Browsing by Subject "Watchful Waiting"

Now showing 1 - 4 of 4
  • Thumbnail Image
    ItemOpen Access
    Multi-faceted strategies improve collection compliance and sample acceptance rate for carbapenem-resistant Enterobacteriaceae (CRE) active surveillance testing.
    (American journal of infection control, 2021-08) Sova, Christopher; Lewis, Sarah S; Smith, Becky A; Reynolds, Staci

    Background

    Active surveillance testing (AST) is one element of a comprehensive Carbapenem-resistant Enterobacteriaceae (CRE) prevention strategy. However, the utility of AST may be impacted by compliance with sample collection and the quality of specimens. Here, we describe strategies used to optimize a CRE AST program at a large academic medical center.

    Methods

    Tests ordered, collected, rejected, and processed were tracked weekly for each participating unit. Sample collection compliance and acceptance rates were calculated and tracked weekly. Strategies were implemented to improve collection compliance and sample acceptance rates, including computerized provider order entry, printed educational materials, and audit and feedback. Weekly dedicated Infection Preventionist (IP) time was estimated.

    Results

    Over 35 months, mean collection compliance increased from 82.7% to 91.2%, and then decreased to 86.2%. Over 27 months, sample acceptance rate increased from 57.7% to 83.6%, and then remained stable at 83.4%. Over 39 months, dedicated weekly IP time decreased 92%.

    Discussion

    Use of evidence-based quality improvement strategies optimized our CRE AST program. Optimizing the AST process aids in early CRE detection, leading to timely isolation and preventing the spread of CRE to other patients. Other hospitals may benefit from these lessons and enhance local AST programs.
  • Thumbnail Image
    ItemOpen Access
    Operative Versus Nonoperative Treatment for Adult Symptomatic Lumbar Scoliosis.
    (The Journal of bone and joint surgery. American volume, 2019-02) Kelly, Michael P; Lurie, Jon D; Yanik, Elizabeth L; Shaffrey, Christopher I; Baldus, Christine R; Boachie-Adjei, Oheneba; Buchowski, Jacob M; Carreon, Leah Y; Crawford, Charles H; Edwards, Charles; Errico, Thomas J; Glassman, Steven D; Gupta, Munish C; Lenke, Lawrence G; Lewis, Stephen J; Kim, Han Jo; Koski, Tyler; Parent, Stefan; Schwab, Frank J; Smith, Justin S; Zebala, Lukas P; Bridwell, Keith H

    Background

    The effectiveness of operative compared with nonoperative treatment at initial presentation (no prior fusion) for adult lumbar scoliosis has not, to our knowledge, been evaluated in controlled trials. The goals of this study were to evaluate the effects of operative and nonoperative treatment and to assess the benefits of these treatments to help treating physicians determine whether patients are better managed operatively or nonoperatively.

    Methods

    Patients with adult symptomatic lumbar scoliosis (aged 40 to 80 years, with a coronal Cobb angle measurement of ≥30° and an Oswestry Disability Index [ODI] score of ≥20 or Scoliosis Research Society [SRS]-22 score of ≤4.0) from 9 North American centers were enrolled in concurrent randomized or observational cohorts to evaluate operative versus nonoperative treatment. The primary outcomes were differences in the mean change from baseline in the SRS-22 subscore and ODI at 2-year follow-up. For the randomized cohort, the initial sample-size calculation estimated that 41 patients per group (82 total) would provide 80% power with alpha equal to 0.05, anticipating 10% loss to follow-up and 20% nonadherence in the nonoperative arm. However, an interim sample-size calculation estimated that 18 patients per group would be sufficient.

    Results

    Sixty-three patients were enrolled in the randomized cohort: 30 in the operative group and 33 in the nonoperative group. Two hundred and twenty-three patients were enrolled in the observational cohort: 112 in the operative group and 111 in the nonoperative group. The intention-to-treat analysis of the randomized cohort found that, at 2 years of follow-up, outcomes did not differ between the groups. Nonadherence was high in the randomized cohort (64% nonoperative-to-operative crossover). In the as-treated analysis of the randomized cohort, operative treatment was associated with greater improvement at the 2-year follow-up in the SRS-22 subscore (adjusted mean difference, 0.7 [95% confidence interval (CI), 0.5 to 1.0]) and in the ODI (adjusted mean difference, -16 [95% CI, -22 to -10]) (p < 0.001 for both). Surgery was also superior to nonoperative care in the observational cohort at 2 years after treatment on the basis of SRS-22 subscore and ODI outcomes (p < 0.001). In an overall responder analysis, more operative patients achieved improvement meeting or exceeding the minimal clinically important difference (MCID) in the SRS-22 subscore (85.7% versus 38.7%; p < 0.001) and the ODI (77.4% versus 38.3%; p < 0.001). Thirty-four revision surgeries were performed in 24 (14%) of the operative patients.

    Conclusions

    On the basis of as-treated and MCID analyses, if a patient with adult symptomatic lumbar scoliosis is satisfied with current spine-related health, nonoperative treatment is advised, with the understanding that improvement is unlikely. If a patient is not satisfied with current spine health and expects improvement, surgery is preferred.

    Level of evidence

    Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
  • Thumbnail Image
    ItemOpen Access
    Optimal management of Riata leads with no known electrical abnormalities or externalization: a decision analysis.
    (Journal of cardiovascular electrophysiology, 2015-02) Pokorney, Sean D; Zhou, Ke; Matchar, David B; Love, Sean; Zeitler, Emily P; Lewis, Robert; Piccini, Jonathan P

    Introduction

    Riata and Riata ST implantable cardioverter-defibrillator (ICD) leads (St. Jude Medical, Sylmar, CA, USA) can develop conductor cable externalization and/or electrical failure. Optimal management of these leads remains unknown.

    Methods and results

    A Markov model compared 4 lead management strategies: (1) routine device interrogation for electrical failure, (2) systematic yearly fluoroscopic screening and routine device interrogation, (3) implantation of new ICD lead with capping of the in situ lead, and (4) implantation of new ICD lead with extraction of the in situ lead. The base case was a 64-year-old primary prevention ICD patient. Modeling demonstrated average life expectancies as follows: capping with new lead implanted at 134.5 months, extraction with new lead implanted at 134.0 months, fluoroscopy with routine interrogation at 133.9 months, and routine interrogation at 133.5 months. One-way sensitivity analyses identified capping as the preferred strategy with only one parameter having a threshold value: when risk of nonarrhythmic death associated with lead abandonment is greater than 0.05% per year, lead extraction is preferred over capping. A second-order Monte Carlo simulation (n = 10,000), as a probabilistic sensitivity analysis, found that lead revision was favored with 100% certainty (extraction 76% and capping 24%).

    Conclusions

    Overall there were minimal differences in survival with monitoring versus active lead management approaches. There is no evidence to support fluoroscopic screening for externalization of Riata or Riata ST leads.
  • Thumbnail Image
    ItemOpen Access
    Utility of observation units for young emergency department chest pain patients.
    (Journal of Emergency Medicine, 2013-02) Ely, Sora; Chandra, Abhinav; Mani, Giselle; Drake, Weiying; Freeman, Debbie; Limkakeng, Alexander T
    BACKGROUND: Determining which patients presenting to the Emergency Department (ED) require further work-up for acute coronary syndrome (ACS) can be difficult. The utility of routine observation for cardiac testing in low-risk young adult patients has been questioned. STUDY OBJECTIVES: We investigated the rate of positive findings yielded by routine cardiac observation unit work-up in patients aged 40 years or younger. METHODS: This was a retrospective observational cohort study of patients aged 18-40 years who were evaluated for ACS in an ED-based observation unit. Data were collected by trained abstractors from electronic medical records. RESULTS: A total of 362 patients met inclusion criteria. Of those, 239 received stress testing, yielding five positive and nine indeterminate results. One other patient had acute troponin elevation while under observation. The positive stress test patients and troponin-elevated patient underwent cardiac angiography. Only one positive stress test patient showed significant coronary stenosis and received coronary interventions. In follow-up data, one patient had an adverse cardiac outcome within 1 year of index visit, but no coronary interventions. Thus, only 3 patients had adverse cardiac events, with only one patient warranting intervention discovered by observation unit stress testing and a second via serial cardiac markers. CONCLUSION: Routine observation of symptomatic young adults for ACS had low yield. Observation identified one patient with acute cardiac marker elevation and further stress testing identified only one patient with intervenable ACS, despite a high false-positive rate. This suggests that observation and stress testing should not be routinely performed in this demographic absent other high-risk features.