Iowa City VA Health Care System

Diabetic retinopathy (DR) has long been recognized as a microvasculopathy, but retinal diabetic neuropathy (RDN), characterized by inner retinal neurodegeneration, also occurs in people with diabetes mellitus (DM). We report that in 45 people with DM and no to minimal DR there was significant, progressive loss of the nerve fiber layer (NFL) (0.25 μm/y) and the ganglion cell (GC)/inner plexiform layer (0.29 μm/y) on optical coherence tomography analysis (OCT) over a 4-y period, independent of glycated hemoglobin, age, and sex. The NFL was significantly thinner (17.3 μm) in the eyes of six donors with DM than in the eyes of six similarly aged control donors (30.4 μm), although retinal capillary density did not differ in the two groups. We confirmed significant, progressive inner retinal thinning in streptozotocin-induced "type 1" and B6.BKS(D)-Lepr(db)/J "type 2" diabetic mouse models on OCT; immunohistochemistry in type 1 mice showed GC loss but no difference in pericyte density or acellular capillaries. The results suggest that RDN may precede the established clinical and morphometric vascular changes caused by DM and represent a paradigm shift in our understanding of ocular diabetic complications.

BACKGROUND: Self-monitoring of blood pressure (BP) appears to reduce BP in hypertension but important questions remain regarding effective implementation and which groups may benefit most. This individual patient data (IPD) meta-analysis was performed to better understand the effectiveness of BP self-monitoring to lower BP and control hypertension. METHODS AND FINDINGS: Medline, Embase, and the Cochrane Library were searched for randomised trials comparing self-monitoring to no self-monitoring in hypertensive patients (June 2016). Two reviewers independently assessed articles for eligibility and the authors of eligible trials were approached requesting IPD. Of 2,846 articles in the initial search, 36 were eligible. IPD were provided from 25 trials, including 1 unpublished study. Data for the primary outcomes-change in mean clinic or ambulatory BP and proportion controlled below target at 12 months-were available from 15/19 possible studies (7,138/8,292 [86%] of randomised participants). Overall, self-monitoring was associated with reduced clinic systolic blood pressure (sBP) compared to usual care at 12 months (-3.2 mmHg, [95% CI -4.9, -1.6 mmHg]). However, this effect was strongly influenced by the intensity of co-intervention ranging from no effect with self-monitoring alone (-1.0 mmHg [-3.3, 1.2]), to a 6.1 mmHg (-9.0, -3.2) reduction when monitoring was combined with intensive support. Self-monitoring was most effective in those with fewer antihypertensive medications and higher baseline sBP up to 170 mmHg. No differences in efficacy were seen by sex or by most comorbidities. Ambulatory BP data at 12 months were available from 4 trials (1,478 patients), which assessed self-monitoring with little or no co-intervention. There was no association between self-monitoring and either lower clinic or ambulatory sBP in this group (clinic -0.2 mmHg [-2.2, 1.8]; ambulatory 1.1 mmHg [-0.3, 2.5]). Results for diastolic blood pressure (dBP) were similar. The main limitation of this work was that significant heterogeneity remained. This was at least in part due to different inclusion criteria, self-monitoring regimes, and target BPs in included studies. CONCLUSIONS: Self-monitoring alone is not associated with lower BP or better control, but in conjunction with co-interventions (including systematic medication titration by doctors, pharmacists, or patients; education; or lifestyle counselling) leads to clinically significant BP reduction which persists for at least 12 months. The implementation of self-monitoring in hypertension should be accompanied by such co-interventions.

The consequences of cerebrovascular disease are among the leading health issues worldwide. Large and small cerebral vessel disease can trigger stroke and contribute to the vascular component of other forms of neurological dysfunction and degeneration. Both forms of vascular disease are driven by diverse risk factors, with hypertension as the leading contributor. Despite the importance of neurovascular disease and subsequent injury after ischemic events, fundamental knowledge in these areas lag behind our current understanding of neuroprotection and vascular biology in general. The goal of this review is to address select key structural and functional changes in the vasculature that promote hypoperfusion and ischemia, while also affecting the extent of injury and effectiveness of therapy. In addition, as damage to the blood-brain barrier is one of the major consequences of ischemia, we discuss cellular and molecular mechanisms underlying ischemia-induced changes in blood-brain barrier integrity and function, including alterations in endothelial cells and the contribution of pericytes, immune cells, and matrix metalloproteinases. Identification of cell types, pathways, and molecules that control vascular changes before and after ischemia may result in novel approaches to slow the progression of cerebrovascular disease and lessen both the frequency and impact of ischemic events.

Macrophages respond to external stimuli with rapid changes in expression of many genes. Different combinations of external stimuli lead to distinct polarized activation patterns, resulting in a spectrum of possible macrophage activation phenotypes. MicroRNAs (miRNAs) are small, noncoding RNAs that can repress the expression of many target genes. We hypothesized that miRNAs play a role in macrophage polarization. miRNA expression profiles were determined in monocyte-derived macrophages (MDMs) incubated in conditions causing activation toward M1, M2a, M2b, or M2c phenotypes. One miRNA guide strand and seven miRNA passenger strands were significantly altered. Changes were confirmed in MDMs from six separate donors. The amplitude of miRNA expression changes in MDMs was smaller than described studies of monocytes responding to inflammatory stimuli. Further investigation revealed this correlated with higher basal miRNA expression in MDMs compared with monocytes. The regulation of M1- and M2b-responsive miRNAs (miR-27a, miR-29b, miR-125a, miR-146a, miR-155, and miR-222) was similar in differentiated THP-1 cells and primary MDMs. Studies in this model revealed cross-talk between IFNγ- and LPS-associated pathways regulating miRNA expression. Furthermore, expression of M1-associated transcripts was increased in THP-1 cells transfected with mimics of miR-29b, miR-125a-5p, or miR-155. The apparent inflammatory property of miR-29b and miR-125a-5p can be at least partially explained by repression of TNFAIP3, a negative regulator of NF-κB signaling. Overall, these data suggest miRNAs can contribute to changes in macrophage gene expression that occur in different exogenous activating conditions. Macrophages respond to external stimuli with rapid changes in expression of many genes. Different combinations of external stimuli lead to distinct polarized activation patterns, resulting in a spectrum of possible macrophage activation phenotypes. MicroRNAs (miRNAs) are small, noncoding RNAs that can repress the expression of many target genes. We hypothesized that miRNAs play a role in macrophage polarization. miRNA expression profiles were determined in monocyte-derived macrophages (MDMs) incubated in conditions causing activation toward M1, M2a, M2b, or M2c phenotypes. One miRNA guide strand and seven miRNA passenger strands were significantly altered. Changes were confirmed in MDMs from six separate donors. The amplitude of miRNA expression changes in MDMs was smaller than described studies of monocytes responding to inflammatory stimuli. Further investigation revealed this correlated with higher basal miRNA expression in MDMs compared with monocytes. The regulation of M1- and M2b-responsive miRNAs (miR-27a, miR-29b, miR-125a, miR-146a, miR-155, and miR-222) was similar in differentiated THP-1 cells and primary MDMs. Studies in this model revealed cross-talk between IFNγ- and LPS-associated pathways regulating miRNA expression. Furthermore, expression of M1-associated transcripts was increased in THP-1 cells transfected with mimics of miR-29b, miR-125a-5p, or miR-155. The apparent inflammatory property of miR-29b and miR-125a-5p can be at least partially explained by repression of TNFAIP3, a negative regulator of NF-κB signaling. Overall, these data suggest miRNAs can contribute to changes in macrophage gene expression that occur in different exogenous activating conditions.

Calcitonin gene-related peptide (CGRP) is a neuropeptide with diverse physiological functions. Its two isoforms (α and β) are widely expressed throughout the body in sensory neurons as well as in other cell types, such as motor neurons and neuroendocrine cells. CGRP acts via at least two G protein-coupled receptors that form unusual complexes with receptor activity-modifying proteins. These are the CGRP receptor and the AMY 1 receptor; in rodents, additional receptors come into play. Although CGRP is known to produce many effects, the precise molecular identity of the receptor(s) that mediates CGRP effects is seldom clear. Despite the many enigmas still in CGRP biology, therapeutics that target the CGRP axis to treat or prevent migraine are a bench-to-bedside success story. This review provides a contextual background on the regulation and sites of CGRP expression and CGRP receptor pharmacology. The physiological actions of CGRP in the nervous system are discussed, along with updates on CGRP actions in the cardiovascular, pulmonary, gastrointestinal, immune, hematopoietic, and reproductive systems and metabolic effects of CGRP in muscle and adipose tissues. We cover how CGRP in these systems is associated with disease states, most notably migraine. In this context, we discuss how CGRP actions in both the peripheral and central nervous systems provide a basis for therapeutic targeting of CGRP in migraine. Finally, we highlight potentially fertile ground for the development of additional therapeutics and combinatorial strategies that could be designed to modulate CGRP signaling for migraine and other diseases.

BACKGROUND: Reducing length of stay (LOS) has been a priority for hospitals and health care systems. However, there is concern that this reduction may result in increased hospital readmissions. OBJECTIVE: To determine trends in hospital LOS and 30-day readmission rates for all medical diagnoses combined and 5 specific common diagnoses in the Veterans Health Administration. DESIGN: Observational study from 1997 to 2010. SETTING: All 129 acute care Veterans Affairs hospitals in the United States. PATIENTS: 4,124,907 medical admissions with subsamples of 2 chronic diagnoses (heart failure and chronic obstructive pulmonary disease) and 3 acute diagnoses (acute myocardial infarction, community-acquired pneumonia, and gastrointestinal hemorrhage). MEASUREMENTS: Unadjusted LOS and 30-day readmission rates with multivariable regression analyses to adjust for patient demographic characteristics, comorbid conditions, and admitting hospitals. RESULTS: For all medical diagnoses combined, risk-adjusted mean hospital LOS decreased by 1.46 days from 5.44 to 3.98 days, or 2% annually (P < 0.001). Reductions in LOS were also observed for the 5 specific common diagnoses, with greatest reductions for acute myocardial infarction (2.85 days) and community-acquired pneumonia (2.22 days). Over the 14 years, risk-adjusted 30-day readmission rates for all medical diagnoses combined decreased from 16.5% to 13.8% (P < 0.001). Reductions in readmissions were also observed for the 5 specific common diagnoses, with greatest reductions for acute myocardial infarction (22.6% to 19.8%) and chronic obstructive pulmonary disease (17.9% to 14.6%). All-cause mortality 90 days after admission was reduced by 3% annually. Of note, hospitals with mean risk-adjusted LOS that was lower than expected had a higher readmission rate, suggesting a modest tradeoff between hospital LOS and readmission (6% increase for each day lower than expected). LIMITATIONS: This study is limited to the Veterans Health Administration system; non-Veterans Affairs admissions were not available. No measure of readmission preventability was used. CONCLUSION: Veterans Affairs hospitals demonstrated simultaneous improvements in hospital LOS and readmissions over 14 years, suggesting that as LOS improved, hospital readmission did not increase. This is important because hospital readmission is being used as a quality indicator and may result in payment incentives. Future work should explore these relationships to see whether a tipping point exists for LOS reduction and hospital readmission. PRIMARY FUNDING SOURCE: Office of Rural Health and the Health Services Research & Development Service, Veterans Health Administration, U.S. Department of Veterans Affairs.

Male C57BL/6J mice raised on high fat diet (HFD) become prediabetic and develop insulin resistance and sensory neuropathy. The same mice given low doses of streptozotocin are a model of type 2 diabetes (T2D), developing hyperglycemia, severe insulin resistance and diabetic peripheral neuropathy involving sensory and motor neurons. Because of suggestions that increased NAD(+) metabolism might address glycemic control and be neuroprotective, we treated prediabetic and T2D mice with nicotinamide riboside (NR) added to HFD. NR improved glucose tolerance, reduced weight gain, liver damage and the development of hepatic steatosis in prediabetic mice while protecting against sensory neuropathy. In T2D mice, NR greatly reduced non-fasting and fasting blood glucose, weight gain and hepatic steatosis while protecting against diabetic neuropathy. The neuroprotective effect of NR could not be explained by glycemic control alone. Corneal confocal microscopy was the most sensitive measure of neurodegeneration. This assay allowed detection of the protective effect of NR on small nerve structures in living mice. Quantitative metabolomics established that hepatic NADP(+) and NADPH levels were significantly degraded in prediabetes and T2D but were largely protected when mice were supplemented with NR. The data justify testing of NR in human models of obesity, T2D and associated neuropathies.

Research has shown that black patients more frequently undergo surgery at low-quality hospitals than do white patients. We assessed the extent to which living in racially segregated areas and living in geographic proximity to low-quality hospitals contribute to this disparity. Using national Medicare data for all patients who underwent one of three high-risk surgical procedures in 2005-08, we found that black patients actually tended to live closer to higher-quality hospitals than white patients did but were 25-58 percent more likely than whites to receive surgery at low-quality hospitals. Racial segregation was also a factor, with black patients in the most segregrated areas 41-96 percent more likely than white patients to undergo surgery at low-quality hospitals. To address these disparities, care navigators and public reporting of comparative quality could steer patients and their referring physicians to higher-quality hospitals, while quality improvement efforts could focus on improving outcomes for high-risk surgery at hospitals that disproportionately serve black patients. Unfortunately, existing policies such as pay-for-performance, bundled payments, and nonpayment for adverse events may divert resources and exacerbate these disparities.

IMPORTANCE: Previous studies suggested that a bundled intervention was associated with lower rates of Staphylococcus aureus surgical site infections (SSIs) among patients having cardiac or orthopedic operations. OBJECTIVE: To evaluate whether the implementation of an evidence-based bundle is associated with a lower risk of S. aureus SSIs in patients undergoing cardiac operations or hip or knee arthroplasties. DESIGN, SETTING, AND PARTICIPANTS: Twenty hospitals in 9 US states participated in this pragmatic study; rates of SSIs were collected for a median of 39 months (range, 39-43) during the preintervention period (March 1, 2009, to intervention) and a median of 21 months (range, 14-22) during the intervention period (from intervention start through March 31, 2014). INTERVENTIONS: Patients whose preoperative nares screens were positive for methicillin-resistant S. aureus (MRSA) or methicillin-susceptible S. aureus (MSSA) were asked to apply mupirocin intranasally twice daily for up to 5 days and to bathe daily with chlorhexidine-gluconate (CHG) for up to 5 days before their operations. MRSA carriers received vancomycin and cefazolin or cefuroxime for perioperative prophylaxis; all others received cefazolin or cefuroxime. Patients who were MRSA-negative and MSSA-negative bathed with CHG the night before and morning of their operations. Patients were treated as MRSA-positive if screening results were unknown. MAIN OUTCOMES AND MEASURES: The primary outcome was complex (deep incisional or organ space) S. aureus SSIs. Monthly SSI counts were analyzed using Poisson regression analysis. RESULTS: After a 3-month phase-in period, bundle adherence was 83% (39% full adherence; 44% partial adherence). Overall, 101 complex S. aureus SSIs occurred after 28,218 operations during the preintervention period and 29 occurred after 14,316 operations during the intervention period (mean rate per 10,000 operations, 36 for preintervention period vs 21 for intervention period, difference, -15 [95% CI, -35 to -2]; rate ratio [RR], 0.58 [95% CI, 0.37 to 0.92]). The rates of complex S. aureus SSIs decreased for hip or knee arthroplasties (difference per 10,000 operations, -17 [95% CI, -39 to 0]; RR, 0.48 [95% CI, 0.29 to 0.80]) and for cardiac operations (difference per 10,000 operations, -6 [95% CI, -48 to 8]; RR, 0.86 [95% CI, 0.47 to 1.57]). CONCLUSIONS AND RELEVANCE: In this multicenter study, a bundle comprising S. aureus screening, decolonization, and targeted prophylaxis was associated with a modest, statistically significant decrease in complex S. aureus SSIs.

Many e-health technologies are available to promote virtual patient-provider communication outside the context of face-to-face clinical encounters. Current digital communication modalities include cell phones, smartphones, interactive voice response, text messages, e-mails, clinic-based interactive video, home-based web-cams, mobile smartphone two-way cameras, personal monitoring devices, kiosks, dashboards, personal health records, web-based portals, social networking sites, secure chat rooms, and on-line forums. Improvements in digital access could drastically diminish the geographical, temporal, and cultural access problems faced by many patients. Conversely, a growing digital divide could create greater access disparities for some populations. As the paradigm of healthcare delivery evolves towards greater reliance on non-encounter-based digital communications between patients and their care teams, it is critical that our theoretical conceptualization of access undergoes a concurrent paradigm shift to make it more relevant for the digital age. The traditional conceptualizations and indicators of access are not well adapted to measure access to health services that are delivered digitally outside the context of face-to-face encounters with providers. This paper provides an overview of digital "encounterless" utilization, discusses the weaknesses of traditional conceptual frameworks of access, presents a new access framework, provides recommendations for how to measure access in the new framework, and discusses future directions for research on access.

BACKGROUND: Full sharing of the electronic health record with patients has been identified as an important opportunity to engage patients in their health and health care. The My HealtheVet Pilot, the initial personal health record of the US Department of Veterans Affairs, allowed patients and their delegates to view and download content in their electronic health record, including clinical notes, laboratory tests, and imaging reports. OBJECTIVE: A qualitative study with purposeful sampling sought to examine patients' views and experiences with reading their health records, including their clinical notes, online. METHODS: Five focus group sessions were conducted with patients and family members who enrolled in the My HealtheVet Pilot at the Portland Veterans Administration Medical Center, Oregon. A total of 30 patients enrolled in the My HealtheVet Pilot, and 6 family members who had accessed and viewed their electronic health records participated in the sessions. RESULTS: Four themes characterized patient experiences with reading the full complement of their health information. Patients felt that seeing their records positively affected communication with providers and the health system, enhanced knowledge of their health and improved self-care, and allowed for greater participation in the quality of their care such as follow-up of abnormal test results or decision-making on when to seek care. While some patients felt that seeing previously undisclosed information, derogatory language, or inconsistencies in their notes caused challenges, they overwhelmingly felt that having more, rather than less, of their health record information provided benefits. CONCLUSIONS: Patients and their delegates had predominantly positive experiences with health record transparency and the open sharing of notes and test results. Viewing their records appears to empower patients and enhance their contributions to care, calling into question common provider concerns about the effect of full record access on patient well-being. While shared records may or may not impact overall clinic workload, it is likely to change providers' work, necessitating new types of skills to communicate and partner with patients.

An Pan, PhD; Li Liu, MD, PhD; Chaolong Wang, PhD; Huan Guo, MD, PhD; Xingjie Hao, PhD; Qi Wang, MD, PhD; Jiao Huang, PhD; Na He, PhD; Hongjie Yu, PhD; Xihong Lin, PhD; Sheng Wei, MD, PhD; Tangchun Wu, MD, PhD

OBJECTIVES: Despite vigorous infection control measures, Clostridium difficile continues to cause significant disease burden. Antibiotic stewardship programmes (ASPs) may prevent C. difficile infections by limiting exposure to certain antibiotics. Our objective was to perform a meta-analysis of published studies to assess the effect of ASPs on the risk of C. difficile infection in hospitalized adult patients. METHODS: Searches of PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature and two Cochrane databases were conducted to find all published studies on interventions related to antibiotic stewardship and C. difficile. Two investigators independently assessed study eligibility and extracted data. Risk of bias was assessed using the Downs and Black tool. Risk ratios were pooled using random effects models. Heterogeneity was evaluated using the I(2) statistic. RESULTS: The final search yielded 891 articles; 78 full articles were reviewed and 16 articles were identified for inclusion. Included articles used quasi-experimental (interrupted time series or before-after) or observational (case-control) study designs. When the results of all studies were pooled in a random effects model, a significant protective effect (pooled risk ratio 0.48; 95% CI: 0.38, 0.62) was observed between ASPs and C. difficile incidence. When stratified by intervention type, a significant effect was found for restrictive ASPs (complete removal of drug or prior approval requirement). Furthermore, ASPs were particularly effective in geriatric settings. CONCLUSIONS: Restrictive ASPs can be used to reduce the risk of C. difficile infection.

Letters10 August 2020Reduced In-Person and Increased Telehealth Outpatient Visits During the COVID-19 PandemicFREEAaron Baum, PhD, Peter J. Kaboli, MD, MS, and Mark D. Schwartz, MDAaron Baum, PhDIcahn School of Medicine at Mount Sinai and VA New York Harbor Healthcare System, New York, New York (A.B.)Search for more papers by this author, Peter J. Kaboli, MD, MSVeterans Rural Health Resource Center–Iowa City VA Office of Rural Health and Center for Access and Delivery Research and Evaluation, Iowa City VA Healthcare System, and University of Iowa Carver College of Medicine, Iowa City, Iowa (P.J.K.)Search for more papers by this author, and Mark D. Schwartz, MDVA New York Harbor Healthcare System and New York University School of Medicine, New York, New York (M.D.S.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-3026 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: During the coronavirus disease 2019 (COVID-19) pandemic, many health systems are postponing outpatient visits and shifting services to telehealth (1). However, the extent to which in-person visits have been reduced and replaced by telehealth visits remains unclear.Objective: To describe changes in the number of in-person, telephone, and video visits at U.S. Department of Veterans Affairs (VA) outpatient facilities during the initial 10 weeks of the COVID-19 pandemic, both overall and stratified by VA clinic.Methods and Findings: The VA is the largest health care provider in the United States and has implemented a robust COVID-19 plan in response to the pandemic. We analyzed data from the VA Corporate Data Warehouse, a national repository of electronic health records from visits to any VA facility that is updated nightly and has been previously assessed for reliability and accuracy (2).The study population included the cohort of adults who visited any VA health care facility between 2008 and 2018. Outcomes included the weekly number of VA outpatient visits, stratified by in-person, telephone, and video visits (based on VA clinic stop codes) and by clinic (based on the substation identifier where the encounter occurred). We limited visits to those classified by the VA as a completed patient encounter, which requires that the provider interacted with the patient and documented a diagnosis or procedure code and treatment plan and that the VA counted the visit toward the provider's workload.We described trends in weekly counts of each outcome during the first 20 weeks of 2016 to 2019 and of 2020. In addition, we reported changes in the count of each outcome during the initial 10-week pandemic period (weeks 11 to 20 of 2020, corresponding to 11 March to 19 May) versus the prior 10 weeks (weeks 1 to 10 of 2020, corresponding to 1 January to 10 March), both overall and by VA clinic.Analyses were done in Stata, version 15 (StataCorp). The Subcommittee for Human Studies at the VA New York Harbor Healthcare System (#01413) approved this study and waived patient informed consent.The number of in-person visits to a VA outpatient facility among patients in our cohort decreased from 18 898 656 in weeks 1 to 10 of 2020 to 8 408 268 in weeks 11 to 20, a reduction of 10 490 388 visits (−55.5%) (Figure 1). During the same period, the number of telephone visits increased from 2 539 685 to 6 070 362 (a 139.0% increase from weeks 1 to 10) and the number of video visits increased from 425 495 to 734 547 (a 72.6% increase from weeks 1 to 10). Overall, the total number of VA outpatient in-person and telehealth visits decreased from 21 863 836 in weeks 1 to 10 of 2020 to 15 213 177 in weeks 11 to 20, a reduction of 6 650 659 visits (−30.4%) (Figure 1). In contrast, the number of in-person, telephone, video, and overall outpatient visits did not change between weeks 1 to 10 and 11 to 20 of 2016 to 2019 (Figure 1).Figure 1. Number of VA outpatient visits per week in 2016 to 2019 and 2020.The solid line represents the total number of VA outpatient (any, in-person, video, and telephone) visits per week during 2020. The dashed line represents the weekly mean of the total number of VA outpatient (any, in-person, video, and telephone) visits per week in 2016 to 2019. Multiple outpatient records for the same person that shared the same date, clinic site, and primary clinic stop code were counted as 1 visit. The vertical line represents the week in 2020 when the COVID-19 pandemic began. COVID-19 = coronavirus disease 2019; VA = U.S. Department of Veterans Affairs. Download figure Download PowerPoint Decreases in in-person visits and increases in telehealth visits were observed in 92.8% of VA clinics (Figure 2). Across clinics, the number of in-person visits decreased by a median of −60.1% (interquartile range, −48.7% to −73.3%), and the number of telehealth visits increased by a median of 116.4% (interquartile range, 55.2% to 210.3%).Figure 2. Percentage of change in in-person and telehealth outpatient visits during the COVID-19 pandemic, by VA clinic.Each circle represents a clinic, and the area of the circle is proportional to the clinic's size (defined as the number of unique patients who visited the clinic during 2019). The horizontal gray lines along the y-axis show the univariate distribution of the percentage of change in telephone and video visits across clinics, and the vertical gray lines along the x-axis show the univariate distribution of the percentage of change in in-person visits across clinics. COVID-19 = coronavirus disease 2019; VA = U.S. Department of Veterans Affairs. Download figure Download PowerPoint Discussion: In this retrospective study of adults using VA care, there were 10 490 388 fewer in-person visits to VA outpatient facilities during the initial 10 weeks of the COVID-19 pandemic than in the preceding 10 weeks. The 56% decrease in in-person visits was partly offset by a more than 2-fold increase in the number of telephone and video visits, but overall there was still a 30% decrease in the number of outpatient visits. Limitations of this study include that veterans are predominantly male and older compared with the overall adult U.S. population and that we did not observe visits to non-VA providers. Further research is needed to understand how decreased access to in-person care and increased use of telehealth services during the pandemic may affect patient outcomes (3–5).References1. Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. N Engl J Med. 2020;382:1679-1681. [PMID: 32160451] doi:10.1056/NEJMp2003539 CrossrefMedlineGoogle Scholar2. Fihn SD, Francis J, Clancy C, et al. Insights from advanced analytics at the Veterans Health Administration. Health Aff (Millwood). 2014;33:1203-11. [PMID: 25006147] doi:10.1377/hlthaff.2014.0054 CrossrefMedlineGoogle Scholar3. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457-502. [PMID: 16202000] CrossrefMedlineGoogle Scholar4. Basu S, Berkowitz SA, Phillips RL, et al. Association of primary care physician supply with population mortality in the United States, 2005-2015. JAMA Intern Med. 2019;179:506-514. [PMID: 30776056] doi:10.1001/jamainternmed.2018.7624 CrossrefMedlineGoogle Scholar5. Baum A, Barnett ML, Wisnivesky J, et al. Association between a temporary reduction in access to health care and long-term changes in hypertension control among veterans after a natural disaster. JAMA Netw Open. 2019;2:e1915111. [PMID: 31722027] doi:10.1001/jamanetworkopen.2019.15111 CrossrefMedlineGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Aaron Baum, PhD; Peter J. Kaboli, MD, MS; Mark D. Schwartz, MDAffiliations: Icahn School of Medicine at Mount Sinai and VA New York Harbor Healthcare System, New York, New York (A.B.)Veterans Rural Health Resource Center–Iowa City VA Office of Rural Health and Center for Access and Delivery Research and Evaluation, Iowa City VA Healthcare System, and University of Iowa Carver College of Medicine, Iowa City, Iowa (P.J.K.)VA New York Harbor Healthcare System and New York University School of Medicine, New York, New York (M.D.S.)See also: Editorial comment (page 116).Disclaimer: The funders had no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. The views expressed in this article are those of the authors and do not necessarily represent the views of the VA or the U.S. government.Financial Support: This material is the result of work supported with resources of the VA New York Harbor Healthcare System. Dr. Kaboli is supported by the VA, Veterans Health Administration, VA Office of Rural Health and Office of Research and Development, and the Health Services Research and Development service through the Center for Access and Delivery Research and Evaluation (CIN 13-412).Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-3026.Reproducible Research Statement: Study protocol: Not available. Statistical code: Available from Dr. Baum (e-mail, aaron.baum@mssm.edu). Data set: Access to the underlying data is restricted to VA employees with an institutional review board–approved and VA-approved research project.Corresponding Author: Aaron Baum, PhD, Icahn School of Medicine at Mount Sinai and VA New York Harbor Healthcare System, 1216 Fifth Avenue, Suite 559, New York, NY 10029; e-mail, aaron.baum@mssm.edu.This article was published at Annals.org on 10 August 2020. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoVirtual Care and the Pandemic: Are We Reaching All Patients? Carolyn M. 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reviewVeterans’ ambulatory care experience during COVID-19: veterans’ access to and satisfaction with primary care early in the pandemicA multicentre validation study of a smartphone application to screen hand arthritisOutpatient visit trends for internal medicine ambulatory care sensitive conditions after the COVID-19 pandemic: a time-series analysisExploring the Digital Divide among the Bhutanese Refugee Community during COVID-19: Engaged Research in ActionTelemedicine, safe medication stewardship, and COVID-19: Digital transformation during a global pandemicAn Analysis of Google Trends During COVID-19: Determining Public Urological Cancer ConcernsThe use of virtual visits for obesity pharmacotherapy in patients with overweight or obesity compared with in‐person encountersHospital-based ambulatory clinic adoption of video and telephone visits before and during the COVID-19 pandemic: a convergent mixed-methods studyInfluence of the COVID-19 Pandemic on Overall Physician Visits and 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the pandemic on fear of contagion, blood pressure management and adherence to medication in hypertensive older adults in TurkeyAccess to Telepharmacy Services May Reduce Hospital Admissions in Outpatient Populations During the COVID-19 PandemicChanges in industry marketing payments to physicians during the covid-19 pandemic: quasi experimental, difference-in-difference studyBehavioral activation for live-in migrant home care workers and care recipients in Israel: a pilot studyImplementation of Telehealth for Psychiatric Care in VA Emergency Departments and Urgent Care ClinicsUsing Administrative Data to Examine Telemedicine Usage Among Medicaid Beneficiaries During the Coronavirus Disease 2019 PandemicHow essential are in‐person clinic visits during maintenance treatment of children with acute lymphoblastic leukemia?Quality of Care and Outcomes for Patients with Acute Ischemic Stroke and Transient Ischemic Attack During the COVID-19 PandemicImpact of COVID-19 on People Experiencing 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COVID-19 Maintained Quality but Served Fewer PatientsImpact of telehealth on health care resource utilization during the COVID-19 pandemicTrends and Disparities in the Use of Telehealth Among Injured Workers During the COVID-19 PandemicImpact of transition from face‐to‐face to telehealth on behavioral obesity treatment during the COVID‐19 pandemicTelehealth Use Among Older Adults During COVID-19: Associations With Sociodemographic and Health Characteristics, Technology Device Ownership, and Technology LearningManagement of colorectal cancer during the COVID‐19 pandemic: Recommendations from a statewide multidisciplinary cancer collaborativeMedication prescribing in face-to-face versus telehealth consultations during the COVID-19 pandemic in Australian general practice: a retrospective observational studyTelehealth-based diagnostic testing in general practice during the COVID-19 pandemic: an observational studyVirtual Specialist Care during the COVID-19 Pandemic: A Multi-Method Study of Patient Experience (Preprint)Leveraging Telehealth to Improve Diabetes CareDevelopment of telemedicine tools with an emphasis on visual observationTreatment Persistence of Renin-Angiotensin-Aldosterone-System Inhibitors Over Time in Heart Failure with Reduced Ejection FractionDisruption of Medical Care among Individuals in the Southeastern United States during the COVID-19 PandemicUse of Wearables and Implantable Devices to Monitor Pulmonary Health in the Outpatient SettingUse of Extended Reality in Medicine During the Covid-19 PandemicA multicenter randomized controlled trial comparing gamification with remote monitoring against standard rehabilitation for patients after arthroscopic shoulder Visits and Among Patients With During the COVID-19 Health Care During the COVID-19 Pandemic: Managing the Health for the of Chronic Conditions: Systematic of Health and in Adults with of the COVID-19 pandemic on in for A health Care Utilization Among Veterans Health Administration Enrollees 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BACKGROUND: Intimate partner violence (IPV) is of particular concern during pregnancy when not one, but two lives are at risk. Previous meta-analyses have suggested an association between IPV and adverse birth outcomes; however, many large studies have since been published, illustrating the need for updated pooled effect estimates. OBJECTIVES: To evaluate the relationship between IPV during pregnancy and the risk of preterm birth (PTB), low-birthweight (LBW), and small-for-gestational-age (SGA) infants. SEARCH STRATEGY: We searched PubMed and SCOPUS (from inception until May 2015), and the reference lists of the relevant studies. SELECTION CRITERIA: Observational studies comparing the rates of at least one adverse birth outcome (SGA, LBW, or PTB) in women who experienced IPV during pregnancy and those who did not. DATA COLLECTION AND ANALYSIS: Data extracted from 50 studies were pooled and pooled odds ratios were calculated using random-effects models. MAIN RESULTS: Intimate partner violence (IPV) was significantly associated with PTB (OR 1.91, 95% CI 1.60-2.29) and LBW (OR 2.11, 95% CI 1.68-2.65), although a large level of heterogeneity was present for both (I(2) = 84 and 91%, respectively). The association with SGA was less pronounced and marginally significant (OR 1.37, 95% CI 1.02-1.84), although fewer studies were available for meta-analysis (n = 7). CONCLUSIONS: Our meta-analysis indicates that women who experienced IPV during pregnancy are at increased risk of having a PTB, and an LBW or an SGA infant. More studies examining the association between IPV and SGA are needed. TWEETABLE ABSTRACT: Meta-analysis of IPV during pregnancy finds increased risk for preterm birth, LBW and SGA infants.

Colonization with health care-associated pathogens such as Staphylococcus aureus, enterococci, Gram-negative organisms, and Clostridium difficile is associated with increased risk of infection. Decolonization is an evidence-based intervention that can be used to prevent health care-associated infections (HAIs). This review evaluates agents used for nasal topical decolonization, topical (e.g., skin) decolonization, oral decolonization, and selective digestive or oropharyngeal decontamination. Although the majority of studies performed to date have focused on S. aureus decolonization, there is increasing interest in how to apply decolonization strategies to reduce infections due to Gram-negative organisms, especially those that are multidrug resistant. Nasal topical decolonization agents reviewed include mupirocin, bacitracin, retapamulin, povidone-iodine, alcohol-based nasal antiseptic, tea tree oil, photodynamic therapy, omiganan pentahydrochloride, and lysostaphin. Mupirocin is still the gold standard agent for S. aureus nasal decolonization, but there is concern about mupirocin resistance, and alternative agents are needed. Of the other nasal decolonization agents, large clinical trials are still needed to evaluate the effectiveness of retapamulin, povidone-iodine, alcohol-based nasal antiseptic, tea tree oil, omiganan pentahydrochloride, and lysostaphin. Given inferior outcomes and increased risk of allergic dermatitis, the use of bacitracin-containing compounds cannot be recommended as a decolonization strategy. Topical decolonization agents reviewed included chlorhexidine gluconate (CHG), hexachlorophane, povidone-iodine, triclosan, and sodium hypochlorite. Of these, CHG is the skin decolonization agent that has the strongest evidence base, and sodium hypochlorite can also be recommended. CHG is associated with prevention of infections due to Gram-positive and Gram-negative organisms as well as Candida. Conversely, triclosan use is discouraged, and topical decolonization with hexachlorophane and povidone-iodine cannot be recommended at this time. There is also evidence to support use of selective digestive decontamination and selective oropharyngeal decontamination, but additional studies are needed to assess resistance to these agents, especially selection for resistance among Gram-negative organisms. The strongest evidence for decolonization is for use among surgical patients as a strategy to prevent surgical site infections.

BACKGROUND: The high prevalence of methicillin-resistant S. aureus (MRSA) has led clinicians to select antibiotics that have coverage against MRSA, usually vancomycin, for empiric therapy for suspected staphylococcal infections. Clinicians often continue vancomycin started empirically even when methicillin-susceptible S. aureus (MSSA) strains are identified by culture. However, vancomycin has been associated with poor outcomes such as nephrotoxicity, persistent bacteremia and treatment failure. The objective of this study was to compare the effectiveness of vancomycin versus the beta-lactam antibiotics nafcillin and cefazolin among patients with MSSA bacteremia. The outcome of interest for this study was 30-day in-hospital mortality. METHODS: This retrospective cohort study included all adult in-patients admitted to a tertiary-care facility between January 1, 2003 and June 30, 2007 who had a positive blood culture for MSSA and received nafcillin, cefazolin or vancomycin. Cox proportional hazard models were used to assess independent mortality hazards comparing nafcillin or cefazolin versus vancomycin. Similar methods were used to estimate the survival benefits of switching from vancomycin to nafcillin or cefazolin versus leaving patients on vancomycin. Each model included statistical adjustment using propensity scores which contained variables associated with an increased propensity to receive vancomycin. RESULTS: 267 patients were included; 14% (38/267) received nafcillin or cefazolin, 51% (135/267) received both vancomycin and either nafcillin or cefazolin, and 35% (94/267) received vancomycin. Thirty (11%) died within 30 days. Those receiving nafcillin or cefazolin had 79% lower mortality hazards compared with those who received vancomycin alone (adjusted hazard ratio (HR): 0.21; 95% confidence interval (CI): 0.09, 0.47). Among the 122 patients who initially received vancomycin empirically, those who were switched to nafcillin or cefazolin (66/122) had 69% lower mortality hazards (adjusted HR: 0.31; 95% CI: 0.10, 0.95) compared to those who remained on vancomycin. CONCLUSIONS: Receipt of nafcillin or cefazolin was protective against mortality compared to vancomycin even when therapy was altered after culture results identified MSSA. Convenience of vancomycin dosing may not outweigh the potential benefits of nafcillin or cefazolin in the treatment of MSSA bacteremia.

Abstract and purpose The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. 1 This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

OBJECTIVE: To evaluate studies assessing the effectiveness of a bundle of nasal decolonization and glycopeptide prophylaxis for preventing surgical site infections caused by Gram positive bacteria among patients undergoing cardiac operations or total joint replacement procedures. DESIGN: Systematic review and meta-analysis. DATA SOURCES: PubMed (1995 to 2011), the Cochrane database of systematic reviews, CINAHL, Embase, and clinicaltrials.gov were searched to identify relevant studies. Pertinent journals and conference abstracts were hand searched. Study authors were contacted if more data were needed. ELIGIBILITY CRITERIA: Randomized controlled trials, quasi-experimental studies, and cohort studies that assessed nasal decolonization or glycopeptide prophylaxis, or both, for preventing Gram positive surgical site infections compared with standard care. PARTICIPANTS: Patients undergoing cardiac operations or total joint replacement procedures. DATA EXTRACTION AND STUDY APPRAISAL: Two authors independently extracted data from each paper and a random effects model was used to obtain summary estimates. Risk of bias was assessed using the Downs and Black or the Cochrane scales. Heterogeneity was assessed using the Cochran Q and I(2) statistics. RESULTS: 39 studies were included. Pooled effects of 17 studies showed that nasal decolonization had a significantly protective effect against surgical site infections associated with Staphylococcus aureus (pooled relative risk 0.39, 95% confidence interval 0.31 to 0.50) when all patients underwent decolonization (0.40, 0.29 to 0.55) and when only S aureus carriers underwent decolonization (0.36, 0.22 to 0.57). Pooled effects of 15 prophylaxis studies showed that glycopeptide prophylaxis was significantly protective against surgical site infections related to methicillin (meticillin) resistant S aureus (MRSA) compared with prophylaxis using β lactam antibiotics (0.40, 0.20 to 0.80), and a non-significant risk factor for methicillin susceptible S aureus infections (1.47, 0.91 to 2.38). Seven studies assessed a bundle including decolonization and glycopeptide prophylaxis for only patients colonized with MRSA and found a significantly protective effect against surgical site infections with Gram positive bacteria (0.41, 0.30 to 0.56). CONCLUSIONS: Surgical programs that implement a bundled intervention including both nasal decolonization and glycopeptide prophylaxis for MRSA carriers may decrease rates of surgical site infections caused by S aureus or other Gram positive bacteria.

BACKGROUND: Previous studies indicate that vancomycin is inferior to beta-lactams for treatment of methicillin-susceptible Staphylococcus aureus (MSSA) bloodstream infections. However, it is unclear if this association is true for empiric and definitive therapy. Here, we compared beta-lactams with vancomycin for empiric and definitive therapy of MSSA bloodstream infections among patients admitted to 122 hospitals. METHODS: This retrospective cohort study included all patients admitted to Veterans Affairs hospitals from 2003 to 2010 who had positive blood cultures for MSSA. Hazard ratios (HR) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards regression. Empiric therapy was defined as starting treatment 2 days before and up to 4 days after the first MSSA blood culture was collected. Definitive therapy was defined as starting treatment between 4 and 14 days after the first positive blood culture was collected. RESULTS: Patients who received empiric therapy with a beta-lactam had similar mortality compared with those who received vancomycin (HR, 1.03; 95% CI, .89-1.20) after adjusting for other factors. However, patients who received definitive therapy with a beta-lactam had 35% lower mortality compared with patients who received vancomycin (HR, 0.65; 95% CI, .52-.80) after controlling for other factors. The hazard of mortality decreased further for patients who received cefazolin or antistaphylococcal penicillins compared with vancomycin (HR, 0.57; 95% CI, .46-.71). CONCLUSIONS: For patients with MSSA bloodstream infections, beta-lactams are superior to vancomycin for definitive therapy but not for empiric treatment. Patients should receive beta-lactams for definitive therapy, specifically antistaphylococcal penicillins or cefazolin.