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To evaluate the clinical impact of an antimicrobial stewardship program (ASP) on high-risk pediatric patients.
Retrospective cohort study.
Free-standing pediatric hospital.
This study included patients who received an ASP review between March 3, 2008, and March 2, 2017, and were considered high-risk, including patients receiving care by the neonatal intensive care (NICU), hematology/oncology (H/O), or pediatric intensive care (PICU) medical teams.
The ASP recommendations included stopping antibiotics; modifying antibiotic type, dose, or duration; or obtaining an infectious diseases consultation. The outcomes evaluated in all high-risk patients with ASP recommendations were (1) hospital-acquired Clostridium difficile infection, (2) mortality, and (3) 30-day readmission. Subanalyses were conducted to evaluate hospital length of stay (LOS) and tracheitis treatment failure. Multivariable generalized linear models were performed to examine the relationship between ASP recommendations and each outcome after adjusting for clinical service and indication for treatment.
The ASP made 2,088 recommendations, and 50% of these recommendations were to stop antibiotics. Recommendation agreement occurred in 70% of these cases. Agreement with an ASP recommendation was not associated with higher odds of mortality or hospital readmission. Patients with a single ASP review and agreed upon recommendation had a shorter median LOS (10.2 days vs 13.2 days; P < .05). The ASP recommendations were not associated with high rates of tracheitis treatment failure.
ASP recommendations do not result in worse clinical outcomes among high-risk pediatric patients. Most ASP recommendations are to stop or to narrow antimicrobial therapy. Further work is needed to enhance stewardship efforts in high-risk pediatric patients.
Describe the epidemiological and molecular characteristics of an outbreak of Klebsiella pneumoniae carbapenemase (KPC)–producing organisms and the novel use of a cohorting unit for its control.
A 566-room academic teaching facility in Milwaukee, Wisconsin.
Solid-organ transplant recipients.
Infection control bundles were used throughout the time of observation. All KPC cases were intermittently housed in a cohorting unit with dedicated nurses and nursing aids. The rooms used in the cohorting unit had anterooms where clean supplies and linens were placed. Spread of KPC-producing organisms was determined using rectal surveillance cultures on admission and weekly thereafter among all consecutive patients admitted to the involved units. KPC-positive strains underwent pulsed-field gel electrophoresis and whole-genome sequencing.
A total of 8 KPC cases (5 identified by surveillance) were identified from April 2016 to April 2017. After the index patient, 3 patients acquired KPC-producing organisms despite implementation of an infection control bundle. This prompted the use of a cohorting unit, which immediately halted transmission, and the single remaining KPC case was transferred out of the cohorting unit. However, additional KPC cases were identified within 2 months. Once the cohorting unit was reopened, no additional KPC cases occurred. The KPC-positive species identified during this outbreak included Klebsiella pneumoniae, Enterobacter cloacae complex, and Escherichia coli. blaKPC was identified on at least 2 plasmid backbones.
A complex KPC outbreak involving both clonal and plasmid-mediated dissemination was controlled using weekly surveillances and a cohorting unit.
Introduction: Depending on the time and day of initial Emergency Department (ED) presentation, some patients may require a return to the ED the following day for ultrasound examination. Return visits for ultrasound may be time and resource intensive for both patients and the ED. Qualitative experience suggests that a percentage of return ultrasounds could be performed at a non-ED facility. Our objective was to undertake a retrospective audit of return for ultrasound usage, patterns and outcomes at 2 academic EDs. Methods: A retrospective review of all adult patients returning to the ED for ultrasound at both LHSC ED sites in 2016 was undertaken. Each chart was independently reviewed by two emergency medicine consultants. Charts were assessed for day and time of initial presentation and return, type of ultrasound ordered, and length of ED stay on initial presentation and return visit. Opinion based questions were considered by reviewers, including urgency of diagnosis clarification required, if symptoms were still present on return, and if any medical or surgical treatment or follow up was arranged based on ultrasound results. Agreement between reviewers was assessed. Results: After eliminating charts for which the return visit was not for a scheduled ultrasound examination, 328 patient charts were reviewed. 63% of patients were female and median [IQR] age was 40 years [27-56]. Abdomen/pelvis represented 50% of the ultrasounds; renal 24%; venous Doppler 15.9%. Symptoms were still present and documented in 79% of cases. 22% of cases required a medical intervention and 9% an immediate surgical intervention. 11% of patients were admitted to hospital on their return visit. Outpatient follow-up based on US results was initiated in 29% of cases. Median [IQR] combined LOS was 479.5 minutes [358.5-621.75]. Agreement between reviewers for opinion based questions was poor (63%-96%). Conclusion: Ideally, formal ultrasound should be available on a 24 hour basis for ED patients in order to avoid return visits. A percentage of return for ultrasound examinations do not result in any significant change in treatment. Emergency departments should consider the development of pathways to avoid return visits for follow up ultrasound when possible. The low incidence of surgical treatment in those returning for US suggests that this population could be served in a non-hospital setting. Further research is required to support this conclusion.
The short-term impact of prolonged grief disorder (PGD) following bereavement is well documented. The longer term sequelae of PGD however are poorly understood, possibly unrecognized, and may be incorrectly attributed to other mental health disorders and hence undertreated.
The aims of this study were to prospectively evaluate the prevalence of PGD three years post bereavement and to examine the predictors of long-term PGD in a population-based cohort of bereaved cancer caregivers.
A cohort of primary family caregivers of patients admitted to one of three palliative care services in Melbourne, Australia, participated in the study (n = 301). Sociodemographic, mental health, and bereavement-related data were collected from the caregiver upon the patient's admission to palliative care (T1). Further data addressing circumstances around the death and psychological health were collected at six (T2, n = 167), 13 (T3, n = 143), and 37 months (T4, n = 85) after bereavement.
At T4, 5% and 14% of bereaved caregivers met criteria for PGD and subthreshold PGD, respectively. Applying the total PGD score at T4, linear regression analysis found preloss anticipatory grief measured at T1 and self-reported coping measured at T2 were highly statistically significant predictors (both p < 0.0001) of PGD in the longer term.
For almost 20% of caregivers, the symptoms of PGD appear to persist at least three years post bereavement. These findings support the importance of screening caregivers upon the patient's admission to palliative care and at six months after bereavement to ascertain their current mental health. Ideally, caregivers at risk of developing PGD can be identified and treated before PGD becomes entrenched.
In low- and middle-income countries (LMIC) in general and sub-Sahara African (SSA) countries in particular, there is both a large treatment gap for mental disorders and a relative paucity of empirical evidence about how to fill this gap. This is more so for severe mental disorders, such as psychosis, which impose an additional vulnerability for human rights abuse on its sufferers. A major factor for the lack of evidence is the few numbers of active mental health (MH) researchers on the continent and the distance between the little evidence generated and the policy-making process.
The Partnership for Mental Health Development in Africa (PaM-D) aimed to bring together diverse MH stakeholders in SSA, working collaboratively with colleagues from the global north, to create an infrastructure to develop MH research capacity in SSA, advance global MH science by conducting innovative public health-relevant MH research in the region and work to link research to policy development. Participating SSA countries were Ghana, Kenya, Liberia, Nigeria and South Africa. The research component of PaM-D focused on the development and assessment of a collaborative shared care (CSC) program between traditional and faith healers (T&FHs) and biomedical providers for the treatment of psychotic disorders, as a way of improving the outcome of persons suffering from these conditions. The capacity building component aimed to develop research capacity and appreciation of the value of research in a broad range of stakeholders through bespoke workshops and fellowships targeting specific skill-sets as well as mentoring for early career researchers.
In the research component of PaM-D, a series of formative studies were implemented to inform the development of an intervention package consisting of the essential features of a CSC for psychosis implemented by primary care providers and T&FHs. A cluster randomised controlled trial was next designed to test the effectiveness of this package on the outcome of psychosis. In the capacity-building component, 35 early and mid-career researchers participated in the training workshops and several established mentor-mentee relationships with senior PaM-D members. At the end of the funding period, 60 papers have been published and 21 successful grant applications made.
The success of PaM-D in energising young researchers and implementing a cutting-edge research program attests to the importance of partnership among researchers in the global south working with those from the north in developing MH research and service in LMIC.
In 2018, the Clostridium difficile LabID event methodology changed so that hospitals doing 2-step tests, nucleic acid amplification test (NAAT) plus enzyme immunofluorescence assay (EIA), had their adjustment modified to EIA-based tests, and only positive final tests (eg, EIA) were counted in the numerator. We report the immediate impact of this methodological change at 3 Milwaukee hospitals.
Post-translocation monitoring is fundamental for assessing translocation success and identifying potential threats. We measured outcomes for four cohorts of tuatara Sphenodon punctatus translocated to warmer climates outside of their ecological region, to understand effects of climate warming. Translocation sites were on average 2–4 °C warmer than the source site. We used three short-term measures of success: survival, growth and reproduction. Data on recaptures, morphometric measurements, and reproduction were gathered over 2.5 years following release. Although decades of monitoring will be required to determine long-term translocation success in this species, we provide an interim measure of population progress and translocation site suitability. We found favourable recapture numbers, growth of founders and evidence of reproduction at most sites, with greater increases in body mass observed at warmer, less densely populated sites. Variable growth in the adult population at one translocation site suggested that higher population density, intraspecific competition, and lower water availability could be responsible for substantial weight loss in multiple individuals, and we make management recommendations to reduce population density. Overall, we found that sites with warmer climates and lower population densities were potentially beneficial to translocated tuatara, probably because of enhanced temperature-dependent and density-dependent growth rates. We conclude that tuatara could benefit from translocations to warmer sites in the short term, but further monitoring of this long-lived species is required to determine longer-term population viability following translocation. Future vulnerability to rising air temperatures, associated water availability, and community and ecosystem changes beyond the scope of this study must be considered.
Svetlozarite, previously described as a new member of the mordenite group of zeolites, is reinterpreted as a multiply twinned and highly faulted dachiardite. X-ray diffraction study and transmission electron microscopy revealed (001) twins and (100) stacking faults. The former are attributed at least mainly to the insertion of a b glide plane between dachiardite sheets at each twin interface, which preserves the 5-ring linkages between the sheets. The latter are associated with loss of the C face-centring relation, and are attributed to replacement of shared 5-rings by linked 4-rings in the dachiardite sheets. Further study is needed to determine whether the structural faults in the dachiardite structures are chemically controlled.
OBJECTIVES/SPECIFIC AIMS: The aim of this study is to examine if stable health insurance coverage is associated with improved type 2 diabetes (DM) control and with reduced racial/ethnic health disparities. METHODS/STUDY POPULATION: We utilized EMR data (2005–2013) from 2 large, urban academic health centers with a racially/ethnically diverse patient population to longitudinally examine insurance coverage, and diabetes outcomes (A1C, LDL cholesterol, BP) and management measures (e.g., A1C and BP monitoring). We categorized insurance stability status during each 6-month interval as 6 separate categories based upon type (private, public, uninsured) and continuity of insurance (continuous, switches, or gaps in coverage). We will examine the association between insurance stability status and DM outcomes adjusting for time, age, sex, comorbidities, site of care, education, and income. Additional analysis will examine if insurance stability moderates the impact of race/ethnicity on DM outcomes. RESULTS/ANTICIPATED RESULTS: Overall, we anticipate that stable health insurance coverage will improve measures for DM care, particularly for racially/ethnically diverse patients. DISCUSSION/SIGNIFICANCE OF IMPACT: The finding of an interaction between insurance stability status and race/ethnicity in improved diabetes management and control would inform the national health care policy debate on the impact of stable health insurance.
OBJECTIVES/SPECIFIC AIMS: The aim of this study is to determine whether quantitative measures of knee structures including effusion, bone marrow lesions, cartilage, and meniscal damage can improve upon an existing model of demographic and clinical characteristics to classify accelerated knee osteoarthritis (AKOA). METHODS/STUDY POPULATION: We conducted a case-control study using data from baseline and four annual follow-up visits from the osteoarthritis initiative. Participants had no radiographic knee osteoarthritis (KOA) at baseline. AKOA is defined as progressing from no KOA to advance-stage KOA in at least 1 knee within 48 months. AKOA knees were matched 1:1 based on sex to (1) participants who did not develop KOA within 48 months and (2) participants who developed KOA but not AKOA. Analyses were person based. Classification and regression tree analysis was used to determine the important variables and percent of variance explained. RESULTS/ANTICIPATED RESULTS: A previous classification and regression tree analysis found that age, BMI, serum glucose, and femorotibial angle explained 31% of the variability between those who did and did not develop AKOA. Including structural measurements as candidate variables yielded a model that included effusion, BMI, serum glucose, cruciate ligament degeneration and coronal slope and explained 39% of the variability. DISCUSSION/SIGNIFICANCE OF IMPACT: Knee structural measurements improve classification of participants who developed AKOA Versus those who did not. Further research is needed to better classify patients at risk for AKOA.
Introduction: Early recognition of sepsis can improve patient outcomes yet recognition by paramedics is poor and research evaluating the use of prehospital screening tools is limited. Our objective was to evaluate the predictive validity of the Regional Paramedic Program for Eastern Ontario (RPPEO) prehospital sepsis notification tool to identify patients with sepsis and to describe and compare the characteristics of patients with an emergency department (ED) diagnosis of sepsis that are transported by paramedics. The RPPEO prehospital sepsis notification tool is comprised of 3 criteria: current infection, fever &/or history of fever and 2 or more signs of hypoperfusion (eg. SBP<90, HR 100, RR24, altered LOA). Methods: We performed a review of ambulance call records and in-hospital records over two 5-month periods between November 2014 February 2016. We enrolled a convenience sample of patients, assessed by primary and advanced care paramedics (ACPs), with a documented history of fever &/or documented fever of 38.3°C (101°F) that were transported to hospital. In-hospital management and outcomes were obtained and descriptive, t-tests, and chi-square analyses performed where appropriate. The RPPEO prehospital sepsis notification tool was compared to an ED diagnosis of sepsis. The predictive validity of the RPPEO tool was calculated (sensitivity, specificity, NPV, PPV). Results: 236 adult patients met the inclusion criteria with the following characteristics: mean age 65.2 yrs [range 18-101], male 48.7%, history of sepsis 2.1%, on antibiotics 23.3%, lowest mean systolic BP 125.9, treated by ACP 58.9%, prehospital temperature documented 32.6%. 34 (14.4%) had an ED diagnosis of sepsis. Patients with an ED diagnosis of sepsis, compared to those that did not, had a lower prehospital systolic BP (114.9 vs 127.8, p=0.003) and were more likely to have a prehospital shock index >1 (50.0% vs 21.4%, p=0.001). 44 (18.6%) patients met the RPPEO sepsis notification tool and of these, 27.3% (12/44) had an ED diagnosis of sepsis. We calculated the following predictive values of the RPPEO tool: sensitivity 35.3%, specificity 84.2%, NPV 88.5%, PPV 27.3%. Conclusion: The RPPEO prehospital sepsis notification tool demonstrated modest diagnostic accuracy. Further research is needed to improve accuracy and evaluate the impact on patient outcomes.
The Flint Community Resilience Group (Flint, Michigan USA) and the Centers for Disease Control and Prevention (CDC; Atlanta, Georgia USA) assessed behavioral health concerns among community members to determine the impact of lead contamination of the Flint, Michigan water supply.
A Community Assessment for Public Health Emergency Response (CASPER) was conducted from May 17 through May 19, 2016 using a multi-stage cluster sampling design to select households and individuals to interview.
One-half of households felt overlooked by decision makers. The majority of households self-reported that at least one member experienced more behavioral health concerns than usual. The prevalence of negative quality of life indicators and financial concerns in Flint was higher than previously reported in the Michigan 2012 and 2014 Behavioral Risk Factor Surveillance System (BRFSS) survey.
The following can be considered to guide recovery efforts in Flint: identifying additional resources for behavioral health interventions and conducting follow-up behavioral health assessments to evaluate changes in behavioral health concerns over time; considering the impact of household economic factors when implementing behavioral health interventions; and ensuring community involvement and engagement in recovery efforts to ease community stress and anxiety.
FortenberryGZ, ReynoldsP, BurrerSL, Johnson-LawrenceV, WangA, SchnallA, PullinsP, KieszakS, BayleyegnT, WolkinA. Assessment of Behavioral Health Concerns in the Community Affected by the Flint Water Crisis — Michigan (USA) 2016. Prehosp Disaster Med. 2018;33(3):256–265.
New studies have been published regarding the epidemiology of Clostridium difficile in topics such as asymptomatic C. difficile colonization, community-associated C. difficile infection, environmental contamination outside healthcare settings, animal colonization, and the interactions between C. difficile and the gut microbiome. In addition to summarizing these findings, this review offers a perspective on the potential impact of high-throughput sequencing and other potential techniques on the prevention of C. difficile.
To determine the effect of mandatory and nonmandatory influenza vaccination policies on vaccination rates and symptomatic absenteeism among healthcare personnel (HCP).
Retrospective observational cohort study.
This study took place at 3 university medical centers with mandatory influenza vaccination policies and 4 Veterans Affairs (VA) healthcare systems with nonmandatory influenza vaccination policies.
The study included 2,304 outpatient HCP at mandatory vaccination sites and 1,759 outpatient HCP at nonmandatory vaccination sites.
To determine the incidence and duration of absenteeism in outpatient settings, HCP participating in the Respiratory Protection Effectiveness Clinical Trial at both mandatory and nonmandatory vaccination sites over 3 viral respiratory illness (VRI) seasons (2012–2015) reported their influenza vaccination status and symptomatic days absent from work weekly throughout a 12-week period during the peak VRI season each year. The adjusted effects of vaccination and other modulating factors on absenteeism rates were estimated using multivariable regression models.
The proportion of participants who received influenza vaccination was lower each year at nonmandatory than at mandatory vaccination sites (odds ratio [OR], 0.09; 95% confidence interval [CI], 0.07–0.11). Among HCP who reported at least 1 sick day, vaccinated HCP had lower symptomatic days absent compared to unvaccinated HCP (OR for 2012–2013 and 2013–2014, 0.82; 95% CI, 0.72–0.93; OR for 2014–2015, 0.81; 95% CI, 0.69–0.95).
These data suggest that mandatory HCP influenza vaccination policies increase influenza vaccination rates and that HCP symptomatic absenteeism diminishes as rates of influenza vaccination increase. These findings should be considered in formulating HCP influenza vaccination policies.