A prospective, multicenter study of a pneumonia practice guideline

Two-dimensional 1H detected 13C NMR spectroscopy has been used to study the intracellular metabolism of [3-(13)C]pyruvate in Halobacterium salinarium. The method, resulting in considerable improvement in spectral resolution and signal-to-noise ratio, is well suited for studying transient metabolic intermediates. Pyruvate utilization by the bacterium is a double exponential function with rate constants of 49.13 and 4.67x10(-3) per min. The relative 13C enrichment is the fastest for C-3 glutamate. Glutamate C-4 labeling decreases initially and increases later on during incubation, while glutamine C-3 is high to begin with and exhibits a declining trend. The glutamate labeling indicates a high initial flux through pyruvate carboxylase and extensive randomizing of the label in the tricarboxylic acid cycle.     

HIV antibody testing in a teaching hospital: policy versus practice

The cost of HIV antibody testing can be phenomenal. Thus many countries, Ghana included, have adopted policies to guide physicians in making judicious test requests. An analysis of compliance with this policy in a teaching hospital in Ghana, shows that 70% of physician requests meet the stated Ministry of Health guidelines. However, while 84.5% of all test requests which turned positive were within stated guidelines, 48.6% of those turning out negative were not indicated by the policy. The cost of HIV antibody testing could be minimised if clinicians operated within the stated guidelines which make considerations for judicious use of health resources. Compliance with policy also needs evaluating.     

Why patients fail to attend psychiatric outpatient follow-up: a pilot study

BACKGROUND/AIM: Traditionally, orthotopic liver transplantation has consisted of a total native hepatectomy that included retrohepatic inferior vena cava. The so-called "piggyback" technique was described by Tzakis et al. (2). It consists of a recipient hepatectomy with preservation of the native retrohepatic IVC and subsequent anastomosis of the homograft suprahepatic IVC to a cuff fashioned from the recipient's suprahepatic veins. In this study, a single surgeon's experience with both techniques during the same period of time is discussed to analyze any significant differences in survival, intraoperative blood loss, length of stay in the ICU, and total length of stay in the hospital. MATERIALS AND METHODS: Over a three year period, 128 patients were transplanted at the University of Pittsburgh. Of these, 66 patients (51.6%) had a piggyback (PB) operation while the remaining 62 (48.4%) had a "standard" (ST) operation. RESULTS: The actual 6 month survival was 81.8% in the PB group (54/66) and 74.2% in the ST group (46/62), with no statistical difference between the two. The median intraoperative blood usage was 6 units for the PB group versus 10 units for the ST group (p > 0.02). The median ICU length of stay was the same at 4 days, as was the total hospitalization duration, 21 days. The in-hospital deaths were included in the analysis. CONCLUSIONS: The piggyback technique has some advantages, including less bleeding and absence of brachial plexus or phrenic nerve injury. Several other important considerations are discussed. In conclusion, the results with the piggyback technique are equivalent to those obtained with the standard approach.     

Evaluation of a pneumonia practice guideline in an interventional trial

There are few available data to define the medically necessary duration of stay for patients hospitalized with pneumonia. Therefore, we investigated the safety and effectiveness of a practice guideline that provided information about switching patients from parenteral to oral antimicrobials and early hospital discharge. The study was a prospective controlled study with an alternate month design. The practice guideline was studied in 146 "low-risk" pneumonia patients hospitalized during a 22-month period. Medical care consistent with the practice guideline occurred in 64% and 76% of patients during control and intervention periods, respectively (p=0.15). There were no differences in patient outcomes in the control and intervention groups when measured 1 mo after hospital discharge, including hospital readmission rates, health-related quality of life, and patient satisfaction. Explicit and implicit review revealed that 98.6% (95% confidence interval [CI]: 95.1%, 99.8%) of low-risk patients would not have benefited from continued hospitalization after the fourth hospital day. The 30-d survival rate of the low-risk pneumonia patients was 99.3% (95% CI: 96.2%, 100%) and patient outcomes appeared to be favorable compared with previously published values. We conclude that duration of hospital stay was frequently consistent with the practice guideline in both study groups, and patient outcomes remained unchanged. The guideline will require additional testing before it can be recommended for use.     

Hypertension in Haitians: results of a pilot survey of a public teaching hospital multispecialty clinic

Little is known about hypertension in Haitians. We performed a pilot survey of ambulatory Haitian patients in a multispecialty clinic at a large public teaching hospital. Approximately 10% of the clinic population was of Haitian origin. Clinical data were collected on 88 consecutive Haitian patients. Of these 88, 77 (87.5%) were hypertensive (SBP > or = 140 or DBP > or = 90 mm Hg or taking antihypertensive medication). The characteristics of the hypertensive patients were: age 54.1 +/- 13.0 (s.d.) years; 27 men, 50 women; 12/64 (19%) smoked; 7/63 (11%) used alcohol. Diabetes was present in 21/77 (27%). In patients for whom height and weight were available, obesity was present in 52%. Using JNC V criteria, 18 (23%) had Stage 1, 16 (21%) Stage 2, 18 (23%) Stage 3, and 25 (33%) Stage 4 hypertension. Despite 63/77 (82%) being treated for hypertension, only 20 (26%) were controlled (< 140/< 90 mm Hg). Of those under treatment, 29 were taking one drug; 18 (two drugs); 12 (three drugs); and four (four drugs). Target organ damage was evident in 37 (48%), including coronary artery disease (8), CHF (6), chronic renal failure (15), stroke (9), and LVH by ECG (19). There was evidence of severe noncompliance in 32 (42%). We conclude that in this clinic sample, hypertension was highly prevalent and unusually severe in terms of blood pressure (BP) level, refractoriness to treatment, and target organ consequences. Further studies are indicated.     

Trabeculectomy with releasable sutures: a prospective, randomized pilot study

OBJECTIVE: To compare the short-term and long-term efficacy of using releasable sutures vs conventional interrupted sutures for scleral flap suturing in trabeculectomy. DESIGN: A prospective randomized study. SETTING: A university-affiliated referral eye hospital. PATIENTS: Thirty consecutive patients requiring trabeculectomy for uncontrolled primary glaucoma. INTERVENTION: Fifteen patients underwent trabeculectomy with permanent interrupted sutures; the same number underwent trabeculectomy with releasable sutures. MAIN OUTCOME MEASURES: Incidence of short-term shallowing of anterior chamber or hypotony and related complications, and long-term intraocular pressure control and bleb score. RESULTS: The mean percentage reduction in intraocular pressure on day 1 in the group with releasable sutures was 55.2%, while only a 0.8% reduction in anterior chamber depth was noted. This compared with figures of 59.3% and 10.1%, respectively, in the group without releasable sutures. Hypotony (intraocular pressure < or =6 mm Hg) was noted in 8 (53%) of cases without releasable sutures and 3 (20%) of cases with releasable sutures. Shallow anterior chamber (central anterior chamber depth, < or =1 mm) was noted in 5 (33%) of cases without releasable sutures and 1 (7%) of cases with releasable sutures. The mean +/- SD final bleb score was 5.4 +/- 0.3 in the group with releasable sutures compared with 4.2 +/- 0.6 in the group without releasable sutures (P<.001). The mean +/- SD final intraocular pressure at the end of 12 months was 16.9 +/- 1.2 mm Hg in the group without releasable sutures and 15.0 +/- 0.9 mm Hg in the group with releasable sutures (P<.001). Final intraocular pressure was controlled (intraocular pressure < or =21 mm Hg) in all patients in the group with releasable sutures, giving a success rate of 100%, and in 12 patients in the group without releasable sutures, giving a success rate of 80%. CONCLUSIONS: Use of releasable sutures is an effective way at no extra cost or instrumentation to maximize the long-term bleb score and lower intraocular pressure, and to minimize the short-term complications of trabeculectomy.     

The Medical Polyclinic: an approach to conflicting needs in a teaching hospital

University teaching hospitals have become increasingly aware of their responsibility to improve both the teaching of ambulatory care and the quality of care provided in their clinics. This paper describes how one department of medicine met this challenge by forming a "Medical Polyclinic." The majority of the department's faculty and house staff, at all academic and training levels, participate in a system of ambulatory care with the following objectives: each patient has a single physician whom he sees by appointment and who coordinates his care; all medical subspecialties are available in the same clinic session; the clinic is attractive and efficient. While these goals are not infrequently met in private group practices, they are unusual in a university teaching hospital, where faculty, house staff, students, and patients each have unique needs, not always compatible. The success and problems of the polyclinic approach are discussed.     

Side effects of chiropractic treatment: a prospective study

Bleeding in factor-XI-deficient patients is mainly injury-related. Parameters influencing bleeding particularly in patients with minor factor XI deficiency have not been defined. We utilized a logistic regression model to analyze parameters influencing bleeding tendency in subjects from 45 families with factor XI deficiency. Bleeding manifestations were documented in 58% of 26 homozygous or doubly heterozygous factor-XI-deficient patients, in 20% of 46 heterozygous factor-XI-deficient patients and in 9% of 47 family members with a normal factor XI genotype. Odds ratios for bleeding in homozygotes or double heterozygotes were 13 and in heterozygotes 2.6 with 95% confidence intervals of 3.8-45 and 0.8-9.0, respectively. Bleeding correlated negatively with factor XI level (r = -0.36, P = 0.0001) with major factor XI deficiency being a strong predictor of bleeding (P = 0.011). Minor factor XI deficiency and blood group O slightly contributed to bleeding. Although factor VIII and factor XI levels were correlated (r = 0.48, P = 0.0001), levels of factor VIII and von Willebrand factor were not predictors of bleeding. Bleeding was more common following operative procedure involving mucosal membranes (P < 0.01). The designed model enabled prediction of bleeding manifestations with an overall accuracy of 78% and 82% in heterozygotes.     

Cerebrovascular pathology: inpatient study in a community hospital. A prospective study

We present the preliminary results of six months cerebrovascular pathology follow-up carried out at the Sant Boi Local Hospital as from when a Neurological Unit was set up within the Internal Medecine Service. For this purpose we drew up a prospective study based on questionnaires. A total of 69 neurological patients (2.45% of all those hospitalized) were studied, 62.3% of whom suffered acute stroke. Diagnostic and therapeutic activities were analyzed with regards to the afore mentioned pathology, as well as various data of an epidermiological nature. Lastly we present the experimental multidisciplinary approach to acute stroke as performed during hospitalization by the Internal Medecine Service, Convalescence Unit and an Interdepartmental Socio-Sanitary Functional Unit.     

The medical-psychiatry unit. A pilot study of conjoint care within an Irish general hospital

The establishment of medical-psychiatry units within the general hospital is an important advancement for psychiatry and has met with favorable response within the American health care system. A brief account is given here of the piloting of such a unit within an Irish hospital, and the merits of this strategy are discussed.     

Piperacillin/tazobactam versus imipenem: a double-blind, randomized formulary feasibility study at a major teaching hospital

With the introduction of piperacillin/tazobactam to the North American market, hospitals have been faced with the task of making a decision regarding its formulary role. In view of its broad spectrum of activity, piperacillin/tazobactam could be considered as a formulary alternative to imipenem. To evaluate the formulary feasibility of substituting piperacillin/tazobactam for imipenem, a comparative assessment of these agents in the empiric treatment of serious bacterial infections was undertaken at this tertiary care hospital. This trial was conducted as a randomized, double-blind, single-center study. Consenting adult patients (>16 years of age) who were prescribed imipenem were randomized to receive either 4 g of i.v. piperacillin/tazobactam or imipenem 500 mg of i.v. Q6H with or without concurrent antibiotics. Doses were adjusted according to renal function. There were no restrictions regarding the use of nonstudy antibiotics before and during the study period. Patients with beta-lactam allergies or meningitis or who had received greater than 72 h of previous imipenem therapy were excluded. Patients were evaluated at the end of treatment, at discharge, and at 30 days postdischarge. Endpoints included both clinical and microbiologic efficacy as well as drug toxicity. Over the 433-day study period, 360 imipenem treatment courses were initiated. Of these, 150 treatment courses (75 piperacillin/tazobactam courses and 75 imipenem courses) met study criteria and were subsequently randomized. The distribution of prescriber services for enrolled patients was similar to that for all patients receiving imipenem during the study period (p = 0.15). Also, there were no statistically significant differences in demographic parameters between enrolled and excluded patients. For those patients enrolled in the study, demographic characteristics, treatment course indication(s), and accompanying antibiotics were similar across treatment arms. The mean duration of study drug therapy was 7.7 days (SD, 6.2) for imipenem and 7.5 days (SD, 6.7)for piperacillin/tazobactam (p = 0.84). In the majority of cases, treatment discontinuation occurred as a result of a favorable treatment course outcome, stepdown to a narrower spectrum parenteral agent, or stepdown to an oral agent and did not differ between study drugs (p = 0.73). Clinical and microbiologic treatment course outcomes were also similar across treatment arms. Clinical outcome was deemed successful or improved for 68% of imipenem and 70% of the piperacillin/tazobactam treatment courses (p = 0.54). Fifty-three percent of treatment courses were microbiologically confirmed. Of the 58 courses that were assessed for microbiological outcome, 93% demonstrated successful eradication of the causative pathogens. There was no difference between study drugs (96% imipenem; 90% piperacillin/tazobactam; p = 0.61). The proportion of treatment courses with at least one adverse event was similar between the study drugs (p = 1.0). Nausea and/or vomiting were/was observed more commonly in the imipenem arm (p = 0.03). Discontinuation of therapy due to drug toxicity occurred in 16% of imipenem and 5% of piperacillin/tazobactam treatment courses (p = 0.06). There was no statistically significant difference between the mean treatment course cost for imipenem ($762; range, $55-$3192) versus piperacillin/tazobactam ($696; range, $79-$2967; p = 0.59). In summary, piperacillin/tazobactam seems to represent a suitable alternative to imipenem for several clinical indications including intraabdominal infections, pneumonia, febrile neutropenia, and skin/soft tissue infections in which the causative pathogens are susceptible. However, in view of the prevalence of multiresistant Gram-negative aerobic pathogens at this institution, we do not believe that imipenem can be removed from the drug formulary. In addition, at the currently studied dosing regimen, there seems to be no evidence of a direct cost advantage associated with     

The value of the interview: an orientation and a pilot study.

The most valuable interview is reported to be a standardized one, designed to assess complex, dynamic constellations of traits rather than relatively isolated, static traits. A standardized preemployment interview yielding six "attitude" scores was given to 46 workers, and validated against supervisory ratings. "It is concluded that, properly used, the interview can play a reliable part in the overall assessment of an individual's qualities." (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effects of automated hypnosis and hand warming on migraine:a pilot study

Infection with the cyclophyllidean tapeworm Mesocestoides sp. is recorded in British wild red foxes (Vulpes vulpes cr-cigera) from Scotland and South East England. Previously, the occurence of this parasite in Great Britain has been rarely reported, but the results of the present study indicate that vulpine infection may be common.     

A prospective study of ward referrals for renal disease at a Jamaican and a United Kingdom hospital

Seventy ward referrals for renal disease were prospectively studied at each of two tertiary hospitals: University Hospital of the West Indies (UHWI), Kingston, Jamaica and Nottingham City Hospital (NCH), England. At UHWI, the referral population was significantly younger, 89% being less than 60 years of age compared to 40% at NCH (p < 0.05). The leading cause of acute renal failure (ARF) at UHWI was systemic lupus erythematosus (SLE) followed by acute tubular necrosis (ATN). The leading causes of ARF at NCH were ATN and obstructive uropathy. Primary renal disease and diabetes mellitus were the major causes of end-stage renal disease (ESRD) at both centres, followed by SLE and hypertension at UHWI and renovascular disease and chronic pyelonephritis at NCH. Nephrotic syndrome occurred more frequently at UHWI than at NCH but the numbers were small (p < 0.05). Mortality rates were similar among patients with ARF and nephrotic syndrome at both centres, but were higher for patients with chronic renal failure (CRF) at UHWI than at NCH (p < 0.05). Continuous ambulatory peritoneal dialysis (CAPD) was a frequent mode of renal replacement therapy at NCH (76% v 19% on haemodialysis). At UHWI, CAPD was not available and 45% of patients with ESRD were not offered maintenance dialysis because of inadequate facilities. The major difference in management and outcome between the two centres occurred in cases with CRF, suggesting that survival in patients with CRF in Jamaica could be improved if this therapeutic modality was available.     

Ultrasonography as an aid to diagnosis and treatment in a rural African hospital: a prospective study of 1,119 cases

For the development of a totally implantable ventricular assist system (VAS), we have been developing the vibrating flow pump (VFP), which can generate oscillated blood flow with a relative high frequency (10-50 Hz) for a totally implantable system. In this study, the effects of left ventricular assistance with this unique oscillated blood flow were analyzed by the use of nonlinear mathematics for evaluation as the whole circulatory regulatory system, not as the decomposed parts of the system. Left heart bypasses using the VFP from the left atrium to the descending aorta were performed in chronic animal experiments using healthy adult goats. The ECG, arterial blood pressure, VFP pump flow, and the flow of the descending aorta were recorded in the data recorder during awake conditions and analyzed in a personal computer system through an A-D convertor. By the use of nonlinear mathematics, time series data were embedded into the phase space, the Lyapunov numerical method, fractal dimension analysis, and power spectrum analysis were performed to evaluate nonlinear dynamics. During left ventricular assistance with the VFP, Mayer wave fluctuations were decreased in the power spectrum, the fractal dimension of the hemodynamics was significantly decreased, and peripheral vascular resistance was significantly decreased. These results suggest that nonlinear dynamics, which mediate the cardiovascular dynamics, may be affected during left ventricular (LV) bypass with oscillated flow. The decreased power of the Mayer wave in the spectrum caused the limit cycle attractor of the hemodynamics and decreased peripheral resistance. Decreased sympathetic discharges may be the origin of the decreased Mayer wave and fractal dimension. These nonlinear dynamic analyses may be useful to design optimal VAS control.     

Maintaining a smoke-free policy: an observational and interview study at a university hospital in Sweden

Strategies directed against activated neutrophils have reduced ischemia-induced brain injury. However, therapies targeted specially against the neutrophil adhesion protein L-selectin have not yet been examined in stroke. This study therefore examined the effects of a monoclonal antibody directed against L-selectin in a rabbit model of thromboembolic stroke with (n = 16) or without (n = 10) concomitant t-PA therapy. Rabbits received either the humanized monoclonal antibody DREG200 directed against the L-selectin receptor or humanized control monoclonal antibody HuDREG55 which does not bind to rabbit L-selectin in addition to t-PA therapy (n = 8, each group). HuDREG200 (2 mg kg-1 i.v.) was given as a bolus 3 h following clot embolization, followed immediately by a 2 h intravenous infusion of t-PA (6.3 mg kg-1. Without t-PA therapy rabbits received HuDREG200 (2 mgkg-1, i.v.; n = 5) or HuDREG55 (n = 5) 1 h following clot embolization. The group receiving HuDREG200 in addition to t-PA demonstrated a moderate improvement in brain infarct size (8.4 +/- 2.4 vs. 13.5 +/- 3.5, %hemisphere, mean +/- sem), ICP (final reading 10.0 +/- 1.6 vs. 12.4 +/- 3.0 torr) and restoration in regional cerebral blood flow (30.2 +/- 7.8 vs. 21.6 +/- 10.9 cc 100 g-1 min-1) when compared to t-PA therapy alone although statistical significance was not achieved. No efficacy was demonstrated in the group receiving HUDREG200 without concomitant t-PA therapy. The results suggest the addition of a humanized anti-L-selectin monoclonal antibody HuDREG200 in combination with t-PA may further improve outcome in acute thromboembolic stroke, although future studies are necessary to support these findings.     

Perceptions and practice of universal blood and body fluid precautions by registered nurses at a major Sydney teaching hospital

Detection of Newcastle disease virus (NDV) and avian pathotyping of NDV isolates are extremely important because the appearance of virulent virus has significant economic consequences in terms of vaccination, eradication, and the ability to export poultry products. By using nucleotide and amino acid (aa) homology analysis, we could demonstrate that a NDV broiler isolate is a velogenic virus. This analysis was done after mean death time and intracerebral pathogenicity index tests gave inconsistent results. By establishing a nucleotide sequence dendrogram, we found that the disputed Ber-Tuvia was clearly in the same group as the known Herev-Laet, a velogenic isolate. The difference between Ber-Tuvia 92 and the Herev-Laet velogenic isolate was 6% as opposed to > 16% of the meso- and lentogenic isolates. The Ber-Tuvia isolate contains the Arg/Arg and Lys/Arg aa at positions 112, 113 and 115, 116, respectively, in the fusion protein cleavage aa sequence, which is typical for virulent NDV isolates.