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PubMed2006

Using local microbiologic data to develop institution-specific guidelines for the treatment of hospital-acquired pneumonia.

BACKGROUND: While current guidelines recommend consideration of local microbiologic data when selecting empiric treatment for hospital-acquired pneumonia (HAP), few specifics of how to do this have been offered. METHODS: We conducted a retrospective analysis of HAP pathogens in 111 consecutive patients who acquired HAP during July to December 2004 and had a corresponding positive culture finding for a bacterial pathogen. These data were used to develop institution-specific guidelines. RESULTS: The most common bacteria identified were Staphylococcus aureus, Acinetobacter baumannii, and Pseudomonas aeruginosa, which were associated with 38%, 25%, and 19% of pneumonias, respectively. Susceptibility of Gram-negative bacteria to piperacillin-tazobactam and cefepime was 80% and 81%, respectively. The isolation of organisms resistant to piperacillin-tazobactam or cefepime was significantly more frequent in patients who had been hospitalized > or = 10 days. Of Gram-negative isolates resistant to piperacillin-tazobactam or cefepime, ciprofloxacin was active against < 10%, while amikacin was active against > 80%. New treatment guidelines were developed that divided the American Thoracic Society/Infectious Diseases Society of America "late onset/risk of multidrug-resistant pathogens" group of patients into two subcategories: "early-late" pneumonias (< 10 days of hospitalization) and "late-late" pneumonias (> or = 10 days of hospitalization). Guideline-directed treatment regimens would be predicted to provide adequate initial therapy for > 90% of late-onset pneumonias at our institution. CONCLUSIONS: Current guidelines suggest adding either an aminoglycoside or a fluoroquinolone to beta-lactam therapy for empiric Gram-negative coverage. However, in our institution, adding ciprofloxacin would not appreciably enhance the likelihood of providing initial appropriate antibiotic coverage. This underscores the importance of employing a systematic analysis of local data when developing treatment guidelines.

Anti-Bacterial Agents↗
PubMed1978

An interdisciplinary approach to the dental care of the mentally disabled.

In institutions for mentally disabled persons, dental care of the patient is often difficult because of uncooperative behavior. Premedication is sometimes necessary. The mentally disabled patient frequently receives other medication for behavioral control, cerebral palsy, seizures, or the like, that may interact with the dental premedication. Because of the problems that may develop, a program between an institution's dental department and a university's clinical pharmacy department was developed that provided an approach to the selection of premedication for the dental patient who is mentally disabled.

Adolescent↗
PubMed2000

In the shadow of "death with dignity": medicine and cultural quandaries of the vegetative state.

In this paper I address one site of technological development and cultural production, the permanent or persistent comatose condition and the institutions and practices that enable this life form to exist. As with other medical sites of ambiguity and change under recent scrutiny by anthropologists, the locations in which comatose bodies thrive are those in which the routinization of technology use in the clinic and a legitimating social and economic context come together to permit and create a further remapping of the notions of "life" and "person." I explore the new forms of knowledge, practice, and the body that are created at this site and how they are negotiated, and I discuss how the shifting understanding of "culture" and "nature" both have an impact on and are informed by American quandaries about approaching death. I argue that beings who are neither fully alive, biologically dead, nor "naturally" self-regulating, yet who are sustained by modern medical practice, destabilize the existing social order in ways that are different from other hybrid forms.

Attitude of Health Personnel↗
PubMed2000

Taxonomic anxieties: Axis I and Axis II in prison.

This essay describes the use of the Diagnostic and Statistical Manual of Psychiatry in the prison setting. The distinction between the Axis I disorders (major mental illness) and those designated Axis II (character disorders) is explored in terms of the professional division of labor in prison and the problems posed for prison discipline by "behaviorally disturbed" inmates. Conflicts over diagnosis are placed in ethnographic and historical perspective and form the basis for a discussion of the problematic relationship between disciplinary space and issues of subjection and agency.

Humans↗
PubMed2003

Evidence-based referral results in significantly reduced mortality after congenital heart surgery.

OBJECTIVE: Significant interinstitutional variation in mortality after congenital heart surgery has been demonstrated. Noting an association between reduced mortality and higher volume, a center with a small annual case volume began in August 1998 to selectively refer to high-volume surgical centers based on published or "apparent" low mortality rates for specific cardiac lesions. This study was undertaken to evaluate the effect of evidence-based referral in this practice. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort comparison over a 10-year period for a small Midwestern pediatric cardiology practice. The institutional database was retrospectively reviewed for children (<18 years) undergoing surgery from August 1992 to July 2002. Data were divided into 3 time periods (August 1992 to July 1995, period 1; August 1995 to July 1998, period 2; and August 1998 to July 2002, period 3). Hospital discharge abstract data from 5 states (California, Illinois, Massachusetts, Pennsylvania, and Washington) in 1992, 1996, and 1998 provided contemporaneous benchmarks. Risk adjustment was performed using the Risk Adjustment in Congenital Heart Surgery-1 method. Risk category, age at surgery, prematurity, and major noncardiac structural anomaly were entered into a multivariate logistic regression model to compare in-hospital mortality adjusting for case-mix differences. RESULTS: A total of 514 congenital heart surgical cases were identified from August 1992 to July 2002; 507 cases (98.6%) were assigned to a risk category and analyzed further. Unadjusted in-hospital mortality rates were 9.3% in period 1, 5.9% in period 2, and 1.3% in period 3. Unadjusted mortality rates for cases from benchmark data were 6.4% in 1992, 4.8% in 1996, and 3.7% in 1998. Risk adjusted mortality was comparable to the benchmark data in periods 1 and 2, but superior outcomes (odds ratio = 0.24) were demonstrated in period 3. CONCLUSIONS: Evidence-based referrals from a small-volume pediatric cardiac center to large-volume institutions resulted in a reduction in mortality after congenital heart surgery.

Adolescent↗
PubMed2006

Variation in standards of research compensation and child assent practices: a comparison of 69 institutional review board-approved informed permission and assent forms for 3 multicenter pediatric clinical trials.

OBJECTIVE: To systematically compare standards for compensation and child participant assent in informed permission, assent, and consent forms (IP-A-CFs) approved by 55 local institutional review boards (IRBs) reviewing 3 standardized multicenter research protocols. METHOD: Sixty-nine principal investigators participating in any of 3 national, multicenter clinical trials submitted standardized research protocols for their trials to their local IRBs for approval. Copies of the subsequently IRB-approved IP-A-CFs were then forwarded to an academic clinical research organization. This collection of IRB-approved forms allowed for a quasiexperimental retrospective evaluation of the variation in informed permission, assent, and consent standards operationalized by the local IRBs. RESULTS: Standards for compensation and child participant assent varied substantially across 69 IRB-approved IP-A-CFs. Among the 48 IP-A-CFs offering compensation, monetary compensation was offered by 33 as reimbursement for travel, parking, or food expenses, whereas monetary or material compensation was offered by 22 for subject inconvenience and by 13 for subject time. Compensation ranged widely within and across studies (study 1, $180-1425; study 2, $0-500; and study 3, $0-100). Regarding child participant assent, among the 57 IP-A-CFs that included a form of assent documentation, 33 included a line for assent on the informed permission or consent form, whereas 35 included a separate form written in simplified language. Of the IP-A-CFs that stipulated the documentation of assent, 31 specified > or =1 age ranges for obtaining assent. Informed permission or consent forms were addressed either to parents or child participants. CONCLUSION: In response to identical clinical trial protocols, local IRBs generate IP-A-CFs that vary considerably regarding compensation and child participant assent.

Adolescent↗
PubMed2002

[Changes in nursing: the representation of nurses regarding institutional mobilization].

Big changes have been happening in the society. In this study, we had as objective to show the nurses' representation about the changes in nursing inserted in an institution context. Eighteen nurses at a public, school hospital, which is specialized in cardiology were interviewed. Using the analysis of content according to Bardin' proposal, we construct a representation' scheme that indicates two periods of time, concrete and desirable time, and in order to adapt in a new time it happens in a pace between limits and catalysers of changes' process, to achieve auto-supported existence as a project to become a new professional.

Adult↗
PubMed1981

High blood pressure diagnosis and treatment: consensus recommendations vs actual practice.

Diagnostic and treatment practices of institutional facilities treating high blood pressure in New York City were surveyed by mail in 1978. Respondents were adhering to the treatment recommendations of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure. Ninety-two per cent of respondents reported 90-104 mm Hg as the diastolic blood pressure level at which drug therapy was initiated, indicating a more aggressive approach than was warranted by the information available at the time of the survey.

Adult↗
PubMed1982

Institutional change in delivery of dental services: a marketing perspective.

The recent appearance and growth of new delivery systems for dental services is examined from a marketing perspective. Analysis reveals that the growth of low priced, high throughput operations is consistent not only with marketing principles, but with the development of American retail institutions in general. Options for independent dentists in the face of this new competitive environment are discussed. (Am J Public Health 1982; 72:679-683.)

Delivery of Health Care↗
PubMed2002

No care for the caregivers: declining health insurance coverage for health care personnel and their children, 1988-1998.

OBJECTIVES: This study examined trends in health insurance coverage for health care workers and their children between 1988 and 1998. METHODS: We analyzed data from the annual March supplements of the Current Population Survey (CPS), a Census Bureau survey that collects information about health insurance from a nationally representative sample of noninstitutionalized US residents. RESULTS: Of the health care personnel younger than 65 years, 1.36 million (90% confidence interval [CI] = 1.28 million, 1.45 million) were uninsured in 1998, up 83.4% from 1988; the proportion uninsured rose from 8.4% (90% CI = 7.8%, 9.1%) to 12.2% (90% CI = 11.5%, 12.9%). Declining coverage rates in the growing private-sector health care workforce---and declining health employment in the public sector, which provided health insurance benefits to more of its workers---accounted for the increases. Households with a health care worker included 1.12 million (90% CI = 1.05 million, 1.20 million) uninsured children, accounting for 10.1% (90% CI = 9.5%, 10.8%) of all uninsured children in the United States. CONCLUSIONS: Health care personnel are losing health insurance coverage more rapidly than are other workers. Increasingly, the health care sector is consigning its own workers and their children to the ranks of the uninsured.

Adolescent↗
PubMed1997

Antibiotic treatment of febrile episodes in neutropenic cancer patients. Clinical and economic considerations.

The increased frequency of infections caused by Gram-positive microorganisms, and the expansion of resistant pathogens resulting from institutional therapeutic practices, represent some of the emerging issues of empirical drug treatment of cancer patients with febrile neutropenia. However, the therapeutic strategies for the treatment of these patients have progressed remarkably over the last decade. Individual therapy in the light of the principal clinical features (in particular, the degree and estimated duration of neutropenia, as well the presence of other potential factors favouring infection such as long-standing intravascular catheters) and local microbial ecology have emerged as the leading concepts. Empirical drug monotherapy has been recognised as a feasible alternative to combination therapy, at least in selected low-risk patients. The indiscriminate use of empirical glycopeptides should be discouraged to prevent the emergence of resistant bacteria, especially in centres where methicillin-resistant staphylococci have not yet become a major issue. Empirical antifungal therapy with amphotericin B is still essential for a successful outcome in case of fever persistence or recurrence. Finally, selected febrile neutropenic patients who exhibit a better prognosis can be handled on an outpatient basis. The prophylactic use of haemopoietic growth factors has been shown to augment cost savings substantially in the management of neutropenic patients via a reduction in the duration and severity of the neutropenia, as well as infectious complications. Although data from economic analyses are not yet available, some cost-containment strategies such as outpatient treatment, monotherapy, and use of more convenient antibiotic combinations may lead to a reduction of therapy expenditures for febrile episodes in these patients.

Anti-Bacterial Agents↗
PubMed1999

Counting the costs of drug-related adverse events.

Adverse drug events occur frequently and lead to a significant number of fatalities each year. It has been estimated that fatalities directly attributable to adverse drug reactions are the fourth to sixth leading cause of death in US hospitals, exceeding deaths caused by pneumonia and diabetes. The economic burden resulting from drug-related morbidity and mortality is equally significant and has been conservatively estimated at $US30 billion dollars annually, and could exceed $US130 billion in a worst-case scenario. Since many adverse drug events are considered preventable, increased efforts should be made to avoid classes of drugs that are problem-prone and to initiate diligent monitoring of drugs with predictable toxicities. Programmes should also be implemented that improve medication use practices within institutions. Although nearly all drugs are capable of producing an injury, certain drugs are more likely to do so. Prevention of drug-related morbidity and mortality has become an increasingly important requirement for reducing healthcare expenditures. This article will review studies that examine the economic implications of drug-related adverse events.

Animals↗
PubMedDate not supplied

"Don't tread on me": ethological perspectives on institutionalization.

The concept of dignity is developed from an ethological perspective. Special attention is given to innate, phylogenetically programmed behavior, the role of releasers, the importance of rituals, and the fact that "management problems" in institutions are often cries for dignity. Observations of geriatric patients admitted to a nursing home are given, but it is believed that the generalizations apply equally well to institutionalization in other settings such as residential centers for young people, correctional facilities, or mental hospitals.

Adaptation, Psychological↗