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Objective:Alteration of the colonic microbiota following antimicrobial exposure allows colonization by antimicrobial-resistant organisms (AROs). Ingestion of a probiotic, such as Lactobacillus rhamnosus GG (LGG), could prevent colonization or infection with AROs by promoting healthy colonic microbiota. The purpose of this trial was to determine the effect of LGG administration on ARO colonization in hospitalized patients receiving antibiotics.Design:Prospective, double-blinded, randomized controlled trial of LGG versus placebo among patients receiving broad-spectrum antibiotics.Setting:Tertiary care center.Patients:In total, 88 inpatients receiving broad-spectrum antibiotics were enrolled.Intervention:Patients were randomized to receive 1 capsule containing 1×1010 cells of LGG twice daily (n = 44) or placebo (n = 44), stratified by ward type. Stool or rectal-swab specimens were collected for culture at enrollment, during admission, and at discharge. Using selective media, specimens were cultured for Clostridioides difficile, vancomycin-resistant Enterococcus spp (VRE), and antibiotic-resistant gram-negative bacteria. The primary outcome was any ARO acquisition. Secondary outcomes included loss of any ARO if colonized at enrollment, and acquisition or loss of individual ARO.Results:ARO colonization prevalence at study enrollment was similar (LGG 39% vs placebo 39%). We detected no difference in any ARO acquisition (LGG 30% vs placebo 33%; OR,1.19; 95% CI, 0.38–3.75) nor for any individual ARO acquisition. There was no difference in the loss of any ARO (LGG 18% vs placebo 24%; OR, 1.44; 95% CI, 0.27–7.68) nor for any individual ARO.Conclusion:LGG administration neither prevented acquisition of ARO nor accelerated loss of ARO colonization.

Alteration of the colonic microbiota following antimicrobial exposure allows colonization by antimicrobial-resistant organisms (AROs). Ingestion of a probiotic, such as Lactobacillus rhamnosus GG (LGG), could prevent colonization or infection with AROs by promoting healthy colonic microbiota. The purpose of this trial was to determine the effect of LGG administration on ARO colonization in hospitalized patients receiving antibiotics.Prospective, double-blinded, randomized controlled trial of LGG versus placebo among patients receiving broad-spectrum antibiotics.Tertiary care center.In total, 88 inpatients receiving broad-spectrum antibiotics were enrolled.Patients were randomized to receive 1 capsule containing 1×1010 cells of LGG twice daily (n = 44) or placebo (n = 44), stratified by ward type. Stool or rectal-swab specimens were collected for culture at enrollment, during admission, and at discharge. Using selective media, specimens were cultured for Clostridioides difficile, vancomycin-resistant Enterococcus spp (VRE), and antibiotic-resistant gram-negative bacteria. The primary outcome was any ARO acquisition. Secondary outcomes included loss of any ARO if colonized at enrollment, and acquisition or loss of individual ARO.ARO colonization prevalence at study enrollment was similar (LGG 39% vs placebo 39%). We detected no difference in any ARO acquisition (LGG 30% vs placebo 33%; OR,1.19; 95% CI, 0.38-3.75) nor for any individual ARO acquisition. There was no difference in the loss of any ARO (LGG 18% vs placebo 24%; OR, 1.44; 95% CI, 0.27-7.68) nor for any individual ARO.LGG administration neither prevented acquisition of ARO nor accelerated loss of ARO colonization.

BACKGROUND: Scaphoid fractures treated non-operatively and operatively may be complicated by nonunion. QUESTIONS/PURPOSES: We sought to test the primary hypothesis that the incidence density of scaphoid fracture treatment is higher than previously estimated, to determine the frequency and risk factors for nonunion treatment, and to determine whether the frequency of surgical treatment increased over time. METHODS: The MarketScan(®) database was queried for all records of treatment (casting and surgery) for closed scaphoid fractures over a 6-year period. We examined subsequent claims to determine frequency of additional procedures for nonunion treatment (revision fixation or vascularized grafting occurring 28 days or more after initial treatment). Trend analyses were used to determine whether changes in frequency of surgical treatment or revision procedure occurred. RESULTS: The estimated incidence density of scaphoid fracture is 10.6 per 100,000 person-years in a commercially insured population of less than 65 years of age. Of 8923 closed scaphoid fractures, 29 and 71% were treated with surgery and casting, respectively. The frequency of surgical treatment rose significantly, from 22.1% in 2006 to 34.1% in 2012. The frequency of nonunion treatment was 10.8% after surgery and 3% after casting; neither changed over time. Younger age, male sex, and surgical treatment are associated with a higher risk of nonunion treatment. CONCLUSIONS: Our estimated incidence of scaphoid fracture is higher than previously reported. The increased enthusiasm in the USA to surgically treat scaphoid fractures is reflected by our trend analysis. The frequency of surgical treatment for presumed nonunion after initial surgical management for closed scaphoid fractures exceeded 10%. Given the increased utilization of surgery, surgeons and patients should be aware of the frequency of nonunion treatment to inform treatment decisions. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11420-018-9619-3) contains supplementary material, which is available to authorized users.

Cubital Tunnel Syndrome: Incidence and Demographics in a National Administrative Database Daniel Osei;Andrew Groves;Kerry Bommarito;Wilson Ray; Neurosurgery

Objective To examine the association of clinical chorioamnionitis on cesarean delivery in a national sample of hospital discharges. Data Source Hospital discharge data from the 1998–2010 Nationwide Inpatient Sample. Study Design We performed a cross-sectional study and general linear modeling was used to determine the association of clinical chorioamnionitis on risk of cesarean delivery. Principal Findings A total of 10,843,682 deliveries and 51,799,431 nationally weighted deliveries were identified. Clinical chorioamnionitis was present in 2.9 percent of cesarean and 1.3 percent of vaginal deliveries (p

Background Recent studies in surgical and non-surgical specialties have suggested that patients admitted on the weekend may have worse outcomes. In particular, patients with stroke and acute cardiovascular events have shown worse outcomes with weekend treatment. It is unclear whether this extends to patients with spinal cord injury (SCI). This study was designed to evaluate factors for readmission after index hospitalization for spinal cord injury. Methods This cohort was constructed from the State Inpatient Databases of California, New York, and Florida. For this study 14,396 patients with SCI were identified. The primary outcome measure evaluated was 30-day readmission. Secondary measures include in-hospital complications. Univariate and multivariate analysis were utilized to evaluate covariates. c2, Fisher's exact, and linear, logistic, and modified Poisson regression methods were utilized for statistical analysis. Propensity score methods were used with matched pairs analysis performed by the McNemar's Test. Results Weekend admission was not associated with increased 30- day readmission rates in multivariate analysis. Race and discharge to a facility (RR 1.60 [1.43-1.79]) or home with home care (RR 1.23 [1.07-1.42]), were statistically significant risk factors for readmission. Payor status did not affect rates of readmission. In propensity score matched pairs analysis, weekend admission was not associated with increased odds of 30-day readmission (OR 1.04 [0.89-1.21]). Patients admitted to high volume centers had significantly lower risk of readmission when compared with patients admitted to low volume centers. Conclusions Our results suggest that the weekend effect, described previously in other patient populations, may not play as important a role in patients with SCI.

This prospective cohort study evaluated the presence of MRSA and VRE in the food of hospitalized patients. 149 patients were enrolled and 910 food specimens cultured; 3.2% were positive for MRSA and 2.4% positive for VRE, from a variety of food types.

We utilized an updated nationally representative database to examine associations between maternal age and prevalence of maternal morbidity during complications of labor and delivery. We used hospital inpatient billing data from the 2009 United States Nationwide Inpatient Sample, part of the Healthcare Cost and Utilization Project. To determine whether the likelihood that maternal morbidity during complications of labor and delivery differed among age groups, separate logistic regression models were run for each complication. Age was the main independent variable of interest. In analyses that controlled for demographics and clinical confounders, we found that complications with the highest odds among women, 11-18 years of age, compared to 25-29 year old women, included preterm delivery, chorioamnionitis, endometritis, and mild preeclampsia. Pregnant women who were 15-19 years old had greater odds for severe preeclampsia, eclampsia, postpartum hemorrhage, poor fetal growth, and fetal distress. Pregnant women who were ≥35 years old had greater odds for preterm delivery, hypertension, superimposed preeclampsia, severe preeclampsia, and decreased risk for chorioamnionitis. Older women (≥40 years old) had increased odds for mild preeclampsia, fetal distress, and poor fetal growth. Our findings underscore the need for pregnant women to be aware of the risks associated with extremes of age so that they can watch for signs and symptoms of such complications.

Background MDRO present a greater threat to public health than ever before, and antimicrobial options are decreasing. Altered colonic microbiota following antimicrobial exposure allows for subsequent colonization by MDRO. Ingestion of prophylactic Lactobacillus rhamnosus GG (LGG) could be an approach to prevent the spread of, and subsequent infection due to MDRO, by promoting a healthy bacterial milieu within the colon. Methods This is a prospective, double-blinded, randomized clinical trial in which a total of 87 subjects on broad-spectrum antibiotics were randomized to receive LGG twice daily (n = 43) vs placebo (n = 44). Stool or rectal swab specimens were collected for culture at enrollment, every 3 days during admission, and at discharge. Selective media were used to detect the following MDRO: Clostridioides difficile (CD), vancomycin-resistant Enterococcus (VRE), and antibiotic-resistant Gram-negatives (GN). The primary outcome was MDRO acquisition. Secondary outcomes included analysis for loss of any MDRO if colonized at enrollment, and acquisition or loss of individual MDRO. Results Subjects in both groups had similar prevalence of colonization with any MDRO at study enrollment (LGG 40% vs. placebo 39%), with similar colonization prevalence for individual MDRO (Figure 1). There was no difference in any MDRO acquisition (LGG 27%, placebo 33%, OR 1.36, 95% CI 0.42–4.41) or any individual MDRO acquisition (Figure 2). There was also no difference in loss of any MDRO (LGG 18%, placebo 24%, OR 1.44, 95% CI 0.27–7.68) or any individual MDRO (Figure 2). Conclusion LGG administration did not prevent acquisition of MDRO or accelerate loss of MDRO colonization. Disclosures All authors: No reported disclosures.

Background Clostridium difficile infection (CDI) is a frequent cause of diarrhea among allogeneic hematopoietic cell transplant (HCT) recipients. It is unknown whether risk factors for CDI vary by time posttransplant. Methods We performed a 3-year prospective cohort study of CDI in allogeneic HCT recipients. Participants were enrolled during their transplant hospitalizations. Clinical assessments were performed weekly during hospitalizations and for 12 weeks posttransplant, and monthly for 30 months thereafter. Data were collected through patient interviews and chart review, and included CDI diagnosis, demographics, transplant characteristics, medications, infections, and outcomes. CDI cases were included if they occurred within 1 year of HCT and were stratified by time from transplant. Multivariable logistic regression was used to determine risk factors for CDI. Results One hundred eighty-seven allogeneic HCT recipients were enrolled, including 63 (34%) patients who developed CDI. 38 (60%) CDI cases occurred during the preengraftment period (days 0-30 post-HCT) and 25 (40%) postengraftment (day >30). Lack of any preexisting comorbid disease was significantly associated with lower risk of CDI preengraftment (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.1-0.9). Relapsed underlying disease (OR, 6.7; 95% CI, 1.3-33.1), receipt of any high-risk antimicrobials (OR, 11.8; 95% CI, 2.9-47.8), and graft-versus-host disease (OR, 7.8; 95% CI, 2.0-30.2) were significant independent risk factors for CDI postengraftment. Conclusions A large portion of CDI cases occurred during the postengraftment period in allogeneic HCT recipients, suggesting that surveillance for CDI should continue beyond the transplant hospitalization and preengraftment period. Patients with continued high underlying severity of illness were at increased risk of CDI postengraftment.

OBJECTIVETo determine whetherClostridium difficileis present in the food of hospitalized patients and to estimate the risk of subsequent colonization associated withC. difficilein food.METHODSThis was a prospective cohort study of inpatients at a university-affiliated tertiary care center, May 9, 2011–July 12, 2012. Enrolled patients submitted a portion of food from each meal. Patient stool specimens and/or rectal swabs were collected at enrollment, every 3 days thereafter, and at discharge, and were cultured forC. difficile. Clinical data were reviewed for evidence of infection due toC. difficile.A stochastic, discrete event model was developed to predict exposure toC. difficilefrom food, and the estimated number of new colonization events from food exposures per 1,000 admissions was determined.RESULTSA total of 149 patients were enrolled and 910 food specimens were obtained. Two food specimens from 2 patients were positive forC. difficile(0.2% of food samples; 1.3% of patients). Neither of the 2 patients was colonized at baseline withC. difficile. Discharge colonization status was available for 1 of the 2 patients and was negative. Neither was diagnosed withC. difficileinfection while hospitalized or during the year before or after study enrollment. Stochastic modeling indicated contaminated hospital food would be responsible for less than 1 newly colonized patient per 1,000 hospital admissions.CONCLUSIONSThe recovery ofC. difficilefrom the food of hospitalized patients was rare. Modeling suggests hospital food is unlikely to be a source ofC. difficileacquisition.Infect Control Hosp Epidemiol2016;1401–1407

Background Clostridium difficile infection (CDI) is a common complication of lung and allogeneic hematopoietic cell (HCT) transplant, but the epidemiology and outcomes of CDI after transplant are poorly described. Methods We performed a prospective, multicenter study of CDI within 365 days post-allogeneic HCT or lung transplantation. Data were collected via patient interviews and medical chart review. Participants were followed weekly in the 12 weeks post-transplant and while hospitalized and contacted monthly up to 18 months post-transplantation. Results Six sites participated in the study with 614 total participants; 4 enrolled allogeneic HCT (385 participants) and 5 enrolled lung transplant recipients (229 participants). One hundred and fifty CDI cases occurred within 1 year of transplantation; the incidence among lung transplant recipients was 13.1% and among allogeneic HCTs was 31.2%. Median time to CDI was significantly shorter among allogeneic HCT than lung transplant recipients (27 days vs 90 days; P = .037). CDI was associated with significantly higher mortality from 31 to 180 days post-index date among the allogeneic HCT recipients (Hazard ratio [HR] = 1.80; P = .007). There was a trend towards increased mortality among lung transplant recipients from 120 to 180 days post-index date (HR = 4.7, P = .09). Conclusions The epidemiology and outcomes of CDI vary by transplant population; surveillance for CDI should continue beyond the immediate post-transplant period.

Physicians are encouraged to disclose medical errors to patients, which often requires close collaboration between physicians and risk managers.An anonymous national survey of 2,988 healthcare facility-based risk managers was conducted between November 2004 and March 2005, and results were compared with those of a previous survey (conducted between July 2003 and March 2004) of 1,311 medical physicians in Washington and Missouri. Both surveys included an error-disclosure scenario for an obvious and a less obvious error with scripted response options.More risk managers than physicians were aware that an error-reporting system was present at their hospital (81% versus 39%, p.001) and believed that mechanisms to inform physicians about errors in their hospital were adequate (51% versus 17%, p.001). More risk managers than physicians strongly agreed that serious errors should be disclosed to patients (70% versus 49%, p.001). Across both error scenario, risk managers were more likely than physicians to definitely recommend that the error be disclosed (76% versus 50%, p.001) and to provide full details about how the error would be prevented in the future (62% versus 51%, p.001). However, physicians were more likely than risk managers to provide a full apology recognizing the harm caused by the error (39% versus 21%, p.001).Risk managers have more favorable attitudes about disclosing errors to patients compared with physicians but are less supportive of providing a full apology. These differences may create conflicts between risk managers and physicians regarding disclosure. Health care institutions should promote greater collaboration between these two key participants in disclosure conversations.

This was a randomized controlled pilot study of Lactobacillus rhamnosus GG versus standard of care to prevent gastrointestinal multidrug-resistant organism colonization in intensive care unit patients. Among 70 subjects, there were no significant differences in acquisition or loss of any multidrug-resistant organisms (P>.05) and no probiotic-associated adverse events.Infect. Control Hosp. Epidemiol. 2015;36(12):1451–1454

We sought to determine the incidence of postmastectomy bleeding, identify bleeding predictors, and evaluate the economic impact.Using the 2011 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample, hospital discharges for a primary diagnosis of breast cancer were extracted using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes 85.34-85.48 for mastectomy and diagnosis codes 174.0-174.9 for breast cancer. Discharges with postoperative bleeding were identified using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes 998.11 and 998.12. Discharges with male gender or a history of coagulation disorders were excluded. Bleeding complication rates and reoperation rates were assessed. Predictors and the impact of bleeding on length of stay and hospital costs were determined using regression analysis and projected to the national level.A total of 7907 discharges met inclusion criteria; 201 had bleeding complications (2.54%), with 42 cases requiring reoperation. On univariate analysis, the presence of congestive heart failure (CHF), obesity, diabetes, chronic pulmonary disease, and the absence of concomitant reconstruction were associated with increased bleeding events. On multivariate analysis, only the presence of CHF remained as a significant predictor of bleeding complications (odds ratio [95% confidence interval], 2.45, [1.25-4.92], P = 0.009). On average, bleeding complications extended the length of stay by 1.3 d (P 0.0001) while increasing hospital costs by $5495 per admission (P 0.0001). Projected to a national level, bleeding complications accounted for an additional 1254 d of hospital care at a cost exceeding $5.3 million.Postmastectomy bleeding complications had an incidence of 2.54%, with CHF the only independent predictor identified. Such bleeding events, although infrequent, are associated with substantial economic costs.

Risk managers can play a vital role in promoting transparency in health care and enhancing patient safety. However, little is known about risk managers' patient safety attitudes and experiences. Therefore, the authors surveyed members of the American Society for Healthcare Risk Management, the largest organization of health care risk managers in the country. These risk managers identified important areas for improvement in the reporting and disclosure of medical errors.

BACKGROUND Clostridium difficile infection (CDI) is a frequent cause of diarrhea among allogeneic hematopoietic cell transplant (HCT) recipients. It is unknown whether risk factors for CDI vary by time posttransplant. METHODS We performed a 3-year prospective cohort study of CDI in allogeneic HCT recipients. Participants were enrolled during their transplant hospitalizations. Clinical assessments were performed weekly during hospitalizations and for 12 weeks posttransplant, and monthly for 30 months thereafter. Data were collected through patient interviews and chart review, and included CDI diagnosis, demographics, transplant characteristics, medications, infections, and outcomes. CDI cases were included if they occurred within 1 year of HCT and were stratified by time from transplant. Multivariable logistic regression was used to determine risk factors for CDI. RESULTS One hundred eighty-seven allogeneic HCT recipients were enrolled, including 63 (34%) patients who developed CDI. 38 (60%) CDI cases occurred during the preengraftment period (days 0-30 post-HCT) and 25 (40%) postengraftment (day >30). Lack of any preexisting comorbid disease was significantly associated with lower risk of CDI preengraftment (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.1-0.9). Relapsed underlying disease (OR, 6.7; 95% CI, 1.3-33.1), receipt of any high-risk antimicrobials (OR, 11.8; 95% CI, 2.9-47.8), and graft-versus-host disease (OR, 7.8; 95% CI, 2.0-30.2) were significant independent risk factors for CDI postengraftment. CONCLUSIONS A large portion of CDI cases occurred during the postengraftment period in allogeneic HCT recipients, suggesting that surveillance for CDI should continue beyond the transplant hospitalization and preengraftment period. Patients with continued high underlying severity of illness were at increased risk of CDI postengraftment.

We sought to determine if discharge home with home health care (HHC) is an independent predictor of increased readmission after pancreatectomy.We examined 30-day readmissions in patients undergoing pancreatectomy using the Healthcare Cost and Utilization Project State Inpatient Database for California from 2009 to 2011. Readmissions were categorized as severe or nonsevere using the Modified Accordion Severity Grading System. Multivariable logistic regression models were used to examine the association of discharge home with HHC and 30-day readmission using discharge home without HHC as the reference group. Propensity score matching was used as an additional analysis to compare the rate of 30-day readmission between patients discharged home with HHC with patients discharged home without HHC.Of 3,573 patients who underwent pancreatectomy, 752 (21.0%) were readmitted within 30 days of discharge. In a multivariable logistic regression model, discharge home with HHC was an independent predictor of increased 30-day readmission (odds ratio = 1.37; 95% CI, 1.11-1.69; p = 0.004). Using propensity score matching, patients who received HHC had a significantly increased rate of 30-day readmission compared with patients discharged home without HHC (24.3% vs 19.8%; p0.001). Patients discharged home with HHC had a significantly increased rate of nonsevere readmission compared with those discharged home without HHC, by univariate comparison (19.2% vs 13.9%; p0.001), but not severe readmission (6.4% vs 4.7%; p = 0.08). In multivariable logistic regression models, excluding patients discharged to facilities, discharge home with HHC was an independent predictor of increased nonsevere readmissions (odds ratio = 1.41; 95% CI, 1.11-1.79; p = 0.005), but not severe readmissions (odds ratio = 1.31; 95% CI, 0.88-1.93; p = 0.18).Discharge home with HHC after pancreatectomy is an independent predictor of increased 30-day readmission; specifically, these services are associated with increased nonsevere readmissions, but not severe readmissions.

Staphylococcus aureus is the most frequent organism isolated in osteoarticular infections [1]. The treatment options for S. aureus infections depend on the resistance pattern of the isolate. For methicillin-sensitive S. aureus (MSSA) infections, the drugs of choice are the antistaphylococcal penicillins (oxacillin, nafcillin, and methicillin) [2]. Few studies have compared the standard antistaphylococcal penicillins to newer β-lactam antibiotics such as cephalosporins. Ceftriaxone, a third-generation, long-acting, intravenous cephalosporin, has been shown to be an effective treatment for MSSA infections in general [3, 4]. There are limited data supporting the use of ceftriaxone for the treatment of osteoarticular infections due to MSSA [5], although its bone penetration is similar to that of penicillins [6]. Ceftriaxone is attractive for treatment of bone and joint infections for a number of reasons. It is well tolerated [7] and given once daily, whereas oxacillin is given either 6 times per day or via continuous infusion. Once-daily dosing may improve patients’ adherence to outpatient antibiotic therapy [8]. Also, it is comparatively inexpensive [9]. Because osteoarticular infections require prolonged intravenous treatment courses of at least 4–6 weeks, tolerability, convenience, and cost are important considerations in the antibiotic choice [10]. To our knowledge, there has never been a direct comparison of clinical outcomes in MSSA osteoarticular infections treated with ceftriaxone versus antistaphylococcal penicillins. Our study sought to retrospectively compare treatment outcomes of MSSA osteoarticular infections treated with ceftriaxone versus oxacillin at our institution. We hypothesized that rates of clinical treatment success after 3 and 6 months following the completion of intravenous antibiotics would be similar irrespective of the treatment group. A secondary goal was to compare the tolerability of the 2 medications and the frequency of treatment modifications due to antibiotic toxicity.

Article-at-a-Glance Background To increase error reporting, a better understanding of physicians' and nurses' perspectives regarding medical error reporting in hospitals, barriers to reporting, and possible ways to increase reporting is necessary Methods Nine focus groups—four with 49 staff nurses, two with 10 nurse managers, and three with 30 physicians—from 20 academic and community hospitals were conducted in May–June 2002 in the St. Louis metropolitan area. Qualitative analysis of focus group transcripts characterized participants' perspectives. Results Although participants knew they should report errors associated with serious adverse events, there was much uncertainty about reporting less serious errors or near misses. Nurses were more knowledgeable than physicians about how to report errors. All groups mentioned barriers to reporting, such as fear of reprisals and lack of confidentiality, time, and feedback after an error is reported. Some physicians doubted the benefit of reporting errors, but, generally, both physicians and nurses agreed that reporting was intended to change practice and policy to promote patient safety. Conclusions A culture characterized by anonymous reporting, freedom from repercussions, and feedback about error reports should promote error reporting.

Identifying 30-day readmission diagnoses after Heart Failure (HF) hospitalization is paramount given current hospital performance measures. The 2007-2011 California, New York, and Florida Healthcare Cost and Utilization Project State Inpatient Databases were used to identify adults aged ≥ 18