Gender‐specific Research for Emergency Diagnosis and Management of Ischemic Heart Disease: Proceedings from the 2014 Academic Emergency Medicine Consensus Conference Cardiovascular Research Workgroup

Coronary artery disease (CAD) is the most common cause of death for both men and women. However, over the years, emergency physicians, cardiologists, and other health care practitioners have observed varying outcomes in men and women with symptomatic CAD. Women in general are 10 to 15 years older than men when they develop CAD, but suffer worse postinfarction outcomes compared to age‐matched men. This article was developed by the cardiovascular workgroup at the 2014 Academic Emergency Medicine (AEM) consensus conference to identify sex‐ and gender‐specific gaps in the key themes and research questions related to emergency cardiac ischemia care. The workgroup had diverse stakeholder representation from emergency medicine, cardiology, critical care, nursing, emergency medical services, patients, and major policy‐makers in government, academia, and patient care. We implemented the nominal group technique to identify and prioritize themes and research questions using electronic mail, monthly conference calls, in‐person meetings, and Web‐based surveys between June 2013 and May 2014. Through three rounds of nomination and refinement, followed by an in‐person meeting on May 13, 2014, we achieved consensus on five priority themes and 30 research questions. The overarching themes were as follows: 1) the full spectrum of sex‐specific risk as well as presentation of cardiac ischemia may not be captured by our standard definition of CAD and needs to incorporate other forms of ischemic heart disease (IHD); 2) diagnosis is further challenged by sex/gender differences in presentation and variable sensitivity of cardiac biomarkers, imaging, and risk scores; 3) sex‐specific pathophysiology of cardiac ischemia extends beyond conventional obstructive CAD to include other causes such as microvascular dysfunction, takotsubo, and coronary artery dissection, better recognized as IHD; 4) treatment and prognosis are influenced by sex‐specific variations in biology, as well as patient–provider communication; and 5) the changing definitions of pathophysiology call for looking beyond conventionally defined cardiovascular outcomes to patient‐centered outcomes. These emergency care priorities should guide future clinical and basic science research and extramural funding in an area that greatly influences patient outcomes.     

The predictors of outcome in immunocompetent patients with hematogenous candidiasis.

OBJECTIVE: Clinical parameters that predict outcome in non-immunosuppressed candidemic patients are not fully understood. METHODS: Eighty-one consecutive episodes of candidemia were retrospectively evaluated in 75 patients during 1998-2000. RESULTS: Infection due to Candida albicans was common (n = 30; 37%) followed by Candida glabrata (n = 25; 31%), Candida parapsilosis (n = 14; 17%), Candida tropicalis (n = 6; 7%), Candida krusei (n = 5; 6%), and Candida lusitaniae (n = 1; 1%). Among 70 evaluable patients, 31 (44%) had fungemia-associated mortality; advanced age (P < 0.004), underlying malignancy (P < 0.025), coronary artery disease (P < 0.01), and concurrent non-Candida species fungal infection (P < 0.047) were significant prognosticators of compromised short-term survival by multivariate analysis. Mortality was higher in patients with Candida glabrata (60%) and C. tropicalis (75%) infection compared to 44% deaths in individuals with C. albicans infection (P > 0.1). 11/25 (44%) of non-immunocompromised individuals died and 20/45 (44%) immunosuppressed patients succumbed to fungemia: persistent vs. non-persistent (< 3 days) Candida bloodstream invasion, neutropenia, diabetes mellitus, renal insufficiency, prior antimicrobial therapy, cirrhosis of liver, abdomino-pelvis surgery, and critical-care-unit vs. non critical-care-unit admission did not significantly impact outcome in either group. All 11 infants, including nine with prematurity, survived Candida species bloodstream infection (P < 0.025). CONCLUSIONS: Short-term mortality in candidemic non-immunocompromised patients was comparable to fungemia-associated deaths in immunosuppressed patients. Ischemic heart disease has appeared as a new predictor of unfavorable outcome in patients with hematogenous candidiasis.     

A point survey of periurban and urban malaria in Karachi

A point survey of malaria in Karachi revealed a concentration of malaria cases in the periurban perimeter and marginal areas where immigrating groups, including Afghan refugees and Biharis from Bangladesh are concentrated. Populations of Anopheles stephensi, Karachi's main vector, were low, and were feeding chiefly on buffaloes which are also concentrated along the periurban perimeter. Maintenance of malaria transmission in periurban zones may depend on immigration of susceptibles, bovid hosts which help maintain zoophilic vector populations, and mosquito breeding sites in water tanks or buffalo hoofprints. The vector's switch to man-biting behaviour may occur either due to a 'spillover' effect from buffalo corrals to surrounding houses, or when buffaloes become less available for biting. Four types of chromosome inversions were found in the Karachi An. stephensi; as this species is not a vector in similar habitats in Lahore and Pondicherry where such inversions are not prevalent, it is likely that its status as a vector is related to chromosomal polymorphism influencing behaviour.     

The risk of infection after nasal colonization with Staphylococcus aureus

Purpose

Nasal, axillary, or inguinal colonization with Staphylococcus aureus generally precedes invasive infection. Some studies have found that colonization with methicillin-resistant S. aureus (MRSA) poses a greater risk of clinical infection than colonization with methicillin-susceptible S. aureus (MSSA). However, the magnitude of risk is unclear.

Methods

We undertook a systematic review to provide an overall estimate of the risk of infection following colonization with MRSA compared with colonization by MSSA. Ten observational studies, with a total of 1170 patients, were identified that provided data on both MSSA and MRSA colonization and infection. A random-effects model was used to obtain pooled estimates of the odds ratio and 95% confidence interval.

Results

Overall, colonization by MRSA was associated with a 4-fold increase in the risk of infection (odds ratio 4.08, 95% confidence interval, 2.10-7.44). Studies differed in the choice of patient population, severity of illness, and frequency of sampling to detect colonization.

Conclusion

Further research is needed to identify effective methods for sustained eradication of MRSA carriage to reduce the high risk of subsequent infection.     

Reduction in nosocomial infection with improved hand hygiene in intensive care units of a tertiary care hospital in Argentina

BACKGROUND: Hand hygiene is a fundamental measure for the control of nosocomial infection. However, sustained compliance with hand hygiene in health care workers is poor. We attempted to enhance compliance with hand hygiene by implementing education, training, and performance feedback. We measured nosocomial infections in parallel. METHODS: We monitored the overall compliance with hand hygiene during routine patient care in intensive care units (ICUs); 1 medical surgical ICU and 1 coronary ICU, of 1 hospital in Buenos Aires, Argentina, before and during implementation of a hand hygiene education, training, and performance feedback program. Observational surveys were done twice a week from September 2000 to May 2002. Nosocomial infections in the ICUs were identified using the National Nosocomial Infections Surveillance (NNIS) criteria, with prospective surveillance. RESULTS: We observed 4347 opportunities for hand hygiene in both ICUs. Compliance improved progressively (handwashing adherence, 23.1% (268/1160) to 64.5% (2056/3187) (RR, 2.79; 95% CI: 2.46-3.17; P < .0001). During the same period, overall nosocomial infection in both ICUs decreased from 47.55 per 1000 patient-days (104/2187) to 27.93 per 1000 patient days (207/7409) RR, 0.59; 95% CI: 0.46-0.74, P < .0001). CONCLUSION: A program consisting of focused education and frequent performance feedback produced a sustained improvement in compliance with hand hygiene, coinciding with a reduction in nosocomial infection rates in the ICUs.     

A proposed set of metrics for standardized outcome reporting in the management of low back pain

Background and purpose

Outcome measurement has been shown to improve performance in several fields of healthcare. This understanding has driven a growing interest in value-based healthcare, where value is defined as outcomes achieved per money spent. While low back pain (LBP) constitutes an enormous burden of disease, no universal set of metrics has yet been accepted to measure and compare outcomes. Here, we aim to define such a set.

Patients and methods

An international group of 22 specialists in several disciplines of spine care was assembled to review literature and select LBP outcome metrics through a 6-round modified Delphi process. The scope of the outcome set was degenerative lumbar conditions.

Results

Patient-reported metrics include numerical pain scales, lumbar-related function using the Oswestry disability index, health-related quality of life using the EQ-5D-3L questionnaire, and questions assessing work status and analgesic use. Specific common and serious complications are included. Recommended follow-up intervals include 6, 12, and 24 months after initiating treatment, with optional follow-up at 3 months and 5 years. Metrics for risk stratification are selected based on pre-existing tools.

Interpretation

The outcome measures recommended here are structured around specific etiologies of LBP, span a patient’s entire cycle of care, and allow for risk adjustment. Thus, when implemented, this set can be expected to facilitate meaningful comparisons and ultimately provide a continuous feedback loop, enabling ongoing improvements in quality of care. Much work lies ahead in implementation, revision, and validation of this set, but it is an essential first step toward establishing a community of LBP providers focused on maximizing the value of the care we deliver.Measurement of outcomes in healthcare has well documented benefits as well as challenges (Porter 2005, Institute of Medicine 2006). Simply asking providers to report their outcomes has been shown to improve performance (Porter et al. 2010). Additionally, understanding one’s results empowers a provider to continuously learn from and refine the care he or she delivers (Porter and Teisberg 2004). On a broad scale, outcome reporting also facilitates dissemination of best practices between physicians and makes it possible to compare the quality delivered by different providers, allowing patients to make intelligent choices about where to seek care (Porter and Teisberg 2004). This type of continuous improvement and informed decision making could be an important driving force in improving healthcare delivery by refocusing the system on value (defined as the outcomes of care divided by the cost). The concept of “value-based healthcare” has been gaining attention both throughout the medical field (Porter and Teisberg 2005, Porter 2009) and specifically within the realm of spine care (McGirt et al. 2014a, 2014b). With evolving reimbursement systems in many countries, it is also conceivable that there will be growing interest in “value-based reimbursement” in the future, with payment levels adjusted based on outcomes. This type of scheme will only be fair with a broadly-accepted and risk-adjusted set of outcome metrics.Low back pain (LBP) is a growing problem and constitutes a major component of the global burden of disease (Murray et al. 2012). Measuring outcomes in the field of low back pain is challenging. Numerous disease states affect the lower back, resulting in low back pain, leg pain, or both; to compare outcomes, patients must be accurately stratified by both diagnosis and severity. Moreover, existing treatment algorithms are complex and often controversial, including both operative and nonoperative options and frequently requiring multidisciplinary provider teams. Additionally, low back pain rarely causes death or other objective endpoints, so outcomes are best measured with patient-reported metrics, which are inherently subjective and require thorough psychometric testing.A substantial amount of work on the design of outcome metrics has already been done in the field of low back pain, and there are several well-validated tools for measuring disease-specific outcomes (Longo et al. 2010). Similarly, several large registries are already in existence, collecting outcomes along with many other data points (Röder et al. 2005, McGirt et al. 2013, Strömqvist et al. 2013, add later spine registry study, will be published in the same issue). Previous consensus-based efforts have been made to define sets of outcome measures or domains for research purposes (Deyo et al. 1998, Pincus et al. 2008, Chiarotto et al. 2014, Deyo et al. 2014). Still, the field of low back pain care has not yet developed a universal international set of outcomes to be measured and compared as a part of standard clinical practice. This type of outcome set requires availability and validity in many languages, requires capacity for case-mix adjustment to ensure that comparisons are made fairly, and should focus on the outcomes that matter most to patients. The purpose of this study was to define such a set based on international and interdisciplinary expert and patient opinion.