Bedside prediction scoring for emergent diagnosis of late onset neonatal sepsis

@#<p style="text-align: justify;"><strong>BACKGROUND:</strong> Late Onset Neonatal Sepsis (LONS) or nosocomial sepsis has a significant mortality and morbidity that leads to overtreatment. Overtreatment happens when antibiotics are frequently started and/or shifted, eventually leading to increasing antimicrobial resistamce in NICU.<br /><strong>OBJECTIVE: </strong>To validate bedside nosocomial sepsis scoringdeveloped by Okascharoen in 2005.<br /><strong>METHODOLOGY:</strong> All neonates admitted in NICU suspected of LONS were enrolled. Using Okascharoe scoring, subjects were scored based hypotension/poor perfusion, abnormal body temperature, respiratory insufficiency, complete blood count, and length of umbilical catheter use. Growth of organisms during blood culture is considered positive outcome and is considered confirmed sepsis.<br /><strong>RESULTS:</strong> Of the one-hundred-nineteen (119) subjects included in the analysis, 59 were confirmed sepsis and 60 were LONS negative. Subjects with confirmed sepsis had more events of hypotension/poor perfusion (p < 0.001; -0.141, -0.438), thrombocytopenia (p 0.000; -0.169, -0489), and prolonged umbilical catheter usage (p 0.014; -0.051, -0.311). The ROC curve has an AUC of 0.753 (p < 0.001; 0.664-0.842), which means a randomly chosen neonate with LONS will have a higher predicted score than a neonate without LONS. The sensitivity of this tool was 0.92 (0.82-0.97) and specificity of this tool was 0.32 (0.21-0.46) in this setting. The positive LR =1.35 (1.12-1.64) while the negative LR = 0.26 (0.10-0.65)<br /><strong>CONCLUSION:</strong> This scoring is a valid tool that can be used in point-of-care scoring for antibiotic stewardship in a neonate with suspected sepsis.<br /><strong>RECOMMENDATION:</strong> it is recommended that a score > 5 be used to be predictive of late onset sepsis, and this would have sensitivity of 83.3%, specificity of 61%, positive predictive value of 68.5% and a negative predictive value of 78.3%</p>

Level of understanding and areas of application of cochrane reviews among practicing physicians affiliated with the Philippine General Hospital

Objective. The main objective of this study is to determine the level of understanding, accessibility and areas of application of Cochrane reviews (CR) among medical practitioners affiliated with a tertiary care medical center in Metro Manila, Philippines. Study Design. Survey using a self-administered questionnaire was conducted. Target Population and Setting. Consultant doctors of the Philippine General Hospital (PGH) were invited to participate. The PGH is the national university hospital of the Philippines and is a tertiary referral center and teaching hospital of the University of the Philippines Manila. Sampling Scheme. 101 doctors were chosen by stratified random sampling with the clinical department as the stratification variable. Strata samples were targeted according to strata size (proportional to size). Measurement Instrument. Eight domains that are important in the understanding of the CR were included in a 25-item multiple-choice questionnaire. In addition, facilitating factors and barriers to the application of CR or systematic reviews (SR) were asked. Data Analysis. Using a 25-point Multiple Choice Questionnaire, the knowledge of the respondents was measured and the mean score was estimated at a 95% confidence level. The percentage of CR awareness was also estimated at 95% confidence level. Facilitating factors and barriers in the use of SR were described. In addition, the following post-hoc analyses were done: descriptions of the total score according to gender, age, year graduated and year of last training. Results. Of 101 consultants invited, 59 participated (58% response rate) within the 6-month data collection period. The mean age was 47.2 years with a standard deviation (SD) of 7.8 years. Forty-five respondents (76%) had their last formal medical-related training from 1991 onwards. The mean score was 14.7 points (SD 6.7) using the 25-item multiple choice questions on concepts and principles of systematic reviews. Of these 59 respondents, 49 (83.0%: 95% CI: 75.2 - 90.9) indicated that they were aware of the existence of CR. Of those who were aware of CR, 42 (85.7%, 95% CI: 75.9 -95.6) have actually used them. The following factors help the respondents use CR: efficient Internet access, working knowledge of research methodology, working knowledge of how to critically appraise the medical literature, and familiarity with the terms used in the review. On the other hand, the following were considered barriers: inefficient access, poor knowledge of general research methodology, poor understanding of the principles of Evidence-based medicine (EBM) and difficulty in understanding the reviews. Conclusion. Practicing physicians in a tertiary university hospital in the Philippines were only able to get about 60% of the principles and concepts of understanding SR. Eighty three percent of them are aware of CR. Access to internet, familiarity with terms and working knowledge of CR and evidence-based medicine are the facilitating factors for application of the results of SR and CR. Although most claimed to use the SR results in literature reviews, only about 60% are able to use them in teaching, clinical practice or health policy development.

Cost-benefit analysis of the newborn screening program of the Philippines

BACKGROUND: Newborn Screening (NBS) is a public health activity aimed at the early identification of infants who are affected by certain genetic/metabolic/infectious conditions. A cost analysis is critical for national implementation for integration as a public health program. OBJECTIVES: 1) To determine the incidence rates of congenital hypothyroidism (CH), congenital adrenal hyperplasia (CAH), galactosemia (GAL), phenylketonuria (PKU) and glucose-6-phosphate dehydrogenase (G6PD) deficiency; and 2) To determine whether NBS is cost-beneficial for each disorder individually or in combination, from a societal perspective. STUDY DESIGN: Cross sectional survey and cost-benefit analysis. SUBJECTS AND METHODS: The study was conducted through a screening survey of the original 24 Metro Manila hospitals. Newborns were screened for CH, CAH, GAL, PKU and G6PD deficiency after the 24th hour of life. Those who screened positive underwent serum confirmatory testing. Using incidence rates from the screening survey, a population of 1.5 million, and different screening combinations, the costs for the detection and treatment of the five disorders were compared to the benefits projected from preventing the corresponding complications and consequent productivity losses. For economic evaluation, we compared sequential analysis of doing tandem/multiple testing for the different disorders vs a "do-nothing" alternative. Sensitivity analyses for different incidence and discount rates were conducted to test the strength of the conclusions. RESULTS: The incidences of the disorders with 95% confidence intervals are: CH is 1:3 235 (1:2 219 - 1:5 946); CAH is 1:7 455 (1:4 046 - 1: 14245); GAL is 1: 106 006 (1: 44 218-1:266 796); and G6PD deficiency is 1:167 (1:151 - 1: 186). Screened individually, CH and G6PD deficiency had net benefits of US$ 5.29 M and US$ 15.44 M, respectively. The other conditions yielded net costs when screened individually - CAH (US$ 2.61 M), GAL (US$ 0.90 M) and PKU (US$ 6.74 M). Pairing the disorders with CH showed the following benefit:cost ratios - CH + CAH, 1.3; CH + GAL, 2.0; CH + G6PD deficiency, 3.4; and CH + PKU, 0.9. Combining disorders resulted in the following benefit:cost ratios - CH + CAH + GAL, 1.2; CH + CAH + GAL + PKU, 0.8; and CH + CAH + GAL + G6PD deficiency, 2.1. Screening for the 5 disorders in tandem resulted in a benefit:cost ratio of 1.4 and a net benefit of US$ 11.42 M.

Cost-benefit analysis of a neonatal screening program for congenital hypothyroidism in Metro Manila

BACKGROUND: Neonatal mass screening has led to the early diagnosis and management of congenital endocrine and metabolic diseases. The effectiveness and efficiency of neonatal screening had been well established for congenital hypothyroidism (CH) in other settings. OBJECTIVES: 1) To determine the incidence of CH; and 2) To determine whether a newborn screening program (NSP) for CH is cost-beneficial from a societal perspective. DESIGN: Screening survey with cost-benefit analysis. SUBJECTS AND METHODS: Newborns from the original 24 hospitals in Metro Manila that started newborn screening were screened for CH after the 48th hour of life. Confirmatory tests were performed for those who screened positive. Using the incidence from the survey, the costs for the detection and treatment of CH were compared to the projected benefits of preventing the mental retardation and consequent productivity losses. Sensitivity analyses for incidence rates, discount rates and timing of blood collection were included. RESULTS: A total of 28,088 newborns (40% of 69,391 live births) were screened. Ninety-two were recalled for confirmatory testing after the initial screen; 8 were diagnosed with CH. Assuming that a cohort of 200,000 newborns would be screened in one year, the net costs for the screening program were US$ 2.4M. If the timing of blood collection was after the 24th hour, there was instead a net benefit of US$ 0.6M. The incidence of CH among the hospital admissions in Metro Manila was 0.037% (95% CI 0.009 - 0.064%). CONCLUSIONS: The net cost of a screening program for CH taken after 48 hours was US$ 2.4M. Newborn screening for CH was cost-beneficial if blood collection occurred after the 24th hour so that expense of an additional hospital day was not incurred. In order to realize the costing benefits illustrated by this study, the timing of sample collection was moved to a day earlier (after 24 hours of age) beginning in 2000.

Cost-benefit analysis of newborn screening for galactosemia in the Philippines.

To determine the incidence of galactosemia (GAL) in the Philippines and to determine whether newborn screening for GAL is cost-beneficial from a societal perspective, cost-benefit analysis was performed. Newborn screening for GAL was done after the 24th hour of life using the Beutler test. Patients screened positive were recalled for confirmatory testing. Using incidence rates obtained from the different participating hospitals of the Philippine Newborn Screening Program (PNSP), the costs for the detection and treatment of GAL were compared to the expected benefits by preventing mental retardation, cataracts and other physical disabilities caused by the disorder that would lead to a loss of productivity for the individual. Sensitivity analyses for incidence and discount rates were also included. Of the 157,186 newborns screened by the PNSP since its inception in 1996, 8 screened positive results. Confirmatory testing of these patients showed that 2 had galactosemia. The incidence of galactosemia in this population therefore, is 1 in 106,006 (95% CI= 1:44,218 - 1:266,796). Projecting the figures to the actual birth rate (1.5M newborns/year), the total costs of the screening program amounted to $1.1M, while the total benefits amounted only to $0.2M, yielding net cost of $0.9M. A cost-benefit analysis of the screening program for galactosemia using the incidence 1 in 106,006 demonstrated that the costs of the program outweigh the benefits. The true incidence of galactosemia in the Philippine population may yield an incidence rate that will result in greater net benefits for the program.

Association between hypertension and serum uric acid among Filipinos undergoing executive check-ups

OBJECTIVES: Among relatively healthy Filipinos undergoing executive check-ups (periodic health examinations), the study aims 1.) To determine the correlation of hypertension and serum uric acid, 2.) To determine the association between serum uric acid and age, sex, obesity or relative weight, cigarette smoking, alcohol intake, diabetes mellitus, anti-hypertensive drug intake, cholesterol, and serum triglyceride, and 3.) To determine prevalence of hyperuricemia.METHODS: Retrospective chart review of 2188 adult Filipinos undergoing executive medical check-ups in 6 major hospitals Results: Hyperuricemia was present in 37.9 percent (adjusted prevalence, 95 percentCI 36.0-39.9) (n=845). The mean uric acid was 0.38 mmol/L (95 percent CI 0.37-0.39). It was significantly associated with hypertension at adjusted Odds Ratio 1.27 (95 percent CI 1.05-1.53, p=0.013). The risk factors for hyperuricemia were age, male, weight, smoking, alcohol intake, hypertension, normoglycemia, triglycerides, and cholesterol. After adjustment in a step-wise logistic regression, the independent predictors identified were hypertension, hypercholesterolemia, age, males and non-diabetics.CONCLUSIONS: Hypertension was significantly associated with hyperuricemia among adult Filipinos undergoing periodic health check-ups. The major predictors of elevated serum uric acid were hypertension, male sex, hypercholesterolemia, age and absence of diabetes mellitus. The prevalence of hyperuricemia at 37.9 percent was much higher compared to a previous local study (21 percent) and prevalence studies from other countries (8.4-27.6 percent).

A survey of current prescribing practices in juvenile rheumatoid arthritis among pediatric rheumatologists in North America

Objetivo: Descrever as tendências atuais de prescriçao dos reumatologistas pediátricos da América do Norte no tratamento da artrite reumatóide juvenil (ARJ). Desenho do estudo: Estudo transversal utilizando-se questionários enviados pelo correio. Participantes: Duzentos e dezesseis questionários foram postados com 82 por cento de taxa de resposta. Das 177 respostas somente 130 reumatologistas pediátricos satisfizeram o critério de inclusao. Métodos: Quatro postagens foram realizadas num período de oito semanas. Resultados: Oitenta e um (63 por cento) reumatologistas pediátricos escolheram naproxen como droga inicial para o tratamento da ARJ pauciarticular e 77 (59 por cento) para o tratamento da ARJ de início poliarticular. Para a forma sistêmica, tando os salicilatos como o naproxen foram as preferidas como drogas de início para o controle dos sintomas articulares, enquanto o salicilato foi a droga de escolha de 43 reumatologistas para controlar sintomas sistêmicos. Para a ARJ pauciarticular, o tolmetin foi referido por 50 (38 por cento) reumatologistas como droga subseqüente a ser utilizada se a droga inicial nao apresentar sucesso. Para a forma poliarticular da ARJ, tolmetin, naproxen e indometacina foram referidas como drogas alternativas. Para controlar os sintomas articulares da ARJ de início sistêmico, tolmetin foi escolhido por 32 (24,6 por cento) dos reumatologistas como medicaçao subseqüente, enquanto a prednisona foi escolhida por 38 (29 por cento) reumatologistas para o controle da atividade sistêmica. Os derivados do ácido salicílico foram considerados por 42 (32 por cento) dos reumatologistas como sendo a droga mais efetiva no tratamento da ARJ pauciarticular. Para a ARJ poliarticular, o metotrexato foi a droga de escolha. Os sintomas articulares e sistêmicos da ARJ sistêmico foram referidos como sendo efetivamente controlados pelo prednisona. Conclusao: Naproxen foi escolhido como a droga inicial no tratamento da ARJ pauci e poliarticular. Os salicilatos, metotrexato e prednisona foram as drogas consideradas mais efetivas pelos reumatologistas pediátricos no tratamento das formas pauci, poli e sistêmica da ARJ. Estudos adicionais que priorizem a avaliaçao destas drogas devem ser realizados