Comparative 1-Year Outcomes of Invasive Staphylococcus aureus Infections Among Persons With and Without Drug Use: An Observational Cohort Study.

BACKGROUND: Persons who use drugs (PWUD) face substantial risk of Staphylococcus aureus infections. Limited data exist describing clinical and substance use characteristics of PWUD with invasive S. aureus infections or comparing treatment and mortality outcomes in PWUD vs non-PWUD. These are needed to inform optimal care for this marginalized population. METHODS: We identified adults hospitalized from 2013 to 2018 at 2 medical centers in San Francisco with S. aureus bacteremia or International Classification of Diseases-coded diagnoses of endocarditis, epidural abscess, or vertebral osteomyelitis with compatible culture. In addition to demographic and clinical characteristic comparison, we constructed multivariate Cox proportional hazards models for 1-year infection-related readmission and mortality, adjusted for age, race/ethnicity, housing, comorbidities, and methicillin-resistant S. aureus (MRSA). RESULTS: Of 963 hospitalizations for S. aureus infections in 946 patients, 372 of 963 (39%) occurred in PWUD. Among PWUD, heroin (198/372 [53%]) and methamphetamine use (185/372 [50%]) were common. Among 214 individuals using opioids, 98 of 214 (46%) did not receive methadone or buprenorphine. PWUD had lower antibiotic completion than non-PWUD (70% vs 87%; P < .001). While drug use was not associated with increased mortality, 1-year readmission for ongoing or recurrent infection was double in PWUD vs non-PWUD (28% vs 14%; adjusted hazard ratio [aHR], 2.0 [95% confidence interval {CI}: 1.3-2.9]). MRSA was independently associated with 1-year readmission for infection (aHR, 1.5 [95% CI: 1.1-2.2]). CONCLUSIONS: Compared to non-PWUD, PWUD with invasive S. aureus infections had lower rates of antibiotic completion and twice the risk of infection persistence/recurrence at 1 year. Among PWUD, both opioid and stimulant use were common. Models for combined treatment of substance use disorders and infections, particularly MRSA, are needed.

Patient-Directed Discharges Among Persons Who Use Drugs Hospitalized with Invasive Staphylococcus aureus Infections: Opportunities for Improvement.

BACKGROUND: Despite the high burden of Staphylococcus aureus infections among persons who use drugs, limited data exist comparing outcomes of patient-directed discharge (known as discharge against medical advice) compared with standard discharge among persons who use drugs hospitalized with S. aureus infection. METHODS: We conducted a retrospective study of hospitalizations among adults with S. aureus bacteremia, endocarditis, epidural abscess, or vertebral osteomyelitis at 2 San Francisco hospitals between 2013 and 2018. We compared odds of 1-year readmission for infection persistence or recurrence and 1-year mortality via multivariable logistic regression models adjusting for age, sex, Charlson comorbidity index, and homelessness. RESULTS: Overall, 80 of 340 (24%) of hospitalizations for invasive S. aureus infections among persons who use drugs involved patient-directed discharge. More than half of patient-directed discharges 41 of 80 (51%) required readmission for persistent or recurrent S. aureus infection compared with 54 of 260 (21%) patients without patient-directed discharge (adjusted odds ratio 3.8, 95% confidence interval [CI] 2.2-6.7). One-year cumulative mortality was 15% after patient-directed discharge compared with 11% after standard discharge (P = .02); however, this difference was not significant after adjustment for mortality risk factors. More than half of deaths in the patient-directed discharge group (7 of 12, 58%) were due to drug overdose; none was due to S. aureus infection. CONCLUSIONS: Among persons who use drugs hospitalized with invasive S. aureus infection, odds of hospital readmission for infection were almost 4-fold higher following patient-directed discharge compared with standard discharge. All-cause 1-year mortality was similarly high in both groups, and drug overdose was a common cause of death in patient-directed discharge group.

Morning report goes virtual: learner experiences in a virtual, case-based diagnostic reasoning conference.

OBJECTIVES: Participation in case-based diagnostic reasoning (DR) conferences has previously been limited to those who can attend in-person. Technological advances have enabled these conferences to migrate to virtual platforms, creating an opportunity to improve access and promote learner participation. We describe the design and evaluation of virtual morning report (VMR), a novel case-based DR conference that aimed to expand access to these conferences, leverage a virtual platform to create new opportunities for learner participation, and improve learner confidence in performing DR. METHODS: VMR took place on a videoconferencing platform. Participants included health professions students, post-graduate trainees, and practitioners. In designing VMR, we adapted concepts from the experience-based model of learning to design opportunities for learner participation. Teaching strategies were informed by information-processing and situativity theories. We evaluated learner experiences in VMR using a survey with open and closed-ended questions. Survey items focused on accessing case-based teaching conferences outside of VMR, participant perceptions of the educational value of VMR, and VMR's impact on participants' confidence in performing DR. We used thematic analysis to manually code open-ended responses and identify themes. RESULTS: 203 participants (30.2%) completed the survey. 141 respondents (69.5%) reported they did not otherwise have access to a DR conference. The majority of participants reported increased confidence performing DR. Respondents highlighted that VMR supplemented their education, created a supportive learning environment, and offered a sense of community. CONCLUSIONS: VMR can expand access to DR education, create new opportunities for learner participation, and improve learner confidence in performing DR.

One Minute of Marijuana Secondhand Smoke Exposure Substantially Impairs Vascular Endothelial Function.

BACKGROUND: Despite public awareness that tobacco secondhand smoke (SHS) is harmful, many people still assume that marijuana SHS is benign. Debates about whether smoke-free laws should include marijuana are becoming increasingly widespread as marijuana is legalized and the cannabis industry grows. Lack of evidence for marijuana SHS causing acute cardiovascular harm is frequently mistaken for evidence that it is harmless, despite chemical and physical similarity between marijuana and tobacco smoke. We investigated whether brief exposure to marijuana SHS causes acute vascular endothelial dysfunction. METHODS AND RESULTS: We measured endothelial function as femoral artery flow-mediated dilation (FMD) in rats before and after exposure to marijuana SHS at levels similar to real-world tobacco SHS conditions. One minute of exposure to marijuana SHS impaired FMD to a comparable extent as impairment from equal concentrations of tobacco SHS, but recovery was considerably slower for marijuana. Exposure to marijuana SHS directly caused cannabinoid-independent vasodilation that subsided within 25 minutes, whereas FMD remained impaired for at least 90 minutes. Impairment occurred even when marijuana lacked cannabinoids and rolling paper was omitted. Endothelium-independent vasodilation by nitroglycerin administration was not impaired. FMD was not impaired by exposure to chamber air. CONCLUSIONS: One minute of exposure to marijuana SHS substantially impairs endothelial function in rats for at least 90 minutes, considerably longer than comparable impairment by tobacco SHS. Impairment of FMD does not require cannabinoids, nicotine, or rolling paper smoke. Our findings in rats suggest that SHS can exert similar adverse cardiovascular effects regardless of whether it is from tobacco or marijuana.