Limited reduction in Clostridioides difficile and Methicillin-Resistant Staphylococcus aureus with the use of an aerosolized hydrogen peroxide disinfection system in tertiary health care facilities in Alberta, Canada.

BACKGROUND: Nonmanual room disinfection systems may reduce the transmission of infections. A variety of systems have emerged; however, a paucity of evidence exists to make an evidence-informed decision for the implementation of a specific system. Alberta Health Services assessed one of these systems. METHODS: A quasi-experimental prepost design assessed an aerosolized hydrogen peroxide disinfection system on 6 units at 3 acute care facilities in Alberta. To assess clinical effectiveness an interrupted time-series analysis with Poisson distribution compared changes in hospital-acquired Clostridioides difficile infection (HA-CDI) and hospital-acquired Methicillin-resistant Staphylococcus aureus (HA-MRSA) between preintervention, intervention, and postintervention periods. To assess operational feasibility cleaning turnaround time, time to operate, and utilization were considered. A participatory research framework was used to understand the benefits and challenges of operationalization. RESULTS: Incidence rate ratio (IRR) of HA-CDI decreased by 25.7% on FMC-A and 6.9% on RAH-B. Following withdrawal, the IRR of HA-CDI continued to decrease. IRR of HA-MRSA decreased by 25.0% on RAH-B. Following withdrawal, the IRR of HA-MRSA continued to decrease. None of the results were statistically significant. The average time to operate was 3.2 hours. Utilization was between 1.7% and 25.6%. Most staff reported benefits and challenges. DISCUSSION: None of the changes observed in HA-CDI and HA-MRSA after the introduction of the aerosolized hydrogen peroxide system were statistically significant. While most respondents reported multiple benefits and challenges in using the system, the core challenge was delays in inpatient admissions due to the time operate the system. CONCLUSION: Successful implementation of a nonmanual room disinfection system as an addition to standard cleaning and disinfection requires significant investment and must consider a variety of factors.

Influence of neighborhood-level socioeconomic deprivation and individual socioeconomic position on risk of developing type 2 diabetes in older men: a longitudinal analysis in the British Regional Heart Study cohort.

INTRODUCTION: Evidence from longitudinal studies on the influence of neighborhood socioeconomic deprivation in older age on the development of type 2 diabetes mellitus (T2DM) is limited. This study investigates the prospective associations of neighborhood-level deprivation and individual socioeconomic position (SEP) with T2DM incidence in older age. RESEARCH DESIGN AND METHODS: The British Regional Heart Study studied 4252 men aged 60-79 years in 1998-2000. Neighborhood-level deprivation was based on the Index of Multiple Deprivation quintiles for participants' 1998-2000 residential postcode. Individual SEP was defined as social class based on longest-held occupation. A cumulative score of individual socioeconomic factors was derived. Incident T2DM cases were ascertained from primary care records; prevalent cases were excluded. Cox proportional hazard models were used to examine the associations. RESULTS: Among 3706 men, 368 incident cases of T2DM were observed over 18 years. The age-adjusted T2DM risk increased from the least deprived quintile to the most deprived: HR per quintile increase 1.14 (95% CI 1.06 to 1.23) (p=0.0005). The age-adjusted T2DM HR in social class V (lowest) versus social class I (highest) was 2.45 (95% CI 1.36 to 4.42) (p=0.001). Both associations attenuated but remained significant on adjustment for other deprivation measures, becoming non-significant on adjustment for body mass index and T2DM family history. T2DM risk increased with cumulative individual adverse socioeconomic factors: HR per point increase 1.14 (95% CI 1.05 to 1.24). CONCLUSIONS: Inequalities in T2DM risk persist in later life, both in relation to neighborhood-level and individual-level socioeconomic factors. Underlying modifiable risk factors continue to need to be addressed in deprived older age populations to reduce disease burden.

Development of machine learning models for the detection of surgical site infections following total hip and knee arthroplasty: a multicenter cohort study.

BACKGROUND: Population based surveillance of surgical site infections (SSIs) requires precise case-finding strategies. We sought to develop and validate machine learning models to automate the process of complex (deep incisional/organ space) SSIs case detection. METHODS: This retrospective cohort study included adult patients (age ≥ 18 years) admitted to Calgary, Canada acute care hospitals who underwent primary total elective hip (THA) or knee (TKA) arthroplasty between Jan 1st, 2013 and Aug 31st, 2020. True SSI conditions were judged by the Alberta Health Services Infection Prevention and Control (IPC) program staff. Using the IPC cases as labels, we developed and validated nine XGBoost models to identify deep incisional SSIs, organ space SSIs and complex SSIs using administrative data, electronic medical records (EMR) free text data, and both. The performance of machine learning models was assessed by sensitivity, specificity, positive predictive value, negative predictive value, F1 score, the area under the receiver operating characteristic curve (ROC AUC) and the area under the precision-recall curve (PR AUC). In addition, a bootstrap 95% confidence interval (95% CI) was calculated. RESULTS: There were 22,059 unique patients with 27,360 hospital admissions resulting in 88,351 days of hospital stay. This included 16,561 (60.5%) TKA and 10,799 (39.5%) THA procedures. There were 235 ascertained SSIs. Of them, 77 (32.8%) were superficial incisional SSIs, 57 (24.3%) were deep incisional SSIs, and 101 (42.9%) were organ space SSIs. The incidence rates were 0.37 for superficial incisional SSIs, 0.21 for deep incisional SSIs, 0.37 for organ space and 0.58 for complex SSIs per 100 surgical procedures, respectively. The optimal XGBoost models using administrative data and text data combined achieved a ROC AUC of 0.906 (95% CI 0.835-0.978), PR AUC of 0.637 (95% CI 0.528-0.746), and F1 score of 0.79 (0.67-0.90). CONCLUSIONS: Our findings suggest machine learning models derived from administrative data and EMR text data achieved high performance and can be used to automate the detection of complex SSIs.

The incidence rates of surgical site infections following total hip and knee arthroplasty were 0.5 and 0.52 per 100 surgical procedures. The incidence of SSIs varied significantly between care facilities (ranging from 0.53 to 1.71 per 100 procedures). The optimal machine learning model achieved a ROC AUC of 0.906 (95% CI 0.835­0.978), PR AUC of 0.637 (95% CI 0.528­0.746), and F1 score of 0.79 (0.67­0.90).

Complex cardiac implantable electronic device infections in Alberta, Canada: An epidemiologic cohort study of validated administrative data.

OBJECTIVE: To establish the epidemiology of cardiac implantable electronic device (CIED) infections in Alberta, Canada, using validated administrative data. DESIGN: Retrospective, population-based cohort study. SETTING: Alberta Health Services is a province-wide health system that services all of Alberta, Canada. PARTICIPANTS: Adult patients who underwent first-time CIED implantation or generator replacement in Alberta, Canada, between January 1, 2011, and December 31, 2019. METHODS: CIED implant patients were identified from the Paceart database. Patients who developed an infection within 1 year of the index procedure were identified through validated administrative data (International Classification of Diseases, Tenth Revision in Canada). Demographic characteristics of patients were summarized. Logistic regression models were used to analyze device type, comorbidities, and demographics associated with infection rates and mortality. RESULTS: Among 27,830 CIED implants, there were 205 infections (0.74%). Having 2 or more comorbidities was associated with higher infection risk. Generator replacement procedures (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.34-0.84; P = .008), age increase of every 10 years (OR, 0.73; 95% CI, 0.66-0.82; P ≤ .001), and index procedure after 2014 were associated with decreased risk. Comparing the infected to uninfected groups, the hospitalization rates were 2.63 compared to 0.69, and the mortality rates were 10.73% compared to 3.49%, respectively (P < .001). CONCLUSIONS: There is a slightly lower overall rate of CIED infections Alberta, Canada compared to previously described epidemiology. Implants after 2014, and generator replacements showed a decreased burden of infection. Patients with younger age, and 2 or more comorbidities are at greatest risk of CIED infection. The burden of hospitalization and mortality is substantially higher in infected patients.

Gastric Neuroendocrine Tumor Treatment and Survival Outcome Depends on Facility Type.

BACKGROUND: Gastric neuroendocrine tumors (gNETs) are rare cancers for which surgery may improve survival. We aim to determine if facility type affects treatment and survival outcomes. METHODS: The NCDB was queried for patients with gNET from 2004-2016 and stratified into Academic/Research Program (ARP), Community Cancer Program (CCP), Comprehensive Community Cancer Program (CCCP), or Integrated Network Cancer Program (INCP). Overall survival along with clinical and demographic features was compared. RESULTS: Median survival was improved in patients treated at an academic program: 137.3 months versus 88.0, 96.3, and 100.2 for CCP, CCCP, INCP, respectively (P < .0001). Patients treated at academic centers were more likely to have surgery (64.2% vs 59.1%, 57.5%, 51.4%, P < .0001). After propensity matching for age, race, grade, stage, insurance status, and comorbidity score, survival benefit from treatment at an academic center remained (P = .03), particularly for patients undergoing surgery (P < .0001) and chemotherapy (P = .04). CONCLUSION: Patients with gNET treated at an academic hospital had improved median survival after propensity matching and may benefit from treatment at academic rather than community medical centers.

The associated impact of standardized admission screening on vancomycin-resistant Enterococci bloodstream infections.

OBJECTIVE: To determine whether discontinuing active screening for vancomycin-resistant Enterococcus (VRE) in Alberta, Canada, acute-care facilities had an associated impact on the rate of rise of hospital-acquired (HA) VRE bloodstream infection (VRE-BSI). SETTING: Acute-care facilities in Alberta, Canada. PATIENTS: All patients who were admitted to Alberta Health Services or Covenant Health acute-care facilities between January 1, 2013, and March 31, 2020, and who met the definition for hospital-acquired VRE-BSI were included in the analyses. METHODS: An intervention time-series Poisson regression was used to determine the slope change in VRE incidence between the pre- and postintervention (screening) periods. The patient population was separated into 3 cohorts: group 1 (low risk, VRE screening stopped), group 2 (high risk, VRE screening stopped), and group 3 (high risk, VRE screening continued). For all groups, a level- and slope-change model was used. RESULTS: We did not find a statistically significant difference in the slope change or rate of rise in VRE-BSI before and after the intervention, with incidence rate ratio (IRRs) of 1.015 (95% confidence interval [CI], 0.982-1.049), 1.025 (95% CI, 0.967-1.086), and 0.989 (95% CI, 0.924-1.059) for groups 1, 2 and 3, respectively. CONCLUSIONS: In Alberta, the rate of HA VRE-BSI has remained consistent, and our findings indicate that there has been no increase in the rate of rise of HA VRE-BSI in sites or units that discontinued screening for VRE, regardless of patient risk group.

Validating administrative data to identify complex surgical site infections following cardiac implantable electronic device implantation: a comparison of traditional methods and machine learning.

BACKGROUND: Cardiac implantable electronic device (CIED) surgical site infections (SSIs) have been outpacing the increases in implantation of these devices. While traditional surveillance of these SSIs by infection prevention and control would likely be the most accurate, this is not practical in many centers where resources are constrained. Therefore, we explored the validity of administrative data at identifying these SSIs. METHODS: We used a cohort of all patients with CIED implantation in Calgary, Alberta where traditional surveillance was done for infections from Jan 1, 2013 to December 31, 2019. We used this infection subgroup as our "gold standard" and then utilized various combinations of administrative data to determine which best optimized the sensitivity and specificity at identifying infection. We evaluated six approaches to identifying CIED infection using administrative data, which included four algorithms using International Classification of Diseases codes and/or Canadian Classification of Health Intervention codes, and two machine learning models. A secondary objective of our study was to assess if machine learning techniques with training of logistic regression models would outperform our pre-selected codes. RESULTS: We determined that all of the pre-selected algorithms performed well at identifying CIED infections but the machine learning model was able to produce the optimal method of identification with an area under the receiver operating characteristic curve (AUC) of 96.8%. The best performing pre-selected algorithm yielded an AUC of 94.6%. CONCLUSIONS: Our findings suggest that administrative data can be used to effectively identify CIED infections. While machine learning performed the most optimally, in centers with limited analytic capabilities a simpler algorithm of pre-selected codes also has excellent yield. This can be valuable for centers without traditional surveillance to follow trends in SSIs over time and identify when rates of infection are increasing. This can lead to enhanced interventions for prevention of SSIs.

Risk of transmission of respiratory viruses during aerosol-generating medical procedures (AGMPs) revisited in the COVID-19 pandemic: a systematic review.

BACKGROUND: In many jurisdictions healthcare workers (HCWs) are using respirators for aerosol-generating medical procedures (AGMPs) performed on adult and pediatric populations with all suspect/confirmed viral respiratory infections (VRIs). This systematic review assessed the risk of VRIs to HCWs in the presence of AGMPs, the role respirators versus medical/surgical masks have on reducing that risk, and if the risk to HCWs during AGMPs differed when caring for adult or pediatric patient populations. MAIN TEXT: We searched MEDLINE, EMBASE, Cochrane Central, Cochrane SR, CINAHL, COVID-19 specific resources, and MedRxiv for English and French articles from database inception to September 9, 2021. Independent reviewers screened abstracts using pre-defined criteria, reviewed full-text articles, selected relevant studies, abstracted data, and conducted quality assessments of all studies using the ROBINS-I risk of bias tool. Disagreements were resolved by consensus. Thirty-eight studies were included; 23 studies on COVID-19, 10 on SARS, and 5 on MERS/ influenza/other respiratory viruses. Two of the 16 studies which assessed associations found that HCWs were 1.7 to 2.5 times more likely to contract COVID-19 after exposure to AGMPs vs. not exposed to AGMPs. Eight studies reported statistically significant associations for nine specific AGMPs and transmission of SARS to HCWS. Intubation was consistently associated with an increased risk of SARS. HCWs were more likely (OR 2.05, 95% CI 1.2-3.4) to contract human coronaviruses when exposed to an AGMP in one study. There were no reported associations between AGMP exposure and transmission of influenza or in a single study on MERS. There was limited evidence supporting the use of a respirator over a medical/surgical mask during an AGMP to reduce the risk of viral transmission. One study described outcomes of HCWs exposed to a pediatric patient during intubation. CONCLUSION: Exposure to an AGMP may increase the risk of transmission of COVID-19, SARS, and human coronaviruses to HCWs, however the evidence base is heterogenous and prone to confounding, particularly related to COVID-19. There continues to be a significant research gap in the epidemiology of the risk of VRIs among HCWs during AGMPs, particularly for pediatric patients. Further evidence is needed regarding what constitutes an AGMP.

Antimicrobial use in Canadian acute-care hospitals: Findings from three national point-prevalence surveys between 2002 and 2017.

OBJECTIVES: The Canadian Nosocomial Infection Surveillance Program conducted point-prevalence surveys in acute-care hospitals in 2002, 2009, and 2017 to identify trends in antimicrobial use. METHODS: Eligible inpatients were identified from a 24-hour period in February of each survey year. Patients were eligible (1) if they were admitted for ≥48 hours or (2) if they had been admitted to the hospital within a month. Chart reviews were conducted. We calculated the prevalence of antimicrobial use as follows: patients receiving ≥1 antimicrobial during survey period per number of patients surveyed × 100%. RESULTS: In each survey, 28-47 hospitals participated. In 2002, 2,460 (36.5%; 95% CI, 35.3%-37.6%) of 6,747 surveyed patients received ≥1 antimicrobial. In 2009, 3,566 (40.1%, 95% CI, 39.0%-41.1%) of 8,902 patients received ≥1 antimicrobial. In 2017, 3,936 (39.6%, 95% CI, 38.7%-40.6%) of 9,929 patients received ≥1 antimicrobial. Among patients who received ≥1 antimicrobial, penicillin use increased 36.8% between 2002 and 2017, and third-generation cephalosporin use increased from 13.9% to 18.1% (P < .0001). Between 2002 and 2017, fluoroquinolone use decreased from 25.7% to 16.3% (P < .0001) and clindamycin use decreased from 25.7% to 16.3% (P < .0001) among patients who received ≥1 antimicrobial. Aminoglycoside use decreased from 8.8% to 2.4% (P < .0001) and metronidazole use decreased from 18.1% to 9.4% (P < .0001). Carbapenem use increased from 3.9% in 2002 to 6.1% in 2009 (P < .0001) and increased by 4.8% between 2009 and 2017 (P = .60). CONCLUSIONS: The prevalence of antimicrobial use increased between 2002 and 2009 and then stabilized between 2009 and 2017. These data provide important information for antimicrobial stewardship programs.

Whole Blood in Trauma Resuscitation: What Is the Real Cost?

INTRODUCTION: Whole blood (WB) has gained popularity in trauma resuscitation within the past 5 y. Previously, its civilian use was limited due to advances in blood component fractionation and fears of hemolysis and infectious disease transmission. Although there are studies and review articles on the efficacy of WB, the analysis of cost pertaining to the use of WB is limited. MATERIALS AND METHODS: We performed a retrospective 1:1 propensity-matched analysis of 280 subjects comparing trauma patients receiving resuscitation with blood component therapy (BCT) to those receiving WB plus BCT between January 2014 and July 2019. WB was used for patients who arrived in hemorrhagic shock with systolic blood pressure <90 mmHg due to either penetrating or blunt trauma. Endpoints included the number of units of WB, packed red blood cells (PRBCs), fresh frozen plasma (FFP), platelets, and cryoprecipitate each patient received. Institution costs for each component were compared in the form of price ratios. Comparisons were made using Wilcoxon rank-sum tests with a P value of ≤0.05 considered statistically significant. RESULTS: The use of WB was associated with a statistically significant decrease in the number of PRBCs used when compared to BCT. This holds true with the cost of PRBCs being lower among the WB group when the price is controlled. Similarly, a trend was found where FFP, platelets, and cryoprecipitate use and cost showed an absolute decrease between WB and BCT groups. The use of WB is associated with decreased total cost as well (P = 0.1660), although not statistically significant. CONCLUSIONS: Adding WB to BCT for trauma resuscitation was associated with lower red blood cell use and cost. A similar trend was found that absolute total cost and absolute cost of FFP, platelets, and cryoprecipitate use was lower when WB was added. WB wastage was minimized due to repurposing WB into PRBCs when WB lifespan ended.

Drug prescriptions and dementia incidence: a medication-wide association study of 17000 dementia cases among half a million participants.

BACKGROUND: Previous studies have suggested that some medications may influence dementia risk. We conducted a hypothesis-generating medication-wide association study to investigate systematically the association between all prescription medications and incident dementia. METHODS: We used a population-based cohort within the Secure Anonymised Information Linkage (SAIL) databank, comprising routinely-collected primary care, hospital admissions and mortality data from Wales, UK. We included all participants born after 1910 and registered with a SAIL general practice at ≤60 years old. Follow-up was from each participant's 60th birthday to the earliest of dementia diagnosis, deregistration from a SAIL general practice, death or the end of 2018. We considered participants exposed to a medication if they received ≥1 prescription for any of 744 medications before or during follow-up. We adjusted for sex, smoking and socioeconomic status. The outcome was any all-cause dementia code in primary care, hospital or mortality data during follow-up. We used Cox regression to calculate hazard ratios and Bonferroni-corrected p values. RESULTS: Of 551 344 participants, 16 998 (3%) developed dementia (median follow-up was 17 years for people who developed dementia, 10 years for those without dementia). Of 744 medications, 221 (30%) were associated with dementia. Of these, 217 (98%) were associated with increased dementia incidence, many clustering around certain indications. Four medications (all vaccines) were associated with a lower dementia incidence. CONCLUSIONS: Almost a third of medications were associated with dementia. The clustering of many drugs around certain indications may provide insights into early manifestations of dementia. We encourage further investigation of hypotheses generated by these results.

A comparison of surgical site infections following total hip replacement and total knee replacement surgeries identified by Infection Prevention and Control and the National Surgical Quality Improvement Program in Alberta, Canada.

OBJECTIVE: To understand how the different data collections methods of the Alberta Health Services Infection Prevention and Control Program (IPC) and the National Surgical Quality Improvement Program (NSQIP) are affecting reported rates of surgical site infections (SSIs) following total hip replacements (THRs) and total knee replacements (TKRs). DESIGN: Retrospective cohort study. SETTING: Four hospitals in Alberta, Canada. PATIENTS: Those with THR or TKR surgeries between September 1, 2015, and March 31, 2018. METHODS: Demographic information, complex SSIs reported by IPC and NSQIP were compared and then IPC and NSQIP data were matched with percent agreement and Cohen's κ calculated. Statistical analysis was performed for age, gender and complex SSIs. A P value <.05 was considered significant. RESULTS: In total, 7,549 IPC and 2,037 NSQIP patients were compared. The complex SSI rate for NSQIP was higher compared to IPC (THR: 1.19 vs 0.68 [P = .147]; TKR: 0.92 vs 0.80 [P = .682]). After matching, 7 SSIs were identified by both IPC and NSQIP; 3 were identified only by IPC, and 12 were identified only by NSQIP (positive agreement, 0.48; negative agreement, 1.0; κ = 0.48). CONCLUSIONS: Different approaches to monitor SSIs may lead to different results and trending patterns. NSQIP reports total SSI rates that are consistently higher than IPC. If systems are compared at any point in time, confidence on the data may be eroded. Stakeholders need to be aware of these variations and education provided to facilitate an understanding of differences and a consistent approach to SSI surveillance monitoring over time.

Effect of preoperative radiation on free flap outcomes for head and neck reconstruction: An updated systematic review and meta-analysis.

BACKGROUND: There is an ongoing debate about whether neoadjuvant radiation therapy is associated with higher rates of postoperative complications after head and neck reconstruction. Herle et al. conducted a systematic review in 2014 of 24 studies, finding higher complication rates in irradiated fields. We sought to perform an exhaustive updated systematic review and meta-analysis. METHODS: We conducted an updated systematic review of the literature, as outlined in our protocol, which was registered on PROSPERO. Databases included Medline, Embase, Cochrane Central, and Web of Science. There were no limits placed on the date range, place of publication, or origin. Exclusion criteria included patients less than 18 years of age, studies with less than 20 participants (n < 20), case studies, skull base reconstructions, and local tissue rearrangements. The combined results of the studies and relative risks (RR) were calculated. RESULTS: 53 studies were included for analysis, including 5,086 free flaps in an irradiated field, and 9,110 free flaps in a non-irradiated field. Of the 53 studies, 21 studies overlapped with those discussed in Herle et al.'s study, with a total of 32 additional studies. Neoadjuvant radiation was found to be a statistically significant risk factor for postoperative complications (RR 1.579, P < 0.001), total flap failure (RR, 1.565; P < 0.001), and fistula (RR, 1.810; P < 0.001). Our work reaffirmed the findings of the Herle et al. CONCLUSION: Preoperative radiation was associated with a statistically significant increase in the risk of total flap failure, fistula, and total complications but not partial flap failure. These high-morbidity complications must be taken into consideration when determining which patients should receive neoadjuvant radiation therapy.

Prevalence of antimicrobial-resistant organisms in smaller Canadian hospitals: Community, Rural, and Northern Acute Care Point Prevalence (CNAPP-19) Survey, 2019.

Background: The availability of national data on the prevalence of antimicrobial resistant infections in smaller, community, northern and rural acute care hospitals is limited. The objective of this article is to determine the prevalence of infections caused by selected antimicrobial-resistant organisms (AROs) in these smaller hospitals. Methods: A point prevalence survey was conducted by 55 hospitals between February and May 2019 and included representation from all 10 Canadian provinces. Eligible hospitals were those with 350 or fewer beds. Data were collected on hospital characteristics. De-identified patient data were collected on selected infections (pneumonia, urinary tract infections, bloodstream infections, skin/soft tissue infections, surgical site infections, and Clostridioides difficile infections) for selected AROs (methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococci, extended-spectrum ß-lactamase-producing organisms and carbapenemase-producing organisms). Data on antimicrobial prescribing and infection prevention and control precautions were also collected. Results: A total of 3,640 patients were included in the survey. Median patient age was 73 years, and 52.8% (n=1,925) were female. Selected infections were reported in 14.4% (n=524) of patients, of which 6.9% (n=36) were associated with an ARO infection. Infection prevention and control additional precautions were in place for 13.7% (n=500) of patients, of which half (51.0%, n=255) were due to an ARO. Approximately one third (35.2%, n=1,281) of patients had at least one antimicrobial prescribed. Conclusion: Antimicrobial-resistant organisms remain a serious threat to public health in Canada. The results of this survey warrant further investigation into AROs in smaller Canadian hospitals as a potential reservoir of antimicrobial resistance.

Effect of Daily Dosage of Morphine Milligram Equivalents on Free Flap Complications: A Single-Institution Retrospective Study.

INTRODUCTION: There appears to be an association between preoperative opioid use and postoperative complications. We sought to determine whether patients with a history of chronic opiate use (defined as 3 months or more of sustained use) prior to undergoing free flap surgery have higher rates of 30-day complications. METHODS: A retrospective review of patients undergoing free flaps from 2015 to 2020 was performed. Patient characteristics were analyzed, including daily preoperative dose of opiates, which were then converted to morphine milligram equivalents; intra-operative variables such as estimated blood loss and operating room time; and 30-day outcomes, including wound and flap complications, return to the operating room, and readmissions. RESULTS: One hundred fifty-five patients received 160 free flaps. Of these flaps, 50/160 (31%) were performed on patients with an opiate prescription for at least three months prior to surgery. Using multivariable analysis, morphine milligram equivalents, a surrogate for opioid dose, were significantly associated with flap complications (odds ratio (OR) 1.011, 95% confidence interval (CI) 1.003-1.020, p<0.01), partial flap loss (OR 1.010, 95% CI 1.003-1.019, p<0.01), and surgical site infections (OR 1.017, 95% CI 1.007-1.027, p<0.01). Additionally, estimated blood loss was associated with partial flap loss (OR 4.838, 95% CI 1.589-14.728, p<0.006), and operating room time was also associated with flap complications (OR 1.337, 95% CI 1.152-1.150, p<0.01). CONCLUSION: Chronic preoperative opioid use is common for free flap surgery, and according to our single-center experience, higher daily doses are a risk factor for flap complications and surgical site infections. These findings add to the growing body of evidence that opioid use is a modifiable risk factor that may increase surgical morbidity.

The use of laboratory-identified event surveillance to classify adverse outcomes due to Clostridioides difficile infection in Canadian long-term care facilities.

OBJECTIVE: Adverse outcomes following Clostridioides difficile infection (CDI) are not often reported for long-term care facility (LTCF) residents. We focused on the adverse outcomes due to CDI identified in Alberta LTCFs. METHODS: All positive Clostridioides difficile stool specimens identified by laboratory-identified (LabID) event surveillance in Alberta from 2011 to 2018, along with Alberta Continuing Care Information System, were used to define CDI in Alberta LTCFs. CDI cases were classified as long-term care onset, hospital onset, and community onset. Laboratory records were linked to provincial databases to analyze acute-care admissions and mortality within 30-day post CDI. Age, sex, case classification, episode, and operator type, were investigated using logistic regression. RESULTS: Overall, 902 CDI cases were identified in 762 LTCF residents. Of all CDI events, 860 (95.3%) were long-term care onset, 38 (4.2%) were hospital onset, and 4 (0.4%) were community onset. The CDI rate was 2.0 of 100,000 resident days. In total, 157 residents (20.6%) had 30-day all-cause mortality, 126 CDI cases (14.0%) had 30-day all-cause acute-care admissions. The 30-day all-cause mortality rate was significantly higher in residents aged >80 versus ≤80 years (24.9 vs 12.3 per 100 residents; P < .05). Residents aged >80 years, with hospital-onset CDI, and those staying in private or voluntary LTCFs were more likely to have 30-day all-cause acute-care admissions. CONCLUSIONS: The prevalence of CDI adverse outcomes is in LTCFs was found to be high using LabID event surveillance. Annual review of CDI adverse outcomes using LabID event can minimize the burden of surveillance and standardize the process across all Alberta LTCFs.

Clostridioides difficile infections in Alberta: The validity of administrative data using ICD-10 diagnostic codes for CDI surveillance versus clinical infection surveillance.

BACKGROUND: Clostridioides difficile infection (CDI) is one of the most common health care-associated infections. This study assessed the validity of the Discharge Abstract Database (DAD) compared to a traditional clinical surveillance method for identifying CDI. METHODS: Retrospective analysis of all DAD records with International Statistical Classification of Diseases and Related Health Problems 10th Revision (ie, ICD-10) diagnostic code A04.7 (enterocolitis due to CDI) between April 2015 and March 2019 were compared to a clinical dataset of positive inpatient CDI for all acute care facilities in Alberta, Canada. Sensitivity and positive predictive values were calculated using R version 3.6.0. RESULTS: The DAD had a sensitivity of 85.0% (95% confidence interval: 84.1%-85.8%) and a positive predictive value of 80.0% (95% confidence interval: 79.2%-80.0%). The CDI rate per 1,000 admissions over the study period was 28% higher in the DAD compared to Infection Prevention and Control surveillance. DISCUSSION: The DAD does not distinguish symptomatic cases from asymptomatic cases and so indicators to identify symptomatic disease would need to be applied, potentially through a linkage to antibiotic treatment orders available in patient management systems. CONCLUSIONS: The DAD is moderately sensitive for identifying symptomatic CDI cases in Alberta, Canada and caution should be applied when interpreting rates based on administrative data.

Implications for Telemedicine for Surgery Patients After COVID-19: Survey of Patient and Provider Experiences.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has expanded the utilization of telemedicine in clinical practice to minimize potential risks to both patients and providers. We aim to describe the perception of telemedicine by both surgical patients and providers to understand the preferences for future incorporation in future surgical practice. METHODS: An anonymous survey was administered to providers that transitioned clinic visits to telemedicine encounters since the start of the COVID-19 pandemic. In the second part of the study, patients who underwent video telemedicine appointments answered survey questions via telephone. RESULTS: Twenty-six out of 36 (72.7%) providers responded. Over 75% reported that they could effectively communicate with patients over telemedicine. Six (23.1%) reported that they could adequately assess surgical sites. Of 361 patients, 187 consented to the study (consent rate 51.8%). Among patients, the most common result to choose a telemedicine appointment was to avoid the risk of COVID-19 transmission (84, 44.9%), though the minority reported that they would choose telemedicine after the pandemic (64, 34.2%). Those patients who would choose an in-person visit were more likely to have a higher Charlson Comorbidity Score, body mass index, and use friends or family for transportation. In open-ended feedback, patients suggested that telemedicine would be better suited for long-term follow-up rather than the immediate postoperative setting. CONCLUSIONS: Patients and providers reported a high degree of satisfaction using telemedicine during the COVID-19 pandemic but noted concern with limited physical examinations. Telemedicine may be suited for preoperative evaluation and medium-term and long-term postoperative follow-up for surgical patients.

Accuracy of identifying incident stroke cases from linked health care data in UK Biobank.

OBJECTIVE: In UK Biobank (UKB), a large population-based prospective study, cases of many diseases are ascertained through linkage to routinely collected, coded national health datasets. We assessed the accuracy of these for identifying incident strokes. METHODS: In a regional UKB subpopulation (n = 17,249), we identified all participants with ≥1 code signifying a first stroke after recruitment (incident stroke-coded cases) in linked hospital admission, primary care, or death record data. Stroke physicians reviewed their full electronic patient records (EPRs) and generated reference standard diagnoses. We evaluated the number and proportion of cases that were true-positives (i.e., positive predictive value [PPV]) for all codes combined and by code source and type. RESULTS: Of 232 incident stroke-coded cases, 97% had EPR information available. Data sources were 30% hospital admission only, 39% primary care only, 28% hospital and primary care, and 3% death records only. While 42% of cases were coded as unspecified stroke type, review of EPRs enabled a pathologic type to be assigned in >99%. PPVs (95% confidence intervals) were 79% (73%-84%) for any stroke (89% for hospital admission codes, 80% for primary care codes) and 83% (74%-90%) for ischemic stroke. PPVs for small numbers of death record and hemorrhagic stroke codes were low but imprecise. CONCLUSIONS: Stroke and ischemic stroke cases in UKB can be ascertained through linked health datasets with sufficient accuracy for many research studies. Further work is needed to understand the accuracy of death record and hemorrhagic stroke codes and to develop scalable approaches for better identifying stroke types.

Malignant Phyllodes Tumor in an Adolescent Female: A Rare Case Report and Review of the Literature.

Primary breast neoplasms are rare in adolescent females, most of which are benign. Phyllodes tumors constitute a remarkably small subset of breast neoplasms (0.3-0.9%) with malignant phyllodes tumors being even more uncommon. Malignant phyllodes tumors tend to progress rapidly though only 1.5% metastasize. They are also associated with a higher rate of recurrence than their benign counterparts, underlying the importance of adequate surgical margins. It is therefore imperative to be able to identify these tumors early allowing for prompt resection and close follow-up. Here, we present the rare case of a 17-year-old female presenting with a rapidly enlarging breast mass, which was ultimately found to be a malignant phyllodes tumor. We further performed a review of the literature to highlight only 22 other cases reported in adolescent females.