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.

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.

Abstract WP415: Electronic Stroke Care Pathway Significantly Increases Quality Improvement Metric Documentation and Patient Education

Introduction: Stroke accounts for 1 in 20 deaths in the US, and increasing stroke healthcare costs are projected to rise to $185 billion yearly by 2030. Care Pathways use standardized electronic medical record (EMR) documentation, order sets, and clinical decision support to streamline institution-wide care delivery and have been shown to improve outcomes. We hypothesize that the Acute Ischemic Stroke (AIS) Care Pathway increases EMR documentation of quality improvement metrics.

Methods: The AIS Care Pathway was implemented starting in 11/2015. It streamlines workflow by providing users with EMR documentation tools, order sets, and clinical aids. We compared the documentation of quality improvement metrics in patients on and off the Care Path, including stroke education and documentation of last known well (LKW), NIH stroke scale (NIHSS), and modified Rankin Scale (mRS).

Results: In 2017, 2,728 patients were diagnosed with AIS; 77% of patients were placed On Care Path, and 23% were Not On Care Path. Documentation of LKW (81% vs 29%, p<0.01), admission NIHSS (100% vs 62%, p<0.01), admission mRS (99% vs 60%, p<0.01), discharge NIHSS (75% vs 46%, p<0.01), and discharge mRS (78% vs 49%, p<0.01) were significantly higher for patients On Care Path compared to those Not On Care Path (Table 1). Likewise, a higher proportion of patients On Care Path received nursing stroke education (74% vs 48%, p<0.01).

Conclusions: AIS Care Pathway significantly increases documentation of quality improvement metrics and education related to stroke care. These are electronically abstracted data that can eliminate the need for manual abstraction.

HPA genotyping by PCR sequence-specific priming (PCR-SSP): a streamlined method for rapid routine investigations

We describe a streamlined method for the simultaneous identification of alleles of the human platelet antigens (HPA) 1-5. The method employs the polymerase chain reaction with sequence specific primers (PCR-SSP). Although PCR-SSP has been applied to HPA genotyping, all methods previously described have required different reaction mixes and PCR conditions. We have designed a set of sequence-specific primers for HPA 1-5 which react optimally under identical reaction and PCR conditions. Comparative testing with reference samples gave 100% concordance. The advantages of this method include speed; accuracy; smaller sample requirements and no reliance on human typing sera or platelet integrity. The method also has the potential to be applied to amniotic fluid. Simplified DNA techniques will lead to more extensive and proficient platelet antigen typing. This will facilitate accurate laboratory diagnosis of alloimmune thrombocytopenia and the provision of HPA-matched blood products.

Analysis of HLA-class-II-encoded antigen-processing genes TAP1 and TAP2 in primary biliary cirrhosis

The search for genes involved in the aetiology of primary biliary cirrhosis (PBC) has centred on the major histocompatibility complex (MHC) on chromosome 6. Genotyping studies have confirmed an association with HLA class II allele DR8. We investigated polymorphisms in two newly identified genes (TAP1 and TAP2) situated close to the DR locus and thought to encode membrane transporter molecules involved in endogenous antigen processing. Genomic DNA extracted from PBC patients was compared with local healthy controls. TAP1 was analysed by amplification refractory mutation system (ARMS) PCR, and two alleles (A and B) were identified. In 126 PBC patients and 116 controls, allele frequencies were (A:B) 81:19% and 79:21%, respectively (NS). TAP2 analysis was by PCR followed by Bfal restriction digest, and again two alleles (A and B) were identified. Their frequencies in 109 PBC patients and 96 controls were (A:B) 76:24% and 73:27%, respectively (NS). No TAP1-TAP2 haplotype was associated with PBC. TAP allele frequencies were estimated within the DR8 subgroups (22 PBC, 14 controls). B allele frequency for TAP1 was increased in both DR8-positive PBC patients and controls compared with DR8-negative patients and controls (41% vs. 14% in PBC; 43% vs. 18% in controls), but no disease association was found. However, the increased frequency of TAP1B in DR8-positive subjects (42% DR8-positive vs. 16% DR8-negative, p < 0.001) indicates linkage disequilibrium between these two loci.

Primary biliary cirrhosis: contribution of HLA class II allele DR8

Primary biliary cirrhosis is a chronic cholestatic disease of unknown aetiology which predominantly affects middle-aged women. It is thought to be autoimmune in nature, but unlike many autoimmune diseases no clear HLA association has been described. Several studies have suggested conflicting associations with HLA class II, although a DR8 association is most frequently described. To test the hypothesis that primary biliary cirrhosis is associated with a certain HLA class II locus we genotyped 130 patients with the disease from the north-east region of England and 363 local healthy controls. HLA-DRB1 and confirmatory DQA and DQB genotypes were determined by TaqI restriction fragment DNA length polymorphism analysis. In addition, a polymerase chain reaction technique (double ARMS) was used to investigate the DRB3 locus (DR52) in 98 primary biliary cirrhosis patients and 107 local controls. We found an increased frequency of HLA-DR8 (18.5% vs 9.2%, p < 0.005, relative risk of 2.0 [1.3-3.1]) in the primary biliary cirrhosis group. HLA-DR8-positive primary biliary cirrhosis patients had a higher serum bilirubin level (p = 0.03) than DR8-negative patients. There was no difference in the DR52 frequencies and no association with markers of disease severity. These results support earlier serological findings, although the association between primary biliary cirrhosis and DR8 is weaker than previously described. In addition, DR8-positivity may identify a clinical subgroup with a worse prognosis.