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OBJECTIVES/GOALS: As hospitals across the nation respond to the need to address community violence, there is a dearth of Hospital-based Violence Intervention Programs (HVIPs) in the South despite having disproportionate rates. This research aims to identify key factors and strategies for implementation of an HVIP among rural patient populations in a southern state. METHODS/STUDY POPULATION: Semi-structured interviews will be conducted with medical providers, social service organizations, and patients transferred from four high-risk rural areas in Arkansas. Data will be analyzed using Framework Analysis, a rapid analysis approach involving framework development, code application, impactful statement identification, and content analysis. Evidence- Based Quality Improvement (EBQI), a group consensus making process, will be conducted to identify key implementation strategies and factors to adapt based interview findings. Priority areas for adaptation will be identified via systematic rating. The EBQI team, including researchers and key rural stakeholders will engage in a series of discussion, vote on final strategies, and develop a guide for future HVIP implementation and pilot testing. RESULTS/ANTICIPATED RESULTS: Findings from this study will result in a prioritized list of barriers and facilitators across sample groups. Factors will be rated by level of importance. Cluster maps will display the relationships among factors. Go and no-go zones will be identified based on importance and feasibility. Implementation strategies will be mapped to barriers and facilitators. DISCUSSION/SIGNIFICANCE: The findings will result in a culturally and geographically relevant HVIP model and package of implementation strategies to test in future hybrid trials (feasibility pilot & multi-site RCT); and shape the future of violence prevention efforts in healthcare settings across the rural South.
To develop a fully automated algorithm using data from the Veterans’ Affairs (VA) electrical medical record (EMR) to identify deep-incisional surgical site infections (SSIs) after cardiac surgeries and total joint arthroplasties (TJAs) to be used for research studies.
Retrospective cohort study.
This study was conducted in 11 VA hospitals.
Patients who underwent coronary artery bypass grafting or valve replacement between January 1, 2010, and March 31, 2018 (cardiac cohort) and patients who underwent total hip arthroplasty or total knee arthroplasty between January 1, 2007, and March 31, 2018 (TJA cohort).
Relevant clinical information and administrative code data were extracted from the EMR. The outcomes of interest were mediastinitis, endocarditis, or deep-incisional or organ-space SSI within 30 days after surgery. Multiple logistic regression analysis with a repeated regular bootstrap procedure was used to select variables and to assign points in the models. Sensitivities, specificities, positive predictive values (PPVs) and negative predictive values were calculated with comparison to outcomes collected by the Veterans’ Affairs Surgical Quality Improvement Program (VASQIP).
Overall, 49 (0.5%) of the 13,341 cardiac surgeries were classified as mediastinitis or endocarditis, and 83 (0.6%) of the 12,992 TJAs were classified as deep-incisional or organ-space SSIs. With at least 60% sensitivity, the PPVs of the SSI detection algorithms after cardiac surgeries and TJAs were 52.5% and 62.0%, respectively.
Considering the low prevalence rate of SSIs, our algorithms were successful in identifying a majority of patients with a true SSI while simultaneously reducing false-positive cases. As a next step, validation of these algorithms in different hospital systems with EMR will be needed.
Background: Daptomycin is considered an effective alternative to vancomycin in patients with methicillin-resistant Staphylococcus aureus bloodstream infection (MRSA BSI). Objective: We investigated the real-world effectiveness of recommended daptomycin doses compared with vancomycin. Methods: This nationwide retrospective cohort study included patients from 124 Veterans’ Affairs hospitals who had a MRSA BSI and were initially treated with vancomycin during 2007–2014. Patients were categorized into 3 groups by daptomycin dose calculated using adjusted body weight: low (>6 mg/kg/day), standard (6–8 mg/kg/day), and high (≥8 mg/kg/day). International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes were used to identify other prior or concurrent infections and comorbidities. Multivariate cox regression was used to compare 30-day all-cause mortality as the primary outcome comparing patients on either low-dose, standard-dose, or high-dose daptomycin with vancomycin. Hazard ratio (HR) and 95% confidence intervals (CIs) were reported. Results: Of the 7,518 patients in the cohort, 683 (9.1%) were switched to daptomycin after initial treatment with vancomycin for their MRSA BSI episode. A low dose of daptyomycin was administered to 181 patients (26.5%), a standard dose was given to 377 patients (55.2%), and a high dose was administered to 125 patients (18.3%). Dose groups differed significantly in body mass index (BMI), presence of an osteomyelitis diagnosis, and diagnosis of diabetes. Thirty-day mortality was significantly lower in daptomycin patients than in those given vancomycin (11.3% vs 17.6%; P < .0001). Treatment with daptomycin was associated with improved 30-day survival compared with vancomycin (HR, 0.66; 95% CI, 0.53–0.84), after adjusting for age, BMI, diagnosis of endovascular infection, skin and soft-tissue infection and osteomyelitis, hospitalization in the prior year, immunosuppression, diagnosis of diabetes, and vancomycin minimum inhibitory concentration (MIC). Treatment with a standard dose of daptomycin was associated with lower mortality compared with vancomycin (HR, 0.63; 95% CI, 0.46–0.86). High and low daptomycin dose groups had a trend toward improved 30-day survival compared with vancomycin (Fig. 1). In 2 separate sensitivity analyses excluding vancomycin patients, there was no difference in 30-day mortality between a standard dose and a high dose (HR, 1.01; 95% CI, 0.51–1.97). However, we detected a trend toward poor survival with a low dose compared with a standard dose (HR, 1.21; 95% CI, 0.73–2.02). Conclusions: A standard dose of daptomycin was significantly associated with lower 30-day mortality compared with continued vancomycin treatment. Accurate dosage of daptomycin and avoidance of low-dose daptomycin should be a part of good antibiotic stewardship practice.
Background: Studies of interventions to decrease rates of surgical site infections (SSIs) must include thousands of patients to be statistically powered to demonstrate a significant reduction. Therefore, it is important to develop methodology to extract data available in the electronic medical record (EMR) to accurately measure SSI rates. Prior studies have created tools that optimize sensitivity to prioritize chart review for infection control purposes. However, for research studies, positive predictive value (PPV) with reasonable sensitivity is preferred to limit the impact of false-positive results on the assessment of intervention effectiveness. Using information from the prior tools, we aimed to determine whether an algorithm using data available in the Veterans Affairs (VA) EMR could accurately and efficiently identify deep incisional or organ-space SSIs found in the VA Surgical Quality Improvement Program (VASQIP) data set for cardiac and orthopedic surgery patients. Methods: We conducted a retrospective cohort study of patients who underwent cardiac surgery or total joint arthroplasty (TJA) at 11 VA hospitals between January 1, 2007, and April 30, 2017. We used EMR data that were recorded in the 30 days after surgery on inflammatory markers; microbiology; antibiotics prescribed after surgery; International Classification of Diseases (ICD) and current procedural terminology (CPT) codes for reoperation for an infection related purpose; and ICD codes for mediastinitis, prosthetic joint infection, and other SSIs. These metrics were used in an algorithm to determine whether a patient had a deep or organ-space SSI. Sensitivity, specificity, PPV and negative predictive values (NPV) were calculated for accuracy of the algorithm through comparison with 30-day SSI outcomes collected by nurse chart review in the VASQIP data set. Results: Among the 11 VA hospitals, there were 18,224 cardiac surgeries and 16,592 TJA during the study period. Of these, 20,043 were evaluated by VASQIP nurses and were included in our final cohort. Of the 8,803 cardiac surgeries included, manual review identified 44 (0.50%) mediastinitis cases. Of the 11,240 TJAs, manual review identified 71 (0.63%) deep or organ-space SSIs. Our algorithm identified 32 of the mediastinitis cases (73%) and 58 of the deep or organ-space SSI cases (82%). Sensitivity, specificity, PPV, and NPV are shown in Table 1. Of the patients that our algorithm identified as having a deep or organ-space SSI, only 21% (PPV) actually had an SSI after cardiac surgery or TJA. Conclusions: Use of the algorithm can identify most complex SSIs (73%–82%), but other data are necessary to separate false-positive from true-positive cases and to improve the efficiency of case detection to support research questions.
Twain’s two most important contemporaries were William Dean Howells and Henry James. Howells was a friend and champion of both writers, although Twain and James expressed distaste toward each other. Each in his own way was an important figure in the emerging literary realism. Although Twain claimed that he preferred reading history and biography over novels and literature, he was an avid reader of his contemporaries’ works, even if he often criticized them. Harriet Beecher Stowe was his next-door neighbor, and he entertained fellow writers in his Hartford mansion. Twain was a champion of some younger writers, although he wearied at the constant demands for advice and help from emerging writers.
In this cohort of Escherichia coli and Klebsiella spp hospital-onset bacteremia, isolated fluoroquinolone resistance had a larger relative impact on mortality than other phenotypic resistance patterns. This finding may support stewardship efforts targeting unnecessary fluoroquinolone use and increased attention from infection prevention and control departments.
OBJECTIVES/SPECIFIC AIMS: High-sensitivity diagnostics for early infant diagnosis (EID) of HIV at the point of care (POC) are not widely available. Lateral flow immunoassays (LFA) can detect HIV-p24, but are not sensitive enough in practice. With improvements, LFA are a compelling platform for POC in EID. We used functionalized magnetic beads and immunocomplex dissociation to improve sensitivity of HIV-p24 LFA. Here, we evaluate the utility for LFA to quantitatively report HIV-p24 concentration and estimate HIV viral load. Using purified p24 protein and virion constructs, we determined the limits of detection for HIV-p24 using LFA rapid tests. Using measurements from HIV-p24 ELISA, laboratory-developed RT-qPCR, droplet digital PCR, and gold standard clinical viral load, we further characterized the relationship between HIV-p24 concentration, HIV genomic RNA, and LFA test line signal. METHODS/STUDY POPULATION: We measured HIV-p24 concentration by ELISA (R&D Systems) and LFA (Alere Determine HIV-1/2 Ab/Ag Combo). An LFA reader instrument was used to image test lines and measure test line signal on the LFA. HIV viral loads were measured using RT-qPCR and droplet digital RT-PCR protocols adapted in our lab. We obtained gold standard viral load measurements using the Roche Cobas TaqMan system at Vanderbilt University Medical Center. Data analysis was performed using Prism 7 and Stata 14. RESULTS/ANTICIPATED RESULTS: LFA test line signal increases in a predictable, dose-dependent manner and correlates with concentration of purified HIV-p24 with a linear range between 50 and 1000 pg/mL (Spearman r=1; p=0.0004). We compared p24 concentration (ELISA). We evaluated the utility of LFA to quantify HIV-p24 from virions suspended in human plasma, which increased the limit of detection for HIV-p24 to 100 pg/mL and shifted the linear range 100–10,000 pg/mL (Spearman r=0.77; p<0.001). To evaluate the relationship between HIV-p24 concentration and concentration of HIV RNA, we employed 3 molecular techniques. The LFA is capable of detecting HIV-p24 concentrations that correspond to a range of viral loads between 653,000 and 1655 copies of viral RNA/mL. DISCUSSION/SIGNIFICANCE OF IMPACT: Our preliminary results are very promising, indicating that commercially available LFA can quantitatively measure HIV-p24 concentration to low levels. When coupled with our analysis of the relationship between HIV-p24 concentration and HIV RNA concentration, LFA may be a potential platform allowing us to estimate HIV viral burden at clinically relevant levels. Our next steps will be to evaluate this relationship in primary, clinical specimens in collaboration with the Tennessee Center for AIDS Research. We will incorporate technologies to improve the sensitivity of these LFA and evaluate their performance in field settings in Zambia. Our findings are broadly applicable for use in HIV care and treatment programs and early infant diagnosis programs around the world.
Using a stochastic version of the POLYSYS modeling framework, an examination of projected variability in agricultural prices, supply, demand, stocks, and incomes is conducted for corn, wheat, soybeans, and cotton during the 1998–2006 period. Increased planting flexibility introduced in the 1996 farm bill results in projections of significantly higher planted acreage variability compared to recent historical levels. Variability of ending stocks and stock-to-use ratios is projected to be higher for corn and soybeans and lower for wheat and cotton compared to the 1986–96 period. Significantly higher variability is projected for corn prices, with wheat and soybean prices also being more variable. No significant change in cotton price variability is projected.
Lutein and zeaxanthin are xanthophyll carotenoids present in highly pigmented vegetables and fruits. Lutein is selectively accumulated in the brain relative to other carotenoids. Recent evidence has linked lutein to cognition in older adults, but little is known about lutein in young children, despite structural brain development. We determined lutein intake using FFQ, one 24 h recall and three 24 h recalls, plasma lutein concentrations and their association with cognition in 160 children 5·6–5·9 years of age, at low risk for neurodevelopmental delay. Plasma lutein was skewed, with a median of 0·23 (2·5th to 95th percentile range 0·11–0·53) µmol/l. Plasma lutein showed a higher correlation with lutein intake estimated as the average of three 24 h recalls (r 0·479; P = 0·001), rather than one 24 h recall (r 0·242; P = 0·003) or FFQ (r 0·316; P = 0·001). The median lutein intake was 697 (2·5th to 95th percentile range 178–5287) µg/d based on three 24 h recalls. Lutein intake was inversely associated with SFA intake, but dietary fat or SFA intakes were not associated with plasma lutein. No associations were found between plasma lutein or lutein intake and any measure of cognition. While subtle independent effects of lutein on child cognition are possible, separating these effects from covariates making an impact on both child diet and cognition may be difficult.
In most of the cost-utility literature, quality-adjusted life-year (QALY) gains are interpreted as a measure of social value. Given this interpretation, the validity of different multi-attribute health-state scaling instruments may be tested by comparing the values they provide on the 0–1 QALY scale with directly elicited preferences for person trade-offs between different treatments (equivalence of numbers of different patients treated). Norwegian and Australian public preferences as measured by the person trade-off suggest that the EuroQol Instrument assigns excessively low values to health states. This seems to be even more true of the McMaster Health Classification System. The Quality of Well-being Scale appears to compress states toward the middle of the 0–1 scale. By contrast, the Rosser/Kind index fits reasonably well with directly measured person trade-off data.
A history of hospital admission in the prior year was the most sensitive predictor of methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococcus colonization at admission to a Veterans Affairs Medical Center (VAMC) but missed more than one-third of carriers and required screening more than one-half of admitted patients.
Sober (1992) has recently evaluated Brandon's (1982, 1990; see also 1985, 1988) use of Salmon's (1971) concept of screening-off in the philosophy of biology. He critiques three particular issues, each of which will be considered in this discussion.
Sixty-six patients were assessed clinically, psychologically and physiologically before operation, at six weeks and at a mean of 16 months following stereotactic limbic leucotomy. Seventy-three per cent were clinically improved at six weeks and 76 per cent at 16 months. In obsessional neurosis, 89 per cent of patients showed definite clinical improvement at 16 months; in chronic anxiety, 66 per cent were improved; in depression, 78 per cent; and in the small number of schizophrenics treated the improvement rate was over 80 per cent. Self-assessment and observer-assessment questionnaires and scales measuring Depression, Anxiety, Neuroticism, Hysterical symptoms and Obsessional symptoms and traits all showed highly significant reductions of mean scores at 16 months. There was no fall-off in intelligence, and adverse effects were minimal. Limbic leucotomy, with its enhanced accuracy and safety, compares very favourably with similarly assessed, more extensive ‘free-hand’ procedures, and in obsessional neurosis and chronic anxiety the results are superior.
The neurophysiological aspects and operative technique of stereotactic limbic leucotomy have been described in a previous paper (Kelly, Richardson and Mitchell-Heggs, 1973). The present investigation is a prospective study designed to assess the results of such surgery in a group of 40 severely ill psychiatric patients, who had failed to respond satisfactorily to every other type of treatment. The results have been assessed clinically, psychologically and physiologically, in a very detailed way, at six weeks; a similar follow-up at one year is in progress. A comparison is made between the results of the present series and those of a previous: study (Kelly et al., 1972), in which more extensive leucotomy operations were carried out, and similar means of assessment were employed.
Psychosurgery has always been, and is likely to remain, a controversial subject. Blind operations lack precision and can lead to adverse personality changes or other serious side-effects. Open surgery is becoming less acceptable because of the difficulties of accurately assessing the extent of a lesion and its exact location. The introduction of stereotactic techniques enables far smaller lesions to be placed with a high degree of accuracy, and increased knowledge of the limbic system has contributed to advances in this field.
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