Post-procedural Antibiotic Use and Associated Outcomes After Common Urologic Procedures Across a National Healthcare System.

OBJECTIVE: To quantify the benefits and harms of post-procedural antibiotic use after common urologic procedures. MATERIALS AND METHODS: This retrospective cohort study included patients who underwent an endoscopic urologic procedure (transurethral resection of bladder tumor, transurethral resection of prostate, or ureteroscopy) within the Veterans Health Administration between January 1, 2017 and June 30, 2021. A post-procedural antibiotic was any qualifying antibiotic prescribed for administration on the day after the procedure. Guidelines generally do not recommend post-procedural antibiotics for surgical prophylaxis. Outcomes included unplanned return visits and Clostridioides difficile infection within 30 days. Log-binomial models with risk-adjustment were used to measure the association between post-procedural antibiotic use and outcomes. Hospital-level observed-to-expected (O:E) ratios were constructed to compare post-procedural antibiotic use. RESULTS: There were 74,629 qualifying procedures across 105 hospitals; 27,422 (36.7%) received post-procedural antibiotics (median 3 days, IQR 3-6). An unplanned return visit occurred in 20.2% of patients who received post-procedural antibiotics vs 17.2% who did not (adjusted RR 1.032, 95% CI 0.999-1.066). C. difficile infection was diagnosed in 0.27% vs 0.10% in those who received and did not receive post-procedural antibiotics (adjusted RR 1.67, 95% CI 1.13-2.45). The O:E ratio for post-procedural antibiotic use ranged from 0.46 among hospitals in the lowest-use quartile to 1.93 in the highest-use quartile. CONCLUSION: Post-procedural antibiotics were frequently prescribed after urologic procedures with large inter-facility variability even after adjusting for case-mix differences. Post-procedural antibiotic use was associated with increased risk for C. difficile infection but not fewer unplanned return visits. Efforts to reduce guideline-discordant use of post-procedural antibiotics are needed.

Evaluation of the HealthImpact Diabetes Risk Model in the Veterans Health Administration.

BACKGROUND: HealthImpact is a novel algorithm using administrative health care data to stratify patients according to risk for incident diabetes. OBJECTIVES: To (a) independently assess the predictive validity of HealthImpact and (b) explore its utility in diabetes screening within a nationally integrated health care system. METHODS: National Veterans Health Administration data were used to create 2 cohorts. The replication cohort included patients without diagnosed diabetes as of October 1, 2012, to determine if HealthImpact scores were significantly associated with diabetes (type 1 or 2) incidence within the subsequent 3 years. The utility cohort included patients without diagnosed diabetes as of August 1, 2015, and assessed diabetes screening rates in the 2 years surrounding this index date, stratified by HealthImpact scores. RESULTS: The 3-year incidence of diabetes in the replication cohort (n = 3,287,240) was 9.1%. Of 100,617 (3.1%) patients with HealthImpact scores > 90, 30,028 developed diabetes, yielding a positive predictive value of 29.8%. These patients accounted for 9.9% of all incident diabetes cases (sensitivity). Sensitivity and negative predictive value improved with descending HealthImpact threshold scores (e.g., > 75, > 50), whereas specificity and positive predictive value declined. Of 3,499,406 patients in the utility cohort, 85.3% received either a blood glucose or hemoglobin A1c test during the 2-year observation period. Among 101,355 patients with a HealthImpact score > 90, nearly all (98.3%) were screened, and 86.3% had an A1c test. CONCLUSIONS: Our independent analysis corroborates the validity of HealthImpact in stratifying patients according to diabetes risk. However, its practical utility to enhance diabetes screening in a real-world clinical environment will be strongly dependent on the pattern and frequency of existing screening practices. DISCLOSURES: This work was supported by the Iowa City VA Health Care System and by the Department of Veterans Affairs, Office of Research and Development, Health Services Research and Development Service (Lund, CIN 13-412). The authors have no conflicts of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the U.S. government.

Increased risk of respiratory illness associated with kerosene fuel use among women and children in urban Bangalore, India.

BACKGROUND: Kerosene is a widely used cooking and lighting fuel in developing countries. The potential respiratory health effects of cooking with kerosene relative to cooking with cleaner fuels such as liquefied petroleum gas (LPG) have not been well characterised. METHODS: We sampled 600 households from six urban neighbourhoods in Bangalore, India. Each household's primary cook, usually the woman of the house, was interviewed to collect information on current domestic fuel use and whether there was any presence of respiratory symptoms or illness in her or in the children in the household. Our analysis was limited to 547 adult females (ages 18-85) and 845 children (ages 0-17) in households exclusively cooking with either kerosene or LPG. We investigated the associations between kerosene use and the likelihood of having respiratory symptoms or illness using multivariate logistic regression models. RESULTS: Among adult women, cooking with kerosene was associated with cough (OR=1.88; 95% CI 1.19 to 2.99), bronchitis (OR=1.54; 95% CI 1.00 to 2.37), phlegm (OR=1.51; 95% CI 0.98 to 2.33) and chest illness (OR=1.61; 95% CI 1.02 to 2.53), relative to cooking with LPG in the multivariate models. Among children, living in a household cooking with kerosene was associated with bronchitis (OR=1.91; 95% CI 1.17 to 3.13), phlegm (OR=2.020; 95% CI 1.29 to 3.74) and chest illness (OR=1.70; 95% CI 0.99 to 2.90) after adjusting for other covariates. We also found associations between kerosene use and wheezing, difficulty breathing and asthma in adults and cough and wheezing in children, though these associations were not statistically significant. CONCLUSIONS: Women and children in households cooking with kerosene were more likely to have respiratory symptoms and illnesses compared with those in households cooking with LPG. Transitioning from kerosene to LPG for cooking may improve respiratory health among adult women and children in this population.

The relationship between various exposure metrics for elongate mineral particles (EMP) in the taconite mining and processing industry.

Different dimensions of elongate mineral particles (EMP) have been proposed as being relevant to respiratory health end-points such as mesothelioma and lung cancer. In this article, a methodology for converting personal EMP exposures measured using the National Institute for Occupational Safety and Health (NIOSH) 7400/7402 methods to exposures based on other size-based definitions has been proposed and illustrated. Area monitoring for EMP in the taconite mines in Minnesota's Mesabi Iron Range was conducted using a Micro Orifice Uniform Deposit Impactor (MOUDI) size-fractionating sampler. EMP on stages of the MOUDI were counted and sized according to each EMP definition using an indirect-transfer transmission electron microscopy (ISO Method 13794). EMP were identified using energy-dispersive x-ray and electron diffraction analysis. Conversion factors between the EMP counts based on different definitions were estimated using (1) a linear regression model across all locations and (2) a location-specific ratio of the count based on each EMP definition to the NIOSH 7400/7402 count. The highest fractions of EMP concentrations were found for EMP that were 1-3 µm in length and 0.2-0.5 µm in width. Therefore, the current standard NIOSH Method 7400, which only counts EMP >5 µm in length and ≥ 3 in aspect ratio, may underestimate amphibole EMP exposures. At the same time, there was a high degree of correlation between the exposures estimated according to the different size-based metrics. Therefore, the various dimensional definitions probably do not result in different dose-response relationships in epidemiological analyses. Given the high degree of correlation between the various metrics, a result consistent with prior research, a more reasonable metric might be the measurement of all EMP irrespective of size. [Supplementary materials are available for this article. Go to the publisher's online edition of Journal of Occupational and Environmental Hygiene for the following free supplemental resource: figures detailing EMP concentration.].

Sunlight and other determinants of circulating 25-hydroxyvitamin D levels in black and white participants in a nationwide U.S. study.

Circulating 25-hydroxyvitamin D (25(OH)D), a marker for vitamin D status, is associated with bone health and possibly cancers and other diseases; yet, the determinants of 25(OH)D status, particularly ultraviolet radiation (UVR) exposure, are poorly understood. Determinants of 25(OH)D were analyzed in a subcohort of 1,500 participants of the US Radiologic Technologists (USRT) Study that included whites (n = 842), blacks (n = 646), and people of other races/ethnicities (n = 12). Participants were recruited monthly (2008-2009) across age, sex, race, and ambient UVR level groups. Questionnaires addressing UVR and other exposures were generally completed within 9 days of blood collection. The relation between potential determinants and 25(OH)D levels was examined through regression analysis in a random two-thirds sample and validated in the remaining one third. In the regression model for the full study population, age, race, body mass index, some seasons, hours outdoors being physically active, and vitamin D supplement use were associated with 25(OH)D levels. In whites, generally, the same factors were explanatory. In blacks, only age and vitamin D supplement use predicted 25(OH)D concentrations. In the full population, determinants accounted for 25% of circulating 25(OH)D variability, with similar correlations for subgroups. Despite detailed data on UVR and other factors near the time of blood collection, the ability to explain 25(OH)D was modest.

Variability and reproducibility of circulating vitamin D in a nationwide U.S. population.

CONTEXT: Most studies examining associations between circulating vitamin D and disease are based on a single measure of vitamin D, which may not reflect levels over time, particularly because vitamin D concentrations vary by season. Few studies evaluated how well multiple 25-hydroxyvitamin D [25(OH)D] measures track within the same individual over time. OBJECTIVE: This study examined variability and reproducibility of vitamin D by evaluating repeat measurements of plasma 25(OH)D concentrations while accounting for determinants of circulating concentrations including dietary supplement use and latitude of residence from a population of U.S. radiologic technologists. DESIGN AND PARTICIPANTS: We analyzed circulating 25(OH)D in blood samples taken from 538 men and women from a prospective, nationwide study at two time points within a 1-yr period, most measured in different seasons. Inter- and intra-individual variability, reliability coefficients, and measurement error were examined. RESULTS: The spearman rank correlation between two measurements of 25(OH)D concentrations was moderate (r = 0.75, P < 0.001) and did not vary significantly by participant characteristics including age, race, or latitude. The intraclass correlation coefficient was 0.72 (95% confidence interval = 0.68-0.76). The deattenuation factor of plasma 25(OH)D levels was 1.39, suggesting that a single measure of vitamin D on a continuous scale in regression analyses may result in attenuated relationships of about 40%. CONCLUSION: Our results suggest that a single blood sample obtained in spring or fall provides a reasonable average for 25(OH)D over a 1-yr period, but additional studies are needed to estimate variability and agreement in plasma 25(OH)D measurements over longer intervals and younger populations.

Sunlight, hormone replacement status and colorectal cancer risk in postmenopausal women.

A reanalysis of the Women's Health Initiative (WHI) randomized clinical trial found a significant interaction between supplementation with vitamin D/calcium and estrogen therapy and the risk of colorectal cancer risk, with reduced risks from supplementation limited to the placebo arms of the estrogen trials. To explore whether the vitamin D effects are modified by estrogen therapy, we report a largely cross-sectional, analysis of the association between sun exposure, which is an important vitamin D source, and colorectal cancer risk among postmenopausal women in the U.S. Radiologic Technologists study. Among 21,695 participants, there were a total of 108 cases. Sun exposure was based on time outdoors and on ambient ultraviolet radiation (UV) exposure based on residence linked to erythemal exposures derived from the Total Ozone Mapping Spectrometer database. Although there was no relationship between outdoor time or ambient UV measure and colorectal cancer risk in current hormone replacement therapy (HRT) users, in never/past HRT users, there was an inverse association with higher ambient UV exposure, RR for highest vs. lowest tertile = 0.40; 95% CI 017, 0.93; p for trend = 0.04. Non-significant lower risks were also associated with higher levels of outdoor time (> or = 3.5 hr/week) in never/past HRT users. The interaction between both indicators of sun exposure and HRT and CRC risk was not significant. These data, although exploratory, are consistent with evidence from the WHI suggesting a decrease in colorectal cancer risk may be associated with vitamin D exposure among postmenopausal women who are not taking HRT, but not among current HRT users.

Relationship between coffee cultivation practices in Colombia and exposure to infection with Leishmania.

The inhabitants of coffee-growing municipalities consistently report the highest annual rates of cutaneous leishmaniasis in Colombia. During the last two decades most Colombian coffee growers have changed from the traditional system of cultivation, where the crop is grown under different species of shade trees, to an intensified system where it is grown at high densities in full sunlight. This change may affect transmission of Leishmania spp. to humans in several ways, probably resulting from reduced human-vector contact. The responses of residents of traditional and intensified coffee plantations to the leishmanin skin test were compared to ascertain whether intensification has indeed affected Leishmania transmission. Although prevalence of infection was significantly higher (P< or =0.01) among residents of traditional plantations (26.8%) than among those of intensified ones (13.2%), no significant difference could be demonstrated with respect to incidence of infection at the time of the study. Similar rates of infection were found for men and women, although the incidence of infection was significantly higher among the latter in intensified plantations. Changes to the type of data collected and the data collection process will facilitate the evaluation of the long-term effects of intensification of coffee plantations on Leishmania transmission.

Gene silencing in phlebotomine sand flies: Xanthine dehydrogenase knock down by dsRNA microinjections.

Lutzomyia longipalpis are vectors of medically important visceral leishmaniasis in South America. Blood-fed adult females digest large amounts of protein, and xanthine dehydrogenase is thought to be a key enzyme involved in protein catabolism through the production of urate. Large amounts of heme are also released during digestion with potentially damaging consequences, as heme can generate oxygen radicals that damage lipids, proteins and nucleic acids. However, urate is an antioxidant that may prevent such oxidative damage produced by heme. We investigated xanthine dehydrogenase by developing the RNAi technique for sand flies and used this technique to knock down the Lu. longipalpis xanthine dehydrogenase gene to evaluate its role in survival of adult females after blood feeding. The gene sequence of Lu. longipalpis xanthine dehydrogenase is described together with expression in different life cycle stages and RNAi knock down. Semi-quantitative RT-PCR of xanthine dehydrogenase expression showed a significant increase in expression after bloodmeal ingestion. Microinjection of dsRNA via the thorax of 1-day-old adult female sand flies resulted in approximately 40% reduction of xanthine dehydrogenase gene expression in comparison to flies injected with a control dsRNA. A significant reduction of urate in the whole body and excretions of Lu. longipalpis was observed after dsRNA xanthine dehydrogenase microinjection and feeding 96h later on rabbit blood. Sand flies injected with XDH dsRNA also exhibit significantly reduced life span in comparison with the mock-injected group when fed on sucrose or when rabbit blood fed, showing that urate could be indeed an important free radical scavenger in Lu. longipalpis. The demonstration of xanthine dehydrogenase knock down by dsRNA microinjection, low mortality of microinjected insects and the successful bloodfeeding of injected insects demonstrated the utility of RNAi as a tool for functional analysis of genes in phlebotomine sand flies.

Transmission of Leishmania in coffee plantations of Minas Gerais, Brazil

Transmission of Leishmania was studied in 27 coffee plantations in the Brazilian State of Minas Gerais. Eighteen females and six males (11.6 percent of the people tested), aged between 7-65 gave a positive response to the Montenegro skin test. Awareness of sand flies based on the ability of respondents to identify the insects using up to seven predetermined characteristics was significantly greater among inhabitants of houses occupied by at least one Mn+ve individual. Five species of phlebotomine sand fly, including three suspected Leishmania vectors, were collected within plantations under three different cultivation systems. Four of these species i.e., Lu. fischeri (Pinto 1926), Lu. migonei (França 1920), Lu. misionensis (Castro 1959) and Lutzomyia whitmani (Antunes & Coutinho 1939) were collected in an organic plantation and the last of these was also present in the other two plantation types. The remaining species, Lu. intermedia (Lutz & Neiva 1912), was collected in plantations under both the "adensado" and "convencional" systems. The results of this study indicate that transmission of Leishmania to man in coffee-growing areas of Minas Gerais may involve phlebotomine sand flies that inhabit plantations