Federal Retail Pharmacy Program Contributions to Bivalent mRNA COVID-19 Vaccinations Across Sociodemographic Characteristics - United States, September 1, 2022-September 30, 2023.

The Federal Retail Pharmacy Program (FRPP) facilitated integration of pharmacies as partners in national efforts to scale up vaccination capacity during the COVID-19 pandemic emergency response. To evaluate FRPP's contribution to vaccination efforts across various sociodemographic groups, data on COVID-19 bivalent mRNA vaccine doses administered during September 1, 2022-September 30, 2023, were evaluated from two sources: 1) FRPP data reported directly to CDC and 2) jurisdictional immunization information systems data reported to CDC from all 50 states, the District of Columbia, U.S. territories, and freely associated states. Among 59.8 million COVID-19 bivalent vaccine doses administered in the United States during this period, 40.5 million (67.7%) were administered by FRPP partners. The proportion of COVID-19 bivalent doses administered by FRPP partners ranged from 5.9% among children aged 6 months-4 years to 70.6% among adults aged 18-49 years. Among some racial and ethnic minority groups (e.g., Hispanic or Latino, non-Hispanic Black or African American, non-Hispanic Native Hawaiian or other Pacific Islander, and non-Hispanic Asian persons), ≥45% of COVID-19 bivalent vaccine doses were administered by FRPP partners. Further, in urban and rural areas, FRPP partners administered 81.6% and 60.0% of bivalent vaccine doses, respectively. The FRPP partnership administered approximately two thirds of all bivalent COVID-19 vaccine doses in the United States and provided vaccine access for persons across a wide range of sociodemographic groups, demonstrating that this program could serve as a model to address vaccination services needs for routine vaccines and to provide health services in other public health emergencies.

An ex vivo biomechanical comparison of two suture materials and two pattern combinations for equine superficial digital flexor tendon tenorrhaphy.

OBJECTIVE: To compare biomechanical characteristics of three-loop pulley (3LP) pattern versus Bunnell technique (BT) using polydioxanone (PDS) suture; to determine the influence of polyester tape (PT) versus PDS on the BT for equine superficial digital flexor tendon (SDFT) tenorrhaphy; to compare BT with PT versus 3LP with PDS. STUDY DESIGN: Ex vivo biomechanical study. SAMPLE POPULATION: Forty equine forelimb SDFT. METHODS: Two experiments were performed: (1) 10 SDFT pairs were repaired with 3LP or BT using PDS; (2) 10 SDFT pairs were repaired with PDS or PT using BT. Load at failure, mode of failure, load at 2 mm gap, and gap at failure were obtained using a material testing machine. RESULTS: In experiment 1, 3LP + PDS1 had higher loads at failure (p < .001) and at 2 mm gap (p < .001), and smaller gap at failure than BT + PDS1 (p = .024). In experiment 2, BT + PT2 had higher loads at failure (p < .001) and at 2 mm gap (p = .001), and larger gap at failure (p = .004) than the BT + PDS2 . 3LP + PDS1 and BT + PT2 mostly failed by suture/implant pull-through while BT + PDS failed by suture breakage. BT + PT2 had greater load (p = .035) and gap at failure (p < .001) than 3LP + PDS1, with no difference in load at 2 mm gap (p = .14). CONCLUSION: The use of BT may be justified over 3LP if combined with PT. However, the larger size of the PT required stab incisions in the tendon for placement and was subjectively more difficult to place than PDS. CLINICAL SIGNIFICANCE: The BT + PT, although the strongest among the tested repairs, would only be able to withstand 12%-24% of the load encountered by the SDFT at walk.

Use of a Barbed Knotless Suture for Laparoscopic Ablation of the Nephrosplenic Space in 8 Horses.

OBJECTIVE: To evaluate use of a knotless suture for laparoscopic closure of the equine nephrosplenic space. STUDY DESIGN: Experimental in vivo study. ANIMALS: Normal horses without previous history of abdominal surgery (n=8). METHODS: The nephrosplenic space was closed under laparoscopic visualization using a unidirectional, barbed 0 metric absorbable suture (copolymer of glycolic acid and trimethylene carbonate). Intracorporeal suturing of the nephrosplenic space was performed in a cranial-to-caudal direction in a simple continuous fashion. Repeat evaluation was performed laparoscopically in 2 horses and by necropsy in 6 horses. The length of closure was measured and nature of the healed tissue was evaluate grossly. RESULTS: Total surgery time was 65-167 minutes (mean ± SD, 89.6 ± 22.6). Suturing time was 30-65 minutes (40.4 ± 16.3). Second laparoscopy in 2 horses was performed at days 198 and 227. Necropsy was performed at day 69-229 postoperatively (132.7 ± 63.0) in 6 horses. The closure measured 12-14 cm in length (13 ± 1) and consisted of mature fibrous tissue bridging the splenic capsule and the nephrosplenic ligament. No residual suture material was identified grossly in any horses. The procedure was easily performed; extracorporeal suture management to hold it taut was unnecessary since the barbs had excellent purchase in the apposed tissues, and intracorporeal knot tying was not required. CONCLUSION: The barbed knotless suture appears to be a valid alternative to facilitate laparoscopic closure of the nephrosplenic space in normal horses; however, further work is necessary to investigate its suitability in clinically affected horses.

Ex-Vivo Evaluation of a Modified Teno Fix(®) Device Repair Pattern Versus a 3-Loop Pulley for Repair of Equine Flexor Tendons.

OBJECTIVE: To compare the load to ultimate failure, load to a 2 mm gap, mode of failure, and gap at failure (mm) of the Teno Fix(®) (TF) to the 3-loop pulley (3LP) for repair of equine tendon lacerations. The use of 4TF devices versus 5TF devices on load to ultimate failure and load to a 2 mm gap was also compared. STUDY DESIGN: Ex vivo biomechanical study; unbalanced incomplete block (horse) design. SAMPLES: Cadaveric equine forelimb superficial digital flexor tendon (n = 20 paired tendons). METHODS: Ten tendon pairs were selected randomly and repaired with a 3LP and 4TF pattern, and 10 tendon pairs repaired with a 3LP and 5TF pattern. Load to ultimate failure, load to a 2 mm gap, mode of failure, and gap at failure were obtained using materials testing. RESULTS: The 3LP had a significantly greater ultimate load to failure (P < .001, respectively) and a significantly higher load to a 2 mm gap than both TF repairs (P < .001, respectively). The most frequent mode of failure was suture pull-out for the 3LP and anchor pull-out for the TF. Gap at failure was significantly larger in the 3LP than both TF repairs (P < .001). The ultimate load to failure was significantly higher for the 5TF than the 4TF (P = .004) but there was no significant difference in load to a 2 mm gap, or gap at failure between both TF repairs (P = .11, P = .15, respectively). CONCLUSIONS: Neither TF repair was stronger than the 3LP in load to ultimate failure and load to a 2 mm gap. Addition of a fifth TF device significantly increased the load to ultimate failure but did effect the load to a 2 mm gap over the 4TF.

Symptomatic cholelithiasis: a different disease in men? Connecticut Laparoscopic Cholesystectomy Registry.

OBJECTIVE: To determine the importance of gender in the clinical presentation and subsequent clinical outcome (risk of conversion from laparoscopic to open technique and risk of postoperative mortality) for patients undergoing cholecystectomy. SUMMARY BACKGROUND DATA: Age and clinical presentation have consistently been found to be important predictors of cholecystectomy outcomes; male gender has been cited in disparate studies as possibly having prognostic significance. METHOD: A statewide cholecystectomy registry (30,145 cases between 1989-1993) was analyzed. Hierarchical log-linear modeling was used to identify associations between characteristics of clinical presentation. Multivariate logistic regression analysis was used to determine predictions of conversion and mortality. RESULTS: Male gender was associated with twice the expected incidence of acute cholecystitis and pancreatitis in the elderly (> or = 65 years). Males had a significantly increased risk for conversion to open technique, but this decreased during the time frame of the study. Mortality was twice as high among males (confidence interval, 1.4-2.9, p = 0.0001). CONCLUSIONS: Males presenting for cholecystectomy are more likely to have severe disease. Independent of clinical presentation, they face increased risks of conversion to open technique and of postoperative mortality.

Bile duct injuries, 1989-1993. A statewide experience. Connecticut Laparoscopic Cholecystectomy Registry.

OBJECTIVE: To review the incidence of major bile duct injuries (MBDI) during the shift from open (OC) to laparoscopic cholecystectomy (LC). DESIGN: Cohort analysis; minimum 15-month patient follow-up. SETTING: Acute care Connecticut hospitals. PATIENTS: Medical records of 30211 patients with cholecystectomy (OC or LC) reviewed; 47 cases of MBDI confirmed. MAIN OUTCOME MEASURE: Rate of MBDI. RESULTS: The incidence of MBDI in Connecticut hospitals rose from 0.04% in 1989 to 0.24% in 1991, then decreased to 0.11% in 1993. The increase was due to increased numbers of cholecystectomies and the initial increased risk of injury with LC. The 1990-through-1993 trend of decreasing incidence of LC MBDI was statistically significant (P=.02). By 1993, the difference between LC and OC was no longer significant (P=.81). Acute cholecystitis (odds ratio, 3.3) and gallstone pancreatitis (odds ratio, 3.6) increased the risk of MBDI during LC (P<.001). The LC MBDI more commonly were ductal excision or transections and often were not diagnosed intraoperatively. Intraoperative cholangiography facilitated intraoperative recognition and repair. Most patients (89%) underwent definitive management of the MBDI at the hospital of origin; of those, 5% required further interventions. CONCLUSIONS: Surgeries for acute cholecystitis and gallstone pancreatitis are associated with an increased risk for MBDI. Ductal anatomy, the timing of recognition of injury, and the method of repair dictate patient outcomes. Most patients are successfully managed at the hospital of origin, with good long-term results. Late bile duct strictures appear rare.

Verification of information in a large medical database using linkages with external databases.

Efforts to utilize Uniform Hospital Discharge Data Sets (UHDDS) for epidemiological studies have been hampered by the limitations of those databases. The purpose of this paper is to illustrate that linking to external databases can provide the verification necessary to overcome many of those limitations. This method has dramatically altered study design at the Connecticut Hospital Research and Education Foundation and has provided an efficient method for specifying data collection weaknesses within the resident databases.

Comparison of mortality rates for open and closed cholecystectomy in the elderly: Connecticut statewide survey.

The objective was to determine the safety of laparoscopic cholecystectomy for patients 65 years of age and older with symptomatic uncomplicated chronic gallbladder disease by comparing the mortality rate with open cholecystectomy. Connecticut Hospital Information Management Exchange and the Connecticut Society of American Board of Surgeons established a Connecticut Laparoscopic Registry made up of 33 acute care hospitals. A cohort longitudinal retrospective statewide registry collected data mortality rates on all 2865 elderly patients undergoing open (OC) or closed (LC) cholecystectomy for uncomplicated chronic cholecystitis. A database was established and continuously monitored from October 1, 1988, to December 31, 1992. Seven hundred sixty-one patients over 65 years of age underwent open cholecystectomy for uncomplicated chronic cholecystectomy during fiscal year 1989, with a mortality rate of 1.4%. The mortality rate of a similar cohort of patients who underwent laparoscopic cholecystectomy during fiscal years 1991 and 1992 was 0.3% and 0.6%, respectively. The mortality rate was further broken down into age subsets 65-69, 70-79, and 80+. The prelaparoscopic era (FY 1989) age subsets were compared with those of the laparoscopic era (FY 1991 and 1992). A statistically significant reduction (p = 0.01) in mortality rate was noted in the 70-79 age group following laparoscopic surgery. Laparoscopic cholecystectomy in the elderly for the treatment of symptomatic, uncomplicated chronic cholecystitis is as safe if not safer than open cholecystectomy as measured by mortality rate.

The "Toward Excellence in Care" program: a statewide indicator project.

BACKGROUND: The "Toward Excellence in Care" program was launched by Connecticut hospitals and physicians in 1988 to develop and use quality-of-care indicators for use in quality improvement. METHODOLOGY: Data came primarily from the Connecticut Health Information Management and Exchange (CHIME) database, which contains discharge abstract information, UB (uniform billing)-82 information, and additional data elements, for all of Connecticut's 34 acute care hospitals. Linkages also occur with the state mortality database, the trauma registry, and with admission/discharge data within and across Connecticut hospitals. The "Toward Excellence in Care" program staff help the hospital use the data on indicator reports for quality improvement. EXAMPLE: On receiving a report on care for patients with acute myocardial infarction (AMI) a program representative summarized opportunities for improvement. The data were then disseminated to both the cardiology and the hospitalwide quality improvement staffs. Cardiologists conducted chart review on 100% of patients included in the last time-frame on the report (for example, fiscal year 1991). The quality improvement professional documented the system of care for an AMI patient. Recommended actions included adoption of a policy for emergency department administration of thrombolytic therapy before a cardiology consultation, and modification of the postcoronary care program. CONCLUSIONS: Progress in addressing four challenges-easing the burden of data collection on the hospitals, maximizing acceptance of information by hospitals and physicians, risk adjusting data to permit comparison of outcomes, and facilitating understanding of reports--is reflected in expanding use of the "Toward Excellence in Care" program.

Laparoscopic cholecystectomy. A statewide experience. The Connecticut Laparoscopic Cholecystectomy Registry.

The explosion in laparoscopic cholecystectomy has posed many questions about its safety compared with the "gold standard" of open cholecystectomy. A statewide database was established in Connecticut to study these issues. Thirty-three (97%) of 34 hospitals in Connecticut participated in the study, which began at the inception of the laparoscopic procedure. Four thousand six hundred forty laparoscopic cholecystectomies were performed between May 1, 1990, and September 30, 1991. The overall conversion rate to open cholecystectomy was 6.9%. Conversions were more frequent with acute cholecystitis, in the elderly, and early in a surgeon's experience. The overall technical complication rate was 4.7%; common bile duct injuries occurred in 15 patients (0.3%). Complications decreased with increasing experience, to 0.98% after a surgeon's 75th procedure. Six patients (0.13%) died following laparoscopic cholecystectomy. The overall mortality rate associated with cholecystectomy fell during the study period. The frequency of cholecystectomy in Connecticut increased 29% with the advent of the laparoscopic procedure. The introduction of laparoscopic cholecystectomy has resulted in an increased frequency of surgery without an increase in surgical mortality. The incidence of common bile duct injuries was low. The decreasing incidence of technical complications demonstrates the learning curve for the procedure.