scholarly journals PCR Cycle-Threshold-Derived Toxin Identifies Patients at Low-Risk for Complications of C. difficile Infection Who Do Not Require Treatment

2017 ◽  
Vol 4 (suppl_1) ◽  
pp. S395-S395 ◽  
Author(s):  
Matthew Hitchcock ◽  
Marisa Holubar ◽  
Lucy Tompkins ◽  
Niaz Banaei
Keyword(s):  
Treated Patient ◽  
Retrospective Chart Review ◽  
Patient Characteristics ◽  
Low Risk ◽  
Review Time ◽  
Cycle Threshold ◽  
Crude Mortality ◽  
Chi Squared ◽  
High Negative Predictive Value ◽  
The Impact

Abstract Background Literature suggests that toxin detection differentiates those who require treatment for C. difficile infection (CDI) from those who do not. In-house studies have shown that free toxin can be predicted with high negative predictive value at a predefined cycle threshold (CT) using Xpert tcdB PCR (Cepheid, Sunnyvale, CA). In October 2016, CT-toxin was added to the PCR result and a comment recommends against CDI therapy if CT-toxin is negative (CTtox-). Here we evaluate the effect of this reporting on treatment rates and outcomes of CTtox- patients. Methods Patients tested from October 2016 to Apr. 2017 with a positive Xpert PCR and CTtox- result were included. Clinical data were collected by retrospective chart review and analyzed with the Chi squared and Student t-tests using SPSS. Due to multiple comparisons, α=0.01. Results Of 1516 Xpert PCR tests, 248 (16.4%) were positive and 98 (39.5%) were CTtox-. Of these, 54 (55.7%) were treated. Patient characteristics and data at testing are shown below. There were no cases of CDI-related septic shock or toxic megacolon on review. Time to diarrhea resolution was significantly shorter in untreated patients and there was no difference in crude mortality or later onset of CTtox+ CDI. Conclusion This study demonstrates the impact of stand-alone PCR assay with toxin prediction on reducing CDI therapy rates and provides further evidence that PCR+/toxin- patients are at low risk for CDI-related complications and do not require treatment, though more data is needed in transplant populations. Disclosures N. Banaei, Cepheid: Collaborator, Research Contractor and Scientific Advisor, honorarium for advisory role and Research support

scholarly journals Diagnostic Disparity of Previous and Revised American Thoracic Society Guidelines for Idiopathic Pulmonary Fibrosis

2015 ◽  
Vol 22 (2) ◽  
pp. 86-90 ◽  
Author(s):  
Lee Fidler ◽  
Shane Shapera ◽  
Shikha Mittoo ◽  
Theodore K Marras
Keyword(s):  
Idiopathic Pulmonary Fibrosis ◽  
Pulmonary Fibrosis ◽  
Diagnostic Criteria ◽  
Retrospective Chart Review ◽  
Patient Characteristics ◽  
Disease Diagnosis ◽  
American Thoracic Society ◽  
Patient Classification ◽  
High Resolution Computed Tomography ◽  
The Impact

BACKGROUND: A revised guideline for the diagnosis of idiopathic pulmonary fibrosis (IPF) was formulated by the American Thoracic Society (ATS) in 2011 to improve disease diagnosis and provide a simplified algorithm for clinicians. The impact of these revisions on patient classification, however, remain unclear.OBJECTIVE: To examine the concordance between diagnostic guidelines to understand how revisions impact patient classification.METHODS: A cohort of 54 patients with either suspected IPF or a working diagnosis of IPF was evaluated in a retrospective chart review, in which patient data were examined according to previous and revised ATS guidelines. Patient characteristics influencing the fulfillment of diagnostic criteria were compared using one-way ANOVA and χ2tests.RESULTS: Revised and previous guideline criteria for IPF were met in 78% and 83% of patients, respectively. Revised guidelines modified a classification based on previous guidelines in 28% of cases. Fifteen percent of patients meeting previous ATS guidelines failed to meet revised criteria due to a lack of honeycombing on high-resolution computed tomography and the absence of a surgical lung biopsy. Patients failing to meet previous and revised diagnostic criteria for IPF were younger.CONCLUSION: The revised guidelines for the diagnosis of IPF classify a substantial proportion of patients differently than the previous guidelines.

scholarly journals Dual Reporting of Clostridioides difficile PCR and Predicted Toxin Result Based on PCR Cycle Threshold Reduces Treatment of Toxin-Negative Patients without Increases in Adverse Outcomes

2019 ◽  
Vol 57 (11) ◽  
Author(s):  
Matthew M. Hitchcock ◽  
Marisa Holubar ◽  
Catherine A. Hogan ◽  
Lucy S. Tompkins ◽  
Niaz Banaei
Keyword(s):  
Nucleic Acid ◽  
Chart Review ◽  
Patient Characteristics ◽  
Adverse Outcomes ◽  
Nucleic Acid Amplification ◽  
Content Type ◽  
Cycle Threshold ◽  
Clostridioides Difficile ◽  
All Cause Mortality ◽  
High Negative Predictive Value

ABSTRACT Nucleic acid amplification tests are commonly used to diagnose Clostridioides difficile infection (CDI). Two-step testing with a toxin enzyme immunoassay is recommended to discriminate between infection and colonization but requires additional resources. Prior studies showed that PCR cycle threshold (CT) can predict toxin positivity with high negative predictive value. Starting in October 2016, the predicted toxin result (CT-toxin) based on a validated cutoff was routinely reported at our facility. To evaluate the clinical efficacy of this reporting, all adult patients with positive GeneXpert PCR results from October 2016 through October 2017 underwent a chart review to measure the recurrence of or conversion to a CT-toxin+ result and 30-day all-cause mortality. There were 482 positive PCR tests in 430 unique patients, 282 CT-toxin+ and 200 CT-toxin−. Patient characteristics were similar at testing, though CT-toxin+ patients had higher white blood cell (WBC) counts (12.5 × 103 versus 9.3 × 103 cells/μl; P = 0.001). All cases (n = 21) of fulminant CDI had a CT-toxin+ result. Index CT-toxin+ patients were significantly more likely to have a CT-toxin+ result within 90 days than CT-toxin− patients (17.4% [n = 49] versus 8.0% [n = 16], respectively; P = 0.003). Thirty-day all-cause mortality was higher in CT-toxin− patients (11.1% versus 6.8%; P = 0.1), though no deaths in CT-toxin− patients were directly attributable to CDI. Of the 200 CT-toxin− patients, 51.5% (n = 103) were treated for CDI. The rates of conversion to a CT-toxin+ result (8.8% versus 7.2%; P = 0.8) and all-cause mortality (8.8% versus 13.4%; P = 0.3) were similar between treated and untreated CT-toxin− patients, respectively. CT-based toxin prediction may identify patients at higher risk for CDI-related complications and reduce treatment among CT-toxin− patients.

Abstract WMP89: Stroke Code De-escalation: Safety and Outcomes

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jessica Jarnot ◽  
Christopher Streib ◽  
Angela Heyer ◽  
Amy Reichert ◽  
David Anderson ◽  
...  
Keyword(s):  
Chart Review ◽  
Healthcare Providers ◽  
Retrospective Chart Review ◽  
Before And After ◽  
Chi Squared ◽  
Cost Implications ◽  
The Impact ◽  
Timely Treatment ◽  
Iv Tpa ◽  
Missed Opportunity

Introduction: “Stroke codes” (SCs) facilitate the timely treatment of acute ischemic stroke (AIS) with IV tPA or intra-arterial thrombectomy (IAT), but are inherently resource-intensive and can expose patients to unnecessary and potentially harmful interventions. While all healthcare providers are encouraged to activate SCs, this might lead to low SC-to-treatment-ratios (SCTR). We examined the impact of de-escalation of stroke codes (DSCs) on SCTR. Methods: DSCs were initiated in our institution in January 2015. All DSCs were reviewed for the patient’s eligibility for IV tPA or IAT, and reason for de-escalation. We reviewed all stroke codes 12 months before and after the initiation of this process and compared the SCTR by chi-squared testing. Results: In 2014, prior to DSCs, 253 SCs resulted in 22 AIS interventions (22 IV tPA) for a SCTR of 8.7%. In 2015, 348 SCs were activated with 64 subsequent DSCs (18.4%) and 45 AIS interventions (38 IV tPA, 7 IAT, 7 both), for a SCTR of 15.8%. The improvement in SCTR after introducing DSCs was statistically significant (p=0.012). When restricting the analysis to IV tPA interventions alone, there remained a trend (p=0.068) towards improvement in SCTR. Retrospective chart review did not reveal any DSC cases that resulted in missed opportunity for IV TPA or IAT treatment. No DSCs were due to an acute ICH. Justifications for de-escalations are summarized in figure 1. Conclusions: The introduction of DSCs resulted in a statistically significant absolute improvement in SCTR of 7.1%. Importantly, DSCs did not result in any eligible AIS patient forgoing IV tPA or IAT, nor missed ICH. More research is needed to increase the yield of stroke codes, refine the criteria for both activating and de-escalating them, and quantify the resource and cost implications of such de-escalations.

Readmissions After Lobectomy in an Era of Increasing Minimally Invasive Surgery: A Statewide Analysis

2019 ◽  
Vol 14 (5) ◽  
pp. 453-462
Author(s):  
Brandon S. Hendriksen ◽  
Michael F. Reed ◽  
Matthew D. Taylor ◽  
Christopher S. Hollenbeak
Keyword(s):  
Minimally Invasive ◽  
Surgical Approach ◽  
Health Care Cost ◽  
Thoracoscopic Surgery ◽  
Patient Characteristics ◽  
Open Approach ◽  
Minimally Invasive Surgical ◽  
Chi Squared ◽  
The Impact ◽  
Video Assisted Thoracoscopic Surgery

Objective Utilization of minimally invasive surgical modalities for lobectomy is increasing. Lobectomy can be associated with notable rates of readmission. As use of these modalities increases, evaluation of the impact on readmission is warranted. Methods Data from the Pennsylvania Health Care Cost Containment Council were used to identify lobectomy operations performed in Pennsylvania from 2011 through 2014. Operations were stratified by approach: open, video-assisted thoracoscopic surgery (VATS) or robotic. Differences in patient characteristics were assessed with analysis of variance and chi-squared tests. Logistic regression modeled risk of 30-day readmission and linear regression modeled length of stay (LOS) after controlling for confounders. Results We evaluated 4,939 lobectomy operations (2,501 open, 1,944 VATS, 494 robotic) with 583 readmissions (11.8%). Robotic cases increased 333% over 4 years. VATS and open cases increased 38% and 22%, respectively. Surgical approach was not associated with hospital readmission (VATS odds ratio (OR) = 0.95; P = 0.632; and robotic OR = 1.02; P = 0.916). Longer LOS was associated with a greater likelihood of readmission (OR = 1.58; P = 0.002). LOS was 1 day less for VATS ( P < 0.001) and 1.5 days less for robotic lobectomy ( P < 0.001) when compared to an open approach. The most common reasons for readmission were respiratory complications and nonrespiratory infection. Conclusions Surgical approach does not directly affect readmission. However, minimally invasive lobectomy appears to be associated with shorter LOS and results in more patients discharged home. Decreased LOS and discharge home are associated with fewer readmissions.

Novel Technique to Reduce the Incidence of SSI after Colorectal Surgery

2019 ◽  
Vol 85 (7) ◽  
pp. 695-699
Author(s):  
Danielle Kay ◽  
Avinash Bhakta ◽  
Jitesh A. Patel ◽  
Jon S. Hourigan ◽  
Shyanie Kumar ◽  
...  
Keyword(s):  
Health Care Cost ◽  
Demographic Data ◽  
Retrospective Chart Review ◽  
Patient Characteristics ◽  
University Of Kentucky ◽  
Significant Difference ◽  
Acs Nsqip Database ◽  
The University ◽  
The Impact ◽  
Wound Class

SSI is a leading cause of morbidity and increases health-care cost after colorectal operations. It is a key hospital-level patient safety indicator. Previous literature has identified perioperative risk factors associated with SSI and interventions to decrease rate of infection. The purpose of this study was to evaluate the impact of blowhole closure on the rate of superficial and deep SSI. The ACS-NSQIP database was queried for patients undergoing colectomy at the University of Kentucky from 2013 to 2016. Retrospective chart review was performed to gather demographic data and perioperative variables. Wounds left open and packed were excluded. Rates of postoperative SSI were measured between the groups. One thousand eighty-three patients undergoing elective and emergent colectomy were reviewed. Nine hundred and forty-five had closed incision and 138 had blowhole closure. Patient characteristics between the groups were well matched. Patients with a blowhole closure were more likely to have an open procedure ( P = 0.037) and a higher wound class ( P < 0.001). The rate of superficial and deep SSI was 9.1 per cent in patients with a closed incision and 5.1 per cent in patients with blowhole closure ( P = 0.142). With adjustment for approach and wound class, blowhole closure decreased the incidence of SSI ( P = 0.04). There was no significant difference in morbidity or mortality. Patients undergoing elective and emergent colectomy had decreased incidence of SSI when blowhole closure was used. Given that it does not increase resource usage and its technical ease, blowhole closure should become the standard method of surgical wound closure.

Minimally Invasive Lobectomy Modality and Other Predictors of Conversion to Thoracotomy

2019 ◽  
Vol 14 (4) ◽  
pp. 342-352 ◽  
Author(s):  
Brandon S. Hendriksen ◽  
Christopher S. Hollenbeak ◽  
Matthew D. Taylor ◽  
Michael F. Reed
Keyword(s):  
Risk Factors ◽  
Propensity Score ◽  
Minimally Invasive ◽  
Propensity Score Matching ◽  
Thoracoscopic Surgery ◽  
Patient Characteristics ◽  
Logistic Regression Models ◽  
Conversion Rates ◽  
Chi Squared ◽  
The Impact

Objective Minimally invasive approaches to lobectomy are increasing. Rates of conversion to thoracotomy are well reported but risk factors are poorly understood. This study aimed to determine the impact of surgical modality (video-assisted thoracoscopic surgery [VATS] and robotic) on conversion as well as to identify other risk factors for conversion. Methods The National Cancer Database (NCDB) was used to identify patients who underwent minimally invasive lobectomy between 2010 and 2015. Patient characteristics were compared between VATS and robotic approaches using chi-squared tests and t-tests. Logistic regression models were used to control for covariates and identify factors associated with all minimally invasive conversion, VATS conversion, and robotic conversion. Propensity score matching was used to compare conversion rates of VATS and robotic lobectomy. Results The study included 51,723 patients with lung cancer who underwent minimally invasive lobectomy (VATS or robotic). Conversion was identified in 7,109 (7.3%) operations. The odds of VATS conversions were nearly twice that of robotic conversions (OR 1.94 P < 0.0001). After controlling for VATS and robotic patient imbalances with propensity score matching, there was a 5% difference in conversion rates (14% vs. 9%, P < 0.0001). Other predictors of minimally invasive conversion included community hospitals, tumor size 4.5 cm or greater, and an increasing Charlson comorbidity index ( P < 0.03 for all). Conclusions VATS is associated with nearly twice the odds of conversion as robotic lobectomy. Identifying specific risk factors for both VATS and robotic conversions may aid in appropriate modality selection and reduction of conversions.

Travel Time Influences Readmission Risk: Geospatial Mapping of Surgical Readmissions

2017 ◽  
Vol 83 (6) ◽  
pp. 573-582 ◽  
Author(s):  
Florence E. Turrentine ◽  
Patrick J. Buckley ◽  
Min-Woong Sohn ◽  
Michael D. Williams
Keyword(s):  
Travel Time ◽  
General Surgery ◽  
Rural Areas ◽  
Graphical Representation ◽  
Discharge Planning ◽  
Retrospective Chart Review ◽  
Patient Characteristics ◽  
Care Organization ◽  
Improvement Program ◽  
The Impact

The University of Virginia (UVA) has recently become an Accountable Care Organization (ACO), intensifying efforts to provide better care for individuals. UVA's ACO population resides across the entire Commonwealth, with a large percentage of patients living in rural areas. To provide better health for this population, the central tenet of the ACO mission, we identified geographic risk factors influencing hospital readmission. We analyzed the relationship between the distance of patients’ residence to the nearest hospital and 30-day readmission in general surgery patients. A retrospective chart review using January 1, 2011 through October 31, 2013 American College of Surgeons National Surgical Quality Improvement Program data for general surgery procedures was conducted. ArcGIS mapped street addresses provided graphical representation of distance between surgical population and the nearest hospital. We analyzed the impact on readmission, of time traveled, insurance status, and median household income. Each increase of 10 minutes in travel time from the patient's residence to the nearest hospital, not just UVA, was associated with a 9 per cent increase in the probability of readmission after adjusting for patient characteristics, preoperative comorbidities, laboratory values, and postoperative complications before or after discharge (odds ratio = 1.09; 95% confidence interval = 1.01–1.17; P = 0.019). Unlike urban hospitals, those serving rural populations may be at particular risk of postsurgical readmissions. Patients living furthest from a hospital facility are most at risk for readmission after a general surgery procedure. This vulnerable population may benefit most from comprehensive discharge planning.

Predictors of toxicity to concurrent chemoradiation (CRT) in patients (pts) with locally advanced head and neck squamous cell cancer (HNSCC)

2007 ◽  
Vol 25 (18_suppl) ◽  
pp. 16540-16540
Author(s):  
R. Yelamanchili ◽  
S. Hotte ◽  
J. Julian ◽  
J. Wright
Keyword(s):  
Alcohol Intake ◽  
Cell Cancer ◽  
Locally Advanced ◽  
Retrospective Chart Review ◽  
Patient Characteristics ◽  
Cancer Center ◽  
Alcohol Abusers ◽  
Heavy Alcohol ◽  
Significant Difference ◽  
The Impact

16540 Background: A number of studies have evaluated the impact of prognostic factors on survival but very few have studied their role as determinants of toxicity, especially outside of the context of clinical trials. We set out to identify patient characteristics that are likely to predict toxicity to chemotherapy (CT) with daily cisplatin 6mg/m2 and radiation therapy (RT) in pts with locally advanced HNSCC. Methods: Retrospective chart review of above pts at the Juravinski Cancer Center from 2000 through 2004. A number of pt characteristics were analysed. Toxicity outcomes evaluated were completion of CT and of RT, rise in serum Cr , hematologic suppression, need for extra hydration, and need for extra antiemetics. Results: The charts of 108 pts were reviewed. Median follow-up was 36 months. Five year projected OS and PFS were 78% and 57% in our study compared to 53% and 47% in a published EORTC trial (NEJM, 2004). Median duration of PFS was 64 months in our study compared to 55 months in the EORTC trial. Median OS was not reached in our study. Nineteen percent completed CT and 81% completed RT, 17% had full course of CRT. Thirty-nine percent required extra hydration and 50% required extra antiemetics. Twenty four percent had elevated creatinine levels and 20.4% had hematologic suppression. Logistic regression was used to search for significant correlations between pt characteristics and outcomes. Pts with occasional alcohol intake were more likely to complete RT than heavy alcohol abusers (OR 8.9; P 0.04). Pts with occasional alcohol intake were more likely to get extra hydration than heavy alcohol abusers (OR 5.1; P 0.008).Hematologic suppression was more likely with increasing age (OR 1.08;P 0.015).No significant difference in toxicity outcomes was observed between males and females. Conclusions: This review demonstrated that CRT with daily cisplatin is associated with significant toxicity and most pts are unable to receive full treatment . A number of pt variables might predict increased susceptibility to toxicity. This should be validated in a prospective study. Median PFS in our series appear to be at least as good as previously published reports of CRT using daily cisplatin as well as dose schedules but toxicity does not appear greatly reduced. No significant financial relationships to disclose.

scholarly journals 1048Characteristics of ST-Elevation Myocardial Infarction (STEMI) patients in Asia Pacific: findings from the ASPECT collaboration

2021 ◽  
Vol 50 (Supplement_1) ◽  
Author(s):  
HuiJun Chih ◽  
Angela Brennan ◽  
KK Yeo ◽  
Mark Chan ◽  
Bryan Yan ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Hong Kong ◽  
Coronary Artery ◽  
Artery Bypass ◽  
Patient Characteristics ◽  
Stemi Patient ◽  
Asia Pacific ◽  
Chi Squared ◽  
History Of ◽  
The Impact

Abstract Background The Asia Pacific Evaluation of Cardiovascular Therapies (ASPECT) Collaboration was established to better understand the characteristics of patients undergoing PCI and cardiac interventions across the Asia Pacific region, including STEMI. The aim of this study was to compare STEMI patient characteristics across Asia Pacific (AP) countries in order to understand regional differences. Methods Each site across Australia, Singapore, Malaysia, Vietnam and Hong Kong provided de-identified individual patient data. Comparison of characteristics by sites were performed using one-way ANOVA, Kruskal-Wallis or Chi-squared tests, using Stata 14.2. Results Of the 12,620 cases, there were more males (p &lt; 0.001) and the average of patients’ age ranged from 55 (Malaysia) to 68 (Vietnam) years old. Family history of coronary artery disease was not common amongst Hong Kong (1%) and Singaporean (12%) patients, and most patients did not have history of congestive heart failure, peripheral vascular disease or coronary artery bypass grafting. History of dyslipidaemia varied significantly among patients in Malaysia (98%) and Vietnam (12%) (p &lt; 0.001). About 37% of the Malaysian patients had previous myocardial infarction, which is greater than twice of other cohorts (p &lt; 0.001). Most cohort had either normal or mild ejection fraction (EF) but 40% of the Singaporean patients had severely reduced EF (p &lt; 0.001). Conclusions Patient characteristics varied significantly across AP countries. On-going analyses will focus on the impact of varying patient characteristics on clinical outcomes. Key messages As characteristics varied, prevention and procedural strategies need to be adapted carefully. Additional input from other AP countries will better inform these strategies.

Response to Chemotherapy in Overweight/Obese Patients With Low-Risk Gestational Trophoblastic Neoplasia

2015 ◽  
Vol 25 (4) ◽  
pp. 734-740 ◽  
Author(s):  
Izildinha Maestá ◽  
Neil S. Horowitz ◽  
Donald P. Goldstein ◽  
Marilyn R. Bernstein ◽  
Luz Angela C. Ramírez ◽  
...  
Keyword(s):  
New England ◽  
Single Agent ◽  
Patient Characteristics ◽  
Low Risk ◽  
Obese Patients ◽  
Gestational Trophoblastic Neoplasia ◽  
Gynecology And Obstetrics ◽  
Response To Chemotherapy ◽  
Significant Difference ◽  
The Impact

ObjectiveDespite rising global obesity rates, the impact of obesity on gestational trophoblastic neoplasia (GTN) remains uninvestigated. This study aimed at investigating whether overweight/obesity relates to response to chemotherapy in low-risk GTN patients.MethodsThis nonconcurrent cohort study included 300 patients with International Federation of Gynecology and Obstetrics–defined postmolar low-risk GTN treated with a single-agent chemotherapy—methotrexate or actinomycin-D (actD)—between 1973 and 2012 at the New England Trophoblastic Disease Center. Chemotherapy dosing was based on actual body weight regardless of obesity status, except for 5-day courses or pulse regimens of actD. Patients were classified as overweight/obese (body mass index [BMI] ≥25 kg/m2) or non-overweight/obese (BMI <25 kg/m2). Information on patient characteristics and response to chemotherapy (need for second-line chemotherapy, reason for changing to an alternative chemotherapy, number of cycles, need for combination chemotherapy, and time to human chorionic gonadotropin remission) was obtained.ResultsOf 300 low-risk GTN patients, 81 (27%) were overweight/obese. Overweight/obese patients were older than the non-overweight/obese patients (median age: 30 vs 28 years, P = 0.004). First-line therapy using actD was more frequent in overweight/obese patients (6.2% vs 1.4%, P = 0.036). Resistance and toxicity were similar between groups. No significant difference in the number of chemotherapy cycles needed for remission or time required to achieve remission was found between groups.ConclusionsNo association between overweight/obesity and low-risk GTN outcomes was found. Current chemotherapy dosing using BMI seems to be appropriate for overweight/obese patients with low-risk GTN.

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