National Hospitalization Rates and In-Hospital Mortality Rates of HIV-Related Opportunistic Infections in the United States, 2011-2018.

BACKGROUND: Human immunodeficiency virus (HIV)-related opportunistic infections (OIs) cause substantial morbidity and mortality among people with HIV (PWH). US hospitalization and in-hospital mortality rates associated with OIs have not been published using data from the past decade. METHODS: We analyzed the National Inpatient Sample for the years 2011 through 2018. We used sociodemographic, financial, and hospital-level variables and identified hospitalizations for PWH and OI diagnoses. Using survey-weighted methods, we estimated all OI-related US hospitalization rates and in-hospital mortality per 100 000 PWH and modeled associated factors using survey-based multivariable logistic regression techniques. RESULTS: From 2011 to 2018, there were an estimated 1 710 164 (95% confidence interval [CI], 1 659 566-1 760 762) hospital discharges for PWH with 154 430 (95% CI, 148 669-159 717 [9.2%]) associated with an OI, of which 9336 (95% CI, 8813-9857; 6.0%) resulted in in-hospital mortality. Variables associated with higher odds of OI-related hospitalizations (compared to without an OI) included younger age, male sex, non-White race/ethnicity, and being uninsured (all likelihood ratio [LR] P < .001). Higher OI-related mortality was associated with older age (LR P < .001), male sex (LR P = .001), Hispanic race/ethnicity (LR P < .001), and being uninsured (LR P = .009). The OI-related hospitalization rate fell from 2725.3 (95% CI, 2266.9-3183.7) per 100 000 PWH in 2011 to 1647.3 (95% CI, 1492.5-1802.1) in 2018 (P < .001), but the proportion of hospitalizations with mortality was stable (5.9% in 2011 and 2018). CONCLUSIONS: Our findings indicate an ongoing need for continued funding of HIV testing, health insurance for all PWH, OI screening initiatives, review of current prophylaxis guidelines, and recruitment of more HIV clinicians.

Longitudinal Trends in the Diagnosis of Attention-Deficit/Hyperactivity Disorder and Stimulant Use in Preschool Children on Medicaid.

OBJECTIVES: To describe trends in the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and prescribing of stimulants in preschool-age children receiving Medicaid and to identify factors associated with the receipt of psychosocial care. STUDY DESIGN: Data were extracted from 2012-2016 Kentucky Medicaid claims for children aged <6 years. ADHD was identified using International Classification of Diseases, Tenth Revision codes F90.0, F90.1, F90.2, F90.8, and F90.9. Psychosocial therapy was defined as having at least 1 relevant Current Procedural Terminology code in a claim within the year. A generalized linear model with a logit link and binomial distribution was used to assess factors associated with receipt of psychosocial treatment in 2016. RESULTS: More than 2500 (1.24%) preschool-aged children receiving Medicaid had a diagnosis of ADHD in 2016, with 988 (38.2%) of those receiving a stimulant medication. Children in foster care were diagnosed with and/or treated for ADHD 4 times more often than other Medicaid recipients. Of the 1091 preschoolers receiving stimulants, 99 (9%) did not have a diagnosis of ADHD. There were no significant differences in diagnoses by race/ethnicity, but children reported to be black, Hispanic, or other race/ethnicity received stimulants at a lower rate than white children. Positive predictors for receiving psychosocial therapy in 2016 included having the diagnosis but not receiving a stimulant, having at least 1 prescription written by a psychiatrist, having comorbidities, and age. The use of stimulants in children aged <6 years declined from 0.9% in 2012 to 0.5% in 2016. CONCLUSIONS: Promising trends demonstrate a decreasing use of stimulants in preschoolers; however, continued vigilance is needed to promote the optimal use of psychosocial interventions.

Regional Cerebral Oxygen Saturation Level Predicts 30-Day Mortality Rate After Left Ventricular Assist Device Surgery.

OBJECTIVE: Left ventricular assist device (LVAD) surgery is complex, high risk, and expensive. The authors' hypothesis is baseline regional cerebral oxygen saturation (rSO2) might be a predictor of postoperative clinical outcomes. DESIGN: Retrospective review of 210 consecutive continuous flow LVAD patients between 2008 and 2014. The primary measure is 30-day mortality rate and secondary measures include modified major adverse cardiocerebral events (MACE), length of stay (LOS), and intensive care unit (ICU) stay. Multiple logistic regression models were applied to examine if a binary outcome variable, such as 30-day mortality and MACE, is associated with rSO2 at baseline. Log-linear model was used to examine whether LOS or ICU stay hours is associated with rSO2 at baseline. SETTING: Single institution, academic hospital. PARTICIPANTS: Patients who received LVAD surgery ​at Jewish Hospital, Louisville, KY. INTERVENTIONS: All patients received LVAD surgery. Cerebral oximetry monitoring was used in both the preoperative and intraoperative periods. MEASUREMENTS AND MAIN RESULTS: The authors found that higher rSO2 at baseline is associated with lower 30-day mortality with an odds ratio of 0.94 and 95% confidence interval (0.888, 0.995) for every 1% increase of rSO2. For secondary outcomes, baseline rSO2 was not significantly associated with MACE, requirement for postoperative renal failure/dialysis, reoperation for bleeding, and LOS or ICU hours. CONCLUSIONS: Regional cerebral oxygen saturation levels at baseline are significantly associated with 30-day mortality after LVAD surgeries.

Comparison of In-person Versus Online Comprehensive Pelvic Floor Rehabilitation Program Following Prostatectomy.

OBJECTIVE: To compare continence outcomes in post-prostatectomy patients undergoing supervised in-person versus online pelvic floor muscle training and pelvic floor education (iPMFT vs oPFMT/PFE). Despite the proven benefit of in-person PFMT for urinary incontinence (UI) following prostatectomy, numerous barriers impede access. We developed a comprehensive online program to deliver oPFMT/PFE. METHODS: We performed a retrospective review of patients receiving iPFMT versus oPFMT/PFE with minimum 12-month follow-up. Outcomes were assessed at 3 weeks, 3-, 6-, and 12 months following robotic-assisted laparoscopic prostatectomy using validated ICIQ-MLUTS and IIQ-7 questionnaires and additional items (daily pad use [PPD] and satisfaction). The primary study outcome was ICIQ-MLUTS SUI domain score (SDS). Secondary outcomes were PPD, PPD cure (0 PPD at 12 months), SUI cure (12-month SDS=baseline score), and QOL score (IIQ-7 Sum). RESULTS: Analysis included 41 men. Though men enrolled in oPFMT/PFE demonstrated lower SUI domain scores than iPFMT at most time points (3wk P <.01, 3 mo P = .04, 6 mo P = .15, 12 mo P = .04), the rate of improvement from 3 weeks to other time points was similar between groups (P = NS at all time points). SDS Cure was no different for oPFMT/PFE (75%, 15/20) compared to iPFMT (60%, 12/20, P = .3). PPD and IIQ-7 were also similar at all time points and demonstrated a similar rate of decrease over time through 12 months. CONCLUSION: Significant and similar improvements in UI and QOL are seen both in men completing iPFMT or oPFMT/PFE programs. Our novel online program provides another option to improve PFMT/PFE access in men undergoing RALP.

Immunogenicity and safety of an Entamoeba histolytica adjuvanted protein vaccine candidate (LecA+GLA-3M-052 liposomes) in rhesus macaques.

Entamoeba histolytica, the causative agent of amebiasis, is one of the top three parasitic causes of mortality worldwide. However, no vaccine exists against amebiasis. Using a lead candidate vaccine containing the LecA fragment of Gal-lectin and GLA-3M-052 liposome adjuvant, we immunized rhesus macaques via intranasal or intramuscular routes. The vaccine elicited high-avidity functional humoral responses as seen by the inhibition of amebic attachment to mammalian target cells by plasma and stool antibodies. Importantly, antigen-specific IFN-γ-secreting peripheral blood mononuclear cells (PBMCs) and IgG/IgA memory B cells (BMEM) were detected in immunized animals. Furthermore, antigen-specific antibody and cellular responses were maintained for at least 8 months after the final immunization as observed by robust LecA-specific BMEM as well as IFN-γ+ PBMC responses. Overall, both intranasal and intramuscular immunizations elicited a durable and functional response in systemic and mucosal compartments, which supports advancing the LecA+GLA-3M-052 liposome vaccine candidate to clinical testing.

Indications for continuous electroencephalographic (cEEG) monitoring: What do they tell us?

OBJECTIVE: While studies have explored clinical and EEG predictors of seizures on continuous EEG (cEEG), the role of cEEG indications as predictors of seizures has not been studied. Our study aims to fill this knowledge gap. METHODS: We used the prospective cEEG database at Cleveland Clinic for the 2016 calendar year. Patients ≥ 18 years who underwent cEEG for the indication of altered mental status (AMS) and seizure-like events (SLE: motor or patient-reported events) were included. Baseline characteristics and EEG findings were compared between the two groups. Multivariable regression was used to compare the two groups and identify seizure detection risk factors. RESULTS: Of 2227 patients (mean age 59.4 years) who met the inclusion criteria, 882 (50% females) underwent cEEG for AMS and 1345(51% females) for SLE. SLE patients were younger(OR: 0.988, CI: 0.98-0.99, p < 0.001), had longer monitoring(OR:1.04, CI:1.00-1.07, p = 0.033), were more likely to have epilepsy-related-breakthrough seizures(OR:25.9, CI:0.5.89-115, p < 0.001), psychogenic non-epileptic spells (OR:6.85, CI:1.60-29.3, p = 0.008), were more awake (p < 0.001) and more likely to be on anti-seizure medications(OR:1.60, CI:1.29-1.98, p < 0.001). On multivariable analysis, SLE was an independent predictor of seizure detection (OR: 2.60, CI: 1.77-3.88, p < 0.001). SIGNIFICANCE: Our findings highlight the differences in patients undergoing cEEG for AMS vs. SLE. SLE as a cEEG indication represents an independent predictor of seizures on cEEG and, therefore, deserves special attention. Future multicenter studies are needed to validate our findings.

Discriminatory capacity of prenatal ultrasound measures for large-for-gestational-age birth: A Bayesian approach to ROC analysis using placement values.

Predicting large fetuses at birth is of great interest to obstetricians. Using an NICHD Scandinavian Study that collected longitudinal ultrasound examination data during pregnancy, we estimate diagnostic accuracy parameters of estimated fetal weight (EFW) at various times during pregnancy in predicting large-for-gestational-age. We adopt a placement value based Bayesian regression model with random effects to estimate ROC curves. The use of placement values allows us to model covariate effects directly on the ROC curves and the adoption of a Bayesian approach accommodates the a priori constraint that an ROC curve of EFW near delivery should dominate another further away. The proposed methodology is shown to perform better than some alternative approaches in simulations and its application to the Scandinavian Study data suggests that diagnostic accuracy of EFW can improve about 65% from week 17 to 37 of gestation.

Estimation of multiple ordered ROC curves using placement values.

In many diagnostic accuracy studies, a priori orders may be available on multiple receiver operating characteristic curves. For example, being closer to delivery, fetal ultrasound measures in the third trimester should be no less accurate than those in the second trimester in predicting small-for-gestational-age births. Such an a priori order should be incorporated in estimating receiver operating characteristic curves and associated summary accuracy statistics, as it can potentially improve statistical efficiency of these estimates. Early work in the literature has mainly taken an indirect approach to this task and has induced the desired a priori order through modeling test score distributions. We instead propose a new strategy that incorporates the order directly through the modeling of receiver operating characteristic curves. We achieve this by exploiting the link between placement value (the relative position of a diseased test score in the healthy score distribution), the cumulative distribution function of placement value, and receiver operating characteristic curve, and by building stochastically ordered random variables through mixture distributions. We take a Bayesian semiparametric approach in using Dirichlet process mixture models so that the placement values can be flexibly modeled. We conduct extensive simulation studies to examine the performance of the proposed methodology and apply the new framework to data from obstetrics and women's health studies.

A note on modeling placement values in the analysis of receiver operating characteristic curves.

Recent advances in receiver operating characteristic (ROC) curve analyses advocate modeling of placement value (PV), a quantity that measures the position of diseased test scores relative to the healthy population. Compared to traditional approaches, this PV-based alternative works directly with ROC curves and is attractive when assessing covariate effects on, or incorporating a priori constraints of, ROC curves. Several distributions can be used to model the PV, yet little guidelines exist in the literature on which to use. Through extensive simulation studies, we investigate several parametric models for PV when data are generated from a variety of mechanisms. We discuss the pros and cons of each of these models and illustrate their applications with data from a study of prenatal ultrasound examinations and large-for-gestational age birth.

Cefdinir Use in the Kentucky Medicaid Population: A Priority for Outpatient Antimicrobial Stewardship.

Cefdinir is frequently prescribed for pediatric infections despite lack of first-line indications. We reviewed Kentucky Medicaid claims from 2012 through 2016. Cefdinir prescriptions and spending significantly increased over the study period. Upper respiratory infections accounted for the majority of use. Inappropriate cefdinir use should be a priority for stewardship efforts.

Preoperative Functional Platelet Number Is Inversely Associated With 30-Day Mortality After Cardiac Surgery: A Retrospective Cohort Study.

Background. We hypothesize that preoperative functional platelet number (platelet count multiplied by platelet aggregation percentage) are associated with 30-day mortality after cardiac surgery. Methods. We linked our preoperative testing database with the STS (Society of Thoracic Surgeon) database to form a study cohort of 1390 patients who had cardiac surgeries between January 2008 and December 2013. Preoperative tests of platelet count and platelet aggregation were routinely performed on all cardiac surgical patients within 24 hours before entering the operating room. Multiple logistic regression models were used to determine whether functional platelet number are associated with 30-day mortality, modified composite major adverse cardiocerebral events, postoperative renal failure or requirement for new renal replacement therapy, and reoperation for bleeding. Log-linear models were used to examine whether functional platelet numbers are associated with hospital length of stay and intensive care unit length of stay. Results. Functional platelet number had an inverse association with 30-day mortality, and each 50 × 109/L increase in functional platelet number resulted in decreased 30-day mortality (odds ratio of 0.767 with 95% confidence interval = 0.591-0.996). For secondary outcomes, functional platelet number was neither associated with major adverse cardiocerebral event nor length of stay. However, we found that each 50 × 109/L increase in functional platelet number was associated with decreased reoperations for bleeding (odds ratio of 0.778 with 95% confidence interval = 0.636-0.951). Conclusions. The preoperative functional platelet number had significant associations with 30-day mortality after cardiac surgery. Functional platelet number could be used to guide timing of cardiac surgery, especially as more and more patients are receiving antiplatelet medications nowadays.