Successful modeling of long term outcomes in end-stage renal disease patients undergoing percutaneous coronary intervention with drug-eluting stents.

OBJECTIVES: The objective of this study is to identify and model risk factors for major adverse cardiac events (MACE) and all-cause mortality among patients with ESRD treated with PCI using DES. BACKGROUND: Patients with end-stage renal disease (ESRD) have poor long-term outcomes after percutaneous coronary intervention (PCI) compared with non-ESRD patients. However, there is a paucity of literature regarding risk factors associated with outcomes of ESRD patients after PCI with drug-eluding stents (DES). METHODS: This retrospective cohort study includes all patients with ESRD who underwent first-time PCI with DES at a single, high-volume hospital between 1/1/2005 and 12/31/2015, with follow-up through 9/1/2019. Primary outcomes were MACE (cardiac death, myocardial infarction, or unplanned revascularization) and all-cause mortality. RESULTS: Five-year MACE was 83.0% and five-year morality was 77.9% in patients with ESRD (n = 285). Among ESRD patients, factors independently associated with MACE were C-reactive peptide level, SYNTAX score, peripheral vascular occlusive disease, hemoglobin, and treatment of a restenotic lesion (c-index = 0.66). Factors independently associated with mortality in ESRD patients were age, SYNTAX score, non-use of statins at baseline, insulin-dependent diabetes, chronic obstructive pulmonary disease (COPD), peripheral vascular occlusive disease, and platelet count (c-index = 0.65). CONCLUSIONS: Despite relatively poor 1-and 5-year outcomes among ESRD patients after PCI, risk of MACE and mortality among this cohort can be successfully modelled, which meaningfully informs clinicians regarding management of ESRD patients with coronary artery disease (CAD). Further investigations are necessary to determine whether or not outcomes might be improved through risk profile modification.

Real-time polymerase chain reaction (PCR) cycle threshold and Clostridioides difficile infection outcomes.

OBJECTIVE: Clostridioides difficile infection (CDI) causes significant morbidity and mortality; however, the diagnosis of CDI remains controversial. The primary aim of our study was to evaluate the association of polymerase chain reaction (PCR) cycle threshold (Ct) values with CDI disease severity, recurrence, and mortality among adult patients with CDI. DESIGN: Retrospective cohort study. SETTING: Single tertiary-care hospital. PATIENTS: Adult patients diagnosed with hospital-onset, healthcare facility-associated CDI from June 2014 to September 2015. METHODS: We performed a retrospective chart review of included patients. Univariate and multivariable logistic regression methods were used to evaluate the association between Ct values and CDI severity, 8-week recurrence, and 30-day mortality. RESULTS: Among 318 included patients, 51% were male and the mean age was 62 years; ~32% of the patients developed severe CDI and 11% developed severe-complicated CDI. The 30-day all-cause mortality rate was 11% and the 8-week recurrence rate was 9.5%. The overall mean Ct value was 32.9 (range, 23-40). Multivariable analyses showed that lower values of PCR Ct were associated with increased odds of 30-day morality (odds ratio [OR] 0.83; 95% confidence interval [CI], 0.72-0.96) but were not independently associated with CDI severity (OR, 0.99; 95% CI, 0.90-1.09) or recurrence (OR, 0.88; 95% CI, 0.77-1.00). CONCLUSIONS: Our findings suggest that PCR Ct values at the time of diagnosis may have a limited predictive value and utility in clinical decision making for inpatients with CDI. Larger, prospective studies across different patient populations are needed to confirm our findings.

End-stage renal disease as an independent risk factor for in-hospital mortality after coronary drug-eluting stenting: Understanding and modeling the risk.

OBJECTIVES: We sought to compare in-hospital outcomes between patients with and without end-stage renal disease (ESRD) undergoing coronary drug-eluting stent (DES) placement and to model risk of in-hospital adverse postpercutaneous coronary intervention (PCI) events in ESRD patients. BACKGROUND: The effect of ESRD on the risk of in-hospital complications after DES PCI is relatively unclear, as is the ability to prospectively stratify risk in this population. METHODS: Consecutive patients undergoing first-time DES between April 1, 2003 and June 30, 2018 at a single tertiary care hospital were included in a prospective registry. Outcomes in those with ESRD were compared to those without ESRD. The primary endpoint was in-hospital all-cause mortality; secondary endpoints included in-hospital major adverse cardiac events (MACE)-defined as cardiac death, myocardial infarction, or unplanned revascularization-and major bleeding. Multivariate logistic regression modeling was used to identify factors associated with each outcome and to generate risk scores. RESULTS: Among 18,134 patients in the study population, 382 (2.1%) had ESRD. ESRD was associated with increased risk of in-hospital mortality (7.1 vs. 2.9%, p < .001), in-hospital MACE (6.3 vs. 2.1%, p < .001), and major bleeding (12.0 vs. 2.6%, p < .001). After multivariable risk adjustment, ESRD was independently associated with in-hospital mortality (odds ratio: 1.83, 95% confidence interval: 1.04-3.23, p = .04) but not MACE or major bleeding. Among patients with ESRD, risks of MACE and major bleeding were successfully modeled (c-statistics = .72 and .85, respectively). CONCLUSIONS: ESRD is independently associated with increased risk of in-hospital mortality after coronary DES. Future studies are necessary to validate risk models derived to identify high-risk ESRD patients.

The Impact of Clinical Decision Support Alerts on Clostridioides difficile Testing: A Systematic Review.

BACKGROUND: Several studies have investigated the utility of electronic decision support alerts in diagnostic stewardship for Clostridioides difficile infection (CDI). However, it is unclear if alerts are effective in reducing inappropriate CDI testing and/or CDI rates. The aim of this systematic review was to determine if alerts related to CDI diagnostic stewardship are effective at reducing inappropriate CDI testing volume and CDI rates among hospitalized adult patients. METHODS: We searched Ovid Medline and 5 other databases for original studies evaluating the association between alerts for CDI diagnosis and CDI testing volume and/or CDI rate. Two investigators independently extracted data on study characteristics, study design, alert triggers, cointerventions, and study outcomes. RESULTS: Eleven studies met criteria for inclusion. Studies varied significantly in alert triggers and in study outcomes. Six of 11 studies demonstrated a statistically significant decrease in CDI testing volume, 6 of 6 studies evaluating appropriateness of CDI testing found a significant reduction in the proportion of inappropriate testing, and 4 of 7 studies measuring CDI rate demonstrated a significant decrease in the CDI rate in the postintervention vs preintervention period. The magnitude of the increase in appropriate CDI testing varied, with some studies reporting an increase with minimal clinical significance. CONCLUSIONS: The use of electronic alerts for diagnostic stewardship for C. difficile was associated with reductions in CDI testing, the proportion of inappropriate CDI testing, and rates of CDI in most studies. However, broader concerns related to alerts remain understudied, including unintended adverse consequences and alert fatigue.

Can an Academic RVU Model Balance the Clinical and Research Challenges in Surgery?

OBJECTIVE: The purpose of this study is to identify perceptions of academic surgeons regarding academic productivity and assess its relationship to clinical productivity. We hypothesized that these perceptions would vary based on respondent characteristics including clinical activity and leadership roles. DESIGN: This retrospective, survey-based study was performed from August 26, 2019 to September 26, 2019. SETTING: The setting was academic surgical departments across the US. PARTICIPANTS: The survey instrument was administered to faculty members of the Association of Program Directors in Surgery. A total of 105 academic surgeons responded. RESULTS: Most respondents were Program Directors (59%) of general surgery programs. Of the participants, 30% identified as Professor, 36% as Associate Professor, and 15% as Assistant Professor. Respondents agreed that multiple academic pursuits or factors should count towards academic productivity including the following (in descending order): completing a first-authored manuscript (98.8%), completing a senior-authored manuscript (97.7%), chairing a national committee (94.1%), serving on a national committee (88.2%), completing a second-authored manuscript (88.0%), completing a first lecture (83.7%), completing a middle-authored manuscript (71.8%), completing a lecture (whether or not repeated) (70.9%), impact factor of journal (60.7%), and attendance at grand rounds (57.0%). Perspectives did not vary significantly based on surgeon demographics, clinical setting, or leadership role (p > 0.05). CONCLUSIONS: Perceptions regarding what constitutes academic productivity and merit a reduction in clinical expectation are remarkably similar across multiple surgeon characteristics including demographics, academic title, leadership role, and practice environment.

Monitoring the effectiveness of daily cleaning practices in an intensive care unit (ICU) setting using an adenosine triphosphate (ATP) bioluminescence assay.

BACKGROUND: The degree to which daily intensive care unit (ICU) cleaning practices impacts bacterial burden is controversial. The study aimed to assess the utility of using adenosine triphosphate (ATP) bioluminescence assays for monitoring effectiveness of daily cleaning in ICU environments. METHODS: We sampled 364 total samples from 57 patient rooms and 18 common areas in 3 medical ICUs over 12 weeks, before and after routine daily cleaning. Endpoints were ATP levels (relative light units, RLU) and bacterial bioburden (colony forming units, CFU). RESULTS: High-touch surfaces in ICU patient rooms and common areas were contaminated before and after cleaning. Routine cleaning significantly reduced bacterial burden in patient rooms (0.14 log10 CFU reduction, P = .008; 0.21 log10 RLU reduction, P < .001) and in ICU common areas (1.18 log10 CFU reduction, P < .001; 0.72 log10 RLU reduction, P < .001). Among sites with colony counts >20 CFUs, the proportion of sites with ATP readings >250 RLU was significantly higher than those with ATP readings ≤250 RLU (90.0% vs 10.0%, P < .05). CONCLUSION: Routine cleaning significantly reduced bacterial burden on ICU environment surfaces. Although not an alternative to culture methods, ATP assays may be a useful technique to provide rapid feedback on surface cleanliness in ICU settings.

Perceptions of Patients, Health Care Workers, and Environmental Services Staff Regarding Ultraviolet Light Room Decontamination Devices.

BACKGROUND: Mobile ultraviolet C (UV-C) room decontamination devices are widely used in health care facilities; however, there is limited information on the perceptions of patients, health care workers (HCWs), and environmental services staff (EVS-staff) regarding their use for environmental decontamination. METHODS: An anonymous questionnaire was administered to participants in 4 medical/surgical units of a tertiary care hospital where UV-C devices were deployed for a 6-month period. Survey questions assessed perceptions regarding the importance of environmental disinfection, effectiveness of UV-C decontamination, willingness to delay hospital admission in order to use UV-C, and safety of UV-C devices. RESULTS: Questionnaires were completed by 102 patients, 130 HCWs, and 47 EVS-staff. All of the HCWs and EVS-staff and 99% of the patients agreed that environmental disinfection is important to reduce the risk of exposure from contaminated surfaces. Ninety-eight percent of the EVS-staff, 89% of the HCWs, and 96% of the patients felt that the use of UV-C as an adjunct to routine cleaning increased confidence that rooms are clean. Ninety-four percent of the EVS-staff, 85% of the HCWs, and 90% of the patients expressed a willingness to delay being admitted to a room in order to have UV-C decontamination completed. Seventy-nine percent of the EVS-staff, 76% of the HCWs, and 86% of the patients had no concerns about the safety of UV-C devices. CONCLUSIONS: Patients, HCWs, and EVS-staff agreed that environmental disinfection is important and that UV-C devices are efficacious and safe. Educational tools are needed to allay safety concerns expressed by a minority of HCWs and EVS-staff.

Effectiveness of daily chlorhexidine bathing for reducing gram-negative infections: A meta-analysis.

OBJECTIVE: Multiple studies have demonstrated that daily chlorhexidine gluconate (CHG) bathing is associated with a significant reduction in infections caused by gram-positive pathogens. However, there are limited data on the effectiveness of daily CHG bathing on gram-negative infections. The aim of this study was to determine whether daily CHG bathing is effective in reducing the rate of gram-negative infections in adult intensive care unit (ICU) patients. DESIGN: We searched MEDLINE and 3 other databases for original studies comparing daily bathing with and without CHG. Two investigators extracted data independently on baseline characteristics, study design, form and concentration of CHG, incidence, and outcomes related to gram-negative infections. Data were combined using a random-effects model and pooled relative risk ratios (RRs), and 95% confidence intervals (CIs) were derived. RESULTS: In total, 15 studies (n = 34,895 patients) met inclusion criteria. Daily CHG bathing was not significantly associated with a lower risk of gram-negative infections compared with controls (RR, 0.89; 95% CI, 0.73-1.08; P = .24). Subgroup analysis demonstrated that daily CHG bathing was not effective for reducing the risk of gram-negative infections caused by Acinetobacter, Escherichia coli, Klebsiella, Enterobacter, or Pseudomonas spp. CONCLUSIONS: The use of daily CHG bathing was not associated with a lower risk of gram-negative infections. Further, better designed trials with adequate power and with gram-negative infections as the primary end point are needed.