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An international perspective on hospitalized patients with viral community-acquired pneumonia.

Thu, 11/08/2018 - 07:46
Related Articles

An international perspective on hospitalized patients with viral community-acquired pneumonia.

Eur J Intern Med. 2018 Nov 03;:

Authors: Radovanovic D, Sotgiu G, Jankovic M, Mahesh PA, Marcos PJ, Abdalla MI, Di Pasquale MF, Gramegna A, Terraneo S, Blasi F, Santus P, Aliberti S, Reyes LF, Restrepo MI, GLIMP Study Group, Aruj PK, Attorri S, Barimboim E, Caeiro JP, Garzón MI, Cambursano VH, Ceccato A, Chertcoff J, Cordon Díaz A, de Vedia L, Ganaha MC, Lambert S, Lopardo G, Luna CM, Malberti AG, Morcillo N, Tartara S, Pensotti C, Pereyra B, Scapellato PG, Stagnaro JP, Shah S, Lötsch F, Thalhammer F, Anseeuw K, Francois CA, Van Braeckel E, Vincent JL, Djimon MZ, Aranha Nouér S, Chipev P, Encheva M, Miteva D, Petkova D, Balkissou AD, Pefura Yone EW, Mbatchou Ngahane BH, Shen N, Xu JF, Bustamante Rico CA, Buitrago R, Pereira Paternina FJ, Kayembe Ntumba JM, Vladic-Carevic V, Jakopovic M, Matkovic Z, Mitrecic I, Bouchy Jacobsson ML, Bro Christensen A, Heitmann Bødtger UC, Meyer CN, Vestergaard Jensen A, El-Said Abd El-Wahhab I, Elsayed Morsy N, Shafiek H, Sobh E, Abdulsemed KA, Bertrand F, Brun-Buisson C, de Montmollin E, Fartoukh M, Messika J, Tattevin P, Khoury A, Ebruke B, Dreher M, Kolditz M, Meisinger M, Pletz MW, Hagel S, Rupp J, Schaberg T, Spielmanns M, Creutz P, Suttorp N, Siaw-Lartey B, Dimakou K, Papapetrou D, Tsigou E, Ampazis D, Kaimakamis E, Bhatia M, Dhar R, D'Souza G, Garg R, Koul PA, Jayaraj BS, Narayan KV, Udnur HB, Krishnamurthy SB, Kant S, Swarnakar R, Salvi S, Limaye S, Golshani K, Keatings VM, Martin-Loeches I, Maor Y, Strahilevitz J, Battaglia S, Carrabba M, Ceriana P, Confalonieri M, d'Arminio Monforte A, Del Prato B, De Rosa M, Fantini R, Fiorentino G, Gammino MA, Menzella F, Milani G, Nava S, Palmiero G, Petrino R, Gabrielli B, Rossi P, Sorino C, Steinhilber G, Zanforlin A, Franzetti F, Carone M, Patella V, Scarlata S, Comel A, Kurahashi K, Aoun Bacha Z, Barajas Ugalde D, Ceballos Zuñiga O, Villegas JF, Medenica M, van de Garde EMW, Raj Mihsra D, Shrestha P, Ridgeon E, Ishola Awokola B, Nwankwo ONO, Olufunlola AB, Olumide S, Ukwaja KN, Irfan M, Minarowski L, Szymon S, Froes F, Leuschner P, Meireles M, Ferrão C, Leuschner P, Neves J, Ravara SB, Brocovschii V, Ion C, Rusu D, Toma C, Chirita D, Dorobat CM, Birkun A, Kaluzhenina A, Almotairi A, Bukhary ZAA, Edathodu J, Fathy A, Mushira Abdulaziz Enani A, Eltayeb Mohamed N, Ulhadi Memon J, Bella A, Bogdanović N, Milenkovic B, Pesut D, Borderìas L, Bordon Garcia NM, Cabello Alarcón H, Cilloniz C, Torres A, Diaz-Brito V, Casas X, Encabo González A, Fernández-Almira ML, Gallego M, Gaspar-GarcÍa I, González Del Castillo J, Javaloyes Victoria P, Laserna Martínez E, Malo de Molina R, Menéndez R, Pando-Sandoval A, Prat Aymerich C, Lacoma de la Torre A, García-Olivé I, Rello J, Moyano S, Sanz F, Sibila O, Rodrigo-Troyano A, Solé-Violán J, Uranga A, van Boven JFM, Vendrell Torra E, Pujol JA, Feldman C, Kee Yum H, Fiogbe AA, Yangui F, Bilaceroglu S, Dalar L, Yilmaz U, Bogomolov A, Elahi N, Dhasmana DJ, Feneley A, Hancock C, Hill AT, Rudran B, Ruiz-Buitrago S, Campbell M, Whitaker P, Youzguin A, Singanayagam A, Allen KS, Brito V, Dietz J, Dysart CE, Kellie SM, Franco-Sadud RA, Meier G, Gaga M, Holland TL, Bergin SP, Kheir F, Landmeier M, Lois M, Nair GB, Patel H, Reyes K, Rodriguez-Cintron W, Saito S, Soni NJ, Noda J, Hinojosa CI, Levine SM, Angel LF, Anzueto A, Scott Whitlow K, Hipskind J, Sukhija K, Totten V, Wunderink RG, Shah RD, Mateyo KJ, Carugati M, Morosi M, Monge E

Abstract
BACKGROUND: Who should be tested for viruses in patients with community acquired pneumonia (CAP), prevalence and risk factors for viral CAP are still debated. We evaluated the frequency of viral testing, virus prevalence, risk factors and treatment coverage with oseltamivir in patients admitted for CAP.
METHODS: Secondary analysis of GLIMP, an international, multicenter, point-prevalence study of hospitalized adults with CAP. Testing frequency, prevalence of viral CAP and treatment with oseltamivir were assessed among patients who underwent a viral swab. Univariate and multivariate analysis was used to evaluate risk factors.
RESULTS: 553 (14.9%) patients with CAP underwent nasal swab. Viral CAP was diagnosed in 157 (28.4%) patients. Influenza virus was isolated in 80.9% of cases. Testing frequency and viral CAP prevalence were inhomogeneous across the participating centers. Obesity (OR 1.59, 95%CI: 1.01-2.48; p = 0.043) and need for invasive mechanical ventilation (OR 1.62, 95%CI: 1.02-2.56; p = 0.040) were independently associated with viral CAP. Prevalence of empirical treatment with oseltamivir was 5.1%.
CONCLUSION: In an international scenario, testing frequency for viruses in CAP is very low. The most common cause of viral CAP is Influenza virus. Obesity and need for invasive ventilation represent independent risk factors for viral CAP. Adherence to recommendations for treatment with oseltamivir is poor.

PMID: 30401576 [PubMed - as supplied by publisher]

Lay navigation across the cancer continuum for older cancer survivors: Equally beneficial for Black and White survivors?

Tue, 11/06/2018 - 07:30
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Lay navigation across the cancer continuum for older cancer survivors: Equally beneficial for Black and White survivors?

J Geriatr Oncol. 2018 Oct 30;:

Authors: Pisu M, Rocque GB, Jackson BE, Kenzik KM, Sharma P, Williams CP, Kvale EA, Taylor RA, Williams GR, Azuero A, Li Y, Acemgil A, Martin MY, Demark-Wahnefried W, Turkman Y, Fouad M, Rocconi RP, Sullivan M, Cantuaria G, Partridge EE, Meneses K

Abstract
OBJECTIVES: The Patient Care Connect Program (PCCP), through lay navigators' distress assessments and assistance, was shown to lower healthcare utilization and costs in older cancer survivors. PCCP benefits and assistance needs for disadvantaged minorities (e.g., Black) vs. Whites are unknown.
MATERIALS AND METHODS: We examined the PCCP impact with retrospective analyses of Medicare claims (2012-2015). Outcomes were quarterly costs and utilization (emergency room (ER), hospitalizations) for navigated and matched survivors. Repeated measures generalized linear models with normal (costs), and Poisson (utilization) distributions assessed differences in trends overall and separately for Blacks and Whites. With distress data for navigated survivors, we assessed high distress (score > 3), ≥1 distress cause (overall, by domain), and ≥ 1 assistance request by minority group.
RESULTS: Beneficiaries were: 772 Black and 5350 White navigated, and 770 Black and 5348 White matched survivors. Impact was: i) costs: -$557.5 Blacks (p < .001), -$813.4 Whites (p < .001); ii) ER: Incidence Rate Ratio (IRR) 0.97 Blacks (NS), 0.93 Whites (p < .001); iii) hospitalizations: IRR 0.97 Blacks (NS), 0.91 Whites (p < .001). There was no significant difference in impact across minority groups. No significant differences were found in high distress (29% Black, 25.1% White), ≥1 distress cause (61.6% Black, 57.8% White), or ≥ 1 assistance request (64.5% Black, 59.1% White). Blacks were more likely to have ≥1 distress cause in the Practical domain.
CONCLUSION: The PCCP may benefit both Black and White older cancer survivors. Programs should consider the proportion of older survivors with high distress, and the specific needs of minorities.

PMID: 30389494 [PubMed - as supplied by publisher]

Clinical Outcomes for Diabetic Foot Ulcers Treated with Clostridial Collagenase Ointment or with a Product Containing Silver.

Wed, 10/31/2018 - 07:56
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Clinical Outcomes for Diabetic Foot Ulcers Treated with Clostridial Collagenase Ointment or with a Product Containing Silver.

Adv Wound Care (New Rochelle). 2018 Oct 01;7(10):339-348

Authors: Motley TA, Caporusso JM, Lange DL, Eichelkraut RA, Cargill DI, Dickerson JE

Abstract
Objective: To compare outcomes of diabetic foot ulcers (DFUs) treated with clostridial collagenase ointment (CCO) or silver-containing products, both in combination with sharp debridement as needed. Approach: One hundred two subjects with qualifying DFUs were randomized to daily treatment with either CCO or a silver-containing product for 6 weeks followed by a 4 -week follow-up period. The primary outcome was the mean percent reduction in DFU area. A secondary outcome was the incidence of ulcer infections between groups. Results: At the end of treatment, the mean percent reduction in area from baseline of DFUs treated with CCO was 62% (p < 0.0001) and with silver was 40% (p < 0.0001). The difference between groups-22%-was not statistically significant (p = 0.071). Among ulcers closed by the end of treatment, the mean time to closure was 31.1 ± 9.0 days versus 37.1 ± 7.7 days, respectively (not statistically significant). There was a numerically greater incidence of target ulcer infections in the silver group (11, 21.6%) than in the CCO group (5, 9.8%; p = 0.208). No clinically relevant safety signals were identified in either group. Innovation: CCO treatment can progress a wound toward closure. Ulcer infection prophylaxis may not be sacrificed when treating DFU with CCO in lieu of silver-containing products. Conclusion: Both CCO and silver-containing products promote significant reduction in DFU area over 6 weeks of treatment with no clinically relevant safety concerns. Mean percent reduction in lesion area was numerically (22%) but not significantly greater with CCO compared to silver, as was time to ulcer closure, with an incidence of ulcer infection at least as low as for silver-containing products.

PMID: 30374419 [PubMed]

Measuring childhood cancer late effects: evidence of a healthy survivor effect.

Wed, 10/31/2018 - 07:56
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Measuring childhood cancer late effects: evidence of a healthy survivor effect.

Eur J Epidemiol. 2017 12;32(12):1089-1096

Authors: Asdahl PH, Ojha RP, Winther JF, Holmqvist AS, de Fine Licht S, Gudmundsdottir T, Madanat-Harjuoja L, Tryggvadottir L, Andersen KK, Hasle H, ALiCCS study group

Abstract
INTRODUCTION: Given considerable focus on health outcomes among childhood cancer survivors, we aimed to explore whether survivor bias is apparent during long-term follow-up of childhood cancer survivors.
METHODS: We identified all 1-year survivors of cancer diagnosed before 20 years of age in Denmark, Finland, Iceland, and Sweden. From the general population, we randomly sampled a comparison cohort. Study individuals were followed for hospitalizations for diseases of the gastroenterological tract, endocrine system, cardiovascular system, or urinary tract from the start of the cancer registries to 2010. We estimated cumulative incidence with death as competing risk and used threshold regression to compare the hazards of the diseases of interest at ages 20, 40, 60, and 75 years.
RESULTS: Our study included 27,007 one-year survivors of childhood cancer and 165,620 individuals from the general population. The cumulative incidence of all four outcomes was higher for childhood cancer survivors during early adulthood, but for three outcomes, the cumulative incidence was higher for the general population after age 55 years. The hazard ratios (HRs) decreased for all outcomes with increasing age, and for two of the outcomes, the hazards were higher for the general population at older ages (endocrine diseases: age-specific HRs = 3.0, 1.4, 1.0, 0.87; Cardiovascular diseases: age-specific HRs = 4.1, 1.4, 0.97, 0.84).
CONCLUSIONS: Our findings provide empirical evidence that survivor bias attenuates measures of association when comparing survivors with the general population. The design and analysis of studies among childhood cancer survivors, particularly as this population attains older ages, should account for survivor bias to avoid misinterpreting estimates of disease burden.

PMID: 29185125 [PubMed - indexed for MEDLINE]

Late-Onset T1DM and Older Age Predict Risk of Additional Autoimmune Disease.

Sat, 10/27/2018 - 08:12
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Late-Onset T1DM and Older Age Predict Risk of Additional Autoimmune Disease.

Diabetes Care. 2018 Oct 25;:

Authors: Hughes JW, Bao YK, Salam M, Joshi P, Kilpatrick CR, Juneja K, Nieves D, Bouhairie V, Jordan OJ, Blustein EC, Tobin GS, McGill JB

Abstract
OBJECTIVE: Type 1 diabetes (T1DM) is associated with other autoimmune diseases (AIDs), which may have serious health consequences. The epidemiology of AIDs in T1DM is not well defined in adults with T1DM. In this cross-sectional cohort study, we sought to characterize the incident ages and prevalence of AIDs in adults with T1DM across a wide age spectrum.
RESEARCH DESIGN AND METHODS: A total of 1,212 adults seen at the Washington University Diabetes Center from 2011 to 2018 provided informed consent for the collection of their age, sex, race, and disease onset data. We performed paired association analyses based on age onset of T1DM. Multivariate logistic regression was used to evaluate the independent effects of sex, race, T1DM age of onset, and T1DM duration on the prevalence of an additional AID.
RESULTS: Mean age of T1DM onset was 21.2 ± 14.4 years. AID incidence and prevalence increased with age. Female sex strongly predicted AID risk. The most prevalent T1DM-associated AIDs were thyroid disease, collagen vascular diseases, and pernicious anemia. T1DM age of onset and T1DM duration predicted AID risk. Patients with late-onset T1DM after 30 years of age had higher risks of developing additional AIDs compared with patients with younger T1DM onset.
CONCLUSIONS: The prevalence of AIDs in patients with T1DM increases with age and female sex. Later onset of T1DM is an independent and significant risk factor for developing additional AIDs. Individuals who are diagnosed with T1DM at older ages, particularly women, should be monitored for other autoimmune conditions.

PMID: 30361208 [PubMed - as supplied by publisher]

Healthcare utilization, Medicare spending, and sources of patient distress identified during implementation of a lay navigation program for older patients with breast cancer.

Wed, 10/24/2018 - 08:27
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Healthcare utilization, Medicare spending, and sources of patient distress identified during implementation of a lay navigation program for older patients with breast cancer.

Breast Cancer Res Treat. 2018 01;167(1):215-223

Authors: Rocque GB, Williams CP, Jones MI, Kenzik KM, Williams GR, Azuero A, Jackson BE, Halilova KI, Meneses K, Taylor RA, Partridge E, Pisu M, Kvale EA

Abstract
PURPOSE: Despite benefits for patients, sustainability of breast cancer navigation programs is challenging due to the lack of reimbursement for navigators. This analysis describes distress reported by breast cancer patients to navigators and the impact of navigation on healthcare utilization for older adults with breast cancer.
METHODS: We conducted a retrospective cohort study of Medicare administrative claims data and patient-reported distress assessments. The primary outcome was Medicare spending per beneficiary per quarter. Secondary outcomes included (1) the number of hospitalizations or ER visits in each quarter; (2) distress levels; and (3) causes of distress reported by patients to their navigators. A subset analysis was conducted for stage I/II/III versus stage IV patients.
RESULTS: 776 navigated and 776 control patients were included in the analysis. The average age at diagnosis was 74 years; 13% of the subjects were African American; 95% of patients had stage I-III. Medicare spending declined faster for the navigated group than the matched comparison group by $528 per quarter per patient (95% CL -$667, -$388). Stage I/II/III navigated patients showed a statistically significant decline in Medicare spending, ER visits, and hospitalizations over time compared to the matched comparison group. No differences were observed for stage IV patients. Eighteen percent of patients reported moderate distress. Informational and physical distress were more common in late stage than in early-stage breast cancer.
CONCLUSIONS: Lay navigation reduced healthcare utilization in older adults with breast cancer, with the greatest impact observed in early-stage breast cancer patients.

PMID: 28900752 [PubMed - indexed for MEDLINE]

American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update.

Tue, 10/23/2018 - 05:02
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American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update.

J Am Coll Surg. 2017 01;224(1):59-74

Authors: Ban KA, Minei JP, Laronga C, Harbrecht BG, Jensen EH, Fry DE, Itani KM, Dellinger EP, Ko CY, Duane TM

PMID: 27915053 [PubMed - indexed for MEDLINE]

StatPearls

Fri, 10/19/2018 - 17:15
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StatPearls

Book. 2018 01

Authors:

Abstract
Chorioamnionitis is an infection that can occur before labor, during labor, or after delivery. It can be acute, subacute, or chronic. Subacute chorioamnionitis is associated with chronic lung disease in the infant.[1] Chronic chorioamnionitis is associated with retinopathy of prematurity, very low birth weight, and impaired brain development in the premature infant. Chronic chorioamnionitis is common.[2][3][4] This terminology refers to histologic chorioamnionitis. Histologic chorioamnionitis at term is rarely infectious. In general, the clinical presentation of chorioamnionitis is defined as acute chorioamnionitis. The Greek etymology of the words chorion and amnion mean fetal membrane and itis means inflammation. Further description denotes chorioamnionitis includes the amniotic fluid. Chorioamnionitis may be identified postdelivery or postmortem on a pathologic review of the placenta and cord. In histologic chorioamnionitis, symptoms may be absent, and the placenta or cultures may not show evidence of chorioamnionitis. Most commonly, chorioamnionitis is associated with preterm labor, prolonged rupture of membranes, prolonged labor, tobacco use, nulliparous pregnancy, meconium stained fluid, multiple vaginal exams post rupture of membranes, and in women with known bacterial or viral infections. However, it can occur at term and in women without prior infections. Left untreated, chorioamnionitis can lead to morbidity and mortality for the mother and neonate. Neonatal morbidity and mortality increase in severity and occurrence with earlier gestations. Antibiotic therapy has been shown to reduce the incidence and severity of the infection in both the mother and neonate. However, antibiotics do not eradicate the infection in all cases.


PMID: 30335284

Gabapentin-induced eczematous drug eruption of the bilateral foot.

Wed, 10/17/2018 - 08:01
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Gabapentin-induced eczematous drug eruption of the bilateral foot.

Foot (Edinb). 2018 Jun 18;37:45-47

Authors: Ernst JJ, Ryba D

Abstract
Drug eruptions represent a wide spectrum of cutaneous reactions to various pharmaceutical agents. Given their complexity and varied patterns of presentation, these phenomena are the subject of study of many fields of medicine. Gabapentin is a widely prescribed medication, with numerous drug reactions previously reported. We present what we believe to be a unique presentation of a gabapentin-induced drug eruption primarily affecting the feet.

PMID: 30326409 [PubMed - as supplied by publisher]

Stability of Locking Plate and Compression Screws for Lapidus Arthrodesis: A Biomechanical Comparison of Plate Position.

Tue, 10/16/2018 - 05:13
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Stability of Locking Plate and Compression Screws for Lapidus Arthrodesis: A Biomechanical Comparison of Plate Position.

J Foot Ankle Surg. 2018 May - Jun;57(3):466-470

Authors: Drummond D, Motley T, Kosmopoulos V, Ernst J

Abstract
Lapidus (first tarsometatarsal joint) arthrodesis is an established and widely used procedure for the management of moderate to severe hallux valgus, especially in cases involving hypermobility of the first tarsometatarsal joint. Multiple fixation methods are available, and several previous investigations have studied the relative strengths of these methods, including dorsomedial and plantar plating comparisons. However, these studies compared plates of varying designs and mechanical properties and used varying modes of compression and interfragmentary screw techniques. The present study mechanically investigated the resulting motion, stiffness, and strength of identical locking plate constructs fixed at various anatomic positions around the first tarsometatarsal joint. In a bench-top study, fourth-generation composite bones were divided into 3 fixation groups, each having identical interfragmentary screw applications, and randomized to 1 of 3 plate positions: dorsal, medial, or plantar. The plates applied in each case were identical locking plates, precontoured to fit the anatomy. Each construct was experimentally tested using a cantilever bending approach. The outcomes obtained were stiffness, yield force, displacement at yield, ultimate force, and displacement at ultimate force. The plantar plate position showed superior initial stiffness and force to ultimate failure. The plantar and medial plate positions exhibited superior force to yield. The medial plate position was superior regarding displacement tolerated before the yield point and catastrophic failure. The dorsal plate position was not superior for any outcome measured. Plantar and medial plating each offered biomechanical benefits. Clinical studies using similarly matched constructs are required to show whether these findings translate into improved clinical outcomes.

PMID: 29472168 [PubMed - indexed for MEDLINE]

Concordance with NCCN treatment guidelines: Relations with health care utilization, cost, and mortality in breast cancer patients with secondary metastasis.

Mon, 10/15/2018 - 05:47

Concordance with NCCN treatment guidelines: Relations with health care utilization, cost, and mortality in breast cancer patients with secondary metastasis.

Cancer. 2018 Oct 14;:

Authors: Rocque GB, Williams CP, Kenzik KM, Jackson BE, Azuero A, Halilova KI, Ingram SA, Pisu M, Forero A, Bhatia S

Abstract
BACKGROUND: The impact of National Comprehensive Cancer Network (NCCN) treatment guideline concordance on costs, health care utilization, and mortality for patients with breast cancer and secondary metastases is unknown.
METHODS: From 2007 to 2013, women with early-stage breast cancer who received treatment for secondary metastases (n = 5651) were evaluated for first recorded systemic therapy concordance with NCCN guidelines within the Surveillance, Epidemiology, and End Results Program-Medicare linked database. Generalized linear and mixed effects models evaluated factors associated with nonconcordance and the relation between concordance status and health care utilization and costs. Mortality risk was estimated with Cox regression.
RESULTS: Eighteen percent of the patients received nonconcordant therapy, with the most common being single-agent, human epidermal growth factor receptor 2 (HER2)-targeted therapy (36%), therapy mismatched with the estrogen receptor/HER2 status (11%), unapproved bevacizumab regimens (10%), and adjuvant regimens in a metastatic setting (6%). A younger age, a hormone receptor-negative status, and a HER2-positive status were associated with nonconcordance (P < .05). Nonconcordance was associated with 22% and 21% increased rates of emergency department visits and hospitalizations, respectively, and $1765 higher average monthly Medicare costs. Differences in adjusted mortality risk were noted by the category of nonconcordance; single-agent, HER2-targeted therapy was associated with decreased mortality risk (hazard ratio [HR], 0.66; 95% confidence limit [CL], 0.57-0.76), and increased mortality risk was observed with unapproved bevacizumab use (HR, 1.40; 95% CL, 1.13-1.74).
CONCLUSIONS: Most patients (82%) received treatment consistent with NCCN guidelines. Nonconcordant treatment was associated with higher health care utilization and costs, with mortality differences observed by the type of guideline deviation. Consideration of both patient and financial outcomes will be important as health systems increase the emphasis on guideline-based care.

PMID: 30317547 [PubMed - as supplied by publisher]

Treatment patterns for ductal carcinoma in situ with close or positive mastectomy margins.

Thu, 10/04/2018 - 07:29
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Treatment patterns for ductal carcinoma in situ with close or positive mastectomy margins.

J Surg Res. 2018 Nov;231:36-42

Authors: Jones CE, Richman J, Jackson BE, Wallace AS, Krontiras H, Urist MM, Bland KI, Parker CC

Abstract
BACKGROUND: Mastectomy remains an effective treatment for ductal carcinoma in situ (DCIS) but whether further therapy is warranted for close or positive margins is controversial. We aim to characterize the treatment practices of DCIS throughout the United States in patients who undergo mastectomy with close or positive margins to better understand the use of postmastectomy radiation therapy (PMRT).
MATERIALS AND METHODS: Using the 2004-2013 National Cancer Database, we identified all female patients with a diagnosis of DCIS who underwent mastectomy. Distributional characteristics were summarized for overall and margin-stratified samples. Characteristic differences were assessed by region and receipt of radiation. Chi-square and independent sample t-tests were used to assess differences for categorical and continuous variables, respectively.
RESULTS: In 21,591 patients who met inclusion criteria, 470 patients with close/positive margins were identified. Sixteen percent of patients with close/positive margins received PMRT compared to 1.5% with negative margins (P < 0.01). There was no difference in PMRT and patient race, insurance status, treatment facility, or endocrine therapy. Patients with close/positive margins who received PMRT were more likely to be in an urban setting from the Midwest (24.6%) and Northeast (21.8%) compared to the West (11.0%) and South (10.7%) (P < 0.01).
CONCLUSIONS: Use of PMRT for DCIS following mastectomy with close/positive margins differs across the country. Regional variations in treatment patterns reinforce a need to determine whether PMRT improves survival to establish treatment guidelines.

PMID: 30278953 [PubMed - in process]

The Global Alliance for Infections in Surgery: defining a model for antimicrobial stewardship-results from an international cross-sectional survey.

Tue, 10/02/2018 - 17:06
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The Global Alliance for Infections in Surgery: defining a model for antimicrobial stewardship-results from an international cross-sectional survey.

World J Emerg Surg. 2017;12:34

Authors: Sartelli M, Labricciosa FM, Barbadoro P, Pagani L, Ansaloni L, Brink AJ, Carlet J, Khanna A, Chichom-Mefire A, Coccolini F, Di Saverio S, May AK, Viale P, Watkins RR, Scudeller L, Abbo LM, Abu-Zidan FM, Adesunkanmi AK, Al-Dahir S, Al-Hasan MN, Alis H, Alves C, Araujo da Silva AR, Augustin G, Bala M, Barie PS, Beltrán MA, Bhangu A, Bouchra B, Brecher SM, Caínzos MA, Camacho-Ortiz A, Catani M, Chandy SJ, Jusoh AC, Cherry-Bukowiec JR, Chiara O, Colak E, Cornely OA, Cui Y, Demetrashvili Z, De Simone B, De Waele JJ, Dhingra S, Di Marzo F, Dogjani A, Dorj G, Dortet L, Duane TM, Elmangory MM, Enani MA, Ferrada P, Esteban Foianini J, Gachabayov M, Gandhi C, Ghnnam WM, Giamarellou H, Gkiokas G, Gomi H, Goranovic T, Griffiths EA, Guerra Gronerth RI, Haidamus Monteiro JC, Hardcastle TC, Hecker A, Hodonou AM, Ioannidis O, Isik A, Iskandar KA, Kafil HS, Kanj SS, Kaplan LJ, Kapoor G, Karamarkovic AR, Kenig J, Kerschaever I, Khamis F, Khokha V, Kiguba R, Kim HB, Ko WC, Koike K, Kozlovska I, Kumar A, Lagunes L, Latifi R, Lee JG, Lee YR, Leppäniemi A, Li Y, Liang SY, Lowman W, Machain GM, Maegele M, Major P, Malama S, Manzano-Nunez R, Marinis A, Martinez Casas I, Marwah S, Maseda E, McFarlane ME, Memish Z, Mertz D, Mesina C, Mishra SK, Moore EE, Munyika A, Mylonakis E, Napolitano L, Negoi I, Nestorovic MD, Nicolau DP, Omari AH, Ordonez CA, Paiva JA, Pant ND, Parreira JG, Pędziwiatr M, Pereira BM, Ponce-de-Leon A, Poulakou G, Preller J, Pulcini C, Pupelis G, Quiodettis M, Rawson TM, Reis T, Rems M, Rizoli S, Roberts J, Pereira NR, Rodríguez-Baño J, Sakakushev B, Sanders J, Santos N, Sato N, Sawyer RG, Scarpelini S, Scoccia L, Shafiq N, Shelat V, Sifri CD, Siribumrungwong B, Søreide K, Soto R, de Souza HP, Talving P, Trung NT, Tessier JM, Tumbarello M, Ulrych J, Uranues S, Van Goor H, Vereczkei A, Wagenlehner F, Xiao Y, Yuan KC, Wechsler-Fördös A, Zahar JR, Zakrison TL, Zuckerbraun B, Zuidema WP, Catena F

Abstract
BACKGROUND: Antimicrobial Stewardship Programs (ASPs) have been promoted to optimize antimicrobial usage and patient outcomes, and to reduce the emergence of antimicrobial-resistant organisms. However, the best strategies for an ASP are not definitively established and are likely to vary based on local culture, policy, and routine clinical practice, and probably limited resources in middle-income countries. The aim of this study is to evaluate structures and resources of antimicrobial stewardship teams (ASTs) in surgical departments from different regions of the world.
METHODS: A cross-sectional web-based survey was conducted in 2016 on 173 physicians who participated in the AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections) project and on 658 international experts in the fields of ASPs, infection control, and infections in surgery.
RESULTS: The response rate was 19.4%. One hundred fifty-six (98.7%) participants stated their hospital had a multidisciplinary AST. The median number of physicians working inside the team was five [interquartile range 4-6]. An infectious disease specialist, a microbiologist and an infection control specialist were, respectively, present in 80.1, 76.3, and 67.9% of the ASTs. A surgeon was a component in 59.0% of cases and was significantly more likely to be present in university hospitals (89.5%, p < 0.05) compared to community teaching (83.3%) and community hospitals (66.7%). Protocols for pre-operative prophylaxis and for antimicrobial treatment of surgical infections were respectively implemented in 96.2 and 82.3% of the hospitals. The majority of the surgical departments implemented both persuasive and restrictive interventions (72.8%). The most common types of interventions in surgical departments were dissemination of educational materials (62.5%), expert approval (61.0%), audit and feedback (55.1%), educational outreach (53.7%), and compulsory order forms (51.5%).
CONCLUSION: The survey showed a heterogeneous organization of ASPs worldwide, demonstrating the necessity of a multidisciplinary and collaborative approach in the battle against antimicrobial resistance in surgical infections, and the importance of educational efforts towards this goal.

PMID: 28775763 [PubMed - indexed for MEDLINE]

Short-Course Antimicrobial Therapy Does Not Increase Treatment Failure Rate in Patients with Intra-Abdominal Infection Involving Fungal Organisms.

Tue, 09/25/2018 - 12:35
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Short-Course Antimicrobial Therapy Does Not Increase Treatment Failure Rate in Patients with Intra-Abdominal Infection Involving Fungal Organisms.

Surg Infect (Larchmt). 2018 May/Jun;19(4):376-381

Authors: Elwood NR, Guidry CA, Duane TM, Cuschieri J, Cook CH, O'Neill PJ, Askari R, Napolitano LM, Namias N, Dellinger EP, Watson CM, Banton KL, Blake DP, Hassinger TE, Sawyer RG

Abstract
BACKGROUND: Fungi frequently are isolated in intra-abdominal infections (IAI). The Study to Optimize Peritoneal Infection Therapy (STOP-IT) recently suggested short-course treatment for patients with IAI. It remains unclear whether the presence of fungi in IAI affects the optimal duration of Antimicrobial therapy. We hypothesized that a shorter treatment course in IAI with fungal organisms would be associated with a higher rate of treatment failure.
METHODS: Patients enrolled in the STOP-IT trial were stratified according to the presence or absence of a fungal isolate. They were analyzed as a subgroup based on original randomization to either the control group or an experimental group that received a four-day course of Antimicrobial therapy and by comparison with those without a fungal component to their infection. Descriptive comparisons were performed using a χ2, Fisher exact, or Kruskal-Wallis test as appropriate. The primary outcome was a composite of recurrent IAI, surgical site infection, and death.
RESULTS: A total of 411 patients in the study (79%) had available culture data, of which 58 (14%) had positive fungal cultures. The most common organisms were Candida albicans and C. glabrata. The treatment failure rate was equivalent in the experimental and control arms (29.6% vs. 22.6%; p = 0.54). Patients with fungal isolates were more likely to have malignant disease (25.9% vs. 9.6%; p = 0.0004) and coronary artery disease (22% vs. 12%; p = 0.04), but were otherwise similar to those without fungal isolates. Patients with fungal isolates had more hospital days (median 10 vs. 7; p < 0.0001) and more days to resumption of enteral intake (median 5 vs. 3; p = 0.0006), but there was no difference in the composite outcome.
CONCLUSIONS: Patients with IAI involving fungal organisms randomized to a shorter course of Antimicrobial therapy had no difference in the rate of treatment failure. These results suggest that the presence of fungi in IAI may not indicate independently the need for a longer course of Antimicrobial therapy.

PMID: 29565726 [PubMed - indexed for MEDLINE]

Comparison of pharmacy students' self-efficacy to address cessation counseling needs for traditional and electronic cigarette use.

Sat, 09/22/2018 - 12:59
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Comparison of pharmacy students' self-efficacy to address cessation counseling needs for traditional and electronic cigarette use.

Curr Pharm Teach Learn. 2018 Jul;10(7):955-963

Authors: Nduaguba SO, Ford KH, Bamgbade BA, Ubanyionwu O

Abstract
BACKGROUND AND PURPOSE: This study assessed pharmacy students' self-rated ability to provide cessation counseling for e-cigarette use and traditional cigarette smoking.
EDUCATIONAL ACTIVITY AND SETTING: A cross-sectional study was conducted in spring 2014 at The University of Texas at Austin. Participants included first through fourth year (P1-P4) doctor of pharmacy (PharmD) students. Perceived confidence and knowledge to counsel on cigarette smoking cessation and e-cigarette cessation were self-rated and based on the Ask-Advise-Assess-Assist-and Arrange (5 A's) follow-up model as well as general counseling skills for recreational nicotine product use cessation. Comparisons were made between students' confidence to counsel patients on traditional cigarette smoking cessation and e-cigarette cessation and by class level.
FINDINGS: Compared to cigarette smoking cessation counseling, students were less confident in their ability to counsel on e-cigarette cessation using the 5 A's model and general counseling skills. Students perceived themselves to be less knowledgeable about the harmful effects of e-cigarettes, pharmacists' role in counseling on e-cigarette cessation, and how patients can benefit from e-cigarette cessation counseling. A higher proportion of students reported having no training on e-cigarette cessation compared to cigarette smoking cessation (59% vs 9%).
SUMMARY: Targeted training on how to counsel patients on e-cigarette cessation should be included in pharmacy curricula. Such training is expected to increase the confidence of pharmacists-in-training to address the needs of patients who use e-cigarettes.

PMID: 30236434 [PubMed - in process]

Risks predicting prolonged hospital discharge boarding in a regional acute care hospital.

Wed, 09/19/2018 - 08:03
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Risks predicting prolonged hospital discharge boarding in a regional acute care hospital.

BMC Health Serv Res. 2018 01 30;18(1):59

Authors: Shaikh SA, Robinson RD, Cheeti R, Rath S, Cowden CD, Rosinia F, Zenarosa NR, Wang H

Abstract
BACKGROUND: Prolonged hospital discharge boarding can impact patient flow resulting in upstream Emergency Department crowding. We aim to determine the risks predicting prolonged hospital discharge boarding and their direct and indirect effects on patient flow.
METHODS: Retrospective review of a single hospital discharge database was conducted. Variables including type of disposition, disposition boarding time, case management consultation, discharge medications prescriptions, severity of illness, and patient homeless status were analyzed in a multivariate logistic regression model. Hospital charges, potential savings of hospital bed hours, and whether detailed discharge instructions provided adequate explanations to patients were also analyzed.
RESULTS: A total of 11,527 admissions was entered into final analysis. The median discharge boarding time was approximately 2 h. Adjusted Odds Ratio (AOR) of patients transferring to other hospitals was 7.45 (95% CI 5.35-10.37), to court or law enforcement custody was 2.51 (95% CI 1.84-3.42), and to a skilled nursing facility was 2.48 (95% CI 2.10-2.93). AOR was 0.57 (95% CI 0.47-0.71) if the disposition order was placed during normal office hours (0800-1700). AOR of early case management consultation was 1.52 (95% CI 1.37-1.68) versus 1.73 (95% CI 1.03-2.89) for late consultation. Eighty-eight percent of patients experiencing discharge boarding times within 2 h of disposition expressed positive responses when questioned about the quality of explanations of discharge instructions and follow-up plans based on satisfaction surveys. Similar results (86% positive response) were noted among patients whose discharge boarding times were prolonged (> 2 h, p = 0.44). An average charge of $6/bed/h was noted in all hospital discharges. Maximizing early discharge boarding (≤ 2 h) would have resulted in 16,376 hospital bed hours saved thereby averting $98,256.00 in unnecessary dwell time charges in this study population alone.
CONCLUSION: Type of disposition, case management timely consultation, and disposition to discharge dwell time affect boarding and patient flow in a tertiary acute care hospital. Efficiency of the discharge process did not affect patient satisfaction relative to the perceived quality of discharge instruction and follow-up plan explanations. Prolonged disposition to discharge intervals result in unnecessary hospital bed occupancy thereby negatively impacting hospital finances while delivering no direct benefit to patients.

PMID: 29378577 [PubMed - indexed for MEDLINE]

Association between emergency physician self-reported empathy and patient satisfaction.

Fri, 09/14/2018 - 07:53
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Association between emergency physician self-reported empathy and patient satisfaction.

PLoS One. 2018;13(9):e0204113

Authors: Wang H, Kline JA, Jackson BE, Laureano-Phillips J, Robinson RD, Cowden CD, d'Etienne JP, Arze SE, Zenarosa NR

Abstract
BACKGROUND: Higher physician self-reported empathy has been associated with higher overall patient satisfaction. However, more evidence-based research is needed to determine such association in an emergent care setting.
OBJECTIVE: To evaluate the association between physician self-reported empathy and after-care instant patient-to-provider satisfaction among Emergency Department (ED) healthcare providers with varying years of medical practice experience.
RESEARCH DESIGN: A prospective observational study conducted in a tertiary care hospital ED.
METHODS: Forty-one providers interacted with 1,308 patients across 1,572 encounters from July 1 through October 31, 2016. The Jefferson Scale of Empathy (JSE) was used to assess provider empathy. An after-care instant patient satisfaction survey, with questionnaires regarding patient-to-provider satisfaction specifically, was conducted prior to the patient moving out of the ED. The relation between physician empathy and patient satisfaction was estimated using risk ratios (RR) and their corresponding 95% confidence limits (CL) from log-binomial regression models.
RESULTS: Emergency Medicine (EM) residents had the lowest JSE scores (median 111; interquartile range [IQR]: 107-122) and senior physicians had the highest scores (median 119.5; IQR: 111-129). Similarly, EM residents had the lowest percentage of "very satisfied" responses (65%) and senior physicians had the highest reported percentage of "very satisfied" responses (69%). There was a modest positive association between JSE and satisfaction (RR = 1.04; 95% CL: 1.00, 1.07).
CONCLUSION: This study provides evidence of a positive association between ED provider self-reported empathy and after-care instant patient-to-provider satisfaction. Overall higher empathy scores were associated with higher patient satisfaction, though minor heterogeneity occurred between different provider characteristics.

PMID: 30212564 [PubMed - in process]

Antibiotics versus No Antibiotics for the Treatment of Acute Uncomplicated Diverticulitis: Review of the Evidence and Future Directions.

Wed, 09/12/2018 - 08:59
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Antibiotics versus No Antibiotics for the Treatment of Acute Uncomplicated Diverticulitis: Review of the Evidence and Future Directions.

Surg Infect (Larchmt). 2018 Sep 11;:

Authors: Huston JM, Zuckerbraun BS, Moore LJ, Sanders JM, Duane TM

Abstract
BACKGROUND: Acute diverticulitis occurs in 25% of individuals with diverticular disease and is associated with significant morbidity and mortality rates. Disease severity is classified as uncomplicated or complicated, with the latter including perforation, fistula, obstruction, or distant abscess. Uncomplicated diverticulitis often improves without surgery or invasive therapies. Administration of antibiotics is a standard of care for treatment of acute uncomplicated diverticulitis. However, recent data suggest antibiotics do not influence outcomes significantly. To address these conflicting approaches, the Surgical Infection Society hosted an Update Symposium at its 37th Annual Meeting examining the role of antibiotics in the treatment of acute uncomplicated diverticulitis. Here, we provide a synopsis of the symposium's findings and a brief review of recent prospective and randomized clinical trials on the topic.
METHODS: A search of Embase, MEDLINE, and the Cochrane Library was performed for prospective series and randomized clinical trials published between January 1, 2010, and January 1, 2018, comparing outcomes of antibiotic versus no antibiotic therapy for acute uncomplicated diverticulitis.
RESULTS: We identified two single-center prospective series and two randomized clinical trials comparing outcomes for patients with acute uncomplicated diverticulitis treated with antibiotics versus no antibiotics.
CONCLUSION: Current evidence does not support administration of antibiotics to improve outcomes in carefully selected healthy patients with acute uncomplicated left-sided diverticulitis. Further studies should help identify specific subpopulations of patients who would derive benefit from antibiotic therapy and help define appropriate antibiotic regimens and treatment durations that minimize cost, adverse effects, and risk of anti-microbial resistance.

PMID: 30204549 [PubMed - as supplied by publisher]

Lifestyle Factors and Health-Related Quality of Life in Adult Survivors of Childhood Cancer: A Report From the St. Jude Lifetime Cohort Study.

Wed, 09/12/2018 - 08:59
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Lifestyle Factors and Health-Related Quality of Life in Adult Survivors of Childhood Cancer: A Report From the St. Jude Lifetime Cohort Study.

Cancer. 2018 Sep 11;:

Authors: Zhang FF, Hudson MM, Huang IC, Bhakta N, Ness KK, Brinkman TM, Klosky J, Lu L, Chen F, Ojha RP, Lanctot JQ, Robison LL, Krull KR

Abstract
BACKGROUND: Survivors of childhood cancer report poor health-related quality of life (HRQOL). Modifiable lifestyle factors such as nutrition and physical activity represent opportunities for interventions to improve HRQOL.
METHODS: The authors examined the association between modifiable lifestyle factors and HRQOL among 2480 adult survivors of childhood cancer in the St. Jude Lifetime Cohort Study. Dietary intake, physical activity, cigarette smoking, and alcohol consumption were assessed through questionnaires. Weight and height were measured in the clinic. HRQOL was evaluated using the Medical Outcome Study 36-Item Short Form Survey. The physical component summary (PCS), mental component summary (MCS), and 8 domain scores of HRQOL were calculated. Multivariable linear regression models were used to estimate regression coefficients (β) associated with HRQOL differences.
RESULTS: Being physically active (PCS β = 3.10; and MCS β = 1.48) was associated with higher HRQOL whereas current cigarette smoking (PCS β = -2.30; and MCS β = -6.49) and obesity (body mass index ≥30 kg/m2 ) (PCS β = -3.29; and MCS β = -1.61) were associated with lower HRQOL in both the physical and mental domains. Better diet (Healthy Eating Index-2015) was associated with higher physical HRQOL (PCS β = 1.79). Moderate alcohol consumption was associated with higher physical (PCS β = 1.14) but lower mental (MCS β = -1.13) HRQOL (all P <.05). Adherence to multiple healthy lifestyle factors demonstrated a linear trend with high scores in both physical and mental HRQOL (highest vs lowest adherence: PCS β = 7.60; and MCS β = 5.76 [P for trend, <.0001]).
CONCLUSIONS: The association between healthy lifestyle factors and HRQOL is cumulative, underscoring the importance of promoting multiple healthy lifestyles to enhance HRQOL in long-term survivors of childhood cancer.

PMID: 30204245 [PubMed - as supplied by publisher]

Socioeconomic factors and parity of access to robotic surgery in a county health system.

Wed, 09/12/2018 - 04:28
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Socioeconomic factors and parity of access to robotic surgery in a county health system.

J Robot Surg. 2018 Mar;12(1):35-41

Authors: Tatebe LC, Gray R, Tatebe K, Garcia F, Putty B

Abstract
Equal access to novel surgical technologies remains a policy concern as hospitals adopt robotic surgery with increasing prevalence. This study sought to determine whether socioeconomic factors influence access to robotic surgery. All laparoscopic and robotic fundoplications and paraesophageal hernia repairs performed by a surgical group over 6 years at a county and two neighboring private hospitals were identified. Robotic use by hospital setting, age, gender, reported ethnicity, estimated income, insurance payer, and diagnosis were examined. Of 418 patients identified, 180 (43%) presented to the county hospital, where subjects were younger (51.1 versus 56.2 years, p < 0.001) with lower estimated income ($50,289 versus $62,959, p < 0.001). In the county setting, there was no difference in reported ethnicity (p = 0.169), estimated income (p = 0.081), or insurance payer (p = 0.535) between groups treated laparoscopically versus robotically. There was no difference in the treatment groups by estimated income in the private hospital setting (p = 0.308). Overall higher estimated income and insurance payer were associated with a higher chance of undergoing robotic procedures (p < 0.001). Presence of a paraesophageal hernia was associated with increased chance of undergoing robotic therapy in all comparisons (p < 0.001). No disparity in access to robotic surgery offered in the county hospital was observed based on age, gender, reported ethnicity, estimated income, or insurance payer. Patients with higher income and private insurers were more likely to present to the private hospital setting where robotics is utilized more often. The presence of a paraesophageal hernia was a significant factor in determining robotic therapy in both settings.

PMID: 28247092 [PubMed - indexed for MEDLINE]

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