A Physician-Driven Quality Improvement Stewardship Intervention Using Lean Six Sigma Improves Patient Care for Community-Acquired Pneumonia.

Introduction: The Infectious Diseases Society of America (IDSA) recommends a minimum of 5 days of antibiotic therapy in stable patients who have community-acquired pneumonia (CAP). However, excessive duration of therapy (DOT) is common. Define, measure, analyze, improve, and control (DMAIC) is a Lean Six Sigma methodology used in quality improvement efforts, including infection control; however, the utility of this approach for antimicrobial stewardship initiatives is unknown. To determine the impact of a prospective physician-driven stewardship intervention on excess antibiotic DOT and clinical outcomes of patients hospitalized with CAP. Our specific aim was to reduce excess DOT and to determine why some providers treat beyond the IDSA minimum DOT. Methods: A single-center, quasi-experimental quality improvement study evaluating rates of excess antimicrobial DOT before and after implementing a DMAIC-based antimicrobial stewardship intervention that included education, prospective audit, and feedback from a physician peer, and daily tracking of excess DOT on a Kaizen board. The baseline period included retrospective CAP cases that occurred between October 2018 and February 2019 (control group). The intervention period included CAP cases between October 2019 and February 2020 (intervention group). Results: A total of 123 CAP patients were included (57 control and 66 intervention). Median antibiotic DOT per patient decreased (8 versus 5 days; p < 0.001), and the proportion of patients treated for the IDSA minimum increased (5.3% versus 56%; p < 0.001) after the intervention. No differences in mortality, readmission, length of stay, or incidence of Clostridioides difficile infection were observed between groups. Almost half of the caregivers surveyed were aware that as few as 5 days of antibiotic treatment could be appropriate. Conclusions: A physician-driven antimicrobial quality improvement initiative designed using DMAIC methodology led to reduced DOT and increased compliance with the IDSA treatment guidelines for hospitalized patients with CAP reduced without negatively affecting clinical outcomes.

Familial incidence of the congenital torcular dural arteriovenous shunt: Case report and review of the literature.

Congenital dural sinus malformations are rare but can be major causes of mortality and morbidity in the pediatric population if not detected and managed urgently. Lesions involving large draining sinus structures such as superior sagittal sinus and torcular herophili can result in significant intracranial circulation impairment mostly due to venous drainage disturbance. Early detection plays a pivotal role in the outcome of the patients. Rarely familial incidence of some types of arteriovenous malformations in isolation from other congenital hereditary disorders has been reported. Knowledge of the familial association of congenital dural sinus malformations may raise the awareness for considering the possibility of occurrence of these lesions in the relatives of index cases. Herein, we describe the occurrence of giant torcular dural shunt in two pediatric cousins treated with endovascular embolization.

Age-Related Changes of Normal Cerebral and Cardiac Blood Flow in Children and Adults Aged 7 Months to 61 Years.

BACKGROUND: Cerebral and cardiac blood flow are important to the pathophysiology and development of cerebro- and cardiovascular diseases. The purpose of this study was to investigate the age dependence of normal cerebral and cardiac hemodynamics in children and adults over a broad range of ages. METHODS AND RESULTS: Overall, 52 children (aged 0.6-17.2 years) and 30 adults (aged 19.2-60.7 years) without cerebro- and cardiovascular diseases were included in this study. Intracranial 4-dimensional flow and cardiac 2-dimensional phase-contrast magnetic resonance imaging were performed for all participants to measure flow parameters in the major intracranial vessels and aorta. Total cerebral blood flow (TCBF), cardiac and cerebral indexes, brain volume, and global cerebral perfusion (TCBF/brain volume) were evaluated. Flow analysis revealed that TCBF increased significantly from age 7 months to 6 years (P<0.001) and declined thereafter (P<0.001). Both cardiac and cerebral indices declined with age (P<0.001). The ratio of TCBF to ascending aortic flow declined rapidly until age 18 years (P<0.001) and remained relatively stable thereafter. Age-related changes of cerebral vascular peak velocities exhibited a trend similar to TCBF. By comparison, aortic peak velocities maintained relatively high levels in children and declined with age in adults (P<0.001). TCBF significantly correlated with brain volume in adults (P=0.005) and in 2 pediatric subgroups, aged <7 years (P<0.001) and 7 to 18 years (P=0.039). CONCLUSIONS: Cerebral and cardiac flow parameters are highly associated with age. The findings collectively highlight the importance of age-matched control data for the characterization of intracranial and cardiac hemodynamics.

Focal stenosis of the sigmoid sinus causing intracranial venous hypertension: Case report, endovascular management, and review of the literature.

Regardless of the underlying pathology, elevated intracranial pressure is the endpoint of any impairment in either cerebrospinal fluid (CSF) absorption (including arachnoid villi) or intracranial venous drainage. In all age groups, the predominant final common pathway for CSF drainage is the dural venous sinus system. Intracranial venous hypertension (ICVH) is an important vascular cause of intracranial hypertension (and its subsequent sequelae), which has often been ignored due to excessive attention to the arterial system and, specifically, arteriovenous shunts. Various anatomical and pathological entities have been described to cause ICVH. For the second time, we present a unique case of severe focal stenosis in the distal sigmoid sinus associated with concurrent hypoplasia of the contralateral transverse sinus causing a significant pressure gradient and intracranial hypertension, which was treated with endovascular stent placement and angioplasty.

Complex Alterations of Intracranial 4-Dimensional Hemodynamics in Vein of Galen Aneurysmal Malformations During Staged Endovascular Embolization.

BACKGROUND: Vein of Galen aneurysmal malformations (VGAMs) are rare congenital cerebral arteriovenous shunts often treated by staged endovascular embolization early in life. Treatment-induced changes in intracranial hemodynamics and their impact on the clinical management of VGAM patients remain unclear. OBJECTIVE: To evaluate hemodynamic alterations in the cerebral arterial and venous network in pediatric patients with VGAMs during staged embolizations. METHODS: Serial 4-dimensional flow magnetic resonance imaging (21 scans) was performed in 6 VGAM patients (3 female; mean age, 2.1 ± 4.0 years) undergoing staged embolization. Time-integrated pathlines were used to visualize 3-dimensional blood flow changes in intracranial arterial and venous systems. Total cerebral arterial inflow (flow in bilateral internal carotid arteries plus basilar artery), arteriovenous shunt flow, and blood flow in other major cerebral arteries (middle cerebral artery; posterior cerebral artery) were quantified for all patients. RESULTS: Intracranial 3-dimensional blood flow visualization demonstrated marked reduction of arteriovenous shunting and distinct hemodynamic alterations after embolization. From baseline to endpoint embolization, total cerebral arterial inflow dropped by 40.2% (from 22.70 ± 6.54 mL/s to 13.57 ± 4.87 mL/s), corresponding to arteriovenous shunt flow reduction of 73.5% (from 9.69 ± 6.16 mL/s to 2.57 ± 3.79 mL/s). In addition, the ipsilateral posterior cerebral artery/middle cerebral artery flow ratio decreased by 86.9% (from 4.20 ± 6.28 to 0.55 ± 0.23). CONCLUSION: Hemodynamic alterations in VGAMs after embolization can be visualized and quantified using 4-dimensional flow magnetic resonance imaging. Cerebral arterial inflow and arteriovenous shunt flow reduction and complex flow redistribution after embolization illustrate the potential of 4-dimensional flow magnetic resonance imaging to better evaluate the efficacy of interventions and monitor treatment effects.

Prevalence and airborne spore levels of Stachybotrys spp. in 200 houses with water incursions in Houston, Texas.

Two hundred homes with a history of water incursion were sampled for fungi to determine the prevalence and airborne spore levels of Stachybotrys spp. Sampling methods included room air, surface, and wall cavity air sampling. Stachybotrys spp. were detected with at least one of the methods in 58.5% of the houses tested, but only 9.6% of the room air samples contained Stachybotrys spores. Aerosolization of Stachybotrys spores was correlated with both wall cavity and surface contamination. However, after adjustment for the surface effect, Stachybotrys spores detected in wall cavities were not a significant factor contributing to spores detected in room air samples. We conclude that Stachybotrys spp. are commonly found on water-damaged building materials. In addition, the observations made in this study suggest that the impact on the living space air is low if the fungal spores are contained within a wall cavity.

Hollow-fiber ultrafiltration of Cryptosporidium parvum oocysts from a wide variety of 10-L surface water samples.

An optimized hollow-fiber ultrafiltration system (50 000 MWCO) was developed to concentrate Cryptosporidium oocysts from 10-L samples of environmental water. Seeded experiments were conducted using a number of surface-water samples from the southwestern U.S.A. and source water from four water districts with histories of poor oocyst recovery. Ultrafiltration produced a mean recovery of 47.9% from 19 water samples (55.3% from 39 individual tests). We also compared oocyst recoveries using the hollow-fiber ultrafiltration system with those using the Envirochek filter. In limited comparison tests, the hollow-fiber ultrafiltration system produced recoveries similar to those of the Envirochek filter (hollow fiber, 74.1% (SD = 2.8); Envirochek, 71.9% (SD = 5.2)) in low-turbidity (3.9 NTU) samples and performed better than the Envirochek filter in high-turbidity (159.0 NTU) samples (hollow fiber, 27.5%; Envirochek, 0.4%). These results indicate that hollow-fiber ultrafiltration can efficiently recover oocysts from a wide variety of surface waters and may be a cost-effective alternative for concentrating Cryptosporidium from water, given the reusable nature of the filter.

Effects of pH and magnetic material on immunomagnetic separation of Cryptosporidium oocysts from concentrated water samples.

In this study, we examined the effect that magnetic materials and pH have on the recoveries of Cryptosporidium oocysts by immunomagnetic separation (IMS). We determined that particles that were concentrated on a magnet during bead separation have no influence on oocyst recovery; however, removal of these particles did influence pH values. The optimal pH of the IMS was determined to be 7.0. The numbers of oocysts recovered from deionized water at pH 7.0 were 26.3% higher than those recovered from samples that were not at optimal pH. The results indicate that the buffers in the IMS kit did not adequately maintain an optimum pH in some water samples. By adjusting the pH of concentrated environmental water samples to 7.0, recoveries of oocysts increased by 26.4% compared to recoveries from samples where the pH was not adjusted.

Occurrence of Cryptosporidium and Giardia in wild ducks along the Rio Grande River valley in southern New Mexico.

Fecal samples were taken from wild ducks on the lower Rio Grande River around Las Cruces, N. Mex., from September 2000 to January 2001. Giardia cysts and Cryptosporidium oocysts were purified from 69 samples by sucrose enrichment followed by cesium chloride (CsCl) gradient centrifugation and were viewed via fluorescent-antibody (FA) staining. For some samples, recovered cysts and oocysts were further screened via PCR to determine the presence of Giardia lamblia and Crytosporidium parvum. The results of this study indicate that 49% of the ducks were carriers of Cryptosporidium, and the Cryptosporidium oocyst concentrations ranged from 0 to 2,182 oocysts per g of feces (mean +/- standard deviation, 47.53 +/- 270.3 oocysts per g); also, 28% of the ducks were positive for Giardia, and the Giardia cyst concentrations ranged from 0 to 29,293 cysts per g of feces (mean +/- standard deviation, 436 +/- 3,525.4 cysts per g). Of the 69 samples, only 14 had (oo)cyst concentrations that were above the PCR detection limit. Samples did test positive for Cryptosporidium sp. However, C. parvum and G. lamblia were not detected in any of the 14 samples tested by PCR. Ducks on their southern migration through southern New Mexico were positive for Cryptosporidium and Giardia as determined by FA staining, but C. parvum and G. lamblia were not detected.