Central-line-associated bloodstream infections and central-line-associated non-CLABSI complications among pediatric oncology patients.

OBJECTIVE: To assess central venous catheter (CVC) harm in pediatric oncology patients, we explored risks for central-line-associated bloodstream infections (CLABSIs) and central-line-associated non-CLABSI complications (CLANCs). DESIGN: Retrospective cohort study. SETTING: Midwestern US pediatric oncology program. PATIENTS: The study cohort comprised 592 pediatric oncology patients seen between 2006 and 2016. METHODS: CLABSIs were defined according to Centers for Disease Control and Prevention (CDC)/National Health Safety Network (NHSN) definitions. CLANCs were classified using a novel definition requiring CVC removal. Patient-level and central-line-level risks were calculated using a negative binomial model to adjust for correlations between total events and line numbers. RESULTS: CVCs were inserted in 62% of patients, with 175,937 total catheter days. The inpatient CLABSI and CLANC rates were 5.8 and 8.5 times higher than outpatient rates. At the patient level, shared risks included acute myeloid leukemia (AML) and age <1 year at diagnosis. At the line level, shared risks included age <1 year at diagnosis, non-mediports, and >1 lumen. AML was a CLABSI-specific risk. CLANC-specific risks included non-brain-tumor diagnosis, younger age at diagnosis or central-line placement, and age <1 year at diagnosis or line placement. Multivariable risks were for CLABSI >1 lumen and for CLANC age <1 year at placement. CONCLUSIONS: Among patients with CVCs, CLABSI and CLANC rates were similar, higher among inpatients than outpatients. For both CLABSIs and CLANCs, infants and patients with AML were at higher risk. In both univariate and multivariate models, lines with >1 lumen were associated with CLABSIs and placement during infancy with CLANCs.

Preoperative assessment using the five-factor modified frailty index: A call for standardized preoperative assessment and prehabilitation services in gynecologic oncology.

OBJECTIVE: To evaluate if the 5-factor modified frailty index (mFI) is associated with postoperative complications, readmissions or non-home discharge in gynecologic cancer patients undergoing surgery. METHODS: Patients with a diagnosis of gynecologic cancer (cervical, uterine, or ovarian cancer) who underwent surgery between 2014 and 2018 were identified through the National Surgical Quality Improvement Program (NSQIP) database. The 5-factor mFI was applied and patients classified into 6 categories (mFI groups 0,1,2, 3, 4 and 5). The incidence of 30-day complications, readmissions and non-home discharge was evaluated. Multivariable logistic regression models were used to determine the association between mFI category and readmissions/ complications. Adjusted probabilities of events were calculated based on patient characteristics. RESULTS: At total of 31,181 gynecologic cancer cases were included in the analysis: N = 2968 (9.4%) cervical, N = 20,862 (66.4%) uterine, and N = 7351 (23.4%) ovarian cancers. Of all patients, 46.1% were in category 0, 36.5% category 1, and 1% category 3-5. Factors associated with increased mFI included older age, African American race, laparoscopic surgery and obesity. A significant dose-response relationship between higher mFI and readmission and 30-day complications was noted on adjusted multivariable analysis (adjusted OR 2.37 (1.65-3.45) and 2.10 (1.59-2.75) for readmissions and complications, respectively, in mFI category 3-5). These associations were consistent within each cancer type. CONCLUSIONS: The 5-factor mFI universally predicts postoperative readmissions, 30-day complications and non-home discharge in patients with gynecologic cancer. Incorporation of mFI into routine preoperative assessment can identify patients for non-surgical treatments, prehabiliatation and short term home assessments.

Vascular Risk Factor Prevalence and Trends in Native Americans with Ischemic Stroke.

INTRODUCTION: Native Americans have a higher incidence and prevalence of stroke and the highest stroke-related mortality among race-ethnic groups in the United States. We aimed to analyze trends in the ischemic stroke (IS) vascular risk factor prevalence in Native Americans along with a comparison to the other race-ethnic groups. METHODS: National Inpatient Sample (NIS) database was used to explore the prevalence of risk factors among hospitalized IS patients during 2000 - 2016. Prevalence estimates were calculated for each risk factor within each race-ethnic group in 6 time periods. Linear trends were explored using linear regression models, with differences in trends between the Native American group and the other race-ethnic groups assessed using interaction terms. The analysis accounted for the complex sampling design, including hospital clusters, NIS stratum, and trend weights for analyzing multiple years of NIS data. RESULTS: Native Americans constituted 5472 of the 1,278,784 IS patients. The age-and-sex-standardized prevalence of hypertension (slope = 2.24, p < 0.001), hyperlipidemia (slope = 6.29, p < 0.001), diabetes (slope = 2.04, p = 0.005), atrial fibrillation/flutter (trend slope = 0.80, p = 0.011), heart failure (trend slope = 0.73, p = 0.036) smoking (trend slope= 3.65, p < 0.001), and alcohol (slope = 0.60, p = 0.019) increased among Native Americans. They showed larger increases in hypertension prevalence compared to Blacks, Hispanics, and Asian/Pacific Islanders and in smoking prevalence compared to Hispanics and Asian/Pacific Islanders. By the year 2015-2016, Native Americans had the highest overall prevalence of diabetes, coronary artery disease, smoking, and alcohol among all race-ethnic groups. CONCLUSION: The prevalence of most vascular risk factors among ischemic stroke patients has increased in Native Americans over the last two decades. Significantly larger increases in hypertension and smoking prevalence were seen in Native Americans compared to other groups along with them having the highest prevalence in multiple risk factors in recent years.

"Living Well with Chronic Pain": Integrative Pain Management via Shared Medical Appointments.

OBJECTIVE: To evaluate the effectiveness of a multidisciplinary, nonpharmacological, integrative approach that uses shared medical appointments to improve health-related quality of life and reduce opioid medication use in patients with chronic pain. DESIGN: This is a retrospective, pre-post review of "Living Well with Chronic Pain" shared medical appointments (August 2016 through May 2018). SETTING: The appointments included eight 3-hour-long visits held once per week at an outpatient wellness facility. SUBJECTS: Patients with chronic, non-cancer-related pain. METHODS: Patients received evaluation and evidence-based therapies from a team of integrative and lifestyle medicine professionals, as well as education about nonpharmacological therapeutic approaches, the etiology of pain, and the relationship of pain to lifestyle factors. Experiential elements focused on the relaxation techniques of meditation, yoga, breathing, and hypnotherapy, while patients also received acupuncture, acupressure, massage, cognitive behavioral therapy, and chiropractic education. Patients self-reported data via the Patient-Reported Outcomes Measurement Information System (PROMIS-57) standardized questionnaire. Use of opioid medications was evaluated in morphine milligram equivalents. RESULTS: A total of 178 participants completed the PROMIS-57 questionnaire at the first and the last visits. Statistically significant improvements in all domains (Physical Functioning, Anxiety, Depression, Fatigue, Social Roles, Pain Interference, and Sleep Disturbance) were observed (P < 0.001) between the pre-intervention (visit 1) and post-intervention (visit 8) scores. Average opioid use decreased nonsignificantly over the 8-week intervention, but the lower rate of opioid use was not sustained at 6 and 12 months' follow-up. CONCLUSIONS: Patients suffering from chronic pain who participated in a multidisciplinary, nonpharmacological treatment approach delivered via shared medical appointments experienced reduced pain and improved measures of physical, mental, and social health without increased use of opioid pain medications.

Choroid plexus tumors in adult and pediatric populations: the Cleveland Clinic and University Hospitals experience.

Choroid plexus tumors (CPT) are rare neoplasms accounting for 1-4% of all pediatric brain tumors. They are divided into choroid plexus papilloma (CPP), atypical choroid plexus papilloma (APP) and choroid plexus carcinoma (CPC). CPTs are known to primarily affect children less than 2 years of age. Gross total resection is the most important predictor of survival especially in CPC. Although small case series have been published, limited clinical data are available to describe treatment and outcome of CPTs. More clinical data would be necessary to complete the picture, particularly in populations that are not age limited. Here we share data from the two major hospitals in Cleveland to describe treatment and outcome of adult and pediatric patients. We performed a retrospective analysis of patients with CPT seen in Cleveland Clinic from 1990 to 2015 and at University Hospitals from 1994 to 2015. Results were compared to previously published historical controls. We identified 30 cases with CPT, including 22 pediatric and eight adult cases; 11 females and 19 males. The mean age at presentation was 12.4 years with a median age of 4.5 years (range 2 months-51 years). Gross total surgical resection was achieved in 22, subtotal resection in four, partial resection in two and unknown in two. The histology was CPP in 23 patients, two of whom developed recurrence requiring repeat resection and adjuvant therapy. Median event free survival (EFS) for CPP patients was 7.6 years. The histology was CPC in seven patients. All CPC patients were treated with adjuvant therapy. Median EFS of CPC patients was 4.4 years. Overall survival of all CPT patients was 100% with a median follow up of 7 years. A systematic literature review identified 1012 CPT patients treated from 1989 to 2013. The mean and median age of CPT patients was 13 and 3 years respectively. The median survival of 541 CPP patients was undefined vs. 2.7 years for the 452 CPC patients. The difference between the two populations was highly significant (p < 0.001). Kaplan-Meier survival curves comparing CPTs at Cleveland Clinic and University Hospitals versus a systematic literature review showed a statistically significant advancement in overall survival among the patients treated at Cleveland Clinic and University Hospitals. Our data are consistent with the literature review regarding epidemiology, clinical presentation, and treatment modalities but differed in regards to survival. Differences in survival may be related to different methods of data collection or details in patient care.

Contemporary bloodletting in cardiac surgical care.

BACKGROUND: Health care providers are seldom aware of the frequency and volume of phlebotomy for laboratory testing, bloodletting that often leads to hospital-acquired anemia. Our objectives were to examine the frequency of laboratory testing in patients undergoing cardiac surgery, calculate cumulative phlebotomy volume from time of initial surgical consultation to hospital discharge, and propose strategies to reduce phlebotomy volume. METHODS: From January 1, 2012 to June 30, 2012, 1,894 patients underwent cardiac surgery at Cleveland Clinic; 1,867 had 1 hospitalization and 27 had 2. Each laboratory test was associated with a test name and blood volume. Phlebotomy volume was estimated separately for the intensive care unit (ICU), hospital floors, and cumulatively. RESULTS: A total of 221,498 laboratory tests were performed, averaging 115 tests per patient. The most frequently performed tests were 88,068 blood gas analyses, 39,535 coagulation tests, 30,421 complete blood counts, and 29,374 metabolic panels. Phlebotomy volume differed between ICU and hospital floors, with median volumes of 332 mL and 118 mL, respectively. Cumulative median volume for the entire hospital stay was 454 mL. More complex procedures were associated with higher overall phlebotomy volume than isolated procedures; eg, combined coronary artery bypass grafting (CABG) and valve procedure median volume was 653 mL (25th/75th percentiles, 428 of 1,065 mL) versus 448 mL (284 of 658 mL) for isolated CABG and 338 mL (237 of 619) for isolated valve procedures. CONCLUSIONS: We were astonished by the extent of bloodletting, with total phlebotomy volumes approaching amounts equivalent to 1 to 2 red blood cell units. Implementation of process improvement initiatives can potentially reduce phlebotomy volumes and resource utilization.

Is it time to refine? An exploration and simulation of optimal antibiotic timing in general surgery.

BACKGROUND: Postoperative infections increase morbidity, resource use, and costs. Our objective was to examine whether within guideline recommendations an optimal time exists for an initial dose of antibiotic to reduce postoperative infections in general surgery, and to simulate the magnitude of a reduction in infections should an optimal time be implemented. STUDY DESIGN: The population consisted of 6,731 patients who underwent 7,095 general surgery procedures between January 5, 2006 and June 25, 2012. Patients with pre-existing infections, such as pneumonia and sepsis, and patients with no recorded use of antibiotics were excluded, as were patients on vancomycin and surgical procedures longer than 4 hours in duration. The final analysis dataset included 4,453 patients. The National Surgical Quality Improvement Program was used for perioperative variables and outcomes. The end point was a composite of wound disruption; superficial, deep, organ space, surgical site infections; and sepsis. Semi-parametric logistic regression was used to study the association between antibiotic timing and infection. RESULTS: There were 444 (10%) patients with a primary end point of infectious complication. A nonlinear "bowl-shaped" relationship between duration of interval from antibiotic administration and surgical incision and infection was observed; lowest risk corresponding to administration time close to incision was 4 minutes before incision (95% one-sided CI, 0-18 minutes). The model suggested optimal timing would result in an 11.3% reduction in the primary infection end point. CONCLUSIONS: Risk of infectious complications decreased as antibiotic administration moved closer to incision time. These data suggest an opportunity to reduce infections by 11.3% by targeting initial antibiotic administration closer to incision.

Serious fall injuries in hospitalized patients with and without cancer.

Characteristics of adults hospitalized with and without cancer were compared to determine factors of serious injuries after fall events. More patients with cancer who had a serious injury received corticosteroids (P = .005) and were treated on a palliative care floor. More patients without cancer had higher prevalence of stroke (P = .026) and diabetes (P = .041) history and were treated on a surgical floor. Future research is needed to identify interventions that could prevent serious injuries after fall events.

Predictors of a fall event in hospitalized patients with cancer.

PURPOSE/OBJECTIVES: To determine predictors of fall events in hospitalized patients with cancer and develop a scoring system to predict fall events. DESIGN: Retrospective medical record review. SETTING: A 1,200-bed tertiary care hospital in northeastern Ohio. SAMPLE: 145 patients with cancer who did not have a fall event were randomly selected from all oncology admissions from February 2006-January 2007 and compared to 143 hospitalized patients with cancer who had a fall event during the same period. METHODS: Multivariable logistic regression models predicting falls were fit. Risk score analysis was completed using bootstrap samples to evaluate discrimination between patients who did or did not fall and agreement between predicted and actual fall status. A nomogram of risk scores was created. MAIN RESEARCH VARIABLES: Fall episodes during hospitalization and patient characteristics that predict falls. FINDINGS: While patients were hospitalized for cancer care, their predictors of a fall episode were low pain level, abnormal gait, cancer type, presence of metastasis, antidepressant and antipsychotic medication use, and blood product use (all p < 0.02); risk model c-statistic was 0.89. CONCLUSIONS: For hospitalized patients with cancer, predictors reflecting greater fall episode risk can be assessed easily by nursing staff and acted on when the risk is sufficiently high. IMPLICATIONS FOR NURSING: Understanding specific risk factors of falls in an adult oncology population may lead to interventions that reduce fall risk.

Chronic disease risks in young adults with autism spectrum disorder: forewarned is forearmed.

An emerging, cost-effective method to examine prevalent and future health risks of persons with disabilities is electronic health record (EHR) analysis. As an example, a case-control EHR analysis of adults with autism spectrum disorder receiving primary care through the Cleveland Clinic from 2005 to 2008 identified 108 adults with autism spectrum disorder. In this cohort, rates of chronic disease included 34.9% for obesity, 31.5% for hyperlipidemia, and 19.4% for hypertension. Compared with a control cohort of patients from the same health system matched for age, sex, race, and health insurance status, adults with autism spectrum disorder were more likely to be diagnosed with hyperlipidemia (odds ratio  =  2.0, confidence interval  =  1.2-3.4, p  =  .012). Without intervention, adults with autism spectrum disorder appear to be at significant risk for developing diabetes, coronary heart disease, and cancer by midlife.

Survival rates of children with acute lymphoblastic leukemia presenting to a pediatric rheumatologist in the United States.

BACKGROUND: Approximately 30% of pediatric acute lymphoblastic leukemia patients present with musculoskeletal symptoms and are often referred first to a pediatric rheumatologist. We examined the survival and causes of death of these patients presenting to a pediatric rheumatologist and compared the rates with that reported in the hematology-oncology literature. PROCEDURE: We used the Pediatric Rheumatology Disease Registry, including 49,023 patients from 62 centers, newly diagnosed between 1992 and 2001. Identifiers were matched with the Social Security Death Index censored for March 2005. Deaths were confirmed by death certificates, referring physicians, and medical records. Causes of death were derived by chart review or from the death certificate. RESULTS: There were 7 deaths of 89 patients (7.9%, 95% confidence interval: 3.9%-15.4%) with acute lymphoblastic leukemia with a 5-year survival rate of 95.5% (88.3 to 98.3) and 10-year survival rate of 89.8% (79.0% to 95.2%). The causes of death were sepsis (bacterial and/or fungal) in 4 (57%) patients, the disease in 2 (29%) and post bone-marrow transplantation in 1 (14%). CONCLUSION: The overall survival of patients with acute lymphoblastic leukemia seen first by pediatric rheumatologists is higher than the range reported in the pediatric oncology literature for the same period of diagnosis.

Nighttime noise issues that interrupt sleep after cardiac surgery.

Patients' perceptions of noise events that prevent/interrupt nighttime sleep after cardiac surgery and sleep promotion aids were studied for associations with patient characteristics. Overhead paging, equipment, and loud communication prevented/interrupted nighttime sleep; however, most patient characteristics were not associated with the presence or absence of these noise events. Patients selected pain medication to promote sleep. Other sleep aids were used infrequently. Behavioral and structural noise reduction interventions are needed to minimize sleep interruptions.

Mortality outcomes in pediatric rheumatology in the US.

OBJECTIVE: To describe mortality rates, causes of death, and potential mortality risk factors in pediatric rheumatic diseases in the US. METHODS: We used the Indianapolis Pediatric Rheumatology Disease Registry, which includes 49,023 patients from 62 centers who were newly diagnosed between 1992 and 2001. Identifiers were matched with the Social Security Death Index censored for March 2005. Deaths were confirmed by death certificates, referring physicians, and medical records. Causes of death were derived by chart review or from the death certificate. Standardized mortality ratios (SMRs) and 95% confidence intervals (95% CIs) were determined. RESULTS: After excluding patients with malignancy, 110 deaths among 48,885 patients (0.23%) were confirmed. Patients had been followed up for a mean +/- SD of 7.9 +/- 2.7 years. The SMR of the entire cohort was significantly decreased (0.65 [95% CI 0.53-0.78]), with differences in patients followed up for > or =9 years. The SMR was significantly greater for systemic lupus erythematosus (3.06 [95% CI 1.78-4.90]) and dermatomyositis (2.64 [95% CI 0.86-6.17]) but not for systemic juvenile rheumatoid arthritis (1.8 [95% CI 0.66-3.92]). The SMR was significantly decreased in pain syndromes (0.41 [95% CI 0.21-0.72]). Causes of death were related to the rheumatic diagnosis (including complications) in 39 patients (35%), treatment complications in 11 (10%), non-natural causes in 25 (23%), background disease in 23 (21%), and were unknown in 12 patients (11%). Rheumatic diagnoses, age at diagnosis, sex, and early use of systemic steroids and methotrexate were significantly associated with the risk of death. CONCLUSION: Our findings indicate that the overall mortality rate for pediatric rheumatic diseases was not increased. Even for the diseases and conditions associated with increased mortality, mortality rates were significantly lower than those reported in previous studies.

Breast reduction: does the tumescent technique affect reimbursement?

BACKGROUND: Breast reduction is a very common procedure within the field of plastic surgery, with many techniques. These techniques include differences in the location of the pedicles and of the scars. Another variation on the technique for breast reduction relates to preoperative infiltration of an epinephrine solution to reduce blood loss and operative time. The authors' technique for breast reduction and its effect on insurance reimbursement has not previously been discussed in a large prospective study. METHODS: The authors performed a prospective study to compare a cohort of 50 patients undergoing a traditional breast reduction without infiltration of epinephrine followed by electrocautery for resection versus 50 patients receiving tumescent infiltration of epinephrine followed by sharp resection. RESULTS: The patients who underwent the tumescent technique for breast reduction had shorter operative times and similar blood loss and pain compared with the traditional technique. The use of tumescence did not cause a significant difference in the weight of the amount resected when compared with the dry, pathologic weight. CONCLUSIONS: In the first large prospective cohort study involving this technique, the authors can demonstrate the many advantages of the tumescent technique and refute their concern that tumescence can cause inaccurate weight measurements that might interfere with insurance reimbursement based on resected weight.