Molecular weight distribution of pretreated thickened waste activated sludge and fat, oil, and grease

Co-digestion samples containing thickened waste activated sludge and fat, oil and grease were subjected to three different pretreatment methods, i.e., microwave at 175 °C, hyper-thermophilic stage at 70 °C, and conventional heat at 70 °C. The soluble matter extracted from the un-pretreated and pretreated samples were subjected to an ultrafiltration (UF) process using four different membrane sizes (300, 100, 10, and 1 kDa) for molecular weight distribution analysis. Every pretreatment method had a different effect on the solubilization and redistribution of the soluble matter (SCOD and TVFA). For example while MW pretreatment resulted in a significant increase in the SCOD at the lowest molecular weight (< 1 kDa) and at the highest molecular weight (> 300 kDa), Hyper pretreatment caused the majority of the SCOD ( ̴ 62.7% of total SCOD) to be concentrated at the smaller molecular weight range (< 10 kDa). The MW and hyper-thermophilic pretreatments were much more effective in increasing samples solubilization and biogas production compared to the conventional heat pretreatment. The hyper-thermophilic samples had the maximum improvement in cumulative biogas production from all the molecular weights compared to MW- and Heat-pretreated samples; Hyper-pretreated samples achieved 86.5% higher cumulative biogas production compared to the control.

The Role of Home Environments in Allergic Disease

Allergic diseases are surprisingly common, chronic health conditions. The primary location where the vast majority of people are exposed to allergens and other substances is in their home. This means it is important to understand home environments and how a home's systems function and interact-and that how we occupy these spaces plays a crucial role in both environmental exposure and management of allergic disease. This review provides an overview of what is understood about home environmental exposure and its impact on our health, and proposes a systematic process for using a patient's environmental history to develop individualized, manageable and cost-effective recommendations. Once occupant-related information has been gathered, a home environmental exposure assessment should be performed focused on identifying the relationships between any identified sources of contaminants and the housing systems, and conditions that may be contributing to exposure. The results and recommendations from this assessment can then be used to guide exposure-reduction efforts by patients and/or their caregivers in an effort to improve disease management. In this review, we'll discuss three different types of home interventions-active, which must be routinely performed by the patient and/or caregiver, passive, which are interventions that work without routine, direct interaction from the homeowner, and behavioral changes in how the home environment is cleaned and maintained for long-term reduction of allergens. In this review, and others evaluated for this discussion, a significant number of home environmental assessment and intervention programs were shown to be cost effective, with the majority of programs showing a net positive return on investment. It is important to recognize that to be cost effective, the level and intensity of services offered through home visit programs need be stratified, based on the estimated health risks of the patient, in order to tailor the assessment and target the interventions to a patient's needs while maximizing cost effectiveness.

Gas Chromatographic Method for Putrescine and Cadaverine in Canned Tuna and Mahimahi and Fluorometric Method for Histamine (Minor Modification of AOAC Official Method 977.13): Collaborative Study

A collaborative study was conducted to test a modification to the AOAC fluorometric method for histamine (AOAC® Official Method 977.13) that substitutes 75% methanol as the extracting solvent. All other steps remain unchanged. The extracts prepared with 75% methanol were also used to collaboratively test a gas chromatographic (GC) method for determination of putrescine and cadaverine in seafood. In the GC method, the extracted diamines are converted to fluorinated derivatives, the reaction mixtures are passed through solid-phase extraction columns, and the derivatives are quantitated by electron capture GC after separation on an OV-225 column. Fourteen laboratories using the GC method for putrescine and cadaverine and 16 laboratories using the fluorometric method for histamine analyzed 14 canned tuna and raw mahimahi (including blind duplicates and a spike) containing 0.2-2.6 ppm putrescine, 0.6-9.1 ppm cadaverine, and 0.6-154 ppm histamine. At the 5 ppm level, recoveries ranged from 71 to 102% for putrescine and 77 to 112% for cadaverine; the respective repeatability relative standard deviations (RSDr) were 5.2 and 15%, and the respective reproducibility relative standard deviations (RSDR) were 8.8 and 18%. At the 50 ppm level, histamine recoveries ranged from 84 to 125%, RSDr was 3.6%, and RSDR was 9.4%. The GC method for determination of putrescine in canned tuna and cadaverine in canned tuna and mahimahi has been adopted first action by AOAC INTERNATIONAL, and the AOAC Official Method 977.13, Histamine in Seafood, Fluorometric Method, has been modified

Effect on 30-Day Readmissions after Early Versus Delayed Discharge after Uncomplicated Transcatheter Aortic Valve Implantation (from the Nationwide Readmissions Database)

Early discharge after transcatheter aortic valve implantation has been shown to be safe in single-center studies and trials, but outcomes in broader clinical practice are unknown. Using the National Readmission Databases (1/2014 to 9/2015), we compared 30-day readmission rates between early (<3 days) and late (≥3 days) discharges after uncomplicated endovascular TAVR in a propensity-matched cohort. We examined factors associated with failure of early discharge by testing for interactions of patient factors with discharge strategy. Among 4,955 hospitalizations for uncomplicated TAVR, 1,857 (37%) were discharged early with substantial site-level variability (range 0% to 87%; median odds ratio 3.69). In the propensity matched cohort (n = 3,346), there were similar rates of 30-day readmission by discharge strategy (early vs late: 10.3% vs 10.6%; stratified log-rank p = 0.555). There was a statistically significant interaction between discharge strategy and number of chronic conditions (p = 0.007), where readmission rates were lower in patients discharged early in those with 0 to 4 chronic conditions, but not in those with 5 to 10 or >10. In conclusion, in a large "real-world" cohort, early discharge after uncomplicated TAVR was not associated with a higher rate of 30-day rehospitalization, yet there was significant variability across US hospitals. No patient characteristics were associated with increased risk of readmission with early discharge.

Definitions of post-coronary artery bypass grafting myocardial infarction: variations in incidence and prognostic significance

OBJECTIVES

Using data from the CORONARY trial (n = 4752), we evaluated the incidence and prognostic significance of myocardial infarction (MI) applying different definitions based on peak postoperative creatine kinase-MB isoenzyme and cardiac troponin levels. We then aimed to identify the peak cardiac troponin during the first 3 postoperative days that was independently associated with a 2-fold increase in 30-day mortality.

METHODS

To combine different assays, we analysed cardiac troponins in multiples of their respective upper limit of normal (ULN). We identified the lowest threshold with a hazard ratio (HR) >2 for 30-day mortality independent of EuroSCORE and on- versus off-pump surgery.

RESULTS

Depending on the definition used based on creatine kinase-MB, the incidence of MI after coronary artery bypass grafting (CABG) ranged from 0.6% to 19% and the associated HRs for 30-day mortality ranged from 2.7 to 6.9. Using cardiac troponin (1528 patients), the incidence of MI ranged from 1.7% to 13% depending on the definition used with HRs for 30-day mortality ranging from 5.1 to 7.2. The first cardiac troponin threshold we evaluated, 180xULN, was associated with an adjusted HR for 30-day mortality of 7.6 [95% confidence interval (CI) 3.4-17.1] when compared to <130xULN. The next independent threshold was 130xULN with an adjusted HR for 30-day mortality of 7.8 (95% CI 2.3-26.1). The next cardiac troponin tested threshold (70xULN) did not meet criteria for significance.

CONCLUSIONS

Our results illustrate that the incidence and prognosis of a post-CABG MI varies based on the definition used. Validated post-CABG MI diagnostic criteria formulated from their independent association with important clinical outcomes are needed.

Comparing different methods of indexing commercial health care prices

Objective

To compare different methods of indexing health care service prices for the commercially insured population across geographic markets.

Data Sources

Health Care Cost Institute commercial claims data from 2012 to 2016.

Study Design

We compare price indices computed using methods with differing levels of computational intensity: weighted‐average versus regression‐based methods. We separately compute indices of the prices paid for set of common inpatient and set of common outpatient services in different markets across the United States using each type of method. We subsequently examined the variation of and correlations between the resulting index values.

Data Collection/Extraction Methods

We computed health care service price indices separately using samples of inpatient and outpatient facility claims from 2012 to 2016 across 112 Core‐Based Statistical Areas. Within each category of services, claims were limited to members under the age of 65 with employer‐sponsored insurance. Both samples were limited to a common set of services that made up nearly 80 percent of the service use in the full sample every year.

Principal Findings

We found that the methods studied produced highly correlated price indices (r > .94) with similar distributions across years for both inpatient and outpatient services.

Conclusions

Our findings suggest that weighted‐average methods, which are much less computationally intensive, will generate results similar to regression‐based methods.

The learning curve on uniportal video-assisted thoracic surgery: An analysis of proficiency

OBJECTIVES

Minimally invasive techniques for lung cancer surgery have revolutionized thoracic surgery, and single-port approaches are becoming increasingly used. We analyzed our experience with uniportal video-assisted thoracoscopic surgery for lobectomy to identify the number of procedures necessary to achieve proficiency according to clinical outcomes.

METHODS

We queried our institutional prospective database for all single-port lobectomies in patients with early-stage lung cancer performed by a single surgeon from 2014 to 2017; 274 patients met the inclusion criteria. Using cubic splines, we derived 3 distinct learning phases based on the length of the procedure. Blood loss, additional port insertion, and conversion to thoracotomy were also compared according to these learning phases.

RESULTS

The initial phase (procedures 1-60) had the longest procedure times and the most variability in procedure length (158.8 ± 52.2 minutes) compared with the transition phase (procedures 61-140; 145.9 ± 43.8 minutes) and the proficient phase (procedures 141-274; 117.9 ± 32.6 minutes, P < .001). Blood loss (156 mL vs 130.4 mL vs 64.9 mL, P = .003), conversion rate to thoracotomy (11.7% vs 3.8% vs 0.7%, P = .001), and need for a second incision (8.3% vs 5% vs 0.7%, P = .025) were all highest during the initial phase. In a multivariable model, there was a significant interaction between procedure number and learning phase (P = .003), indicating that the effect of each additional procedure on procedure length differed in each phase.

CONCLUSIONS

In this analysis, a distinct learning curve for uniportal video-assisted thoracoscopic surgery lobectomy was observed. Procedure time decreased sharply at approximately the 60th procedure, but 80 additional lobectomies were required to master the approach.

High prevalence of non-alcoholic fatty liver disease in patients with inflammatory bowel disease receiving anti-tumor necrosis factor therapy

Background:

Non-alcoholic fatty liver disease (NAFLD) is common in patients with inflammatory bowel disease (IBD). This study evaluated the prevalence of NAFLD and the associated risk factors among IBD patients who received anti-tumor necrosis factor (TNF) therapy.

Methods:

Adult IBD patients receiving anti-TNF therapy (infliximab, adalimumab, certolizumab, golimumab) were enrolled. Hepatic steatosis was assessed by abdominal ultrasound. Patients with a history of excessive alcohol or recent steroid use were excluded. Univariate and multivariate analysis were performed.

Results:

Eighty patients, 55% male, mean age 42±15 years, were enrolled. The sonographic prevalence of NAFLD was 54% (43/80), significantly higher than the general prevalence in the US adult population (30%) (P<0.0001). NAFLD patients had a significantly higher proportion of males, as well as greater body weight and body mass index, compared to non-NAFLD. The Crohns disease activity index (CDAI) was significantly higher among patients with NAFLD. Multivariate analysis demonstrated that a higher CDAI was independently associated with NAFLD, with an odds ratio of 1.6 (95% confidence interval 1.05-2.44; P=0.03).

Conclusions:

The presence of IBD is strongly associated with NAFLD. We identified a high prevalence of NAFLD among IBD patients receiving anti-TNF. CDAI was independently associated with hepatic steatosis. Further studies are still needed to evaluate the pathophysiology of NAFLD development and disease progression among IBD populations.

Centralized Communication of Blood Culture Results Leveraging Antimicrobial Stewardship and Rapid Diagnostics

Objective

This study aimed to determine if integrating antimicrobial stewardship program (ASP) personnel with rapid diagnostic testing resulted in improved outcomes for patients with positive blood cultures.

Method

Beginning in 2016, Saint Luke’s Health System (SLHS) implemented a new process where all positive blood cultures were communicated to ASP personnel or SLHS pharmacy staff. Pharmacists then became responsible for interpreting results, assessing patient specific information, and subsequently relaying culture and treatment information to providers. This was a multisite, pre-post, quasi-experimental study (Pre: August to December 2014; Post: August to December 2016). Patients 18 years of age and older with a positive blood culture during admission were included (2014, n = 218; 2016, n = 286). Coprimary outcomes of time to optimal and appropriate therapy were determined from time of culture positivity via gram stain. Secondary outcomes focused on clinical, process, and fiscal endpoints. A pre-post intervention physician survey was conducted to assess the impact on antimicrobial decision making and perceived effect on patient outcomes.

Results

There was no difference in time to appropriate therapy groups (P = .079). Time to optimal therapy was 9.2 hours shorter in 2016 (P = .004). Provider surveys indicated the process improved communication among clinicians and facilitated a shared decision-making process with a perceived improvement in patient care.

Conclusions

An ASP-led blood culture communication process for patients with positive blood cultures was shown to improve time to optimal therapy, support physicians in their decision making on critical lab data, and improve the care for hospitalized patients.

Preimplant Phosphodiesterase-5 Inhibitor Use Is Associated With Higher Rates of Severe Early Right Heart Failure After Left Ventricular Assist Device Implantation

Background Early right heart failure (RHF) occurs commonly in left ventricular assist device (LVAD) recipients, and increased right ventricular (RV) afterload may contribute. Selective pulmonary vasodilators, like phosphodiesterase-5 inhibitors (PDE5i), are used off-label to reduce RV afterload before LVAD implantation, but the association between preoperative PDE5i use and early RHF after LVAD is unknown. Methods and Results We analyzed adult patients from the INTERMACS registry (Interagency Registry for Mechanically Assisted Circulatory Support) who received a continuous flow LVAD after 2012. Patients on PDE5i were propensity-matched 1:1 to controls. The primary outcome was the incidence of severe early RHF, defined as the composite of death from RHF within 30 days, need for RV assist device support within 30 days, or use of inotropes beyond 14 days. Of 11 544 continuous flow LVAD recipients, 1199 (10.4%) received preoperative PDE5i. Compared to controls, patients on PDE5i had higher pulmonary artery systolic pressure (53.4 mm Hg versus 49.5 mm Hg) and pulmonary vascular resistance (2.6 WU versus 2.3 WU; P<0.001 for both). Before propensity matching, the incidence of severe early RHF was higher among patients on PDE5i than in controls (29.4% versus 23.1%; unadjusted odds ratio (OR), 1.32; 95% CI, 1.17-1.50). This association persisted after propensity matching (PDE5i, 28.9% versus control 23.7%; OR, 1.31; 95% CI, 1.09-1.57), driven by a higher incidence of prolonged inotropic support. Similar results were observed across a wide range of subgroups stratified by markers of pulmonary vascular disease and RV dysfunction. Conclusions Patients treated with preoperative PDE5i had markers of increased RV afterload and HF severity compared to unmatched controls. Even after propensity matching, patients receiving preimplant PDE5i therapy had higher rates of post-LVAD RHF.

Candidaemia and a risk predictive model for overall mortality: a prospective multicentre study

Background

Candidaemia is associated with high mortality. Variables associated with mortality have been published previously, but not developed into a risk predictive model for mortality. We sought to describe the current epidemiology of candidaemia in Australia, analyse predictors of 30-day all-cause mortality, and develop and validate a mortality risk predictive model.

Methods

Adults with candidaemia were studied prospectively over 12 months at eight institutions. Clinical and laboratory variables at time of blood culture-positivity were subject to multivariate analysis for association with 30-day all-cause mortality. A predictive score for mortality was examined by area under receiver operator characteristic curves and a historical data set was used for validation.

Results

The median age of 133 patients with candidaemia was 62 years; 76 (57%) were male and 57 (43%) were female. Co-morbidities included underlying haematologic malignancy (n = 20; 15%), and solid organ malignancy in (n = 25; 19%); 55 (41%) were in an intensive care unit (ICU). Non-albicans Candida spp. accounted for 61% of cases (81/133). All-cause 30-day mortality was 31%. A gastrointestinal or unknown source was associated with higher overall mortality than an intravascular or urologic source (p < 0.01). A risk predictive score based on age > 65 years, ICU admission, chronic organ dysfunction, preceding surgery within 30 days, haematological malignancy, source of candidaemia and antibiotic therapy for ≥10 days stratified patients into < 20% or ≥ 20% predicted mortality. The model retained accuracy when validated against a historical dataset (n = 741).

Conclusions

Mortality in patients with candidaemia remains high. A simple mortality risk predictive score stratifying patients with candidaemia into < 20% and ≥ 20% 30-day mortality is presented. This model uses information available at time of candidaemia diagnosis is easy to incorporate into decision support systems. Further validation of this model is warranted.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4065-5) contains supplementary material, which is available to authorized users.

Abstract 196: Omission of Heart Transplant Recipients from the Appropriate Use Criteria for Revascularization and Impact on High-Volume Heart Transplant Centers

Background: For heart transplant recipients, guidelines endorse routine coronary angiography and percutaneous coronary intervention (PCI) to screen for and treat cardiac allograft vasculopathy (CAV). However, current Appropriate Use Criteria for Revascularization (AUC-R) do not recognize CAV as a unique PCI indication, and thus PCI for CAV is often labeled “rarely appropriate (RA).” The AUC-R’s omission of CAV patients, and its impact on RA PCI rates and hospital pay-for-performance reimbursement have never been described.

Methods: Using NCDR CathPCI Registry data, we identified all elective PCIs from 96 Medicare-approved heart transplant centers between 2009Q3 and 2017Q2. NCDR-reported rates of RA elective PCI were compared before and after exclusion of CAV patients using paired t-tests. The annual pay-for-performance financial incentives potentially lost by heart transplant centers were estimated based on AUC-R performance thresholds published by Anthem Blue Cross and Blue Shield’s Quality-In-Sights®: Hospital Incentive Program (Q-HIP®).

Results: Of 168,802 elective PCIs performed in heart transplant centers, 1,854 (1.1%) were for CAV. CAV patients, compared with non-heart transplant recipients, were more frequently asymptomatic (81.9% vs. 33.4%, p<0.001) and had lower rates of prior stress testing (15.0% vs. 58.4%, p<0.001), resulting in higher RA PCI rates (66.0% vs 16.9%, p<0.001). In transplant centers, the absolute difference in RA rates (before vs. after exclusion of CAV patients) was directly associated with the proportion of total PCIs performed in CAV patients (p<0.001, Figure ). In a sample of 16 heart transplant centers participating in Q-HIP® during the 2017 calendar year measurement period, 2 (13%) centers could have each observed reimbursement increases estimated at ~$90,000 dollars if their Q-HIP® scorecards were re-scored after excluding CAV patients.

Conclusion: Two-thirds of PCI cases in CAV patients are deemed RA by the AUC-R. The failure of the AUC-R to recognize CAV as a unique PCI indication may lead to inflated RA PCI rates and has the potential for substantial negative pay-for-performance implications in heart transplant centers. The AUC-R should recognize CAV as a unique PCI indication so that heart transplant centers are not penalized for performing PCI for CAV.