Ohio State University Wexner Medical Center Research Articles

Prevalence of Electrographic Seizures in Hospitalized Patients With Altered Mental Status With No Significant Seizure Risk Factors Who Underwent Continuous EEG Monitoring: A Retrospective Study.

The objective of this study is to evaluate the prevalence of electrographic seizures in hospitalized patients with altered mental status and no significant risk factors for seizures. We retrospectively reviewed over a six-year period (2013-2019) the medical records of all adults admitted at Ohio State University Wexner Medical Center (OSUWMC), who underwent continuous electroencephalography (cEEG) monitoring for > 48 hours. Our primary objective was to identify the prevalence of electrographic seizures in patients with altered mental status and no significant acute or remote risk factors for seizures. A total of 1966 patients were screened for the study, 1892 were excluded (96.2%) and 74 patients met inclusion criteria. Electrographic seizures were identified in seven of 74 patients (9.45%). We found a significant correlation between electrographic seizures and a history of hepatic cirrhosis, n= 4 (57%), (p=0.035), acute chronic hepatic failure during admission, 71% (n=5), (p=0.027), and hyperammonemia (p =0.009). In this retrospective study of patients with altered mental status and no significant acute or remote risk factors for seizures who underwent cEEG monitoring for > 48 hours, electrographic seizures were identified in 9.45%. Electrographic seizures were associated with hepatic dysfunction and hyperammonemia. Based on our results, cEEG monitoring should be considered in patients with altered mental status and hepatic dysfunction even in the absence of other seizure risk factors.

Weight Gain in People with HIV: The Role of Demographics, Antiretroviral Therapy, and Lifestyle Factors on Weight.

We explored factors associated with weight gain among people with HIV (PWH) on antiretroviral therapy (ART) at The Ohio State University Wexner Medical Center (OSUWMC). This was a retrospective cohort study of adult PWH on ART for ≥3 months. Patients with CD4+ T cell count <200 cells/mm3, viral load >200 copies/mL, history of malignancy, or pregnancy were excluded. Eight hundred seventy patients met criteria. The primary outcome was percent weight change over the follow-up period (Δ = relative effects). The secondary outcome was the odds of ≥5 kg weight gain over the study period. The effects of concurrent medications, medical comorbidities, ART combinations, and lifestyle behaviors on these outcomes were modeled using mixed effects regression analyses. Over a mean follow-up of 1.86 years, the study population gained a mean percent weight of 2.12% ± 0.21% (p < .001) with the odds of ≥5 kg weight gain of 0.293 (p < .001). Males gained an average of 1.88% ± 0.22% over follow up, while females gained an average of 3.37% ± 0.51% over follow up (p = .008 for the difference). In regression models, combination therapy with tenofovir alafenamide (TAF) and integrase strand transfer inhibitor (INSTI) containing regimens was associated with an increase in weight over the study period (Δ = 2.14% ± 0.45%, p < .001 and Δ = 1.09% ± 0.39%, p = .005, respectively). Increasing age was significantly associated with a decrease in percent weight change over the study period (Δ = -0.68% ± 0.18% per year, p < .001). Self-reported improvement in diet was associated with a decrease in weight change (Δ = -1.99% ± 0.47%, p ≤ .001) and reduced odds of ≥5 kg weight gain (odds ratio = 0.70, 95% confidence interval = 0.50-0.97, p = .03). Factors associated with weight gain include therapy with TAF and INSTI. Diet may play an influential role in attenuating weight gain in PWH.

AB1855 SUSAC SYNDROME: CASE SERIES FROM ADULT &amp; PEDIATRIC TERTIARY ACADEMIC MEDICAL CENTERS

BackgroundSusac Syndrome (SS) is a rare autoimmune endotheliopathy that affects the brain, retina, and inner ear, characterized by a clinical triad of encephalopathy, branch retinal artery occlusion (BRAO), and sensorineural hearing loss (SNHL)[1]. Brain MRI, fluorescein angiogram (FA), and audiometry help to establish a diagnosis[2]. The clinical presentation of SS is often variable leading to a delay in the diagnosis.ObjectivesThis study aims to compare clinical features and therapeutic strategies in adult and pediatric populations with Susac Syndrome.MethodsThis was a retrospective chart review of cases with a diagnosis of SS from December 2010 to December 2020 at The Ohio State University Wexner Medical Center (OSUWMC) and Nationwide Children’s Hospital in Columbus, Ohio, USA (tertiary care centers). We analyzed the following: age, gender, ethnicity, symptoms at the time of presentation, diagnostic studies, autoimmune serologies, brain MRI, FA, audiometry, treatment approaches, and outcomes.ResultsAll the patients (seven adult- patients and two pediatric-onset patients) identified as females, and the majority (78%) were Caucasian. The age at presentation ranged from 10 to 45 years old with a mean age of 38 years. The time to diagnosis ranged from 3 to 17 months with a mean of 7.8 months. The most common symptoms at onset included dizziness, hearing loss, and visual change. ESR was elevated in 50% with a range of 23 to 52 mm/hr (normal&lt;30 mm/hr). CRP was elevated in 22% of patients with a range of 11 to 22 mg/dl (normal &lt;10 mg/dL). Low to medium titer ANA was positive in 30%. FA detected unilateral or bilateral BRAO in seven patients (78%). Sensorineural hearing loss was confirmed on audiogram testing in 7 of 9 patients, and 44% of patients had bilateral hearing loss. 88% of our patient population had evidence of corpus callosal involvement (“snowball lesions”) in the brain MRI. CSF study was done in 5 patients - 4/5 had elevated CSF protein at 77 mg/dL (range 15-45 mg/dL) and the mean cell count was &lt;3 (normal), without any oligoclonal bands. One patient had a brain biopsy.The most common initial treatment was high-dose steroids followed by a taper. Oral immunosuppressive therapy with mycophenolate mofetil (MMF) was initiated in 78% and was maintained in 56% of patients, who remained stable. Intravenous immunoglobulin (IVIG) was initially used in 56% of patients. Two patients transitioned from MMF to azathioprine due to pregnancy. Due to the severity of the disease, one patient transitioned from MMF to tacrolimus and Rituximab. 20% had a disease flare after the initial therapy requiring additional immunosuppression.ConclusionOur series highlights the rarity of SS. A neurologic exam, brain MRI, fluorescein angiogram, and audiogram should be performed in every case. A brain biopsy is not necessary for the diagnosis, unless for exclusion. BRAO was detected in 75% of our patients, highlighting the importance of an ophthalmology evaluation with FA, even in the absence of visual symptoms. In our series, only 20% presented with the full clinical triad of visual, auditory, and central nervous system symptoms, indicating that presentation of SS is often incomplete and diagnosis relies on a high index of suspicion[3]. Treatment depends on the severity of the presentation and involves the use of high-dose corticosteroids along with immunosuppression including mycophenolate, IVIG, tacrolimus, rituximab, and cyclophosphamide[4].

Infrequent intrahousehold transmission of Clostridioides difficile between pet owners and their pets.

Companion animals have been shown to carry Clostridioides difficile strains that are similar or identical to strains found in people, and a small number of studies have shown that pets carry genetically identical C. difficile isolates as their owners, suggesting inter-species transmission. However, the directionality of transmission is ultimately unknown, and the frequency with which animals acquire C. difficile following their owners' infection is unclear. The goal of this study was to assess how often pets belonging to people with C. difficile infection carry genetically related C. difficile isolates. We enrolled pet owners from two medical institutions (University of Pennsylvania Health System (UPHS) and The Ohio State University Wexner Medical Center (OSUWMC)) who had diarrhoea with or without positive C. difficile assays and tested their faeces and their pets' faeces for C. difficile using both anaerobic culture and PCR assays. When microorganisms were obtained from both the owner and pet and had the same toxin profile or ribotype, isolates underwent genomic sequencing. Faecal samples were obtained from a total of 59 humans, 72 dogs and 9 cats, representing 47 complete households (i.e. where a sample was available from the owner and at least one pet). Of these, C. difficile was detected in 30 humans, 10 dogs and 0 cats. There were only two households where C. difficile was detected in both the owner and pet. In one of these households, the C. difficile isolates were of different toxin profiles/ribotypes (A+/B+ / RT 499 from the owner, A-/B- / RT PR22386 from the dog). In the other household, the isolates were genetically identical (one SNP difference). Interestingly, the dog from this household had recently received a course of antibiotics (cefpodoxime and metronidazole). Our findings suggest that inter-species transmission of C. difficile occurs infrequently in households with human C. difficile infections.

Exploration of Differences between Women Who Do and Do Not Disclose Their Marijuana Use during Pregnancy.

This study aimed to explore demographic and health-related factors that may differentiate women who do and do not disclose their marijuana use during pregnancy. The current study is a secondary analysis of data from a prospective cohort of pregnant women identified as using marijuana during pregnancy via a variety of assessment tools including self-report, urine screen, and obstetrics record abstraction. The cohort included a convenience sample of women recruited from several antenatal clinics at The Ohio State University Wexner Medical Center (OSUWMC). To be eligible, women needed to be within the first or second trimester of their pregnancy, 16 to 50 years of age, able to communicate in English, and intended to deliver at OSUWMC. Chi-square, independent samples t-tests, and logistic regression analyses were used to explore differences between those who did and did not disclose their use in relation to physical and mental health diagnoses, adverse experiences, use of other substances, and demographics. Women who used marijuana during their pregnancy and had mental/physical health data available comprised the current sample (n = 109). Women who attended college were more likely to disclose their marijuana use compared with women who did not attend college (p < 0.001). Women who experienced homelessness (p < 0.01) or self-reported alcohol use during pregnancy (p < 0.001) were significantly more likely to disclose their marijuana use. Findings, suggesting disclosure of other substance use and adverse experiences, such as homelessness, may increase the likelihood that pregnant women will voluntarily disclose their marijuana use to providers. Findings did not reflect racial differences nor significant differences in mental/physical health status among women based on their disclosure. Future research with larger datasets is needed to build on these findings by confirming results, as well as exploring additional factors, that may more effectively differentiate women who are unlikely to disclose their prenatal marijuana use from those who do disclose their use. · Women with higher education were more likely to self-disclose their prenatal marijuana use.. · Women who experienced homelessness were more likely to self-disclose their prenatal marijuana use.. · Self-disclosure of prenatal alcohol use was related to self-disclosure of prenatal marijuana use.

Genomic Study on Blood Culture Isolates From Patients With Staphylococcus Infection-associated Glomerulonephritis

IntroductionStaphylococcus infection-associated glomerulonephritis (SAGN), is an autoimmune sequela of infection affecting a subset of infected patients without specific predictive factors, frequently presenting with acute nephritic syndrome and propensity for chronic kidney disease. We performed a comparative genotypic and phenotypic analysis of S. aureus isolates from patients that did and those that did not develop SAGN.MethodsWe had 22 culture-proven cases of SAGN from Ohio State University Wexner Medical Center (OSUWMC) from 2004 to 2016, 9 of 22 being blood cultures, with archived isolates. These, along with blood culture isolates from 12 patients with no clinical evidence of SAGN (between ages 40 to 80 years) over the same period were used for genotyping. For host demographic comparison, we used all available SAGN cases (n = 85, including those with positive cultures other than blood; and patients with kidney biopsies received from referring hospitals) and all OSUWMC patients with positive Staphylococcus cultures without glomerulonephritis (GN) (n = 23,496).ResultsMultiple sequence types (STs) suggesting strain diversity was seen in the GN isolates with mainly clonal complexes (CC) 5 and 59. Mutations in the agr operon were identified in significantly higher number of the GN isolates (83%) than non-GN isolates (16%). Significant differences in β-hemolysis and biofilm formation was also observed between the groups.ConclusionThe functionality of these agr mutants remains to be seen, but the presently known effects of reduced agr function, namely increased surface adhesins, biofilm formation, and persistent bacteremia could be important microbial factors predisposing to SAGN and testing for them early during infection could help to predict its development.

Impact of a pharmacist-led tacrolimus management protocol in the outpatient setting

BackgroundClinical pharmacists are often used to make recommendations regarding tacrolimus therapy in the post transplant setting.Therapeutic drug monitoring (TDM) of tacrolimus after transplant is based on trough levels in the setting of predetermined institutional immunosuppression goals. To evaluate time within therapeutic range (TTR) of tacrolimus the Rosendaal method can be utilized. ObjectiveOur study aimed to compare objective therapeutic drug monitoring outcomes after the implementation of a pharmacist driven tacrolimus management protocol (postprotocol initiation) with previous management by providers (preprotocol initiation). Practice descriptionThe Ohio State University Wexner Medical Center (OSUWMC) is a 700-bed academic medical center in Columbus, OH. On average, OSUWMC completes more than 300 kidney transplants each year. There are 6 abdominal transplant pharmacists (including one postgraduate year 2 transplant pharmacy resident) that rotate through the inpatient and outpatient setting. Practice innovationA pharmacist-led tacrolimus management protocol in kidney transplant recipients was initiated in October 2018 at our institution, which enabled pharmacists to dose and adjust tacrolimus in the outpatient setting in accordance with prespecified goals. Evaluation methodsThis single-center retrospective analysis included adult kidney transplant recipients on de novo tacrolimus. Patient’s tacrolimus levels were evaluated for 6 months after transplant. The mean tacrolimus percent TTR and the median coefficient of variation (CV) were calculated and compared in postprotocol initiation group (n = 85) with preprotocol initiation group (n = 39). TTR was calculated using the Rosendaal method. ResultsThere was no statistically significant difference between the preprotocol initiation and postprotocol initiation group mean TTR (59.6% vs. 60.5%, P = 0.723), mean CV from 0-3 months after transplant (36.3 vs. 36.0, P = 0.900), and mean CV from at least 3-6 months after transplant (24.5 vs. 22.7, P = 0.351). Rejection rates, development of donor-specific antibodies, and renal function were similar between groups. ConclusionBased on our findings, transplant pharmacists were equally as effective at maintaining tacrolimus percent TTR and CV in the designated kidney transplant recipients included in the management protocol compared with primary management by other transplant providers. The delegation of tacrolimus management to clinical pharmacists is a viable alternative to primary management by outpatient practitioners.

Improving Provisioning of an Inpatient Portal: Perspectives from Nursing Staff.

Inpatient portals are recognized to provide benefits for both patients and providers, yet the process of provisioning tablets to patients by staff has been difficult for many hospitals. Our study aimed to identify and describe practices important for provisioning an inpatient portal from the perspectives of nursing staff and provide insight to enable hospitals to address challenges related to provisioning workflow for the inpatient portal accessible on a tablet. Qualitative interviews were conducted with 210 nursing staff members across 26 inpatient units in six hospitals within The Ohio State University Wexner Medical Center (OSUWMC) following the introduction of tablets providing access to an inpatient portal, MyChart Bedside (MCB). Interviews asked questions focused on nursing staffs' experiences relative to MCB tablet provisioning. Verbatim interview transcripts were coded using thematic analysis to identify factors associated with tablet provisioning. Unit provisioning performance was established using data stored in the OSUWMC electronic health record about provisioning status. Provisioning rates were divided into tertiles to create three levels of provisioning performance: (1) higher; (2) average; and (3) lower. Three themes emerged as critical strategies contributing to MCB tablet provisioning success on higher-performing units: (1) establishing a feasible process for MCB provisioning; (2) having persistent unit-level MCB tablet champions; and (3) having unit managers actively promote MCB tablets. These strategies were described differently by staff from the higher-performing units when compared with characterizations of the provisioning process by staff from lower-performing units. As inpatient portals are recognized as a powerful tool that can increase patients' access to information and enhance their care experience, implementing the strategies we identified may help hospitals' efforts to improve provisioning and increase their patients' engagement in their health care.

Transmission of COVID-19 on an Inpatient Hospital Prison Unit

Background: Prison populations have been disproportionally affected by COVID-19, partly due to challenges related to social distancing. Data on viral transmission dynamics in inpatient prison units remain limited. The Ohio State University Wexner Medical Center (OSUWMC) has a 24-bed inpatient prison unit in collaboration with the Ohio Department of Rehabilitations and Corrections (ODRC). The unit has 5 shared rooms holding 4 patients each and 4 single-patient rooms. Several cases of inpatient transmission of COVID-19 were identified on the inpatient prison unit. Methods: An IRB-approved retrospective chart review was conducted to evaluate inpatient transmission dynamics of hospital-acquired (HCA) COVID-19. All ODRC patients admitted from March 1 to April 24, 2020, were included. Patients assigned to the prison unit during their hospital stay were evaluated for potential HCA COVID-19, defined as a positive SARS-CoV-2 test ≥4 days after admission. Patient characteristics, testing data, symptoms, aerosol-generating procedures (AGPs), and room assignments were reviewed. Healthcare workers (HCWs) and correction officers (COs) working on the unit who tested positive during this period were identified. Results: In total, 142 ODRC patients were admitted during the study period and 89% had a positive SARS-CoV-2 testing prior to or during admission. Also, 61 patients (43%) were assigned to the prison unit. Moreover, 8 patients on the unit met potential HCA COVID-19 definition with 7 linked to 3 distinct clusters. Also, 7 COs had COVID-19 (outside hospital exposure) and 5 HCWs acquired COVID-19 from patient exposure on the unit. In cluster 1, 4 patients admitted to the same room developed HCA COVID-19. A symptomatic index patient not tested on admission given an atypical presentation required CPAP and frequent nebulizer treatments. In cluster 2, 1 patient from cluster 1 was transferred to another room. The new roommate subsequently developed HCA COVID-19. In cluster 3, a symptomatic correctional officer was assigned to 2 patients in a shared room; the patients later developed HCA COVID-19. Conclusions: Three patient clusters of HCA COVID-19 on a prison unit were identified. Aerosol transmission potentially played a role in cluster 1. Inpatient transmission within the unit prompted updated guidance for ODRC admissions, including universal SARS-CoV-2 admission testing, excluding patients requiring AGPs from shared rooms, and preemptive isolation for patients from an ODRC facility experiencing a COVID-19 surge. Universal testing was quickly expanded to all inpatient admissions. HCWs and COs were also linked to inpatient transmission, highlighting the importance of strict infection control practices for patient populations who cannot socially distance.Funding: NoDisclosures: None

Estrogen Receptor Is Expressed in Uveal Melanoma: A Potential Target for Therapy

Background: Metastatic uveal melanoma (UM) has no effective treatment. To date, no publications have reported immunohistochemical evidence of estrogen receptors (ERs) in UM; however, changes in pathologic reporting for ER in breast carcinoma prompted a re-examination of ER in UM, as it could represent a potential therapeutic target. Objective: To determine if UM tumors express ER by immunohistochemistry (IHC) using current methodology for breast cancer and to evaluate ER gene expression using a publicly available UM database. Methods: A retrospective IHC analysis with clinical correlation was performed on 2 cohorts: 57 cases from the Cleveland Clinic (CC) and 50 from the Ohio State University Wexner Medical Center (OSUWMC). Analysis of The Cancer Genome Atlas Project (TCGA) UM Dataset of 80 patients was also performed. Results: Presence of ER was detected by IHC in 20 of 34 (59%) analyzable cases in the CC cohort. Of the 50 patients in the OSU cohort, 52 specimens from 47 patients were sufficient for analysis. Of these 47 cases, 29 (62%) had tumor that was ER positive in ≥1% nuclei. In the second cohort, positivity was classified as positive (≥10% nuclei, 34% cases) or low positive (1–9% nuclei, 28% cases). In 5 patients, there were paired samples, that is, primary tumor and subsequent recurrence or metastasis, with concordance for ER in 4 of 5 cases. In the TCGA database, elevated ESR1 and ESR2 gene expression was identified in a subset of UM tumors with poor genetic prognostic features. Conclusions and Relevance: Potentially actionable ER expression is present in greater than half of UM cases by IHC. Gene expression of ESR1 and ESR2 was elevated in a subset of UM tumors with poor prognostic features. These data provide a rationale to evaluate ER as a potential target for therapy in UM.

Mask Up: Academic-Community-Government Partnerships to Advance Public Health During COVID-19.

Mask Up: Academic-Community-Government Partnerships to Advance Public Health During COVID-19.

Viral transport media for COVID-19 testing

Precautionary measures of physical isolation, social distancing, and masks have all aided in controlling the spread of COVID-19. However, detection of the virus is crucial to implement isolation of infected individuals. This paper presents the innovative repurposing of lab materials, workspace, and personnel in response to the COVID-19-induced shutdown and consequential shortage of commercially made virus transport media (VTM). This method for VTM production highlights the ability of standard research labs to fulfill the needs of those affected by the pandemic and potential recurrence of outbreaks. Further, the collaboration of the various entities at The Ohio State University Wexner Medical Center (OSUWMC) allowed for efficient production and distribution of VTM tubes to facilitate mass COVID-19 testing. We propose that implementation of this process by university research labs would enable quicker interventions, potentially better outcomes, and prevention of further spread of disease.

The Safety and Efficacy of Verapamil Versus Diltiazem Continuous Infusion for Acute Rate Control of Atrial Fibrillation at an Academic Medical Center.

Due to critical shortages of intravenous diltiazem in 2018, the Ohio State University Wexner Medical Center (OSUWMC) adopted intravenous verapamil as an alternative. However, there is a paucity of data supporting the use of intravenous verapamil infusions for rate control in the acute treatment of atrial arrhythmias. The purpose of this study was to determine the safety and efficacy of intravenous verapamil as compared with diltiazem for the acute treatment of atrial arrhythmias. This retrospective, case-control study compared patients who received verapamil infusions between June 1 and September 30, 2018, with patients who received diltiazem infusions between June 1 and September 30, 2017, at OSUWMC. Patients were matched 1:1 based on age, sex, and the presence of comorbid heart failure with reduced ejection fraction (≤40%). A total of 73 patients who received at least 1 verapamil infusion and 73 patients who received at least 1 diltiazem infusion met inclusion criteria. The composite need for inotrope or vasopressor was similar for both groups (5% with verapamil versus 4% with diltiazem, P = .999). The rate of hypotension was similar between groups (37% versus 33% experiencing a systolic blood pressure <90 mm Hg, P = .603, and 27% versus 23% experiencing a mean arterial pressure <65 mm Hg, P = .704), as was the rate of bradycardia (19% versus 18%, P = .831). The efficacy outcomes of this study were similar for both groups, with 89% of patients in the verapamil group and 90% of patients in the diltiazem group achieving a heart rate less than 110 beats per minute (P = .785). Intravenous verapamil and diltiazem infusions had similar safety and efficacy outcomes when used for acute treatment of atrial arrhythmias in the institutional setting.

Describing the Challenges Faced by Newly Prepared DNP Graduates in the Acute Care Setting

Since the development and introduction of the doctor of nursing practice (DNP) degree in 2004, the number of doctoral-prepared nurses has increased dramatically. The purpose of this article is to review the current challenges faced by DNP-prepared nurses as they enter the acute health care setting, and to share strategies we are exploring to enhance and showcase DNP practices and outcomes. In collaboration with our doctor of philosophy nursing colleagues, it is critical that we conduct studies that document the impact that DNP graduates have on health care organizations and, most importantly, patient outcomes. Since the development and introduction of the doctor of nursing practice (DNP) degree in 2004, the number of doctoral-prepared nurses has increased dramatically. The purpose of this article is to review the current challenges faced by DNP-prepared nurses as they enter the acute health care setting, and to share strategies we are exploring to enhance and showcase DNP practices and outcomes. In collaboration with our doctor of philosophy nursing colleagues, it is critical that we conduct studies that document the impact that DNP graduates have on health care organizations and, most importantly, patient outcomes. Ruth Labardee, DNP, RN, CNL, NEA-BC, is the director of health system nursing quality and evidence-based practice at The Ohio State University Wexner Medical Center (OSUWMC) in Columbus, Ohio, and assistant professor of clinical practice at The Ohio State University College of Nursing. She can be reached at [email protected] Jacalyn Buck, PhD, RN, NEA-BC, FAONL, is the chief nursing officer at University Hospital, Ross Heart Hospital, Brain and Spine Hospital and Dodd Rehabilitation Hospital at OSUWMC, and assistant professor of clinical practice at The Ohio State University College of Nursing. Rebecca Coffey, PhD, MSN, CNP, is a nurse practitioner for the Burn Center at OSUWMC. Kerry Dhakal, MAA, MLS, is an assistant professor, and research and education librarian at The Ohio State University. Deborah Francis, DNP, RN-BC, APRN-CNS, is a medical surgical clinical nurse specialist at OSUWMC. Deborah Seeling, DNP, RN, APRN-CNP, FNP-C, is a family nurse practitioner at The Ohio State University Hospital East, and an assistant professor of clinical practice at The Ohio State University College of Nursing. Esther Chipps, PhD, RN, NEA-BC, is a nurse scientist at OSUWMC and associate professor of clinical nursing at The Ohio State University College of Nursing.

1086. Antimicrobial Stewardship: From Bedside to Man’s Best Friend

BackgroundAntimicrobial stewardship plays an integral role in ensuring appropriate antimicrobial use in the inpatient hospital setting and is now required by The Joint Commission. Although it is well established that antimicrobial misuse and overuse has societal and ecological implications, the same regulations do not yet apply to our veterinary and agricultural counterparts.MethodsAt The Ohio State University Wexner Medical Center (OSUWMC), the Antimicrobial Stewardship Program (ASP) was created in 2007. A partnership was formed with The Ohio State University Veterinary Medical Center (OSUVMC) in 2017 and was leveraged through a pre-existing campus-wide One Health initiative. The goal was to develop a comprehensive Veterinary Hospital ASP. “The Core Elements of Hospital Antibiotic Stewardship Programs” (Centers for Disease Control and Prevention) and “The Core Principles of Antibiotic Stewardship in Veterinary Medicine” (American Veterinary Medical Association) were also referenced for guidance.ResultsSpecific initiatives within the OSUVMC ASP were modeled after similar interventions in the OSUWMC including development of antibiotic use guidelines by animal type for commonly encountered infections, antimicrobial utilization tracking, antibiogram creation, and both active and passive surveillance of targeted resistant pathogens. A mobile-friendly website was created to allow providers easy access to these ASP tools. Overall antimicrobial prescriptions decreased 22.4% following the first year of program implementation. Planning is currently underway for an ASP outreach program to local veterinary practices to increase awareness of ASP and improve antimicrobial prescribing. A parallel outreach program with rural Ohio hospitals is underway at OSUWMC.ConclusionA comprehensive veterinary hospital ASP was successfully implemented in collaboration with OSUWMC counterparts using successful human interventions applied in the animal setting. Optimizing antimicrobial use and resistance at both sites will likely prevent resistance transmission between these geographically proximate hospitals. Sharing the details of our approach may benefit other institutions looking to expand their stewardship reach.Disclosures All authors: No reported disclosures.

Interventions to Reduce Burnout and Improve Resilience: Impact on a Health System's Outcomes.

With the continuously changing health care environment and dramatic shift in patient demographics, institutions have the responsibility of identifying and dedicating resources for maintaining and improving wellness and resilience among front line providers to assure the quality of patient care. Our institution, the Ohio State University Wexner Medical Center (OSUWMC), has addressed the goal to decrease burnout for providers in a multistep, multiprofessional, and multiyear program starting firstly with institutional cultural change then focused provider interventions, and lastly, proactive resilience engagement. We describe herein our approach and outcomes as measured by provider wellness and health system outcomes. In addition, we address the overall feasibility and effectiveness of these programs in promoting provider compassion and mindfulness while reducing burnout and improving resilience. Institutional culture change and readiness were initiated in 2010 with the introduction of Crew Resource Management training for all providers across the OSUWMC. This multiyear program was implemented and has been sustained to the current day. Focused interventions to improve mindfulness were undertaken in the form of both Mindfulness in Motion (MIM) training for intensive care unit personnel and a "flipped classroom" mindfulness training for faculty and residents. Lastly, sustainable changes were introduced in the form of the Gabbe Health and Wellness program which consists of interprofessional MIM training and other wellness offerings for staff, faculty, and residents embedded across the entire medical center. The introduction of Crew Resource Management in 2010 continues to be endorsed and supported throughout OSUWMC for all providers, including residents and students. The improvements seen have not only improved patient satisfaction but also reduced patient safety events and improved national reputation for the institution as a whole. Subsequently, MIM training for intensive care unit providers has resulted in improved resilience as well as decreased patient safety events. In addition, the "flipped classroom" mindfulness training for residents and faculty has resulted in improvements in providing calm and compassionate care, improvements in physician wellbeing, and reductions in emotional exhaustion and depersonalization. Lastly, implementing the Gabbe Health and Wellness program inclusive of interprofessional MIM training for staff, faculty, and residents has resulted in significant reductions in burnout while significantly increasing resilience postintervention. The engagement from staff and enthusiasm to continue this program have escalated and been positively accepted across OSUWMC. To reduce the incidence of burnout, improve resilience, and ultimately improve patient outcomes, a health system must identify and prioritize a commitment and dedication of resources to develop and sustain a multimodal and interprofessional approach to change. These initiatives at OSU originated with cultural transformation allowing the acceptance of change in the form of mindfulness training, resilience building, and the engagement of organizational science, so as to demonstrate the outcomes and impact to the health system and academic peers. Herein we describe the work that has been done thus far, both published and in progress, to understand our journey.

Development and Evaluation of Predictive Models Designed to Drive an Intelligent Clinical Decision Support System for Optimizing Inpatient Glycemic Control

Background: Achieving glycemic control in critically ill patients is of paramount importance, and has been linked to reductions in mortality, ICU length of stay (LOS), and morbidities such as infection, regardless whether or not the patient has diabetes. The myriad of illnesses and patient conditions render maintenance of glycemic control very challenging in this setting. Methods: This study involved collection of continuous glucose monitoring (CGM) data, and other associated measures, from the electronic medical records of 127 patients for the first 72 hours of ICU admission at The Ohio State University Wexner Medical Center (OSWMC). Data collected was used to develop a neural network-based predictive models. Findings: The model was shown to be accurate in predicting glucose using patient data not leveraged for model training. Model error, expressed as mean absolute difference percent, was 10.6% and 15.9% with respect to interstitial and serum blood glucose values, respectively. Clarke Error Grid Analysis (CEGA) of model predictions with respect to the reference CGM and blood glucose measurements revealed that >99% of model predictions could be regarded as clinically acceptable. Interpretation: The noted clinical acceptability of these models illustrates their potential utility within a clinical decision support system to assist healthcare providers in the optimization of glycemic management in critical care patients. Funding Statement: This study was supported by a $98,366 grant provided by the State of Ohio's Third Frontier Program (Grant #TECG20140125) and $20,000 provided by the Department of Anesthesiology at OSUWMC. Declaration of Interests: Dr. Jaume has nothing to disclose. Mr. Owais has nothing to disclose. Dr. Papadimos has nothing to disclose. Dr. Tripathi has nothing to disclose. Dr. Mavarez Martinez has nothing to disclose. Dr. Cameron has received one initial payment from the University of Toledo that was due to an initial licensing fee paid by Analytic Diabetic Systems, Inc. as part of licensing the patents referenced above as part of potential future commercial product development of a clinical decision support system. Dr. Pappada reports grants and personal fees from Analytic Diabetic Systems, Inc., personal fees from University of Toledo, during the conduct of the study; In addition, Drs. Pappada and Cameron hold patents (U.S. Patent No. 8,762,306 B2 and U.S. Patent No. 9,076,107 B2) related to the GlyCU CDSS with royalties paid to the University of Toledo and Co-Inventors (Drs. Pappada and Cameron) from Analytic Diabetic Systems, Inc. Dr. Pappada is on the Board of Directors for Analytic Diabetic Systems, Inc. and is a Co-Founder of the company, and holds an equity position in the corporation. Ethics Approval Statement: The study protocol was approved by The Ohio State University Institutional Review Board. All patients or their next of kin (if the patient had lost decision-making capacity) provided written informed consent.

Disposable Patterned Electroceutical Dressing (PED-10) Is Safe for Treatment of Open Clinical Chronic Wounds.

Objective: To evaluate if patterned electroceutical dressing (PED) is safe for human chronic wounds treatment as reported by wound care providers. Approach: This work reports a pilot feasibility study with the primary objective to determine physically observable effects of PED application on host tissue response from a safety evaluation point of view. For this pilot study, patients receiving a lower extremity amputation with at least one open wound on the part to be amputated were enrolled. Patients were identified through the Ohio State University Wexner Medical Center (OSUWMC) based on inclusion and exclusion criteria through prescreening through the Comprehensive Wound Center's (CWC) Limb Preservation Program and wound physicians and/or providers at OSUWMC. Wounds were treated with the PED before amputation surgery. Results: The intent of the study was to identify if PED was safe for clinical application based on visual observations of adverse or lack of adverse events on skin and wound tissue. The pilot testing performed on a small cohort (N = 8) of patients showed that with engineered voltage regulation of current flow to the open wound, the PED can be used with little to no visually observable adverse effects on chronic human skin wounds. Innovation: The PED was developed as a second-generation tunable electroceutical wound care dressing, which could potentially be used to treat wounds with deeper infections compared with current state of the art that treats wounds with treatment zone limited to the surface near topical application. Conclusion: Technology advances in design and fabrication of electroceutical dressings were leveraged to develop a tunable laboratory prototype that could be used as a disposable low-cost electroceutical wound care dressing on chronic wounds. Design revisions of PED-1 (1 kΩ ballast resistor) circumvented previously observed adverse effects on the skin in the vicinity of an open wound. PED-10 (including a 10 kΩ ballast resistor) was well tolerated in the small cohort of patients (N = 8) on whom it was tested, and the observations reported here warrant a larger study to determine the clinical impact on human wound healing and infection control.

Anticoagulant-Related Nephropathy in Kidney Biopsy: A Single-Center Report of 41 Cases

Rationale & ObjectiveIn 2009, the first case of acute kidney injury and occlusive red blood cell (RBC) tubular casts associated with a high international normalized ratio in a patient receiving warfarin was identified. This entity, named warfarin-related nephropathy, was later renamed anticoagulant-related nephropathy (ARN) after similar cases with other anticoagulants were described. We provide our 10-year experience with ARN based on a single-center kidney biopsy laboratory.Study DesignThe kidney pathology database at the Ohio State University Wexner Medical Center (OSUWMC) was searched for native kidney biopsy cases consistent with ARN. Clinical data were obtained from patient medical records.Setting & ParticipantsNative kidney biopsies evaluated between January 1, 2009, and December 31, 2017 at OSUWMC.ResultsAmong 8,636 native kidney biopsies reviewed at the OSUWMC, there were 41 (0.5%) patients for whom deterioration in kidney function could not be explained by kidney biopsy findings alone if anticoagulation was not considered. There were 63% men and 95% were white; average age was 62 ± 14 years. Most were on warfarin therapy (N = 28), although cases were also attributed to direct-acting anticoagulants (N = 2), antiplatelet medications (N = 1), heparin or enoxaparin (N = 4), and disseminated intravascular coagulopathy (N = 6). Morphologically, there was acute tubular necrosis and RBC casts. The majority of biopsies had an underlying glomerular disease and many patients had positive serologic test results. In all these cases, the severity of kidney failure, RBC tubular casts, and hematuria were disproportionate to glomerular morphologic changes.LimitationsSelection bias in the decision to perform a kidney biopsy.ConclusionsARN is an uncommon diagnosis in kidney pathology practice, but it should be considered when the number of RBC tubular casts is disproportionate to the severity of glomerular changes in a kidney biopsy in patients either receiving anticoagulation therapy or who presented with acute coagulopathy. Our data suggest that anticoagulation aggravates underlying glomerular diseases rather than directly affecting the glomerular filtration barrier.

Progression of care among women who use a midwife for prenatal care: Who remains in midwife care?

Prenatal care provided by midwives provides a safe and cost-effective alternative to care provided by physicians. However, no studies have evaluated the frequency of women who leave midwifery care, in a hospital setting. Our study objectives were to measure the frequency of transfers of care to physicians, to describe the sociodemographic and pregnancy-related characteristics of women who transferred to the care of a physician during prenatal care and at delivery, and to assess correlates of these transfers. We used electronic medical records to perform a retrospective cohort study of women who delivered at The Ohio State University Wexner Medical Center (OSUWMC) and had at least one prenatal care visit within OSUWMC's network. We report descriptive findings, using proportions and means with standard deviations. We used logistic regression, with Firth's bias correction as necessary, to assess correlates of transferring to a physician during prenatal care and at delivery. Most women who initiated prenatal care with a midwife remained in midwifery care throughout delivery, with 4.7% transferring to a physician during prenatal care, and an additional 21.4% transferring to a physician during delivery. After adjusting for pregnancy-related factors, the black race was statistically significantly associated with leaving midwifery care during prenatal care (adjusted odds ratio AOR 3.0 [95% CI 1.4-6.6]) and delivery (AOR 2.5 [95% CI 1.5-4.3]). Findings indicate that most women remain in midwifery care throughout pregnancy, but raise important questions with respect to the possible role that race has in pregnancy care.