Biomedical subjects
Publications and source records attributed to M D Nettleman.
Travelers to developing countries are at risk for diseases ranging from traveler's diarrhea to malaria. Immunizations, medications, and sensible precautions can ensure a safe trip in most areas of the world. This article presents an overview of how to prepare the international traveler.
Foresight and planning can reduce stress associated with a JCAHO survey. Important resources for the epidemiologist include the Comprehensive Accreditation Manual for Hospitals, recommendations from previous JCAHO surveys, and educational meetings. Communication with colleagues who have been reviewed recently is an invaluable means of preparing for future surveys. Finally, although JCAHO accreditation is important, it is equally important to realize that the primary purpose of quality improvement programs is to improve the structure, process, and outcome of care.
OBJECTIVE: To assess the cost of the mandatory use of high-efficiency particulate respirators to treat patients with known or suspected tuberculosis. DESIGN: A questionnaire was used to determine the number of high-efficiency particulate respirators required and the number of cases of tuberculosis in employees that could potentially be prevented. Indirect costs included the training and fitness testing of employees. The clinical efficacy of respirators is not known. To provide a best-case scenario, it was assumed that the respirators could prevent as many as 25% of tuberculosis cases in health care workers. SETTING: 159 acute care facilities administered by the Department of Veterans Affairs. PARTICIPANTS: Quality improvement, infection control, and employee health specialists. MEASUREMENTS: Cost of the respirators compared with their maximum predicted efficacy. RESULTS: The use of the respirators would cost $7 million per case of tuberculosis prevented and $100 million per life saved. CONCLUSIONS: High-efficiency particulate respirators are a costly means of trying to prevent tuberculosis. Costs could be reduced by reusing masks or by restricting the number of health care workers allowed to have contact with potentially infectious patients. As the health care budget undergoes further restrictions, specific means of accommodating the cost of new regulations must be found.
BACKGROUND: Although it has been recommended that all patients suspected of having tuberculosis be placed in isolation, the feasibility of this recommendation has not been investigated. METHODS: Forty-three patients with pulmonary tuberculosis were compared with 43 control subjects. The control subjects had submitted expectorated sputum, and were culture negative. Variables included chest roentgenogram results, and risk factors used by the Centers for Disease Control and Prevention (Atlanta, Ga) to identify patients at increased risk for tuberculosis. RESULTS: Potential control subjects outnumbered patients by 92:1. Although a positive tuberculin skin test, foreign birth, and weight loss were more common in the patients, 86% of the control subjects had at least one risk factor for tuberculosis. Chest roentgenograms consistent with tuberculosis (cavities or apical or nodular infiltrates) were found in 86% of the patients, but in only 16% of the control subjects (odds ratio, 31.7; 95% confidence interval, 8.6 to 127.7). The positive and negative predictive values of a consistent chest roentgenogram were 6% and 99.8%, respectively. The sensitivity of testing a single sputum specimen was 81%, yet almost half of the control subjects had only one specimen submitted. Of the inpatient cases, 58% were not identified on admission with a median delay of 13 days before isolation. CONCLUSIONS: Isolating all the patients at the time sputum is submitted for testing is not practical and would have resulted in a 92-fold overuse of isolation rooms. The chest roentgenogram was of great value in identifying patients who did not require isolation and was the best available means of identifying inpatients at high risk for active pulmonary tuberculosis.
OBJECTIVE: To determine the importance of procedure-related complications on a general medical service. DESIGN: A retrospective cohort study with one-to-one matching. Complications were identified through chart review by nurse-technicians using standard definitions. SETTING: The internal medicine service of a 900-bed university hospital. PATIENTS: One hundred seven cases with noninfectious, procedure-related complications and 107 closely matched controls who underwent the same procedures without complication. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The mortality rate was 28% for cases compared with 11% for controls, resulting in an excess mortality rate of 17% (p = 0.02). Cases who survived to discharge had an excess length of stay of seven days (p = 0.001). The excess cost per case was $12,913. Importantly, median reimbursement was only $2,064 higher for cases than for controls. Adjusting for age and APACHE II (severity of illness) score, procedure-related complications were associated with a 3.4-fold increase in the relative risk of in-hospital mortality (95% CI: 1.5 to 7.7). Surveillance data were useful in directing quality improvement activities that resulted in a 66% reduction in the rate of pneumothorax following thoracentesis. CONCLUSIONS: Procedure-related complications were associated with prolonged and expensive hospitalization and were a marker for patients at high risk for in-hospital mortality. Programs to reduce complications on the general medical service have an enormous potential to benefit both patients and hospitals.
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Explore the source record for details and available documents.
OBJECTIVE: To investigate trends in plasmid types of methicillin-resistant Staphylococcus aureus over a 3-year period and determine the clinical impact of plasmid typing. DESIGN: Restriction endonuclease analysis of plasmid DNA (REAP) was used to type 270 clinical isolates. SETTING: A Veterans Affairs Medical Center. RESULTS: Forty-four different REAP types were identified and, of these, 23 appeared only once. Types designed as V1 and V2 were more commonly found in nosocomial cases than in community-acquired cases (p < .05); whereas the K and D types were more common in isolates from community-acquired cases (p < .05). In 30 (11%) isolates, no plasmid was detected. When combined with epidemiological data, REAP typing revealed 4 small outbreaks that would have been missed using traditional epidemiological methods alone. In large outbreaks involving 10 or more cases, REAP typing data revealed unsuspected patterns of transmission. CONCLUSIONS: Multiple plasmid types were present in this endemic setting. Restriction endonuclease analysis of plasmid DNA was a practical and valuable adjunct to traditional epidemiological methods.
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Travel medicine is an exciting and rewarding field. This article has provided an overview of basic sources of information. The interested clinician will find many other sources of information on special topics or on travelers with special medical conditions.
BACKGROUND: Antimicrobials are a major part of hospital pharmacy budgets and must be considered in resource planning and spending projections. Logically, trends in antimicrobial usage should be linked to trends in resistant pathogens. OBJECTIVE: To examine long-term trends in antimicrobial use over a 15-year period (1978 to 1992) and contrast them with changes in pathogens causing nosocomial bacteremia. SETTING: A 900-bed, tertiary care teaching hospital. METHODS: Pharmacy records were reviewed to identify parenteral antimicrobial agents administered to adult inpatients. Results were expressed in average daily adult doses per 1,000 patient days. RESULTS: Chloramphenicol use decreased, while use of penicillin G, antistaphylococcal penicillins, first-generation cephalosporins, and aminoglycosides remained relatively stable. In contrast, there was a sharp increase in the use of second- and third-generation cephalosporins (7-fold and 6.5-fold increase, respectively), vancomycin (161-fold increase), metronidazole (32-fold increase) and amphotericin B (35-fold increase). The proportion of nosocomial bacteremias due to methicillin-resistant gram-positive bacteria rose, but gentamicin resistance in gram-negatives remained at low levels. During the past 14 years, the percentage of patients receiving at least one parenteral antimicrobial rose from 23% to 44%. Among patients receiving antimicrobials, the average number of different agents used per patient increased from 1.8 to 2.1. CONCLUSIONS: If newer agents were available, use of older agents usually declined. If newer alternatives were not available, use of older agents rose sharply. The increased use of antimicrobials in adults was related to the expanded proportion of patients receiving these agents.
As a result of many interacting variables, including crowded shelters and limited access to health care, homeless persons are at high risk for tuberculosis. Using traditional approaches, control of tuberculosis in this population has been difficult. Decision analysis was used to investigate the cost-effectiveness of BCG (bacillus Calmette-Guérin) vaccination in persons attending homeless shelters. This vaccination was cost-effective over a wide range of assumptions. Using conservative assumptions, a vaccine that was at least 40 percent effective would result in a net cost savings. If the efficacy of the vaccine were 50 percent, $4,000 would be saved, 12 life-years gained, and 23 cases of active tuberculosis prevented for every 1,000 persons vaccinated. Further study of the BCG vaccine in homeless persons and other populations at risk is warranted.
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Explore the source record for details and available documents.
Data from around the world verify the escalating incidence of infections caused by methicillin-resistant Staphylococcus aureus (MRSA). Since MRSA are spread primarily on the hands of health care workers, rates of infection are a function of infection control activities within institutions. Moreover, infections with MRSA are serious and often life-threatening. Thus, there are compelling medical and ethical reasons to invest in control measures. Currently available data suggest the efficacy of three measures: (a) identification of the entire patient reservoir (cases and carriers) for purposes of isolation; (b) strict handwashing between patients to prevent transmission; and (c) treatment of the carrier state in health care workers and patients during periods of high infection rates with safe and effective topical agents such as mupirocin.
Sustained control of endemic methicillin-resistant Staphylococcus aureus (MRSA) originating from multiple sources has not been reported. We describe a simple, inexpensive program based on feedback to physicians that resulted in significant reduction of nosocomial MRSA. When nosocomial cases were identified, the epidemiologist contacted the team resident to encourage increased emphasis on hand washing. Handouts, periodic hand cultures of house staff, and monthly presentations at morning report were also employed. In the first 15 months, nosocomial MRSA decreased from 1.025 to 0.508 cases per 1,000 patient days (p less than 0.01). Monthly rates were significantly decreased for 9 months of 1989 and the first 2 months of 1990. Feedback and assignment of responsibility resulted in a 50% reduction in nosocomial MRSA that has been sustained for 15 months.
OBJECTIVE: To determine the relative cost and benefit of aerosolized pentamidine and the combination product of sulfamethoxazole and trimethoprim sulfate as secondary prophylaxis for Pneumocystis carinii pneumonia. DESIGN: A Markov-based cost-benefit analysis was performed. Drug efficacies, toxicities, and mortality rates were drawn from the current literature. SETTING: Hypothetical. PATIENT POPULATION: Patients infected with the human immunodeficiency virus who had had at least one episode of P carinii pneumonia. INTERVENTIONS: Regimen 1 required the use of aerosolized pentamidine as the sole first-line prophylactic agent in all patients. Regimen 2 required the use of sulfamethoxazole-trimethoprim in all patients who had no history of a toxic reaction to the drug; only patients with a history of toxic effects and those who developed toxic effects while receiving the drug would receive aerosolized pentamidine. Regimen 3 required that no secondary prophylaxis be given. MAIN OUTCOME MEASURES: Net cost, median patient survival, and 5-year survival for each regimen and for regimens 1 and 2 compared with regimen 3. MAIN RESULTS: Regimen 2 was dominant, with a net cost of $6332 per patient and a median survival of 2.050 years. Compared with no prophylaxis, regimen 2 resulted in a savings of $16,503 per patient and a 0.696-year increase in median survival. Compared with regimen 1, regimen 2 resulted in a savings of $2904 and a 0.067-year increase in median survival. CONCLUSIONS: Secondary prophylaxis for P carinii saves money and extends survival. Current data suggest that sulfamethoxazole-trimethoprim should be given whenever it can be tolerated. Use of aerosolized pentamidine as a first-line agent would result in a modest increase in cost and a decrease in life expectancy.
We investigated the cost-effectiveness of strategies for screening pregnant women for Chlamydia trachomatis. Screening was not cost-effective unless certain conditions were met. Direct antigen testing of all pregnant women would be cost-effective if the test cost less than $6.30 or the prevalence of infection exceeded 6%. However, the positive predictive value of the test was only 51%. Culturing was not cost-effective until the prevalence of infection exceeded 14.8%. If a direct antigen test cost less than $3.90 or prevalence exceeded 8.7%, direct antigen testing of all women and using culture to confirm positive direct antigen tests would be cost-effective. If a direct antigen test cost $8.00 and culture cost $25.00, the excess cost of performing a direct antigen test in all women and confirming positive results with culture would be $2.09 per pregnant woman. Screening all pregnant women for chlamydia is not cost-effective, but the excess cost is modest when direct antigen tests are used.