Search

To determine risk factors and time course for repeat procedures after ureteroscopy (URS) or shockwave lithotripsy (SWL) procedure using a large employer-based claims database.We identified all patients who underwent treatment for ureteral or renal stone with URS or SWL from January 1, 2007 to December 31, 2014 using the IBM MarketScan Commercial Database. Repeat stone procedure was evaluated after a 90-day grace period from the index procedure. Patients were followed until December 31, 2017. We performed multivariate analyses using Cox proportional hazards to determine independent risk factors for repeat procedure after the initial stone removal.A total of 189,739 patients underwent a SWL or URS and were included in the study. The incidence of repeat procedure per 100 person years was 6.8, and 4.4 after SWL and URS, respectively. The median time to reoperation was 12.5 months for SWL and 14.6 months for URS. On multivariable analysis, SWL was associated with an increased risk of repeat procedure compared to URS. (HR = 1.63). Paralysis, neurogenic bladder and inflammatory bowel disease were also associated with an increased risk of repeat procedure (HR = 1.66, 1.40, and 1.36 respectively) CONCLUSION: In a large national cohort, patients with paralysis and neurogenic bladder had a significantly higher risk of repeat stone procedure. SWL was associated with higher risk of repeat procedure than URS. Urologists can use these data to identify and counsel patients at high risk for need for recurrent procedure.

Background Preeclampsia is associated with increased risk of future heart failure (HF), but the relationship between preeclampsia and HF subtypes are not well-established. Objectives The objective of this analysis was to identify the risk of HF with preserved ejection fraction (HFpEF) following a delivery complicated by preeclampsia/eclampsia. Methods A retrospective cohort study using the New York and Florida state Healthcare Cost and Utilization Project State Inpatient Databases identified delivery hospitalizations between 2006 and 2014 for women with and without preeclampsia/eclampsia. The authors identified women admitted for HF after discharge from index delivery hospitalization until September 30, 2015, using International Classification of Diseases-9th Revision-Clinical Modification diagnosis codes. Patients were followed from discharge to the first instance of primary outcome (HFpEF hospitalization), death, or end of study period. Secondary outcomes included hospitalization for any HF and HF with reduced ejection fraction, separately. The association between preeclampsia/eclampsia and HFpEF was analyzed using Cox proportional hazards models. Results There were 2,532,515 women included in the study: 2,404,486 without and 128,029 with preeclampsia/eclampsia. HFpEF hospitalization was significantly more likely among women with preeclampsia/eclampsia, after adjusting for baseline hypertension and other covariates (aHR: 2.09; 95% CI: 1.80-2.44). Median time to onset of HFpEF was 32.2 months (interquartile range: 0.3-65.0 months), and median age at HFpEF onset was 34.0 years (interquartile range: 29.0-39.0 years). Both traditional (hypertension, diabetes mellitus) and sociodemographic (Black race, rurality, low income) risk factors were also associated with HFpEF and secondary outcomes. Conclusions Preeclampsia/eclampsia is an independent risk factor for future hospitalizations for HFpEF.

BACKGROUND CONTEXT There is growing interest among payers in profiling hospital value and quality-of-care, including both the cost and safety of common surgeries, such as lumbar fusion. Nonetheless, there is sparse evidence describing the statistical reliability of such measures when applied to lumbar fusion for spondylolisthesis. PURPOSE To evaluate the reliability of 90-day inpatient hospital costs, overall complications, and rates of serious complications for profiling hospital performance in lumbar fusion surgery for spondylolisthesis. STUDY DESIGN/SETTING Data for this analysis came from State Inpatient Databases from nine states made available through the Healthcare Cost and Utilization Project. PATIENT SAMPLE Patients undergoing elective lumbar spine fusion for spondylolisthesis from 2010 to 2017 in participating states. OUTCOME MEASURES Statistical reliability, defined as the ability to distinguish true performance differences across hospitals relative to statistical noise. Reliability was assessed separately for 90-day inpatient costs (standardized across years to 2019 dollars), overall complications, and serious complication rates. METHODS Statistical reliability was measured as the amount of variation between hospitals relative to the total amount of variation for each measure. Total variation includes both between-hospital variation (“signal”) and within-hospital variation (“statistical noise”). Thus, reliability equals signal over (signal plus noise) and ranges from 0 to 1. To adjust for differences in patient-level risk and procedural characteristics, hierarchical linear and logistic regression models were created for the cost and complication outcomes. Random hospital intercepts were used to assess between-hospital variation. We evaluated the reliability of each measure by study year and examined the number of hospitals meeting different thresholds of reliability by year. RESULTS We included a total of 66,571 elective lumbar fusion surgeries for spondylolisthesis performed at 244 hospitals during the study period. The mean 90-day hospital cost was $30,827 (2019 dollars). 12.0% of patients experienced a complication within 90 days of surgery, including 7.8% who had a serious complication. The median reliability of 90-day cost ranged from 0.97to 0.99 across study years, and there was a narrow distribution of reliability values. By comparison, the median reliability for the overall complication metric ranged from 0.22 to 0.44, and the reliability of the serious complication measure ranged from 0.30 to 0.49 across the study years. At least 96% of hospitals had high (> 0.7) reliability for cost in any year, whereas only 0-9% and 0-11% of hospitals reached this cutoff for the overall and serious complication rate in any year, respectively. By comparison, 10%–69% of hospitals per year achieved a more moderate threshold of 0.4 reliability for overall complications, compared to 21%–80% of hospitals who achieved this lower reliability threshold for serious complications. CONCLUSIONS 90-day inpatient costs are highly reliable for assessing variation across hospitals, whereas overall and serious complications are only moderately reliable for profiling performance. These results support the viability of emerging bundled payment programs that assume true differences in costs of care exist across hospitals.

Background Preoperative opioid use is associated with increased health care use after elective abdominal surgery. However, the scope of preoperative opioid use and its association with outcomes have not been described in elective pulmonary resection. This study aimed to characterize prevalent preoperative opioid use in patients undergoing elective pulmonary resection and compare clinical outcomes between patients with and without preoperative opioid exposure. Methods The study investigators assembled a retrospective cohort of adult patients undergoing elective pulmonary resection by using the IBM Watson Health MarketScan Database (2007 to 2015). The study compared opioid-naive patients with patients with a history of preoperative opioid exposure (>0 morphine milligram equivalent prescription filled within 90 days before surgery). Multivariable logistic and linear regressions adjusting for patient sociodemographic, comorbidity, and operative characteristics were used to compare odds of postoperative complication, prolonged length-of-stay (>14 days), 30-day postdischarge emergency department visits, 90-day readmissions, and 90-day costs. Results The study identified 14,373 patients, 4502 (31.3%) of whom had opioid exposure before pulmonary resection. In multivariable regression, patients with preoperative opioid exposure had significantly higher odds of experiencing a prolonged length of stay (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.11 to 1.58), 30-day emergency department visits (OR, 1.24; 95% CI, 1.01 to 1.41), and 90-day readmissions (OR, 1.41; 95% CI, 1.28 to 1.55). Adjusted 90-day costs were approximately 5% higher for patients with preoperative opioid use (P Conclusions One-third of patients who underwent pulmonary resection used opioids preoperatively and were at risk of experiencing adverse outcomes and having significantly higher health care use. They represent a unique high-risk population that will require novel, targeted interventions.

Introduction Women with gestational diabetes are 7 times more likely to develop type 2 diabetes and require lifelong diabetes screening. Loss of health coverage after pregnancy, as occurs in states that did not expand Medicaid, limits access to guideline-driven follow-up care and fosters health inequity. This study aims to understand the factors associated with the receipt of postpartum diabetes screening for women with gestational diabetes in a state without Medicaid expansion. Methods Electronic health record and Medicaid claims data were linked to generate a retrospective cohort of 1,078 women with gestational diabetes receiving care in Federally Qualified Health Centers in Missouri from 2010 to 2015. In 2019–2020, data were analyzed to determine the factors associated with the receipt of recommended postpartum diabetes screening (fasting plasma glucose, 2-hour oral glucose tolerance test, or HbA1c in specified timeframes) using a Cox proportional hazards model through 18 months of follow-up. Results Median age in this predominantly urban population was 28 (IQR=24−33) years. Self-reported racial or ethnic minorities comprised more than half of the population. Only 9.7% of women were screened at 12 weeks, and 20.8% were screened at 18 months. Prenatal certified diabetes education (adjusted hazard ratio=1.74, 95% CI=1.22, 2.49) and access to public transportation (adjusted hazard ratio=1.70, 95% CI=1.13, 2.54) were associated with increased screening in a model adjusted for race/ethnicity, the total number of prenatal visits, the use of diabetes medication during pregnancy, and a pregnancy-specific comorbidity index that incorporated age. Conclusions This study underscores the importance of access to public transportation, prenatal diabetes education, and continued healthcare coverage for women on Medicaid to support the receipt of guideline-recommended follow-up care and improve health equity.

Background Negative pressure wound therapy (NPWT) is commonly used to manage complex wounds in the pediatric population. With recently developed portable NPWT devices, providers have the opportunity to transition NPWT to the outpatient setting. However, there are no studies describing outpatient NPWT in pediatric patients. Therefore, the purpose of our study was to leverage a population-level analysis to advance our current knowledge about outpatient NPWT use in pediatric patients. Materials and methods We analyzed the Truven Health Analytics MarketScan Commercial Claims Database from 2006 to 2014 to identify children treated with NPWT. We compared patient characteristics, indications, complications before and after NPWT, health care utilization within 30 d of NPWT initiation, and health care cost profile of patients treated with NPWT primarily as outpatients versus inpatients. Outpatient NPWT was defined as patients with ≤50% of NPWT coded during an inpatient hospitalization, whereas inpatient NPWT was defined as patients with >50% of NPWT. Results We identified 3184 patients (1621 inpatients and 1563 outpatients) aged 0-17 y, who were treated with NPWT from 2006 to 2014. Outpatient NPWT was implemented across multiple ages, comorbidities, and indications, with a low complication rate (2.4%). After controlling for hematologic comorbidity and indications, outpatient NPWT was associated with lower risk of complications (odds ratio: 0.57, 95% confidence interval 0.38-0.86) and lower median total costs ($5602.03) compared with inpatient ($15,233.21) therapy. Conclusions Outpatient NPWT management in pediatric patients was associated with low complication rates. Additional studies are necessary to determine the most overall cost-effective treatment setting for NPWT in the pediatric population.

Objectives To test the hypothesis that increasing latency from diagnosis to delivery in patients with preterm hypertensive disorders of pregnancy is associated with an increased maternal risk of cardiovascular admission after delivery. Study design Retrospective cohort from the IBM MarketScan® Commercial Database from 2006 to 2016. Patients age 15–45 years with a preterm delivery complicated by a hypertensive disorder of pregnancy, at least 6 months of continuous insurance coverage prior to delivery and at least 365 days of coverage post-delivery were included. Main outcome measures Hospital readmission after delivery for a composite of acute cardiovascular events (cardiomyopathy, heart failure, cardiac arrest, myocardial infarction) or cerebrovascular events. Cox proportional hazards were used to estimate the risk of the primary outcome for each week of latency from diagnosis to delivery. Results There were 34,989 women in the study with a median follow-up of 2.57 years (IQR 1.66 to 1.54 years) with a median time from diagnosis to delivery of three days (IQR 0 to 14 days). An increasing time from diagnosis to delivery was associated with an increased risk of an acute cardiovascular event (adjusted HR 1.06, 95% CI 1.01, 1.11 per week), in models adjusted for maternal comorbidities and demographic factors. Later gestational age at diagnosis was associated with a decreased risk of maternal cardiovascular admission after delivery (aHR 0.94, 95% CI 0.91, 0.98 for each week increase in gestational age). Conclusions Prolonging expectant management of preterm hypertensive disorders of pregnancy is associated with an increased risk of maternal cardiovascular disease after delivery.

Background Although new persistent opioid use and high-risk prescribing have been recognized as important postoperative complications among younger patients (18–64 years of age), little is known about the incidence for postoperative opioid use among older patients (>65 years of age). Methods We analyzed a 20% national sample of Medicare Part D claims among beneficiaries >65 years of age who underwent a major or minor surgical procedure between January 1, 2009, and June 30, 2015. We identified patients without an opioid prescription fill in the year before surgery and examined their perioperative and 6-month postoperative opioid prescription fills to examine the incidence of new persistent opioid use and high-risk prescribing. Results We identified 81,839 opioid naive patients who underwent surgery and filled an opioid prescription perioperatively. Overall, 9.8% developed new persistent opioid use. Risk factors for new persistent opioid use included major surgery (adjusted odds ratio [aOR] 1.24, 95% confidence interval [CI] 1.17–1.31), more comorbid conditions (aOR 1.71, 95% CI 1.58–1.84), mood disorders (aOR 1.16, 95% CI 1.09–1.24), suicide or self-harm (aOR 1.60, 95% CI 1.05–2.44), substance abuse disorders (aOR 1.38, 95% CI 1.20–1.59), filling an opioid prescription before surgery (aOR 1.67, 95% CI 1.58–1.77), higher amounts of opioids filled (aOR 1.44, 95% CI 1.37–1.52), black race (aOR 1.23, 95% CI 1.12–1.36), and Medicaid eligibility (aOR 1.45, 95% CI 1.35–1.55). Conclusion About 10% of Medicare beneficiaries who were previously opioid naive continue to fill opioids past 3 months after surgery. In addition to comorbidities and mental health conditions, new persistent opioid use is associated with surgery type, preoperative opioid fill, high-risk prescribing practices, and sociodemographic factors.

BACKGROUND. Minimally invasive lobectomy is associated with decreased morbidity and length of stay. However, there have been few published analyses using recent, population-level data to compare clinical outcomes and cost by surgical approach, inclusive of robotic-assisted thoracoscopic surgery (RATS). The objective of this study was to compare outcomes and hospitalization costs among patients undergoing open, video-assisted thoracoscopic surgery (VATS) and RATS lobectomy. METHODS. We identified patients who underwent elective lobectomy in the Healthcare Cost and Utilization Project Florida State Inpatient Database (2008 to 2014). Hierarchical logistic and linear regression models were used to compare in-hospital mortality, postoperative complications, prolonged length of stay, 30-day readmissions, and index hospitalization costs among cohorts. RESULTS. We identified 15,038 patients, of whom 8501 (56.5%), 4608 (30.7%), and 1929 (12.8%) underwent open, VATS, and RATS lobectomy, respectively. Robotic-assisted lobectomies comprised less than 1% of total lobectomy volume in 2008, and grew to 25% of lobectomy volume by 2014. Both VATS and RATS lobectomies were associated with decreased in-hospital mortality compared with thoracotomy (VATS odds ratio 0.69, 95% confidence interval, 0.50 to 0.94; RATS odds ratio 0.58, 95% confidence interval, 0.35 to 0.96; P = .016). After adjusting for patient age, sex, income, comorbidities, and hospital teaching status, VATS lobectomy was 2% less expensive (P = .007) and robotic-assisted lobectomy was 13% more expensive (P < .001) than the open approach. CONCLUSIONS. Minimally invasive approaches were associated with improved clinical outcomes compared with open lobectomy. However, only robotic-assisted lobectomy has had rapid growth in utilization. Despite additional cost, RATS lobectomy appears to provide a viable minimally invasive alternative for general thoracic procedures.

Summary Background Candida bloodstream infection is associated with high mortality. Infectious disease consultation improves outcomes in several infections, including Staphylococcus aureus and cryptococcosis, as well as multidrug-resistant organisms. We aimed to examine the association between infectious disease consultation and differences in management with mortality in candida bloodstream infections. Methods In this retrospective, single-centre cohort study, we reviewed the medical charts of all patients admitted to Barnes-Jewish Hospital (St Louis, MO, USA), a tertiary referral centre, aged 18 years or older with candida bloodstream infection from 2002 to 2015. We collected data for demographics, comorbidities, predisposing factors, all-cause mortality, antifungal use, central-line removal, and ophthalmological and echocardiographic evaluation to assess 90-day all-cause mortality between individuals with and without an infectious disease consultation. For the survival analysis we used Cox proportional hazards model with inverse weighting by propensity score to assess the effects of infectious disease consultation on mortality and differences in management. Findings Between Jan 1, 2002, and Dec 31, 2015, of 1794 patients assessed for eligibility, we analysed 1691 patients with candida bloodstream infection; 776 (45·9%) who had an infectious disease consultation and 915 (54·1%) who did not have an infectious disease consultation. All 1691 patients were included in the analysis. None were missing data. Most underlying comorbidities were evenly distributed between groups. 90-day mortality was lower in the infectious disease consultation group than in patients who did not receive an infectious disease consultation (29% [222/776] vs 51% [468/915]; p Interpretation Patients with candida bloodstream infection receiving an infectious disease consultation have lower mortality. This finding might be attributable to these individuals receiving a higher number of non-pharmacological, evidence-based interventions and lower amounts of non-treatment. These data suggest that an infectious disease consultation should be an integral part of clinical care of patients with candida bloodstream infection. Funding Astellas Global Development Pharma, Washington University Institute of Clinical and Translational Sciences, and the Agency for Healthcare Research and Quality.

Background: There are no validated tools guiding the appropriate level-of-care for children with minor head trauma (MHT) and radiographic intracranial injuries. We developed and externally validated a clinical decision support tool for risk-stratifying these patients. Methods: The derivation cohort included children enrolled in the PECARN head injury study from 2004-2006. The validation group consisted of a separate cohort of children with MHT treated at six centers from 2006-2019. Children < 18 years were included if they presented within 24 hours of injury, had a Glasgow Coma Scales (GCS) score of 13-15, and had intracranial injury on neuroimaging. A risk model was developed using recursive partitioning to predict serious neurological events, defined as neurosurgical intervention, intubation longer than 24 hours due to head injury, or death from head injury. Risk thresholds were determined for clinical decision-making. This model was compared to a logistic regression model previously developed using the PECARN cohort. Findings: Based on 839 patients meeting inclusion criteria in the PECARN cohort, the tree-based model included seven predictors, with midline shift, depressed skull fracture, epidural hematoma, and GCS score being the most influential. Three risk thresholds were evaluated to classify patients as ‘low’ risk. In the validation cohort consisting of 1,630 patients, the most conservative cutoff (i.e. any predictor present) identified 119/119 children with serious neurological events (sensitivity 100%; 95% CI 96·9-100), but had the lowest specificity (26.3%; 95% CI 24·1-28·6). All three thresholds had negative predictive values above 99% and collectively outperformed the logistic regression model. Using these thresholds, a clinical decision support tool was created that identified 75% of the population as ‘low’ or ‘very low’ risk. Interpretation: We developed and validated a clinical decision support tool that accurately risk-stratifies children with MHT and radiographic intracranial injuries. This tool can potentially improve patient safety and reduce resource use. Funding : Thrasher Research Fund and the Agency for Healthcare Research and Quality. Funding Statement: This study was funded by grants from the Agency for Healthcare Research and Quality (1F32HS027075-01A1) and the Thrasher Research Fund (#15024). Declaration of Interests: MAO reports grant funding from Merck, Sanofi Pasteur, and Pfizer, and consulting fees from Pfizer. EJ reports medical expert testimony and patent holdings (US Patent 9993631). DDL has received research funds and/or research equipment for unrelated projects from Medtronic, Inc., Karl Storz, Inc., and Microbot Medical, Inc, and has received philanthropic equipment contributions for humanitarian relief work from Karl Storz, Inc. and Aesculap, Inc. No other authors disclose any competing interests. Ethics Approval Statement: All data analyzed were from the deidentified, public-use dataset, and consequently the Washington University in St. Louis Human Research Protection Office deemed the analysis not subject to institutional review board (IRB) oversight.

Purpose Trigger digit release (TDR) performed in an office-based procedure room (PR) setting minimizes surgical costs compared with that performed in an operating room (OR); yet, it remains unclear whether the rates of major complications differ by setting. We hypothesized that surgical setting does not have an impact on the rate of major complications after TDR. Methods Adult patients who underwent isolated TDR from 2006 to 2015 were identified from the MarketScan commercial database (IBM) using the provider current procedural terminology code 26055 with a concordant diagnosis on the same claim line (International Classification of Diseases, ninth revision, clinical modification 727.03). The PR cohort was defined by presence of a place-of-service code for an in-office procedure without OR or ambulatory center revenue codes, or anesthesiologist claims, on the day of the surgery. The OR cohort was defined by presence of an OR revenue code. We identified major medical complications, surgical site complications, as well as iatrogenic neurovascular and tendon complications within 90 days of the surgery using International Classification of Diseases , ninth revision, clinical modification diagnosis and/or current procedural terminology codes. Multivariable logistic regression was used to compare the risk of complications between the PR and OR groups while controlling for Elixhauser comorbidities, smoking, and demographics. Results For 7,640 PR and 29,962 OR cases, the pooled rate of major medical complications was 0.99% (76/7,640) and 1.47% (440/29,962), respectively. The PR setting was associated with a significantly lower risk of major medical complications in the multivariable analysis (adjusted odds ratio 0.76; 95% confidence interval 0.60–0.98). The pooled rate of surgical site complications was 0.67% (51/7,640) and 0.88% (265/29,962) for the PR and OR cases, respectively, with no difference between the surgical settings in the multivariable analysis (adjusted odds ratio 0.81; 95% confidence interval 0.60–1.10). Iatrogenic complications were infrequently observed (PR 5/7,640 [0.07%]; OR 26/29,962 [0.09%]). Conclusions Compared with performing TDR in the OR using a spectrum of commonly used anesthesia types, performing TDR in the PR using local-only anesthesia was associated with a comparably low risk of major medical complications, surgical complications, and iatrogenic complications. Type of study/level of evidence Prognostic II.

Background The prevalence and difference in likely indications of urinary catheterization (UC) in treated-and-released emergency department (ED) visits between men and women are currently unknown. Methods This was a cross-sectional analysis using the 2013 National Emergency Department Sample for all treated-and-released visits in persons aged ≥18 years. The prevalence of conditions associated with UC visits in men and women were identified. A hierarchical ranking was used to categorize diagnosis codes identified during ED visits into clinically meaningful categories to assess conditions for UC. Results In 2013, there were 87,797,062 treated-and-released ED visits in adults. The rate of UC in treated-and-released ED visits in adults was 4.3 per 1,000 visits, with 6.5 per 1,000 visits in men and 2.7 per 1,000 visits in women. Using the hierarchal ranking, a higher proportion of UC visits in men were coded for acute urinary retention, and a higher proportion of UC visits in women were coded for neurologic, cognitive, and psychiatric conditions. Conclusions The rate of UC in treated-and-released ED visits was higher in men than women, and UC rate increased with age. The heterogeneity of conditions coded in UC visits in women compared with men may suggest more potentially avoidable UC in women in the treated-and-released ED population. If confirmed, this would suggest opportunities for quality improvement in the ED to prevent overutilization of urinary catheters.

Study Objective Evaluate racial/ethnic variation in hysterectomy surgical route in women likely eligible for minimally invasive hysterectomy. Design Cross-sectional study. Setting Multistate including Colorado, Florida, Maryland, New Jersey, and New York. Patients Women aged ≥18 years without diagnoses of leiomyomas, obesity, or previous abdominopelvic surgery who underwent hysterectomy for benign conditions from the State Inpatient and Ambulatory Surgery Databases, 2010–2014. Interventions None. Primary exposure is race/ethnicity. Measurements and Main Results Racial/ethnic variation in annual hysterectomy rates and surgical route. To calculate hysterectomy rates per 100 000 women/year, denominators were adjusted for the proportion of women with previous hysterectomy. A marginal structural log binomial regression model was used to estimate adjusted standardized prevalence ratios (aPRs) for vaginal or laparoscopic vs abdominal hysterectomy, controlling for clustering within hospitals. In addition, hospitals were stratified into quintiles to examine surgical route in hospitals that serve a higher vs lower proportion of African American patients. A total of 133 082 adult women underwent hysterectomy for benign conditions from 2010 to 2014. Annual laparoscopic rates increased more slowly for African Americans (1.6-fold) than for whites (1.8-fold) and Hispanics (1.9-fold). African American and Hispanic women were less likely to undergo vaginal (aPR = 0.93; 95% confidence interval [CI], 0.90–0.96 and aPR = 0.95; 95% CI 0.93–0.97, respectively) and laparoscopic hysterectomy (aPR = 0.90; 95% CI, 0.87–0.94 and aPR = 0.95; 95% CI, 0.92–0.98, respectively) than white women; Asian/Pacific Islander women were less likely to undergo vaginal hysterectomy (aPR = 0.88; 95% CI, 0.81–0.96). Hospitals serving a higher proportion of African American persons performed more abdominal and fewer vaginal procedures across all groups, and more racial/ethnic minority women sought care at those hospitals than white women. Conclusion African American, Hispanic, and Asian/Pacific Islander women eligible for minimally invasive hysterectomy were more likely than white women to receive abdominal hysterectomy. The proportion of all women undergoing abdominal hysterectomy was highest at hospitals serving higher proportions of African American persons. This difference in treatment type can lead to disparities in outcomes, in part owing to their association with complications.

Clostridioides (Clostridium) difficile is the leading cause of healthcare-associated infectious diarrhea in the developed world. Retrospective studies have shown a lower incidence of C. difficile infection (CDI) in Japan than in Europe or North America. Prospective studies are needed to determine if this is due lack of testing for C. difficile or a true difference in CDI epidemiology. A prospective cohort study of CDI was conducted from May 2014 to May 2015 at 12 medical facilities (20 wards) in Japan. Patients with at least three diarrheal bowel movements (Bristol stool grade 6–7) in the preceding 24 h were enrolled. CDI was defined by positive result on enzyme immunoassay for toxins A/B, nucleic acid amplification test for the toxin B gene or toxigenic culture. C. difficile isolates were subjected to PCR-ribotyping (RT), slpA-sequence typing (slpA-ST), and antimicrobial susceptibility testing. The overall incidence of CDI was 7.4/10,000 patient-days (PD). The incidence was highest in the five ICU wards (22.2 CDI/10,000 PD; range: 13.9–75.5/10,000 PD). The testing frequency and CDI incidence rate were highly correlated (R2 = 0.91). Of the 146 isolates, RT018/018″ was dominant (29%), followed by types 014 (23%), 002 (12%), and 369 (11%). Among the 15 non-ICU wards, two had high CDI incidence rates (13.0 and 15.9 CDI/10,000 PD), with clusters of RT018/slpA-ST smz-02 and 018”/smz-01, respectively. Three non-RT027 or 078 binary toxin-positive isolates were found. All RT018/018” isolates were resistant to moxifloxacin, gatifloxacin, clindamycin, and erythromycin. This study identified a higher CDI incidence in Japanese hospitals than previously reported by actively identifying and testing patients with clinically significant diarrhea. This suggests numerous patients with CDI are being overlooked due to inadequate diagnostic testing in Japan.

Background The optimal and practical laboratory diagnostic approach for detection of Clostridioides difficile to aid in the diagnosis of C. difficile infection (CDI) is controversial. A two-step algorithm with initial detection of glutamate dehydrogenase (GDH) or nucleic acid amplification test (NAAT) alone are recommended as a predominant method for C. difficile detection in developed countries. The aim of this study was to compare the performance of enzyme immunoassays (EIA) detecting toxins A and B, NAAT detecting the toxin B gene, and GDH compared to toxigenic culture (TC) for C. difficile as the gold standard, in patients prospectively and actively assessed with clinically significant diarrhea in 12 medical facilities in Japan. Methods A total of 650 stool specimens were collected from 566 patients with at least three diarrheal bowel movements (Bristol stool grade 6–7) in the preceding 24 h. EIA and GDH were performed at each hospital, and NAAT and toxigenic C. difficile culture with enriched media were performed at the National Institute of Infectious Diseases. All C. difficile isolates recovered were analyzed by PCR-ribotyping. Results Compared to TC, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of EIA were 41%, 96%, 75% and 84%, respectively, and for NAAT were 74%, 98%, 91%, and 92%, respectively. In 439 specimens tested with GDH, the sensitivity, specificity, PPV, and NPV were 73%, 87%, 65%, and 91%, and for an algorithm (GDH plus toxin EIA, arbitrated by NAAT) were 71%, 96%, 85%, and 91%, respectively. Among 157 isolates recovered, 75% of isolates corresponded to one of PCR-ribotypes (RTs) 002, 014, 018/018”, and 369; RT027 was not isolated. No clear differences in the sensitivities of any of EIA, NAAT and GDH for four predominant RTs were found. Conclusion The analytical sensitivities of NAAT and GDH-algorithm to detect toxigenic C. difficile in this study were lower than most previous reports. This study also found low PPV of EIAs. The optimal method to detect C. difficile or its toxins to assist in the diagnosis of CDI needs further investigation.

Background Stillbirth has been associated with emotional and psychological symptoms. The association between stillbirth and diagnosed postpartum psychiatric illness is less well-known. Objectives To determine whether women have higher risk of developing clinician-diagnosed psychiatric morbidity in the year after stillbirth versus livebirth. Study Design This retrospective cohort study used International Classification of Diseases, 9 th Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes to identify participants, exposures, and outcomes within the Florida State Inpatient and State Emergency Department (ED) Databases. The first delivery of female Florida residents aged 13 to 55 years old from 2005 to 2014 was included; women with ICD-9-CM coding for psychiatric illness or substance use during pregnancy were excluded. The exposure was an ICD-9-CM diagnosis code during delivery hospitalization of a stillbirth ≥ 23 weeks gestation. The primary outcome was a primary or secondary ICD-9-CM diagnosis code during an ED encounter or inpatient admission within one year of delivery for a composite of psychiatric morbidity: suicide attempt, depression, anxiety, post-traumatic stress disorder, psychosis, acute stress reaction, or adjustment disorder. The secondary outcome was a substance use composite: drug or alcohol use or dependence. We compared outcomes after delivery of stillbirth versus livebirth using multivariable logistic regression adjusting for maternal sociodemographic factors, medical comorbidities, and severe intrapartum morbidity. We also used Cox proportional hazard models and tested for violation of the proportional hazard assumption to identify the highest risk time within the year after stillbirth delivery for the primary outcome, adjusting for the same factors and morbidities as in the logistic regression model. Results 8292 women with stillborn singletons and 1,194,758 with liveborn singletons were included. Within one year of hospital discharge after stillbirth, 4.0% (n=331) of women had an ED encounter or inpatient admission coded for psychiatric morbidity: the risk was nearly 2.5 times higher compared to livebirth (1.6% (n=19,746); adjusted odds ratio (aOR) 2.47 (95% Confidence Interval (CI) 2.20 – 2.77)). Women also had higher risk of having an ED encounter or inpatient admission coded for drug or alcohol use or dependence in the year following delivery of stillbirth versus livebirth (124 (1.5%) versus 7033 (0.6%); aOR 2.41 (95% CI 1.99 – 2.90)). Cox proportional hazard modeling suggested that highest risk interval for postpartum psychiatric illness was within four months of stillbirth delivery (adjusted hazard ratio (aHR) 3.26 (95% CI 2.63 – 4.04), though the risk remained high during the four to twelve months after delivery (aHR 2.42 (95% CI 2.13 – 2.76). Conclusions Coding for psychiatric illness or substance misuse in ED visits or hospital admissions in the year after delivery of livebirths was not uncommon, corresponding to nearly two per 100 women. However, having a stillbirth was associated with increased risk of both psychiatric morbidity (corresponding to 1 per 25 women) and substance misuse (corresponding to 3 in 100 women), with the highest risk of postpartum psychiatric morbidity occurring from delivery until four months postpartum.

Background International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding for cytomegalovirus (CMV) has been used as a proxy for active CMV infection or disease occurring in the inpatient setting in retrospective studies of kidney transplant recipients using large amounts of administrative data. However, the accuracy of inpatient CMV coding has not been determined. Methods We identified 393 kidney transplant recipients who were readmitted to Barnes-Jewish Hospital in St. Louis, Missouri from January 1, 2007 to December 31, 2011 to determine the accuracy of the ICD-9-CM diagnosis code for CMV (078.5) in identifying active CMV infection or disease (asymptomatic viremia, CMV syndrome, or tissue-invasive CMV disease) in the inpatient setting, using microbiological, histopathologic, or ophthalmologic evidence for CMV as the gold standard. Results The sensitivity and positive predictive value of CMV coding in identifying active CMV infection or disease were 0.77 and 0.71, respectively. The specificity and negative predictive value were both 0.98. The sensitivity of CMV coding in identifying CMV syndrome or tissue-invasive CMV disease was 0.93. Conclusions CMV coding had good accuracy in identifying active CMV infection or disease among readmitted kidney transplant recipients in our hospital. Further validation studies of CMV coding in other hospitals are needed to obtain more generalizable estimates of the accuracy of CMV coding.

The impact of recurrent Clostridium difficile infections (CDIs) on hospital readmissions is unknown. The objective of this study was to determine whether recurrent CDI was independently associated with the number of hospital readmissions and days readmitted.We performed a retrospective cohort study at an academic, urban, tertiary care hospital. Data were collected from electronic medical records and supplemented with chart review. CDI patients were followed for 180 days to ascertain the number of hospital readmissions and total days readmitted. Univariate and multivariable negative binomial regression models were used to evaluate factors, including CDI recurrence, associated with hospital readmissions.The study included 3,950 patients with CDI from 2003-2009, including 413 patients with recurrent CDI. Recurrent CDI patients were significantly more likely to have at least 1 readmission (85% vs 41%; P.001) and had more days readmitted (mean = 18.6 vs 7.6; P.001) than patients without recurrent CDI. In multivariable analysis, recurrent CDI was independently associated with number of readmissions (rate ratio = 2.54; 95% confidence interval [CI], 2.21-2.91) and days readmitted (rate ratio = 3.97; 95% CI, 3.11-5.08) after adjustment for demographics, comorbidities, and medications.Recurrent CDI patients are significantly more likely than patients without a recurrence to be readmitted and spend increased time readmitted to the hospital.

Clostridium difficile infection (CDI) is the most common cause of infectious health care-associated diarrhea and is a major burden to patients and the health care system. The incidence and severity of CDI remain at historically high levels. This article reviews the morbidity, mortality, and costs associated with CDI.

Neurofibromatosis type 1 has been linked to several neurological conditions, including epilepsy, Parkinson disease, headache, multiple sclerosis, and sleep disturbances, predominantly through case reports and patient series that lack comparison groups. Our objective was to assess whether specific neurological conditions occur more frequently in individuals with neurofibromatosis type 1 versus those without neurofibromatosis type 1.We used the 2006-2010 MarketScan Commercial Claims and Encounters database to examine associations between neurological conditions and neurofibromatosis type 1. The neurofibromatosis type 1 group was identified through ≥2 International Classification of Diseases, Ninth Revision, Clinical Modification neurofibromatosis codes (237.70, 237.71) occurring ≥30 days apart or one inpatient neurofibromatosis code. A nonneurofibromatosis type 1 comparison group was frequency matched to the neurofibromatosis type 1 group on age and enrollment length at a 10:1 ratio. Unconditional logistic regression was employed to calculate adjusted odds ratios and 95% confidence intervals for associations between neurofibromatosis and neurological conditions.Compared with the nonneurofibromatosis type 1 group (n = 85,790), the neurofibromatosis type 1 group (n = 8,579) had significantly higher odds of health insurance claims for epilepsy (odds ratio: 7.3; 95% confidence interval: 6.4-8.3), Parkinson disease (odds ratio: 3.1; 95% confidence interval: 1.3-7.5), headache (odds ratio: 2.9; 95% confidence interval: 2.6-3.1), multiple sclerosis (odds ratio: 1.9; 95% confidence interval: 1.2-2.9), and sleep disturbances/disorder (odds ratio: 1.4; 95% confidence interval: 1.2-3.6).This large study provides strong evidence for positive associations between several neurological conditions and neurofibromatosis type 1.

Background Delayed-onset cytomegalovirus (CMV) disease can occur among heart transplant recipients after stopping anti-CMV prophylaxis. We evaluated a large, retrospective cohort of heart transplant recipients in the United States through the use of billing data from 3 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) to determine the epidemiology of delayed-onset CMV disease coded during hospital readmission. Methods We identified 2280 adult heart transplant recipients from 2004 to 2010 through the use of the California, Florida, and New York SID. Demographics, comorbidities, heart failure etiology, CMV disease, and inpatient death were identified. CMV disease was classified as early-onset (≤100 days) or delayed-onset (>100 days after transplant). Possible tissue invasion by CMV was determined through the use of codes for CMV pneumonitis, hepatitis, and gastrointestinal endoscopy. Multivariate analysis was performed with the use of Cox proportional hazards models. Results Delayed-onset CMV disease occurred in 7.5% (170/2280) and early-onset CMV disease occurred in 2.0% (45/2280) of heart transplant recipients. Risk factors for delayed-onset CMV disease included residence in a non-metropolitan locale (aHR. 1.8; 95% confidence interval [CI], 1.0–3.3) and ischemic cardiomyopathy as heart failure etiology (aHR, 1.8; 95% CI, 1.3–2.5). Inpatient death >100 days after transplant was associated with delayed-onset CMV disease with possible tissue invasion (aHR, 2.0; 95% CI, 1.1–3.8), transplant failure or rejection (aHR, 4.0; 95% CI, 2.7–5.8), and renal failure (aHR, 1.5; 95% CI, 1.1–2.0). Conclusions Delayed-onset CMV disease is more common than early-onset CMV disease among heart transplant recipients. These results suggest that delayed-onset tissue-invasive CMV disease may be associated with an increased risk of death.

Purpose We hypothesized that patients with preoperative opioid prescriptions and diagnoses of depression and anxiety would be at increased risk for prolonged opioid prescriptions after surgery for brachial plexus injury (BPI). Methods Using an administrative database of privately insured patients, we assembled a cohort of BPI surgery patients and a control group of non-BPI patients, matching for age, sex, and year. Pharmacy claims for prescriptions filled for opioids and neuropathic pain medications were examined 12 months before surgery to 180 days after surgery. The primary outcome was prolonged opioid prescription, defined as receiving a prescription 90 to 180 days after the index (BPI surgery or randomly selected date of service for controls). Multivariable regression was used to examine risk factors for postoperative opioid use, including diagnoses of depression, anxiety, drug abuse, tobacco use, and preoperative use of opioids and neuropathic pain medications. A subgroup analysis was performed for opioid-naive BPI patients between 30 days to 1 year before surgery. Results Among BPI surgery patients (n = 1,936), 27.7% had prolonged opioid prescriptions. Among opioid-naive BPI patients (n = 911), 10.8% had prolonged opioid prescriptions. In controls (n = 19,360), frequency of prolonged opioid prescriptions was 0.11%. Among all BPI patients, after adjustment for age and sex, predictors of prolonged postoperative opioid prescriptions in BPI patients were preoperative opioids, preoperative neuropathic pain medication use, histories of drug abuse, tobacco use, and anxiety. Conclusions Prolonged postoperative opioids prescriptions after BPI reconstruction are higher than previous estimates among other surgical patients. In addition to establishing normative data among this population, our findings serve to increase awareness of risk factors for prolonged opioids after BPI reconstruction and encourage coordinated multidisciplinary care. Type of study/level of evidence Prognostic II.

Background Although Medicaid expansion has improved access to primary care services, its impact on surgical specialty utilization remains unclear. The aim of this study is to determine whether Medicaid expansion is associated with increased utilization rates of total hip arthroplasty (THA) and total knee arthroplasty (TKA) in Illinois (which expanded Medicaid) relative to Missouri (which did not expand Medicaid). Methods Using administrative data sources, we analyzed 374,877 total hospitalizations (236,333 in Illinois and 138,544 in Missouri) for THA/TKA from 2011 to 2016 (Illinois’ Medicaid expansion date: January 1, 2014). Results The percentage of THA/TKA funded by Medicaid in Illinois was 2.4% in 2013 and 3.9% in 2016 (Missouri 2013: 2.7%; 2016: 2.6%). A difference-in-difference analysis (adjusted for patient age and gender, county-level Area Deprivation Index, and number of orthopedic surgeons) demonstrated a statistically significant increase in Medicaid-funded THA/TKA in Illinois in 2016 compared to 2013 (P = .012). Conclusion Our study demonstrates that Medicaid expansion in Illinois was associated with increased utilization of THA and TKA. Further study is needed to understand the impact of Medicaid expansion in other states and for other procedures.

Purpose Reactive depression and anxiety are common after major life changes such as brachial plexus injuries (BPI). The purpose of this study was to evaluate the incidence and risk factors for coded depression and coded anxiety among patients with BPI using a national database of commercial insurance claims. Methods We used the Truven MarketScan database from 2007 to 2013 to identify commercially insured patients aged 18 to 64 years who underwent BPI surgery. For comparison, a control group without BPI was frequency-matched 10:1 by age group, sex, number of provider visits, and length of insurance enrollment. Using International Classification of Diseases, Ninth Revision diagnosis codes and pharmacy claims, we identified coded depression and coded anxiety in the 12 months before and 12 months after BPI surgery. Multivariable Cox regression models were used to determine risk factors for coded depression or coded anxiety, adjusting for known risk factors for depression or anxiety (eg, alcohol, substance abuse). Results We identified 1,843 patients with BPI and 18,430 controls. Within the 12 months preceding surgery, coded depression and coded anxiety were present in 38% and 42%, respectively, of the BPI group; both were present in 25% and either was present in 54%. The rate of new-onset/postoperatively coded depression among patients with BPI was 142.1/1,000 person-years (12%) and of new-onset/postoperatively coded anxiety was 273.6/1,000 person-years (20%). Patients with BPI were significantly more likely than controls to develop new-onset/postoperatively coded depression (hazard ratio = 1.3; confidence interval [CI], 1.1–1.5) and new-onset/postoperatively coded anxiety (HR = 2.1 [CI, 1.8–2.4]). Conclusions Patients undergoing BPI surgery have a high prevalence of coded depression and coded anxiety in the 12 months before surgery and are at higher risk for developing new-onset/postoperatively coded depression and coded anxiety within 1 year after surgery. These findings can be used by BPI surgeons to inform perioperative counseling, guide emotional recovery from injury, and facilitate coordinated or colocated care with mental health professionals. Type of study/level of evidence Prognostic II.

Objectives Dihydropyridine calcium channel blockers (DH-CCB) are associated with lower-extremity edema (LEE). Loop diuretics have been used inappropriately to treat DH-CCB–associated LEE, constituting a prescribing cascade (PC). The aim of this work was to identify the prevalence and factors associated with potential DH-CCB–LEE–loop diuretic PC. Methods The 2014 National Ambulatory Medical Care Survey was used to identify patient visits in which a DH-CCB was continued. The definition of a potential PC was the continuation or initiation of a loop diuretic in the absence of congestive heart failure, cancer, obstructive sleep apnea, chronic kidney disease or end-stage renal disease, obesity, or resistant hypertension. Multivariable logistic regression was used to identify factors related to a potential PC, including demographic information, number of medications, number of patient visits in the previous 12 months, and comorbid conditions. Results Among the estimated 47.5 million patient visits in which a DH-CCB was continued, 4.6% had a potential PC. Visits in patients 65 to 84 years of age (odds ratio [OR] 2.56, 95% CI 1.20–5.43) and 85 years of age and older (OR 3.89, 95% CI 1.76–8.61) were more likely to have potential PC compared with patients 18 to 64 years of age. Visits in patients with 5 to 7 (OR 3.75, 95% CI 1.72–8.19), 8 to 11 (OR 2.20, 95% CI 1.09–4.44), and 12 or more (OR 5.23, 95% CI 2.29–11.94) medications were more likely to have potential PC compared with patients with 4 or fewer medications. Conclusion A potential DH-CCB–associated LEE loop diuretic PC was present in approximately 2.2 million patient visits in which DH-CCB was continued. Older age and an increasing number of concomitant medications were associated with this potential PC.

BACKGROUND CONTEXT National estimates of Staphylococcus aureus infections after elective spinal surgeries based on microbiology results are limited. PURPOSE We assessed 180-day S. aureus cumulative incidence after elective spinal surgeries in real-world hospital settings and projected the US national burden of such infections. STUDY DESIGN/SETTING Observational study of the US Premier Healthcare Database (PHD). PATIENT SAMPLE Adults ≥18 years with spinal surgery performed during an elective inpatient or hospital-based outpatient encounter from 6/1/2010 to 6/30/2015. Elective admissions were defined according to hospital UB-04 forms. Encounters with first procedures >2 days after admission, emergency department charges, or without availability of 180-day continuous postprocedure reporting by the facility were excluded. Spinal surgeries included laminectomy (N=19,281 inpatient; 24,712 outpatient), fusion-primary (N=65,135 inpatient; 7,555 outpatient), fusion-revision (N=3,828 inpatient; 112 outpatient), and “other” spinal surgery (vertebral fracture repair, lesion excision, meningocele repair, chordotomy) (N=3,670 inpatient; 8,953 outpatient), which were defined using ICD-9-CM procedure and CPT codes according to established National Hospital Surveillance Network (NHSN) groupings and other procedure codes. If greater than one surgery was performed, one procedure per discharge was assigned according to highest expected NHSN infection risk. OUTCOME MEASURES Outcomes included overall and invasive S. aureus infections within 180-days of elective spinal surgery. Microbiology results and ICD diagnosis codes were used to define invasive (eg, bloodstream, deep wound and organ/space SSI) and overall (ie, invasive, superficial SSI, UTI, and respiratory) infections. METHODS Postsurgical S. aureus infection incidence estimates were calculated using data from 181 representative PHD hospitals reporting microbiology results. To estimate the national infection burden, surgery-specific S. aureus incidence proportions were multiplied by the number of nationally projected inpatient elective surgeries (overall and by category), calculated using surgery counts in the entire PHD (N=665 hospitals) and established weights based on hospital characteristics. RESULTS Among 91,914 inpatient elective spinal surgeries, overall and invasive S. aureus infection incidence within 180-days was 1.10% and 0.50%, respectively. The “other spine” category had the highest infection incidence (1.83% overall; 1.04% invasive), followed by fusion-revision (1.62% overall; 0.76% invasive), laminectomy (1.09% overall; 0.49% invasive), and fusion-primary (1.03% overall; 0.45% invasive). Nationally, this translated to an estimated annual 4,539 S. aureus infections (2,054 invasive) among 413,673 elective inpatient spinal surgeries. Following 41,332 hospital-based outpatient elective spinal surgeries performed at microbiology-reporting PHD hospitals, 180-day overall and invasive S. aureus incidence was 0.73% and 0.32%, respectively. CONCLUSIONS To our knowledge, this is the most comprehensive estimate of US postsurgical S. aureus infection incidence among elective spinal surgeries based on real-world microbiology data. These results may help guide targeted infection prevention efforts. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Staphylococcus aureus bacteremia results in substantial mortality. Infectious diseases specialist consultation can improve adherence to evidence-based management of S. aureus bacteremia, but its effect on mortality is unclear.A 2-year prospective cohort study of patients with S. aureus bacteremia was performed at a large tertiary care hospital. Patients who died within 2 days of diagnosis were excluded. Independent risk factors for 28-day mortality were determined.Among 341 patients with S. aureus bacteremia, 189 (55%) were male, 196 (58%) were Caucasian, 185 (54%) had methicillin-resistant S. aureus, 108 (32%) had nosocomial bacteremia, and 231 (68%) had a central venous catheter at the time of diagnosis. The median age was 56 years (range 22-95 years). A total of 111 patients (33%) had an infectious diseases consultation. Fifty-four patients (16%) died within 28 days after diagnosis. Factors associated with mortality were intensive care unit admission 48 hours or less after the first positive blood culture (adjusted hazard ratio, 4.65; 95% confidence interval [CI], 2.65-8.18), cirrhosis (adjusted hazard ratio, 4.44; 95% CI, 2.40-8.20), and advanced age (adjusted hazard ratio, 1.27 per every 10 years of age; 95% CI, 1.08-1.50). Infectious diseases consultation was associated with a 56% reduction in 28-day mortality (adjusted hazard ratio, 0.44; 95% CI, 0.22-0.89).Only one third of patients with S. aureus bacteremia in this cohort had an infectious diseases specialist consultation. Infectious diseases consultation was independently associated with a reduction in 28-day mortality. Routine infectious diseases consultation should be considered for patients with S. aureus bacteremia, especially those with greater severity of illness or multiple comorbidities.

Identification of modifiable risk factors for sternal infection is essential for the development and institution of practices that decrease the incidence of these infections. This study analyzed 4004 consecutive patients undergoing coronary artery bypass grafting performed at a single institution between January 1996 and May 2003. Specific risk factors for both superficial and deep sternal wound infection were identified by univariate and multivariate analysis. The incidence of superficial sternal wound infections was 2.2% (N = 87) while the incidence of deep sternal wound infections was 1.8% (N = 73). Risk factors for superficial sternal infection identified by multivariate analysis include increasing body mass index (BMI) (OR 1.089, 95% CI 1.057-1.122, P0.001), female gender (OR 1.412, 1.108-1.717, P = 0.036), active smoking (OR 1.856, 1.079-3.193, P = 0.025), utilization of bilateral internal mammary arteries (OR 7.546, 3.175-17.935, P0.001), and transfusion ofor =4 units of packed red blood cells postoperatively (OR 2.009, 1.158-3.485, P = 0.013). Risk factors for deep sternal infection include increasing BMI (OR 1.077, 1.042-1.114, P0.001), diabetes mellitus (OR 2.412, 1.376-4.231, P = 0.002), and transfusion withor =2 units of platelets postoperatively (OR 2.787, 1.279-6.071, P = 0.010). These data suggest that cessation of smoking, improved blood glucose management, preoperative weight loss, limitation of transfusions, and discriminate use of bilateral internal mammary arteries are all practices that may decrease the incidence of postoperative wound complications following coronary revascularization.

Objective: We sought to determine risk factors for deep and superficial chest wound infections after coronary artery bypass graft surgery to develop predictive models. Methods: We retrospectively analyzed data collected on 1980 consecutive patients undergoing coronary artery bypass surgery at our institution between January 1, 1996, and June 30, 1999, by using the Society of Thoracic Surgery database. Independent risk factors for surgical-site infection were identified with multivariate logistic regression. Results: There were 37 (1.9%) deep chest and 46 (2.3%) superficial chest surgical-site infections. Obese diabetic patients had a 7.7-fold increased risk of deep chest infections after controlling for intra-aortic balloon pump use (odds ratio, 3.1) and postoperative transfusion (odds ratio, 2.3). Independent risk factors for superficial surgical-site infections included obesity (odds ratio, 3.1), diabetes in persons 65 years of age or older (odds ratio, 2.7), and current smoking (odds ratio, 2.5). Use of antiplatelet drugs was associated with a lower risk of superficial infections (odds ratio, 0.4). Predicted operative mortality as a marker of severity of illness was not clearly predictive of deep or superficial surgical-site infection. Mortality in the year after the operation was increased in patients with deep chest infections compared with that seen in uninfected control subjects (8/37 [21.6%] vs 114/1612 [7.1%], P =.004) but not in patients with superficial chest infections (7/47 [15.2%] vs 114/1612 [7.1%], P =.075). Conclusions: Risk factors for deep and superficial chest surgical-site infections after coronary artery bypass surgery differ, suggesting different mechanisms of pathogenesis. Appropriate risk stratification models specific to these important outcomes must be developed. J Thorac Cardiovasc Surg 2002;124:136-45

Serum specimens from 246 women of childbearing age were tested for immunoglobulin G (IgG) antibodies to Toxoplasma gondii by four different commercial assays: Abbott IMx microparticle enzyme immunoassay (EIA), Mercia Toxo-G EIA, Bartels Prima EIA, and bioMerieux Vitek (VIDAS) enzyme-linked fluorescent assay. A total of 27 specimens were initially positive with all four assays, 202 specimens were negative, and 17 specimens were discrepant (disagreement among the assays). After repeating tests for the 17 discrepant samples, five resolved (one was positive and four were negative). The 12 remaining discrepant samples were tested by an indirect fluorescent antibody (IFA) assay for Toxoplasma IgG antibodies; five specimens were positive for Toxoplasma IgG by IFA. The resolved sensitivities of the various kits ranged from 88% (bioMerieux VIDAS) to 94% (Abbott IMx), and the specificities were all 98%-99%. These results show that the four serologic tests used for detection of Toxoplasma IgG give very similar results and can all be readily used by clinical laboratories for screening purposes.