RESUMEN
Coronavirus disease 2019 (COVID-19) can progress to cytokine storm that is associated with organ dysfunction and death. The purpose of the present study is to determine clinical characteristics associated with 28 day in-hospital survival in patients with coronavirus disease 2019 (COVID-19) that received tocilizumab. This was a retrospective observational cohort study conducted at a five hospital health system in Michigan, United States. Adult patients with confirmed COVID-19 that were admitted to the hospital and received tocilizumab for cytokine storm from March 1, 2020 through April 3, 2020 were included. Patients were grouped into survivors and non-survivors based on 28 day in-hospital mortality. Study day 0 was defined as the day tocilizumab was administered. Factors independently associated with in-hospital survival at 28 days after tocilizumab administration were assessed. Epidemiologic, demographic, laboratory, prognostic scores, treatment, and outcome data were collected and analyzed. Clinical response was collected and defined as a decline of two levels on a six-point ordinal scale of clinical status or discharged alive from the hospital. Of the 81 patients included, the median age was 64 (58-71) years and 56 (69.1%) were male. The 28 day in-hospital mortality was 43.2%. There were 46 (56.8%) patients in the survivors and 35 (43.2%) in the non-survivors group. On study day 0 no differences were noted in demographics, clinical characteristics, severity of illness scores, or treatments received between survivors and non-survivors. C-reactive protein was significantly higher in the non-survivors compared to survivors. Compared to non-survivors, recipients of tocilizumab within 12 days of symptom onset was independently associated with survival (adjusted OR: 0.296, 95% CI: 0.098-0.889). SOFA score ≥8 on day 0 was independently associated with mortality (adjusted OR: 2.842, 95% CI: 1.042-7.753). Clinical response occurred more commonly in survivors than non-survivors (80.4% vs. 5.7%; p < 0.001). Improvements in the six-point ordinal scale and SOFA score were observed in survivors after tocilizumab. Early receipt of tocilizumab in patients with severe COVID-19 was an independent predictor for in-hospital survival at 28 days.
Asunto(s)
Anticuerpos Monoclonales Humanizados/administración & dosificación , Proteína C-Reactiva/análisis , Infecciones por Coronavirus/tratamiento farmacológico , Síndrome de Liberación de Citoquinas/tratamiento farmacológico , Neumonía Viral/tratamiento farmacológico , Adulto , Anciano , Betacoronavirus/inmunología , COVID-19 , Infecciones por Coronavirus/sangre , Infecciones por Coronavirus/inmunología , Infecciones por Coronavirus/mortalidad , Síndrome de Liberación de Citoquinas/sangre , Síndrome de Liberación de Citoquinas/inmunología , Síndrome de Liberación de Citoquinas/mortalidad , Femenino , Mortalidad Hospitalaria , Humanos , Infusiones Intravenosas , Interleucina-6/inmunología , Interleucina-6/metabolismo , Masculino , Michigan/epidemiología , Persona de Mediana Edad , Puntuaciones en la Disfunción de Órganos , Pandemias , Neumonía Viral/sangre , Neumonía Viral/inmunología , Neumonía Viral/mortalidad , Pronóstico , Receptores de Interleucina-6/antagonistas & inhibidores , Receptores de Interleucina-6/metabolismo , Estudios Retrospectivos , SARS-CoV-2 , Análisis de Supervivencia , Factores de Tiempo , Tiempo de Tratamiento , Resultado del Tratamiento , Tratamiento Farmacológico de COVID-19RESUMEN
PURPOSE: The purpose of this study was to describe how the discharge medication cost inquiry (DMCI) consult order and workflow were created and used to communicate transition of care needs and medication access barriers before discharge. SUMMARY: Health-system pharmacists collaborated with the information technology department to develop the DMCI consult order and workflow. This institutional review board-approved retrospective case study evaluated use of the DMCI consult order throughout the health system. Outcomes that could not be retrieved electronically were collected for every third patient encounter using manual chart review. The DMCI consult order was used at each hospital in the health system. Physicians placed the most DMCI consult orders; however, pharmacists at the large academic tertiary hospital utilized the DMCI consult order the most. The DMCI consult order was sent most frequently for anticoagulants. Although most medications were covered by insurance, the tool and workflow identified barriers to medication access. Almost 90% of the patients with a DMCI consult order had at least one prescription generated on discharge. CONCLUSION: The DMCI consult order is a novel electronic tool to aid in communicating discharge medication needs. When incorporated into care transition planning, the DMCI consult order and workflow provide a model to ensure patients have access to medications. It can also be used to document and evaluate the role of pharmacy in transitions of care in the health system.
Asunto(s)
Alta del Paciente , Servicio de Farmacia en Hospital , Electrónica , Accesibilidad a los Servicios de Salud , Humanos , Conciliación de Medicamentos , Farmacéuticos , Estudios RetrospectivosRESUMEN
OBJECTIVES: The Centers for Medicare and Medicaid Services Severe Sepsis and Septic Shock Management Bundle (SEP-1) assesses antibiotic administration, lactate measurement, and blood culture collection within 3 h of severe sepsis onset. The impact of the SEP-1 3-hour bundle among patients with severe sepsis is not extensively described. This investigation aimed to describe the impact of 3-hour bundle compliance on 28-day in-hospital mortality in patients with severe sepsis. STUDY DESIGN: This was a retrospective, propensity adjusted, nested case-control study assessing the impact of compliance with a 3-hour sepsis bundle among patients with severe sepsis. SETTING: This study was conducted at a large, academic, tertiary care medical center in Detroit, Michigan from July 1, 2017 to December 31, 2019. PATIENTS: Cases were defined as those suffering 28-day in-hospital mortality. Controls were defined as those surviving at or discharged by 28 days. Patients were separated based on 3-hour bundle compliance or noncompliance. Nested and overall cohorts were assessed. Severe sepsis time zero was manually validated. Patients with shock, requiring vasopressors within 8 h of time zero, or those not meeting SEP-1 inclusion criteria were excluded. INTERVENTION: The primary outcome was the propensity adjusted odds of 28-day in-hospital mortality among 3-hour bundle compliant versus noncompliant patients. Secondary outcomes included mortality for individual bundle element compliance, progression to septic shock, and predictors of mortality according to logistic regression. RESULTS: A total of 325 compliant and 325 noncompliant patients were included. The median Sequential Organ Failure Assessment (SOFA) score was three in each group. There was no difference in propensity adjusted odds of mortality among those compliant versus noncompliant with the 3-hour bundle (odds-ratio [OR] 1.039; 95% CI: 0.721-1.497; p = 0.838) or with individual bundle elements. SOFA score and female sex were predictors of mortality. CONCLUSIONS: Three-hour bundle compliance did not impact 28-day in-hospital mortality in patients with severe sepsis. Further research is needed to understand the impact of 3-hour bundle compliance on mortality in severe sepsis.
Asunto(s)
Sepsis , Choque Séptico , Anciano , Estudios de Casos y Controles , Femenino , Adhesión a Directriz , Mortalidad Hospitalaria , Humanos , Medicare , Estudios Retrospectivos , Estados UnidosRESUMEN
The use of metaphor as a conceptual and clinical tool in the treatment situation can enhance the therapeutic alliance and strengthen the effectiveness of therapeutic communication. The evolution of a special metaphoric system of communication in the course of the treatment situation enhances the positive alliance between patient and therapist. In a way analogous to the poetic use of metaphor, the therapeutic use of appropriate metaphors can be a powerful tool because a metaphor is a symbol that represents a condensation of multiple impulses, conflicts, fantasies, and affects. Case material will be presented to illustrate the use of metaphoric communication in the clinical situation.
Asunto(s)
Comunicación , Metáfora , Relaciones Profesional-Paciente , Terapia Psicoanalítica/métodos , Ira/fisiología , Ansiedad/psicología , Ansiedad/terapia , Niño , Mecanismos de Defensa , Trastorno Depresivo/psicología , Trastorno Depresivo/terapia , Fantasía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Trastornos de la Personalidad/terapia , Interpretación Psicoanalítica , Timidez , Transferencia PsicológicaRESUMEN
Case reports are presented of two hyperactive preschool boys, one with severe cognitive and one with emotional problems, treated as a last resort with the Kaiser-Permanente elimination diet. Outcomes suggest further study of the effectiveness of the diet in alleviating symptoms of hyperactivity, especially in the preschool child who is unresponsive to medication and whose hyperactivity may be compounded by other developmental and emotional problems.