Richard S. Johannes

Clinical outcome of the use of enteral stents for palliation of patients with malignant upper GI obstruction

BACKGROUND The endoscopically placed enteral stent has emerged as a reasonable alternative to palliative surgery for malignant intestinal obstruction. This is a report of our experience with the use of enteral stents for nonesophageal malignant upper GI obstruction. METHODS Data on all patients who had undergone enteral stent placement were reviewed. Those with a diagnosis of pancreatic cancer were compared with another similar cohort of patients who underwent palliative gastrojejunostomy. RESULTS Thirty-one procedures were performed on 29 patients (mean age 67.7 years). Thirteen (45%) were men and 16 (55%) women. The diagnoses were gastric (13.8%), duodenal (10.3%), pancreatic (41.4%), metastatic (27.6%), and other malignancies (6.9%). Malignant obstruction occurred at the pylorus (20.7%), first part of duodenum (37.9%), second part of duodenum (27.6%), third part of duodenum (3.5%), and anastomotic sites (10.3%). Twenty-nine (93.5%) procedures were successful and good clinical outcome was achieved in 25 (80.6%). Re-obstruction by tumor ingrowth occurred in 2 patients after a mean of 183 days. The median survival time for patients with pancreatic cancer who underwent enteral stent placement compared with those who underwent surgical gastrojejunostomy was 94 and 92 days, charges were

Morbidity and cost burden of methicillin-resistant Staphylococcus aureus in early onset ventilator-associated pneumonia.

9921 and

Epidemiology of early-onset bloodstream infection and implications for treatment

28,173, and duration of hospitalization was 4 and 14 days, respectively (latter 2 differences with p value < 0.005). CONCLUSION Endoscopic enteral stent placement of nonesophageal malignant upper GI obstruction is a safe, efficacious, and cost-effective procedure with good clinical outcome, lower charges, and shorter hospitalization period than the surgical alternative.

Meta-analysis on central line–associated bloodstream infections associated with a needleless intravenous connector with a new engineering design

IntroductionTo gain a better understanding of the clinical and economic outcomes associated with methicillin-resistant Staphylococcus aureus (MRSA) infection in patients with early onset ventilator-associated pneumonia (VAP), we retrospectively analyzed a multihospital US database to identify patients with VAP over a 24 month period (2002–2003).MethodData recorded included physiologic, laboratory, culture, and other clinical variables from 59 institutions. VAP was defined as new positive respiratory culture after at least 24 hours of mechanical ventilation (MV) and the presence of primary or secondary ICD-9-CM diagnosis codes of pneumonia. Outcomes measures included in-hospital morbidity and mortality for the population overall and after onset of VAP (duration of MV, intensive care unit [ICU] stay, in-hospital stay, and case mix and severity-adjusted operating cost). The overall cost was calculated at the hospital level using the Center for Medicare and Medicaid Services Cost/Charge Index for each calendar year.ResultsA total of 499 patients were identified as having VAP. S. aureus was the leading organism (31% of isolates). Patients with MRSA were significantly older than patients with methicillin-sensitive Staphylococcus aureus (MSSA; median age 74 versus 67 years, P < 0.05) and more likely to be medical patients. Compared with MSSA patients, MRSA patients on average consumed excess resources of 4.4 (95% confidence interval 0.6–8.2) overall MV days, 3.8 (-0.5 to +8.0) days of inpatient length of stay (LOS), 5.3 (1.0–9.7) ICU days, and US

897Feasibility of Using Existing Public and Private Data Sources for Nationwide Medical Device Post-marketing Safety Surveillance

7731 (-US

867Metaanalysis on the Relative Risk of Central Line-associated Bloodstream Infections Associated with a Needless Intravenous Connector with New Engineering Design

8393 to +US

888Performance Characteristics and Associated Outcomes for an Automated Surveillance Tool for Blood Stream Infection

23,856) total cost after controlling for case mix and other factors. Furthermore, MRSA patients needed excess resources after the onset of VAP (4.5 [95% confidence interval 1.0–8.1] MV days, 3.7 [-0.5 to +8.0] inpatient days, and 4.4 [0.4–8.4] ICU days) after controlling for the same case mix and admission severity covariates.ConclusionS. aureus remains a common cause of VAP. VAP due to MRSA was associated with increased overall LOS, ICU LOS, and attributable ICU LOS compared with MSSA-related VAP. Although not statistically significant because of small sample size and large variation, the attributable excess costs of MRSA amounted to approximately US

7125 How best to diagnose ipmt.

8000 per case after controlling for case mix and severity.

7213 Are all colonoscopy preparations the same? a retrospective analysis of over 11,000 colonoscopies.

UNLABELLED HEALTH CARE-ASSOCIATED INFECTIONS: For over 35 years, infections have been divided into hospital acquired or community acquired. In 2002, in a study of bloodstream infections (BSIs), Friedman et al first suggested creating a new classification: health care-associated BSIs. Kollef et al furthered the concept of health care-associated infection in a 2005 population-based study of culture-positive pneumonia cases. Although the site of infection differed, Kollef et als results supported Friedman et als original concept. Then in 2006, Kollef et al reported a population-based study focused specifically on BSIs. Of 6697 reported cases, 468 (7%) had hospital-acquired BSIs; 3705 (55.3%) health care-associated BSIs; and 2524 (37.7%) community-acquired BSIs. The clinical features of those with health care-associated BSIs differed from those with community-acquired BSIs. For several organisms, including Staphylococcus aureus, Streptococcus pneumoniae, and gram-negative organisms, the frequencies for health care-associated and hospital-acquired BSIs were similar to each other but significantly different from community-acquired BSIs. After controlling for several clinical features, methicillin-resistant Staphylococcus aureus had the largest odds ratio for predicting in-hospital mortality. Both hospital-acquired and health care-acquired cases were independent risk factors for in-hospital mortality. IMPLICATIONS FOR TREATMENT Is more aggressive, empiric, gram-positive therapy warranted for this potentially sicker patient group? Wunderink pointed out the potential unintended consequences of such an approach and the paucity of good tools for early recognition of sickest patients. A study by Shorr et al of systemic inflammatory response syndrome, organ dysfunction, and mortality suggested that there may be approaches that could be used to stratify cases into high-risk groups who may benefit from more aggressive therapy. Most recently, Micek et al found that in health care-associated pneumonia cases, inappropriate initial empiric antibiotic treatment is an independent predictor of mortality. Treatment recommendations are evolving. SUMMARY For pneumonia and BSIs, health care-associated infections appear to be distinct entities. However, operational definitions still vary. Compared with hospital-acquired cases, health care-associated cases have different clinical characteristics. The outcomes of health care-associated infections tend to be intermediate of the community-acquired and hospital-acquired groups. Further research is urgently needed on the implications of health care-associated infection for early therapy.

Epidemiology and Outcomes of Health-care–Associated Pneumonia: Results From a Large US Database of Culture-Positive Pneumonia

BACKGROUND Intravenous needleless connectors (NCs) with a desired patient safety design may facilitate effective intravenous line care and reduce the risk for central line-associated bloodstream infection (CLA-BSI). We conducted a meta-analysis to determine the risk for CLA-BSI associated with the use of a new NC with an improved engineering design. METHODS We reviewed MEDLINE, Cochrane Database of Systematic Reviews, Embase, ClinicalTrials.gov, and studies presented in 2010-2012 at infection control and infectious diseases meetings. Studies reporting the CLA-BSIs in patients using the positive-displacement NC (study NC) compared with negative- or neutral-displacement NCs were analyzed. We estimated the relative risk of CLA-BSIs with the study NC for the pooled effect using the random effects method. RESULTS Seven studies met the inclusion criteria: 4 were conducted in intensive care units, 1 in a home health setting, and 2 in long-term acute care settings. In the comparator period, total central venous line (CL) days were 111,255; the CLA-BSI rate was 1.5 events per 1,000 CL days. In the study NC period, total CL days were 95,383; the CLA-BSI rate was 0.5 events per 1,000 CL days. The pooled CLA-BSI relative risk associated with the study NC was 0.37 (95% confidence interval, 0.16-0.90). CONCLUSION The NC with an improved engineering design is associated with lower CLA-BSI risk.