Association of Aspirin With Prevention of Venous Thromboembolism in Patients After Total Knee Arthroplasty Compared With Other Anticoagulants: A Noninferiority Analysis.

Importance: There has been significant debate in the surgical and medical communities regarding the appropriateness of using aspirin alone for venous thromboembolism (VTE) prophylaxis following total knee arthroplasty (TKA). Objective: To determine the acceptability of aspirin alone vs anticoagulant prophylaxis for reducing the risk of postoperative VTE in patients undergoing TKA. Design, Setting, and Participants: Noninferiority study of a retrospective cohort of TKA cases submitted to the Michigan Arthroplasty Registry Collaborative Quality Initiative at 29 member hospitals, ranging from small community hospitals to large academic and nonacademic medical centers in Michigan. The study included 41 537 patients who underwent primary TKA between April 1, 2013, and October 31, 2015. Clinical events were monitored for 90 days after surgery. Data were analyzed between September and October 2016. Exposures: The method of pharmacologic prophylaxis: neither aspirin nor anticoagulants for 668 patients (1.6%), aspirin only for 12 831 patients (30.9%), anticoagulant only (eg, low-molecular-weight heparin, warfarin, and Xa inhibitors) for 22 620 patients (54.5%), and both aspirin/anticoagulant for 5418 patients (13.0%). Most patients were also using intermittent pneumatic compression stockings. Main Outcome and Measures: The primary composite outcome was the first occurrence of VTE or death. The noninferiority margin was specified as 0.3. The secondary outcome was bleeding events. Results: Of the 41 537 patients, 14 966 were men (36%), and the mean age was 65.8 years. A VTE event occurred in 573 of 41 537 patients (1.38%); 32 of 668 (4.79%) who received no pharmacologic prophylaxis, 149 of 12 831 (1.16%) treated with aspirin alone, 321 of 22 620 (1.42%) with anticoagulation alone, and 71 of 5418 (1.31%) prescribed both aspirin and anticoagulation. Aspirin only was noninferior for the composite VTE outcome compared with those receiving other chemoprophylaxis (adjusted odds ratio, 0.85; 95% CI, 0.68-1.07, P for inferiority = .007). Bleeding occurred in 457 of 41 537 patients (1.10%), 10 of 668 (1.50%) without prophylaxis, 116 of 12 831 (0.90%) in the aspirin group, 258 of 22 620 (1.14%) with anticoagulation, and 73 of 5418 (1.35%) of those receiving both. Aspirin alone was also noninferior for bleeding complications (adjusted odds ratio, 0.80; 95% CI, 0.63-1.00, P for inferiority <.001). Conclusions and Relevance: In this study of patients undergoing TKA, aspirin was not inferior to other anticoagulants in the postoperative rate of VTE or death. Aspirin alone may provide similar protection from postoperative VTE compared with other anticoagulation treatments.

Quality Initiative Programs Can Decrease Total Joint Arthroplasty Transfusion Rates-A Multicenter Study Using the MARCQI Total Joint Registry Database.

BACKGROUND: The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) noted wide variability between member hospitals in blood transfusion rates after primary total hip and knee arthroplasty (THA and TKA). Blood transfusion has substantial risks and accepted recommendations exist to guide transfusion practices. MARCQI began an initiative to decrease unnecessary transfusions by identifying/reporting outliers, discussing conservative transfusion practices, and recommending transfusion guidelines. There was a later recommendation to consider intraoperative use of tranexamic acid. METHODS: All MARCQI-registered unilateral TKA and THA cases from the 28 member hospitals (pre-November 2013) were included. For 3 time periods (before November 13, 2013; November 13, 2013, to November 12, 2014; and after November 12, 2014), we calculated average risk and range of transfusion, transfusion with nadir hemoglobin >8 g/dL, mean length of stay, and 90-day risk of discharge to nursing home, readmission, deep infection, and emergency department visits. RESULTS: For THA, risk and range of transfusion decreased over the 3 time periods: 12.6% (2.5%-36.2%), 7.6% (2.2%-23.8%), and 4.5% (0.7%-14.4%); for TKA, 6.3% (1.3%-15.6%), 3.1% (0%-12.5%), and 1.3% (0%-7.4%). Decreases were also noted for transfusion with a nadir hemoglobin >8 g/dL with a near elimination of "unnecessary" transfusions. There was no evidence of increase in length of stay, discharge to nursing home, readmission, deep infection, or emergency department visits. CONCLUSION: A simple intervention can decrease unnecessary blood transfusions during and after elective primary unilateral THA or TKA. A collaborative registry can be used effectively to improve the quality of patient care and set a new benchmark for transfusion.

Data Sharing Between Providers and Quality Initiatives Eliminate Unnecessary Nursing Home Admissions.

BACKGROUND: The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) has monitored discharge disposition, after total hip and knee arthroplasties, since inception in 2012 and found the standardized risk of extended care facility (ECF) placement to be highly variable between hospitals. METHODS: The variation in standardized risks of ECF placement among MARCQI member sites was reported to the collaborative. At the May 2, 2014 quarterly meeting, a quality initiative was started, emphasizing the wide variability between hospitals, the contribution of hospital and surgeon to that variability using median odds ratios, and the need for outlier hospitals to initiate quality improvement (QI) processes. Patients from 29 hospitals that were members of MARCQI before the intervention were included in this analysis. We compared standardized risks before and after the intervention in the entire cohort, and for 3 hospitals that implemented institution-specific QI projects. We report changes in ECF placement, length of stay, emergency room visits, and readmissions over time. RESULTS: This study includes 31,347 patients before and 20,879 patients after the implementation of the quality initiative. The range in standardized risk dropped from 9.4%-46.1% to 9.4%-32.4% and the average dropped from 23.0% to 19.6%. Three outlier hospitals decreased their absolute risk of ECF placement by 12.2%, 8.9%, and 12.4% after QI, without increases in adverse outcomes. CONCLUSION: Discharge to ECF after primary hip and knee arthroplasties is highly variable and influenced by hospital and surgeon practices. Hospital-level QI measures can decrease ECF admissions.

The Michigan Experience with Safety and Effectiveness of Tranexamic Acid Use in Hip and Knee Arthroplasty.

BACKGROUND: The efficacy of tranexamic acid (TXA) in reducing blood loss and transfusion requirements in total hip and knee arthroplasty has been well established in small controlled clinical trials and meta-analyses. The purpose of the current study was to determine the risks and benefits of TXA use in routine orthopaedic surgical practice on the basis of data from a large, statewide arthroplasty registry. METHODS: From April 18, 2013, to September 30, 2014, there were 23,236 primary total knee arthroplasty cases and 11,489 primary total hip arthroplasty cases completed and registered in the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI). We evaluated the association between TXA use and hemoglobin drop, transfusion, length of stay (LOS), venous thromboembolism (VTE), readmission, and cardiovascular events by fitting mixed-effects generalized linear and mixed-effects Cox models. We used inverse probability of treatment weighting to enhance causal inference. RESULTS: For total hip arthroplasty, TXA use was associated with a smaller drop in hemoglobin (mean difference = -0.65 g/dL; 95% confidence interval [CI] = -0.60 to -0.71 g/dL), decreased odds of blood transfusion (odds ratio [OR] = 0.72; 95% CI = 0.60 to 0.86), and decreased readmissions (OR = 0.77; 95% CI = 0.64 to 0.93) compared with no TXA use. There was no effect on VTE (hazard ratio [HR] = 0.91; 95% CI = 0.62 to 1.33), LOS (incident rate ratio [IRR] = 1.00; 95% CI = 0.97 to 1.03), or cardiovascular events (OR = 0.85; 95% CI = 0.47 to 1.52). For total knee arthroplasty, TXA was associated with a smaller drop in hemoglobin (mean difference = -0.68 g/dL; 95% CI = -0.64 to -0.71 g/dL) and one-fourth the odds of blood transfusion (OR = 0.26; 95% CI = 0.21 to 0.31). There was an association with decreased risk of VTE within 90 days after surgery (HR = 0.56; 95% CI = 0.42 to 0.73), slightly decreased LOS (IRR = 0.93; 95% CI = 0.92 to 0.95), and no association with readmissions (OR = 0.90; 95% CI = 0.79 to 1.04) or cardiovascular events (OR = 1.12; 95% CI = 0.74 to 1.71). CONCLUSIONS: In routine orthopaedic surgery practice, TXA use was associated with decreased blood loss and transfusion risk for both total knee and total hip arthroplasty, without evidence of increased risk of complications. TXA use was also associated with reduced risk of readmission among total hip arthroplasty patients and reduced risk of VTE among total knee arthroplasty patients, and did not have an adverse effect on cardiovascular complications in either group. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Reference range for tissue oxygen saturation in pregnancy using near-infrared spectroscopy.

OBJECTIVE: To estimate the reference range of tissue oxygen saturation (StO2) values in pregnancy. Near-infrared spectroscopy-derived StO2 is a noninvasive continuous measure used to predict hypoperfusion. Normal StO2 values have not been established in pregnant women. STUDY DESIGN: We enrolled 154 healthy pregnant women from an obstetric and gynecology resident clinic. Three sequential measurements were taken after securing the StO2 probe to the thenar eminence of one hand. One-way ANOVA was used to test for differences between trimesters and non-parametric methods to establish a reference range with 95% CI on the limits. RESULTS: The reference interval for the entire cohort of pregnant women is 73% (95% CI 72-75) to 92% (95% CI 89-93), similar to the normal range in the general population. We found no statistically significant difference in StO2 measurements between trimesters. Due to inadequate sample sizes we could not estimate a valid reference range for each trimester. CONCLUSION: We estimated a reference range for StO2 values in normal pregnant women. This information may contribute to the study of StO2 monitoring to predict impending shock in the obstetric patient.

Mind the (knowledge) gap: the effect of a communication instrument on emergency department patients' comprehension of and satisfaction with care.

OBJECTIVES: We developed a communication instrument to be used in the Emergency Department (ED) and hypothesized that use of this guide would increase patient comprehension of and satisfaction with care. METHODS: This multi-site trial enrolled 643 patients in treatment and control groups. Comprehension of care was assessed by chart review and satisfaction measured via validated survey. RESULTS: Use of the instrument was not associated with improvements in patient knowledge about their care, with a mean of 4.6 (95% CI: 4.8-5.8) comprehension defects in the control group and 4.4 (95% CI: 3.9-4.9) in the treatment group. There was no significant effect on patient satisfaction 76.4% versus 76.9%, p=0.34. Elderly patients in both groups were found to have 1.1 (p<0.01) more knowledge gaps than younger patients. CONCLUSION: Patients frequently misunderstand medical care in the ED. Comprehension decreases with increasing age. An isolated communication instrument does not improve satisfaction with or understanding of the care received. PRACTICE IMPLICATIONS: Providing a structured place for providers and patients to record details of care does not seem to improve satisfaction with or comprehension of care. Interventions that focus on communication skills and face time with patients may prove more effective.

A Delphi Method Analysis to Create an Emergency Medicine Educational Patient Satisfaction Survey.

INTRODUCTION: Feedback on patient satisfaction (PS) as a means to monitor and improve performance in patient communication is lacking in residency training. A physician's promotion, compensation and job satisfaction may be impacted by his individual PS scores, once he is in practice. Many communication and satisfaction surveys exist but none focus on the emergency department setting for educational purposes. The goal of this project was to create an emergency medicine-based educational PS survey with strong evidence for content validity. METHODS: We used the Delphi Method (DM) to obtain expert opinion via an iterative process of surveying. Questions were mined from four PS surveys as well as from group suggestion. The DM analysis determined the structure, content and appropriate use of the tool. The group used four-point Likert-type scales and Lynn's criteria for content validity to determine relevant questions from the stated goals. RESULTS: Twelve recruited experts participated in a series of seven surveys to achieve consensus. A 10-question, single-page survey with an additional page of qualitative questions and demographic questions was selected. Thirty one questions were judged to be relevant from an original 48-question list. Of these, the final 10 questions were chosen. Response rates for individual survey items was 99.5%. CONCLUSION: The DM produced a consensus survey with content validity evidence. Future work will be needed to obtain evidence for response process, internal structure and construct validity.

You've got mail and need follow-up: the effect and patient perception of e-mail follow-up reminders after emergency department discharge.

OBJECTIVES: The hypothesis was that a reminder about recommended primary care physician (PCP) follow-up, sent via e-mail to patients discharged from the emergency department (ED), would increase the proportion of patients who followed up with their PCPs within the recommended time frame. Patient receptiveness to e-mail follow-up reminders was also assessed. METHODS: This was a mixed methods clinical intervention study with subjects randomized either to receive the usual care discharge instructions only or to also receive a reminder e-mail message the day after the ED visit. The reminder e-mail contained the subject's PCP's name and address and the recommended PCP follow-up time interval. A blinded review of outpatient PCP medical records was conducted to determine whether and when follow-up occurred. Researchers attempted to contact patients with a telephone survey 2 weeks after their ED visits. The primary outcomes between groups were compared using chi-square tests and relative risks (RRs) with 95% confidence intervals (CIs). RESULTS: Thirty-three percent of the intervention group and 32% of the control group followed-up as recommended (RR = 1.04, 95% CI = 0.81 to 1.33); 52% of the intervention group and 48% of the control group followed-up within 10 days of the recommended time (RR = 1.08, 95% CI = 0.91 to 1.29). The 334 patients (57%) successfully contacted via telephone demonstrated a high interest in receiving future e-mail reminders (75%), with the group that received e-mail reminders more likely to want one in the future than those who did not receive e-mail reminders (82.5% vs. 69.76%; p = 0.04). CONCLUSIONS: E-mail reminders sent after ED visits did not improve patients' adherence to the recommended timing of primary care follow-up contained in discharge instructions. Subjects in both the control and the intervention groups favorably viewed the concept of e-mail reminders, suggesting that the value of e-mail reminders after ED discharge may be in areas such as patient satisfaction that were not specifically targeted for measurement in this study.

(1,3)-ß-d-glucan in cerebrospinal fluid for diagnosis of fungal meningitis associated with contaminated methylprednisolone injections.

Prompt diagnosis and treatment of fungal meningitis are critical, but culture is insensitive. (1,3)-ß-d-Glucan (BDG) testing is FDA approved for serological diagnosis of invasive fungal disease; however, BDG testing is not approved for cerebrospinal fluid (CSF), and the appropriate cutoff value is unknown. We aimed to validate the diagnostic accuracy of CSF BDG measurements for fungal meningitis among patients exposed to contaminated methylprednisolone acetate (MPA). A retrospective observational study was conducted at St. Joseph Mercy Hospital and Vanderbilt University from November 2013 to February 2014. Patients were included if they had received a contaminated MPA injection. Cases were classified as probable or proven meningitis according to Centers for Disease Control and Prevention guidelines. CSF BDG testing was performed according to the package insert instructions for serum samples, and results were validated using Clinical and Laboratory Standards Institute procedures (MiraVista Diagnostics). Of 233 patients, 45 had meningitis (28 proven cases), 53 had spinal/paraspinal infections (19 proven cases), and 135 did not develop disease. Using the manufacturer's cutoff value (≥80 pg/ml), the sensitivity and specificity were 96% and 95%, respectively, for proven meningitis and 84% and 95% for probable or proven meningitis. Receiver operating characteristic analysis identified the optimal cutoff value for proven meningitis to be 66 pg/ml (sensitivity, 100%; specificity, 94%) and that for probable or proven meningitis to be 66 pg/ml (sensitivity, 91%; specificity, 92%). Our results suggest that CSF BDG measurements are highly sensitive and specific for the diagnosis of fungal meningitis associated with contaminated MPA injections. Further study on the utility of CSF BDG testing for other types of fungal meningitis is needed.

A multifactorial intervention for hospital opioid management.

OBJECTIVE: To determine whether an educational intervention combined with a voluntary decision support system improves inpatient pain control. DESIGN: Retrospective serial cross-sectional study. SETTING: Community teaching hospital. PATIENTS: Patients admitted to internal medicine teaching service from October to December 2011 and 2012. The study cohorts consisted of a random sample of 75 patients each from both time periods. INTERVENTIONS: Beginning in August 2012, internal medicine residents participated in an interactive training session on the use of opioids for hospitalized patients and concurrently, a user initiated voluntary computerized decision support system (CDSS), in the form of computer order entry (COE) and pocket cards were introduced. The COE options correspond to the standardized opioid dosing regimen on the pocket card. Pain scores and opioid doses and demographic information were obtained from administrative databases. Additional covariates were abstracted via programmed electronic medical record (EMR) review. MAIN OUTCOME MEASURES: Pre- and postintervention, maximum reported pain score in every 8-hour period from first analgesic dose, to 72 hours after the first analgesic dose, were compared by fitting a multivariable linear mixed model. Naloxone use was a surrogate measure for secondary outcome of opioid overdose. RESULTS: The intervention had no effect on maximum pain score (MPS) over time, p = 0.0930. The estimated mean MPS (95% confidence interval) was 4.7 (3.9, 5.5) preintervention and 5.2 (4.4, 6.0) postintervention. CONCLUSIONS: A combination of a resident educational intervention, CDSS, and pocket cards did not improve MPSs over time for patients on an internal medicine teaching service.

Alopecia and nail changes associated with voriconazole therapy.

BACKGROUND: Voriconazole was 1 of 2 antifungal agents recommended for treatment of fungal infections associated with injection of contaminated methylprednisolone. Alopecia and nail changes are not commonly reported side effects of voriconazole. Having noted increasing hair loss among our patients treated with voriconazole, we sought to determine the prevalence and characteristics of alopecia associated with this agent. METHODS: Patients who received voriconazole for at least 1 month for probable or confirmed fungal infection were eligible to complete a survey regarding alopecia and nail changes. For those patients who reported alopecia, additional questions about reversal of hair loss were asked after voriconazole had been stopped for at least 3 months. RESULTS: A total of 152 of 175 eligible patients (87%) completed the survey. One hundred twenty-five (82%) reported alopecia. Hair loss on the scalp was noted in 120 (96%), arms and legs in 52 (42%), and eyebrows and eyelashes in 47 each (38%). Nineteen patients (15%) reported wearing a wig or hat because of extensive hair loss. Alopecia developed a mean (standard deviation) of 75 (54) days after initiation of voriconazole. Of 114 patients who were off voriconazole for at least 3 months, hair loss had stopped in 94 (82%) and regrowth had begun in 79 (69%), including those who were changed to either itraconazole or posaconazole. Nail changes or loss occurred in 106 (70%) patients. CONCLUSIONS: Alopecia and nail changes were common adverse effects associated with voriconazole therapy during the multistate fungal outbreak.

Procalcitonin as a marker of serious bacterial infections in febrile children younger than 3 years old.

OBJECTIVES: There is no perfectly sensitive or specific test for identifying young, febrile infants and children with occult serious bacterial infections (SBIs). Studies of procalcitonin (PCT), a 116-amino-acid precursor of the hormone calcitonin, have demonstrated its potential as an acute-phase biomarker for SBI. The objective of this study was to compare performance of serum PCT with traditional screening tests for detecting SBIs in young febrile infants and children. METHODS: This was a prospective, multicenter study on a convenience sample from May 2004 to December 2005. The study was conducted in four emergency departments (EDs): one pediatric ED and three EDs with pediatric units, all with academic faculty on staff. A total of 226 febrile children 36 months old or younger who presented to the four participating EDs and were evaluated for SBI by blood, urine, and/or cerebral spinal fluid (CSF) cultures were included. RESULTS: The test characteristics (with 95% confidence intervals [CIs]) of the white blood cell (WBC) counts including neutrophil and band counts were compared with PCT for identifying SBI. Thirty children had SBIs (13.3%, 95% CI = 8.85 to 17.70). Four (13.3%) had bacteremia (including one with meningitis), 18 (60.0%) had urinary tract infections (UTIs), and eight (26.6%) had pneumonia. Children with SBIs had higher WBC counts (18.6 × 10(9)  ± 8.6 × 10(9) cells/L vs. 11.5 × 10(9)  ± 5.3 × 10(9) cells/L, p < 0.001), higher absolute neutrophil counts (ANCs; 10.6 × 10(9)  ± 6.7 × 10(9) cells/L vs. 5.6 × 10(9)  ± 3.8 × 10(9) cells/L, p = 0.009), higher absolute band counts (0.90 × 10(9)  ± 1.1 × 10(9) cells/L vs. 0.35 × 10(9)  ± 0.6 × 10(9) cells/L, p = 0.009), and higher PCT levels (2.9 ± 5.6 ng/mL vs. 0.4 ± 0.8 ng/mL, p = 0.021) than those without SBIs. In a multivariable logistic regression analysis, the absolute band count and PCT were the two screening tests independently associated with SBI, although the area under the receiver operating characteristic (ROC) curve for PCT was the largest (0.80, 95% CI = 0.71 to 0.89). CONCLUSIONS: Procalcitonin is a more accurate biomarker than traditional screening tests for identifying young febrile infants and children with serious SBIs. Further study on a larger cohort of young febrile children is required to definitively determine the benefit of PCT over traditional laboratory screening tests for SBIs.

Impact of a new senior emergency department on emergency department recidivism, rate of hospital admission, and hospital length of stay.

STUDY OBJECTIVE: Senior (geriatric) emergency departments (EDs) are an emerging phenomenon across the United States, designed to provide greater comfort for elders, screening for common morbidities, and selective contact with social workers. We hypothesize that the senior ED will reduce recidivism, rate of admission, and hospital length of stay. METHODS: This was a pre/postintervention observational study of seniors (≥65 years) before and after opening of a new senior ED in a large community hospital. Older nonseniors treated during the same periods were included to detect temporal trend bias. Outcomes included admission to the hospital, hospital length of stay, and ED return visits. Cox proportional hazards models, controlling for patient age, sex, triage level, insurance type, admission on the index visit, and hospital length of stay, were used to test association with time to return within 30 and 180 days. Multivariable regression modeling was used to determine whether the intervention was associated with admission on the index visit, and hospital length of stay. RESULTS: There was no significant difference in time to return within 30 days (HR=1.09; 95% confidence interval [CI] 0.95 to 1.23), 180 days (HR=0.99; 95% CI 0.91 to 1.08), or average hospital length of stay. Risk of being admitted on the index visit was lower for seniors treated in the senior ED compared with the regular ED (Relative Risk=0.93; 95% CI 0.89 to 0.98). CONCLUSION: A new senior ED was not associated with reduced ED recidivism or hospital length of stay, but was associated with decreased rate of admission.

Spinal and paraspinal fungal infections associated with contaminated methylprednisolone injections.

BACKGROUND: A nationwide outbreak of fungal infections was traced to injection of Exserohilum-contaminated methylprednisolone. We describe our experience with patients who developed spinal or paraspinal infection after injection of contaminated methylprednisolone. METHODS: Data were assembled from the Michigan Department of Community Health, electronic medical records, and magnetic resonance imaging (MRI) reports. RESULTS: Of 544 patients who received an epidural injection from a contaminated lot of methylprednisolone at a pain clinic in southeastern Michigan, 153 (28%) were diagnosed at our institution with probable or confirmed spinal or paraspinal fungal infection at the injection site. Forty-one patients had both meningitis and spinal or paraspinal infection, and 112 had only spinal or paraspinal infection. Magnetic resonance imaging abnormalities included abscess, phlegmon, arachnoiditis, and osteomyelitis. Surgical debridement in 116 patients revealed epidural phlegmon and epidural abscess most often. Among 26 patients with an abnormal MRI but with no increase or change in chronic pain, 19 (73%) had infection identified at surgery. Fungal infection was confirmed in 78 patients (51%) by finding hyphae in tissues, positive polymerase chain reaction, or culture. Initial therapy was voriconazole plus liposomal amphotericin B in 115 patients (75%) and voriconazole alone in 38 patients (25%). As of January 31, 2014, 20 patients remained on an azole agent. Five patients died of infection. CONCLUSIONS: We report on 153 patients who had spinal or paraspinal fungal infection at the site of epidural injection of contaminated methylprednisolone. One hundred sixteen (76%) underwent operative debridement in addition to treatment with antifungal agents.

Magnetic resonance imaging screening to identify spinal and paraspinal infections associated with injections of contaminated methylprednisolone acetate.

IMPORTANCE: Injection of contaminated methylprednisolone has resulted in an unprecedented nationwide outbreak of Exserohilum rostratum fungal infections, manifested initially as meningitis and/or basilar stroke. Insidious onset of spinal or paraspinal infection at the injection site has been increasingly reported and is occurring months after receipt of injection with the contaminated drug. The clinical findings are often subtle and similar to those that led the patient to undergo the methylprednisolone injection. OBJECTIVE: To determine if patients who had not presented for medical care but who had received contaminated methylprednisolone developed spinal or paraspinal infection at the injection site using contrast-enhanced magnetic resonance imaging (MRI) screening. DESIGN, SETTING, AND PARTICIPANTS: There were 172 patients who had received an injection of contaminated methylprednisolone from a highly contaminated lot (No. 06292012@26) at a pain facility but had not presented for medical care related to adverse effects after the injection. Screening MRI was performed between November 9, 2012, and April 30, 2013. MAIN OUTCOMES AND MEASURES: Number of persons identified with previously undiagnosed spinal or paraspinal infection. RESULTS: Of the 172 patients screened, MRI was abnormal in 36 (21%), showing epidural or paraspinal abscess or phlegmon, arachnoiditis, spinal osteomyelitis or diskitis, or moderate to severe epidural, paraspinal, or intradural enhancement. Of the 115 patients asked about new or worsening back or neck pain, lower extremity weakness, or radiculopathy symptoms, 35 (30%) had at least 1 symptom. Thirty-five of the 36 patients with abnormal MRIs met the Centers for Disease Control and Prevention (CDC) case definition for probable (17 patients) or confirmed (18 patients) fungal spinal or paraspinal infection. All 35 patients were treated with antifungal agents (voriconazole, with or without liposomal amphotericin B), and 24 required surgical debridement. At the time of surgery, 17 of 24 patients (71%), including 5 patients who denied having symptoms, had laboratory evidence of fungal infection. CONCLUSIONS AND RELEVANCE: Among patients who underwent screening MRI to look for infection at the site of injection of contaminated methylprednisolone, 21% had an abnormal MRI, and all but one met CDC criteria for probable or confirmed fungal spinal or paraspinal infection. Screening MRI led to identification of patients who had minimal or no symptoms of spinal or paraspinal infection and allowed early initiation of medical and surgical treatment.

Clinical and economic outcomes from a community hospital's antimicrobial stewardship program.

BACKGROUND: Data from community antimicrobial stewardship programs (ASPs) are limited. We describe clinical and economic outcomes from the first year of our hospital's ASP. METHODS: The ASP team comprised 2 infectious disease physicians and 3 intensive care unit pharmacists. The team prospectively audited the new starts and weekly use of 8 target antimicrobials: aztreonam, caspofungin, daptomycin, ertapenem, linezolid, meropenem, tigecycline, and voriconazole. Using administrative data, outcomes from the first year of the program, including death within 30 days of hospitalization, readmission within 30 days of discharge, and development of Clostridium difficile infection (CDI), were compared with outcomes from a similar period before institution of the program. RESULTS: A total of 510 antimicrobial orders were reviewed, of which 323 (63%) were appropriate, 94 (18%) prompted deescalation, 61 (12%) were denied, and 27 (5%) led to formal consultation with an infectious disease physician. On multivariate analysis, implementation of the ASP was associated with an approximate 50% reduction in the odds of developing CDI (odds ratio, 0.46; 95% confidence interval, 0.25-0.82). The ASP was not associated with decreased mortality at 30 days after discharge or readmission rate. The antimicrobial cost per patient-day decreased by 13.3%, from $10.16 to $8.81. The antimicrobial budget decreased by 15.2%, resulting in a total savings of $228,911. There was a 25.4% decrease in defined daily doses of the target antimicrobials. CONCLUSIONS: Implementation of the ASP was associated with significant reductions in CDI rate, antimicrobial use, and pharmacy costs.

Implementation of a novel communication tool and its effect on patient comprehension of care and satisfaction.

BACKGROUND: Emergency department (ED) communication has been demonstrated as requiring improvement and ED patients have repeatedly demonstrated poor comprehension of the care they receive. Through patient focus groups, the authors developed a novel tool designed to improve communication and patient comprehension. STUDY DESIGN: This is a prospective, randomised controlled clinical trial to test the efficacy of a novel, patient-centred communication tool. Patients in a small community hospital ED were randomised to receive the instrument, which was utilised by the entire ED care team and served as a checklist or guide to the patients' ED stay. At the end of the ED stay, patients completed a survey of their comprehension of the care and a communication assessment tool-team survey (a validated instrument to assess satisfaction with communication). Three blinded chart reviewers scored patients' comprehension of their ED care as concordant, partially concordant or discordant with charted care. The authors tested whether there was a difference in satisfaction using a two-sample t test and a difference in comprehension using ordinal logistic regression analysis. RESULTS: 146 patients were enrolled in the study with 72 randomised to receive the communication instrument. There was no significant difference between groups in comprehension (OR=0.65, 95% CI 0.34 to 1.23, p=0.18) or communication assessment tool-team scores (difference=0.2, 95% CI: -3.4 to 3.8, p=0.91). CONCLUSIONS: Using their novel communication tool, the authors were not able to show a statistically significant improvement in either comprehension or satisfaction, though a tendency towards improved comprehension was seen.

Does preoperative anemia adversely affect colon and rectal surgery outcomes?

BACKGROUND: Complications associated with blood transfusions have resulted in widespread acceptance of low hematocrit levels in surgical patients. However, preoperative anemia seems to be a risk factor for adverse postoperative outcomes in certain surgical patients. This study investigated the National Surgical Quality Improvement Program (NSQIP) database to determine if preoperative anemia in patients undergoing open and laparoscopic colectomies is an independent predictor for an adverse composite outcome (CO) consisting of myocardial infarction, stroke, progressive renal insufficiency or death within 30 days of operation, or for an increased hospital length of stay (LOS). STUDY DESIGN: Hematocrit levels were categorized into 4 classes: severe, moderate, mild, and no anemia. From 2005 to 2008, the NSQIP database recorded 23,348 elective open and laparoscopic colectomies that met inclusion criteria. Analyses using multivariable models, controlling for potential confounders and stratifying on propensity score, were performed. RESULTS: Compared with nonanemic patients, those with severe, moderate, and mild anemia were more likely to have the adverse CO with odds ratios of 1.83 (95% CI 1.05 to 3.19), 2.19 (95 % CI 1.63 to 2.94), and 1.49 (95% CI 1.20 to 1.86), respectively. Patients with a normal hematocrit had a reduced hospital LOS, compared with those with severe, moderate, and mild anemia (p < 0.01). A history of cardiovascular disease did not significantly influence these findings. CONCLUSIONS: This large multicenter database analysis suggests that the presence of severe and moderate and even mild preoperative anemia is an independent risk factor for complications and a longer hospital stay after colon surgery.

Does intrathecal morphine sulfate provide preemptive analgesia for patients undergoing stapled hemorrhoidopexy?

OBJECTIVE: Surgical excision of hemorrhoids is characterized by a prolonged and painful postoperative course. This double-blind, randomized, prospective, controlled trial was conducted to determine if morphine sulfate provides additional pain relief after stapled hemorrhoidopexy when added to a standard lidocaine spinal anesthetic. It was hypothesized that the addition of morphine sulfate to a spinal anesthetic would decrease postoperative pain. INTERVENTIONS: Thirty-four patients were randomized prospectively to receive a spinal block with either lidocaine or lidocaine plus morphine sulfate. Patients were followed postoperatively for 42 days to record Numeric Pain Scale (NPS) values and to record analgesic use. Patients also filled out a Short Form 36 (SF-36) Health Survey Questionnaire preoperatively and at days 3, 14, and 28 after their operation to assess physical and mental well-being. Longitudinal mixed models were used to determine whether there was a difference in maximum pain, average pain, narcotic analgesic use, and physical or mental well-being over time. RESULTS: No group differences were found in maximum or average NPS, analgesic use, mental well-being, or time to complete pain relief. There was a four-point difference in mean scores for physical well-being, favoring the lidocaine plus morphine group. CONCLUSIONS: This study provides evidence that intrathecal morphine sulfate does not significantly alter postoperative pain, narcotic use, or well-being when used as preemptive analgesia for patients undergoing stapled hemorrhoidopexy.