Publications by authors named "Thomas C Bailey"

76 Publications

Comment on "Colchicine for acute gout".

Acad Emerg Med 2022 Jun 25;29(6):811. Epub 2022 Apr 25.

Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.

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http://dx.doi.org/10.1111/acem.14505DOI Listing
June 2022

Impact of risk-based sexually transmitted infection screening in the emergency department.

Acad Emerg Med 2022 Jul 22;29(7):879-889. Epub 2022 Apr 22.

Institute for Informatics, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA.

Objectives: Sexually transmitted infections (STIs), including chlamydia, gonorrhea, and human immunodeficiency virus (HIV) pose a significant health burden in adolescents. Many adolescents receiving care in the emergency department (ED) are in need of testing, regardless of their chief complaint. Our objective was to determine whether an electronic, risk-based STI screening program in our ED was associated with an increase in STI testing among at-risk adolescents.

Methods: We conducted a retrospective cohort analysis of patient outcomes in our pediatric ED after integrating an Audio-enhanced Computer-Assisted Self-Interview (ACASI) as standard of care. It obtained a focused sexual history and generated STI testing recommendations. Patient answers and testing recommendations were integrated in real-time into the electronic health record. Patients who tested positive received treatment according to our standard-of-care practices. All patients 15-21 years of age were asked to complete this on an opt-out basis, regardless of the reason for their ED visit. Exclusions included those unable to independently use a tablet, severe illness, sexual assault, or non-English speaking. Our primary outcome was to describe STI-testing recommendations and test results among ACASI participants. We also compared STI testing between ACASI participants and those who were eligible but did not use it.

Results: In the first 13 months, 28.9% (1788/6194) of eligible adolescents completed the ACASI and 44.2% (321/790) accepted recommended STI testing. The mean age of participants was 16.6 ± 1.3 years, with 65.4% (1169) being female. Gonorrhea/chlamydia testing was significantly higher among participants vs. non-participants (20.1% [359/1788] vs 4.8% [212/4406]; p < 0.0001). The proportion of positive STI tests was similar between the two groups: 24.8% (89/359) vs. 24.5% (52/212; p = 0.94) were positive for chlamydia and/or gonorrhea, while 0.6% (2/354) participants vs. 0% non-participants (p > 0.99) were positive for HIV. Among participants whose chief complaints were unlikely to be related to STIs but accepted recommended testing, 20.9% (37/177) were positive for gonorrhea or chlamydia.

Conclusions: Our program facilitated STI testing in the ED and identified many adolescents with STIs, even when their ED complaint was for unrelated reasons. More rigorous implementation is needed to determine the impact of deployment of ACASI to all eligible adolescents and addressing barriers to accepting STI testing recommendations.
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http://dx.doi.org/10.1111/acem.14465DOI Listing
July 2022

Risk factors for mortality and multidrug resistance in pulmonary tuberculosis in Guatemala: A retrospective analysis of mandatory reporting.

J Clin Tuberc Other Mycobact Dis 2021 Dec 15;25:100287. Epub 2021 Nov 15.

Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, USA.

Background: Risk factors for mortality and MDR-TB in Guatemala are poorly understood. We aimed to identify risk factors to assist in targeting public health interventions.

Methods: We performed a retrospective study of adults with pulmonary TB reported to the Guatemalan TB Program between January 1, 2016 and December 31, 2017. The primary objective was to determine risk factors for mortality in pulmonary TB. The secondary objective was to determine risk factors associated with MDR-TB.

Results: Among 3,945 patients with pulmonary TB, median age was 39 years (IQR 25-54), 59% were male, 25% of indigenous ethnicity, 1.1% had MDR-TB and 3.9% died. On multivariable analysis, previous TB treatment (odds ratio [OR] 3.57, CI 2.24-5.68 [p < 0.001]), living with HIV (OR 3.98, CI 2.4-6.17 [p < 0.001]), unknown HIV diagnosis (OR 2.65, CI 1.68-4.18 [p < 0.001]), indigenous ethnicity (OR 1.79, CI 1.18-2.7 [p = 0.005]), malnutrition (OR 7.33, CI 3.24-16.59 [p < 0.001]), and lower educational attainment (OR 2.86, CI 1.43-5.88 [p = 0.003]) were associated with mortality. Prior treatment (OR 53.76, CI 25.04-115.43 [p < 0.001]), diabetes (OR 4.13, CI 2.04-8.35 [p < 0.001]), and indigenous ethnicity (OR 11.83, CI 1.46-95.73 [p = 0.02]) were associated with MDR-TB.

Conclusions: In Guatemala, both previous TB treatment and indigenous ethnicity were associated with higher TB mortality and MDR-TB risk among patients with pulmonary TB.
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http://dx.doi.org/10.1016/j.jctube.2021.100287DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8608588PMC
December 2021

Comparative Genomics of Mycobacterium avium Complex Reveals Signatures of Environment-Specific Adaptation and Community Acquisition.

mSystems 2021 Oct 19;6(5):e0119421. Epub 2021 Oct 19.

The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA.

Nontuberculous mycobacteria, including those in the Mycobacterium avium complex (MAC), constitute an increasingly urgent threat to global public health. Ubiquitous in soil and water worldwide, MAC members cause a diverse array of infections in humans and animals that are often multidrug resistant, intractable, and deadly. MAC lung disease is of particular concern and is now more prevalent than tuberculosis in many countries, including the United States. Although the clinical importance of these microorganisms continues to expand, our understanding of their genomic diversity is limited, hampering basic and translational studies alike. Here, we leveraged a unique collection of genomes to characterize MAC population structure, gene content, and within-host strain dynamics in unprecedented detail. We found that different MAC species encode distinct suites of biomedically relevant genes, including antibiotic resistance genes and virulence factors, which may influence their distinct clinical manifestations. We observed that M. avium isolates from different sources-human pulmonary infections, human disseminated infections, animals, and natural environments-are readily distinguished by their core and accessory genomes, by their patterns of horizontal gene transfer, and by numerous specific genes, including virulence factors. We identified highly similar MAC strains from distinct patients within and across two geographically distinct clinical cohorts, providing important insights into the reservoirs which seed community acquisition. We also discovered a novel MAC genomospecies in one of these cohorts. Collectively, our results provide key genomic context for these emerging pathogens and will facilitate future exploration of MAC ecology, evolution, and pathogenesis. Members of the Mycobacterium avium complex (MAC), a group of mycobacteria encompassing M. avium and its closest relatives, are omnipresent in natural environments and emerging pathogens of humans and animals. MAC infections are difficult to treat, sometimes fatal, and increasingly common. Here, we used comparative genomics to illuminate key aspects of MAC biology. We found that different MAC species and M. avium isolates from different sources encode distinct suites of clinically relevant genes, including those for virulence and antibiotic resistance. We identified highly similar MAC strains in patients from different states and decades, suggesting community acquisition from dispersed and stable reservoirs, and we discovered a novel MAC species. Our work provides valuable insight into the genomic features underlying these versatile pathogens.
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http://dx.doi.org/10.1128/mSystems.01194-21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8525567PMC
October 2021

Diagnostic Accuracy of Health Care Administrative Diagnosis Codes to Identify Nontuberculous Mycobacteria Disease: A Systematic Review.

Open Forum Infect Dis 2021 May 20;8(5):ofab035. Epub 2021 May 20.

Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA.

Background: Health care administrative database research frequently uses standard medical codes to identify diagnoses or procedures. The aim of this review was to establish the diagnostic accuracy of codes used in administrative data research to identify nontuberculous mycobacterial (NTM) disease, including lung disease (NTMLD).

Methods: We searched Ovid Medline, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from inception to April 2019. We included studies assessing the diagnostic accuracy of (ICD-9-CM) diagnosis codes to identify NTM disease and NTMLD. Studies were independently assessed by 2 researchers, and the Quality Assessment of Diagnostic Accuracy Studies 2 tool was used to assess bias and quality.

Results: We identified 5549 unique citations. Of the 96 full-text articles reviewed, 7 eligible studies of moderate quality (3730 participants) were included in our review. The diagnostic accuracy of ICD-9-CM diagnosis codes to identify NTM disease varied widely across studies, with positive predictive values ranging from 38.2% to 100% and sensitivity ranging from 21% to 93%. For NTMLD, 4 studies reported diagnostic accuracy, with positive predictive values ranging from 57% to 64.6% and sensitivity ranging from 21% to 26.9%.

Conclusions: Diagnostic accuracy measures of codes used in health care administrative data to identify patients with NTM varied across studies. Overall the positive predictive value of ICD-9-CM diagnosis codes alone is good, but the sensitivity is low; this method is likely to underestimate case numbers, reflecting the current limitations of coding systems to capture NTM diagnoses.
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http://dx.doi.org/10.1093/ofid/ofab035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8134528PMC
May 2021

Outcomes of Outpatient Parenteral Antimicrobial Therapy With Ceftriaxone for Methicillin-Susceptible Bloodstream Infections-A Single-Center Observational Study.

Open Forum Infect Dis 2020 Sep 13;7(9):ofaa341. Epub 2020 Aug 13.

Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA.

Background: bloodstream infections (BSIs) are associated with significant morbidity and mortality. Ceftriaxone is convenient for outpatient parenteral antimicrobial therapy (OPAT), but data for this indication are limited.

Methods: Adult patients with methicillin-susceptible (MSSA) BSI discharged on OPAT with cefazolin, oxacillin, or ceftriaxone for at least 7 days were included. We compared outcomes of ceftriaxone vs either oxacillin or cefazolin. Ninety-day all-cause mortality, readmission due to MSSA infection, and microbiological failure were examined as a composite outcome and compared among groups. Rates of antibiotic switches due to intolerance were assessed.

Results: Of 243 patients included, 148 (61%) were discharged on ceftriaxone and 95 (39%) were discharged on either oxacillin or cefazolin. The ceftriaxone group had lower rates of intensive care unit care, endocarditis, and shorter duration of bacteremia, but higher rates of cancer diagnoses. There was no significant difference in the composite adverse outcome in the oxacillin or cefazolin group vs the ceftriaxone group (18 [19%] vs 31 [21%]; = .70), comprising microbiological failure (6 [6.3%] vs 9 [6.1%]; = .94), 90-day all-cause mortality (7 [7.4%] vs 15 [10.1%]; = .46), and readmission due to MSSA infection (10 [10.5%] vs 13 [8.8%]; = .65). Antibiotic intolerance necessitating a change was similar between the 2 groups (4 [4.2%] vs 6 [4.1%]; = .95).

Conclusions: For patients with MSSA BSI discharged on OPAT, within the limitations of the small numbers and retrospective design we did not find a significant difference in outcomes for ceftriaxone therapy when compared with oxacillin or cefazolin therapy.
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http://dx.doi.org/10.1093/ofid/ofaa341DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7470468PMC
September 2020

Closing the Brief Case: "Not Positive" or "Not Sure"-COVID-19-Negative Results in a Symptomatic Patient.

J Clin Microbiol 2020 07 23;58(8). Epub 2020 Jul 23.

Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA

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http://dx.doi.org/10.1128/JCM.01196-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7383537PMC
July 2020

The Brief Case: "Not Positive" or "Not Sure"-COVID-19-Negative Results in a Symptomatic Patient.

J Clin Microbiol 2020 Jul 23;58(8). Epub 2020 Jul 23.

Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA

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http://dx.doi.org/10.1128/JCM.01195-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7383542PMC
July 2020

A Cluster of Cefepime-induced Neutropenia During Outpatient Parenteral Antimicrobial Therapy.

Clin Infect Dis 2019 07;69(3):534-537

Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine.

A cluster of cefepime-induced neutropenia (CIN) was identified from June 2017 to May 2018 in a regional outpatient parenteral antimicrobial therapy population. Our data suggest prolonged courses of cefepime (≥2 weeks), administered by rapid intravenous push, were associated with a higher risk of CIN.
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http://dx.doi.org/10.1093/cid/ciy1112DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6637276PMC
July 2019

Emergency Department Directors Are Willing to Expand Reproductive Health Services for Adolescents.

J Pediatr Adolesc Gynecol 2019 Apr 17;32(2):170-174. Epub 2018 Oct 17.

Department of Internal Medicine, Washington University School of Medicine, St Louis, Missouri.

Study Objective: Nearly 20 million adolescents receive emergency department (ED) care each year, many of whom have untreated reproductive health issues. ED visits represent an opportunity to provide appropriate care, however, ED physician reproductive health care practices and capabilities in the United States have not been described. We sought to characterize pediatric ED director's individual practice and ED system resources for providing adolescent reproductive health care.

Design, Setting, Participants, And Interventions: We invited pediatric ED division and/or medical directors nationally to participate in an anonymous, online survey.

Main Outcome Measures: Outcomes included ED directors' personal practice regarding providing adolescent patients reproductive health care, and their ED's resources and standard practice regarding screening adolescents for sexually transmitted infections (STIs) and other reproductive health concerns.

Results: One hundred thirty-five of 442 (30.5%) ED directors responded. Respondents were 73% (90/124) male, with a median of 18 (interquartile range, 13-23) years of experience and 63% (84/134) working in urban EDs. Seventy-one percent (90/130) preferred face-to-face interviews for obtaining a sexual history, but only 59% (77/130) of participants "always ask parents to leave the room for sensitive questions." Eighty-four percent (106/127) were receptive to pregnancy prevention interventions being initiated in the ED, with 75% (80/106) of those willing to provide an intervention. Only 16% (21/128) indicated their ED has a universal STI screening program, and only 18% (23/126) "always" successfully notify patients of a positive STI test.

Conclusion: ED directors are comfortable providing adolescent reproductive health care, and many individual- and ED-level opportunities exist to provide improved reproductive health care for adolescents in the ED.
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http://dx.doi.org/10.1016/j.jpag.2018.09.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6401284PMC
April 2019

Using wearable technology to predict health outcomes: a literature review.

J Am Med Inform Assoc 2018 09;25(9):1221-1227

Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.

Objective: To review and analyze the literature to determine whether wearable technologies can predict health outcomes.

Materials And Methods: We queried Ovid Medline 1946 -, Embase 1947 -, Scopus 1823 -, the Cochrane Library, clinicaltrials.gov 1997 - April 17, 2018, and IEEE Xplore Digital Library and Engineering Village through April 18, 2018, for studies utilizing wearable technology in clinical outcome prediction. Studies were deemed relevant to the research question if they involved human subjects, used wearable technology that tracked a health-related parameter, and incorporated data from wearable technology into a predictive model of mortality, readmission, and/or emergency department (ED) visits.

Results: Eight unique studies were directly related to the research question, and all were of at least moderate quality. Six studies developed models for readmission and two for mortality. In each of the eight studies, data obtained from wearable technology were predictive of or significantly associated with the tracked outcome.

Discussion: Only eight unique studies incorporated wearable technology data into predictive models. The eight studies were of moderate quality or higher and thereby provide proof of concept for the use of wearable technology in developing models that predict clinical outcomes.

Conclusion: Wearable technology has significant potential to assist in predicting clinical outcomes, but needs further study. Well-designed clinical trials that incorporate data from wearable technology into clinical outcome prediction models are required to realize the opportunities of this advancing technology.
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http://dx.doi.org/10.1093/jamia/ocy082DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7263786PMC
September 2018

Tobacco Use Prevalence and Smoking Cessation Pharmacotherapy Prescription Patterns Among Hospitalized Patients by Medical Specialty.

Nicotine Tob Res 2019 04;21(5):631-637

Department of Psychiatry, Washington University School of Medicine, Saint Louis, MO.

Introduction: Effective smoking cessation medications are readily available but may be underutilized in hospital settings. In our large, tertiary care hospital, we aimed to (1) characterize patient tobacco use prevalence across medical specialties, (2) determine smoking cessation pharmacotherapy prescription variation across specialties, and (3) identify opportunities for improvement in practice.

Methods: Using electronic health records at Barnes Jewish Hospital, we gathered demographic data, admitting service, admission route, length of stay, self-reported tobacco use, and smoking cessation prescriptions over a 6-year period, from 2010 to 2016. We then compared tobacco use prevalence and smoking cessation prescriptions across medical specialties using a cross-sectional, retrospective design.

Results: Past 12-month tobacco use was reported by patients in 27.9% of inpatient admissions; prescriptions for smoking cessation pharmacotherapy were provided during 21.5% of these hospitalizations. The proportion of patients reporting tobacco use was highest in psychiatry (55.3%) and lowest in orthopedic surgery (17.1%). Psychiatric patients who reported tobacco use were most likely to receive pharmacotherapy (71.8% of admissions), and plastic surgery patients were least likely (4.7% of admissions). Compared with Caucasian tobacco users, African American patients who used tobacco products were less likely to receive smoking cessation medications (adjusted odds ratio [aOR] = 0.65; 95% confidence interval [CI] = 0.62 to 0.68).

Conclusions: Among hospitalized tobacco users, safe and cost-effective pharmacotherapies are under-prescribed. We identified substantial variation in prescribing practices across different medical specialties and demographic groups, suggesting the need for an electronic medical record protocol that facilitates consistent tobacco use cessation pharmacotherapy treatment.

Implications: Tobacco use cessation pharmacotherapy is underutilized during hospitalization, and prescription rates vary greatly across medical specialties and patient characteristics. Hospitals may benefit from implementing policies and practices that standardize and automate the offer of smoking pharmacotherapy for all hospitalized patients who use tobacco.
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http://dx.doi.org/10.1093/ntr/nty031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6468129PMC
April 2019

Diagnosis of Latent Tuberculous Infection.

Authors:
Thomas C Bailey

Ann Intern Med 2016 Sep;165(6):447-448

From Washington University School of Medicine, St. Louis, Missouri.

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http://dx.doi.org/10.7326/L16-0194DOI Listing
September 2016

Epidemiology and Outcomes of Nontuberculous Mycobacterial Infections in Solid Organ Transplant Recipients at a Midwestern Center.

Transplantation 2016 05;100(5):1073-8

1 Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO. 2 Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO.

Background: Nontuberculous mycobacterial (NTM) infections have the potential to affect outcomes in solid organ transplant (SOT) recipients.

Methods: Retrospective cohort of adults who underwent SOT at a Midwestern hospital between January 1, 2004, and December 31, 2013. NTM-infected patients had at least 1 positive culture for NTM posttransplant. NTM disease was defined by 1) American Thoracic Society/Infectious Disease Society of America criteria for respiratory specimens or 2) NTM cultured from a sterile site with a compatible clinical syndrome. The remaining NTM infected patients were classified as colonized. Cox regression analysis was used to determine the association of NTM with mortality among lung transplant recipients.

Results: Of 3338 SOT recipients, 50 (1.5%) had NTM infection during a median 1038 days (range, 165-3706) follow-up posttransplant. Forty-three patients (86%) with NTM infection were lung transplant recipients; 18 of 43 (41.8%) were treated for NTM and 6 (13.9%) met disease criteria. Isolation of the same species on multiple occasions was associated with treatment among the colonized lung transplant recipients (8/12 [67%] vs 3/25 [12%] who were not treated, P = 0.014). NTM infection was not associated with increased mortality in lung transplant recipients (9/43 [20.9%] in infected died versus 161/510 [31.6%] in uninfected, age-adjusted hazard ratio, 0.56; 95% confidence interval, 0.2-1.1; P = 0.091). Three of 6 lung transplant recipients with NTM disease died compared with 6 of 37 colonized (hazard ratio, 7.0; 95% confidence interval, 1.5-31.5; P = 0.003).

Conclusions: Among SOT patients, NTM were most frequently identified from lung transplant recipients. NTM infection was not associated with increased mortality, although NTM disease was associated with increased mortality compared with colonization in lung transplant recipients.
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http://dx.doi.org/10.1097/TP.0000000000001123DOI Listing
May 2016

The number of discharge medications predicts thirty-day hospital readmission: a cohort study.

BMC Health Serv Res 2015 Jul 23;15:282. Epub 2015 Jul 23.

Division of Pulmonary & Critical Care Medicine, Washington University School of Medicine, 660 South Euclid Ave., Campus Box 8052, St. Louis, MO, 63110, USA.

Background: Hospital readmission occurs often and is difficult to predict. Polypharmacy has been identified as a potential risk factor for hospital readmission. However, the overall impact of the number of discharge medications on hospital readmission is still undefined.

Methods: To determine whether the number of discharge medications is predictive of thirty-day readmission using a retrospective cohort study design performed at Barnes-Jewish Hospital from January 15, 2013 to May 9, 2013. The primary outcome assessed was thirty-day hospital readmission. We also assessed potential predictors of thirty-day readmission to include the number of discharge medications.

Results: The final cohort had 5507 patients of which 1147 (20.8 %) were readmitted within thirty days of their hospital discharge date. The number of discharge medications was significantly greater for patients having a thirty-day readmission compared to those without a thirty-day readmission (7.2 ± 4.1 medications [7.0 medications (4.0 medications, 10.0 medications)] versus 6.0 ± 3.9 medications [6.0 medications (3.0 medications, 9.0 medications)]; P < 0.001). There was a statistically significant association between increasing numbers of discharge medications and the prevalence of thirty-day hospital readmission (P < 0.001). Multiple logistic regression identified more than six discharge medications to be independently associated with thirty-day readmission (OR, 1.26; 95 % CI, 1.17-1.36; P = 0.003). Other independent predictors of thirty-day readmission were: more than one emergency department visit in the previous six months, a minimum hemoglobin value less than or equal to 9 g/dL, presence of congestive heart failure, peripheral vascular disease, cirrhosis, and metastatic cancer. A risk score for thirty-day readmission derived from the logistic regression model had good predictive accuracy (AUROC = 0.661 [95 % CI, 0.643-0.679]).

Conclusions: The number of discharge medications is associated with the prevalence of thirty-day hospital readmission. A risk score, that includes the number of discharge medications, accurately predicts patients at risk for thirty-day readmission. Our findings suggest that relatively simple and accessible parameters can identify patients at high risk for hospital readmission potentially distinguishing such individuals for interventions to minimize readmissions.
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http://dx.doi.org/10.1186/s12913-015-0950-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4512093PMC
July 2015

Mortality Prediction in ICUs Using A Novel Time-Slicing Cox Regression Method.

AMIA Annu Symp Proc 2015 5;2015:1289-95. Epub 2015 Nov 5.

Department of Computer Science and Engineering, Washington University, St. Louis, MO.

Over the last few decades, machine learning and data mining have been increasingly used for clinical prediction in ICUs. However, there is still a huge gap in making full use of the time-series data generated from ICUs. Aiming at filling this gap, we propose a novel approach entitled Time Slicing Cox regression (TS-Cox), which extends the classical Cox regression into a classification method on multi-dimensional time-series. Unlike traditional classifiers such as logistic regression and support vector machines, our model not only incorporates the discriminative features derived from the time-series, but also naturally exploits the temporal orders of these features based on a Cox-like function. Empirical evaluation on MIMIC-II database demonstrates the efficacy of the TS-Cox model. Our TS-Cox model outperforms all other baseline models by a good margin in terms of AUC_PR, sensitivity and PPV, which indicates that TS-Cox may be a promising tool for mortality prediction in ICUs.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4765560PMC
April 2018

Mycobacterium ulcerans infection imported from Australia to Missouri, USA, 2012.

Emerg Infect Dis 2014 Nov;20(11):1876-9

Buruli ulcer, the third most common mycobacterial disease worldwide, rarely affects travelers and is uncommon in the United States. We report a travel-associated case imported from Australia and review 3 previous cases diagnosed and treated in the United States. The differential diagnoses for unusual chronic cutaneous ulcers and those nonresponsive to conventional therapy should include Mycobacterium ulcerans infection.
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http://dx.doi.org/10.3201/eid2011.131534DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4214291PMC
November 2014

Cost-effectiveness of using Quantiferon Gold (QFT-G)® versus tuberculin skin test (TST) among U.S. and foreign born populations at a public health department clinic with a low prevalence of tuberculosis.

Public Health Nurs 2014 Mar-Apr;31(2):144-52. Epub 2013 Sep 30.

St Louis County Department of Health, Communicable Disease Control Services Division (CDCS), Berkeley, Missouri.

Objective: The purpose of this study was to determine the cost benefit to routinely using QFT-G versus the standard TST for screening U.S. and foreign born populations at a public health department clinic with a low prevalence of tuberculosis.

Design And Sample: A comparative cost analysis of the monetization between QFT-G and TST was conducted: Data from the health department's Chest Clinic patients seen in 2007 were used to model cost predictions.

Measures: The net costs of screening, x-rays, the standard 9 months of latent tuberculosis infection treatment, laboratory, and administration for U.S. born patients and foreign born patients were investigated.

Results: There are no apparent cost savings for U.S. born individuals, but due to the higher specificity of QFT-G for foreign born BCG-vaccinated individuals, there are unnecessary expenditures associated with the higher number of false positives incurred when using TST compared with QFT-G on 1,000 foreign born individuals (69%, 18%).

Conclusion: QFT-G is cost-effective and should be used at local health department clinics that want to achieve savings in screening and treating those suspected of having TB infection, especially for high-risk populations such as foreign born individuals.
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http://dx.doi.org/10.1111/phn.12083DOI Listing
May 2014

Body temperature patterns as a predictor of hospital-acquired sepsis in afebrile adult intensive care unit patients: a case-control study.

Crit Care 2013 Sep 12;17(5):R200. Epub 2013 Sep 12.

Introduction: Early treatment of sepsis improves survival, but early diagnosis of hospital-acquired sepsis, especially in critically ill patients, is challenging. Evidence suggests that subtle changes in body temperature patterns may be an early indicator of sepsis, but data is limited. The aim of this study was to examine whether abnormal body temperature patterns, as identified by visual examination, could predict the subsequent diagnosis of sepsis in afebrile critically ill patients.

Methods: Retrospective case-control study of 32 septic and 29 non-septic patients in an adult medical and surgical ICU. Temperature curves for the period starting 72 hours and ending 8 hours prior to the clinical suspicion of sepsis (for septic patients) and for the 72-hour period prior to discharge from the ICU (for non-septic patients) were rated as normal or abnormal by seven blinded physicians. Multivariable logistic regression was used to compare groups in regard to maximum temperature, minimum temperature, greatest change in temperature in any 24-hour period, and whether the majority of evaluators rated the curve to be abnormal.

Results: Baseline characteristics of the groups were similar except the septic group had more trauma patients (31.3% vs. 6.9%, p = .02) and more patients requiring mechanical ventilation (75.0% vs. 41.4%, p = .008). Multivariable logistic regression to control for baseline differences demonstrated that septic patients had significantly larger temperature deviations in any 24-hour period compared to control patients (1.5°C vs. 1.1°C, p = .02). An abnormal temperature pattern was noted by a majority of the evaluators in 22 (68.8%) septic patients and 7 (24.1%) control patients (adjusted OR 4.43, p = .017). This resulted in a sensitivity of 0.69 (95% CI [confidence interval] 0.50, 0.83) and specificity of 0.76 (95% CI 0.56, 0.89) of abnormal temperature curves to predict sepsis. The median time from the temperature plot to the first culture was 9.40 hours (IQR [inter-quartile range] 8.00, 18.20) and to the first dose of antibiotics was 16.90 hours (IQR 8.35, 34.20).

Conclusions: Abnormal body temperature curves were predictive of the diagnosis of sepsis in afebrile critically ill patients. Analysis of temperature patterns, rather than absolute values, may facilitate decreased time to antimicrobial therapy.
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http://dx.doi.org/10.1186/cc12894DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3906745PMC
September 2013

A case of Apophysomyces trapeziformis necrotizing soft tissue infection.

Int J Infect Dis 2013 Dec 26;17(12):e1240-2. Epub 2013 Jul 26.

Division of Infectious Diseases, Washington University School of Medicine, 660 S. Euclid, St. Louis, MO 63110, USA. Electronic address:

Mucormycosis is a rare and devastating disease. Apophysomyces trapeziformis is an environmental mold that was recently implicated in several cases of cutaneous and soft tissue mucormycosis in victims of a tornado in Joplin, Missouri. Here, we report a case of Apophysomyces trapeziformis necrotizing soft tissue infection in a resident of Joplin 10 months after the disaster and without preceding trauma. Aspects of histological and microbiological diagnosis are also reviewed.
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http://dx.doi.org/10.1016/j.ijid.2013.06.008DOI Listing
December 2013

A trial of a real-time alert for clinical deterioration in patients hospitalized on general medical wards.

J Hosp Med 2013 May 25;8(5):236-42. Epub 2013 Feb 25.

Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO 63110, USA.

Background: With limited numbers of intensive care unit (ICU) beds available, increasing patient acuity is expected to contribute to episodes of inpatient deterioration on general wards.

Objective: To prospectively validate a predictive algorithm for clinical deterioration in general-medical ward patients, and to conduct a trial of real-time alerts based on this algorithm.

Design: Randomized, controlled crossover study.

Setting/patients: Academic center with patients hospitalized on 8 general wards between July 2007 and December 2011.

Interventions: Real-time alerts were generated by an algorithm designed to predict the need for ICU transfer using electronically available data. The alerts were sent by text page to the nurse manager on intervention wards.

Measurements: Intensive care unit transfer, hospital mortality, and hospital length of stay.

Results: Patients meeting the alert threshold were at nearly 5.3-fold greater risk of ICU transfer (95% confidence interval [CI]: 4.6-6.0) than those not satisfying the alert threshold (358 of 2353 [15.2%] vs 512 of 17678 [2.9%]). Patients with alerts were at 8.9-fold greater risk of death (95% CI: 7.4-10.7) than those without alerts (244 of 2353 [10.4%] vs 206 of 17678 [1.2%]). Among patients identified by the early warning system, there were no differences in the proportion of patients who were transferred to the ICU or who died in the intervention group as compared with the control group.

Conclusions: Real-time alerts were highly specific for clinical deterioration resulting in ICU transfer and death, and were associated with longer hospital length of stay. However, an intervention notifying a nurse of the risk did not result in improvement in these outcomes.
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http://dx.doi.org/10.1002/jhm.2009DOI Listing
May 2013

Paragonimus kellicotti flukes in Missouri, USA.

Emerg Infect Dis 2012 Aug;18(8):1263-7

Department of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri 63110, USA.

Paragonimiasis is an infection caused by lung flukes of the genus Paragonimus. In Asia, P. westermani infections are relatively common because of dietary practices. However, in North America, cases of paragonimiasis, which are caused by P. kellicotti flukes, are rare. Only 7 autochthonous cases of paragonimiasis were reported during 1968-2008. In 2009, we reported 3 new case-patients with paragonimiasis who had been seen at our medical center over an 18-month period. Six additional case-patients were identified in St. Louis, Missouri, USA, and treated at Washington University-affiliated health centers in 2009-2010. We report detailed descriptions of these case-patients, which includes unusual clinical manifestations. We also describe public health interventions that were undertaken to inform the general public and physicians about the disease and its mode of transmission.
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http://dx.doi.org/10.3201/eid1808.120335DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3414046PMC
August 2012

Chest CT features of North American paragonimiasis.

AJR Am J Roentgenol 2012 May;198(5):1076-83

Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA.

Objective: The purpose of this study was to characterize the chest CT findings of North American paragonimiasis due to Paragonimus kellicotti in the largest (to our knowledge) case series reported to date and to compare the findings with those reported for paragonimiasis infections in other regions.

Materials And Methods: A retrospective review was performed of chest CT examinations of eight patients with North American paragonimiasis treated at our institution between 2006 and 2010. Findings were characterized by site of involvement, including lungs and pleura, heart and pericardium, lymph nodes, and upper abdomen.

Results: The most common chest CT findings in this case series were pleural effusions and internal mammary and cardiophrenic lymphadenopathy. Pulmonary parenchymal findings included peripheral lung nodules of 1-3.5 cm in size with surrounding ground-glass opacity; many nodules had a linear track to the pleural surface that may correspond to the worm's burrow tunnel. Pericardial involvement (5/8 patients) and omental inflammation (5/7 patients), which are uncommon in Asian paragonimiasis, were common in this series.

Conclusion: Pleural and pulmonary features of North American paragonimiasis are generally similar to those reported from Asia. The presence of a track between a pulmonary nodule and the pleura may help distinguish paragonimiasis from mimickers, including chronic eosinophilic pneumonia, tuberculosis, fungal infection, or malignancy. Pericarditis, lymphadenopathy, and omental inflammation were more common in our series than in reports on paragonimiasis from other regions. These differences may be related to the infecting parasite species or to the fact that radiologic examinations in the present series were performed relatively early in the course of infection.
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http://dx.doi.org/10.2214/AJR.11.7530DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3832351PMC
May 2012

Toward a two-tier clinical warning system for hospitalized patients.

AMIA Annu Symp Proc 2011 22;2011:511-9. Epub 2011 Oct 22.

Department of Computer Science and Engineering, Washington University, St. Louis, MO, USA.

Clinical study has found early detection and intervention to be essential for preventing clinical deterioration in patients at general hospital units. In this paper, we envision a two-tiered early warning system designed to identify the signs of clinical deterioration and provide early warning of serious clinical events. The first tier of the system automatically identifies patients at risk of clinical deterioration from existing electronic medical record databases. The second tier performs real-time clinical event detection based on real-time vital sign data collected from on-body wireless sensors attached to those high-risk patients. We employ machine-learning techniques to analyze data from both tiers, assigning scores to patients in real time. The assigned scores can then be used to trigger early-intervention alerts. Preliminary study of an early warning system component and a wireless clinical monitoring system component demonstrate the feasibility of this two-tiered approach.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3243239PMC
February 2013

Unrecognized fatalities related to colchicine in hospitalized patients.

Clin Toxicol (Phila) 2011 Aug 8;49(7):648-52. Epub 2011 Jul 8.

Division of Emergency Medicine, Washington University, Saint Louis, MO 63110, USA.

Background: Colchicine is commonly used for the treatment of gout and occasionally for other inflammatory diseases. It has a narrow therapeutic index and the potential for severe or fatal toxicity.

Objectives: We sought to determine (1) the frequency of colchicine toxicity among hospitalized patients taking colchicine who died during an admission, (2) the likelihood that colchicine contributed to death, (3) whether patients were taking interacting medications that could have contributed to toxicity, and (4) whether colchicine dosing among these patients adhered to established guidelines.

Methods: We conducted an IRB-approved, retrospective chart review at an urban, tertiary care, 1228-bed, university hospital. Subjects included hospitalized patients who received colchicine and died in hospital between 1 January 2000 and 28 February 2007. We reviewed charts for signs and symptoms of colchicine toxicity. An expert panel reviewed each case and classified the likelihood of colchicine toxicity, the likelihood of a causal role of colchicine in the death using the WHO classification system, and the appropriateness of colchicine dosing.

Results: Thirty-seven hospitalized patients who died during the 86-month study period received colchicine. Toxicity was unlikely in 20/37, possible in 8/37, likely in 5/37, and certain in 4/37. A contributing role for colchicine in causing death was unlikely in 24/37, possible in 7/37, likely in 3/37, and certain in 3/37. Colchicine doses (based on creatinine clearance) exceeded the accepted range for 12 patients, including 10 of 17 cases of toxicity and 8 of 13 cases of death classified as possible or higher. Seventeen patients received interacting medications, including 8 of 17 cases of toxicity and 8 of 13 cases of death classified as possible or higher.

Conclusion: Colchicine toxicity was frequent in this cohort and may have contributed to about one-third of the deaths. Inappropriate dosing of colchicine occurred frequently and was related to toxicity and death.
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http://dx.doi.org/10.3109/15563650.2011.589844DOI Listing
August 2011

Importance of routine public health influenza surveillance: detection of an unusual W-shaped influenza morbidity curve.

Am J Epidemiol 2009 Dec 10;170(12):1533-40. Epub 2009 Nov 10.

Communicable Disease Control Services, St Louis County Department of Health, Clayton, MO 63105, USA.

Seasonal influenza causes excess morbidity and mortality at the extremes of age: It disproportionately affects the very young and the very old, typically resulting in "U"-shaped age-distributed curves. By means of a well-established public health department surveillance system using positive influenza tests submitted from sentinel sites, the authors generated annual influenza-specific morbidity curves over a 10-year period (1998-2008) for St. Louis County, Missouri. The authors detected an unusually high incidence of cases of medically attended test-positive influenza, particularly in young adults, during the 2007-2008 season, resulting in an unexpected "W"-shaped age-distributed morbidity curve that was distinctly unique in comparison with the prior 9 influenza seasons. Public health influenza surveillance programs are useful tools for detecting emerging epidemiologic trends that may have clinical importance.
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http://dx.doi.org/10.1093/aje/kwp305DOI Listing
December 2009

Clinical validation of the AHRQ postoperative venous thromboembolism patient safety indicator.

Jt Comm J Qual Patient Saf 2009 Jul;35(7):370-6

Department of Medicine, Washington University School of Medicine, St. Louis, USA.

Background: The Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs) screen for potentially preventable complications in hospitalized patients using hospital administrative data. The PSI for postoperative venous thromboembolism (VTE) relies on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for deep vein thrombosis (DVT) or pulmonary embolism (PE) in secondary diagnoses fields. In a clinical validation study of the PSI for postoperative VTE, natural language processing (NLP), supplemented by pharmacy and billing data, was used to identify VTE events missed by medical records coders.

Methods: In a retrospective review of postsurgical discharges, charts were processed using the AHRQ PSI software. Cases were identified as possible false negatives by flagging charts for possible VTEs using pharmacy and billing data to identify all patients who were therapeutically anticoagulated or had placement of an inferior vena caval filter. All charts were reviewed by a physician blinded to screening results. Physician interpretation was considered the gold standard for VTE classification.

Results: The AHRQ PSI had a positive predictive value (PPV) of .545 (95% confidence interval [CI], .453-.634) and a negative predictive value (NPV) of .997 (95% CI, .995-.999). Sensitivity was .87 and specificity was .98. Secondary coding review suggested that all 9 false-negative results were miscoded; if they had been properly coded, the sensitivity would increase to 1.00. Most false-positive cases resulted from superficial venous clots identified by the PSI due to coding ambiguity.

Discussion: The VTE PSI performed well as a screening tool but generated a significant number of false-positive cases, a problem that could be substantially reduced with improved coding methods.
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http://dx.doi.org/10.1016/s1553-7250(09)35052-7DOI Listing
July 2009

Computerized surveillance for adverse drug events in a pediatric hospital.

J Am Med Inform Assoc 2009 Sep-Oct;16(5):607-12. Epub 2009 Jun 30.

St. Louis Children's Hospital, One Children's Place, St Louis, MO 63110, USA.

There are limited data on adverse drug event rates in pediatrics. The authors describe the implementation and evaluation of an automated surveillance system modified to detect adverse drug events (ADEs) in pediatric patients. The authors constructed an automated surveillance system to screen admissions to a large pediatric hospital. Potential ADEs identified by the system were reviewed by medication safety pharmacists and a physician and scored for causality and severity. Over the 6 month study period, 6,889 study children were admitted to the hospital for a total of 40,250 patient-days. The ADE surveillance system generated 1226 alerts, which yielded 160 true ADEs. This represents a rate of 2.3 ADEs per 100 admissions or 4 per 1,000 patient-days. Medications most frequently implicated were diuretics, antibiotics, immunosuppressants, narcotics, and anticonvulsants. The composite positive predictive value of the ADE surveillance system was 13%. Automated surveillance can be an effective method for detecting ADEs in hospitalized children.
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http://dx.doi.org/10.1197/jamia.M3167DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2744710PMC
January 2010

Reliable real-time clinical monitoring using sensor network technology.

AMIA Annu Symp Proc 2009 Nov 14;2009:103-7. Epub 2009 Nov 14.

Washington University in St. Louis, St. Louis, MO, USA.

We propose wireless sensor networks composed of nodes using low-power 802.15.4 radios as an enabling technology for patient monitoring in general hospital wards. A key challenge for such applications is to reliably deliver sensor data from mobile patients. We propose a monitoring system with two types of nodes: patient nodes equipped with wireless pulse oximeters and relays nodes used to route data to a base station. A reliability analysis of data collection from mobile users shows that mobility leads to packet losses exceeding 30%. The majority of packet losses occur between the mobile subjects and the first-hop relays. Based on this insight we developed the Dynamic Relay Association Protocol (DRAP), an effective mechanism for discovering the right relays for patient nodes. DRAP enables highly reliable data collection from mobile subjects. Empirical evaluation showed that DRAP delivered at least 96% of data from multiple users. Our results demonstrate the feasibility of wireless sensor networks for real-time clinical monitoring.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2815421PMC
November 2009

Natural language processing to identify adverse drug events.

AMIA Annu Symp Proc 2008 Nov 6:961. Epub 2008 Nov 6.

BJC HealthCare, Center for Healthcare Quality & Effectiveness; Washington University School of Medicine, St. Louis, MO, USA.

We tested and adapted Cancer Text Information Extraction System (caTIES), a publicly available natural language processing tool (NLP), as a method for identifying terms suggestive of adverse drug events (ADEs). Although caTIES was intended to extract concepts from surgical pathology reports, we report that it can successfully be used to search for ADEs on a much broader range of documents.
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November 2008
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