US trends of in-hospital morbidity and mortality for acute myocardial infarctions complicated by cardiogenic shock

BACKGROUND

There is limited real-world data highlighting recent temporal in-hospital morbidity and mortality trends for cases of acute myocardial infarction complicated by cardiogenic shock. The role of mechanical circulatory support within this patient population remains unclear.

METHODS

The US National Inpatient Sample database was sampled from 2011 to 2018 identifying 206,396 hospitalizations with a primary admission diagnosis of ST- or Non-ST elevation myocardial infarction complicated by cardiogenic shock. The primary outcomes included trends of all-cause in-hospital mortality, mechanical circulatory support use, and sex-specific trends for acute myocardial infarction complicated by cardiogenic shock (AMI-CS) over the study period.

RESULTS

The annual number of AMI-CS hospitalizations increased from 22,851 in 2011 to 30,015 in 2018 and in-hospital mortality trends remained similar (42.9 % to 43.7 %, ptrend < 0.001). The proportion of patients receiving any temporary MCS device decreased (46.4 % to 44.4 %). The use of intra-aortic balloon pump (IABP) decreased (44.9 % to 32.9 %) and the use of any other non-IABP MCS device increased (2.5 % to 15.6 %), ptrend<0.001. Sex-specific mortality indicate female in-hospital mortality remained similar (50.3 % to 51 %, ptrend<0.001), but higher than male in-hospital mortality, which increased non-significantly (38.8 % to 40.2 %, ptrend = 0.372).

CONCLUSIONS

From 2011 to 2018, hospitalizations for AMI-CS patients have increased in number. However, there has been no recent appreciable change in AMI-CS mortality despite a changing treatment landscape with decreasing use of IABPs and increasing use of non-IABP MCS devices. Further research is necessary to examine the appropriate use of MCS devices within this population.

Dientamoeba fragilis associated with microbiome diversity changes in acute gastroenteritis patients

This study examined the correlation between intestinal protozoans and the bacterial microbiome in faecal samples collected from 463 patients in New Zealand who were diagnosed with gastroenteritis. In comparison to traditional microscopic diagnosis methods, Multiplexed-tandem PCR proved to be more effective in detecting intestinal parasites. Among the identified protozoans, Blastocystis sp. and Dientamoeba fragilis were the most prevalent. Notably, D. fragilis was significantly associated with an increase in the alpha-diversity of host prokaryotic microbes. Although the exact role of Blastocystis sp. and D. fragilis as the primary cause of gastroenteritis remains debatable, our data indicates a substantial correlation between these protozoans and the prokaryote microbiome of their hosts, particularly when compared to other protists or patients with gastroenteritis but no detectable parasitic cause. These findings underscore the significance of comprehending the contributions of intestinal protozoans, specifically D. fragilis, to the development of gastroenteritis and their potential implications for disease management.

From farm sustainability to ecosystem sustainability: Exploring the limitations of farm-applied aquaculture eco-certification schemes

Aquaculture eco-certification schemes provide standards against which individual farms are assessed, and those farms that comply with eco-certification criteria receive certified status. These schemes aim to improve aquaculture sustainability, but the site-by-site approach of eco-certification can be a barrier to the inclusion of ecosystem perspectives in the evaluation of farm sustainability. However, the ecosystem approach to aquaculture demands a management approach that considers broader scale ecosystem impacts. This study explored how eco-certification schemes and processes account for potential ecosystem impacts of salmon farms. Interviews with eco-certification auditors, salmon producers, and eco-certification staff were conducted. The experience of participants and information from eco-certification scheme criteria and other eco-certification scheme documents were used to identify thematic challenges associated with the consideration of ecosystem impacts including: assessing far-field impacts, managing cumulative effects, and anticipating ecosystem risks. Results indicate that eco-certification schemes work within the limitations of farm-scale application of global eco-certification standards to address potential ecosystem impacts by: (1) including eco-certification scheme criteria that address ecosystem impacts, (2) relying on the experience, expertise, and judgement of eco-certification auditors, and (3) referencing and deferring to local regulations. Results indicate that eco-certification schemes can address ecosystem impacts to some degree, despite their site-by-site approach. The integration of additional tools while supporting the capacity of farms to apply those tools, as well as increasing transparency during compliance assessment could help eco-certification schemes shift from providing assurance of farm sustainability to providing assurance of ecosystem sustainability.

Atrioventricular nodal ablation with pacemaker implant is associated with improved safety outcomes compared to pulmonary vein isolation of atrial fibrillation with heart failure

Background

Pulmonary vein isolation (PVI) and atrioventricular nodal ablation (AVNA) with pacemaker implant have both been advocated for patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF). Direct comparisons between the two are limited.

Purpose

We sought to compare outcomes and complications following PVI versus AVNA with implant of a cardiac implantable electronic device (CIED) among patients with AF and HFrEF.

Methods

We queried the National Inpatient Sample from 2011 to 2019, using relevant ICD-9 and -10 diagnostic and procedural codes for AF, HFrEF, ablation, and CIED implant to identify our study cohort. Exclusion criteria included presence of a pre-existing CIED, ventricular arrhythmias, non-AF supraventricular arrhythmias, and surgical AF ablation. Baseline characteristics included age, sex, race, and comorbidities related to AF and cardiovascular disease. Severity of comorbidities was assessed via Deyo-Charlson Comorbidity Index (Deyo-CCI). Outcomes investigated include all-cause mortality, major adverse cardiovascular events (MACE), extra-cardiac procedural complications, length of stay, and total hospital charges. Outcomes associations were analyzed using multivariate logistic regression adjusted for baseline characteristics that were significantly different (P&lt;0.05) between cohorts expressed as adjusted odds ratios (aOR) and 95% confidence intervals (CI). SPSS v28.0 (IBM, Armonk, NY) was used to carry out all calculations.

Results

We identified 3,565 encounters for PVI and 1,355 for AVNA with CIED implant among hospitalized patients with AF and HFrEF. Patients who underwent AVNA were more often older (73.8 vs 66.2 years), with more severe comorbidities (mean Deyo-CCI score 2.9 vs 2.6) and were more likely to have an emergent procedure performed (81.3% vs 69.7%; p&lt;0.001 for all). However, the AVNA cohort had less mortality (0.5% vs 1.2%, p=0.03), MACE (6.1% vs 7.8%, p=0.04), and total complications (12.7% vs 16.3%, p=0.002), but longer hospital stay (8.0 vs 6.5 days) and higher total charges ($201,100 vs $159,382; p&lt;0.001 for both). After adjusting for confounders, AVNA remained independently associated with decreased odds of mortality (aOR: 0.370; 95% CI [0.159–0.862], p=0.02), MACE (aOR: 0.552; 95% CI [0.420–0.726], p&lt;0.001), and total complications (aOR: 0.708; 95% CI [0.589–0.852], p&lt;0.001).

Conclusion

Despite older age with more severe comorbidities and less elective procedures, hospitalized patients with AF and HFrEF who underwent AVNA with CIED implant had improved safety outcomes compared to PVI. Further studies comparing the intermediate and long-term outcomes and efficacy between therapies are needed to better delineate which would best serve this population.

Funding Acknowledgement

Type of funding sources: None.

Assessing outcomes following catheter ablation of ventricular tachycardia in patients with durable left ventricular assist devices

Background

Management of ventricular tachycardia (VT) after implant of a durable left ventricular assist device (LVAD) is challenging, without consensus on optimal therapy. Multiple small studies have examined catheter ablation of VT in these patients with low reported incidence of complications.

Purpose

We sought to evaluate periprocedural outcomes following VT ablation among LVAD recipients.

Methods

We queried the National Inpatient Sample from 2011 to 2019 to conduct our study. Baseline characteristics include age, sex, race, and comorbidities related to cardiovascular disease. Comorbidity severity was assessed using the Deyo-Charlson Comorbidity Index (Deyo-CCI). Patients with any supraventricular arrhythmias were excluded. Outcomes investigated include heart transplant procedure, all-cause mortality, major adverse cardiovascular events (MACE), and periprocedural complications. Multivariate regression was used to analyze outcomes associations adjusted for baseline characteristics that were significantly different (P&lt;0.05) between cohorts expressed as adjusted odds ratios (aOR) and 95% confidence intervals (CI). SPSS v28.0 (IBM, Armonk, NY) was used to carry out all calculations.

Results

We identified 56 patients who underwent ablation among 2,202 LVAD recipients hospitalized for VT. Patients who underwent ablation were more likely to have ischemic cardiomyopathy (33.9% vs. 22.2%, p=0.03) or an automated implantable cardioverter-defibrillator (55.4% vs 34.3%, p=0.001). There were otherwise no significant differences between cohorts (mean Deyo-CCI score of 2.3 for both, p=0.48). Between those who did and did not undergo ablation, there were no significant differences in heart transplant (5.4 vs 5.0%, p=0.9), mortality (7.1% vs 7.0%, p=0.96), total strokes (3.6% vs 5.0%, p=0.48), myocardial infarction (3.6% vs 4.6%, p=0.71), overall MACE (8.9% vs 10.2%, p=0.26) or total complications (35.7% vs 41.9%, p=0.35). There were no incidents of pump thrombosis in the ablation group, but 92 events (4.3%) were found in the medical therapy group. Multivariate analysis affirmed no significant association between ablation and mortality (aOR 1.277, CI [0.450–3.629]), MACE (aOR 1.125, CI [0.436–2.902]), or total complications (aOR 0.932, CI [0.528–1.645]).

Conclusion

Overall complications following VT ablation among LVAD patients were higher than previously reported but no statistically significant differences were found compared to conservative management. While ablation appears safe to perform, particularly among those with structural heart disease and ischemic cardiomyopathy, longer duration studies are needed to determine the efficacy of this procedure.

Funding Acknowledgement

Type of funding sources: None.

Gender disparities in ventricular tachycardia: evaluating clinical outcomes and interventions

Background

Gender differences in the etiology of ventricular arrhythmia are well-known and can potentially affect clinical outcomes. Women have been under-represented in studies investigating ventricular tachycardia (VT). Thus, gender differences in clinical outcomes of VT are poorly defined.

Purpose

We sought to elucidate the clinical outcomes and interventions among women with VT.

Methods

We used the National Inpatient Sample to identify patients aged 18 and older admitted with VT from 2011 to 2019. Observations missing data on age, sex and mortality were excluded. Baseline characteristics include age, race, and comorbidities related to cardiovascular disease. Severity of comorbidities was assessed via the Deyo-Charlson Comorbidity Index (Deyo-CCI) score. Outcomes investigated include all-cause mortality, major adverse cardiovascular events (MACE), and incidence of catheter ablation, cardioversion, and automated implantable cardioverter defibrillator (AICD) insertion. Gender and outcomes association were analyzed using multivariable logistic regression adjusted for baseline characteristics that were significantly different (P&lt;0.05) between cohorts expressed as adjusted odds ratios (aOR) and 95% confidence intervals (CI). SPSS v28.0 (IBM, Armonk, NY) was used to carry out all calculations.

Results

Between 2011 and 2019, there were an estimated 3,544,445 hospital admissions for VT, of which, 33.8% were women, who were more likely to be older (69.2 vs 68.0 years) and of minority descent (30.3% vs 26.7%) compared to men. Women were less likely to have coronary artery disease (43.5% vs 62.2%) or ischemic cardiomyopathy (5.0% vs 11.9%) and had a lower mean Deyo-CCI score (2.2 vs 2.4; p&lt;0.001 for all). Women had a higher incidence of mortality (10.6% vs 9.2%) and ischemic stroke (5.3% vs 4.5%), but less acute coronary syndrome (17.6% vs 21.4%; p&lt;0.001 for all). Overall incidence of MACE was lower among women (28.6% vs 31.4%; p&lt;0.001). Multivariate regression analysis demonstrated that female sex remained independently associated with increased odds for all-cause mortality (aOR: 1.089; 95% CI: [1.062–1.116], p&lt;0.001) although decreased odds for MACE (aOR: 0.952; 95% CI: [0.939–0.965]). Female sex was also independently associated with decreased odds for cardioversion (aOR: 0.936; 95% CI: [0.910–0.963]), AICD insertion, (aOR: 0.737; 95% CI: [0.711–0.764]) and ablation (aOR: 0.806; 95% CI: [0.766–0.847]; all p&lt;0.001).

Conclusion

In this retrospective analysis of patients hospitalized with VT, women had less coronary artery disease and less MACE, yet all-cause mortality was higher. Female sex was also independently associated with fewer interventions, including AICD insertion and ablation. Although there are gender differences in risk factors and causes of VT, this does not fully explain disparities in care and outcomes. Further studies are needed to explore and elucidate these gender disparities.

Funding Acknowledgement

Type of funding sources: None.

Measurement properties of the WHO Disability Assessment Schedule 2.0 for evaluating functional status after inpatient surgery

BACKGROUND

Expert recommendations propose the WHO Disability Assessment Schedule (WHODAS) 2.0 as a core outcome measure in surgical studies, yet data on its long-term measurement properties remain limited. These were evaluated in a secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) prospective cohort.

METHODS

Participants were adults (40 years of age or older) who underwent inpatient non-cardiac surgery. The 12-item WHODAS and EQ-5DTM-3L questionnaires were administered preoperatively (in person) and 1 year postoperatively (by telephone). Responsiveness was characterized using standardized response means (SRMs) and correlation coefficients between change scores. Construct validity was evaluated using correlation coefficients between 1-year scores and comparisons of WHODAS scores across clinically relevant subgroups.

RESULTS

The analysis included 546 patients. There was moderate correlation between changes in WHODAS and various EQ-5DTM subscales. The strongest correlation was between changes in WHODAS and changes in the functional domains of the EQ-5D-3L-for example, mobility (Spearman's rho 0.40, 95 per cent confidence interval [c.i.] 0.32 to 0.48) and usual activities (rho 0.45, 95 per cent c.i. 0.30 to 0.52). When compared across quartiles of EQ-5D index change, median WHODAS scores followed expected patterns of change. In subgroups with expected functional status changes, the WHODAS SRMs ranged from 'small' to 'large' in the expected directions of change. At 1 year, the WHODAS demonstrated convergence with the EQ-5D-3L functional domains, and good discrimination between patients with expected differences in functional status.

CONCLUSION

The WHODAS questionnaire has construct validity and responsiveness as a measure of functional status at 1 year after major surgery.

Abstract P036: The Association Of CD4:CD8 Ratio With Cardiometabolic Risk Factors In People With HIV

Background: In People with HIV (PWH) with virologic suppression, the CD4:CD8 ratio inversely correlates with immune senescence response. The association between CD4:CD8 ratio and cardiovascular (CV) risk in PWH remains unclear.

Methods: A retrospective chart review was performed of patients who received HIV care at the University of Miami/Jackson Memorial Hospital between 2017-2019 with available CD4: CD8 ratio (n=1,137). We stratified patients according to the CD4:CD8 ratio ≥1 or <1, and compared available data.

Results: The prevalence of CD4:CD8 ratio <1 was 69.5%. A ratio <1 was associated with male gender (57.1% vs 45.8%, p<0.001), lower body mass index (28.29 vs 29.80 kg/m2, p=0.001), lower HDL cholesterol (Chol) (47.57 vs. 53.25 mg/dL, p<0.001), higher total Chol/HDL (4.22 vs. 3.8, p=0.001), higher CRP levels (4.94 vs. 2.61 mg/L, and less statin use (25% vs 35.3%, p<0.001), p=0.02) compared to those with a ratio ≥1. Those with a CD4:CD8 ratio <1 were more likely to have a detectable viral load (35.9% vs. 14.6%. p<0.001), have been on antiretroviral therapy for <6 months (4% vs 1.5%, p=0.27), to be current smokers (27.6% vs. 16.5%, p<0.001), current drug users (9.7% vs 5.5%, p=0.025), and had higher rates of atrial fibrillation/flutter (1.9% vs 0%, p=0.008) than those with a ratio ≥1.

Conclusion: Patients with an inverted CD4:CD8 ratio had higher total Chol/HDL levels, which has been associated with a higher risk of CV disease. Statin use in this high-risk population was lower despite having more CV risk factors and atrial fibrillation/flutter. Further studies are needed to determine the usefulness of the CD4:CD8 ratio as a marker of immune activation and predictor of CV risk in PWH.

The association of racial differences with in-hospital outcomes of patients admitted for sinus node dysfunction

Background

The impact of race and its related social determinants of health on cardiovascular disease outcomes has been well documented. However, limited data exist regarding the association of race with in-hospital outcomes in patients admitted for sinus node dysfunction (SND).

Objective

To evaluate whether racial disparities exist in outcomes for patients hospitalized with a primary diagnosis of SND.

Methods

The National Inpatient Sample was queried from 2011 to 2018 for relevant ICD-9 and ICD-10 diagnosis and procedure codes. Baseline characteristics and in-hospital outcomes in patients with a primary diagnosis of SND were compared among White and non-White patients. A multivariate logistic regression model was used to adjust for potential confounding factors and statistically significant comorbidities between both cohorts.

Results

We identified 655,139 persons admitted with a primary diagnosis of SND, 520,926 (79.5%) of whom were White. Non-White patients had significantly higher all-cause mortality, length of stay, and total hospital cost. There were lower odds of pacemaker insertion (adjusted odds ratio [aOR] 1.13 [95% confidence interval (CI) 1.11–1.15]), temporary transvenous pacing (aOR 1.15 [95% CI 1.11–1.22]), and cardioversion (aOR 1.50 [95% CI 1.42–1.58]) in non-White patients. A subgroup analysis was performed and non-Hispanic Black race was predictive of a decreased odds of pacemaker insertion, cardioversion/defibrillation, and temporary transvenous pacing.

Conclusion

Significant differences of in-hospital outcomes exist between White and non-White patients with SND. These findings appeared to be primarily driven by disparities in non-Hispanic Black patients. Increased recognition and focused efforts to mitigate these disparities will improve the care of underrepresented populations treated for SND.

Micromolar Metabolite Measurement in an Electronically Multiplexed Format

The detection of metabolites such as choline in blood are important in clinical care for patients with cancer and cardiovascular disease. Choline is only present in human blood at low concentrations hence accurate measurement in an affordable point-of-care format is extremely challenging. Integration of microfluidics on to complementary metal-oxide semiconductor (CMOS) technology has the potential to enable advanced sensing technologies with extremely low limit of detection that are well suited to multiple clinical metabolite measurements. Although CMOS and microfluidics are individually mature technologies, their integration has presented challenges that we overcome in a novel, cost-effective, single-step process. To demonstrate the process, we present the microfluidic integration of a metabolomics-on-CMOS point-of-care platform with four capillary microfluidic channels on top of a CMOS optical sensor array. The fabricated device was characterised to verify the required structural profile, mechanical strength, optical spectra, and fluid flow. As a proof of concept, we used the device for the in-vitro quantification of choline in human blood plasma with a limit of detection of 3.2 M and a resolution of 1.6 M.

Effect of Gender on Prognosis in Patients With Takotsubo Syndrome (from a Nationwide Perspective)

Takotsubo syndrome (TTS) largely affects postmenopausal women but has been shown to carry increased mortality risk in men. We sought to evaluate nationwide in-hospital outcomes between men and women admitted with TTS to better characterize these disparities. Using the National Inpatient Sample database from 2011 to 2018, we identified a total of 48,300 hospitalizations with the primary diagnosis of TTS. The primary end point was in-hospital all-cause mortality. Secondary end points included in-hospital complications, length of stay, and discharge disposition. Men with TTS accounted for 8.9% of hospitalizations, were younger in age (62.0 ± 15.1 vs 66.8 ± 12.1 years, p <0.001), and were more frequently Black (9.7% vs 5.8%, p <0.001). Nationwide TTS mortality rates were 1.1% overall and may be improving, but remained higher in men than in women (2.2% vs 1.0%, p <0.001). Male gender was associated with increased all-cause mortality (adjusted odds ratios 2.41, 95% confidence interval 1.88 to 3.10, p <0.001), greater length of stay, and discharge complexity. Men carried increased co-morbidity burden associated with increased cardiogenic shock or mortality, including atrial fibrillation, thrombocytopenia, chronic kidney disease, and chronic obstructive pulmonary disease. Men more frequently developed acute kidney injury, ventricular arrhythmias, cardiac arrest, and respiratory failure. Male gender remains associated with nearly 2.5-fold increase in in-hospital mortality risk. In conclusion, early identification of patients with high-risk co-morbidities and close monitoring for arrhythmias, renal injury, or cardiogenic shock may reduce morbidity and mortality.

Comparison of household income in in-hospital outcomes after implantation of left ventricular assist device

INTRODUCTION

Due to the inability to keep up with the demand for heart transplantation, there is an increased utilization of left ventricular assist devices (LVAD). However, paucity of data exists regarding the association of household income with in-hospital outcomes after LVAD implantation.

METHODS

Retrospective cohort study using the NIS to identify all patients ⩾18 years who underwent LVAD implantation from 2011 to 2017. Statistical analysis was performed comparing low household income (⩽50th percentile) and high income (>50th percentile).

RESULTS

A total of 25,503 patients underwent LVAD implantation. The low-income group represented 53% and the high-income group corresponded to 47% of the entire cohort. The low-income group was found to be younger (mean age 55 ± 14 vs 58 ± 14 years), higher proportion of females (24% vs 22%), and higher proportion of blacks (32% vs 16%, p < 0.001 for all). The low-income group was found to have higher prevalence of hypertension, chronic pulmonary disease, smoking, dyslipidemia, obesity, and pulmonary hypertension (p < 0.001 for all). However, the high-income cohort had higher rate of atrial tachyarrhythmias and end-stage renal disease (p < 0.001). During hospitalization, patients in the high-income group had increased rates of ischemic stroke, acute kidney injury, acute coronary syndrome, bleeding, and need of extracorporeal membrane oxygenation (p < 0.001 for all). We found that the unadjusted mortality had an OR 1.30 (CI 1.21-1.41, p < 0.001) and adjusted mortality of OR 1.14 (CI 1.05-1.23, p = 0.002).

CONCLUSION

In patients undergoing LVAD implantation nationwide, low-income was associated with increased comorbidity burden, younger age, and fewer in-hospital complications and all-cause mortality.

Differences in obstetrical care and outcomes associated with the proportion of the obstetrician's shift completed

BACKGROUND

Understanding and improving obstetrical quality and safety is an important goal of professional societies, and many interventions such as checklists, safety bundles, educational interventions, or other culture changes have been implemented to improve the quality of care provided to obstetrical patients. Although many factors contribute to delivery decisions, a reduced workload has addressed how provider issues such as fatigue or behaviors surrounding impending shift changes may influence the delivery mode and outcomes.

OBJECTIVE

The objective was to assess whether intrapartum obstetrical interventions and adverse outcomes differ based on the temporal proximity of the delivery to the attending's shift change.

STUDY DESIGN

This was a secondary analysis from a multicenter obstetrical cohort in which all patients with cephalic, singleton gestations who attempted vaginal birth were eligible for inclusion. The primary exposure used to quantify the relationship between the proximity of the provider to their shift change and a delivery intervention was the ratio of time from the most recent attending shift change to vaginal delivery or decision for cesarean delivery to the total length of the shift. Ratios were used to represent the proportion of time completed in the shift by normalizing for varying shift lengths. A sensitivity analysis restricted to patients who were delivered by physicians working 12-hour shifts was performed. Outcomes chosen included cesarean delivery, episiotomy, third- or fourth-degree perineal laceration, 5-minute Apgar score of <4, and neonatal intensive care unit admission. Chi-squared tests were used to evaluate outcomes based on the proportion of the attending's shift completed. Adjusted and unadjusted logistic models fitting a cubic spline (when indicated) were used to determine whether the frequency of outcomes throughout the shift occurred in a statistically significant, nonlinear pattern RESULTS: Of the 82,851 patients eligible for inclusion, 47,262 (57%) had ratio data available and constituted the analyzable sample. Deliveries were evenly distributed throughout shifts, with 50.6% taking place in the first half of shifts. There were no statistically significant differences in the frequency of cesarean delivery, episiotomy, third- or fourth-degree perineal lacerations, or 5-minute Apgar scores of <4 based on the proportion of the shift completed. The findings were unchanged when evaluated with a cubic spline in unadjusted and adjusted logistic models. Sensitivity analyses performed on the 22.2% of patients who were delivered by a physician completing a 12-hour shift showed similar findings. There was a small increase in the frequency of neonatal intensive care unit admissions with a greater proportion of the shift completed (adjusted P=.009), but the findings did not persist in the sensitivity analysis.

CONCLUSION

Clinically significant differences in obstetrical interventions and outcomes do not seem to exist based on the temporal proximity to the attending physician's shift change. Future work should attempt to directly study unit culture and provider fatigue to further investigate opportunities to improve obstetrical quality of care, and additional studies are needed to corroborate these findings in community settings.

Cardiovascular disease and prevention among people living with HIV in South Florida

Antiretroviral therapy (ART) has improved survival of patients living with HIV (PLWH); however, this has been accompanied by an increase in cardiovascular disease (CVD). Although preventative measures for CVD among the general population are well described, information is limited about CVD prevention among PLWH. The goal of this study was to characterize the prevalence of CVD in our population and to assess the use of primary and secondary prevention.We performed a retrospective review of PLWH receiving primary care at a large academic center in Miami, Florida. We characterized the prevalence of CVD, CVD risk, and the use of aspirin and statins for primary and secondary CVD prevention.A total of 985 charts were reviewed (45% women, 55% men). Average age was 52.2 years. Average CD4 count was 568 cells/microL. 92.9% were receiving ART, and 71% were virologically suppressed. The median 10-year ASCVD risk was 7.3%. The prevalence of CVD was 10.4% (N = 102). The odds of having CVD was lower in patients on ART (OR 0.47, 95% CI: 0.25-0.90, P = .02). The use of medications for primary and secondary prevention of CVD based on current guidelines was low: 15% and 37% for aspirin respectively, and 25% and 44% for statins.CVD risk and rates of CVD are high among PLWH and receiving ART could protect against CVD. However, the use of medications for primary and secondary prevention is low. Increased awareness of CVD risk-reduction strategies is needed among providers of PLWH to decrease the burden of CVD.

An analysis of the spatio-temporal occurrence of anthelmintic veterinary drug residues in groundwater

Anthelmintics are antiparasitic drugs used to control helminthic parasites such as nematodes and trematodes in animals, particularly those exposed through pasture-based production systems. Even though anthelmintics have been shown to be excreted into the environment in relatively high amounts as unmetabolized drug or transformation products (TPs), there is still only limited information available on their environmental occurrence, particularly in groundwater, which has resulted in them being considered as potential emerging contaminants of concern. A comprehensive study was carried out to investigate the occurrence of 40 anthelmintic residues (including 13 TPs) in groundwaters (and associated surface waters) throughout the Republic of Ireland. The study focused on investigating the occurrence of these contaminants in karst and fractured bedrock aquifers, with a total of 106 sites (88 groundwaters and 18 surface waters) samples during spring 2017. Seventeen anthelmintic compounds consisting of eight parent drugs and nine TPs were detected at 22% of sites at concentrations up to 41 ng L^-1. Albendazole and its TPs were most frequently detected residues, found at 8% of groundwater sites and 28% of surface water sites. Multivariate statistical analysis identified several source and pathway factors as being significantly related to the occurrence of anthelmintics in groundwater, however there was an evident localised effect which requires further investigation. An investigation of the temporal variations in occurrence over a 13 month period indicated a higher frequency and concentration of anthelmintics during February/March and again later during August/September 2018, which coincided with periods of increased usage and intensive meteorological events. This work presents the first detections of these contaminants in Irish groundwater and it contributes to broadening our understanding of anthelmintics in the environment. It also provides insight to seasonal trends in occurrence, which is critical for assessing potential future effects and implications of climate change.

Bionematicides as an alternative to methyl bromide fumigation

Fumigant use in perennial crops can be reduced through prolonging the life of existing orchards. The longer an orchard remains healthy and productive, the less often it will be terminated, fumigated, and replanted. Two trials were conducted to determine the effectiveness of DiTera, a toxin produced by the fungus (Myrothecium verrucaria) and Nema-Q, an extract of the soap bark tree (Quillaja saponaria) for management of root-lesion (Pratylenchus vulnus) and ring (Mesocriconema xenopla) nematodes on walnuts. In the first trial, spring and fall treatments of DiTera were applied each year for four years to variety ‘Chandler’ scion on seedling ‘Paradox’ rootstock, and to own-rooted ‘Chandler’ trees. On ‘Paradox’ rootstock, both DiTera and Nema-Q increased walnut yields (P ≤ 0.05) and produced more vigorous trees (P ≤ 0.05) without significant reductions in nematode populations (P ≤ 0.05). A second trial was conducted with three rates of DiTera and four rates of Nema-Q, combinations of the two products, and an untreated control on ‘Chandler’ scion on ‘Paradox’ rootstock. The highest rate of Nema-Q (P ≤ 0.05), and a combination treatment of DiTera plus Nema-Q (P ≤ 0.05) increased trunk circumference. Several treatments showed reductions in root-lesion and ring nematodes (P ≤ 0.05). Bionematicides can improve yield, growth, and vigor in walnut orchards infested with plant-parasitic nematodes.

Cardiac Catheterization Procedures in Patients with HIV: A Retrospective Analysis

With the advent of effective antiretroviral therapies, there has been a decrease in HIV-related mortality, but an increase in non-AIDS-related comorbidities including cardiovascular disease (CVD). We sought to investigate current status of cardiac catheterization (CC) procedures in people with HIV (PWH). This is a retrospective study done at a University Hospital in South Florida between 2017 and 2019. Medical records from 985 PWH indicated that CC was performed in 1.9% of the cases. Of the PWH who underwent CC, 68% were found to have obstructive coronary artery disease (CAD). Among obstructive CAD cases, PCI was performed in 77% and CABG in 21% of cases; 26% had a repeat procedure and 11% died from non-cardiac causes. When comparing PWH who had CC to those who did not, there was a significantly higher rate of statin use (63% vs. 25%, p < 0.015) and a higher prevalence of low ejection fraction (38% vs. 11%, p = 0.004) among those patients who underwent CC. However, there was no significant difference in the prevalence of hypertension (p = 0.13), HbA1c levels (p = 0.32), CD4 count (p = 0.45) nor in undetectable viral load status (p = 0.75) after controlling for age, sex and BMI. Despite the finding of traditional CVD risk factors among PWH, there were no differences in HIV-related factors among patients requiring CC, supporting the importance of optimization of traditional CVD risk factors in this population.

Comparison of in-hospital outcomes of patients undergoing catheter ablation for typical versus atypical atrial flutter

BACKGROUND

Catheter ablation (CA) is indicated as definitive therapy for patients with either typical or atypical atrial flutter (TAFlutter and AAFlutter, respectively) which is unresponsive to medical therapy. There is a paucity of data regarding in-hospital outcomes of patients undergoing CA.

METHODS

Retrospective study using the NIS to identify patients ≥18 years who underwent CA between 2015 and 2017. Individuals were identified using ICD-10-CM/PCS for TAFlutter, AAFlutter, and CA.

RESULTS

A total of 17,390 patients underwent CA for Aflutter (33% AAFlutter and 67% TAFlutter). The TAFlutter group was younger (mean 65.9 years vs. 67.2 years), with less females (30% vs. 43%, p ≤ 0.001 for both) compared to the AAFlutter group. The TAFlutter group had a higher rate of diabetes, tobacco use, obesity, and chronic obstructive pulmonary disease (p ≤ 0.001 for all). The AAFlutter cohort had increased prior strokes and atrial fibrillation (p ≤ 0.001 for both). The mean CHA₂DS₂-VASc score was found to be 2.3 in AAFlutter compared to 2.1 in TAFlutter (p ≤ 0.001). There were significantly higher proportions of thromboembolic events, transfusions, and longer length of stay in the TAFlutter group (p ≤ 0.001 for all) with the AAFlutter group having significantly higher rates of cardioversion, implantation of cardiac devices, and increased hospital charges (p ≤ 0.001 for all); no significant difference was found in mortality after controlling for comorbidities.

CONCLUSIONS

We found higher complication rates in CA for patients with TAFlutter, but no difference in in-hospital all-cause mortality. Variation in CA depending upon the mechanism of AFlutter may underlie these differences, and warrant further study.

Racial disparities in the utilization and in-hospital outcomes of percutaneous left atrial appendage closure among patients with atrial fibrillation

BACKGROUND

Select patients with atrial fibrillation and contraindication to anticoagulation may benefit from percutaneous left atrial appendage closure (pLAAC).

OBJECTIVE

The purpose of this study was to evaluate racial disparities in the nationwide utilization and outcomes of pLAAC.

METHODS

We identified 16,830 hospitalizations for pLAAC between 2015 and 2017 using the National Inpatient Sample. Baseline characteristics, in-hospital mortality, complications, length of stay, and discharge disposition were assessed between White and Black/African American (AA) populations.

RESULTS

Black/AA patients represented 4.1% of nationwide pLAAC recipients and were younger, more likely to be female, and had greater prevalence of hypertension, heart failure, hyperlipidemia, obesity, chronic kidney disease, and prior stroke history (P <.001 for all). Black/AA patients had significantly increased length of stay and nonroutine discharge (P <.001 for both) but comparable in-hospital mortality to White patients. Black/AA patients suffered from greater postoperative stroke (0.7% vs 0.2%), acute kidney injury (4.5% vs 2.1%), bleeding requiring transfusion (4.5% vs 1.4%), and venous thromboembolism (0.7% vs 0.1%; P <.01 for all). After controlling for possible confounding factors, Black/AA race was independently associated with significantly increased odds of bleeding requiring blood transfusion, stroke, venous thromboembolism, and nonroutine discharge.

CONCLUSION

Among pLAAC recipients nationwide, Black/AA populations were underrepresented and had greater complication rates, length of stay, and discharge complexity. This study highlights the importance of addressing ongoing racial disparities in both utilization and outcomes of pLAAC.

An investigation of anticoccidial veterinary drugs as emerging organic contaminants in groundwater

Intensification of the food production system to meet increased global demand for food has led to veterinary pharmaceuticals becoming a critical component in animal husbandry. Anticoccidials are a group of veterinary products used to control coccidiosis in food-producing animals, with primary prophylactic use in poultry production. Excretion in manure and subsequent land-spreading provides a potential pathway to groundwater. Information on the fate and occurrence of these compounds in groundwater is scant, therefore these substances are potential emerging organic contaminants of concern. A study was carried out to investigate the occurrence of anticoccidial compounds in groundwater throughout the Republic of Ireland. Twenty-six anticoccidials (6 ionophores and 20 synthetic anticoccidials) were analysed at 109 sites (63 boreholes and 46 springs) during November and December 2018. Sites were categorised and selected based on the following source and pathway factors: (a) the presence/absence of poultry activity (b) predominant aquifer category and (c) predominant groundwater vulnerability, within the zone of contribution (ZOC) for each site. Seven anticoccidials, including four ionophores (lasalocid, monensin, narasin and salinomycin) and three synthetic anticoccidials (amprolium, diclazuril and nicarbazin), were detected at 24% of sites at concentrations ranging from 1 to 386 ng L^-1. Monensin and amprolium were the two most frequently detected compounds, detected at 15% and 7% of sites, respectively. Multivariate statistical analysis has shown that source factors are the most significant drivers of the occurrence of anticoccidials, with no definitive relationships between occurrence and pathway factors. The study found that the detection of anticoccidial compounds is 6.5 times more likely when poultry activity is present within the ZOC of a sampling point, compared to the absence of poultry activity. This work presents the first detections of these contaminants in Irish groundwater and it contributes to broadening our understanding of the environmental occurrence and fate of anticoccidial veterinary products.

Location and Setting of the Mars InSight Lander, Instruments, and Landing Site

Knowing precisely where a spacecraft lands on Mars is important for understanding the regional and local context, setting, and the offset between the inertial and cartographic frames. For the InSight spacecraft, the payload of geophysical and environmental sensors also particularly benefits from knowing exactly where the instruments are located. A ~30 cm/pixel image acquired from orbit after landing clearly resolves the lander and the large circular solar panels. This image was carefully georeferenced to a hierarchically generated and coregistered set of decreasing resolution orthoimages and digital elevation models to the established positive east, planetocentric coordinate system. The lander is located at 4.502384°N, 135.623447°E at an elevation of -2,613.426 m with respect to the geoid in Elysium Planitia. Instrument locations (and the magnetometer orientation) are derived by transforming from Instrument Deployment Arm, spacecraft mechanical, and site frames into the cartographic frame. A viewshed created from 1.5 m above the lander and the high-resolution orbital digital elevation model shows the lander is on a shallow regional slope down to the east that reveals crater rims on the east horizon ~400 m and 2.4 km away. A slope up to the north limits the horizon to about 50 m away where three rocks and an eolian bedform are visible on the rim of a degraded crater rim. Azimuths to rocks and craters identified in both surface panoramas and high-resolution orbital images reveal that north in the site frame and the cartographic frame are the same (within 1°).

The EVITA evidence action tool to improve evidence-based policymaking for public mental health

The estimated global disease burden of mental illness is 32.4% of years lived with disability. Mental health is a critical determinant for public health, and government-level action is needed for integration of mental health into public health. But in many low/middle-income countries (LMICs) mental health is absent on the policy agenda, despite up to 90% of people with mental illness lacking treatment. Evidence on cost-effective treatments is available, but translation of research into policy is a 'wicked' problem and often fails. We investigate the inter-relationships of research evidence and mental health policymaking in LMICs and present a framework/advocacy tool to guide and support evidence-based public mental health policymaking.

Using a mixed-methods approach, we conducted a systematic review, based on which we developed a provisional framework (EVITA), revised and validated it through expert in-depth interviews. We then empirically tested the EVITA framework against three case studies (provincial, national, global level, South Africa). We collected qualitative data through expert interviews/documentary analysis, coded and analysed the data in NVivo, and finalised the framework and action tool.

We identified agenda-setting as a research theory gap in the context of mental health knowledge translation in LMICs. Thus we developed the EVITA framework for evidence-based mental health policy agenda-setting, and validated it against empirical case studies. Our findings suggest that behavioural methods can support interventions to improve research uptake.

The EVITA action tool has been theoretically and empirically validated, and includes policy agenda-setting and behavioural methods as a novel, effective mechanisms for improving evidence-based policymaking in public mental health. EVITA has the potential to improve the challenging process of research evidence translation into policy/practice in LMICs, and may be applicable to other neglected health areas/countries.

Key messages

The new validated EVITA framework uses agenda-setting and behavioural methods to improve knowledge exchange for better evidence-informed, potentially more effective, public mental health policymaking. The EVITA action tool helps researchers, policymakers & others to strategically take action for public mental health agenda-setting and advocacy interventions for evidence-based policymaking in LMICs.

Abstract 364: Evaluating the Impact of Economic Disparities on the Distribution of Wearable Cardioverter-defibrillator in Patients Post Myocardial Infarction With a Reduced Ejection Fraction

Background: Current guidelines recommend wearable cardioverter-defibrillator (WCD) for primary prevention of sudden cardiac death (SCD) in patients with ischemic cardiomyopathy and ejection fraction (EF) less than 35% if they are within 40 days of an ischemic event or within 90 days if revascularized. We sought to assess what impact economic factors have on determining which patients receive a WCD and their post-discharge outcomes.

Methods: This is a single-center, retrospective cohort study investigating outcomes in patients admitted for myocardial infarction at a large, academic, tertiary referral center, who qualified for WCD over an 18-month period. Patients were stratified based on if a WCD was received or not upon discharge. Demographic, clinical, and diagnostic cardiovascular information, including EF, were obtained. Low income patients were identified as living in an area where median household income is less than $30000 annually.

Results: Fifty-four patients were included in this study and mean age of all patients was 62.5 (± 10.19) years old. The mean EF was comparable between those discharged with versus without a WCD (24.88 ± 7.13 and 24.5 ± 7.5, respectively; p=0.860). Patients who were discharged without a WCD were more likely to be self-pay or receiving Medicaid (3.6% vs 38.5%; 17.9% vs 23.1%), and more likely to come from a low-income area (47.36% vs 55.55%). During a follow up period of 40 and 90 days, the mortality in those without WCD trended to be higher, approaching statistical significance (p = 0.09). Two patients from each cohort received an ICD following the defined period.

Conclusion: The current WCD guidelines were based on observational studies. The results from the first randomized control trial investigating WCD use (VEST trial) have led to questions regarding its actual benefit. However, important limitations to VEST include low WCD usage, and non-compliance to wearing the WCD. Here we have demonstrated that WCD use in patients with immediate post-infarct cardiomyopathy with reduced EF trended towards improved mortality. Economic factors negatively impact who receives this life-saving device. Future directions from our study include stratifying patients based on severity of disease (e.g. severely reduced EF (<25%), evidence of new onset reduced EF and prioritizing patients likely to be more compliant). More studies are needed to further investigate economic disparities associated with use of the WCD.

Associations between postpartum fertility phenotypes and genetic traits in seasonal-calving, pasture-based lactating dairy cows

The objective of this study was to evaluate the associations between corpus luteum (CL) status, uterine health, body condition score (BCS), metabolic status, and parity at wk 3 and 7 postpartum in seasonal-calving, pasture-based, lactating dairy cows. The associations between those phenotypes and individual genetic traits were also evaluated. First- and second-parity spring-calving lactating dairy cows (n = 2,600) from 35 dairy farms in Ireland were enrolled. Farms were visited every 2 weeks; cows that were at wk 3 (range 14 to 27 DIM) and wk 7 (range 42 to 55 DIM) postpartum were examined. Body condition score was measured using a scale of 1 to 5 with 0.25 increments. Transrectal ultrasound examination was performed at wk 3 and 7 postpartum to determine presence or absence of CL and ultrasound reproductive tract score. Blood samples were collected at each visit and the concentrations of glucose, β-hydroxybutyrate (BHB), and fatty acids (FA) were analyzed by using enzymatic colorimetry. Cows were grouped into 3 BCS categories [low (≤2.5), target (≥2.75 and ≤3.25), and high (≥3.5)]; 2 CL status categories: (present or absent); 2 uterine health status (UHS) categories (normal and abnormal); and 3 metabolic status categories [good (high glucose, low fatty acids and BHB), poor (low glucose, high fatty acids and BHB), and moderate (all other combinations)]. Fisher's exact test was used to test associations between variables and was supplemented by logistic regression. We found associations between UHS (wk 3 and 7), BCS (wk 3 and 7), parity (wk 3 and 7) metabolic status (wk 3), and predicted transmitting ability for calving interval (PTA for CIV; wk 3) and CL status. Cows that had abnormal UHS, low BCS, primiparity, and poor metabolic status, and were in the quartile with the greatest PTA for CIV were less likely to have had CL present at wk 3 and 7 postpartum. We also found associations between CL status (wk 3 and 7), BCS (wk 3 and 7), parity (wk 3 and 7), and PTA for CIV (wk 3) and UHS. Cows that did not have a CL present had low BCS, primiparity, and that were in the quartile with greatest PTA for CIV, had a greater risk of abnormal UHS at wk 3 and 7 postpartum. We observed strong associations between CL status, UHS, BCS, metabolic status, parity, and individual genetic traits at wk 3 and 7 postpartum in seasonal-calving, pasture-based lactating dairy cows. Achieving target BCS and good metabolic status, and selecting cows based on PTA for CIV, are all expected to increase the likelihood of hastening the resumption of estrous cyclicity and enhancing uterine health during the postpartum period.

Fertility of fresh and frozen sex-sorted semen in dairy cows and heifers in seasonal-calving pasture-based herds

Our objective in this study was to evaluate the reproductive performance of dairy heifers and cows inseminated with fresh or frozen sex-sorted semen (SS) in seasonal-calving pasture-based dairy herds. Ejaculates of 10 Holstein-Friesian bulls were split and processed to provide (1) fresh conventional semen at 3 × 10⁶ sperm per straw (CONV); (2) fresh SS at 1 × 10⁶ sperm per straw (SS-1M); (3) fresh SS semen at 2 × 10⁶ sperm per straw (SS-2M); and (4) frozen SS at 2 × 10⁶ sperm per straw (SS-FRZ). Generalized linear mixed models were used to evaluate the effect of semen treatment and other explanatory variables on pregnancy per artificial insemination (P/AI) in heifers (n = 3,214) and lactating cows (n = 5,457). In heifers, P/AI was greater for inseminations with CONV (60.9%) than with SS-FRZ (52.8%) but did not differ from SS-1M (54.2%) or SS-2M (53.5%). Cows inseminated with CONV had greater P/AI (48.0%) than cows inseminated with SS, irrespective of treatment (SS-1M, SS-2M, and S-FROZEN; 37.6, 38.9, and 40.6%, respectively). None of the SS treatments differed from each other with regard to P/AI in either heifers or cows. The relative performance of SS compared with CONV was also examined [i.e., relative P/AI = (SS P/AI)/(CONV P/AI) × 100]. Frozen SS achieved relative P/AI >84%. Bull affected P/AI in both heifers and cows, but no bull by semen treatment interaction was observed. In heifers, P/AI increased with increasing predicted transmitting ability for milk protein percentage. In cows, P/AI increased with increasing Economic Breeding Index (EBI) and with days in milk (DIM) at AI but decreased with increasing EBI milk subindex, parity and with DIM². Cows in parity ≥5 had the lowest P/AI and differed from cows in parities 1, 2, or 3. Dispatch-to-AI interval of fresh semen did not affect P/AI in lactating cows, but a dispatch-to-AI interval by bull interaction was detected whereby P/AI was constant for most bulls but increased with greater dispatch-to-AI intervals for 2 bulls. In conclusion, frozen SS achieved greater P/AI relative to conventional semen than was previously reported in lactating cows. Fresh SS did not achieve greater P/AI than frozen SS, regardless of whether the sperm dose per straw was 1 × 10⁶ or 2 × 10⁶. A bull effect for all semen treatments, as well as a dispatch-to-AI interval by bull interaction for fresh semen, highlights the importance of using a large team of bulls for breeding management.

Neonatal outcomes of elective early-term births after demonstrated fetal lung maturity

BACKGROUND

Studies of early-term birth after demonstrated fetal lung maturity show that respiratory and other outcomes are worse with early-term birth (37⁰-38⁶ weeks) even after demonstrated fetal lung maturity when compared with full-term birth (39⁰-40⁶ weeks). However, these studies included medically indicated births and are therefore potentially limited by confounding by the indication for delivery. Thus, the increase in adverse outcomes might be due to the indication for early-term birth rather than the early-term birth itself.

OBJECTIVE

We examined the prevalence and risks of adverse neonatal outcomes associated with early-term birth after confirmed fetal lung maturity as compared with full-term birth in the absence of indications for early delivery.

STUDY DESIGN

This is a secondary analysis of an observational study of births to 115,502 women in 25 hospitals in the United States from 2008 through 2011. Singleton nonanomalous births at 37-40 weeks with no identifiable indication for delivery were included; early-term births after positive fetal lung maturity testing were compared with full-term births. The primary outcome was a composite of death, ventilator for ≥2 days, continuous positive airway pressure, proven sepsis, pneumonia or meningitis, treated hypoglycemia, hyperbilirubinemia (phototherapy), and 5-minute Apgar <7. Logistic regression and propensity score matching (both 1:1 and 1:2) were used.

RESULTS

In all, 48,137 births met inclusion criteria; the prevalence of fetal lung maturity testing in the absence of medical or obstetric indications for early delivery was 0.52% (n = 249). There were 180 (0.37%) early-term births after confirmed pulmonary maturity and 47,957 full-term births. Women in the former group were more likely to be non-Hispanic white, smoke, have received antenatal steroids, have induction, and have a cesarean. Risks of the composite (16.1% vs 5.4%; adjusted odds ratio, 3.2; 95% confidence interval, 2.1-4.8 from logistic regression) were more frequent with elective early-term birth. Propensity scores matching confirmed the increased primary composite in elective early-term births: adjusted odds ratios, 4.3 (95% confidence interval, 1.8-10.5) for 1:1 and 3.5 (95% confidence interval, 1.8-6.5) for 1:2 matching. Among components of the primary outcome, CPAP use and hyperbilirubinemia requiring phototherapy were significantly increased. Transient tachypnea of the newborn, neonatal intensive care unit admission, and prolonged neonatal intensive care unit stay (>2 days) were also increased with early-term birth.

CONCLUSION

Even with confirmed pulmonary maturity, early-term birth in the absence of medical or obstetric indications is associated with worse neonatal respiratory and hepatic outcomes compared with full-term birth, suggesting relative immaturity of these organ systems in early-term births.

Rationale and development of a business case for antimicrobial stewardship programs in acute care hospital settings

Background

Antimicrobial stewardship programs (ASPs) have been shown to reduce inappropriate antimicrobial use and its consequences. However, these programs lack legislative requirements in many places and it can be difficult to determine what human resources are required for these programs and how to create a business case to present to hospital administrators for program funding. The objectives of the current paper were to review legislative requirements and outline human resource requirements for ASPs, and to create a base business case for ASPs.

Methods

A working group of antimicrobial stewardship experts from across Canada met to discuss the necessary components for creation of a business case for antimicrobial stewardship. A narrative review of the literature of the regulatory requirements and human resource recommendations for ASPs was conducted. Informed by the review and using a consensus decision-making process, the expert working group developed human resource recommendations based on a 1000 bed acute care health care facility in Canada. A spreadsheet based business case model for ASPs was also created.

Results

Legislative and /or regulatory requirements for ASPs were found in 2 countries and one state jurisdiction. The literature review and consensus development process recommended the following minimum human resources complement: 1 physician, 3 pharmacists, 0.5 program administrative and coordination support, and 0.4 data analyst support as full time equivalents (FTEs) per 1000 acute care beds. Necessary components for the business case model, including the human resource requirements, were determined to create a spreadsheet based model.

Conclusions

There is evidence to support the negative outcomes of inappropriate antimicrobial use as well as the benefits of ASPs. Legislative and /or regulatory requirements for ASPs are not common. The available evidence for human resource recommendations for ASPs using a narrative review process was examined and a base business case modelling scenario was created. As regulatory requirements for ASPs increase, it will be necessary to create accurate business cases for ASPs in order to obtain the necessary funding to render these programs successful.

Electronic supplementary material

The online version of this article (10.1186/s13756-018-0396-z) contains supplementary material, which is available to authorized users.