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Introduction: Several risk factors are associated with acute venous thromboembolism (VTE) after total joint arthroplasty (TJA). However, there is a lack of literature regarding the cumulative impact of multiple risk factors. To address this gap, we utilized the PearlDiver database, an insurance billing claims database containing de-identified data from 91 million orthopedic patients., Methods: The PearlDiver database was queried for records of patients who underwent total hip and knee arthroplasty from 2010 to 2019 using ICD-10 and CPT codes. Twelve persistent and two transient risk factors were analyzed for their association with the occurrence of acute VTE within three months after surgery. Univariate and logistic regression analyses with odds ratios (ORs) and confidence intervals (CIs) were conducted to determine the odds associated with each risk factor and the impact of multiple concurrent risk factors., Results: A total of 988,675 patients who underwent hip and knee arthroplasty met the inclusion criteria, of whom 1.5% developed acute VTE after three months. The prevalence of VTE risk factors ranged from 0.2 to 38.6%. Individual, persistent risk factors demonstrated 14-84% increased odds of VTE compared to a 1.2% increase for a transient risk factor (acute myocardial infarction). Three or more persistent risk factors were associated with a higher risk of VTE., Conclusion and Relevance: Persistent risk factors were associated with a higher incidence of postoperative VTE than transient risk factors. An incremental increase in risk was noted if three or more persistent risk factors were present., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Kumar et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: The COVID-19 pandemic has compelled a majority of hospital systems to reduce surgical and procedural volumes in an attempt to preserve resources. Elective surgery and procedures resumption has proven to be a calculated risk between COVID-19 exposure and resource depletion and patient morbidity and mortality from surgical deferral., Methods: Within a few days of halting elective surgery and procedures, our 7-hospital (2427 in-patient beds, 26,647 inpatient surgeries) healthcare system developed a multidisciplinary Pivot Plan with the primary outcome of a phased resumption of elective surgery and procedures. The plan entailed the integration of our electronic medical record, order entry automatization, perioperative staff utilization, partnering with primary care providers, and a stepwise COVID-19 testing algorithm based on a predetermined hierarchy of case acuity and timeliness of patient care., Results: The Pivot Plan was instituted on May 10, 2020. Since then, 22,624 patients have been tested for COVID-19 in anticipation of an elective surgery and procedures; 140 (0.62%) tested positive for COVID-19 and had their procedure deferred. As our testing capability has increased, we have been able to increase our added elective surgery and procedures capacity from 13 cases per day to 531 cases per day. In turn, we have seen the case volume increase by 52%., Conclusion: Our academic healthcare system located in one of the initial COVID-19 hotspots in the United States has successfully resumed elective surgery and procedures in part due to a receptive and supportive culture based upon nimbleness, agility, and rapid integration of multiple resources from a cohort of diverse disciplines applied to the perioperative services workflow., (© 2020 The Authors.)

Mohs micrographic surgery (MMS) is a specialised micrographic technique used for the treatment of locally invasive skin cancers. Despite being a relatively low risk surgery, the overall complication rates range between 1.6% and 3%. Common complications include postoperative haemorrhage, haematoma formation, wound infection, wound dehiscence and flap/graft necrosis. Osteomyelitis after dermatological cancer surgery is exceedingly rare. There have only been two cases of osteomyelitis in association with Mohs surgery reported in the literature to date. Here, we describe an epidemiologically atypical patient who initially presented with fever and altered mental status and later found to have calvarial osteomyelitis, intracranial abscess (empyema) and meningoencephalitis as a result of Mohs surgery. Although rare, it is a predictable side effect postsurgery, and prevention of such complications are critical to decrease morbidity and mortality in patients undergoing MMS., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

A urinary tract infection (UTI) disease state management guideline, including risk-based antimicrobial recommendations, Foley catheter management and transitions of care, was implemented. This study evaluated the outcomes associated with implementation of the guideline. A retrospective study was conducted between 1 July 2013 and 30 September 2013 (pre-implementation) and between 1 July 2014 and 30 September 2014 (post-implementation). Symptomatic patients treated for UTI within 24 h with an identified pathogen were included. Risk-based patient groups were community-acquired UTI, healthcare-associated UTI, or extended-spectrum β-lactamase (ESBL) history in prior 12 months. Recommended antimicrobials were ceftriaxone, cefepime ± vancomycin, or doripenem ± vancomycin, respectively. Given the low post-implementation guideline adherence, pre- and post-groups were combined to evaluate potential guideline value. Length of stay (LOS) decreased when guidelines were followed [5 (IQR 4-7) days vs. 6 (IQR 4-8) days; P = 0.03] or appropriate therapy (according to in vitro susceptibilities) was given [5 (IQR 4-7) days vs. 6 (IQR 4-9) days; P = 0.03]. Those receiving guideline-recommended antimicrobials were more likely to have appropriate therapy within 24 h (84.4% vs. 64.2%; P <0.001). On multivariate analysis, intensive care unit (ICU) admission and admission from home were associated with longer and shorter LOS, respectively. Despite less than anticipated adherence, these data suggest that the established disease state management guideline can improve outcomes in patients admitted with UTI., (Copyright © 2016 Elsevier B.V. and International Society of Chemotherapy. All rights reserved.)

Background: Urinary tract infections (UTI) are among the most common bacterial diseases worldwide, with significant clinical and economic burden. Surveillance of pathogen epidemiology and risk factors for resistant pathogens in the hospital setting may improve the management of UTI., Objective: To evaluate microbiology and antimicrobial susceptibility of UTI pathogens, with associated costs, in hospitalized patients., Methods: Patients diagnosed with UTI between July and September 2013 were retrospectively screened for clinical symptoms and treatment within 24 hours of admission, then categorized into groups: community acquired (Group 1); recent healthcare exposure (Group 2); or a history of identification of an extended-spectrum beta lactamase (ESBL)-producing organism (Group 3). Clinical, epidemiological, and financial data were compared between groups., Results: From 308 included patients, a total of 216 pathogens were identified. Escherichia coli was most commonly identified pathogen, but frequencies differed between groups (p = 0.002), as did those of ESBL-producing pathogens (p < 0.001) and Pseudomonas aeruginosa (p = 0.005). Appropriate empirical therapy also differed between groups (p = 0.003). Length of stay was longer for healthcare associated UTI with inappropriate empirical therapy (5.2 versus 6.3 days, p = 0.016). Increased cost was associated with factors other than antimicrobial costs. Intensive care unit (ICU) stay (p < 0.001), care facility at discharge (p = 0.001), Foley catheter (FC) present on admission (p = 0.002), and Charlson comorbidity index (CCI) (p = 0.017) predicted increased cost overall, while ICU stay (p < 0.001), time to appropriate therapy (p < 0.001), and CCI (p = 0.015) predicted higher cost in patients with pathogens identified., Conclusions: Changes in antimicrobial susceptibility are evident with exposure to healthcare, the presence of a FC, and a history of resistant pathogens. Risk-based empirical prescribing and rapid de-escalation may improve care and reduce costs.