Costs and savings associated with infection control measures that reduced transmission of vancomycin-resistant enterococci in an endemic setting.

OBJECTIVE: To determine the costs and savings of a 15-component infection control program that reduced transmission of vancomycin-resistant enterococci (VRE) in an endemic setting. DESIGN: Evaluation of costs and savings, using historical control data. SETTING: Adult oncology unit of a 650-bed hospital. PARTICIPANTS: Patients with leukemia, lymphoma, and solid tumors, excluding bone marrow transplant recipients. METHODS: Costs and savings with estimated ranges were calculated. Excess length of stay (LOS) associated with VRE bloodstream infection (BSI) was determined by matching VRE BSI patients with VRE-negative patients by oncology diagnosis. Differences in LOS between the matched groups were evaluated using a mixed-effect analysis of variance linear-regression model. RESULTS: The cost of enhanced infection control strategies for 1 year was $116,515. VRE BSI was associated with an increased LOS of 13.7 days. The savings associated with fewer VRE BSI ($123,081), fewer patients with VRE colonization ($2,755), and reductions in antimicrobial use ($179,997) totaled $305,833. Estimated ranges of costs and savings for enhanced infection control strategies were $97,939 to $148,883 for costs and $271,531 to $421,461 for savings. CONCLUSION: The net savings due to enhanced infection control strategies for 1 year was $189,318. Estimates suggest that these strategies would be cost-beneficial for hospital units where the number of patients with VRE BSI is at least six to nine patients per year or if the savings from fewer VRE BSI patients in combination with decreased antimicrobial use equalled $100,000 to $150,000 per year.

Intravenous anesthesia with propofol for painful procedures in children with cancer.

OBJECTIVE: To study the safety and efficacy of propofol-based intravenous anesthesia in children with cancer undergoing painful procedures. METHODS: This study is a retrospective analysis of data collected from 52 consecutive children who underwent 335 procedures using propofol anesthesia. These data were routinely collected in all patients: time to induction, duration of the procedure, time to recover, and the doses of the drugs used. Monitoring with electrocardiography and pulse oximetry was continuous during the procedure; blood pressures were recorded before and after the procedure and every 5 to 10 minutes during the procedure. The patients received one of these four propofol-based intravenous regimens according to the anesthesiologist's preference: propofol only; propofol plus fentanyl; propofol plus midazolam; or propofol, fentanyl, and midazolam. The efficacy of sedation was rated by this scoring system: 3 = no movement during procedure; 2 = minimal movement that did not interfere with the procedure; 1 = moderate movement requiring physical restraint to complete the procedure. RESULTS: There were six episodes of mild hypoxia (oxygen saturation 85%-94%) and one episode of laryngospasm. None required intubation. Two patients had agitation and one patient had emesis during the postrecovery phase. There was no difference in the efficacy of sedation between the four regimens. Patients receiving the combination of propofol, fentanyl, and midazolam received the least amount of propofol and required the least time to recover. There were no life-threatening complications. CONCLUSIONS: Propofol-based anesthesia, when administered by an anesthesiologist in a controlled setting, is safe and effective for performing painful procedures in children with cancer.

Reduced risk of low weight births among indigent women receiving care from nurse-midwives.

STUDY OBJECTIVE: To examine the effect of a comprehensive prenatal and delivery programme administered by nurse-midwives on the risk of low weight births among indigent women. STUDY DESIGN: Historical prospective study. Birth outcomes among the cohort were compared with all county births during the same period, adjusting for maternal age and race. Results are expressed as relative risks with 95% confidence intervals. SETTING: An enhanced Medicaid funded pre-natal programme administered by nurse-midwives from 1992 to 1994 in Westchester County, New York. PARTICIPANTS: Indigent mothers (n = 1443), between the ages of 15 and 44, who were residents of Westchester County and indicated having Medicaid or no health care coverage. RESULTS: There were 1474 live births among cohort mothers. Mean (SD) gestational age was 39.4 (1.9) weeks. Less than 6% of births occurred before 37 weeks gestation. The mean birth weight of cohort infants was 3365.6 (518.6) g. Only 4.1% of the cohort births were less than 2500 g. Compared with all county births, the cohort showed a 41% reduction in the risk of low weight births (RRlbw = 0.59, 95% CI: 0.46 to 0.73, p < .001) and a 56% reduction when compared with county Medicaid births only (RR = 0.44, 95% CI: 0.34 to 0.57, p < .005) adjusting for maternal age and race. Larger reductions were found for very low weight births. CONCLUSIONS: Mothers need not be considered at high risk for adverse pregnancy outcomes based on their socioeconomic status alone. Moreover, a comprehensive prenatal programme administered by nurse-midwives may promote a reduction in adverse pregnancy outcomes among indigent mothers.

Infection-control measures reduce transmission of vancomycin-resistant enterococci in an endemic setting.

BACKGROUND: Vancomycin-resistant enterococci (VRE) are nosocomial pathogens in many U. S. hospitals. OBJECTIVE: To determine whether enhanced infection-control strategies reduce transmission of VRE in an endemic setting. DESIGN: Prospective cohort study. SETTING: Adult oncology inpatient unit. PATIENTS: 259 patients evaluated during use of enhanced infection-control strategies and 184 patients evaluated during use of standard infection-control practices. INTERVENTIONS: Patient surveillance cultures were taken, patients were assigned to geographic cohorts, nurses were assigned to patient cohorts, gowns and gloves were worn on room entry, compliance with infection-control procedures was monitored, patients were educated about VRE transmission, patients taking antimicrobial agents were evaluated by an infectious disease specialist, and environmental surveillance was performed. MEASUREMENTS: VRE infection rates, VRE colonization rates, and changes in antimicrobial use. RESULTS: During use of enhanced infection-control strategies, incidence of VRE bloodstream infections decreased significantly (0.45 patients per 1000 patient-days compared with 2.1 patients per 1000 patient-days; relative rate ratio, 0.22 [95% CI, 0.05 to 0.92]; P = 0.04), as did VRE colonization (10.3 patients per 1000 patient-days compared with 20.7 patients per 1000 patient-days; relative rate ratio, 0.5 [CI, 0.33 to 0.75]; P < 0.001). Use of all antimicrobial agents except clindamycin and amikacin was significantly reduced. CONCLUSION: Enhanced infection-control strategies reduced VRE transmission in an oncology unit in which VRE were endemic.

Patient notification and follow-up of abnormal test results. A physician survey.

OBJECTIVE: To investigate physician practices in the handling of patients' test results from the time the test was ordered until the time any required follow-up was completed. METHODS: Survey of 161 attending physicians and 101 residents in family practice and internal medicine practicing at a large urban teaching hospital and 21 suburban primary care practices in Southeastern Michigan. The survey included questions about physician demographics, and whether physicians have methods for ensuring that (1) the results of all tests ordered are received, (2) all patients are notified of results, (3) all patient notification is documented, and (4) all required follow-up is done. Physicians were also asked to self-rate the reliability of their methods and the importance of various steps in the handling of patients' test results. RESULTS: The response rate was 79% for both attending physicians and residents. Approximately 17% to 32% of physicians reported having no reliable method to make sure that the results of all tests ordered are received. One third of physicians do not always notify patients of abnormal results. The most common reasons reported for not notifying patients were that the results were trivial and that the patient was expected to return to the clinic soon. Residents were significantly less likely to document notifying patients of abnormal results (P < .001). Only 23% of physicians reported having a reliable method for identifying patients overdue for follow-up. CONCLUSIONS: Lack of methods to ensure that the results of tests ordered were received, dependence on follow-up visits to inform patients of results, and lack of documentation were relatively common among physicians surveyed. These could lead to an increased risk of malpractice litigation and suboptimal patient care.

Parkinson's disease mortality and the industrial use of heavy metals in Michigan.

Parkinson's disease (PD) mortality rates in Michigan counties for 1986-1988 were calculated with respect to potential heavy metal exposure (iron, zinc, copper, mercury, magnesium, and manganese) from industry based on recent census data. Individuals were counted as a PD death if the diagnosis was listed as an "underlying" or "related" cause of death on the death certificate. Counties with an industry in the paper, chemical, iron, or copper related-industrial categories (ICs) had statistically significantly (p < 0.05) higher PD death rates than counties without these industries. Significant correlations of chemical (rs = 0.22; p = 0.05), paper (rs = 0.22; p = 0.05) and iron (rs = 0.29; p = 0.008) industry densities with PD death rates were also present. Counties were divided into high (> 15/100,000 individuals 45 years old and over) and low (< = 15/100,000) PD death rate counties by cluster analysis. Geographically, counties with high PD mortality were located mainly in the southern half of the lower peninsula and eastern half of the upper peninsula; low PD death rate counties formed two distinct clusters in the western edge of the upper peninsula and the north-central portion of the lower peninsula. Other possible risk factors that may explain the varied distribution of PD death rates in Michigan were examined. Those significantly correlated with PD mortality included population density (rs = 0.31; p = 0.005), farming density (rs = 0.25; p = 0.02), and well water use (rs = -0.24; p = 0.03). These ecologic findings suggest a geographic association between PD mortality and the industrial use of heavy metals.

Death in the city. An American childhood tragedy.

OBJECTIVE: To look at trends in mortality and homicide rates in a specific metropolitan area, comparing the urban and suburban mortality trends. DESIGN: Descriptive study of mortality rates. Linear regression determined whether changes in mortality rates over time represented significant trends. SETTING: Industrial metropolitan area in the United States, population, 2,337,891. PARTICIPANTS: Pediatric deaths (1 to 18 years of age) in a 9-year period. Population characteristics: 36% black, 64% white, 50% each urban and suburban. MAIN OUTCOME MEASURES: Pediatric mortality rates for 1980 through 1988, grouped by urban vs suburban, age, gender, and race. Rates calculated using national census figures and plotted over time. RESULTS: There was a 50% increase in all-cause mortality in the urban pediatric population as compared with no change or a slight decline in the suburban and national populations. The increase was found in the black urban population. Homicide showed the largest increase (252%). Firearm-related homicides accounted for the majority of homicide deaths. CONCLUSIONS: (1) There were significant differences in mortality between the urban and suburban pediatric populations. (2) The increase in homicides, specifically firearm homicides, in the urban population accounted for the increase in overall mortality rates. (3) The increase in homicide rates was significant only for the 10- to 14-year-old males and the 15- to 18-year-old male and female portions of the black urban population. (4) Firearm homicides have become epidemic in the black urban population we studied.

A diversified set of testicular cell proteins specified by genes within the mouse t complex.

We have conducted a comparative high-resolution, two-dimensional gel analysis of testicular cell proteins synthesized by inbred mice congenic for a series of t haplotypes on the 129/SvJ background. At least nine t haplotype-specific proteins can be identified within the 1000 most prominent proteins observed. Apparent allelic wild-type forms of six of these t complex proteins (TCPs) have also been identified, and evidence from cell-free translation experiments indicates that all of these are coded for directly by genes within the t complex. Eight of the mutant t-haplotype-specific proteins are expressed in an identical form by testicular cells carrying any one of the complete t haplotypes analyzed. The ninth protein is polymorphic among different t haplotypes, as well as among different inbred strains of mice. Partial t haplotypes were used to map the genes specifying the expression of each TCP protein to a subregion of the t complex. The accumulated data suggest a subset of TCP proteins that are most likely to be involved in t haplotype effects on germ cell differentiation and fertility.