Last data update: Jun 24, 2024. (Total: 47078 publications since 2009)
Records 1-22 (of 22 Records) |
Query Trace: Graber J [original query] |
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Firefighting, per- and polyfluoroalkyl substances, and DNA methylation of genes associated with prostate cancer risk
Quaid M , Goodrich JM , Calkins MM , Graber JM , Urwin D , Gabriel J , Caban-Martinez AJ , Petroff RL , Grant C , Beitel SC , Littau S , Gulotta JJ , Wallentine D , Hughes J , Burgess JL . Environ Mol Mutagen 2024 ![]() Prostate cancer is the leading incident cancer among men in the United States. Firefighters are diagnosed with this disease at a rate 1.21 times higher than the average population. This increased risk may result from occupational exposures to many toxicants, including per- and polyfluoroalkyl substances (PFAS). This study assessed the association between firefighting as an occupation in general or PFAS serum levels, with DNA methylation. Only genomic regions previously linked to prostate cancer risk were selected for analysis: GSTP1, Alu repetitive elements, and the 8q24 chromosomal region. There were 444 male firefighters included in this study, with some analyses being conducted on fewer participants due to missingness. Statistical models were used to test associations between exposures and DNA methylation at CpG sites in the selected genomic regions. Exposure variables included proxies of cumulative firefighting exposures (incumbent versus academy status and years of firefighting experience) and biomarkers of PFAS exposures (serum concentrations of 9 PFAS). Proxies of cumulative exposures were associated with DNA methylation at 15 CpG sites and one region located within FAM83A (q-value <0.1). SbPFOA was associated with 19 CpG sites (q < 0.1), but due to low detection rates, this PFAS was modeled as detected versus not detected in serum. Overall, there is evidence that firefighting experience is associated with differential DNA methylation in prostate cancer risk loci, but this study did not find evidence that these differences are due to PFAS exposures specifically. |
Prevalence and predictors of colon and prostate cancer screening among volunteer firefighters: The United States Firefighter Cancer Assessment and Prevention Study
Shah NN , Steinberg MB , Calkins MM , Caban-Martinez AJ , Burgess JL , Austin E , Hollerbach BS , Edwards DL , Black TM , Black K , Hinton KM , Kubiel BS , Graber JM . Am J Ind Med 2024 BACKGROUND: Although firefighters have increased risk for colon and prostate cancer, limited information exists on screening practices for these cancers in volunteer firefighters who compose two-thirds of the US fire service. We estimated the prevalence of colon and prostate cancer screening among volunteer firefighters using eligibility criteria from 4 evidence-based screening recommendations and evaluated factors influencing screening. METHODS: We evaluated colon (n = 569) and prostate (n = 498) cancer screening prevalence in a sample of US volunteer firefighters using eligibility criteria from the US Preventive Services Taskforce (USPSTF), National Fire Protection Association, American Cancer Society, and National Comprehensive Cancer Network. We assessed associations with fire service experience, demographics, and cancer risk perception based on USPSTF guidelines. RESULTS: For those eligible based on USPSTF guidelines, colon and prostate cancer screening prevalence was 51.7% (95% CI: 45.7, 57.8) and 48.8% (95% CI: 40.0, 57.6), respectively. Higher odds of colon and prostate cancer screening were observed with older age and with some college education compared to those with less education. Fire service experience and cancer risk perception were not associated with screening practices. CONCLUSION: This is the first large study to assess colon and prostate cancer screening among US volunteer firefighters based on different screening guidelines. Our findings suggest gaps in cancer prevention efforts in the US volunteer fire service. Promoting cancer screening education and opportunities for volunteer firefighters by their fire departments, healthcare professionals, and public health practitioners, may help to address the gaps. |
Comparison of serum PFAS concentrations in incumbent and recruit firefighters and longitudinal assessment in recruits
Nematollahi AJ , Fisher JM , Furlong MA , Beamer PI , Goodrich JM , Graber JM , Calafat AM , Botelho JC , Beitel SC , Littau SR , Gulotta JJ , Wallentine DD , Burgess JL . J Occup Environ Med 2023 OBJECTIVE: Firefighters are occupationally exposed to per- and polyfluoroalkyl substances (PFAS). This study objective was to compare serum PFAS concentrations in incumbent and recruit firefighters and evaluate temporal trends among recruits. METHODS: Serum PFAS concentrations were measured in 99 incumbent and 55 recruit firefighters at enrollment in 2015-2016, with follow-up 20-37 months later for recruits. Linear and logistic regression and linear mixed-effects models were used for analyses. Fireground exposure impact on PFAS concentrations was investigated using adjusted linear and logistic regression models. RESULTS: Incumbents had lower n-PFOA and PFNA than recruits and most PFAS significantly decreased over time among male recruits. No significant links were found between cumulative fireground exposures and PFAS concentrations. CONCLUSIONS: Serum PFAS concentrations were not increased in incumbent firefighters compared with recruits and were not associated with cumulative fireground exposures. |
Firefighting and cancer: A meta-analysis of cohort studies in the context of cancer hazard identification
DeBono NL , Daniels RD , Beane Freeman LE , Graber JM , Hansen J , Teras LR , Driscoll T , Kjaerheim K , Demers PA , Glass DC , Kriebel D , Kirkham TL , Wedekind R , Filho AM , Stayner L , Schubauer-Berigan MK . Saf Health Work 2023 14 (2) 141-152 Objective: We performed a meta-analysis of epidemiological results for the association between occupational exposure as a firefighter and cancer as part of the broader evidence synthesis work of the IARC Monographs program. Methods: A systematic literature search was conducted to identify cohort studies of firefighters followed for cancer incidence and mortality. Studies were evaluated for the influence of key biases on results. Random-effects meta-analysis models were used to estimate the association between ever-employment and duration of employment as a firefighter and risk of 12 selected cancers. The impact of bias was explored in sensitivity analyses. Results: Among the 16 included cancer incidence studies, the estimated meta-rate ratio, 95% confidence interval (CI), and heterogeneity statistic (I2) for ever-employment as a career firefighter compared mostly to general populations were 1.58 (1.14–2.20, 8%) for mesothelioma, 1.16 (1.08–1.26, 0%) for bladder cancer, 1.21 (1.12–1.32, 81%) for prostate cancer, 1.37 (1.03–1.82, 56%) for testicular cancer, 1.19 (1.07–1.32, 37%) for colon cancer, 1.36 (1.15–1.62, 83%) for melanoma, 1.12 (1.01–1.25, 0%) for non-Hodgkin lymphoma, 1.28 (1.02–1.61, 40%) for thyroid cancer, and 1.09 (0.92–1.29, 55%) for kidney cancer. Ever-employment as a firefighter was not positively associated with lung, nervous system, or stomach cancer. Results for mesothelioma and bladder cancer exhibited low heterogeneity and were largely robust across sensitivity analyses. Conclusions: There is epidemiological evidence to support a causal relationship between occupational exposure as a firefighter and certain cancers. Challenges persist in the body of evidence related to the quality of exposure assessment, confounding, and medical surveillance bias. © 2023 Occupational Safety and Health Research Institute |
Comparability of in-person and web screening: Does mode affect what households report
Graber JE , Williams D , Clark J . PLoS One 2022 17 (10) e0277017 Household screening is common when information about characteristics of household members is needed for selection of survey respondents. When key characteristics have a low prevalence, or are oversampled, this can result in a large number of sampled households screened, many of which have no persons selected. For in-person surveys this can be inefficient and costly, especially in an environment of declining response. A multimode design using a mail, push-to-web approach is an attractive alternative due to lower cost and high internet penetration. However, little is known about the comparable data quality properties between in-person and web modes. While in-person screening is considered a gold standard approach, respondents may fail to report household members and interviewers may unintentionally screen out reluctant respondents. Similarly, those self-responding sometimes fail to report unrelated household members or young children. In this study we compared in-person and web screening in the National Health and Nutrition Examination Survey. Households were randomly selected to complete a self-administered web screener and subsequently be screened by an interviewer during an in-person visit. We report on the comparability of household characteristics between modes to determine if web screening provides data equivalent to in-person screening. We examine time between the web and in-person screening to see if true change can account for differences. In the presence of conflicting data, we examine selection criteria based on the screening responses to see how inaccuracies affect selection status, or if inaccuracies or person omissions are systematically related to a specific mode. Approximately 93% (80/86) of households agreed on selection status between the web and in-person modes. Household composition matched fully for 84% (72/86) of households. These results indicate that web screening is a viable option enumerating households in population surveys. |
Serum per- and polyfluoroalkyl substance concentrations in four municipal US fire departments
Burgess JL , Fisher JM , Nematollahi A , Jung AM , Calkins MM , Graber JM , Grant CC , Beitel SC , Littau SR , Gulotta JJ , Wallentine DD , Hughes RJ , Popp C , Calafat AM , Botelho JC , Coleman AD , Schaefer-Solle N , Louzado-Feliciano P , Oduwole SO , Caban-Martinez AJ . Am J Ind Med 2022 66 (5) 411-423 BACKGROUND: Firefighters have occupational and environmental exposures to per- and polyfluoroalkyl substances (PFAS). The goal of this study was to compare serum PFAS concentrations across multiple United States fire departments to National Health and Nutrition Examination Survey (NHANES) participants. METHODS: Nine serum PFAS were compared in 290 firefighters from four municipal fire departments (coded A-D) and three NHANES participants matched to each firefighter on sex, ethnicity, age, and PFAS collection year. Only Departments A and C had sufficient women study participants (25 and six, respectively) to compare with NHANES. RESULTS: In male firefighters compared with NHANES, geometric mean perfluorohexane sulfonate (PFHxS) was elevated in Departments A-C, sum of branched perfluoromethylheptane sulfonate isomers (Sm-PFOS) was elevated in all four departments, linear perfluorooctane sulfonate (n-PFOS) was elevated in Departments B and C, linear perfluorooctanoate (n-PFOA) was elevated in Departments B-D, and perfluorononanoate (PFNA) was elevated in Departments B-D, but lower in A. In male firefighters compared with NHANES, perfluoroundecanoate (PFUnDA) was more frequently detected in Departments B and D, and 2-(N-methyl-perfluorooctane sulfonamido) acetate (MeFOSAA) was less frequently detected in Departments B-D. In female firefighters compared with NHANES, PFHxS and Sm-PFOS concentrations were elevated in Departments A and C. Other PFAS concentrations were elevated and/or reduced in only one department or not significantly different from NHANES in any department. CONCLUSIONS: Serum PFHxS, Sm-PFOS, n-PFOS, n-PFOA, and PFNA concentrations were increased in at least two of four fire departments in comparison to NHANES. |
Differences in hypertension and stage II hypertension by demographic and risk factors, obtained by two different protocols in US adults: National Health and Nutrition Examination Survey, 2017-2018
Ostchega Y , Hughes JP , Kit B , Chen TC , Nwankwo T , Commodore-Mensah Y , Graber JE , Nguyen DT . Am J Hypertens 2022 35 (7) 619-626 OBJECTIVE: To compare prevalence of hypertension and stage II hypertension assessed by two blood pressure observation protocols. METHODS: Participants aged 18 years and older (n = 4,689) in the National Health and Nutrition Examination Survey (NHANES 2017-2018) had their blood pressure (BP) measured following two protocols: the legacy auscultation protocol [AP] and oscillometric protocol [OP]. The order of protocols was randomly assigned. Prevalence estimates for hypertension (BP 130/80 mm Hg or use of medication for hypertension) and stage II hypertension (BP 140/90 mm Hg) were determined overall, by demographics, and by risk factors for each protocol. Ratios (OP% AP%) and Kappa statistics were calculated. RESULTS: Age-adjusted hypertension prevalence was 44.5% (95% CI: 41.1%-48.0%) using OP and 45.1% (95%CI: 41.5%-48.7%) using AP, prevalence ratio=0.99, (95% CI=0.94-1.04)). Age-adjusted Stage II hypertension prevalence was 15.8% (95% CI: 13.6%-18.2%) using AP and 17.1% (95% CI: 14.7%-19.7%) using OP, prevalence ratio=0.92, (95% CI=0.81-1.04)). For both hypertension and Stage II hypertension, the prevalence ratios by demographics and by risk factors all included unity in their 95% CI, except for Stage II hypertension in adults 60+ years (ratio: 0.88 (95% CI: 0.78-0.98)). Kappa for agreement between protocols for hypertension and stage II hypertension were 0.75 (95% CI=0.71-0.79) and 0.67 (95% CI=0.61-0.72), respectively. CONCLUSIONS: In adults and for nearly all subcategories there were no significant differences in prevalence of hypertension and stage II hypertension between protocols, indicating that protocol change may not affect the national prevalence estimates of hypertension and stage II hypertension. |
The National Health and Nutrition Examination Survey (NHANES), 2021-2022: Adapting Data Collection in a COVID-19 Environment.
Paulose-Ram R , Graber JE , Woodwell D , Ahluwalia N . Am J Public Health 2021 111 (12) 2149-2156 The National Health and Nutrition Examination Survey (NHANES) is a unique source of national data on the health and nutritional status of the US population, collecting data through interviews, standard exams, and biospecimen collection. Because of the COVID-19 pandemic, NHANES data collection was suspended, with more than a year gap in data collection. NHANES resumed operations in 2021 with the NHANES 2021-2022 survey, which will monitor the health and nutritional status of the nation while adding to the knowledge of COVID-19 in the US population. This article describes the reshaping of the NHANES program and, specifically, the planning of NHANES 2021-2022 for data collection during the COVID-19 pandemic. Details are provided on how NHANES transformed its participant recruitment and data collection plans at home and at the mobile examination center to safely collect data in a COVID-19 environment. The potential implications for data users are also discussed. (Am J Public Health. 2021;111(12):2149-2156. https://doi.org/10.2105/AJPH.2021.306517). |
Per-and polyfluoroalkyl substances, epigenetic ageand DNA methylation: across-sectional study of firefighters
Goodrich JM , Calkins MM , Caban-Martinez AJ , Stueckle T , Grant C , Calafat AM , Nematollahi A , Jung AM , Graber JM , Jenkins T , Slitt AL , Dewald A , Cook Botelho J , Beitel S , Littau S , Gulotta J , Wallentine D , Hughes J , Popp C , Burgess JL . Epigenomics 2021 13 (20) 1619-1636 Background: Per- and polyfluoroalkyl substances (PFASs) are persistent chemicals that firefighters encounter. Epigenetic modifications, including DNA methylation, could serve as PFASs toxicity biomarkers. Methods: With a sample size of 197 firefighters, we quantified the serum concentrations of nine PFASs, blood leukocyte DNA methylation and epigenetic age indicators via the EPIC array. We examined the associations between PFASs with epigenetic age, site- and region-specific DNA methylation, adjusting for confounders. Results: Perfluorohexane sulfonate, perfluorooctanoate (PFOA) and the sum of branched isomers of perfluorooctane sulfonate (Sm-PFOS) were associated with accelerated epigenetic age. Branched PFOA, linear PFOS, perfluorononanoate, perfluorodecanoate and perfluoroundecanoate were associated with differentially methylated loci and regions. Conclusion: PFASs concentrations are associated with accelerated epigenetic age and locus-specific DNA methylation. The implications for PFASs toxicity merit further investigation. |
Differences in hypertension prevalence and hypertension control by urbanization among adults in the United States, 2013-2018
Ostchega Y , Hughes JP , Zhang G , Nwankwo T , Graber J , Nguyen DT . Am J Hypertens 2021 35 (1) 31-41 OBJECTIVE: To examine the associations between urbanization and hypertension, stage II hypertension, and hypertension control. METHODS: Data on 16,360 U.S. adults aged 18 years or older from the 2013-2018 National Health and Nutrition Examination Survey (NHANES) were used to estimate the prevalence of hypertension (blood pressure (BP) ≥130/80 mm Hg or use of medication for hypertension), stage II hypertension (BP ≥140/90 mm Hg), and hypertension control (BP < 130/80 mm Hg among hypertensives) by urbanization, classified by levels of metropolitan statistical areas as large MSAs (population ≥ 1,000,000), medium to small MSAs (population 50,000-999,999), and non-MSAs (population <50,000)). RESULTS: All prevalence ratios (PRs) were compared with large MSAs and adjusted for demographics and risk factors. The PRs of hypertension were 1.07 (95% CI= 0.99-1.14) for adults residing in medium to small MSAs and 1.06 (95% CI=0.99- 1.13) for adults residing in non-MSAs, For stage II hypertension, the PRs were higher for adults residing in medium to small MSAs 1.21 (95% CI =1.06-1.36) but not for adults residing in non-MSAs 1.06 (95% CI= 0.88-1.29). For hypertension control, the PRs were 0.96 (95% CI=0.91-1.01) for adults residing in medium to small MSAs and 1.00 (95% CI=0.93-1.06) for adults residing in non-MSAs. CONCLUSION: Among U.S. adults, urbanization was associated with stage II hypertension. |
Injection drug use-associated candidemia: Incidence, clinical features, and outcomes, east Tennessee, 2014-2018
Rossow JA , Gharpure R , Brennan J , Relan P , Williams SR , Vallabhaneni S , Jackson BR , Graber CR , Hillis SR , Schaffner W , Dunn JR , Jones TF . J Infect Dis 2020 222 S442-s450 BACKGROUND: Injection drug use (IDU) is an established but uncommon risk factor for candidemia. Surveillance for candidemia is conducted in East Tennessee, an area heavily impacted by the opioid crisis and IDU. We evaluated IDU-associated candidemia to characterize the epidemiology and estimate the burden. METHODS: We assessed the proportion of candidemia cases related to IDU during January 1, 2014-September 30, 2018, estimated candidemia incidence in the overall population and among persons who inject drugs (PWID), and reviewed medical records to compare clinical features and outcomes among IDU-associated and non-IDU candidemia cases. RESULTS: The proportion of IDU-associated candidemia cases in East Tennessee increased from 6.1% in 2014 to 14.5% in 2018. Overall candidemia incidence in East Tennessee was 13.5/100 000, and incidence among PWID was 402-1895/100 000. Injection drug use-associated cases were younger (median age, 34.5 vs 60 years) and more frequently had endocarditis (39% vs 3%). All-cause 30-day mortality was 8% among IDU-associated cases versus 25% among non-IDU cases. CONCLUSIONS: A growing proportion of candidemia in East Tennessee is associated with IDU, posing an additional burden from the opioid crisis. The lower mortality among IDU-associated cases likely reflects in part the younger demographic; however, Candida endocarditis seen among approximately 40% underscores the seriousness of the infection and need for prevention. |
Burden of Candidemia in the United States, 2017
Tsay SV , Mu Y , Williams S , Epson E , Nadle J , Bamberg WM , Barter DM , Johnston HL , Farley MM , Harb S , Thomas S , Bonner LA , Harrison LH , Hollick R , Marceaux K , Mody RK , Pattee B , Shrum Davis S , Phipps EC , Tesini BL , Gellert AB , Zhang AY , Schaffner W , Hillis S , Ndi D , Graber CR , Jackson BR , Chiller T , Magill S , Vallabhaneni S . Clin Infect Dis 2020 71 (9) e449-e453 BACKGROUND: Candidemia is a common healthcare-associated bloodstream infection with high morbidity and mortality. There are no current estimates of candidemia burden in the United States. METHODS: In 2017, the Centers for Disease Control and Prevention (CDC) conducted active population-based surveillance for candidemia through the Emerging Infections Program (EIP) in 45 counties in nine states encompassing ~17 million persons (5% of the national population). Laboratories serving the catchment area population reported all blood cultures with Candida, and a standard case definition was applied to identify cases that occurred in surveillance area residents. Burden of cases and mortality was estimated by extrapolating surveillance area cases to national numbers using 2017 national census data. RESULTS: We identified 1,226 candidemia cases across nine surveillance sites in 2017. Based on this, we estimated 22,660 (95% confidence interval [CI]: 20,210-25,110) cases of candidemia occurred in the United States in 2017. Overall estimated incidence was 7.0 cases per 100,000 persons, with highest rates in adults >/=65 years (20.1/100,000), males (7.9/100,000), and those of black race (12.3/100,000). An estimated 3,380 (95% CI: 1,318-5,442) deaths occurred within seven days of a positive Candida blood culture and 5,628 (95% CI: 2,465-8,791) deaths occurred during the hospitalization with candidemia. CONCLUSIONS: Our analysis highlights the substantial burden of candidemia in the U.S. Because candidemia is only one form of invasive candidiasis, the true burden of invasive infections due to Candida is higher. Ongoing surveillance can support future burden estimates and help assess the impact of prevention interventions. |
The effect of laboratory test-based clinical decision support tools on medication errors and adverse drug events: A laboratory medicine best practices systematic review
Whitehead NS , Williams L , Meleth S , Kennedy S , Ubaka-Blackmoore N , Kanter M , O'Leary KJ , Classen D , Jackson B , Murphy DR , Nichols J , Stockwell D , Lorey T , Epner P , Taylor J , Graber ML . J Appl Lab Med 2019 3 (6) 1035-1048 BACKGROUND: Laboratory and medication data in electronic health records create opportunities for clinical decision support (CDS) tools to improve medication dosing, laboratory monitoring, and detection of side effects. This systematic review evaluates the effectiveness of such tools in preventing medication-related harm. METHODS: We followed the Laboratory Medicine Best Practice (LMBP) initiative's A-6 methodology. Searches of 6 bibliographic databases retrieved 8508 abstracts. Fifteen articles examined the effect of CDS tools on (a) appropriate dose or medication (n = 5), (b) laboratory monitoring (n = 4), (c) compliance with guidelines (n = 2), and (d) adverse drug events (n = 5). We conducted meta-analyses by using random-effects modeling. RESULTS: We found moderate and consistent evidence that CDS tools applied at medication ordering or dispensing can increase prescriptions of appropriate medications or dosages [6 results, pooled risk ratio (RR), 1.48; 95% CI, 1.27-1.74]. CDS tools also improve receipt of recommended laboratory monitoring and appropriate treatment in response to abnormal test results (6 results, pooled RR, 1.40; 95% CI, 1.05-1.87). The evidence that CDS tools reduced adverse drug events was inconsistent (5 results, pooled RR, 0.69; 95% CI, 0.46-1.03). CONCLUSIONS: The findings support the practice of healthcare systems with the technological capability incorporating test-based CDS tools into their computerized physician ordering systems to (a) identify and flag prescription orders of inappropriate dose or medications at the time of ordering or dispensing and (b) alert providers to missing laboratory tests for medication monitoring or results that warrant a change in treatment. More research is needed to determine the ability of these tools to prevent adverse drug events. |
Editorial for "Long-Term Health Effects of the 9/11 Disaster" in International Journal of Environmental Research and Public Health, 2019
Brackbill RM , Graber JM , Robison WAA . Int J Environ Res Public Health 2019 16 (18) The call for articles on the long term health effects of the 11 September 2001 terrorist attacks (9/11) has resulted in twenty-three papers that add a significant amount of information to the growing body of research on the effects of the World Trade Center (WTC) disaster almost two decades later [...]. |
Interventions to prevent iatrogenic anemia: a Laboratory Medicine Best Practices systematic review
Whitehead NS , Williams LO , Meleth S , Kennedy SM , Ubaka-Blackmoore N , Geaghan SM , Nichols JH , Carroll P , McEvoy MT , Gayken J , Ernst DJ , Litwin C , Epner P , Taylor J , Graber ML . Crit Care 2019 23 (1) 278 BACKGROUND: As many as 90% of patients develop anemia by their third day in an intensive care unit (ICU). We evaluated the efficacy of interventions to reduce phlebotomy-related blood loss on the volume of blood lost, hemoglobin levels, transfusions, and incidence of anemia. METHODS: We conducted a systematic review and meta-analysis using the Laboratory Medicine Best Practices (LMBP) systematic review methods for rating study quality and assessing the body of evidence. Searches of PubMed, Embase, Cochrane, Web of Science, PsychINFO, and CINAHL identified 2564 published references. We included studies of the impact of interventions to reduce phlebotomy-related blood loss on blood loss, hemoglobin levels, transfusions, or anemia among hospital inpatients. We excluded studies not published in English and studies that did not have a comparison group, did not report an outcome of interest, or were rated as poor quality. Twenty-one studies met these criteria. We conducted a meta-analysis if > 2 homogenous studies reported sufficient information for analysis. RESULTS: We found moderate, consistent evidence that devices that return blood from flushing venous or arterial lines to the patient reduced blood loss by approximately 25% in both neonatal ICU (NICU) and adult ICU patients [pooled estimate in adults, 24.7 (95% CI = 12.1-37.3)]. Bundled interventions that included blood conservation devices appeared to reduce blood loss by at least 25% (suggestive evidence). The evidence was insufficient to determine if these devices reduced hemoglobin decline or risk of anemia. The evidence suggested that small volume tubes reduced the risk of anemia, but was insufficient to determine if they affected the volume of blood loss or the rate of hemoglobin decline. CONCLUSIONS: Moderate, consistent evidence indicated that devices that return blood from testing or flushing lines to the patient reduce the volume of blood loss by approximately 25% among ICU patients. The results of this systematic review support the use of blood conservation systems with arterial or venous catheters to eliminate blood waste when drawing blood for testing. The evidence was insufficient to conclude the devices impacted hemoglobin levels or transfusion rates. The use of small volume tubes may reduce the risk of anemia. |
Neonatal and pediatric candidemia: Results from population-based active laboratory surveillance in four US locations, 2009-2015
Benedict K , Roy M , Kabbani S , Anderson EJ , Farley MM , Harb S , Harrison LH , Bonner L , Wadu VL , Marceaux K , Hollick R , Beldavs ZG , Zhang AY , Schaffner W , Graber CR , Derado G , Chiller TM , Lockhart SR , Vallabhaneni S . J Pediatric Infect Dis Soc 2018 7 (3) e78-e85 Introduction: Candida is a leading cause of healthcare-associated bloodstream infections in the United States. Infants and children have unique risk factors for candidemia, and the Candida species distribution in this group is different that among adults; however, candidemia epidemiology in this population has not been described recently. Methods: We conducted active population-based candidemia surveillance in 4 US metropolitan areas between 2009 and 2015. We calculated incidences among neonates (0-30 days old), infants (0-364 days old), and noninfant children (1-19 years old), documented their clinical features and antifungal drug resistance. Results: We identified 307 pediatric candidemia cases. Incidence trends varied according to site, but overall, the incidence in neonates decreased from 31.5 cases/100000 births in 2009 to 10.7 to 11.8 cases/100000 births between 2012 and 2015, the incidence in infants decreased from 52.1 cases/100000 in 2009 to 15.7 to 17.5 between 2012 and 2015, and the incidence in noninfant children decreased steadily from 1.8 cases/100000 in 2009 to 0.8 in 2014. Common underlying conditions were prematurity in neonates (78%), surgery in nonneonate infants (38%), and malignancy in noninfant children (28%). Most neonate cases were caused by C albicans (67%), whereas non-C. albicans species accounted for 60% of cases in nonneonate infants and noninfant children. Fluconazole and echinocandin resistance rates were low overall. Thirty-day crude mortality was 13%. Conclusions: The incidence of candidemia among neonates and infants declined after 2009 but remained stable from 2012 to 2015. Antifungal drug resistance is uncommon. Reasons for the lack of recent declines in neonatal and infant candidemia deserve further exploration. In this article, we describe the epidemiology of candidemia in children in the United States and on the basis of data collected as part of US Centers for Disease Control and Prevention active population-based surveillance. Trends in incidence, clinical characteristics, species distribution, and resistance rates are presented. |
Interventions to improve follow-up of laboratory test results pending at discharge: A systematic review
Whitehead NS , Williams L , Meleth S , Kennedy S , Epner P , Singh H , Wooldridge K , Dalal AK , Walz SE , Lorey T , Graber ML . J Hosp Med 2018 13 (9) 631-636 Failure to follow up test results pending at discharge (TPAD) from hospitals or emergency departments is a major patient safety concern. The purpose of this review is to systematically evaluate the effectiveness of interventions to improve follow-up of laboratory TPAD. We conducted literature searches in PubMed, CINAHL, Cochrane, and EMBASE using search terms for relevant health care settings, transition of patient care, laboratory tests, communication, and pending or missed tests. We solicited unpublished studies from the clinical laboratory community and excluded articles that did not address transitions between settings, did not include an intervention, or were not related to laboratory TPAD. We also excluded letters, editorials, commentaries, abstracts, case reports, and case series. Of the 9,592 abstracts retrieved, 8 met the inclusion criteria and reported the successful communication of TPAD. A team member abstracted predetermined data elements from each study, and a senior scientist reviewed the abstraction. Two experienced reviewers independently appraised the quality of each study using published LMBP A-6 scoring criteria. We assessed the body of evidence using the A-6 methodology, and the evidence suggested that electronic tools or one-on-one education increased documentation of pending tests in discharge summaries. We also found that automated notifications improved awareness of TPAD. The interventions were supported by suggestive evidence; this type of evidence is below the level of evidence required for LMBP recommendations. We encourage additional research into the impact of these interventions on key processes and health outcomes. |
Elevated blood lead levels associated with retained bullet fragments - United States, 2003-2012
Weiss D , Tomasallo CD , Meiman JG , Alarcon W , Graber NM , Bisgard KM , Anderson HA . MMWR Morb Mortal Wkly Rep 2017 66 (5) 130-133 An estimated 115,000 firearm injuries occur annually in the United States, and approximately 70% are nonfatal. Retained bullet fragments (RBFs) are an infrequently reported, but important, cause of lead toxicity; symptoms are often nonspecific and can appear years after suffering a gunshot wound. Adult blood lead level (BLL) screening is most commonly indicated for monitoring of occupational lead exposure; routine testing of adults with RBFs is infrequent. States collaborate with CDC's National Institute for Occupational Safety and Health (NIOSH) to monitor elevated BLLs through the Adult Blood Lead Epidemiology and Surveillance (ABLES) program. To help assess the public health burden of RBFs, data for persons with BLLs ≥10 mug/dL reported to ABLES during 2003-2012 were analyzed. An RBF-associated case was defined as a BLL ≥10 mug/dL in a person with an RBF. A non-RBF-associated case was defined as a BLL ≥10 mug/dL without an RBF. During 2003-2012, a total of 145,811 persons aged ≥16 years with BLLs ≥10 mug/dL were reported to ABLES in 41 states. Among these, 457 RBF-associated cases were identified with a maximum RBF-associated BLL of 306 mug/dL. RBF-associated cases accounted for 0.3% of all BLLs ≥10 mug/dL and 4.9% of BLLs ≥80 mug/dL. Elevated BLLs associated with RBFs occurred primarily among young adult males in nonoccupational settings. Low levels of suspicion of lead toxicity from RBFs by medical providers might cause a delay in diagnosis. Health care providers should inquire about an RBF as the potential cause for lead toxicity in an adult with an elevated BLL whose lead exposure is undetermined. |
Think twice: A cognitive perspective of an antibiotic timeout intervention to improve antibiotic use
Jones M , Butler J , Graber CJ , Glassman P , Samore MH , Pollack LA , Weir C , Goetz MB . J Biomed Inform 2016 71S S22-S31 OBJECTIVES: To understand clinicians' impressions of and decision-making processes regarding an informatics-supported antibiotic timeout program to re-evaluate the appropriateness of continuing vancomycin and piperacillin/tazobactam. METHODS: We implemented a multi-pronged informatics intervention, based on Dual Process Theory, to prompt discontinuation of unwarranted vancomycin and piperacillin/tazobactam on or after day three in a large Veterans Affairs Medical Center. Two workflow changes were introduced to facilitate cognitive deliberation about continuing antibiotics at day three: 1) teams completed an electronic template note, and 2) a paper summary of clinical and antibiotic-related information was provided to clinical teams. Shortly after starting the intervention, six focus groups were conducted with users or potential users. Interviews were recorded and transcribed. Iterative thematic analysis identified recurrent themes from feedback. RESULTS: Themes that emerged are represented by the following quotations: 1) captures and controls attention ("it reminds us to think about it"), 2) enhances informed and deliberative reasoning ("it makes you think twice"), 3) redirects decision direction ("...because [there was no indication] I just [discontinued] it without even trying"), 4) fosters autonomy and improves team empowerment ("the template... forces the team to really discuss it"), and 5) limits use of emotion-based heuristics ("my clinical concern is high enough I think they need more aggressive therapy..."). CONCLUSIONS: Requiring template completion to continue antibiotics nudged clinicians to re-assess the appropriateness of specified antibiotics. Antibiotic timeouts can encourage deliberation on overprescribed antibiotics without substantially curtailing autonomy. An effective nudge should take into account clinician's time, workflow, and thought processes. |
Taking an Antibiotic Time-out: Utilization and Usability of a Self-Stewardship Time-out Program for Renewal of Vancomycin and Piperacillin-Tazobactam
Graber CJ , Jones MM , Glassman PA , Weir C , Butler J , Nechodom K , Kay CL , Furman AE , Tran TT , Foltz C , Pollack LA , Samore MH , Goetz MB . Hosp Pharm 2015 50 (11) 1011-24 BACKGROUND: Antibiotic time-outs can promote critical thinking and greater attention to reviewing indications for continuation. OBJECTIVE: We pilot tested an antibiotic time-out program at a tertiary care teaching hospital where vancomycin and piperacillin-tazobactam continuation past day 3 had previously required infectious diseases service approval. METHODS: The time-out program consisted of 3 components: (1) an electronic antimicrobial dashboard that aggregated infection-relevant clinical data; (2) a templated note in the electronic medical record that included a structured review of antibiotic indications and that provided automatic approval of continuation of therapy when indicated; and (3) an educational and social marketing campaign. RESULTS: In the first 6 months of program implementation, vancomycin was discontinued by day 5 in 93/145 (64%) courses where a time-out was performed on day 4 versus in 96/199 (48%) 1 year prior (P = .04). Seven vancomycin continuations via template (5% of time-outs) were guideline-discordant by retrospective chart review versus none 1 year prior (P = .002). Piperacillin-tazobactam was discontinued by day 5 in 70/105 (67%) courses versus 58/93 (62%) 1 year prior (P = .55); 9 continuations (9% of time-outs) were guideline-discordant versus two 1 year prior (P = .06). A usability survey completed by 32 physicians demonstrated modest satisfaction with the overall program, antimicrobial dashboard, and renewal templates. CONCLUSIONS: By providing practitioners with clinical informatics support and guidance, the intervention increased provider confidence in making decisions to de-escalate antimicrobial therapy in ambiguous circumstances wherein they previously sought authorization for continuation from an antimicrobial steward. |
Incidence of medically-attended norovirus-associated acute gastroenteritis in four Veteran's Affairs Medical Center populations in the United States, 2011-2012
Grytdal SP , Rimland D , Shirley SH , Rodriguez-Barradas MC , Goetz MB , Brown ST , Lucero-Obusan C , Holodniy M , Graber C , Parashar U , Vinje J , Lopman B . PLoS One 2015 10 (5) e0126733 An estimated 179 million acute gastroenteritis (AGE) illnesses occur annually in the United States. The role of noroviruses in hospital-related AGE has not been well-documented in the U. S. We estimated the population incidence of community- acquired outpatient and inpatient norovirus AGE encounters, as well as hospital-acquired inpatient norovirus AGE among inpatients at four Veterans Affairs (VA) Medical Centers (VAMCs). Fifty (4%) of 1,160 stool specimens collected ≤7 days from symptom onset tested positive for norovirus. During a one year period, the estimated incidence of outpatient, community- and hospital-acquired inpatient norovirus AGE was 188 cases, 11 cases, and 54 cases/ 100,000 patients, respectively. This study demonstrates the incidence of outpatient and community- and hospital-acquired inpatient norovirus AGE among the VA population seeking care at these four VAMCs. |
Respiratory disease mortality among US coal miners; results after 37 years of follow-up
Graber JM , Stayner LT , Cohen RA , Conroy LM , Attfield MD . Occup Environ Med 2014 71 (1) 30-9 OBJECTIVES: To evaluate respiratory related mortality among underground coal miners after 37 years of follow-up. METHODS: Underlying cause of death for 9033 underground coal miners from 31 US mines enrolled between 1969 and 1971 was evaluated with life table analysis. Cox proportional hazards models were fitted to evaluate the exposure-response relationships between cumulative exposure to coal mine dust and respirable silica and mortality from pneumoconiosis, chronic obstructive pulmonary disease (COPD) and lung cancer. RESULTS: Excess mortality was observed for pneumoconiosis (SMR=79.70, 95% CI 72.1 to 87.67), COPD (SMR=1.11, 95% CI 0.99 to 1.24) and lung cancer (SMR=1.08; 95% CI 1.00 to 1.18). Coal mine dust exposure increased risk for mortality from pneumoconiosis and COPD. Mortality from COPD was significantly elevated among ever smokers and former smokers (HR=1.84, 95% CI 1.05 to 3.22; HRK=1.52, 95% CI 0.98 to 2.34, respectively) but not current smokers (HR=0.99, 95% CI 0.76 to 1.28). Respirable silica was positively associated with mortality from pneumoconiosis (HR=1.33, 95% CI 0.94 to 1.33) and COPD (HR=1.04, 95% CI 0.96 to 1.52) in models controlling for coal mine dust. We saw a significant relationship between coal mine dust exposure and lung cancer mortality (HR=1.70; 95% CI 1.02 to 2.83) but not with respirable silica (HR=1.05; 95% CI 0.90 to 1.23). In the most recent follow-up period (2000-2007) both exposures were positively associated with lung cancer mortality, coal mine dust significantly so. CONCLUSIONS: Our findings support previous studies showing that exposure to coal mine dust and respirable silica leads to increased mortality from malignant and non-malignant respiratory diseases even in the absence of smoking. |
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