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Kirschen MP, Lewis A, Rubin MA, Varelas PN, Greer DM. Beyond the Final Heartbeat: Neurological Perspectives on Normothermic Regional Perfusion for Organ Donation after Circulatory Death. Ann Neurol 2024; 95:1035-1039. [PMID: 38501716 DOI: 10.1002/ana.26926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 02/28/2024] [Accepted: 03/09/2024] [Indexed: 03/20/2024]
Abstract
Normothermic regional perfusion (NRP) has recently been used to augment organ donation after circulatory death (DCD) to improve the quantity and quality of transplantable organs. In DCD-NRP, after withdrawal of life-sustaining therapies and cardiopulmonary arrest, patients are cannulated onto extracorporeal membrane oxygenation to reestablish blood flow to targeted organs including the heart. During this process, aortic arch vessels are ligated to restrict cerebral blood flow. We review ethical challenges including whether the brain is sufficiently reperfused through collateral circulation to allow reemergence of consciousness or pain perception, whether resumption of cardiac activity nullifies the patient's prior death determination, and whether specific authorization for DCD-NRP is required. ANN NEUROL 2024;95:1035-1039.
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Affiliation(s)
- Matthew P Kirschen
- Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ariane Lewis
- Departments of Neurology and Neurosurgery, New York University, Langone Medical Center, New York, NY, USA
| | - Michael A Rubin
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - David M Greer
- Department of Neurology, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
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Rubin MA. Author Response: What Is the Ideal Brain Criterion of Death? Nonclinical Considerations: The UDDA Revision Series. Neurology 2024; 102:e209285. [PMID: 38621187 DOI: 10.1212/wnl.0000000000209285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
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Greer DM, Kirschen MP, Lewis A, Gronseth GS, Rae-Grant A, Ashwal S, Babu MA, Bauer DF, Billinghurst L, Corey A, Partap S, Rubin MA, Shutter L, Takahashi C, Tasker RC, Varelas PN, Wijdicks E, Bennett A, Wessels SR, Halperin JJ. Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline. Neurology 2023; 101:1112-1132. [PMID: 37821233 PMCID: PMC10791061 DOI: 10.1212/wnl.0000000000207740] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/28/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The purpose of this guideline is to update the 2010 American Academy of Neurology (AAN) brain death/death by neurologic criteria (BD/DNC) guideline for adults and the 2011 American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care Medicine guideline for infants and children and to clarify the BD/DNC determination process by integrating guidance for adults and children into a single guideline. Updates in this guideline include guidance related to conducting the BD/DNC evaluation in the context of extracorporeal membrane oxygenation, targeted temperature management, and primary infratentorial injury. METHODS A panel of experts from multiple medical societies developed BD/DNC recommendations. Because of the lack of high-quality evidence on the subject, a novel, evidence-informed formal consensus process was used. This process relied on the panel experts' review and detailed knowledge of the literature surrounding BD/DNC to guide the development of preliminary recommendations. Recommendations were formulated and voted on, using a modified Delphi process, according to the 2017 AAN Clinical Practice Guideline Process Manual. MAJOR RECOMMENDATIONS Eighty-five recommendations were developed on the following: (1) general principles for the BD/DNC evaluation, (2) qualifications to perform BD/DNC evaluations, (3) prerequisites for BD/DNC determination, (4) components of the BD/DNC neurologic examination, (5) apnea testing as part of the BD/DNC evaluation, (6) ancillary testing as part of the BD/DNC evaluation, and (7) special considerations for BD/DNC determination.
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Affiliation(s)
- David M Greer
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Matthew P Kirschen
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Ariane Lewis
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Gary S Gronseth
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Alexander Rae-Grant
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Stephen Ashwal
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Maya A Babu
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - David F Bauer
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Lori Billinghurst
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Amanda Corey
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Sonia Partap
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Michael A Rubin
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Lori Shutter
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Courtney Takahashi
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Robert C Tasker
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Panayiotis Nicolaou Varelas
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Eelco Wijdicks
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Amy Bennett
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - Scott R Wessels
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
| | - John J Halperin
- From the Department of Neurology (D.M.G., C.T.), Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, MA; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania; Departments of Neurology and Neurosurgery (A.L.), NYU Langone Medical Center, New York City; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; Department of Neurology (A.R.-G.), Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, OH; Departments of Pediatrics and Neurology (S.A.), Loma Linda University School of Medicine, CA; Surgical Affiliates Management Group (M.A.B.), Grand Forks, ND; Department of Neurosurgery (D.F.B.), Baylor College of Medicine, Texas Children's Hospital, Houston; Department of Neurology (L.B.), University of Pennsylvania, Philadelphia; Atlanta VA Medical Center and Department of Radiology and Imaging Science (A.C.), Emory University, GA; Departments of Neurology and Pediatrics (S.P.), Stanford University, Palo Alto, CA; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Departments of Critical Care Medicine, Neurology, and Neurosurgery (L.S.), University of Pittsburgh, PA; Department of Anesthesia (R.C.T.), Boston Children's Hospital, MA; Department of Neurology (P.N.V.), Albany Medical College, NY; Department of Neurology (E.W.), Mayo Clinic, Rochester, MN; American Academy of Neurology (A.B., S.R.W.), Minneapolis, MN; and Department of Neurosciences (J.J.H.), Overlook Medical Center, Summit, NJ
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4
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Evans ME, Simbartl LA, McCauley BP, Flarida LK, Jones MM, Harris AD, Perencevich EN, Rubin MA, Hicks NR, Kralovic SM, Roselle GA. Active Surveillance and Contact Precautions for Preventing Methicillin-Resistant Staphylococcus aureus Healthcare-Associated Infections During the COVID-19 Pandemic. Clin Infect Dis 2023; 77:1381-1386. [PMID: 37390613 DOI: 10.1093/cid/ciad388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 06/06/2023] [Accepted: 06/21/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND Statistically significant decreases in methicillin-resistant Staphylococcus aureus (MRSA) healthcare-associated infections (HAIs) occurred in Veterans Affairs (VA) hospitals from 2007 to 2019 using a national policy of active surveillance (AS) for facility admissions and contact precautions for MRSA colonized (CPC) or infected (CPI) patients, but the impact of suspending these measures to free up laboratory resources for testing and conserve personal protective equipment for coronavirus disease 2019 (COVID-19) on MRSA HAI rates is not known. METHODS From July 2020 to June 2022 all 123 acute care VA hospitals nationwide were given the rolling option to suspend (or re-initiate) any combination of AS, CPC, or CPI each month, and MRSA HAIs in intensive care units (ICUs) and non-ICUs were tracked. RESULTS There were 917 591 admissions, 5 225 174 patient-days, and 568 MRSA HAIs. The MRSA HAI rate/1000 patient-days in ICUs was 0.20 (95% confidence interval [CI], .15-.26) for facilities practicing "AS + CPC + CPI" compared to 0.65 (95% CI, .41-.98; P < .001) for those not practicing any of these strategies, and in non-ICUs was 0.07 (95% CI, .05-.08) and 0.12 (95% CI, .08-.19; P = .01) for the respective policies. Accounting for monthly COVID-19 facility admissions using a negative binomial regression model did not change the relationships between facility policy and MRSA HAI rates. There was no significant difference in monthly facility urinary catheter-associated infection rates, a non-equivalent dependent variable, in the policy categories in either ICUs or non-ICUs. CONCLUSIONS Facility removal of MRSA prevention practices was associated with higher rates of MRSA HAIs in ICUs and non-ICUs.
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Affiliation(s)
- Martin E Evans
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, US Department of Veterans Affairs, Washington, DC, USA
- Lexington Veterans Affairs Healthcare System, Lexington, Kentucky, USA
- Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky School of Medicine, Lexington, Kentucky, USA
| | - Loretta A Simbartl
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, US Department of Veterans Affairs, Washington, DC, USA
| | - Brian P McCauley
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, US Department of Veterans Affairs, Washington, DC, USA
| | - Linda K Flarida
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, US Department of Veterans Affairs, Washington, DC, USA
| | - Makoto M Jones
- VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Anthony D Harris
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - Michael A Rubin
- VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Natalie R Hicks
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, US Department of Veterans Affairs, Washington, DC, USA
| | - Stephen M Kralovic
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, US Department of Veterans Affairs, Washington, DC, USA
- Cincinnati Veterans Affairs Healthcare System, Cincinnati, Ohio, USA
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Gary A Roselle
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, US Department of Veterans Affairs, Washington, DC, USA
- Cincinnati Veterans Affairs Healthcare System, Cincinnati, Ohio, USA
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
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5
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Bryarly MA, Rubin MA, Stuve O. Perspective: Industry-patient relationships for the promotion of pharmaceutical agents. Ther Adv Neurol Disord 2023; 16:17562864231207560. [PMID: 37920862 PMCID: PMC10619335 DOI: 10.1177/17562864231207560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 09/25/2023] [Indexed: 11/04/2023] Open
Affiliation(s)
- Meredith A. Bryarly
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Peter O’Donnell Brain Institute, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Michael A. Rubin
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Peter O’Donnell Brain Institute, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Olaf Stuve
- Department of Neurology, University of Texas Southwestern Medical Center, 6000 Harry Hines Blvd, Dallas, TX 75390-8813, USA
- Neurology Section, VA North Texas Health Care System, Dallas, TX, USA
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6
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Kass JS, Rubin MA. Medicolegal and Ethical Issues in Neurology. Neurol Clin 2023; 41:ix-x. [PMID: 37407108 DOI: 10.1016/j.ncl.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Affiliation(s)
- Joseph S Kass
- Department of Neurology, Menninger Department of Psychiatry and Behavioral Sciences, Center for Medical Ethics and Health Policy, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX 77030, USA.
| | - Michael A Rubin
- Departments of Neurology and Neurological Surgery, Peter O'Donnell Jr Brain Institute, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8855, USA.
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7
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Rubin MA, Riecke J, Heitman E. Futility and Shared Decision-Making. Neurol Clin 2023; 41:455-467. [PMID: 37407099 DOI: 10.1016/j.ncl.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
Medical futility is an ancient and yet consistent challenge in clinical medicine. The means of balancing conflicting priorities and stakeholders' preferences has changed as much as the science that powers the understanding and treatment of disease. The introduction of patient self-determination and choice in medical decision-making shifted the locus of power in the physician-patient relationship but did not obviate the physician's responsibilities to provide benefit and prevent harm. As we have refined the process in time, new paradigms, specialists, and tools have been developed to help navigate the ever-changing landscape.
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Affiliation(s)
- Michael A Rubin
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8855, USA; Department of Neurological Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8855, USA.
| | - Jenny Riecke
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8855, USA; Department of Palliative Care, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8855, USA
| | - Elizabeth Heitman
- Program in Ethics in Science and Medicine, Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, NC5.832, Dallas, TX 75390-9070, USA; Department of Applied Clinical Research, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, NC5.832, Dallas, TX 75390-9070, USA
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8
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Rubin MA. What Is the Ideal Brain Criterion of Death? Nonclinical Considerations: The UDDA Revision Series. Neurology 2023; 101:86-87. [PMID: 37429721 DOI: 10.1212/wnl.0000000000207360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/15/2023] [Indexed: 07/12/2023] Open
Affiliation(s)
- Michael A Rubin
- From the Departments of Neurology and Neurosurgery, UT Southwestern Medical Center, Dallas, TX.
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Menon S, Moch H, Berney DM, Cree IA, Srigley JR, Tsuzuki T, Compérat E, Hartmann A, Netto G, Rubin MA, Gill AJ, Turajlic S, Tan PH, Raspollini MR, Tickoo SK, Amin MB. WHO 2022 classification of penile and scrotal cancers: updates and evolution. Histopathology 2023; 82:508-520. [PMID: 36221864 DOI: 10.1111/his.14824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 09/06/2022] [Accepted: 09/25/2022] [Indexed: 11/29/2022]
Abstract
Squamous cell carcinoma (SCC) is the most common malignant tumour of the penis. The 2022 WHO classification reinforces the 2016 classification and subclassifies precursor lesions and tumours into human papillomavirus (HPV)-associated and HPV-independent types. HPV-associated penile intraepithelial neoplasia (PeIN) is a precursor lesion of invasive HPV- associated SCC, whereas differentiated PeIN is a precursor lesion of HPV-independent SCC. Block-type positivity of p16 immunohistochemistry is the most practical daily utilised method to separate HPVassociated from HPVindependent penile SCC. If this is not feasible, the term SCC, not otherwise specified (NOS) is appropriate. Certain histologies that were previously classified as "subtypes" are now grouped, and coalesced as "patterns", under the rubric of usual type SCC and verrucous carcinoma (e.g. usual-type SCC includes pseudohyperplastic and acantholytic/pseudoglandular carcinoma, and carcinoma cuniculatum is included as a pattern of verrucous carcinoma). If there is an additional component of the usual type of invasive SCC (formerly termed hybrid histology), the tumour would be a mixed carcinoma (e.g. carcinoma cuniculatum or verrucous carcinoma with usual invasive SCC); in such cases, reporting of the relative percentages in mixed tumours may be useful. The consistent use of uniform nomenclature and reporting of percentages will inform the refinement of future reporting classification schemes and guidelines/recommendations. The classification of scrotal tumours is provided for the first time in the fifth edition of the WHO Blue book, and it follows the schema of penile cancer classification for both precursor lesions and the common SCC of the scrotum. Basal cell carcinoma of the scrotum may have a variable clinical course and finds a separate mention.
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Affiliation(s)
- S Menon
- Department of Pathology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - H Moch
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Switzerland
| | - D M Berney
- Barts Cancer Institute, London, UK
- Department of Cellular Pathology, Barts Health NHS Trust, London, UK
| | - I A Cree
- Head, WHO Classification of Tumours Head, Evidence Synthesis and Classification, International Agency for Research on Cancer (IARC), World Health Organization, Lyon, France
| | - J R Srigley
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - T Tsuzuki
- Department of Surgical Pathology, Aichi Medical University, Aichi, Japan
| | - E Compérat
- Department of Pathology, Medical University of Vienna, General Hospital of Vienna, Wien, AT, Austria
| | - A Hartmann
- Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander-Universitat Erlangen-Nurnberg, Erlangen, Germany
| | - G Netto
- Heersink School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - M A Rubin
- Department of Biomedical Research (DBMR), Bern Center for Precision Medicine Inselspital University Hospital Bern, Bern, Switzerland
| | - A J Gill
- Sydney Medical School Sydney, The University of Sydney, NSW, Australia
- Royal North Shore Hospital, NSW Health Pathology, Department of Anatomical Pathology St Leonards, NSW, Australia
- Royal North Shore Hospital, Pathology Group, Kolling Institute of Medical Research, St Leonards, NSW, Australia
| | - S Turajlic
- The Francis Crick Institute, London and The Royal Marsden NHS Foundation Trust, London, UK
| | - P H Tan
- Division of Pathology, Singapore General Hospital, Singapore
| | - M R Raspollini
- Histopathology and Molecular Diagnostics University Hospital Careggi, Florence, Florence, Italy
| | - S K Tickoo
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - M B Amin
- The University of Tennessee Health Science Center College of Medicine Memphis, Tennessee, USA
- Department of Urology, University of Southern California, Keck School of Medicine, USA
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Jagsi R, Beeland TD, Sia K, Szczygiel LA, Allen MR, Arora VM, Bair-Merritt M, Bauman MD, Bogner HR, Daumit G, Davis E, Fagerlin A, Ford DE, Gbadegesin R, Griendling K, Hartmann K, Hedayati SS, Jackson RD, Matulevicius S, Mugavero MJ, Nehl EJ, Neogi T, Regensteiner JG, Rubin MA, Rubio D, Singer K, Tucker Edmonds B, Volerman A, Laney S, Patton C, Escobar Alvarez S. Doris Duke Charitable Foundation Fund to Retain Clinical Scientists: innovating support for early-career family caregivers. J Clin Invest 2022; 132:166075. [PMID: 36453546 PMCID: PMC9711869 DOI: 10.1172/jci166075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
| | | | - Kevin Sia
- Doris Duke Charitable Foundation, New York, New York, USA
| | | | - Matthew R. Allen
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Vineet M. Arora
- University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | | | | | - Hillary R. Bogner
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Gail Daumit
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Esa Davis
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Angela Fagerlin
- University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, Utah, USA
| | - Daniel E. Ford
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | | | | | | | | | | | | | | | - Tuhina Neogi
- Boston University School of Medicine, Boston, Massachusetts, USA
| | | | - Michael A. Rubin
- University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, Utah, USA
| | - Doris Rubio
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | | | - Anna Volerman
- University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
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11
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Vivo A, Fitzpatrick MA, Suda KJ, Jones MM, Perencevich EN, Rubin MA, Ramanathan S, Wilson GM, Evans ME, Evans CT. Epidemiology and outcomes associated with carbapenem-resistant Acinetobacter baumannii and carbapenem-resistant Pseudomonas aeruginosa: a retrospective cohort study. BMC Infect Dis 2022; 22:491. [PMID: 35610601 PMCID: PMC9128216 DOI: 10.1186/s12879-022-07436-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 04/19/2022] [Indexed: 11/21/2022] Open
Abstract
Background Carbapenem-resistant Acinetobacter baumannii (CRAB) and carbapenem-resistant Pseudomonas aeruginosa (CRPA) are a growing threat. The objective of this study was to describe CRAB and CRPA epidemiology and identify factors associated with mortality and length of stay (LOS) post-culture. Methods This was a national retrospective cohort study of Veterans with CRAB or CRPA positive cultures from 2013 to 2018, conducted at Hines Veterans Affairs Hospital. Carbapenem resistance was defined as non-susceptibility to imipenem, meropenem and/or doripenem. Multivariable cluster adjusted regression models were fit to assess the association of post-culture LOS among inpatient and long-term care (LTC) and to identify factors associated with 90-day and 365-day mortality after positive CRAB and CRPA cultures. Results CRAB and CRPA were identified in 1,048 and 8,204 unique patients respectively, with 90-day mortality rates of 30.3% and 24.5% and inpatient post-LOS of 26 and 27 days. Positive blood cultures were associated with an increased odds of 90-day mortality compared to urine cultures in patients with CRAB (OR 6.98, 95% CI 3.55–13.73) and CRPA (OR 2.82, 95% CI 2.04–3.90). In patients with CRAB and CRPA blood cultures, higher Charlson score was associated with increased odds of 90-day mortality. In CRAB and CRPA, among patients from inpatient care settings, blood cultures were associated with a decreased LOS compared to urine cultures. Conclusions Positive blood cultures and more comorbidities were associated with higher odds for mortality in patients with CRAB and CRPA. Recognizing these factors would encourage clinicians to treat these patients in a timely manner to improve outcomes of patients infected with these organisms. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07436-w.
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Affiliation(s)
- Amanda Vivo
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Medical Center, Hines, IL, USA. .,Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Medical Center, 5000 S. 5th Avenue (151H), Building 1, Room D322, Hines, IL, 60141, USA.
| | - Margaret A Fitzpatrick
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Medical Center, Hines, IL, USA.,Department of Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, PA, USA.,School of Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Makoto M Jones
- Department of Veterans' Affairs, VA Salt Lake City Healthcare System, Salt Lake City, UT, USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Eli N Perencevich
- Department of Veterans' Affairs, Iowa City VA Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Michael A Rubin
- Department of Veterans' Affairs, VA Salt Lake City Healthcare System, Salt Lake City, UT, USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Swetha Ramanathan
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Medical Center, Hines, IL, USA
| | - Geneva M Wilson
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Medical Center, Hines, IL, USA.,Department of Preventive Medicine, Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Martin E Evans
- MRSA/MDRO Program, VHA National Infectious Diseases Service, VA Central Office and the Lexington VA Medical Center, Lexington, KY, USA.,Department of Internal Medicine, University of Kentucky School of Medicine, Lexington, KY, USA
| | - Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Medical Center, Hines, IL, USA.,Preventive Medicine and Center for Health Services and Outcomes Research, Northwestern University, Chicago, IL, USA
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12
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Taylor LP, Besbris JM, Graf WD, Rubin MA, Cruz-Flores S, Epstein LG. Clinical Guidance in Neuropalliative Care: An AAN Position Statement. Neurology 2022; 98:409-416. [PMID: 35256519 DOI: 10.1212/wnl.0000000000200063] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 01/03/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Lynne P Taylor
- From the Department of Neurology (L.P.T.), University of Washington, Seattle; Department of Supportive Care Medicine and Neurology (J.M.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Pediatrics (Division of Neurology) (W.D.G.), Connecticut Children's, University of Connecticut, Farmington; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (S.C.C.-F.), Texas Tech University Center, El Paso; and Department of Pediatrics and Neurology (L.G.E.), Northwestern University School of Medicine, Chicago, IL.
| | - Jessica M Besbris
- From the Department of Neurology (L.P.T.), University of Washington, Seattle; Department of Supportive Care Medicine and Neurology (J.M.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Pediatrics (Division of Neurology) (W.D.G.), Connecticut Children's, University of Connecticut, Farmington; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (S.C.C.-F.), Texas Tech University Center, El Paso; and Department of Pediatrics and Neurology (L.G.E.), Northwestern University School of Medicine, Chicago, IL
| | - William D Graf
- From the Department of Neurology (L.P.T.), University of Washington, Seattle; Department of Supportive Care Medicine and Neurology (J.M.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Pediatrics (Division of Neurology) (W.D.G.), Connecticut Children's, University of Connecticut, Farmington; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (S.C.C.-F.), Texas Tech University Center, El Paso; and Department of Pediatrics and Neurology (L.G.E.), Northwestern University School of Medicine, Chicago, IL
| | - Michael A Rubin
- From the Department of Neurology (L.P.T.), University of Washington, Seattle; Department of Supportive Care Medicine and Neurology (J.M.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Pediatrics (Division of Neurology) (W.D.G.), Connecticut Children's, University of Connecticut, Farmington; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (S.C.C.-F.), Texas Tech University Center, El Paso; and Department of Pediatrics and Neurology (L.G.E.), Northwestern University School of Medicine, Chicago, IL
| | - Salvador Cruz-Flores
- From the Department of Neurology (L.P.T.), University of Washington, Seattle; Department of Supportive Care Medicine and Neurology (J.M.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Pediatrics (Division of Neurology) (W.D.G.), Connecticut Children's, University of Connecticut, Farmington; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (S.C.C.-F.), Texas Tech University Center, El Paso; and Department of Pediatrics and Neurology (L.G.E.), Northwestern University School of Medicine, Chicago, IL
| | - Leon G Epstein
- From the Department of Neurology (L.P.T.), University of Washington, Seattle; Department of Supportive Care Medicine and Neurology (J.M.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Pediatrics (Division of Neurology) (W.D.G.), Connecticut Children's, University of Connecticut, Farmington; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (S.C.C.-F.), Texas Tech University Center, El Paso; and Department of Pediatrics and Neurology (L.G.E.), Northwestern University School of Medicine, Chicago, IL
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Chiong W, Tolchin BD, Bonnie RJ, Busl K, Cruz-Flores S, Epstein LG, Greene EP, Illes J, Kirschen M, Larriviere DG, Mantri S, Rubin MA, Stern BJ, Taylor LP. Decisions With Patients and Families Regarding Aducanumab in Alzheimer Disease, With Recommendations for Consent: AAN Position Statement. Neurology 2022; 98:154-159. [PMID: 34789544 DOI: 10.1212/wnl.0000000000013053] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/02/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Winston Chiong
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Katharina Busl
- Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Salvador Cruz-Flores
- Department of Neurology, Paul L. Foster School of Medicine Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Leon G Epstein
- Departments of Neurology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ericka P Greene
- Department of Neurology, Houston Methodist Hospital, Houston, TX, USA
| | - Judy Illes
- Neuroethics Canada and Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Matthew Kirschen
- Departments of Anesthesia & Critical Care, Pediatrics and Neurology, Children's Hospital of Pennsylvania, Philadelphia, PA, USA
| | | | - Sneha Mantri
- Department of Neurology, Duke University, Durham, NC, USA
| | - Michael A Rubin
- Departments of Neurology & Neurotherapeutics and Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Barney J Stern
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Lynne P Taylor
- Departments of Neurology and Neurosurgery, University of Washington, Seattle, WA, USA
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14
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Busl KM, Rubin MA, Tolchin BD, Larriviere D, Epstein L, Kirschen M, Taylor LP. Use of Social Media in Health Care-Opportunities, Challenges, and Ethical Considerations: A Position Statement of the American Academy of Neurology. Neurology 2021; 97:585-594. [PMID: 34864637 DOI: 10.1212/wnl.0000000000012557] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/30/2021] [Indexed: 01/26/2023] Open
Affiliation(s)
- Katharina M Busl
- From the Departments of Neurology and Neurosurgery (K.M.B.), College of Medicine, University of Florida, Gainesville; Department of Neurology (M.A.R.), UT Southwestern, Dallas, TX; Department of Neurology (B.D.T.), Yale University Medical School, New Haven, CT; Department of Neurology (D.L.), Ochsner Medical Center, Jefferson, LA; Department of Pediatric Neurology (L.E.), Northwestern University, Evanston, IL; Department of Pediatric Medicine (M.K.), Children's Hospital of Philadelphia, PA; and Department of Neurology (L.P.T.), University of Washington, Seattle.
| | - Michael A Rubin
- From the Departments of Neurology and Neurosurgery (K.M.B.), College of Medicine, University of Florida, Gainesville; Department of Neurology (M.A.R.), UT Southwestern, Dallas, TX; Department of Neurology (B.D.T.), Yale University Medical School, New Haven, CT; Department of Neurology (D.L.), Ochsner Medical Center, Jefferson, LA; Department of Pediatric Neurology (L.E.), Northwestern University, Evanston, IL; Department of Pediatric Medicine (M.K.), Children's Hospital of Philadelphia, PA; and Department of Neurology (L.P.T.), University of Washington, Seattle
| | - Benjamin D Tolchin
- From the Departments of Neurology and Neurosurgery (K.M.B.), College of Medicine, University of Florida, Gainesville; Department of Neurology (M.A.R.), UT Southwestern, Dallas, TX; Department of Neurology (B.D.T.), Yale University Medical School, New Haven, CT; Department of Neurology (D.L.), Ochsner Medical Center, Jefferson, LA; Department of Pediatric Neurology (L.E.), Northwestern University, Evanston, IL; Department of Pediatric Medicine (M.K.), Children's Hospital of Philadelphia, PA; and Department of Neurology (L.P.T.), University of Washington, Seattle
| | - Dan Larriviere
- From the Departments of Neurology and Neurosurgery (K.M.B.), College of Medicine, University of Florida, Gainesville; Department of Neurology (M.A.R.), UT Southwestern, Dallas, TX; Department of Neurology (B.D.T.), Yale University Medical School, New Haven, CT; Department of Neurology (D.L.), Ochsner Medical Center, Jefferson, LA; Department of Pediatric Neurology (L.E.), Northwestern University, Evanston, IL; Department of Pediatric Medicine (M.K.), Children's Hospital of Philadelphia, PA; and Department of Neurology (L.P.T.), University of Washington, Seattle
| | - Leon Epstein
- From the Departments of Neurology and Neurosurgery (K.M.B.), College of Medicine, University of Florida, Gainesville; Department of Neurology (M.A.R.), UT Southwestern, Dallas, TX; Department of Neurology (B.D.T.), Yale University Medical School, New Haven, CT; Department of Neurology (D.L.), Ochsner Medical Center, Jefferson, LA; Department of Pediatric Neurology (L.E.), Northwestern University, Evanston, IL; Department of Pediatric Medicine (M.K.), Children's Hospital of Philadelphia, PA; and Department of Neurology (L.P.T.), University of Washington, Seattle
| | - Matthew Kirschen
- From the Departments of Neurology and Neurosurgery (K.M.B.), College of Medicine, University of Florida, Gainesville; Department of Neurology (M.A.R.), UT Southwestern, Dallas, TX; Department of Neurology (B.D.T.), Yale University Medical School, New Haven, CT; Department of Neurology (D.L.), Ochsner Medical Center, Jefferson, LA; Department of Pediatric Neurology (L.E.), Northwestern University, Evanston, IL; Department of Pediatric Medicine (M.K.), Children's Hospital of Philadelphia, PA; and Department of Neurology (L.P.T.), University of Washington, Seattle
| | - Lynne P Taylor
- From the Departments of Neurology and Neurosurgery (K.M.B.), College of Medicine, University of Florida, Gainesville; Department of Neurology (M.A.R.), UT Southwestern, Dallas, TX; Department of Neurology (B.D.T.), Yale University Medical School, New Haven, CT; Department of Neurology (D.L.), Ochsner Medical Center, Jefferson, LA; Department of Pediatric Neurology (L.E.), Northwestern University, Evanston, IL; Department of Pediatric Medicine (M.K.), Children's Hospital of Philadelphia, PA; and Department of Neurology (L.P.T.), University of Washington, Seattle
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15
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Affiliation(s)
- Michael A Rubin
- Salt Lake Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
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16
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Rubin MA, Kirschen MP, Lewis A. The Neurocritical Care Brain Death Determination Course: Purpose, Design, and Early Findings. Neurocrit Care 2021; 35:913-915. [PMID: 34131839 DOI: 10.1007/s12028-021-01275-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Michael A Rubin
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, USA.
| | - Mathew P Kirschen
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ariane Lewis
- New York University Langone Medical Center, New York, NY, USA
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17
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Wilson GM, Suda KJ, Fitzpatrick MA, Bartle B, Pfeiffer CD, Jones M, Rubin MA, Perencevich E, Evans M, Evans CT. Risk Factors Associated with Carbapenemase Producing Carbapenem-Resistant Enterobacteriaceae (CP-CRE) Positive Cultures in a Cohort of U.S. Veterans. Clin Infect Dis 2021; 73:1370-1378. [PMID: 33973631 DOI: 10.1093/cid/ciab415] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Carbapenem-resistant Enterobacterales (CRE) cause approximately 13,100 infections with 8% mortality in the United States annually. The subset of carbapenemase-producing CRE (CP-CRE) infections have much higher mortality rates (40% -50%). There has been little research on characteristics unique to CP-CRE. The goal of this study was to assess differences between those with nonCP-CRE and CP-CRE cultures in U.S. Veterans. METHODS A retrospective cohort of Veterans with CRE cultures from 2013-2018 and their demographic, medical, and facility level covariates were collected. Clustered multiple logistic regression models were used to assess independent factors associated with CP-CRE. RESULTS 3,096 unique patients with cultures positive for either nonCP-CRE or CP-CRE were included. Being African American (Odds Ratio (OR)=1.44 (95% Confidence Interval (CI) 1.15,1.80), diagnosis in 2017 (OR=3.11 (95% CI 2.13,4.54)) or 2018 (OR=3.93 (95%CI 2.64,5.84)), congestive heart failure (OR=1.35 (95%CI 1.11,1.64)), and gastroesophageal reflux disease (OR=1.39 (95%CI 1.03,1.87)) were associated with CP-CRE cultures. 752 (24.3%) patients had no known antibiotic exposure in the year before culture; these individuals had a comparatively increased frequency of prolonged PPI use (17.3% vs 5.6%). DISCUSSION Among a cohort of patients with CRE, African Americans, individuals with congestive heart failure, and patients with gastroesophageal reflux disease had greater odds of having a CP-CRE culture. Roughly one in four patients with CP-CRE had no known antibiotic exposure in the year before their positive culture.
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Affiliation(s)
- Geneva M Wilson
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines Jr. Veterans Affairs Hospital, Hines, IL,USA
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Heath Care System, Pittsburgh, PA, USA.,University of Pittsburgh School of Medicine, Department of Medicine, Pittsburgh, PA, USA
| | - Margaret A Fitzpatrick
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines Jr. Veterans Affairs Hospital, Hines, IL,USA.,Department of Medicine, Division of Infectious Diseases, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Brian Bartle
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines Jr. Veterans Affairs Hospital, Hines, IL,USA
| | - Christopher D Pfeiffer
- Department of Veterans Affairs, Portland VA Healthcare System, Portland, OR, USA.,Department of Medicine, Division of Infectious Diseases, Oregon Health Science University, Portland, OR, USA
| | - Makoto Jones
- Department of Veterans Affairs, VA Salt Lake City Healthcare System, Salt Lake City, UT, USA.,Department of Medicine, Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - Michael A Rubin
- Department of Veterans Affairs, Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Eli Perencevich
- Department of Veterans Affairs, Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Martin Evans
- Department of Veterans Affairs, Lexington VA Medical Center, Lexington, KY, USA
| | - Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines Jr. Veterans Affairs Hospital, Hines, IL,USA.,Department of Preventive Medicine, Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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18
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Rubin MA, Nelson RE, Samore MH. Matching Methods to Problems: Using Data Science and Transmission Modeling to Combat Antimicrobial Resistance. Clin Infect Dis 2021; 72:S74-S76. [PMID: 33512529 DOI: 10.1093/cid/ciaa1691] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/31/2020] [Indexed: 11/13/2022] Open
Abstract
Antimicrobial resistance is a growing worldwide crisis, declared by the World Health Organization as "one of the principal threats to global public health today." The emergence and spread of antimicrobial resistance is a multifaceted problem that spans all aspects of healthcare, and research efforts to advance the field must likewise employ investigators with a diverse set of expertise and a variety of approaches and study designs who recognize and address the unique challenges of infectious-disease and antimicrobial-resistance research. An understanding of transmission dynamics and externalities, both positive and negative, is critical to any assessment of the impact of an intervention or policy related to infectious disease, infection prevention, or antimicrobial stewardship, in order to create a more comprehensive and accurate estimate of the costs and outcomes associated with an intervention. These types of advanced studies are necessary if we are to significantly alter the course of this crisis and improve the outlook for our future.
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Affiliation(s)
- Michael A Rubin
- Salt Lake Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Richard E Nelson
- Salt Lake Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Matthew H Samore
- Salt Lake Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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19
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Nelson RE, Goto M, Samore MH, Jones M, Stevens VW, Evans ME, Schweizer ML, Perencevich EN, Rubin MA. Expanding an Economic Evaluation of the Veterans Affairs (VA) Methicillin-resistant Staphylococcus aureus (MRSA) Prevention Initiative to Include Prevention of Infections From Other Pathogens. Clin Infect Dis 2021; 72:S50-S58. [PMID: 33512526 DOI: 10.1093/cid/ciaa1591] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND In October 2007, Veterans Affairs (VA) launched a nationwide effort to reduce methicillin-resistant Staphylococcus aureus (MRSA) transmission called the National MRSA Prevention Initiative. Although the initiative focused on MRSA, recent evidence suggests that it also led to a significant decrease in hospital-onset (HO) gram-negative rod (GNR) bacteremia, vancomycin-resistant Enterococci (VRE), and Clostridioides difficile infections. The objective of this analysis was to evaluate the cost-effectiveness and the budget impact of the initiative taking into account MRSA, GNR, VRE, and C. difficile infections. METHODS We developed an economic model using published data on the rate of MRSA hospital-acquired infections (HAIs) and HO-GNR bacteremia in the VA from October 2007 to September 2015, estimates of the attributable cost and mortality of these infections, and the costs associated with the intervention obtained through a microcosting approach. We explored several different assumptions for the rate of infections that would have occurred if the initiative had not been implemented. Effectiveness was measured in life-years (LYs) gained. RESULTS We found that during fiscal years 2008-2015, the initiative resulted in an estimated 4761-9236 fewer MRSA HAIs, 1447-2159 fewer HO-GNR bacteremia, 3083-3602 fewer C. difficile infections, and 2075-5393 fewer VRE infections. The initiative itself was estimated to cost $561 million over this 8-year period, whereas the cost savings from prevented MRSA HAIs ranged from $165 to $315 million and from prevented HO-GNR bacteremia, CRE and C. difficile infections ranged from $174 to $200 million. The incremental cost-effectiveness of the initiative ranged from $12 146 to $38 673/LY when just including MRSA HAIs and from $1354 to $4369/LY when including the additional pathogens. The overall impact on the VA's budget ranged from $67 to$195 million. CONCLUSIONS An MRSA surveillance and prevention strategy in VA may have prevented a substantial number of infections from MRSA and other organisms. The net increase in cost from implementing this strategy was quite small when considering infections from all types of organisms. Including spillover effects of organism-specific prevention efforts onto other organisms can provide a more comprehensive evaluation of the costs and benefits of these interventions.
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Affiliation(s)
- Richard E Nelson
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Michihiko Goto
- Iowa City Veterans Affairs Health Care System, Iowa City, IA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Matthew H Samore
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Makoto Jones
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Vanessa W Stevens
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Martin E Evans
- Veterans Affairs Medical Center, Lexington, Kentucky, USA.,Department of Internal Medicine, University of Kentucky, Lexington, Kentucky, USA.,MRSA/MDRO Program, National Infectious Diseases Service, Veterans Health Administration, Lexington, Kentucky, USA
| | - Marin L Schweizer
- Iowa City Veterans Affairs Health Care System, Iowa City, IA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Eli N Perencevich
- Iowa City Veterans Affairs Health Care System, Iowa City, IA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Michael A Rubin
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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20
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Derington CG, Cohen JB, Mohanty AF, Greene TH, Cook J, Ying J, Wei G, Herrick JS, Stevens VW, Jones BE, Wang L, Zheutlin AR, South AM, Hanff TC, Smith SM, Cooper-DeHoff RM, King JB, Alexander GC, Berlowitz DR, Ahmad FS, Penrod MJ, Hess R, Conroy MB, Fang JC, Rubin MA, Beddhu S, Cheung AK, Xian W, Weintraub WS, Bress AP. Angiotensin II receptor blocker or angiotensin-converting enzyme inhibitor use and COVID-19-related outcomes among US Veterans. PLoS One 2021; 16:e0248080. [PMID: 33891615 PMCID: PMC8064574 DOI: 10.1371/journal.pone.0248080] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/19/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) may positively or negatively impact outcomes in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We investigated the association of ARB or ACEI use with coronavirus disease 2019 (COVID-19)-related outcomes in US Veterans with treated hypertension using an active comparator design, appropriate covariate adjustment, and negative control analyses. METHODS AND FINDINGS In this retrospective cohort study of Veterans with treated hypertension in the Veterans Health Administration (01/19/2020-08/28/2020), we compared users of (A) ARB/ACEI vs. non-ARB/ACEI (excluding Veterans with compelling indications to reduce confounding by indication) and (B) ARB vs. ACEI among (1) SARS-CoV-2+ outpatients and (2) COVID-19 hospitalized inpatients. The primary outcome was all-cause hospitalization or mortality (outpatients) and all-cause mortality (inpatients). We estimated hazard ratios (HR) using propensity score-weighted Cox regression. Baseline characteristics were well-balanced between exposure groups after weighting. Among outpatients, there were 5.0 and 6.0 primary outcomes per 100 person-months for ARB/ACEI (n = 2,482) vs. non-ARB/ACEI (n = 2,487) users (HR 0.85, 95% confidence interval [CI] 0.73-0.99, median follow-up 87 days). Among outpatients who were ARB (n = 4,877) vs. ACEI (n = 8,704) users, there were 13.2 and 14.8 primary outcomes per 100 person-months (HR 0.91, 95%CI 0.86-0.97, median follow-up 85 days). Among inpatients who were ARB/ACEI (n = 210) vs. non-ARB/ACEI (n = 275) users, there were 3.4 and 2.0 all-cause deaths per 100 person months (HR 1.25, 95%CI 0.30-5.13, median follow-up 30 days). Among inpatients, ARB (n = 1,164) and ACEI (n = 2,014) users had 21.0 vs. 17.7 all-cause deaths, per 100 person-months (HR 1.13, 95%CI 0.93-1.38, median follow-up 30 days). CONCLUSIONS This observational analysis supports continued ARB or ACEI use for patients already using these medications before SARS-CoV-2 infection. The novel beneficial association observed among outpatients between users of ARBs vs. ACEIs on hospitalization or mortality should be confirmed with randomized trials.
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Affiliation(s)
- Catherine G. Derington
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Jordana B. Cohen
- Department of Medicine, Renal-Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - April F. Mohanty
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States of America
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Tom H. Greene
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - James Cook
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States of America
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Jian Ying
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT, United States of America
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States of America
| | - Guo Wei
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States of America
| | - Jennifer S. Herrick
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT, United States of America
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States of America
| | - Vanessa W. Stevens
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT, United States of America
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States of America
| | - Barbara E. Jones
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States of America
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Libo Wang
- Department of Medicine, Division of Cardiology, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Alexander R. Zheutlin
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Andrew M. South
- Department of Pediatrics, Section of Nephrology, Brenner Children’s Hospital, Wake Forest School of Medicine, Winston Salem, NC, United States of America
- Division of Public Health Sciences, Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston Salem, NC, United States of America
| | - Thomas C. Hanff
- Department of Medicine, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Steven M. Smith
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, United States of America
| | - Rhonda M. Cooper-DeHoff
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, United States of America
- Department of Medicine, University of Florida, College of Medicine, Gainesville, FL, United States of America
| | - Jordan B. King
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT, United States of America
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States of America
| | - G. Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Dan R. Berlowitz
- Department of Public Health; University of Massachusetts Lowell, Lowell, MA, United States of America
- Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States of America
| | - Faraz S. Ahmad
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - M. Jason Penrod
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Rachel Hess
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT, United States of America
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Molly B. Conroy
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT, United States of America
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - James C. Fang
- Department of Medicine, Division of Cardiology, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Michael A. Rubin
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States of America
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Srinivasan Beddhu
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Alfred K. Cheung
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Weiming Xian
- Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States of America
- Department of Pharmacology and Experimental Therapeutics, Boston University School of Medicine, Boston, MA, United States of America
| | | | - Adam P. Bress
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT, United States of America
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States of America
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21
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Abstract
INTRODUCTION The proportion of hospitals with specialist palliative care services in the USA has increased substantially over the past decade. Severe acute brain injury presents with unique challenges, especially regarding quality of life. The growth and increased recognition of neurocritical care as a subspecialty has not been paralleled by studies regarding how best to integrate palliative care for this unique patient population. Thus, we surveyed members of the Neurocritical Care Society (NCS) to explore current practice patterns, perceptions, and preferences regarding integration of palliative care in the neurological intensive care unit (Neuro-ICU). METHODS We created a 19-item survey using SurveyMonkey to assess practice patterns, perceptions, and preferences of neurointensivists regarding integration of palliative care in the Neuro-ICU. The survey, approved by the NCS research committee, was distributed to all active members of the NCS. RESULTS A total of 424 NCS members representing 19% of the 2200 list serve members completed the survey. The majority (58%) of respondents were attending physicians, who worked primarily in a dedicated Neuro-ICU (67%), at university affiliated academic medical centers (65%). Palliative care consultations are utilized infrequently (< 11%) by the majority of the respondents (59%). The most common indication for a palliative consultation was to discuss goals of care and make treatment decisions (73%). A large majority (77%) either agreed or strongly agreed that palliative care services were utilized in the management of difficult cases apart from discussions regarding withdrawal of life sustaining therapy. Palliative care needs of Neuro-ICU patients were considered different from patients in other ICUs by the majority of respondents (66%). CONCLUSION Our study provides insights into the current perceptions, practice patterns, and preferences of neurointensivists as it relates to palliative care consultation in the Neuro-ICU.
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Affiliation(s)
- Barak Bar
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA.
| | | | - Michael A Rubin
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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22
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Rubin MA. Guidance for Physicians Who Wish to Influence Policy Development on Determination of Death by Neurologic Criteria. AMA J Ethics 2020; 22:E1033-E1037. [PMID: 33419504 DOI: 10.1001/amajethics.2020.1033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Physicians have a long-standing obligation to consider social implications of their practice and its potential influences on health policy. One example of a practice's influence on policy is determining death by neurologic criteria. By lobbying policymakers, maintaining their diagnostic skills, participating in national medical societies, and contributing to robust discourse, physicians can positively influence practice and policy about death determination by neurologic criteria.
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Affiliation(s)
- Michael A Rubin
- Associate professor of neurology and neurological surgery at the UT Southwestern Medical Center's Peter O'Donnell Jr. Brain Institute in Dallas. Texas
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23
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Vosoughi A, Zhang T, Shohdy KS, Vlachostergios PJ, Wilkes DC, Tagawa ST, Nanus SM, Molina AM, Beltran H, Sternberg CN, Motanagh S, Robinson BD, Xiang J, Chung WK, Rubin MA, Elemento O, Sboner A, Mosquera JM, Faltas BM. Common deleterious germline variants shape the urothelial cancer genome. Urol Oncol 2020. [DOI: 10.1016/j.urolonc.2020.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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24
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Rubin MA, Bonnie RJ, Epstein L, Hemphill C, Kirschen M, Lewis A, Suarez JI. AAN position statement: The COVID-19 pandemic and the ethical duties of the neurologist. Neurology 2020; 95:167-172. [PMID: 32414880 DOI: 10.1212/wnl.0000000000009744] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 05/05/2020] [Indexed: 11/15/2022] Open
Abstract
Patients, clinicians, and hospitals have undergone monumental changes during the coronavirus disease 2019 (COVID-19) pandemic. This crisis has forced us to consider the obligations that we neurologists have to our individual patients as well as the greater community. By returning to our fundamental understanding of these duties, we can ensure that we are providing the most ethically appropriate contingency and crisis care possible. We recommend specific adaptations to both the inpatient and outpatient settings, as well as changes to medical and trainee education. Furthermore, we explore the daunting but potentially necessary implementation of scare resource allocation protocols. As the pandemic evolves, we will need to adapt continuously to these rapidly changing circumstances and consider both national and regional standards and variation.
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Affiliation(s)
- Michael A Rubin
- From the Department of Neurology & Neurotherapeutics and Neurological Surgery (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Schools of Law, Medicine, and Public Policy (R.J.B.), University of Virginia, Charlottesville; Department of Pediatrics (L.E.), Northwestern University Feinberg School of Medicine, Chicago, IL; Departments of Neurology and Neurological Surgery (C.H.), University of California, San Francisco; Departments of Anesthesiology, Critical Care Medicine, Pediatrics and Neurology (M.K.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurology and Neurosurgery (A.L.), New York University Langone Medical Center, New York; and Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery (J.I.S.), The Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Richard J Bonnie
- From the Department of Neurology & Neurotherapeutics and Neurological Surgery (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Schools of Law, Medicine, and Public Policy (R.J.B.), University of Virginia, Charlottesville; Department of Pediatrics (L.E.), Northwestern University Feinberg School of Medicine, Chicago, IL; Departments of Neurology and Neurological Surgery (C.H.), University of California, San Francisco; Departments of Anesthesiology, Critical Care Medicine, Pediatrics and Neurology (M.K.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurology and Neurosurgery (A.L.), New York University Langone Medical Center, New York; and Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery (J.I.S.), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Leon Epstein
- From the Department of Neurology & Neurotherapeutics and Neurological Surgery (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Schools of Law, Medicine, and Public Policy (R.J.B.), University of Virginia, Charlottesville; Department of Pediatrics (L.E.), Northwestern University Feinberg School of Medicine, Chicago, IL; Departments of Neurology and Neurological Surgery (C.H.), University of California, San Francisco; Departments of Anesthesiology, Critical Care Medicine, Pediatrics and Neurology (M.K.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurology and Neurosurgery (A.L.), New York University Langone Medical Center, New York; and Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery (J.I.S.), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Claude Hemphill
- From the Department of Neurology & Neurotherapeutics and Neurological Surgery (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Schools of Law, Medicine, and Public Policy (R.J.B.), University of Virginia, Charlottesville; Department of Pediatrics (L.E.), Northwestern University Feinberg School of Medicine, Chicago, IL; Departments of Neurology and Neurological Surgery (C.H.), University of California, San Francisco; Departments of Anesthesiology, Critical Care Medicine, Pediatrics and Neurology (M.K.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurology and Neurosurgery (A.L.), New York University Langone Medical Center, New York; and Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery (J.I.S.), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthew Kirschen
- From the Department of Neurology & Neurotherapeutics and Neurological Surgery (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Schools of Law, Medicine, and Public Policy (R.J.B.), University of Virginia, Charlottesville; Department of Pediatrics (L.E.), Northwestern University Feinberg School of Medicine, Chicago, IL; Departments of Neurology and Neurological Surgery (C.H.), University of California, San Francisco; Departments of Anesthesiology, Critical Care Medicine, Pediatrics and Neurology (M.K.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurology and Neurosurgery (A.L.), New York University Langone Medical Center, New York; and Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery (J.I.S.), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ariane Lewis
- From the Department of Neurology & Neurotherapeutics and Neurological Surgery (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Schools of Law, Medicine, and Public Policy (R.J.B.), University of Virginia, Charlottesville; Department of Pediatrics (L.E.), Northwestern University Feinberg School of Medicine, Chicago, IL; Departments of Neurology and Neurological Surgery (C.H.), University of California, San Francisco; Departments of Anesthesiology, Critical Care Medicine, Pediatrics and Neurology (M.K.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurology and Neurosurgery (A.L.), New York University Langone Medical Center, New York; and Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery (J.I.S.), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jose I Suarez
- From the Department of Neurology & Neurotherapeutics and Neurological Surgery (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Schools of Law, Medicine, and Public Policy (R.J.B.), University of Virginia, Charlottesville; Department of Pediatrics (L.E.), Northwestern University Feinberg School of Medicine, Chicago, IL; Departments of Neurology and Neurological Surgery (C.H.), University of California, San Francisco; Departments of Anesthesiology, Critical Care Medicine, Pediatrics and Neurology (M.K.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurology and Neurosurgery (A.L.), New York University Langone Medical Center, New York; and Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery (J.I.S.), The Johns Hopkins University School of Medicine, Baltimore, MD
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25
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Vaughn VM, Seelye SM, Wang XQ, Wiitala WL, Rubin MA, Prescott HC. Inpatient and Discharge Fluoroquinolone Prescribing in Veterans Affairs Hospitals Between 2014 and 2017. Open Forum Infect Dis 2020; 7:ofaa149. [PMID: 32500088 DOI: 10.1093/ofid/ofaa149] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 04/23/2020] [Indexed: 11/13/2022] Open
Abstract
Background Between 2007 and 2015, inpatient fluoroquinolone use declined in US Veterans Affairs (VA) hospitals. Whether fluoroquinolone use at discharge also declined, in particular since antibiotic stewardship programs became mandated at VA hospitals in 2014, is unknown. Methods In this retrospective cohort study of hospitalizations with infection between January 1, 2014, and December 31, 2017, at 125 VA hospitals, we assessed inpatient and discharge fluoroquinolone (ciprofloxacin, levofloxacin, moxifloxacin) use as (a) proportion of hospitalizations with a fluoroquinolone prescribed and (b) fluoroquinolone-days per 1000 hospitalizations. After adjusting for illness severity, comorbidities, and age, we used multilevel logit and negative binomial models to assess for hospital-level variation and longitudinal prescribing trends. Results Of 560219 hospitalizations meeting inclusion criteria as hospitalizations with infection, 37.4% (209602/560219) had a fluoroquinolone prescribed either during hospitalization (32.5%, 182337/560219) or at discharge (19.6%, 110003/560219). Hospitals varied appreciably in inpatient, discharge, and total fluoroquinolone use, with 71% of hospitals in the highest prescribing quartile located in the Southern United States. Nearly all measures of fluoroquinolone use decreased between 2014 and 2017, with the largest decreases found in inpatient fluoroquinolone and ciprofloxacin use. In contrast, there was minimal decline in fluoroquinolone use at discharge, which accounted for a growing percentage of hospitalization-related fluoroquinolone-days (52.0% in 2014; 61.3% by 2017). Conclusions Between 2014 and 2017, fluoroquinolone use decreased in VA hospitals, largely driven by decreased inpatient fluoroquinolone (especially ciprofloxacin) use. Fluoroquinolone prescribing at discharge, as well as levofloxacin prescribing overall, is a growing target for stewardship.
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Affiliation(s)
- Valerie M Vaughn
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Sarah M Seelye
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Xiao Qing Wang
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Wyndy L Wiitala
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Michael A Rubin
- VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Hallie C Prescott
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
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26
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Nelson RE, Evans ME, Simbartl L, Jones M, Samore MH, Kralovic SM, Roselle GA, Rubin MA. Methicillin-resistant Staphylococcus aureus Colonization and Pre- and Post-hospital Discharge Infection Risk. Clin Infect Dis 2020; 68:545-553. [PMID: 30107401 DOI: 10.1093/cid/ciy507] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 08/03/2018] [Indexed: 12/28/2022] Open
Abstract
Background The Department of Veterans Affairs implemented an active surveillance program for methicillin-resistant Staphylococcus aureus (MRSA) in 2007 in which acute care inpatients are tested for MRSA carriage on admission, unit-to-unit transfer, and discharge. Using these data, we followed patients longitudinally to estimate the difference in infection rates for those who were not colonized, those who were colonized on admission (importers), and those who acquired MRSA during their stay. We examined MRSA infections that occurred prior to discharge and at 30, 90, 180, and 365 days after discharge. Methods We constructed a dataset of 985626 first admissions from January 2008 through December 2015 who had surveillance tests performed for MRSA carriage. We performed multivariable Cox proportional hazards and logistic regression models to examine the relationship between MRSA colonization status and infection. Results The MRSA infection rate across the predischarge and 180-day postdischarge time period was 5.5% in importers and 7.0% in acquirers without a direct admission to the intensive care unit (ICU) and 11.4% in importers and 11.7% in acquirers who were admitted directly to the ICU. The predischarge hazard ratio for MRSA infection was 29.6 (95% confidence interval [CI], 26.5-32.9) for importers and 28.8 (95% CI, 23.5-35.3) for acquirers compared to those not colonized. Fully 63.9% of all MRSA pre- and postdischarge infections among importers and 61.2% among acquirers occurred within 180 days after discharge. Conclusions MRSA colonization significantly increases the risk of subsequent MRSA infection. In addition, a substantial proportion of MRSA infections occur after discharge from the hospital.
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Affiliation(s)
- Richard E Nelson
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Martin E Evans
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Cincinnati, Ohio.,Lexington Veterans Affairs Medical Center, University of Kentucky College of Medicine, Lexington.,Department of Internal Medicine, University of Kentucky College of Medicine, Lexington
| | - Loretta Simbartl
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Cincinnati, Ohio
| | - Makoto Jones
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Matthew H Samore
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Stephen M Kralovic
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Cincinnati, Ohio.,Cincinnati Veterans Affairs Medical Center, University of Cincinnati School of Medicine, Ohio.,Department of Internal Medicine, University of Cincinnati School of Medicine, Ohio
| | - Gary A Roselle
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Cincinnati, Ohio.,Cincinnati Veterans Affairs Medical Center, University of Cincinnati School of Medicine, Ohio.,Department of Internal Medicine, University of Cincinnati School of Medicine, Ohio
| | - Michael A Rubin
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
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27
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Gillessen S, Omlin A, Attard G, de Bono JS, Efstathiou E, Fizazi K, Halabi S, Nelson PS, Sartor O, Smith MR, Soule HR, Akaza H, Beer TM, Beltran H, Chinnaiyan AM, Daugaard G, Davis ID, De Santis M, Drake CG, Eeles RA, Fanti S, Gleave ME, Heidenreich A, Hussain M, James ND, Lecouvet FE, Logothetis CJ, Mastris K, Nilsson S, Oh WK, Olmos D, Padhani AR, Parker C, Rubin MA, Schalken JA, Scher HI, Sella A, Shore ND, Small EJ, Sternberg CN, Suzuki H, Sweeney CJ, Tannock IF, Tombal B. Management of patients with advanced prostate cancer: recommendations of the St Gallen Advanced Prostate Cancer Consensus Conference (APCCC) 2015. Ann Oncol 2019; 30:e3. [PMID: 27141017 DOI: 10.1093/annonc/mdw180] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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28
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Vander Weg MW, Perencevich EN, O’Shea AMJ, Jones MP, Vaughan Sarrazin MS, Franciscus CL, Goedken CC, Baracco GJ, Bradley SF, Cadena J, Forrest GN, Gupta K, Morgan DJ, Rubin MA, Thurn J, Bittner MJ, Reisinger HS. Effect of Frequency of Changing Point-of-Use Reminder Signs on Health Care Worker Hand Hygiene Adherence: A Cluster Randomized Clinical Trial. JAMA Netw Open 2019; 2:e1913823. [PMID: 31642930 PMCID: PMC6820039 DOI: 10.1001/jamanetworkopen.2019.13823] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Although hand hygiene (HH) is considered the most effective strategy for preventing hospital-acquired infections, HH adherence rates remain poor. OBJECTIVE To examine whether the frequency of changing reminder signs affects HH adherence among health care workers. DESIGN, SETTING, AND PARTICIPANTS This cluster randomized clinical trial in 9 US Department of Veterans Affairs acute care hospitals randomly assigned 58 inpatient units to 1 of 3 schedules for changing signs designed to promote HH adherence among health care workers: (1) no change; (2) weekly; and (3) monthly. Hand hygiene rates among health care workers were documented at entry and exit to patient rooms during the baseline period from October 1, 2014, to March 31, 2015, of normal signage and throughout the intervention period of June 8, 2015, to December 28, 2015. Data analyses were conducted in April 2018. INTERVENTIONS Hospital units were randomly assigned into 3 groups: (1) no sign changes throughout the intervention period, (2) signs changed weekly, and (3) signs changed monthly. MAIN OUTCOMES AND MEASURES Hand hygiene adherence as measured by covert observation. Interrupted time series analysis was used to examine changes in HH adherence from baseline through the intervention period by group. RESULTS Among 58 inpatient units, 19 units were assigned to the no change group, 19 units were assigned to the weekly change group, and 20 units were assigned to the monthly change group. During the baseline period, 9755 HH opportunities were observed at room entry and 10 095 HH opportunities were observed at room exit. During the intervention period, a total of 15 855 HH opportunities were observed at room entry, and 16 360 HH opportunities were observed at room exit. Overall HH adherence did not change from baseline compared with the intervention period at either room entry (4770 HH events [48.9%] vs 3057 HH events [50.1%]; P = .14) or exit (6439 HH events [63.8%] vs 4087 HH events [65.2%]; P = .06). In units that changed signs weekly, HH adherence declined from baseline at room entry (-1.9% [95% CI, -2.7% to -0.8%] per week; P < .001) and exit (-0.8% [95% CI, -1.5% to 0.1%] per week; P = .02). No significant changes in HH adherence were observed in other groups. CONCLUSIONS AND RELEVANCE The frequency of changing reminder signs had no effect on HH rates overall. Units assigned to change signs most frequently demonstrated worsening adherence. Considering the abundance of signs in the acute care environment, the frequency of changing signs did not appear to provide a strong enough cue by itself to promote behavioral change. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02223455.
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Affiliation(s)
- Mark W. Vander Weg
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa, Iowa City
- Department of Psychological and Brain Sciences, University of Iowa, Iowa City
| | - Eli N. Perencevich
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa, Iowa City
- Department of Epidemiology, University of Iowa, Iowa City
| | - Amy M. J. O’Shea
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa, Iowa City
| | - Michael P. Jones
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa
- Department of Biostatistics, University of Iowa, Iowa City
| | - Mary S. Vaughan Sarrazin
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa, Iowa City
| | - Carrie L. Franciscus
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa
| | - Cassie Cunningham Goedken
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa
| | | | | | - Jose Cadena
- South Texas Veterans Health Care System, San Antonio
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio
| | | | | | | | | | - Joseph Thurn
- Minneapolis VA Medical Center, Minneapolis, Minnesota
| | - Marvin J. Bittner
- Nebraska-Western Iowa Veterans Affairs Health Care System, Omaha, Nebraska
| | - Heather Schacht Reisinger
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa, Iowa City
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29
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Malaiyandi DP, Henderson GV, Rubin MA. Transfusion of Blood Products in the Neurocritical Care Unit: An Exploration of Rationing and Futility. Neurocrit Care 2019; 28:296-301. [PMID: 29288291 DOI: 10.1007/s12028-017-0478-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Rationing is the allocation of scarce resources, which in healthcare necessarily requires withholding potentially beneficial treatments from some individuals. While it often entails a negative connotation, rationing is unavoidable because need is limitless and resources are not. How rationing occurs is important, because it not only affects individual lives, but also reflects society's most important values. At the core of any rationing, decision is how much a limited resource may benefit a patient, which can be particularly difficult to determine in the practice of neurocritical care, as prognosis is often uncertain. We present a case for the consideration of futility and blood product rationing in neurocritical care.
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Affiliation(s)
- Deepa P Malaiyandi
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Galen V Henderson
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical Center, Boston, MA, USA
| | - Michael A Rubin
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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30
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Stevens VW, Khader K, Echevarria K, Nelson RE, Zhang Y, Jones M, Timbrook TT, Samore MH, Rubin MA. Use of Oral Vancomycin for Clostridioides difficile Infection and the Risk of Vancomycin-Resistant Enterococci. Clin Infect Dis 2019; 71:645-651. [DOI: 10.1093/cid/ciz871] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 08/30/2019] [Indexed: 12/30/2022] Open
Abstract
Abstract
Background
Vancomycin is now a preferred treatment for all cases of Clostridioides difficile infection (CDI), regardless of disease severity. Concerns remain that a large-scale shift to oral vancomycin may increase selection pressure for vancomycin-resistant Enterococci (VRE). We evaluated the risk of VRE following oral vancomycin or metronidazole treatment among patients with CDI.
Methods
We conducted a retrospective cohort study of patients with CDI in the US Department of Veterans Affairs health system between 1 January 2006 and 31 December 2016. Patients were included if they were treated with metronidazole or oral vancomycin and had no history of VRE in the previous year. Missing data were handled by multiple imputation of 50 datasets. Patients treated with oral vancomycin were compared to those treated with metronidazole after balancing on patient characteristics using propensity score matching in each imputed dataset. Patients were followed for VRE isolated from a clinical culture within 3 months.
Results
Patients treated with oral vancomycin were no more likely to develop VRE within 3 months than metronidazole-treated patients (adjusted relative risk, 0.96; 95% confidence interval [CI], .77 to 1.20), equating to an absolute risk difference of −0.11% (95% CI, −.68% to .47%). Similar results were observed at 6 months.
Conclusions
Our results suggest that oral vancomycin and metronidazole are equally likely to impact patients’ risk of VRE. In the setting of stable CDI incidence, replacement of metronidazole with oral vancomycin is unlikely to be a significant driver of increased risk of VRE at the patient level.
In this multicenter, retrospective cohort study of patients with Clostridioides difficile infection, the use of oral vancomycin did not increase the risk of vancomycin-resistant Enterococci infection at 3 or 6 months compared to metronidazole.
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Affiliation(s)
- Vanessa W Stevens
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Karim Khader
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Kelly Echevarria
- Antimicrobial Stewardship Task Force, Pharmacy Benefits Management Program, US Department of Veterans Affairs, Hines, Illinois, USA
- South Texas Veterans Affairs Health Care System, San Antonio, Texas, USA
| | - Richard E Nelson
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Yue Zhang
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Makoto Jones
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Tristan T Timbrook
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- University of Utah Health, Salt Lake City, Utah, USA
| | - Matthew H Samore
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Michael A Rubin
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Aksenov NA, Skomorokhov AA, Aksenov AV, Voskressensky LG, Rubin MA. Michael addition to 3-(2-nitrovinyl)indoles – route toward aliphatic nitro compounds with heterocyclic substituents. Chem Heterocycl Compd (N Y) 2019. [DOI: 10.1007/s10593-019-02493-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Management of patients with terminal brain disorders can be medically, socially, and ethically complex. Although a growing number of feasible treatment options may exist, there are times when further treatment can no longer meaningfully improve either quality or length of life. Clinicians and patients should discuss goals of care while patients are capable of making their own decisions. However, because such discussions can be challenging, they are often postponed. These discussions are then conducted with patients' health care proxies after patients lose the capacity to make their own decisions. Disagreements may arise when a patient's surrogate desires continued aggressive interventions that are either biologically futile (incapable of producing the intended physiologic result) or potentially inappropriate (potentially capable of producing the patient's intended effect but in conflict with the medical team's ethical principles). This article explores best practices in addressing these types of conflicts in the critical care unit, but these concepts also broadly apply to other sites of care.
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Pauli C, Moch H, Rubin MA. [Establishment of a living biobank : Improved guidance of precision cancer care with in vitro and in vivo cancer models]. Pathologe 2019; 38:160-168. [PMID: 28956107 DOI: 10.1007/s00292-017-0346-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Precision oncology is a clinical approach aimed towards tailoring treatment strategies for patients based on the genetic profile of each patient's cancer. The integration of a living biobank, consisting of patient-derived tumor organoids and PDXs, with next generation sequencing approaches and high-throughput drug screening help to guide clinical decision-making and clinical trial development. METHODS Tumor organoids derived from fresh tumor samples were used for in vitro and in vivo high-throughput drug testing. RESULTS Over a period of two years we established 56 in vitro tumor organoids and 19 in vivo xenografts from 18 different solid tumor types. Tumor morphology and molecular profiles show good concordance between the in vitro and in vivo models compared to their native tumor. High-throughput drug screening (up to 160 drugs) has been tested on eight tumor organoid lines. Seven of them underwent an additional combination drug screen. We nominated several targeted small molecules and novel combinations that have been validated in corresponding xenograft models. CONCLUSION This precision medicine approach outlines the integration of genomic data with drug screening from personalized preclinical cancer models to guide precision cancer care. It also fuels next generation research and has been implemented for clinical trial development.
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Affiliation(s)
- C Pauli
- Institut für Pathologie und Molekularpathologie, UniversitätsSpital Zürich, Schmelzbergstrasse 12, 8091, Zürich, Schweiz. .,Englander Institute for Precision Medicine, Weill Cornell Medicine, New York, USA.
| | - H Moch
- Institut für Pathologie und Molekularpathologie, UniversitätsSpital Zürich, Schmelzbergstrasse 12, 8091, Zürich, Schweiz
| | - M A Rubin
- Englander Institute for Precision Medicine, Weill Cornell Medicine, New York, USA.,Departement Klinische Forschung, Medizinische Fakultät, Universität Bern, Bern, Schweiz
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34
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Russell JA, Epstein LG, Greer DM, Kirschen M, Rubin MA, Lewis A. Brain death, the determination of brain death, and member guidance for brain death accommodation requests: AAN position statement. Neurology 2019; 92:228-232. [PMID: 30602465 DOI: 10.1212/wnl.0000000000006750] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 09/27/2018] [Indexed: 11/15/2022] Open
Abstract
The American Academy of Neurology holds the following positions regarding brain death and its determination, and provides the following guidance to its members who encounter resistance to brain death, its determination, or requests for accommodation including continued use of organ support technology despite neurologic determination of death.
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Affiliation(s)
- James A Russell
- From the Division of Neurology (J.A.R.), Lahey Hospital and Medical Center, Burlington; Department of Neurology (D.M.G.), Boston University, MA; Neurology Division (L.G.E.), Ann & Robert H. Lurie Children's Hospital of Chicago, IL; Neurology Division (M.P.K.), The Children's Hospital of Philadelphia, PA; Department of Neurology and Neurotherapeutics (M.R.), UT Southwestern Medical Center, Dallas, TX; and Neurology Department (A.L.), New York University Langone Center, New York.
| | - Leon G Epstein
- From the Division of Neurology (J.A.R.), Lahey Hospital and Medical Center, Burlington; Department of Neurology (D.M.G.), Boston University, MA; Neurology Division (L.G.E.), Ann & Robert H. Lurie Children's Hospital of Chicago, IL; Neurology Division (M.P.K.), The Children's Hospital of Philadelphia, PA; Department of Neurology and Neurotherapeutics (M.R.), UT Southwestern Medical Center, Dallas, TX; and Neurology Department (A.L.), New York University Langone Center, New York
| | - David M Greer
- From the Division of Neurology (J.A.R.), Lahey Hospital and Medical Center, Burlington; Department of Neurology (D.M.G.), Boston University, MA; Neurology Division (L.G.E.), Ann & Robert H. Lurie Children's Hospital of Chicago, IL; Neurology Division (M.P.K.), The Children's Hospital of Philadelphia, PA; Department of Neurology and Neurotherapeutics (M.R.), UT Southwestern Medical Center, Dallas, TX; and Neurology Department (A.L.), New York University Langone Center, New York
| | - Matthew Kirschen
- From the Division of Neurology (J.A.R.), Lahey Hospital and Medical Center, Burlington; Department of Neurology (D.M.G.), Boston University, MA; Neurology Division (L.G.E.), Ann & Robert H. Lurie Children's Hospital of Chicago, IL; Neurology Division (M.P.K.), The Children's Hospital of Philadelphia, PA; Department of Neurology and Neurotherapeutics (M.R.), UT Southwestern Medical Center, Dallas, TX; and Neurology Department (A.L.), New York University Langone Center, New York
| | - Michael A Rubin
- From the Division of Neurology (J.A.R.), Lahey Hospital and Medical Center, Burlington; Department of Neurology (D.M.G.), Boston University, MA; Neurology Division (L.G.E.), Ann & Robert H. Lurie Children's Hospital of Chicago, IL; Neurology Division (M.P.K.), The Children's Hospital of Philadelphia, PA; Department of Neurology and Neurotherapeutics (M.R.), UT Southwestern Medical Center, Dallas, TX; and Neurology Department (A.L.), New York University Langone Center, New York
| | - Ariane Lewis
- From the Division of Neurology (J.A.R.), Lahey Hospital and Medical Center, Burlington; Department of Neurology (D.M.G.), Boston University, MA; Neurology Division (L.G.E.), Ann & Robert H. Lurie Children's Hospital of Chicago, IL; Neurology Division (M.P.K.), The Children's Hospital of Philadelphia, PA; Department of Neurology and Neurotherapeutics (M.R.), UT Southwestern Medical Center, Dallas, TX; and Neurology Department (A.L.), New York University Langone Center, New York
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Abstract
Consciousness defines our humanity more than any other biologic phenomena that a clinician might be called upon to examine, diagnose, or treat. When family comes to the bedside of a patient, they hope to find them talking, thinking, and feeling. The complexity of consciousness allows an expansive gradation of dysfunction such that we must consider numerous potential insults, possible interventions, and often an unknown likelihood of recovery. As value-laden questions are more often in the hands of surrogate decision makers, the neurologist is given the herculean task of not only diagnosing and treating alterations of consciousness but also predicting the likely course of the disease to empower surrogates to make a choice most consistent with the preferences of the patient. The degree of uncertainty in the diagnosis and prognosis demands that the clinician consider the ethics of the diagnosis, treatment, and prognostication of disorders of consciousness. Expectations of acute and chronic care, the extent of the formal neurological investigation, the potential of therapeutic trials, the self-fulfilling prophecy that can occur with prognostication, and the challenges of shared decision making are all subjects that we explore.
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Affiliation(s)
- Spencer Septien
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, Texas
| | - Michael A Rubin
- Division of Neurocritical Care, Department of Neurology and Neurotherapeutics, Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
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Nelson RE, Jones M, Liu CF, Samore MH, Evans ME, Stevens VW, Reese T, Rubin MA. The Impact of Healthcare-Associated Methicillin-Resistant Staphylococcus aureus Infections on Postdischarge Health Care Costs and Utilization across Multiple Health Care Systems. Health Serv Res 2018; 53 Suppl 3:5419-5437. [PMID: 30298924 DOI: 10.1111/1475-6773.13063] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE To measure how much of the postdischarge cost and utilization attributable to methicillin-resistant Staphylococcus aureus (MRSA) health care-associated infections (HAIs) occur within the US Department of Veterans Affairs (VA) system and how much occurs outside. DATA SOURCES/STUDY SETTING Health care encounters from 3 different settings and payment models: (1) within the VA; (2) outside the VA but paid for by the VA (purchased care); and (3) outside the VA and paid for by Medicare. STUDY DESIGN Historical cohort study using data from admissions to VA hospitals between 2007 and 2012. METHODS We assessed the impact of a positive MRSA test result on costs and utilization during the 365 days following discharge using inverse probability of treatment weights to balance covariates. PRINCIPAL FINDINGS Among a cohort of 152,687 hospitalized Veterans, a positive MRSA test result was associated with an overall increase of 6.6 (95 percent CI: 5.7-7.5) inpatient days and $9,237 (95 percent CI: $8,211-$10,262) during the postdischarge period. VA inpatient admissions, Medicare reimbursements, and purchased care payments accounted for 60.6 percent, 22.5 percent, and 16.9 percent of these inpatient costs. CONCLUSIONS While most of the excess postdischarge health care costs associated with MRSA HAIs occurred in the VA, non-VA costs make up an important subset of the overall burden.
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Affiliation(s)
- Richard E Nelson
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Makoto Jones
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Chuan-Fen Liu
- Veterans Affairs Puget Sound Health Care System, Seattle, WA.,Department of Health Services, University of Washington, Seattle, WA
| | - Matthew H Samore
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Martin E Evans
- Lexington Veterans Affairs Medical Center, Lexington, KY.,MRSA/MDRO Program, National Infectious Diseases Service, Veterans Health Administration, Lexington, KY.,Department of Internal Medicine, University of Kentucky, Lexington, KY
| | - Vanessa W Stevens
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Thomas Reese
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, UT
| | - Michael A Rubin
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
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37
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Affiliation(s)
- Michael A Rubin
- Salt Lake Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS 2.0) Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - Matthew H Samore
- Salt Lake Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS 2.0) Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
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38
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Toth DJA, Khader K, Slayton RB, Kallen AJ, Gundlapalli AV, O'Hagan JJ, Fiore AE, Rubin MA, Jernigan JA, Samore MH. The Potential for Interventions in a Long-term Acute Care Hospital to Reduce Transmission of Carbapenem-Resistant Enterobacteriaceae in Affiliated Healthcare Facilities. Clin Infect Dis 2018; 65:581-587. [PMID: 28472233 DOI: 10.1093/cid/cix370] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 04/18/2017] [Indexed: 01/01/2023] Open
Abstract
Background Carbapenem-resistant Enterobacteriaceae (CRE) are high-priority bacterial pathogens targeted for efforts to decrease transmissions and infections in healthcare facilities. Some regions have experienced CRE outbreaks that were likely amplified by frequent transmission in long-term acute care hospitals (LTACHs). Planning and funding of intervention efforts focused on LTACHs is one proposed strategy to contain outbreaks; however, the potential regional benefits of such efforts are unclear. Methods We designed an agent-based simulation model of patients in a regional network of 10 healthcare facilities including 1 LTACH, 3 short-stay acute care hospitals (ACHs), and 6 nursing homes (NHs). The model was calibrated to achieve realistic patient flow and CRE transmission and detection rates. We then simulated the initiation of an entirely LTACH-focused intervention in a previously CRE-free region, including active surveillance for CRE carriers and enhanced isolation of identified carriers. Results When initiating the intervention at the first clinical CRE detection in the LTACH, cumulative CRE transmissions over 5 years across all 10 facilities were reduced by 79%-93% compared to no-intervention simulations. This result was robust to changing assumptions for transmission within non-LTACH facilities and flow of patients from the LTACH. Delaying the intervention until the 20th CRE detection resulted in substantial delays in achieving optimal regional prevalence, while still reducing transmissions by 60%-79% over 5 years. Conclusions Focusing intervention efforts on LTACHs is potentially a highly efficient strategy for reducing CRE transmissions across an entire region, particularly when implemented as early as possible in an emerging outbreak.
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Affiliation(s)
- Damon J A Toth
- Department of Veterans Affairs, Salt Lake City Health Care System, Utah.,Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City
| | - Karim Khader
- Department of Veterans Affairs, Salt Lake City Health Care System, Utah.,Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City
| | - Rachel B Slayton
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alexander J Kallen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Adi V Gundlapalli
- Department of Veterans Affairs, Salt Lake City Health Care System, Utah.,Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City
| | - Justin J O'Hagan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anthony E Fiore
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Michael A Rubin
- Department of Veterans Affairs, Salt Lake City Health Care System, Utah.,Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City
| | - John A Jernigan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew H Samore
- Department of Veterans Affairs, Salt Lake City Health Care System, Utah.,Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City
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39
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Affiliation(s)
- Michael A Rubin
- Salt Lake Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS 2.0) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Matthew H Samore
- Salt Lake Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS 2.0) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Anthony D Harris
- VA Maryland Healthcare System, Baltimore
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
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Nelson RE, Deka R, Khader K, Stevens VW, Schweizer ML, Rubin MA. Dynamic transmission models for economic analysis applied to health care-associated infections: A review of the literature. Am J Infect Control 2017; 45:1382-1387. [PMID: 28958442 DOI: 10.1016/j.ajic.2017.02.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 02/23/2017] [Accepted: 02/24/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cost-effectiveness analyses are an important methodology in assessing whether a health care technology is suitable for widespread adoption. Common models used by economists, such as decision trees and Markov models, are appropriate for noninfectious diseases where treatment and exposure are independent. Diseases whose treatment and exposure are dependent require dynamic models to incorporate the nonlinear transmission effect. Two different types of models are often used for dynamic cost-effectiveness analyses: compartmental models and individual models. In this methodology-focused literature review, we describe each model type and summarize the literature associated with each using the example of health care-associated infections (HAIs). METHODS We conducted a review of the literature to identify dynamic cost-effectiveness analyses that examined interventions to prevent or treat HAIs. To be included in the review, studies needed to have each of 3 necessary components: involve economics, such as cost-effectiveness analysis and evidence of economic theory, use a dynamic transmission model, and examine HAIs. RESULTS Of the 9 articles published between 2005 and 2016 that met criteria to be included in our study, 3 used compartmental models and 6 used individual models. CONCLUSIONS Very few published studies exist that use dynamic transmission models to conduct economic analyses related to HAIs and even fewer studies have used these models to perform cost-effectiveness analyses.
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Affiliation(s)
- Richard E Nelson
- Veterans Affairs Salt Lake City Health Care System, IDEAS Center, Salt Lake City, UT; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT.
| | - Rishi Deka
- Veterans Affairs Salt Lake City Health Care System, IDEAS Center, Salt Lake City, UT; Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT
| | - Karim Khader
- Veterans Affairs Salt Lake City Health Care System, IDEAS Center, Salt Lake City, UT; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Vanessa W Stevens
- Veterans Affairs Salt Lake City Health Care System, IDEAS Center, Salt Lake City, UT; Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT
| | - Marin L Schweizer
- Iowa City Veterans Affairs Health Care System, Iowa City, IA; Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Michael A Rubin
- Veterans Affairs Salt Lake City Health Care System, IDEAS Center, Salt Lake City, UT; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
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Lee D, Fontugne J, Gumpeni N, Park K, MacDonald TY, Robinson BD, Sboner A, Rubin MA, Mosquera JM, Barbieri CE. Molecular alterations in prostate cancer and association with MRI features. Prostate Cancer Prostatic Dis 2017; 20:430-435. [PMID: 28762374 DOI: 10.1038/pcan.2017.33] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 05/22/2017] [Accepted: 06/04/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Multiparametric magnetic resonance imaging (mpMRI) has been increasingly used for prostate cancer (PCa). Recent studies identified distinct molecular subclasses of PCa with recurrent genomic alterations. However, the associations between molecular alterations in PCa and characteristics on mpMRI are unknown. Therefore, the objective of this study was to investigate recurrent molecular alterations in PCa and their associations with mpMRI features. METHODS Sixty-two PCa nodules >0.5 cm had a preoperative mpMRI. Nodules were evaluated for ERG rearrangement, PTEN deletion, SPINK1 overexpression, SPOP mutation and CHD1 deletion. Each PCa focus was matched to the corresponding location on mpMRI. Lesions were scored by single observer according to the PI-RADSv2 scale. RESULTS Of the 62 nodules, 22 (35.5%) were ERG positive, 6 (9.7%) had SPINK1 overexpression, 6 (9.7%) had SPOP mutations, 4 (6.5%) had CHD1 deletions and 1 (1.6%) had PTEN deletion. All of the nodules with CHD1 deletions were not visible on mpMRI (P=0.037). All of the nodules with SPINK1 overexpression were visible on mpMRI, although the association was not statistically significant (P=0.06). There were no significant associations between any molecular alteration with the severity of the PI-RADS scores (all P>0.05). CONCLUSIONS This investigation represents the first description of an association between recurrent molecular alterations and the characterization of PCa nodules on mpMRI. This study can be considered hypothesis-generating for future studies to rigorously evaluate the association of specific PCa molecular subclasses with imaging features and potentially define specific subsets of PCa for which the utility of MRI is higher or lower.
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Affiliation(s)
- D Lee
- Department of Urology, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA
| | - J Fontugne
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA.,Caryl and Israel Englander Institute for Precision Medicine, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA
| | - N Gumpeni
- Department of Radiology, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA
| | - K Park
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA
| | - T Y MacDonald
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA.,Caryl and Israel Englander Institute for Precision Medicine, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA.,Sandra and Edward Meyer Cancer Center, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA
| | - B D Robinson
- Department of Urology, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA.,Department of Pathology and Laboratory Medicine, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA.,Caryl and Israel Englander Institute for Precision Medicine, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA.,Sandra and Edward Meyer Cancer Center, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA
| | - A Sboner
- Department of Urology, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA.,Caryl and Israel Englander Institute for Precision Medicine, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA.,Sandra and Edward Meyer Cancer Center, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA.,Department of Computational Biomedicine, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA
| | - M A Rubin
- Department of Urology, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA.,Department of Pathology and Laboratory Medicine, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA.,Caryl and Israel Englander Institute for Precision Medicine, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA.,Sandra and Edward Meyer Cancer Center, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA
| | - J M Mosquera
- Department of Urology, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA.,Department of Pathology and Laboratory Medicine, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA.,Caryl and Israel Englander Institute for Precision Medicine, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA.,Sandra and Edward Meyer Cancer Center, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA
| | - C E Barbieri
- Department of Urology, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA.,Department of Pathology and Laboratory Medicine, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA.,Sandra and Edward Meyer Cancer Center, Weill Cornell Medicine and New York-Presbyterian, New York, NY, USA
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Weir CR, Rubin MA, Nebeker J, Samore M. Modeling the mind: How do we design effective decision-support? J Biomed Inform 2017; 71S:S1-S5. [PMID: 28603041 DOI: 10.1016/j.jbi.2017.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 06/04/2017] [Accepted: 06/05/2017] [Indexed: 11/15/2022]
Affiliation(s)
- Charlene R Weir
- IDEAS 2.0 Center, George E. Whalen VA Medical Center, Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, USA.
| | - Michael A Rubin
- IDEAS 2.0 Center, George E. Whalen VA Medical Center, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Jonathan Nebeker
- IDEAS 2.0 Center, George E. Whalen VA Medical Center, Division of Geriatrics, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Matthew Samore
- IDEAS 2.0 Center, George E. Whalen VA Medical Center, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA.
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43
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Stevens VW, Nelson RE, Schwab-Daugherty EM, Khader K, Jones MM, Brown KA, Greene T, Croft LD, Neuhauser M, Glassman P, Goetz MB, Samore MH, Rubin MA. Comparative Effectiveness of Vancomycin and Metronidazole for the Prevention of Recurrence and Death in Patients With Clostridium difficile Infection. JAMA Intern Med 2017; 177:546-553. [PMID: 28166328 DOI: 10.1001/jamainternmed.2016.9045] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Metronidazole hydrochloride has historically been considered first-line therapy for patients with mild to moderate Clostridium difficile infection (CDI) but is inferior to vancomycin hydrochloride for clinical cure. The choice of therapy may likewise have substantial consequences on other downstream outcomes, such as recurrence and mortality, although these secondary outcomes have been less studied. OBJECTIVE To evaluate the risk of recurrence and all-cause 30-day mortality among patients receiving metronidazole or vancomycin for the treatment of mild to moderate and severe CDI. DESIGN, SETTING, AND PARTICIPANTS This retrospective, propensity-matched cohort study evaluated patients treated for CDI, defined as a positive laboratory test result for the presence of C difficile toxins or toxin genes in a stool sample, in the US Department of Veterans Affairs health care system from January 1, 2005, through December 31, 2012. Data analysis was performed from February 7, 2015, through November 22, 2016. EXPOSURES Treatment with vancomycin or metronidazole. MAIN OUTCOMES AND MEASURES The outcomes of interest in this study were CDI recurrence and all-cause 30-day mortality. Recurrence was defined as a second positive laboratory test result within 8 weeks of the initial CDI diagnosis. All-cause 30-day mortality was defined as death from any cause within 30 days of the initial CDI diagnosis. RESULTS A total of 47 471 patients (mean [SD] age, 68.8 [13.3] years; 1947 women [4.1%] and 45 524 men [95.9%]) developed CDI, were treated with vancomycin or metronidazole, and met criteria for entry into the study. Of 47 147 eligible first treatment episodes, 2068 (4.4%) were with vancomycin. Those 2068 patients were matched to 8069 patients in the metronidazole group for a total of 10 137 included patients. Subcohorts were constructed that comprised 5452 patients with mild to moderate disease and 3130 patients with severe disease. There were no differences in the risk of recurrence between patients treated with vancomycin vs those treated with metronidazole in any of the disease severity cohorts. Among patients in the any severity cohort, those who were treated with vancomycin were less likely to die (adjusted relative risk, 0.86; 95% CI, 0.74 to 0.98; adjusted risk difference, -0.02; 95% CI, -0.03 to -0.01). No significant difference was found in the risk of mortality between treatment groups among patients with mild to moderate CDI, but vancomycin significantly reduced the risk of all-cause 30-day mortality among patients with severe CDI (adjusted relative risk, 0.79; 95% CI, 0.65 to 0.97; adjusted risk difference, -0.04; 95% CI, -0.07 to -0.01). CONCLUSIONS AND RELEVANCE Recurrence rates were similar among patients treated with vancomycin and metronidazole. However, the risk of 30-day mortality was significantly reduced among patients who received vancomycin. Our findings may further justify the use of vancomycin as initial therapy for severe CDI.
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Affiliation(s)
- Vanessa W Stevens
- IDEAS 2.0 Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake City, Utah2Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Richard E Nelson
- IDEAS 2.0 Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake City, Utah2Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | | | - Karim Khader
- IDEAS 2.0 Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake City, Utah2Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Makoto M Jones
- IDEAS 2.0 Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake City, Utah2Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Kevin A Brown
- IDEAS 2.0 Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake City, Utah4Public Health Ontario, Toronto, Ontario, Canada
| | - Tom Greene
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Lindsay D Croft
- IDEAS 2.0 Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake City, Utah2Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | | | - Peter Glassman
- VA Pharmacy Benefits Management Services, Hines, Illinois6VA Greater Los Angeles Healthcare System, Los Angeles, California
| | | | - Matthew H Samore
- IDEAS 2.0 Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake City, Utah2Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Michael A Rubin
- IDEAS 2.0 Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake City, Utah2Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
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Stutzman SE, Olson DM, Greilich PE, Abdulkadir K, Rubin MA. The Patient and Family Perioperative Experience During Transfer of Care: A Qualitative Inquiry. AORN J 2017; 105:193-202. [DOI: 10.1016/j.aorn.2016.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 05/05/2016] [Accepted: 12/07/2016] [Indexed: 11/28/2022]
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Abstract
The concepts of medical futility and rationing are often misunderstood and lead to significant consternation when resources are stretched and pediatric intensive care unit (PICU) beds are unavailable. While the two concepts overlap, each has its own distinct application and moral justification. Most importantly, we should avoid using one to justify the other. Bioethics professionals should assist critical care clinicians in clarifying when each rubric should be applied as well as how to develop policies to standardize the approach.
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Affiliation(s)
- Michael A Rubin
- Assistant professor of neurology, neurotherapeutics, and neurosurgery at the University of Texas (UT) Southwestern Medical Center in Dallas, and a neurointensivist, and a chair of the UT Southwestern University Hospitals ethics committee and the ethics section of the Neurocritical Care Society, and vice chair of the ethics section of the American Academy of Neurology
| | - Robert D Truog
- Frances Glessner Lee Professor of Medical Ethics, Anaesthesia, & Pediatrics at Harvard Medical School in Boston, where he serves as director of the Center for Bioethics, and an attending physician in the pediatric intensive care unit, and the executive director of the Institute for Professionalism & Ethical Practice
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Rubin MA, Bonomo J. Neurocritical Care Society Views on "Potentially Inappropriate Treatments in Intensive Care Units". Am J Respir Crit Care Med 2016; 193:466-7. [PMID: 26871674 DOI: 10.1164/rccm.201510-2086le] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Michael A Rubin
- 1 University of Texas Southwestern Medical Center Dallas, Texas
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Nelson RE, Stevens VW, Khader K, Jones M, Samore MH, Evans ME, Douglas Scott R, Slayton RB, Schweizer ML, Perencevich EL, Rubin MA. Economic Analysis of Veterans Affairs Initiative to Prevent Methicillin-Resistant Staphylococcus aureus Infections. Am J Prev Med 2016; 50:S58-S65. [PMID: 27102860 PMCID: PMC7909478 DOI: 10.1016/j.amepre.2015.10.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 10/12/2015] [Accepted: 10/22/2015] [Indexed: 11/26/2022]
Abstract
INTRODUCTION In an effort to reduce methicillin-resistant Staphylococcus aureus (MRSA) transmission through universal screening and isolation, the Department of Veterans Affairs (VA) launched the National MRSA Prevention Initiative in October 2007. The objective of this analysis was to quantify the budget impact and cost effectiveness of this initiative. METHODS An economic model was developed using published data on MRSA hospital-acquired infection (HAI) rates in the VA from October 2007 to September 2010; estimates of the costs of MRSA HAIs in the VA; and estimates of the intervention costs, including salaries of staff members hired to support the initiative at each VA facility. To estimate the rate of MRSA HAIs that would have occurred if the initiative had not been implemented, two different assumptions were made: no change and a downward temporal trend. Effectiveness was measured in life-years gained. RESULTS The initiative resulted in an estimated 1,466-2,176 fewer MRSA HAIs. The initiative itself was estimated to cost $207 million during this 3-year period, while the cost savings from prevented MRSA HAIs ranged from $27 million to $75 million. The incremental cost-effectiveness ratios ranged from $28,048 to $56,944/life-years. The overall impact on the VA's budget was $131-$179 million. CONCLUSIONS Wide-scale implementation of a national MRSA surveillance and prevention strategy in VA inpatient settings may have prevented a substantial number of MRSA HAIs. Although the savings associated with prevented infections helped offset some but not all of the cost of the initiative, this model indicated that the initiative would be considered cost effective.
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Affiliation(s)
- Richard E Nelson
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah.
| | - Vanessa W Stevens
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah
| | - Karim Khader
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Makoto Jones
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Matthew H Samore
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Martin E Evans
- Veterans Affairs Medical Center, Lexington, Kentucky; MRSA/MDRO Program, National Infectious Disease Service, Veterans Health Administration, Lexington, Kentucky; Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - R Douglas Scott
- Division of Healthcare Quality Promotion, CDC, Atlanta, Georgia
| | | | - Marin L Schweizer
- Iowa City Veterans Affairs Health Care System, Iowa City, Iowa; Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Eli L Perencevich
- Iowa City Veterans Affairs Health Care System, Iowa City, Iowa; Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Michael A Rubin
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
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Toth DJA, Gundlapalli AV, Khader K, Pettey WBP, Rubin MA, Adler FR, Samore MH. Estimates of Outbreak Risk from New Introductions of Ebola with Immediate and Delayed Transmission Control. Emerg Infect Dis 2016. [PMID: 26196264 PMCID: PMC4517734 DOI: 10.3201/eid2108.150170] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Identifying incoming patients can have a larger risk-reduction effect than efforts to reduce transmissions from identified patients. While the ongoing Ebola outbreak continues in the West Africa countries of Guinea, Sierra Leone, and Liberia, health officials elsewhere prepare for new introductions of Ebola from infected evacuees or travelers. We analyzed transmission data from patients (i.e., evacuees, international travelers, and those with locally acquired illness) in countries other than the 3 with continuing Ebola epidemics and quantitatively assessed the outbreak risk from new introductions by using different assumptions for transmission control (i.e., immediate and delayed). Results showed that, even in countries that can quickly limit expected number of transmissions per case to <1, the probability that a single introduction will lead to a substantial number of transmissions is not negligible, particularly if transmission variability is high. Identifying incoming infected travelers before symptom onset can decrease worst-case outbreak sizes more than reducing transmissions from patients with locally acquired cases, but performing both actions can have a synergistic effect.
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Carter ME, Divita G, Redd A, Rubin MA, Samore MH, Gupta K, Trautner BW, Gundlapalli AV. Finding 'Evidence of Absence' in Medical Notes: Using NLP for Clinical Inferencing. Stud Health Technol Inform 2016; 226:79-82. [PMID: 27350471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Extracting evidence of the absence of a target of interest from medical text can be useful in clinical inferencing. The purpose of our study was to develop a natural language processing (NLP) pipelineto identify the presence of indwelling urinary catheters from electronic medical notes to aid in detection of catheter-associated urinary tract infections (CAUTI). Finding clear evidence that a patient does not have an indwelling urinary catheter is useful in making a determination regarding CAUTI. We developed a lexicon of seven core concepts to infer the absence of a urinary catheter. Of the 990,391 concepts extractedby NLP from a large corpus of 744,285 electronic medical notes from 5589 hospitalized patients, 63,516 were labeled as evidence of absence.Human review revealed three primary causes for false negatives. The lexicon and NLP pipeline were refined using this information, resulting in outputs with an acceptable false positive rate of 11%.
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Affiliation(s)
- Marjorie E Carter
- VA Salt Lake City Health Care System & University of Utah, Salt Lake City, UT, USA
| | - Guy Divita
- VA Salt Lake City Health Care System & University of Utah, Salt Lake City, UT, USA
| | - Andrew Redd
- VA Salt Lake City Health Care System & University of Utah, Salt Lake City, UT, USA
| | - Michael A Rubin
- VA Salt Lake City Health Care System & University of Utah, Salt Lake City, UT, USA
| | - Matthew H Samore
- VA Salt Lake City Health Care System & University of Utah, Salt Lake City, UT, USA
| | - Kalpana Gupta
- VA Boston Health Care System and Boston University, Boston, MA, USA
| | - Barbara W Trautner
- Center for Innovations in Quality Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - Adi V Gundlapalli
- VA Salt Lake City Health Care System & University of Utah, Salt Lake City, UT, USA
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Aksenov AV, Nadein ON, Aksenov NA, Skomorokhov AA, Aksenova IV, Rubin MA. Microwave synthesis of 2-[(E)-2-(1H-indol-3-yl)vinyl]hetarenes. Chem Heterocycl Compd (N Y) 2015. [DOI: 10.1007/s10593-015-1788-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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