Impact of COVID-19 on urgent care diagnoses and the new AXR metric

We examined the antibiotic prescribing rate for respiratory diagnoses (AXR) before and after onset of the COVID-19 pandemic in urgent care clinics. At the onset, AXR declined substantially due to changes in case mix. Using AXR as a stewardship metric requires monitoring of changes in case mix.

Impact of an antibiotic stewardship initiative on urgent-care respiratory prescribing across patient race, ethnicity, and language

We conducted a post hoc analysis of an antibiotic stewardship intervention implemented across our health system's urgent-care network to determine whether there was a differential impact among patient groups. Respiratory urgent-care antibiotic prescribing decreased for all racial, ethnic, and preferred language groups, but disparities in antibiotic prescribing persisted.

Instrumented Static and Reactive Balance in Collegiate Athletes: Normative Values and Minimal Detectable Change

CONTEXT

Wearable sensors are increasingly popular in concussion research because of their objective quantification of subtle balance deficits. However, normative data and minimum detectable change values are necessary to serve as a references for diagnostic use and tracking longitudinal recovery.

OBJECTIVE

Identify normative values and minimal detectable change values for instrumented static and reactive balance tests, an instrumented static Mediolateral Root Mean Square (ML RMS) sway standing balance assessment, and the instrumented, modified Push & Release (I-mP&R), respectively.

DESIGN

Cross-Sectional Study.

SETTING

Clinical Setting.

PATIENTS OR OTHER PARTICIPANTS

Normative static ML RMS sway and I-mP&R data were collected on 377 (n=184 females) healthy National Collegiate Athletic Association Division I athletes at the beginning of their competitive seasons. Test-retest data were collected in 36 healthy control athletes based on standard recovery timelines after concussion.

RESULTS

Descriptive statistics, intraclass correlation coefficients (ICC), and minimal detectable change (MDC) values were calculated for primary outcomes of mediolateral (ML) root-mean-square (RMS) sway in a static double limb-stance standing on firm ground and a foam block, and time to stability and latency from the I-mP&R in single- and dual-task conditions.

RESULTS

Normative outcomes across static ML RMS sway and I-mP&R were sensitive to sex and type of footwear. ML RMS sway demonstrated moderate reliability in the firm condition (ICC=0.73; MDC=2.7cm/s2), but poor reliability in the foam condition (ICC=0.43; MDC=11.1cm/s2). Single- and dual-task time to stability from the I-mP&R exhibited good reliability (ICC=0.84 and 0.80, respectfully; MDC=0.25s, 0.59s, respectfully). Latency from the I-mP&R had poor to moderate reliability (ICC=0.38, 0.55; MDC=107ms, 105ms).

CONCLUSIONS

Sex-matched references should be used for instrumented static and reactive balance assessments. Footwear may explain variability in static ML RMS sway and time to stability of the I-mP&R. Moderate-to-good reliability suggest time to stability from the I-mP&R and ML RMS static sway on firm ground can be used for longitudinal assessments.

Beyond antibiotic prescribing rates: first-line antibiotic selection, prescription duration, and associated factors for respiratory encounters in urgent care

Objective

Assess urgent care (UC) clinician prescribing practices and factors associated with first-line antibiotic selection and recommended duration of therapy for sinusitis, acute otitis media (AOM), and pharyngitis.

Design

Retrospective cohort study.

Participants

All respiratory UC encounters and clinicians in the Intermountain Health (IH) network, July 1st, 2019-June 30th, 2020.

Methods

Descriptive statistics were used to characterize first-line antibiotic selection rates and the duration of antibiotic prescriptions during pharyngitis, sinusitis, and AOM UC encounters. Patient and clinician characteristics were evaluated. System-specific guidelines recommended 5-10 days of penicillin, amoxicillin, or amoxicillin-clavulanate as first-line. Alternative therapies were recommended for penicillin allergy. Generalized estimating equation modeling was used to assess predictors of first-line antibiotic selection, prescription duration, and first-line antibiotic prescriptions for an appropriate duration.

Results

Among encounters in which an antibiotic was prescribed, the rate of first-line antibiotic selection was 75%, the recommended duration was 70%, and the rate of first-line antibiotic selection for the recommended duration was 53%. AOM was associated with the highest rate of first-line prescriptions (83%); sinusitis the lowest (69%). Pharyngitis was associated with the highest rate of prescriptions for the recommended duration (91%); AOM the lowest (51%). Penicillin allergy was the strongest predictor of non-first-line selection (OR = 0.02, 95% CI [0.02, 0.02]) and was also associated with extended duration prescriptions (OR = 0.87 [0.80, 0.95]).

Conclusions

First-line antibiotic selection and duration for respiratory UC encounters varied by diagnosis and patient characteristics. These areas can serve as a focus for ongoing stewardship efforts.

The Effectiveness of a Mindfulness-Based Intervention Integrated with Physical Therapy (MIND-PT) for Postsurgical Rehabilitation After Lumbar Surgery: A Protocol for a Randomized Controlled Trial as Part of the Back Pain Consortium (BACPAC) Research Program

BACKGROUND

Improving pain management for persons with chronic low back pain (LBP) undergoing surgery is an important consideration in improving patient-centered outcomes and reducing the risk of persistent opioid use after surgery. Nonpharmacological treatments, including physical therapy and mindfulness, are beneficial for nonsurgical LBP through complementary biopsychosocial mechanisms, but their integration and application for persons undergoing surgery for LBP have not been examined. This study (MIND-PT) is a multisite randomized trial that compares an enriched pain management (EPM) pathway that integrates physical therapy and mindfulness vs usual-care pain management (UC) for persons undergoing surgery for LBP.

DESIGN

Participants from military treatment facilities will be enrolled before surgery and individually randomized to the EPM or UC pain management pathways. Participants assigned to EPM will receive presurgical biopsychosocial education and mindfulness instruction. After surgery, the EPM group will receive 10 sessions of physical therapy with integrated mindfulness techniques. Participants assigned to the UC group will receive usual pain management care after surgery. The primary outcome will be the pain impact, assessed with the Pain, Enjoyment, and General Activity (PEG) scale. Time to opioid discontinuation is the main secondary outcome.

SUMMARY

This trial is part of the National Institutes of Health Helping to End Addiction Long-term (HEAL) initiative, which is focused on providing scientific solutions to the opioid crisis. The MIND-PT study will examine an innovative program combining nonpharmacological treatments designed to improve outcomes and reduce opioid overreliance in persons undergoing lumbar surgery.

Implementation of an Antibiotic Stewardship Initiative in a Large Urgent Care Network

Importance

Urgent Care (UC) encounters result in more inappropriate antibiotic prescriptions than other outpatient setting. Few stewardship interventions have focused on UC.

Objective

To evaluate the effectiveness of an antibiotic stewardship initiative to reduce antibiotic prescribing for respiratory conditions in a UC network.

Design, Setting, and Participants

This quality improvement study conducted in a UC network with 38 UC clinics and 1 telemedicine clinic included 493 724 total UC encounters. The study compared the antibiotic prescribing rates of all UC clinicians who encountered respiratory conditions for a 12-month baseline period (July 1, 2018, through June 30, 2019) with an intervention period (July 1, 2019, through June 30, 2020). A sustainability period (July 1, 2020, through June 30, 2021) was added post hoc.

Interventions

Stewardship interventions included (1) education for clinicians and patients, (2) electronic health record (EHR) tools, (3) a transparent clinician benchmarking dashboard, and (4) media. Occurring independently but concurrent with the interventions, a stewardship measure was introduced by UC leadership into the quality measures, including a financial incentive.

Main Outcomes and Measures

The primary outcome was the percentage of UC encounters with an antibiotic prescription for a respiratory condition. Secondary outcomes included antibiotic prescribing when antibiotics were not indicated (tier 3 encounters) and first-line antibiotics for acute otitis media, sinusitis, and pharyngitis. Interrupted time series with binomial generalized estimating equations were used to compare periods.

Results

The baseline period included 207 047 UC encounters for respiratory conditions (56.8% female; mean [SD] age, 30.0 [21.4] years; 92.0% White race); the intervention period included 183 893 UC encounters (56.4% female; mean [SD] age, 30.7 [20.8] years; 91.2% White race). Antibiotic prescribing for respiratory conditions decreased from 47.8% (baseline) to 33.3% (intervention). During the initial intervention month, a 22% reduction in antibiotic prescribing occurred (odds ratio [OR], 0.78; 95% CI, 0.71-0.86). Antibiotic prescriptions decreased by 5% monthly during the intervention (OR, 0.95; 95% CI, 0.94-0.96). Antibiotic prescribing for tier 3 encounters decreased by 47% (OR, 0.53; 95% CI, 0.44-63), and first-line antibiotic prescriptions increased by 18% (OR, 1.18; 95% CI, 1.09-1.29) during the initial intervention month. Antibiotic prescriptions for tier 3 encounters decreased by an additional 4% each month (OR, 0.96; 95% CI, 0.94-0.98), whereas first-line antibiotic prescriptions did not change (OR, 1.00; 95% CI, 0.99-1.01). Antibiotic prescribing for respiratory conditions remained stable in the sustainability period.

Conclusions and relevance

The findings of this quality improvement study indicated that a UC antibiotic stewardship initiative was associated with decreased antibiotic prescribing for respiratory conditions. This study provides a model for UC antibiotic stewardship.

Thromboelastography and Its Use in Pediatric Trauma Patients

BACKGROUND/PURPOSE

Thromboelastography's (TEG's) use in pediatric trauma patients is not widely studied. Identifying clotting cascade defects can direct decision making regarding blood product transfusion.

METHODS

We performed a single-center retrospective review of all level 1 pediatric trauma patients. Data collected included demographics, diagnoses, Injury Severity Score, intensive care unit length of stay (ICU LOS), mortality, TEG values, and blood products received. We identified TEG values associated with mortality, ICU LOS, and need for blood product transfusion.

RESULTS

A total of 237 trauma 1 patients were identified. After exclusions, 148 patients were included for analysis. Most patients were below TEG transfusion cut points. Patients with elevated reaction time, K value, and fibrinolysis at 30 minutes had increased odds of mortality with odds ratios of 1.71 (95% confidence interval [CI], 1.22-2.40), 1.94 (95% CI, 1.23-3.05), and 1.15 (95% CI, 1.03-1.28), respectively. For ICU LOS, elevated reaction time, K value, and fibrinolysis at 30 minutes, α angle, and maximum amplitude demonstrated hazard ratios of 0.76 (95% CI, 0.65-0.88), 0.82 (95% CI, 0.64-1.0), 0.95 (95% CI, 0.88-0.99), 1.05 (95% CI, 1.02-1.08), and 1.04 (95% CI, 1.01-1.06), respectively. There was no association between TEG and blood product transfusion.

CONCLUSIONS

Coagulopathic patients based on TEG had higher mortality. All TEG values, as they moved toward transfusion-trigger cut points, were associated with increased mortality.

1739. An Exploratory Analysis to Examine Urgent Care Antibiotic Prescribing Inequities in a Vertically Integrated Healthcare System

Background

Previous studies have shown antibiotic prescribing differences based on patient demographics which may represent inequitable care. Our objective was to perform an exploratory analysis of antibiotic prescribing rates for respiratory conditions to better understand possible inequities and identify disparities in our health system.

Methods

This was a retrospective cohort study of urgent care encounters for respiratory conditions in the Intermountain Healthcare (IH) network from July 1st 2018 – June 30th 2019. Individual respiratory encounters were identified using a validated methodology based on ICD10 codes. Overall antibiotic prescribing rates and rates for Tier 1 (antibiotics indicated), 2 (sometimes indicated), and 3 (not indicated, eg bronchitis) conditions were assessed. Prescribing rates for categories in which inequities might exist, including age, weight, patient race/ethnicity, preferred language, provider type, and provider/patient gender combinations, were examined. We considered an absolute percentage difference between groups within a category of ≥5.0% to represent a potential disparity.

Results

93,588 (48.5%) of 193,107 respiratory urgent care encounters were associated with an antibiotic prescription. Overall antibiotic prescribing rates (Results Image 1) were higher in white compared to non-white patients (49.0% vs 38.2%) and in those reporting non-Hispanic ethnicity compared to Hispanics (49.1% vs 43.2%). Patients over 18 years-old were prescribed antibiotics more frequently than younger patients. Among Tier 3 encounters male providers prescribed antibiotics more frequently for male patients than female providers did for female patients (20.8% vs 15.6). Overweight and obese patients with Tier 3 diagnoses received antibiotic prescriptions more frequently than non-obese patients (22.8% vs 15.3%). Minimal differences between patients who preferred English and those who preferred non-English languages were observed. Results Image 1 - Table 1

Overall antibiotic prescribing rates and antibiotic prescribing rates for Tier 3 conditions for urgent care respiratory condition encounters July 1st, 2018 – June 30th, 2019*¥. *Tier 3 codes are those where antibiotics are not indicated (eg bronchitis). ¥Absolute differences of ≥5.0% between groups within each category are indicated in bold.

Conclusion

Antibiotic prescribing rates for respiratory conditions in urgent care encounters in our system differed based on race, ethnicity, age, obesity, and gender. These differences may represent biases contributing to inequities in care and may serve as potential targets for improved stewardship efforts.

Disclosures

All Authors: No reported disclosures.

Urgent-care antibiotic prescribing: An exploratory analysis to evaluate health inequities

Healthcare disparities and inequities exist in a variety of environments and manifest in diagnostic and therapeutic measures. In this commentary, we highlight our experience examining our organization's urgent care respiratory encounter antibiotic prescribing practices. We identified differences in prescribing based on several individual characteristics including patient age, race, ethnicity, preferred language, and patient and/or clinician gender. Our approach can serve as an electronic health record (EHR)-based methodology for disparity and inequity audits in other systems and for other conditions.

A cohort of pediatric injury patients from a hospital-based trauma registry in Northern Tanzania

Introduction

Pediatric injuries in low- and middle-income countries are a leading cause of morbidity and mortality worldwide. Implementing hospital-based trauma registries can reduce the knowledge gap in both hospital care and patient outcomes and lead to quality improvement initiatives. The goal of this study was to create a pediatric trauma registry to provide insight into the epidemiology, outcomes, and factors associated with poor outcomes in injured children.

Methods

This was a prospective observational study in which a pediatric trauma registry was implemented at a large zonal referral hospital in Northern Tanzania. Data included demographics, hospital-based care, and outcomes including morbidity and mortality. Data were input into REDCap© and analyzed using ANOVA and Chi-squared tests in SAS(Version 9.4)©.

Results

365 patients were enrolled in the registry from November 2020 to October 2021. The majority were males (n=240, 65.8%). Most were children 0-5 years (41.7%, n=152), 34.5% (n=126) were 6-11 years, and 23.8% (n=87) were 12-17 years. The leading causes of pediatric injuries were falls (n=137, 37.5%) and road traffic injuries (n=125, 34.5%). The mortality rate was 8.2% (n=30). Of the in-hospital deaths, 43.3% were children with burn injuries who also had a higher odds of mortality than children with other injuries (OR 8.72, p<0.001). The factors associated with in-hospital mortality and morbidity were vital sign abnormalities, burn severity, abnormal Glasgow Coma Score, and ICU admission.

Conclusion

The mortality rate of injured children in our cohort was high, especially in children with burn injuries. In order to reduce morbidity and mortality, interventions should be prioritized that focus on pediatric injured patients that present with abnormal vital signs, altered mental status, and severe burns. These findings highlight the need for health system capacity building to improve outcomes of pediatric injury patients in Northern Tanzania.

Three delays model applied to pediatric injury care seeking in Northern Tanzania: A mixed methods study

Pediatric injuries are a leading cause of morbidity and mortality in low-and middle-income countries. Timely presentation to care is key for favorable outcomes. The goal of this study was to identify and examine delays that children experience between injury and receiving definitive care at a zonal referral hospital in Northern Tanzania. Between November 2020 and October 2021, we enrolled 348 pediatric trauma patients, collecting quantitative data on referral and timing information. In-depth interviews (IDIs) to explain and explore delays to care were completed with a sub-set of 30 family members. Data were analyzed according to the Three Delays Model. 81.0% (n = 290) of pediatric injury patients sought care at an intermediary facility before reaching the referral hospital. Time from injury to presentation at the referral hospital was 10.2 hours [IQR 4.8, 26.5] if patients presented first to clinics, 8.0 hours [IQR 3.9, 40.0] if patients presented first to district/regional hospitals, and 1.4 hours [IQR 0.7, 3.5] if patients presented directly to the referral hospital. In-hospital mortality was 8.2% (n = 30); 86.7% (n = 26) of these children sought care at an intermediary facility prior to reaching the referral hospital. IDIs revealed themes related to each delay. For decision to seek care (Delay 1), delays included emergency recognition, applying first aid, and anticipated challenges. For reaching definitive care (Delay 2), delays included caregiver rationale for using intermediary facilities, the complex referral system, logistical challenges, and intermediary facility delays. For receiving definitive care (Delay 3), wait time and delays due to treatment cost existed at the referral hospital. Factors throughout the healthcare system contribute to delays in receipt of definitive care for pediatric injuries. To minimize delays and improve patient outcomes, interventions are needed to improve caregiver and healthcare worker education, streamline the current trauma healthcare system, and improve quality of care in the hospital setting.

Postbariatric hypoglycemia: symptom patterns and associated risk factors in the Longitudinal Assessment of Bariatric Surgery study

BACKGROUND

Postbariatric hypoglycemia (PBH) can be a devastating complication for which current therapies are often incompletely effective. More information is needed regarding frequency, incidence, and risk factors for PBH.

OBJECTIVES

To examine hypoglycemia symptoms following Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB) and baseline and in-study risk factors.

SETTING

Multicenter, at 10 US hospitals in 6 geographically diverse clinical centers.

METHODS

A prospective, longitudinal cohort study of adults undergoing RYGB or LAGB as part of clinical care between 2006 and 2009 were recruited and followed until January 31, 2015, with baseline and annual postoperative research assessments. We analyzed baseline prevalence and post-operative incidence and frequency of self-reported hypoglycemia symptoms as well as potential preoperative risk factors.

RESULTS

In all groups, postoperative prevalence of hypoglycemia symptoms was 38.5%. Symptom prevalence increased postoperatively from 2.8%-36.4% after RYGB in patients without preoperative diabetes (T2D), with similar patterns in prediabetes (4.9%-29.1%). Individuals with T2D had higher baseline hypoglycemia symptoms (28.9%), increasing after RYGB (57.9%). Hypoglycemia symptoms were lower after LAGB, with 39.1% reported hypoglycemia symptoms at only 1 postoperative visit with few (4.0%) having persistent symptoms at 6 or more annual visits. Timing of symptoms was not restricted to the postprandial state. Symptoms of severe hypoglycemia were reported in 2.6-3.6% after RYGB. The dominant risk factor for postoperative symptoms was preoperative symptoms; additionally, baseline selective serotonin (SSRI) and serotonin-norepinephrine (SNRI) reuptake inhibitor use was also associated with increased risk in multivariable analysis. Weight loss and regain were not related to hypoglycemia symptom reporting.

CONCLUSION

Hypoglycemia symptoms increase over time after RYGB, particularly in patients without diabetes. In a small percentage, symptoms can be persistent or severe and require hospitalization. Preoperative hypoglycemia symptoms and SSRI/SNRI use in RYGB patients without diabetes is associated with increased risk of symptoms.

Blood transfusion and mortality in children with severe anaemia in a malaria-endemic region

BACKGROUND

In children in sub-Saharan Africa, severe anaemia (SA) is an important cause of mortality, and malaria is a primary cause. The World Health Organization (WHO) recommends blood transfusion for all children with haemoglobin (Hb) <4 g/dL and for those with Hb 4-6 g/dL with signs of instability. In sub-Saharan Africa, evidence of the effect on mortality of transfusion in children with SA with and without malaria is mixed.

AIM

To determine in children with and without malaria whether receipt of transfusion was associated with lower mortality at WHO transfusion thresholds.

METHODS

This was a retrospective cohort study of 1761 children with SA (Hb ≤6 g/dL) admitted to Kamuzu Central Hospital in Malawi. In those whose Hb was 4-6 g/dL, mortality was compared by transfusion, stratified by haemoglobin, malaria status and signs of instability.

RESULTS

Children with profound anaemia (Hb <4 g/dL) and malaria were the only subgroup who had a significant decrease in the odds of in-hospital death if they received a transfusion (OR 0.43, p = 0.01). Although children with Hb 4-6 g/dL and at least one sign of instability had higher mortality than children with none, there was no difference in the odds of mortality between those who received a transfusion and those who did not (OR 1.16, p = 0.62).

CONCLUSIONS

This study suggests that transfusion of children with profound anaemia and malaria may confer increased in-hospital survival. An understanding of the factors associated with mortality from SA will allow for interventions to prioritise the provision of limited blood.

Longitudinal Changes in Prorenin and Renin in the Chronic Renal Insufficiency Cohort

INTRODUCTION

Prorenin, a precursor of renin, and renin play an important role in regulation of the renin-angiotensin system. More recently, receptor-bound prorenin has been shown to activate intracellular signaling pathways that mediate fibrosis, independent of angiotensin II. Prorenin and renin may thus be of physiologic significance in CKD, but their plasma concentrations have not been well characterized in CKD.

METHODS

We evaluated distribution and longitudinal changes of prorenin and renin concentrations in the plasma samples collected at follow-up years 1, 2, 3, and 5 of the Chronic Renal Insufficiency Cohort (CRIC) study, an ongoing longitudinal observational study of 3,939 adults with CKD. Descriptive statistics and multivariable regression of log-transformed values were used to describe cross-sectional and longitudinal variation and associations with participant characteristics.

RESULTS

A total of 3,361 CRIC participants had plasma available for analysis at year 1. The mean age (±standard deviation, SD) was 59 ± 11 years, and the mean estimated glomerular filtration rate (eGFR, ± SD) was 43 ± 17 mL/min per 1.73 m2. Median (interquartile range) values of plasma prorenin and renin at study entry were 4.4 (2.1, 8.8) ng/mL and 2.0 (0.8, 5.9) ng/dL, respectively. Prorenin and renin were positively correlated (Spearman correlation 0.51, p < 0.001) with each other. Women and non-Hispanic blacks had lower prorenin and renin values at year 1. Diabetes, lower eGFR, and use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, statins, and diuretics were associated with higher levels. Prorenin and renin decreased by a mean of 2 and 5% per year, respectively. Non-Hispanic black race and eGFR <30 mL/min/1.73 m2 at year 1 predicted a steeper decrease in prorenin and renin over time. In addition, each increase in urinary sodium excretion by 2 SDs at year 1 increased prorenin and renin levels by 4 and 5% per year, respectively.

DISCUSSION/CONCLUSIONS

The cross-sectional clinical factors associated with prorenin and renin values were similar. Overall, both plasma prorenin and renin concentrations decreased over the years, particularly in those with severe CKD at study entry.

The impact of beta-lactam allergy labels on hospitalized children

BACKGROUND AND OBJECTIVES

Antibiotic allergy labels are common and are frequently inaccurate. Previous studies among adults demonstrate that β-lactam allergy labels may lead to adverse outcomes, including prescription of broader-spectrum antibiotics, increased costs, and increased lengths of stay, among others. However, data among pediatric patients are lacking, especially in the United States. In this study, we sought to determine the impact of β-lactam allergy labels in hospitalized children with regards to clinical and economic outcomes.

METHOD

This retrospective cohort study included pediatric patients 30 days to 17 years old, hospitalized at Intermountain Healthcare facilities from 2007 to 2017, who received ≥1 dose of an antibiotic during their admission. Patients with β-lactam allergies were matched to nonallergic patients based on age, sex, clinical service line, admission date, academic children's hospital or other hospital admission, and the presence of chronic, comorbid conditions. Outcomes included receipt of broader-spectrum antibiotics, clinical outcomes including length of stay and readmission, and antibiotic and hospitalization costs.

RESULTS

In total, 38,906 patients were identified. The prevalence of antibiotic allergy increased from 0.9% among those < 1 year peaked at 10.6% by age 17. Patients with β-lactam allergy received broader-spectrum antibiotics and experienced higher antibiotic costs than nonallergic controls. However, there were no differences in the length of stay, readmission rates, or total number of days of antibiotics between allergic and nonallergic patients.

CONCLUSIONS

Hospitalized pediatric patients with β-lactam allergy labels receive broader-spectrum antibiotics and experience increased antibiotic costs. This represents an important opportunity for allergy delabeling and antibiotic stewardship.

16. SCORE-UC: Antibiotic Stewardship in Urgent Care

Background

Urgent care (UC) is a rapidly growing site of healthcare delivery. The CDC developed Core Elements for Outpatient Antibiotic Stewardship to guide development of outpatient stewardship but little experience exists in applying Core Elements to UC settings. Our objective was to evaluate the effectiveness of a UC stewardship program in a health system.

Figure

Methods

We designed a UC stewardship program for Intermountain Healthcare’s 39 UC sites based on CDC Core Elements. The pre-intervention period was Aug 2017-June 2019. The intervention period was 12 months from Jul 2019 -June 2020. The program consisted of education for patients/providers about appropriate diagnosis and prescribing for respiratory conditions; media campaigns; EHR tools; and a prescribing dashboard for clinicians. The primary outcome was the percentage of respiratory visits where an antibiotic was prescribed. Secondary outcomes included the percentage of encounters receiving antibiotics for conditions where no antibiotics are indicated (e.g. bronchitis) and the percentage of encounters receiving first-line recommended therapy for conditions in which antibiotics may be warrented (otitis media, sinusitis, and pharyngitis). We used a binomial mixed effects hierarchical model to calculate the odds of antibiotic prescribing associated with the intervention period accounting for pre-intervention trends. Models account for clustering within providers and clinics. We present the results of an interim analysis after 7 months of the intervention.

Results

The overall number of UC encounters during the study period was 1,559,403 and 41.5% were for respiratory conditions. The percentage of patients with respiratory conditions that received an antibiotic prescription declined from 49.9% pre-intervention to 35.3% during the intervention (OR 0.73, 95% CI: 0.71, 0.76), reaching a low of 30% during February 2020 (Figure). Prescribing for conditions where antibiotics are not indicated decreased (OR 0.31, 95% CI 0.26–0.36) and first line recommended therapy increased (OR 1.28, 95% CI 1.20–1.26) during the intervention.

Conclusion

After 7 months of a planned 12 month intervention, the UC stewardship program was associated with improved antibiotic prescribing.

Disclosures

Rajendu Srivastava, MD, AHRQ, NIH, CDC (Grant/Research Support, I hold grants from AHRQ, NIH and CDC for a variety of clinical research and implementation studies)IPASS Patient Safety Institute (Other Financial or Material Support, I am a physician founder of this company to spread handoff best practices and reduce adverse events. My employer holds my equity in this company.)

1957. Impact of β-Lactam Antibiotic Allergy on Antimicrobial Use, Clinical Outcomes, and Costs for Hospitalized Children

Background

Methods

Results

Conclusion

Disclosures

The Association between Objectively Measured Physical Activity and the Gut Microbiome among Older Community Dwelling Men

OBJECTIVES

To determine the relationship between objectively measured physical activity (PA) and the gut microbiome among community-dwelling older men.

DESIGN

Cross-sectional study.

SETTING

Osteoporotic Fractures in Men (MrOS) cohort participants at Visit 4 (2014-16).

PARTICIPANTS

Eligible men (n=373, mean age 84 y) included participants with 5-day activity assessment with at least 90% wear time and analyzed stool samples.

MEASUREMENTS

PA was measured with the SenseWear Pro3 Armband and stool samples analyzed for 16S v4 rRNA marker genes using Illumina MiSeq technology. Armband data together with sex, height, and weight were used to estimate total steps, total energy expenditure, and level of activity. 16S data was analyzed using standard UPARSE workflow. Shannon and Inverse Simpson indices were measures of (within-participant) α-diversity. Weighted and unweighted Unifrac were measures of (between-participant) β-diversity. We used linear regression analysis, principal coordinate analysis, zero-inflated Gaussian models to assess association between PA and α-diversity, β-diversity, and specific taxa, respectively, with adjustments for age, race, BMI, clinical center, library size, and number of chronic conditions.

RESULTS

PA was not associated with α-diversity. There was a slight association between PA and β-diversity (in particular the second principal coordinate). Compared to those who were less active, those who had higher step counts had higher relative abundance of Cetobacterium and lower relative abundance of taxa from the genera Coprobacillus, Adlercreutzia, Erysipelotrichaceae CC-115 after multivariable adjustment including age, BMI, and chronic conditions. There was no consistent pattern by phylum.

CONCLUSION

There was a modest association between levels of PA and specific gut microbes among community-dwelling older men. The observed associations are consistent with the hypothesis that underlying health status and composition of the host microbiome are related.

The Burden of Pediatric Neurocritical Care in the United States

BACKGROUND

Disorders requiring pediatric neurocritical care (PNCC) affect thousands of children annually. We aimed to quantify the burden of PNCC through generation of national estimates of disease incidence, utilization of critical care interventions (CCI), and hospital outcomes.

METHODS

We performed a retrospective cohort analysis of the Kids Inpatient Database over three years to evaluate pediatric traumatic brain injury, neuro-infection or inflammatory diseases, status epilepticus, stroke, hypoxic ischemic injury after cardiac arrest, and spinal cord injury. We evaluated use of CCI, death, length of stay, hospital charges, and poor functional outcome defined as receipt of tracheostomy or gastrostomy or discharge to a medical care facility.

RESULTS

At least one CCI was recorded in 67,058 (23%) children with a primary neurological diagnosis, and considered a PNCC admission. Over half of PNCC admissions had at least one chronic condition, and 23% were treated in children's hospitals. Mechanical ventilation was the most common CCI, but utilization of CCIs varied significantly by diagnosis. Among PNCC admissions, 8110 (12%) children died during hospitalization and 14,067 (21%) children had poor functional outcomes. PNCC admissions cumulatively accounted for over 1.5 million hospital days and over $4 billion in hospital costs in the study years. Most PNCC admissions, across all diagnoses, had prolonged hospitalizations (more than one week) with an average cost of $39.9 thousand per admission.

CONCLUSIONS

This large, nationally representative study shows PNCC diseases are a significant public health burden with substantial risk to children's health. More research is needed to improve outcomes in these vulnerable children.

Clinical Characteristics of Patients With Renal Cell Carcinoma and Metastasis to the Thyroid Gland

Introduction:

Renal cell carcinoma (RCC) is the most common malignancy to metastasize to the thyroid gland. The aims of this study are as follows: (1) to analyze the clinical characteristics of patients with thyroid involvement of RCC and (2) in patients with RCC thyroid metastasis, to determine whether RCC metastasis to glandular organs only portends a better prognosis compared with other patterns of RCC metastasis.

Methods:

Patients from Wake Forest Baptist Medical Center (WFBMC) diagnosed with thyroid metastasis from RCC were identified and medical records retrospectively examined. A systematic review of the literature for cases of RCC involving the thyroid gland was also performed. The clinical characteristics of the institutional cohort and the cases from the literature review were compared. Descriptive statistical analysis was performed, and overall survival (OS) was summarized using Kaplan-Meier methods.

Results:

The median OS for the WFBMC cohort was 56.4 months. In the literature review cohort, OS of patients with RCC thyroid metastasis was 213.6 months, and there was no statistically significant survival difference based on the site of metastasis. Median survival after thyroid metastasis from RCC for the WFBMC and literature cohort was 21.6 and 45.6 months, respectively.

Conclusions:

Metastatic RCC should be included in the differential of a new thyroid mass. Treatment directed at the thyroid metastasis results in prolonged survival in some cases. Further analysis into the genomic differences and mechanisms of thyroid metastasis is warranted.

Prognostic Factors and Significance of Gastrointestinal Leak After Cytoreductive Surgery (CRS) with Heated Intraperitoneal Chemotherapy (HIPEC)

BACKGROUND

Gastrointestinal leak (GIL) after cytoreductive surgery with heated intraperitoneal chemotherapy (CRS/HIPEC) is associated with significant morbidity and mortality. This study aimed to identify GIL prognostic factors and its impact on overall survival.

METHODS

A retrospective analysis of a prospectively maintained database comprising 1270 CRS/HIPEC procedures was performed. Type of GIL, functional and resection status, morbidity, mortality, and survival were reviewed.

RESULTS

Gastrointestinal leaks were identified in 8.7% (110/1270) of CRS/HIPEC procedures, including 53 anastomotic leaks (4.2%), 53 hollow viscus perforations (4.2%), and four leaks at unknown sites. The multivariate predictors of leak were Eastern Cooperative Oncology Group (ECOG) functional status (ECOG 1 vs. 0: odds ratio [OR] 2.12, p = 0.009; ECOG 2 vs. 0: OR 2.90, p = 0.004), and number of anastomoses (OR 5.34; p < 0.0001). The in-hospital mortality rate for the GIL cohort was 21.8% (24/110), with a 72% (80/110) reoperation rate. The leak cohort had a higher major morbidity rate (88.3 vs. 23.3%; p < 0.0001), a longer hospital stay (39.0 vs. 9.9 days; p < 0.0001), and a longer intensive care unit (ICU) stay (7.7 vs. 1.7 days; p = 0.0003). After surgical mortality was excluded, the overall survival periods for the leak and no-leak patients with complete cytoreduction were respectively 1.5 and 4.98 years (p = 0.0001). Clinically significant decreases in survival were observed for all primary malignancies.

CONCLUSIONS

Gastrointestinal leak after CRS/HIPEC is a source of significant mortality, with a decrease in overall survival even after complete CRS. Preoperative functional status and number of anastomoses are predictors of leak for CRS/HIPEC patients.

Comparison of observed to predicted outcomes using the ACS NSQIP risk calculator in patients undergoing pancreaticoduodenectomy

BACKGROUND

Postoperative outcomes predicted by the ACS NSQIP universal risk calculator have not been validated for specific procedures like pancreaticoduodenectomy (PD).

METHODS

A random sample of 400 PD patients from the NSQIP database was analyzed. Patients were categorized into four groups of 100 each based on ICD-9 diagnosis (211.6, 157.0, 156.2, and 577.1). Estimated risks of postoperative outcomes recorded by the calculator were compared to observed outcomes using the Brier Score (BS). The calculated BS was compared to a null model BS. A BS of zero indicated perfect prediction, while a BS of one indicated the poorest prediction.

RESULTS

BS for all groupings was generally low, reflecting good prediction. BS for any and major complications was higher (0.23 and 0.22, respectively). This was also seen within ICD-9 subgroups. For patients with ampullary cancer, BS for these outcomes was higher (0.27 and 0.26, respectively). Comparison to the null model BS (0.24 and 0.24, respectively) correlated lesser predictive accuracy of the calculator for this subgroup.

CONCLUSIONS

The ACS NSQIP risk calculator, although accurate in predicting outcomes in patients undergoing PD, shows variation when accounting for specific ICD-9 diagnoses. Incorporating the diagnosis may better guide surgeons and patients preoperatively in making informed decisions. J. Surg. Oncol. 2016;114:157-162. © 2016 Wiley Periodicals, Inc.

Cell line modeling to study biomarker panel in prostate cancer

BACKGROUND

African-American men with prostate cancer (PCa) present with higher-grade and -stage tumors compared to Caucasians. While the disparity may result from multiple factors, a biological basis is often strongly suspected. Currently, few well-characterized experimental model systems are available to study the biological basis of racial disparity in PCa. We report a validated in vitro cell line model system that could be used for the purpose.

METHODS

We assembled a PCa cell line model that included currently available African-American PCa cell lines and LNCaP (androgen-dependent) and C4-2 (castration-resistant) Caucasian PCa cells. The utility of the cell lines in studying the biological basis of variance in a malignant phenotype was explored using a multiplex biomarker panel consisting of proteins that have been proven to play a role in the progression of PCa. The panel expression was evaluated by Western blot and RT-PCR in cell lines and validated in human PCa tissues by RT-PCR. As proof-of-principle to demonstrate the utility of our model in functional studies, we performed MTS viability assays and molecular studies.

RESULTS

The dysregulation of the multiplex biomarker panel in primary African-American cell line (E006AA) was similar to metastatic Caucasian cell lines, which would suggest that the cell line model could be used to study an inherent aggressive phenotype in African-American men with PCa. We had previously demonstrated that Protein kinase D1 (PKD1) is a novel kinase that is down regulated in advanced prostate cancer. We established the functional relevance by over expressing PKD1, which resulted in decreased proliferation and epithelial mesenchymal transition (EMT) in PCa cells. Moreover, we established the feasibility of studying the expression of the multiplex biomarker panel in archived human PCa tissue from African-Americans and Caucasians as a prelude to future translational studies.

CONCLUSION

We have characterized a novel in vitro cell line model that could be used to study the biological basis of disparity in PCa between African-Americans and Caucasians.

Rates and patterns of recurrence following complete resection of Hilar cholangiocarcinoma: Results from the U.S. Extrahepatic Biliary Consortium

324

Background: Data for incidence and patterns of recurrence after surgical resection of Hilar cholangiocarcinoma have been derived largely from single institution series. We sought to assess factors associated with recurrence, recurrence patterns and their impact on outcomes. Methods: Patients with Hilar cholangiocarcinoma that underwent R0/R1 resection without 30-day mortality from surgery were analyzed from a 10-institution database. Results: 193 patients with recurrence data available were identified. Of these 95 (49%) recurred with median time to recurrence of 15.2 months and overall survival (OS) of 24.3 months. Univariate analysis identified age (HR 1.02, CI 1.004-1.036; p = 0.01), pre-op CA 19-9 (HR 1.02, CI 1.004-1.035; p = 0.02), positive lymph nodes (HR 1.72, CI 1.187-2.478; p = 0.004) and perineural invasion (HR 1.78, CI 1.125-2.802, p = 0.01) as factors predicting worse disease free survival. On multivariate analysis, only age (HR 1.032, CI 1.01-1.06, p = 0.007) and pre-op CA 19-9 (HR 1.02, CI 1.01-1.04, p = 0.013) remained significant. 67 patients (70.5%) had distant recurrence (DR) with or without locoregional recurrence (LR) while 28 patients (29.5%) had LR only. Of patients that had DR, 42 (63.6%) had liver, 23 (34.9%) had peritoneal, 8 (12.1%) had lung and 5 (7.6%) had other sites including distant nodal metastases. Median time to recurrence (13.6 vs 17.7 months, p = 0.07), time from recurrence to death (5.9 vs 4.5 months, p = 0.72) and OS (24.4 vs 25.3 months, p = 0.3), was not significantly different between patients who had LR or DR with or without LR. Among patients that recurred, tumor size, lymph node status, resection status (R0/R1), extent of resection and adjuvant therapy were not significantly associated with the type of recurrence. Conclusions: Hilar cholangiocarcinoma is an aggressive cancer with high rates of predominantly distant recurrence associated with poor survival. Further investigation is warranted to determine the role and potential type of adjuvant therapy in order to improve outcomes after surgical resection.

Effect of preoperative bilirubin on outcomes of completely resected hilar cholangiocarcinoma: A multi-institutional analysis

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Background: Perioperative and long-term outcomes of patients with Hilar cholangiocarcinoma (HC) and preoperative hyperbilirubinemia have not been clearly defined. Methods: Patients with HC undergoing hepatectomy with a complete (R0/R1) resection between 2000 and 2014 were identified within a 10-institution prospectively maintained database. Using receiver operating characteristic curves from logistic regression models, a peak bilirubin cutoff point that minimized the difference between the sensitivity and specificity, was determined. Factors affecting perioperative complications were estimated using logistic regression. Results: 191 of 328 (58.2%) patients who underwent complete resection with a hepatectomy, with available preoperative bilirubin data were analyzed. 37.2% (n = 71) had bilirubin > 7.9. Patients with higher preoperative bilirubin were more likely to have a higher CA 19-9 (1776±3721.5 vs 302.1±518.6, p = 0.0006), more comorbidities (1.6±0.8 vs 1.4±0.9; p = 0.002), preoperative biliary drainage (PBD) (91.4% vs 75.6%, p = 0.007), positive lymph nodes (48.5% vs 31.5%, p = 0.025) and perioperative death (14.5% vs 5.2%, p = 0.0292). Multivariate analysis identified PBD (OR 3.2, CI 1.4-7.5; p = 0.008) and smoking (OR 2.3, CI 1.2-4.4; p = 0.016) to be independent predictors of any and major complications. Peak bilirubin > 7.9 (OR 3.1, CI 1.1-8.9; p = 0.04) and preoperative systemic sepsis (PSS) (OR 5.0, CI 1.2-21.5; p = 0.03) were associated with increased risk of postoperative mortality. However, on multivariate analysis only PSS was significant (OR 14.4, CI 2.2-93.9; p = 0.005); 5/13 (23.1%) of patients with PSS died within 30 days after surgery. Conclusions: PSS portends increased operative mortality in HC patients undergoing hepatectomy, independent of preoperative peak bilirubin levels. Prevention and aggressive treatment of PSS should be the priority in the preoperative optimization of these patients.

Bile duct surgery in the treatment of hepatobiliary and gallbladder malignancies: effects of hepatic and vascular resection on outcomes

BACKGROUND

Resection of the bile duct is required for the treatment of cholangiocarcinoma and is sometimes indicated in resections of liver and gallbladder malignancies. The goal of this retrospective review was to characterize surgical outcomes in patients submitted to bile duct resection for malignancy when additional procedures, specifically hepatic or vascular resections, were performed.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was searched to identify a total of 747 patients who underwent: (i) biliary-enteric anastomosis (BEA) only (Group 1, n = 266); (ii) BEA with hepatic resection (Group 2, n = 439), or (iii) BEA with hepatic and vascular resection (Group 3, n = 42). Postoperative outcomes were compared and regression-adjusted risk factors were analysed to produce observed and expected (O/E) morbidity and mortality ratios.

RESULTS

The performance of hepatic and vascular resections significantly increased rates of overall morbidity (P < 0.001) and mortality (P = 0.021). Risk-adjusted O/E mortality ratios in Groups 1, 2 and 3 were 1.44 [95% confidence interval (CI) 0.84-2.30], 2.16 (95% CI 1.51-2.98) and 5.92 (95% CI 2.54-11.66), respectively. Multivariate analysis identified Group 2 (P < 0.001) and Group 3 (P = 0.001) status as independent predictors of morbidity, and Group 3 status (P = 0.008) as independently associated with mortality. More than 30% of deaths were associated with pulmonary complications and septic shock.

CONCLUSIONS

The addition of hepatic and vascular resections to bile duct resection significantly increased morbidity and mortality. The high O/E mortality ratios for patients in Groups 2 and 3 suggest these outcomes can be improved.

Abstract 4342: Differential expression of novel PKD1 related biomarker panel in African American men with prostate cancer

Background: Prostate Cancer (PCa) exhibits striking racial disparity and is presented more aggressively in African Americans (AAs) than Caucasians (CAs). We have previously reported that the dysregulation of PKD1-centered signaling in primary AA prostate cancer cell line E006AA is akin to more aggressive Caucasian cell line C4-2. As PKD1 plays a central role in several cellular mechanisms that contribute in aggressive malignant phenotype, we defined a PKD1 related biomarker panel consisting of 11 biomarkers and explored whether PKD1 centered signaling would be differentially regulated in AA compared to CA PCa. Methods: PKD1 related biomarker panel consisted of PKD1, AR, HSP27, N-Cadherin, Snail, Vimentin, MMP-2, MMP-9, MT-1, E-cadherin, beta-Catenin. The validity of the PKD1 related biomarker panel in PCa was evaluated on available microarray databases (cbioportal.org). The differential expression of the biomarker panel was quantified on PCa tissue samples from15 AA and 15 CA men with matching Gleason score obtained from tumor tissue bank of Comprehensive Cancer Center of Wake Forest University. Results: The cbioportal consisted of six different PCa databases with approximately 662 human PCa samples in total. In average, PKD1 related biomarker panel was altered 47.7% in available cases. Quantification of the PKD1 related biomarker panel regarding gene expression demonstrated a trend toward higher expression of majority of biomarkers in AA samples in compare to CAs. However, only variances in expression of MMP2 (P&lt;0.0001) and MT1A (P = 0.03) were significantly different between AAs and CAs. The results obtained from human PCa samples showed a moderate correlation with previously reported cell line data which showed significantly higher expression of EMT markers N-Cadherin, Vimentin and Snail in AA cell line in compare to CA cell lines. Conclusion: The differential expression of PKD1 related biomarker panel in AAs in compare to CAs suggests a biological basis for disparity in PCa. Besides, relatively high altered PKD1 related biomarker panel in available microarray databases suggests the potential of the panel as a tool in diagnosis of aggressive phenotype in PCa.

Citation Format: Bita Nickkholgh, Xiaolan Fang, Shira M. Winters, Nora Fino, KC. Balaji. Differential expression of novel PKD1 related biomarker panel in African American men with prostate cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4342. doi:10.1158/1538-7445.AM2015-4342