Skin and soft tissue infections in hospitalised patients with diabetes: culture isolates and risk factors associated with mortality, length of stay and cost.

AIMS/HYPOTHESIS: Skin and soft tissue infections (SSTIs) cause substantial morbidity in persons with diabetes. There are few data on pathogens or risk factors associated with important outcomes in diabetic patients hospitalised with SSTIs. METHODS: Using a clinical research database from CareFusion, we identified 3,030 hospitalised diabetic patients with positive culture isolates and a diagnosis of SSTI in 97 US hospitals between 2003 and 2007. We classified the culture isolates and analysed their association with the anatomic location of infection, mortality, length of stay and hospital costs. RESULTS: The only culture isolate with a significantly increased prevalence was methicillin-resistant Staphylococcus aureus (MRSA); prevalence for infection of the foot was increased from 11.6 to 21.9% (p < 0.0001) and for non-foot locations from 14.0% to 24.6% (p = 0.006). Patients with non-foot (vs foot) infections were more severely ill at presentation and had higher mortality rates (2.2% vs 1.0%, p < 0.05). Significant independent risk factors associated with higher mortality rates included having a polymicrobial culture with Pseudomonas aeruginosa (OR 3.1), a monomicrobial culture with other gram-negatives (OR 8.9), greater illness severity (OR 1.9) and being transferred from another hospital (OR 5.1). These factors and need for major surgery were also independently associated with longer length of stay and higher costs. CONCLUSIONS/INTERPRETATION: Among diabetic patients hospitalised with SSTI from 2003 to 2007, only MRSA increased in prevalence. Patients with non-foot (vs foot) infections were more severely ill. Independent risk factors for increased mortality rates, length of stay and costs included more severe illness, transfer from another hospital and wound cultures with Pseudomonas or other gram-negatives.

The early prediction of mortality in acute pancreatitis: a large population-based study.

BACKGROUND: Identification of patients at risk for mortality early in the course of acute pancreatitis (AP) is an important step in improving outcome. METHODS: Using Classification and Regression Tree (CART) analysis, a clinical scoring system was developed for prediction of in-hospital mortality in AP. The scoring system was derived on data collected from 17,992 cases of AP from 212 hospitals in 2000-2001. The new scoring system was validated on data collected from 18,256 AP cases from 177 hospitals in 2004-2005. The accuracy of the scoring system for prediction of mortality was measured by the area under the receiver operating characteristic curve (AUC). The performance of the new scoring system was further validated by comparing its predictive accuracy with that of Acute Physiology and Chronic Health Examination (APACHE) II. RESULTS: CART analysis identified five variables for prediction of in-hospital mortality. One point is assigned for the presence of each of the following during the first 24 h: blood urea nitrogen (BUN) >25 mg/dl; impaired mental status; systemic inflammatory response syndrome (SIRS); age >60 years; or the presence of a pleural effusion (BISAP). Mortality ranged from >20% in the highest risk group to <1% in the lowest risk group. In the validation cohort, the BISAP AUC was 0.82 (95% CI 0.79 to 0.84) versus APACHE II AUC of 0.83 (95% CI 0.80 to 0.85). CONCLUSIONS: A new mortality-based prognostic scoring system for use in AP has been derived and validated. The BISAP is a simple and accurate method for the early identification of patients at increased risk for in-hospital mortality.

The safety of intravenous diuretics alone versus diuretics plus parenteral vasoactive therapies in hospitalized patients with acutely decompensated heart failure: a propensity score and instrumental variable analysis using the Acutely Decompensated Heart Failure National Registry (ADHERE) database.

BACKGROUND: The treatment of acute decompensated heart failure remains problematic and most often requires parenteral therapies. Significant concerns have been expressed regarding risks and benefits of individual therapies, especially nesiritide (NES), but few studies have compared the relative safety of varied intravenous therapies on clinical outcomes. METHODS: We compared the safety of intravenous diuretics (DIUR), inotropes (INO), and vasodilators (nitroglycerin [NTG]) on mortality rates and worsening renal function in 99,963 inpatients with acutely decompensated heart failure (ADHF). Patients with a diagnosis of ADHF within 48 hours were grouped by intended primary treatment (intravenous agents administered during the first 2 hours of intravenous therapy). Treatments studied were (a) intended monotherapy (DIUR), (b) intended combination therapy (DIUR + NES, NTG, or INO), and (c) sequential therapy (intended DIUR monotherapy followed by a second agent administered >2 hours later). Propensity-matched cohorts and instrumental analysis were used to adjust for differences among patients in treatment groups. RESULTS: Intended DIUR monotherapy yielded an unadjusted inpatient mortality rate of 3.2%. After intended DIUR monotherapy, inpatient mortality was not higher for sequential use of NES than for sequential use of NTG (3.4% vs 6.2%, P = .0028). In all regimens, INOs were associated with higher inpatient mortality than were diuretics or vasodilators used alone. The rate of worsening renal function was higher with combination of diuretic-based regimens with NES (risk ratio 1.44, P < .0001) or NTG (RR 1.2, P = .012) compared with diuretics alone. CONCLUSIONS: Compared with alternative intravenous regimens, administration of vasodilators, including NES, was not associated with increased inpatient mortality. A large randomized controlled clinical trial is being planned to prospectively address the question of risks and benefits of NES for ADHF.

Adverse outcomes from hospital-acquired infection in Pennsylvania cannot be attributed to increased risk on admission.

In July 2005, Pennsylvania became the first state in the nation to publicly report statewide data on hospital-acquired infections (HAI). The published research brief revealed that 11 668 hospitalizations with HAI had markedly different mortality rates, lengths of stay (LOS), and charges than cases without HAI did. To avoid a possibly biased comparison, a 5 to 1 propensity-matched cohort study was performed. Nine cohorts (ie, heart failure, chronic obstructive pulmonary disease, respiratory failure, pneumonia, hip fracture, major surgical complications, colonic resection, diabetes, and gastrointestinal bleeding) were examined for differences in mortality, LOS, and hospital charges. Statistically significant increases in mortality, LOS, and charges were found among HAI cases. HAI cases had more than a 4 times higher median charge than nonHAI controls did. Observed differences in mortality, LOS, and charges between HAI and non-HAI cases in Pennsylvania cannot be explained on the basis of increased disease-specific severity at the time of admission.

Morbidity and cost burden of methicillin-resistant Staphylococcus aureus in early onset ventilator-associated pneumonia.

INTRODUCTION: To gain a better understanding of the clinical and economic outcomes associated with methicillin-resistant Staphylococcus aureus (MRSA) infection in patients with early onset ventilator-associated pneumonia (VAP), we retrospectively analyzed a multihospital US database to identify patients with VAP over a 24 month period (2002-2003). METHOD: Data recorded included physiologic, laboratory, culture, and other clinical variables from 59 institutions. VAP was defined as new positive respiratory culture after at least 24 hours of mechanical ventilation (MV) and the presence of primary or secondary ICD-9-CM diagnosis codes of pneumonia. Outcomes measures included in-hospital morbidity and mortality for the population overall and after onset of VAP (duration of MV, intensive care unit [ICU] stay, in-hospital stay, and case mix and severity-adjusted operating cost). The overall cost was calculated at the hospital level using the Center for Medicare and Medicaid Services Cost/Charge Index for each calendar year. RESULTS: A total of 499 patients were identified as having VAP. S. aureus was the leading organism (31% of isolates). Patients with MRSA were significantly older than patients with methicillin-sensitive Staphylococcus aureus (MSSA; median age 74 versus 67 years, P < 0.05) and more likely to be medical patients. Compared with MSSA patients, MRSA patients on average consumed excess resources of 4.4 (95% confidence interval 0.6-8.2) overall MV days, 3.8 (-0.5 to +8.0) days of inpatient length of stay (LOS), 5.3 (1.0-9.7) ICU days, and US7731 dollars (-US8393 dollars to +US23,856 dollars) total cost after controlling for case mix and other factors. Furthermore, MRSA patients needed excess resources after the onset of VAP (4.5 [95% confidence interval 1.0-8.1] MV days, 3.7 [-0.5 to +8.0] inpatient days, and 4.4 [0.4-8.4] ICU days) after controlling for the same case mix and admission severity covariates. CONCLUSION: S. aureus remains a common cause of VAP. VAP due to MRSA was associated with increased overall LOS, ICU LOS, and attributable ICU LOS compared with MSSA-related VAP. Although not statistically significant because of small sample size and large variation, the attributable excess costs of MRSA amounted to approximately US8000 dollars per case after controlling for case mix and severity.

Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia.

CONTEXT: Traditionally, pneumonia developing in patients outside the hospital is categorized as community acquired, even if these patients have been receiving health care in an outpatient facility. Accumulating evidence suggests that health-care-associated infections are distinct from those that are truly community acquired. OBJECTIVE: To characterize the microbiology and outcomes among patients with culture-positive community-acquired pneumonia (CAP), health-care-associated pneumonia (HCAP), hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP). DESIGN AND SETTING: A retrospective cohort study based on a large US inpatient database. PATIENTS: A total of 4,543 patients with culture-positive pneumonia admitted into 59 US hospitals between January 1, 2002, and December 31, 2003, and recorded in a large, multi-institutional database of US acute-care hospitals (Cardinal Health-Atlas Research Database; Cardinal Health Clinical Knowledge Services; Marlborough, MA). MAIN MEASURES: Culture data (respiratory and blood), in-hospital mortality, length of hospital stay (LOS), and billed hospital charges. RESULTS: Approximately one half of hospitalized patients with pneumonia had CAP, and > 20% had HCAP. Staphylococcus aureus was a major pathogen in all pneumonia types, with its occurrence markedly higher in the non-CAP groups than in the CAP group. Mortality rates associated with HCAP (19.8%) and HAP (18.8%) were comparable (p > 0.05), and both were significantly higher than that for CAP (10%, all p < 0.0001) and lower than that for VAP (29.3%, all p < 0.0001). Mean LOS varied significantly with pneumonia category (in order of ascending values: CAP, HCAP, HAP, and VAP; all p < 0.0001). Similarly, mean hospital charge varied significantly with pneumonia category (in order of ascending value: CAP, HCAP, HAP, and VAP; all p < 0.0001). CONCLUSIONS: The present analysis justified HCAP as a new category of pneumonia. S aureus was a major pathogen of all pneumonias with higher rates in non-CAP pneumonias. Compared with CAP, non-CAP was associated with more severe disease, higher mortality rate, greater LOS, and increased cost.

Clinical outcome of the use of enteral stents for palliation of patients with malignant upper GI obstruction.

BACKGROUND: The endoscopically placed enteral stent has emerged as a reasonable alternative to palliative surgery for malignant intestinal obstruction. This is a report of our experience with the use of enteral stents for nonesophageal malignant upper GI obstruction. METHODS: Data on all patients who had undergone enteral stent placement were reviewed. Those with a diagnosis of pancreatic cancer were compared with another similar cohort of patients who underwent palliative gastrojejunostomy. RESULTS: Thirty-one procedures were performed on 29 patients (mean age 67.7 years). Thirteen (45%) were men and 16 (55%) women. The diagnoses were gastric (13.8%), duodenal (10.3%), pancreatic (41.4%), metastatic (27.6%), and other malignancies (6.9%). Malignant obstruction occurred at the pylorus (20.7%), first part of duodenum (37.9%), second part of duodenum (27.6%), third part of duodenum (3.5%), and anastomotic sites (10.3%). Twenty-nine (93.5%) procedures were successful and good clinical outcome was achieved in 25 (80.6%). Re-obstruction by tumor ingrowth occurred in 2 patients after a mean of 183 days. The median survival time for patients with pancreatic cancer who underwent enteral stent placement compared with those who underwent surgical gastrojejunostomy was 94 and 92 days, charges were $9921 and $28,173, and duration of hospitalization was 4 and 14 days, respectively (latter 2 differences with p value < 0.005). CONCLUSION: Endoscopic enteral stent placement of nonesophageal malignant upper GI obstruction is a safe, efficacious, and cost-effective procedure with good clinical outcome, lower charges, and shorter hospitalization period than the surgical alternative.

Designing an emergency medicine physician workstation to support risk management in decision making.

The practice of emergency medicine requires rapid decision making. The speed of decision making in the face of limited information contributes to the high risk of medical malpractice suits. We explore design approaches to an emergency physician electronic medical record product, EMstation, that may reduce the risk of adverse medical events by providing cues and tools while the patient may still be in the emergency department. EMstation is an Emergency Medicine Physician Workstation base on a Microsoft Windows 3.1 user interface. Because adaptation and adaptability to physician needs are critical to user acceptance, design to workflow, multisite end user customization, and integrated database support are used to support risk management documentation in EMstation. This article describes techniques that can be incorporated into electronic medical products which may prevent adverse medical events.

The role of automated speech recognition in endoscopic data collection.

Speech recognition technology has developed substantially in the past half decade. Currently, large vocabulary, speaker independent, discrete recognizers are the state-of-the-art. This will change. Moderate sized, continuous recognition systems now exist in research settings. However, it is unlikely that such systems will be widely available until the mid to late 1990's. The accuracy rates of current speech recognition systems are high. Consequently, speech accuracy is not the current limiting aspect of using ASR. The limiting aspect of using ASR technology is the approach to integrating speech functionality into applications. One approach is to use ATNs as models of natural language to support both an input strategy and a text generation system. ATNs provide approaches to both syntactical correctness and semantic richness. This is an approach which plays to the strengths of the discrete nature of current speech technology and also provides a methodology for the capture and archiving of highly detailed information. The ATN approach avoids the natural language parsing problem created by a fully free form dictation interface. Evolving along with the underlying speech technology are standards in the definitions and criteria used in endoscopic practice. There are clear benefits from standards in this area. However, it is likely that this will also take several years and may never yield a universally accepted lexicon. Furthermore, there will be user interface barriers to surmount in any system attempting to use speech as an input modality. Because of the relatively large vocabularies used in medical discourse, the user interface will need to be carefully crafted.(ABSTRACT TRUNCATED AT 250 WORDS)

The quality of gastroenterological reports based on free text dictation: an evaluation in endoscopy and ultrasonography.

The majority of physicians consider the use of free dictation for medical reports to be essential in many domains. One of the main criticisms of structured data entry is the possible lack of flexibility and completeness. Electronic documentation systems exist for endoscopy and ultrasonography examinations which are based on structured input as well as on free dictation. Endoscopy and ultrasonography reports based on free dictation were evaluated for omissive errors. The data evaluated was drawn from a database of 18,239 gastroscopy and 3,340 colonoscopy reports dictated by 28 physicians over 74 months, and 18,834 ultrasonography reports dictated by 37 physicians over 42 months. The error rates varied from 0% to 41.8% depending upon the particular feature and the particular examination, but were usually below 15%. The results were independent of the experience of the examiner. This study provides baseline measurements of omissive error rates for selected findings in gastrointestinal endoscopy and abdominal ultrasonography which can be used as standards for the development and evaluation of systems for collection of clinical data.

Computer-based reconstructions of the cardiac ventricles of human embryos.

The early appearance and relatively large size of the embryonic heart suggest that cardiac function is critical to early development. Previous studies had shown that an index derived from curvature and thickness of the ventricular wall provides an estimate of the pressure generating capacity of the myocardium. To obtain an estimate of the functional capability of the embryonic ventricle, images of serial histologic sections of eight normal human embryos, ranging from stages 9-23, from the Carnegie Embryological Collection were chosen for study. The contours of ventricular components were digitized and entered into a computer, and three-dimensional (3-D) reconstructions were created. Volumes of the components of the ventricles were determined, including the compact or outer portion of the ventricular wall, the cardiac jelly, the overall volume containing trabeculated myocardium in each ventricle, and the proportion of that volume consisting of muscle. The results showed a highly significant increase in overall ventricular size as a function of Carnegie stage and crown-rump length. Cardiac jelly was prominent in the early stages but was progressively replaced by the trabeculated muscle. The volume containing trabeculae had a consistent proportion of muscle, averaging 65%, for all stages after its appearance in stage 13. Curvature and thickness measurements of the compact part of the ventricles were made from images of the reconstructions. The mean curvature-thickness index (CTI) for the embryo hearts ranged from 0.24-0.61, and there was a significant increase in the index as a function of stage and crown-rump length.(ABSTRACT TRUNCATED AT 250 WORDS)

A longitudinal survey of self-reported bowel habits in the United States.

Information concerning bowel habits was gathered from a representative sample of 14,407 United States adults in the first National Health and Nutrition Examination Survey in 1971-1975 and approximately 10 years later among the same individuals. The prevalence of self-reported constipation, diarrhea, infrequent defecation (three or fewer bowel movements per week), and frequent defecation (two or more bowel movements per day) increased with aging. Women were more likely than men (P less than 0.05) to report constipation (20.8% compared to 8.0%) and infrequent defecation (9.1% compared to 3.2%). Blacks were more likely than whites to report infrequent defecation (P less than 0.05). Older respondents reporting constipation were more likely to use laxatives or stool softeners than younger respondents reporting constipation, but they were also less likely to have infrequent defecation. To evaluate factors predictive of impaired bowel function, case definitions were created using information concerning complaint of constipation, laxative use, frequency of defecation, and stool consistency. Female gender, black race, fewer years of education, low physical activity, and symptoms of depression were independent risk factors for impaired bowel function. This study provides national estimates of bowel complaints and their natural history and examines possible risk factors for constipation.

Prevalence of gallstone disease in Hispanic populations in the United States.

The 1982-1984 Hispanic Health and Nutrition Examination Survey used ultrasonography to investigate the epidemiology of gallstone disease. Mexican American, Cuban American, and Puerto Rican men and women, aged 20-74 yr, were selected from household samples in Texas, New Mexico, Arizona, Colorado, California, Connecticut, New Jersey, New York, and Florida. Ultrasonography was performed on 2299 persons. The age-adjusted prevalence of gallstone disease (gallstones + cholecystectomy) among Mexican American men (7.2%) was 1.7 times that of Cuban American men and 1.8 times that of Puerto Rican men. The prevalence for Mexican American women (23.2%) was 1.5 times that of Cuban American women and 1.7 times that of Puerto Rican women. Rates were about three times higher among women than men and increased with age in both sexes and all ethnic groups except older Puerto Rican women. Among Mexican American women aged 60-74 yr, the prevalence of gallstone disease reached 44.1%. These results support the hypothesis that Mexican Americans are at increased risk of gallstone disease.

Prescription-writing with a PC.

We described the development of an automated system to perform writing of prescriptions and associated advice. A prototype computer program has been in operation in a dermatologist's office for three years. All prescriptions are routinely generated using the system. The program, originally developed for a multi-user computer system, now operates in a self-contained personal computer. The program is constructed to use external human-readable files as the drug formulary or data base. Experience with this system and efforts to expand its applicability to another ambulatory care setting (gastroenterology) are described. Rapid access to drug names and related information is achieved using diagnosis-specific subsets contained in the personally defined formulary. This organization supports rapid pruning of the list of drugs. From this point, a prescription of the selected drug is displayed on a video terminal. The base-level prescription is easily modified using only five keys organized in a cluster. Preliminary training and performance studies are summarized.

Effect of physician tutorials on prescribing patterns of graduate physicians.

Pessimism has been expressed in the medical literature as to the efficacy of educational interventions in modifying practice patterns of graduate physicians. As a result, a prospective controlled trial of a specific form of educational intervention, the physician tutorial, was designed to test this belief. Physicians in the experimental group were surveyed to assess their knowledge of the effectiveness, cost and side effects of antibiotics used in the treatment of a preselected index condition, and a tutorial was developed to modify suboptimal prescribing patterns. Antibiotic usage patterns were initially similar for the experimental and control physicians. Prescribing patterns afterwards were statistically different, with the experimental physicians increasing their prescription of the encouraged antibiotics and decreasing that of the discouraged antibiotics. This was accompanied by a statistically significant decrease in direct drug charges. These results suggest that educational programs can be effective in modifying graduate physician prescribing practices.

Non-traumatic hemobilia.

A case of gastrointestinal bleeding due to hemobilia is presented. Extensive preoperative evaluation, including arteriography, did not unambiguously identify the source of hemorrhage. The differential diagnosis of this treatable cause of gastrointestinal bleeding is discussed.