Efficacy and safety of ceftolozane/tazobactam as therapeutic option for complicated skin and soft tissue infections by MDR/XDR Pseudomonas aeruginosa in patients with impaired renal function: a case series from a single-center experience.

INTRODUCTION: Pseudomonas aeruginosa (PA) is a known cause of skin and soft tissue infections (SSTIs). Therapeutic options against multidrug-resistant (MDR) and extensively drug-resistant (XDR) strains of PA are limited, especially in patients with impaired renal function. Ceftolozane/tazobactam (C/T) is a novel beta-lactam/beta-lactamase inhibitor with powerful anti-PA activity. Thanks to its characteristics, it appears to be the best available anti-pseudomonal drug in many clinical scenarios. A case series of four adult patients followed between January 2018 and May 2019 is reported. All subjects presented complicated SSTIs by MDR- or XDR-PA and were affected by chronic kidney disease. RESULTS: C/T was used as a monotherapy in three cases and in combination regimen in the remaining case. In two cases, C/T was the first-line option, in the remaining ones was the salvage treatment. All patients were successfully treated without worsening of renal function and without any other adverse events. CONCLUSIONS: C/T may represent a useful option against MDR- and XDR-PA strains responsible of complicated SSTIs in patients affected by impaired renal function.

Macroscopic locoregional relapse from prostate cancer: which role for salvage radiotherapy?

INTRODUCTION: Salvage radiotherapy (SRT) after radical prostatectomy for prostate cancer (PCa) is recommended as soon as PSA rises above 0.20 ng/ml, but many patients (pts) still experience local macroscopic relapse. The aim of this multicentric retrospective analysis was to evaluate the role of SRT in pts with macroscopic relapse. MATERIALS AND METHODS: From 2001 to 2016, 105 consecutive pts with macroscopic PCa relapse underwent SRT ± androgen deprivation therapy (ADT). Mean age was 72 years. At time of relapse, 29 pts had a PSA value < 1.0 ng/mL, 50 from 1.1 to 5, and 25 pts > 5. Before SRT, 23 pts had undergone 18F-choline PET and 15 pts pelvic MRI. Ninety-four pts had prostatic bed relapse only, and four nodal involvement. Fifty-one pts were previously submitted to first-line ADT, while 6 pts received ≥ 2 lines. RESULTS: At a median follow-up of 52 months, 89 pts were alive, while 16 were dead. Total RT dose to macroscopic lesions was > 70 Gy in 58 pts, 66-70 Gy in 43, and < 66 Gy in 4 pts. In 72 pts, target volume encompassed only the prostatic bed with sequential boost to macroscopic site; 33 pts received prophylactic pelvic RT. Ten-year overall survival was 76.1%, while distant metastasis-free survival was 73.3%. No grade 4-5 toxicities were found. CONCLUSIONS: SRT ± ADT for macroscopic relapse showed a favorable oncological outcome supporting its important role in this scenario. Data from this series suggest that SRT may either postpone ADT or improve results over ADT alone in appropriately selected pts.

Beyond the hype: a taxonomy of e-health business models.

This paper describes a business model of e-commerce, its application to health care, and the reasons why the health policy community should monitor its development. The business model identifies the market barriers health e-commerce firms must overcome and provides perspective on opportunities for building a health care data infrastructure that is capable of delivering both a private and a public good.

A worldwide assessment of medical journal editors' practices and needs--results of a survey by the World Association of Medical Editors.

OBJECTIVES: To identify editors interested in participating in a global organisation and communication network of medical editors; to assess current use of the peer-review process; and to determine current computer capabilities, needs, and interests of medical journal editors around the world. DESIGN: Mail survey of senior editors at 727 medical journals. SETTING: Fifty-seven countries worldwide. RESULTS: Two hundred and sixty-nine editors (37%) responded. Eighty-seven per cent of responding editors expressed interest in a global organisation of medical editors. Almost all editors (94%) reported using peer-review systems. Practices varied widely across journals, but in most cases were not highly correlated with the countries' level of development: 44% reported formal orientation for reviewers; 71% used specific instructions; 39% required reviewers to disclose conflicts of interest; 36% masked the identity of authors; and 42% graded reviews for quality. Seventy-eight per cent of editors reported using a computer in their work and 47% had Internet access; two-thirds of those without access expected to have Internet access within 18 months. CONCLUSIONS: There was strong interest among respondents in a global organisation for medical editors. Peer review was widely reported by medical journal editors throughout the world, although specific practices varied widely. Half of the responding editors reported having access to the Internet, making participation in a worldwide computer network of editors feasible.

[Total quality management in healthcare. The European Foundation for Quality Management Model]. / Gestão da qualidade em saúde. O modelo da European Foundation for Quality Management.

After presenting the quality model adapted by the health authorities, the authors refer to the development of quality methodology to the present day, and the importance of the self assessment of Quality focusing on the one according to the European Foundation For Quality Management (EFQM) adapted by healthcare organisations. Each criteria of the EFQM model is presented and its potential as a motivation for change by means of self assessment is discussed.

Anesthetic efficacy of the supplemental intraosseous injection for teeth with irreversible pulpitis.

The purpose of this study was to determine the efficacy of a supplemental intraosseous injection (IOI) of 2% lidocaine with 1:100,000 epinephrine using the Stabident device, after conventional anesthetic methods had failed. Patients who experienced pain during endodontic access and required a supplemental IOI using 0.45 to 0.90 ml of the local anesthetic were identified. All 37 of the patients treated had teeth diagnosed with irreversible pulpitis. Thirty-four of the teeth were mandibular posterior teeth, 2 were maxillary posterior teeth, and 1 was a maxillary anterior tooth. Patients with maxillary teeth had received infiltration anesthesia, and those with mandibular teeth had received an inferior alveolar nerve block in conjunction with long buccal infiltration. A minimum of 3.6 ml of local anesthetic was used with the conventional techniques. Modified visual analogue scales, coupled with operator evaluations, were used to measure success. The Stabident IOI was an effective supplemental anesthetic technique in 89% (+/- 5.1) or 33/37 patients evaluated. The 95% confidence interval was 74 to 97%. The IOI was successful in 91% (+/- 4.9) of the mandibular posterior teeth (31/34), and 67% of the maxillary teeth (2/3).

Potential savings from using information technology applications in health care in the United States.

We reviewed economic evaluations of information technology (IT) applications in health care in the United States. National estimates suggest that fully automating administrative functions would save the system $5 to $8 billion per year. Hospital-specific estimates suggest that individual facilities could save $0.5 to $3 million annually from various clinical IT applications.

Profiling resource use by primary-care practices: managed Medicare implications.

Variations in elderly Medicare beneficiaries' health service use are examined using a 100-percent sample of fee-for-service (FFS) claims data from Alabama, Iowa, and Maryland. Provider specialty, group practice type, practice size, and location are found to be significant factors affecting hospital and ambulatory care utilization and cost, after controlling for patient and regional characteristics. These results provide insights into utilization and cost expectations from different types of primary-care gatekeepers as the Medicare managed care market develops.

Variation in office-based quality. A claims-based profile of care provided to Medicare patients with diabetes.

OBJECTIVES: To demonstrate that claims data "profiling" can be used as an ongoing method to support ambulatory care quality improvement; to measure the quality of office-based care provided to elderly patients with diabetes in three states; and to identify factors associated with better attainment of quality standards. STUDY DESIGN: A cross-sectional study based on a 100% sample of the Medicare claims (Part B and Part A) submitted between July 1, 1990, and June 30, 1991. SETTING: All primary care practices (both solo and group) actively seeing Medicare patients with diabetes in Alabama, Iowa, and Maryland (n = 2980). PATIENTS: All elderly (> or = 65 years) Medicare patients seen by the study physicians and assigned a diagnosis of diabetes (n = 97,388) by any office-based physician during the year. MAIN OUTCOME MEASURES: The proportion of patients with diabetes receiving the following procedures (from any provider) at least once during the study period: hemoglobin A1C measurement, ophthalmologic examination, total cholesterol measurement, and blood glucose measurement. We considered the first three services to be optimally recommended and blood glucose measurement to be of limited use. RESULTS: Based on analyses of services provided in the ambulatory setting, we found that 84% of diabetics did not appear to receive the recommended hemoglobin A1C measurement, 54% did not see an ophthalmologist, and 45% received no cholesterol screening. Practice patterns varied considerably across the three states (up to 2.38-fold), even after adjusting for patient case mix and physician characteristics. Patients of general practitioners were less likely to meet recommended quality criteria than patients of internists or family practitioners. Patients receiving care from rural practitioners were less likely to receive services, either recommended or not, than those in urban locations. CONCLUSIONS: Elderly patients with diabetes do not appear to be receiving optimal care. This study underscores the value of practice guideline development and dissemination in the ambulatory arena. This study provides substantial evidence that existing administrative claims data can be used to support ambulatory quality improvement activities.

Developing a quality improvement database using health insurance data: a guided tour with application to Medicare's National Claims History file.

Health policy researchers are increasingly turning to insurance claims to provide timely information on cost, utilization, and quality trends in health care markets. This research offers an in-depth description of how to systematically transform raw inpatient and ambulatory claims data into useful information for health care management and research using the Health Care Financing Administration's National Claims History file as an example. The topics covered include: (a) understanding the contents and architecture of claims data, (b) creating analytic files from raw claims, (c) technical innovations for health policy studies, (d) assessing data accuracy, (d) the costs of using claims data, and (e) ensuring confidentiality. In summary, claims data are found to have great potential for quality of care analysis. As in any analysis, careful development of a database is required for scientific research. The methods outlined in this study offer health data novices as well as experienced analysts a series of strategies to maximize the value of claims data for health policy analysis.

Focus on quality: profiling physicians' practice patterns.

This article presents a physician practice profiling system developed using Medicare data to evaluate the quality of care provided by primary care physicians. We discuss four attributes to physicians' practice profiles that make them useful for quality improvement: flexibility, user involvement in developing profiles, explicit plans for evaluation, and fairness to groups of providers. This system serves as a model for physician profiling with a focus on quality of care measurement.

Priority setting in medical technology and medical practice assessment.

This study seeks to assist in setting priorities for assessing medical practices and technologies when assessment resources are scarce. It develops an objective index of expected gain from technology assessment, using modified DRG-level data on hospitalizations in NY State. The index uses standard economic concepts to combine measures of resource use, the coefficient of variation in use rates across regions, and the rate at which the incremental value of a medical intervention changes as its rate of use changes, providing a dollar-valued welfare loss from variations. For the entire US in 1987, the highest index occurred for coronary artery bypass graft ($0.95 billion per year), but most of the high-index interventions were nonsurgical, including hospitalizations for psychosis ($0.74 billion per year), cardiac catheterization ($0.62 billion per year), chronic obstructive lung disease ($0.55 billion per year), angina pectoris ($0.46 billion per year), adult gastroenteritis ($0.38 billion per year), adult pneumonia ($0.32 billion per year) and medical back problems ($0.28 billion per year). The top 25 interventions create an annual welfare loss of exceeding $7 billion. The present value of convincingly assessing the correct way to use these interventions sums many years of annual gains from eliminating these welfare losses. The gains from eliminating unexplained variation in medical practices appear greatly larger than costs of necessary studies.