Effect of providers' procedural volume complexity on in-hospital complications and length of stay for gastric bypass surgery

Obesity and morbid obesity represent one of the major public health problems in the United States (U.S.) that affects nearly one-third of the adult American population. Gastric bypass (GB) is a complex operation, performed in a high-risk morbidly obese population, requiring well-trained surgeons and well-equipped hospital facilities to ensure optimal surgical outcomes. The volume-outcomes relationship is well-established for providers (both surgeons and hospitals) performing GB procedures. However, the findings of improved outcomes after GB for high volume providers have been attributed only to the high volume of GB and not the volume of other non-gastric bypass (non-GB) procedures. The studies in this dissertation were undertaken to examine the effect of provider?s (general surgeon and hospital) non-GB complex (non-GBC) and non-complex (non-GBNC) volume on in-hospital complications and length of stay (LOS) for patients undergoing GB. The population-based studies used a combination of various existing retrospective data to address the research objectives. The datasets used include: a two-year (2003- 2004) Florida hospital inpatient discharge data as the main analytic dataset, the 2003- 2005 work Relative Value Units (RVU) data (available from the Physician Fee Schedule from the Centers of Medicare and Medicaid, to segment the provider?s non-GB case load into non-GBC and non-GBNC procedures performed by a provider per year), 2005 Florida hospital characteristics file, 2005 Florida surgeon characteristics file, and 2004 Area Resource File data. Separate generalized estimating equation (GEE) regression models, adjusting standard errors for the non-nested surgeon and hospital cluster effect, were constructed for each outcome: composite complications (one or more complications), technical complications (including unexpected reoperations, splenic injury, hemorrhage, anastomotic leaks, small bowel obstructions, and wound), systemic complications (including pulmonary, cardiac, thromboembolic, genitourinary tract, and postoperative shock), and LOS. Covariates included were patient characteristics, year, surgeon GB volume, and hospital characteristics. In adjusted analyses, the gastric bypass patients operated by general surgeons with high non-GBNC volume (>142 procedures/year) had 70% and 88% higher likelihood of composite and systemic complications, respectively. In contrast, those operated at hospitals with high non-GBNC volume (>6,478 procedures/year) had 49% and 40% lower likelihood of composite and technical complications, respectively. There was no clear association between providers? high non-GBC volume and adverse outcomes. Furthermore, patients operated by general surgeons with high GB volume (>50 GBs/year) had 27% and 41% lower likelihood of composite and systemic complications, respectively. However, those operated at hospital?s with high GB volume (>125 GBs/year) had 30% lower likelihood of technical complications. The study findings suggest that while provider GB volume matters for in-hospital complications, the complexity of overall surgical load also matters for general surgeons but the overall scale matters for hospitals to deliver better in-hospital outcomes for GB. In particular, the outcomes may improve if GB patients avoided general surgeons with a high volume of non-complex procedures and if GB patients avoided hospitals with low total volume

Emerging Strategies to Combat ESKAPE Pathogens in the Era of Antimicrobial Resistance: A Review

The acronym ESKAPE includes six nosocomial pathogens that exhibit multidrug resistance and virulence: Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp. Persistent use of antibiotics has provoked the emergence of multidrug resistant (MDR) and extensively drug resistant (XDR) bacteria, which render even the most effective drugs ineffective. Extended spectrum β-lactamase (ESBL) and carbapenemase producing Gram negative bacteria have emerged as an important therapeutic challenge. Development of novel therapeutics to treat drug resistant infections, especially those caused by ESKAPE pathogens is the need of the hour. Alternative therapies such as use of antibiotics in combination or with adjuvants, bacteriophages, antimicrobial peptides, nanoparticles, and photodynamic light therapy are widely reported. Many reviews published till date describe these therapies with respect to the various agents used, their dosage details and mechanism of action against MDR pathogens but very few have focused specifically on ESKAPE. The objective of this review is to describe the alternative therapies reported to treat ESKAPE infections, their advantages and limitations, potential application in vivo, and status in clinical trials. The review further highlights the importance of a combinatorial approach, wherein two or more therapies are used in combination in order to overcome their individual limitations, additional studies on which are warranted, before translating them into clinical practice. These advances could possibly give an alternate solution or extend the lifetime of current antimicrobials

Real-world comparison of bleeding risks among non-valvular atrial fibrillation patients prescribed apixaban, dabigatran, or rivaroxaban

Limited real-world data are available regarding the comparative safety of non-vitamin K antagonist oral anticoagulants (NOACs). The objective of this retrospective claims observational cohort study was to compare the risk of bleeding among non-valvular atrial fibrillation (NVAF) patients prescribed apixaban, dabigatran, or rivaroxaban. NVAF patients aged ≥18 years with a 1-year baseline period were included if they were new initiators of NOACs or switched from warfarin to a NOAC. Cox proportional hazards modelling was used to estimate the adjusted hazard ratios of any bleeding, clinically relevant non-major (CRNM) bleeding, and major inpatient bleeding within 6 months of treatment initiation for rivaroxaban and dabigatran compared to apixaban. Among 60,227 eligible patients, 8,785 were prescribed apixaban, 20,963 dabigatran, and 30,529 rivaroxaban. Compared to dabigatran or rivaroxaban patients, apixaban patients were more likely to have greater proportions of baseline comorbidities and higher CHA2DS2-VASc and HAS-BLED scores. After adjusting for baseline clinical and demographic characteristics, patients prescribed rivaroxaban were more likely to experience any bleeding (HR: 1.35, 95% confidence interval [CI]: 1.26-1.45), CRNM bleeding (HR: 1.38, 95% CI: 1.27-1.49), and major inpatient bleeding (HR: 1.43, 95% CI: 1.17-1.74), compared to patients prescribed apixaban. Dabigatran patients had similar bleeding risks as apixaban patients. In conclusion, NVAF patients treated with rivaroxaban appeared to have an increased risk of any bleeding, CRNM bleeding, and major inpatient bleeding, compared to apixaban patients. There was no significant difference in any bleeding, CRNM bleeding, or inpatient major bleeding risks between patients treated with dabigatran and apixaban

Introduction of the Tools for Economic Analysis of Patient Management Interventions in Heart Failure Costing Tool: A User-Friendly Spreadsheet Program to Estimate Costs of Providing Patient-Centered Interventions

Background—Patient-centered health care interventions, such as heart failure disease management programs, are under increasing pressure to demonstrate good value. Variability in costing methods and assumptions in economic evaluations of such interventions limit the comparability of cost estimates across studies. Valid cost estimation is critical to conducting economic evaluations and for program budgeting and reimbursement negotiations. Methods and Results—Using sound economic principles, we developed the Tools for Economic Analysis of Patient Management Interventions in Heart Failure (TEAM-HF) Costing Tool, a spreadsheet program that can be used by researchers and health care managers to systematically generate cost estimates for economic evaluations and to inform budgetary decisions. The tool guides users on data collection and cost assignment for associated personnel, facilities, equipment, supplies, patient incentives, miscellaneous items, and start-up activities. The tool generates estimates of total program costs, cost per patient, and cost per week and presents results using both standardized and customized unit costs for side-by-side comparisons. Results from pilot testing indicated that the tool was well-formatted, easy to use, and followed a logical order. Cost estimates of a 12-week exercise training program in patients with heart failure were generated with the costing tool and were found to be consistent with estimates published in a recent study. Conclusions—The TEAM-HF Costing Tool could prove to be a valuable resource for researchers and health care managers to generate comprehensive cost estimates of patient-centered interventions in heart failure or other conditions for conducting high-quality economic evaluations and making well-informed health care management decisions

Health disparities and social determinants of health among African-American women undergoing percutaneous coronary interventions (PCI).

This review of minority health describes the existing health disparities, the barriers to healthcare access and utilization, the role of three social determinants of health [i.e., (1) socioeconomic status, (2) education, and (3) stress and/or depression], the existing public-policies; and a health literacy strategy addressing social determinants of health to reduce disparities and improve outcomes in African-American women undergoing Percutaneous Coronary Intervention (PCI). Insurance, geography, facility-types, physician referral-bias, and cultural-differences pose as potential significant barriers to healthcare access and utilization. Likewise, lower socioeconomic-status, lack of education, and higher stress and/or depression is associated with adverse health-outcomes for this population. Although the elimination of health disparities is a national priority, comprehensive educational approaches focusing on cross-cultural communication, language barriers, cultural-sensitivity, and cultural-competence are needed

Feasibility, effectiveness, and students' attitude toward using WhatsApp in histology teaching and learning

OBJECTIVE: The present study assessed the feasibility, effectiveness, and students' attitude toward histology teaching using WhatsApp. MATERIALS AND METHODS: We conducted 6 months of histology teaching session on a “Histology learning WhatsApp group” consisting of 250 1st-year medical graduate students at Dr. S.N. Medical College, Jodhpur. A teacher posted a digital image of histology slides created using a mobile camera; a slide diagram sketched using hematoxylin and eosin pencil, identification points, and detail description of slide followed by discussion of queries. The feasibility was measured by adequate enrollment of students in the WhatsApp group, drop-out rate during the teaching period, acceptability of the by students based on their feedback, and perception of the teacher. To study the effectiveness, we conducted an online test pre- and posttests after every 2 months. The Student's attitude WhatsApp learning was assessed using the prevalidated feedback questionnaire. RESULTS: All the 1st-year medical graduate students admitted in the year 2016 enrolled and most of them were actively participated in the discussion conducted on WhatsApp group with zero dropout rate. Students' feedback indicated that students enjoyed learning using WhatsApp with better participation than traditional teaching method. Students liked anytime, anywhere learning using WhatsApp and it helped them to clear doubts. The statistical difference between average pre- and posttest scores (6.54 ± 2.33 and 16.37 ± 3.32, respectively) were statistically significant. CONCLUSIONS: We conclude that histology teaching using WhatsApp learning group is feasible, effective, and student-friendly method. It should be used more frequently to complement traditional teaching

Peer-assisted teaching method to foster learning physiological basis of electrocardiography among 1st year medical graduate students: An interventional study

INTRODUCTION: In peer-assisted teaching (PAT) method, students are encouraged to prepare, organize, and construct their learning program under the guidance of a teacher. The objective of the present study is to assess the benefits and outcome of PAT on students' understanding and knowledge of one of the important and difficult topics, “physiological basis of electrocardiography (ECG).” METHODS: A nonrandomized, interventional study was carried out in the department of physiology. Five peer tutors were selected and trained in the basics of ECG by a senior faculty of physiology for 12–14 h sessions over the 6-week period. These peer tutors then conducted a day-long workshop on five different subtopics of ECG, which was attended by 184 1st year medical students. Evaluation of the workshop was done through pre/posttest 20-item questionnaire score analysis and feedback questionnaire using a 5-point Likert scale items. RESULTS: The average pre- and posttest scores were 6.6 ± 2.73 and 13.3 ± 4.73, respectively. The average posttest scores were higher and statistically significant compared to pretest (R2 = 0.4275; P 70% improvement from the pretest score, and 44.78% had more than 50% improvement in their posttest scores. CONCLUSION: We received a predominantly positive feedback for the usefulness of peer teaching as a learning method. Thus, PAT was found to be a feasible and effective way of teaching the difficult concepts in physiology

Antibiofilm and antipersister activity of acetic acid against extensively drug resistant Pseudomonas aeruginosa PAW1.

Pseudomonas aeruginosa is an ESKAPE pathogen associated with difficult-to-treat burn wound and surgical-site infections. This study aimed to characterise an extensively drug resistant (XDR) P. aeruginosa isolate (designated PAW1) and to investigate the antibiofilm and antipersister effect of acetic acid on PAW1. PAW1 was identified using biotypic (VITEK) and genotypic (16S rDNA) analysis. Minimum inhibitory concentration (MIC) and disc susceptibility testing showed high level resistance against all antibiotics from classes including beta lactams, cephems, carbapenems and fluoroquinolones. It was therefore identified as extensively drug resistant (XDR), showing resistance to all antibiotics except for, aminoglycoside (gentamicin and netilmicin) and lipopeptides (polymyxin B). Time kill assays showed antibiotic tolerant, persister cell formation in presence of 100X MICs of gentamicin and polymyxin B. Other virulence traits such as ability to produce lipase, protease, haemolysin, and siderophores and to form biofilms were additional factors which may contribute to its pathogenicity. PAW1 showed promising susceptibility against acetic acid with MIC and minimum biofilm inhibitory concentration of 0.156% (v/v). Percent viability of PAW1 was dependent on dose and treatment time of acetic acid. 0.625% acetic acid treatment of 5 minutes was effective in killing >90% planktonic cells showing lesser toxicity to L929 cells (IC50 = 0.625%). Biofilm disruption caused due to acetic acid was also dose dependent, showing 40.57% disruption after treatment with 0.625% acetic acid for 5 minutes. FESEM imaging and live dead staining of planktonic and biofilm forms of PAW1 confirmed that acetic acid treatment caused 19.04% of cell shrinkage and disruption of extracellular matrix resulting in killing of cells. Antipersister activity of acetic acid was demonstrated by showing complete killing of PAW1 at 4X MIC. Overall, this study characterised an XDR isolate P. aeruginosa showing resistance and tolerance to various antibiotics. Antipersister and antibiofilm effect of acetic acid demonstrates the importance of forgotten topical agents as an effective strategy to treat XDR pathogens

Real-world comparison of major bleeding risk among non-valvular atrial fibrillation patients initiated on apixaban, dabigatran, rivaroxaban, or warfarin:A propensity score matched analysis

SummaryIn addition to warfarin, there are four non-vitamin K antagonist oral anticoagulants (NOACs) available for stroke prevention in non valvular atrial fibrillation (NVAF). There are limited data on the comparative risks of major bleeding among newly anticoagulated NVAF patients who initiate warfarin, apixaban, dabigatran, or rivaroxaban, when used in ‘real world’ clinical practice. The study used the Truven MarketScan® Commercial &amp; Medicare supplemental US claims database. NVAF patients aged ≥18 years newly prescribed an oral anticoagulant 01JAN2013–31DEC2014, with a ≥1-year baseline period, were included (study period: 01JAN2012–31DEC2014). Major bleeding was defined as bleeding requiring hospitalisation. Propensity score matching (PSM) was used to balance age, sex, region, baseline comorbidities, and comedications. Cox proportional hazards models were used to estimate the PSM hazard ratio (HR) of major bleeding. Among 45,361 newly anticoagulated NVAF patients, 15,461 (34.1 %) initiated warfarin, 7,438 (16.4 %) initiated apixaban, 17,801 (39.2 %) initiated rivaroxaban, and 4,661 (10.3 %) initiated dabigatran. Compared to matched warfarin initiators, apixaban (HR: 0.53; 95 % CI: 0.39–0.71) and dabigatran (HR: 0.69; 95 % CI: 0.50–0.96) initiators had a significantly lower risk of major bleeding. Patients initiating rivaroxaban (HR: 0.98; 95 % CI: 0.83–1.17) had a non-significant difference in major bleeding risk compared to matched warfarin patients. When comparisons were made between NOACs, matched rivaroxaban patients had a significantly higher risk of major bleeding (HR: 1.82; 95 % CI: 1.36–2.43) compared to apixaban patients. The differences for apixaban-dabigatran and dabigatran-rivaroxaban matched cohorts were not statistically significant. Among newly anticoagulated NVAF patients in the real-world setting, apixaban and dabigatran initiation was associated with significantly lower risk of major bleeding compared to warfarin initiation. When compared to apixaban, rivaroxaban initiation was associated with significantly higher risk of major bleeding.Note: The review process for this paper was fully handled by Christian Weber, Editor in Chief.Supplementary Material to this article is available online at www.thrombosis-online.com.</jats:p