized a NP/CDCES (Nurse Practitioner/Certified Diabetes Care and Education Specialist) to manage and educate at-risk patients during initial hospitalization as well as close follow-up post discharge with an end point of reduction in readmissions.

Methods: Over the course of 21 months, 79 hospitalized patients with diabetes were identified as high-risk for intervention based on: previous admission, diabetes ketoacidosis/ hyperosmolar hyperglycemic syndrome, new DM diagnosis, new to insulin, high-dose steroid use/tapers, or per provider discretion. The NP/CDCES provided DM management, education, and coordinated discharge plans during hospitalization. Patients were also called post-discharge for acute management/interventions and had a 2-4 week DM clinic follow-up visit with the same NP/CDCES. Results: The major endpoint was number of readmissions within 180 days of discharge after intervention compared to number of previous readmissions pre-intervention. Change in hemoglobin A1C, time to post-hospital phone call, and time to outpatient follow up were also evaluated. Pre- and post-intervention readmission rates remained unchanged; average pre-intervention readmissions per patient was 1.7 versus 1.88 post-intervention readmissions (p=0.74). However, a secondary endpoint of reduction in hemoglobin A1C was found to be statistically significant, with a mean decrease in A1C of 0.97% per patient (p=0.0025). Time to post-hospital phone call and early follow up did not affect readmission rates.

Conclusion: While targeted inpatient-to-outpatient intervention for high-risk patients with diabetes did not reduce future readmission rates, our data suggests that coordinated inpatient intervention with close hospital follow-up may improve A1c in high-risk patients with diabetes.

Kristine Grdinovac

University of Kansas Medical Center

Background

Deviations from analytic intent (DAIs) include 1) publication bias and 2) selective reporting bias. We previously identified an instance of selective reporting bias (PMID 28192789), that per the authors of a well-done clinical practice guideline (CPG), ‘probably’ affected their clinical recommendation. We now quantify the possibility that both DAIs affected another well-done CPG's recommendation.

Methods

We studied the clinical recommendation for topical non-steroidal anti-inflammatory drugs (NSAIDs) to reduce acute (PMIDs 32805126, 32805127), non-back pain for 1 to 7 days per a guideline by the American College of Physicians (ACP). For the clinical recommendation, we quantified the proportion of patients registered at one trial registry (ClinicalTrials.gov) that were later published at PubMed, and the proportion of patients published at PubMed that were previously registered. We extracted results from the published CPG, its evidence review, and information graciously provided by the review’s authors. In addition, we searched clinicaltrials.gov for relevant trials.

Results

The CPG reported finding 27 relevant trials with 4777 subjects at PubMed (ACP Supplement Table 6). Of the 27 trials, 2 were registered at ClinicalTrials.gov and 5 at other registries. This resulted in 1179 of 4777 (25%) of published subjects being registered.

The CPG found that 11 additional trials were registered at ClinicalTrials.gov but not published (ACP Appendix 2). We located one additional registration. The CPG found two additional trials were both registered and published yielding a total of 3787 subjects registered in 14 trials. Of these, 314 subjects were in 2 trials (8% of registered subjects) that were subsequently published. Two of the trials were registered but not published posted negative results at ClinicalTrials.gov. The ten registered trials without results were registered by industry between the years 2007 and 2019 (median year of registration 2009).

Discussion

In the current analysis, 75% of published subjects are susceptible to selective reporting bias due to not being registered while 92% of registered subjects are susceptible to publication bias due to not being published. Supporting this concern are the two trials that posted but did not publish results are negative.

Both guidelines comply with the Appraisal of Guidelines for Research and Evaluation II (AGREEII), comply with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and are considered Trustworthy. The current analysis, along with our previous analysis, support that CPGs, even when following best practice, are subject to DAIs.

We suggest that CPGs routinely report these two rates of possible biases to aid interpretation of recommendations. Further research is needed of signals that DAI rates may be affecting conclusions of CPGs.

Robert Badgett

KUK School of Medicine Wichita, Internal Medicine. Mayo Clinic

Background: Although growing evidence links beta-amyloid (Aβ) and neuronal hyperexcitability in preclinical mouse models of Alzheimer’s disease (AD), a similar association in humans is yet to be established. The first aim of the study was to determine the association between elevated Aβ (Aβ+) and cognitive processes measured by the P3 event-related potential in cognitively normal (CN) older adults. The second aim was to compare event-related power between CNAβ+ and CNAβ. Methods: CNAβ+ participants (n = 17, age: 73 ± 5, 11 women, MOCA scores 26 ± 2) and 17 CNAβ- participants group-matched for age, sex, and MOCA completed a working memory task (n-back with n = 0, 1, 2) test while wearing a 256-channel EEG net. P3 peak amplitude and latency of the target, nontarget and task difference (nontarget – target), and event-related power in the delta, theta, alpha, and beta bands, extracted from Fz, Cz, and Pz were compared between groups using linear mixed models. P3 amplitude of the task effect at Fz, and event-related spectral power in the delta band were considered main outcomes. Mean Aβ standard uptake value ratios (SUVR) using positron emission tomography were correlated with P3 amplitude and latency of the task effect using Pearson r. Results: P3 peak amplitude of the task effect (p = 0.048) at Fz was lower in the CNAβ+ group. Similarly, power was lower in the delta band (p = 0.04) for nontargets at Fz in CNAβ+ participants. CNAβ+ participants also demonstrated higher theta and alpha power in channels at Cz and Pz, but no changes in P3 ERP. Strong correlations were found between mean Aβ SUVR and latency of the 1-back (r = -0.69; p = 0.003) and 2-back (r = -0.69; p = 0.004) of the task effect at channel Fz in the CNAβ+ group. Conclusions: Our data suggests that elevated amyloid in cognitive normal older adults is associated with neuronal hyperexcitability. The decreased P3 task difference likely reflects early impairments in working memory processes. Further research is warranted to determine the validity of ERP in predicting clinical, neurobiological, and functional manifestations of AD.

Hannes Devos

University of Kansas Medical Center

Jamie Myers

University of Kansas Medical Center, School of Nursing

The International Society for Professional Identity in Nursing (ISPIN) convened in 2018 to call out and define professional identity in nursing, and to add language and new knowledge to the discipline on this topic. To date, two 50-person, international think tanks and one virtual forum have produced 46 publications, webinars and podcasts, 15 national and international presentations and a conceptual model that has been tested and validated with both US educated and foreign-educated nurses.

More than 250 nurse leaders have come forward to participate in various ISPIN work groups, including propelling the science, educational dissemination, and using science to define and claim the brand image of nursing. Five research studies are in progress, including one on instrument development. The international impact is noted in that 48 countries were represented on five Sigma webinars on Professional Identity in Nursing in the fall of 2020.

Through an intense, scientific process of gleaning subject matter expert knowledge, the ISPIN has defined Professional Identity in Nursing as " a sense of oneself, in relationship with others, that is influenced by the characteristics, norms and values of the nursing discipline, resulting in the individual thinking, acting and feeling like a nurse." Again, through a thoughtful iterative process the ISPIN has named the four domains of Professional Identity in Nursing: 1) Values and Ethics, 2) Knowledge, 3) Leadership, and 4) Professional Comportment. This work and the instrument development that is in process will make explicit what professional Identity in nursing means.

The hope is that every student nurse and every nurse in practice--worldwide--can gain a clearer understanding of professional identity of nursing using the ´signposts´ of values and ethics, knowledge, leadership and professional comportment.

Nelda Godfrey

University of Kansas Medical Center (SSO) and California State University Long Beach