Uncaptured rates of postpartum venous thromboembolism: a US national analysis

OBJECTIVE

To quantify the proportion of postpartum venous thromboembolism (VTE) readmissions, including those that occur at different hospitals from index admission, and describe risk factors for this outcome.

DESIGN

Retrospective observational study.

SETTING

US hospitals included in the Nationwide Readmissions Database.

SAMPLE

A total of 3 719 238 patients >14 years of age with a delivery-associated hospitalisation in 2014.

METHODS

Univariate analysis was performed to identify patient and hospital factors associated with readmissions. Significant factors were included in multivariate logistic regression to identify independent risk factors. Results were weighted for national estimates.

MAIN OUTCOME MEASURES

Readmission with VTE to both index and different hospitals at 30, 60 and 90 days.

RESULTS

The VTE cumulative readmission rate was 0.053% (n = 1477), 0.063% (n = 1765) and 0.069% (n = 1938) at 30, 60 and 90 days, respectively. Patients were readmitted to different hospitals 31% of the time within 90 days. Risk factors for different hospital VTE readmission were unique and included younger age and initial admission to a small/medium-sized hospital. Initial admission to a for-profit hospital increased the likelihood of readmission to a different hospital.

CONCLUSIONS

Nearly one in three postpartum VTEs are missed by the current quality metrics, with significant implications for outcomes and quality. For-profit hospitals have a significant portion of their VTE readmissions hidden, falsely lowering their readmission rates relative to public hospitals.

TWEETABLE ABSTRACT

US analysis shows 1 in 3 readmissions for postpartum venous thromboembolism currently missed.

Pharmacokinetics and pharmacodynamics of the novel monobactam LYS228 in a neutropenic murine thigh model of infection

Objectives

The neutropenic murine thigh infection model and a dose-fractionation approach were used to determine the pharmacokinetic/pharmacodynamic (PK/PD) relationship of LYS228, a novel monobactam antibiotic with activity against Enterobacteriaceae including carbapenem-resistant strains.

Methods

Mice (n = 4 per group) were inoculated with Enterobacteriaceae strains via intramuscular injection. Two hours post-bacterial inoculation, treatment with LYS228 was initiated. Animals were euthanized with CO2 24 h after the start of therapy and bacterial counts (log10 cfu) per thigh were determined. PK parameters were calculated using free (f) plasma drug levels.

Results

Following a dose-fractionation study, non-linear regression analysis determined that the predominant PK/PD parameter associated with antibacterial efficacy of LYS228 was the percentage of the dosing interval that free drug concentrations remained above the MIC (%fT>MIC). In a dose-dependent manner, LYS228 reduced the thigh bacterial burden in models established with Enterobacteriaceae producing β-lactamase enzymes of all classes (e.g. ESBLs, NDM-1, KPC, CMY-2 and OXA-48). The range of the calculated static dose was 86-649 mg/kg/day for the isolates tested, and the magnitude of the driver of efficacy was 37-83 %fT>MIC. %fT>MIC was confirmed as the parameter predominantly driving efficacy as evidenced by a strong coefficient of determination (r2 = 0.68). Neutrophils had minimal impact on the effect of LYS228 in the murine thigh infection model.

Conclusions

LYS228 is efficacious in murine thigh infection models using β-lactamase-producing strains of Enterobacteriaceae, including those expressing metallo-β-lactamases, ESBLs and serine carbapenemases, with the PK/PD driver of efficacy identified as %T>MIC.

Injectable or transdermal flunixin meglumine improves pregnancy rates in embryo transfer recipient beef cows without altering returns to estrus

OBJECTIVES

were to determine effects of 1) injectable or transdermal flunixin meglumine (FM) at embryo transfer (ET) compared to an untreated control group on pregnancy per ET (P/ET; ∼35 d after ET); 2) embryo and recipient factors on P/ET; 3) FM on hormone concentrations; and 4) FM on returns to estrus. Angus-cross beef cows (n = 1145) at five locations were scored for body condition (BCS; 1-9) and temperament (0 or 1) and given Select-Synch + CIDR. Recipient cows with a corpus luteum (CL) ≥1.5 cm received a frozen-thawed embryo 7 d after estrus and were concurrently given 1.1 mg/kg injectable FM im (INJFM; n = 384), 3.3 mg/kg transdermal FM pour on (TDFM; n = 388), or nothing (CON group; n = 373). Blood samples were collected at ET and 7 d later (60 cows). Accounting for temperament (P < 0.05), ET difficulty score (1-3, easy to difficult; P < 0.01), treatment by temperament (P < 0.001) and treatment by embryo quality (P < 0.05), FM treatments affected P/ET (P < 0.05). The P/ET for cows given INJFM [62.8% (241/384)] or TDFM [58.7% (228/388)] were not different (P = 0.26), but they were greater (P = 0.01 and P = 0.04, respectively) than P/ET for controls [51.2% (191/373)]. The P/ET was greater for calm versus excitable cows, 60.2 (463/769) and 52.4% (197/376), respectively (P < 0.01) and was lower for difficulty score 3 [49.2% (156/317)] compared to score 1 [62.7% (254/405; P < 0.001) or score 2 [59.1% (250/423; P < 0.01)]. There was no effect (P > 0.1) of cow age, BCS, or stage of embryo development on P/ET. Pregnancy rates for embryo quality grade 1 (excellent/good) and grade 2 (fair) were 60.4% (314/520) and 55.4% (346/625), respectively (P > 0.05). Percentages of non-pregnant recipient cows in estrus from Days 18-26 did not differ among treatment groups (P > 0.1). Control cows had lower progesterone concentrations and greater substance-P, PGFM and 8-isoprostane PGF2α concentrations at 7 d after ET compared to FM-treated cows (P < 0.05). In conclusion, injectable or transdermal FM improved pregnancy rates in ET recipients, without affecting nonpregnant cows return to estrus.

Prolonged and large outbreak of invasive group A Streptococcus disease within a nursing home: repeated intrafacility transmission of a single strain

OBJECTIVES

Multiple invasive group A Streptococcus (GAS) infections were reported to public health by a skilled nursing facility (facility A) in Illinois between May 2014 and August 2016. Cases continued despite interventions including antibiotic prophylaxis for all residents and staff. Two other geographically close facilities reported contemporaneous outbreaks of GAS. We investigated potential reasons for ongoing transmission.

METHODS

We obtained epidemiologic data from chart review of cases and review of facility and public health records from previous investigations into the outbreak. Infection control practices at facility A were observed and evaluated. Whole genome sequencing followed by phylogenetic analysis was performed on available isolates from the three facilities.

RESULTS

From 2014 to 2016, 19 invasive and 60 noninvasive GAS infections were identified at facility A occurring in three clusters. Infection control evaluations during clusters 2 and 3 identified hand hygiene compliance rates of 14% to 25%, appropriate personal protective equipment use in only 33% of observed instances, and deficient wound-care practices. GAS isolates from residents and staff of all three facilities were subtype emm89.0; on phylogenetic analysis, facility A isolates were monophyletic and distinct.

CONCLUSIONS

Inadequate infection control and improper wound-care practices likely led to this 28-month-long outbreak of severe infections in a skilled nursing facility. Whole genome sequencing and phylogenetic analysis suggested that intrafacility transmission of a single highly transmissible GAS strain was responsible for the outbreak in facility A. Integration of genomic epidemiology tools with traditional epidemiology and infection control assessments was helpful in investigation of a facility-wide outbreak.

Reproductive outcomes in oocyte donation cycles are associated with donor BMI

STUDY QUESTION

When adjusting for recipient BMI, is donor body mass index (BMI) associated with IVF outcomes in donor oocyte IVF cycles?

SUMMARY ANSWER

Increasing oocyte donor BMI is associated with a reduction in clinical pregnancy and live birth rates.

WHAT IS KNOWN ALREADY

Increased BMI has been associated with suboptimal reproductive outcomes, particularly in assisted reproductive technology (ART) cycles. However, it remains unclear if this association implies an effect of BMI on oocyte quality and/or endometrial receptivity.

STUDY DESIGN, SIZE, DURATION

A retrospective cohort study of two hundred and thirty five consecutive fresh donor oocyte IVF cycles from 1 January 2007 through 31 December 2013 at the Massachusetts General Hospital (MGH) Fertility Center.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Analyses included a total of 202 oocyte donors and 235 total cycles. Following adjustments for recipient BMI, the relationship between donor BMI (categorized into quartiles) and IVF outcomes was assessed.

MAIN RESULTS AND THE ROLE OF CHANCE

In the entire (anonymous and known) donor population, a reduced odds of clinical pregnancy (P-trend = 0.046) and live birth (P-trend = 0.06) was observed with increasing BMI quartile. Compared with quartile 1 (BMI 17.8-21.1), odds ratio (OR) (95% CI) of clinical pregnancy was 0.9 (0.4-2.0), 0.5 (0.2-1.1) and 0.5 (0.2-1.1), and OR of live birth was 1.1 (0.5-2.6), 0.6 (0.3-1.2) and 0.6 (0.3-1.2) for quartiles 2 through 4 respectively. In anonymous donors only, the odds of clinical pregnancy (P-trend = 0.02) and live birth (P-trend = 0.03) also declined as BMI quartile increased. Compared with quartile 1 (BMI 17.8-21.1), odds ratio (OR) (95% CI) of clinical pregnancy was 0.7 (0.3-1.7), 0.5 (0.2-1.1) and 0.4 (0.1-0.9), and OR of live birth was 0.9 (0.4-2.2), 0.5 (0.3-1.2) and 0.4 (0.2-1.1) for quartiles 2 through 4 respectively.

LIMITATIONS, REASONS FOR CAUTION

Limitations include the retrospective design, sample size and data from a single institution. Clinical application may not be limited to oocyte donors, though caution should be used prior to applying these principles to the general population. Data should not be interpreted to mean that all oocyte donors should be restricted to a BMI of less than 21.2 kg/m(2).

WIDER IMPLICATIONS OF THE FINDINGS

Following adjustments for the respective BMI of the oocyte donor and recipient, this study demonstrates an association of preconception BMI with subsequent IVF outcomes. The observations of this study are consistent with prior animal studies, suggest a possible effect of BMI at the oocyte level prior to fertilization and implantation, and warrant further investigation.

STUDY FUNDING/COMPETING INTERESTS

None.

Effect of gender and race on the week 48 findings in treatment-naïve, HIV-1-infected patients enrolled in the randomized, phase III trials ECHO and THRIVE

OBJECTIVES

A week 48 efficacy and safety analysis with respect to gender and race was conducted using pooled data from the phase III, double-blind, double-dummy efficacy comparison in treatment-naïve, HIV-infected subjects of TMC278 and efavirenz (ECHO) and TMC278 against HIV, in a once-daily regimen versus efavirenz (THRIVE) trials.

METHODS

Treatment-naïve, HIV-1-infected adults were randomized to receive rilpivirine (RPV; TMC278) 25 mg once a day (qd), or efavirenz (EFV) 600 mg qd, plus tenofovir/emtricitabine (ECHO) or tenofovir/emtricitabine, zidovudine/lamivudine or abacavir/lamivudine (THRIVE).

RESULTS

A total of 1368 participants (76% male and 61% White, of those with available race data) were randomized and treated. No gender-related differences in response rate (percentage of patients with HIV-1 viral load < 50 HIV-1 RNA copies/mL, using an intent-to-treat, time-to-loss-of-virological-response algorithm) were observed (RPV: men, 85%; women, 83%; EFV: men, 82%; women, 83%). Response rates were lower in Black compared with Asian and White participants (RPV: 75% vs. 95% and 85%, respectively; EFV: 74% vs. 93% and 83%, respectively); this finding was mostly a result of higher discontinuation and virological failure rates in Black patients. Safety findings were generally similar across race and gender subgroups. However, nausea occurred more commonly in women than in men in both treatment groups. In men, diarrhoea was more frequent in the EFV group, and abnormal dreams/nightmares were more frequent in men in both the EFV and RPV groups.

CONCLUSIONS

Overall response rates were high for both RPV and EFV. No gender differences were observed. However, response rates were lower among Black patients, regardless of treatment group. Gender appeared to influence the incidence of gastrointestinal adverse events and abnormal dreams/nightmares for both treatments.

Enhanced local processing of dynamic visual information in autism: evidence from speed discrimination

An important issue for understanding visual perception in autism concerns whether individuals with this neurodevelopmental disorder possess an advantage in processing local visual information, and if so, what is the nature of this advantage. Perception of movement speed is a visual process that relies on computation of local spatiotemporal signals but requires the comparison of information from more than a single spatial location or temporal point. This study examined speed discrimination in adolescents (ages 13-18 years old) with autism spectrum disorders (ASD). Compared to healthy controls (n=17), individuals with ASD (n=19) showed similarly precise speed discrimination when two comparison motion stimuli (random dot patterns) were presented closely in time (0.5s). With a longer temporal interval (3s) between the motion stimuli, individuals with ASD outperformed healthy controls on speed discrimination. On a second task--global motion perception--in which individuals were asked to detect coherent motion, individuals with ASD exhibited slightly degraded performance levels. The observed temporally selective enhancement in speed discrimination indicates that a local processing advantage in autism develops over a longer temporal range and is not limited to the spatial domain. These results suggest a dynamic perceptual mechanism for understanding, and therapeutically addressing, atypical visual processing in this neurodevelopmental disorder.

A randomised controlled trial using mobile advertising to promote safer sex and sun safety to young people

Mobile phone text messages (SMS) are a promising method of health promotion, but a simple and low cost way to obtain phone numbers is required to reach a wide population. We conducted a randomised controlled trial with simultaneous brief interventions to (i) evaluate effectiveness of messages related to safer sex and sun safety and (ii) pilot the use of mobile advertising for health promotion. Mobile advertising subscribers aged 16-29 years residing in Victoria, Australia (n = 7606) were randomised to the 'sex' or 'sun' group and received eight messages during the 2008-2009 summer period. Changes in sex- and sun-related knowledge and behaviour were measured by questionnaires completed on mobile phones. At follow-up, the sex group had significantly higher sexual health knowledge and fewer sexual partners than the sun group. The sun group had no change in hat-wearing frequency compared with a significant decline in hat-wearing frequency in the sex group. This is the first study of mobile advertising for health promotion, which can successfully reach most young people. Challenges experienced with project implementation and evaluation should be considered as new technological approaches to health promotion continue to be expanded.

Human embryonic stem cell-derived cardiomyocytes engraft but do not alter cardiac remodeling after chronic infarction in rats

Previous studies indicated that, in an acute myocardial infarction model, human embryonic stem cell-derived cardiomyocytes (hESC-CM) injected with a pro-survival cocktail (PSC) can preserve contractile function. Because patients with established heart failure may also benefit from cell transplantation, we evaluated the physiological effects of hESC-CM transplanted into a chronic model of myocardial infarction. Intramyocardial injection of hESC-CM with PSC was performed in nude rats at 1 month following ischemia-reperfusion. The left ventricular function of hESC-CM injected rats was evaluated at 1, 2 and 3 months after the cell injection procedure and was compared to 3 control groups (rats injected with serum-free media, PSC only, or non-cardiac human cells in PSC). Histology at 3 months revealed that human cardiomyocytes survive, develop increased sarcomere organization and are still proliferating. Despite successful engraftment, both echocardiography and MRI analyses showed no significant difference in left ventricular structure or function between these 4 groups at any time point of the study, suggesting that human cardiomyocytes do not affect cardiac remodeling in a rat model of chronic myocardial infarction. When injected into a chronic infarct model, hESC-CM can engraft, survive and form grafts with striated cardiomyocytes at least as well as was previously observed in an acute myocardial infarction model. However, although hESC-CM transplantation can attenuate the progression of heart failure in an acute model, the same hESC-CM injection protocol is insufficient to restore heart function or to alter adverse remodeling of a chronic myocardial infarction model.

Enteric dysganglionosis resembling intestinal neuronal dysplasia in a foal with bacterial colitis

A 5-day-old quarter horse colt with a history of hypothermia, agonal breathing, and diarrhea was euthanized. At necropsy, numerous slightly raised, discrete, closely approximated submucosal nodules were observed in the colon and small intestine. Histologically, these nodules were composed of expanded submucosal mesenchyme that contained numerous neurons either individually or in ganglia. Thirty-two percent of these ganglia included 8 or more neurons, in contrast to 6% in an age-matched foal. Some nodules had necrosuppurative inflammation with vasculitis, thrombosis, and bacterial colonization. A few heterotopic neurons were randomly distributed in the mucosa and the muscularis mucosa. Histologic changes were most consistent with intestinal neuronal dysplasia, a disease of the submucosal plexus described in humans.

Does the frequency of HIV and STI testing among men who have sex with men in primary care adhere with Australian guidelines?

OBJECTIVES

Australian guidelines recommend annual testing for HIV and sexually transmitted infections (STIs) for all men who have sex with men (MSM) and 3-6 monthly testing for those at higher risk as defined by behavioural criteria. We assessed HIV/STI re-testing rates among MSM attending primary care clinics.

METHODS

We conducted a retrospective follow-up of HIV negative MSM tested for HIV or STIs (chlamydia or syphilis) at four primary care clinics in the 9-month period: April to December 2006. Re-testing rates for these infections were calculated over 18 months. Logistic regression was undertaken to identify predictors of guideline adherence.

RESULTS

Of the MSM requiring annual HIV testing according to the guidelines, the re-testing rates at 1 y were 35% (762/2163). Among the higher risk MSM, 6-monthly HIV re-testing rates were 15% (283/1862). Within the subgroup who reported 11 or more male sexual partners within the past 6 months, HIV re-testing rates within 6 months were 19%. Independent predictors of HIV re-testing within 6 months in higher-risk MSM were reporting 11 or more male sexual partners in the last 6 months (AOR 3.1, 95% CI 1.8 to 4.8); being born overseas (AOR 2.0, 95% CI 1.2 to 3.4); and previous HIV testing more than 12 months earlier (AOR 3.3, 95% CI 1.9 to 5.5).

CONCLUSION

There is poor adherence to national guidelines that recommend regular re-testing of MSM for STIs, particularly among those at higher risk who require more frequent testing. Clinical strategies are urgently needed to encourage more frequent HIV/STI testing among MSM, especially in the higher risk subgroup.

Changes in equipment sharing in injecting drug users in Sydney 1989-1990

We investigated levels of equipment sharing in injecting drug users in Sydney, Australia, in two consecutive samples recruited in a non-treatment setting using similar methodology in 1989 (n = 1,245) and 1990 (n = 550). Comparison between the two waves of the study indicated that there were consistent and major reductions in percentage of time used equipment was re-used, and number of people from whom used equipment had been accepted. There was a corresponding significant and major increase in use of sterile injection equipment, obtained more frequently in the second sample from needle and syringe exchanges. The proportion of respondents reporting they had never shared equipment rose significantly. These data suggest that there is a continuing increase in the adoption of safer injecting practices and utilisation of needle and syringe exchanges over time in response to the threat of HIV transmission in injecting drug users.

Alcohol and recreational drug use by HIV-seropositive homosexual men

The objectives of this study were to describe the patterns of alcohol and recreational drug use of HIV-seropositive homosexual men and to determine the effect of alcohol use on HIV risk-taking behaviour. Of particular interest was the effect of knowledge of HIV status on these behaviours. Information on alcohol and drug use was obtained from 485 HIV-seropositive homosexual and bisexual men presenting to a HIV-antibody testing and medical management clinic. Heavy alcohol use was common, with 46.2% reporting consumption of six or more standard drinks on one day recently. Men who knew that they were HIV infected drank significantly more than those men who had yet to learn of their HIV status at the time of interview. There was clear evidence in this study for a role of alcohol use in HIV risk-taking behaviour. Almost one-third (27%) of the HIV-seropositive men reported unprotected anal intercourse during the previous 3 months with approximately one-third of these (27/76, 35.5%) nominating alcohol as contributing to their high HIV-risk behaviour.

HIV risk exposure of injecting drug users in Sydney

One thousand two hundred and forty-five Sydney injecting drug users (IDUs) were interviewed by questionnaire in 1989 to determine demographic and behavioural characteristics. One-sixth (16.7%) were considered to be at low risk of HIV from either needle sharing or sexual transmission as they had either never shared injecting equipment, or had not shared for years, or cleaned their injecting equipment effectively on 100% of the occasions when they did share; and were either celibate or monogamous or, if they had multiple partners, had not had unsafe sex in the previous 6 months. Over half (50.7%) had either unsafe injecting or sexual behaviour with the remaining third (32.6%) engaging in both unsafe injecting and sexual practises. Women were more at risk from sharing injection equipment than men but men were more at risk from sexual transmission than women. Increasing age was associated with greater likelihood of safer sex but age had no effect on injecting practises. There was no relationship between unsafe injecting and sexual practises. Amphetamine use was associated with low risk injecting practises while heroin use was associated with low risk sexual transmission. These findings indicate appreciable residual risk behaviour sufficient to allow for at least a slow diffusion of HIV among injecting drug users.

Predictors of unsafe injecting drug use

This paper reports on the incidence of unsafe injecting and the factors which influence this practice in a sample of 1245 Sydney injecting drug users (IDUs). Using a needle and syringe after someone else at some time in the last six months was reported in 41.6% of the sample. Taking into account those who claimed always to clean used needles with virucidal methods, 32.9% had placed themselves at risk of HIV infection from shared needles in the six months prior to interview.Seven factors were predictive of unsafe behaviour. These were (a) the amount spent per week on drugs, (b) the number of times a single needle was used prior to disposal, (c) having shared with a person who is now HIV infected, (d) having a regular sexual partner, (e) the proportion of times high, stoned or drunk when injecting, (f) being part of a group that injects together and (g) having been in prison.

Comparison of different methodologies for CD4 estimation in a clinical setting

OBJECTIVE

To compare flow cytometry assays, using traditional dual platform (DP) or newer single platform (SP) for CD4 enumeration.

METHOD

Records of subjects enrolled in four separate clinical trials using the same central laboratory [SP methodology (Trucount)] were reviewed retrospectively. Eighteen subjects had 60 matching contemporaneous samples at multiple timepoints.

RESULTS

DP flow cytometry yielded higher CD4 counts in 50/60 assays (83%). CD4 count and percentage by the two methods showed strong correlation for the counts (r=0.965, P<0.0001) and percentages (r=0.959, P<0.0001). Bland-Altman plot analysis showed that the limits of variation were within agreeable limits of +/-2SD in 56/60 (93.3%) samples tested. Twenty-five (42%) samples had a difference of >50 cells/microL. Of these six (24%) exceeded 100 cells.

CONCLUSION

This study is in agreement with previous reports of strong correlation between DP and SP flow cytometry. This review found differences in CD4 counts in a high proportion of samples tested highlighting the importance for clinicians to be aware of such differences when interpreting results from the two methods.