Utah Hospital Research Articles

737: Optimal BMI for use of external fetal ECG for fetal heart rate assessment in labor

We have previously shown that in obese women, an external fetal electrocardiogram (fECG) monitoring device generates more interpretable fetal heart rate (FHR) data compared to standard external Doppler monitoring (SEM). We sought to identify the BMI cutoff where a fECG monitoring system would be preferable to SEM to optimize the amount of interpretable FHR data provided in a clinical setting. Secondary analysis of a randomized controlled trial at 4 Utah hospitals. 218 patients with singleton, term pregnancies, were enrolled at labor admission and randomized in blocks based on BMI to fECG or SEM. The proportion of interpretable 10-minute FHR tracing segments was determined following tracing evaluation by two reviewers blinded to study device allocation. A 10-minute FHR segment was deemed interpretable if tracing baseline and periodic changes could be discerned. The proportion of total interpretable minutes of FHR tracing was also evaluated. Mixed effects logistic regression models were fit to predict 10-minute and 1-minute FHR segment interpretability. Akaike information criteria (AIC) were determined to identify the optimal BMI cutoff, indicating when fECG device use consistently provides more interpretable FHR data compared to SEM. Regression model AIC plot identified BMI ≥ 31 as the ideal cut off point for fECG device performance, where fECG generated consistently more interpretable 10-minute FHR tracing segments compared to SEM (Figure 1). For the 1-minute FHR tracing analysis, an even lower BMI cut off point of 25 was identified based on AIC estimates, where fECG generated a higher proportion of interpretable minutes of FHR tracing compared to SEM at BMI 25 (Figure 2). fECG consistently generated more interpretable 10 and 1-minute FHR tracing segments compared to SEM in women with BMI > 31 and > 25, respectively. Obese women with BMI > 31 may benefit from use of the fECG device in labor.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

128: Comparison of fetal ECG and standard external Doppler monitoring performance during second stage of labor

Maternal expulsive efforts may result in loss of fetal heart rate (FHR) monitoring data, potentially leading to unrecognized fetal compromise. We sought to determine if an external fetal electrocardiogram (fECG) monitoring device could provide more interpretable FHR data during the second stage of labor compared to standard external Doppler monitoring (SEM). Secondary analysis of a randomized controlled trial at 4 Utah hospitals. Patients with singleton, term pregnancies, were enrolled at labor admission and randomized in blocks based on body mass index (BMI) to fECG or SEM. Women were included in this analysis if they reached the second stage of labor while remaining on assigned study device (fECG or SEM). The primary outcome for this analysis was the proportion of interpretable 10-minute FHR tracing segments during the second stage of labor, where tracings were evaluated by two reviewers blinded to study device allocation. Tracing segments were deemed interpretable if FHR baseline and periodic changes could be discerned. The proportion of total interpretable minutes of FHR tracing was also evaluated. A mixed effects logistic regression model was fit to predict 10 and 1-minute FHR tracing segment interpretability. Study arm, labor stage, and interaction between device and labor stage were included in the model. Of the 218 women randomized in the initial study, 50 women in the fECG group and 67 in the SEM group reached the second stage of labor while remaining on their originally assigned study device. Maternal demographics and clinical outcomes were similar between arms. fECG generated significantly more interpretable 10-minute segment FHR data in the second stage, where fECG use resulted in almost double the amount of interpretable 10-minute FHR tracing segments compared to SEM (Figure 1). Similar findings were noted in the 1-minute segment FHR tracing analysis (Figure 2). These findings highlight the clinical utility of fECG, particularly during the second stage of labor, when FHR tracing signal quality is often compromised.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

University of Utah to establish new mental health institute

The University of Utah hopes to become a national leader in mental health delivery with a $150 million gift from the Huntsman family to establish a new institute, The Salt Lake Tribune reported Nov. 4. The major gift will create the Huntsman Mental Health Institute to bolster the existing University Neuropsychiatric Institute and psychiatry department, with a focus on improving public awareness of mental illness, research into genetic causes and access — especially for college‐age and rural patients, said university President Ruth Watkins. “This is transformative for the university, for the state, and can serve as a model for others as well,” Watkins said. The university didn't yet have details as to how many clinicians, researchers and staff members would be hired with the gift. But Watkins said the institute will have a strong emphasis on innovative new ways to provide services to patients more efficiently in a state with some of the worst mental health statistics. Access to mental health care is a pervasive issue across the state, with less than half of Utahans with mental health problems receiving treatment, according to research released this summer by the Ken C. Gardner Policy Institute and the Utah Hospital Association.

457. Cutibacterium (Propionibacterium) acnes Infection Rate and Optimization of Surgical Culture Duration

Background Cutibacterium acnes is part of the normal skin and gastrointestinal tract flora that is increasingly recognized as a causative organism of surgical infections. Distinguishing between infection and contamination is difficult. The standard culture duration for C. acnes has not been determined. As a slow-growing organism, a prolonged incubation of 10–14 days is adopted in many laboratories. Ideally, only samples with high pretest probability for infection should be worked up this way, otherwise resources are overutilized with likely no benefits and potential harms to patients. We conduct a study to assess the optimal incubation duration for C. acnes.MethodsWe retrospectively reviewed microbiologic and clinical data of patients who underwent surgical procedures at the Veterans Affairs (VA) Hospital and the University of Utah Hospital in Salt Lake City, Utah, between 2015 and 2018 for which prolonged incubation of surgical samples was requested. Samples that grew C. acnes were divided into three groups (infection, contaminant, indeterminate) based on the quantity of growth and the number of positive samples (Figure 1). Samples in the “indeterminate” group were re-classified into the other two groups based on clinical criteria (Figure 2). Time to culture positivity (TTP) was calculated for each group.Results741 patients contributed to a total of 909 surgical cases. There were 2,401 samples collected resulting in 4,408 bacterial cultures. C. acnes grew in 131 cases (14.41%). Fifty-five cases (44%) fulfilled the criteria for true infections and 70 cases (56%) were contaminants. 6 cases were lost to follow-up. The mean TTP of the infection and the contamination groups were 5.60 + 0.76 days and 8.67 + 0.81 days, respectively. The TTP of C. acnes from specimens of true surgical infections was significantly shorter than that of contaminants by the mean of 3.07 days (95% CI: -4.22 to -1.92); P < 0.001.ConclusionUsing our microbiological and clinical criteria to differentiate infections and contaminations, this study provides evidence that surgical sample cultures should be held no longer than 7 days to limit the effect of contaminated C. acnes on cultures and reduce unnecessary antimicrobial use. Disclosures All authors: No reported disclosures.

Antibiotic Treatment of Suspected and Confirmed Neonatal Sepsis Within 28 Days of Birth: A Retrospective Analysis.

Neonatal sepsis causes significant mortality and morbidity worldwide. Diagnosis is usually confirmed via blood culture results. Blood culture sepsis confirmation can take days and suffer from contamination and false negatives. Empiric therapy with antibiotics is common. This study aims to retrospectively describe and compare treatments of blood culture-confirmed and unconfirmed, but suspected, sepsis within the University of Utah Hospital system. Electronic health records were obtained from 1,248 neonates from January 1, 2006, to December 31, 2017. Sepsis was categorized into early-onset (≤3 days of birth, EOS) and late-onset (>3 and ≤28 days of birth, LOS) and categorized as culture-confirmed sepsis if a pathogen was cultured from the blood and unconfirmed if all blood cultures were negative with no potentially contaminated blood cultures. Of 1,010 neonates in the EOS cohort, 23 (2.3%) were culture-confirmed, most with Escherichia coli (42%). Treatment for unconfirmed EOS lasted an average of 6.1 days with primarily gentamicin and ampicillin while confirmed patients were treated for an average of 12.3 days with increased administration of cefotaxime. Of 311 neonates in the LOS cohort, 62 (20%) were culture-confirmed, most culturing coagulase negative staphylococci (46%). Treatment courses for unconfirmed LOS lasted an average of 7.8 days while confirmed patients were treated for an average of 11.4 days, these patients were primarily treated with vancomycin and gentamicin. The use of cefotaxime for unconfirmed EOS and LOS increased throughout the study period. Cefotaxime administration was associated with an increase in neonatal mortality, even when potential confounding factors were added to the logistic regression model (adjusted odds ratio 2.8, 95%CI [1.21, 6.88], p = 0.02). These results may not be generalized to all hospitals and the use of cefotaxime may be a surrogate for other factors. Given the low rate of blood culture positive diagnosis and the high exposure rate of empiric antibiotics, this patient population might benefit from improved diagnostics with reevaluation of antibiotic use guidelines.

High peak PM2.5 exposure during pregnancy and preterm birth risk in Utah, USA

OPS 54: Air pollution and pregnancy outcomes, Room 117, Floor 1, August 28, 2019, 1:30 PM - 3:00 PM Background/Aim: Studies of preterm birth (≤37 weeks) in association with air pollution have primarily examined chronic average exposures for whole pregnancies/trimesters. Utah is known for valley air inversions which cause relatively short intervals of high exposure to particulate matter <2.5 microns (PM2.5). We examined peak exposures to evaluate whether experiencing particularly high levels during any week of gestation was associated with preterm risk. Methods: PM2.5 was estimated by modified CMAQ models. We classified peaks as a weekly average of >35 ug/m3, which is the US 24-hour regulatory standard, or >18.23 ug/m3, the 95th percentile in our data. Clinical information, including gestational age, was derived from electronic hospital records for 112,203 pregnancies among 50,005 women delivering at 20 Utah hospitals. Results: The preterm birth rate was 7.7%. During each week of gestation, 9.5-13.0/1,000 pregnancies were exposed to an average PM2.5 >35 ug/m3 and 50.6-67.0/1,000 exposed to >18.23 ug/m3. At least one peak exposure week was experienced in 33.5% of pregnancies. Modified Poisson regression models with generalized estimating equations to control for multiple pregnancies to the same woman were adjusted for maternal age, race/ethnicity, BMI, smoking, alcohol use, parity, insurance status, marital status, asthma and ambient temperature. For each first trimester peak exposure week, the relative risk (RR) of preterm birth increased 5-6% (>35 ug/m3 RR=1.06; 95% CI=1.01-1.11; >18.23 ug/m3 RR=1.05; 95% CI=1.02-1.07). Similar results were seen considering the proportion of peak weeks over the whole pregnancy with 3-4% increases (>35 ug/m3 RR=1.04; 95% CI=1.00-1.08; >18.23 ug/m3 RR=1.03; 95% CI=1.01-1.05) and during the first 28 weeks with 2-3% increases (>35 ug/m3 RR=1.03; 95% CI=0.99-1.06; >18.23 ug/m3 RR=1.02; 95% CI=1.01-1.04). Second trimester results were null. Conclusions: We found that even one high week of exposure, particularly in the first trimester, was associated with increased preterm birth in a population of low-risk women.

Lower Proportion of Hospitalizations among Non-Homebound Patients Who Received Home Care after Hospital Discharge for Acute Heart Failure Hospitalization

Introduction Frequent rehospitalizations among patients with heart failure (HF) result in patient burden and cost. Homebound patients with HF qualify for home care after hospital discharge. Whether non-homebound HF patients could also benefit from home care (HC) services through improved transition from hospital to home has not been tested. Hypothesis Home care nursing visits for non-homebound HF patients are likely to improve transition of care from the inpatient to home setting, and result in reduced rehospitalization. Methods We included patients who were discharged between November 2017 and October 2018 from University of Utah hospital, had primary or secondary diagnoses of HF, were ambulatory and ineligible for HC at hospital discharge, and lived within the Salt Lake City area. Patients were either referred for HC services upon hospital discharge or released to home with no intervention. HC services for these patients were provided free of charge. Patients who received the intervention had at least one HC visit by a nurse if they agreed to it while in the hospital. HC nurses followed a modified version of the Discharge Checklist from the American Heart Association's Rise Above Heart Failure materials. We removed questions that would have been addressed in the hospital, maintained those that targeted self-management and medication management and added questions specific to the home environment. This checklist was used by healthcare providers when assisting patients with their transition to home. HC visit nurses provided education as appropriate based on patients’ responses. We used descriptive statistics to compare readmission before or after 30 days by intervention status. Results There were 319 patients that met the eligibility criteria; 60.2% were male, 81.8% were white, and the average age was 62.1. Of the 319 eligible patients, a convenience sample of 70 patients were approached and referral was placed for HC. Of these, 61 patients received HC visits and 9 declined. Based on patient responses to the Checklist, key areas addressed during HC visits were medication management, self-care and adherence to heart failure behaviors. Seven of the 61 patients who received HC (11.5%) were readmitted at ≤30 days after discharge, compared to 55/258 (21.3%) who did not receive HC visits (p = 0.08). Conclusions In this ongoing quality improvement pilot study, we tested utility of HC visits to improve transitions of care after discharge for HF exacerbation in ambulatory patients. We identified specific teaching opportunities related to medication management, self-care and adherence to heart failure behaviors. We show that compared to patients who did not receive HC visits, a lower proportion of patients who received HC visits were readmitted at ≤30 days after discharge. Further testing of this strategy seems warranted.

Accuracy of ICD-10 codes for identifying hospitalizations for acute anticoagulation therapy-related bleeding events

IntroductionAdministratively coded data are frequently used in observational research to identify outcome events. With the transition to the new International Classification of Diseases coding system's 10th version (ICD-10), information is needed about the coding accuracy for bleeding events in anticoagulated patients. We aimed to determine ICD-10 code accuracy for bleeding events in anticoagulated patients admitted to the hospital. MethodsThis cross-sectional study retrospectively examined charts of anticoagulated patients who were admitted to the University of Utah Hospital between October 1, 2017 and December 31, 2017. Two trained chart abstractors blinded to ICD-10 code status independently reviewed medical charts to determine the presence or absence of bleeding events. ICD-10 code status in any diagnosis position was unblinded and code accuracy was assessed using sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPV) along with 95% confidence intervals (CI). ResultsOut of 661 admissions, 487 unique patients and 71 bleeding events were identified. Gastrointestinal tract bleeding and intracranial hemorrhage comprised 32.4% and 19.7% of bleeding events respectively. ICD-10 code sensitivity was 91.4% (95% CI, 82.3–96.8), specificity was 90.2% (87.5–92.5), PPV was 52.5% (43.2–61.6) and NPV 98.9% (97.6–99.6). Individual codes for intracranial hemorrhages and gastrointestinal tract bleeding had similar accuracy as the overall set of bleeding codes. ConclusionsOur results demonstrate that ICD-10 codes can reliably rule-out hospitalizations for bleeding events in patients receiving anticoagulation therapy. Due to unacceptable false positive rates ICD-10 codes should not be used for identifying bleeding complications without confirmatory chart review.

Clinician Perspectives Regarding In-Hospital Cardiac Arrest Resuscitation: A Multicenter Survey.

Evaluate clinicians' sentiments about participating in cardiac arrest resuscitations and identify factors associated with confidence in resuscitation of cardiac arrest. Electronic survey. Twenty-one hospitals in Utah and Idaho. All attending physicians, residents, and nurses in a multilevel healthcare system likely to participate in an in-hospital cardiac arrest resuscitation at least once every 2 years. None. A survey instrument evaluating clinician perceptions of in-hospital cardiac arrest resuscitation participation was developed after literature review and iteratively revised based on expert input and cognitive pretesting. Survey responses were collected anonymously. Sixty percent of 1,642 contacted clinicians (n = 977) submitted complete responses, of whom 874 met study inclusion criteria (190 attending physicians, 576 nurses, and 110 residents). Most respondents (74%) participated in less than or equal to six in-hospital cardiac arrest events per year, and 41% of respondents were most likely to participate in in-hospital cardiac arrest resuscitation at a community, rural, or critical access hospital. Confidence in in-hospital cardiac arrest participation was high overall (92%), but lower among residents (86%) than nurses (91%) or attending physicians (96%; p = 0.008). Fewer residents (52%) than nurses (73%) or attending physicians (95%; p < 0.001) reported feeling confident leading in-hospital cardiac arrest teams. Residents (63%) and attending physicians (36%) were more likely to worry about making errors during an in-hospital cardiac arrest event than nurses (18%; p < 0.001). Only 15% of residents and 50% of respondents overall reported they were both confident participating in in-hospital cardiac arrest resuscitation and did not worry about making errors. In-hospital cardiac arrest participation frequency was the dominant predictor of respondents' confidence leading or participating in an in-hospital cardiac arrest resuscitation. Many clinicians, especially residents, who participate in or lead in-hospital cardiac arrest resuscitation events lack confidence or worry about management errors. Hospitals-particularly smaller hospitals-should consider methods to provide in-hospital cardiac arrest teams additional "effective experience," potentially using simulation or telemedicine consultation.

52: Evaluation of an external fetal ECG monitoring system: a randomized controlled trial

To compare interpretability of two intrapartum abdominal fetal heart rate (FHR) monitoring strategies. We hypothesized that an external fetal electrocardiogram (fECG) monitoring system, a new technology using cable-free abdominal pads, would produce more interpretable FHR data compared to standard of care (SOC) external Doppler FHR monitoring. Randomized trial conducted at 4 Utah hospitals. Patients were enrolled at labor admission and randomized in blocks based on body mass index (BMI) to SOC or fECG. Primary outcome was the percentage of interpretable minutes of FHR tracing. An interpretable minute was defined as >25% FHR data present and no more than 25% continuous missing FHR data or artifact present. FHR tracings were read in blinded fashion by two reviewers. We also considered the rate of successful device set up, defined as the ability to obtain any interpretable FHR tracing, as well as the number of interpretable 10 minute FHR segments, device adjustments, clinical outcomes, and patient/provider device satisfaction as determined by Likert scale survey. We calculated that 100 patients per arm (200 total) would be needed to detect a 5% difference in interpretability with 95% power. 218 women were randomized, 108 to fECG and 110 to SOC (Figure). Device set up failure occurred more often in the fECG group (7.4% vs 0% for SOC). There were no differences in the primary outcome or 10 minute FHR segment analyses, but fECG produced more interpretable FHR tracing in BMI≥30 (Table). Maternal demographics and clinical outcomes were similar between arms. More device changes occurred in the fECG group, however fECG use required fewer nursing adjustments compared to SOC. There was no difference in physician device satisfaction between groups, but fECG generated higher patient device satisfaction scores. Although the primary outcome did not differ between groups, patients preferred the fECG system. Significant differences were noted with BMI stratification, where fECG outperformed SOC in women with BMI≥30. To our knowledge, this is the first randomized clinical comparison of an external fECG device and SOC. Further investigation should focus on predictors of fECG device failure and determining settings in which fECG may be the preferred and more cost-effective FHR monitoring strategy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

701. Rapid Detection of Antimicrobial Resistance Determinants with the BioFire® System

BackgroundAntimicrobial-resistant (AMR) bacteria are a rising healthcare concern and are associated with an estimated five-fold increase in mortality for infected patients. Correct treatment requires antimicrobial susceptibility knowledge, but standard testing methods require multiple days for an accurate phenotype. Rapid identification of AMR immediately after blood culture positivity could potentially improve health outcomes, lower economic cost, prevent the spread of multidrug-resistant outbreaks and assist with antimicrobial stewardship goals.MethodsThe BioFire® Antimicrobial Resistance (AMR) Panel is a research use only multiplex-nested PCR system with 47 assays for 30 genes conferring resistance to cephalosporins, carbapenems, aminoglycosides, and fluoroquinolones which can be found in E. coli, K. pneumoniae, P. aeruginosa, A. baumannii, and E. cloacae complex. We tested 86 residual positive blood culture samples collected from Primary Children’s Hospital, University of Utah Hospital and Huntsman Cancer Hospital with the BioFire AMR Panel. Molecular genotypic results were compared with phenotypic susceptibility information for each blood culture specimen to confirm resistance detections.ResultsOf the 86 samples tested, there were 33 cultures phenotypically resistant (beyond intrinsic resistance) to at least one antibiotic class targeted by the panel. BioFire AMR Panel identified resistance to gentamicin, cefoxitin, all penicillins tested, and ciprofloxacin with 100% positive predictive value (PPV). For tobramycin, ceftazidime, and ceftriaxone, the PPV was greater than 85%. Carbapenem resistance was not detected, likely due to the low number of resistant organisms present in our patient population.ConclusionThe BioFire AMR Panel provides identification of genetic AMR determinants in a rapid, easy-to-use system that accurately correlates with phenotypic data for specific antimicrobials. Studies will continue to test additional clinical samples at various geographical locations to further evaluate the relationship between genotypic and phenotypic resistance assessment.Data presented is from an assay that has not been cleared or approved by US FDA or other regulatory agencies for in vitro diagnostic use.Disclosures S. Marxreiter, NIH NIAID: Grant Investigator, Research grant. BioFire Diagnostics, LLC: Employee, Salary. E. Lo, BioFire Diagnostics, LLC: Employee, Salary. NIH NIAID: Grant Investigator, Research grant. C. Oswald, BioFire Diagnostics, LLC: Employee, Salary. NIH NIAID: Grant Investigator, Research grant. A. Hopper, Primary Children’s Hospital: Investigator, Research grant. B. Barr, Primary Children’s Hospital: Grant Investigator, Research grant. J. A. Daly, Primary Children’s Hospital: Grant Investigator, Research grant. University of Utah: Grant Investigator, Research grant. C. C. Ginocchio, Biomerieux: Employee, Salary. R. Crisp, BioFire Diagnostics, LLC: Employee, Salary. A. Hemmert, BioFire Diagnostics, LLC: Employee, Salary. NIH NIAID: Grant Investigator, Research grant.

Can Social Media Help Us in Advancing Our Agenda?

Can Social Media Help Us in Advancing Our Agenda?

Association of Exfoliation Syndrome With Risk of Indirect Inguinal Hernia

Exfoliation syndrome (XFS) is a systemic connective tissue disease, and abnormal connective tissue metabolism is implicated in inguinal hernias (IH). Associating XFS with comorbid conditions may illuminate their underlying pathophysiology and affect clinical screening and treatment. Exfoliation syndrome involves altered systemic extracellular matrix (ECM) homeostasis involving elastin metabolism. Hernias occur owing to abnormal ECM synthesis, metabolism, or repair. Inguinal hernias involve weakening or rupture of the abdominal/groin wall. To determine an association between patients with XFS and patients with IH in Utah, possibly differing between direct or indirect hernia. Cross-sectional study in a large health care system of Utah hospitals and clinics. Conditional logistic regression odds ratios were used to estimate risk of XFS in patients with IH overall and by subtype (direct or indirect) compared with control individuals. Codes specific to direct and indirect IH with additional medical records review of 186 procedures were used to classify IH subtypes that were not prespecified. Bootstrap resampling with jackknife estimation used to calculate 95% confidence intervals. The model accounted for matching on sex and age and adjusted for body mass index and tobacco use. Population-based sample using medical records from 1996 to 2015 that identified 2594 patients 40 years or older on January 1, 1996, with surgical IH repair and 12 966 random control patients with no IH history matched 5:1 on sex and birth year. Data were analyzed between September 10, 2017, and October 23, 2017. Exfoliation syndrome outcome defined by diagnosis codes for XFS or exfoliation glaucoma from 1996 to 2015. Participants were primarily white (2532 of 2594 patients, [96.1%]; 12 454 of 12 966 control individuals [97.6%]) and non-Hispanic (2396 of 2594 patients [92.4%]); 250 participants were women (9.6%). Of study participants, 22 patients with IH and 43 control individuals were diagnosed as having XFS, respectively. Patients with IH had a 2.3-fold risk for an XFS diagnosis compared with control individuals (95% CI, 1.4-3.5; P = .03), and XFS risk with indirect IH appeared especially pronounced. Inguinal hernia was associated with an increased risk of XFS in this Utah population. Further work is needed to understand the pathophysiology, genetics, and environmental factors contributing to both diseases.

Questions Posed by Residents in the Operating Room: A Thematic Analysis

Questioning behavior is a type of intraoperative communication for which little information exists on the types of questions that residents ask. The purpose of this study is to describe and identify themes of questions asked by residents in the operating room. Trained observers documented questions asked by residents during operations. Thematic analysis was applied. University of Utah Hospital (Salt Lake City, Utah) operating rooms; institutional. A total of 10 general surgical residents (postgraduate year 1 to 5) were observed along with 10 attending general surgeons. Cases were purposefully selected to be broadly representative of general surgery cases. Thematic saturation occurred following examination of 16 operative cases, which included 178 questions asked by residents. Two broad categories of questions emerged: case-related (71%) and noncase-related (29%), with multiple subcategories within the 2 groups. Case-related subcategories included operative techniques, logistics, patient care, and other. Questions unrelated to the case included subcategories of social, work-related but unrelated to case, other. Less than 1% of questions asked by residents during operations were reflective. Most questions related to the case were technical and most of those unrelated to the case were social; almost all questions were transactional in nature. Our identification of questioning themes by residents expands understanding of resident questioning behaviors, and therefore may enable residents and faculty to be more effective in establishing entrustment.

Outbreak of E. coli O157:H7 Infections Associated with Exposure to Animal Manure in a Rural Community - Arizona and Utah, June-July 2017.

On June 26, 2017, a hospital in southern Utah notified the Utah Department of Health of Shiga toxin-producing Escherichia coli (STEC) O157:H7 infections in two children from a small community on the Arizona-Utah border. Both children developed hemolytic uremic syndrome, characterized by hemolytic anemia, acute kidney failure, and thrombocytopenia and died within a few days of illness onset. Over the next few days, several more STEC-associated illnesses were reported in residents of the community. A joint investigation by local and state health agencies from Arizona and Utah and CDC was initiated to identify the outbreak source and prevent additional cases; a total of 12 cases were identified, including the two children who died. Investigators initially explored multiple potential sources of illness; epidemiologic and environmental information revealed cow manure contact as the likely initial cause of the outbreak, which was followed by subsequent person-to-person transmission. One of the outbreak strains was isolated from bull and horse manure collected from a yard near a community household with two ill children. Local health agencies made recommendations to the public related to both animal contact and hand hygiene to reduce the risk for STEC transmission. Animal or animal manure contact should be considered a potential source of STEC O157:H7 during outbreaks in communities where ruminants are kept near the home.

Pharmacokinetics of Continuous Infusion Beta-lactams in the Treatment of Acute Pulmonary Exacerbations in Adult Patients With Cystic Fibrosis

Several clinical trials have shown the efficacy of continuous infusion beta-lactam (BL) antibiotics in patients with cystic fibrosis (CF); however, little is known about pharmacokinetic changes during the treatment of an acute pulmonary exacerbation (APE). Identifying and understanding these changes may assist in optimizing antibiotic dosing during APE treatment. This study was a retrospective cohort study of 162 adult patients with CF admitted to the University of Utah Hospital between January 1, 2008, and May 15, 2014, for treatment of an APE with both a continuous infusion BL and IV tobramycin. We extracted the administered doses of continuous infusion BLs and tobramycin along with serum drug concentrations and calculated medication clearance rates. The primary outcome was change in clearance rates of continuous infusion BLs between day 2 and day 7 of APE treatment. The BL clearance rate increased 20.7%(95%CI, 11.42 to 32.49; P< .001), whereas the tobramycin clearance rate decreased 6.3%(95%CI, -12.29 to -4.45; P< .001). The mean percent predicted FEV1 increased between admission and discharge by 12.2%(95%CI, -13.81 to -10.55; P< .001). Clinicians should monitor BL levels along with aminoglycoside levels and make dose adjustments to maximize the chance of optimal antibiotic treatment. Continuous infusion BL and tobramycin clearance can change dramatically during the treatment of an APE, which may necessitate significant changes in dosing to achieve optimal antibiotic levels. Clearance rates of these antibiotics may change in opposite directions, requiring specific monitoring of each medication.

Su1146 THE YIELD OF MUCOSAL BIOPSY COMPARED TO BRUSH CYTOLOGY FOR ESOPHAGEAL CANDIDIASIS DURING UPPER ENDOSCOPY

Candidal esophagitis is increasingly suspected and diagnosed in both immunocompetent and immunocompromised patients with esophageal symptoms and endoscopic evidence of esophageal candidiasis. Endoscopic sampling optons for diagnosis include mucosal biopsy and brush cytology. However, the relative yield of esophageal biopsy compared brushing to has not been clearly delineated. To evaluate the yield, sensitivity, and specificity of upper endoscopy directed mucosal biopsy vs. brush cytology in the diagnosis of esophageal candidiasis. A retrospective chart review of patients undergoing EGD evaluation for suspected esophageal candidiasis at the University of Utah Hospitals from 12/2002 -7/2013 was performed. Patients were included if they had esophageal symptoms (heartburn, chest pain, dysphagia, and/or odynophagia), endoscopic evidence of esophageal candidasis and had both mucosal biopsies and brush cytology performed. History of malignancy, organ transplant, or immunosuppressant medication use was noted. 55 patients underwent a total of 55 EGDs in which both brush cytology and mucosal biopsies were performed. Esophageal candidiasis was defined as pathology positive for candidiasis with esophageal symptoms. The mean age of the patients was 51.2 years with 49% male. 44% were immunosuppressed. Overall 23% (11/55) of suspected cases were positive for candida. Brush cytology had a sensitivity of 92% (95% CI: 64-100%) and a specificity of 26% (95% CI: 14-42%). Mucosal biopsy had a sensitivity of 100% (95% CI: 75-100%) and a specificity of 93% (95% CI: 81-99%). Positve and negative predictive value were also higher for mucosal biopsy compared to brush cytology. Table 1 The sensitivity of brushing and biopsy for esophageal candidias are similar and high. However, biopsy is more specific for the diagnosis of esophageal candidiasis. Mucosal biopsy is the preferred endoscopic sampling option for diagnosis of esophageal candidiasis.

The Ethical and Legal Implications of a Nurse's Arrest in Utah.

Editor's note: On July 26, 2017, Alex Wubbels, the charge nurse on the burn unit at the University of Utah Hospital in Salt Lake City, was arrested for refusing to allow a police officer to draw blood from an unconscious patient in her care. Her arrest, during which she was forcefully placed in handcuffs and dragged out of the hospital, was documented on body camera video and drew national attention. We asked our ethical and legal contributing editors to provide some insight on the issues of this case.

A pilot study evaluating biomarker development for drug-induced chronic eczematous eruptions of aging individuals.

Identifying the drug(s) responsible for drug-induced chronic eczematous eruptions of aging individuals (CEEA) is a clinical challenge in patients on multiple medications. Reliable in vitro testing methods and biomarkers are needed to identify the causative agent and allow simultaneous assessment of T-cell responses to multiple drugs being taken concurrently. This study examined the feasibility of using in vitro, drug-specific T cell activation responses as a biomarker for drug-induced CEEA. This was a single center, proof-of-concept pilot study at the University of Utah Hospital, Salt Lake City, Utah. Eight aging study subjects having a history suggestive of chronic eczematous drug eruptions suspected to have resulted from calcium channel blocker (CCB) and/or hydrochlorothiazide (HCTZ) hypersensitivity plus three matched aging control subjects were identified. Drug patch testing for CCB and/or HCTZ, in vitro drug antigen-induced lymphocyte proliferation assays, and multianalyte-determined cytokine release assays were performed before and after HCTZ and/or CCB incubation. All study and control subject blood samples tested failed to demonstrate detectable enhanced lymphocyte proliferation or cytokine release to in vitro CCBs or HCTZ challenge when tested with a fairly wide range of drug concentrations. Additionally, none of the enrolled patients developed a positive patch test to CCBs and/or HCTZ. This pilot study aimed to correlate in vitro drug-induced T lymphocyte transformation and cytokine production with the presence of drug-induced CEEA. Failure to identify T cell proliferative responses to CCB drug antigens in our in vitro studies could have, in part, resulted from a pharmacologic inhibiting effect of CCB on T cell activation.

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OBJECTIVES/SPECIFIC AIMS: Issues with recruiting the targeted number of participants in a timely manner often results in underpowered studies, with more than 60% of clinical studies failing to complete or requiring extensions due to enrollment issues. The objective of this study is to develop and implement a scalable, organization wide platform to enhance accrual into clinical research studies. METHODS/STUDY POPULATION: We are developing and evaluating an informatics platform called Utah Utility for Research Recruitment (U2R2). U2R2 consists of 2 components: (i) Semantic Matcher: an automated trial criterion to patient matching component that also reports uncertainty associated with the match, and (ii) Match Delivery: mechanisms to deliver the list of matched patients for different research and clinical settings. As a first step, we limited the Semantic Matcher to utilize only structured data elements from the patient record and trial criteria. We are now including distributional semantic methods to match complete patient records and trial criteria as documents. We evaluated the first phase of U2R2 based on a randomized trial with a target enrollment of 220 participants that compares 2 treatment strategies for managing back pain (physical therapy and usual care) for individuals consulting a nonsurgical provider and symptomatic &lt;90 days. RESULTS/ANTICIPATED RESULTS: U2R2 identified 9370 patients from the University of Utah Hospitals and Clinics as potential matches. Of these 9370, 1145 responded to the Back Pain study research team’s email or phone communications, and were further screened by phone. In total, 250 participants completed a screening visit, resulting in the current study enrollment of 130 participants. Forty-three of 1145 patients refused to participate, and 50 participants no-showed their screening visit. DISCUSSION/SIGNIFICANCE OF IMPACT: A recruitment platform can enhance potential participant identification, but requires attention to multiple issues involved with clinical research studies. Clinical eligibility criteria are usually unstructured and require human mediation and abstraction into discrete data elements for matching against patient records. In addition, key eligibility data are often embedded within text in the patient record. Distributional semantic approaches, by leveraging this content, can identify potential participants for screening with more specificity. The delivery of the list of matched patient results should consider characteristics of the research study, population, and targeted enrollment (eg, back pain being a common disorder and the possibility of the patient visiting different types of clinics), as well as organizational and socio-technical issues surrounding clinical practice and research. Embedding the delivery of match results into the clinical workflow by utilizing user-centered design approaches and involving the clinician, the clinic, and the patient in the recruitment process, could yield higher accrual indices.