Reduced Mortality With Ondansetron Use in SARS-CoV-2-Infected Inpatients.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has led to a surge in clinical trials evaluating investigational and approved drugs. Retrospective analysis of drugs taken by COVID-19 inpatients provides key information on drugs associated with better or worse outcomes. METHODS: We conducted a retrospective cohort study of 10 741 patients testing positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection within 3 days of admission to compare risk of 30-day all-cause mortality in patients receiving ondansetron using multivariate Cox proportional hazard models. All-cause mortality, length of hospital stay, adverse events such as ischemic cerebral infarction, and subsequent positive COVID-19 tests were measured. RESULTS: Administration of ≥8 mg of ondansetron within 48 hours of admission was correlated with an adjusted hazard ratio for 30-day all-cause mortality of 0.55 (95% CI, 0.42-0.70; P < .001) and 0.52 (95% CI, 0.31-0.87; P = .012) for all and intensive care unit-admitted patients, respectively. Decreased lengths of stay (9.2 vs 11.6; P < .001), frequencies of subsequent positive SARS-CoV-2 tests (53.6% vs 75.0%; P = .01), and long-term risks of ischemic cerebral ischemia (3.2% vs 6.1%; P < .001) were also noted. CONCLUSIONS: If confirmed by prospective clinical trials, our results suggest that ondansetron, a safe, widely available drug, could be used to decrease morbidity and mortality in at-risk populations.

A Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Prediction Model From Standard Laboratory Tests.

BACKGROUND: With the limited availability of testing for the presence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus and concerns surrounding the accuracy of existing methods, other means of identifying patients are urgently needed. Previous studies showing a correlation between certain laboratory tests and diagnosis suggest an alternative method based on an ensemble of tests. METHODS: We have trained a machine learning model to analyze the correlation between SARS-CoV-2 test results and 20 routine laboratory tests collected within a 2-day period around the SARS-CoV-2 test date. We used the model to compare SARS-CoV-2 positive and negative patients. RESULTS: In a cohort of 75 991 veteran inpatients and outpatients who tested for SARS-CoV-2 in the months of March through July 2020, 7335 of whom were positive by reverse transcription polymerase chain reaction (RT-PCR) or antigen testing, and who had at least 15 of 20 lab results within the window period, our model predicted the results of the SARS-CoV-2 test with a specificity of 86.8%, a sensitivity of 82.4%, and an overall accuracy of 86.4% (with a 95% confidence interval of [86.0%, 86.9%]). CONCLUSIONS: Although molecular-based and antibody tests remain the reference standard method for confirming a SARS-CoV-2 diagnosis, their clinical sensitivity is not well known. The model described herein may provide a complementary method of determining SARS-CoV-2 infection status, based on a fully independent set of indicators, that can help confirm results from other tests as well as identify positive cases missed by molecular testing.

Carbon monoxide poisoning surveillance in the Veterans Health Administration, 2010-2017.

BACKGROUND: Exposure to carbon monoxide (CO), the odorless, colorless gas resulting from incomplete combustion of hydrocarbons, is preventable. Despite the significant risk of morbidity and mortality associated with CO poisoning, there currently exists no active national CO surveillance system in the United States (U.S.). Our study aims to use electronic health record data to describe the epidemiology of CO poisoning in the Veterans Health Administration healthcare population. METHODS: We identified unique inpatient and outpatient encounters coded with International Classification of Diseases (ICD) codes for CO poisoning and analyzed relevant demographic, laboratory, treatment, and death data from January 2010 through December 2017 for Veterans across all 50 U.S. states and Puerto Rico. Statistical methods used were 95% CI calculations and the two-tailed z test for proportions. RESULTS: We identified 5491 unique patients with CO poisoning, of which 1755 (32%) were confirmed/probable and 3736 (68%) were suspected. Unintentional poisoning was most common (72.9%) overall. Age less than 65 years, residence in Midwest U.S. Census region versus South or West, and winter seasonal trend were characteristics associated with confirmed/probable CO poisoning. Twenty-six deaths (1.5%) occurred within 30 days of confirmed/probable CO poisoning and were primarily caused by cardiovascular events (42%) or anoxic encephalopathy (15%). CONCLUSIONS: Our findings support the use of ICD-coded data for targeted CO poisoning surveillance, however, improvements are needed in ICD coding to reduce the percentage of cases coded with unknown injury intent and/or CO poisoning source. Prevalence of CO poisoning among Veterans is consistent with other U.S. estimates. Since most cases are unintentional, opportunities exist for provider and patient education to reduce risk.

Zika virus infection in the Veterans Health Administration (VHA), 2015-2016.

BACKGROUND: Zika virus (ZIKV) is an important flavivirus infection. Although ZIKV infection is rarely fatal, risk for severe disease in adults is not well described. Our objective was to describe the spectrum of illness in U.S. Veterans with ZIKV infection. METHODOLOGY: Case series study including patients with laboratory-confirmed or presumed positive ZIKV infection in all Veterans Health Administration (VHA) medical centers. Adjusted odds ratios of clinical variables associated with hospitalization and neurologic complications was performed. PRINCIPAL FINDINGS: Of 1,538 patients tested between 12/2015-10/2016 and observed through 3/2017, 736 (48%) were RT-PCR or confirmed IgM positive; 655 (89%) were male, and 683 (93%) from VA Caribbean Healthcare System (VACHCS). Ninety-four (13%) were hospitalized, 91 (12%) in the VACHCS. Nineteen (3%) died after ZIKV infection. Hospitalization was associated with increased Charlson co-morbidity index (adjusted odds ratio [OR] 1.2; 95% confidence interval [CI], 1.1-1.3), underlying connective tissue disease (OR, 29.5; CI, 3.6-244.7), congestive heart failure (OR, 6; CI, 2-18.5), dementia (OR, 3.6; CI, 1.1-11.2), neurologic symptom presentation (OR, 3.9; CI, 1.7-9.2), leukocytosis (OR, 11.8; CI, 4.5-31), thrombocytopenia (OR, 7.8; CI, 3.3-18.6), acute kidney injury (OR, 28.9; CI, 5.8-145.1), or using glucocorticoids within 30 days of testing (OR, 13.3; CI 1.3-133). Patients presenting with rash were less likely to be hospitalized (OR, 0.29; CI, 0.13-0.66). Risk for neurologic complications increased with hospitalization (OR, 5.9; CI 2.9-12.2), cerebrovascular disease (OR 4.9; CI 1.7-14.4), and dementia (OR 2.8; CI 1.2-6.6). CONCLUSION: Older Veterans with multiple comorbidities or presenting with neurologic symptoms were at increased risk for hospitalization and neurological complications after ZIKV infection.

Epidemiologic Review of Veterans Health Administration Patients with Isolation of Nontuberculous Mycobacteria after Cardiopulmonary Bypass Procedures.

We evaluated the isolation of postoperative nontuberculous mycobacteria (NTM) associated with heater-cooler devices (HCDs) used during cardiopulmonary bypass (CPB) surgery in the Veterans Health Administration from January 1, 2010, to December 31, 2016. In more than 38,000 CPB procedures, NTM was isolated in 111 patients; 1 Mycobacterium chimaera mediastinitis case and 1 respiratory isolate were found. Infect Control Hosp Epidemiol 2017;38:1103-1106.

Comparative assessment of antimicrobial usage measures in the Department of Veterans Affairs.

We compared 2 data sources--antimicrobial orders and bar-coded medication administration (BCMA)--for calculating the number of grams used, grams used based on defined daily dose, and days of therapy at one Veterans Affairs Medical Center for 2009-2010. The number of grams used calculated from BCMA data provided the most informative antimicrobial utilization measure.

Anticoagulation-related outcomes in patients receiving warfarin after starting levofloxacin or gatifloxacin.

STUDY OBJECTIVE: To compare anticoagulation-related outcomes in patients receiving stable dosages of warfarin who started levofloxacin or gatifloxacin therapy. DESIGN: Retrospective medical record review. SETTING: Veterans Affairs medical center. PATIENTS: Of 92 patients receiving the same dosages of warfarin for at least 4 weeks before starting antibiotic therapy, 54 received levofloxacin between January and September 2003, and 38 received gatifloxacin between January and September 2004. MEASUREMENTS AND MAIN RESULTS: Data were obtained through the hospital's pharmacy, laboratory, and general patient databases and through electronic medical records. The INRs evaluated were prefluoroquinolone use, defined as the last INR measured before the start of antibiotic therapy (up to 4 wks earlier), and postfluoroquinolone use, defined as any INR measured during antibiotic therapy through 1 week after discontinuation of the antibiotic. Analyzed outcomes included the percentage of patients with postfluoroquinolone INRs that were above 4, that exceeded the therapeutic goal, or that exceeded the goal by more than 1 point; INR changes of more than 0.5, 1, or 1.5 points above the INR before fluoroquinolone use; major or minor bleeding events; requirement for vitamin K administration; warfarin dosage reduction or withholding doses; and warfarin-related hospital, emergency, or urgent care admissions or visits. No significant differences were noted in baseline characteristics with regard to age, sex, prefluoroquinolone INR, or anticoagulation indications between the two groups. The percentage of patients with a postfluoroquinolone INR above 4 was 2% (1 of 54 patients) in the levofloxacin group versus 21% (8 of 38 patients) in the gatifloxacin group (p=0.003). The percentage of patients receiving vitamin K in the levofloxacin and gatifloxacin groups was 0% (0 of 54 patients) and 11% (4 of 38, p=0.026), respectively. For the other anticoagulation-related outcomes, no significant differences were noted between the groups. CONCLUSION: Patients receiving warfarin who take gatifloxacin may be at higher risk for an INR above 4 compared with those taking levofloxacin. Close monitoring of warfarin therapy while concomitantly receiving gatifloxacin is warranted.

Effects of a tablet-splitting program in patients taking HMG-CoA reductase inhibitors: analysis of clinical effects, patient satisfaction, compliance, and cost avoidance.

OBJECTIVE: The primary objective was to determine the effect of a hydroxymethylglutaryl- CoA reductase inhibitor (HMG) tablet-splitting program on laboratory outcomes (lipid panel and liver enzyme tests). Other objectives were to assess patient compliance and satisfaction with splitting tablets and to measure the reduction in drug acquisition costs. METHODS: Patients at a Veterans Affairs Health Care System facility were included in this study if they participated in the HMG tablet-splitting program between April and September 2000. Patients taking the same drug and dosage before and after implementation of the program were asked to complete a mailed questionnaire designed to measure satisfaction and compliance with the program. Data collected through electronic charts included patient demographics, prescribed medication, and the values for lipid panel and liver function tests. RESULTS: A total of 2,019 patients were included in the study. The total cost avoidance achieved over one year for atorvastatin, lovastatin, and simvastatin was 138,108 dollars (N=2,019). The majority of patients who responded to the questionnaire were satisfied and compliant with tablet splitting. In the laboratory analysis (N=512), there was no difference between prevalues and postvalues for total cholesterol and triglycerides. There was a statistically, but not clinically, significant decrease in LDL (102 versus 97, P<0.001) and increase in HDL (46 versus 48, P<0.001), AST (26 versus 28, P<0.001), and ALT (24 versus 26, P=0.006) after the initiation of tablet splitting. CONCLUSION: Tablet splitting of HMGs had no short-term negative effects on laboratory outcomes and favorable effects on humanistic outcomes as measured by patient satisfaction and compliance. Tablet splitting of HMGs is an effective way to reduce costs and nearly double the number of patients who can be treated for the same expense.