Targets for antibiotic and healthcare resource stewardship in inpatient community-acquired pneumonia: a comparison of management practices with National Guideline Recommendations.

PURPOSE: Community-acquired pneumonia (CAP) is the most common infection leading to hospitalization in the USA. The objective of this study was to evaluate management practices for inpatient CAP in relation to Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) guidelines to identify opportunities for antibiotic and health care resource stewardship. METHODS: This was a retrospective cohort study of adults hospitalized for CAP at a single institution from 15 April 2008 to 31 May 2009. RESULTS: Of the 209 patients with CAP who presented to Denver Health Medical Center during the study period and were hospitalized, 166 (79 %) and 43 (21 %) were admitted to a medical ward and the intensive care unit (ICU), respectively. Sixty-one (29 %) patients were candidates for outpatient therapy per IDSA/ATS guidance with a CURB-65 score of 0 or 1 and absence of hypoxemia. Sputum cultures were ordered for 110 specimens; however, an evaluable sample was obtained in only 49 (45 %) cases. Median time from antibiotic initiation to specimen collection was 11 [interquartile range (IQR) 6-19] h, and a potential pathogen was identified in only 18 (16 %) cultures. Blood cultures were routinely obtained for both non-ICU (81 %) and ICU (95 %) cases, but 15 of 36 (42 %) positive cultures were false-positive results. The most common antibiotic regimen was ceftriaxone + azithromycin (182, 87 % cases). Discordant with IDSA/ATS recommendations, oral step-down therapy consisted of a new antibiotic class in 120 (66 %), most commonly levofloxacin (101, 55 %). Treatment durations were typically longer than suggested with a median of 10 (IQR 8-12) days. CONCLUSIONS: In this cohort of patients hospitalized for CAP, management was frequently inconsistent with IDSA/ATS guideline recommendations, revealing potential targets to reduce unnecessary antibiotic and healthcare resource utilization.

[Current concepts of patient safety: rapid response system]. / Aktuelle Konzepte der Patientensicherheit : Das "Rapid-response"-System.

The "100,000 lives campaign" initiated a wide-spread implementation of rapid response teams in the United States. A standardized rapid response system (RRS) is designed to reduce the preventable mortality of hospitalized patients who frequently have progressive signs of physiological deterioration minutes to hours before cardiac arrest. The implementation and maturation of a team-based RRS has been shown to significantly reduce the incidence of "COR zero" calls and, in some studies, the in-hospital mortality rate. An alternative model to rapid response teams has been recently proposed which is based on defined clinical triggers to initiate a "rapid response escalation". This clinical triggers program overcomes the classic limitations of a team-based system, such as the overuse of resources and the fragmentation of patient care. The present review outlines the basic RRS concept with a focus on the debate related to the "perfect" patient safety system, namely the validity of a distinct rapid response teams approach versus a trigger-based escalation modality. The implementation of a standardized RRS should also be considered in German hospitals with the aim of improving patient safety and reducing preventable in-hospital mortality.

Tramadol-associated pericarditis.

Tramadol, marketed as Ultram in the United States, is as a non-scheduled narcotic analgesic based on its low abuse liability. It is indicated for the treatment of moderately severe pain; however, multiple adverse effects have been reported with its use including seizures, anaphylaxis, angioedema, bronchospasm, and serotonin syndrome. An association between tramadol and pericarditis has not been previously reported. We describe the case of an 88 year-old male who developed acute pericarditis 2 days following tramadol initiation. The temporal relationship between drug initiation and pericarditis as well as the resolution of symptoms upon drug discontinuation suggested a potential association. Although pericarditis has not been described with tramadol administration, clinicians should be aware of a possible association.

Osteoporosis: prevention and treatment in anorexia nervosa.

One of the most serious and potentially permanently disabling medical complications of anorexia nervosa is osteoporosis, which greatly increases the long-term risk of bone fractures. The decreased bone density in patients with anorexia nervosa (AN) is due to the many effects on bone metabolism of amenorrhea, reduced levels of insulin growth factor-1 (IGF-1), high cortisol levels and weight loss. Although estrogen replacement therapy is clearly efficacious in preventing postmenopausal osteoporosis, its efficacy in AN is uncertain. Clinicians caring for patients with AN need to be aware of this because, despite such therapy, there may be an inexorable decline in bone mineral density in what is a relatively young group of patients. AN frequently has its onset during adolescence, when peak bone mass is normally reached, and an anorectic episode in youth may permanently impair skeletal integrity and lead to debilitating fractures and pain. It is important to recognise this formidable risk, counsel AN patients about the longterm and possibly permanent sequelae of low body weight, use densitometry to screen for bone loss and treat it accordingly. The most effective treatment is still early weight restoration and the resumption of menses.

Treatment of hypertension in type 2 diabetes.

Hypertension is one of the most common medical conditions in the United States, affecting 50 million American adults and accounting for one of four physician office visits. It is often undetected and undertreated, creating significant public health consequences. In diabetes, hypertension is an even greater problem, as diabetes has become the most common single cause of end-stage renal disease (ESRD) in the world, and diabetes is increasing in prevalence. The most important factor in slowing the decline of renal function in diabetes is aggressive treatment of hypertension. Recent guidelines have emphasized that the target blood pressure levels for patients with diabetes should be lower than in other hypertensive groups. The best specific approach for the treatment of hypertension in diabetic patients is the subject of much debate. It may be in the end that the specific drug choice has less overall importance than the actual attainment of adequate blood pressure control. In addition, more credence must be placed on the value of treating systolic hypertension than has traditionally been given. Coexisting diabetes and hypertension are a common clinical scenario that can set off a vicious cycle of increasing renal damage, rising blood pressure, and increased cardiovascular morbidity and mortality. Treatment often requires multiple drugs to effectively preserve renal function and prevent complications.

Diagnosis and care of patients with anorexia nervosa in primary care settings.

Anorexia nervosa is a psychiatric disorder characterized by abnormal eating behaviors that results in weight loss and has serious potential medical consequences. Most of these complications are readily treatable if diagnosed and attended to early in the course of the illness. In caring for patients with anorexia nervosa, the primary care physician has several critical roles. Because patients deny the severity of their illness, they delay seeking psychiatric treatment. The primary care physician must be skilled in recognizing this disorder, as well as in diagnosing and effectively treating the medical complications while educating the patient about them. The primary care physician is also involved with arranging and coordinating a comprehensive and multidisciplinary program, including dietary and mental health treatment. The multidisciplinary team is responsible for ensuring safe weight restoration and a judicious refeeding treatment plan. In addition to establishing the diagnosis and treating the multiple medical complications associated with anorexia nervosa, the primary care physician plays a central role in maintaining continuity of care despite the fact that successful care may require a variety of treatment settings. Factors that foster good prognoses for this increasingly common and often protracted eating disorder include early diagnosis and skilled medical intervention to prevent the inexorable physical decline that marked weight loss can cause.

Use of curanderismo in a public health care system.

BACKGROUND: Curanderismo ("the healing") is a centuries-old synthesis of Mexican Indian culture and beliefs. OBJECTIVE: To evaluate the rate of use of curanderismo among Hispanic subjects seeking medical care at the Denver Health Medical Center, Denver, Colo. METHODS: We conducted a survey of 405 Hispanic subjects attending outpatient primary and urgent care clinics at Denver Health Medical Center, the public hospital system for Denver. The main outcome measure was independent predictors of use of curanderos. RESULTS: Of the 405 subjects, 118 (29.1%) (95% confidence interval, 20.9-37.3) had been to a curandero at some time in their lives. Of all the subjects, 91.3% knew what a curandero was. Univariate analyses demonstrated an association between those who had been to a curandero and level of income, level of education, and whether the subject was bilingual. The results of fitting a stepwise logistic regression model revealed an independent association with subjects who had been to a curandero and level of household income (>$20 000 vs <$10 000), with an odds ratio of 2.19 (95% confidence interval, 1.20-4.01) (P =.01), and level of education (post--high school vs elementary school), with an odds ratio of 3.16 (95% confidence interval, 1.45-6.86) (P =.004). CONCLUSIONS: Many Hispanic patients who receive their health care at a public hospital system use the services of curanderos. This potentially has important implications for their health care.

Russian immigrant cardiovascular risk assessment.

Immigration from the former Soviet Union has been increasing. In 1990, there were 454,000 Russian immigrants living in the United States. Lifestyle habits prevalent in Russia, including smoking, alcoholism, and little preventive health, are compelling medical and economic reasons to understand the health status of this population. This study identified a cohort of Russian-born subjects living in Denver to characterize their cardiovascular risk profile. Using a risk assessment questionnaire, 204 Russian immigrants were screened. Seventy-one percent had Medicaid insurance; 14 percent were medically indigent. Those aged 55 to 64 years had a higher prevalence of hyperlipidemia (p < 0.04) and hypertension (p < 0.03) than U.S. counterparts; those age 20 to 34 and 65 to 74 years had a higher prevalence of hypertension (p < 0.00001). Almost half of the participants had two or more cardiac risk factors. Cardiac risk factor identification and intervention programs may help to reduce the health care costs for these patients.

Predicting patient visits to an urgent care clinic using calendar variables.

OBJECTIVE: To develop a prediction equation for the number of patients seeking urgent care. METHODS: In the first phase, daily patient volume from February 1998 to January 1999 was matched with calendar and weather variables, and stepwise linear regression analysis was performed. This model was used to match staffing to patient volume. The effects were measured through patient complaint and "left without being seen" rates. The second phase was undertaken to develop a model to account for the continual yearly increase in patient volume. For this phase daily patient volume from February 1998 to April 2000 was used; the patient volume from May 2000 to July 2000 was used as a validation set. RESULTS: First-phase prediction equation was: daily patient volume = 66.2 + 11.1 January + 4.56 winter + 47.2 Monday + 37.3 Tuesday + 35.6 Wednesday + 28.2 Thursday + 24.2 Friday + 7.96 Saturday + 10.1 day after a holiday. This equation accounted for 75.2% of daily patient volume (p<0.01). Inclusion of significant weather variables only minimally improved the predictive ability (r(2) = 0.786). The second-phase final model was: daily patient volume = 57.2 + 0.035 Newdate + 52.0 Monday + 44. 2 Tuesday + 39.2 Wednesday + 30.2 Thursday + 26.5 Friday + 10.9 Saturday + 12.2 February + 3.9 March, which accounted for 72.7% of the daily variation (p<0.01). The model predicted the patient volume in the validation set within +/-11%. When the first-phase model was used to predict patient volume and thus staffing, the percentage of patients who left without being seen decreased by 18. 5% and the number of patient complaints dropped by 30%. CONCLUSIONS: Use of a prediction equation allowed for improved accuracy in staffing patterns with associated improvement in measures of patient satisfaction.

Glycemic control in English- vs Spanish-speaking Hispanic patients with type 2 diabetes mellitus.

BACKGROUND: Hispanic individuals compose the fastest growing minority group in the United States, yet little is known about how language impacts their health care. The primary objective of this study was to determine whether the inability to speak English adversely affected glycemic control in Hispanic patients with type 2 diabetes mellitus. METHODS: This retrospective cohort study selected 183 Hispanic patients with type 2 diabetes mellitus aged 35 to 70 years from a public health care system; patients were Spanish-speaking (SS) only, and control patients were English-speaking (ES) or bilingual. Clinical information was collected via telephone survey, and data on health care use, diagnosis, and glycosylated hemoglobin A(1c) (HbA(1c)) values were obtained from administrative and laboratory information systems. RESULTS: Values of HbA(1c) for SS (mean, 9.1%; range, 5.0%-15.3%) and ES (mean, 9.0%; range, 4.9%-16.2%) patients with diabetes mellitus and the total number of hospitalizations related and unrelated to diabetes mellitus did not differ (P =.86). Spanish-speaking patients had a diagnosis of diabetes mellitus for fewer years than ES patients (8.2 and 11.2 years, respectively; P =. 01). Spanish-speaking patients were less likely to understand their prescriptions; 22% of SS patients reported no comprehension vs 3% of ES patients (P =.001). There was a trend toward decreased prevalence of insulin use among SS patients compared with ES patients (30% vs 42%, respectively; P =.07). CONCLUSIONS: Glycemic control in Hispanic patients was not related to their ability to speak English. This finding may be explained by a high degree of language concordance between patients and providers.

Refeeding the patient with anorexia nervosa.

Successful treatment of persons with anorexia nervosa is possible when a multidisciplinary team consisting of a mental health professional, a dietician, and a medical professional with expertise in eating disorders direct treatment. One of the primary goals of treatment is the restoration of weight. Refeeding by oral, enteral, or parenteral routes is a cornerstone of treatment but must be under-taken with care in order to avoid the widespread dysfunction associated with the refeeding syndrome.

Medical complications of bulimia nervosa.

Bulimia nervosa (BN) is a prevalent illness. There are multiple different medical complications that impact the overall treatment plan and prognosis of these patients. Practitioners should be alert for medical complications that are a direct result of the mode of purging behavior utilized by the bulimic patient. The treatment will proceed most smoothly if the primary care physician and the mental health professional work collaboratively and have clear and frequent communication.

Cervical cancer screening in the urgent care setting.

OBJECTIVE: To determine the feasibility of cervical cancer screening in an urgent care clinic. DESIGN: Prospective randomized trial. SETTING: Public teaching hospital. PATIENTS: Women presenting to the urgent care clinic whose evaluation necessitated a pelvic examination were eligible for participation. Women who had a hysterectomy, had a documented Pap test at our institution in the past year, did not speak English or Spanish, or had significant vaginal bleeding were excluded. Women presenting to the gynecology clinic for a scheduled Pap test were used as a comparison group for rates of follow-up, Pap smear adequacy, and Pap smear abnormalities. INTERVENTIONS: Women randomized to the intervention group had a Pap test performed as part of their pelvic examination, while women in the usual care group were encouraged to schedule an appointment in the gynecology clinic at a later date. The women in the two groups completed identical questionnaires regarding cervical cancer risk factors and demographic information. MEASUREMENTS AND MAIN RESULTS: Ninety-four (84.7%) of 111 women in the intervention group received a Pap test, as compared with 25 (29%) of 86 in the usual care group (P <.01). However, only 5 (24%) of 21 women with abnormal Pap smears in the intervention group received follow-up compared with 6 (60%) of 10 women seen during the same time period in the gynecology clinic for self-referred, routine annual examinations (P =.11). Pap smears obtained in the urgent care clinic were similar to those in the gynecology clinic with regard to abnormality rate (22.3% vs 20%; P =.75, respectively) and specimen adequacy (67% vs 72%; P =.54, respectively). CONCLUSIONS: Urgent care clinic visits can be used as opportunities to perform Pap test screening in women who are unlikely to adhere to cervical cancer screening recommendations. However, to accrue the full potential benefit from this intervention, an improved process to ensure patient follow-up must be developed.