Timing of Transport of Patients with COVID-19.

RATIONALE: The objective of this study was to evaluate the risk of mortality or ECMO cannulation for patients with confirmed or suspected COVID-19 transferred from sending hospitals to receiving tertiary care centers as a function of the duration of time at the sending hospital. OBJECTIVE: To determine outcomes of critically ill patients with COVID-19 who were transferred to tertiary or quarternary care medical centers. MATERIALS AND METHODS: Retrospective cohort study of critical care transports of patients to one of seven consortium tertiary care centers from March 1, 2020, through September 4, 2020. Age 14 years and older with confirmed or suspected COVID-19 transported from a sending hospital to a receiving tertiary care center by the critical care transport organization. RESULTS: Patients transported with confirmed or suspected COVID-19 to tertiary care centers had a mortality rate of 38.0%. Neither the number of days admitted, nor the number of days intubated at the sending hospital correlated with mortality (correlation coefficient 0.051 and -0.007, respectively). Similarly, neither the number of days admitted, nor number of days intubated at the sending hospital correlated with ECMO cannulation (correlation coefficient 0.008 and -0.036, respectively). CONCLUSION: It may be reasonable to transfer a critically ill COVID-19 patient to a tertiary care center even if they have been admitted at the sending hospital for several days.

Air Versus Ground Transport Times in an Urban Center.

PURPOSE: Given that the benefits of helicopter transport vary with geography and healthcare systems, we assessed transport times for rotor wing versus ground transport over a 10 year period in an urban setting. MATERIALS AND METHODS: All completed transports from 153 sending hospitals in New England from 2009 through 2018 to 8 local tertiary care centers were extracted from an administrative database. The primary outcome of interest was patient-loaded transport time for rotor wing versus ground transports. Overall, 25,483 patient transports met the inclusion criteria and were included in this study. We assessed patient-loaded transport time for all transports, and determined mean time to arrive at the scene, scene to patient time, the bedside time, and distance at which the patient-loaded transport time was faster for rotor wing than for ground transport. We also performed subgroup analyses, evaluating transport times by time of day, day of the week, and destination. RESULTS: The most common indication for transport was adult trauma, (n = 6,008, 23.6%) followed by adult cardiac (n = 4359, 17.1%), adult neuro (3729 14.6%), and adult medical (n = 3691, 14.5%). The median miles traveled for all transports was 26.0, IQR 14-38, ranging from 1 to 264 miles. The median patient-loaded transport time was 27 min (IQR 15-40) for all transports. Nearly all time intervals were shorter for rotor wing versus ground transports, and patient-loaded transport time was significantly shorter at 15 minutes compared to 38 minutes (IQR 12-22 vs 28-33, p < 0.001). There was no distance at which the patient-loaded transport time was faster for ground transport than for rotor wing. CONCLUSIONS: In over 25,000 transports over 10 years, in a compact metropolitan area with relatively short transport distances and times, the use of the helicopter was associated with substantial time savings.

Ventilator Management in Metformin-Associated Lactic Acidosis: A Case Report.

The initiation of mechanical ventilation in the setting of profound metabolic acidosis can be a particular challenge in the transport environment. The classic teaching is that patients with severe acidemia should not be intubated, if possible, because they are often able to better maintain their own compensatory minute ventilation compared with clinician management with the mechanical ventilator. In this case, a patient had profound metformin-associated lactic acidosis with a pH of 6.51 and required intubation for deteriorating mental status with an inability to protect her airway. Maintaining adequate minute ventilation can be directly in conflict with the evidence-based approach of low tidal volume ventilation for all patients. When patients have profound metabolic acidosis without evidence of acute respiratory distress syndrome, increasing the tidal volume slightly to allow for more efficient respiration can be an effective strategy to maintain acid-base status.

Postintubation Sedation After a Formulary Change From Succinylcholine to Rocuronium in a Critical Care Transport Organization.

OBJECTIVE: Rocuronium is increasingly used as a first-line neuromuscular blocker (NMB) in rapid sequence intubation by transport teams. Prior work has shown that rocuronium is associated with a delay in postintubation sedation compared with intubation with succinylcholine. METHODS: Boston MedFlight is a consortium-based transport organization. In 2017, the intubation protocol and formulary for Boston MedFlight was changed to replace succinylcholine with rocuronium. We performed a retrospective review of patients intubated by the critical care transport teams from January 2017 through December 2019. RESULTS: We analyzed data for 264 intubations, 92 with succinylcholine and 172 with rocuronium. Ketamine and etomidate were the most common induction agents. The mean time from NMB administration to the first dose of sedation was 9.2 minutes (95% confidence interval, 5.4-23.7) for the succinylcholine cohort and 14.8 minutes (95% confidence interval, 8.4-38.0; P < .001) for the rocuronium cohort. After neuromuscular blockade, the total hourly weight-adjusted fentanyl dose was significantly lower for patients intubated with rocuronium compared with succinylcholine. CONCLUSIONS: Intubation with rocuronium was associated with a longer time until the administration of sedation and decreased postneuromuscular blockade fentanyl administration compared with intubation with succinylcholine. These findings suggest opportunities for improvement in sedation and analgesia practices after rocuronium rapid sequence intubation.

Operational Policies and Procedures for Critical Care Transport During a Respiratory Pandemic.

The severe acute respiratory syndrome coronavirus 2 pandemic of 2020 to 2021 created unprecedented challenges for health care organizations, including those in the critical care transport sector. Critical care transport services had to rapidly adjust to changing patient demographics, distribution of diagnoses, and transport utilization stratagem. To evolve with the pandemic, organizations developed new protocols and guidelines in rapid succession. The growth bore out of a need to cater to this new patient population and their safety as well as the safety of the crewmembers from severe acute respiratory syndrome coronavirus 2. The critical changes to operations involved adaptability, efficient communication, continual reassessment, and implementation of novel approaches. Although these lessons learned were specific to coronavirus disease 2019, many processes will apply to future respiratory epidemics and pandemics. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) pandemic of 2020 to 2021 created unprecedented challenges for health care organizations, including critical care transport (CCT) organizations. The changes were numerous, including a change in the patient population, with a rapid decrease in trauma and pediatrics to a preponderance of adult patients with acute hypoxemic respiratory failure. CCT teams were called on to transport these patients at potential risk to themselves, especially early in 2020, before the effectiveness of personal protective equipment (PPE) was determined. Even seemingly simple tasks, such as defining a person under investigation (PUI) for coronavirus disease 2019 (COVID-19), varied from institution to institution, putting transport organizations in the middle of conflicts. Agility has always been an essential part of any CCT organization because clinicians and managers must adapt to an unpredictable environment. However, the frequency and speed of changes occurring during the COVID-19 pandemic were unprecedented. This report offers our best practices based on our experience and the available data. Although these procedures were developed for the COVID-19 pandemic, they will logically apply to future respiratory outbreaks and illuminate helpful changes for otherwise quotidian operations.

Surgeon Scorecards Improve Muscle Sampling on Transurethral Resection of Bladder Tumor and Recurrence Outcomes in Patients with Nonmuscle Invasive Bladder Cancer.

PURPOSE: The presence of detrusor muscle is essential for accurate staging of T1 cancers. Detrusor muscle presence can be a quality indicator of transurethral resection of bladder tumor for nonmuscle invasive bladder cancer. We hypothesized that increasing surgeon awareness of personal and institutional detrusor muscle sampling rates could improve resection quality and long-term oncologic outcomes. MATERIALS AND METHODS: A retrospective review of transurethral resections of bladder tumor from 1/2006 to 2/2018 was performed. The presence of detrusor muscle in the pathology report and transurethral resection specimen were extracted from records. Individual surgeon scorecards were created and distributed. Rates of detrusor muscle sampling were compared prior to and 12 months after distribution. Chart review was done to compare 3-year recurrence and progression outcomes before and after distribution of scorecards. RESULTS: The rate of detrusor muscle sampling increased from 36% (1,250/3,488) to 54% (202/373) (p=0.001) in the 12 months after scorecard distribution, ie from 30% (448/1,500) to 55% (91/165) (p <0.001) in Ta tumors and from 47% (183/390) to 72% (42/58) (p <0.001) in T1 tumors. Pathological reporting of muscle also improved for all samples (73%, 2,530/3,488 to 90%, 334/373, p <0.001), Ta (75%, 1,127/1,500 to 94%, 155/165, p <0.001) and T1 (93%, 362/390 to 100%, 58/58, p=0.04). On multivariate Cox regression analysis, the surgeon scorecard was associated with decreased 3-year risk of recurrence (HR 0.63, 95% CI 0.40-0.99). CONCLUSIONS: Creation and distribution of individual surgeon scorecards improved detrusor muscle sampling on transurethral resection and was associated with decreased risk of disease recurrence. Quality evaluation of transurethral resection of bladder tumor may contribute to improved outcomes of patients with nonmuscle invasive bladder cancer.

Critical Care Transport of Patients With COVID-19.

PURPOSE: Critical care transport is associated with a high rate of adverse events, and the risks and outcomes of transporting critically ill patients during the COVID-19 pandemic have not been previously described. MATERIALS AND METHODS: We performed a retrospective review of transports of subjects with suspected or confirmed COVID-19 from sending hospitals to tertiary care hospitals in Boston. Follow-up data were obtained for patients transported between March 1st and April 20th, 2020. RESULTS: Of 254 charts identified, 250 patients were transported. Nine patients (3.5%) had cardiac arrest prior to transport. Twenty-nine (11.6%) had hypotension, 22 (8.8%) had a critical desaturation, and 4 (1.6%) had both en route. Hospital follow-up data were available for 189 patients. Of those intubated during their hospitalization, 44 (25.0%) had died, 59 (33.5%) had been extubated, and 13 (17.6%) had been discharged alive. For the subgroup with prior cardiac arrest, follow-up data available for 6. Of these 6, 2 died and 4 (66.7%) have been discharged alive. CONCLUSIONS: Few patients with COVID-19 had an adverse event in transport. The in-hospital mortality rate was 25%, with a 33.5% extubation rate. Patients resuscitated from cardiac arrest prior to transport had a 66.7% discharge rate among those transported to consortium hospitals.

Transport of a Nonintubated Prone Patient with Severe Hypoxemic Respiratory Failure Due to COVID-19.

With the COVID-19 pandemic, healthcare systems have been facing an unprecedented, large-scale respiratory disaster. Prone positioning improves mortality in severe hypoxemic respiratory failure, including COVID-19. While this is effective for intubated patients with moderate-to-severe ARDS, it has also been shown to be beneficial for non-intubated patients. Critical care transport (CCT) has become an essential component of combating COVID-19, frequently transporting patients to receive advanced respiratory therapies and distribute patients in concert with available resources. With increasing awake proning, CCT teams may encounter patients supported in the prone position. Historically, transporting in the prone position has not been embraced due to substantial risks of desaturation during transport. In this case report, we describe the first known report of transporting a non-intubated, critically ill COVID-19 patient in the prone position.

Surgical versus Medical Castration for Metastatic Prostate Cancer: Use and Overall Survival in a National Cohort.

PURPOSE: Surgical castration for metastatic prostate cancer is used less frequently than medical castration yet costs less, requires less followup and may be associated with fewer adverse effects. We evaluated temporal trends and factors associated with the use of surgical castration. MATERIALS AND METHODS: This retrospective cohort study sampled 24,805 men with newly diagnosed (de novo) metastatic prostate cancer from a national cancer registry in the United States (2004 to 2016). Multivariable logistic regression assessed the association between sociodemographic factors and surgery. Multivariable Cox regression evaluated the association between castration type and overall survival. RESULTS: Overall 5.4% of men underwent surgical castration. This figure decreased from 8.5% in 2004 to 3.5% in 2016 (per year later OR 0.89, 95% CI 0.87-0.91, p <0.001). Compared to Medicare, private insurance was associated with less surgery (OR 0.73, 95% CI 0.61-0.87, p <0.001) while Medicaid or no insurance was associated with more surgery (OR 1.68, 95% CI 1.34-2.11, p <0.001 and OR 2.12, 95% CI 1.58-2.85, p <0.001, respectively). Regional median income greater than $63,000 was associated with less surgery (vs income less than $38,000 OR 0.61, 95% CI 0.43-0.85, p=0.004). After a median followup of 30 months castration type was not associated with differences in survival (surgical vs medical HR 1.02, 95% CI 0.95-1.09, p=0.6). CONCLUSIONS: In a contemporary, real-world cohort surgical castration use is low and decreasing despite its potential advantages and similar survival rate compared to medical castration. Men with potentially limited health care access undergo more surgery, perhaps reflecting a provider bias toward the perceived benefit of permanent castration.

The Effect of Lights and Sirens on Critical Care Transport Time.

BACKGROUND: In the prehospital setting, the use of ambulance lights and sirens (L&S) has been found to result in minor decreases in transport times, but has not been studied in interfacility transportation. OBJECTIVE: The objective of this study was to evaluate the indications for L&S and the impact of L&S on transport times in interfacility critical care transport. METHODS: We performed a retrospective analysis using administrative data from a large, urban critical care transportation organization. The indications for L&S were assessed and the transport times with and without L&S were compared using distance matching for common transport routes. Median times were compared for temporal subgroups. RESULTS: L&S were used in 7.3% of transports and were most strongly associated with transport directly to the operating room (odds ratio 15.8; 95% confidence interval 6.32-39.50; p < 0.001). The timing of the transport was not associated with L&S use. For all transports, there was a significant decrease in the transport time using L&S, with a median of 8 min saved, corresponding to 19.5% of the overall transportation time without L&S (33 vs. 41 min; p < 0.001). The reduction in transport times was consistent across all temporal subgroups, with a greater time reduction during rush hour transports. CONCLUSIONS: The use of L&S during interfacility critical care transport was associated with a statistically significant time reduction in this urban, single-system retrospective analysis. Although the use of L&S was not associated with rush-hour transports, the greatest time reduction was associated with L&S transport during these hours.

Predictive Utility of Prior Negative Urine Cultures in Women with Suspected Recurrent Uncomplicated Urinary Tract Infections.

PURPOSE: Guidelines recommend treating women who have symptoms of an uncomplicated urinary tract infection with antimicrobials without performing a urine culture. However, 10% to 50% of women with urinary tract infection symptoms are found to have a negative culture. Urinalysis data are useful to predict a negative culture. We evaluated how a previous negative culture predicts the likelihood of a subsequent negative culture. MATERIALS AND METHODS: We gathered retrospective data on women 18 years old or older with symptoms of an uncomplicated urinary tract infection who submitted urine cultures as outpatients from 2011 to 2017. Univariate analysis and multivariable regression models were used to determine the likelihood ratios and risk ratios of predicting a negative culture. RESULTS: Of the 20,759 patients 9,271 (44.7%) had a negative culture, defined as less than 103 CFU/ml, and 6,958 (33.5%) had at least 1 prior culture, including 4,510 (64.8%) with at least 1 prior negative culture and 2,634 (58.4%) with a subsequent negative culture. Variables associated with an increased likelihood of another negative culture were a prior negative culture (LR 1.43, 95% CI 1.387-1.475), prior negative culture and negative urinalysis (LR 1.839, 95% CI 1.768-1.913), and vaginal irritation and/or discharge (LR 1.335, 95% CI 1.249-1.427, each p <0.001). Urinalysis had 83% specificity and 78% positive predictive value. These values were significantly enhanced if the patient had a prior negative culture without a prior positive culture (95% and 87%, respectively). CONCLUSIONS: In women with recurrent urinary tract infection symptoms a previous negative culture and negative urinalysis are highly predictive of another negative culture. Women with recurrent urinary tract infection symptoms, and negative urinalysis and urine cultures may benefit from further evaluation.

Establishment of a new prostate cancer multidisciplinary clinic: Format and initial experience.

BACKGROUND: The use of multidisciplinary clinics (MDCs) for outpatient cancer evaluation is increasing. MDCs may vary in format, and data on whether MDCs change prostate cancer (PCa) care are limited. Here we report on the setup and design of a relatively new PCa MDC clinic. Because MDC evaluation was associated with a comprehensive re-evaluation of all patients' staging and risk stratification data, we studied the frequency of changes in PCa grade and stage upon MDC evaluation, which provides a unique estimate of the magnitude of pathology, radiology, and exam-based risk stratification in a modern tertiary setting. METHODS: In 2008-2012, 887 patients underwent consultation for newly diagnosed PCa at the Johns Hopkins Hospital (JHH) weekly MDC. In a same-day process, patients are interviewed and examined in a morning clinic. Examination findings, radiology studies, and biopsy slides are then reviewed during a noon conference that involves real-time collaboration among JHH attending specialty physicians: urologists, radiation oncologists, medical oncologists, pathologists, and radiologists. During afternoon consultations, attending physicians appropriate to each patient's eligible treatment options individually meet with patients to discuss management strategies and/or clinical trials. Retrospective chart review identified presenting tumor characteristics based on outside assessment, which was compared with stage and grade as determined at MDC evaluation. RESULTS: Overall, 186/647 (28.7%) had a change in their risk category or stage. For example, 2.9% of men were down-classified as very-low-risk, rendering them eligible for active surveillance. 5.7% of men thought to have localized cancer were up-classified as metastatic, thus prompting systemic management approaches. Using NCCN guidelines as a benchmark, many men were found to have undergone non-indicated imaging (bone scan 23.9%, CT/MRI 47.4%). The three most chosen treatments after MDC evaluation were external beam radiotherapy ± androgen deprivation (39.3%), radical prostatectomy (32.0%), and active surveillance/expectant management (12.9%). CONCLUSIONS: A once-weekly same-day evaluation that involves simultaneous data evaluation, management discussion, and patient consultations from a multidisciplinary team of PCa specialists is feasible. Comprehensive evaluation at a tertiary referral center, as demonstrated in a modern MDC setting, is associated with critical changes in presenting disease classification in over one in four men.

Fluoroquinolone resistance in the rectal carriage of men in an active surveillance cohort: longitudinal analysis.

PURPOSE: Rectal swabs can identify men with fluoroquinolone resistant bacteria and decrease the infection rate after transrectal ultrasound guided prostate biopsy by targeted antimicrobial prophylaxis. We evaluated the rate of fluoroquinolone resistance in an active surveillance cohort with attention to factors associated with resistance and changes in resistance with time. MATERIALS AND METHODS: We evaluated 416 men with prostate cancer on active surveillance who underwent rectal swabs to assess the rate of fluoroquinolone resistance compared to that in men undergoing diagnostic transrectal ultrasound guided prostate biopsy. The chi-square test and Student t-test were used to compare categorical and continuous variables, respectively. Poisson regression analysis was used for multivariate analysis. RESULTS: On the initial swab fluoroquinolone resistance was found in 95 of 416 men (22.8%) on active surveillance compared to 54 of 221 (24.4%) in the diagnostic biopsy cohort (p = 0.675). Diabetes was found in 4.0% of the fluoroquinolone sensitive group vs 14.7% of the resistant group (p <0.001). Biopsy history was not associated with resistance. Of those with a resistant first swab 62.9% had a resistant second swab and 88.9% of those with 2 resistant swabs showed resistance on the third swab. Of men with a sensitive first swab 10.6% showed resistance on the second swab and 10.6% of those with 2 sensitive swabs had resistant third swabs. CONCLUSIONS: One of 4 men who present for surveillance and diagnostic transrectal ultrasound guided prostate biopsy have rectal flora resistant to fluoroquinolone. Resistance is significantly associated with diabetes but the number of prior biopsies is not. Men with fluoroquinolone resistant flora tend to remain resistant with time.

Trends in renal surgery: robotic technology is associated with increased use of partial nephrectomy.

PURPOSE: Underuse of partial vs radical nephrectomy for renal tumors was noted in recent population based analyses. An explanation is the learning curve associated with laparoscopic partial nephrectomy. We analyzed state trends in renal surgery and their relationship to the introduction of robotic technology. MATERIALS AND METHODS: We used the Maryland HSCRC (Health Services Cost Review Commission) database to identify patients who underwent radical or partial nephrectomy, or renal ablation from 2000 to 2011. Utilization trends, and associated patient and hospital factors were analyzed using multivariate logistic regression. ICD-9 robotic modifier codes were established in October 2008. RESULTS: Of the 14,260 patients included in analysis 11,271 (79.0%), 2,622 (18.4%) and 367 (2.6%) underwent radical and partial nephrectomy, and renal ablation, respectively. Partial nephrectomy increased from 8.6% in 2000 to 27% in 2011. Open radical nephrectomy decreased by 33%, while minimally invasive radical nephrectomy increased by 15%. Robot-assisted laparoscopic partial nephrectomy increased from 2008 to 2011, attaining a 14% rate at university and 10% at nonuniversity hospitals (p = 0.03). It was associated with increased partial nephrectomy (OR 9.67, p <0.001). Younger age, male gender and low patient complexity predicted partial nephrectomy on overall analysis, while higher hospital volume and university status were predictors only in earlier years. CONCLUSIONS: Partial nephrectomy use increased in Maryland from 2001 to 2011, which was facilitated by robotic technology. Associations with hospital factors decreased with time. These data suggest that robotic technology may enable surgeons across practice settings to more frequently perform nephron sparing surgery.

Inflammatory bowel disease induces inflammatory and pre-neoplastic changes in the prostate.

BACKGROUND: Inflammatory bowel disease (IBD) has been implicated as a risk factor for prostate cancer, however, the mechanism of how IBD leads to prostate tumorigenesis is not known. Here, we investigated whether chronic intestinal inflammation leads to pro-inflammatory changes associated with tumorigenesis in the prostate. METHODS: Using clinical samples of men with IBD who underwent prostatectomy, we analyzed whether prostate tumors had differences in lymphocyte infiltrate compared to non-IBD controls. In a mouse model of chemically-induced intestinal inflammation, we investigated whether chronic intestinal inflammation could be transferred to the wild-type mouse prostate. In addition, mouse prostates were evaluated for activation of pro-oncogenic signaling and genomic instability. RESULTS: A higher proportion of men with IBD had T and B lymphocyte infiltration within prostate tumors. Mice with chronic colitis showed significant increases in prostatic CD45 + leukocyte infiltration and elevation of three pro-inflammatory cytokines-TIMP-1, CCL5, and CXCL1 and activation of AKT and NF-kB signaling pathways. Lastly, mice with chronic colitis had greater prostatic oxidative stress/DNA damage, and prostate epithelial cells had undergone cell cycle arrest. CONCLUSIONS: These data suggest chronic intestinal inflammation is associated with an inflammatory-rich, pro-tumorigenic prostatic phenotype which may explain how gut inflammation fosters prostate cancer development in men with IBD.

Clinical Policies and Procedures for Critical Care Transport during a Respiratory Pandemic.

The severe acute respiratory syndrome coronavirus disease-2 (SARS-CoV-2) pandemic of 2020-2021 created unprecedented challenges for clinicians in critical care transport (CCT). These CCT services had to rapidly adjust their clinical approaches to evolving patient demographics, a preponderance of respiratory failure, and transport utilization stratagem. Organizations had to develop and implement new protocols and guidelines in rapid succession, often without the education and training that would have been involved pre-coronavirus disease 2019 (COVID-19). These changes were complicated by the need to protect crew members as well as to optimize patient care. Clinical initiatives included developing an awake proning transport protocol and a protocol to transport intubated proned patients. One service developed a protocol for helmet ventilation to minimize aerosolization risks for patients on noninvasive positive pressure ventilation (NIPPV). While these clinical protocols were developed specifically for COVID-19, the growth in practice will enhance the care of patients with other causes of respiratory failure. Additionally, these processes will apply to future respiratory epidemics and pandemics.

Prior Placement of Male Urethral Slings Can Increase the Need for Revision of Artificial Urinary Sphincters.

BACKGROUND: Recurrent stress urinary incontinence (SUI) following male sling can be managed surgically with artificial urinary sphincter (AUS) insertion. Prior small, single-center retrospective studies have not demonstrated an association between having failed a sling procedure and worse AUS outcomes. The aim of this study was to compare outcomes of primary AUS placement in men who had or had not undergone a previous sling procedure. METHODS: A retrospective review of all AUS devices implanted at a single academic center during 2000-2018 was performed. After excluding secondary AUS placements, revision and explant procedures, 135 patients were included in this study, of which 19 (14.1%) patients had undergone prior sling procedures. RESULTS: There was no significant difference in demographic characteristics between patients undergoing AUS placement with or without a prior sling procedure. Average follow up time was 28.0 months. Prior sling was associated with shorter overall device survival, with an increased likelihood of requiring revision or replacement of the device (OR 4.2 (1.3-13.2), p = 0.015) as well as reoperation for any reason (OR 3.5 (1.2-9.9), p = 0.019). While not statistically significant, patients with a prior sling were more likely to note persistent incontinence at most recent follow up (68.8% vs. 42.7%, p = 0.10). CONCLUSIONS: Having undergone a prior sling procedure is associated with shorter device survival and need for revision or replacement surgery. When considering patients for sling procedures, patients should be counseled regarding the potential for worse AUS outcomes should they require additional anti-incontinence procedures following a failed sling.

ECMO Transport without Physicians or Additional Clinicians.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has accelerated rapidly for patients in severe cardiac or respiratory failure. As a result, ECMO networks are being developed across the world using a "hub and spoke" model. Current guidelines call for all patients transported on ECMO to be accompanied by a physician during transport. However, as ECMO centers and networks grow, the increasing number of transports will be limited by this mandate. OBJECTIVES: The aim of this study was to compare rates of adverse events occurring during transport of ECMO patients with and without an additional clinician, defined as a physician, nurse practitioner (NP), or physician assistant (PA). METHODS: This is a retrospective cohort study of all adults transported while cannulated on ECMO from 2011-2018 via ground and air between 21 hospitals in the northeastern United States, comparing transports with and without additional clinicians. The primary outcome was the rate of major adverse events, and the secondary outcome was minor adverse events. RESULTS: Over the seven-year study period, 93 patients on ECMO were transported. Twenty-three transports (24.7%) were accompanied by a physician or other additional clinician. Major adverse events occurred in 21.5% of all transports. There was no difference in the total rate of major adverse events between accompanied and unaccompanied transports (P = .91). Multivariate analysis did not demonstrate any parameter as being predictive of major adverse events. CONCLUSIONS: In a retrospective cohort study of transports of ECMO patients, there was no association between the overall rate of major adverse events in transport and the accompaniment of an additional clinician. No variables were associated with major adverse events in either cohort.

Algorithms Using Previous Resistance, Prior Antimicrobial Prescriptions, and Patient Place of Residence Enhance Empirical Therapy for Women With Uncomplicated Urinary Tract Infections.

OBJECTIVE: To evaluate how previous antimicrobial resistance, prior prescription data, and patient place of residence (ZIP code) can guide empirical therapy for uncomplicated urinary tract infections (UTI). Guidelines recommend empirical antimicrobial selection for women with symptoms of uncomplicated UTIs, most commonly trimethoprim-sulfamethoxazole (SXT), nitrofurantoin (NIT), or ciprofloxacin (CIP). Previous antimicrobial resistance and prior prescription data are potential predictors of resistance in subsequent urine cultures for UTIs. Also, there is evidence of geographic clustering of antimicrobial resistance for UTIs. METHODS: Retrospective data from women (age ≥18) with an assigned diagnosis of UTI, submitting urine cultures as outpatients (2011-2018), were gathered. Univariate analyses and multivariable regression models were used to determine odds ratios for predicting resistance to SXT, NIT, and CIP on the 2011-2017 data. Antimicrobial choice algorithms were created using 2011-2017 results and tested on 2018 data. RESULTS: In the training cohort, 9455 women had diagnoses of uncomplicated UTIs and positive urine cultures. Prevalence of resistance for SXT, NIT, and CIP was 19.4%, 12.1%, and 10.3%, respectively. A urine culture with previous resistance, prior antimicrobial prescription within 2 years and ZIP code were the strongest predictors of a subsequent resistant culture. An algorithm based on these data had a success rate of 92.2%, compared to provider's choice (87.5%, P <.001) or best theoretical outcomes with guidelines (90.0%, P = .048). CONCLUSION: Previous resistance, prior prescriptions, and patient ZIP code are predictors of subsequent resistance in patients with uncomplicated UTIs. Algorithms using these data can outperform real-world outcomes and guidelines.