Shayna E. Rich

Impact of empiric antibiotic therapy on outcomes in patients with Pseudomonas aeruginosa bacteremia

ABSTRACT The impact of appropriate empirical antimicrobial therapy for Pseudomonas aeruginosa bacteremia on patient outcomes has not been clearly established. We assessed the effect of appropriate empirical therapy on in-hospital mortality and length of stay (LOS) among patients with P. aeruginosa bacteremia. This was a retrospective cohort study of inpatients with a positive blood culture for P. aeruginosa between January 2001 and June 2005. Empirical therapy was defined as appropriate if the patient received an antibiotic the organism was susceptible to between 8 h before culture collection and the time the susceptibility results were available. The severity of the illness was measured 24 h before culture collection. The data were analyzed using logistic regression (in-hospital mortality) and linear regression (LOS). Overall, there were 167 episodes of P. aeruginosa bacteremia, 123 (86%) of which received appropriate empirical antibiotics. Sixty-one patients died (36.5%). The median time from culture collection to susceptibility results was 3.4 days. After we adjusted for age, severity of illness, and time at risk, we found that the appropriate empirical therapy was not significantly associated with mortality (odds ratio = 0.96; 95% confidence interval = 0.31 to 2.93). There was a 7% reduction in the mean LOS for patients who had received appropriate therapy at the time susceptibility results were available compared to those who did not (P = 0.74). These data suggest that the use of appropriate empirical therapy, i.e., before susceptibility results are known may not be as critical to patient outcomes as other studies have suggested.

Improved Survival with Radiation Therapy in High Grade Soft Tissue Sarcomas of the Extremities: A SEER Analysis

PURPOSE The benefit of radiation therapy in extremity soft tissue sarcomas remains controversial. The purpose of this study was to determine the effect of radiation therapy on overall survival among patients with primary soft tissue sarcomas of the extremity who underwent limb-sparing surgery. METHODS AND MATERIALS A retrospective study from the Surveillance, Epidemiology, and End Results (SEER) database that included data from January 1, 1988, to December 31, 2005. A total of 6,960 patients constituted the study population. Overall survival curves were constructed using the Kaplan-Meir method and for patients with low- and high-grade tumors. Hazard ratios were calculated based on multivariable Cox proportional hazards models. RESULTS Of the cohort, 47% received radiation therapy. There was no significant difference in overall survival among patients with low-grade tumors by radiation therapy. In high-grade tumors, the 3-year overall survival was 73% in patients who received radiation therapy vs. 63% for those who did not receive radiation therapy (p < 0.001). On multivariate analysis, patients with high-grade tumors who received radiation therapy had an improved overall survival (hazard ratio 0.67, 95% confidence interval 0.57-0.79). In patients receiving radiation therapy, 13.5% received it in a neoadjuvant setting. The incidence of patients receiving neoadjuvant radiation did not change significantly between 1988 and 2005. CONCLUSIONS To our knowledge, this is the largest population-based study reported in patients undergoing limb-sparing surgery for soft tissue sarcomas of the extremities. It reports that radiation was associated with improved survival in patients with high-grade tumors.

Pressure Ulcers in Elderly Patients with Hip Fracture Across the Continuum of Care

OBJECTIVES: To identify care settings associated with greater pressure ulcer risk in elderly patients with hip fracture in the postfracture period.

Declining Use of Radiotherapy in Stage I and II Hodgkin’s Disease and Its Effect on Survival and Secondary Malignancies

PURPOSE Concerns regarding long-term toxicities have led some to withhold radiotherapy (RT) for the treatment of Stage I and II Hodgkins disease (HD). The present study was undertaken to assess the use of RT for HD and its effect on overall survival and the development of secondary malignancies. METHODS AND MATERIALS The present study included data from the Surveillance, Epidemiology, and End Results database from patients aged ≥ 20 years who had been diagnosed with Stage I or II HD between 1988 and 2006. Overall survival was estimated using the Kaplan-Meier method, and the Cox multivariate regression model was used to analyze trends. RESULTS A total of 12,247 patients were selected, and 51.5% had received RT. The median follow-up for the present cohort was 4.9 years, with 21% of the cohort having >10 years of follow-up. Between 1988 and 1991, 62.9% had undergone RT, but between 2004 and 2006, only 43.7% had undergone RT (p < .001). The 5-year overall survival rate was 76% for patients who had not received RT and 87% for those who had (p < .001). The hazard ratio adjusted for other variables in the regression model showed that patients who had not undergone RT (hazard ratio, 1.72; 95% confidence interval, 1.72-2.02) was associated with significantly worse survival compared with patients who had received RT. The actuarial rate of developing a second malignancy was 14.6% vs. 15.0% at 15 years for those who had and had not undergone RT, respectively (p = .089). CONCLUSIONS The present study is one of the largest studies to examine the role of RT for Stage I and II HD. Our results revealed a survival benefit with the addition of RT with no increase in the development of secondary malignancies compared with patients who had not received RT. Furthermore, the present nationwide study revealed a >20% absolute decrease in the use of RT from 1988 to 2006.

Frequent manual repositioning and incidence of pressure ulcers among bed-bound elderly hip fracture patients

Frequent manual repositioning is an established part of pressure ulcer prevention, but there is little evidence for its effectiveness. This study examined the association between repositioning and pressure ulcer incidence among bed‐bound elderly hip fracture patients, using data from a 2004–2007 cohort study in nine Maryland and Pennsylvania hospitals. Eligible patients (n=269) were age ≥65 years, underwent hip fracture surgery, and were bed‐bound at index study visits (during the first 5 days of hospitalization). Information about repositioning on the days of index visits was collected from patient charts; study nurses assessed presence of stage 2+ pressure ulcers 2 days later. The association between frequent manual repositioning and pressure ulcer incidence was estimated, adjusting for pressure ulcer risk factors using generalized estimating equations and weighted estimating equations. Patients were frequently repositioned (at least every 2 hours) on only 53% (187/354) of index visit days. New pressure ulcers developed at 12% of visits following frequent repositioning vs. 10% following less frequent repositioning; the incidence rate of pressure ulcers per person‐day did not differ between the two groups (incidence rate ratio 1.1, 95% confidence interval 0.5–2.4). No association was found between frequent repositioning of bed‐bound patients and lower pressure ulcer incidence, calling into question the allocation of resources for repositioning.

Use of Pressure-Redistributing Support Surfaces Among Elderly Hip Fracture Patients Across the Continuum of Care: Adherence to Pressure Ulcer Prevention Guidelines

PURPOSE To estimate the frequency of use of pressure-redistributing support surfaces (PRSS) among hip fracture patients and to determine whether higher pressure ulcer risk is associated with greater PRSS use. DESIGN AND METHODS Patients (n = 658) aged >or=65 years who had surgery for hip fracture were examined by research nurses at baseline and on alternating days for 21 days. Information on PRSS use and pressure ulcer risk factors was recorded at each assessment visit. Other information was obtained by interview and chart review. RESULTS A PRSS was observed at 36.4% of the 5,940 study visits. The odds of PRSS use were lower in the rehabilitation setting (adjusted odds ratio [OR] 0.4, 95% confidence interval [CI] 0.3-0.6), in the nursing home (adjusted OR 0.2, 95% CI 0.1-0.3), and during readmission to the acute setting (adjusted OR 0.6, 95% CI 0.4-0.9) than in the initial acute setting. There was wide variation in frequency of PRSS use by admission hospital, even after adjusting for pressure ulcer risk factors. The relationships between PRSS use and pressure ulcer risk factors were not strong. IMPLICATIONS In this study of hip fracture patients, adherence to guidelines for PRSS use was low and was based more on facility-related factors than on patient risk. There is an urgent need for health care providers to improve strategies for the prevention of pressure ulcers in high-risk patients.

Pressure Ulcer Preventive Device Use Among Elderly Patients Early in the Hospital Stay

Background: Clinical guidelines for the prevention of pressure ulcers advise that pressure-reducing devices should be used for all patients at risk of or with pressure ulcers and that all pressure ulcers should be documented in the patient record. Adherence to these guidelines among elderly hospital patients early in the hospital stay has not been examined in prior studies. Objective: The objective of this study was to examine adherence to guidelines by determining the frequency and correlates of use of preventive devices early in the hospital stay of elderly patients and by determining the frequency and correlates of recording pressure ulcers in the patient record. Methods: This was a cross-sectional study of 792 patients aged 65 years or older admitted through the emergency department to the inpatient medical service at two teaching hospitals in Philadelphia, Pennsylvania, between 1998 and 2001. Patients were examined by a research nurse on Hospital Day 3 (median of 48 hours after admission) to determine the use of preventive devices, presence of pressure ulcers, and risk of pressure ulcers (by Norton scale). Data on additional risk factors were obtained from the admission nursing assessment in the patient record. Data on documentation of pressure ulcers were obtained by chart abstraction. Results: Only 15% of patients had any preventive devices in use at the time of the examination. Among patients considered at risk of pressure ulcers (Norton score ≤14), only 51% had a preventive device. In multivariable analyses, high risk of pressure ulcers was associated with use of preventive devices (odds ratio = 41.8, 95% confidence interval = 14.0-124.6), whereas the type and stage of pressure ulcer were not. Documentation of a pressure ulcer was present for only 68% of patients who had a pressure ulcer according to the research examination. Discussion: Use of preventive devices and documentation of pressure ulcers are suboptimal even among patients at high risk.

Care-related risk factors for hospital-acquired pressure ulcers in elderly adults with hip fracture

To identify care‐related factors associated with hospital‐acquired pressure ulcers (HAPUs).

Pressure-Redistributing Support Surface Use and Pressure Ulcer Incidence in Elderly Hip Fracture Patients

OBJECTIVES: To evaluate the association between pressure‐redistributing support surface (PRSS) use and incident pressure ulcers in older adults with hip fracture.

Trends in self-reported health care provider recommendations for colorectal cancer screening by race

OBJECTIVE To examine whether a racial difference exists in self-reported recommendations for colorectal cancer screening from a health care provider, and whether this difference has changed over time. METHOD Secondary analysis of the 2002, 2004, 2006, and 2008 Maryland Cancer Surveys, cross-sectional population-based random-digit-dial surveys on cancer screening. Participants were 11,368 White and 2495 Black Maryland residents age ≥ 50 years. RESULTS For each race, recommendations for colonoscopy/sigmoidoscopy increased over time (67%-83% for Whites, 57%-74% for Blacks; p<0.001 for both), but the race difference remained approximately 10% at each survey. Among respondents without a colonoscopy in the last 10 years (n=5081), recommendations for fecal occult blood test (FOBT) in the past year decreased over time for Whites (37%-24%, p<0.001) and for Blacks (36-28%, p=0.05), with no difference by race in any year. In multivariable analysis, the effect of race on the odds of reporting a provider recommendation did not vary significantly across time for either test (p=0.80 for colonoscopy/sigmoidoscopy, p=0.24 for FOBT for effect modification by year). CONCLUSION Whites were more likely than Blacks to report ever receiving a provider recommendation for colonoscopy/sigmoidoscopy. Although the proportion of patients receiving recommendations for colonoscopy/sigmoidoscopy increased over time, the gap between races remained unchanged.