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Identification of allergens causing medical adhesive contact allergy is difficult.To characterize the demographics, clinical characteristics, patch test results, and occupational data for North American Contact Dermatitis Group patients with medical adhesive contact allergy.A retrospective study of 43,722 North American Contact Dermatitis Group patients patch tested from 2001 to 2018 with medical adhesive (tapes/bandaids/adhesive aids/suture glue) sources, positive patch test results, and final primary diagnoses of allergic contact dermatitis.In total, 313 (0.7%) patients met the inclusion criteria. Compared with other patients with final primary diagnoses of allergic contact dermatitis, patients with a medical adhesive allergy were less likely to be male (odds ratio, 0.58; 95% CI, 0.45-0.77) and/or aged40 years (odds ratio, 0.76; 95% CI, 0.60-0.96). The most common North American Contact Dermatitis Group screening series allergens were colophony (80.7%), balsam of Peru (3.9%), 2-hydroxyethyl methacrylate (2.7%), and carba mix (2.7%). One-fourth of the patients (79/313, 25.2%) had positive patch test reactions to supplemental allergens/materials, and 54 (17.3%) of the 313 patients only had reactions to supplemental allergens/materials.Results of comprehensive patch testing may be prone to referral population selection bias and may not be representative of the general dermatology population.Colophony was the most common allergen. Supplemental allergens and materials should be tested in the evaluation of a suspected medical adhesive contact allergy.

ImportancePatient-submitted images vary considerably in quality and usefulness. Studies that characterize patient-submitted images in a real-life setting are lacking.ObjectiveTo evaluate the quality and perceived usefulness of patient-submitted images as determined by dermatologists and characterize agreement of their responses.Design, Setting, and ParticipantsThis survey study included patient images submitted to the Department of Dermatology at Duke University (Durham, North Carolina) between August 1, 2018, and December 31, 2019. From a total pool of 1200 images, 10 dermatologists evaluated 200 or 400 images each, with every image being evaluated by 3 dermatologists. Data analysis occurred during the year leading up to the article being written.Main Outcomes and MeasuresThe primary outcomes were the responses to 2 questions and were analyzed using frequency counts and interrater agreement (Fleiss κ) to assess image quality and perceived usefulness. We performed a random-effects logistic regression model to investigate factors associated with evaluators’ decision-making comfort. We hypothesized that most images would be of low quality and perceived usefulness, and that interrater agreement would be poor.ResultsA total of 259 of 2915 patient-submitted images (8.9%) did not depict a skin condition at all. The final analysis comprised 3600 unique image evaluations. Dermatologist evaluators indicated that 1985 images (55.1%) were useful for medical decision-making and 2239 (62.2%) were of sufficient quality. Interrater agreement for a given image’s diagnostic categorization was fair to substantial (κ range, 0.36-0.64), while agreement on image quality (κ range, 0.35-0.47) and perceived usefulness (κ range, 0.29-0.38) were fair to moderate. Senior faculty had higher odds of feeling comfortable with medical decision-making than junior faculty (odds ratio [OR], 3.68; 95% CI, 2.9-4.66; P P P = .01) compared with inflammatory skin conditions and that were in focus (OR, 5.56; 95% CI, 4.63-6.67; P Conclusions and RelevanceIn this survey study including 10 dermatologists, a slight majority of patient-submitted images were judged to be of adequate quality and perceived usefulness. Fair agreement between dermatologists was found regarding image quality and perceived usefulness, suggesting that store-and-forward teledermatology initiatives should consider a physician’s individual experiences and comfort level. The study results suggest that images are most likely to be useful when they are in focus and reviewed by experienced attending physicians for wound surveillance, but dermatologists may be burdened by irrelevant or unsuitable images.

In this case series, ustekinumab therapy demonstrated efficacy in some patients with severe hidradenitis suppurativa previously treated with adalimumab and/or infliximab. Larger prospective studies are needed to evaluate ustekinumab as a treatment option for recalcitrant hidradenitis suppurativa.

Differences in consumer product availability, distribution, and use may lead to national differences in contact sensitization frequencies. Objective The aim of the study was to describe the differences in contact allergy between the United States (US) and Canada. Methods This is a retrospective cross-sectional analysis of the North American Contact Dermatitis Group data from 2005 to 2016. Frequencies of demographics, clinical characteristics, positive reactions, trends, and occupations were calculated. Results A total of 28,640 patients underwent patch testing. At least 1 positive patch test was observed in 18,599 patients (US, 11,641 [66.5%]; Canada, 6958 [62.5%]). When comparing the 2 groups, US positive reactions were more likely to occur in male patients (odds ratio [OR] = 1.40, 95% confidence interval [CI] = 1.31-1.49), older than 40 years (OR = 1.30, 95% CI = 1.22-1.38), Black (OR = 2.67, 95% CI = 2.24-3.19) or Hispanic race (OR = 3.53, 95% CI = 2.61-4.78), and/or patients with scattered generalized dermatitis (OR = 1.96, 95% CI = 1.80-2.13). They were less likely to occur in patients with eczema (OR = 0.61, 95% CI = 0.57-0.65) and Asian race (OR = 0.50, 95% CI = 0.44-0.56). Nickel (US, 16.0%; Canada, 22.4%) and methylisothiazolinone (US, 13.4%; Canada, 11.0%) were the top allergens. The third most frequent was neomycin (US, 11.7%) and fragrance mix I (Canada, 10.2%). Conclusions National differences in allergen prevalence and trends exist in North America.

Background Two previous reports from the same group concluded that the analytical reliability of Instrumentation Laboratory GEM4000 analyzers (GEM4K) deteriorated during a 24-hour period, based on results between samples from the same patient but collected at different times. Our routine blood gas Between-Laboratory Survey is done every 2 weeks using a freshly pooled heparinized blood sample taken to each analyzer location to verify comparability among our GEM4K and Radiometer ABL90 (Rad90) blood gas analyzers. Because another report found a few very large differences in glucose results between the GEM4K and central laboratory analyzers, we reviewed the glucose results on plasma from our Chemistry Between-Laboratory Surveys that includes comparisons between our central laboratory analyzers (Beckman DxC800; DxC800) and our GEM4K and Rad90 blood gas analyzers. Method Using data from our Blood Gas and Chemistry Surveys over a 55-week period, we calculated the mean, standard deviation (SD), and concentration intervals of the 27 sets of results by the GEM4K or Rad90 analyzers. Agreement in plasma glucose between DxC800 and blood gas analyzers was evaluated by the limits of agreement and intraclass correlation coefficient analysis. Results For each analyte, the Rad90 had lower average SD than the GEM4K for the 55-week period, although both brands of analyzers showed acceptable performance. For plasma glucose results on our Chemistry Survey, the GEM4K results agreed more closely with the DxC800 results than the Rad90 results. Conclusions Based on both our Blood Gas and Chemistry Surveys, we conclude that both brands of analyzers performed within analytically and clinically acceptable limits throughout the year, with no evidence for the type of errors reported previously.

Background Hidradenitis suppurativa (HS) and atopic dermatitis (AD) are both chronic inflammatory skin diseases. An association between these 2 conditions can have important potential implications for elucidating pathogenesis, disease course, and treatment. Objective To investigate the association between AD and HS. Methods We performed a retrospective cohort study of patients seen at Duke University Medical Center from 2007 to 2017 who had AD compared with a control group without an AD diagnosis. The association of AD and HS was evaluated using a logistic regression model after adjusting for other confounders including age, sex, and race. Results Of 28,780 patients with an AD diagnosis, 325 (1.1%) were diagnosed with HS compared with 76 (0.2%) within the 48,383 patients in the non-AD group. An adjusted logistic regression model demonstrated an increased odds ratio of having HS diagnosis in the AD group as compared with the control non-AD group (odds ratio: 5.57, 95% confidence interval: 4.30-7.21, P Limitations This was a retrospective study performed at a single institution with the possibility of surveillance bias being present. Conclusions Patients with AD are more likely to be diagnosed with HS than patients without AD. Further research is needed to understand the pathophysiologic mechanism and potential treatment implications.

Objectives The aim of this multisite quality improvement study was to evaluate patients’ experiences with the patient-centered pathology (PCP) consultation program and to determine whether PCP enhanced their care experience. Methods Patients were invited to attend PCP consultations to review their pathology report and slides and have their questions answered by the pathologist privately, with the option to attend the appointment with family members or friends for support. A patient experience questionnaire (PEQ) was administered to patients, who participated voluntarily in the PCP, and survey data were collected and stored in REDCap. Statistical analysis was performed using SAS 9.4 (SAS Institute). Results Sixty-seven patients (95.5% female) aged 18 to 84 years across 4 institutions completed the PEQ. Overall, 58% and 15.8% of patients had breast and brain tumors, respectively, and 59.7% of tumors were newly diagnosed. Most patients thought it was important for them to learn as much as they could about their health condition. However, the majority of patients reported some degree of difficulty learning about their health condition based on written information, despite 97% having completed high school and/or further education. The majority of patients rated their pathologist as “excellent” across communication metrics. Ultimately, 100% of respondents were satisfied, found their visits to be useful, and would recommend the PCP to other patients. Conclusions Patients found that personalized clinical encounters with pathologists improved their understanding of their health condition and their satisfaction with their care experience. Patients thought pathologists communicated respectfully, effectively, and empathetically.

IMPORTANCE When fragrance- and botanical-related (F/BR) allergy is identified, concomitant reaction (CR) frequencies can help direct avoidance recommendations. OBJECTIVE This study aimed to determine the CR rates for F/BR allergens. DESIGN A retrospective cross-sectional analysis of the North American Contact Dermatitis Group data 2007-2016 was conducted. Frequencies of demographics, positive reactions, strength of reactions, trends, and CR rates were calculated. RESULTS A total of 5504 (22.7%) of 24,246 patients had F/BR allergic reactions. The F/BR-sensitive patients were more likely to be female, older than age 40 years, and White and have face, leg, or anal/genital dermatitis. Top allergens included fragrance mix I (FMI, 10.6%), Myroxylon pereirae (balsam of Peru [BOP], 8%), and fragrance mix II (FMII, 4.9%). There were increasing trends for FMI, FMII, cinnamic aldehyde, and Compositae mix and decreasing trends for BOP and propolis. When patients were positive to any F/BR allergen, they were likely to be positive to FMI, FMII, and BOP. Concomitant reactions were bidirectional between multiple fragrance allergens and propolis, colophony, and Compositae mix. CONCLUSIONS Concomitant reactions were identified between fragrances, between fragrances and BR allergens, and between BR allergens and fragrances. If CRs of greater than 10% suggest cross-reactivity, then all patients with fragrance sensitivity should avoid BR allergens and vice versa.

What is known and objective Invasive fungal infections often occur in patients with comorbidities that complicate oral administration. Serum concentrations of isavuconazole were characterized after enteral tube administration. Case description Thirteen of 14 isavuconazole concentrations were >1 mg/dl (median 1.6 mg/dl) among those receiving enteral tube administration, which was comparable to intravenous (median 1.9 mg/dl). Higher concentrations were observed during oral administration (median 3 mg/dl). What is new and conclusion Administration of isavuconazole via tube resulted in concentrations comparable to FDA-approved routes of administration. This route may be feasible and appropriate for select patients.

The diagnosis of invasive adenocarcinoma of the gallbladder can sometimes be challenging. The presence of true desmoplastic reaction facilitates the diagnosis of invasion. However, desmoplasia-like changes can be observed in benign gallbladder conditions, and recognition of desmoplasia may be challenging based on morphology. In this study, we tested the expression pattern of microfibril-associated protein 5 (MFAP5), a promising immunohistochemical marker for desmoplasia, in benign gallbladders with desmoplasia-like reaction and gallbladders with invasive adenocarcinoma. We also evaluated the diagnostic utility of MFAP5 in challenging cases with an interobserver agreement study. The results showed that all benign cases retained intact/positive MFAP5 staining pattern in periglandular connective tissue, whereas 79.3% (23 out of 29) of cases of adenocarcinomas demonstrated diffuse and complete loss of MFAP5 staining in the tumor stroma. Interobserver agreement was improved by 2.66 times when images of MFAP5 immunohistochemistry were provided. In conclusion, MFAP5 expression is downregulated in the desmoplastic stroma of gallbladder adenocarcinoma and may provide a useful diagnostic marker in difficult cases.

ObjectiveTo examine the longitudinal health care resource utilization, in-hospital mortality, and incidence of downstream complications of bacterial meningitis in the United States.MethodsUsing IBM MarketScan, we retrieved data on adult patients with a diagnosis of bacterial meningitis admitted to a US hospital between 2008 and 2015. Patients were stratified into groups (1) with/without prior head trauma/neurosurgical complications, (2) nosocomial/community acquisition, and (3) Gram-negative/positive bacteria. Cost data were collected for up to 2 years and analyzed with descriptive statistics and longitudinal modeling.ResultsAmong 4,496 patients with bacterial meningitis, 16.5% and 4.6% had preceding neurosurgical complications and head injuries, respectively. Lumbar punctures were performed in 37.3% of patients without prior trauma/complications who went on to develop nosocomial meningitis, and those with prior head injuries or complications had longer initial hospital stays (17.0 days vs 8.0 days). Within a month of diagnosis, 29.2% of patients with bacterial meningitis had experienced downstream complications, most commonly hydrocephalus (12.7%). The worst 30-day mortality was due to tuberculous (12.3%) and streptococcal meningitis (7.2%). Overall, prior head trauma and complications were associated with higher costs. Community-acquired bacterial meningitis had lower median baseline costs relative to the nosocomial group (no head trauma/complication: $17,152 vs $82,778; head trauma/complication: $92,428 vs $168,309) but higher median costs within 3 months of diagnosis (no head trauma/complication: $47,911 vs $34,202; head trauma/complication: $89,207 vs $58,947). All costs demonstrated a sharp decline thereafter.ConclusionsBacterial meningitis remains costly and devastating, especially for those who experience traumatic head injuries or have a complicated progress after neurosurgery.

BACKGROUND Contact dermatitis is a common disease that is associated with impaired quality of life. OBJECTIVE We examined the effect of travel distance and other socioeconomic factors on duration of dermatitis before presentation at the Duke Contact Dermatitis and Patch Testing Center. METHODS This is a retrospective study of patients who underwent patch testing from March 1, 2012, to August 1, 2018. Associations between duration of dermatitis, distance to clinic, and socioeconomic factors (age, race, payor group, county poverty rate, rural-urban status) were examined. RESULTS The median duration of dermatitis was 14 months (Q1 = 7 months; Q3 = 36 months), and the median distance to clinic was 18 miles (Q1 = 7 miles; Q3 = 45.9 miles). For a 50-mile increase in the distance from the patient's zip code to the clinic, the median duration of dermatitis increased by 17.9% (P < 0.001). For every 5% increase in the county poverty rate, the median duration of dermatitis increased by 16.3% (n = 29; P = 0.032). Trends were noted for a longer duration of dermatitis based on insurance payor, rural-urban status, and race. CONCLUSIONS Distance to patch test provider and county poverty status are important measures of access for patients with dermatitis.

Background Patch testing is the criterion standard for diagnosis and management of allergic contact dermatitis. Limitations on the number of allergens tested can negatively impact patient care. Objective This study reports clinical practice patterns of American Contact Dermatitis Society (ACDS) members. Methods In October and November 2018, the US-based members of the ACDS received an electronic survey regarding their procedures and experiences with patch testing. We evaluated the type of practice, number of patients tested, type of screening and supplemental series, number of allergens tested, and billing and reimbursement concerns. Results There were 149 respondents; 62% use ACDS Core 80, 70% "sometimes" or "always" test with supplemental series, and 70% "sometimes" or "always" test patient products. Participants estimated that supplemental series identify relevant allergens 35% of the time. Approximately 66% most commonly test more than 81 allergens per patient, and 78% expressed concerns regarding fair reimbursement. Conclusions Most ACDS members routinely test more than 81 allergens per patient. Barriers to fair payment for beyond a fixed number of patches at any one visit may impede the diagnosis of allergic contact dermatitis, prolong suffering, and worsen outcomes.

BACKGROUND: Hypoglycemia is a major limiting factor in the glycemic management of diabetes. As a method of treating hypoglycemia, the American Diabetes Association (ADA) recommends glucagon to be prescribed for all individuals at increased risk of clinically significant hypoglycemia. Glucagon emergency kits have been shown to reduce emergency department visits, and overall health care cost. Despite these known benefits, glucagon continues to be under-prescribed. Previous pharmacist-led interventions embedded in a single clinic have been shown to positively affect the rate of glucagon prescribing in patients with diabetes OBJECTIVES: To compare the rate of glucagon prescribing between quality improvement remote pharmacist outreach to multiple primary care and endocrinology specialty clinics and the control group in the one month period following pharmacist-led provider outreach. METHODS: Single-center, two-arm study with simple randomization design RESULTS: Upon pharmacist outreach, 61 of 109 patients (56.0%) in the outreach group were prescribed a glucagon product within one month of their primary care provider (PCP) or endocrinology appointment compared to 1 of 113 (0.9%) of patients in the control group (p-value

Retrospective cohort study.We aimed to characterize the treatment patterns and the associated costs in patients with cerebrospinal fluid (CSF) leak after spine procedures in the United States.CSF leak is a common complication after spinal procedures. However, there is a little data regarding the national patterns of treatment choice and the associated health care resource utilization.We utilized the IBM MarketScan Research databases to retrospectively analyze adult US patients diagnosed with CSF leak within 30 days of spine procedures between 2001 and 2018. Treatment prevalence, treatment failure, and health care resource utilization data within 30 days of the CSF leak were collected. A subanalysis was performed on patients who received epidural blood patches (EBP) to better understand health care utilization attributable to this treatment modality.Twenty one thousand four hundred fourteen patients were identified. The most common causes of CSF leak were diagnostic spinal tap (59.2%) and laminectomy/discectomy (18.7%). With regard to treatment prevalence, 40.4% of the patients (n=8651) had conservative medical management, 46.6% (n=9987) received epidural blood patch repair, 9.6% required surgical repair (n=2066), and 3.3% (n=710) had lumbar drain/puncture. Nine hundred sixty-seven (9.7%), 150 (21.1%), and 280 (13.5%) patients failed initial EBP, lumbar drain, and surgery, respectively, and the overall failure rate was 10.9% (n=1397). The median 30-day total cost across all groups was $5,101. Patients who received lumbar drain ($22,341) and surgical repair ($30,199) had higher 30-day median total costs than EBP ($8,140) or conservative management ($17,012). The median 30-day total cost for patients whose EBP failed ($8,179) was substantially greater than those with a successful EBP repair ($3,439).National treatment patterns and costs for CSF leaks were described. When used in the correct patient cohort, EBP has the lower failure rates and costs than comparable alternatives. EBP may be considered more often in situations where conservative management or lumbar drains are currently being used.

BACKGROUND: The optimal approach to blood pressure (BP) management in acute ischemic stroke remains unclear. The purpose of this study was to determine if an intermittent (labetalol or hydralazine) or continuous infusion (nicardipine or clevidipine) antihypertensive strategy facilitated timelier alteplase administration. METHODS: Patients ≥18 years who presented to the emergency department (ED) between September 1, 2013 and August 31, 2020, received alteplase for acute ischemic stroke, and required BP management with an intravenous antihypertensive were included in this multicenter, retrospective cohort study. Exclusion criteria were initial administration of a non-study antihypertensive, initial study antihypertensive administration >2 hours prior to or any time following alteplase, or receipt of both an intermittent and continuous infusion antihypertensive prior to alteplase. The primary endpoint was the time from ED presentation to alteplase administration. RESULTS: During the study period, 122 patients received an intermittent antihypertensive and 57 patients received a continuous infusion antihypertensive. The median door-to-needle time was 53 minutes for patients who received an intermittent antihypertensive compared to 57 minutes for those who received a continuous infusion antihypertensive (p=0.17). Secondarily, the proportion of patients who achieved the BP target

Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating neurological condition. Endovascular coiling or surgical clipping have equivocal success rates, but relatively little is known regarding the health economics and complications of these procedures at the population level. We aimed to analyze the complication profiles and healthcare resource utilization (HRCU) associated with the treatment of aSAH in the USA. We performed a retrospective analysis utilizing the IBM MarketScan database between 2008 and 2015. Primary outcomes included economic analysis stratified by post-operative complication; determination of the effect of several factors on total cost by multivariable regression; and analysis of the incidence, timing, and associated HCRU of aSAH-related post-operative complications. Of the 2374 patients meeting inclusion criteria for economic analysis, 1783 (75.1%) patients had at least one of the ten complications. The most common complications included hydrocephalus (43.8%), transient cerebral ischemia (including vasospasm) (30.6%), ischemic stroke (29.1%), syndrome of inappropriate antidiuretic hormone (SIADH)/hyposmolarity/hyponatremia (22.1%), and seizures (14.9%). Patients who experienced complications had higher median 90-day total costs [$161,127 (Q1 to Q3, $101,411 to $257,662)] than those who did not [$97,376 (Q1 to Q3, $55,692 to $147,447)]. Length of stay was longest for those with pulmonary embolism and pneumonia (27 days) and shortest for those with SIADH/hyposmolarity/hyponatremia (16 days). Brain compression/herniation had the highest mortality rate (19.5%). In total, 14.6% of all patients experienced a readmission within 30 days. In conclusion, patients with aSAH have high post-operative complication rates and costs. Development of novel interventions to reduce complications and improve outcomes is crucial.

Background Urinary tract infections (UTIs) are often misdiagnosed or treated with exceedingly broad-spectrum antibiotics, leading to negative downstream effects. We aimed to implement antimicrobial stewardship (AS) strategies targeting UTI prescribing in the emergency department (ED). Methods We conducted a quasi-experimental prospective AS intervention outlining appropriate UTI diagnosis and management across 3 EDs, within an academic and 2 community hospitals, in North Carolina, United States. The study was divided into 3 phases: a baseline period and 2 intervention phases. Phase 1 included introduction of an ED-specific urine antibiogram and UTI guideline, education, and department-specific feedback on UTI diagnosis and antibiotic prescribing. Phase 2 included re-education and provider-specific feedback. Eligible patients included adults with an antibiotic prescription for UTI diagnosed in the ED from 13 November 2018 to 1 March 2021. Admitted patients were excluded. The primary outcome was guideline-concordant antibiotic use, assessed using an interrupted time-series regression analysis with 2-week intervals. Results Overall, 8742 distinct patients with 10 426 patient encounters were included. Ninety-two percent of all encounters (n = 9583) were diagnosed with cystitis and 8.1% with pyelonephritis (n = 843). There was an initial 15% increase in guideline-concordant antibiotic prescribing in phase 1 compared with the preintervention period (incidence rate ratio [IRR], 1.15; 95% confidence interval [CI], 1.03–1.29). A significant increase in guideline-concordant prescriptions was seen with every 2-week interval during phase 2 (IRR, 1.03; 95% CI, 1.01–1.04). Conclusions This multifaceted AS intervention involving a guideline, education, and provider-specific feedback increased guideline-concordant antibiotic choices for treat-and-release patients in the ED.

OBJECTIVE: Identify risk factors associated with airway foreign bodies in children in the United States and report observed trends over time. DATA SOURCE: KID database (2000–2009). METHODS: ICD-9-CM codes for airway foreign bodies were used to identify patients. Risk factors were used for univariate analysis and a multivariate model to identify any increased risk of mortality. These factors were then also trended over time. RESULTS: Children with airway foreign bodies demonstrate similar risk factors as previously reported, such as male gender, age less than five years old, and lack of private insurance. The weighted mortality rate for pediatric inpatients with airway foreign bodies was about 2.75%. Fortunately, the rate remained relatively unchanged from 2000 to 2009. Geographically, urban hospital settings appeared to be more affected. Increased risks of mortality were noted for older age, urban hospital setting, and teaching hospital status. CONCLUSIONS: Our findings confirm previous findings and identified that the diagnosis of airway foreign bodies in children were associated with male gender, age less than five years old, lack of private insurance, and geographic location in an urban setting. Further investigation may be warranted to provide clarity on other factors found to have increased association with mortality for quality improvement.

Background Urinary tract infections (UTIs) are the most common outpatient indication for antibiotics and an important target for antimicrobial stewardship (AS) activities. With The Joint Commission standards now requiring outpatient AS, data supporting effective strategies are needed. Methods We conducted a 2-phase, prospective, quasi-experimental study to estimate the effect of an outpatient AS intervention on guideline-concordant antibiotic prescribing in a primary care (PC) clinic and an urgent care (UC) clinic between August 2017 and July 2019. Phase 1 of the intervention included the development of clinic-specific antibiograms and UTI diagnosis and treatment guidelines, presented during educational sessions with clinic providers. Phase 2, consisting of routine clinic- and provider-specific feedback, began ~12 months after the initial education. The primary outcome was percentage of encounters with first- or second-line antibiotics prescribed according to clinic-specific guidelines and was assessed using an interrupted time series approach. Results Data were collected on 4724 distinct patients seen during 6318 UTI encounters. The percentage of guideline-concordant prescribing increased by 22% (95% CI, 12% to 32%) after Phase 1 education, but decreased by 0.5% every 2 weeks afterwards (95% CI, –0.9% to 0%). Following routine data feedback in Phase 2, guideline concordance stabilized, and significant further decline was not seen (–0.6%; 95% CI, –1.6% to 0.4%). This shift in prescribing patterns resulted in a 52% decrease in fluoroquinolone use. Conclusions Clinicians increased guideline-concordant prescribing, reduced UTI diagnoses, and limited use of high-collateral damage agents following this outpatient AS intervention. Routine data feedback was effective to maintain the response to the initial education.

Background Preservatives are often necessary components of commercial products. Large-scale North American studies on preservative allergy are limited. Objective To evaluate demographics, positive patch test reactions (PPTRs), clinical relevance, and trends for preservatives tested by the North American Contact Dermatitis Group. Methods We conducted a retrospective cross-sectional analysis of North American Contact Dermatitis Group patch testing results of preservatives from 1994 through 2016. Results A total of 50,799 patients were tested; 11,338 (22.3%) had a PPTR to at least 1 preservative. The most frequent reactions were to methylisothiazolinone 0.2% aqueous (aq) (12.2%), formaldehyde 2% aq (7.8%), formaldehyde 1% aq (7.8%), quaternium-15 2% petrolatum (pet) (7.7%), and methyldibromo glutaronitrile/phenoxyethanol 2% pet (5.1%). Paraben mix 12% pet (1%), iodopropynyl butylcarbamate 0.1% pet (0.4%), benzyl alcohol 1% pet (0.3%), and phenoxyethanol 1% pet (0.2%) had the lowest PPTRs. Linear regression analysis of preservatives tested showed that only methylchloroisothiazolinone/methylisothiazolinone 0.01% aq (parameter estimate, 0.42; 95% CI, 0.17-0.66; P Limitations Collected variables are dependent on clinical judgment. Results may be prone to referral selection bias. Conclusions This large North American study provides insight on preservative PPTRs and trends from 1994 through 2016.

OBJECTIVE Postoperative hydrocephalus occurs in one-third of children after posterior fossa tumor resection. Although models to predict the need for CSF diversion after resection exist for preoperative variables, it is unknown which postoperative variables predict the need for CSF diversion. In this study, the authors sought to determine the clinical and radiographic predictors for CSF diversion in children following posterior fossa tumor resection. METHODS This was a retrospective cohort study involving patients ≤ 18 years of age who underwent resection of a primary posterior fossa tumor between 2000 and 2018. The primary outcome was the need for CSF diversion 6 months after surgery. Candidate predictors for CSF diversion including age, race, sex, frontal occipital horn ratio (FOHR), tumor type, tumor volume and location, transependymal edema, papilledema, presence of postoperative intraventricular blood, and residual tumor were evaluated using a best subset selection method with logistic regression. RESULTS Of the 63 included patients, 26 (41.3%) had CSF diversion at 6 months. Patients who required CSF diversion had a higher median FOHR (0.5 vs 0.4) and a higher percentage of postoperative intraventricular blood (30.8% vs 2.7%) compared with those who did not. A 0.1-unit increase in FOHR or intraventricular blood was associated with increased odds of CSF diversion (OR 2.9 [95% CI 1.3–7.8], p = 0.02 and OR 20.2 [95% CI 2.9–423.1], p = 0.01, respectively) with an overfitting-corrected concordance index of 0.68 (95% CI 0.56–0.80). CONCLUSIONS The preoperative FOHR and postoperative intraventricular blood were significant predictors of the need for permanent CSF diversion within 6 months after posterior fossa tumor resection in children.

We aimed to assess procedural trends for tracheostomy placement in the management of children with subglottic stenosis. We hypothesize that with increased use of less invasive airway interventions for subglottic stenosis, tracheostomy may be performed less frequently over time.Data were collected from the Kids' Inpatient Database (KID) for pediatric discharges with an admission diagnosis of subglottic stenosis (Stenosis of larynx: ICD-9 code 478.74) from across the United States for years 2000, 2003, 2006, 2009, and 2012. The number of overall procedures and specific airway procedures including tracheostomy (ICD-9-CM codes 31.1, 31.29) were evaluated.A weighted estimate of 18,124 pediatric discharges with a diagnosis of subglottic stenosis were identified. Overall, there was an increase in the mean number of procedures performed during hospitalization from 2000 to 2012 (p 0.001); however, there was a decrease in the proportion of children undergoing tracheostomy placement (p 0.001).Trends over the past decade from a US national database have revealed decreasing tracheostomy placement in hospitalized pediatric patients with subglottic stenosis. This may be due to a change in paradigm with increased use of less invasive, possibly endoscopic, treatment in this patient population. Further investigations may be helpful to identify management paradigms to optimize care in order to help avoid tracheostomy placement.

Introduction. Paediatric bacterial meningitis remains a costly disease, both financially and clinically. Hypothesis/Gap Statement. Previous epidemiological and cost studies of bacterial meningitis (BM) have largely focused on adult populations or single pathogens. There have been few recent, large-scale studies of pediatric BM in the USA. Aim. We examined healthcare resource utilization (HCRU) and associated morbidity and mortality of community-acquired versus nosocomial bacterial infections in children across the USA. Methodology. The IBM MarketScan Research databases were used to identify patients Results. We identified 1928 cases of paediatric BM without prior head trauma or neurological/systemic complications. Of these, 15.4 % were nosocomial and 84.6 % were community-acquired infections. After diagnostic lumbar puncture (37.1 %), the most common neurosurgical procedure was placement of ventricular catheter (12.6 %). The 30-day complication rates for nosocomial and community-acquired infections were 40.5 and 45.9 %, respectively. The most common complications were hydrocephalus (20.8 %), intracranial abscess (8.8 %) and cerebral oedema (8.1 %). The 30-day in-hospital mortality rates for nosocomial and community-acquired infections were 2.7 and 2.8 %, respectively. Median length of admission was 14.0 days (Q1: 7 days, Q3: 26 days). Median 90-day cost was $40 861 (Q1: $11 988, Q3: $114,499) for the nosocomial group and $56 569 (Q1: $26 127, Q3: $142 780) for the community-acquired group. In multivariable regression, the 90-day post-diagnosis total costs were comparable between groups (cost ratio: 0.89; 95 % CI: 0.70 to 1.13), but at 2 years post-diagnosis, the nosocomial group was associated with 137 % higher costs (CR: 2.37, 95 % CI: 1.51 to 3.70). Conclusion. In multivariable analysis, nosocomial infections were associated with significantly higher long-term costs up to 2 years post-infection. Hydrocephalus, intracranial epidural abscess and cerebral oedema were the most common complications, and lumbar punctures and ventricular catheter placement were the most common neurosurgical procedures. This study represents the first nation-wide, longitudinal comparison of the outcomes and considerable HCRU of nosocomial versus community-acquired paediatric BM, including characterization of complications and procedures contributing to the high costs of these infections.

IMPORTANCE: There are limited data on which factors affect the critical and complex decision to withdraw life-supporting treatment (LST) in patients with severe traumatic brain injury (sTBI). OBJECTIVE: To determine demographic and clinical factors associated with the decision to withdraw LST in patients with sTBI. DESIGN, SETTING, AND PARTICIPANTS: This retrospective analysis of inpatient data from more than 825 trauma centers across the US in the American College of Surgeons Trauma Quality Improvement Program database from January 2013 to December 2015 included adult patients with sTBI and documentation of a decision regarding withdrawal of LST (WLST). Data analysis was conducted in September 2019. MAIN OUTCOMES AND MEASURES: Factors associated with WLST in sTBI. RESULTS: A total of 37931 patients (9817 women [25.9%]) were included in the multivariable analysis; 7864 (20.7%) had WLST. Black patients (4806 [13.2%]; odds ratio [OR], 0.66; 95% CI, 0.59-0.72; P

Flipped and traditional classroom models were compared in the Duke University Medical Center (Durham, North Carolina) dermatology residency program for the 2014-2015 academic year. The residents participated in 12 lectures-6 traditional and 6 flipped-that were paired for similar content. Each lecture was followed by a survey comprised of 10 factual questions and 10 perception questions. Generalized linear regression models were used to study the differences in quiz scores between the 2 classroom models after adjusting for other baseline covariates. There was not a significant difference in mean factual quiz scores between the two classroom models. Results indicated significant perception differences in favor of the flipped classroom model, such as participation (P.001), enjoyment (P=.038 and P=.026), efficiency (P=.033), and boards (P=.050) and clinical preparedness (P=.034).

Introduction. Previous studies of viral encephalitis have focused on acute costs, estimating incidence at 7.3 per 100 000 and total US annual charges at $2 billion in 2010. Aim. We aim to quantify the most updated longitudinal health economic impact of viral encephalitis in the USA from 2008 to 2015. Methodology. Data on patients diagnosed with viral encephalitis were obtained from the Truven Health Analytics MarketScan database. Patients with a primary diagnosis of viral encephalitis, from herpetic viruses and other viral aetiologies (e.g. West Nile fever) were included in the analysis. Data concerning healthcare resource utilization, inpatient mortality, length of stay and accrued healthcare costs were collected for up to 5 years. Results. Among 3985 patients with continuous enrolment for 13 months prior to the encephalitis diagnosis, more non-herpes simplex encephalitis (61.7 %) than herpes simplex encephalitis (HSE; 38.3 %) cases were recorded, with the majority concentrated in the southern USA (29.2 %). One-year inpatient mortality was 6.2 %, which over a 5-year period rose to 8.9 % for HSE and 5.8 % for all other viral encephalitides. HSE resulted in longer cumulative stays in the hospital (11 days vs. 4 days; P=0.0025), and accrued 37 % higher first-year costs, after adjusting for known confounders [P

BACKGROUND: The number needed to treat or excise (NNT) is commonly used to measure the number of skin biopsies performed to detect one melanoma. The NNT for melanoma varies widely between clinical settings. OBJECTIVE: To provide a formal statistical comparison of the efficacy of melanoma detection between different clinical settings. METHODS: A systematic review and meta-analysis of all relevant observational studies on NNT in relation to melanoma was performed on MEDLINE. We performed a random effects model meta-analysis and reported NNTs with 95% confidence intervals (CIs). The subgroup analysis was related to clinical setting. RESULTS: In all, 29 papers including a total of 398,549 biopsies/excisions were analyzed. The overall NNT was 9.71 (95% CI, 7.72-12.29): 22.62 (95% CI, 12.95-40.10) for primary care, 9.60 (95% CI, 6.97-13.41) for dermatologist, and 5.85 (95% CI, 4.24-8.27) for pigmented lesion specialists. LIMITATIONS: There is heterogeneity in data reporting and possibility of missing studies. In addition, the incidence of melanoma varies among clinical settings and could affect NNT calculations. CONCLUSION: Specialists have the lowest NNT, followed by dermatologists, suggesting involving specialists in the diagnosis and treatment of pigmented skin lesions can likely improve patient outcomes.

Introduction Immune checkpoint pathway markers induce immune tolerance to non–small cell lung cancer (NSCLC). Therapeutic antibodies targeting the programmed cell death 1 (PD-1)/programmed cell death ligand 1 (PD-L1) pathway have demonstrated efficacy in tumors expressing relatively high PD-L1 levels. Minimally invasive endobronchial ultrasound-guided fine needle aspiration allows patients with inoperable tumors or comorbidities to attain a confirmatory diagnosis. The aims of the present study were to determine whether PD-L1 testing is equivalent to cytology and biopsy or resection specimens at different tumor proportion score cutoffs and for different NSCLC subtypes. Materials and methods Data were retrospectively collected for patients with paired NSCLC cytology and surgical resection specimens from May 4, 2007 to May 4, 2017. The Food and Drug Administration–approved Dako PD-L1 immunohistochemistry 22C3 pharmDx kit was used to measure PD-L1 on paired cytology cell block and biopsy or resection specimens, and the PD-L1 tumor proportion scores were recorded. Statistical analysis of categorical and continuous variables was performed using SAS, version 9.4. Results A total of 53 paired cytology and resection samples (27 adenocarcinoma, 25 squamous cell carcinoma, and 1 unclassified) were analyzed. Supposing the resection specimen to reflect the true PD-L1 expression, the sensitivity, specificity, positive predictive value, negative predictive value, and overall agreement for the cytology method was 73.3%, 65.2%, 73.3%, 65.2%, and 69.8%, respectively. For high PD-L1 expression (≥50%), the cytology method demonstrated an overall agreement of 79.2%. The overall agreement between methods was 81.5% and 76% for cases of adenocarcinoma and squamous cell carcinoma, respectively. Conclusions NSCLC cytology samples from endobronchial ultrasound-guided fine needle aspiration are suitable for PD-L1 testing, especially using a high PD-L1 expression cutoff of ≥50% and for adenocarcinoma.

In order to configure the parameters of the hybrid energy storage system (HESS), based on the typical working conditions of the trolley, a matching optimization method of the hybrid energy storage trolley system considering the whole life cycle cost of the whole vehicle is proposed. The method establishes a multi-objective and multi-constrained configuration optimization model with the lowest life cycle cost (LCC) and the smallest volume as the objective function of the energy storage system. The enumeration method is used to solve the multi-objective and multi-constraint model to obtain the Pareto frontier. The recommended scheme with acceptable volume and economy is given. The simulation results show that the configured hybrid system can meet the design requirements. After optimizing, the power system cost during the whole vehicle life cycle decreases from 3.85 million yuan to less than 1.5 million yuan, which has important reference value for designing and operating the hybrid energy storage tram.