Citations

Abstract Background Cardiac valve tissue obtained during the surgical management of infective endocarditis (IE) and sent for culture may influence postoperative antibiotic therapy. We sought to identify clinical and microbiologic risk factors associated with positive valve cultures (PVC) and IE relapses in a cohort of patients undergoing surgical management. Methods This is a retrospective, multi-center study of patients with surgical management during the acute (<42 days) course of IE-directed antibiotic therapy. The rate of PVC, IE relapse, and mortality were collected. Univariate and multivariable logistic regressions were performed to identify risk factors associated with PVC. Results Of 113 patients included, 36 (31.9%) had PVC. Univariate and multivariable analyses showed preoperative antibiotic duration and pathogens were associated with PVC. Median (IQR) days of preoperative antibiotics were 6.5 (4.0-11.0) for patients with PVC compared to 13.0 (8.0-21.0) for those with negative valve cultures (NVC). In a multivariable model, preoperative antibiotic administration decreased the risk of PVC (OR 0.85 per day, CI 0.77-0.91). Enterococcal IE increased the risk of PVC compared to streptococcal IE (OR 4.16, CI 1.07-17.48). Of note, 33 (63.2%) patients with NVC received a median (IQR) of 8 (5, 18.5) days of intravenous antibiotics per patient. Only one IE relapse was identified and occurred in a patient with NVC. Conclusions Both preoperative antibiotic duration and causative pathogen were associated with PVC. IE relapses were rare and unrelated to PVC. There may be an opportunity to shorten postoperative antibiotic durations following surgical management in patients with IE.

Prolonged durations of hypotension during septic shock promote organ injury and mortality. Empirical evidence suggests that earlier vasopressin initiation may improve outcomes in septic shock. The objective of this study was to determine the effect of a ready-to-use vasopressin formulation availability in intensive care unit automated dispensing cabinets on outcomes in septic shock. This was a pre-post quasi experimental study of adults admitted for septic shock who received vasopressin as a second line vasopressor after norepinephrine. Inverse probability of treatment weighting with propensity scores was used to balance baseline covariates between those who received the ready-to-use vasopressin product and the traditional pharmacy-compounded vasopressin product. Outcomes included time from vasopressin order to administration, time to target mean arterial pressure, length of stay, and mortality. A total of 1104 patients with septic shock were included. After propensity score adjustment, the ready-to-use group was associated with faster time to vasopressin administration (17 vs 41 min, P < 0.001), faster time to target mean arterial pressure (hazard ratio 1.29, 95% CI 1.14 to 1.47, P < 0.001), and a shorter length of intensive care unit stay (hazard ratio 1.23, 95% CI 1.06 to 1.43, P = 0.006) as the compounded group. Mortality was not significantly different. In patients with septic shock, availability of a ready-to-use vasopressin product in the intensive care unit automated medication dispensing cabinet was associated with faster time to administration, improved time to target mean arterial pressure, and reduced duration of intensive care.

IMPORTANCE: Phenobarbital use in ICU alcohol withdrawal syndrome (AWS) may reflect severe or refractory withdrawal and treatment escalation, making multicenter data important to understand its use within ICU practice and its relationship with clinical outcomes. OBJECTIVES: To evaluate phenobarbital use in real-world ICU AWS as a marker of severe or refractory withdrawal and treatment escalation. We also examined its association with time-to-discharge and safety outcomes compared with nonphenobarbital regimens. DESIGN, SETTING, AND PARTICIPANTS: Multicenter retrospective cohort study using multiple imputation and propensity score matching. Adults with AWS, defined as Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) score greater than or equal to 10, were included if they received a phenobarbital-based or nonphenobarbital-based regimen in ICUs across a large academic health system from June 30, 2017, to July 1, 2024. Postoperative ICU admissions were excluded. MAIN OUTCOMES AND MEASURES: Primary outcomes were time to ICU and hospital discharge alive from treatment initiation. Safety outcomes were hypotension, new intubation, and aspiration within 48 hours. RESULTS: Of 1216 patients, 345 (28.4%) received phenobarbital. Before matching, phenobarbital-treated patients had higher CIWA-Ar, Acute Physiology and Chronic Health Evaluation III, and pre-ICU benzodiazepine exposure, consistent with more severe or refractory withdrawal. In adjusted time-to-discharge models, phenobarbital use was not significantly associated with time to hospital discharge alive (discharge rate ratio [DRR], 0.91; 95% CI, 0.74–1.12; p = 0.370) or ICU discharge alive (DRR, 0.77; 95% CI, 0.59–1.01; p = 0.057). Hypotension and intubation were similar, and aspiration was less frequent with phenobarbital. CONCLUSIONS: In a contemporary ICU cohort, phenobarbital use reflected treatment escalation in patients with more severe or refractory AWS. After adjustment, time to ICU and hospital discharge alive did not differ significantly, hypotension and intubation were similar, and aspiration was less frequent with phenobarbital. Future studies should define optimal timing, dosing, and patient selection.

Abstract Introduction: Asynchronous online courses are plagued with the challenge of engaging students consistently. Behavioral interventions, such as bottlenecks (enforced deadlines) and nudges (automated reminders), may modulate behaviors that lead to engagement and can now be easily applied and measured in a Learning Management System (LMS). Methods: This study included three groups of three asynchronous online courses each over three academic quarters. Two distinct behavioral interventions, bottlenecks and nudges, were implemented to increase engagement with the course compared to non-intervention controls. Results: The results showed that behavioral intervention tools increase student engagement with course materials by measures of increased student access to the course and reduced time to quiz completion. However, there was no significant impact in grades across the three groups. Conclusion: The use of nudges and bottlenecks as behavioral interventions to increase engagement in asynchronous courses for Clinical and Translational Science Education is recommended as part of best practice in course design with the same or similar structure.

Background: Patients with primary sclerosing cholangitis (PSC) are at risk for developing gallbladder neoplasia (GBN) and biliary neoplasia, including cholangiocarcinoma (CCA), because of chronic inflammation and an underlying field effect. However, the risk of CCA after GBN detection in those with PSC remains poorly understood. We aimed to determine if the incidence of CCA is higher in those with GBN. Methods: We conducted a retrospective review of adult patients with large-duct PSC seen at Mayo Clinic between January 1, 1995, and December 31, 2019. Incidence rates for CCA development were calculated. Cox regression analyses were performed to determine features associated with CCA development beginning at the time of PSC diagnosis. Results: Our study included 1,829 patients with PSC. CCA and GBN developed in 334 (18.26%) and 71 individuals (3.88%), respectively. Among those with GBN, 14 (19.72%) developed CCA. The annual incidence of CCA was nearly twofold higher in patients with GBN (4.34% versus 2.21%). GBN was associated with CCA in an unadjusted analysis (hazard ratio 2.14 [95% CI 1.16–3.94]). When adjusting for other predictors of CCA, an association between GBN and CCA may remain. Conclusions: While few patients with PSC develop GBN, this subgroup is more likely to develop CCA. Consequently, once GBN is detected, clinicians should consider more intensive screening for CCA.

Abstract Background Outpatient parenteral antimicrobial therapy (OPAT) allows patients to complete extended antimicrobial treatment at home, improving quality of life and reducing healthcare costs. National guidelines outline best practices for antimicrobial administration, vascular access management, monitoring, and recommend involving an infectious disease physician and a multidisciplinary team. Evaluating adherence to these practices can identify improvement opportunities and enhance outcomes. The primary objective of this study was to assess patient outcomes related to adherence to OPAT best practices at Mayo Clinic Health System – Southwest Wisconsin (MCHS–SWWI). Secondary objectives included evaluating adherence to key process metrics and identifying associations between baseline characteristics and outcomes. Methods This retrospective cohort study included adults discharged from MCHS–SWWI on home OPAT from November 2021 to July 2024. Patients were excluded if under 18 years old or if they received OPAT in non-home settings (e.g., skilled nursing, infusion center). Data on process metrics, outcomes, and safety were collected through manual chart review. These findings were evaluated against established best practices to assess the OPAT program's adherence and determine the impact of this adherence on patient outcomes. Statistical analysis used Pearson’s chi-square tests and Wilcoxon rank sum tests to measure associations of patient characteristics with outcomes. Results A total of 164 patients were included. The MCHS-SWWI OPAT program demonstrated high adherence ( &gt; 85%) to majority of established best practices. Successful OPAT completion occurred in 92.7% of patients, and overall incidence of adverse events and poor outcomes was generally low. Adherence to best practices was below 85% for vascular access selection (81.7%) and completion of weekly labs and vascular access care throughout the OPAT course (∼69%). Conclusion High adherence to OPAT best practices led to a generally low incidence of adverse events, treatment failures, and other unfavorable patient outcomes. The results of this study provide valuable insights to guide institutional quality improvement initiatives aimed at optimizing patient outcomes in OPAT therapy through targeted interventions. Disclosures All Authors: No reported disclosures

AbstractEndoscopic eradication therapy (EET) is recommended for the management of dysplastic Barrett’s esophagus (BE) and intramucosal adenocarcinoma. Both radiofrequency (RFA) and cryoballoon ablation (CBA) can induce complete remission of intestinal metaplasia (CRIM). We aimed to compare long-term durability following CRIM in patients treated with RFA vs. CBA.We conducted a retrospective cohort study to analyze patient outcomes following EET with RFA or CBA at two referral centers. We measured and compared the recurrence rate of BE, with or without dysplasia, after CRIM, using Cox proportional hazard models and propensity score-matched analyses. Our secondary aim was to identify predictors of recurrence.681 patients who achieved CRIM were included (RFA 610; CBA 71), with median follow-up of 4.1 years and 4.4 years following RFA and CBA, respectively. A multivariable model revealed a higher risk of any recurrence with RFA (hazard ratio [HR] 2.19, 95%CI 1.18–4.06; P = 0.01), but not dysplastic recurrence (HR 0.88, 95%CI 0.39–1.97; P = 0.75). However, a comparable risk of “any recurrence” was observed after excluding intestinal metaplasia of the gastroesophageal junction (HR 1.18, 95%CI 0.61–2.30; P = 0.62). Propensity score-matched analysis (54 cases in each group) showed that the two groups had comparable recurrence risk. Baseline maximum BE length was associated with a higher risk of any recurrence (HR 1.07; P<0.001) and dysplastic recurrence (HR 1.11; P = 0.001).The rates of any BE recurrence and dysplastic recurrence were comparable with the two modalities in this nonrandomized study.

Background: Fecal microbiota transplantation (FMT) is a successful therapy for Clostridioides difficile infection (CDI). FMT from overweight donors is speculated to influence the recipient’s body mass index (BMI) after administration for CDI. Objectives: We investigated changes in the recipient’s BMI after FMT in relation to the donor’s BMI. Design: We conducted a retrospective cohort study involving patients who underwent FMT for recurrent CDI at Mayo Clinic between 2012 and 2019. Methods: We analyzed demographic and donor data for patients undergoing FMT at Mayo Clinic (2012–2019). Recipient BMI (pre- and post-FMT) and donor BMI were extracted from medical records. Mixed-effects linear regression was used to evaluate the impact of donor BMI, donor BMI category, recipient baseline BMI, time before and after FMT, and interactions between these variables on overall BMI change and BMI change per month. Kaplan–Meier curves were used to assess BMI changes (⩾5 units) based on the last recorded post-FMT BMI. Results: We analyzed data from 401 patients with recorded BMI measurements before and after FMT. The median age of the recipients at the time of FMT was 59.1 years (interquartile range (IQR): 40.5–70.1 years), with 61.6% being female. The median BMI for recipients prior to FMT was 26.7 kg/m² (IQR: 22.7–31.6 kg/m²), while the median BMI of the donors was 24.5 kg/m2 (IQR: 23.9–27.5 kg/m2). Stool from donors with a normal BMI was used for 58.2% of recipients, while 41.8% received stool from pre-obese donors. Donor BMI data were missing for 3.2% of recipients. Donor BMI was not significantly associated with changes in recipient BMI; for each 1-unit increase in donor BMI, a 0.01-unit monthly increase was observed (95% confidence interval: −0.0003, 0.02; p = 0.11). The log-rank test for BMI increases (⩾+5) and decreases (⩽−5) revealed no significant differences among the donor BMI groups (Chi-squared = 4.4, p = 0.1 for increases, Chi-squared = 2, p = 0.4 for decreases). Conclusion: The lack of impact of donor BMI on BMI changes post-FMT suggests that these changes are more dependent on the recipient’s metabolic profile. Prospective, controlled trials are required to analyze these results more comprehensively.

Abstract Background Clozapine is effective for treatment-resistant schizophrenia and bipolar disorder but is often discontinued due to adverse effects. This study compared early clozapine discontinuation rates and reasons in patients with mood and psychotic disorders. Methods Data from all individuals with mood or psychotic disorders who initiated clozapine for the first time at the inpatient psychiatric unit of Mayo Clinic, Rochester, Minnesota, between 2014 and 2022 were retrospectively analyzed. Early clozapine discontinuation, defined as discontinuation within 90 days of initiation, was the primary outcome. Cox proportional hazards regression was used to assess factors associated with discontinuation. Results Of 83 patients (mood group n = 37, psychosis group n = 46), those in the mood group were older (P = 0.022) and more likely to be nonsmokers (P = 0.034). The overall 90-day clozapine discontinuation rate was 45.7%. Early discontinuation was significantly higher in the mood group than in the psychosis group (hazard ratio = 2.41, 95% confidence interval = 1.26–4.64, P = 0.008). Other factors associated with early discontinuation were female sex (P = 0.033), older age (P = 0.026), and nonsmoking (P = 0.001). In multivariable analysis, smoking status was the only factor significantly inversely associated with early clozapine discontinuation (hazard ratio = 0.47, 95% confidence interval = 0.22–0.99, P = 0.048), while diagnostic group, sex, and age did not show significant associations (all P > 0.05). Discontinuations were primarily due to adverse drug reactions in both groups. Conclusions Nearly half of the patients discontinued clozapine early, with higher rates in the mood group. Studies should further explore potential pharmacodynamic and pharmacokinetic factors associated with discontinuation, including the influence of smoking. Careful monitoring and personalized management of side effects are crucial for optimizing clozapine therapy and improving treatment outcomes.

Objective Identify sociodemographic factors and comorbidities predictive of nasoalveolar molding (NAM) treatment completion and noncompletion in infants with cleft lip with or without (+/–) cleft palate in a rural-suburban population. Design Retrospective cohort study. Setting Tertiary medical center. Patients, Participants Infants diagnosed with cleft lip +/- cleft palate who initiated NAM treatment between 2013 and 2023. Forty-seven patients met inclusion criteria. Main Outcome Measure(s) Prevalence of NAM treatment completion, defined as continued attendance of NAM appointments until initial lip repair surgery. Results NAM treatment noncompletion rate of 23.4%. Noncomplete NAM treatment was associated with greater additional unscheduled NAM visits ( P < .001); increased days inpatient after birth ( P < .001); NICU admission ( P < .001); public insurance ( P = .007); preterm birth ( P = .008); history of social work visits ( P = .024); increased comorbidities ( P = .028); non-Caucasian race ( P = .034); and presence of siblings ( P = .036). Associated comorbidities included use of feeding tube ( P < .001); and conditions related with renal ( P < .001); cardiac ( P = .004); failure to thrive ( P = .009); syndromes ( P = .009); orthopedic ( P = .011); pulmonary ( P = .022); and ophthalmologic systems ( P = .041). Conclusions Increased overall health complexity, public insurance status, and need for social work support were identified as factors associated with NAM noncompletion. These variables can help identify patients at risk of noncompletion and empower providers to supply individualized support and resources.