Unusually High Incidences of Pseudomonas Bacteremias Within Topical Polymyxin–Based Decolonization Studies of Mechanically Ventilated Patients: Benchmarking the Literature

Abstract Background Topical polymyxin (PM)–based regimens to decolonize patients receiving prolonged mechanical ventilation (MV) have been widely studied. However, paradoxical bacteremia incidences remain unexplained. Methods The literature was searched for studies of topical PM–based regimens used to decontaminate MV patients reporting incidences of overall and Pseudomonas bacteremia data. In addition, observational groups without any intervention and trials of various interventions other than topical PM (non-PM studies) served to provide external benchmarks and additional points of reference, respectively. The bacteremia incidences were extracted from the control and intervention (component) groups of these studies and compared with metaregression using generalized estimating equation methods. Results The summary odds ratio derived from studies of topical PM–based interventions against overall bacteremia was 0.60 (95% confidence interval [CI], 0.53–0.69). Benchmark incidences per 100 MV patients for overall (mean, 8.9%; 95% CI, 6.9% to 10.9%) and Pseudomonas (mean, 0.7%; 95% CI, 0.5% to 1.1%) bacteremia were derived from 16 observational studies. By contrast, among 17 studies of topical PM, the mean incidences among control groups for overall (mean, 15.3%; 95% CI, 11.5% to 20.3%) and Pseudomonas (mean, 1.6%; 95% CI, 0.9% to 3.1%) bacteremia were both higher, whereas these incidences in the intervention groups for both topical PM and non-PM studies were in each case more similar to the respective benchmarks. These paradoxical incidences cannot readily be explained in metaregression models. Conclusions Paradoxically, despite an apparent prevention effect of topical PM–based methods against bacteremia overall, the incidences of Pseudomonas bacteremia within the component groups of these studies are unusually high vs literature-derived benchmarks.

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The Perfidious Effect of Topical Placebo: Calibration of Staphylococcus aureus Ventilator-Associated Pneumonia Incidence within Selective Digestive Decontamination Studies versus the Broader Evidence Base

Antimicrobial Agents and Chemotherapy ◽

10.1128/aac.00424-13 ◽

2013 ◽

Vol 57 (9) ◽

pp. 4524-4531 ◽

Cited By ~ 16

Author(s):

James C. Hurley

Keyword(s):

Staphylococcus Aureus ◽

Observational Studies ◽

Estimating Equation ◽

Evidence Base ◽

Selective Digestive Decontamination ◽

Generalized Estimating Equation ◽

Ventilator Associated Pneumonia ◽

Control Groups ◽

Content Type ◽

The Mean

ABSTRACTAmong various methods for preventing ventilator-associated pneumonia (VAP), the evidence base for selective digestive decontamination (SDD) appears most compelling. However, the extent ofStaphylococcus aureusemergence with SDD use remains uncertain. Groups from 37 observational studies and component (control and intervention) groups from 58 studies of SDD and other methods of VAP prevention were sourced exclusively from 10 systematic reviews.S. aureusas a proportion of VAP isolates (S. aureusisolate proportion [S. aureusIP]) among component groups was calibrated versus that among observational groups (the benchmark). The influence of topical placebo used for blinding purposes and other group-level factors was estimated using generalized estimating equation methods (GEE). The meanS. aureusIP is 22% (95% confidence interval [CI], 19 to 25) for 37 observational groups versus 32% (24 to 41) and 20% (15 to 25) for 22 control groups from the SDD evidence base which did versus did not receive topical placebo, respectively. In GEE models including all 148 observational and component groups, membership of a control (P= 0.03) or intervention (P< 0.001) group of an SDD study that used topical placebo was associated with higherS. aureusIP, whereas, in contrast, membership of these groups was without effect onPseudomonas aeruginosa. Topical placebo is implicated as a vehicle for selective cross-infection withS. aureuswithin the specific context of the SDD evidence base. This effect of topical placebo is perfidious; it could contribute to the higher VAP incidence and inflate the apparent “effectiveness” of SDD. The SDD evidence base requires reappraisal.

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Incidences ofPseudomonas aeruginosa-Associated Ventilator-Associated Pneumonia within Studies of Respiratory Tract Applications of Polymyxin: Testing the Stoutenbeek Concurrency Postulates

Antimicrobial Agents and Chemotherapy ◽

10.1128/aac.00291-18 ◽

2018 ◽

Vol 62 (8) ◽

Cited By ~ 4

Author(s):

James C. Hurley

Keyword(s):

Respiratory Tract ◽

Estimating Equation ◽

Ventilator Associated Pneumonia ◽

Control Groups ◽

Content Type ◽

Mechanically Ventilated ◽

Concurrent Control ◽

Component Group ◽

Funnel Plots ◽

The Mean

ABSTRACTRegimens containing topical polymyxin appear highly effective at preventing ventilator-associated pneumonia (VAP) overall and, more so, VAP caused by Gram-negative bacteria. However, Stoutenbeek's postulates that VAP incidences within studies of topical antibiotics depend on the context of whether the component (control and intervention) groups of each study were concurrent versus nonconcurrent remain untested. The literature was searched for concurrent control (CC) versus nonconcurrent control (NCC) designed studies of respiratory tract applications of topical polymyxin to mechanically ventilated (MV) patients that reported incidences ofPseudomonas-associated ventilator-associated pneumonia (PsVAP). Studies of various interventions other than topical polymyxin (nonpolymyxin studies) served to provide additional points of reference. The PsVAP incidences within the component groups of all studies were benchmarked against groups from observational studies. This was undertaken by meta-regression using generalized estimating equation methods. Dot plots, caterpillar plots, and funnel plots enable visual benchmarking. The PsVAP benchmark (and 95% confidence interval [CI]) derived from 102 observational groups is 4.6% (4.0 to 5.3%). In contrast, the mean PsVAP within NCC polymyxin intervention groups (1.6%; CI, 1.0 to 4.5%) is lower than that of all other component group categories. The mean PsVAP within CC polymyxin control groups (9.9%; CI, 7.6 to 12.8%) is higher than that of all other component group categories. The PsVAP incidences of control and intervention groups of studies of respiratory tract applications of polymyxin are dependent on whether the groups were within a concurrent versus nonconcurrent study. Stoutenbeek's concurrency postulates are validated.

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Relapses and disease-modifying drug treatment in pregnancy and live birth in US women with MS

Neurology ◽

10.1212/wnl.0000000000006382 ◽

2018 ◽

Vol 91 (17) ◽

pp. e1570-e1578 ◽

Cited By ~ 22

Author(s):

Maria K. Houtchens ◽

Natalie C. Edwards ◽

Amy L. Phillips

Keyword(s):

Live Birth ◽

Odds Ratio ◽

Emergency Room Visit ◽

Outpatient Visit ◽

Estimating Equation ◽

Generalized Estimating Equation ◽

Administrative Claims ◽

Second Trimester ◽

Disease Modifying ◽

Relapse Rates

ObjectiveTo evaluate relapse rates and disease-modifying drug (DMD) treatment in US women with multiple sclerosis (MS) and a live birth.MethodsThis retrospective administrative claims database study used US commercial health plan data from women with MS and a live birth from January 1, 2006, to June 30, 2015. Relapses and DMD treatment were evaluated 1-year prepregnancy, during pregnancy, during puerperium (6 weeks postpregnancy), and 1-year postpregnancy. Relapse was defined as MS-related hospitalization, emergency room visit, or outpatient visit with corticosteroid prescription within 7 days. Generalized estimating equation models for longitudinal data tested for differences between prepregnancy vs the other time periods.ResultsA total of 2,158 patients were eligible. The odds of relapse declined during pregnancy (odds ratio [OR] 0.623, 95% confidence interval [CI] 0.521–0.744; p < 0.0001), increased during puerperium (OR 1.710, 95% CI 1.358–2.152; p < 0.0001), and ended at a higher level during the last 3 postpartum quarters (OR 1.216, 95% CI 1.052–1.406; p = 0.0081). The proportion of women with DMD treatment was rather low overall: approximately 20% prepregnancy, bottoming to 1.9% during the second trimester, and peaking at 25.5% 9 to 12 months postpartum. DMD treatment declined significantly during pregnancy (OR 0.171, 95% CI 0.144–0.203; p < 0.0001), remained lower during puerperium (OR 0.361, 95% CI 0.312–0.418; p < 0.0001), and ended at a higher level during the last 3 postpartum quarters (OR 1.259, 95% CI 1.156–1.371; p < 0.0001).ConclusionsThe rate of MS relapse decreased during pregnancy, increased 6 months postpartum, and decreased 6 to 12 months postpartum. DMD treatment was uncommon in the year before pregnancy, further decreased immediately prepregnancy and during pregnancy, and increased postpartum.

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Gradual Reduction of Endotracheal Tube Diameter during Mechanical Ventilation via Different Humidification Devices

Anesthesiology ◽

10.1097/00000542-199612000-00015 ◽

1996 ◽

Vol 85 (6) ◽

pp. 1341-1349. ◽

Cited By ~ 95

Author(s):

Maria Cristina Villafane ◽

Gilda Cinnella ◽

Frederic Lofaso ◽

Daniel Isabey ◽

Alain Harf ◽

...

Keyword(s):

Mechanical Ventilation ◽

Prolonged Mechanical Ventilation ◽

Water System ◽

Hot Water ◽

Mechanically Ventilated ◽

Mean Diameter ◽

The Mean ◽

Heat And Moisture

Background Limited data suggest that increased resistance to flow within endotracheal tubes (ETT) may occur in patients whose lungs are mechanically ventilated for more than 48 h, especially when airway humidification is inadequate. This could lead to sudden ETT obstruction or induce excessive loading during spontaneous breathing. Methods Twenty-three such patients were randomly assigned to three types of airway humidifier based on three different working principles: a Fisher Paykell hot water system (n = 7), a Pall BB2215 heat and moisture exchanger (HME) hydrophobic filter (n = 8), and a Dar Hygrobac 35254111 HME hygroscopic filter (n = 8). The decrease in internal pressure along the ETT and the flow rate were measured in each patient every 2 days. An "effective inner diameter" was derived from these measurements and allowed the inner ETT configuration to be monitored. Results On the first day of intubation, the mean diameter was similar in the three groups, and was slightly smaller than the in vitro diameter (mean +/- SD: 7.6 +/- 0.6 mm for Fisher-Paykell, 7.7 +/- 0.4 for Pall, and 7.5 +/- 0.4 for Dar). The mean diameter tended to decrease from day to day. At the end of the study, the overall reduction in mean diameter was significantly greater with the hydrophobic HME (Pall) than with the two other systems (Pall: -6.5 +/- 4% vs. 2.5 +/- 2.5% for Dar and 1.5 +/- 3% for Fisher-Paykell; P < 0.01 with analysis of variance). The same was true of the mean reduction in effective inner ETT diameter expressed per day of ventilation (-1.6 +/- 1.5% per day for Pall vs. -0.5 +/- 0.4% for Dar and -0.2 +/- 0.4% for Fisher-Paykell; P < 0.01). In four patients, the ETT became obstructed and emergency repeated tracheal intubation was required. The Pall HME and the Fisher-Paykell system were being used in three and one patient, respectively. Before obstruction, the reduction in ETT diameter was significantly greater for these four patients than for the remaining 23 patients (7.8 +/- 1.4% vs. 3.1 +/- 4.1%; P < 0.01). Conclusions During prolonged mechanical ventilation, significant alterations in inner ETT configuration occur frequently and are influenced by the type of humidification device used. In vivo monitoring of ETT mechanical properties might be clinically useful.

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The Effect of Hollyhock (Althaea officinalis L) Leaf Compresses Combined With Warm and Cold Compress on Breast Engorgement in Lactating Women

Journal of Evidence-Based Complementary & Alternative Medicine ◽

10.1177/2156587215617106 ◽

2016 ◽

Vol 22 (1) ◽

pp. 25-30 ◽

Cited By ~ 3

Author(s):

Shahla Khosravan ◽

Hossein Mohammadzadeh-Moghadam ◽

Fatemeh Mohammadzadeh ◽

Samane Ajam Khames Fadafen ◽

Malihe Gholami

Keyword(s):

Significant Relationship ◽

Intervention Group ◽

Estimating Equation ◽

Generalized Estimating Equation ◽

Control Groups ◽

Lactating Women ◽

Significant Difference ◽

Althaea Officinalis ◽

And Control ◽

Generalized Estimating

Breast engorgement affects lactation. The present study was conducted to determine the effect of hollyhock combined with warm and cold compresses on improving breast engorgement in lactating women. Participants included 40 women with breast engorgement divided into intervention and control groups, with participants in both groups being applied routine interventions and warm compress before nursing and a cold compress after nursing; however, the intervention group was also applied hollyhock compress. Both groups received these treatments 6 times during 2 days. The data collected were analyzed in SPSS-16 using a generalized estimating equation. According to the results, a significant difference was observed in the overall breast engorgement severity in the intervention group ( P < .001). The severity of breast engorgement was also found to have a significant relationship with time ( P < .001). According to the findings, hollyhock leaf compress combined with performing routine interventions for breast engorgement can improve breast engorgement.

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Quality improvement teams, super-users, and nurse champions: a recipe for meaningful use?

Journal of the American Medical Informatics Association ◽

10.1093/jamia/ocw029 ◽

2016 ◽

Vol 23 (6) ◽

pp. 1195-1198 ◽

Cited By ~ 6

Author(s):

Christopher M Shea ◽

Kristin L Reiter ◽

Mark A Weaver ◽

Jordan Albritton

Keyword(s):

Quality Improvement ◽

Correlation Matrix ◽

Odds Ratio ◽

Meaningful Use ◽

Estimating Equation ◽

Generalized Estimating Equation ◽

Clinical Data Warehouse ◽

Working Correlation ◽

Stage 1 ◽

Super Users

Abstract Objective This study assessed whether having an electronic health record (EHR) super-user, nurse champion for meaningful use (MU), and quality improvement (QI) team leading MU implementation is positively associated with MU Stage 1 demonstration. Methods Data on MU demonstration of 596 providers in 37 ambulatory care clinics came from the clinical data warehouse and administrative systems of UNC Health Care. We surveyed the 37 clinics about champions, super-users, and QI teams. We used generalized estimating equation methods with an independence working correlation matrix to account for clustering within clinics and to weight contributions from each clinic according to clinic size. Results Having a QI team lead MU implementation was significantly associated with MU demonstration (odds ratio, OR = 3.57, 95% CI, 1.83-6.96, P < .001, Table 2 ). Having neither a nurse champion nor an EHR super-user was significant. Conclusion Our findings support the alignment of MU with QI efforts by having the QI team lead MU implementation.

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A Longitudinal Study of Changes in Cognition Among Older Thais: Studying From the Kanchanaburi Demographic Surveillance System

Gerontology and Geriatric Medicine ◽

10.1177/2333721419862885 ◽

2019 ◽

Vol 5 ◽

pp. 233372141986288

Author(s):

Natchaphon Auampradit ◽

Patama Vapattanawong ◽

Sureeporn Punpuing ◽

Malee Sunpuwan ◽

Tawanchai Jirapramukpitak

Keyword(s):

Cognitive Impairment ◽

Odds Ratio ◽

Surveillance System ◽

Wealth Index ◽

Estimating Equation ◽

Demographic Surveillance System ◽

Generalized Estimating Equation ◽

Delayed Recall ◽

Longitudinal Effects ◽

Working Status

Objectives: To examine the impacts of changes in social determinants of health (SDH) toward changes in cognition. Methods: Longitudinal data came from the Kanchanaburi Demographic Surveillance System (KDSS) collected in 2007 and 2011. Cognitive impairment was measured by category fluency and delayed recall. Generalized estimating equation (GEE) was used to investigate changes in cognition by taking SDH and other variables including age, gender, marital status, education, and depression into the model. Results: GEE revealed longitudinal effects of wealth index and working status against cognition. Older Thais living with richest wealth index (odds ratio [OR] = 0.54; 95% confidence interval [CI] = 0.31-0.94) and still being employed (OR = 0.65; 95% CI = 0.47-0.89) were less likely to have cognitive impairment. Discussion: Poorer wealth index and being unemployed were served as a risk factor for cognitive impairment over time. Increasing age was still the major risk for cognitive impairment.

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Contemporary Trends in the Treatment of Mild Ischemic Stroke with Intravenous Thrombolysis: Paul Coverdell National Acute Stroke Program

Cerebrovascular Diseases ◽

10.1159/000517969 ◽

2021 ◽

pp. 1-7

Author(s):

Ganesh Asaithambi ◽

Xin Tong ◽

Sallyann M. Coleman King ◽

Mary G. George

Keyword(s):

Ischemic Stroke ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Intravenous Thrombolysis ◽

Estimating Equation ◽

National Institutes Of Health ◽

Generalized Estimating Equation ◽

Mild Stroke ◽

The Impact ◽

Program Data

Background: Presentation with mild symptoms is a common reason for intravenous thrombolysis (IVT) nonuse among acute ischemic stroke (AIS) patients. We examined the impact of IVT on the outcomes of mild AIS over time. Methods: Using the Paul Coverdell National Stroke Program data, we examined trends in IVT utilization from 2010 to 2019 among AIS patients presenting with National Institutes of Health Stroke Scale (NIHSS) scores ≤5. Outcomes adjudicated included rates of discharge to home and ability to ambulate independently at discharge. We used generalized estimating equation models to examine the effect of IVT on outcomes of AIS patients presenting with mild symptoms and calculated adjusted odds ratio (AOR) with 95% confidence intervals (CI). Results: During the study period, 346,762 patients presented with mild AIS symptoms. Approximately 6.2% were treated with IVT. IVT utilization trends increased from 3.7% in 2010 to 7.7% in 2019 (p < 0.001). Patients treated with IVT had higher median NIHSS scores upon presentation (IVT 3 [2, 4] vs. no IVT 2 [0, 3]). Rates of discharge to home (AOR 2.06, 95% CI: 1.99–2.13) and ability to ambulate at time of discharge (AOR 1.82, 95% CI: 1.76–1.89) were higher among those treated with IVT. Conclusion: There was an increased trend in IVT utilization among AIS patients presenting with mild symptoms. Utilization of IVT increased the odds of being discharged to home and the ability to ambulate at discharge independently in patients with mild stroke.

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The Clinical Usefulness of the Platelet Aggregation Test for the Diagnosis of Heparin-Induced Thrombocytopenia

Thrombosis and Haemostasis ◽

10.1055/s-0038-1651610 ◽

1993 ◽

Vol 69 (04) ◽

pp. 344-350 ◽

Cited By ~ 175

Author(s):

B H Chong ◽

J Burgess ◽

F Ismail

Keyword(s):

Platelet Aggregation ◽

Heparin Therapy ◽

Serotonin Release ◽

Point System ◽

Control Groups ◽

Heparin Induced Thrombocytopenia ◽

Heparin Concentration ◽

Release Test ◽

The Mean ◽

Normal Controls

SummaryThe platelet aggregation test is widely used for the diagnosis of heparin-induced thrombocytopenia (HIT), a potentially serious complication of heparin therapy. We have evaluated its sensitivity and specificity in comparison with those of the 14C-serotonin release test. The sensitivity of the platelet aggregation test was found to vary with the heparin concentration and the donor of the platelets used in the test. The optimal heparin concentrations were between 0.1 and 1.0 U/ml. Using these heparin concentrations, the mean sensitivity varied from 39% (with the least reactive platelets) to 81% (with the most reactive platelets). In comparison, the sensitivity of the release test ranged from 65% to 94%. The specificities of the platelet aggregation test were 82%, 90% and 100% for the following control groups: (1) non-thrombocytopenic patients given heparin, (2) patients with thrombocytopenia due to other causes, and (3) normal controls not given heparin, respectively. The corresponding specificities for the release test was 94%, 90% and 100%. The specificities can be further increased to 100% for all controls with the adoption of a two-point system which defines a positive result as one in which platelet aggregation occurs with a low heparin concentration (0.5 U/ml) but not with 100 U heparin/ml. For optimal results, a two-point platelet aggregation test should be performed with heparin concentrations of 0.5 and 100 U/ml and using platelets of more reactive donors.

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The Quantitation of Platelet Aggregation Induced by Four Compounds: A Study in Relation to Myocardial Infarction

Thrombosis and Haemostasis ◽

10.1055/s-0038-1655660 ◽

1966 ◽

Vol 16 (03/04) ◽

pp. 752-767 ◽

Cited By ~ 23

Author(s):

J. R O’Brien ◽

F. C Path ◽

Joan B. Heywood ◽

J. A Heady

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Platelet Aggregation ◽

Platelet Rich Plasma ◽

Myocardial Infarct ◽

Control Groups ◽

The Mean ◽

Platelet Shape

SummaryMethods for measuring and comparing day to day differences in the response of platelet aggregation in platelet-rich plasma to added ADP, 5-H.T., adrenaline and collagen are reported. Platelet aggregation induced by ADP, 5-H.T. and adrenaline was studied in patients with acute myocardial infarction and in others 3 months to 5 years after an infarct; some were receiving anti-coagulants and others not: these three groups were compared with three control groups. The mean platelet shape was rounder and the response to ADP and to 5-H.T. and one parameter of the response to adrenaline was significantly greater in all groups of patients with myocardial infarct taken together than in the controls. The platelet-rich plasma from patients with recent infarction were most responsive to ADP and 5-H.T. immediately after the infarct. Anti-coagulants had no effect on these tests. However, there was wide variation within the individuals and much overlap between groups, and these tests can only reliably distinguish between groups and not between individuals. The significance of these findings is discussed.

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