489 research outputs found
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Evaluation of uncomplicated acute respiratory tract infection management in veterans: A national utilization review.
BackgroundAntibiotics are overprescribed for acute respiratory tract infections (ARIs). Guidelines provide criteria to determine which patients should receive antibiotics. We assessed congruence between documentation of ARI diagnostic and treatment practices with guideline recommendations, treatment appropriateness, and outcomes.MethodsA multicenter quality improvement evaluation was conducted in 28 Veterans Affairs facilities. We included visits for pharyngitis, rhinosinusitis, bronchitis, and upper respiratory tract infections (URI-NOS) that occurred during the 2015-2016 winter season. A manual record review identified complicated cases, which were excluded. Data were extracted for visits meeting criteria, followed by analysis of practice patterns, guideline congruence, and outcomes.ResultsOf 5,740 visits, 4,305 met our inclusion criteria: pharyngitis (n = 558), rhinosinusitis (n = 715), bronchitis (n = 1,155), URI-NOS (n = 1,475), or mixed diagnoses (>1 ARI diagnosis) (n = 402). Antibiotics were prescribed in 68% of visits: pharyngitis (69%), rhinosinusitis (89%), bronchitis (86%), URI-NOS (37%), and mixed diagnosis (86%). Streptococcal diagnostic testing was performed in 33% of pharyngitis visits; group A Streptococcus was identified in 3% of visits. Streptococcal tests were ordered less frequently for patients who received antibiotics (28%) than those who did not receive antibiotics 44%; P < .01). Although 68% of visits for rhinosinusitis had documentation of symptoms, only 32% met diagnostic criteria for antibiotics. Overall, 39% of patients with uncomplicated ARIs received appropriate antibiotic management. The proportion of 30-day return visits for ARI care was similar for appropriate (11%) or inappropriate (10%) antibiotic management (P = .22).ConclusionsAntibiotics were prescribed in most uncomplicated ARI visits, indicating substantial overuse. Practice was frequently discordant with guideline diagnostic and treatment recommendations
Drugs of Last Resort? The Use of Polymyxins and Tigecycline at US Veterans Affairs Medical Centers, 2005–2010
Multidrug-resistant (MDR) and carbapenem-resistant (CR) Gram-negative pathogens are becoming increasingly prevalent around the globe. Polymyxins and tigecycline are among the few antibiotics available to treat infections with these bacteria but little is known about the frequency of their use. We therefore aimed to estimate the parenteral use of these two drugs in Veterans Affairs medical centers (VAMCs) and to describe the pathogens associated with their administration. For this purpose we retrospectively analyzed barcode medication administration data of parenteral administrations of polymyxins and tigecycline in 127 acute-care VAMCs between October 2005 and September 2010. Overall, polymyxin and tigecycline use were relatively low at 0.8 days of therapy (DOT)/1000 patient days (PD) and 1.6 DOT/1000PD, respectively. Use varied widely across facilities, but increased overall during the study period. Eight facilities accounted for three-quarters of all polymyxin use. The same statistic for tigecycline use was twenty-six VAMCs. There were 1,081 MDR or CR isolates during 747 hospitalizations associated with polymyxin use (1.4/hospitalization). For tigecycline these number were slightly lower: 671 MDR or CR isolates during 500 hospitalizations (1.3/hospitalization) (p = 0.06). An ecological correlation between the two antibiotics and combined CR and MDR Gram-negative isolates per 1000PD during the study period was also observed (Pearson’s correlation coefficient r = 0.55 polymyxin, r = 0.19 tigecycline). In summary, while polymyxin and tigecycline use is low in most VAMCs, there has been an increase over the study period. Polymyxin use in particular is associated with the presence of MDR Gram-negative pathogens and may be useful as a surveillance measure in the future
Identifying Complexity in Infectious Diseases Inpatient Settings: An Observation Study
Background Understanding complexity in healthcare has the potential to reduce decision and treatment uncertainty. Therefore, identifying both patient and task complexity may offer better task allocation and design recommendation for next-generation health information technology system design.
Objective To identify specific complexity-contributing factors in the infectious disease domain and the relationship with the complexity perceived by clinicians.
Method We observed and audio recorded clinical rounds of three infectious disease teams. Thirty cases were observed for a period of four consecutive days. Transcripts were coded based on clinical complexity-contributing factors from the clinical complexity model. Ratings of complexity on day 1 for each case were collected. We then used statistical methods to identify complexity-contributing factors in relationship to perceived complexity of clinicians.
Results A factor analysis (principal component extraction with varimax rotation) of specific items revealed three factors (eigenvalues \u3e 2.0) explaining 47% of total variance, namely task interaction and goals (10 items, 26%, Cronbach’s Alpha = 0.87), urgency and acuity (6 items, 11%, Cronbach’s Alpha = 0.67), and psychosocial behavior (4 items, 10%, Cronbach’s alpha = 0.55). A linear regression analysis showed no statistically significant association between complexity perceived by the physicians and objective complexity, which was measured from coded transcripts by three clinicians (Multiple R-squared = 0.13, p = 0.61). There were no physician effects on the rating of perceived complexity.
Conclusion Task complexity contributes significantly to overall complexity in the infectious diseases domain. The different complexity-contributing factors found in this study can guide health information technology system designers and researchers for intuitive design. Thus, decision support tools can help reduce the specific complexity-contributing factors. Future studies aimed at understanding clinical domain-specific complexity-contributing factors can ultimately improve task allocation and design for intuitive clinical reasoning
Circular Polarization from Gamma-ray Burst Afterglows
We investigate the circular polarization (CP) from Gamma-Ray Burst (GRB)
afterglows. We show that a tangled magnetic field cannot generate CP without an
ordered magnetic field because there is always an oppositely directed field, so
that no handedness exists. This implies the observation of CP could be a useful
probe of an ordered field, which carries valuable information on the GRB
central engine. By solving the transfer equation of polarized radiation, we
find that the CP reaches 1% at radio frequencies and 0.01% at optical for the
forward shock, and 10-1% at radio and 0.1-0.01% at optical for the reverse
shock.Comment: 12 pages, 3 figure
O/IR Polarimetry for the 2010 Decade (GAN): Science at the Edge, Sharp Tools for All
Science opportunities and recommendations concerning optical/infrared
polarimetry for the upcoming decade in the field of Galactic science.
Community-based White Paper to Astro2010 in response to the call for such
papers.Comment: White Paper to the Galactic Neighborhood (GAN) Science Frontiers
Panel of the Astro2010 Decadal Surve
Trends in Antibiotic Use and Nosocomial Pathogens in Hospitalized Veterans With Pneumonia at 128 Medical Centers, 2006-2010
This national Department of Veterans Affairs study of hospitalizations for pneumonia found a dramatic increase in broad-spectrum antibiotic use from 2006 to 2010, without an increase in nosocomial pathogens or improvement in the match between coverage and pathoge
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Decreases in Antimicrobial Use Associated With Multihospital Implementation of Electronic Antimicrobial Stewardship Tools.
BackgroundAntimicrobial stewards may benefit from comparative data to inform interventions that promote optimal inpatient antimicrobial use.MethodsAntimicrobial stewards from 8 geographically dispersed Veterans Affairs (VA) inpatient facilities participated in the development of antimicrobial use visualization tools that allowed for comparison to facilities of similar complexity. The visualization tools consisted of an interactive web-based antimicrobial dashboard and, later, a standardized antimicrobial usage report updated at user-selected intervals. Stewards participated in monthly learning collaboratives. The percent change in average monthly antimicrobial use (all antimicrobial agents, anti-methicillin-resistant Staphylococcus aureus [anti-MRSA] agents, and antipseudomonal agents) was analyzed using a pre-post (January 2014-January 2016 vs July 2016-January 2018) design with segmented regression and external comparison with uninvolved control facilities (n = 118).ResultsIntervention sites demonstrated a 2.1% decrease (95% confidence interval [CI], -5.7% to 1.6%) in total antimicrobial use pre-post intervention vs a 2.5% increase (95% CI, 0.8% to 4.1%) in nonintervention sites (absolute difference, 4.6%; P = .025). Anti-MRSA antimicrobial use decreased 11.3% (95% CI, -16.0% to -6.3%) at intervention sites vs a 6.6% decrease (95% CI, -9.1% to -3.9%) at nonintervention sites (absolute difference, 4.7%; P = .092). Antipseudomonal antimicrobial use decreased 3.4% (95% CI, -8.2% to 1.7%) at intervention sites vs a 3.6% increase (95% CI, 0.8% to 6.5%) at nonintervention sites (absolute difference, 7.0%; P = .018).ConclusionsComparative data visualization tool use by stewards at 8 VA facilities was associated with significant reductions in overall antimicrobial and antipseudomonal use relative to uninvolved facilities
Disparities in COVID-19 related outcomes in the United States by race and ethnicity pre-vaccination era: an umbrella review of meta-analyses
BackgroundMeta-analyses have investigated associations between race and ethnicity and COVID-19 outcomes. However, there is uncertainty about these associations’ existence, magnitude, and level of evidence. We, therefore, aimed to synthesize, quantify, and grade the strength of evidence of race and ethnicity and COVID-19 outcomes in the US.MethodsIn this umbrella review, we searched four databases (Pubmed, Embase, the Cochrane Database of Systematic Reviews, and Epistemonikos) from database inception to April 2022. The methodological quality of each meta-analysis was assessed using the Assessment of Multiple Systematic Reviews, version 2 (AMSTAR-2). The strength of evidence of the associations between race and ethnicity with outcomes was ranked according to established criteria as convincing, highly suggestive, suggestive, weak, or non-significant. The study protocol was registered with PROSPERO, CRD42022336805.ResultsOf 880 records screened, we selected seven meta-analyses for evidence synthesis, with 42 associations examined. Overall, 10 of 42 associations were statistically significant (p ≤ 0.05). Two associations were highly suggestive, two were suggestive, and two were weak, whereas the remaining 32 associations were non-significant. The risk of COVID-19 infection was higher in Black individuals compared to White individuals (risk ratio, 2.08, 95% Confidence Interval (CI), 1.60–2.71), which was supported by highly suggestive evidence; with the conservative estimates from the sensitivity analyses, this association remained suggestive. Among those infected with COVID-19, Hispanic individuals had a higher risk of COVID-19 hospitalization than non-Hispanic White individuals (odds ratio, 2.08, 95% CI, 1.60–2.70) with highly suggestive evidence which remained after sensitivity analyses.ConclusionIndividuals of Black and Hispanic groups had a higher risk of COVID-19 infection and hospitalization compared to their White counterparts. These associations of race and ethnicity and COVID-19 outcomes existed more obviously in the pre-hospitalization stage. More consideration should be given in this stage for addressing health inequity
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Electronic Detection of MRSA Infections in a National VA Population Augments Current Manual Process
Abstract Background: Automated measurement of hospital-acquired infections (HAIs) can improve the efficiency and reliability of surveillance. Within the VA, inpatient MRSA HAIs are manually reviewed and reported to the Inpatient Evaluation Center (IPEC). These MRSA HAI metrics are used as part of facility rankings to compare quality. However, IPEC uses CDC surveillance definitions which may vary in interpretation across facilities and not reflect all clinically relevant MRSA events. Thus, we sought to compare this manual process to a previously-developed electronic algorithm for detecting clinical MRSA infections to evaluate whether the algorithm could be used to expand MRSA surveillance activities. Methods: Electronic data were extracted from the national VA healthcare system during the period from January 1, 2014–December 31, 2014. The electronic detection algorithm defined MRSA infections as a culture positive for MRSA from a sterile site or from a non-sterile site with receipt of an antimicrobial with MRSA activity ± 5 days from the date of culture collection. Cultures obtained ≥48 hours after admission were classified as HAI. IPEC data for five facilities was extracted and IPEC rates were compared with rates estimated by the electronic algorithm. Flagged infections at one facility were manually reviewed to evaluate any discordances. Results: N = 14,260 MRSA clinical cultures were identified in 9,209 unique patients. Of these, 1,703 met definition for MRSA HAI infection. Electronic algorithm detected MRSA HAI rates varied widely across 137 facilities (Figure 1), ranked by rate per 1,000 patient-days. IPEC rates were universally lower than estimates derived using the MRSA electronic detection tool. Discordance in the estimates was attributable to infections present on admission, differences in capture of surgical site infections, and differences between clinical and surveillance definitions of infection. Conclusion: Applying the MRSA algorithm provided additional information about the burden of MRSA infections across the VA. This algorithm could be used as a tool to complement IPEC reporting and further inform infection prevention activities. Disclosures All authors: No reported disclosures
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