Infections after the use of alemtuzumab in solid organ transplant recipients: a comparative study

We undertook a retrospective cohort study comparing infection in solid organ transplant recipients receiving alemtuzumab (n = 726) versus basiliximab (n = 215) or antithymocyte globulin (ATG) (n = 85). Eighty-one percent of patients had kidney transplants. Overall, 33% of patients in the alemtuzumab group (240/724) developed infection compared with 40% (87/215) in the basiliximab group (odds ratio [OR], 0.72; 95% confidence interval [CI], 0.53–0.99; P = .04). The frequency of infection was similar in the alemtuzumab and ATG groups (33% versus 36%, respectively, P = .53). The frequency of fungal infections, most caused by Candida spp., was similar in the alemtuzumab and basiliximab groups (10% versus 9%); disseminated fungal infection occurred in 68% of the patients with fungal infection receiving alemtuzumab and in 30% of the patients with fungal infection receiving basiliximab (OR, 4.76; 95% CI, 1.58–14.28; P = .003). Basiliximab posed a higher risk than alemtuzumab for infection. Disseminated candidal infections were more common in patients receiving alemtuzumab.     

Herpes simplex virus lower respiratory tract infection in patients with solid tumors

BACKGROUND:

The clinical significance of herpes simplex virus (HSV) isolated in lower respiratory tract specimens (LRTS) of patients with solid tumors (ST) is unknown. In the current study, the authors attempted to determine the clinical relevance of this finding among ST patients.

METHODS:

The authors reviewed records of ST patients admitted to the study institution between April 2000 and April 2004 with clinical and radiologic evidence of pneumonia, and HSV identified in LRTS by culture alone or culture and cytology. Patients were categorized as having proven (HSV identified by culture and cytology from the LRTS), probable (HSV as the sole pathogen by culture alone), and possible (HSV along with copathogens identified by culture) HSV pneumonia.

RESULTS:

Forty‐five ST patients with either proven (6 patients), probable (25 patients), or possible (14 patients) HSV pneumonia were identified. When compared with patients with probable or possible HSV pneumonia, more patients with proven infection were on mechanical ventilation (40% vs 50% vs 100%, respectively; P = .03), and had longer length of stay in the intensive care unit (12 days vs 13 days vs 26 days, respectively; P = .05). The overall mortality rate was 22% (10 patients). Four of 25 (16%) patients who received HSV‐directed antiviral therapy died during their hospital stay versus 6 of 20 (30%) who were not treated (P = .3). None of the 6 patients with proven HSV pneumonia who were treated with acyclovir died. On univariate analysis, risk factors for mortality included underlying breast cancer, an Acute Physiology and Chronic Health Evaluation (APACHE) II score >15, admission to the intensive care unit, and use of mechanical ventilation and vasopressors (all P ≤ .05), with underlying breast cancer and APACHE II score >15 being found to be independent predictors of death by multiple logistic regression analysis (all P ≤ .05).

CONCLUSIONS:

Having a proven HSV pneumonia appears to be associated with high morbidity and with no increase in mortality in ST patients. This subset of patients appears to benefit from acyclovir therapy. Cancer 2009. © 2008 American Cancer Society.     

Antimicrobial catheters in the ICU: is the juice worth the squeeze?

Catheter-related bloodstream infection is one of the most serious complications of central venous access devices. Antimicrobial-coated catheters represent one novel strategy to prevent catheter-related bloodstream infection. A comprehensive economic evaluation is essential to guide informed decision-making regarding the adoption of this technology and its expected benefits in healthcare institutions.     

What Is the Quality of Surgical Care for Patients with Hip Fractures at Critical Access Hospitals?

BackgroundCritical access hospitals (CAHs) play an important role in providing access to care for many patients in rural communities. Prior studies have shown that these facilities are able to provide timely and quality care for patients who undergo various elective and emergency general surgical procedures. However, little is known about the quality and reimbursement of surgical care for patients undergoing surgery for hip fractures at CAHs compared with non-CAH facilities.Questions/purposesAre there any differences in 90-day complications, readmissions, mortality, and Medicare payments between patients undergoing surgery for hip fractures at CAHs and those undergoing surgery at non-CAHs?MethodsThe 2005 to 2014 Medicare 100% Standard Analytical Files were queried using ICD-9 procedure codes to identify Medicare-eligible beneficiaries undergoing open reduction and internal fixation (79.15, 79.35, and 78.55), hemiarthroplasty (81.52), and THA (81.51) for isolated closed hip fractures. This database was selected because the claims capture inpatient diagnoses, procedures, charged amounts and paid claims, as well as hospital-level information of the care, of Medicare patients across the nation. Patients with concurrent fixation of an upper extremity, lower extremity, and/or polytrauma were excluded from the study to ensure an isolated cohort of hip fractures was captured. The study cohort was divided into two groups based on where the surgery took place: CAHs and non-CAHs. A 1:1 propensity score match, adjusting for baseline demographics (age, gender, Census Bureau-designated region, and Elixhauser comorbidity index), clinical characteristics (fixation type and time to surgery), and hospital characteristics (whether the hospital was located in a rural ZIP code, the average annual procedure volume of the operating facility, hospital bed size, hospital ownership and teaching status), was used to control for the presence of baseline differences in patients presenting at CAHs and those presenting at non-CAHs. A total of 1,467,482 patients with hip fractures were included, 29,058 of whom underwent surgery in a CAH. After propensity score matching, each cohort (CAH and non-CAH) contained 29,058 patients. Multivariate logistic regression analyses were used to assess for differences in 90-day complications, readmissions, and mortality between the two matched cohorts. As funding policies of CAHs are regulated by Medicare, an evaluation of costs-of-care (by using Medicare payments as a proxy) was conducted. Generalized linear regression modeling was used to assess the 90-day Medicare payments among patients undergoing surgery in a CAH, while controlling for differences in baseline demographics and clinical characteristics.ResultsPatients undergoing surgery for hip fractures were less likely to experience many serious complications at a critical access hospital (CAH) than at a non-CAH. In particular, after controlling for patient demographics, hospital-level factors and procedural characteristics, patients treated at a CAH were less likely to experience: myocardial infarction (3% (916 of 29,058) versus 4% (1126 of 29,058); OR 0.80 [95% CI 0.74 to 0.88]; p < 0.001), sepsis (3% (765 of 29,058) versus 4% (1084 of 29,058); OR 0.69 [95% CI 0.63 to 0.78]; p < 0.001), acute renal failure (6% (1605 of 29,058) versus 8% (2353 of 29,058); OR 0.65 [95% CI 0.61 to 0.69]; p < 0.001), and Clostridium difficile infections (1% (367 of 29,058) versus 2% (473 of 29,058); OR 0.77 [95% CI 0.67 to 0.88]; p < 0.001) than undergoing surgery in a non-CAH. CAHs also had lower rates of all-cause 90-day readmissions (18% (5133 of 29,058) versus 20% (5931 of 29,058); OR 0.83 [95% CI 0.79 to 0.86]; p < 0.001) and 90-day mortality (4% (1273 of 29,058) versus 5% (1437 of 29,058); OR 0.88 [95% CI 0.82 to 0.95]; p = 0.001) than non-CAHs. Further, CAHs also had risk-adjusted lower 90-day Medicare payments than non-CAHs (USD 800, standard error 89; p < 0.001).ConclusionPatients who received hip fracture surgical care at CAHs had a lower risk of major medical and surgical complications than those who had surgery at non-CAHs, even though Medicare reimbursements were lower as well. Although there may be some degree of patient selection at CAHs, these facilities appear to provide high-value care to rural communities. These findings provide evidence for policymakers evaluating the impact of the CAH program and allocating funding resources, as well as for community members seeking emergent care at local CAH facilities.Level of EvidenceLevel III, therapeutic study.     

What are the costs of glenohumeral osteoarthritis in the year prior to a total shoulder arthroplasty (TSA)?

ABSTRACT

Objectives: To identify patterns of health-care utilization and costs associated with management of glenohumeral osteoarthritis in the year prior to undergoing an anatomic total shoulder arthroplasty (ATSA).

Methods: The PearlDiver Humana database, an administrative database of Medicare Advantage (MA) and Commercial insurance beneficiaries was queried for active records of patients undergoing a primary ATSA from the fourth quarter of 2010–2015. Pre-operative health-care utilization was categorized as 1) Procedures & Anesthesia, 2) Office visits, 3) Radiology, 4) Injections – a) Steroid injections and b) Hyaluronic Acid (HA) injections, 5) Physical Therapy, 6) Non-opioid pain medications and 7) Opioids. Overall costs/reimbursement and Per-patient average reimbursements (PPARs) were calculated for each category.

Results: A total of 3,920 patients (MA = 3,691; Commercial = 229) undergoing primary ATSA were retrieved. Based on defined categories, the total costs prior to ATSA were $368,137 and $2,812,617 for Commercial and MA beneficiaries, respectively. Overall 1-year PPAR for each category was as follows: Procedures & Anesthesia (MA = $1765; Commercial = $5333), Office visits (MA = $441; Commercial = $396); Radiology (MA = $253; Commercial = $558), Injections (MA = $117, Commercial = $173), Physical therapy (MA = $473; Commercial = $372), Non-opioid pain meds (MA = $49; Commercial = $147) and Opioids (MA = $26; Commercial = $49). The highest utilization was seen in the three months prior to ATSA with 42–81% of overall PPAR being accounted for various categories.

Conclusion: A high utilization of all health-care resource categories was noted within three months prior to surgery. Providers should consider judicious use of such interventions, particularly in patients which ultimately require surgery in a short frame of time, to reduce the costs associated with the overall episode of care.     

Experimental Design and Surgical Approach to Create a Spinal Fusion Model in a New Zealand White Rabbit (Oryctolagus cuniculus)

There are several animal models routinely used for study of the spinal fusion process and animal selection largely depends on the scientific question to be answered. This review outlines the advantages and disadvantages of various animal models used to study spinal fusion and describes the New Zealand White (NSW) rabbit which is the most popular preclinical model to study spinal fusion. We outline critical steps required in planning and performing spinal fusion surgery in this model. This includes determination of the required animal number to obtain statistical significance, an outline of appropriate technique for posterolateral fusion and other components of completing a study. As advances in drug delivery move forward and our understanding of the cascade of gene expression occurring during the fusion process grows, performing and interpreting preclinical animal models will be vital to validating new therapies to enhance spinal fusion.