Objective: A scoping review was undertaken to understand the extent of literature on librarian involvement in competency-based medical education (CBME). Methods: We followed Joanna Briggs Institute methodology and PRISMA-ScR reporting guidelines. A search of peer-reviewed literature was conducted on December 31, 2022, in Medline, Embase, ERIC, CINAHL Complete, SCOPUS, LISS, LLIS, and LISTA. Studies were included if they described librarian involvement in the planning, delivery, or assessment of CBME in an LCME-accredited medical school and were published in English. Outcomes included characteristics of the inventions (duration, librarian role, content covered) and of the outcomes and measures (level on Kirkpatrick Model of Training Evaluation, direction of findings, measure used). Results: Fifty studies were included of 11,051 screened: 46 empirical studies or program evaluations and four literature reviews. Studies were published in eight journals with two-thirds published after 2010. Duration of the intervention ranged from 30 minutes to a semester long. Librarians served as collaborators, leaders, curriculum designers, and evaluators. Studies primarily covered asking clinical questions and finding information and most often assessed reaction or learning outcomes. Conclusions: A solid base of literature on librarian involvement in CBME exists; however, few studies measure user behavior or use validated outcomes measures. When librarians are communicating their value to stakeholders, having evidence for the contributions of librarians is essential. Existing publications may not capture the extent of work done in this area. Additional research is needed to quantify the impact of librarian involvement in competency-based medical education.

Introduction: Test characteristics of fecal immunochemical tests (FITs) vary based on threshold, and may vary based on location within the colon; however, published studies are inconsistent. We conducted a systematic review to determine the effect of location on test characteristics for colorectal cancer (CRC) and advanced adenomas (AA). Methods: We searched Ovid MEDLINE, PubMed, EMBASE, and Cochrane Library for studies on FIT where colonoscopy was the reference standard and contained FIT test characteristics based on location within the colon (μg/g). Two authors independently reviewed all citations to identify relevant studies, abstracted study characteristics and numerical data, and assessed study quality (QUADAS). For summary-level estimates, we used a univariate generalized linear mixed model to simultaneously estimate pooled sensitivity and specificity separately for CRC and advanced adenomas. We compared proximal and distal sensitivity for CRC and AA in pre-specified groups based on specific FIT or threshold using random effects logistic regression with a test for differences between subgroups. Results: From 705 titles, we reviewed 522 unique citations and abstracts when available, from which we reviewed 21 full-text articles, selecting 14 articles meeting inclusion criteria (Figure). The 14 studies included 30 FIT analyses and examined 10 different FITs, 5 of which were tested at > 1 threshold. Mean patient age (11 studies) was 59.4 years; 64.3% (13 studies) were women. All studies were of high quality. Among 34,790 individuals, there were 259 (94 proximal, 165 distal) CRCs (0.7%) and 2450 (1097 proximal, 1371 distal AAs (7.0%). Test characteristics for proximal and distal CRC and AA by threshold are in the Table. For both CRC and AA, test characteristics varied by threshold, but not location. For CRC, the < 10 µg/g threshold had the greatest numerical difference in sensitivity: 0.86 proximal vs 0.76 distal, but was not statistically significant (P=0.76). For AA, the ≥ 20 µg threshold had the largest numerical difference: 0.14 proximal vs. 0.24 distal) but did not reach statistical significance (P = 0.0518). All other comparisons were not statistically significant (P > 0.85 for CRC and P > 0.21 for AA). Conclusion: In this systematic review of FIT test characteristics for CRC and AA, we found that test characteristics varied by threshold. For the most used test thresholds, sensitivity for AA was numerically greater for the distal colon, but none of the differences was statistically significant. Table 1. - Quantitative and Comparative Results Univariate Summary Results for Colorectal Cancer (CRC) P-value 1 Proximal Distal Threshold (µg/g) N of Subjects N of CRCsProximal N of CRCs Distal N of Studies Sensitivity [95% CI] Specificity [95% CI] N of Studies Sensitivity [95% CI] Specificity [95%CI] Proximal vs distal (sensitivity only) < 10 (all studies) 4074 7 21 3 0.86 [0.42; 0.98] 0.90 [0.82; 0.94] 2 0.76 [0.54; 0.90] 0.91 [0.81; 0.96] ---- < 10 (excluding Graser 2009) 3789 6 21 2 0.83 [0.37; 0.98] 0.91 [0.81; 0.96] 2 0.76 [0.54; 0.90] 0.91 [0.81; 0.96] 0.71 10 (all studies) 13476 34 85 6 0.74 [0.56; 0.86] 0.93 [0.88; 0.96] 5 0.74 [0.57; 0.86] 0.91 [0.87; 0.94] ---- 10 (excluding Levy 2014) 13259 33 85 5 0.76 [0.58; 0.87] 0.91 [0.87; 0.94] 5 0.74 [0.57; 0.86] 0.91 [0.87; 0.94] 0.86 11-19 14882 43 104 6 0.81 [0.52; 0.94] 0.93 [0.88; 0.95] 6 0.81 [0.68; 0.90] 0.93 [0.88; 0.95] 0.99 >=20 18675 81 142 10 0.75 [0.65; 0.83] 0.95 [0.93; 0.97] 10 0.76 [0.68; 0.82] 0.95 [0.93; 0.97] 0.90 Univariate Summary Results for Advanced Adenoma (AA) Proximal Distal Threshold µg/g N of Subjects N of AA Proximal N of AA Distal N of Studies Sensitivity [95%CI] Specificity [95% CI] N of Studies Sensitivity [95% CI] Specificity [95% CI] < 10 4074 112 239 3 0.25 [0.14; 0.40] 0.90 [0.82; 0.94] 3 0.32 [0.26; 0.38] 0.90 [0.82; 0.94] 0.38 10 13805 370 552 7 0.2090 [0.12; 0.35] 0.94 [0.90; 0.96] 7 0.31 [0.23; 0.40] 0.94 [0.89; 0.96] 0.21 11-19 14882 449 664 6 0.26 [0.17; 0.39] 0.93 [0.88; 0.95] 6 0.32 [0.23; 0.42] 0.93 [0.88; 0.95] 0.51 >=20 19750 942 1172 14 0.14 [0.08; 0.22] 0.95 [0.93; 0.96] 14 0.24 [0.18; 0.32] 0.95 [0.93; 0.96] 0.0518 Note: Univariate summary estimates are shown for both sensitivity and specificity with 95% confidence intervals in brackets. Estimates were obtained using a random effects logistic regression model.1P-value for difference between proximal and distal sensitivity from random effects logistic regression model. Figure 1.: PRISMA Flow Diagram

OBJECTIVE:To evaluate the difference in pharygocutaneous fistula (PCF) development between pectoralis major flap onlay and interpositional reconstructions after salvage total laryngectomy (STL).DATA SOURCES:Medline, Cochrane, Embase, Web of Science, CINAHL, and ClinicalTrials.gov.REVIEW METHODS:A systematic review was performed during January 2020. English articles were included that described minor and major PCF rates after STL reconstructed with pectoralis major onlay or interposition. PCFs were classified as major when conservative therapy was unsuccessful and/or revision surgery was needed. Articles describing total laryngopharyngectomies were excluded. Meta-analyses of the resulting data were performed.RESULTS:Twenty-four articles met final criteria amassing 1304 patients. Three articles compared onlay with interposition, and 18 compared onlay with primary closure. Pectoralis interposition demonstrated elevated odds ratio (OR) of PCF formation as compared with onlay (OR, 2.34; P < .001). Onlay reconstruction reduced overall (OR, 0.32; P < .001) and major (OR, 0.21; P < .001) PCF development as compared with primary pharyngeal closure alone. Data were insufficient to compare interposition against primary closure.CONCLUSIONS:This research shows evidence that pectoralis onlay after STL diminishes the odds of total and major PCF development. Pectoralis interposition reconstruction showed elevated odds of PCF formation as compared with pectoralis onlay.

Objectives This research project aims to determine the potential differential impact of two curricular approaches to teaching evidence-based medicine (EBM) on student performance on an EBM assignment administered during the first year of clerkship. A meaningful result would be any statistically significant difference in scores on the assignment given to measure student performance. Design In order to assess and compare student learning under the different curricula, the principal investigator and a team of five faculty members blinded to assignment date and other possibly identifying details used a modified version of the previously validated Fresno rubric to retrospectively grade 3 years’ worth of EBM assignments given to students in clerkship rotations 1–3 (n=481) during the Internal Medicine clerkship. Specifically, EBM performance in three separate student cohorts was examined. Setting The study took place at a large Midwestern medical school with nine campuses across the state of Indiana. Participants Study participants were 481 students who attended the medical school and completed the Internal Medicine clerkship between 2017 and 2019. Interventions Prior to the inception of this study, our institution had been teaching EBM within a discrete 2-month time period during medical students’ first year. During a large-scale curricular overhaul, the approach to teaching EBM was changed to a more scaffolded, integrated approach with sessions being taught over the course of 2 years. In this study, we assess the differential impact of these two approaches to teaching EBM in the first 2 years of medical school. Main outcome measures We used clerkship-level EBM assignment grades to determine whether there was a difference in performance between those students who experienced the old versus the new instructional model. Clerkship EBM assignments given to the students used identical questions each year in order to have a valid basis for comparison. Additionally, we analysed average student grades across the school on the EBM portion of step 1. Results Four hundred and eighty-one assignments were graded. Mean scores were compared for individual questions and cumulative scores using a one-way Welch Analysis of Variance test. Overall, students performed 0.99 of a point better on the assignment from year 1 (Y1), prior to EBM curriculum integration, to year 3 (Y3), subsequent to EBM integration (p≤0.001). Statistically significant improvement was seen on questions measuring students’ ability to formulate a clinical question and critically appraise medical evidence. Additionally, on the United States Medical Licensing Examination (USMLE) step 1, we found that student scores on the EBM portion of the examination improved from Y1 to Y3. Conclusions Results of this study suggest that taking a scaffolded, curriculum-integrated approach to EBM instruction during the preclinical years increases, or at the very least does not lessen, student retention of and ability to apply EBM concepts to patient care. Although it is difficult to fully attribute students’ retention and application of EBM concepts to the adoption of a curricular model focused on scaffolding and integration, the results of this study show that there are value-added educational effects to teaching EBM in this new format. Overall, this study provides a foundation for new research and practice seeking to improve EBM instruction. Trial registration number IRB approval (Protocol number 1907054875) was obtained for this study.

Key PointsQuestionWhat is the incidence of hospital-onset Clostridium difficile infection (CDI) and its associated length of stay? FindingsThis systematic review and meta-analysis of 13 studies using patient-days as the denominator found that the incidence of hospital-onset CDI was 8.3 cases per 10000 patient-days. Among propensity score-matched studies of the length of stay, the mean difference in length of stay between patients with and those without CDI varied from 3.0 to 21.6 days. MeaningPooled estimates from currently available literature suggest that CDI is associated with a large burden on the US health care system. This systematic review and meta-analysis of 13 studies analyzes the incidence of Clostridium difficile infection and its associated hospital length of stay in the United States. ImportanceAn understanding of the incidence and outcomes of Clostridium difficile infection (CDI) in the United States can inform investments in prevention and treatment interventions. ObjectiveTo quantify the incidence of CDI and its associated hospital length of stay (LOS) in the United States using a systematic literature review and meta-analysis. Data SourcesMEDLINE via Ovid, Cochrane Library Databases via Wiley, Cumulative Index of Nursing and Allied Health Complete via EBSCO Information Services, Scopus, and Web of Science were searched for studies published in the United States between 2000 and 2019 that evaluated CDI and its associated LOS. Study SelectionIncidence data were collected only from multicenter studies that had at least 5 sites. The LOS studies were included only if they assessed postinfection LOS or used methods accounting for time to infection using a multistate model or compared propensity score-matched patients with CDI with control patients without CDI. Long-term-care facility studies were excluded. Of the 119 full-text articles, 86 studies (72.3%) met the selection criteria. Data Extraction and SynthesisTwo independent reviewers performed the data abstraction and quality assessment. Incidence data were pooled only when the denominators used the same units (eg, patient-days). These data were pooled by summing the number of hospital-onset CDI incident cases and the denominators across studies. Random-effects models were used to obtain pooled mean differences. Heterogeneity was assessed using the I-2 value. Data analysis was performed in February 2019. Main Outcomes and MeasuresIncidence of CDI and CDI-associated hospital LOS in the United States. ResultsWhen the 13 studies that evaluated incidence data in patient-days due to hospital-onset CDI were pooled, the CDI incidence rate was 8.3 cases per 10000 patient-days. Among propensity score-matched studies (16 of 20 studies), the CDI-associated mean difference in LOS (in days) between patients with and without CDI varied from 3.0 days (95% CI, 1.44-4.63 days) to 21.6 days (95% CI, 19.29-23.90 days). Conclusions and RelevancePooled estimates from currently available literature suggest that CDI is associated with a large burden on the health care system. However, these estimates should be interpreted with caution because higher-quality studies should be completed to guide future evaluations of CDI prevention and treatment interventions.

Background/Objective: The prevalence of shift work ranges around 20% among American and European workers and is significantly higher in the healthcare field. Variable work schedules among shift workers are associated with adverse health effects, including the increased risk of metabolic disorders and obesity. This systematic review aims to evaluate the association between shift work and type 2 diabetes/insulin resistance. Methods: This research is part of a more extensive systematic review that has been registered on Prospero. Due to time constraints, we began with a scoping search with the goal of completing a rapid review. Searches were completed using the Ovid and PubMed databases with the following keywords and subject headings: Health Personnel; Shift Work Schedule; Circadian Rhythm; Work Schedule Tolerance; Metabolic Diseases; Overweight; Glucose Metabolism Disorders; Lipid Metabolism Disorders; Malabsorption Syndromes; Metabolic Syndrome; and Diabetes Mellitus. The resulting articles were uploaded onto Covidence for screening and data extraction. After screening the abstracts for diabetes and insulin resistance, eight articles were selected for the full-text screening of which data extraction was performed on three. Results: Overall, 163,555 participants performing evening, night, rotating shifts, or regular shifts were identified in the three studies. The average age of study participants was found to be 44.0 yrs, 163,422 were females (>99.9%), and of the total participants, 98,303 subjects were shift workers (60.10%). For healthcare shift workers, there was a significant association between shift work and diabetes across all three studies; however, the effect was modest (relative risk in the range of 1.19-1.26). Conclusion: There is a positive relationship between shift work and diabetes among healthcare workers. Therefore, strategies focusing on reducing shift work or treating these workers as a high-risk group for diabetes by taking measures to minimize other exposures will be beneficial in reducing the incidence of diabetes among this population.

Over the years, library collections have vastly changed due to an ever-growing presence of resources available online. Many libraries have experienced a dramatic decrease in the circulation of physical materials with the shift to online availability of materials. It is of great value to ensure libraries are meeting the needs of their users, and this can be accomplished by identifying their information-seeking patterns. The aim of this article is to examine how faculty use the library and to identify what services and resources are of value to their work.

Background Although acute myocardial infarction is a common cause of out-of-hospital cardiac arrest (OHCA), the role of early coronary angiography in OHCA remains uncertain. We conducted a meta-analysis of observational studies to determine the association of early coronary angiography with survival in OHCA. Methods We searched multiple electronic databases for published studies on early coronary angiography in OHCA between 1 January 1990 and 18 January 2017. Studies were included if (1) restricted to only OHCA, (2) included an exposure group that underwent early coronary angiography within 1  day of arrest onset and a concurrent control group that did not undergo early coronary angiography, and (3) reported survival outcomes. We used a random-effects model to obtain pooled OR. I2 statistics and Cochran’s Q test were used to determine between-study heterogeneity. Results A total of 17 studies with 14 972 patients were included, of whom 6424 (44%) received early coronary angiography. Early coronary angiography was associated with higher odds of survival (pooled OR 2.54 (95% CI 1.94 to 3.33)) and survival with favourable neurological outcome (pooled OR 2.37 (95%  CI 1.71 to 3.28)). However, there was substantial heterogeneity in our pooled estimate (I2=88%  and p value for Cochran’s test <0.0001 for both outcomes). The large heterogeneity in pooled estimates was reduced after including adjusted estimates when available, and was explained by differences in methodological rigour and characteristics of included studies. Conclusion Among patients resuscitated from OHCA, early coronary angiography is associated with increased survival to discharge and favourable neurological outcome.

Background:Carbapenem-resistant Enterobacteriaceae (CRE) pose an urgent public health threat in the United States. An important step in planning and monitoring a national response to CRE is understanding its epidemiology and associated outcomes. We conducted a systematic literature review of studies that investigated incidence and outcomes of CRE infection in the US.Methods:We performed searches in MEDLINE via Ovid, CDSR, DARE, CENTRAL, NHS EED, Scopus, and Web of Science for articles published from 1/1/2000 to 2/1/2016 about the incidence and outcomes of CRE at US sites.Results:Five studies evaluated incidence, but many used differing definitions for cases. Across the entire US population, the reported incidence of CRE was 0.3-2.93 infections per 100,000 person-years. Infection rates were highest in long-term acute-care (LTAC) hospitals. There was insufficient data to assess trends in infection rates over time. Four studies evaluated outcomes. Mortality was higher in CRE patients in some but not all studies.Conclusion:While the incidence of CRE infections in the United States remains low on a national level, the incidence is highest in LTACs. Studies assessing outcomes in CRE-infected patients are limited in number, small in size, and have reached conflicting results. Future research should measure a variety of clinical outcomes and adequately adjust for confounders to better assess the full burden of CRE.

Background:An important measure of successful sarcoma treatment is the surgical tumor margin, yet defining and reporting the tumor margin has remained a source of controversy. Our study sought to determine whether there is a need to be more specific in classifying a margin by distinguishing a 'close' margin, or if simply calling a margin positive or negative is sufficient.Methods:We performed a comprehensive literature search in which all studies were reviewed independently by two separate reviewers. Studies eligible for inclusion and data analysis consisted of those that reported on at least ten patients with a primary sarcoma of the extremities who received limb-salvage or amputation surgery with a report of the final surgical margin as well as the histologic grade. Only studies that provided local recurrence outcomes with a minimum follow-up of two years were included.Results:Our literature search and article exclusion process resulted in 22 articles that contained 498 patients for data analyses. We found that the Enneking classification system distinguishes between intralesional, marginal, and wide/ radical margins, and that a close margin behaves closer to a positive margin than a negative margin. When all tumors were analyzed, a marginal margin gave a recurrence rate of 50.48% compared to an intralesional margin recurrence rate of 75.76% and a wide/ radical margin of 7.22%. A marginal margin set to a positive margin gave the highest sensitivity compared to comparing marginal margins to wide and intralesional margins alone. This was also observed when tumors were stratified into high-grade osteosarcomas treated with chemotherapy. In addition, we found that chemotherapy dramatically reduced local recurrence rates in osteosarcoma.Conclusions:Our literature search and data analysis showed that the Enneking classification system was able to give more information on local recurrence compared to a simple dichotomous system, and therefore may be considered a more successful predictor of treatment outcomes. As a result, this investigation may lead a suggestion of a practice-changing proposal of how surgical margins in sarcoma should be reported universally amongst multiple disciplines and institutions.Level of Evidence: II.

AIM:To systematically review reports on deceased-donor-lobar lung transplantation (ddLLTx) and uniformly describe size matching using the donor-to-recipient predicted-total lung-capacity (pTLC) ratio.METHODS:We set out to systematically review reports on ddLLTx and uniformly describe size matching using the donor-to-recipient pTLC ratio and to summarize reported one-year survival data of ddLLTx and conventional-LTx. We searched in PubMed, CINAHL via EBSCO, Cochrane Database of Systematic Reviews via Wiley (CDSR), Database of Abstracts of Reviews of Effects via Wiley (DARE), Cochrane Central Register of Controlled Trials via Wiley (CENTRAL), Scopus (which includes EMBASE abstracts), and Web of Science for original reports on ddLLTx.RESULTS:Nine observational cohort studies reporting on 301 ddLLTx met our inclusion criteria for systematic review of size matching, and eight for describing one-year-survival. The ddLLTx-group was often characterized by high acuity; however there was heterogeneity in transplant indications and pre-operative characteristics between studies. Data to calculate the pTLC ratio was available for 242 ddLLTx (80%). The mean pTLCratio before lobar resection was 1.25 ± 0.3 and the transplanted pTLCratio after lobar resection was 0.76 ± 0.2. One-year survival in the ddLLTx-group ranged from 50%-100%, compared to 72%-88% in the conventional-LTx group. In the largest study ddLLTx (n = 138) was associated with a lower one-year-survival compared to conventional-LTx (n = 539) (65.1% vs 84.1%, P < 0.001).CONCLUSION:Further investigations of optimal donor-to-recipient size matching parameters for ddLLTx could improve outcomes of this important surgical option.

BACKGROUND Information about the health and economic impact of infections caused by vancomycin-resistant enterococci (VRE) can inform investments in infection prevention and development of novel therapeutics. OBJECTIVE To systematically review the incidence of VRE infection in the United States and the clinical and economic outcomes. METHODS We searched various databases for US studies published from January 1, 2000, through June 8, 2015, that evaluated incidence, mortality, length of stay, discharge to a long-term care facility, readmission, recurrence, or costs attributable to VRE infections. We included multicenter studies that evaluated incidence and single-center and multicenter studies that evaluated outcomes. We kept studies that did not have a denominator or uninfected controls only if they assessed postinfection length of stay, costs, or recurrence. We performed meta-analysis to pool the mortality data. RESULTS Five studies provided incidence data and 13 studies evaluated outcomes or costs. The incidence of VRE infections increased in Atlanta and Detroit but did not increase in national samples. Compared with uninfected controls, VRE infection was associated with increased mortality (pooled odds ratio, 2.55), longer length of stay (3-4.6 days longer or 1.4 times longer), increased risk of discharge to a long-term care facility (2.8- to 6.5-fold) or readmission (2.9-fold), and higher costs ($9,949 higher or 1.6-fold more). CONCLUSIONS VRE infection is associated with large attributable burdens, including excess mortality, prolonged in-hospital stay, and increased treatment costs. Multicenter studies that use suitable controls and adjust for time at risk or confounders are needed to estimate the burden of VRE infections. Infect Control Hosp Epidemiol. 2017;38:203–215

Background: Idiopathic hyperammonemia syndrome (IHS) is an uncommon, often deadly complication of solid organ transplantation. IHS cases in solid organ transplantation seem to occur predominantly in lung transplant (LTx) recipients. However, to the best of our knowledge, the occurrence of IHS has not been systematically evaluated. We set out to identify all reported cases of IHS following nonliver solid organ transplantations.Methods: Retrospective review of our institutional experience and systematic review of the literature.Results: At our institution six cases (of 844 nonliver solid organ transplants) of IHS were identified: five occurred following LTx (incidence 3.9% [lung] vs 0.1% [nonlung], P=. 004). In the systematic review, 16 studies met inclusion criteria, reporting on 32 cases of IHS. The majority of IHS cases in the literature (81%) were LTx-recipients. The average peak reported ammonia level was 1039 mu mol/L occurring on average 14.7 days post-transplant. Mortality in previously reported IHS cases was 69%. A single-center experience suggested that, in addition to standard treatment for hyperammonemia, early initiation of high intensity hemodialysis to remove ammonia was associated with increased survival. In the systematic review, mortality was 40% (four of 10) with intermittent hemodialysis, 75% (nine of 12) with continuous veno-venous hemodialysis, and 100% in six subjects that did not receive renal replacement to remove ammonia. Three reports identified infection with urease producing organisms as a possible etiology of IHS.Conclusion: IHS is a rare but often fatal complication that primarily affects lung transplant recipients within the first 30 days.

In 2015, two librarians at the Hardin Library for the Health Sciences at the University of Iowa turned their dreams into a reality and secured funding to build a zombie-themed evidence-based medicine game. The game features a "choose your own adventure" style that takes students through a scenario where a disease outbreak is taking place and a resident is asked to use evidence-based medicine skills to select a screening and diagnostic tool to use on potentially infected patients. Feedback on the game has been positive, and future plans include building additional modules on therapy, harm, and prognosis.

BACKGROUND Despite a reported worldwide increase, the incidence of extended-spectrum β-lactamase (ESBL) Escherichia coli and Klebsiella infections in the United States is unknown. Understanding the incidence and trends of ESBL infections will aid in directing research and prevention efforts. OBJECTIVE To perform a literature review to identify the incidence of ESBL-producing E. coli and Klebsiella infections in the United States. DESIGN Systematic literature review. METHODS MEDLINE via Ovid, CINAHL, Cochrane library, NHS Economic Evaluation Database, Web of Science, and Scopus were searched for multicenter (≥2 sites), US studies published between 2000 and 2015 that evaluated the incidence of ESBL- E. coli or ESBL- Klebsiella infections. We excluded studies that examined resistance rates alone or did not have a denominator that included uninfected patients such as patient days, device days, number of admissions, or number of discharges. Additionally, articles that were not written in English, contained duplicated data, or pertained to ESBL organisms from food, animals, or the environment were excluded. RESULTS Among 51,419 studies examined, 9 were included for review. Incidence rates differed by patient population, time, and ESBL definition and ranged from 0 infections per 100,000 patient days to 16.64 infections per 10,000 discharges and incidence rates increased over time from 1997 to 2011. Rates were slightly higher for ESBL- Klebsiella infections than for ESBL- E. coli infections. CONCLUSION The incidence of ESBL- E. coli and ESBL- Klebsiella infections in the United States has increased, with slightly higher rates of ESBL- Klebsiella infections. Appropriate estimates of ESBL infections when coupled with other mechanisms of resistance will allow for the appropriate targeting of resources toward research, drug discovery, antimicrobial stewardship, and infection prevention. Infect Control Hosp Epidemiol 2017;38:1209–1215

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A systematic literature review and meta-analysis was performed to identify effectiveness of mupirocin decolonization in prevention of Staphylococcus aureus infections, among nonsurgical settings. Of the 15 662 unique studies identified up to August 2015, 13 randomized controlled trials, 22 quasi-experimental studies, and 1 retrospective cohort study met the inclusion criteria. Studies were excluded if mupirocin was not used for decolonization, there was no control group, or the study was conducted in an outbreak setting. The crude risk ratios were pooled (cpRR) using a random-effects model. We observed substantial heterogeneity among included studies (I(2) = 80%). Mupirocin was observed to reduce the risk for S. aureus infections by 59% (cpRR, 0.41; 95% confidence interval [CI], .36-.48) and 40% (cpRR, 0.60; 95% CI, .46-.79) in both dialysis and nondialysis settings, respectively. Mupirocin decolonization was protective against S. aureus infections among both dialysis and adult intensive care patients. Future studies are needed in other settings such as long-term care and pediatrics.

BACKGROUND:We conducted a systematic review and network meta-analysis to examine comparative efficacy and tolerability of pharmacologic interventions for pulmonary arterial hypertension (PAH). METHODS:MEDLINE, the Cochrane Register, EMBASE, CINAHL, and clinicaltrials.gov were searched (January 1, 1990 to March 3, 2016). Randomized controlled trials (RCTs) studying the approved pharmacologic agents endothelin receptor antagonists (ERA), phosphodiesterase inhibitors (PDE5i), the oral/inhaled (PO/INH) and IV/subcutaneous (SC) prostanoids, and riociguat and selexipag, alone or in combination, for pulmonary arterial hypertension (PAH) and reporting at least one efficacy outcome were selected. RESULTS:Thirty-one RCTs with 6,565 patients were selected. In network meta-analysis, when compared with a median placebo rate of 14.5%, clinical worsening was estimated at 2.8% with riociguat (risk ratio [RR], 0.19; 95% CI, 0.05-0.76); at 3.9% with ERA + PDE5i (RR, 0.27; 95% CI, 0.14-0.52), and at 5.7% with PDE5i (RR, 0.39; 95% CI, 0.24-0.62). For improvement in functional status, when compared with 16.2% in the placebo group, improvement in at least one New York Heart Association/World Health Organization (NYHA/WHO) functional class was estimated at 81.8% with IV/SC prostanoids (RR, 5.06; 95% CI, 2.3211.04), at 28.3% with ERA + PDE5i (RR, 1.75; 95% CI, 1.05-2.92), and at 25.2% with ERA (RR, 1.56; 95% CI, 1.22-2.00). Differences in mortality were not significant. Adverse events leading to discontinuation of therapy were highest with the PO/INH prostanoids (RR, 2.92; 95% CI, 1.68-5.06) and selexipag (RR, 2.06; 95% CI, 1.04-3.88) compared with placebo. CONCLUSIONS:Currently approved pharmacologic agents have varying effects on morbidity and functional status in patients with PAH. Future comparative effectiveness trials are warranted with a focus on a patient-centered approach to therapy. REGISTRATION:PROSPERO CRD42016036803.