145. SARS-CoV-2 (COVID-19) Testing Experience within a Military Treatment Facility

Abstract Background The Walter Reed National Military Medical Center (WRNMMC) established a consolidated COVID-19 screening area (CSA) beginning in March 2020 to provide beneficiary and staff testing via a drive-through site. Testing was available to all patients and WRNMMC staff regardless of beneficiary status. Presented is a descriptive analysis of our testing operations and positivity rates within a closed medical system from March 2020 to April 2021. Methods For quality and process improvement, we compiled daily testing logs from March 2020 to April 2021 from the CSA. These logs included patient demographics, reason for testing, test result, testing platform, and occupational status at the hospital. We determined positivity rates in various subgroups – asymptomatic, symptomatic, pre-operative, in order to track testing use and access. Additionally, we compared the overall positivity rate to the surrounding civilian community by pulling data from the Maryland Department of Health’s COVID database. Results Over the course of nearly 14 months of testing availability, 34,694 beneficiaries were screened with 41,582 individual tests. After May 2020, the monthly overall positivity rate varied from 1.99% to 11.92%, peaking in December 2020 (with high rates in November 2020, 7.52% and January 2021, 9.53%), correlating with or exceeding elevated positivity rates in Montgomery County (November 2020: 4.91%; December 2020: 6.48%; January 2021: 6.51%). When examining only symptomatic individuals, the positivity rate is notably much higher, with monthly rates varying from 6.40% to 21.10%, with a similar peak in December 2020. After full implementation of pre-operative screening for procedures with aerosolization potential in June 2020, the range of positivity rates was 0.28%-1.66%. Since vaccination for COVID-19 became widely available beginning in Feb 2021, the preoperative positivity rate has remained below 0.85%. Conclusion Our institutional experience is unique in its ability to offer universal access to COVID-19 testing for beneficiaries and staff of the DoD under direction of the ID service. Our process serves as a model for public and occupational health response, and may guide lab resource and real-time staffing management in support of COVID-19 diagnostics at a medical center. Disclosures All Authors: No reported disclosures

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Trends in Surgical Case Volume During Pacific Partnership Missions Onboard USNS Mercy

Military Medicine ◽

10.1093/milmed/usab500 ◽

2021 ◽

Author(s):

Alicia G Sykes ◽

Jason B Brill ◽

James D Wallace ◽

Clara Lee ◽

Paul R Lewis ◽

...

Keyword(s):

General Surgery ◽

Medical Center ◽

Case Volume ◽

Surgical Specialty ◽

Average Case ◽

Patient Demographics ◽

Surgical Case ◽

Institutional Review ◽

Included Patient ◽

The U.S

ABSTRACT Introduction Since 2006, the U.S. Navy has conducted six Pacific Partnership (PP) missions throughout Southeast Asia on board the U.S. Naval Ship Mercy (T-AH 19). This study describes trends in overall and surgical specialty operative volumes to better understand the burden of surgical disease treated during these humanitarian and civic assistance (HCA) operations. This information can assist medical planners and surgical leaders involved in future humanitarian missions. Materials and Methods Following approval from the Naval Medical Center San Diego Institutional Review Board, a retrospective review of surgical case data was performed for the six PP missions from 2006 to 2018. Data collected included patient demographics, Current Procedural Terminology codes, and surgical specialty. The primary outcome was surgical case volume per specialty. Secondary outcomes included surgical staffing per mission and overall trends in operative volume. Results A total of 3,826 operative procedures were performed during the study period. Mission years in which case volume for both general surgery and ophthalmology were below their respective medians were associated with the least total surgical services to host nations (HNs). The number of active duty Navy surgeons varied with each mission; however, the staffing for a PP mission generally included at least two general surgeons, one ophthalmologist, one plastic surgeon, one pediatric surgeon, one orthopedic surgeon, one otolaryngologist, one oral surgeon, one urologist, and one obstetrician–gynecologist. Case volume per surgeon was highest in 2006 (50 cases per surgeon) and decreased after 2006, reaching an all-time low during the 2018 PP mission (10 cases per surgeon). Pediatric surgery and plastic surgery had the highest average case volumes per surgeon at 58 and 46 cases per surgeon, respectively, while oromaxillofacial surgery and neurosurgery had the lowest average case volumes per surgeon at 9 and 14 cases per surgeon, respectively. Conclusions Operative volume on military HCA missions is greatly influenced by the priorities of the HN, the mission focus, the number of individuals from the HN that present for screening, and the availability of personnel and resources available on the hospital ship. Future mission planning should optimize general surgery and ophthalmology staffing and essential equipment, as total mission case volumes were highly dependent upon the productivity of these two specialties. Careful determination of the surgical needs of HNs should serve as a guide for the selection of subspecialists to maximize effectiveness in future military HCA missions.

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195. Antimicrobial Stewardship Incorporating New Antimicrobials for Use against Multi-Drug Resistant Pseudomonas aeruginosa in Cystic Fibrosis

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.239 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S102-S102

Author(s):

Jinhee Jo ◽

Anne J Gonzales-Luna ◽

Kevin W Garey

Keyword(s):

Cystic Fibrosis ◽

Pseudomonas Aeruginosa ◽

Clinical Outcomes ◽

Antimicrobial Stewardship ◽

Medical Center ◽

Descriptive Analysis ◽

The United States ◽

Forced Expiratory Volume ◽

Exacerbation Rate ◽

Patient Demographics

Abstract Background Cystic fibrosis (CF) is a life-limiting genetic disease affecting approximately 80,000 people worldwide, including 30,000 in the United States. Chronic Pseudomonas aeruginosa (PA) infections in CF often develop to be multidrug-resistant (MDR) and are associated with worse clinical outcomes. Ceftolozane/Tazobactam (C/T) has shown benefits over other standards of therapy in selected populations with MDR-PA infections, but studies are lacking in the CF population. The objective of this study was to evaluate the current use and antimicrobial stewardship of C/T in CF patients with MDR-PA. Methods This is a retrospective study of hospitalized CF patients with infections due to positive cultures for MDR-PA from 2016–2019 at Baylor St. Luke’s Medical Center in Houston, Texas. Electronic medical records were reviewed for patient demographics, presence of infectious diseases (ID) consult, antibiotics use, and clinical outcomes. A descriptive analysis was performed to compare the patient demographics and clinical outcomes between patients receiving C/T-based and non-C/T therapies. Results A total of 56 CF patients with positive MDR-PA cultures were identified (18 receiving C/T and 38 receiving non-C/T antibiotics). Most MDR-PA was cultured from the lungs (94.6%, 54/56). Patient age, weight, and body mass index were similar between those receiving C/T and non-C/T therapies as was the overall duration of antibiotic therapy 16.3 (± 8.7) vs. 13.9 (± 3.5) days in C/T and non-C/T groups, respectively. More patients in the C/T group had severe forced expiratory volume in 1 s (FEV1) [£40%] at baseline (66.7% vs. 21.1%) and higher ICU admission rates (44.4% vs 2.6%). All C/T patients had an ID consult placed (3 ± 3.1 days after admission) but none in the non-C/T group. The 30-day recurrent pulmonary exacerbation rate was comparable between C/T and non-C/T groups (22.2% vs. 15.8%). Conclusion C/T was reserved for the sickest group of CF patients with severe FEV1. Given the devastating disease progression with MDR organisms in CF, new antibiotics with better clinical outcomes against chronic MDR-PA should be considered earlier in therapy for this population. Larger studies are warranted to analyze cost-effectiveness and clinical outcomes. Disclosures Kevin W. Garey, PharMD, MS, FASHP, Merck & Co. (Grant/Research Support, Scientific Research Study Investigator)

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Skilled Migrants in the Swedish Labour Market: An Analysis of Employment, Income and Occupational Status

Sustainability ◽

10.3390/su13063428 ◽

2021 ◽

Vol 13 (6) ◽

pp. 3428

Author(s):

Nahikari Irastorza ◽

Pieter Bevelander

Keyword(s):

Labour Market ◽

Descriptive Analysis ◽

Occupational Status ◽

Division Of Labour ◽

Skilled Immigrants ◽

Highly Educated ◽

Highly Skilled Migrants ◽

Highly Skilled ◽

Integration Of Immigrants ◽

Employment Rates

In a globalised world with an increasing division of labour, the competition for highly skilled individuals—regardless of their origin—is growing, as is the value of such individuals for national economies. Yet the majority of studies analysing the economic integration of immigrants shows that those who are highly skilled also have substantial hurdles to overcome: their employment rates and salaries are lower and they face a higher education-to-occupation mismatch compared to highly skilled natives. This paper contributes to the paucity of studies on the employment patterns of highly skilled immigrants to Sweden by providing an overview of the socio-demographic characteristics, labour-market participation and occupational mobility of highly educated migrants in Sweden. Based on a statistical analysis of register data, we compare their employment rates, salaries and occupational skill level and mobility to those of immigrants with lower education and with natives. The descriptive analysis of the data shows that, while highly skilled immigrants perform better than those with a lower educational level, they never catch up with their native counterparts. Our regression analyses confirm these patterns for highly skilled migrants. Furthermore, we find that reasons for migration matter for highly skilled migrants’ employment outcomes, with labour migrants having better employment rates, income and qualification-matched employment than family reunion migrants and refugees.

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Value of Three-Dimensional Digital Subtraction Angiography for Detection and Classification of Intracranial Aneurysm Remnants After Clipping

Operative Neurosurgery ◽

10.1093/ons/opab087 ◽

2021 ◽

Author(s):

Serge Marbacher ◽

Matthias Halter ◽

Deborah R Vogt ◽

Jenny C Kienzler ◽

Christian T J Magyar ◽

...

Keyword(s):

Intracranial Aneurysm ◽

Digital Subtraction Angiography ◽

Diagnostic Yield ◽

Three Dimensional ◽

P Value ◽

Digital Subtraction ◽

Patient Demographics ◽

Included Patient ◽

2D And 3D

Abstract BACKGROUND The current gold standard for evaluation of the surgical result after intracranial aneurysm (IA) clipping is two-dimensional (2D) digital subtraction angiography (DSA). While there is growing evidence that postoperative 3D-DSA is superior to 2D-DSA, there is a lack of data on intraoperative comparison. OBJECTIVE To compare the diagnostic yield of detection of IA remnants in intra- and postoperative 3D-DSA, categorize the remnants based on 3D-DSA findings, and examine associations between missed 2D-DSA remnants and IA characteristics. METHODS We evaluated 232 clipped IAs that were examined with intraoperative or postoperative 3D-DSA. Variables analyzed included patient demographics, IA and remnant distinguishing characteristics, and 2D- and 3D-DSA findings. Maximal IA remnant size detected by 3D-DSA was measured using a 3-point scale of 2-mm increments. RESULTS Although 3D-DSA detected all clipped IA remnants, 2D-DSA missed 30.4% (7 of 23) and 38.9% (14 of 36) clipped IA remnants in intraoperative and postoperative imaging, respectively (95% CI: 30 [ 12, 49] %; P-value .023 and 39 [23, 55] %; P-value = <.001), and more often missed grade 1 (< 2 mm) clipped remnants (odds ratio [95% CI]: 4.3 [1.6, 12.7], P-value .005). CONCLUSION Compared with 2D-DSA, 3D-DSA achieves a better diagnostic yield in the evaluation of clipped IA. Our proposed method to grade 3D-DSA remnants proved to be simple and practical. Especially small IA remnants have a high risk to be missed in 2D-DSA. We advocate routine use of either intraoperative or postoperative 3D-DSA as a baseline for lifelong follow-up of clipped IA.

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Epidemiology of Clavicle Fractures Sustained at a Colorado Ski Resort

Orthopaedic Journal of Sports Medicine ◽

10.1177/23259671211006722 ◽

2021 ◽

Vol 9 (5) ◽

pp. 232596712110067

Author(s):

Lauren Oberle ◽

Lauren Pierpoint ◽

Jack Spittler ◽

Morteza Khodaee

Keyword(s):

Medical Center ◽

Descriptive Analysis ◽

Clavicle Fracture ◽

Sports Injury ◽

Common Mechanism ◽

Ski Resort ◽

Incidence Data ◽

Injury Mechanisms ◽

Fracture Diagnosis ◽

Clavicle Fractures

Background: Although clavicle fractures are a common sports injury, there are limited studies on the incidence and causes of clavicle fractures among winter sports athletes. Purpose: To evaluate the characteristics and injury mechanisms associated with clavicle fractures among patients evaluated at a Colorado ski resort. Study Design: Descriptive epidemiology study. Methods: This was a retrospective descriptive analysis of patients with clavicle fractures at the Denver Health Winter Park Medical Center during the 2012-2013 to 2016-2017 ski seasons. Chart review was performed on the patient cohort to confirm clavicle fracture diagnosis and to evaluate factors associated with clavicle fracture. Results: A total of 393 clavicle fractures (6.2% of total clinic visits) occurred during the study period, corresponding to an overall clavicle fracture incidence of 8.4 per 100,000 participant-visits. The mean patient age was 26.4 years (range, 5-73 years). The majority were middle-third fractures (85.5%), occurring mainly in men (87.3%). More than half of the fractures were comminuted (54.5%) and occurred in snowboarders (55.0%). The most common mechanism of injury was a fall onto snow while skiing or snowboarding (92.4%). Women sustained more clavicle fractures while skiing compared with snowboarding (82.0% vs 18.0%; P < .001), while men sustained more fractures while snowboarding compared with skiing (60.3% vs 39.7%; P < .001). Conclusion: Clavicle fractures are relatively common, but there are scant incidence data for clavicle fractures in mountain sports. Consistent with prior studies, clavicle fractures were more common in younger patients and men. The most common anatomic fracture location was the midclavicle. A greater proportion of clavicle fractures among men were sustained during snowboarding and among women during skiing.

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Epidural analgesia in a paediatric teaching hospital: Trends, developments, and a brief review of literature

Proceedings of Singapore Healthcare ◽

10.1177/2010105817733997 ◽

2017 ◽

Vol 27 (1) ◽

pp. 49-54 ◽

Cited By ~ 3

Author(s):

Jolin Wong ◽

Serene Siu Tin Lim

Keyword(s):

Epidural Analgesia ◽

Teaching Hospital ◽

Perioperative Period ◽

Review Of Literature ◽

Good Tool ◽

Patient Demographics ◽

Included Patient ◽

Continuous Epidural Analgesia ◽

Continued Use

Introduction: Continuous epidural analgesia has proven to be a good tool in the anaesthetist’s quest to provide excellent pain relief for an extended perioperative period. Pharmaceutical advances provide us with a larger array of both local anaesthetic (LA) drugs and additives that can prolong the duration or enhance the quality of analgesia, or both. The avoidance of LA toxicity is of paramount importance for safe prescription, especially in the high-risk neonatal and infant cohort, and all patients stand to benefit from ‘safer’ LA agents and adjuvants that promote the use of a lowered concentration of epidural LA infusions. We present a descriptive review of trends in epidural prescription and technique in our hospital. Methods: Our observational study was conducted over a period of 19 years in a tertiary paediatric teaching hospital. Prospectively collected data that included patient demographics, level of epidural catheter insertion, LA drugs and adjuvants used, as well as postoperative infusion rates, were then analysed retrospectively. Results: There was a decline in the use of paediatric epidural analgesia. Over the study period, we also observed a shift in preference of LAs and adjuvant drugs toward safer alternatives. Conclusion: Paediatric epidural analgesia is gradually being superseded by other analgesic modalities with superior safety profiles (e.g. peripheral neural blockade). However, indications remain for its continued use, and anaesthetists should be familiar with its technical aspects and pitfalls.

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Baerveldt shunt surgery versus combined Baerveldt shunt and phacoemulsification: a prospective comparative study

British Journal of Ophthalmology ◽

10.1136/bjophthalmol-2017-310698 ◽

2017 ◽

Vol 102 (9) ◽

pp. 1248-1253 ◽

Cited By ~ 1

Author(s):

Mohamad El Wardani ◽

Ciara Bergin ◽

Kenza Bradly ◽

Eamon Sharkawi

Keyword(s):

Complication Rates ◽

Failure Rates ◽

Shunt Surgery ◽

Patient Demographics ◽

Aqueous Shunt ◽

Included Patient ◽

Significant Difference ◽

Negative Effect ◽

Prospective Comparative Study ◽

Baerveldt Tube

AimTo examine the efficacy and safety of Baerveldt tube (BT) implantation compared with combined phacoemulsification and Baerveldt tube (PBT) implantation in patients with refractory glaucoma.MethodsSeventy-six eyes of 76 patients were enrolled, 38 pseudophakic eyes underwent BT implantation alone and 38 phakic eyes underwent the BT implantation combined with phacoemulsification. Groups were matched for preoperative intraocular pressure (IOP) and number of glaucoma medications. Preoperative and postoperative measures recorded included patient demographics, visual acuity (VA), IOP, number of antiglaucoma medications and all complications. Patients were followed up for a minimum of 36 months. Failure was defined as: inadequate IOP control (IOP≤5 mm Hg/>21 mm Hg/<20% reduction from baseline, reoperation for glaucoma, loss of light perception vision, or removal of the implant).ResultsThere was a significant difference in failure rates between groups at 36 months (PBT 37% vs BT 15%, P=0.02). There was no significant difference for PBT versus BT in preoperative baseline ocular characteristics. At 36 months: median IOP=14 mm Hg vs 12 mm Hg, P=0.04; mean number of antiglaucomatous medications=1.7 vs 1.3, P=0.61; median VA=0.8 vs 0.7, P=0.44. Postoperative complication rates were similar in both groups (n=5 vs 5; 13% vs 13%).ConclusionsFailure rates were significantly greater in the PBT group at 3 years. Median IOP was also significantly higher in the PBT group. These results suggest that combining phacoemulsification with aqueous shunt surgery may have a negative effect on long-term shunt bleb survival.

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A descriptive analysis of the impact of COVID-19 on Emergency Department attendance and visit characteristics in Singapore

10.21203/rs.3.rs-149642/v2 ◽

2021 ◽

Author(s):

Mei Qiu Lim ◽

Fahad Javaid Siddiqui ◽

Seyed Ehsan Saffari ◽

Andrew Fu Wah Ho ◽

Johannes Nathaniel Min Hui Liew ◽

...

Keyword(s):

Emergency Department ◽

Severe Disease ◽

Descriptive Analysis ◽

Circuit Breaker ◽

Historical Period ◽

Management Planning ◽

Crowd Management ◽

Patient Demographics ◽

Icd 10 ◽

The Impact

Abstract Background: The coronavirus disease 2019 (COVID-19) has impacted the utilisation of Emergency Department (ED) services worldwide. This study aims to describe the changes in attendance of a single ED and corresponding patient visit characteristics before and during the COVID-19 period. Methods: In a single-centre retrospective cohort study, we used descriptive statistics to compare ED attendance, patient demographics and visit characteristics during the COVID-19 period (1 January – 28 June 2020) and its corresponding historical period in 2019 (2 January – 30 June 2019). Results: Mean ED attendance decreased from 342 visits/day in the pre-COVID-19 period, to 297 visits/day in the COVID-19 period. This was accompanied by a decline in presentations in nearly every ICD-10-CM diagnosis category except for respiratory-related diseases. Notably, we observed reductions in visits by critically ill patients and severe disease presentations during the COVID-19 period. We also noted a shift in ED patient case-mix from ‘Non-fever’ cases to ‘Fever’ cases, likely giving rise to two distinct trough-to-peak visit patterns during the pre-Circuit Breaker and Circuit Breaker period. Conclusions: This descriptive study revealed distinct ED visit trends across different time periods. The COVID-19 pandemic caused a reduction in ED attendances amongst patients with low-acuity conditions and those with highest priority for emergency care. This raises concern about treatment-seeking delays and possible impact on health outcomes. The downward trend in low-acuity presentations also presents learning opportunities for ED crowd management planning in a post-COVID-19 era.

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Comparative Analysis of Two-Piece Extended Peritoneal Dialysis Catheters with Remote Exit-Site Locations and Conventional Abdominal Catheters

Peritoneal Dialysis International ◽

10.3747/pdi.2009.00004 ◽

2010 ◽

Vol 30 (1) ◽

pp. 46-55 ◽

Cited By ~ 17

Author(s):

John H. Crabtree ◽

Raoul J. Burchette

Keyword(s):

Poisson Regression ◽

Coagulase Negative Staphylococcus ◽

Site Location ◽

Exit Site ◽

Exit Site Infection ◽

Catheter Survival ◽

Patient Demographics ◽

Kaplan Meier ◽

Included Patient ◽

Upper Abdomen

BackgroundAn alternative peritoneal catheter exit-site location is sometimes needed in patients with obesity, floppy skin folds, intestinal stomas, urinary and fecal incontinence, and chronic yeast intertrigo. Two-piece extended catheters permit remote exit-site locations away from problematic abdominal conditions.ObjectiveThe effect on clinical outcomes by remotely locating catheter exit sites to the upper abdomen or chest was compared to conventional lower abdominal sites.MethodsIn a nonrandomized design, peritoneal access was established with 158 extended catheters and 270 conventional catheters based upon body habitus and special clinical needs. Prospective data collection included patient demographics, infectious and mechanical complications, and catheter survival.ResultsKaplan–Meier survival time until first exit-site infection was longer for extended catheters ( p = 0.03). Poisson regression showed no difference in exit site, subcutaneous tunnel, and peritonitis infection rates; however, the proportion of catheters lost during peritonitis episodes was significantly greater for extended catheters ( p = 0.007) and appeared to be due primarily to coagulase-negative staphylococcus organisms. Poisson regression showed interactions of body mass index (BMI) and diabetic status in determining catheter loss from peritonitis for both catheter types ( p = 0.02). Extended catheter patients had higher BMI and diabetes prevalence ( p < 0.0001). Overall extended catheter survival at 1, 2, and 3 years (92%, 80%, 71%) trended lower than conventional devices (93%, 87%, 80%; p = 0.0505).ConclusionsExtended catheters enable peritoneal access for patients in whom conventional catheter placement would be difficult or impossible. Certain patient and extended-catheter characteristics may contribute to loss from peritonitis.

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The approach to an isolated close anterior margin in breast conserving surgery

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2019.0017 ◽

2019 ◽

Vol 101 (4) ◽

pp. 268-272

Author(s):

L O’Connell ◽

S Walsh ◽

D Evoy ◽

A O’Doherty ◽

C Quinn ◽

...

Keyword(s):

Local Recurrence ◽

Anterior Margin ◽

Residual Disease ◽

Breast Conserving Surgery ◽

University Hospital ◽

Single Institution ◽

Close Margin ◽

Patient Demographics ◽

Included Patient ◽

Tumour Characteristics

Introduction Although close radial margins after breast-conserving surgery routinely undergo re-excision, appropriate management of patients with close anterior margins remains a topic of controversy. An increasing body of literature suggests that re-excision of close anterior margins yields low rates of residual malignancy and may only be necessary in selected patients. The aim of this study was to examine the management of close anterior margins after breast conserving surgery in a single institution and to analyse the rate of residual disease in re-excised anterior margins. Methods All patients having breast conserving surgery at St Vincent’s University Hospital from January 2008 to December 2012 were reviewed retrospectively. Data collected included patient demographics, tumour characteristics, margin positivity, re-excision rates and definitive histology of the re-excision specimens. A close margin was defined as les than 2 mm. Results A total of 930 patients were included with an average age of 65 years (range 29–94 years). Of these, 121 (13%) had a close anterior margin. Further re-excison of the anterior margin was carried out in 37 patients (30.6%) and a further 16 (13.2%) proceeded to mastectomy. Residual disease was found in 18.5% (7/36) of those who underwent re-excision and 7/16 (43.75%) of those who underwent mastectomy. Overall, 11.57% (14/121) of patients with close anterior margins were subsequently found to have residual disease. Conclusion The low yield of residual disease in re-excised anterior margins specimens supports the concept that routine re-excision of close anterior margins is not necessary. Further research is required to definitively assess its influence on the risk of local recurrence.

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