Research Spotlight

Zeber, J. E., C. Pfeiffer, J. W. Baddley, J. Cadena-Zuluaga, E. M. Stock, L. A. Copeland, J. Hendricks, J. Mohammadi, M. I. Restrepo and C. Jinadatha (2018). “Effect of pulsed xenon ultraviolet room disinfection devices on microbial counts for methicillin-resistant Staphylococcus aureus and aerobic bacterial colonies.” Am J Infect Control 46(6): 668-673.

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BACKGROUND: Inadequate environmental disinfection represents a serious risk for health care-associated infections. Technologic advancements in disinfection practices, including no-touch devices, offer significant promise to improve infection control. We evaluated one such device, portable pulsed xenon ultraviolet (PX-UV) units, on microbial burden during an implementation trial across 4 Veterans Affairs hospitals. METHODS: Environmental samples were collected before and after terminal room cleaning: 2 facilities incorporated PX-UV disinfection into their cleaning protocols and 2 practiced manual disinfection only. Specimens from 5 high-touch surfaces were collected from rooms harboring methicillin-resistant Staphylococcus aureus (MRSA) or aerobic bacteria colonies (ABC). Unadjusted pre-post count reductions and negative binomial regression modeled PX-UV versus manual cleaning alone. RESULTS: Seventy samples were collected. Overall, PX-UV reduced MRSA and ABC counts by 75.3% and 84.1%, respectively, versus only 25%-30% at control sites. Adjusting for baseline counts, manually cleaned rooms had significantly higher residual levels than PX-UV sites. Combined analyses revealed an incident rate ratio of 5.32 (P = .0024), with bedrails, tray tables, and toilet handrails also showing statistically superior PX-UV disinfection. CONCLUSIONS: This multicenter study demonstrates significantly reduced disinfection across several common pathogens in facilities using PX-UV devices. Clinical impact of laboratory reductions on infection rates was not assessed, representing a critical future research question. However, such approaches to routine cleaning suggest a practical strategy when integrated into daily hospital operations.

Wilson, G., K. Kurian, S. Zamin, J. Urbanczyk, T. Haneke, C. Simonsen, S. Mehta, M. Suresh and J. Michel (2018). “Rates of Echocardiography, Coronary Angiography, and Coronary Intervention Associated With Troponin Testing in Hospitalized Patients.” Am J Cardiol 121(11): 1299-1303.

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Diagnosis of acute myocardial infarction (AMI) often depends on detection of cardiac troponin elevation >99th percentile. However, troponin elevation is commonly found in patients without AMI. We have previously reported an association between troponin elevation and rates of electrocardiogram (ECG), echocardiography (ECHO), and coronary angiography (CAG) in patients with a primary diagnosis of sepsis. We hypothesized that elevated troponin might be associated with greater use of ECHO and CAG in primary diagnoses other than sepsis and that this correlation might also include percutaneous coronary intervention (PCI). We reviewed all inpatient admissions to nine hospitals in Texas in 2016 collecting primary International Statistical Classification of Diseases and Related Health Problems (International Classification of Diseases-10) diagnoses, troponin test data, and the presence of ECHO, CAG, or PCI during hospitalization. We identified 56,895 unique inpatient admissions, of which 14,326 (25.2%) were associated with troponin testing. Of patients tested, 26.1% had one or more troponin I values >/=0.1 ng/ml (99th percentile). Primary ICD-10 diagnoses were grouped into (1) AMI, (2) primary diagnosis other than AMI (non-AMI), (3) congestive heart failure (CHF), (4) sepsis, and (5) Other excluding AMI, CHF, or sepsis. Troponin testing was itself associated with greater utilization of ECHO, CAG, and PCI in all groups except CHF. Troponin I values >/=0.1 ng/ml were associated with increased rates of ECHO, CAG, and PCI across all groups.

Widmer, R. J., M. W. Cullen, B. R. Salonen, K. K. Sundsted, D. Raslau, A. B. Mohabbat, B. M. Dougan, D. M. Bierle, D. K. Lawson, A. J. Widmer, M. Bundrick, P. Gaba, R. Tellez, D. R. Schroeder, R. B. McCully and K. F. Mauck (2018). “Cardiac Events after Noncardiac Surgery in Patients Undergoing Preoperative Dobutamine Stress Echocardiography: Findings From the Mayo Poce-DSE Investigators.” Am J Med 131(6): 702, e715-702, e722.

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BACKGROUND: Current guidelines support the use of dobutamine stress echocardiography (DSE) prior to noncardiac surgery in higher-risk patients who are unable to perform at least 4 metabolic equivalents of physical activity. We evaluated postoperative outcomes of patients in different operative risk categories after preoperative DSE. METHODS: We collected data from the medical record on 4494 patients from January 1, 2006 to December 31, 2011 who had DSE up to 90 days prior to a noncardiac surgery. Patients were divided into low, intermediate, and high preoperative surgery-specific risk. Baseline demographic data and risk factors were abstracted from the medical record, as were postoperative cardiac events including myocardial infarction, cardiac arrest, and mortality within 30 days after surgery. RESULTS: There were 103 cardiac outcomes (2.3%), which included myocardial infarction (n = 57, 1.3%), resuscitated cardiac arrest (n = 26, 0.6%), and all-cause mortality (n = 40, 0.9%). Cardiac event rates were 0.0% (95% confidence interval [CI], 0.0%-3.9%) in the low-surgical-risk group, 2.1% (95% CI, 1.6%-2.5%) in the intermediate-surgical-risk group, and 3.4% (95% CI, 2.0%-4.4%) in the high-risk group. Thirty-day postoperative mortality rates were 0%, 0.9%, and 0.8% for the low-risk, intermediate-risk, and high-risk surgical groups, respectively, and were not statistically different. CONCLUSIONS: These findings demonstrate low cardiac event rates in patients who underwent a DSE prior to noncardiac surgery. The previously accepted construct of low-, intermediate-, and high-risk surgeries based on postoperative events of <1%, 1%-5%, and >5% overestimates the actual risk in contemporary settings.

Wesson, D. E. and H. E. Kitzman (2018). “How Academic Health Systems Can Achieve Population Health in Vulnerable Populations Through Value-Based Care: The Critical Importance of Establishing Trusted Agency.” Acad Med 93(6): 839-842.

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Improving population health may require health systems to proactively engage patient populations as partners in the implementation of healthy behaviors as a shared value using strategies that incentivize healthy outcomes for the population as a whole. The current reactive health care model, which focuses on restoring the health of individuals after it has been lost, will not achieve the goal of improved population health. To achieve this goal, health systems must proactively engage in partnerships with the populations they serve. Health systems will need the help of community entities and individuals who have the trust of the population being served and are willing to act on behalf of the health system if they are to achieve this effective working partnership. The need for these trusted agents is particularly pertinent for vulnerable and historically underserved segments of the population. In this Invited Commentary, the authors discuss ways by which health systems might identify, engage, and leverage trusted agents to improve the health of the population through value-based care.

Wasek, B., E. Arning and T. Bottiglieri (2018). “The use of microwave irradiation for quantitative analysis of neurotransmitters in the mouse brain.” J Neurosci Methods. May 23. [Epub ahead of print].

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BACKGROUND: Assessing neurotransmitter metabolism in the brain is essential in studying the effects of drugs, dietary modification and characterizing transgenic mouse models of human neurodegenerative diseases. Regional brain concentrations of parent neurotransmitters and related metabolites are informative and provide a snap shot of the steady-state levels. The choice in method of sacrificing mice may differ from one laboratory to another, and the technique in removal of brain may have limitations depending on speed in which tissue can be dissected and frozen to prevent post-mortem changes. NEW METHODS: In order to better assess neurotransmitter metabolism in an effective and standardized manner we evaluated microwave irradiation as a method of sacrificing mice. Mice were sacrificed by CO2 asphyxiation followed by cervical dislocation or microwave irradiation at 4 Kw for 1.1s. Brain tissue was harvested into five regions and stored at -80 degrees C until analysis by either LC-MS/MS for acetylcholine, choline and GABA, or HPLC-EC for dopamine, serotonin and norepinephrine and related metabolites. RESULTS: The results of our study showed considerable differences in the levels of neurotransmitters between the two methods of sacrifice. Overall, the concentrations of neurotransmitters were higher in mice sacrificed by microwave irradiation, except for GABA, which was lower. COMPARISON WITH EXISTING METHOD(S): Previous microwave irradiation studies employed presently outdated equipment and neurotransmitter analysis methods, and were not as comprehensive. CONCLUSIONS: The combination of microwave irradiation with LC-MS/MS and HPLC-EC detection allows accurate and sensitive measurement of several neurotransmitter systems in discrete mouse brain regions.