The relation between resource use and in-hospital mortality for patients with acquired immunodeficiency syndrome-related Pneumocystis carinii pneumonia.

A central issue in health policy with regard to the acquired immunodeficiency syndrome (AIDS) is whether quality of care and patient outcomes are affected by resource constraints. In an earlier study of 15 California hospitals between October 1986 and October 1987, we observed a markedly lower in-hospital mortality rate for Pneumocystis carinii pneumonia in the group of patients treated in hospitals that had a high level of experience with AIDS relative to the group treated in hospitals with low experience. We present the patterns of resource use at hospitals with high and low AIDS familiarity. Average charges and resource use did not differ between the two groups of hospitalized patients; however, there were marked variations in how the resources were used. Among survivors, patients who received care at hospitals with high AIDS familiarity stayed in the hospital longer, underwent a bronchoscopy more often, stayed in an intensive care unit longer, and accrued higher average total charges than patients at hospitals with low AIDS familiarity. Conversely, among nonsurvivors, a greater intensity of care was received at the hospitals with low AIDS familiarity. These results suggest that, in these 15 hospitals, the markedly higher rate of in-hospital death at hospitals with low AIDS familiarity was not related to the quantity of resources that were used; rather it was related to differences in how the resources were used. Our results show that additional resources significantly improved the chances of in-hospital survival for patients at hospitals with high AIDS familiarity, but did not affect the chances of survival in hospitals with low AIDS familiarity. Our findings suggest that physicians in those hospitals in which the care of patients with AIDS is relatively infrequent might improve the chances of in-hospital survival of patients with AIDS by more timely and efficient use of resources.

Improved outcomes in intensive care units for AIDS-related Pneumocystis carinii pneumonia: 1987-1991.

Respiratory failure due to Pneumocystis carinii pneumonia (PCP) is the most common complication requiring an intensive care unit (ICU) for persons with AIDS. In this study, we evaluated patterns of ICU use for ICU patients with first-episode PCP in 15 Veterans Administration Medical Centers from 1987 to 1991. Twelve percent of all patients with PCP received care in the ICU. The survival rates improved steadily during these years. Although there was little variation in the relative frequency of ICU use, the effectiveness of ICU use appeared to improve over time. In the more recent years, relatively more survivors and relatively fewer nonsurvivors received care in an ICU. Changes in medical practice such as adjunctive use of steroids for severe cases of PCP and more effective use of scarce resources may account for the improved survival rates for patients with PCP who are treated in an ICU.

Cultivating curricular reform.

Since the 1960s there has been pressure to reform medical education in a more humanistic direction. One reason this has been difficult is that most medical schools have been forced to maintain themselves on resources allocated to support research and the technology of specialized tertiary care. Nevertheless, many people believe that medical education can still change because of changes taking place outside the sciences, such as a redefinition of the meaning of health and the need to provide better health care to the U.S. population at a lower cost. Taking this optimistic view will help strengthen reformers' resolve for curricular change and the incorporation of important areas such as family violence into medical students' education. There are numerous barriers to curricular change. Yet there are useful principles that can guide reform efforts, such as having an explicit rationale for the desired change, focusing on educational goals rather than on resources for their implementation, recruiting support from the departmental and school leadership, anticipating negative reactions, and recognizing the need for negotiation. There are also principles to foster successful implementation, the most important of which is to have everyone involved agree on the goals of the new program and participate in the process. The way to increase an emphasis on family violence issues is to find areas in the curriculum where these issues can be integrated with current teaching. Finally, a medical school curriculum on family violence does not need to be all-inclusive, but instead should prepare a good foundation so that students can expand their knowledge and skills during residency training and medical practice.

Graduate medical education in ambulatory care.

Graduate medical education is currently in transition, with educators being asked to re-examine the extent to which hospital-based teaching models still provide adequate comprehensive training. To educate future physicians adequately, the Department of Veterans Affairs (VA) will have to change its system for delivering ambulatory care services and for teaching in ambulatory care settings. Workshop discussions focused on five major areas regarding educating residents in the ambulatory setting: educational goals and objectives, clinical experiences, curriculum development and evaluation, faculty issues, and fellowship opportunities. Recommendations include the need for residency programs to develop explicit educational goals and objectives for resident training, the identification of transdepartmental needs and coordinated planning, the support of academic clinical faculty, research and development of educational programs, and further development of fellowship training in ambulatory care. Further integration of ambulatory care activities in graduate training will require significant effort, a shift in manpower and resources and, more fundamentally, a shift in attitude and commitment at all levels of the VA and medical schools.

Status report on ambulatory care and education in the VA Western Region and western medical schools.

Since the initial 1988 Ambulatory Care and Education (ACE) conference, reported in the October 1989 supplement to Academic Medicine, the Western Region Veterans Health Administration and its 11 affiliated western medical schools have established several programs and related activities that implement strategic ACE recommendations. This report gives an update on the ACE Advisory Group; the Pilot Ambulatory Care and Education (PACE) Center at the VA Medical Center, Sepulveda, California; other innovative ambulatory care and education projects; the second ACE Development Conference; and future activities in the expanded Western Region of the Department of Veterans Affairs.

Psychotropic medication use during pregnancy.

Women can have severe and at times life-threatening psychiatric illness during pregnancy. When nonpharmacologic interventions have been attempted and are insufficient, psychotropic medication use is often necessary. The available data on prescription neuroleptic drugs suggest that with the proper selection, use, and supervision, they can be used during pregnancy. The same cannot be said for lithium carbonate or most antidepressants owing to the risks of teratogenicity and toxicity to the fetus. It is prudent to avoid all medication use, if possible, during the first trimester, but deciding how and when to institute treatment depends on an assessment of the risks associated both with the drug and with the untreated illness.

Adult scurvy.

Scurvy was diagnosed in two elderly alcoholic men in our emergency department. Both were ambulatory and had perifollicular petechiae and ecchymoses of the lower extremities and hypertrophic erythematous gingival lesions. There diets were deficient in fresh fruits and vegetables. Treatment with oral ascorbic acid resulted in dramatic resolution of the signs and symptoms. The first patient was admitted to the hospital, where extensive diagnostic studies failed to reveal other etiological explanations for the cutaneous lesions. The second patient was successfully treated as an outpatient.

The role of antibiotic tolerance in the response to treatment of pyelonephritis due to Staphylococcus aureus in rats.

The effect of tolerance to methicillin on the response to treatment of hematogenous pyelonephritis due to Staphylococcus aureus was evaluated in rats. Tolerance was defined as a ratio of minimal bactericidal concentration to minimal inhibitory concentration of greater than or equal to 32. Rats that were infected with tolerant or nontolerant stains of S. aureus were treated with methicillin with equal success as judged by the number of bacteria in the kidneys and the proportion of rats with infected kidneys. In this animal model, tolerance does not play a role in the outcome of treatment.

Experimental Escherichia coli endocarditis in rats: roles of serum bactericidal activity and duration of catheter placement.

Studies were undertaken to investigate the relationship of the sensitivity of Escherichia coli to the bactericidal properties of serum and the ability of different strains to induce and sustain endocardial infection in rats. Strains of E. coli demonstrated different degrees of serum sensitivity, as determined by a method which employed concentrations of serum from 10 to 95% and periods of incubation as long as 24 h. The greater the serum sensitivity of the E. coli strain, the less able it was to initiate infection and the more rapidly it was spontaneously eliminated from established infections. Endocardial infection with E. coli was established by intravenous challenge in rats with polyethylene catheters passing through the aortic valve into the left ventricle. An E. coli strain of low serum sensitivity was used; the initiation of infection depended upon the length of time the catheter had been in place and, in addition, whether the catheter was in place at the time of bacterial challenge. Removal of the catheter permitted spontaneous sterilization of the endocardial vegetations. The time necessary for sterilization was in direct proportion to the length of time the catheter remained in place following bacterial challenge. If the catheter was not removed, sterilization of the endocardial vegetations did not take place. These studies suggest that serum bactericidal activity is an important host defense mechanism, acting to prevent the initiation of endocarditis in the case of highly serum-sensitive E. coli and to sterilize experimentally induced endocarditis in the case of less-serum-sensitive bacteria. The catheter used to induce nonbacterial endocardial vegetations favored the colonization of vegetations by E. coli, and it delayed the spontaneous sterilization of infected vegetations which occurred in relation to the susceptibility of the strain to the bactericidal properties of the serum. This effect of the catheter was not attributable to bacteria remaining viable in its lumen, nor was it attributable to inhibition of the bactericidal capacity of the serum as measured in vitro. Whatever the mechanism responsible for the catheter effect, experimental studies of the evolution of infections established with this technique must take into consideration the duration of catheter placement and whether and for how long it was present before or after inoculation with test bacteria.

Antibiotic prophylaxis against streptomycin-resistant and -susceptible Streptococcus faecalis endocarditis in rabbits.

This report describes the capacities of ampicillin, vancomycin, streptomycin, gentamicin, and combinations thereof to prevent endocarditis in rabbits challenged with either streptomycin-resistant (three strains) or streptomycin-susceptible (one strain) Streptococcus faecalis. Vancomycin (15 mg/kg) alone was effective in preventing infection with three of four strains, including two which were streptomycin resistant. Vancomycin (30 mg/kg) alone was effective against the other streptomycin-resistant strain. The vancomycin-gentamicin combination was the only therapeutic regimen to demonstrate complete prophylaxis for all strains regardless of streptomycin susceptibility. The ampicillin-gentamicin combination was variably effective despite in vitro synergism.

Treatment of staphylococcal pyelonephritis in rats with N-formimidoyl thienamycin.

The therapeutic efficacy of N-formimidoyl thienamycin alone or coadministered with MK0791, an inhibitor of renal dehydropeptidase-I, compared to methicillin in experimental pyelonephritis in rats was investigated. Pyelonephritis was produced with a methicillin-sensitive strain (2776) and a methicillin-resistant strain (Berman) of Staphylococcus aureus. N-formimidoyl thienamycin alone or coadministered with the inhibitor was significantly better than methicillin when treating methicillin-sensitive or methicillin-resistant infection. There was a trend suggesting that N-formimidoyl thienamycin coadministered with MK0791 was overall the best agent. These studies show that N-formimidoyl thienamycin is efficacious in the treatment of S. aureus pyelonephritis in the rat regardless of methicillin sensitivity, and this agent plus the dehydropeptidase inhibitor should be considered in the treatment of such infections.

Variables in demonstrating methicillin tolerance in Staphylococcus aureus strains.

Certain technical considerations which affected the status of methicillin tolerance in Staphylococcus aureus strains were studied. Methods which consistently demonstrated tolerance or intolerance of a given strain were avoidance of inoculum splashing, use of stationary-phase inoculum, 24-h tube incubation, and minimization of antibiotic carry-over. These studies suggested a need for the establishment of a standardized reference for the determination of tolerance.

Effect of iron on acute pyelonephritis and later chronic changes.

Administration of iron to rats exacerbated early inflammatory changes of pyelonephritis produced by intravenous inoculation of Escherichia coli. This effect was noted with four of eight strains of E. coli tested and was dependent on bacterial inoculum. Despite this increase in severity of acute pyelonephritis as judged by numbers of bacteria in the kidney and careful gross and microscopic evaluation, there was no enhancement of chronic changes seen 6 months later.