Importance Sepsis is present in many hospitalizations that culminate in death. The contribution of sepsis to these deaths, and the extent to which they are preventable, is unknown. Objective To estimate the prevalence, underlying causes, and preventability of sepsis-associated mortality in acute care hospitals. Design, Setting, and Participants Cohort study in which a retrospective medical record review was conducted of 568 randomly selected adults admitted to 6 US academic and community hospitals from January 1, 2014, to December 31, 2015, who died in the hospital or were discharged to hospice and not readmitted. Medical records were reviewed from January 1, 2017, to March 31, 2018. Main Outcomes and Measures Clinicians reviewed cases for sepsis during hospitalization using Sepsis-3 criteria, hospice-qualifying criteria on admission, immediate and underlying causes of death, and suboptimal sepsis-related care such as inappropriate or delayed antibiotics, inadequate source control, or other medical errors. The preventability of each sepsis-associated death was rated on a 6-point Likert scale. Results The study cohort included 568 patients (289 [50.9%] men; mean [SD] age, 70.5 [16.1] years) who died in the hospital or were discharged to hospice. Sepsis was present in 300 hospitalizations (52.8%; 95% CI, 48.6%-57.0%) and was the immediate cause of death in 198 cases (34.9%; 95% CI, 30.9%-38.9%). The next most common immediate causes of death were progressive cancer (92 [16.2%]) and heart failure (39 [6.9%]). The most common underlying causes of death in patients with sepsis were solid cancer (63 of 300 [21.0%]), chronic heart disease (46 of 300 [15.3%]), hematologic cancer (31 of 300 [10.3%]), dementia (29 of 300 [9.7%]), and chronic lung disease (27 of 300 [9.0%]). Hospice-qualifying conditions were present on admission in 121 of 300 sepsis-associated deaths (40.3%; 95% CI 34.7%-46.1%), most commonly end-stage cancer. Suboptimal care, most commonly delays in antibiotics, was identified in 68 of 300 sepsis-associated deaths (22.7%). However, only 11 sepsis-associated deaths (3.7%) were judged definitely or moderately likely preventable; another 25 sepsis-associated deaths (8.3%) were considered possibly preventable. Conclusions and Relevance In this cohort from 6 US hospitals, sepsis was the most common immediate cause of death. However, most underlying causes of death were related to severe chronic comorbidities and most sepsis-associated deaths were unlikely to be preventable through better hospital-based care. Further innovations in the prevention and care of underlying conditions may be necessary before a major reduction in sepsis-associated deaths can be achieved.

/pdf/prevalence-underlying-causes-and-preventability-of-sepsis-2xs3t6s507.pdf

Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals

Antibiotics are among the most common medications prescribed in nursing homes. The annual prevalence of antibiotic use in residents of nursing homes ranges from 47% to 79%, and more than half of antibiotic courses initiated in nursing-home settings are unnecessary or prescribed inappropriately (wrong drug, dose, or duration). Inappropriate antibiotic use is associated with a variety of negative consequences including Clostridioides difficile infection (CDI), adverse drug effects, drug-drug interactions, and antimicrobial resistance. In response to this problem, public health authorities have called for efforts to improve the quality of antibiotic prescribing in nursing homes.

Reliability of nonlocalizing signs and symptoms as indicators of the presence of infection in nursing-home residents.

Importance Hospitalizations for infections among nursing home (NH) residents remain common despite national initiatives to reduce them. Cognitive impairment, which markedly affects quality of life and caregiving needs, has been associated with hospitalizations, but the association between infection-related hospitalizations and long-term cognitive function among NH residents is unknown. Objective To examine whether there are changes in cognitive function before vs after infection-related hospitalizations among NH residents. Design, Setting, and Participants This cohort study used data from the Minimum Data Set 3.0 linked to Medicare hospitalization data from 2011 to 2017 for US nursing home residents aged 65 years or older who had experienced an infection-related hospitalization and had at least 2 quarterly Minimum Data Set assessments before and 4 or more after the infection-related hospitalization. Analyses were performed from September 1, 2019, to December 21, 2020. Exposure Infection-related hospitalization lasting 1 to 14 days. Main Outcomes and Measures Using an event study approach, associations between infection-related hospitalizations and quarterly changes in cognitive function among NH residents were examined overall and by sex, age, Alzheimer disease and related dementias (ADRD) diagnosis, and sepsis vs other infection-related diagnoses. Resident-level cognitive function was measured using the Cognitive Function Scale (CFS), with scores ranging from 1 (intact) to 4 (severe cognitive impairment). Results Of the sample of 20 698 NH residents, 71.0% were women and 82.6% were non-Hispanic White individuals; the mean (SD) age at the time of transfer to the hospital was 82 (8.5) years. The mean CFS score was 2.17, and the prevalence of severe cognitive impairment (CFS score, 4) was 9.0%. During the first quarter after an infection-related hospitalization, residents experienced a mean increase of 0.06 points in CFS score (95% CI, 0.05-0.07 points; P < .001), or 3%. The increase in scores was greatest among residents aged 85 years or older vs younger residents by approximately 0.022 CFS points (95% CI, 0.004-0.040 points; P < .05). The prevalence of severe cognitive impairment increased by 1.6 percentage points (95% CI, 1.2-2.0 percentage points; P < .001), or 18%; the increases were observed among individuals with ADRD but not among those without it. After an infection-related hospitalization, cognition among residents who had experienced sepsis declined more than for residents who had not by about 0.02 CFS points (95% CI, 0.00-0.04 points; P < .05). All observed differences persisted without an accelerated rate of decline for at least 6 quarters after infection-related hospitalization. No differences were observed by sex. Conclusions and Relevance In this cohort study, infection-related hospitalization was associated with immediate and persistent cognitive decline among nursing home residents, with the largest increase in CFS scores among older residents, those with ADRD, and those who had experienced sepsis. Identification of NH residents at risk of worsened cognition after an infection-related hospitalization may help to ensure that their care needs are addressed to prevent further cognitive decline.

/pdf/association-of-infection-related-hospitalization-with-41l0qychqh.pdf

Association of Infection-Related Hospitalization With Cognitive Impairment Among Nursing Home Residents.

Despite the current understanding of the pathophysiology of sepsis and advances in its treatment, the rate of sepsis is increasing globally. Sepsis is a common cause of hospitalization in older adults, and infections are among the most common diagnoses among residents transferred to the hospital from long-term care facilities (LTCFs). LTCFs and hospitals are facing financial and regulatory requirements to reduce potentially preventable emergency department visits, hospitalizations, and hospital readmissions due to infections and other causes. In addition, the human and financial costs of these events are substantial. Current criteria for early identification of sepsis have low sensitivity and specificity among LTCF residents. Early diagnosis must focus on changes in clinical, mental, and functional status, and vital signs including pulse oximetry. Laboratory data can increase the suspicion of sepsis, but the availability of testing and timing of results limits its usefulness in most LTCFs.While new diagnostic criteria for sepsis are being developed and validated in the LTCF setting, clinical practice and decision support tools are available to guide management. Most LTFCs do not have the capabilities to manage sepsis based on current guidelines despite availability of qualified nursing staff and clinicians. Thus excluding circumstances in which a resident's desire is palliative or hospice care without transfer to a hospital, most LTCFs will continue to transfer residents with severe infections at risk for evolving into sepsis to an acute hospital setting. J Am Geriatr Soc 67:2234-2239, 2019.

Sepsis in Older Adults in Long-Term Care Facilities: Challenges in Diagnosis and Management

Early Identification and Management of Sepsis in Nursing Facilities: Challenges and Opportunities.

Comparison of Postprostatic Artery Embolization Cone-Beam CT and Estimated Radiopaque Particle Distribution on Follow-up Imaging: A Case Report.

Background: Prostatic artery embolization (PAE) has emerged as a treatment option in the management of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). Management guidelines addressing PAE remain mixed with recommendations for more long-term trials comparing the procedure to standard therapies.
Materials and Methods: This review presents PAE indications and technical considerations. To evaluate recent updates to the PAE evidence base, a limited literature search of the last 2 years was conducted. Three recent randomized controlled trials (RCTs), comparing PAE to either transurethral resection of the prostate (TURP) or sham procedure, were identified and analyzed.
Results: PAE and TURP performed similarly in significant reductions in international prostate symptoms score (IPSS) and Quality of life (QoL) scoring at 3 and 12 months. The majority of improvement after PAE occurred within a few months, with potentially greater effect in patients with larger prostates and severe symptoms. TURP was generally superior in functional outcomes such as peak urinary flow (Qmax), prostate volume (PV) reduction and post void residual (PVR), although TURP patients underperformed in Qmax improvement in one trial. PAE was superior to sham procedure in all relevant outcomes at 6 months. Overall, complication rates were lower with PAE than with TURP.
Conclusions: PAE and TURP produced similar significant improvements in LUTS. Functional improvements favored TURP while complication rates favored PAE. Clinical improvement after PAE significantly surpassed initial placebo effects of sham procedure. Further comparative studies with longer term follow-up are still needed.

/pdf/update-on-prostatic-artery-embolization-3t0qcolq97.pdf

Update on Prostatic Artery Embolization

Two-sample testing is a fundamental problem in statistics, and many famous two-sample tests are designed to be fully non-parametric. These existing methods perform well with location and scale shifts but are less robust when faced with more exotic classes of alternatives, and rejections from these tests can be difficult to interpret. Here, we propose a new univariate non-parametric two-sample test, AUGUST, designed to improve on these aspects. AUGUST tests for inequality in distribution up to a predetermined resolution using symmetry statistics from binary expansion. The AUGUST statistic is exactly distribution-free and has a well-understood asymptotic distribution, permitting fast p-value computation. In empirical studies, we show that AUGUST has power comparable to that of the best existing methods in every context, as well as greater power in some circumstances. We illustrate the clear interpretability of AUGUST on NBA shooting data.

The AUGUST Two-Sample Test: Powerful, Interpretable, and Fast

Meeting the Need for IR Training in Kenya.

Can Sepsis Be Detected in the Nursing Home Prior to the Need for Hospital Transfer

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