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Approximately 20% of patients with symptomatic syndrome-associated coronavirus-2 (SARS-CoV-2) infection have gastrointestinal bleeding and/or diarrhea. Most are managed without endoscopic evaluation because the risk of practitioner infection outweighs the value of biopsy analysis unless symptoms are life-threatening. As a result, much of what is known about the gastrointestinal manifestations of coronavirus disease-2019 (COVID-19) has been gleaned from surgical and autopsy cases that suffer from extensive ischemic injury and/or poor preservation. There are no detailed reports describing any other gastrointestinal effects of SARS-CoV-2 even though >3,000,000 people have died from COVID-19 worldwide. The purpose of this study is to report the intestinal findings related to SARS-CoV-2 infection by way of a small case series including one with evidence of direct viral cytopathic effect and 2 with secondary injury attributed to viral infection. Infection can be confirmed by immunohistochemical stains directed against SARS-CoV-2 spike protein, in situ hybridization for spike protein-encoding RNA, and ultrastructural visualization of viruses within the epithelium. It induces cytoplasmic blebs and tufted epithelial cells without inflammation and may not cause symptoms. In contrast, SARS-CoV-2 infection can cause gastrointestinal symptoms after the virus is no longer detected, reflecting systemic activation of cytokine and complement cascades rather than direct viral injury. Reversible mucosal ischemia features microvascular injury with hemorrhage, small vessel thrombosis, and platelet-rich thrombi. Systemic cytokine elaboration and dysbiosis likely explain epithelial cell injury that accompanies diarrheal symptoms. These observations are consistent with clinical and in vitro data and contribute to our understanding of the protean manifestations of COVID-19.

BACKGROUND: Delays in biologic or small molecule medication administration are associated with increased adverse events, hospitalization, and surgery in inflammatory bowel disease (IBD). We evaluated the impact of a quality improvement (QI) intervention on the time to administration of biologics or small molecules (TABS) in IBD. METHODS: Data were retrospectively extracted for IBD patients prescribed biologics or small molecules from a convenience sample of providers participating in an accredited QI educational intervention (baseline cohort). Subsequent to the intervention, data were prospectively collected from patients prescribed these medications (post-intervention cohort). Dates related to steps between a treatment decision to medication administration were collected. The primary outcome compared TABS in baseline and post-intervention cohorts. RESULTS: Eighteen physicians provided survey- and patient data for 200 patients in each cohort (n=400). The median time to medication administration (TABS) decreased from baseline to post-intervention cohorts (30 days vs. 26 days, p=0.04). Emergency room visits prior to medication administration also decreased (25.5% vs. 12.5%, p=0.001). Similar numerical TABS reductions were observed in subgroups limited to physicians providing patients to both cohorts and for individual medications prescribed. Primary contributors to delays included filling prescriptions subsequent to insurance approval and dispensation subsequent to this. CONCLUSION: A QI intervention successfully reduced medication administration times (TABS) by accelerating provider-dependent steps. This intervention was associated with reduced emergency room visits. We propose TABS as a quality metric to assess effective delivery of therapies in IBD. Further evaluation of QI interventions, patient education on prescription drug insurance, and quality metrics are warranted.

Acute-on-chronic liver failure (ACLF) carries high short-term mortality. The North American Consortium for the Study of End-Stage Liver Disease (NACSELD)-ACLF score, positive if ≥2 organ failures are present, is a bedside tool that predicts short-term mortality in patients with cirrhosis. However, it was created using major liver referral centers, where a minority of patients with cirrhosis are hospitalized. Therefore, this study used the Nationwide Inpatient Sample, a nationally representative database, from 2005 to 2014 to externally validate the NACSELD-ACLF score in a cohort of patients with decompensated cirrhosis who were identified by a validated algorithm. Organ failures were identified using diagnosis codes. The primary objective was to evaluate the association between the NACSELD-ACLF score and inpatient mortality, whereas secondary objectives compared outcomes depending on presence of infection or hospitalization at a transplant center. Multivariate logistic regression was used to compare outcomes, and area under the curve was calculated. There were 1,523,478 discharges that were included with 106,634 (7.0%) having a positive NACSELD-ACLF score. Patients were a mean 58 years old, and a majority were white men. Infection was present in 33.7% of the sample. Inpatient survival decreased with each organ failure and if infection was present. Patients with the NACSELD-ACLF score had significantly lower inpatient survival on crude (94% versus 48%; P < 0.001) and multivariate analysis (odds ratio [OR], 0.08; 95% confidence interval [CI], 0.07-0.08) and area under the receiver operating characteristic curve 0.77 (95% CI, 0.77-0.78). Liver transplant centers had clinically similar but significantly better survival at each organ failure, in patients with the NACSELD-ACLF score, and on multivariate analysis (OR, 1.17; 95% CI, 1.13-1.22). Using a national cohort, our study validated the NACSELD-ACLF score as an excellent, simple bedside tool to predict short-term survival in patients with decompensated cirrhosis.

Economic evaluation of a randomized clinical trial.Compare costs and cost-effectiveness of usual primary care management for patients with acute low back pain (LBP) with or without the addition of early physical therapy.Low back pain is among the most common and costly conditions encountered in primary care. Early physical therapy after a new primary care consultation for acute LBP results in small clinical improvement but cost-effectiveness of a strategy of early physical therapy is unknown.Economic evaluation was conducted alongside a randomized clinical trial of patients with acute, nonspecific LBP consulting a primary care provider. All patients received usual primary care management and education, and were randomly assigned to receive four sessions of physical therapy or usual care of delaying referral consideration to permit spontaneous recovery. Data were collected in a randomized trial involving 220 participants age 18 to 60 with LBP16 days duration without red flags or signs of nerve root compression. The EuroQoL EQ-5D health states were collected at baseline and after 1-year and used to compute the quality adjusted life year (QALY) gained. Direct (health care utilization) and indirect (work absence or reduced productivity) costs related to LBP were collected monthly and valued using standard costs. The incremental cost-effectiveness ratio was computed as incremental total costs divided by incremental QALYs.Early physical therapy resulted in higher total 1-year costs (mean difference in adjusted total costs = $580, 95% CI: $175, $984, P = 0.005) and better quality of life (mean difference in QALYs = 0.02, 95% CI: 0.005, 0.35, P = 0.008) after 1-year. The incremental cost-effectiveness ratio was $32,058 (95% CI: $10,629, $151,161) per QALY.Our results support early physical therapy as cost-effective relative to usual primary care after 1 year for patients with acute, nonspecific LBP.2.

BACKGROUND Although multiple clinical trials are currently testing different stem cell therapies as treatment alternatives for many neurodegenerative diseases and spinal cord injury, the optimal injection parameters have not yet been defined. OBJECTIVE To test the spinal cord's tolerance to increasing volumes and numbers of stem cell injections in the pig. METHODS Twenty-seven female Gottingen minipigs received human neural progenitor cell injections using a stereotactic platform device. Cell transplantation in groups 1 to 5 (5-7 pigs in each) was undertaken with the intent of assessing the safety of an injection volume escalation (10, 25, and 50 µL) and an injection number escalation (20, 30, and 40 injections). Motor function and general morbidity were assessed for 21 days. Full necropsy was performed; spinal cords were analyzed for graft survival and microscopic tissue damage. RESULTS No mortality or permanent surgical complications were observed during the 21-day study period. All animals returned to preoperative baseline within 14 days, showing complete motor function recovery. The histological analysis showed that there was no significant decrease in neuronal density between groups, and cell engraftment ranged from 12% to 31% depending on the injection paradigm. However, tissue damage was identified when injecting large volumes into the spinal cord (50 μL). CONCLUSION This series supports the functional safety of various injection volumes and numbers in the spinal cord and gives critical insight into important safety thresholds. These results are relevant to all translational programs delivering cell therapeutics to the spinal cord.

EXECUTIVE SUMMARYDespite the benefits of computerized provider order entry (CPOE), numerous reports of unexpected CPOE-related safety concerns have surfaced. As part of a larger project to improve the safety of electronic health records (EHRs), we developed and field tested a CPOE "safety self-assessment" guide through literature searches, expert opinion, and site visits. We then conducted a field test of this guide with nine hospital chief medical informatics officers (CMIOs), who were identified through the Association of Medical Directors of Information Systems. The CPOE safety selfassessment guide was sent electronically to the CMIOs. Once the assessments were returned, we conducted structured telephone interviews for further comments about the guide's format and content. The CMIOs in our study found the CPOE safety guide useful and relatively easy to complete, taking no more than 30 minutes. Analysis of responses to the guide suggest that most recommended practices were implemented inconsistently across facilities. Despite consensus for certain CPOE best practices in the medical literature and among experts, there appeared to be considerable variation among CMIOs' opinions of best practices. Interview data suggested this inconsistency was mostly due to system limitations and/or differing opinions about the necessity of certain EHR-related safety measures. Despite the absence of consensus on best practices, a self-assessment safety guide provides a practical starting point for organizations to assess and improve safety and the effectiveness of their CPOE system.BACKGROUND AND SIGNIFICANCEThe use of electronic health records (EHRs) and computerized provider order entry (CPOE) with advanced clinical decision support (CDS) has the potential to increase efficiency, reduce harm, and improve patient safety (Amarasingham, Plantinga, DienerWest, Gaskin, & Powe, 2009; Ammenwerth, Schnell-Inderst, Machan, & Sieben, 2008; Bates et al., 1999, 2001; Bobb et al., 2004; Franklin, O'Grady, Donyai, Jacklin, & Barber, 2007; Mekhjian et al., 2002; Sittig & Stead, 1994; Sittig & Singh, 2012; Wolfstadt et al., 2008). Despite these potential benefits, several barriers limit the adoption of these technologies, including high costs, major time commitments for training personnel, interruptions in workflow, and medical practitioners' reluctance to move away from traditional paper records (Kuperman & Gibson, 2003; Ash, Gorman, & Hersh, 1998; Wang & Huang, 2012).To encourage widespread implementation of fully functional EHRs (i.e., EHRs that contain integrated CPOE and CDS applications), the U.S. Congress passed the Health Information Technology for Economic and Clinical Health (HITECH) Act as part of the 2009 American Recovery and Reinvestment Act (GPO, 2010). In 2010, HITECH allocated financial incentives totaling almost $27 billion to hospitals and eligible professionals (i.e., doctors of medicine or osteopathy, doctors of dental surgery or dental medicine, doctors of podiatrie medicine, doctors of optometry, and chiropractors) who are able to demonstrate the "meaningful use" of EHRs, a critical component of which is CPOE with CDS (Wright, Feblowitz, Samal, McCoy, & Sittig, 2014). In view of the time limits on these incentives and the eventual financial penalties for nonadopters, since May 2012, 62,226 of the estimated 509,328 eligible physicians have attested to meaningful use of EHRs under the Medicare program (Vest, Yoon, & Bossak, 2013; Wright et al" 2013). Similarly, whereas only 27% of hospitals used CPOE in 2008, by 2012 the figure was 72% (Charles, King, Furukawa, & Patel, 2013).CPOE has been described primarily as an innovation to improve patient safety, yet the implementation of CPOE within EHRs also has potential to introduce novel and unexpected risks. For example, Horsky, Kuperman, and Patel (2005) identified a series of errors in potassium chloride ordering resulting from a confluence of factors, including (1) misunderstandings about the patient's current potassium level due to ineffective display of recent laboratory results; (2) confusing displays of current orders and recent medication administrations; (3) misunderstandings surrounding the different meanings of "total volume" when ordering time-limited, continuous intravenous drips and amountlimited, intravenous bolus injections; and (4) use of free-text versus coded (i. …

This article complements a series of six impairment-specific reports of multi-year data from the Uniform Data System for Medical Rehabilitation database (UDSMR® database) providing national benchmarking information for follow-up information on key rehabilitation outcomes. The current report includes follow-up data on a subset of patients with stroke, traumatic brain injury, lower extremity fracture, lower extremity joint replacement, traumatic spinal cord injury, or debility who received inpatient rehabilitation services from 2002 through 2010 in facilities that subscribed to the UDSMR. Recent reports published in this journal contain the admission and discharge benchmark information for patients in these rehabilitation impairment categories.1–6 An earlier report containing follow-up information from 1994–1996 was also published in this journal.7 Following a debilitating illness or injury, patients and family members universally desire recovery of functional independence to enable a return to community living. Traditionally, inpatient providers have had no established need and few if any resources to document patient outcomes and experiences following discharge. The Affordable Care Act8 contains several provisions (e.g. readmission reduction, bundled payments, and care coordination) that expand provider accountability beyond the immediate stay. In other words, the financial incentives (penalties) included in these provisions have heightened the interest of upstream providers in the downstream care and longer-term outcomes their patients experience. Implicit in this expanded episode-of-care framework are the needs and impacts of family caregivers and the understanding that longer-term recovery of health status and independence are largely a function of a person’s combined formal and informal care networks.9 Our goal for this report was to display yearly aggregated summaries of select rehabilitation outcomes in a natural, meaningful sequence (admission, discharge, follow-up) for patients within the six largest impairment groups receiving inpatient medical rehabilitation services. We believe this information can serve as a valuable resource for all stakeholders working to improve the long-term outcomes, care transitions, and/or care coordination for persons requiring intensive post-acute rehabilitation services.

This report summarizes information for patients with debility who received comprehensive inpatient rehabilitation services in facilities that subscribed to the UDSMR from 2000 through 2010. The objective of this report is to provide benchmark information for important rehabilitation outcomes such as length of stay (LOS), functional status, and discharge setting for inpatient rehabilitation impairment groups. This article represents the sixth in the series of impairment-specific longitudinal reports from the Uniform Data System for Medical Rehabilitation (UDSMR®) database using information from 2000 and forward. Previous reports presented data on patients receiving inpatient rehabilitation for stroke,1 traumatic brain injury,2 lower limb joint replacement,3 hip fracture,4 and spinal cord injury.5 This series represents an extension of previous reports published in this journal, which provided single-year summaries. The last annual benchmark report contained data for the most common rehabilitation impairment categories during 1999: stroke, orthopedic diagnoses, brain dysfunction, spinal cord dysfunction, and other neurologic conditions.6 This report is the first UDSMR longitudinal benchmark study focusing on the debility impairment group. This impairment group has become more prevalent in inpatient rehabilitation facilities (IRF). Debility accounted for 6.1% of Medicare inpatient rehabilitation cases in 2004 and has increased to 10.4% of cases during the first half of 2011.7 Patients with debility have “generalized deconditioning not attributable to any of the other Impairment Groups,”8;9 such as a neurological, orthopedic, or cardiopulmonary diagnoses. This report displays trends in rehabilitation information and outcomes over time as a resource for researchers, administrators, policy makers, clinicians, individuals and their families, and other stakeholders in quality improvement efforts.

This study aimed to determine the predictors of discharge to acute care after inpatient rehabilitation in severely affected stroke patients.This was a retrospective study using data from the Uniform Data System for Medical Rehabilitation (UDSMR) between 2008 and 2009. The main outcome variable was discharge location, which included discharge to acute care or discharge to the community after inpatient rehabilitation. The study sample included 223 of the most severely affected stroke patients (Case-Mix Group 0110 of Medicare reimbursement classification), of whom 86 were discharged to acute care from after the inpatient medical rehabilitation setting; 137 similarly classified stroke patients were discharged to the community after inpatient medical rehabilitation. The variables examined were Functional Independence Measure ratings, co-morbid medical conditions, and four groups of stroke-related neurologic deficits (hemiparesis, dysphagia, language deficits, and other stroke-related neurologic deficits). The groups were devised based on International Classification of Diseases, 9th Revision codes.There were no significant demographic differences between the two groups-those discharged to the acute care hospital and those discharged to the community. There was a difference in admission Functional Independence Measure ratings, whereby patients discharged to acute care were significantly lower (P0.05) on admission motor and cognitive function than were patients discharged to the community. When controlling for 19 groups of co-morbid medical conditions and 4 groups of stroke-related neurologic deficits, there was no significant difference between patients being discharged to an acute care hospital and those discharged to the community.In the current study, controlling for impairment (stroke), severity of condition, demographic variables, inpatient rehabilitation admission day of the week and discharge day of the week, prehospitalization living setting, prehospitalization living with (alone, family, other), payer (secondary insurance coverage), onset days, co-morbid medical conditions, and classification of stroke-related neurologic deficits, the only variable predictive of discharge to the acute care hospital from an inpatient rehabilitation facility is function at admission, mainly the admission motor Functional Independence Measure rating. If clinicians routinely assess the functional status of patients during the preadmission screening process, it may aid in identifying whether the patient is at an increased risk of being readmitted to the acute care hospital.

This study aimed to provide benchmarking information from a large national sample of patients receiving inpatient rehabilitation after a traumatic spinal cord injury.This was an analysis of secondary data from 891 inpatient medical rehabilitation facilities in the United States that contributed traumatic spinal cord injury data to the Uniform Data System for Medical Rehabilitation from January 2002 to December 2010. Variables analyzed included demographic information (age, sex, marital status, race/ethnicity, prehospital living setting, discharge setting), hospitalization information (length of stay, program interruptions, payer, onset date, rehabilitation impairment group, International Classification of Diseases 9 codes for admitting diagnosis, co-morbidities), and functional status (Functional Independence Measure [FIM] instrument ratings at admission and discharge, FIM efficiency, FIM gain).The final sample included 47,153 patients with traumatic spinal cord injury. Overall, the mean length of stay was 26.2 ± 23.2 days: yearly means ranged from 29.7 ± 25.4 in 2002 to 22.9 ± 18.9 in 2009. FIM total admission and discharge ratings also declined during the 8-yr study period; admission decreased from 60.5 ± 17.4 to 55.9 ± 16.3; discharge decreased from 86.1 ± 23.8 to 82.4 ± 23.4. Rehabilitation efficiency (FIM gain per day) remained relatively stable over time (1.6 ± 1.7 points per day). The percentage of all patients discharged to the community ranged from 75.8% to 71.5% per year. Wheelchair users stayed in rehabilitation longer than did persons who could walk (34.6 ± 217.4 vs. 17.4 ± 14.1 days) and also experienced less functional improvement (21.6 ± 15.8 vs. 29.6 ± 16.3 FIM points).National data from persons with traumatic spinal cord injury in 2002-2010 indicate that lengths of stay declined, but efficiency in functional independence was stable to slightly increased. More than 70% of patients were consistently discharged to community settings after inpatient rehabilitation.

This study aimed to compare the functional outcomes and discharge locations of older adults admitted to inpatient rehabilitation with debility (International Classification of Diseases, 9th Revision, Clinical Modification, [ICD-9-CM] code 799.3) with those of patients with a nondebility generalized weakness diagnosis (ICD-9-CM codes 728.2, 728.87, and 780.79).This is a retrospective cohort study using 2002-2003 information from the Uniform Data System for Medical Rehabilitation. Patients were 65 yrs or older admitted to inpatient rehabilitation with a primary diagnosis of debility (n = 14,835) and nondebility generalized weakness (n = 6,403). Primary outcome measures were change in functional status, including efficiency (functional status change divided by length of stay in days), and discharge setting.The efficiency of the patients with nondebility generalized weakness (1.8 ± 1.9) was statistically greater than that of patients with debility (1.7 ± 2.1, P = 0.002), and significantly more patients with nondebility generalized weakness were discharged home (70% vs. 68%, P = 0.003).From a clinical standpoint, the functional recovery and rate of discharge to home of inpatient rehabilitation patients with nondebility generalized weakness are nearly identical to those of patients with debility. Although it would require a policy change, we recommend using a single diagnostic code for all of these patients to further research in this area of rehabilitation.