A regionally tailored epidemiological forecast and monitoring program to guide a healthcare system in the COVID-19 pandemic.

BACKGROUND: During the COVID-19 pandemic, analytics and predictive models built on regional data provided timely, accurate monitoring of epidemiological behavior, informing critical planning and decision-making for health system leaders. At Atrium Health, a large, integrated healthcare system in the southeastern United States, a team of statisticians and physicians created a comprehensive forecast and monitoring program that leveraged an array of statistical methods. METHODS: The program utilized the following methodological approaches: (i) exploratory graphics, including time plots of epidemiological metrics with smoothers; (ii) infection prevalence forecasting using a Bayesian epidemiological model with time-varying infection rate; (iii) doubling and halving times computed using changepoints in local linear trend; (iv) death monitoring using combination forecasting with an ensemble of models; (v) effective reproduction number estimation with a Bayesian approach; (vi) COVID-19 patients hospital census monitored via time series models; and (vii) quantified forecast performance. RESULTS: A consolidated forecast and monitoring report was produced weekly and proved to be an effective, vital source of information and guidance as the healthcare system navigated the inherent uncertainty of the pandemic. Forecasts provided accurate and precise information that informed critical decisions on resource planning, bed capacity and staffing management, and infection prevention strategies. CONCLUSIONS: In this paper, we have presented the framework used in our epidemiological forecast and monitoring program at Atrium Health, as well as provided recommendations for implementation by other healthcare systems and institutions to facilitate use in future pandemics.

Barbed Versus Nonbarbed Suture for Posterior Colporrhaphy: A Randomized Controlled Trial.

IMPORTANCE: There is limited literature or even consensus on the suture material used for posterior vaginal repairs. OBJECTIVES: This study aimed to compare outcomes of barbed versus nonbarbed delayed absorbable suture used for posterior colporrhaphy. STUDY DESIGN: This study conducted a randomized controlled trial of 72 women undergoing posterior repair using standardized technique-concurrent procedures permitted with barbed (n = 36) or nonbarbed (n = 36) suture. Standardized examinations, validated questionnaires, and a visual analog scale (VAS) were completed at baseline, 6 weeks, and 12 months, and a telephone interview was conducted at 6 months. The primary outcome was posterior compartment pain at 6 weeks, measured by a VAS. RESULTS: Seventy-two women enrolled, with follow-up rates 6 weeks (100%), 6 months (90.3%), and 12 months (73.6%). Demographics were similar between groups. A VAS with movement was not different between groups at 6 weeks. The odds of experiencing vaginal pain, having myofascial pain on examination, or being sexually active postoperatively were not different between the groups. There were no differences in the length of posterior colporrhaphy, surgical times, or hospital length of stay between the groups. Suture passes were lower in the nonbarbed group (median, 4 vs 7; P = <0.001), and suture burden was higher in the nonbarbed group (median, 26.9 vs 10.5 cm; P = <0.001). There was overall improvement in Pelvic Floor Distress Inventory Short Form 20 prolapse and colorectal subscores but no differences between groups. Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire Short Form 12 scores improved, and dyspareunia decreased at 6 and 12 months in both groups. In addition, there were few anatomic recurrences at 6 weeks (0%) and 12 months (3.4%) and few adverse events. CONCLUSIONS: This study found no differences in primary or secondary outcomes; however, both suture types resulted in clinical improvements in quality-of-life measures and sexual function.

Outcomes and antibiotic use in patients with coronavirus disease 2019 (COVID-19) admitted to an intensive care unit.

Antibiotic overuse is high in patients hospitalized with coronavirus disease 2019 (COVID-19) despite a low documented prevalence of bacterial infections in many studies. In this study evaluating 65 COVID-19 patients in the intensive care unit, empiric broad-spectrum antibiotics were often overutilized with an inertia to de-escalate despite negative culture results.

Association of race and acute kidney injury among patients admitted with Coronavirus disease of 2019 (COVID-19).

BACKGROUND: COVID-19 is a multi-organ system disease, and rates of acute kidney injury (AKI) have varied significantly. Our objective was to evaluate the prevalence of AKI among hospitalized COVID-19-positive patients in a large hospital system in the Southeast of the USA. MATERIALS AND METHODS: This was a cohort study of admitted patients discharged between March 1, 2020 and April 30, 2020 at Atrium Health who had tested positive for COVID-19 by polymerase chain reaction testing of a nasopharyngeal swab. The positive test had been within 2 weeks prior to or after admission. AKI was defined and staged using the Kidney Disease Improving Global Outcomes (KDIGO) 2012 AKI criteria. Patient-level data including demographic characteristics, Charlson Comorbidity Index, and other comorbidities were also obtained. RESULTS: Of the admitted patients with COVID-19, 74 of 254 (29.1%, 95% CI 23.6 - 35.1%) had AKI. Participants with AKI compared to those without AKI tended to be ≥ 65 years of age (57 vs. 39%; p = 0.01), male (62 vs. 46%; p = 0.02), African American (70 vs. 45%; p < 0.01), have a diagnosis of chronic kidney disease (28 vs. 15%; p = 0.01), and a higher median Charlson Comorbidity Index score (6.5 vs. 4.0; p < 0.01). After adjusting for other factors, African Americans had three times the odds of developing AKI compared to other racial groups among patients admitted with a COVID-19 diagnosis (OR 3.09; 95% CI 1.49 - 6.41). CONCLUSION: Among the 254 patients hospitalized with COVID-19, we observed a high prevalence of AKI. However, a majority of survivors demonstrated renal recovery at the time of discharge. African American race was strongly associated with development of AKI and portended a poor prognosis.

Body mass index and age are associated with ventricular end-diastolic pressure in adults with a Fontan circulation.

INTRODUCTION: Systemic ventricular end-diastolic pressure is an important haemodynamic variable in adult patients with Fontan circulation. Risk factors associated with elevated end-diastolic pressure have not been clearly identified in this population. METHODS: All patients > 18 years with Fontan circulation who underwent cardiac catheterisation at our centre between 1/08 and 3/19 were included. Relevant patient variables were extracted. Univariate and multivariate general linear models were analysed to identify variables associated with end-diastolic pressure. RESULTS: Forty-two patients were included. Median age was 24.0 years (20.9-29.0) with a body mass index of 23.7 kg/m2 (21.5-29.7). 10 (23.8%) patients had a systemic right ventricle. The median (Interquartile range) and mean pulmonary artery pressure were 11.0 mmHg (9.0-12.0) and 16.0 mmHg (13.0-18.0), respectively. On univariate analysis, end-diastolic pressure was positively associated with body mass index (p < 0.01), age > 25 years (p = 0.04), symptoms of heart failure (p < 0.01), systemic ventricular systolic pressure (p = 0.03), pulmonary artery mean pressure (p < 0.01), and taking diuretics (p < 0.01) or sildenafil (p < 0.01). End-diastolic pressure was negatively associated with aortic saturation (p < 0.01). On multivariate analysis, end-diastolic pressure was positively associated with age ≥ 25 years (p < 0.01), and body mass index (p = 0.04). CONCLUSIONS: In a cohort of adult patients with Fontan circulation undergoing catheterisation, end-diastolic pressure was positively associated with age ≥ 25 years and body mass index on multivariate analysis. Maintaining a healthy body mass index may offer haemodynamic benefit in adults with Fontan physiology.

Empiric aztreonam is associated with increased mortality compared to beta-lactams in septic shock.

PURPOSE: To determine if aztreonam as initial empiric treatment of adult septic shock is associated with increased mortality compared to the use of anti-pseudomonal beta-lactam agents. METHODS: This was a multicenter, retrospective cohort study of 582 adult emergency department patients admitted to 12 acute care facilities within a single health system from January 2014 to December 2017 with septic shock receiving either aztreonam or an anti-pseudomonal beta-lactam for empiric treatment and discharged with an infection-related ICD-9 or ICD-10 code. The primary endpoint was in-hospital mortality. RESULTS: Initial exposure to aztreonam was associated with increased hospital mortality compared to treatment with an anti-pseudomonal beta-lactam agent (22.7% vs. 12.9%, OR = 1.98, 95% CI: 1.27-3.11). When adjusted for APACHE II score, the treatment group effect on mortality remained statistically significant (OR = 1.74, 95% CI: 1.08-2.80). Aztreonam use was also associated with increased utilization of aminoglycosides (28.9% vs. 12.4%, p < 0.0001) and fluoroquinolones (50.5% vs. 25.8%, p < 0.01). There was no difference in hospital or intensive care unit length of stay in surviving patients between the two groups. CONCLUSIONS: Compared to anti-pseudomonal beta-lactams, empiric treatment with aztreonam is associated with increased mortality and greater antibiotic exposure among patients with acute septic shock. These findings suggest that treatment with anti-pseudomonal beta-lactams should be prioritized over allergy avoidance whenever feasible.

Racial Disparities in Prostate Specific Antigen Screening and Referral to Urology in a Large, Integrated Health Care System: A Retrospective Cohort Study.

PURPOSE: Contemporary trends and racial disparities in prostate cancer screening and referral to urology for prostate cancer risk are not well characterized, despite consensus that Black men are at higher risk for poor prostate cancer outcomes. The objective of this study was to characterize current racial disparities in prostate cancer screening and referral from primary care to urology for prostate cancer concern within our large, integrated health care system. MATERIALS AND METHODS: This retrospective cohort study used data from Atrium Health's enterprise data warehouse, which includes patient information from more than 900 care locations across North Carolina, South Carolina and Georgia. We included all men seen in the ambulatory or outpatient setting between 2014 and 2019 who were ≥40 years old. Clinical and demographic data were collected for all men, including age and race. Racial outcomes were reported for all groups with >2% representation in the population. Between-group comparisons were determined using chi-squared analysis, Wilcoxon rank sum testing and multivariable logistic regression, with significance defined as p <0.05. RESULTS: We observed a significant decrease in prostate specific antigen testing across all age and racial groups in a cohort of 606,985 men at Atrium Health, including 87,189 Black men, with an overall relative decline of 56%. As compared to White men, Black men were more likely to undergo prostate specific antigen testing (adjusted OR 1.24, 95% CI 1.22-1.26) and be referred to urology for prostate cancer (adjusted OR 1.94, 95% CI 1.75-2.16). CONCLUSIONS: There was a continued significant decline in prostate cancer screening between 2014 and 2019. Despite having modestly elevated odds of being screened for prostate cancer compared to White men, Black men are relatively underscreened when considering that those who undergo prostate specific antigen screening are more likely to be referred by primary care to urology for additional prostate cancer diagnostic evaluation.

Identification of patient variables that are associated with ventricular end-diastolic pressure before the bidirectional Glenn operation.

INTRODUCTION: Systemic ventricular end-diastolic pressure is important in patients with single ventricle heart disease. Predictors of an elevated systemic ventricular end-diastolic pressure prior to bidirectional Glenn operation have been incompletely identified. METHODS: All patients who underwent bidirectional Glenn operation operation at our centre between January 2007 and March 2017 were retrospectively identified and patient variables were extracted. For patients who had undergone Fontan operation at the time of this study, post-Fontan patient variables were also extracted. RESULTS: One-hundred patients were included with a median age at pre-bidirectional Glenn operation catheterisation of 4.5 months. In total, 71 (71%) patients had a systemic right ventricle. At the pre-bidirectional Glenn operation catheterisation, the mean systemic ventricular end-diastolic pressure was higher amongst those with systemic right ventricle compared to left ventricle (9.1 mmHg ± 2.1 versus 7.7 ± 2.7 mmHg, p < 0.01). On univariate analysis, pre-bidirectional Glenn operation systemic ventricular end-diastolic pressure was positively associated with the presence of a systemic right ventricle (p < 0.01), history of recoarctation (p = 0.03), history of Norwood operation (p = 0.04), and ventricular systolic pressure (p < 0.01). On multivariate analysis, systemic ventricular end-diastolic pressure was positively associated with the presence of a systemic right ventricle (p < 0.01) and ventricular systolic pressure (p < 0.01). Amongst those who had undergone Fontan operation at the time of study (n = 49), those with a higher pre-bidirectional Glenn operation systemic ventricular end-diastolic pressure were more likely to have experienced death, transplantation, or listed for transplantation (p = 0.02) and more likely to have had heart failure symptoms (p = 0.04) at a mean time from Fontan of 5.2 years ± 1.3. CONCLUSIONS: In patients undergoing bidirectional Glenn operation operation, the volume-loaded, pre-bidirectional Glenn operation state may expose diastolic dysfunction that has prognostic value.

The Association Between Antibiotic Delay Intervals and Hospital Mortality Among Patients Treated in the Emergency Department for Suspected Sepsis.

OBJECTIVES: Rapid delivery of antibiotics is a cornerstone of sepsis therapy, although time targets for specific components of antibiotic delivery are unknown. We quantified time intervals comprising the task of antibiotic delivery and evaluated the association between interval delays and hospital mortality among patients treated in the emergency department for suspected sepsis. DESIGN: Retrospective cohort. SETTING: Twelve hospitals in Southeastern United States from 2014 to 2017. PATIENTS: Twenty-four thousand ninety-three encounters among 20,026 adults with suspected sepsis in 12 emergency departments. MEASUREMENTS AND MAIN RESULTS: We divided antibiotic administration into two intervals: time from emergency department triage to antibiotic order (recognition delay) and time from antibiotic order to infusion (administration delay). We used generalized linear mixed models to evaluate associations between these intervals and hospital mortality. Median time from emergency department triage to antibiotic administration was 3.4 hours (interquartile range, 2.0-6.0 hr), separated into a median recognition delay (time from emergency department triage to antibiotic order) of 2.7 hours(interquartile range, 1.5-4.7 hr) and median administration delay (time from antibiotic order to infusion) of 0.6 hours (0.3-1.2 hr). Adjusting for other risk factors, both recognition delay and administration delay were associated with mortality, but pairwise comparison with a no-delay reference group was not significant for up to 6 hours of recognition delay or up to 1.5 hours of administration delay. CONCLUSIONS: Both recognition delays and administration delays were associated with increased hospital mortality, but only for longer delays. These results suggest that both metrics may be important to measure and improve for patients with suspected sepsis but do not support targets less than 1 hour.

Association of 5-Alpha Reductase Inhibitor Use with Prostate Specific Antigen Level at the Time of Urology Referral in a Retrospective Cohort at a Large, Integrated Health Care System.

INTRODUCTION: 5-Alpha reductase inhibitor (5-ARI) use leads to a 50% decline in serum prostate specific antigen (PSA) without a concomitant decrease in prostate cancer (PCa) risk. We hypothesize that failure to account for the effect of 5-ARI use on serum PSA leads to increased PCa risk at urology referral among 5-ARI users. METHODS: This is a retrospective cohort study for the years 2018-2019. Atrium Health is a large, vertically integrated health system with over 900 care locations in North Carolina and South Carolina. Men ≥40 years old during 2018-2019 who had a PSA test performed were included. We determined differences in corrected serum PSA level at the time of referral to urology. 5-ARI users and nonusers were compared using the chi-square test, Student's t-test and gamma regression. RESULTS: From 2018-2019, there were 91,368 men who underwent PSA testing, including 2,939 5-ARI users. At referral, 5-ARI users had similar uncorrected median PSA (5.8 vs 5.6 ng/ml, p=0.05). After correcting for the effect of 5-ARIs on PSA, 5-ARI users had a median PSA of 11.6 ng/ml at urology referral, compared to 5.6 ng/ml in nonusers. CONCLUSIONS: Men taking 5-ARIs have higher corrected serum PSA at time of referral to urology. As the unadjusted PSA at referral to urology for PCa risk was similar between 5-ARI users and nonusers, this indicates that the effect of 5-ARI use on serum PSA levels is not routinely accounted for when assessing PCa risk.

Improving antibiotic prescribing for pediatric acute respiratory tract infections: A cluster randomized trial to evaluate individual versus clinic feedback.

Objective: To assess the effect of individual compared to clinic-level feedback on guideline-concordant care for 3 acute respiratory tract infections (ARTIs) among family medicine clinicians caring for pediatric patients. Design: Cluster randomized controlled trial with a 22-month baseline, 26-month intervention period, and 12-month postintervention period. Setting and participants: In total, 26 family medicine practices (39 clinics) caring for pediatric patients in Virginia, North Carolina, and South Carolina were selected based upon performance on guideline-concordance for 3 ARTIs, stratified by practice size. These were randomly allocated to a control group (17 clinics in 13 practices) or to an intervention group (22 clinics in 13 practices). Interventions: All clinicians received an education session and baseline then monthly clinic-level rates for guideline-concordant antibiotic prescribing for ARTIs: upper respiratory tract infection (URI), acute bacterial sinusitis (ABS), and acute otitis media (AOM). For the intervention group only, individual clinician performance was provided. Results: Both intervention and control groups demonstrated improvement from baseline, but the intervention group had significantly greater improvement compared with the control group: URI (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.37-1.92; P < 0.01); ABS (OR, 1.45; 95% CI, 1.11-1.88; P < 0.01); and AOM (OR, 1.59; 95% CI, 1.24-2.03; P < 0.01). The intervention group also showed significantly greater reduction in broad-spectrum antibiotic prescribing percentage (BSAP%): odds ratio 0.80, 95% CI 0.74-0.87, P < 0.01. During the postintervention year, gains were maintained in the intervention group for each ARTI and for URI and AOM in the control group. Conclusions: Monthly individual peer feedback is superior to clinic-level only feedback in family medicine clinics for 3 pediatric ARTIs and for BSAP% reduction. Trial registration: ClinicalTrials.gov identifier: NCT04588376, Improving Antibiotic Prescribing for Pediatric Respiratory Infection by Family Physicians with Peer Comparison.

Pediatric Pain Assessment in the Emergency Department: Patient and Caregiver Agreement Using the Wong-Baker FACES and the Faces Pain Scale-Revised.

OBJECTIVE: This study aimed to assess the agreement between patients presenting to the pediatric emergency department (ED) with acute pain and their caregivers when using the Wong-Baker FACES (WBF) and Faces Pain Scale-Revised (FPS-R). METHODS: This was a prospective, observational study examining patients 3 to 7.5 years old presenting to a pediatric ED with acute pain. Participants completed the WBF and FPS-R twice during their ED evaluation. Caregivers rated their child's pain using both the WBF and FPS-R at the same time points. Intraclass correlations (ICCs) were calculated between caregiver and child reports at each time point, and Bland-Altman plots were created. RESULTS: Forty-six subjects were enrolled over 5 months. Mean age was 5.5 ± 1.2 years. Average initial child pain scores were 6.6 ± 2.8 (WBF) and 6.1 ± 3.3 (FPS-R), and repeat scores were 3.3 ± 3.4 (WBF) and 3.1 ± 3.3 (FPS-R). Average initial caregiver pain scores were 6.3 ± 2.4 (WBF) and 6.2 ± 2.3 (FPS-R), and repeat scores were 3.4 ± 2.0 (WBF) and 3.4 ± 2.1 (FPS-R). On initial assessment, ICCs between children and caregivers using the FPS-R and WBF were 0.33 and 0.22, respectively. On repeat assessment, the ICCs were 0.31 for FPS-R and 0.26 for WBF. Bland-Altman plots showed poor agreement but no systematic bias. CONCLUSION: There was poor agreement between caregivers and children when using the WBF and FPS-R for assessment of acute pain in the ED. Caregiver report should not be used as a substitute for self-report of pain if possible.

Meropenem-Vaborbactam versus Ceftazidime-Avibactam for Treatment of Carbapenem-Resistant Enterobacteriaceae Infections.

The comparative efficacy of ceftazidime-avibactam and meropenem-vaborbactam for treatment of carbapenem-resistant Enterobacteriaceae (CRE) infections remains unknown. This was a multicenter, retrospective cohort study of adults with CRE infections who received ceftazidime-avibactam or meropenem-vaborbactam for ≥72 hours from February 2015 to October 2018. Patients with a localized urinary tract infection and repeat study drug exposures after the first episode were excluded. The primary endpoint was clinical success compared between treatment groups. Secondary endpoints included 30- and 90-day mortality, adverse events (AE), 90-day CRE infection recurrence, and development of resistance in patients with recurrent infection. A post hoc subgroup analysis was completed comparing patients who received ceftazidime-avibactam monotherapy, ceftazidime-avibactam combination therapy, and meropenem-vaborbactam monotherapy. A total of 131 patients were included (ceftazidime-avibactam, n = 105; meropenem-vaborbactam, n = 26), 40% of whom had bacteremia. No significant difference in clinical success was observed between groups (62% versus 69%; P = 0.49). Patients in the ceftazidime-avibactam arm received combination therapy more often than patients in the meropenem-vaborbactam arm (61% versus 15%; P < 0.01). No difference in 30- and 90-day mortality resulted, and rates of AE were similar between groups. In patients with recurrent infection, development of resistance occurred in three patients that received ceftazidime-avibactam monotherapy and in no patients in the meropenem-vaborbactam arm. Clinical success was similar between patients receiving ceftazidime-avibactam and meropenem-vaborbactam for treatment of CRE infections, despite ceftazidime-avibactam being used more often as a combination therapy. Development of resistance was more common with ceftazidime-avibactam monotherapy.

Effect of a Virtual Patient Navigation Program on Behavioral Health Admissions in the Emergency Department: A Randomized Clinical Trial.

IMPORTANCE: The number of patients presenting to emergency departments (EDs) for psychiatric care continues to increase. Psychiatrists often make a conservative recommendation to admit patients because robust outpatient services for close follow-up are lacking. OBJECTIVE: To assess whether the availability of a 45-day behavioral health-virtual patient navigation program decreases hospitalization among patients presenting to the ED with a behavioral health crisis or need. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial enrolled 637 patients who presented to 6 EDs spanning urban and suburban locations within a large integrated health care system in North Carolina from June 12, 2017, through February 14, 2018; patients were followed up for up to 45 days. Eligible patients were aged 18 years or older, with a behavioral health crisis and a completed telepsychiatric ED consultation. The availability of the behavioral health-virtual patient navigation intervention was randomly allocated to specific days (Monday through Friday from 7 am to 7 pm) so that, in a 2-week block, there were 5 intervention days and 5 usual care days; 323 patients presented on days when the program was offered, and 314 presented on usual care days. Data analysis was performed from March 7 through June 13, 2018, using an intention-to-treat approach. INTERVENTIONS: The behavioral health-virtual patient navigation program included video contact with a patient while in the ED and telephonic outreach 24 to 72 hours after discharge and then at least weekly for up to 45 days. MAIN OUTCOMES AND MEASURES: The primary outcome was the conversion of an ED encounter to hospital admission. Secondary outcomes included 45-day follow-up encounters with a self-harm diagnosis and postdischarge acute care use. RESULTS: Among 637 participants, 358 (56.2%) were men, and the mean (SD) age was 39.7 (16.6) years. The conversion rates were 55.1% (178 of 323) in the intervention group vs 63.1% (198 of 314) in the usual care group (odds ratio, 0.74; 95% CI, 0.54-1.02; P = .06). The percentage of patient encounters with follow-up encounters having a self-harm diagnosis was significantly lower in the intervention group compared with the usual care group (36.8% [119 of 323] vs 45.5% [143 of 314]; P = .03). CONCLUSIONS AND RELEVANCE: Although the primary result did not reach statistical significance, there is a strong signal of potential positive benefit in an area that lacks evidence, suggesting that there should be additional investment and inquiry into virtual behavioral health programs. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03204643.

Impact of Education and Peer Comparison on Antibiotic Prescribing for Pediatric Respiratory Tract Infections.

INTRODUCTION: Inappropriate prescribing of broad-spectrum antibiotics is a significant modifiable risk factor for the development of antibiotic resistance. The objective was to improve guideline-concordant care for 3 common acute respiratory tract infections (ARTIs) and to reduce broad-spectrum antibiotic prescribing in ambulatory pediatric patients. METHODS: Quality measures were developed for 3 ARTIs: viral upper respiratory infection (URI), acute bacterial sinusitis (ABS), and acute otitis media (AOM). Among 22 pediatric clinics, a collaborative of 10 was identified for intervention using baseline data for each ARTI, and 3 plan-do-study-act cycles were planned and completed. Outcomes included guideline-concordant antibiotic utilization and broad-spectrum antibiotic prescribing percentage (BSAP%). Comparison in number of diagnoses for the ARTI measures and total antibiotic prescribing over time served as balancing measures. RESULTS: Collaborative clinics had baseline medians for appropriate or first-line treatment of 70% for URI, 53% for ABS, and 36% for AOM. To reach targets for URI, ABS, and AOM required 6, 14, and 18 months, respectively. At 42 months, performance for all 3 ARTIs remained ≥90%. BSAP% decreased from a baseline of 57% to 34% at 24 months. There was a limited effect from financial incentives but a significant decrease was noted in total antibiotic utilization. Diagnosis shifting may have occurred for URI and ABS while the rates for diagnoses for AOM declined over time. CONCLUSIONS: Through education and peer comparison feedback, guideline-concordant care for 3 ARTIs in collaborative clinics improved and remained beyond above targets and was accompanied by reductions in BSAP% and total antibiotic prescribing.

Effectiveness of oral antibiotics for definitive therapy of non-Staphylococcal Gram-positive bacterial bloodstream infections.

BACKGROUND: Data on the effectiveness of definitive oral (PO) antibiotics for BSIs in preparation for discharge from hospital are lacking, particularly for Gram-positive bacterial BSIs (GP-BSI). The objective of this study was to determine rates of treatment failure based on bioavailability of PO antimicrobial agents used for GP-BSI. METHODS: This was a single-center, retrospective cohort study of adult inpatients admitted to an academic medical center over a three-year period. Patients with a non-staphylococcal GP-BSI who received intravenous antibiotics and were then switched to PO antibiotics for at least a third of their treatment course were included. The cohort was stratified into high (⩾90%) and low (<90%) bioavailability groups. The primary endpoint was the proportion of patients experiencing clinical failure in each group. Secondary endpoints included clinical failure stratified by antibiotic group, bactericidal versus bacteriostatic PO agents, and organism. RESULTS: A total of 103 patients met criteria for inclusion, which failed to reach the a priori power calculation. Of the patients included, 26 received high bioavailability agents and 77 received low bioavailability agents. Infections originated largely from a pulmonary source (30%) and were caused primarily by streptococcal species (75%). Treatment failure rates were 19.2% in the high bioavailability group and 23.4% in the low bioavailability group (p = 0.66). Clinical failure stratified by subgroups also did not yield statistically significant differences. CONCLUSIONS: Clinical failure rates were similar among patients definitively treated with high or low bioavailability agents for GP-BSI, though the study was underpowered to detect such a difference.

Retrograde type A dissection after thoracic endovascular aortic repair for type B aortic dissection.

BACKGROUND: The purpose of this study was to evaluate clinical, anatomic, and procedural characteristics of patients who developed retrograde type A dissection (RTAD) after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). METHODS: Between January 2012 and January 2017, there were 186 patients who underwent TEVAR for TBAD at a multidisciplinary aortic center. Patients who developed RTAD after TEVAR (n = 15) were compared with those who did not (no-RTAD group, n = 171). Primary outcomes were survival and need for reintervention. RESULTS: The incidence of RTAD in our sample was 8% (n = 15). Kaplan-Meier estimates found that no-RTAD patients had better survival (P = .04). Survival rates at 30 days, 1 year, and 3 years were 93%, 60%, and 60% for RTAD patients and 94%, 87%, and 80% for no-RTAD patients. One RTAD was diagnosed intraoperatively, 5 were diagnosed within 30 days of the index procedure, 6 were diagnosed within 1 year, and 3 were diagnosed after 1 year. Reintervention for RTAD was undertaken in 10 of 15 patients, with a 50% survival rate after reintervention. Partial or complete false lumen thrombosis was more frequently present in RTAD patients (P = .03). RTAD patients more frequently presented with renal ischemia (P = .04). Most RTAD patients (93%, RTAD patients; 64%, no-RTAD patients; P = .02) had a proximal landing zone in zone 0, 1, or 2. Aortic diameter was more frequently ≥40 mm in the RTAD group (47%, RTAD patients; 21%, no-RTAD patients; P = .05). Patients with RTAD had stent grafts placed in the renovisceral arteries for complicated dissections, and this approached significance (P = .05). Three RTAD patients had a type II arch (20%) compared with 53 no-RTAD patients (31%; P = .6), but a comparison of type II arch with type I or type III found no statistical significance (P = .6). No correlations were found between ratio of descending to ascending diameters, average aortic sizing, graft size, or bare-metal struts at proximal attachment zone and development of RTAD. We found no statistically significant differences in demographics, genetic disease, comorbidities, or previous repairs. CONCLUSIONS: The development of RTAD after TEVAR for TBAD does not appear to be correlated with any easily identifiable demographic feature but appears to be correlated with proximal landing zones in zone 1 and 2 and an ascending diameter >4 cm. Furthermore, the presence of partial or complete false lumen thrombosis as well as more complicated presentation with renal ischemia was significantly more frequent in patients with RTAD. TBAD patients should be observed long term, as type A dissections in our patients occurred even after 1 year.

When Less Is More: Minimally Invasive Surgery Compared with Laparotomy for Interval Debulking After Neoadjuvant Chemotherapy in Women with Advanced Ovarian Cancer.

STUDY OBJECTIVE: To compare outcomes of advanced ovarian cancer patients who had minimally invasive surgery (MIS) with outcomes of advanced ovarian cancer patients who had laparotomy for interval cytoreduction after neoadjuvant chemotherapy (NACT). DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: One large teaching hospital with a tertiary referral function for gynecologic oncology and MIS. PATIENTS: All consecutive patients with stages III to IV epithelial ovarian, tubal, or peritoneal cancer who underwent MIS or laparotomy for interval cytoreduction after at least 1 NACT cycle from 2006 to 2017 at 1 institution. INTERVENTIONS: Patients underwent either MIS or laparotomy for interval cytoreduction after at least 1 cycle of NACT. MEASUREMENTS AND MAIN RESULTS: Medical records were reviewed and data abstracted and analyzed. Survival was estimated by the Kaplan-Meier method, and outcomes were compared with Fisher's exact test, Student's t test, Wilcoxon rank sum test, and the log-rank test. In total, 157 assessable patients underwent interval cytoreductive surgery through MIS (n = 53) or laparotomy (n = 104). MIS was completed without conversion in 44 of 53 patients (83%), of whom 20 required a hand port and/or mini-laparotomy. R-zero and optimal resections were achieved in 60.4% and 96.3% of MIS patients respectively, compared with 42.3% and 82.7% of laparotomy patients (p = .02). MIS patients had lower estimated blood loss (EBL; 156 vs 278 mL, p <.001), fewer intraoperative transfusions (2% vs 17%, p = .006), and shorter hospital stay (3.0 vs 5.7 days, p < .001). Operative time was longer (171 vs 150 minutes, p = .007), but complications, intensive care unit stay, readmission, median progression-free survival (27 vs 29 months, p = .45), and median overall survival (37 vs 35 months, p = .74) were similar. CONCLUSION: MIS is feasible and effective for interval cytoreduction after NACT in advanced ovarian cancer patients. MIS is associated with less EBL, lower transfusion rate, and shorter length of hospital stay with no difference in patient outcomes.