Impact of medication intensification on 30-day hospital readmissions in a geriatric trauma population: A multicenter cohort study.

BACKGROUND: Fall-related injuries are a significant health issue that occur in 25% of older adults and account for a significant number of trauma-related hospitalizations. Although medication intensification may increase the risk of hospital readmissions in non-trauma patients, data on a geriatric trauma population are lacking. OBJECTIVE: The primary objective was to evaluate the effect of medication intensification on 30-day hospital readmissions in geriatric patients hospitalized for fall-related injuries. METHODS: This multicenter, retrospective cohort study included patients with geriatric who presented to one of three trauma centers within a large, health-system between January 1, 2018 and December 31, 2020. Patients at least 65 years old admitted with a fall-related injury were eligible for inclusion. Patients were grouped according to medication changes at discharge, which included intensified and non-intensified groups. Medication intensification included increased dose(s) or initiation of new agents. The primary outcome was the 30-day hospital readmission rate. RESULTS: Of the 870 patients included (median [interquartile range, IQR] age, 82 [74-89] years, 522 (60%) female, and 220 (25%) with a previous fall), there were 471 (54%) and 399 (46%) patients in the intensified and non-intensified groups, respectively. The intensified group had a higher 30-day hospital readmission rate (21% intensified vs. 16% non-intensified, p = 0.043; number needed to harm 20) based on an unweighted analysis. According to a weighted propensity score logistic regression, medication intensification was associated with higher 30-day hospital readmissions (24% [95% confidence interval [CI] 19-31%] intensified vs. 15% [95% CI 11-20%] non-intensified, p = 0.018). These results were consistent within competing risk models accounting for death (cause-specific model: hazard ratio [HR] 1.63 [95% CI 1.07-2.49], p = 0.023; Fine-Gray model: HR 1.64 [95% CI 1.07-2.50], p = 0.022). CONCLUSIONS: In a geriatric trauma population hospitalized after a fall, intensification of medications may pose an increased risk of 30-day hospital readmission.

Food as medicine: a quasi-randomized control trial of two healthy food interventions for chronic disease management among ambulatory patients at an urban academic center.

BACKGROUND: Globally, poor nutrition is a driver of many chronic diseases and is responsible for more deaths than any other risk factor. Accordingly, there is growing interest in the direct provision of healthy foods to patients to tackle diet-linked chronic diseases and mortality. AIM: To assess the effect of two healthy food interventions in conjunction with nutrition counseling and education on select chronic disease markers, food insecurity, diet quality, depression, and on self-efficacy for healthy eating, healthy weight, and chronic disease management. METHODS: This parallel-arm quasi-randomized control trial will be conducted between January 2022 and December 2023. Seventy adult patients recruited from a single academic medical center will be randomly assigned to receive either: i) daily ready-made frozen healthy meals or ii) a weekly produce box and recipes for 15 weeks. Participants will, additionally, take part in one individual nutrition therapy session and watch videos on healthy eating, weight loss, type 2 diabetes, and hypertension. Data on weight, height, glycated hemoglobin, blood pressure, and diabetes and blood pressure medications will be collected in-person at the baseline visit and at 16 weeks from baseline and via medical chart review at six months and 12 months from enrollment. The primary outcome of the study is weight loss at 16 weeks from baseline. Pre- and post-intervention survey data will be analyzed for changes in food insecurity, diet quality, depression, as well as self-efficacy for health eating, healthy weight, and chronic disease management. Through retrospective chart review, patients who received standard of care will be matched to intervention group participants as controls based on body mass index, type 2 diabetes, and/or hypertension. FINDINGS: By elucidating the healthy food intervention with better health outcomes, this study aims to offer evidence that can guide providers in their recommendations for healthy eating options to patients.

Outcomes Related to Cardiac Enhanced Recovery After Surgery Protocol.

OBJECTIVES: The objective of this study was to assess the quality of pain control and outcomes in patients who underwent coronary artery bypass graft (CABG) over a period of 96 hours preimplementation of a cardiac enhanced recovery after surgery (C-ERAS) protocol compared with postimplementation. DESIGN: Single-center, retrospective cohort study. SETTING: Cleveland Clinic Akron General Hospital. PARTICIPANTS: Patients ≥18 years of age who underwent CABG surgery and received perioperative pain management pre- and post-C-ERAS protocol implementation at admission to Cleveland Clinic Akron General Hospital. INTERVENTIONS: A hospital C-ERAS protocol that included a multimodal analgesia approach to postoperative pain management. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the amount of opioid used measured in morphine milligram equivalents (MME) within 96 hours postoperatively. A total of 146 charts were reviewed, with 133 included (66 pre-C-ERAS and 67 post-C-ERAS). There was a significant reduction in median MMEs 96 hours postoperatively post-C-ERAS (98 [52-135] v 211 [130-290], p < 0.001). Additionally, a significant reduction in median MMEs was observed post-C-ERAS before (65 [43-100] v 129 [95-165], p < 0.001) and after (10 [0-40] v 68 [21-141], p < 0.001) chest tube removal and for the entire prescription at discharge (0 [0-109] v 90 [0-210], p = 0.005). CONCLUSIONS: Implementing a C-ERAS protocol within a CABG surgery patient population reduced the amount of MME.

A Comparison of Variable Versus Fixed Insulin Infusion Rate on Resolution of Diabetic Ketoacidosis.

BACKGROUND: Diabetic ketoacidosis (DKA) is a well-known, potentially fatal complication of diabetes. The American Diabetes Association hyperglycemic crises guidelines suggest the use of intravenous insulin in patients presenting with DKA, along with a recommended rate of glucose reduction of 50-75 mg/dL/h. However, no specific guidance is provided regarding how to best achieve this rate of glucose decline. STUDY QUESTION: Is there a difference in time to DKA resolution between a variable intravenous insulin infusion strategy and a fixed infusion strategy in the absence of an institutional protocol? STUDY DESIGN: Single-center, retrospective cohort study of DKA patient encounters in 2018. MEASURES AND OUTCOMES: Insulin infusion strategy was considered to be variable if the infusion rate changed within the first 8 hours of therapy or was considered fixed if the rate remained unchanged for the same period. The primary outcome was time to resolution of DKA. Secondary outcomes were hospital length of stay, intensive care unit length of stay, hypoglycemia, mortality, and DKA recurrence. RESULTS: The median time to resolution of DKA was 9.3 hours in the variable infusion group compared with 7.8 hours in the fixed infusion group (HR, 0.82; 95% CI, 0.43-1.5, P = 0.5360). Severe hypoglycemia was observed in 13% of patients in the variable infusion group and in 50% of patients in the fixed infusion group ( P = 0.006). CONCLUSIONS: In this analysis, insulin infusion strategy (variable vs. fixed) was not associated with a significant difference in the time to resolution of DKA in the absence of an institutional protocol. The fixed infusion strategy was associated with a higher incidence of severe hypoglycemia.

Evaluation of intravenous lorazepam dosing strategies and the incidence of refractory status epilepticus.

INTRODUCTION: Status epilepticus (SE) is a neurological emergency associated with high mortality if not identified and treated promptly. For the emergent treatment of SE, the recommended intravenous (IV) lorazepam dose is 0.1 mg/kg/dose, up to a maximum of 4 mg. It has been shown that lorazepam is commonly under dosed in SE, but there is conflicting data on whether this has a negative impact on patient outcomes. This study assessed any dose less than 4 mg to help identify the effects of under dosing lorazepam in SE. METHODS: This was a retrospective cohort study of patients admitted to a quaternary health system between October 1, 2017 and September 30, 2019 that experienced SE and were initially treated with IV lorazepam. Patients were divided into two cohorts, less than 4 mg or 4 mg, based on the initial one-time dose of lorazepam received. The primary outcome was the proportion of patients that progressed to refractory status epilepticus (RSE) that received an initial IV lorazepam dose of 4 mg compared to less than 4 mg for the treatment of SE. Secondary outcomes evaluated include length of stay, mortality, time in SE, number of seizures, cumulative lorazepam dose prior to urgent therapy, number of lorazepam doses prior to urgent therapy, time to urgent therapy, appropriately dosed urgent therapy, and number of antiepileptic drugs given in SE. RESULTS: One hundred twenty patients were included in this study (107 patients received less than 4 mg and 13 patients received 4 mg). All patients included in the study were greater than 40 kg. The primary outcome of progression to RSE was observed in a significantly greater proportion of patients in the less than 4 mg group compared to the 4 mg group (93 [87%] vs. 8 [62%], p = 0.03). There was no difference in hospital or intensive care unit length of stay. However, there was an increased rate of in-hospital mortality in patients who received 4 mg compared to less than 4 mg (5 [39%] vs. 12[11%], p = 0.02). DISCUSSION: The majority of patients in the study received less than the recommended dose of IV lorazepam for SE. Patients who received less than 4 mg experienced an increased progression to RSE, which supports current guideline recommended dosing. While there was an increased rate of mortality in patients who received 4 mg compared to less than 4 mg, time in SE was prolonged in the patient population and severity of illness was only available for a limited number of patients included.

Performance of different body weights in the Cockcroft-Gault equation in critically ill patients with and without augmented renal clearance: A multicenter cohort.

STUDY OBJECTIVE: The primary objective was to evaluate the performance of the Cockcroft-Gault (CG) equation with different body weights (BWs) compared to a measured creatinine clearance (mCrCl) in an intensive care unit (ICU) population with and without augmented renal clearance (ARC). DESIGN: Multicenter, retrospective cohort. SETTING: Two ICUs in the United States and four ICUs from a previous international observational analysis. PATIENTS: Adult ICU patients admitted from January 1, 2010 to July 30, 2020 with at least one mCrCl collected within the initial 10 days of hospitalization were eligible for inclusion. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the performance of the CG equation in ARC (mCrCl≥130 ml/min/1.73 m2 ) and non-ARC (mCrCl<130 ml/min/1.73 m2 ) patients. Correlation was analyzed by Pearson's correlation coefficient, bias by mean difference, and accuracy by the percentage of patients within 30% of the mCrCl. A total of 383 patients were included, which provided 1708 mCrCl values. The majority were male (n = 239, 62%), median age of 55 years [IQR 40-65] with a surgical diagnosis (n = 239, 77%). ARC was identified in 229 (60%) patients. The ARC group had lower Scr values (0.6 [0.5-0.7] vs. 0.7 [0.6-0.9] mg/dl, p < 0.001) and higher mCrCl (172.8 (SD 39.1) vs. 89.9 mL/min/1.73 m2 (SD 25.4), p < 0.001) compared with the non-ARC group, respectively. Among non-ARC patients there was a moderate correlation (r = 0.33-0.39), moderate accuracy (range 48-58%), and low bias (range of -12.9 to 17.1) among the different BW estimations with the adjusted BW having the better performance. Among ARC patients there was low correlation (r = 0.24-0.28), low to moderate accuracy (range 38-70%), and high bias (range of -58.5 to -21.6). CONCLUSIONS: The CG-adjusted BW had the best performance in the non-ARC patients, while CG performed poorly with any BW in ARC patients. Although the CG equation remains the standard equation for estimating CrCl in the ICU setting, a new, validated equation is needed for patients with ARC.

Comparison of 4F-PCC and aPCC time to administration and outcomes for oral anticoagulant-related ICH.

INTRODUCTION: Intracranial hemorrhages (ICHs) are associated with increased morbidity and mortality. Use of oral anticoagulants are a potential risk factor for ICH, and reversal of the anticoagulant with agents such as Four-Factor Prothrombin Complex Concentrate (4F-PCC) or Activated Prothrombin Complex Concentrate (aPCC) is vital to prevent hematoma expansion. The objective of the study was to the compare the time to administration and outcomes of 4F-PCC or aPCC in patients with ICH taking an oral anticoagulant. METHODS: This was a multicenter, retrospective cohort chart review of patients with ICH taking an oral anticoagulants who received 4F-PCC or aPCC over a two year period. The primary outcome of the study was to the compare the time to administration of 4F-PCC or aPCC in patients with ICH on an oral anticoagulant. Secondary outcomes included evaluating mortality rate, modified Rankin scale (mRs) score, presence of worsening bleed volume on first computed tomography (CT) six hours after the initial reading, and hospital and intensive care unit (ICU) length of stay. The tertiary outcome was to evaluate the effect of risk factors for delay on time to administration, with delay being greater than 60 min. RESULTS: A total of 350 patient charts were reviewed and 193 patients (4F-PCC [n = 99] and aPCC [n = 94]) were included in the study. There was no significant difference in the primary outcome of median time to administration for the 4F-PCC group (141 min, IQR [93-185]) compared to aPCC (121 min, IQR [107-194]; p = 0.08). No difference was identified between the two groups for all secondary outcomes. Only time to CT results was found to be a risk factor for administration delay (OR, 1.160; 95% CI, 1.073-1.255; p < 0.001). DISCUSSION: In patients with ICH taking oral anticoagulants, there was no significant difference in the time to administration between 4F-PCC and aPCC. More prospective randomized controlled trials are warranted to determine an ideal reversal time to improve patient outcomes.

Incidence of Sudden Cardiac Arrest and Death in Young Athletes and Military Members: A Systematic Review and Meta-Analysis.

OBJECTIVE: To evaluate the quality of the evidence on the incidence of sudden cardiac arrest (SCA) and sudden cardiac death (SCD) in athletes and military members and estimate the annual incidence of SCA and SCD. DATA SOURCES: We searched MEDLINE, Embase, Cochrane CENTRAL, Web of Science, BIOSIS, Scopus, SPORTDiscus, PEDro, and ClinicalTrials.gov from inception to dates between February 21 and July 29, 2019. STUDY SELECTION: Studies in which the incidence of SCA, SCD, or both in athletes or military members aged <40 years was reported were eligible for inclusion. We identified 40 studies for inclusion. DATA EXTRACTION: Risk of bias (ROB) was assessed using a validated, customized tool for prevalence studies. Twelve had a low ROB, while the remaining 28 had a moderate or high ROB. Data were extracted for narrative review and meta-analysis. DATA SYNTHESIS: Random-effects meta-analysis was performed in studies judged to have a low ROB in 2 categories: (1) 5 studies of regional- or national-level data, including athletes at all levels and both sexes, demonstrated 130 SCD events with a total of 11 272 560 athlete-years, showing a cumulative incidence rate of 0.98 (95% CI = 0.62, 1.53) per 100 000 athlete-years and high heterogeneity (I2 = 78%) and (2) 3 studies of competitive athletes aged 14 to 25 years were combined for a total of 183 events and 17 798 758 athlete-years, showing an incidence rate of 1.91 (95% CI = 0.71, 5.14) per 100 000 athlete-years and high heterogeneity (I2 = 97%). The remaining low-ROB studies involved military members and were not synthesized. CONCLUSIONS: The worldwide incidence of SCD is rare. Low-ROB studies indicated the incidence was <2 per 100 000 athlete-years. Overall, the quality of the available evidence was low, but high-quality individual studies inform the question of incidence levels. PROSPERO REGISTRATION: CRD42019125560.

Screening Electrocardiogram in Young Athletes and Military Members: A Systematic Review and Meta-Analysis.

OBJECTIVE: To determine the effect of electrocardiogram (ECG) screening on the prevention of sudden cardiac arrest and death in young athletes and military members. DATA SOURCES: MEDLINE, Embase, CENTRAL, Web of Science, BIOSIS, Scopus, SPORTDiscus, PEDro, and ClinicalTrials.gov were searched from inception to dates between February 21 and July 29, 2019. STUDY SELECTION: Randomized and nonrandomized controlled trials in which preparticipation examination including ECG was the primary intervention used to screen athletes or military members aged ≤40 years. Acceptable control groups were those receiving no screening, usual care, or preparticipation examination without ECG. Three published studies and 1 conference abstract were identified for inclusion. DATA EXTRACTION: In all 4 studies, risk of bias was assessed using the Cochrane risk-of-bias tool and was found to be generally high. Two studies had data extracted for random effects meta-analysis, and the remaining study and conference abstract were included in the narrative review. The overall quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation approach. DATA SYNTHESIS: We included 4 nonrandomized studies (11 689 172 participants), of which all had a high risk of bias. Pooled data from 2 studies (n = 3 869 274; very low-quality evidence) showed an inconclusive 42% relative decrease in risk of sudden cardiac death (relative risk = 0.58; 95% CI = 0.23, 1.45), equating to an absolute risk reduction of 0.0016%. The findings were consistent with a potential 77% relative decreased risk to a 45% relative increased risk in participants screened using ECG. Heterogeneity was found to be high, as measured using I2 statistic (71%). Data from the remaining study and abstract were similarly inconclusive. CONCLUSIONS: Existing evidence for the effect of ECG screening is inconclusive and of very low quality. In our meta-analysis, we observed that screening ECG may result in a considerable benefit or harm to participants. Higher-quality studies are needed to reduce this uncertainty.

Evaluation of levocarnitine, lactulose, and combination therapy for the treatment of valproic acid-induced hyperammonemia in critically ill patients.

INTRODUCTION: Critically ill patients treated with valproic acid are at risk for hyperammonemic encephalopathy. Both levocarnitine and lactulose, either alone or in combination, have been used for the treatment of hyperammonemia associated with valproic acid, however they have not been directly compared in the literature. The aim of this study was to compare the effect of levocarnitine, lactulose, and combination therapy for the treatment of valproic acid-induced hyperammonemia in critically ill patients. METHODS: This was a retrospective, system-wide, cohort study of critically ill patients who received valproic acid and levocarnitine, lactulose, or combination therapy from January 1, 2012 to October 31, 2019. The primary outcome of the study was the change in ammonia level from baseline to the lowest point within the first 48 h of treatment. Secondary outcomes included the change in ammonia levels within the first 7 days, the incidence of a clinically significant reduction, ICU length of stay, hospital length of stay, and hospital mortality. RESULTS: A total of 371 charts were reviewed and 114 patients (levocarnitine [n = 15], lactulose [n = 72], and combination [n = 27]) were included. No difference in the primary outcome was observed (levocarnitine [11umol/L] vs. lactulose [20 umol/L] vs. combination [23 umol/L], p = 0.605). The incidence of a clinically significant reduction in ammonia levels at 48 h did not differ between groups, nor did mortality. CONCLUSION: In critically ill patients with valproic acid-induced hyperammonemia, there was no significant difference in the reduction in ammonia levels in the first 48 h of treatment between levocarnitine, lactulose, and combination therapy.

Skin-to-Skin Contact and the Incidence of Transient Tachypnea of the Newborn.

OBJECTIVES: To compare the incidence of transient tachypnea of the newborn (TTN) before and after the implementation of a Baby-Friendly protocol and to determine changes in the rates of TTN symptoms, interventions, completion of skin-to-skin contact. DESIGN: Retrospective cohort study using data in the electronic medical record. SETTING: Community-based tertiary obstetric facility. PARTICIPANTS: We reviewed 934 charts of neonates born at or greater than 34 weeks gestation to women ages 18 years or older and included 790 neonates: 491 in the preimplementation group and 299 in the postimplementation group. Group assignment was based on time of Baby-Friendly protocol implementation. The preimplementation group included neonates born in April, August, and December of 2014, and the postimplementation group included neonates born during these months in 2018. METHODS: The primary outcome was incidence of TTN. Secondary outcomes were rates of the following: tachypnea symptoms, hypoglycemia, antibiotic administration, and completion of skin-to-skin contact. RESULTS: The incidence of TTN was 2% (n = 8/491) in the preimplementation group and 1% (n = 4/299) in the postimplementation group (p = 1.000). The rate of tachypnea symptoms decreased from 5% (n = 25/491) to 1% (n = 3/299, p = .003), the rate of hypoglycemia decreased from 11% (n = 54/491) to 3% (n = 10/299, p < .001), and the rate of antibiotic administration decreased from 13% (n = 66/491) to 4% (n = 11/299, p < .001). The skin-to-skin completion rate increased from 16% (n = 79/491) to 61% (n = 183/299, p < .001). CONCLUSION: Although skin-to-skin contact facilitates physiologic transition to extrauterine life, incidence of TTN was not significantly reduced after the implementation of the Baby-Friendly protocol. However, increased practice of skin-to-skin contact was an improvement in care with implications for the transition to extrauterine life.

Continued professional development: A comparison of online vs. in-person workshops.

INTRODUCTION: Pharmacy practice continues to change and therefore requires lifelong health professions education. These practice changes require academics and leaders in pharmacy to identify how to best teach and train pharmacists to manage patient care services. This study assessed whether an online training module is as effective as an in-person workshop to train pharmacists to apply dosing and therapeutic monitoring of vancomycin. METHODS: The primary endpoint measured the difference in average assessment score change between pre- and post-training between intervention groups. All pharmacists completed: (1) a baseline pretest, (2) Session 1 online, (3) Session 2 (an online training module or in-person workshop), (4) a posttest, and (5) a voluntary survey of perceptions on training. RESULTS: A total of 56 pharmacists completed the training, 43% online and 57% in-person. The multiple linear regression included pretest, training method, and pharmacists' role on posttest (R2 = 0.1041 and P = .34). A voluntary anonymous survey about perceptions on the training was completed by 20 participants. On average, perceptions were agreeable on an eight-item Likert scale between groups (Cronbach's alpha = 0.77). The total scores for the Likert scale were 27 ± 3.3 vs. 23 ± 1.6, P = .001, in the online and in-person sessions, respectively. More participants in the online group agreed that they had enough time to comprehend and apply the material, 4 vs. 3 (on the Likert scale). CONCLUSIONS: An online training module is as effective as an in-person workshop at training pharmacists to apply vancomycin dosing and monitoring.

Hemodynamic Adverse Effects of Dexmedetomidine and Propofol in a Critically Ill Trauma and Surgical Population: A Retrospective Cohort.

BACKGROUND: Propofol and dexmedetomidine may cause hemodynamic adverse effects (AEs) and more data are needed in a trauma and surgical population. OBJECTIVE: The objective of this study was to evaluate the rate of hemodynamic AEs requiring an intervention between dexmedetomidine and propofol in a critically ill trauma and surgical population. METHODS: This was a retrospective cohort study at a Level 1 trauma center. Intensive care unit patients admitted from October 1, 2017, through October 31, 2018, were divided into two groups: dexmedetomidine or propofol. The primary end point was the proportion of patients who required a therapeutic intervention for a hemodynamic AE within the first 24 hr of initiation of dexmedetomidine or propofol. RESULTS: A total of 800 charts were reviewed and 85 patients (dexmedetomidine [n = 35] and propofol [n = 50]) were included. The study population consisted of Caucasian (86%) males (61%) with a median age of 61 [interquartile range-IQR 48, 72], and 18% and 24% required antihypertensive and vasopressor agents, respectively. No difference in the primary outcome was observed (17 [49%] vs. 27 [54%], p = .624). There was no difference in the overall incidence of hemodynamic AE (18 [51%] vs. 30 [60%], p = .433). Dexmedetomidine patients had a greater decrease in median heart rate (HR) compared with the propofol (23 [IQR 16, 41] vs. 14 [IQR 5, 24] beats/min, p = .002). CONCLUSIONS: The rate of hemodynamic AEs requiring therapeutic interventions was similar between dexmedetomidine and propofol in a critically ill trauma and surgical population; however, dexmedetomidine may be associated with a larger decrease in HR.

Performance of nasal methicillin-resistant Staphylococcus aureus screening for intra-abdominal infections in critically ill adult patients.

STUDY OBJECTIVE: Intra-abdominal infections (IAIs) are a common reason for intensive care unit (ICU) admissions, and methicillin-resistant Staphylococcus aureus (MRSA) is an uncommon pathogen in IAIs. Although more data are available in the setting of non-abdominal sources, there are limited data on the performance of nasal MRSA screening for MRSA IAIs. The primary objective of this study was to evaluate the performance of nasal MRSA screening for MRSA IAIs in critically ill adult patients. DESIGN: This was a multicenter, retrospective, cohort study. SETTING: A 14-hospital healthcare system between January 1, 2014, and August 31, 2019. PATIENTS: Adult patients admitted to an ICU for at least 24 h with a diagnosis code for an IAI, a nasal MRSA surveillance screen within 30 days, and an intra-abdominal culture were eligible for inclusion. INTERVENTION: The primary outcome was to evaluate the performance of nasal MRSA screening for MRSA IAIs by calculating the accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). MEASUREMENTS AND MAIN RESULTS: Out of 863 patients randomly screened, a total of 192 patients were included. The study population had a mean age of 60 (SD ±15) years, and 101 (53%) patients were male. Six (3.1%) patients were positive for an MRSA IAI, of which four (66.7%) demonstrated a positive nasal MRSA screen. A total of 186 (96.8%) patients were negative for a MRSA IAI, of which 19 (10.2%) were nasal MRSA-positive and 167 (89.8%) were nasal MRSA-negative. Nasal MRSA screening demonstrated the following performance: accuracy 89.1% (95% CI: 83.8%-93.1%), sensitivity 66.7% (95% CI: 22.3%-95.7%), specificity 89.8% (95% CI: 84.5%-93.7%), PPV 17.4% (95% CI: 9.4%-30.0%), and NPV 98.8% (95% CI: 96.4%-99.6%). There were no significant differences in clinical outcomes, including renal replacement-free days, ICU and hospital length of stay, and in-hospital mortality. CONCLUSIONS: Among critically ill adult patients with IAIs, a negative nasal MRSA screen within 30 days may help to empirically exclude MRSA as a causative pathogen.

Professional Women's Softball Injuries: An Epidemiological Cohort Study.

OBJECTIVE: To report the epidemiology of Women's National Professional Fast-Pitch (NPF) softball injuries during the 2017 season. The secondary objective was to evaluate risk factors for pitching injuries. DESIGN/SETTING: Prospective injury data were collected from the primary clinical care of 6 professional softball teams. PARTICIPANTS: The NPF study population consisted of 153 players. INDEPENDENT VARIABLES: Data collection included the following: number of practices each week, diagnosis of the injury, game or practice injury, position played when sustaining the injury, treatment for the injury, number of missed practices and/or games as a result of the injury, and total days until return to play. MAIN OUTCOME MEASURES: Injury rate (IR) overall, IR in position players, and IR in pitchers. Secondary outcomes included risk assessment for injury in pitchers; descriptive statistics on the injuries recorded in all players. RESULTS: Pitchers reported both upper extremity and lower extremity injuries equally, whereas positional players reported more lower extremity injuries. Pitchers were also most likely to be injured during a practice than a game. Overall, there were 3.26 reported game injuries per 1000 athlete exposures (AE) and 4.79 practice injuries per 1000 AE. Pitchers specifically had 1.88 reported game injuries per 1000 AE and 5.66 practice injuries per 1000 AE. CONCLUSIONS: In contrast to previous data, our study showed an increased IR in practice as compared to games in both position players and pitchers. Significant injuries were relatively rare, and most injuries seemed minor, usually with less than 7 days missed, suggesting a relative safety associated with this sport.

Pharmacy-facilitated medication history program at a community teaching hospital: A pre-post study in an emergency department.

PURPOSE: A study was conducted to compare the accuracy of medication histories compiled by pharmacy technicians with histories obtained through the usual multidisciplinary process. METHODS: A retrospective cohort study was conducted at a community teaching hospital from January 2017 through February 2018. Inclusion criteria included patient age of at least 18 years, use of 1 or more medications at the time of admission, and hospital admission through the emergency department. Each electronically documented medication history was assessed for accuracy. The objective was to compare the accuracy of pharmacy technician-collected medication histories to those obtained through the usual multidisciplinary process. RESULTS: Of 215 patients screened, 183 were included in the study: 91 patients whose medication histories were obtained through the usual multidisciplinary process and 92 whose medication histories were collected by pharmacy technicians. Overall, documentation for 1,773 medications listed in medication histories was reviewed. The primary outcome of medication history accuracy occurred 38% of the time with the usual multidisciplinary process and 70% of the time with pharmacy technician collection of medication histories (P < 0.001). CONCLUSION: The study showed that the accuracy of medication histories was improved when histories were obtained by pharmacy technicians instead of via the usual multidisciplinary process.

Impact of Early Reinitiation of Neuropsychiatric Medications on Agitation and Delirium in the Intensive Care Unit: A Retrospective Study.

BACKGROUND: Approximately 17% of intensive care unit (ICU) patients are prescribed at least 1 home neuropsychiatric medication (NPM). When abruptly discontinued, withdrawal symptoms may occur manifesting as agitation or delirium in the ICU setting. OBJECTIVE: To evaluate the impact of early reinitiation of NPMs. METHODS: This was a retrospective, observational cohort of adult ICU patients in a tertiary care hospital. Patients were included if admitted to the ICU and prescribed a NPM prior to arrival. Study groups were based on the timing of reinitiation of at least 50% of NPMs: ≤72 hours (early group) versus >72 hours (late group). RESULTS: The primary outcome was the proportion of patients with at least 1 agitation or delirium episode in the first 72 hours. Agitation and delirium were defined as at least 1 RASS assessment between +2 to +4 and a positive CAM-ICU assessment, respectively. A total of 300 patients were included, with 187 (62%) and 113 (38%) in the early and late groups, respectively. There was no difference in agitation or delirium (late 54 [48%] vs early 62 [33%]; adjusted odds ratio [aOR] = 1.5; 95% CI = 0.8-2.8; P = 0.193). Independent risk factors found to be associated with the primary outcome were restraints (aOR = 12.9; 95% CI = 6.9-24.0; P < 0.001) and benzodiazepines (BZDs; aOR = 2.0; 95% CI = 1.0-3.7; P = 0.038). CONCLUSIONS: After adjustment for baseline differences, there was no difference in agitation or delirium. Independent risk factors were restraint use and newly initiated BZDs.

Incidence and Risk Factors Associated with Multi-Drug-Resistant Pathogens in a Critically Ill Trauma Population: A Retrospective Cohort Study.

Background: Multi-drug resistance is considered a serious health threat particularly in the intensive care unit (ICU) setting. Studies evaluating multi-drug-resistant (MDR) pathogens in critically ill trauma patients are limited. The objectives were to describe the incidence of MDR, extensive-drug-resistant (XDR), and pan-drug-resistant (PDR) organism growth in ICU patients admitted with traumatic injuries and to identify any risk factors associated with MDR growth. Patients and Methods: This was a retrospective single-center cohort study of all ICU adult patients identified via the institution's trauma registry from January 1, 2016 to August 31, 2017. Patients were included if they had positive culture growth with susceptibility data taken during the index hospitalization. Patients were excluded if their cultures were drawn within 48 hours of emergency department triage. Study groups were defined based on the presence of at least one MDR pathogen during the index hospitalization. Results: A total of 2,578 charts were reviewed and 95 patients (mean age, 60 years; 66 males [69%]) with 201 total cultures were included. The majority of positive cultures were from respiratory (69%) and urinary (16%) sources. Of the 201 positive cultures, the majority of species identified was Enterobacteriaceae (47%), Staphylococcus (32%), Enterococcus (7%), Acinetobacter (5%), and Pseudomonas (3%). Of the 95 patients with positive cultures, the incidence of MDR, XDR, and PDR organisms was found to be 31%, 17%, and 0%, respectively. Augmented renal clearance (ARC) was the only risk factor associated with an increased risk for MDR organism growth (adjusted odds ratio 9.78, 95% confidence interval [CI] 2.56-37.41; p = 0.001). Conclusions: In this cohort of critically ill trauma patients, the incidence of an MDR pathogen occurred in 31% of patients. This is the first study to find an association of ARC and multi-drug resistance, which should be further validated as a potential cause for MDR organisms.

Evaluation of dextromethorphan with select antidepressant therapy for the treatment of depression in the acute care psychiatric setting.

INTRODUCTION: Dextromethorphan (DXM), an N-methyl-D-aspartate receptor antagonist, may have ketamine-like antidepressant effects. Dextromethorphan is extensively metabolized via cytochrome P450 (CYP) 2D6, and its half-life in extensive metabolizers is 2 to 4 hours. The purpose of this study was to evaluate the effects of DXM in combination with a moderate-to-strong CYP2D6 inhibitor antidepressant on depression in an acute care psychiatric setting. METHODS: This was a single-center, retrospective chart review of adult patients with a depressive disorder diagnosis. Patients who received select antidepressant therapy with or without scheduled DXM were included. The primary outcome was the difference in time to improvement of depressive symptoms, which was an average composite of physician documentation, nurse documentation, and first time to 24 hours without as-needed anxiolytics or antipsychotics. The study group consisted of patients who received DXM with select antidepressant therapy, whereas the control group included those who received only select antidepressant therapy. RESULTS: A total of 40 patients were included. The median time to clinical improvement was 3.00 days and 2.83 days for the study group and control group, respectively (P = .986). The incidence of perceptual disturbances and delusions was higher in the study group as compared with the control group (55% and 35% vs 30% and 25%, respectively). DISCUSSION: Dextromethorphan was not associated with a rapid antidepressant effect. The commonly used dose of 30 mg daily may have been too low to have an effect; additionally, the most frequently utilized select antidepressant, bupropion, has moderately less CYP2D6 inhibition than fluoxetine and paroxetine.