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1.
Am J Med Sci ; 346(3): 237-9, 2013 Sep.
Article in English | MEDLINE | ID: mdl-23974269

ABSTRACT

Endocarditis caused by Candida dubliniensis is a rare event and limited to few case reports. In this report, the authors present a patient with a history of intravenous drug use and hepatitis C and endocarditis involving a prosthetic aortic valve. Also reviewed are the treatment guidelines for Candida sp. endocarditis.


Subject(s)
Candida , Candidiasis/complications , Endocarditis/microbiology , Amphotericin B/therapeutic use , Antifungal Agents/therapeutic use , Candidiasis/drug therapy , Candidiasis/microbiology , Echinocandins/therapeutic use , Endocarditis/drug therapy , Fluconazole/therapeutic use , Humans , Lipopeptides/therapeutic use , Male , Micafungin , Middle Aged
2.
J Am Med Dir Assoc ; 13(3): 303-7, 2012 Mar.
Article in English | MEDLINE | ID: mdl-21621477

ABSTRACT

INTRODUCTION: Implementation of prophylaxis for venous thomboembolism (VTE) through risk assessment based on clinical practice guidelines (CPGs) is variably adopted in long term care facilities (LTCF). Current guidelines recommend venous thromboembolism prophylaxis (VTE-P) following risk assessment, individualized to patient status. In LTCF, differing comorbidity, life-expectancy, ethical, and quality-of-life issues may warrant a unique approach. This article examines VTE-P practices in LTCF before and after educational intervention to bring practice patterns consistent with CPGs. METHODS: Phase 1 (preceding article in this issue) identified current practice to assess risk and implement VTE-P (17 geographically diverse LTCFs, 3260 total beds). Phase 2 (educational intervention using CPGs) and Phase 3 (outcomes) reexamined VTE-P at the same 17 centers. RESULTS: The frequency of indications for VTE-P and contraindications to anticoagulation were similar during Phases 1 and 3 (all P > .05). In Phase 3, use of aspirin alone decreased more than 50% (P < .0005), whereas use of compression devices increased (P < .0005). Regression models predicted no relationship between any indication or contraindication and VTE-P in Phase 1 (all P > .05) but identified significant relationships between indication and contraindications and VTE-P in Phase 3 (P = .022 to P < .0005), suggesting adequate understanding of current CPGs following education as the basis for improved VTE-P. CONCLUSIONS: The study confirms the presence of significant comorbidity in LTC residents, many with indications for VTE-P, some with contraindications for anticoagulation. Following educational intervention, more residents received VTE-P, influenced by risk-benefit ratio favoring treatment. These findings suggest that even a modest educational intervention significantly improves provider knowledge pertinent to risk assessment consistent with CPG and more appropriate VTE-P.


Subject(s)
Inservice Training , Nursing Homes , Practice Guidelines as Topic , Venous Thromboembolism/prevention & control , Aged , Aged, 80 and over , Anticoagulants/therapeutic use , Female , Health Personnel/education , Humans , Male , Medical Audit , Risk Assessment , United States
3.
J Am Med Dir Assoc ; 13(3): 298-302, 2012 Mar.
Article in English | MEDLINE | ID: mdl-21621480

ABSTRACT

INTRODUCTION: Current guidelines recommend antithrombotic prophylaxis for venous thromboembolism (VTE) using risk assessment, factoring contraindications. This report represents a summary of current practice patterns to prevent VTE in long term care as Phase 1 of a 3-phase educational intervention study. PHASE 1 PARTICIPANTS: Participants were 376 new admissions/readmissions (77 ± 12 [SD] years; 67% female) from 17 geographically diverse long term care facilities (3260 total beds). MEASUREMENTS: The process describes current VTE prophylaxis (VTE-P) practices; a companion article describes the educational intervention (Phase 2) and outcome (Phase 3). Phase 1 data were collected on use of nonpharmacological measures and antithrombotic drugs for VTE-P between July and September 2009. RESULTS: Indications for VTE-P were evident in 85% of new admissions, of which two-thirds received VTE-P. Contraindications for anticoagulation were observed in 54.8% of admissions, including quality of life or patient/caregiver wishes. Logistic regression analysis predicted no relationship between any indication for or any contraindication to VTE-P and use of VTE-P, suggesting an inadequate understanding of current clinical practice guidelines. CONCLUSIONS: Residents of long term care have significant comorbidity that poses risk for VTE; although many received VTE-P, contraindications were common, warranting individualized considerations. The likelihood of VTE-P was greatest following orthopedic surgery, severe trauma, and medical illness.


Subject(s)
Homes for the Aged , Practice Patterns, Physicians' , Venous Thromboembolism/prevention & control , Aged , Aged, 80 and over , Anticoagulants/therapeutic use , Female , Humans , Male , Medical Audit , Risk Management , United States
4.
Am Fam Physician ; 82(5): 480-7, 2010 Sep 01.
Article in English | MEDLINE | ID: mdl-20822082

ABSTRACT

Anemia in older persons is commonly overlooked despite mounting evidence that low hemoglobin levels are a significant marker of physiologic decline. Using the World Health Organization definition of anemia (hemoglobin level less than 13 g per dL [130 g per L] in men and less than 12 g per dL [120 g per L] in women), more than 10 percent of persons older than 65 years are anemic. The prevalence increases with age, approaching 50 percent in chronically ill patients living in nursing homes. There is increasing evidence that even mild anemia is associated with increased morbidity and mortality. Anemia warrants evaluation in all older persons, except those at the end of life or who decline interventions. About one third of persons have anemia secondary to a nutritional deficiency, one third have anemia caused by chronic inflammation or chronic kidney disease, and one third have unexplained anemia. Nutritional anemia is effectively treated with vitamin or iron replacement. Iron deficiency anemia often is caused by gastrointestinal bleeding and requires further investigation in most patients. Anemia of chronic inflammation or chronic kidney disease may respond to treatment of the underlying disease and selective use of erythropoiesis-stimulating agents. The treatment of unexplained anemia is difficult, and there is little evidence that treatment decreases morbidity and mortality, or improves quality of life. Occasionally, anemia may be caused by less common but potentially treatable conditions, such as autoimmune hemolytic anemia, malignancy, or myelodysplastic syndrome.


Subject(s)
Anemia/drug therapy , Anemia/etiology , Aged , Algorithms , Anemia/complications , Anemia/diagnosis , Deficiency Diseases/complications , Erythrocyte Indices , Female , Ferritins/blood , Folic Acid/blood , Hematinics/therapeutic use , Homocysteine/blood , Humans , Inflammation/complications , Iron Compounds/therapeutic use , Male , Medical History Taking , Methylmalonic Acid/blood , Physical Examination , Renal Insufficiency/complications , Reticulocyte Count , Vitamin B 12/blood
5.
Am Fam Physician ; 76(4): 539-44, 2007 Aug 15.
Article in English | MEDLINE | ID: mdl-17853628

ABSTRACT

Vibrio vulnificus infection is the leading cause of death related to seafood consumption in the United States. This virulent, gram-negative bacterium causes two distinct syndromes. The first is an overwhelming primary septicemia caused by consuming raw or undercooked seafood, particularly raw oysters. The second is a necrotizing wound infection acquired when an open wound is exposed to warm seawater with high concentrations of V. vulnificus. Most patients, including those with primary infection, develop sepsis and severe cellulitis with rapid development to ecchymoses and bullae. In severe cases, necrotizing fasciitis can develop. Case-fatality rates are greater than 50 percent for primary septicemia and about 15 percent for wound infections. Treatment of V vulnificus infection includes antibiotics, aggressive wound therapy, and supportive care. Most patients who acquire the infection have at least one predisposing immunocompromising condition. Physician awareness of risk factors for V. vulnificus infection combined with prompt diagnosis and treatment can significantly improve patient outcomes. (Am Fam Physic


Subject(s)
Ostreidae/microbiology , Vibrio Infections , Vibrio vulnificus/pathogenicity , Aged, 80 and over , Animals , Cellulitis/microbiology , Drug Therapy, Combination , Food Microbiology , Humans , Immunocompromised Host , Male , Risk Factors , Seafood , Seawater/microbiology , Sepsis/drug therapy , Sepsis/microbiology , Skin Diseases, Bacterial/complications , Skin Diseases, Bacterial/diagnosis , Skin Diseases, Bacterial/drug therapy , Skin Diseases, Bacterial/etiology , Skin Diseases, Bacterial/mortality , Vibrio Infections/complications , Vibrio Infections/diagnosis , Vibrio Infections/drug therapy , Vibrio Infections/etiology , Vibrio Infections/mortality , Wound Infection/drug therapy , Wound Infection/microbiology
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