BACKGROUND: Antibiotic misuse is common and costly and may promote antibiotic resistance. We tested the efficacy of a targeted one-on-one educational program ("academic detailing") designed to improve the appropriateness of broad-spectrum antibiotic use. METHODS: A randomized controlled trial was conducted in a large US teaching hospital. During an 18-week study period, 17 general medical, oncology, and cardiology services either received academic detailing or did not. The intervention was prompted by an order for either levofloxacin or ceftazidime that led to a computer-based review of data for that patient. Orders for the 2 target antibiotics deemed unnecessary by a priori criteria were included in the study. The primary outcome examined was the number of days that unnecessary levofloxacin or ceftazidime was administered in intervention and control groups. RESULTS: Before the trial, intervention and control services had similar prescribing patterns for the target antibiotics; the drugs were used for similar indications throughout the study period. During the intervention, there was a reduction of 37% in days of unnecessary levofloxacin or ceftazidime use per 2-week interval on services randomized to the educational intervention vs control services (P< .001). In multivariable analyses controlling for baseline prescribing and study interval, the rate of unnecessary use of the 2 target antibiotics was reduced by 41% on the intervention services compared with controls (95% confidence interval, 44%-78%; P< .001). Length of stay, intensive care unit transfers, readmission rates, and in-hospital death rates were similar in both groups (P> or =.10 for all). CONCLUSION: Targeted one-on-one education is a practical, effective, and safe method for reducing excessive broad-spectrum antibiotic use.

Aged↗

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[Comparison of the effect of TSH and fluoride on the adenylate cyclase activity of cold thyroid nodules (author's transl)].

Using a simple and reliable assay technique in which the actuel amount of cyclic AMP generated during incubation is determined by competitive protein binding assay, adenylate cyclase activity was measured in 7 cold nodules and 3 samples of normal thyroid tissue. Mitochondrial fraction prepared from surgically obtained tissues was used as the source of the enzyme. We observed an increased adenylate cyclase activity in cold nodules as compared to normal. More importantly, this activity was much more responsive to TSH in cold nodules than in normal (maximal stimulation: 1050+/-200% vs 320+/-120%). Also, maximal TSH stimulation was similar to that elucited by fluoride in the cold nodules but only one-third in normal tissue. These results suggest that higher efficiency of TSH in cold nodules may be related to increased TSH binding or coupling of TSH receptors with the caralytic subunit of adenylate cyclase.

Adenoma↗

PubMedDate not supplied

Geriatric assessment: methods for clinical decision making.

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Aged↗

PubMedDate not supplied

Dynamic assessment of cognitive and cardiovascular performance in the elderly.

Dynamic measures of cardiovascular and cognitive performance have been used as a preliminary step toward developing predictors of decline in functional performance in older persons. Both batteries use multiple measures to examine the cooperativity of various aspects of performance, and both examine the subject's response to naturally occurring stresses. In these two senses, the measures are dynamic. For the cardiovascular measure we conducted ambulatory monitoring of blood pressure and pulse at 7.5-min intervals over a 24-h period. These parameters were analyzed simultaneously to examine changes in one relative to the others, using spectroscopy. After appropriate filtering, several dominant ultradian rhythms were noted, with periods of 47 min, 180 min and 6 to 8 h, the latter rhythm being present only in subjects aged greater than or equal to 60. A battery of computer-administered cognitive tests was developed to assess reaction time, visual recognition memory and word recognition memory. This testing allows for both a time and performance level grading. The results of the computer battery correspond well with those for standard neuropsychological tests. In general, performance declined with age, and reaction time increased. The computerized tests are faster, more consistently administered, and do not rely on a skilled professional for administration or analysis. They also provide a wide variety of measures that can be used in isolating components of performance. Once the acceptability and tolerance of older subjects toward such testing was established, attention shifted to questions of measurement stability and discriminant validity. Since the project's primary purpose is to predict subtle measures of decline in function, the battery's ultimate test is in its ability to correctly identify those about to change functional status. However, many different measures of status change are possible, and the predictive accuracy will depend on the outcome chosen. Subsequent work will focus on the predictors to refine measures and compare data collected at one point in time with the predictive power of change scores that reflect the individual subject's "signature." By-products of this work include a wealth of longitudinal physiologic and neuropsychologic data on older persons and tools that may be useful to the practicing physician.

Aged↗

PubMedDate not supplied

Education in the clinical years: delusion or reality.

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Clinical Clerkship↗