Length Of Treatment Research Articles

Evaluating Nutritional Selection and Outcomes in Neonatal Abstinence Syndrome: A Retrospective Review.

The rising incidence of neonatal abstinence syndrome (NAS) has amplified the importance of nonpharmacological interventions in its management, which include the selection of feedings. With the goal of obtaining an accurate assessment of the effects of current feeding practices in NAS infants in our neonatal intensive care unit, we conducted a retrospective review of NAS infants at our hospital over a 3-year period to determine their nutritional selections and evaluate their length of stay (LOS), length of treatment (LOT), and growth outcomes. Retrospective chart review of term infants (≥37 weeks of gestation) with NAS. Maternal and infant demographics and characteristics were recorded. Infants were grouped based on majority (>50% of total feeding) nutritional selections and LOS, LOT, and growth parameters were evaluated. Linear regression was used to compare group outcomes. Significance was set at a p-value <0.05. A total of 70 infants were included and grouped based on majority feeds into maternal breast milk (MBM), standard term formula (STF), low lactose formula (LLF), and extensively hydrolyzed formula (EHF) groups. Feeding selections were provider-dependent and infants were placed on MBM or STF as an initial selection. In all infants included in our review, LLF was selected as the first choice following MBM or STF for increased gastrointestinal (GI) disturbance-related Finnegan Neonatal Abstinence Scoring scores and changed to EHF if LLF failed to improve the GI-related symptoms. The STF-fed infants had the shortest LOS, and none of these infants required pharmacological treatment. The LOT and LOS were similar in the MBM- and LLF-fed groups. Infants who were EHF fed had the longest LOT and LOS. All feeding groups demonstrated appropriate growth. Nutritional selections in our NAS infants were modified for the severity of their withdrawal symptoms. All nutritional modifications driven by severity of withdrawal symptoms supported favorable growth outcomes in the infants. · Our NAS infants were fed with multiple types of nutrition.. · Infants with severe NAS required more elemental feeds.. · All formula selections supported favorable growth..

Identifying excessive length of antibiotic treatment duration for hospital-acquired infections: a semi-automated approach to support antimicrobial stewardship

BackgroundAvoiding excessive antibiotic treatment duration is a fundamental goal in antimicrobial stewardship. Manual collection of data is a time-consuming process, but a semi-automated approach for data extraction has been shown feasible for community-acquired infections (CAI). Extraction of data however may be more challenging in hospital-acquired infections (HAI). The aim of this study is to explore whether semi-automated data extraction of treatment duration is also feasible and accurate for HAI.MethodsData from a university-affiliated hospital over the period 1-6-2020 until 1-6-2022 was used for this study. From the Electronic Health Record, raw data on prescriptions, registered indications and admissions was extracted and processed to define treatment courses. In addition, clinical notes including prescription instructions were obtained for the purpose of validation. The derived treatment course was compared to the registered indication and the actual length of treatment (LOT) in the clinical notes in a random sample of 5.7% of treatment courses, to assess the accuracy of the data for both CAI and HAI.ResultsIncluded were 10.564 treatment courses of which 73.1% were CAI and 26.8% HAI. The registered indication matched the diagnosis as recorded in the clinical notes in 79% of treatment courses (79.2% CAI, 78.5% HAI). Higher error rates were seen in urinary tract infections (UTIs) (29.0%) and respiratory tract infections (RTIs) (20.5%) compared to intra-abdominal infections (7.4%), or skin or soft tissue infections (11.1%), mainly due to incorrect specification of the type of UTI or RTI. The LOT was accurately extracted in 98.5% of courses (CAI 98.2%, HAI 99.3%) when compared to prescriptions in the EHR. In 21% of cases however the LOT did not match with the clinical notes, mainly if patients received treatment from other health care providers preceding or following the present course.ConclusionSemi-automatic data extraction can yield reliable information about the indication and LOT in treatment courses of hospitalized patients, for both HAI and CAI. This can provide stewardship programs with a surveillance tool for all in-hospital treated infections, which can be used to achieve stewardship goals.

Short term outcomes of neonatal opioid withdrawal syndrome: a comparison of two approaches.

To evaluate outcomes in opioid exposed neonates (OENs) assessed by the Eat, Sleep, Console (ESC) tool compared to the Finnegan Neonatal Abstinence Scoring System (FNASS). Retrospective analysis of a statewide database of OENs from 2017 to 2020 with birthing hospitals classified based on the assessment tool used. Four main outcomes were examined using multivariable and Poisson logistic regression models. Of 2375 OENs, 42.1% received pharmacotherapy (PT) with a consistent decrease in PT, length of treatment (LOT), and length of stay (LOS) over the study period. There was no change in use of mother's own milk (MoM). While outcomes were significantly associated with several specific variables, there were no differences in outcomes between assessment methods. While there was a significant decrease over time in PT, LOT, and LOS, improvements were independent of the assessment tool used and likely related to the increased use of non-pharmacologic care.

Neonatal Abstinence Signs during Treatment: Trajectory, Resurgence and Heterogeneity.

Neonatal abstinence syndrome (NAS) presents with a varying severity of withdrawal signs and length of treatment (LOT). We examined the course and relevance of each of the NAS withdrawal signs during treatment in a sample of 182 infants with any prenatal opioid exposure, gestational age ≥ 35 weeks, without other medical conditions, and meeting the criteria for pharmacological treatment. Infants were monitored using the Finnegan Neonatal Abstinence Scoring Tool. Daily mean Finnegan scores were estimated using linear mixed models with random subject effects to account for repeated withdrawal scores from the same subject. Daily item prevalence was estimated using generalized estimating equations with a within-subject exchangeable correlation structure. The median LOT was 12.86 days. The prevalence of withdrawal signs decreased from day one to day three of treatment. However, certain central nervous system (CNS) and gastrointestinal (GI) signs showed sporadic increases in prevalence notable around two weeks of treatment, accounting for increases in Finnegan scores that guided pharmacotherapy. We question whether the resurgence of signs with a prolonged LOT is mainly a consequence of opioid tolerance or withdrawal. Monitoring CNS and GI signs throughout treatment is crucial. Future studies directed to better understand this clinical phenomenon may lead to the refining of NAS pharmacotherapy and perhaps the discovery of treatment alternatives.

Antibiotic Consumption in a Cohort of Hospitalized Adults with Viral Respiratory Tract Infection.

Development of antibiotic resistance, a threat to global health, is driven by inappropriate antibiotic usage. Respiratory tract infections (RTIs) are frequently treated empirically with antibiotics, despite the fact that a majority of the infections are caused by viruses. The purpose of this study was to determine the prevalence of antibiotic treatment in hospitalized adults with viral RTIs, and to investigate factors influencing the antibiotic decision-making. We conducted a retrospective observational study of patients ≥ 18 years, hospitalized in 2015-2018 with viral RTIs. Microbiological data were taken from the laboratory information system and information on antibiotic treatment drawn from the hospital records. To investigate decisions for prescribing antibiotic treatment, we evaluated relevant factors such as laboratory and radiological results, in addition to clinical signs. In 951 cases without secondary bacterial RTIs (median age 73 years, 53% female), 720 (76%) were prescribed antibiotic treatment, most frequently beta-lactamase-sensitive penicillins, but cephalosporins were prescribed as first-line in 16% of the cases. The median length of treatment (LOT) in the patients treated with antibiotics was seven days. Patients treated with antibiotics had an average of two days longer hospital stay compared to patients with no such treatment, but no difference in mortality was found. Our study revealed that there is still a role for antimicrobial stewardship to further improve antibiotic use in patients admitted for viral RTIs in a country with relatively low antibiotic consumption.

1782. Antimicrobial Stewardship Opportunities in Gram-Negative Bacteremia Treatment at a Community Teaching Hospital

Abstract Background Gram Negative Bacteremia (GNB) is frequently encountered among hospitalized patients. In contrast to traditional 14-day lengths of treatment (LOT), recent literature supports a shorter (7-day) LOT for uncomplicated GNB with adequate source control, and the effectiveness of oral antibiotics. The goal of the following is to outline current practices of GNB treatment and identify opportunities for antibiotic stewardship (AS). Methods This study retrospectively reviewed all cases of uncomplicated GNB at a 528-bed community teaching hospital in Rochester, NY from January 2021 through March 2022. Demographic, laboratory, microbiologic, antibiotic therapy data, results of follow-up blood cultures (FUBC), hospital length of stay and 30-day readmission were collected. Exclusions were complicated or polymicrobial bacteremia, deaths during treatment, or prolonged hospitalization due to other medical factors. Influences of Infectious diseases (ID) or AS consult on treatment and outcomes were compared to cases with no consult. Continuous variables were analyzed using unpaired t-tests; categorical variables were analyzed using Fischer’s exact test and Chi-square as appropriate. Results 133 cases met inclusion criteria. Demographic and laboratory data are in Table 1. The frequency of bacteria isolated and source of infection are in Figure 1 and Figure 2. ID was significantly more often consulted for central line infections (17% vs 3%, p=0.01), and significantly less frequently involved in urinary tract infections (39% vs 69%, p=0.009). While total LOT were similarly longer than current literature supports (11.7 vs 12.5 days, p=0.2644), cases without ID consultation received significantly more days of oral treatment (4.7 vs 7.1 days, p=0.0275). There were no significant differences between receipt and no receipt of AS recommendations. Conclusion GNB continued to receive longer LOTs than current literature recommends, with longer IV durations recommended by ID consultants compared to those without ID consult. Educational initiatives regarding the safety of shorter LOT for GNB, including the efficacy of oral antibiotics, are needed and should include ID specialists. Disclosures All Authors: No reported disclosures.

Morphine versus methadone for neonatal opioid withdrawal syndrome: a randomized controlled pilot study

BackgroundNeonatal Opioid Withdrawal Syndrome (NOWS) is a significant public health issue and while millions of neonates are affected each year, an optimal pharmacologic weaning protocol has yet to be demonstrated. In this study, we compare hospital length of stay (LOS) and length of treatment (LOT) for treatment of neonatal opioid withdrawal (NOWS) with morphine versus methadone.MethodsThis was a single-site, open-label, randomized controlled pilot study conducted from October 2016-September 2018. Infants were eligible if their primary in-utero drug exposure was heroin, oral opioids, or methadone and they were born at greater than or equal to 34 weeks gestation. Infants were excluded for serious medical comorbidities and primary in-utero exposure to buprenorphine.ResultsSixty-one infants were enrolled; 30 were randomized to methadone treatment, and 31 to morphine treatment. Overall 46% of infants required treatment for NOWS. LOS and LOT for infants treated with morphine was 17.9 days and 14.7 days respectively, compared to 16.1 days and 12.8 days for babies treated with methadone (p = 0.5, p = 0.54). Infants treated with morphine received lower total morphine equivalents than those treated with methadone (9.7 vs. 33, p < 0.01). Three treated infants in the methadone group required transfer to the Neonatal Intensive Care Unit, versus no infants in the morphine group.ConclusionsInfants treated with morphine versus methadone had no significant differences in LOS or LOT in this pilot study. Infants treated with methadone received up to 3 times the opioid based on morphine equivalents as infants treated with morphine and had more transfers to the NICU for over sedation.Clinical trial registrationMorphine Versus Methadone for Opiate Exposed Infants With Neonatal Abstinence Syndrome NCT02851303, initiated 01/08/2016.

Impact and quality of antimicrobial use in a referral pediatric intensive care unit

IntroductionWe aimed to describe antimicrobial use (AU) and quality of prescriptions (QP) in a 28-bed medical-surgical PICU of a European referral children's hospital during 2019. MethodsAU data were expressed as days-of-therapy (DOT) over 100 days-present (DP) and as length-of-treatment (LOT). QP was based on monthly cross-sectional point-prevalence surveys. Length-of-stay (LOS), readmission rates (RR), and mortality rates (MR) were also collected. ResultsPICU AU accounted for 13.5% of the global hospital AU; the median PICU density of AU was 1.4 (IQR 1.3–1.5) times higher than that of the rest of the hospital areas. Antibacterials represented 88.5% of the overall AU, cefazolin and amoxicillin-clavulanate being the most used drugs. A high QP rate was observed (149/168 optimal, 88.9%), with room for improvement in prophylactic regimens and de-escalation of broad-spectrum regimens. LOT, LOS, RR, and MR remained stable. ConclusionsPICU AU represented a major portion of the global hospital AU. Despite high QP rates, prophylactic and broad-spectrum antibiotic regimens were optimizable.

Reversal of SARS-CoV2-Induced Hypoxia by Nebulized Sodium Ibuprofenate in a Compassionate Use Program.

IntroductionSodium ibuprofenate in hypertonic saline (NaIHS) administered directly to the lungs by nebulization and inhalation has antibacterial and anti-inflammatory effects, with the potential to deliver these benefits to hypoxic patients. We describe a compassionate use program that offered this therapy to hospitalized COVID-19 patients.MethodsNaIHS (50 mg ibuprofen, tid) was provided in addition to standard of care (SOC) to hospitalized COVID-19 patients until oxygen saturation levels of > 94% were achieved on ambient air. Patients wore a containment hood to diminish aerosolization. Outcome data from participating patients treated at multiple hospitals in Argentina between April 4 and October 31, 2020, are summarized. Results were compared with a retrospective contemporaneous control (CC) group of hospitalized COVID-19 patients with SOC alone during the same time frame from a subset of participating hospitals from Córdoba and Buenos Aires.ResultsThe evolution of 383 patients treated with SOC + NaIHS [56 on mechanical ventilation (MV) at baseline] and 195 CC (21 on MV at baseline) are summarized. At baseline, NaIHS-treated patients had basal oxygen saturation of 90.7 ± 0.2% (74.3% were on supplemental oxygen at baseline) and a basal respiratory rate of 22.7 ± 0.3 breath/min. In the CC group, basal oxygen saturation was 92.6 ± 0.4% (52.1% were on oxygen supplementation at baseline) and respiratory rate was 19.3 ± 0.3 breath/min. Despite greater pulmonary compromise at baseline in the NaIHS-treated group, the length of treatment (LOT) was 9.1 ± 0.2 gs with an average length of stay (ALOS) of 11.5 ± 0.3 days, in comparison with an ALOS of 13.3 ± 0.9 days in the CC group. In patients on MV who received NaIHS, the ALOS was lower than in the CC group. In both NaIHS-treated groups, a rapid reversal of deterioration in oxygenation and NEWS2 scores was observed acutely after initiation of NaIHS therapy. No serious adverse events were considered related to ibuprofen therapy. Mortality was lower in both NaIHS groups compared with CC groups.ConclusionsTreatment of COVID-19 pneumonitis with inhalational nebulized NaIHS was associated with rapid improvement in hypoxia and vital signs, with no serious adverse events attributed to therapy. Nebulized NaIHS s worthy of further study in randomized, placebo-controlled trials (ClinicalTrials.gov: NCT04382768).Supplementary InformationThe online version contains supplementary material available at 10.1007/s40121-021-00527-2.

Impact and quality of antimicrobial use in a referral pediatric intensive care unit

IntroductionWe aimed to describe antimicrobial use (AU) and quality of prescriptions (QP) in a 28-bed medical-surgical PICU of a European referral children's hospital during 2019. MethodsAU data were expressed as days-of-therapy (DOT) over 100 days-present (DP) and as length-of-treatment (LOT). QP was based on monthly cross-sectional point-prevalence surveys. Length-of-stay (LOS), readmission rates (RR), and mortality rates (MR) were also collected. ResultsPICU AU accounted for 13.5% of the global hospital AU; the median PICU density of AU was 1.4 (IQR 1.3–1.5) times higher than that of the rest of the hospital areas. Antibacterials represented 88.5% of the overall AU, cefazolin and amoxicillin-clavulanate being the most used drugs. A high QP rate was observed (149/168 optimal, 88.9%), with room for improvement in prophylactic regimens and de-escalation of broad-spectrum regimens. LOT, LOS, RR, and MR remained stable. ConclusionsPICU AU represented a major portion of the global hospital AU. Despite high QP rates, prophylactic and broad-spectrum antibiotic regimens were optimizable.

Quality Initiative to Reduce High-Flow Nasal Cannula Duration and Length of Stay in Bronchiolitis

High-flow nasal cannula (HFNC) use in bronchiolitis may prolong length of stay (LOS) if weaned more slowly than medically indicated. We aimed to reduce HFNC length of treatment (LOT) and inpatient LOS by 12 hours in 0- to 18-month-old patients with bronchiolitis on the pediatric hospital medicine service. After identifying key drivers of slow weaning, we recruited a multidisciplinary "Wean Team" to provide education and influence provider weaning practices. We then implemented a respiratory therapist-driven weaning protocol with supportive sociotechnical interventions (huddles, standardized orders, simplification of protocol) to reduce LOT and LOS and promote sustainability. In total, 283 patients were included: 105 during the baseline period and 178 during the intervention period. LOT and LOS control charts revealed special cause variation at the start of the intervention period; mean LOT decreased from 48.2 to 31.2 hours and mean LOS decreased from 84.3 to 60.9 hours. LOT and LOS were less variable in the intervention period compared with the baseline period. There was no increase in PICU transfers or 72-hour return or readmission rates. We reduced HFNC LOT by 17 hours and LOS by 23 hours for patients with bronchiolitis via multidisciplinary collaboration, education, and a respiratory therapist-driven weaning protocol with supportive interventions. Future steps will focus on more judicious application of HFNC in bronchiolitis.

Transcutaneous Auricular Neurostimulation (tAN): A Novel Adjuvant Treatment in Neonatal Opioid Withdrawal Syndrome.

Maternal opioid use during pregnancy is a growing national problem and can lead to newborns developing neonatal opioid withdrawal syndrome (NOWS) soon after birth. Recent data demonstrates that nearly every 15 min a baby is born in the United States suffering from NOWS. The primary treatment for NOWS is opioid replacement therapy, commonly oral morphine, which has neurotoxic effects on the developing brain. There is an urgent need for non-opioid treatments for NOWS. Transcutaneous auricular neurostimulation (tAN), a novel and non-invasive form of electrostimulation, may serve as a promising alternative to morphine. tAN is delivered via a multichannel earpiece electrode worn on and around the left ear, targeting two cranial nerves—the vagus and trigeminal nerves. Prior research suggests that auricular neurostimulation exerts an anxiolytic effect on the body by releasing endogenous opioids and reduces withdrawal symptoms in adults actively withdrawing from opioids. In this first-in-human prospective, open-label trial, we investigated tAN as an adjuvant to morphine therapy in eight infants >33 weeks gestational age suffering from NOWS and receiving oral morphine treatment. Infants received tAN for 30 min 1 h before receiving a morphine dose. tAN was delivered at 0.1 mA below perception intensity at two different nerve targets on the ear: Region 1, the auricular branch of the vagus nerve; and Region 2, the auriculotemporal nerve. tAN was delivered up to four times daily for a maximum of 12 days. The primary outcome measures were safety [heart rate monitoring, Neonatal Infant Pain Scale (NIPS), and skin irritation] and morphine length of treatment (LOT). tAN was well-tolerated and resulted in no unanticipated adverse events. Comparing to the national average of 23 days, the average oral morphine LOT was 13.3 days (median 9 days) and the average LOT after tAN initiation was 7 days (median 6 days). These preliminary data suggest that tAN is safe and may serve as a promising alternative adjuvant for treating NOWS and reducing the amount of time an infant receives oral morphine.

Reversal of SARS-CoV-2 Induced Hypoxia by Nebulized Sodium-Ibuprofen

Background: Sodium-ibuprofenate in hypertonic saline (NaIHS) administered directly to the lungs by nebulization and inhalation has antibacterial and anti-inflammatory effects with the potential to deliver these benefits to hypoxic patients. We describe a compassionate use program that offered this therapy to hospitalized COVID-19 patients.Methods: NaIHS (50 mg ibuprofen, tid) was provided in addition to standard of care to hospitalized Covid-19 patients until oxygen saturation levels of >94% were achieved on ambient air. Patients wore a containment hood to diminish aerosolization. Outcome data from participating patients treated at multiple hospitals in Argentina between April 04, 2020, through October 31, 2020 are summarized.Results: 383 patients were treated, including 327 not on mechanical ventilation at baseline (MV) and 56 ICU patients receiving MV. For those not on baseline MV (59±0.8 years), 64% were male, most with at least one recognized risk factor for disease severity, and mean NEWS2 score prior to treatment initiation of 7.0±0.1. The average length of stay (ALOS) was 11.5±0.3 days and length of treatment (LOT) 9.0±0.2 days. In patients on baseline MV (60.6±2.2 years), 69.9% were male, baseline mean NEWS2 Score was 8.8±0.4, ALOS 15.5±1.4 days and LOT 10.5±0.7 days. Reversal of deterioration in oxygenation and NEWS2 scores was observed acutely following initiation of therapy. Overall in-hospital mortality was 10.7% among patients not on MV at baseline, and 19.6% among patients receiving MV at baseline. No serious adverse events were considered related to ibuprofen therapy.Conclusions: Treatment of COVID-19 pneumonitis with inhalational nebulized NaIHS was associated with rapid improvement in hypoxia and vital signs, with no serious adverse events attributed to therapy. Nebulized NaIHS is worthy of further study in randomized, placebo-controlled trials.Trial Registration: (ClinicalTrials.gov:NCT04382768).Funding Statement: The study sponsor, Quimica Luar, provided NaIHS under compassionate use, and conducted the analysis of received safety monitoring and outcome data in this report.Declaration of Interests: Authors have nothing to declare. Ethics Approval Statement: Ethical approval was obtained from the Institutional Independent Ethics Committees and district regulatory agencies of Cordoba and Mendoza Provinces for the compassionate use of Luarprofeno® (sodium ibuprofenate in hypertonic saline, or NaIHS, for nebulization).

Buprenorphine pharmacotherapy for the management of neonatal abstinence syndrome in methadone-exposed neonates.

We aimed to compare the outcomes of pharmacotherapy with either buprenorphine or methadone in infants treated for neonatal abstinence syndrome (NAS) secondary to intrauterine exposure to methadone. This is a multi‐center, retrospective cohort study to assess length of treatment (LOT), hospital length of stay (LOS), and cumulative opioid exposure between infants treated with either methadone or buprenorphine for NAS secondary to in utero exposure to methadone. Infants delivered at a gestational age ≥35 weeks and a maternal history of opioid‐use disorder and/or urine drug screen positive for methadone, and postnatal pharmacotherapy for NAS with either buprenorphine or methadone as first‐line opioid replacement therapy, were eligible. Median LOT, LOS, and cumulative opioid exposure were compared between buprenorphine‐ and methadone‐treated infants. A total of 156 infants (48 treated with buprenorphine and 108 with methadone) were identified. The median LOT and LOS for buprenorphine‐treated infants was 8 and 13 days compared with 15 and 20 days for methadone‐treated infants, respectively, P < .001 for both outcomes. Median cumulative opioid dose in morphine equivalents was 0.6 mg/kg for buprenorphine‐treated infants vs 1.05 mg/kg for methadone‐treated infants, P < .001. No adverse effects were noted among either group. Of infants treated with buprenorphine, 34 (71%) required the addition of adjunctive pharmacotherapy during the NICU stay, compared with 31 (32%) in the methadone‐treated group, P = .0008. However, significantly fewer infants treated with buprenorphine required continuation of therapy beyond discharge as compared with those treated with methadone. The difference is most likely a reflection of the protocols used by the sites. In infants that required pharmacotherapy for NAS secondary to intrauterine exposure to methadone, treatment with buprenorphine, compared with methadone therapy, was associated with better outcomes. If confirmed with prospective data, buprenorphine could be considered first‐line therapy for the two medication‐assisted treatment regimens recommended by the American College of Obstetricians and Gynecologists.

Impact of In-utero Exposure to Selective Serotonin Reuptake Inhibitors and Opioids on Neonatal Opioid Withdrawal Syndrome.

The objective of this study was to compare short-term outcomes of neonatal opioid withdrawal syndrome (NOWS) treatment in infants exposed in-utero to opioids and selective serotonin reuptake inhibitors (SSRIs) or opioids alone. This was a retrospective cohort study of mother-infant dyads, 34 weeks or greater gestation, receiving opioids and/or SSRIs during pregnancy. Intravenous or oral methadone was administered according to a pre-existing protocol for NOWS treatment guided by withdrawal scores. Primary outcome was length of treatment (LOT). Secondary outcomes included length of stay (LOS), total methadone exposure, time to symptom control, need for a second agent, and NOWS medications at discharge. Fifty-five mother-infant dyads were included in the study. LOT was longer in the infants in the SSRI plus opioid group but not significantly different [24 ± 23 days (SSRI plus opioid) vs 20 ± 14 days (opioid alone); P = 0.78]. There was a trend towards shorter LOS (30 ± 22 day vs 27 ± 15 days; P = 0.86), lower total methadone exposure (3.2 ± 4.3 mg/kg vs 2.7 ± 5.1 mg/kg; P = 0.66), less time to control symptoms (1 ± 1.7 days vs 0.5 ± 0.36 days; P = 0.31) and less need for a second agent (OR 2.65, 95% CI 0.69-10.5) in the opioid only group, although these observations also did not reach statistical significance. This study could not demonstrate a statistically significant difference in short-term NOWS outcome of LOT between the 2 groups. However, there was a trend towards longer LOT and LOS in the SSRI plus opioid group which could be clinically significant. A larger cohort may detect a true significant difference in these short-term outcomes.

Endograft conformability and aortoiliac tortuosity in endovascular abdominal aortic aneurysm repair.

To determine conformability of stent-grafts in endovascular aneurysm repair (EVAR) using centerline of flow measurements and to compare conformability in patients with severe aortoiliac tortuosity. From 2012 to 2013, 111 consecutive patients (98 men; mean age 75.4±7.7 years) underwent endovascular aneurysm repair with Endurant I and II and Zenith Flex, LP, and Spiral Z stent-grafts; their pre- and post-EVAR computed tomography (CT) studies were retrospectively analyzed using quantitative 3-dimensional imaging software. The length between the lowest renal artery and the iliac bifurcation was measured using centerline of flow and was defined as the treatment length (TL). The difference in TLs pre and post EVAR were compared as a surrogate to evaluate endograft conformability. A total of 203 pre and post EVAR aortoiliac TLs were measured (99 Endurant I, 20 Endurant II, 32 Flex, 6 LP, and 42 Spiral Z). Overall, there was a mean difference of 5.0±7.3 mm or 2.6%±3.9% between the pre- and post-EVAR TLs (p<0.001). No statistically significant difference in TLs was observed among the various stent-grafts (p=0.115). In 40 patients with severe aortoiliac tortuosity, the post-EVAR TL was 16.2±5.5 mm or 8.0%±2.7% shorter than the pre-EVAR TL (p<0.001); again, there was no difference in TLs among the various devices implanted (p=0.737). Overall, there was no difference in treatment lengths before and after EVAR among different stent-grafts, suggesting similar conformability. Interestingly, patients with severe aortoiliac tortuosity were found to have significantly shorter post-EVAR treatment lengths compared to before EVAR, which should be considered when planning EVAR.

Variation in treatment of neonatal abstinence syndrome in US children's hospitals, 2004-2011.

Neonatal abstinence syndrome (NAS) is a drug withdrawal syndrome experienced by opioid-exposed infants. There is no standard treatment for NAS and surveys suggest wide variation in pharmacotherapy for NAS. Our objective was to determine whether different pharmacotherapies for NAS are associated with differences in outcomes and to determine whether pharmacotherapy and outcome vary by hospital. We used the Pediatric Health Information System Database from 2004 to 2011 to identify a cohort of infants with NAS requiring pharmacotherapy. Mixed effects hierarchical negative binomial models evaluated the association between pharmacotherapy and hospital with length of stay (LOS), length of treatment (LOT) and hospital charges, after adjusting for socioeconomic variables and comorbid clinical conditions. Our cohort included 1424 infants with NAS from 14 children's hospitals. Among hospitals in our sample, six used morphine, six used methadone and two used phenobarbital as primary initial treatment for NAS. In multivariate analysis, when compared with NAS patients initially treated with morphine, infants treated with methadone had shorter LOT (incidence rate ratio (IRR) = 0.55; P < 0.0001) and LOS (IRR = 0.60; P < 0.0001). Phenobarbital as a second-line agent was associated with increased LOT (IRR = 2.09; P<0.0001), LOS (IRR = 1.78; P < 0.0001) and higher hospital charges (IRR = 1.84; P < 0.0001). After controlling for case-mix, hospitals varied in LOT, LOS and hospital charges. We found variation in hospital in treatment for NAS among major US children's hospitals. In analyses controlling for possible confounders, methadone as initial treatment was associated with reduced LOT and hospital stay.

A medical procedure-based patient grouping method for an emergency department

Variability and unpredictability are typical characteristics of complex systems such as emergency department (ED) where the patient demand is high and patient conditions are diverse. To tackle the uncertain nature of ED and improve the resource management, it is beneficial to group patients with common features. This paper aims to use self-organizing map (SOM), k-means, and hierarchical methods to group patients based on their medical procedures and make comparisons among these methods. It can be reasonably assumed that the medical procedures received by the patients are directly associated with ED resource consumption. Different grouping techniques are compared using a validity index and the resulting groups are distinctive in the length of treatment (LOT) of patients and their presenting complaints. This paper also discusses how the resulting patient groups can be used to enhance the ED resource planning, as well as to redesign the ED charging policy.

Heliox Therapy in Bronchiolitis: Phase III Multicenter Double-Blind Randomized Controlled Trial

Supportive care remains the mainstay of therapy in bronchiolitis. Earlier studies suggest that helium-oxygen therapy may be beneficial, but evidence is limited. We aimed to compare efficacy of 2 treatment gases, Heliox and Airox (21% oxygen + 79% helium or nitrogen, respectively), on length of hospital treatment for bronchiolitis. This was a multicenter randomized blinded controlled trial of 319 bronchiolitic infant subjects randomly assigned to either gas; 281 subjects completed the study (140 Heliox, 141 Airox), whose data was analyzed. Treatment was delivered via facemask (nasal cannula, if the facemask intolerant) ± continuous positive airway pressure (CPAP). Severe bronchiolitics received CPAP from the start. Primary end point was length of treatment (LoT) required to alleviate hypoxia and respiratory distress. Secondary end-points were proportion of subjects needing CPAP; CPAP (LoT); and change in respiratory distress score. Analysis by intention to treat (all subjects); median LoT (inter-quartile range, days): Heliox 1.90 (1.08-3.17), Airox 1.87 (1.11-3.34), P = .41. Facemask tolerant subgroup: Heliox 1.46 (0.85-1.95), Airox 2.01 (0.93-2.86), P = .03. Nasal cannula subgroup: Heliox 2.51 (1.21-4.32), Airox 2.81 (1.45-4.78), P = .53. Subgroup started on CPAP: Heliox 1.55 (1.38-2.01), Airox 2.26 (1.84-2.73), P = .02. Proportion of subjects needing CPAP: Heliox 17%, Airox 19%, O.R. 0.87 (0.47-1.60), P = .76. Heliox reduced respiratory distress score after 8 hours (mixed models estimate, -0.1298; P < .001). The effect was greater for facemask compared with nasal cannula (mixed models estimate, 0.093; P = .04). Heliox therapy does not reduce LoT unless given via a tight-fitting facemask or CPAP. Nasal cannula heliox therapy is ineffective.

Empirical estimation of beam-on time for prostate cancer patients treated on Tomotherapy

Background and aimThis study proposed a method to estimate the beam-on time for prostate cancer patients treated on Tomotherapy when FW (field width), PF (pitch factor), modulation factor (MF) and treatment length (TL) were given. Material and methodsThe study was divided into two parts: building and verifying the model. To build a model, 160 treatment plans were created for 10 patients. The plans differed in combination of FW, PF and MF. For all plans a graph of beam-on time as a function of TL was created and a linear trend function was fitted. Equation for each trend line was determined and used in a correlation model. Finally, 62 plans verified the treatment time computation model – the real execution time was compared with our estimation and irradiation time calculated based on the equation provided by the manufacturer. ResultsA linear trend function was drawn and the coefficient of determination R2 and the Pearson correlation coefficient r were calculated for each of the 8 trend lines corresponding to the adequate treatment plan. An equation to correct the model was determined to estimate more accurately the beam-on time for different MFs. From 62 verification treatment plans, only 5 disagreed by more than 60s with the real time from the HT software. Whereas, for the equation provided by the manufacturer the discrepancy was observed in 16 cases. ConclusionsOur study showed that the model can well predict the treatment time for a given TL, MF, FW and it can be used in clinical practice.