Francis Hospital Research Articles

Antibiotic Prescribing Practices on Hospital Discharge for Management of Urinary Tract Infections: A Single Center Study

Background: Appropriate antibiotic use has been described as one of the key strategies in tackling antibiotic resistance. Although the majority of antimicrobial therapy is completed following discharge, there lacks clear guidance in addressing antibiotic stewardship in the outpatient setting. Particularly, broader coverage as well as longer durations of therapy are often encountered following hospitalization. In our study we examine the various antibiotic prescribing practices on hospital discharge for management of urinary tract infections (UTI). Methods: We conducted a single-center, retrospective observational chart review of patients discharged from St. Francis Hospital and Medical Center in Hartford between May and July 2022. Medical records were reviewed for patients who were prescribed antibiotic therapy for management of UTI and met inclusion criteria. Variables of interest included type of UTI treated, antibiotic used, duration of antibiotics during and following hospitalization, fluoroquinolone use, as well reported adverse events. Total duration of therapy was defined as days on susceptible antimicrobials with appropriate source control. Results: A total of 84 patients met inclusion criteria. 44 received treatment for simple UTI (sUTI) and 40 for complicated UTI (cUTI). Figure 1 shows the various organisms identified on culture. The most common antimicrobials prescribed on discharge were cefpodoxime and ciprofloxacin [figure 2]. Quinolones were prescribed in 11.4% of sUTIs and 39.1% of cUTIs on hospital discharge. Of those, only one patient had no alternative to quinolone use due to drug allergies. The mean duration of therapy for treatment of sUTI was 6.4 days total (SD 2.40) with 3.9 days outpatient (SD 1.78). The mean duration of therapy for treatment of cUTI was 10.9 days total (SD 3.62) with 6.7 days outpatient (SD 2.99). Comparison of mean durations is shown in figure 3. In 49% of all cases (including both sUTI and cUTI) patients received greater than 7 days of antimicrobial therapy. Conclusion: There is increased evidence favoring shorter courses of antimicrobial therapy for management of both simple and complicated UTIs. A 7-day course has been shown as effective duration of therapy for cUTI with appropriate source control, regardless of presence of bacteremia. Results from our single center-study show both sUTI and cUTI are subject to unnecessarily prolonged durations of therapy on hospital discharge. In addition we noted a significant use of fluoroquinolones in cUTI treatment. We believe stewardship interventions at time of discharge may particularly benefit shorter courses of therapy for cUTI as well as reduced quinolone use.

Impact of Stewardship Pharmacist Driven MRSA Nasal Surveillance and De-escalation of Anti-MRSA Therapy

Background: Intravenous vancomycin is commonly used as initial empiric coverage for pneumonia but is often unnecessary. MRSA nasal surveillance cultures (MRSA nasal swab) have been highlighted in recent literature and the 2019 IDSA Pneumonia Treatment Guidelines as a tool to avoid unnecessary MRSA coverage in pneumonia. A negative MRSA nasal swab can be utilized by clinicians to de-escalate anti-MRSA therapies for pneumonia. The purpose of this study is to determine if implementing stewardship pharmacist driven MRSA nasal surveillance increases use of the test and reduces the inappropriate use of vancomycin for MRSA coverage in patients with pneumonia. Method: This study was a retrospective chart review and was approved by the Trinity Health of New England Institutional Review Board. For this initiative, a stewardship pharmacist evaluated all patients receiving vancomycin for anti-MRSA therapy at Saint Francis Hospital and Medical Center in Hartford, CT. If the patient’s indication was pneumonia and a MRSA nasal swab had not been ordered, the pharmacist contacted the patient’s provider and requested an order for it. Upon receipt of a negative MRSA nasal swab result, the pharmacist recommended discontinuation of vancomycin to the provider if appropriate. Outcomes from the first four weeks of the pharmacist-driven initiative (April 10, 2023 to May 5, 2023) were compared to the four weeks prior to the initiative (March 13, 2023 to April 7, 2023) as a control group. The primary outcome of this study was percentage of patients who received a MRSA nasal swab. Secondary outcomes included percentage of patients who had vancomycin appropriately de-escalated based on MRSA nasal swab results and mean length of vancomycin therapy. Result: 116 patients met inclusion criteria: 61 in the control group and 55 in the intervention group. Percentage of swabs ordered increased from 36.1% (22/61) without pharmacist intervention to 80.0% (44/55) with pharmacist intervention (p < 0 .0001). There were also increased rates of vancomycin de-escalation in patients with pharmacist intervention, with 58.2% (32/55) of patients in the intervention group having vancomycin discontinued following a negative MRSA swab compared to 19.7% (12/61) in the control group (p < 0 .0001). Conclusion: The results suggest implementing a pharmacist driven MRSA nasal surveillance program into practice could increase the number of MRSA nasal swabs ordered and in turn promote more timely de-escalation of vancomycin in patients with pneumonia. The results from this study can be used to support the wide-spread use of pharmacist driven MRSA nasal surveillance protocols at other institutions.

A Retrospective Analysis of Needle Thoracostomies at a Tertiary Level 2 Trauma Center.

A tension pneumothorax is a condition that results in elevated pressure within the pleural space. The effective management of tension pneumothorax relies on needle decompression, commonly performed at the second intercostal space (ICS) midclavicular line (MCL). However, some literature suggests that catheters placed in the second intercostal space midclavicular line are prone to higher failure rates compared to the fifth intercostal space midaxillary line (MAL) (42.5% versus 16.7%, respectively). In this study, we aim to identify and scrutinize the prevalence of prehospital needle decompression from one tertiary care center over eight years and examine their trends, efficacies, or pitfalls. It is hypothesized that preclinical providers are performing needle decompression prematurely and unnecessarily. A set of 90 patient records obtained using the trauma registry at Saint Francis Hospital, Tulsa, Oklahoma, were retrospectively reviewed to evaluate the management and outcomes of tension pneumothorax, as well as the indications documented for needle decompression. Patient charts were reviewed via Epic Hyperspace (Epic, Madison, WI). The Oklahoma Emergency Medical Service Information System (OKEMSIS) also provided information contributing to the sample population. The most documented indications for needle decompressions included diminished or absent breath sounds (52.70%), hypoxia (15.54%), hypotension, and hemodynamic instability (6.76%). Emergency medical services (EMS) reported improvements in 51 (56.67%) patients after needle thoracostomy. Improvements in vital signs after needle decompression were sporadic. The most common complication was catheter dislodging, which occurred most in the second intercostal space midclavicular line. Only nine patients had an oxygen saturation (SpO2) below 92% and a systolic blood pressure (SBP) below 100 mm Hg prior to receiving needle decompression. Current practices for tension pneumothorax show little improvement in vital signs before and after needle decompression. Vital signs prior to needle decompression often do not indicate tension pneumothorax physiology. Preclinical providers may be inappropriately performing needle decompressions, an invasive procedure with complications.

Etiologies and Impact of Exclusion Rates for Transcatheter Mitral and Tricuspid Valve Structural Heart Clinical Trials at a High-Volume Quaternary Care Hospital

There are various devices under clinical investigation for transcatheter mitral valve intervention (TMVI) and tricuspid valve intervention (TTVI), but exclusion rates remain high. We aim to investigate exclusion rates for transcatheter mitral valve repair (TMVr), transcatheter mitral valve replacement (TMVR), transcatheter tricuspid valve repair (TTVr) and transcatheter tricuspid valve replacement (TTVR). There were a total of 129 patients who were referred to St. Francis Hospital & Heart Center valve clinic and completed screening between January 2021 and July 2022. Causes for exclusion were classified into 4 categories: patient withdrawal, anatomic unsuitability, clinical criteria and medical futility. Among 129 patients, the exclusion rates for TMVr, TMVR, TTVr and TTVR were 81%, 85%, 91% and 87%, respectively. Patient withdrawal and medical futility were leading etiologies for exclusion, followed by anatomical unsuitability. TMVr had the highest rate of patient withdrawal (64%), the lowest anatomic unsuitability (5%) due to short posterior leaflet length. Replacement interventions have higher anatomic unsuitability (33%) compared to repair interventions (17%) (p=0.04). Most exclusions of anatomic unsuitability was due to mitral stenosis or small annulus size for TMVR and large annulus size for TTVR. Fifty percent of exclusions from TTVr were due to presence of pacemaker/defibrillator leads. Among patients excluded from their respective trials, patients being referred for TMVr had the highest recurrent hospitalization and repair group had a higher mortality (p<0.01 and p=0.01, respectively). In conclusion, exclusion rates for TMVI and TTVI trials remain high due to various reasons, limiting patients’ enrollment and treatment. This supports the need for further device improvement or exploring alternative means of therapy.

Acceptability to donate human milk among postnatal mothers at St. Francis hospital Nsambya, Uganda: a mixed method study

BackgroundThe World Health Organization recommends the use of donated human milk (HM) as the second-best option for mothers who are temporarily unable to provide sufficient breast milk to meet the needs of their infants. However, HM donation is yet to become an accepted practice in Uganda. We assessed the level of, and factors associated with acceptability to donate HM among postnatal mothers at St. Francis Hospital Nsambya (SFHN).MethodsA cross-sectional sequential explanatory mixed method study was conducted between October 2018 and March 2019. A questionnaire on sociodemography, awareness and likely acceptability to donate HM was administered to 410 postnatal mothers at SFHN. Multivariate logistic regression analysis was undertaken to determine factors associated with acceptance of HM donation. Focus Group Discussions (4) and Key Informants Interviews (4) were used to explore factors influencing behaviours to donate human milk. Qualitative data were analysed using a content thematic approach.ResultsOverall acceptance of donating the HM was 77.6%, and the significant factors were: willingness to express the HM (AOR 7.5; 95% CI 3.01, 18.68); wet-nursing knowledge (AOR 2.3; 95% CI 1.1, 5.0) and visit to under-5 years’ clinic (AOR 21.3; 95% CI 2.3, 196.9). The major themes in relation to accepting to donate HM were wet nursing experience, and confidence in donating the HM, and its perceived effectiveness. There were concerns about the safety and adequacy of HM and fear of transmitting criminal behaviours and mental illness through human milk.ConclusionsAcceptance to donate HM among postnatal mothers at St. Francis Hospital Nsambya was very high. Willingness to express and store human milk, prior knowledge about wet nursing and a visit to an under-five outpatient clinic were associated with acceptance. Thus, establishing a human milk bank is feasible in the study setting.

Setting up the first human milk bank in Uganda: a success story from Nsambya hospital.

The World Health Organization (WHO) strongly recommends the use of donor human milk (DHM) for low birth weight infants when mother's own milk is unavailable or insufficient. However, the use of DHM requires the availability of human milk banks (HMBs), the majority of which are in middle and high-income countries. Developing countries offer multiple opportunities and challenges regarding the establishment and operationalization of HMBs. This study describes the experience in setting up the HMB in Uganda at St. Francis Hospital Nsambya. The establishment of the first HMB in Uganda followed a step-wise approach using the PATH's Resource Toolkit for Establishing and Integrating Human Milk Banks. The steps included: performing a facility readiness assessment, implementing quality control measures, forming and training a committee for the Baby Friendly Hospital Initiative, establishing a monitoring and evaluation system, developing a communication strategy, engaging with the Ministry of Health, providing staff training by a Human Milk Bank consultant, and maintaining regular coordination by a dedicated technical team. A total of 170 donors have been screened and of these 140 have donated milk with a mean age of 26 years since the establishment of the bank in November 2021. A total of 108 admitted neonates have received the milk; majority (88%) are preterm infants with a mean gestational age of 34 weeks. A total of 90 liters have been collected and 76 distributed. The challenges in establishment of the Human Milk bank included: lack of guidelines on human milk banking, use of unpasteurized milk, lack of communication strategy, lack of clear model infrastructure and lactation training. We addressed the challenges: by drafting guidelines, set up a human milk bank and had training on use donor pasteurized milk, designed communication messages through videos and brochures, visited Pumwani hospital and remodeled the Human Milk Bank according to the model at Pumwani, all the health workers in the human milk bank had a training on Lactation. Assessing the experiences and attitudes of mothers, donors, healthcare providers, and hospital leaders revealed concerns about milk safety and fear about potential attachments or acquired traits through the donated milk to the babies that may receive it. Donors viewed milk donation as a life-saving act, although fears of breast cancer and lumps arose from misconceptions. To address these perspectives, creative media, such as videos and messages, were designed to raise awareness, promote behavioral change, and create demand for the HMB services. The establishment and integration of HMB services at hospitals in Uganda is feasible.

1235. A Retrospective Review of Antimicrobial Stewardship Audit and Feedback: Assessing Acceptance of Stewardship Recommendations During the COVID-19 Pandemic

Abstract Background Antimicrobial stewardship is an underutilized strategy to mitigate the impact of antimicrobial resistance. It is well documented that many Antimicrobial Stewardship Programs (ASPs) were tasked with assisting healthcare teams in navigating the COVID-19 pandemic, leaving less time/fewer resources for day-to-day ASP activities. The aim of this study was to evaluate the acceptance of stewardship recommendations during a season when the ASP had less time to perform regular educational activities and handshake stewardship. Methods A retrospective study of patients receiving antimicrobial therapy at Saint Francis Hospital during 12/30/2020-10/01/2022, for which audit and feedback by the ASP was conducted. A well-established ASP existed prior to the pandemic. Independent variables included the reason for intervention, type of infection by organ system, and type of intervention. Interventions included recommendations to stop antibiotics, de-escalation, duration of therapy, ID consultation, or change the route of administration. The primary outcome was the audit and feedback acceptance rate, and the secondary outcome was whether the intervention resulted in infectious disease consultation. Results 297 patients underwent audit and feedback. Interventions most accepted by providers included changing the route of administration (100%) and consulting ID formally (92%). Adjusting the duration of therapy was the least accepted intervention at 78%. Regardless of intervention, 33% of providers requested a formal ID consult. The number of interventions varied sporadically, coinciding with periods of decreased availability by the ASP team and during peak waves of the COVID-19 pandemic. Conclusion Our ASP team, despite decreased resources while battling an ongoing pandemic, were still able to perform audit and feedback to providers with a good acceptance rate of recommendations, consistent with current literature. Having not only an existing but robust ASP prior to the pandemic, allowed continued success with ASP intervention acceptance rates, despite less dedicated time for typical ASP activities during the pandemic. Fostering good relationships between providers and ASP teams, as well as continued support and funding from hospital leadership, are vital to ongoing success. Disclosures All Authors: No reported disclosures

Post-stroke pneumonia: Factors associated with readmission within 90 days of stroke discharge

ObjectiveThe objective was to identify risk and protective factors associated with post-stroke pneumonia readmission. MethodA retrospective chart review was conducted on 365 stroke patients who were admitted to Ascension Via Christi St. Francis Hospital in Wichita, Kansas from January 1, 2015 through January 30, 2020. This case control study used matching by age at a proportion of four control patients to one post-stroke pneumonia patient. Patients with and without post-stroke pneumonia readmission within 90 days of discharge were included in this study. ResultsOf the 3,952 patients diagnosed with stroke, 1.8% (n=73) patients were readmitted with post-stroke pneumonia. Compared to patients who were not readmitted for post-stroke pneumonia, patients with post-stroke pneumonia readmission were more likely to: have used a nasogastric tube during index admission, have used mechanical ventilation during index admission, or have been placed on a nothing-by-mouth diet at discharge. Being placed on nothing-by-mouth for fluids was also a predictor of post-stroke pneumonia readmission. Lack of acquired infection during the index admission was a protective factor for post-stroke pneumonia readmission. DiscussionThe pathophysiology of post-stroke pneumonia is multifactorial and includes consideration of dysphagia severity, bacterial colonization of the oropharynx and feeding tube, and an altered immune system. ConclusionDuring the index admission, patients on nothing-by-mouth were more likely to be readmitted, and infection-free patients were less likely to be readmitted with post-stroke pneumonia. By identifying at-risk patients, clinicians may be able to use this information to tailor future medical interventions to prevent post-stroke pneumonia readmissions.

Siriraj Stroke Score Validity in Distinguishing Ischemic from Haemorrhagic Stroke among Patients with Stroke at Saint Francis Hospital in Kampala, Uganda

Siriraj Stroke Score Validity in Distinguishing Ischemic from Haemorrhagic Stroke among Patients with Stroke at Saint Francis Hospital in Kampala, Uganda

Performance of Different Glucose Testing Methods Amongst Patients of Gestational Diabetes Mellitus in St. Francis Hospital Nsambya, Kampala, Uganda: A CrossSectional and Descriptive Study

Background: Medical examination detects illness or disease risk factors in individuals otherwise well to treat early on and minimize morbidity and death. In spite of recommended GDM screening during prenatal care worldwide and local standards, it has been shown that the procedure has not been properly implemented. A further difficulty might be the lack of consensus worldwide and on local consistence on GDM screening and diagnosis guidelines. Methods: The study was a hospital based cross-sectional and descriptive study that employed both quantitative and qualitative methods of data collection. A descriptive study was concerned with describing the characteristics of a particular individual, or of a group in a given situation. The study was guided by the primary objective of assessing the extent of GDM monitoring among women receiving antenatal care at St. Francis Hospital Nsambya in Kampala, Uganda. Both Capillary and venous blood samples in which plasma/serum was taken from pregnant mothers and their glucose levels estimated using a One touch (Roche Diagnostics) code 298 and plasma calibrated glucometer and Roche Cobas C311fully automated Chemistry Analyser respectively. Both whole blood glucose and plasma/serum glucose was determined as per the principle of enzyme hexokinase (HK) catalyzes the reaction between glucose and adenosine triphosphate (ATP) to form glucose-6-phosphate (G-6-P) and adenosine diphosphate (ADP). In the presence of nicotinamide adenine dinucleotide (NAD), G-6-P is oxidized by the enzyme glucose-6-phosphate Dehydrogenase (G-6-PD) to 6-phosphogluconate and reduced nicotinamide adenine dinucleotide (NADH). The increase in NADH concentration was directly proportional to the glucose concentration and was measured spectrophotometrically at 340 nm. The data was analysed using the McNemar's test to determine the sensitivity, specificity and the direct cost for performing capillary glucose. Receiver operator characteristic and Area under curve analyses to analyze the predictive power of the constructed equation Sensitivity, specificity, false positive rate and false negative rate was computed to validate the capillary method in testing/detecting Gestational Diabetes Mellitus. Data analysis was performed using the SPSS package Results: The results presented below for both capillary and Venous Blood Glucose were based on the principle of glucose oxidase test. Cutoff for the different blood sugar level were as follows; Normal A1C test being &lt; 5.4% and Diabetes being &gt;5.4%. Based on the Venous Blood Glucose tests method, 89.0% (154/173) respondents tested normal, while 11.0% (19/173) had diabetes. However, capillary blood glucose testing method identified 78.6% (136/173)5 respondents as being normal compared 21.4% (37/173) having diabetes. Results obtained from the process indicate capillary glucose blood test for gestation diabetes having very low sensitivity i.e. 30% for gestation diabetes. The findings of the study will help to create public awareness on disease burden, improved diagnosis, classification, management and health policies by the Ministry of Health about Gestational diabetes among Ugandan mothers. Conclusion: Most of the procedures employed to detect and trace for GDM was found to be painful and stressful. The healthcare providers and managers some lacked required skills and knowledge concerning GDM among women and procedural handling was found to be wanting in one case or another. The GDM prevalence was discovered to be slowly increasing even though it was detected to be at low levels at Nsambya hospital but the situation elsewhere might be different. Most of the GDM risk factors were majorly originating from family background, maternal ages discrepancies, and abuse of alcohol. Most GDM challenges were found to be fueled by lack of proper counseling and screening since it wasn’t routine among health care professionals hence lack of expertise and inconsistencies in handling GDM women. Preparing women for GDM screening and diagnosis would have reduced the risks and health challenges faced by pregnant women if they are well prepared and trained before subjecting them to the GDM testing.

In Memoriam: Edward W. Bermes, Jr., PhD, FAACC (1932-2021).

Dr. Edward W. Bermes, Jr., PhD, FAACC, passed away peacefully at home on February 16, 2021, following a long-term illness. He was born in Chicago, Illinois on August 20, 1932. He received his BS in Chemistry from St. Mary’s College in Winona, MN, followed by a MS and Ph.D. in Biochemistry from Loyola University of Chicago (LUC). In 1958, he was appointed Chief Biochemist at Cook County Hospital. On receiving his doctoral degree in 1959, he was appointed Assistant Professor of Biochemistry in LUC’s Stritch School of Medicine (SSOM). During the 1960s, he served as Director of Biochemistry at St. Francis and West Suburban hospitals. In 1969, he was promoted to Associate Professor of Biochemistry and Pathology. Also at that time, he led the creation of a laboratory for a hospital opening on LUC’s new medical center campus (LUMC) in Maywood, IL. By then, Dr. Bermes had become an excellent teacher and welcomed more teaching opportunities. At St. Francis Hospital, he had developed a predoctoral clinical biochemistry program. He codirected it with Dr. Hugh McDonald, Chair of LUC’s Department of Biochemistry and Biophysics. Dr. McDonald was also a charter member and Past-President of AACC (1954). It was challenging to find sites to provide clinical experience for predoctoral trainees until the opening of LUMC, which also became the location for creation of a postdoctoral fellowship program in clinical chemistry. Initially funded through a NIH grant, the postdoctoral program was approved by the American Board of Clinical Chemistry in 1972. Dr. Bermes’ devotion to postdoctoral training led to his serving on the Commission on the Accreditation of Clinical Chemistry Training Programs Board of Directors, and as its president for 8 years. During his career, he trained thousands of students of medicine, graduate schools, medical technology, and clinical laboratory science as well as residents and fellows in pathology, clinical chemistry, and other disciplines. In 1983, his dedication to teaching was recognized with his receiving AACC’s Award for Outstanding Contributions in Education and Training.

Rosa Maria Rodrigues Pereira (1958-2022).

Her interest in bone metabolism started during her internship in rheumatology; she was particularly intrigued by osteoporosis and the negative effects of corticosteroids on the bone. In the 1990s, she began interacting with the endocrinology service led by Professor Aurelio Borelli, probably the only place in São Paulo University that subscribed to the main journals focused on bone research. Despite her limited experience in a basic research laboratory, she decided to face the challenges of a bench research-based postdoctoral fellowship and joined the laboratory of Professor Ernesto Canalis at Saint Francis Hospital, Hartford, CT, USA. She learned bone cell biology and became proficient with the bench research techniques that she established in her lab in São Paulo after her return to Brazil. She created and directed the Laboratory of Bone Metabolism, which became a center of excellence for training students and young physicians from different specialties. She was able to secure financing to acquire one of the few high-resolution peripheral quantitative computed tomography machines available in Brazil. She became a go-to specialist in rare and challenging bone diseases, many of which made their way into high-impact publications. Prof Pereira developed original research directions and extensively published. Her research focused on bone and mineral disorders related to rheumatic diseases, including pediatric rheumatology and inflammatory vascular diseases. During her career, she published 391 original articles, 85 book chapters, and 8 books. She made major contributions to the use of vitamin D, including a randomized clinical trial, whose results were published in JAMA in 2021, demonstrating that among hospitalized patients with COVID-19, a single high dose of vitamin D3 did not impact the length of hospital stay. Prof Pereira contributed to the development of the Brazilian National Guidelines for Prevention and Treatment of Osteoporosis and was the coordinator of the São Paulo Ageing and Health Study, a population-based prospective cohort study in Brazil, which resulted in more than 17 publications focusing on bone microarchitecture and fragility fractures. The outstanding quality of her work has been recognized by more than 80 national and international awards. She held leadership roles with high-profile journals, including the International Advisory Board of The Lancet Rheumatology, and served as the Regional Editor of Journal of Bone and Mineral Research. Prof Pereira was instrumental in the creation of the Brazilian Association of Bone Assessment and Osteometabolism (ABRASSO) in 2007, contributing to the organization of the scientific program at their conferences, where she proudly showcased the results of her research. Despite her many professional commitments, Prof Pereira was a compassionate physician who was fully dedicated to patients with rheumatologic diseases during her 40-year career. She led weekly rheumatology rounds and inspired many students and residents who had the fortune of coming under her wings during her 4-decade-long career. Prof Pereira mentored 7 postdoctoral students, 33 doctoral students, 5 master's degree students, and 22 undergraduate students. They will certainly continue to have the legacy of patient care and academic excellence. Prof Pereira was tireless and determined. Her work schedule included weekdays and weekends; she continued her hectic schedule until just a few weeks before she was overcome by illness. Prof Pereira exemplifies how effective leadership can have long-lasting positive effects on others and on our field at large. Her work and legacy will remain a source of inspiration for new generations of clinicians and researchers who will continue to advance our knowledge of rheumatology and metabolic bone diseases. Prof Pereira will be missed by her family, many lifelong colleagues, friends, and patients. She is survived by her husband, Ricardo, a great motivator and supporter of her academic career. We are now committed to turning sadness into a strength and celebrating Prof Pereira's personal and scientific legacy. The peer review history for this article is available at https://publons.com/publon/10.1002/jbmr.4767. The peer review history for this article is available at https://publons.com/publon/10.1002/jbmr.4767.

Debunking the myth of the ‘mentally ill’ mass shooter

The Depression and Bipolar Support Alliance (DBSA) acknowledges the heaviness that many people around the country are feeling in the wake of the mass shootings at Robb Elementary School in Uvalde, Texas, and Saint Francis Hospital in Tulsa, Oklahoma, which, sadly, follow on the heels of shooting incidents earlier this year in Buffalo, Dallas, and Los Angeles.

Assessment of the effects of rapid diagnostic biofire blood culture identification panel in hospitalized patients

Background: Bloodstream infections (BSIs) have life-threatening consequences; they contribute to increased global morbidity and mortality, particularly in critically ill patients. Consequently, early implementation of effective antimicrobial therapy is crucial. Microbiology stewardship efforts, such as rapid diagnostic testing, streamline healthcare resources while also optimizing clinical outcomes. These outcomes include decreased mortality, fewer days of hospitalization, and more efficient time to appropriate anti-infective regimens. Biofire Blood Culture Identification (BCID) is a 2-stage multiplexed PCR system yielding multiple pathogen etiologies, as well as antimicrobial resistance genes. Results are published ~60 minutes after a blood-culture Gram stain turns positive. The purpose of this study was to assess the clinical impact of rapid diagnostic PCR testing, which was introduced at Saint Francis Hospital in March 2020. Methods: We conducted a single-center, retrospective observational chart review before and after implementation of Biofire BCID, surveying all positive cultures from December 2019 through June 2020. Medical records were more thoroughly reviewed for patients who met study inclusion criteria. The primary outcome of interest, time to appropriate antimicrobial therapy, included both days to targeted therapy in the setting of a probable pathogen, and days to antibiotic discontinuation in the case of a likely contaminant (nonpathogenic normal skin flora introduced into culture at the time of collection or processing). Secondary outcomes included in-hospital mortality (death during hospitalization), and inpatient length of stay (LOS). Wilcoxon rank-sum tests were used for primary outcomes and Fisher exact tests were used for secondary outcomes. Results: Among 643 patients with positive blood cultures, 410 (63.8%) met the criteria. In the study, 220 patients before the intervention and 190 patients after the intervention were reviewed. The difference in mean days to targeted therapy with a probable pathogen and days to antibiotic discontinuation with a likely contaminant were both observed at a significance level (3.62 vs 1.79, P Inpatient mortality rates were higher prior to launching Biofire BCID, but they were not statistically significant (15.5% vs 14.2 %; P = .782). The average LOS before and after implementation was 12.6 days (range, 2–92 days), and 10 days (range, 2–68 days), respectively. This parameter was also not statistically significant (P = .597). Conclusions: We detected a trend toward a significant reduction in time to appropriate antimicrobial therapy following the launch of Biofire BCID. Incorporation of molecular rapid diagnostics for BSI evaluation should be the standard of care in hospital settings.Funding: NoneDisclosures: None

Early Palliative Care Consultation Reduces Length Of Stay And Cost In Patients Hospitalized With Acute Decompensated Heart Failure

Early Palliative Care Consultation Reduces Length Of Stay And Cost In Patients Hospitalized With Acute Decompensated Heart Failure

Fitusiran, an Investigational siRNA Therapeutic Targeting Antithrombin for the Treatment of Hemophilia: First Results from a Phase 3 Study to Evaluate Efficacy and Safety in People with Hemophilia a or B without Inhibitors (ATLAS-A/B)

Fitusiran, an Investigational siRNA Therapeutic Targeting Antithrombin for the Treatment of Hemophilia: First Results from a Phase 3 Study to Evaluate Efficacy and Safety in People with Hemophilia a or B without Inhibitors (ATLAS-A/B)

Decade of Patient Experience Improvement at a Tertiary Care Urban Hospital.

The purpose of this quality management study was to demonstrate how one hospital made a journey from average patient experience to become a regional leader in the experience of patient care for nationally recognized quality and safety metrics. Saint Francis Hospital & Medical Center (SFHMC) located in Hartford, Connecticut, serves a diverse sociodemographic community as part of Trinity Health. "Recommend the Hospital" (RTH) has been the main marker of patient experience at SFHMC and Trinity Health across the United States as part of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). From 2010 to 2019, SFHMC implemented unit-based rounding hospital-wide, adopting charge nurse and executive leadership rounding as standard work. The intense support from senior leadership spurred the implementation of these changes across middle management and all frontline workers. The t test was used to determine differences between the mean RTH scores between SFHMC, Connecticut, and the United States. Patient experience at SFHMC was regularly assessed by Press Ganey surveys and HCAHPS, which demonstrated higher scores than averages for the state of Connecticut and the United States between 2010 and 2019 (both Ps < .001). SFHMC was the top performer with an RTH score of 83%, with the state average being 71% and the national average being 72%. In the years following the implementation of a multipronged low-cost strategy, hospital RTH scores rose linearly from the state and national average. SFHMC observed gains in patient safety and quality scores as measured by national benchmarks, including Leapfrog patient safety scores of 7 A's and 1 B over a 4-year period. SFHMC was the only hospital in Connecticut to receive an A grade 4 years in a row. A combination of nurse-led, unit-based rounding and executive team rounding with a consistent focus on patient experience resulted in significant improvement in RTH scores for a busy teaching urban hospital, with only a modest investment of resources. There was also improvement in quality and safety outcomes, which together with patient experience of care drove fiscal stability in an increasingly value-based health care environment.

HIV sero-positivity and risk factors for ischaemic and haemorrhagic stroke in hospitalised patients in Uganda: A prospective-case-control study

ObjectivesWe examined HIV sero-positivity and risk factors in patients admitted with ischaemic stroke (IS) and haemorrhagic stroke (HS) in Kampala, Uganda. Study designWe conducted a matched case-control study between December 2016 and December 2018 ​at ​St Francis Hospital, Nsambya. MethodsThe study population comprised of stroke cases (adults aged ≥18 years with IS or HS confirmed by neuroimaging) and controls (age- and sex-matched stroke-free adults aged ≥18 years who were recruited from the same hospital as the cases). A comprehensive assessment for sociodemographic, lifestyle and clinical factors was performed using the World Health Organization (WHO) STEP-wise approach to Surveillance (STEPS) for stroke risk factor surveillance. We used conditional logistic regression to identify risk factors associated with IS or HS. ResultsWe enrolled 137 matched case-control pairs; 48 (35%) were men, and the mean ages were 62.4 years (SD ​± ​14.8) for cases and 61.1 years (SD ​± ​14.1) for controls. Of stroke patients, 86 (63%) had IS and 51 (37%) had HS. Overall, HIV sero-positivity was 10% among stroke cases versus 7% among controls. HIV sero-positivity was not significantly associated with stroke (unadjusted odds ratio [uOR] ​= ​1.49, 95% confidence interval [CI] 0.59–3.78). A self-reported family history of diabetes mellitus was associated with an increased risk of all stroke (adjusted odds ratio [aOR] ​= ​4.41, 95% CI 1.47–13.2), as well as for IS and HS separately (aOR ​= ​3.66, 95% CI 1.09–12.4 and aOR ​= ​4.99, 95% CI 1.02–24.4, respectively). High blood pressure (≥140/90 ​mmHg) was associated with an increased risk of all stroke (aOR ​= ​12.3, 95% CI 42–44.1), and this was also true for IS and HS individually (aOR ​= ​6.48, 95% CI 1.15–36.7 and aOR ​= ​5.63, 95% CI 1.74–18.2, respectively). ConclusionsNo association was found between HIV sero-positivity and stroke occurrence among Ugandan stroke patients. Hypertension and a self-reported family history of diabetes mellitus were significant risk factors for both IS and HS. Interventions to reduce hypertension and diabetes mellitus in the Ugandan population are urgently required. Much larger studies are required to demonstrate if any association exists between HIV and stroke.

Prevalence and factors associated with alcohol consumption among persons with diabetes in Kampala, Uganda: a cross sectional study

BackgroundThe prevalence of diabetes has been rising increasing rapidly in middle- and low-income countries. In Africa, the World Health Organization projections anticipate diabetes mellitus to be the seventh leading cause of death in by 2030. Alcohol consumption influences diabetes evolution, in such a way that it can interfere with self-care behaviours which are important determinants of diabetes prognosis. In this study, we evaluated factors associated with alcohol consumption among persons with diabetes in Kampala to inform management policies and improve comprehensive diabetes care.MethodologyA cross-sectional study was conducted systematically among 290 adults with diabetes, attending diabetic clinics at Mulago National Referral Hospital and St Francis Hospital Nsambya. Data were entered and analysed in Epi-Info version 7 and STATA 13 software. Modified Poisson regression was used to identify factors associated with alcohol consumption among persons with diabetes. All tests were two-sided and the significance level for all analyses was set to p < 0.05.ResultsThe prevalence of alcohol consumption among persons with diabetes was 23.45% [95% CI: 18.9–28.7%]. Divorced, separated and widowed patients (Adj PR: 0.42, 95% CI: 0.21–0.83); and Protestant (Adj PR: 0.44, 95% CI: 0.24–0.82); Muslim (Adj PR: 0.30, 95% CI: 0.14–0.62); and Pentecostal (Adj PR: 0.32, 95% CI: 0.15–0.65) patients were less likely to consume alcohol. Diabetic patients who had a diabetes duration greater than 5 years were more likely to consume alcohol (Adj PR: 1.90, 95% CI: 1.25–2.88).ConclusionApproximately one-quarter of participants consumed alcohol. However being catholic, never being married and having diabetes for more than 5 years predisposed persons with diabetes to alcohol consumption. Sensitization messages regarding alcohol consumption among persons with diabetes should be target patients who have never been married and those who have spent more than 5 years with diabetes; religion should also be considered as an important venue for health education in the community.

Electrocardiographic Manifestations of COVID-19: Effect on QRS and QTc

Introduction: Prolonged QT intervals have been reported in patients with COVID-19. Virus particles have been demonstrated in heart tissue and direct effects on cardiac function have been noted. We hypothesize that cardiac electrophysiologic abnormalities may be a direct effect of COVID-19.Methods: 814 patients with RT-PCR proven COVID-19 were admitted and 614 discharged home from St. Francis Hospital Emergency Room (ER) between March-May 2020. Corrected QT (QTc) and QRS intervals were measured from ECG’s performed in the ER prior to intervention or administration of QT prolonging drugs. QTc and QRS intervals were evaluated as a function of disease severity (patients admitted versus discharged home; inpatients admitted to medical vs critical care unit) and cardiac involvement (troponin elevation >0·03 ng/ml, elevated B-natriuretic peptide (BNP) or NT pro-BNP >500 pg/ml). Multivariable analysis was used to test for significance (pResults: Average age was 66 ± 16 years, 45% female, 46% hypertensive, 28% diabetic, average body mass index of 28·7 ± 6·4 kg/m 2 . Baseline QTc of inpatients was prolonged compared to patients discharged home (450·1 ± 30·2 msec versus 423·4 ± 21·7msec, pConclusion: Abnormalities of cardiac activation (QRS) and repolarization (QTc) are direct manifestations of COVID-19 and early markers for progression to severe disease. The ECG, a readily accessible tool, identifies cardiac involvement and can be used to predict disease course and mortality.Funding Statement: Funding provided by the research foundation at Catholic Health of Long Island.Declaration of Interests: None.Ethics Approval Statement: The study was submitted for expedited Internal Review Board Review and received a waiver given its retrospective nature of data analysis in anonymized subjects.