1. In this retrospective study, postoperative antimicrobial prophylaxis following clean or clean-contaminated nonemergent pediatric surgery does not significantly reduce the incidence of surgical site infections (SSI).
2. Rates of postoperative antimicrobial prophylaxis are still quite high in the United States despite current guideline recommendations against its use.
Evidence Rating Level: 2 (Good)
Surgical site infection (SSI) is the most common complication that occurs in pediatric surgery, and it is associated with prolonged hospital stays and excess hospital costs. Appropriate use of intravenous antibiotics is important to decrease the risk of SSI, but overuse of antimicrobial prophylaxis is associated with antimicrobial resistance and adverse events such as allergic reactions, kidney injury, and colitis. Guidelines now recommend the cessation of post-operative prophylaxis following incision closure for clean and clean-contaminated procedures. There is an increasing body of evidence that demonstrates the lack of benefit of extended antibiotic prophylaxis, though it is still quite common in pediatric surgery. The purpose of this study is to examine the association between postoperative antimicrobial prophylaxis and SSI at the hospital level. This study was a retrospective multicenter cohort analysis from 151 participating hospitals in the United States. Included were 40,611 patients under 18 years old who underwent nonemergent clean and clean-contaminated procedures between June 2019 and June 2021. Exclusion criteria included allergies to antibiotics, conditions or medications associated with impaired immune function, and pre-existing infections requiring antibiotics. Overall, the rate of post-operative antimicrobial prophylaxis was 41.6%, with a large variation between individual hospitals. The overall rate of SSI was 1.8%, and there was no association found between postoperative prophylaxis use and SSI outcomes (P=.20), or between prophylaxis use extending for 24 hours after incision closure and SSI outcomes (P=.87). Further stratification by pediatric surgical specialty or type of SSI still resulted in insignificant correlations. Overall, the findings from this retrospective cohort study suggest that post-operative antimicrobial prophylaxis does not decrease the incidence of surgical site infections in a pediatric population undergoing clean or clean-contaminated nonemergent procedures. A limitation of this study was that given its retrospective nature, there may have been errors in misclassification and reported outcomes. In addition, operative details were unfortunately not available for review in this study, which may affect the decision for the administration of antibiotics. For example, if there was gross contamination of the sterile field during the surgery, that would affect decision-making surrounding intravenous antibiotics. This study is an important addition to the growing body of evidence suggesting the limited utility of postoperative prophylactic antibiotics. Furthermore, this study displays quite high rates of postoperative antimicrobial prophylaxis despite current guideline recommendations and serves as an important reminder to reduce unnecessary intravenous antibiotic use, especially in hospitals with much higher rates of use compared to their peers.
1. In this randomized controlled trial, among patients presenting with stable chest pain and an intermediate pre-test probability for obstructive coronary artery disease (CAD), there was no significant difference between men and women who received initial coronary computed tomography (CT) and coronary angiography with respect to major adverse cardiovascular events (MACEs).
2. Women receiving coronary CT as an initial diagnostic test had a lower rate of major procedure-related complications than women receiving coronary angiography as an initial diagnostic test.
Evidence Rating Level: 1 (Excellent)
The incidence of coronary artery disease (CAD) is similarly high in both men and women, and accounts for a high proportion of all-cause death. However, previous evidence has shown that women with stable chest pain and suspected CAD have more severe symptoms but less severe myocardial ischemia and epicardial coronary artery disease when compared to men. However, knowledge of this phenomenon may lead to misdiagnosis and poorer outcomes in women. With respect to diagnosis, while coronary angiography is the gold standard for clinical diagnosis of CAD, coronary computed tomography (CT) has been shown to be clinically useful for the diagnosis of obstructive CAD in patients presenting with stable chest pain and an intermediate pre-test probability. However, coronary CT has been reported to have a comparable or slightly lower accuracy in women than in men, but there is a paucity of high-quality evidence comparing the gender-specific effectiveness of coronary CT and invasive coronary angiography as the initial test. The diagnostic imaging strategies for patients with stable chest pain and intermediate risk of coronary artery disease (DISCHARGE) trial previously showed no difference between an initial coronary CT and initial coronary angiography with regards to major adverse cardiovascular events (MACE), but the aim of this analysis was to assess the gender-specific comparative effectiveness of coronary CT and coronary angiography. The DISCHARGE trial was a prospective randomized controlled trial, including 26 clinical centers in 16 European countries. Included were patients at least 30 years of age, referred for further investigation due to stable chest pain and intermediate pre-test probability of obstructive CAD. Between October 2015 and April 2019, 3,541 patients, 2002 women (57%) and 1559 men (43%), were included in the analysis. With respect to the primary outcome, there was no significant difference in major adverse cardiac events (MACE) between men and women (HR 1.58, 95% CI [0.68, 3.66]; P=0.29), even after further stratification of these events. With respect to secondary outcomes, between men and women, there was no significant interaction between gender and study group for major procedure-related complications (HR 0.28, 95% CI [0.06, 1.33]; P=0.11). However, within gender, the risk of a major procedure-related complication was lower in the coronary CT group than in the coronary angiography group in women (HR 0.14, 95% CI [0.04, 0.46]), but this same correlation was not seen in men. Overall, this post-hoc analysis of the DISCHARGE trial suggests that in patients with stable chest pain and intermediate pre-test probability of obstructive CAD, there is no significant difference in MACEs; though there was a higher risk for procedure-related complications in women receiving coronary angiographies when compared to coronary CTs as the initial intervention. A limitation of this study is that patients were categorized according to gender, and thus the extent of heterogeneity within each gender group with regard to sex is not known. This analysis is an important addition to current evidence studying the differences in the efficacy of diagnostic tests between men and women, as this knowledge allows for more personalized healthcare.
1. In this prospective cohort study, the mortality rate in community-living older persons in the United States following major surgery within one year was 13.4%.
2. Age 90 or above, frailty, and probable dementia were associated with significantly increased one-year mortality rates in community-living older adults following major surgery.
Evidence Rating Level: 2 (Good)
With the aging population in the United States (US), the number of older persons requiring major surgery will also continue to increase. In the geriatric population, priorities for outcomes include preserving functional independence, maintaining health-related quality of life, and relieving symptom burden. Population-based mortality, while imperfect, is a good indicator of the welfare of older persons and will allow us to better understand the scope and scale of mortality after major geriatric surgery. Current estimates of mortality following major geriatric surgery lack important aspects of information including longer follow-up or meaningful geriatric-specific conditions such as frailty or dementia. The objective of this study is to calculate population-based estimates for 1-year mortality following major surgery in community living older US adults and to determine the effect of key demographics. Data were extracted from the National Health and Aging Trends Study (NHATS) linked to records from the Centers for Medicare and Medicaid Services (CMS). Included were community-living patients 65 years or older undergoing major surgery, which was defined as a procedure needing use for general anesthesia for a non-percutaneous non-endoscopic intervention. Major surgeries were included from 2011 through to 2017, and important information was collected such as frailty index (stratified into non-frail, prefrail, and frail) and the presence of dementia. 1,193 major surgeries were included in the analysis, and over one year, there were 206 deaths representing 13.4% mortality. With respect to age stratification, increased mortality was directly associated with increased age, with statistical significance between those aged 65 – 69 and those in the 3 oldest age groups. Furthermore, with respect to sex, men had higher mortality than women, but the findings were not statistically significant. With respect to frailty, mortality was highest in those defined as frail and lowest for those defined as non-frail; the mortality rate was significantly higher in patients defined as prefrail when compared to non-frail (HR 1.94, 95% CI [1.01, 3.73]) and significantly higher in non-frail versus frail (HR 5.31, 95% CI [2.61, 9.39]). In addition, mortality was significantly higher in those with probable dementia when compared to those with no dementia (HR 3.29, 95% CI [2.08, 5.19]). Overall, the findings from this study suggest a high mortality rate of community-living older adults in the US within one year following major surgery. Within subgroups, there are substantial differences in one-year mortality which highlights the prognostic value of age and geriatric conditions such as frailty and dementia. A major limitation of this study is that it only included fee-for-service Medicare beneficiaries, with a penetrance of approximately 25%. In addition, the only measured outcome was mortality, but especially in the geriatric population, additional outcomes such as functional status, quality of life, and days spent at home should be considered as well. This study contributes possible prognostic factors for mortality in older persons following major surgery, and further research into specific risk factors may guide decision-making regarding major surgeries in this patient population in the future.
1. In this prospective randomized controlled trial, in actively smoking pregnant women, findings suggest that offering incentives as part of a smoking cessation program resulted in a significant increase in biochemically confirmed smoking cessation rates in late pregnancy in the United Kingdom (UK).
Evidence Rating Level: 1 (Excellent)
Maternal tobacco smoking is responsible for adverse health outcomes, including death, among women and offspring. Midwives in the United Kingdom (UK) do not have sufficient time and training to counsel mothers who are current smokers, and thus these mothers are offered counseling by dedicated stop-smoking services. However, women who continue to smoke while pregnant may not engage with cessation services, and this study aims to investigate the effect of financial incentives used for maternal smoking cessation services, as there is currently a paucity of high-quality evidence surrounding this topic. The Cessation in Pregnancy Incentives Trial Phase 3 (CPIT III) recruited pregnant women from 7 UK stop smoking services serving maternity hospitals in Scotland, Northern Ireland, and England. Included were English-speaking women that were self-reported smokers, 16 years or older, and before 24 weeks gestation. Women were offered up to £400 pounds in shopping vouchers at four time points throughout the trial: a £50 voucher to engage with the stop smoking service, another £50 voucher if not smoking after four weeks, a £100 voucher if smoke-free after 12 weeks, and a £200 voucher if the patient was verified to have quit smoking in late pregnancy at a random date between 34- and 38-weeks gestation. This randomized controlled trial included 944 participants from 7 sites between January 2018 and April 2020 who were randomized in a 1:1 ratio to the control group or incentive group. Baseline characteristics were similar between the two randomized groups. With respect to the primary outcome, 843 (89.3%) women provided a self-report and biochemical verification of smoking status. With respect to smoking cessation, there was a significantly higher proportion of biochemically verified non-smokers in the group that was offered incentives (126/471 (26.8%)) when compared to participants in the control group (58/470 (12.3%)) (P<0.001). With respect to secondary outcomes, there was a significantly more engagement with stop-smoking services and no significant difference in biochemically verified non-smoking at four weeks after the pre-set stop-smoking date in the incentives group versus the control group (P<0.001). However, at 6 months post-partum, there was no significant difference between groups in biochemically verified non-smokers, though at 6 months there was reduced follow-up compared to previous data. With respect to birth weight, there was a clinically important but not significant difference in patients who adhered to their treatment (adjusted mean difference 0.31 kg, 95% CI [-0.18, 0.80], P=0.22). Overall, the findings from this study suggest that incentives offered in this prospective randomized controlled trial resulted in a significant decrease in maternal smoking rates by the end of pregnancy. A limitation of this study was that almost all participants were white, which decreases the generalizability of the data to other, more diverse populations. Otherwise, this study acts as an important step toward the exploration of healthcare incentives, and further research exploring the effect of incentives on overall healthcare cost burden may encourage further developments in healthcare policy.
Post-acute health care burden after SARS-CoV-2 infection: a retrospective cohort study
1. In this retrospective cohort study, community-dwelling adults that tested positive for SARS-CoV-2 had a significantly increased number of healthcare encounters when compared to their test-negative counterparts.
2. At the 99th percentile of healthcare use, females who tested positive for SARS-CoV-2 had an approximately 7 additional days in hospital per-person-year and males had approximately 9 more days in hospital than their test-negative counterparts.
Evidence Rating Level: 2 (Good)
During the COVID-19 pandemic, there were >600 million infections with SARS-CoV-2 and 6.5 million deaths reported worldwide as of September 2022, though this is likely a gross underestimation as many infections have gone undetected. It is difficult to estimate the public health effects of COVID-19; previous evidence studying the first pandemic wave found increased long-term morbidity in those who were infected with SARS-CoV-2. According to the World Health Organization, approximately 10-20% of those infected develop a post-COVID-19 condition (long COVID), and evidence from before the emergence of the Omicron variant has reported similar findings. Given the extent of the pandemic and long-term consequences, it is imperative for healthcare funders, policy makers, and clinicians to better understand the post-acute infection healthcare burden of COVID-19 to plan accordingly. This retrospective cohort study aims to quantify the burden of healthcare in community-dwelling adults in Ontario. Included were community-dwelling adults who underwent polymerase chain reaction (PCR) testing for SARS-CoV-2 between January 2020 and March 2021 in Ontario. Those with positive test results were matched with a person with a negative test result with similar demographic and health characteristics. The primary outcome in this study was healthcare encounters, including days in hospital, outpatient encounters, home care visits, emergency department visits, and days in a long-term care facility. Overall, more than 11 million PCR tests were completed, with 268,521 individuals testing positive for SARS-CoV-2 (7.4% positivity rate). The matching was successful for 99% of patients; the matched cohort consisted of 531,702 people. With respect to the primary outcome, in females, the per-person-year rates of each type of healthcare encounter were significantly higher in test-positive females than for test-negative females. The absolute increase in total healthcare encounters at the mean was 2.0. However, of note, at the 99th percentile, test-positive females had a greatly increased number of healthcare encounters, including 28.37 more home care encounters per-person-years and 6.48 additional days in hospital. A similar pattern was seen in males, with a significantly higher per-person-year rate for all healthcare encounter types with the exception of home care visits and emergency department visits. The absolute increase in total healthcare encounters at the mean was 0.66. Similar to females, at the 99th percentile, test-positive males had an additional 8.69 days in hospital compared to their test-negative counterparts. Overall, the findings from this retrospective study suggest a significant increase in the healthcare burden following a COVID-19 infection, especially in the top 1% of users of healthcare resources. At the 99th percentile, test-positive females had approximately 7 additional days in hospital per-person-year and males had approximately 9 more days in hospital than their test-negative counterparts. A major limitation of this study was that healthcare burden was likely underestimated due to the decrease in healthcare during the initial COVID-19 pandemic. Furthermore, the severity of healthcare encounters was not considered due to the nature of the data available. In conclusion, this study is incredibly important to quantify the healthcare burden of long COVID on the healthcare system and will hopefully guide future decision-making by stakeholders to prepare for the healthcare demand caused by the COVID-19 pandemic.
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