Keshab Subedi, MS, MSc

Biostatistician

Publications

Alcohol Withdrawal Rates in Hospitalized Patients During the COVID-19 Pandemic
Alcohol Withdrawal Rates in Hospitalized Patients During the COVID-19 Pandemic
Sharma RA, Subedi K, Gbadebo BM, Wilson B, Jurkovitz C, Horton T

JAMA Netw Open 2021 03;4(3):e210422

PMID: 33656526

Abstract

No abstract available.
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Association of Early-Life Social and Digital Media Experiences With Development of Autism Spectrum Disorder-Like Symptoms
Association of Early-Life Social and Digital Media Experiences With Development of Autism Spectrum Disorder-Like Symptoms
Heffler KF, Sienko DM, Subedi K, McCann KA, Bennett DS

JAMA Pediatr 2020 07;174(7):690-696

PMID: 32310265

Abstract

Importance">Despite growing evidence that parent-child interactions and time viewing digital media affect child development, these factors have rarely been studied in association with autism spectrum disorder (ASD) symptoms.</Abstr: Despite growing evidence that parent-child interactions and time viewing digital media affect child development, these factors have rarely been studied in association with autism spectrum disorder (ASD) symptoms.

Objective">To determine the association of experiential factors, including social activities and screen viewing in the first 18 months of life, perinatal factors, and demographic factors, with ASD-like symptoms and risk on the Modified Checklist for Autism in Toddlers (M-CHAT) at 2 years.</Abstr: To determine the association of experiential factors, including social activities and screen viewing in the first 18 months of life, perinatal factors, and demographic factors, with ASD-like symptoms and risk on the Modified Checklist for Autism in Toddlers (M-CHAT) at 2 years.

Design, Setting, and Participants">Data for this cohort study were derived from the National Children's Study, a US multicenter epidemiological study of environmental influences on child health and development. A total of 2152 children were enrolled at birth from October 1, 2010, to October 31, 2012. Data were analyzed from December 1, 2017, to December 3, 2019.</Abstr: Data for this cohort study were derived from the National Children's Study, a US multicenter epidemiological study of environmental influences on child health and development. A total of 2152 children were enrolled at birth from October 1, 2010, to October 31, 2012. Data were analyzed from December 1, 2017, to December 3, 2019.

Exposures">Caregivers reported whether the child viewed television and/or videos (yes or no) at 12 months of age, hours of viewing at 18 months of age, time spent by the caregiver reading to the child (number of days per week compared with daily) at 12 months of age, and frequency of playing with the child (daily or less than daily) at 12 months of age. Prematurity, maternal age at birth, child sex, household income, race/ethnicity, and caregiver English-language status were included in analysis.</Abstr: Caregivers reported whether the child viewed television and/or videos (yes or no) at 12 months of age, hours of viewing at 18 months of age, time spent by the caregiver reading to the child (number of days per week compared with daily) at 12 months of age, and frequency of playing with the child (daily or less than daily) at 12 months of age. Prematurity, maternal age at birth, child sex, household income, race/ethnicity, and caregiver English-language status were included in analysis.

Main Outcomes and Measures">Significant association of exposures with ASD risk by M-CHAT and/or ASD-like symptoms assessed by revised M-CHAT (M-CHAT-R) total score in multiple regression models.</Abstr: Significant association of exposures with ASD risk by M-CHAT and/or ASD-like symptoms assessed by revised M-CHAT (M-CHAT-R) total score in multiple regression models.

Results">Among the 2152 children included in the analysis (1099 boys [51.1%]), television and/or video viewing (yes or no) at 12 months of age was significantly associated with greater ASD-like symptoms at 2 years of age (change, 4.2%; 95% CI, 0.1%-8.3%) but not with ASD risk (risk prevalence rates, 8.3% vs 4.4%; adjusted odds ratio [AOR], 1.40; 95% CI, 0.86-2.29). Similarly, parent-child play daily compared with less than daily was significantly associated with fewer ASD-like symptoms at 2 years of age (change, -8.9%; 95% CI, -16.5% to -0.9%) but not with ASD risk (risk prevalence rates, 6.4% vs 14.0%; AOR, 0.58; 95% CI, 0.31-1.08). However, high screen viewing at 18 months of age was not significantly associated with ASD-like symptoms (change, 10.7%; 95% CI, -2.0% to 23.0%) or ASD risk by M-CHAT (AOR, 1.18; 95% CI, 0.56-2.49) at 2 years of age.</Abstr: Among the 2152 children included in the analysis (1099 boys [51.1%]), television and/or video viewing (yes or no) at 12 months of age was significantly associated with greater ASD-like symptoms at 2 years of age (change, 4.2%; 95% CI, 0.1%-8.3%) but not with ASD risk (risk prevalence rates, 8.3% vs 4.4%; adjusted odds ratio [AOR], 1.40; 95% CI, 0.86-2.29). Similarly, parent-child play daily compared with less than daily was significantly associated with fewer ASD-like symptoms at 2 years of age (change, -8.9%; 95% CI, -16.5% to -0.9%) but not with ASD risk (risk prevalence rates, 6.4% vs 14.0%; AOR, 0.58; 95% CI, 0.31-1.08). However, high screen viewing at 18 months of age was not significantly associated with ASD-like symptoms (change, 10.7%; 95% CI, -2.0% to 23.0%) or ASD risk by M-CHAT (AOR, 1.18; 95% CI, 0.56-2.49) at 2 years of age.

Conclusions and Relevance">This cohort study found greater screen exposure and less caregiver-child play early in life to be associated with later ASD-like symptoms. Further research is needed to evaluate experiential factors for potential risk or protective effects in ASD.</Abstr: This cohort study found greater screen exposure and less caregiver-child play early in life to be associated with later ASD-like symptoms. Further research is needed to evaluate experiential factors for potential risk or protective effects in ASD.

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Nephrology Fellows' and Program Directors' Perceptions of Hospital Rounds in the United States
Nephrology Fellows' and Program Directors' Perceptions of Hospital Rounds in the United States
Boyle SM, Subedi K, Pivert KA, Harhay MN, Baynes-Fields J, Goldman J, Warburton KM

Clin J Am Soc Nephrol 2020 04;15(4):474-483

PMID: 32184295

Abstract

BACKGROUND AND OBJECTIVES">Hospital rounds are a traditional vehicle for patient-care delivery and experiential learning for trainees. We aimed to characterize practices and perceptions of rounds in United States nephrology training programs.</Abstr: Hospital rounds are a traditional vehicle for patient-care delivery and experiential learning for trainees. We aimed to characterize practices and perceptions of rounds in United States nephrology training programs.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS">We conducted a national survey of United States nephrology fellows and program directors. Fellows received the survey after completing the 2019 National Board of Medical Examiners Nephrology In-Training Exam. Program directors received the survey at the American Society of Nephrology's 2019 Nephrology Training Program Directors' Retreat. Surveys assessed the structure and perceptions of rounds, focusing on workload, workflow, value for patient care, and fellows' clinical skill-building. Directors were queried about their expectations for fellow prerounds and efficiency of rounds. Responses were quantified by proportions.</Abstr: We conducted a national survey of United States nephrology fellows and program directors. Fellows received the survey after completing the 2019 National Board of Medical Examiners Nephrology In-Training Exam. Program directors received the survey at the American Society of Nephrology's 2019 Nephrology Training Program Directors' Retreat. Surveys assessed the structure and perceptions of rounds, focusing on workload, workflow, value for patient care, and fellows' clinical skill-building. Directors were queried about their expectations for fellow prerounds and efficiency of rounds. Responses were quantified by proportions.

RESULTS">Fellow and program director response rates were 73% (n=621) and 70% (n=55). Most fellows (74%) report a patient census of >15, arrive at the hospital before 7:00 am (59%), and complete progress notes after 5:00 pm (46%). Among several rounding activities, fellows most valued bedside discussions for building their clinical skills (34%), but only 30% examine all patients with the attending at the bedside. Most directors (71%) expect fellows to both examine patients and collect data before attending-rounds. A majority (78%) of directors commonly complete their documentation after 5:00 pm, and for 36%, after 8:00 pm. Like fellows, directors most value bedside discussion for development of fellows' clinical skills (44%). Lack of preparedness for the rigors of nephrology fellowship was the most-cited barrier to efficient rounds (31%).</Abstr: Fellow and program director response rates were 73% (=621) and 70% (=55). Most fellows (74%) report a patient census of >15, arrive at the hospital before 7:00 am (59%), and complete progress notes after 5:00 pm (46%). Among several rounding activities, fellows most valued bedside discussions for building their clinical skills (34%), but only 30% examine all patients with the attending at the bedside. Most directors (71%) expect fellows to both examine patients and collect data before attending-rounds. A majority (78%) of directors commonly complete their documentation after 5:00 pm, and for 36%, after 8:00 pm. Like fellows, directors most value bedside discussion for development of fellows' clinical skills (44%). Lack of preparedness for the rigors of nephrology fellowship was the most-cited barrier to efficient rounds (31%).

CONCLUSIONS">Hospital rounds in United States nephrology training programs are characterized by high patient volumes, early-morning starts, and late-evening clinical documentation. Fellows use a variety of prerounding styles and examine patients at the beside with their attendings at different frequencies.</Abstr: Hospital rounds in United States nephrology training programs are characterized by high patient volumes, early-morning starts, and late-evening clinical documentation. Fellows use a variety of prerounding styles and examine patients at the beside with their attendings at different frequencies.

PODCAST">This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2020_03_17_CJN.10190819.mp3.Copyright © 2020 by the American Society of Nephrology.</CopyrightInfo: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2020_03_17_CJN.10190819.mp3.

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Alcohol Withdrawal Rates in Hospitalized Patients During the COVID-19 Pandemic
Alcohol Withdrawal Rates in Hospitalized Patients During the COVID-19 Pandemic
Sharma RA, Subedi K, Gbadebo BM, Wilson B, Jurkovitz C, Horton T

JAMA Netw Open 2021 03;4(3):e210422

PMID: 33656526

Abstract

No abstract available.
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Utilization of an ICU Severity of Illness Scoring System to Triage Patients With ST-Elevation Myocardial Infarction
Utilization of an ICU Severity of Illness Scoring System to Triage Patients With ST-Elevation Myocardial Infarction
Norton JM, Reddy PK, Subedi K, Fabrizio CA, Wimmer NJ, Urrutia LE

J Intensive Care Med 2021 Aug;36(8):857-861

PMID: 32519573

Abstract

OBJECTIVE: To subjectively identify low-risk ST-elevation myocardial infarction (STEMI) patients and triage this low-risk population to an intermediate level of care.

BACKGROUND: Many patients with STEMI are admitted to the intensive care unit (ICU), however, a large portion do not merit ICU admission. We sought to examine whether, among post-STEMI patients admitted to the ICU, if an easily obtainable subjective scoring system could predict low-risk patients and safely triage them to an intermediate level of care.

METHODS: Retrospective observational study at Christiana Hospital, a 900-bed regional referral center. Data were defined by the ACTION Registry and CathPCI Registry. Acute Physiology and Chronic Health Evaluation (APACHE) predictions were retrieved for all patients with STEMI and were analyzed for complications, length of stay, and inhospital mortality. We then examined subjective criteria to triage patients with STEMI out of the ICU.

RESULTS: Among 253 patients with STEMI, 179 (70.75%) were classified as low risk (intermediate level care appropriate) and 74 (29.25%) were classified as high risk (ICU appropriate). The mean age was 64.95 years. The APACHE III score was right skewed with a mean of 36.97 and a median of 31. There was a significant difference between the APACHE III score of low-risk patients and the APACHE III score of high-risk patients (P < .001).

CONCLUSION: In conclusion, patients characterized as low risk, as defined by our criteria, had low APACHE III scores and a low likelihood of complications post-STEMI. This low-risk population could potentially be admitted to an intermediate level of care, avoiding the ICU altogether.

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Analysis of Factors Associated With Length of Stay of Opioid-Related Emergency Department Visits
Analysis of Factors Associated With Length of Stay of Opioid-Related Emergency Department Visits
Subedi K

Cureus 2021 Jul;13(7):e16213

PMID: 34367814

Abstract

INTRODUCTION AND OBJECTIVE: Emergency department (ED) length of stay (LOS) is an important indicator of the quality of care in ED and is associated with patients' outcomes and healthcare costs. However, there is limited data on how the patient characteristics affect the ED LOS of opioid-related visits. This study aims to identify and quantify the effect of patient-related characteristics on LOS of opioid-related ED visits.

METHODS: This is a retrospective analysis of electronic health records (EHR) of patients with diagnoses of opioid abuse. The study included patients with a diagnosis of opioid abuse who visited the ED at Christiana Care Hospital from January 1, 2017, to December 31, 2018 (N=5,661). The opioid-related visits were identified using ICD-10 diagnosis codes. We used accelerated failure time (AFT) models, a time-to-event analysis approach to evaluate the relationships of different patient characteristics with ED LOS.

RESULTS: The mean age of the study population was 39 years. The study population had 40% female, 20% Black/African American, and 5% Hispanic or Latino. The prevalence of co-use of cocaine and co-use of alcohol was 11%, and 9%, respectively. Also, 58% had mental health comorbidity, and 1% were homeless. The distribution of ED LOS was right-skewed with a median of 4.3 (IQR: 2.6, 6.8). Co-use of alcohol (time ratio, TR: 1.31, CI: 1.23-1.40), co-use of cocaine (TR: 1.18, CI: 1.11-1.25), the presence of mental health comorbidity (TR: 1.05, CI 1.01-1.09), and homelessness (TR: 1.57, CI: 1.32-1.86) were associated with increased ED LOS.

CONCLUSIONS: Co-use of alcohol, co-use of cocaine, homelessness, and mental health comorbidity are associated with the longer LOS of opioid-related ED visits.

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Outcomes associated with antibiotic administration for isolated maternal fever in labor
Outcomes associated with antibiotic administration for isolated maternal fever in labor
Bank TC, Nuss E, Subedi K, Hoffman MK, Sciscione A

Am J Obstet Gynecol 2021 Aug;():

PMID: 34363779

Abstract

BACKGROUND: The American College of Obstetricians and Gynecologists currently recommends that antibiotic treatment should be considered for women with isolated maternal fevers during labor. However, there is little known about the maternal and neonatal impact of antibiotic treatment in this scenario.

OBJECTIVE: We sought to assess the outcomes in women with a nonsustained, isolated maternal fever treated with antibiotics and compare it with expectant management.

STUDY DESIGN: This was a retrospective cohort study of laboring women with a singleton gestation at term and a single temperature of between 38.0°C and 38.9°C without other evidence of infection (leukocytosis >15,000/mm, fetal tachycardia, malodorous amniotic fluid, suspected alternate source of infection) at a tertiary teaching hospital. A contemporaneously maintained, validated obstetrical database was used to identify women for our cohort. Women with rheumatologic or renal disease, nongestational diabetes, preterm labor, placental abruption, vaginal bleeding, HIV, malpresentation, and fetal anomalies were excluded. The primary outcome was a postpartum fever above 38.0°C. Secondary maternal outcomes were treatment for postpartum endometritis, uterine atony, postpartum hemorrhage, admission to the intensive care unit, and postpartum length of stay. Secondary neonatal outcomes were neonatal intensive care unit admission, 5-minute Apgar score of <7, 5-minute Apgar score of <4, neonatal intensive care unit length of stay, and neonatal antibiotic administration. The results were compared using univariable and multivariable analyses.

RESULTS: From January 1, 2015, to December 31, 2018, 359 women were identified; 85 received antibiotics and 274 did not. The baseline characteristics were similar between the groups, except for gestational age at the time of delivery (39.2 weeks vs 39.5 weeks for the antibiotic and no antibiotic groups, respectively; P=.02). The incidence in postpartum fever showed a downward trend in the antibiotic group (10.59% for the antibiotic group vs 18.98% for the no antibiotic group; P=.07). Significantly fewer women in the antibiotic group were treated for postpartum endometritis (3.53% vs 11.31%; P=.03). Neonatal intensive care unit admission and neonatal antibiotic administration rates were higher in the antibiotic group (41.18% vs 17.88%; P<.001 and 36.47% vs 12.41%; P<.001, respectively). The incidence of 5-minute Apgar score of <7 was higher in the antibiotic group (8.25% vs 2.19%; P=.016). After controlling for age, gestational age, body mass index, group B streptococci status, delivery method, parity, administration of epidural, and receipt of acetaminophen, the odds for postpartum fever were reduced by a factor of 0.42 (95% confidence interval, 0.18-0.99) among women who received antibiotics when compared with those who did not receive antibiotics. Outcome results are presented in Table 2.

CONCLUSION: Although there was a lower rate of treatment for endometritis among women who received antibiotics for a single isolated maternal fever, there was a higher rate of neonatal intensive care unit admissions and 5-minute Apgar score of <7. This indicates that there likely is maternal benefit associated with antibiotic use, however, there are concerns about the neonatal risk.

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An examination of cardiovascular intensive care unit mortality based on admission day and time
An examination of cardiovascular intensive care unit mortality based on admission day and time
Langston MC, Subedi K, Fabrizio C, Wimmer NJ, Choudhry UI, Urrutia LE

Heart Lung ;50(5):579-586

PMID: 34077826

Abstract

BACKGROUND">Recent interest in the 'weekend effect' has been expanded to cardiovascular intensive care units, yet the impact of off-hours admission on mortality and cardiovascular ICU (CICU) length of stay remains uncertain.</Abstr: Recent interest in the 'weekend effect' has been expanded to cardiovascular intensive care units, yet the impact of off-hours admission on mortality and cardiovascular ICU (CICU) length of stay remains uncertain.

OBJECTIVES">We examine the association between CICU admission day and time with mortality. Additionally, length-of-stay was also evaluated in relation to admission time.</Abstr: We examine the association between CICU admission day and time with mortality. Additionally, length-of-stay was also evaluated in relation to admission time.

METHODS">A single-center, retrospective cohort study was conducted including 10,638 adult patients admitted to a CICU in a tertiary-care academic medical center from July 1, 2012 to June 30, 2019. ICU mortality and length-of-stay were assessed by admission day and time adjusting for comorbid conditions and other clinical variables. We used logistic regression models to evaluate the factors associated with mortality and a generalized linear model (GLM) with log link function and gamma distribution was used to evaluate the factors associated with ICU length of stay.</Abstr: A single-center, retrospective cohort study was conducted including 10,638 adult patients admitted to a CICU in a tertiary-care academic medical center from July 1, 2012 to June 30, 2019. ICU mortality and length-of-stay were assessed by admission day and time adjusting for comorbid conditions and other clinical variables. We used logistic regression models to evaluate the factors associated with mortality and a generalized linear model (GLM) with log link function and gamma distribution was used to evaluate the factors associated with ICU length of stay.

RESULTS">Compared to weekday-day admissions, we observed an increased mortality for weekend-day for all admissions (6.5 vs 9.6%, Adjusted OR: 1.32 (1.03-1.72)), and for medical CICU admissions (7.6 vs 9.9%, Adjusted OR: 1.35 (1.02-1.79)). Additionally, compared to weekday-day, weekday-night admission was associated with 7% longer ICU length of stay in surgical ICU patients, 7% shorter length of stay in medical ICU patients.</Abstr: Compared to weekday-day admissions, we observed an increased mortality for weekend-day for all admissions (6.5 vs 9.6%, Adjusted OR: 1.32 (1.03-1.72)), and for medical CICU admissions (7.6 vs 9.9%, Adjusted OR: 1.35 (1.02-1.79)). Additionally, compared to weekday-day, weekday-night admission was associated with 7% longer ICU length of stay in surgical ICU patients, 7% shorter length of stay in medical ICU patients.

CONCLUSION">Admission to this open-model CICU during weekend hours (Saturday 08:00-Sunday 17:59) versus nights or weekdays is associated with increased mortality. ICU staffing care models should not significantly change based on the day of the week.Copyright © 2021 Elsevier Inc. All rights reserved.</CopyrightInfo: Admission to this open-model CICU during weekend hours (Saturday 08:00-Sunday 17:59) versus nights or weekdays is associated with increased mortality. ICU staffing care models should not significantly change based on the day of the week.

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Outcomes With Early Cardiac Catheterization in Out of Hospital Cardiac Arrest Survivors and Utility of a Prognostic Scoring System
Outcomes With Early Cardiac Catheterization in Out of Hospital Cardiac Arrest Survivors and Utility of a Prognostic Scoring System
Vedamurthy D, Singh S, Subedi K, Garratt KN, Wimmer NJ

Cureus 2021 Jul;13(7):e16775

PMID: 34345571

Abstract

Objectives A retrospective study in patients presenting out of hospital cardiac arrest (OHCA) to assess the impact of early cardiac catheterization on survival and cerebral performance category (CPC) on discharge. Background The role of early coronary angiography in OHCA patients remains controversial. The cardiac arrest hospital prognosis (CAHP) scoring system has not been validated in the US population. Methods Inclusion criteria were OHCA patients with a sustained return of spontaneous circulation (ROSC), presumed cardiac cause of arrest, and elements to calculate CAHP score. We compared in-hospital mortality rates and final inpatient CPC in patients who underwent early cardiac catheterization to those with delayed or no cardiac catheterization. We assessed the performance of the CAHP score in the entire OHCA population using receiver-operator curve (ROC) analysis. Results A hundred and fifty-eight patients were included, of which 39 underwent early cardiac catheterization. The mortality rate of the early catheterization group was lower than the delayed or no catheterization group (41% vs 61.3%, p=0.02); the Early cardiac catheterization group had more favorable final hospital CPC scores overall (53.8% vs 24.3%, p<0.001). However, when risk-adjusted, there was no benefit in early catheterization for mortality or CPC level in any of the CAHP score subgroups. CAHP scores showed good discrimination with c-statistics of 0.85 for mortality and 0.90 for the CPC category. Conclusion Early use of cardiac catheterization in OHCA patients with sustained ROSC was not associated with lower mortality rates or higher rates of favorable neurologic recovery when adjusted for baseline risk factors in each of the different CAHP score-based sub-groups. This was despite a higher proportion of patients with STEMI in the early catheterization group. We demonstrated a good fit between observed outcomes and outcomes predicted by the CAHP scoring system.
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Adjustment of high flow nasal cannula rates using real-time work of breathing indices in premature infants with respiratory insufficiency
Adjustment of high flow nasal cannula rates using real-time work of breathing indices in premature infants with respiratory insufficiency
Kovatis KZ, Locke RG, Mackley AB, Subedi K, Shaffer TH

J Perinatol 2021 07;41(7):1711-1717

PMID: 33664469

Abstract

OBJECTIVE">To assess the feasibility of real-time monitoring of work of breathing (WOB) indices and the impact of adjusting HFNC flow on breathing synchrony and oxygen stability in premature infants.</Abstr: To assess the feasibility of real-time monitoring of work of breathing (WOB) indices and the impact of adjusting HFNC flow on breathing synchrony and oxygen stability in premature infants.

STUDY DESIGN">A prospective, observational study of infants stable on HFNC. The flow adjusted per predetermined algorithm. Respiratory inductive plethysmography (RIP) noninvasively measured WOB. A high-resolution pulse oximeter collected oxygen saturation and heart rate data. Summary statistics and mixed linear models were used.</Abstr: A prospective, observational study of infants stable on HFNC. The flow adjusted per predetermined algorithm. Respiratory inductive plethysmography (RIP) noninvasively measured WOB. A high-resolution pulse oximeter collected oxygen saturation and heart rate data. Summary statistics and mixed linear models were used.

RESULTS">Baseline data for 32 infants, final analysis of 21 infants. Eighty-one percent with abnormal WOB. Sixty-two percent demonstrated 20% improvement in WOB. For infants with gestational age <28 weeks, an incremental increase in HFNC flow rate decreased WOB (p < 0.001) and improved oxygen saturation and stability (p < 0.01).</Abstr: Baseline data for 32 infants, final analysis of 21 infants. Eighty-one percent with abnormal WOB. Sixty-two percent demonstrated 20% improvement in WOB. For infants with gestational age <28 weeks, an incremental increase in HFNC flow rate decreased WOB (p < 0.001) and improved oxygen saturation and stability (p < 0.01).

CONCLUSIONS">Premature infants do not receive optimal support on HFNC. The use of a real-time feedback system to adjust HFNC is feasible and improves WOB, oxygen saturation, and oxygen stability. This technology may improve the utility of HFNC in premature infants.© 2021. The Author(s), under exclusive licence to Springer Nature America, Inc. part of Springer Nature.</CopyrightInfo: Premature infants do not receive optimal support on HFNC. The use of a real-time feedback system to adjust HFNC is feasible and improves WOB, oxygen saturation, and oxygen stability. This technology may improve the utility of HFNC in premature infants.

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