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Biomedical subjects

E B Rubenstein

Publications and source records attributed to E B Rubenstein.

At least 37 records · Page 2Linked to original sources
PubMed1996

Outpatient antibiotic treatment in low-risk febrile neutropenic cancer patients.

Traditionally febrile neutropenic patients have been treated with parenteral antibiotics in an inpatient setting; however, recent work by several investigators has demonstrated successful treatment with both parenteral and oral antibiotics in an ambulatory environment. This has been accomplished by identification of low-risk neutropenic patients, advances in broad-spectrum antibiotics with long half-lives and stabilities, the introduction of the oral quinolones, home health-care initiatives, improvements in vascular access devices, and development of technically enhanced antibiotic delivery systems. Outpatient antibiotic therapy for febrile episodes in low-risk neutropenic patients should now be considered an acceptable alternative to hospital-based treatment. This review focuses on the development and rationale of risk stratification and examines the results of various outpatient antibiotic trials recently completed.

Ambulatory Care↗
PubMed1996

Early empiric antibiotic therapy for febrile neutropenia patients at low risk.

Although it is apparent that certain patients with febrile neutropenic episodes can benefit from outpatient antibiotic therapy, not all low-risk patients are treated in this fashion. There are barriers, real and perceived, to implementing this approach for patients, health care providers, and caregivers. Table 3 summarizes the advantages and disadvantages of ambulatory management of febrile neutropenic patients. For many patients and physicians, outpatient oral antibiotics may be preferred, whereas for others a more conservative approach might be needed in order to feel comfortable with treating this population on an outpatient basis. In this situation, patients can be treated in a stepwise fashion as shown in Table 4. These alternatives allow physicians and patients options to discuss when planning treatment strategies for febrile neutropenia.

Administration, Oral↗
PubMed1995

Nature and outcome of febrile episodes in patients with pancreatic and hepatobiliary cancer.

Fifty febrile episodes in patients with hepatobiliary and pancreatic cancer were reviewed. Biliary obstruction often resulting in cholangitis was an important predisposing factor, whereas neutropenia (< 500 PMN/mm3) was uncommon (10%). Microbiologically documented infections originating from the gastrointestinal tract were predominant, with Enterococcus faecalis and Escherichia coli being isolated most often. Non-infectious causes of fever occurred in 16% of patients. Only one patient developed a fungal infection. The overall response rate to therapy was 94%, with 32% being eligible for outpatient management. These data are quite different from those generated from patients with hematologic malignancies and indicate that disease-site specific management guidelines need to be developed for febrile episodes in patients with various underlying neoplasms.

Adult↗
PubMed1995

Vascular access by physician assistants: evaluation of an implantable peripheral port system in cancer patients.

PURPOSE: To determine the ability of a physician assistant (PA) to insert, in an ambulatory setting, a peripheral subcutaneous implanted vascular-access device (VAD) and to evaluate the ability to transfer this training to a second PA. We also evaluated the performance and complications associated with this new device. PATIENTS AND METHODS: The Peripheral Access System (PAS) Port catheter system (Sims-Deltec Inc, St Paul, MN) was inserted in patients who required long-term (> 3 months) vascular access for infusion therapy. RESULTS: The first PA (PA-1) successfully inserted 57 of 62 devices (92%) after gaining experience with the technique in 10 patients (success rate, five of 10 [50%]; P = .003). The second PA (PA-2) was successful in eight of 10 initial attempts (80%) and 25 of 30 overall (83%). Complications were few and limited to phlebitis, thrombosis, and a low infection rate (0.2 per 1,000 catheter days). CONCLUSION: PAs can be taught to insert a peripheral subcutaneous implanted VAD. This technique is transferable from one PA to another, and the device studied is appropriate for outpatient VAD programs.

Adolescent↗
PubMed1994

Outpatient management of febrile episodes in neutropenic cancer patients.

Febrile neutropenic patients have traditionally received hospital-based parenteral antibiotic therapy because of the risk of serious complications and associated mortality. Recently a low-risk subset among febrile neutropenic patients has been identified. Several alternatives to hospital-based therapy have been evaluated in such patients. These include early discharge to home antibiotic therapy after initial stabilization in the hospital, or treatment of the entire febrile episode with intravenous and/or oral antibiotics in an ambulatory setting. A multidisciplinary approach involving the physician and other health-care providers, the patients, and their families, ensures the success of this therapeutic modality. Careful patient selection, daily follow-up, close monitoring for the development of complications and/or adverse reactions, and informed consent along with detailed instructions to patients, minimize the risk of the development of serious complications. Outpatient antibiotic therapy for febrile episodes in low-risk neutropenic patients should now be considered an acceptable alternative to hospital-based therapy.

Adolescent↗
PubMed1994

Costs and benefits of outpatient therapy.

In recent years, much of the care traditionally rendered in hospitals has been shifted to ambulatory settings. This change has been fueled as much by changing patterns of reimbursement as by rapid developments in medicine and technology. The current climate of health-care reform suggests that this trend will continue for the near future. Unfortunately, there are few studies that systematically evaluate the cost effectiveness or benefits of ambulatory care. Among the few such studies published to date, the results are not overwhelmingly positive. While the monetary costs of ambulatory care are generally far lower than inpatient management, several studies suggest that family and household disruption are prominent features of outpatient strategies. Thus, the measurement of the direct and indirect costs and benefits of ambulatory treatment presents a significant challenge to researchers. Development of methodologies to support such studies must be among our highest priorities.

Ambulatory Care↗
PubMed1994

The electronic medical record in a research institution: competing constituencies in a publish or perish world.

The electronic medical record (EMR) has the potential to advance medical research by quantum leaps through improved, low-cost access to high-quality information. To the extent that the EMR enhances the status and power of researchers, it will be greeted with enthusiastic support. To ensure such an outcome, developers must resolve issues introduced by the EMR, such as the added burden of cost for research data, errors in interpretation of EMR-based research data, the introduction of bias into studies, responsibility for the accuracy of EMR-based data, and ownership of EMR-based data.

Bias↗
PubMed1994

Current management of disseminated intravascular coagulation.

Disseminated intravascular coagulation is a complex process seen in a wide variety of clinical disorders. The oncology patient may develop this syndrome either as a result of the neoplasm itself or of the treatment of the neoplasm. An understanding of the pathophysiology of disseminated intravascular coagulation is essential for diagnosis and treatment. Diagnosis is accomplished by correlating clinical and laboratory data. Treatment remains controversial, but reversal of the triggering mechanism is the single most important factor in successful treatment. Other interventions, including the use of heparin, antithrombin III, and hirudin, are being studied. Much remains to be understood about disseminated intravascular coagulation, and controlled clinical trials are needed to define optimal treatment.

Antithrombin III↗
PubMed1993

Outpatient treatment of febrile episodes in low-risk neutropenic patients with cancer.

BACKGROUND: Hospitalization and intravenous (IV) broad-spectrum antibiotics are the standard of care for all febrile neutropenic patients with cancer. Recent work suggests that a low-risk population exists who might benefit from an alternate approach. METHODS: A prospective randomized clinical trial was performed comparing oral ciprofloxacin 750 mg plus clindamycin 600 mg every 8 hours with IV aztreonam 2 g plus clindamycin 600 mg every 8 hours for the empiric outpatient treatment of febrile episodes in low-risk neutropenic patients with cancer. RESULTS: The oral regimen cured 35 of 40 episodes (88% response rate), whereas the IV regimen cured 41 of 43 episodes (95% response rate, P = 0.19). Although the cost of the oral regimen was significantly less than that of the IV regimen (P < 0.0001), it was associated with significant renal toxicity (P < 0.05), which led to early termination of the study. Overall, combining its safety and efficacy, the IV regimen was superior (P = 0.03). CONCLUSIONS: This prospective study suggested that outpatient antibiotic therapy for febrile episodes in low-risk neutropenic patients with cancer is safe and effective. Better oral regimens are needed.

Administration, Oral↗
PubMed1993

Ciprofloxacin-induced nephrotoxicity in patients with cancer.

Nephrotoxicity associated with ciprofloxacin is uncommon. Five patients with cancer who developed acute renal failure that followed treatment with ciprofloxacin are described and an additional 15 cases reported in the literature are reviewed. Other than elevation of serum creatinine levels, characteristic clinical manifestations and abnormal laboratory findings are not frequently present. Allergic interstitial nephritis is believed to be the underlying pathological-process. Definitive diagnosis requires performance of renal biopsy, although this is not always feasible. An improvement in renal function that followed the discontinuation of the offending antibiotic supports the presumptive diagnosis of ciprofloxacin-induced acute renal failure.

Acute Kidney Injury↗