scholarly journals 51. Sustained Impact of an Antimicrobial Stewardship (AS) Initiative Targeting Asymptomatic Bacteriuria and Pyuria in the Emergency Department (ED)

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S145-S146
Author(s):  
Mary Catherine Cash ◽  
Garrett Hile ◽  
James Johnson ◽  
Tyler Stone ◽  
Vera Luther ◽  
...  
Keyword(s):  
Medical Center ◽  
Academic Medical Center ◽  
Inappropriate Prescribing ◽  
Asymptomatic Bacteriuria ◽  
Secondary Outcome ◽  
Indwelling Catheter ◽  
Inappropriate Treatment ◽  
Group 2 ◽  
The Impact ◽  
Group 1

Abstract Background The sustainability of unique AS initiatives are largely unstudied. A multi-faceted initiative to reduce inappropriate treatment of asymptomatic pyuria (ASP) and asymptomatic bacteriuria (ASB) in the ED was implemented at our institution in 2016. A pre-post intervention analysis demonstrated reduction in the inappropriate treatment (tx) of ASP/ASB from 100% to 32% (p< 0.001) following the intervention. The purpose of this present study was to determine the sustained impact of the initiative and determine if re-education provided in Oct 2020 could further reduce inappropriate tx. Methods This was a retrospective, interrupted time series study conducted at an 885 bed academic medical center. Patients (pts) discharged from the ED in Nov 2019 – Feb 2020 (group 1) and Nov 2020 – Feb 2021 (group 2) were retrospectively screened in chronologic order until 50 pts in each group met study criteria. Similar to the 2016 study, pts were included if they were ≥ 18 years old and had a positive urine culture or pyuria. Pts were excluded if they had symptoms of a urinary tract infection (UTI), another infection requiring antibiotics (ABX), indwelling catheter, ureteral stent, or nephrostomy tube, or if pregnant or immunocompromised. The primary outcome was the proportion of pts prescribed ABX within 72 hrs of ED discharge. The secondary outcome was the number of pts returning to the ED with symptomatic UTI within 30 days of discharge. Group 1 was compared to the 2016 study’s post group to determine the sustained impact of the initial initiative; group 2 was compared to group 1 to determine the impact of re-education, which involved a presentation to ED providers and a posted algorithm and fact sheet. Results Results from all time periods are summarized in Table 1. Improvement in inappropriate tx was still noted 3 years after the intervention (28% vs 32%; p = NS). Re-education did not further improve inappropriate prescribing, with 28% of group 2 pts still receiving tx. Table 1. Conclusion The decrease in inappropriate use of ABX for ASP/ASB was still noted 3 years after implementation of a multi-faceted AS initiative. Re-education did not result in further improvement. Disclosures James Johnson, PharmD, FLGT (Shareholder) Vera Luther, MD, Nothing to disclose

The impact of pretreatment absolute lymphocyte count (pALC) and neutrophil-lymphocyte ratio (pNLR) on checkpoint inhibitors (CPIs) response rates in renal cell carcinoma (RCC) and bladder urothelial cancers (BC).

2020 ◽  
Vol 38 (5_suppl) ◽  
pp. 29-29
Author(s):  
Tonjeh Mary Stella Bah ◽  
David Sommerhalder ◽  
Philip A. Haddad
Keyword(s):  
Checkpoint Inhibitors ◽  
Medical Center ◽  
Response Rates ◽  
Neutrophil Lymphocyte Ratio ◽  
Essential Components ◽  
Group A ◽  
Group 2 ◽  
Group B ◽  
The Impact ◽  
Group 1

31 Background: CPIs have been established as essential components of cancer immunotherapy across multiple cancer types with proven clinical benefit, improved outcomes, and less toxicity. Studies in lung and head and neck cancers found that low ALC, a marker of immune exhaustion, was associated with poor response to CPIs and worse progression-free survival. We explored the effect of pALC and pNLR on CPI response rates in patients with RCC and BC. Methods: We retrospectively reviewed every RCC and BC patient that received CPIs at Overton Brooks VA Medical Center and LSUHSC-S between 2015 and 2019. Patients’ pALC and pNLR were calculated. The patients were divided according to pALC into 2 groups: Group A with pALC > 1000 and Group B with pALC < 1000. Similarly, using NLR’s established upper normal limit of 3, 2 groups were created: Group 1 with pNLR < 3 and Group 2 with pNLR > 3. Our primary outcome of interest was defined as the presence or absence of CPI response. Patients who attained stable disease, partial response, and complete response were categorized as responders. Those who progressed on CPIs were labeled as non-responders. The significance of the association between pALC and pNLR groups and the occurrence of any response was analyzed statistically. Results: Twenty patients (13 RCC, 7 BC) were treated with CPIs and had documented responses. Twelve patients had pALC > 1000 (Group A) whereas 8 patients had pALC < 1000 (Group B). Both groups were comparable with respect to age, sex, race, and types of CPIs. Group A had a significantly higher response rate (75% vs 25%, p = 0.027). As to pNLR, 10 patients had pNLR < 3 (Group 1) and another 10 patients had pNLR > 3 (Group 2). Patients with pNLR > 3 had worse response rates to CPIs compared to those with pNLR < 3 (30% vs 80%, p = 0.024). Conclusions: This is the first report from a real-world clinical setting to show a detrimental association between pALC < 1000 and pNLR > 3 and CPI response rates in a retrospective cohort of consecutive non-selected kidney and bladder cancer patients. This association and its clinical utility require further confirmation in a prospective larger cohort.

scholarly journals A randomized controlled trial of online symptom searching to inform patient generated differential diagnoses

2019 ◽  
Vol 2 (1) ◽  
Author(s):  
Seth S. Martin ◽  
Emmanuel Quaye ◽  
Sarah Schultz ◽  
Oluwaseun E. Fashanu ◽  
Jane Wang ◽  
...  
Keyword(s):  
Medical Center ◽  
Controlled Trial ◽  
Academic Medical Center ◽  
Differential Diagnoses ◽  
Secondary Outcome ◽  
Patient Anxiety ◽  
Waiting Room ◽  
Online Searching ◽  
Health Related ◽  
The Impact

Abstract Patient online health searching is now commonplace, however, the accuracy of patient generated differentials for new symptoms and potential for patient anxiety are concerns. We aimed primarily to determine the accuracy of patient generated differentials for new symptoms with and without online searching, and secondarily, to evaluate the impact of searching on anxiety levels. In the waiting room prior to seeing a clinician, 300 patients with new symptoms were randomly assigned 1:1:1 to Google searching with health related features including a symptom search tool vs Google searching with health related features disabled vs no searching. Participants were 18 years or older and presenting to the emergency department of an urban academic medical center with new low-acuity symptoms that were not due to exacerbation of a chronic condition. Search groups received access on a tablet/smartphone to Google searching with or without health related features. Both search groups could access any websites; health related features led the patient to common diagnoses and physician-validated information. The primary outcome was accuracy of the patient generated differential assessed by matching at least two of the top three diagnoses on the clinician’s differential. A secondary outcome was anxiety by a visual analogue scale. Patients were a median of 33.1 (IQI 26.2–45.9) years old, 60% women, 63% black, 82% had a high school education or less, and 45.7% reported having performed an online search prior to presentation. Search group patients spent a median of 3.82 (2.53–5.72) minutes searching online. Similar proportions of patients in each group matched at least two of three clinician diagnoses: 27.0% and 28.3% for Google searching with and without health related features vs 23.8% in the no search group. Patients in the search groups had a similar odds of matching ≥2/3 diagnoses as the no search group [OR (95% CI): 1.23 (0.70–2.13), p = 0.47]. Anxiety was unchanged with online searching. In conclusion, brief online searching in the waiting room did not improve accuracy of patient generated differential diagnoses for new symptoms. The absence of an increase in patient anxiety provides reassurance for subsequent work to refine and investigate online symptom search tools.

scholarly journals Reduced Mortality of Staphylococcus aureus Bacteremia in a Retrospective Cohort Study of 2139 Patients: 2007–2015

2019 ◽  
Vol 70 (8) ◽  
pp. 1666-1674 ◽  
Author(s):  
Eloise D Austin ◽  
Sean S Sullivan ◽  
Nenad Macesic ◽  
Monica Mehta ◽  
Benjamin A Miko ◽  
...  
Keyword(s):  
Staphylococcus Aureus ◽  
Cohort Study ◽  
Medical Center ◽  
Academic Medical Center ◽  
Rapid Diagnostics ◽  
Staphylococcus Aureus Bacteremia ◽  
Group 3 ◽  
Group 2 ◽  
Mssa Infection ◽  
Group 1

Abstract Background Understanding the changing epidemiology of Staphylococcus aureus bacteremia, as well as the variables associated with poor outcomes, can yield insight into potential interventions. Methods This study was a retrospective, observational cohort study of adult patients at an academic medical center in New York City who had S. aureus bloodstream infections between 1 January 2007 and 31 December 2015. Participants were divided into 3 periods: group 1 (2007–2009), group 2 (2010–2012), and group 3 (2013–2015) for trend analysis. All clinical strains were genotyped (spa.). The main outcome was 30-day all-cause mortality. Results There were 1264 episodes of methicillin-susceptible S. aureus (MSSA) and 875 episodes of methicillin-resistant S. aureus (MRSA) bacteremia, with a rising proportion due to MSSA (55% group 1; 59% group 2; 63% group 3; P = .03.) There were no significant changes in average age, gender, Charlson score, and distribution of strain genotypes. Mortality in MRSA infection was unchanged (25% group 1; 25% group 2; 26% group 3), while mortality in MSSA infection significantly declined (18% group 1; 18% group 2; 13% group 3). The average time to antistaphylococcal therapy (AST) in MSSA infection declined during the study (3.7 days group 1; 3.5 group 2; 2.2 group 3). In multivariate analysis, AST within 7 days of initial positive MSSA culture was associated with survival. Conclusions Mortality in MSSA bloodstream infection is declining, associated with a decrease in time to targeted therapy. These results emphasize the potential for rapid diagnostics and early optimization of treatment to impact outcomes in MSSA bacteremia.

Evaluation of an Antimicrobial Stewardship Approach to Minimize Overuse of Antibiotics in Patients with Asymptomatic Bacteriuria

2014 ◽  
Vol 35 (2) ◽  
pp. 193-195 ◽  
Author(s):  
Denise Kelley ◽  
Patrick Aaronson ◽  
Elaine Poon ◽  
Yvette S. McCarter ◽  
Ben Bato ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Medical Center ◽  
Academic Medical Center ◽  
Asymptomatic Bacteriuria ◽  
Antimicrobial Treatment ◽  
Antimicrobial Use ◽  
Educational Initiative ◽  
Educational Initiatives ◽  
Academic Medical ◽  
Inappropriate Treatment

An antimicrobial stewardship educational initiative provided to physicians and pharmacists was evaluated at an academic medical center to minimize inappropriate treatment of asymptomatic bacteriuria (ASB). A significant decrease in empirical antimicrobial use for ASB was observed after education. Multifaceted educational initiatives can reduce inappropriate antimicrobial treatment of ASB.

scholarly journals Impact of a multidisciplinary workflow on safety and management of patients with heparin-induced thrombocytopenia

2020 ◽  
Vol 78 (1) ◽  
pp. 49-59
Author(s):  
Kalynn A Northam ◽  
Sheh-Li Chen ◽  
Andrew P Stivers ◽  
Jonathan D Cicci ◽  
Tanner L Hedrick ◽  
...  
Keyword(s):  
Medical Center ◽  
Academic Medical Center ◽  
Adult Patients ◽  
Secondary Outcome ◽  
Quality Improvement Initiative ◽  
Heparin Induced Thrombocytopenia ◽  
Heparin Administration ◽  
Heparin Allergy ◽  
Laboratory Test Results ◽  
The Impact

Abstract Purpose Heparin-induced thrombocytopenia (HIT) is a serious complication of heparin administration. Management strategies are complex and include discontinuing heparin products, initiating alternative anticoagulants, interpreting laboratory test results, documenting heparin allergies, and providing patient education. Medication error reports and a retrospective review conducted at an academic medical center revealed an opportunity for a quality improvement initiative and led to the creation of a multidisciplinary workflow for the management of HIT. In a pre-post study, the impact of the multidisciplinary workflow on the safety and management of HIT was evaluated. Methods The preimplementation group consisted of adult patients tested for suspected HIT from April 4, 2014, through May 31, 2016; the postimplementation group consisted of adult patients tested from November 1, 2016, through October 31, 2018. The primary outcome was the incidence of heparin product administration while HIT testing was ongoing. The secondary outcome was the rate of appropriate heparin allergy documentation. Results The incidence of heparin product administration while HIT testing results were pending was significantly reduced, from 54.2% to 20.0% (P &lt; 0.001), after workflow implementation. The rate of appropriate heparin allergy documentation significantly increased, from 95.0% to 100% (P &lt; 0.001). Conclusion Implementation of a multidisciplinary workflow for the management of HIT significantly reduced the incidence of heparin administration while testing was ongoing and improved the rate of appropriate heparin allergy documentation.

scholarly journals Improved Outcomes with Concurrent Instrumentation and Fusion of the Sacroiliac Joint in Patients with Long Lumbosacral Constructs

2022 ◽  
pp. 219256822110690
Author(s):  
Mohammad Hassan A. Noureldine ◽  
Jeffrey Farooq ◽  
Jay I. Kumar ◽  
Elliot Pressman ◽  
Emily Coughlin ◽  
...  
Keyword(s):  
Sacroiliac Joint ◽  
Medical Center ◽  
Academic Medical Center ◽  
The United States ◽  
Predisposing Factor ◽  
Heavy Load ◽  
Fusion Device ◽  
Multiple Covariates ◽  
Group 2 ◽  
Group 1

Study Design Retrospective Cohort Study Objective Spinal fusion, specifically constructs connected to pelvic bones, has been consistently reported as a predisposing factor to sacroiliac joint (SIJ) pain. The aim of this study is to compare SIJ outcomes in patients with constructs to the pelvis following instrumentation vs instrumentation plus fusion of the SIJ. Methods Data of study subjects was extracted from a prospectively maintained database as well as retrospectively collected from records at a tertiary academic medical center in the United States between 2018 and 2020. Results A cohort of 103 patients was divided into 2 groups: 65 in Group 1 [S2AI screw without fusion device] and 38 in Group 2 [S2AI screw with fusion device]. None of the patients in Group 2 developed postoperative SIJ pain compared to 44.6% in Group 1. Sacroiliac joint fusion occurred in all Group 2 but none of Group 1 patients. The postoperative Visual Analogue Scale (VAS) for lower extremity (LE) pain (.8 vs .5; P = .03) and postoperative Oswestry Disability Index (ODI) (18.7 vs 14.2; P < .01) were significantly higher in Group 1. The rate of distal junctional break, failure, and/or kyphosis (DJBFK) and time to DJBFK were not significantly different between the two groups, and the rate of DJBFK did not change in the presence of multiple covariates. Conclusion The SIJs carry the heavy load of long lumbosacral fusion constructs extending to the pelvis. Simultaneous SIJ instrumentation and fusion decreases the risk of disability, prevents the development of postoperative SIJ pain, and may also protect the S2AI screw from loosening and failure.

Evaluation of an online motivational interviewing training program for rehabilitation professionals: A pilot study

2021 ◽  
pp. 026921552110029
Author(s):  
Nicole Schechter ◽  
Lester Butt ◽  
Connie Jacocks ◽  
Elena Staguhn ◽  
Renan Castillo ◽  
...  
Keyword(s):  
Motivational Interviewing ◽  
Training Program ◽  
Communication Skills ◽  
Medical Center ◽  
Academic Medical Center ◽  
Online Training ◽  
Rehabilitation Professionals ◽  
Knowledge And Attitudes ◽  
Group 2 ◽  
Group 1

Objective: To investigate the feasibility and effectiveness of an online motivational interviewing training program for rehabilitation professionals. Design: Pre-post design with two groups. Setting: Private rehabilitation hospital and an academic medical center Subjects: Group 1 included 19 motivational interviewing-experienced rehabilitation professionals. Group 2 included 25 motivational interviewing-naïve rehabilitation professionals. Interventions: Group 1 was exposed to an online motivational training program and Group 2 was exposed to an online motivational training program and a live booster session. Main measures: Motivational interviewing communication skills were measured with an adapted Helpful Responses Questionnaire. Knowledge and attitudes were measured with an adapted Motivational Interviewing Knowledge and Attitudes Test. Confidence, importance, and feasibility for implementing motivational interviewing were measured using the Motivational Interviewing Rulers. Results: Group 1 showed improvement in communication skills (2.6/5–3.3/5; P < 0.05) and confidence (6.0/01–7.4/10; P < 0.01) after online training. Improvements seen in skills and confidence were maintained at three months. Group 2 showed improvement in skills (2.1/5–3.3/5; P < 0.001), knowledge (7.7/10–8.5/10; P < 0.01), confidence (6.4/10–7.5/10; P < 0.01), and importance (8.3/10–8.9/10; P < 0.05) after online training. At three-months post-booster, improvements in communication skills and knowledge were maintained. Conclusions: Online training can be a cost and time effective approach to improve rehabilitation professionals’ skills in motivational interviewing. Follow-up training activities are needed to maintain the level of knowledge and skill improvement.

CD34 immunostain increases sensitivity of the diagnosis of fetal vascular malperfusion in placentas from ex-utero intrapartum treatment

2020 ◽  
Vol 0 (0) ◽  
Author(s):  
Jerzy Stanek
Keyword(s):  
Statistical Significance ◽  
Treatment Procedure ◽  
Fetal Survival ◽  
Ex Utero Intrapartum Treatment ◽  
Life Threatening ◽  
Group 2 ◽  
Cd34 Immunostain ◽  
The Impact ◽  
Diaphragmatic Hernias ◽  
Group 1

AbstractShort CommunicationsEXIT (ex-utero intrapartum treatment) procedure is a fetal survival-increasing modification of cesarean section. Previously we found an increase incidence of fetal vascular malperfusion (FVM) in placentas from EXIT procedures which indicates the underlying stasis of fetal blood flow in such cases. This retrospective analysis analyzes the impact of the recently introduced CD34 immunostain for the FVM diagnosis in placentas from EXIT procedures.Objectives and MethodsA total of 105 placentas from EXIT procedures (48 to airway, 43 to ECMO and 14 to resection) were studied. In 73 older cases, the placental histological diagnosis of segmental FVM was made on H&E stained placental sections only (segmental villous avascularity) (Group 1), while in 32 most recent cases, the CD34 component of a double E-cadherin/CD34 immunostain slides was also routinely used to detect the early FVM (endothelial fragmentation, villous hypovascularity) (Group 2). 23 clinical and 47 independent placental phenotypes were compared by χ2 or ANOVA, where appropriate.ResultsThere was no statistical significance between the groups in rates of segmental villous avascularity (29 vs. 34%), but performing CD34 immunostain resulted in adding and/or upgrading 12 more cases of segmental FVM in Group 2, thus increasing the sensitivity of placental examination for FVM by 37%. There were no other statistically significantly differences in clinical (except for congenital diaphragmatic hernias statistically significantly more common in Group 2, 34 vs 56%, p=0.03) and placental phenotypes, proving the otherwise comparability of the groups.ConclusionsThe use of CD34 immunostain increases the sensitivity of placental examination for FVM by 1/3, which may improve the neonatal management by revealing the increased likelihood of the potentially life-threatening neonatal complications.

scholarly journals The negative effects of COVID-19 and national lockdown on emergency surgery morbidity due to delayed access

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Francesco A. Ciarleglio ◽  
Marta Rigoni ◽  
Liliana Mereu ◽  
Cai Tommaso ◽  
Alessandro Carrara ◽  
...  
Keyword(s):  
Emergency Department ◽  
Blood Transfusion ◽  
Emergency Surgery ◽  
Surgical Care ◽  
Close Correlation ◽  
Negative Effects ◽  
Group 2 ◽  
Retrospective Comparative Study ◽  
The Impact ◽  
Group 1

Abstract Background The aim of this retrospective comparative study was to assess the impact of COVID-19 and delayed emergency department access on emergency surgery outcomes, by comparing the main clinical outcomes in the period March–May 2019 (group 1) with the same period during the national COVID-19 lockdown in Italy (March–May 2020, group 2). Methods A comparison (groups 1 versus 2) and subgroup analysis were performed between patients’ demographic, medical history, surgical, clinical and management characteristics. Results Two-hundred forty-six patients were included, 137 in group 1 and 109 in group 2 (p = 0.03). No significant differences were observed in the peri-operative characteristics of the two groups. A declared delay in access to hospital and preoperative SARS-CoV-2 infection rates were 15.5% and 5.8%, respectively in group 2. The overall morbidity (OR = 2.22, 95% CI 1.08–4.55, p = 0.03) and 30-day mortality (OR = 1.34, 95% CI 0.33–5.50, =0.68) were significantly higher in group 2. The delayed access cohort showed a close correlation with increased morbidity (OR = 3.19, 95% CI 0.89–11.44, p = 0.07), blood transfusion (OR = 5.13, 95% CI 1.05–25.15, p = 0.04) and 30-day mortality risk (OR = 8.00, 95% CI 1.01–63.23, p = 0.05). SARS-CoV-2-positive patients had higher risk of blood transfusion (20% vs 7.8%, p = 0.37) and ICU admissions (20% vs 2.6%, p = 0.17) and a longer median LOS (9 days vs 4 days, p = 0.11). Conclusions This article provides enhanced understanding of the effects of the COVID-19 pandemic on patient access to emergency surgical care. Our findings suggest that COVID-19 changed the quality of surgical care with poorer prognosis and higher morbidity rates. Delayed emergency department access and a “filter effect” induced by a fear of COVID-19 infection in the population resulted in only the most severe cases reaching the emergency department in time.

scholarly journals QOL-49. THE IMPACT OF OTOTOXICITY AND VISUAL IMPAIRMENT ON EDUCATION IN CHILDREN TREATED FOR CNS TUMOURS

2020 ◽  
Vol 22 (Supplement_3) ◽  
pp. iii440-iii440
Author(s):  
Harriet Dulson ◽  
Rachel McAndrew ◽  
Mark Brougham
Keyword(s):  
Visual Impairment ◽  
Impaired Hearing ◽  
Cranial Radiotherapy ◽  
Radiotherapy Group ◽  
Platinum Based Chemotherapy ◽  
Cns Tumours ◽  
Group 3 ◽  
Group 2 ◽  
The Impact ◽  
Group 1

Abstract INTRODUCTION Children treated for CNS tumours experience a very high burden of adverse effects. Platinum-based chemotherapy and cranial radiotherapy can cause ototoxicity, which may be particularly problematic in patients who have impaired vision and cognition as a result of their tumour and associated treatment. This study assessed the prevalence of impaired hearing and vision and how this may impact upon education. METHODS 53 patients diagnosed with solid tumours in Edinburgh, UK between August 2013–2018 were included in the study. Patients were split into three groups according to treatment received: Group 1 – cisplatin-based chemotherapy and cranial radiotherapy; Group 2 - platinum-based chemotherapy, no cranial radiotherapy; Group 3 – benign brain tumours treated with surgery only. Data was collected retrospectively from patient notes. RESULTS Overall 69.5% of those treated with platinum-based chemotherapy experienced ototoxicity as assessed by Brock grading and 5.9% of patients had reduced visual acuity. Patients in Group 1 had the highest prevalence of both. 44.4% of patients in Group 1 needed increased educational support following treatment, either with extra support in the classroom or being unable to continue in mainstream school. 12.5% of Group 2 patients required such support and 31.3% in Group 3. CONCLUSIONS Children with CNS tumours frequently require support for future education but those treated with both platinum-based chemotherapy and cranial radiotherapy are at particular risk, which may be compounded by co-existent ototoxicity and visual impairment. It is essential to provide appropriate support for this patient cohort in order to maximise their educational potential.

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