Effect of a Patient Portal Reminder Message After No-Show on Appointment Reattendance in Ophthalmology: A Randomized Clinical Trial.

PURPOSE: To assess the efficacy of electronic health record (EHR) messaging for re-engaging patients with ophthalmology care after a missed appointment. DESIGN: Prospective, randomized clinical trial. METHODS: The study setting was an academic ophthalmology department. The patient population comprised of return patients age 18 years or older with an appointment "no show," or missed appointment. Over 2 phases of recruitment, 362 patients with an active patient portal in the EHR were selected consecutively each business day. Patients were randomized using a web-based tool to receive a reminder to reschedule via a standard mailed letter only (control) or the mailed letter plus an electronic message through the EHR within 1 business day of the missed appointment (intervention). Reengagement with eye care was defined as attendance of a rescheduled appointment within 30 days of the no-show visit. Patient charts were reviewed for demographic and clinical data. RESULTS: The average age of recruited patients was 59.9 years, just under half of the sample was male (42.5%, 154/362), and most patients were White (56.9%, 206/362) or Black (36.2%, 131/362). Patients were most commonly recruited from the retina service (39.2%, 142/362) followed by the glaucoma service (29.3%, 106/362). Many patients in this study had previous no-show appointments, with an average no-show rate of 18.8% out of all scheduled visits across our health system. In total, 22.2% (42/189) of patients in the intervention group attended a follow-up appointment within 30 days of their no-show visit compared to 11.6% (20/173) of the control group (OR, 2.186; 95% CI, 1.225-3.898; P = .008). When including only the 74 patients in the intervention group who read the intervention message in the patient portal, 28.4% (21/74) attended a follow-up compared to 11.6% (20/173) of the control group (P = .001). CONCLUSIONS: EHR-based reminder messages sent within a business day of a missed appointment may promote re-engagement in ophthalmology care after appointment no-show.

Subepidermal calcified nodule presenting as a cutaneous horn: two cases and a review of the literature.

Subepidermal calcified nodules are an uncommon subtype of idiopathic calcinosis cutis. Morphologically, this entity typically present as a single, well-circumscribed, white-yellow nodule. Based on clinical appearance alone, subepidermal calcified nodules are frequently misdiagnosed and often requires histological confirmation. We describe two cases of subepidermal calcified nodules presenting atypically as cutaneous horns. Subepidermal calcified nodules presenting as a cutaneous horn has rarely been reported; on review, there are fewer than 10 such cases have been described within the past 30 years. The cases described here illustrate the clinical variety and should increase awareness of subepidermal calcified nodules presented.

Cross-sector collaboration in Project Catalyst: Creating state partnerships to address the health impact of intimate partner violence.

Intimate Partner Violence and Human Trafficking are major public health problems with myriad health and social consequences. This paper describes a federal initiative in the United States to formalize cross-sector collaborations at the state-level and encourage practice and policy changes intended to promote prevention and improve health and safety outcomes for Intimate Partner Violence/Human Trafficking (IPV/HT) survivors. Project Catalyst Phases I and II (2017-2019) engaged six state leadership teams, consisting of leaders from each state's Primary Care Association, Department of Health, and Domestic Violence Coalition. Leadership teams received training and funding to disseminate information on trauma-informed practices to health centers and integrate IPV/HT considerations into state-level initiatives. At the beginning and end of Project Catalyst, participants completed surveys assessing the status of their collaboration and project goals (e.g., number of state initiatives involving IPV/HT, number of people trained). All domains of collaboration increased from baseline to project end. Largest improvements were seen in 'Communication' and 'Process & Structure,' both of which increased by more than 20% over the course of the project. 'Purpose' and 'Membership Characteristics' increased by 10% and 13%, respectively. Total collaboration scores increased 17% overall. Each state made substantial efforts to integrate and improve responses to IPV/HT in community health centers and domestic violence programs, and integrated IPV/HT response into state-level initiatives. Project Catalyst was successful in facilitating formalized collaborations within state leadership teams, contributing to practice and policy changes intended to improve health and safety for IPV/HT survivors.

Review on the Safety and Efficacy of Brolucizumab for Neovascular Age-Related Macular Degeneration From Major Studies and Real-World Data.

Frequent antivascular endothelial growth factor injections in neovascular age-related macular degeneration (nAMD) often lead to poor compliance and suboptimal outcomes. A longer-acting agent has been a pressing unmet need until recently. Brolucizumab, an antivascular endothelial growth factor agent, is a single-chain antibody fragment approved by the US Food and Drug Administration (FDA) on October 8, 2019, for treating nAMD. It delivers more molecules at equivalent volumes of aflibercept, thus achieving a longer-lasting effect. We reviewed literature published in English between January 2016 and October 2022 from MEDLINE, PubMed, Cochrane database, Embase, and Google scholar using the keywords: "Brolucizumab, real-world data, intraocular inflammation (IOI), safety, and efficacy". Brolucizumab showed reduced injection frequency, better anatomic outcomes, and noninferior vision gains compared with aflibercept in HAWK and HARRIER studies. However, post hoc studies on brolucizumab revealed a higher-than-expected incidence of IOI, leading to the early termination of 3 studies: MERLIN, RAPTOR, and RAVEN for nAMD, branch retinal vein occlusion, and central retinal vein occlusion, respectively. Contrastingly real-world data showed encouraging outcomes in terms of fewer IOI cases. The subsequent amendment of the treatment protocol resulted in reduced IOI. Thereafter US FDA approved its use in diabetic macular edema on June 1, 2022. Based on major studies and real-world data, this review shows that brolucizumab is effective for treating naive and refractory nAMD. The risk of IOI is acceptable and manageable, but proper preinjection screening and high-vigilance care of IOI are needed. More studies are warranted to evaluate further the incidence, best prevention, and treatment measures for IOI.

2018 Infectious Diseases Society of America Clinical Practice Guideline for the Management of Outpatient Parenteral Antimicrobial Therapy.

A panel of experts was convened by the Infectious Diseases Society of America to update the 2004 clinical practice guideline on outpatient parenteral antimicrobial therapy (OPAT) [1]. This guideline is intended to provide insight for healthcare professionals who prescribe and oversee the provision of OPAT. It considers various patient features, infusion catheter issues, monitoring questions, and antimicrobial stewardship concerns. It does not offer recommendations on the treatment of specific infections. The reader is referred to disease- or organism-specific guidelines for such support.

2018 Infectious Diseases Society of America Clinical Practice Guideline for the Management of Outpatient Parenteral Antimicrobial Therapy.

A panel of experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2004 clinical practice guideline on outpatient parenteral antimicrobial therapy (OPAT) [1]. This guideline is intended to provide insight for healthcare professionals who prescribe and oversee the provision of OPAT. It considers various patient features, infusion catheter issues, monitoring questions, and antimicrobial stewardship concerns. It does not offer recommendations on the treatment of specific infections. The reader is referred to disease- or organism-specific guidelines for such support.

Electrochemically Modulated Nitric Oxide Release From Flexible Silicone Rubber Patch: Antimicrobial Activity For Potential Wound Healing Applications.

Herein, we report a novel design and the antimicrobial efficacy of a flexible nitric oxide (NO) releasing patch for potential wound healing applications. The compact sized polydimethylsiloxane (PDMS) planar patch generates NO via electrochemical reduction of nitrite ions mediated by a copper(II)-ligand catalyst using a portable power system and an internal gold coated stainless steel mesh working electrode. Patches are fabricated via soft lithography and 3-D printing. The devices can continuously release NO over 4 days and exhibit potent bactericidal effects on both Escherichia coli and Staphylococcus aureus. The device may provide an effective, safe, and less costly alternative for treating chronic wounds.

Multi-scale analysis of neural activity in humans: Implications for micro-scale electrocorticography.

OBJECTIVE: Electrocorticography grids have been used to study and diagnose neural pathophysiology for over 50 years, and recently have been used for various neural prosthetic applications. Here we provide evidence that micro-scale electrodes are better suited for studying cortical pathology and function, and for implementing neural prostheses. METHODS: This work compares dynamics in space, time, and frequency of cortical field potentials recorded by three types of electrodes: electrocorticographic (ECoG) electrodes, non-penetrating micro-ECoG (µECoG) electrodes that use microelectrodes and have tighter interelectrode spacing; and penetrating microelectrodes (MEA) that penetrate the cortex to record single- or multiunit activity (SUA or MUA) and local field potentials (LFP). RESULTS: While the finest spatial scales are found in LFPs recorded intracortically, we found that LFP recorded from µECoG electrodes demonstrate scales of linear similarity (i.e., correlation, coherence, and phase) closer to the intracortical electrodes than the clinical ECoG electrodes. CONCLUSIONS: We conclude that LFPs can be recorded intracortically and epicortically at finer scales than clinical ECoG electrodes are capable of capturing. SIGNIFICANCE: Recorded with appropriately scaled electrodes and grids, field potentials expose a more detailed representation of cortical network activity, enabling advanced analyses of cortical pathology and demanding applications such as brain-computer interfaces.

Clinical experience with daptomycin for outpatient parenteral antibiotic therapy.

The investigation reviewed the experience of a single institution using outpatient parenteral antibiotic therapy with daptomycin as monotherapy. After institutional review board approval, patients discharged from Baystate Medical Center on daptomycin as monotherapy were investigated for clinical outcome. The authors present their data descriptively comparing the success rates of daptomycin therapy according to clinical factors. Thirty-three persons were included, and all of them survived during the therapy. All patients received 6 to 8 mg/kg/day of daptomycin administered over 30 minutes, were treated between 2 to 8 weeks and received 74% to 90% of therapy after hospital discharge. Ninety-four percent of patients studied were clinically cured. Thirty-three percent of patients with osteomyelitis required surgery for cure, but all successfully completed treatment. Twelve percent had complications that did not alter treatment course. No elevations of creatine phosphokinase were noted; however, this was inconsistently checked. These results indicate that outpatient parenteral antibiotic therapy using daptomycin is a suitable agent for patients with selected Gram-positive bacterial infections. After a relatively brief hospitalization, the majority of patients can complete at least three fourths of total treatment duration outside of the hospital.

Management of infective endocarditis in outpatients: clinical experience with outpatient parenteral antibiotic therapy.

BACKGROUND: There is limited experience in treating infective endocarditis (IE) with outpatient parenteral antibiotic therapy (OPAT). METHODS: Following institutional review board (IRB) approval, patients discharged from Baystate Medical Center with IE documented by modified Duke criteria treated with OPAT were identified. Data obtained included organisms implicated, indications of clinical stability, percentage of total therapy rendered after hospitalization, and one year follow up. RESULTS: Forty-three patients met criteria. Thirty-five percent were infected with staphylococci; 38% harbored streptococci or enterococci. Native valves and left-sided valves each constituted approximately 75% of total. All patients received >4 weeks of therapy, with >66% rendered after hospital discharge A median of 7 days of hemodynamic stability and negative blood cultures occurred prior to discharge. After one year, no patients died from IE. Twenty-three percent were hospitalized during OPAT from intravenous catheter, antibiotic, or other complications, but none for direct complications of IE. CONCLUSIONS: OPAT for IE can be safely utilized, and at least 66% of care can be given in this manner. Our investigation provides enhanced data on employing OPAT for IE caused by staphylococci, left-sided infections, and also provides outcomes after one year after treatment.

Implantable microelectrode arrays for simultaneous electrophysiological and neurochemical recordings.

Implantable microfabricated microelectrode arrays represent a versatile and powerful tool to record electrophysiological activity across multiple spatial locations in the brain. Spikes and field potentials, however, correspond to only a fraction of the physiological information available at the neural interface. In urethane-anesthetized rats, microfabricated microelectrode arrays were implanted acutely for simultaneous recording of striatal local field potentials, spikes, and electrically evoked dopamine overflow on the same spatiotemporal scale. During these multi-modal recordings we observed (1) that the amperometric method used to detect dopamine did not significantly influence electrophysiological activity, (2) that electrical stimulation in the medial forebrain bundle (MFB) region resulted in electrochemically transduced dopamine transients in the striatum that were spatially heterogeneous within at least 200 microm, and (3) following MFB stimulation, dopamine levels and electrophysiological activity within the striatum exhibited similar temporal profiles. These neural probes are capable of incorporating customized microelectrode geometries and configurations, which may be useful for examining specific spatiotemporal relationships between electrical and chemical signaling in the brain.

Complications of viral influenza.

Viral influenza is a seasonal infection associated with significant morbidity and mortality. In the United States more than 35,000 deaths and 200,000 hospitalizations due to influenza occur annually, and the number is increasing. Children aged less than 1 year and adults aged more than 65 years, pregnant woman, and people of any age with comorbid illnesses are at highest risk. Annual vaccination is the cornerstone of prevention, but some older patients may derive less benefit from immunization than otherwise fit individuals. If started promptly, antiviral medications may reduce complications of acute influenza, but increasing resistance to amantadine and perhaps neuraminidase inhibitors underscores the need for novel prevention and treatment strategies. Pulmonary complications of influenza are most common and include primary influenza and secondary bacterial infection. Either may cause pneumonia, and each has a unique clinical presentation and pathologic basis. Staphylococcus aureus, including methicillin-resistant strains, is an important cause of secondary bacterial pneumonia with high mortality. During influenza season, treatment of pneumonia should include empiric coverage for this pathogen. Neuromuscular and cardiac complications are unusual but may manifest in persons of any age.

Antibiotic adverse reactions and drug interactions.

When contemplating antibiotic use, intensivists must consider possible beneficial and harmful drug interactions. After antibiotics are instituted, adverse reactions must be anticipated. Acute illness, comorbidities, and concurrent medications affect the presentation and management of antibiotic-related adverse events. Intensivists should use the fewest possible antibiotics, carefully choosing agents that maximize antimicrobial activity and minimize potential drug interactions and adverse reactions.

Glass nanopore-based ion-selective electrodes.

Glass nanopore-based all-solid-state ion-selective electrodes (ISEs) have been developed to probe the distribution of ionic species at micro- or submicrometer-length scales, e.g., mapping of ion flux through micrometer-sized pores. The all-solid-state ISE was fabricated by sealing a conically etched platinum wire (d = 25-microm; radius of etched tip <10 nm) into a soda lime glass capillary. A Pt disk was exposed by gentle polishing the glass and the disk etched to form a conical pore of submicrometer dimension (radius < approximately 500 nm; depth < approximately 30 microm). Ag was electroplated on the Pt electrode in the pore and gently chloridated to obtain a AgCl/Ag layer within the pore. The AgCl/Ag layer-coated ISE was used as a highly selective Cl- probe in scanning electrochemical microscope experiments to map the ion flux through a micropore. The same ISE was also used as the base transducer of the neutral carrier-doped solvent polymeric membrane. The optimized polymer membranes used for the glass nanopore-based all-solid-state ISE require a higher ratio of plasticizer/polymer (9/1) compared to those for conventional ISE (2/1). An ISE based on deposition of an IrO2 layer at the base of a glass nanopore electrode exhibited a highly sensitive response (79.7 +/- 2.3 mV/pH) to variations in pH and could be used for approximately 3 weeks.

Impact of mandatory inpatient infectious disease consultation on outpatient parenteral antibiotic therapy.

BACKGROUND: Outpatient parenteral antibiotic therapy (OPAT) has had an important impact on infections historically requiring prolonged intravenous antibiotic treatment. Within the past decade, new antibiotics with oral/intravenous bioequivalence, plus recent data on infection management, have increased the potential role of the Infectious Disease (ID) consultant for OPAT. METHODS: We studied the impact of mandatory ID consultation on the use and outcomes of OPAT in patients initially hospitalized. The study was approved by the Institutional Review Board and the Executive Committee of the Medical Staff of Baystate Medical Center. Patients older than 18 years of age being considered for discharge to home on OPAT were identified, primarily through discharge planning. Formal ID consultation was performed to determine both need for OPAT and a variety of issues regarding antibiotic choice. Thirty-day telephone follow-up determined outcomes. Data regarding demographics, outcomes, and costs were analyzed. RESULTS: Forty-four patients received mandatory ID consultation, 39 (88.6%) of whom had some change in antibiotic recommendations. Seventeen (38.6%) were discharged on oral antibiotics, 1 (2.3%) had antibiotics discontinued, 13 (29.6%) had a change in parenteral antibiotic, 5 (11.4%) had a change in antibiotic dose, and 3 (6.8%) had a change in antibiotic duration. Follow-up demonstrated a single rehospitalization for unrelated issues. The total cost savings were 33,667.00 US dollars, approximately 760.00 US dollars per patient. Charges of consults were approximately 11,970.00 US dollars, still resulting in savings of close to 21,700.00 US dollars, or almost 500.00 US dollars per patient. CONCLUSIONS: Mandatory ID consultation resulted in substantial cost savings and excellent outcomes.

Surgical site infections in cardiac surgery: an 11-year perspective.

BACKGROUND: A surgical site infection (SSI) develops in 2% to 5% of patients undergoing operation. We report SSI surveillance at Baystate Medical Center, Springfield, Mass, in coronary artery bypass operation between 1991 and 2001, and demonstrate a substantial decline in SSI rates accomplished with use of multiple intervention strategies. METHODS: Infection documentation used Centers for Disease Control and Prevention (CDC) criteria and a postdischarge questionnaire. Infections were stratified by risk class. Strategies used to lower SSI rates included active surveillance and provision of authenticated SSI rate plus surgeon-specific rates. Interventions included outbreak analyses and targeted nasal mupirocin plus chlorhexidine showering. RESULTS: The rate of coronary artery bypass-related SSIs declined from >8% to <2%, comparing extremely favorably with CDC national data. Percentage of infections documented by postdischarge questionnaire was variable and did not change during the study period. Most SSIs were at the harvest site. Routine implementation of nasal mupirocin plus chlorhexidine preoperative showering effectively disrupted an outbreak of Staphylococcus aureus, and statistically decreased rates of postoperative infections with this organism. CONCLUSION: Regular provision of authenticated and verified data, use of postdischarge questionnaires, and careful attention to adverse trends and outbreaks with appropriate actions can substantially decrease rates of infections in coronary artery bypass operation.