Contemporary procedure characteristics and outcomes of accessory atrioventricular pathway ablations in an integrated community-based health care system using a tiered approach.

BACKGROUND: Since the early descriptions of large series of accessory atrioventricular pathway ablations in adults and adolescents over 20 years ago, there have been limited published reports based on more recent experiences of large referral centers. We aimed to characterize accessory pathway distribution and features in a large community-based population that influence ablation outcomes using a tiered approach to ablation. METHODS: Retrospective analysis of 289 patients (age 14-81) who underwent accessory ablation from 2015-2019 was performed. Pathways were categorized into anteroseptal, left freewall, posteroseptal, and right freewall locations. We analyzed patient and pathway features to identify factors associated with prolonged procedure time parameters. RESULTS: Initial ablation success rate was 94.7% with long-term success rate of 93.4% and median follow-up of 931 days. Accessory pathways were in left freewall (61.6%), posteroseptal (24.6%), right freewall (9.6%), and anteroseptal (4.3%) locations. Procedure outcome was dependent on pathway location. Acute success was highest for left freewall pathways (97.1%) with lowest case times (144 ± 68 min) and fluoroscopy times (15 ± 19 min). Longest procedure time parameters were seen with anteroseptal, left anterolateral, epicardial-coronary sinus, and right anterolateral pathway ablations. CONCLUSIONS: In this community-based adult and adolescent population, majority of the accessory pathways are in the left freewall and posteroseptal region and tend to be more easily ablated. A tiered approach with initial use of standard ablation equipment before the deployment of more advance tools, such as irrigated tips and 3D mapping, is cost effective without sacrificing overall efficacy.

Postdischarge antibiotic use for prophylaxis following spinal fusion.

OBJECTIVE: Despite recommendations to discontinue prophylactic antibiotics after incision closure or <24 hours after surgery, prophylactic antibiotics are continued after discharge by some clinicians. The objective of this study was to determine the prevalence and factors associated with postdischarge prophylactic antibiotic use after spinal fusion. DESIGN: Multicenter retrospective cohort study. PATIENTS: This study included patients aged ≥18 years undergoing spinal fusion or refusion between July 2011 and June 2015 at 3 sites. Patients with an infection during the surgical admission were excluded. METHODS: Prophylactic antibiotics were identified at discharge. Factors associated with postdischarge prophylactic antibiotic use were identified using hierarchical generalized linear models. RESULTS: In total, 8,652 spinal fusion admissions were included. Antibiotics were prescribed at discharge in 289 admissions (3.3%). The most commonly prescribed antibiotics were trimethoprim/sulfamethoxazole (22.1%), cephalexin (18.8%), and ciprofloxacin (17.1%). Adjusted for study site, significant factors associated with prophylactic discharge antibiotics included American Society of Anesthesiologists (ASA) class ≥3 (odds ratio [OR], 1.31; 95% CI, 1.00-1.70), lymphoma (OR, 2.57; 95% CI, 1.11-5.98), solid tumor (OR, 3.63; 95% CI, 1.62-8.14), morbid obesity (OR, 1.64; 95% CI, 1.09-2.47), paralysis (OR, 2.38; 95% CI, 1.30-4.37), hematoma/seroma (OR, 2.93; 95% CI, 1.17-7.33), thoracic surgery (OR, 1.39; 95% CI, 1.01-1.93), longer length of stay, and intraoperative antibiotics. CONCLUSIONS: Postdischarge prophylactic antibiotics were uncommon after spinal fusion. Patient and perioperative factors were associated with continuation of prophylactic antibiotics after hospital discharge.

Assessment of percent positive agreement between fluorescent marker and ATPase for environmental cleaning monitoring during sequential application in an intensive care unit.

Terminal room cleaning is critical in preventing pathogen transmission; however, the optimal cleaning effectiveness assessment modality is still being investigated. We sequentially compared cleanliness assessment agreement between a fluorescent marker and an adenosine triphosphate bioluminescence method, finding no significant differences between modalities.

Implementing Community Baby Showers to Address Infant Mortality in Oklahoma.

IMPORTANCE: Oklahoma has one of the highest rates of infant mortality and poor birth outcomes in the U.S., particularly among minority populations. OBJECTIVES: To describe the formation and implementation of a state-led infant mortality prevention program which sought to: educate minorities about their disproportionate risk for infant mortality; improve pregnancy, infancy, and early childhood outcomes; and prevent infant mortality. DESIGN, SETTING, AND PARTICIPANTS: Participants completed one of many community baby shower events and were evaluated pre- and post-shower on infant mortality and well-baby knowledge. INTERVENTION: The "A Healthy Baby Begins with You" program. Main outcomes and measures. Pre- and post-intervention questionnaires assessing participant knowledge about infant mortality and willingness to share learned knowledge with others in the community. RESULTS: Preliminary results suggest that community baby showers were well-received. Respondents tended to be American Indians, non-Hispanic Whites, or Blacks/African Americans, young adults (aged 20 to 29 years), pregnant women, and mothers of grandparents of young children. Showers were successful in increasing participant knowledge of infant mortality, although these results varied by respondent race and age. Most respondents reported intent to share knowledge acquired during community baby showers with others. CONCLUSIONS AND RELEVANCE: Preliminary findings suggest community baby showers may increase participant knowledge, although future studies are needed to ensure effectiveness across all participant subgroups. This study documents the feasibility and acceptability of a community-based educational program targeting dissemination of infant mortality and well-child information. Barriers and future directions for research and prevention are discussed.

A Clinical Decision Tree to Predict Whether a Bacteremic Patient Is Infected With an Extended-Spectrum ß-Lactamase-Producing Organism.

BACKGROUND: Timely identification of extended-spectrum ß-lactamase (ESBL) bacteremia can improve clinical outcomes while minimizing unnecessary use of broad-spectrum antibiotics, including carbapenems. However, most clinical microbiology laboratories currently require at least 24 additional hours from the time of microbial genus and species identification to confirm ESBL production. Our objective was to develop a user-friendly decision tree to predict which organisms are ESBL producing, to guide appropriate antibiotic therapy. METHODS: We included patients ≥18 years of age with bacteremia due to Escherichia coli or Klebsiella species from October 2008 to March 2015 at Johns Hopkins Hospital. Isolates with ceftriaxone minimum inhibitory concentrations ≥2 µg/mL underwent ESBL confirmatory testing. Recursive partitioning was used to generate a decision tree to determine the likelihood that a bacteremic patient was infected with an ESBL producer. Discrimination of the original and cross-validated models was evaluated using receiver operating characteristic curves and by calculation of C-statistics. RESULTS: A total of 1288 patients with bacteremia met eligibility criteria. For 194 patients (15%), bacteremia was due to a confirmed ESBL producer. The final classification tree for predicting ESBL-positive bacteremia included 5 predictors: history of ESBL colonization/infection, chronic indwelling vascular hardware, age ≥43 years, recent hospitalization in an ESBL high-burden region, and ≥6 days of antibiotic exposure in the prior 6 months. The decision tree's positive and negative predictive values were 90.8% and 91.9%, respectively. CONCLUSIONS: Our findings suggest that a clinical decision tree can be used to estimate a bacteremic patient's likelihood of infection with ESBL-producing bacteria. Recursive partitioning offers a practical, user-friendly approach for addressing important diagnostic questions.

Police Encounters Among Needle Exchange Clients in Baltimore: Drug Law Enforcement as a Structural Determinant of Health.

OBJECTIVES: We piloted a monitoring mechanism to document police encounters around programs targeting people who inject drugs (PWID), and assessed their demographic predictors at 2 Baltimore, Maryland, needle exchange program (NEP) sites. METHODS: In a brief survey, 308 clients quantified, characterized, and sited recent police encounters. Multivariate linear regression determined encounter predictors, and we used geocoordinate maps to illustrate clusters. RESULTS: Within the past 6 months, clients reported a median of 3 stops near NEP sites (interquartile range [IQR] = 0-7.5) and a median of 1 arrest in any location (IQR = 0-2). Three respondents reported police referral to the NEP. Being younger (P = .009), being male (P = .033), and making frequent NEP visits (P = .02) were associated with reported police stops. Among clients reporting arrest or citation for syringe possession, Whites were significantly less likely than non-Whites to report being en route to or from an NEP (P < .001). Reported encounters were clustered around NEPs. CONCLUSIONS: Systematic surveillance of structural determinants of health for PWID proved feasible when integrated into service activities. Improved monitoring is critical to informing interventions to align policing with public health, especially among groups subject to disproportionate levels of drug law enforcement.

Injectable Contraceptive Continuation among Female Exotic Dancers Seeking Mobile Reproductive Health Services.

OBJECTIVES: We describe depot medroxyprogesterone acetate (DMPA) continuation patterns among female exotic dancers receiving reproductive health services at a mobile syringe exchange. METHODS: Clients initiating DMPA between November 2009 and August 2012 were identified retrospectively via chart review. Life table analysis measured continuation. Client characteristics were compared using chi-square tests. RESULTS: Sixty nine clients were identified; 72% were African American and 63% were younger than 25. At three months, 36% of the study sample continued DMPA; those continuing were more likely to be White (p=0.01) and receive other services (p=.01). The 12-month cumulative continuation probability was 0.09. Considering those who had received an injection, continuation proportions were higher (46% at 6; 71% at 12 months). CONCLUSIONS: A subset of female exotic dancers may favor DMPA as a long term contraceptive. Integrating mobile reproductive health services into public health programs can help fulfill the unique health needs of this high-risk population.

Effect of reduced vancomycin susceptibility on clinical and economic outcomes in Staphylococcus aureus bacteremia.

Reduced vancomycin susceptibility (RVS) may lead to poor clinical outcomes in Staphylococcus aureus bacteremia. The objective of this study was to evaluate the clinical and economic impact of RVS in patients with bacteremia due to S. aureus. A cohort study of patients who were hospitalized from December 2007 to May 2009 with S. aureus bacteremia was conducted within a university health system. Multivariable logistic regression and zero-truncated negative binomial regression models were developed to evaluate the association of RVS with 30-day in-hospital mortality, length of stay, and hospital charges. One hundred thirty-four (34.2%) of a total of 392 patients had bacteremia due to S. aureus with RVS as defined by a vancomycin Etest MIC of >1.0 µg/ml. Adjusted risk factors for 30-day in-hospital mortality included the all patient refined-diagnosis related group (APRDRG) risk-of-mortality score (odds ratio [OR], 7.11; 95% confidence interval [CI], 3.04 to 16.6), neutropenia (OR, 13.4; 95% CI, 2.46 to 73.1), white blood cell count (OR, 1.05; 95% CI, 1.01 to 1.09), immunosuppression (OR, 6.31; 95% CI, 1.74 to 22.9), and intensive care unit location (OR, 3.51; 95% CI, 1.65 to 7.49). In multivariable analyses, RVS was significantly associated with increased mortality in patients with S. aureus bacteremia as a result of methicillin-susceptible (OR, 3.90; 95% CI, 1.07 to 14.2) but not methicillin-resistant (OR, 0.53; 95% CI, 0.19 to 1.46) isolates. RVS was associated with greater 30-day in-hospital mortality in patients with bacteremia due to methicillin-susceptible S. aureus but not methicillin-resistant S. aureus. Further research is needed to identify optimal treatment strategies to reduce mortality associated with RVS in S. aureus bacteremia.