Cincinnati Hospital Research Articles

Quality ofIntegration ofAir Force Trauma Surgeons Within the Center forSustainment ofTrauma andReadiness Skills, Cincinnati: A Pilot Study.

While previous studies have analyzed military surgeon experience within military-civilian partnerships (MCPs), there has never been an assessment of how well military providers are integrated within an MCP. The Center for Sustainment of Trauma and Readiness Skills, Cincinnati supports the Critical Care Air Transport Advanced Course and maintains the clinical skills of its staff by embedding them within the University of Cincinnati Medical Center. We hypothesized that military trauma surgeons are well integrated within University of Cincinnati Medical Center and that they are exposed to a similar range of complex surgical pathophysiology as their civilian partners. After Institutional Review Board approval, Current Procedural Terminology (CPT) codes were abstracted from billing data for trauma surgeons covering University of Cincinnati Hospitals in 2019. The number of trauma resuscitations and patient acuity metrics were abstracted from the Trauma Registry and surgeon Knowledge, Skills, and Abilities clinical activity (KSA-CA) scores were calculated using their CPT codes. Finally, surgeon case distributions were studied by sorting their CPT codes into 23 categories based on procedure type and anatomic location. Appropriate, chi-squared or Mann-Whitney U-tests were used to compare these metrics between the military and civilian surgeon groups and the metrics were normalized by the group's full-time equivalent (FTE) to adjust for varying weeks on service between groups. Data were available for two active duty military and nine civilian staff. The FTEs were significantly lower in the military group: military 0.583-0.583 (median 0.583) vs. civilian 0.625-1.165 (median 1.0), P = 0.04. Per median FTE and surgeon number, both groups performed a similar number of trauma resuscitations (civilian 214 ± 54 vs. military 280 ± 13, P = 0.146) and KSA-CA points (civilian 55,629 ± 25,104 vs. military 36,286 ± 11,267; P = 0.582). Although the civilian surgeons had a higher proportion of hernia repairs (P < 0.001) and laparoscopic procedures (P = 0.006), the CPT code categories most relevant to combat surgery (those relating to solid organ, hollow viscus, cardiac, thoracic, abdominal, and tissue debridement procedures) were similar between the surgeon groups. Finally, patient acuity metrics were similar between groups. This is the first assessment of U.S. Air Force trauma surgeon integration relative to their civilian partners within an MCP. Normalized by FTE, there was no difference between the two groups' trauma experience to include patient acuity metrics and KSA-CA scores. The proportion of CPT codes that was most relevant to expeditionary surgery was similar between the military and civilian partners, thus optimizing the surgical experience for the military trauma surgeons within University of Cincinnati Medical Center. The methods used within this pilot study can be generalized to any American College of Surgeons verified Trauma Center MCP, as standard databases were used.

Gestational exposure to environmental chemicals and epigenetic alterations in the placenta and cord blood mononuclear cells

BackgroundExposure to environmental chemicals such as phthalates, phenols, and polycyclic aromatic hydrocarbons (PAHs) during pregnancy can increase the risk of adverse newborn outcomes. We explored the associations between maternal exposure to select environmental chemicals and DNA methylation in cord blood mononuclear cells (CBMC) and placental tissue (maternal and fetal sides) to identify potential mechanisms underlying these associations.MethodThis study included 75 pregnant individuals who planned to give birth at the University of Cincinnati Hospital between 2014 and 2017. Maternal urine samples during the delivery visit were collected and analyzed for 37 biomarkers of phenols (12), phthalates (13), phthalate replacements (4), and PAHs (8). Cord blood and placenta tissue (maternal and fetal sides) were also collected to measure the DNA methylation intensities using the Infinium HumanMethylation450K BeadChip. We used linear regression, adjusting for potential confounders, to assess CpG-specific methylation changes in CBMC (n = 54) and placenta [fetal (n = 67) and maternal (n = 68) sides] associated with gestational chemical exposures (29 of 37 biomarkers measured in this study). To account for multiple testing, we used a false discovery rate q-values < 0.05 and presented results by limiting results with a genomic inflation factor of 1±0.5. Additionally, gene set enrichment analysis was conducted using the Kyoto Encyclopedia of Genes and Genomics pathways.ResultsAmong the 29 chemical biomarkers assessed for differential methylation, maternal concentrations of PAH metabolites (1-hydroxynaphthalene, 2-hydroxyfluorene, 4-hydroxyphenanthrene, 1-hydroxypyrene), monocarboxyisononyl phthalate, mono-3-carboxypropyl phthalate, and bisphenol A were associated with altered methylation in placenta (maternal or fetal side). Among exposure biomarkers associated with epigenetic changes, 1-hydroxynaphthalene, and mono-3-carboxypropyl phthalate were consistently associated with differential CpG methylation in the placenta. Gene enrichment analysis indicated that maternal 1-hydroxynaphthalene was associated with lipid metabolism and cellular processes of the placenta. Additionally, mono-3-carboxypropyl phthalate was associated with organismal systems and genetic information processing of the placenta.ConclusionAmong the 29 chemical biomarkers assessed during delivery, 1-hydroxynaphthalene and mono-3-carboxypropyl phthalate were associated with DNA methylation in the placenta.

Outcomes of continent and incontinent external urinary diversion in management of patients with refractory non-malignant lower urinary tract dysfunction.

To evaluate the early and late outcomes of continent and incontinent external urinary diversion in management of patients with refractory non-malignant lower urinary tract dysfunction (LUTD). The charts of patients with refractory non-malignant LUTD who underwent continent or incontinent external urinary diversion at University of Cincinnati hospitals in the period between March 2012 and December 2019 were retrospectively reviewed. The demographic and baseline characteristics, surgery indications, operative data, early and late outcomes were collected, analyzed, and compared. A total of 78 patients including 55 patients with neurogenic bladder (NGB) and 23 patients with non-neurogenic bladder (non-NGB) refractory non-malignant LUTD were included. Fifty-three patients underwent incontinent urinary diversions (IUD), while 25 patients underwent continent urinary diversions (CUD). During the first 4 postoperative weeks, 53.85% (n=42) of patients developed complications, and the incidence was nonsignificantly higher in patients with NGB than those with non- NGB (56.36% vs 47.83%, p-value=0.490). Fever was exclusively encountered in patients with NGB earlier, while stomal retraction occurred only in patients with non-NGB later. More non- NGB patients had early wound infection. There was an overall improvement of urological symptoms in 52 patients (66.67%), and the rate was non-significantly higher in non-NGB patients than NGB patients (78.26% vs 61.82%, p-value=0.160). Late complications were reported in 47 patients and were more encountered in those with non-NGB than those with NGB (65.22% vs 58.18%). Stomal leakage and stenosis occurred more with CUD than with IUD (52% vs 0% and 28% vs 3.77%, respectively). External urinary diversion can achieve a reasonable level of urological symptoms control in patients with refractory non-malignant LUTD, but with associated adverse outcomes. Although non-significantly, these complications tend to be higher in patients with IUD and/or NGB during the early postoperative period and higher with CUD and/or non-NGB on the long-term.

Efficacy and safety of TURP, HoLEP, and PVP in the management of OAB symptoms complicating BPH in patients with moderately enlarged prostates: A comparative study.

We aimed to compare the effectiveness and safety of transurethral resection of the prostate (TURP), holmium laser enucleation of the prostate (HoLEP), and photoselective vaporization of the prostate (PVP) in management of storage and overactive bladder (OAB) symptoms complicating benign prostatic hyperplasia (BPH) in patients with moderately enlarged prostates. The charts of patients with moderately enlarged prostates and BPH complicated by storage and OAB symptoms who were treated by TURP, HoLEP, and PVP at University of Cincinnati hospitals between March 2012 and December 2020 were retrospectively reviewed and analyzed for changes in storage and OAB symptomatology, International Prostate Symptom Score (IPSS), peak flow rates (Qmax), presence of detrusor overactivity (DO), and postvoid residual (PVR) from baseline to up to six months postoperatively. A total of 204 patients with moderately enlarged prostates and BPH complicated by storage and OAB symptoms were divided into three groups: group 1 (patients who underwent TURP, 89 patients), group 2 (those who underwent HoLEP, 64 patients), and group 3 (those who underwent PVP, 51 patients). TURP, HoLEP, and PVP were associated with significant improvement in urodynamics study (UDS) parameters, patient storage and OAB symptomatology, and IPSS from preoperatively to both three and six months postoperatively in BPH patients with moderately enlarged prostates, with relatively low procedure complication rate and postoperative need for either anticholinergic or procedure. TURP, HoLEP, and PVP are effective and reliable surgical procedures that can be relied upon for BPH patients with moderately enlarged prostates and storage or OAB symptoms, with comparable efficacy and relatively low procedure complication rate and postoperative need for anticholinergic or additional procedure.

Is Holmium Laser Enucleation of Prostate equally effective in management of benign prostatic hyperplasia patients with either voiding or storage lower urinary tract symptoms? A comparative study.

To evaluate and compare the effectiveness and safety of holmium laser enucleation of prostate (HoLEP) in relieving either voiding or storage lower urinary tract symptoms (LUTS) in benign prostatic hyperplasia (BPH) patients. The charts of patients with BPH who underwent HoLEP for either predominant voiding or predominant storage LUTS at University of Cincinnati hospitals in the period between February 2015 and December 2020 were retrospectively reviewed and analyzed for changes in voiding symptomatology, storage symptomatology, hematuria, International Prostate Symptom Score (IPSS), peak flow rates (Qmax), presence of detrusor overactivity (DO), and post-voiding residual urine (PVR) from baseline to up to 6 months postoperatively. A total of 132 patients were included in the analysis. Patients were divided into two groups: Group 1 included BPH patients with predominant voiding LUTS (68 Patients) while group 2 involved those with predominant storage LUTS (64 Patients). HoLEP was equally effective in management of both groups with significant improvement in urodynamics study (UDS) parameters, patient voiding and storage symptomatology, and IPSS from preoperatively to up to 6 months postoperatively with relatively low procedure complication rate and postoperative need for medication or procedure. HoLEP is a safe, effective, and reliable minimally invasive surgical modality that can be relied on for BPH patients with either predominant voiding or predominant storage symptoms with relatively low procedure complicat.

Long-term exposure to fine particulate matter and hospitalization in COVID-19 patients

BackgroundEcological evidence suggests that exposure to air pollution affects coronavirus disease 2019 (COVID-19) outcomes. However, no individual-level study has confirmed the association to date. MethodsWe identified COVID-19 patients diagnosed at the University of Cincinnati hospitals and clinics and estimated particulate matter ≤2.5 μm (PM2.5) exposure over a 10-year period (2008–2017) at their residential zip codes. We used logistic regression to evaluate the association between PM2.5 exposure and hospitalizations for COVID-19, adjusting for socioeconomic characteristics and comorbidities. ResultsAmong the 1128 patients included in our study, the mean (standard deviation) PM2.5 was 11.34 (0.70) μg/m3 for the 10-year average exposure and 13.83 (1.03) μg/m3 for the 10-year maximal exposures. The association between long-term PM2.5 exposure and hospitalization for COVID-19 was contingent upon having pre-existing asthma or chronic obstructive pulmonary (COPD) (Pinteraction = 0.030 for average PM2.5 and Pinteraction = 0.001 for maximal PM2.5). In COVID-19 patients with asthma or COPD, the odds of hospitalization were 62% higher with 1 μg/m3 increment in 10-year average PM2.5 (odds ratio [OR]: 1.62, 95% confidence interval [CI]: 1.00–2.64) and 65% higher with 1 μg/m3 increase in 10-year maximal PM2.5 levels (OR: 1.65, 95% CI: 1.16–2.35). However, among COVID-19 patients without asthma or COPD, PM2.5 exposure was not associated with higher hospitalizations (OR: 0.84, 95% CI: 0.65–1.09 for average PM2.5 and OR: 0.78, 95% CI: 0.65–0.95 for maximal PM2.5). ConclusionsLong-term exposure to PM2.5 is associated with higher odds of hospitalization in COVID-19 patients with pre-existing asthma or COPD.

316. Application of New Consensus Definition Identifies High Numbers of Fracture Related Infections with Negative Cultures

BackgroundFracture related infection (FRI) is a severe complication in trauma surgery but defining the full impact of these infections has been challenging with the lack of clear diagnostic criteria. This is particularly problematic for culture-negative FRI (CNFRI), which lack pathogen identification to guide antimicrobial therapy. However, new consensus definition and criteria for the diagnosis of FRI (Table) may help reduce the risk of diagnostic error. The purpose of this study was to determine the proportion and clinical characteristics of CNFRI cases at a level I trauma hospital using the new diagnostic criteria. MethodsLaboratory reports were used to identify all patients with at least one specimen submitted for microbiology culture by an orthopedic surgeon at our trauma I level hospital in Cincinnati, Ohio during a three-year study period. This cohort was refined by an electronic medical record (EMR) review to select patients that met the diagnostic criteria for suspected/confirmed FRI. The specimen details and results of the cultures were recorded for the first orthopedic surgeon collection for each suspected FRI case. Clinical data, including fracture characteristics, surgical treatment, antibiotic utilization, and patient outcomes were also extracted from the EMR for each case.ResultsA total of 246 patients were identified with at least one culture specimen; 35.8% (n = 88) of these were deemed suspected/confirmed FRI based on consensus guidelines. The cultures for the first orthopedic surgery collection on these FRI were negative for 35% (n = 31). The most common location for CNFRI were proximal lower extremity fractures (52%), a distribution different from that of culture positive (Figure). Culture positive FRI were predominated by Staphylococcus aureus (39%) followed by gram negative rods (23%). ConclusionThis retrospective cohort study identified a sizable proportion of CNFRI at our trauma center using the recently published consensus definition. While further analysis is necessary to determine the exact impact of these new criteria, this suggests that clearer definitions may facilitate improved recognition of CNFRI. Because of the relatively high rates of CNFRI, efforts to standardize laboratory diagnostic processes and case management will be required.DisclosuresHenry C. Sagi, MD, FACS, Conexxions (Board Member)GLW trauma (Consultant)GLW trauma (Shareholder)Stryker (Consultant)

Therapeutic Opportunities for Intestinal Angioectasia- Targeting PPARγ and Oxidative Stress.

Recurrent and acute bleeding from intestinal tract angioectasia (AEC) presents a major challenge for clinical intervention. Current treatments are empiric, with frequent poor clinical outcomes. Improvements in understanding the pathophysiology of these lesions will help guide treatment. Using data from the US Food and Drug Administration (FDA)’s Adverse Event Reporting System (FAERS), we analyzed 12 million patient reports to identify drugs inversely correlated with gastrointestinal bleeding and potentially limiting AEC severity. FAERS analysis revealed that drugs used in patients with diabetes and those targeting PPARγ‐related mechanisms were associated with decreased AEC phenotypes (P < 0.0001). Electronic health records (EHRs) at University of Cincinnati Hospital were analyzed to validate FAERS analysis. EHR data showed a 5.6% decrease in risk of AEC and associated phenotypes in patients on PPARγ agonists. Murine knockout models of AEC phenotypes were used to construct a gene‐regulatory network of candidate drug targets and pathways, which revealed that wound healing, vasculature development and regulation of oxidative stress were impacted in AEC pathophysiology. Human colonic tissue was examined for expression differences across key pathway proteins, PPARγ, HIF1α, VEGF, and TGFβ1. In vitro analysis of human AEC tissues showed lower expression of PPARγ and TGFβ1 compared with controls (0.55 ± 0.07 and 0.49 ± 0.05). National Center for Biotechnology Information (NCBI) Gene Expression Omnibus (GEO) RNA‐Seq data was analyzed to substantiate human tissue findings. This integrative discovery approach showing altered expression of key genes involved in oxidative stress and injury repair mechanisms presents novel insight into AEC etiology, which will improve targeted mechanistic studies and more optimal medical therapy for AEC.

The Midwest ST-Elevation Myocardial Infarction Consortium: Design and Rationale

BackgroundOver the past 20 years, the development of regional ST-elevation myocardial infarction (STEMI) care systems has led to remarkable progress in achieving timely coronary reperfusion with attendant improvement in clinical outcomes, including survival. Despite this progress, contemporary STEMI care does not consistently meet the national guideline-recommended goals, which offers an opportunity for further improvement in STEMI outcomes. The lack of single, comprehensive, national STEMI registry complicates our ability to improve STEMI outcomes in particular for high-risk STEMI subsets such as cardiac arrest (CA) and/or cardiogenic shock (CS). ObjectivesTo address this need, the Midwest STEMI Consortium (MSC) was created as a collaboration of 4 large, regional STEMI care systems to provide a comprehensive, multicenter, and prospective STEMI registry without any exclusionary criteria. MethodsThe MSC is a collaboration of 4 large, regional STEMI care systems: Iowa Heart Center in Des Moines, IA; Minneapolis Heart Institute Foundation in Minneapolis, MN; Prairie Heart Institute in Springfield, IL; and The Christ Hospital in Cincinnati, OH. Each has similar standardized STEMI protocol and together include 6 percutaneous coronary intervention (PCI)-capable hospitals and over 100 non-PCI-capable hospitals. Each center had a prospective database that was transferred to a data coordinating center to create the multicenter database. The comprehensive database includes traditional risk factors, cardiovascular history, medications, time to treatment data, detailed angiographic characteristics, and short- and long-term clinical outcomes up to 5-year for myocardial infarction, stroke, and cardiovascular and all-cause mortality. Ten-year mortality rates were assessed by using national death index. ResultsCurrently, the comprehensive database (03/2003–01/2020) includes 14,911 consecutive STEMI patients with mean age of 62.3 ± 13.6 years, female gender (29%), and left anterior descending artery as the culprit vessel (34%). High risk features included: Age >75 years (19%), left ventricular ejection fraction <35% (15%), CA (10%), and CS (8%). ConclusionThis collaboration of 4 large, regional STEMI care systems with broad entry criteria including high-risk STEMI subsets such as CA and/or CS provides a unique platform to conduct clinical research studies to optimize STEMI care.

Salpingectomy versus Tubal Occlusion for Permanent Contraception during Cesarean Delivery: Outcomes and Physician Attitudes

Compare clinical outcomes and physician attitudes toward tubal occlusion and salpingectomy during cesarean section. Retrospective cohort study with survey. Private hospital in Cincinnati, Ohio. Women aged ≥18 years undergoing permanent contraception during cesarean delivery with and without salpingectomy from January 2016 to December 2017. Rate measurements of permanent contraception during cesarean section by salpingectomy versus tubal occlusion. Online survey assessment of study population physicians' attitudes toward salpingectomy. Study subjects identified using Current Procedural Terminology codes. Subject demographics, operative details, and perioperative morbidity indicators were identified by chart review. A total of 363 subjects were included: 116 (32%) had salpingectomies, and 247 (68%) had tubal occlusions. Study variables were compared using Wilcoxon rank sum and Fisher exact tests. Despite similar cohort demographics, salpingectomy increased mean operative time by 6.5 minutes compared with tubal occlusion (p = .001). Compared with subjects who had a salpingectomy, those who had a tubal occlusion had more postoperative symptomatic anemia (5.7% vs 0.9%) and infection (6.9% vs 1.7%). The primary surgeon was identified by logistic regression as the factor most predictive of salpingectomy (p <.001). Of 30 physicians, 23 (77%) completed the survey, and these physicians performed 80% of procedures. Physicians did not differ by sex, age, years of practice, solo vs group practice, or hospital-employed vs private practice when compared with the number or rate of salpingectomies performed. Cancer risk reduction was the most common physician-identified salpingectomy benefit (17 of 23, 74%). A total of 65% believed that salpingectomy posed additional risks, but 70% believed the benefits were equal to or greater than the risks. Of the 23 (87%) who completed the survey, 20 believed that salpingectomy added no additional operative time and was cost-neutral. Relative to tubal ligation, salpingectomy during cesarean section increases operative time but not perioperative morbidity. Physicians do not seem biased against salpingectomy and express awareness of published benefits and risks, yet it is not the dominant surgical approach.

Editorial introductions

Editorial introductions

Content analysis of requests for religious exemptions from a mandatory influenza vaccination program for healthcare personnel

ObjectiveHaving failed to achieve adequate influenza vaccination rates among employees through voluntary programmes, healthcare organisations have adopted mandatory ones. Some programmes permit religious exemptions, but little is known about who...

Project Spotlight: Precast concrete panels meet structural, design goals in Cincinnati Hospital

The Mercy Health–West Hospital in Cincinnati, Ohio, used insulated sandwich panels to provide energy efficiency and span from column to column. High Concrete Group LLC of Denver, Pa., was selected as the precast producer.

An Electronic Health Record−Based Strategy to Address Child Tobacco Smoke Exposure

A high proportion of children presenting to pediatric urgent cares are exposed to tobacco smoke. An electronic health record-based clinical decision support system for nurses to facilitate guideline-based tobacco smoke exposure screening and counseling for caregivers who smoke was designed and evaluated. A mixed-methods, 3-month, prospective study that began in November 2015, data were analyzed in June 2016. Five urgent cares that were part of a large children's hospital in Cincinnati, OH. Participants were urgent care nurses. The clinical decision support system prompted nurses to Ask, Advise, Assess, and Assist caregivers to quit smoking. Monthly feedback reports were also provided. Clinical decision support system use rates, nurses' attitudes towards tobacco smoke exposure intervention, and percentage of children screened and caregivers counseled. All nurses used the clinical decision support system. Compared with Month 1, nurses were twice as likely to advise and assess during Months 2 and 3. There was significant improvement in nurses feeling prepared to assist caregivers in quitting. Nurses reported that feedback reports motivated them to use the clinical decision support system, and that it was easy to use. Almost 65% of children were screened for tobacco smoke exposure; 19.5% screened positive. Of caregivers identified as smokers, 26% were advised to quit and 29% were assessed for readiness to quit. Of those assessed, 67% were interested in quitting, and of those, 100% were assisted. A clinical decision support system increased rates of tobacco smoke exposure screening and intervention in pediatric urgent cares. Rates might further improve by incorporating all components of the clinical decision support system into the electronic health record. This study is registered at www.clinicaltrials.gov NCT02489708.

Evaluation and Management of Primary Ovarian Insufficiency in Adolescents and Young Adults

Study ObjectiveTo identify clinical features associated with primary ovarian insufficiency (POI) and collect data on the evaluation and treatment received. DesignRetrospective chart review. Data were abstracted on etiology of POI, history, laboratory evaluation, imaging results, return for clinical care, and treatment plans. SettingUrban children's hospital in Cincinnati, Ohio. ParticipantsFifty female patients, age 11-26 years, with initial presentation of POI between January 1, 2006 and December 31, 2015. Main Outcome MeasuresEtiology of POI, bone mineral density (BMD), laboratory evaluation, and services utilized at presentation. ResultsThree hundred thirty-one charts were reviewed, 71 with confirmed diagnosis of POI, and 50 with sufficient data for inclusion. Among the 50, 21 (42%) had Turner syndrome, 18 (36%) remained idiopathic, and 11 (22%) had another condition (eg, autoimmune polyglandular syndrome, galactosemia, etc). Thirty-six (72%) were karyotyped; in 14 (28%), 21-hydroxylase antibodies were measured; 32 (64%) underwent dual-energy x-ray absorptiometry BMD measures of lumbar spine. Eight of 50 patients (16%) reported fracture. Of these, at presentation, 4 (50%) had low BMD, and 2 (25%) had slightly low BMD. On initial spinal dual-energy x-ray absorptiometry, 9 of 32 (28%) had low BMD (Z-score ≤ −2.0) and 7 of 32 (22%) were slightly low (−1.0 to −1.9). All started estrogen therapy within 2 years of presentation. In follow-up, only 2 patients (4%) saw a mental health consultant for emotional support. ConclusionPOI is a model of estrogen deficiency with most cases due to Turner syndrome or idiopathic causes. At presentation, many had low BMD and few were seen for psychological support as part of multidisciplinary care.

Enterovirus D68 Infection Among Children With Medically Attended Acute Respiratory Illness, Cincinnati, Ohio, July-October 2014.

Enterovirus D68 (EV-D68) caused a widespread outbreak of respiratory illness in the United States in 2014, predominantly affecting children. We describe EV-D68 rates, spectrum of illness, and risk factors from prospective, population-based acute respiratory illness (ARI) surveillance at a large US pediatric hospital. Children <13 years of age with ARI and residence in Hamilton County, Ohio were enrolled from the inpatient and emergency department (ED) settings at a children's hospital in Cincinnati, Ohio, from 1 July to 31 October 2014. For each participant, we interviewed parents, reviewed medical records, and tested nasal and throat swabs for EV-D68 using real-time reverse- transcription polymerase chain reaction assay. EV-D68 infection was detected in 51 of 207 (25%) inpatients and 58 of 505 (11%) ED patients. Rates of EV-D68 hospitalization and ED visit were 1.3 (95% confidence interval [CI], 1.0-1.6) and 8.4 per 1000 children <13 years of age, respectively. Preexisting asthma was associated with EV-D68 infection (adjusted odds ratio, 3.2; 95% CI, 2.0-5.1). Compared with other ARI, children with EV-D68 were more likely to be admitted from the ED (P ≤ .001), receive supplemental oxygen (P = .001), and require intensive care unit admission (P = .04); however, mechanical ventilation was uncommon (2/51 inpatients; P = .64), and no deaths occurred. During the 2014 EV-D68 epidemic, high rates of pediatric hospitalizations and ED visits were observed. Children with asthma were at increased risk for medically attended EV-D68 illness. Preparedness planning for a high-activity EV-D68 season in the United States should take into account increased healthcare utilization, particularly among children with asthma, during the late summer and early fall.

227 - Home INR Monitoring Versus Lab Monitoring in Patients With Left Ventricular Assist Device

Introduction: Heart failure patients implanted with an axial or centrifugal left ventricular assist device (LVAD) are treated with warfarin to prevent pump thrombosis. Given the propensity for gastrointestinal bleeding with these patients, careful management of anticoagulation is an essential part of post-operative care. Given the intense involvement of these patients and care-givers, we hypothesized that home monitoring of international normalized ratio (INR) may be more effective than traditional laboratory testing. Methods: We performed a retrospective study of 42 LVAD patients for a six-month period at The Christ Hospital in Cincinnati, OH. INR targets were patient-specific based on clinical history. Twenty-six patients used home testing (HOME: Roche, Alere) with guidance from the LVAD team while 16 patients were monitored using laboratory INR testing (LAB). Monitoring choice was based on patient/physician preference and insurance coverage. Results: Home monitored patients were tested fewer times over the 6 month period than the laboratory group (27 versus 37). In the HOME group, 52% of the INR's were within target range and 48% were outside (26% above and 22% below target). In the LAB group, 36% of INR's were within range and 64% were outside (27% above and 37% below target). Accordingly, percentage of patients experiencing either a bleeding or thrombotic complication was less common in the HOME group compared to LAB (15% versus 25%). Number of thrombotic complications was similar between the two groups, but bleeding complications were less frequent in the HOME group (3 in 26 patients) vs. LAB (7 in 16 patients). Conclusions: LVAD Patients monitored for INR at home required fewer tests, were more likely to be in therapeutic range, and suffered fewer bleeding complications. Relatively low rate of in-target INR's are likely related to narrow ranges and multiple patient factors.

Copper-silver ionization at a US hospital: Interaction of treated drinking water with plumbing materials, aesthetics and other considerations

Tap water sampling and surface analysis of copper pipe/bathroom porcelain were performed to explore the fate of copper and silver during the first nine months of copper-silver ionization (CSI) applied to cold and hot water at a hospital in Cincinnati, Ohio. Ions dosed by CSI into the water at its point of entry to the hospital were inadvertently removed from hot water by a cation-exchange softener in one building (average removal of 72% copper and 51% silver). Copper at the tap was replenished from corrosion of the building’s copper pipes but was typically unable to reach 200 μg/L in first-draw and flushed hot and cold water samples. Cold water lines had >20 μg/L silver at most of the taps that were sampled, which further increased after flushing. However, silver plating onto copper pipe surfaces (in the cold water line but particularly in the hot water line) prevented reaching 20 μg/L silver in cold and/or hot water of some taps. Aesthetically displeasing purple/grey stains in bathroom porcelain were attributed to chlorargyrite [AgCl(s)], an insoluble precipitate that formed when CSI-dosed Ag+ ions combined with Cl− ions that were present in the incoming water. Overall, CSI aims to control Legionella bacteria in drinking water, but plumbing material interactions, aesthetics and other implications also deserve consideration to holistically evaluate in-building drinking water disinfection.

Editorial introductions

Editorial introductions

Intestinal microbiota of preterm infants differ between sites and over time: a comparison of two large neonatal intensive care units (637.8)

Neonatal intensive care units (NICUs) differ in their rates of necrotizing enterocolitis (NEC) and sepsis. Intestinal microbiota are implicated in these diseases, but the microbiota of different NICUs have not been compared. To address this, we included 90 infants &lt;29 weeks gestational age with stool samples collected during week 2 of life who survived free of NEC and sepsis. Infants were enrolled at either Good Samaritan Hospital (GSH) in Cincinnati or University of Alabama Birmingham Medical Center (UAB) in 2010‐2011. The 16s rRNA gene in DNA from stool samples was sequenced with universal primers by Illumina MiSeq. Resulting operational taxonomic unit tables were analyzed for differences between hospitals by year and delivery mode using linear discriminant analysis effect size algorithm (p&lt;0.05). A major shift occurred in the microbiota of UAB infants between 2010 and 2011 with a significant increase in Firmicutes in 2011 ‐ coinciding with a hospital move. At GSH, only minor shifts in microbiota occurred by year. Microbiota differed between the NICUs, with significantly more phylum Bacteroidetes present at UAB in 2011; other differences depended upon delivery mode and year. We conclude that colonizing microbiota differ by NICU and over time. Multi‐site, longitudinal studies of preterm microbiota are needed to assess the impact of intestinal microbiota on conditions affecting preterm infants.Grant Funding Source: Supported by NIAID contract no. HHSN272200900018C; NICHD R01 HD059140; and NIEHS T32 ES010957