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Impact of the COVID-19 Pandemic on Antibiotic Resistant Infection Burden in U.S. Hospitals: Retrospective Cohort Study of Trends and Risk Factors: Annals of Internal Medicine: Vol 178, No 6
Background: In 2022, the U.S. Centers for Disease Control and Prevention reported increases in antimicrobial resistance (AMR) across U.S. hospitals during the COVID-19 pandemic. The key drivers and lasting effects of this phenomenon remain unexplored. Objective: To determine the incidence of AMR infections in U.S. hospitals during and beyond the pandemic and identify factors contributing to AMR. Design: Retrospective cohort study. Setting: 243 U.S. hospitals. Participants: Adult hospitalizations, excluding inpatient transfers. Intervention: Prepandemic (January 2018 to December 2019), peak pandemic (March 2020 to February 2022), and waning pandemic (March to December 2022). Measurements: Incidence of methicillin-resistant Staphylococcus aureus; vancomycin-resistant Enterococci; extended-spectrum cephalosporin-resistant Enterobacterales; and carbapenem-resistant Enterobacterales, Acinetobacter baumannii, and Pseudomonas aeruginosa infections was evaluated among 120 continuously reporting hospitals. Infections detected more than 3 days after admission were classified as hospital-onset. Antibiotic exposure was estimated using a duration- and spectrum-weighted index. A competing risks analysis was done in 243 hospitals to identify risk factors for resistance. Results: During the peak of the COVID-19 pandemic, AMR infections increased from 182 to 193 per 10 000 hospitalizations (6.5% [95% CI, 5.1% to 8.0%]). Hospital-onset AMR infections increased from 28.9 to 38.0 per 10 000 hospitalizations (31.5% [CI, 27.3% to 35.8%]). Factors associated with hospital-onset AMR included illness severity (intensive care unit admission, mechanical ventilation, vasopressors, COVID-19 diagnosis), comorbidities (Elixhauser Comorbidity Index), and prior exposure to antibiotics, but not hospital factors. Prevalence of AMR returned to prepandemic levels as the pandemic waned (182 to 182 per 10 000 hospitalizations; 0.4% [CI, −1.4% to 2.2%]), however, hospital-onset AMR remained above baseline (28.9 to 32.3 per 10 000 hospitalizations; 11.6% [CI, 6.8% to 16.7%]). Limitation: Residual confounding; unknown appropriateness of antibiotics. Conclusion: Sustained increases in hospital-onset AMR infections occurred in U.S. hospitals during the pandemic and were strongly associated with antibiotic exposure. Primary Funding Source: National Institutes of Health Clinical Center; National Heart, Lung, and Blood Institute; and National Institute of Allergy and Infectious Diseases Intramural Research Programs.
Impacts of Communication Type and Quality on Patient Safety Incidents: A Systematic Review: Annals of Internal Medicine: Vol 178, No 5
Background: Poor communication in health care increases the risk for patient safety incidents. However, there is no up-to-date synthesis of these data. Purpose: To synthesize studies investigating how poor communication between health care practitioners and patients (and between different groups of practitioners) affects patient safety. Data Sources: Ovid MEDLINE, CINAHL, APA PsycInfo, CENTRAL, Scopus, and the ProQuest Dissertations & Theses Citation Index from 1 January 2013 to 7 February 2024. Study Selection: Studies published in any language that quantified the effects of poor communication on patient safety. Data Extraction: Two independent reviewers extracted data, assessed risk of bias, and appraised strength of evidence. Study heterogeneity precluded meta-analysis, so results were reported with narrative description, reporting medians and interquartile ranges (IQRs). Data Synthesis: Forty-six eligible studies (67 826 patients) were included. Risk of bias was low for 20, moderate for 16, and high for 10 studies. Four studies investigated whether poor communication was the only identified cause of a patient safety incident; here, poor communication caused 13.2% (IQR, 6.1% to 24.4%) of safety incidents. Forty-two studies investigated whether poor communication contributed to patient safety incidents alongside other causes; here, poor communication contributed to 24.0% (IQR, 12.0% to 46.8%) of safety incidents. Study heterogeneity was high in terms of setting, continent, health care staff, and safety incident type. The strength of the evidence was low or very low. Limitation: There was important study heterogeneity, generally low study quality, and poor reporting of essential data. Conclusion: Poor communication is a major cause of patient safety incidents. Research is needed to develop effective interventions and to learn more about how poor communication leads to patient safety incidents. Primary Funding Source: Stoneygate Trust. (PROSPERO: CRD42024507578)
Trends in Utilization of Glucose- and Weight-Lowering Medications After Tirzepatide Approval in the United States: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 178, No 5
Background: Recent trends in use of tirzepatide, a dual glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide receptor agonist (RA), versus other glucose-lowering medications (GLMs) and weight-lowering medications (WLMs) remain unexplored. Objective: To describe trends in insurance claims for GLMs and WLMs after tirzepatide approval. Design: Population-based cohort study. Setting: Claims data from a large U.S. commercial database (January 2021 to December 2023). Participants: Adults (aged ≥18 years) with type 2 diabetes (T2D) and without diabetes with dispensations for GLMs and WLMs. Any use was defined as medication dispensation regardless of prior use. Incident use was defined as dispensation without use in the preceding year. Measurements: Monthly trends in medication dispensations before and after tirzepatide market entry. Tirzepatide uptake was additionally compared with initial postapproval uptake of other GLMs and WLMs. Results: Tirzepatide dispensations increased markedly among adults with T2D prescribed GLMs, reaching 12.3% of all GLM dispensations by December 2023. Similar patterns were observed for sodium–glucose cotransporter-2 inhibitors (14.5% to 24.4%) and GLP-1 RAs (19.5% to 28.5%). Dispensations of other GLMs, including metformin, declined. Among adults without diabetes but prescribed WLMs, tirzepatide (0.0% to 40.6%) and semaglutide (2.4 mg) (0.0% to 32.2%) dispensations increased sharply, but semaglutide (2.0 mg) was the most frequently dispensed WLM, increasing from 37.8% to 45.7%. Dispensations of other WLMs declined. Similar trends were observed among incident users. Tirzepatide uptake was more rapid and sustained compared with initial postapproval periods for other medications. Limitation: Generalizability to U.S. adults without commercial health insurance is uncertain. Conclusion: These findings highlight the sharp uptake of tirzepatide after U.S. market entry and enhance understanding of the rapidly shifting landscape of prescribing patterns for GLMs and WLMs. Primary Funding Source: National Institute of Diabetes and Digestive and Kidney Diseases.
Glucagon-Like Peptide-1 Receptor Agonists and Incidence of Dementia Among Older Adults With Type 2 Diabetes: A Target Trial Emulation: Annals of Internal Medicine: Vol 178, No 9
Background: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have been shown to decrease blood glucose levels, promote weight loss, and prevent cardiovascular events. However, evidence is limited regarding their effect on dementia, although emerging observational studies, some with serious methodological limitations, have suggested large reductions in dementia associated with GLP-1RAs that may not be entirely causally related. Objective: To compare the effect of GLP-1RAs versus dipeptidyl peptidase-4 inhibitors (DPP4is) as second-line therapy for type 2 diabetes on risk for dementia among older adults. Design: Target trial emulation. Setting: United States from January 2016 to December 2020. Participants: Medicare fee-for-service beneficiaries aged 66 years or older with diabetes who used metformin and did not have dementia at baseline and initiated GLP-1RAs or DPP4is between January 2017 and December 2018. Measurements: Onset of dementia was defined as 1 year before the date of a new dementia diagnosis. Risks were calculated at 30 months in GLP-1RA and DPP4i groups matched in a 1:2 ratio on an estimated propensity score and compared via ratios and differences. Results: Among 2418 patients initiating GLP-1RAs and 4836 matched patients initiating DPP4is, the mean age was 71 years, and 55% were female. Over a median follow-up of 1.9 years, the outcome occurred in 96 patients in the GLP-1RA group and 217 in the DPP4i group. The estimated risk difference at 30 months was −0.93 (95% CI, −2.33 to 0.23) percentage points, and the estimated risk ratio was 0.83 (95% CI, 0.61 to 1.05). The estimated risk ratios were 0.64 (95% CI, 0.46 to 0.93) and 1.22 (95% CI, 0.74 to 1.66) among those younger than 75 years and aged 75 years or older, respectively. Limitations: Potential residual confounding (no data on body mass index, glycemic control, or duration of diabetes), outcome misclassification, and short follow-up. Conclusion: Among older adults with diabetes, no clear evidence was found that the incidence of dementia differed overall between patients using GLP-1RAs versus DPP4is. Under conventional statistical criteria, an effect of GLP-1RAs between a 39% decrease and a 5% increase in risk for dementia was highly compatible with the data, although estimates differed by age. Randomized trials are needed to quantify the effect of GLP-1RAs on dementia. Primary Funding Source: Gregory Annenberg Weingarten, GRoW @ Annenberg.
Implications of the European Association for the Study of Obesity’s New Framework Definition of Obesity: Prevalence and Association With All-Cause Mortality
Background: The European Association for the Study of Obesity (EASO) recently introduced a new framework to define obesity that incorporates anthropometric measures beyond body mass index (BMI) and clinical comorbidities. However, this framework has not been validated. Objective: To describe the distribution of overweight and obesity and determine the prevalence of complications and association of obesity with all-cause mortality using BMI categories and the new EASO framework. Design: Cross-sectional and longitudinal analysis. Setting: NHANES (National Health and Nutrition Examination Survey) from 1999 to 2018 linked to mortality data. Participants: A representative sample of the adult population in the United States aged 18 to 79 years. Measurements: Obesity defined using BMI categories was compared with the new EASO definition. Results: The study population included 44 030 adults. On the basis of the new EASO definition, 18.8% of adults who were previously defined as overweight based on BMI alone were now considered persons with obesity (PWO). Similar mortality risk was found among the newly identified PWO and persons with normal weight (hazard ratio [HR], 0.98 [95% CI, 0.87 to 1.10]), whereas higher risk was seen among persons with BMI of 30 kg/m2 or greater (HR, 1.19 [CI, 1.08 to 1.32]). However, when compared with persons with normal weight who did not have major morbidities, a higher risk was seen among the newly identified PWO (HR, 1.50 [CI, 1.20 to 1.88]), although this higher risk was no greater than the higher risk seen among persons with normal weight and comorbidities (HR, 1.74 [CI, 1.34 to 2.22]). Excess risk was seen among PWO compared with persons with overweight according to both the new EASO framework and the traditional BMI definition. The most prevalent complications among the newly identified PWO were hypertension (79.9%), arthritis (33.2%), diabetes (15.6%), and cardiovascular disease (10.5%). Limitation: Residual confounding; body weight assessed at a single time point. Conclusion: The new EASO framework may provide a more sensitive tool to diagnose obesity than the traditional BMI definition, but whether these newly identified adults with obesity would benefit comparably to obesity treatment as those traditionally included in treatment trials is uncertain. Primary Funding Source: Ariel University and the Holon Institute of Technology, Israel.
Effectiveness of Recombinant Herpes Zoster Vaccine in the U.S. Medicare Population, 2018 to 2019, by Immunocompetence and Prior Receipt of Live Zoster Vaccine
Background: Recombinant zoster vaccine (RZV) was preferentially recommended over live zoster vaccine (ZVL) starting in 2018. Objective: To assess RZV effectiveness using target trial emulation, accounting for prior receipt of ZVL and immunocompetence. Design: Analysis 1 emulated 12 sequential trials of at least 12 months’ duration in which treatment assignment was assessed by real-world vaccination in the month before each trial. Individuals could participate in multiple trials for which they were eligible (for example, no prior RZV vaccination). Pooled vaccine effectiveness (VE) was estimated across the trials using weighted Fine and Gray models with robust variance estimation. Risks were estimated from the cumulative incidence function. Analysis 2 used the same methods to estimate the VE of 2 RZV doses versus 1 dose, with 10 trials beginning 60 days from the first dose. Setting: 20% random sample of fee-for-service Medicare beneficiaries covered by Parts A, B, and D between 2007 and 2019. Participants: Medicare beneficiaries aged 65 years or older with continuous Part D coverage, 6 months of continuous coverage before trial enrollment, no claims for herpes zoster (HZ) since 2007, and no prior RZV vaccination. Intervention: 1 or 2 RZV doses. Measurements: Outcomes were HZ, HZ ophthalmicus, and postherpetic neuralgia. Covariates were age, sex, race, ethnicity, prior ZVL receipt, and immunocompetence. Results: Vaccine effectiveness against any HZ outcome was 56.1% (95% CI, 53.1% to 59.0%), with similar VE between immunocompetent (56.5% [CI, 53.2% to 59.5%]) and immunocompromised (54.2% [CI, 44.7% to 62.1%]) individuals. Individuals vaccinated with ZVL in the past 10 years benefited from RZV. A second RZV dose conferred an additional 67.9% effectiveness against any HZ outcome. Limitation: Limited follow-up; covariate misclassification. Conclusion: Recombinant zoster vaccine is effective in older adults, including immunocompromised adults, and 2 doses were more effective than 1. Prior ZVL recipients should be revaccinated with RZV. Primary Funding Source: National Center for Advancing Translational Sciences.
Epidemiology of Coronary Atherosclerosis Among People Living With HIV in Uganda: A Cross-Sectional Study: Annals of Internal Medicine: Vol 178, No 4
Background: Data on the prevalence of coronary atherosclerotic disease (CAD) in the African region among people with and without HIV are lacking. Objective: To estimate the prevalence of CAD in Uganda and determine whether well-controlled HIV infection is associated with increased presence or severity of CAD. Design: Cross-sectional study. Setting: Southwestern Uganda. Participants: Ambulatory people living with HIV (PWH), aged older than 40 years, taking antiretroviral therapy for 3 or more years, and population-based, age- and sex-similar people without HIV (PWoH). Measurements: Participants had cardiovascular (CV) disease (CVD) risk profiling and computed tomography scanning for detection of CAD, defined as the presence of calcified or noncalcified plaque. Results: Of 630 screened, 586 (93%) met criteria and had evaluable images. Of these, 287 (49.0%) were PWH and nearly all (272 of 287 [95%]) were virologically suppressed. Mean age (57.9 vs. 57.4 years), proportion female (49%), and median CVD risk score (4.1 vs. 3.4) did not differ by HIV serostatus. The prevalence of CAD was low overall (45 of 586 [7.7%]) and among both PWH (26 of 287 [9.1%]) and PWoH (19 of 299 [6.4%]; absolute prevalence difference, 2.7% [95% CI, −1.6% to 7.0%]). Results were similar after adjustment for CVD risk factors. Limitations: Our findings may not generalize to symptomatic populations or those with greater predicted CVD risk. The study was not powered to detect small differences in CAD prevalence between HIV subgroups. Both PWH and PWoH had similar CV risk factor profiles, but residual confounding between HIV and CAD cannot be excluded. Conclusion: The prevalence of CAD in Uganda was low compared with population-based cohorts from the Global North with similar CVD risk profiles and was similar between HIV serostatus subgroups. Our results suggest that CAD may not be a major cause of morbidity in Uganda. Primary Funding Source: National Institutes of Health.
Dementia
Dementia, or major neurocognitive disorder, is defined as a decline in 1 or more cognitive domains that causes impairment in everyday function. Alzheimer disease is the most common type of dementia in the United States, with an estimated 6.9 million adults who have Alzheimer disease and are 65 years or older. This article discusses the latest findings in preventing cognitive decline. It also discusses dementia screening, diagnosis, treatment, and the quality of life for persons with dementia and their caregivers.
In advanced CKD, ACEis or ARBs reduce kidney failure vs. placebo or non-RAAS inhibitors at 34 mo
Source Citation Ku E, Inker LA, Tighiouart H, et al. Angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers for advanced chronic kidney disease: a systematic review and retrospective individual participant–level meta-analysis of clinical trials. Ann Intern Med. 2024;177:953-963. 38950402
Patient Navigation to Improve Colonoscopy Completion After an Abnormal Stool Test Result: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 178, No 5
Background: Patient navigation is a recommended practice of the Guide to Community Preventive Services; little is known about whether it improves colonoscopy completion for adults who have received an abnormal stool test result. Objective: To determine whether patient navigation delivered to persons with an abnormal stool test result increased follow-up colonoscopy completion (primary) at 1 year. Design: Randomized controlled trial. (ClinicalTrials.gov: NCT03925883) Setting: A federally qualified health center (n = 32 clinics) in Washington state. Patients: Persons aged 50 to 75 years with an abnormal fecal test result in the prior month. Intervention: A 6-topic, telephone-based patient navigation program delivered by bilingual (English and Spanish) clinical staff. Measurements: Receipt of follow-up colonoscopy at 1 year (primary); time to colonoscopy receipt (secondary); and program effectiveness by patient characteristics, including patients’ probability of obtaining a colonoscopy without navigation, derived using health record data (secondary). Results: Of 985 participants enrolled (mean age, 61 years [SD, 6.8]; 170 [18%] had a Spanish-language preference listed in the medical record), 967 were included in the primary intention-to-treat analysis (479 in patient navigation, 488 in usual care). Receipt of follow-up colonoscopy was higher in the patient navigation group than in the usual care group (55.1% vs. 42.1%; risk difference, 13.0 percentage points [95% CI, 6.5 to 19.4 percentage points]). The intervention effect was not moderated by patients’ probability of obtaining a colonoscopy without navigation. Limitation: The study was primarily done during the height of the COVID-19 pandemic, which created additional barriers to colonoscopy at the health system and patient levels. Conclusion: These findings support the effectiveness of patient navigation for follow-up colonoscopy completion. Primary Funding Source: National Cancer Institute.