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Objective: To examine surgical site infection rates before and after the addition of a closing protocol to an existing surgical site infection risk-reduction bundle used during cesarean delivery.Methods: We conducted a single-center retrospective cohort study to review the association of a closing protocol with rates of surgical site infection after cesarean delivery. The closing protocol included fresh surgical instruments and physician and scrub nurse glove change before fascia closure. Surgical site infections were defined using Centers for Disease Control and Prevention criteria. Eligible patients underwent cesarean delivery at our institution from July 1, 2013, through December 31, 2015 (n=1,708; preimplementation group), or from June 1, 2016, through April 30, 2018 (n=1,228; postimplementation group).Results: The surgical site infection rate was 2.3% preimplementation and 2.7% postimplementation (difference 0.4%, 95% CI -1.6 to 0.7%]. The mean [SD] duration of the surgical procedure was longer postimplementation (59.6 [23.7] vs 55.6 [21.5] minutes; P<.001).Conclusion: Addition of a closing tray and glove change to our existing surgical site infection risk-reduction bundle was not associated with a reduction in the frequency of postcesarean surgical site infection but was associated with longer operating times. [ABSTRACT FROM AUTHOR]

Objectives: In mechanically ventilated patients, deep sedation is often assumed to induce "respirolysis," that is, lyse spontaneous respiratory effort, whereas light sedation is often assumed to preserve spontaneous effort. This study was conducted to determine validity of these common assumptions, evaluating the association of respiratory drive with sedation depth and ventilator-free days in acute respiratory failure.Design: Prospective cohort study.Setting: Patients were enrolled during 2 month-long periods in 2016-2017 from five ICUs representing medical, surgical, and cardiac specialties at a U.S. academic hospital.Patients: Eligible patients were critically ill adults receiving invasive ventilation initiated no more than 36 hours before enrollment. Patients with neuromuscular disease compromising respiratory function or expiratory flow limitation were excluded.Interventions: Respiratory drive was measured via P0.1, the change in airway pressure during a 0.1-second airway occlusion at initiation of patient inspiratory effort, every 12 ± 3 hours for 3 days. Sedation depth was evaluated via the Richmond Agitation-Sedation Scale. Analyses evaluated the association of P0.1 with Richmond Agitation-Sedation Scale (primary outcome) and ventilator-free days.Measurements and Main Results: Fifty-six patients undergoing 197 bedside evaluations across five ICUs were included. P0.1 ranged between 0 and 13.3 cm H2O (median [interquartile range], 0.1 cm H2O [0.0-1.3 cm H2O]). P0.1 was not significantly correlated with the Richmond Agitation-Sedation Scale (RSpearman, 0.02; 95% CI, -0.12 to 0.16; p = 0.80). Considering P0.1 terciles (range less than 0.2, 0.2-1.0, and greater than 1.0 cm H2O), patients in the middle tercile had significantly more ventilator-free days than the lowest tercile (incidence rate ratio, 0.78; 95% CI, 0.65-0.93; p < 0.01) or highest tercile (incidence rate ratio, 0.58; 95% CI, 0.48-0.70; p < 0.01).Conclusions: Sedation depth is not a reliable marker of respiratory drive during critical illness. Respiratory drive can be low, moderate, or high across the range of routinely targeted sedation depth. [ABSTRACT FROM AUTHOR]

Objective: To characterize the obstetric outcomes and placental pathology in live births arising from vanishing twin pregnancies compared with nonreduced in vitro fertilization (IVF) pregnancies.Methods: This is a retrospective cohort study of live births resulting from fresh embryo transfers after IVF cycles with autologous oocytes from 2004 through 2017 at a large academic fertility center. Clinical information and pathology reports were reviewed. Placental diagnoses were coded using established nosology by expert placental pathologists. Analysis of variance, Kruskal-Wallis, Pearson's χ, and Fisher exact tests were used, as appropriate, to compare pathology categories between pregnancy outcomes. Mixed effects logistic regression models were generated to reveal the association between pregnancy outcome and placenta pathology, controlling for pregnancies arising in the same woman and various suspected confounders.Results: Of 905 fresh autologous IVF cycles with placental pathology available for review, we identified 73 vanishing twin pregnancies (8.1%), 556 singleton pregnancies (61.4%), and 276 twin pregnancies (30.5%). Vanishing twin syndrome was not associated with preterm delivery, route of delivery, growth restriction or other obstetric outcomes as compared with IVF singleton pregnancies. However, vanishing twin syndrome pregnancies showed distinctive placental pathologies including an increased rate of small placentas (less than the 10th percentile by weight), with more anatomical abnormalities than IVF singleton pregnancies (odds ratio 1.73, 95% CI 0.94-3.19; adjusted odds ratio 2.15, 95% CI 1.08-4.28). The frequency of placental vascular and inflammatory pathologies associated with IVF vanishing twin syndrome pregnancies were similar to that of IVF singleton pregnancies. Loss of a twin after 8 weeks of gestation was not associated with greater risks of placental pathologies.Conclusion: In vitro fertilization pregnancies affected by vanishing twin syndrome did not have significant differences in obstetric or perinatal outcomes as compared with twin or singleton gestations. However, early twin loss was potentially associated with differences in placental development associated with a higher rate of small placentas and other anatomic pathologies. [ABSTRACT FROM AUTHOR]

Background: Tibiotalar arthrodesis is a common treatment for end-stage tibiotalar osteoarthritis, and is associated with a long-term risk of concomitant subtalar osteoarthritis. It has been clinically hypothesized that subtalar osteoarthritis following tibiotalar arthrodesis is the product of compensatory subtalar joint hypermobility. However, in vivo measurements of subtalar joint motion following tibiotalar arthrodesis have not been quantified. Using dual-fluoroscopy motion capture, we tested the hypothesis that the subtalar joint of the limb with a tibiotalar arthrodesis would demonstrate differences in kinematics and increased range of motion compared with the subtalar joint of the contralateral, asymptomatic, untreated ankle.Methods: Ten asymptomatic patients who had undergone unilateral tibiotalar arthrodesis at a mean (and standard deviation) of 4.0 ± 1.8 years previously were evaluated during overground walking and a double heel-rise task. The evaluation involved markerless tracking with use of dual fluoroscopy integrated with 3-dimensional computed tomography, which allowed for dynamic measurements of subtalar and tibiotalar dorsiflexion-plantar flexion, inversion-eversion, and internal-external rotation. Range of motion, stance time, swing time, step length, and step width were also measured.Results: During the early stance phase of walking, the subtalar joint of the limb that had been treated with arthrodesis was plantar flexed (-4.7° ± 3.3°), whereas the subtalar joint of the untreated limb was dorsiflexed (4.6° ± 2.2°). Also, during the early stance phase of walking, eversion of the subtalar joint of the surgically treated limb (0.2° ± 2.3°) was less than that of the untreated limb (4.5° ± 3.2°). During double heel-rise, the treated limb exhibited increased peak subtalar plantar flexion (-7.1° ± 4.1°) compared with the untreated limb (0.2° ± 1.8°).Conclusions: A significant increase in subtalar joint plantar flexion was found to be a primary compensation during overground walking and a double heel-rise activity following tibiotalar arthrodesis.Clinical Relevance: Significant subtalar joint plantar flexion compensations appear to occur following tibiotalar arthrodesis. We found an increase in subtalar plantar flexion and considered the potential relationship of this finding with the increased rate of subtalar osteoarthritis that occurs following ankle arthrodesis. [ABSTRACT FROM AUTHOR]

OBJECTIVE: This study was designed to describe variable acuity among 1 population of acute care patients. BACKGROUND: Acuity, defined as the individual patient need for nursing care, can inform level of care, nurse staffing, and the nurse-to-patient assignment. Nurse-generated data in the electronic health record can be mined and analyzed for decision support. METHODS: This study used a descriptive, retrospective analysis of repeated measures of acuity generated from 28 739 nursing assessments of 405 consecutive subjects treated for heart failure (HF) in a 455-bed southern hospital. RESULTS: Patients treated for HF have variable care needs throughout the course of treatment. Univariate analysis of variance and post hoc analysis found that gender, age, type of unit, and length of stay (LOS) had a significant impact on acuity, P < .01, with a very small effect of less than 1%, indicating that acuity should be measured instead of assumed. Patients in medical-surgical and step-down units had highly variable acuity, ranging from ready to discharge to acuity levels consistent with critical care. Across the LOS, the mean acuity stabilized at 12 hours after admission, decreased until 88 hours, then increased steadily through discharge. CONCLUSIONS: Understanding the variability in acuity within an individual patient, or a specific patient population, will contribute to decision support levels of patient care, staffing, nurse-patient assignments, and the cost of care. Frequent, sequential, and real-time measures of acuity may be valuable for tracking patient progress or measuring response to nursing interventions. [ABSTRACT FROM AUTHOR]

Background: Guidelines recommend that patients with low ejection fraction (EF) after myocardial infarction (MI) have their EF reassessed 40 days after MI for implantable cardioverter-defibrillator (ICD) candidacy. This study examines rates of EF reassessment and their association with 1-year ICD implantation in post-MI patients with low EF.Methods: We examined rates of postdischarge EF reassessment and ICD implantation among 10 289 Medicare-insured patients ≥65 years of age with an EF≤35% during the index MI admission from January 2007 through September 2010 in ACTION Registry-GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines). Multivariable Cox models tested the association between time-dependent EF reassessment and 1-year ICD implantation, stratified by revascularization status during the index MI admission.Results: Among patients with EF ≤35% during the index MI admission, 66.8% (95% confidence interval [CI], 65.9-67.8) had EF reassessment within the next year. Revascularized patients were more likely to have EF reassessment (76.9% [95% CI, 75.8-78.0)] versus 53.7% [95% CI, 52.2-55.2]; P<0.001) and had shorter times to EF reassessment (median, 67 versus 84 days; P<0.001) than nonrevascularized patients. Among patients with EF reassessment, only 11% received an ICD within 1 year. Reassessment of EF was associated with a higher likelihood of ICD implantation for both revascularized (unadjusted, 12.1% versus 2.4%, P<0.001; adjusted hazard ratio, 10.6, 95% CI, 7.7-14.8) and nonrevascularized (unadjusted, 10.0% versus 1.7%, P<0.001; adjusted hazard ratio, 6.1, 95% CI, 4.1-9.2) patients.Conclusions: In US practice, EF reassessments are commonly performed among patients with MI with an initially reduced EF. Although 1-year EF reassessment is associated with increased likelihood of ICD implantation, 1-year ICD implantation rates remain very low even among patients with EF reassessment, regardless of revascularization status. [ABSTRACT FROM AUTHOR]

Background: Despite years of research and increasingly evidence-based practice, falls continue to be the most commonly reported adverse events experienced by hospitalized adults. Yet a majority of the relevant research has focused on predicting and preventing falls in general; there has been little focus on injurious falls. Purpose: The purpose of this retrospective study was to determine which patient factors are associated with injurious falls in hospitalized adults. Methods: The study site's adverse event reporting database was used to identify 1,369 patients who fell between January 1, 2006, and October 31, 2013. Of these, 381 (27.8%) subjects suffered injurious falls. Variables of interest included age, sex, fall history, use of diuretics, use of central nervous system medications, cognitive impairment, primary discharge diagnoses, abnormal laboratory values, impaired mobility, and body mass index. Findings: Bivariate analysis revealed a statistically significant association between injurious falls and having a primary discharge diagnosis of "symptoms, signs, and ill-defined conditions." Having this discharge diagnosis was a significant predictor of injurious falls. Conclusions: Findings from this study may help hospital clinicians to better identify which patients are most at risk for injurious falls and to create better fall-related injury prevention interventions. [ABSTRACT FROM AUTHOR]

BACKGROUND: Surgical quality improvement collaboratives (QICs) aim to improve patient outcomes through coaching, benchmarked data reporting, and other activities. Although other regional QICs have formed organically over time, it is unknown whether a comprehensive quality improvement program implemented simultaneously across hospitals at the formation of a QIC would improve patient outcomes. STUDY DESIGN: Patients undergoing surgery at 48 hospitals in the Illinois Surgical Quality Improvement Collaborative (ISQIC) were included. Risk-adjusted rates of postoperative morbidity and mortality were compared from baseline to year 3. Difference-in-differences analyses compared ISQIC hospitals with hospitals in the NSQIP Participant Use File (PUF), which served as a control. RESULTS: There were 180,582 patients who underwent surgery at ISQIC-participating hospitals. Inpatient procedures comprised 100,219 (55.5%) cases. By year 3, risk-adjusted rates of death or serious morbidity decreased in both ISQIC (relative reduction 25.0%, p < 0.001) and PUF hospitals (7.8%, p < 0.001). Adjusted difference-in-differences analysis revealed that ISQIC participation was associated with a significantly greater reduction in death or serious morbidity (odds ratio 0.94, 95% CI 0.90 to 0.99, p = 0.01) compared with PUF hospitals. Relative reductions in risk-adjusted rates of other outcomes were also seen in both ISQIC and PUF hospitals (morbidity 22.4% vs 6.4%; venous thromboembolism 20.0% vs 5.0%; superficial surgical site infection 27.3% vs 7.7%, all p < 0.05), although these difference-in-differences did not reach statistical significance. CONCLUSIONS: Although complication rates decreased at both ISQIC and PUF hospitals, participation in ISQIC was associated with a significantly greater improvement in death or serious morbidity. These results underscore the potential of QICs to improve patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Delirium is a common, underdetected problem that has short- and long-term negative sequelae for critically ill patients. Prompt and accurate delirium identification by nurses can ensure early intervention and treatment to help minimize adverse outcomes. Objectives: To evaluate the relationship between an educational program and the accuracy of registered nurses' (RNs') documentation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), a delirium screening tool. Methods: In a medical ICU at a tertiary academic medical center from September 2015 to March 2016, RNs were reinstructed on use of the CAM-ICU. Registered nurse assessment data were collected retrospectively for 12 months before and after intervention and were compared against the CAM-ICU algorithm using χ² analysis. Results: A total of 10 736 RN assessments in 1020 patients preintervention and 11 068 in 951 patients postintervention were evaluated. Overall RN accuracy improved from 78% to 80% (P = .054). The algorithm determined delirium to be present in 32% versus 30% of all patients preintervention and postintervention, respectively; there was no difference in rate of nurse detection of delirium preintervention and postintervention (54% vs 55%, not statistically significant). The percentage of "inappropriate unable to assess" ratings by nurses decreased from 42% to 37% postintervention (P < .05). Conclusions: After a comprehensive training initiative, there was no significant improvement in CAM-ICU documentation and no improvements in patient delirium identification. Future quality improvement efforts should target reducing the number of assessments that RNs judge to be "unable to assess." Clinical practice must evolve to routinely incorporate RN delirium assessments into the patient's plan of care. [ABSTRACT FROM AUTHOR]

Objective: To compare the reoperation rates for recurrent stress urinary incontinence (SUI) after retropubic and transobturator sling procedures.Methods: We conducted a retrospective cohort study of all women who underwent midurethral sling procedures at a single institution for primary SUI between 2002 and 2012. To minimize bias, women in the two groups were matched on age, body mass index, isolated compared with combined procedure, and preoperative diagnosis. The primary outcome was defined as reoperation for recurrent SUI. Secondary outcomes included intraoperative complications and mesh-related complications requiring reoperation after the index sling procedure.Results: We identified 1,881 women who underwent a sling procedure for primary SUI-1,551 retropubic and 330 transobturator. There was no difference between groups in any of the evaluated baseline variables in the covariate-matched cohort of 570 with retropubic slings and 317 with transobturator slings; results herein are based on the covariate-matched cohort. Women undergoing a transobturator sling procedure had an increased risk of reoperation for recurrent SUI compared with women undergoing a retropubic sling procedure (hazard ratio 2.42, 95% CI 1.37-4.29). The cumulative incidence of reoperation for recurrent SUI by 8 years was 5.2% (95% CI 3.0-7.4%) in the retropubic group and 11.2% (95% CI 6.4-15.8%) in the transobturator group. Women in the retropubic group had a significantly higher rate of intraoperative complications compared with women in the transobturator group (13.7% [78/570] vs 4.7% [15/317]; difference=9.0%, 95% CI for difference 5.3-12.6%); the majority of this difference was due to bladder perforation (7.0% [40/570] vs 0.6% [2/317]; difference=6.4%, 95% CI for difference 4.1-8.7%). The cumulative incidence of sling revision for urinary retention plateaued at 3.2% and 0.4% by 5 years in the two groups.Conclusion: Women with primary SUI treated with a retropubic sling procedure have significantly lower cumulative incidence of reoperation for recurrent SUI compared with women who were treated with a transobturator sling procedure. Retropubic slings were associated with a higher risk of sling revision for urinary retention. [ABSTRACT FROM AUTHOR]

Objective: To compare postpartum contraception use between Somali and non-Somali women.Methods: A retrospective cohort study was performed using the Rochester Epidemiology Project. All Somali women aged 18 and older with live singleton births in Olmsted County, Minnesota, in 2009-2015 (n=317) were included, and a group of age-matched non-Somali women (n=317) were identified. Postpartum contraception was defined as the use of any method within 12 months after the first delivery within the study period. Rates of contraception use and types of contraception used were compared between groups using χ analysis. Among Somali women, an a priori list of factors was evaluated for associations with postpartum contraception use by including these factors in a multivariable logistic regression model.Results: After the index birth, 33 Somali women did not present for follow-up, compared with 12 non-Somali women (10.4% vs 3.8%, difference 6.6%, 95% CI 2.3-10.9%). Somali women were less likely to use postpartum contraception than non-Somali women (69.4% vs 92.8%, odds ratio [OR] 0.18, 95% CI 0.11-0.29). Among those using postpartum contraception, both groups had comparable use of long-acting reversible contraception (LARC) (19.9% vs 23.7%, difference -3.8%, 95% CI -11.8% to 4.0%) and non-LARC hormonal contraception (39.3% vs 42.4%, difference -3.1%, 95% CI -12.7% to 6.0%). However, Somali women were more likely to use less reliable methods (40.3% vs 20.8%, difference 19.5%, 95% CI 11.0-28.5%). Among Somali women, contraception use was less likely with older maternal age (OR 0.12 for oldest vs youngest quartile, 95% CI 0.04-0.37) and more likely with prepregnancy contraception use (OR 15.46, 95% CI 5.18-46.18).Conclusion: Somali women were less likely to use postpartum contraception. Similar practices and beliefs may also be present in other immigrant populations. Recognition of sociocultural differences in immigrant populations and potential health care provider biases may improve patient-provider relationships and counseling practices. [ABSTRACT FROM AUTHOR]

Objectives: Despite the established role of the critical care pharmacist on the ICU multiprofessional team, critical care pharmacist workloads are likely not optimized in the ICU. Medication regimen complexity (as measured by the Medication Regimen Complexity-ICU [MRC-ICU] scoring tool) has been proposed as a potential metric to optimize critical care pharmacist workload but has lacked robust external validation. The purpose of this study was to test the hypothesis that MRC-ICU is related to both patient outcomes and pharmacist interventions in a diverse ICU population.Design: This was a multicenter, observational cohort study.Setting: Twenty-eight ICUs in the United States.Patients: Adult ICU patients.Interventions: Critical care pharmacist interventions (quantity and type) on the medication regimens of critically ill patients over a 4-week period were prospectively captured. MRC-ICU and patient outcomes (i.e., mortality and length of stay [LOS]) were recorded retrospectively.Measurements and Main Results: A total of 3,908 patients at 28 centers were included. Following analysis of variance, MRC-ICU was significantly associated with mortality (odds ratio, 1.09; 95% CI, 1.08-1.11; p < 0.01), ICU LOS (β coefficient, 0.41; 95% CI, 00.37-0.45; p < 0.01), total pharmacist interventions (β coefficient, 0.07; 95% CI, 0.04-0.09; p < 0.01), and a composite intensity score of pharmacist interventions (β coefficient, 0.19; 95% CI, 0.11-0.28; p < 0.01). In multivariable regression analysis, increased patient: pharmacist ratio (indicating more patients per clinician) was significantly associated with increased ICU LOS (β coefficient, 0.02; 0.00-0.04; p = 0.02) and reduced quantity (β coefficient, -0.03; 95% CI, -0.04 to -0.02; p < 0.01) and intensity of interventions (β coefficient, -0.05; 95% CI, -0.09 to -0.01).Conclusions: Increased medication regimen complexity, defined by the MRC-ICU, is associated with increased mortality, LOS, intervention quantity, and intervention intensity. Further, these results suggest that increased pharmacist workload is associated with decreased care provided and worsened patient outcomes, which warrants further exploration into staffing models and patient outcomes. [ABSTRACT FROM AUTHOR]

Objective: To identify independent risk factors for cesarean delivery after induction of labor and to develop a nomogram for predicting cesarean delivery among nulliparous women undergoing induction of labor at term.Methods: This is a retrospective cohort study including nulliparous women with singleton, term (37 0/7 weeks of gestation or greater), cephalic pregnancies undergoing induction of labor from July 1, 2006, through May 31, 2012, at a tertiary care academic center. Inductions were identified using International Classification of Diseases, 9th Revision codes. Demographic, delivery, and outcome data were abstracted manually from the medical record. Women with a contraindication to vaginal delivery (malpresentation, abnormal placentation, prior myomectomy) were excluded. Independent risk factors for cesarean delivery were identified using logistic regression.Results: During the study period, there were 785 nulliparous inductions that met study criteria; 231 (29.4%) underwent cesarean delivery. Independent risk factors associated with an increased risk of cesarean delivery included older maternal age, shorter maternal height, greater body mass index, greater weight gain during pregnancy, older gestational age, hypertension, diabetes mellitus, and initial cervical dilation less than 3 cm. A nomogram was constructed based on the final model with a bias-corrected c-index of 0.709 (95% confidence interval 0.671-0.750).Conclusion: We identified independent risk factors that can be used to predict cesarean delivery among nulliparous women undergoing induction of labor at term. If validated in other populations, the nomogram could be useful for individualized counseling of women with a combination of identifiable antepartum risk factors.Level Of Evidence: II. [ABSTRACT FROM AUTHOR]

BACKGROUND An association exists between chronic lymphocytic leukemia and malignant melanoma. OBJECTIVES To study the clinical behavior of malignant melanoma in patients with chronic lymphocytic leukemia. METHODS A retrospective chart review was conducted of patients with chronic lymphocytic leukemia and malignant melanoma. RESULTS Sixty-nine patients had malignant melanoma and chronic lymphocytic leukemia. The recurrence-free and metastasis-free survival rates at 2, 5, and 10 years were 93.4% and 89.1%, 83.8% and 93.4%, and 87.4% and 82.1%, respectively. No significant difference was observed in age- and sex-adjusted mortality rates between patients with chronic lymphocytic leukemia diagnosed before malignant melanoma and those with chronic lymphocytic leukemia diagnosed after malignant melanoma. LIMITATIONS Retrospective study and small patient population. CONCLUSION Patients with malignant melanoma and chronic lymphocytic leukemia were not shown to have worse survival rates than those with stage IA, IB, and IIA disease. Further research and prospective study are needed. The authors have indicated no significant interest with commercial supporters. [ABSTRACT FROM AUTHOR]