An automated dispensing system for improving medication timing in the emergency department / 世界急诊医学杂志（英文）

BACKGROUND: Numerous medical conditions require timely medication administration in the emergency department (ED). Automated dispensing systems (ADSs) store premixed common doses at the point-of-care to minimize time to administration, but the use of such automation to improved time to medication administration has not been studied. Since vancomycin is a commonly used empiric antimicrobial, we sought to quantify the effect of using an ADS on time to drug delivery in patients presenting to the ED. The study aimed to determine the efficacy of utilizing an ADS to improve time to administration of vancomycin and determine any negative effects on dosing appropriateness.METHODS: The institional review board approved the retrospective quality improvement study took place in a single, urban academic tertiary care ED with an annual census of 80000. Study subjects were all patients receiving vancomycin for the management of sepsis between March 1 to September 30, 2008 and the same time period in 2009. The primary outcome was the proportion of patients who received vancomycin within one hour of bed placement and the secondary outcome was dosing appropriateness.RESULTS: Sixty-three patients had weight and dosing information available (29 before and 34 after intervention) and were included in the study. Before intervention, no patient received vancomycin in less than 60 minutes, while after intervention 14.7％ of the patients received it in less than 60 minutes (difference in proportions 14.7％, 95％ CI 0.39％-30.0％, P=0.04). A similar proportion of the patients received correct dosing before and after intervention (44.8％ vs. 41.2％, difference in proportions 3.7％, 95％ CI -20.0％-26.7％, P=0.770).CONCLUSION: The use of an ADS may improve the timing of medication administration in patients presenting to the ED without affecting dosing appropriateness.

Appraisals of marital conflict and children's adjustment, health, and physiological reactivity.

Children's appraisals of marital conflict were examined as moderators and mediators of conflict and children's adjustment, physical health, and physiological reactivity. Mothers completed measures of marital conflict and children's adjustment and physical health, and elementary school children provided information on their parents' marital conflict, appraisals of perceived threat and self-blame in relation to parents' conflicts, and their internalizing symptomatology. Children's heart rate, systolic and diastolic blood pressure, and skin conductance response and level were examined during both a baseline and an interadult argument. Higher levels of both self-blame and perceived threat functioned as robust vulnerability factors for children exposed to higher levels of marital conflict in relation to internalizing behaviors, health problems, and higher levels of cardiovascular reactivity to the argument. Further, a higher level of perceived threat was a vulnerability factor for externalizing problems associated with exposure to marital conflict.

A novel X chromosome-linked genetic cause of recurrent spontaneous abortion.

OBJECTIVE: Unexplained recurrent spontaneous abortion is a common women's health problem that affects approximately 1 of every 200 women who wish to have children. It has long been assumed that a large proportion of recurrent spontaneous abortion results from genetic problems, but no causative genes have been identified to date. Here, we tested the hypothesis that a subset of women with recurrent spontaneous abortion are carriers of X-linked recessive disorders that result in the loss of male pregnancies. STUDY DESIGN: X chromosome inactivation patterns, an assay used to detect women who are likely to be carriers of X-linked recessive cell-lethal traits, were compared between 105 female patients with idiopathic recurrent pregnancy loss and 101 women (control subjects) with a single successful pregnancy and no history of pregnancy loss. Inheritance patterns and gender of offspring were studied in relevant subsets of participants. RESULTS: Female patients showed a highly statistically significant increase in the frequency of skewed X chromosome inactivation (90%; P < .0005). Female patients with highly skewed X chromosome inactivation showed a significant decrease in male children. Four of 6 families that were studied showed maternal inheritance of the skewed inactivation trait. CONCLUSION: We found the 14% of women with unexplained recurrent pregnancy loss show highly skewed X inactivation, which suggests that they are carriers of X-linked recessive lethal traits. Furthermore, the observed gender bias among women with highly skewed X inactivation suggests selective loss of male conceptions, which is consistent with an X chromosome-linked genetic defect that leads to cell death or growth disadvantage. Identification of such female carriers is important for the reproductive counseling and treatment of these women.

Ty1 retrotransposition and programmed +1 ribosomal frameshifting require the integrity of the protein synthetic translocation step.

Programmed ribosomal frameshifting is utilized by a number of RNA viruses to ensure the correct ratio of viral structural to enzymatic proteins for viral particle assembly. Altering frameshifting efficiencies upsets this ratio, inhibiting virus propagation. Two yeast viruses that induce host cell ribosomes to shift translational reading frame were used as tools to explore the interactions between viruses and host cellular protein synthetic machinery. Previous studies showed that the ribosome-inactivating protein pokeweed antiviral protein specifically inhibited propagation of the Ty1 retrotransposable element of yeast as a consequence of inhibition of programmed +1 ribosomal frameshifting. Here, complementary genetic and pharmacological approaches were employed to test whether inhibition of Ty1 retrotransposition is a general feature of alterations in the translocation step of elongation and +1 frameshifting. The results demonstrate that cells harboring a variety of mutant alleles of two host-encoded proteins that are involved in translocation, eukaryotic elongation factor-2 and the ribosome-associated protein RPP0, have Ty1 propagation defects. We also show that sordarin, a fungus-specific inhibitor of eEF-2 function, specifically inhibits programmed +1 ribosomal frameshifting and Ty1 retrotransposition. These findings serve to link inhibition of Ty1 retrotransposition and +1 frameshifting to changes in the translocation step of elongation.

Employing the clinical service unit model.

Duke University Hospital has instituted a decision tool that enables administrators and medical directors to manage from both the operational (departmental) perspective as well as from the patient population perspective. The tool automates routine reporting, aligns business information with a new, cross-functional management structure, and provides a focus for improvement opportunities.

Exposure to interparental conflict and children's adjustment and physical health: the moderating role of vagal tone.

Physiological regulation, as indexed by baseline vagal tone and delta vagal tone (the change in vagal tone during an attention-demanding or challenging task), was examined as a moderator in the relations between exposure to verbal and physical parental marital conflict and children's adjustment and physical health. Higher vagal tone was posited to serve a protective function (i.e., buffer) for children exposed to higher levels of marital conflict. Seventy-five 8- to 12-year-olds and their mothers completed measures of parental conflict, and children's adjustment and physical health. Children's vagal tone was assessed during baseline conditions and during exposure to an audiotaped interadult argument. Results indicate that higher vagal tone buffered children against increased externalizing, internalizing, and health problems related to exposure to more frequent marital conflict, especially verbal conflict. Further, higher levels of delta vagal tone protected boys against externalizing problems associated with verbal conflict, and health problems associated with physical conflict.

A multicenter, placebo-controlled pilot study of intravenous immune globulin treatment of antiphospholipid syndrome during pregnancy. The Pregnancy Loss Study Group.

OBJECTIVE: Treatment with heparin and low-dose aspirin improves fetal survival among women with antiphospholipid syndrome. Despite treatment, however, these pregnancies are frequently complicated by preeclampsia, fetal growth restriction, and placental insufficiency, often with the result of preterm birth. Small case series suggest that intravenous immune globulin may reduce the rates of these obstetric complications, but the efficacy of this treatment remains unproven. This pilot study was undertaken to determine the feasibility of a multicenter trial of intravenous immune globulin and to assess the impact on obstetric and neonatal outcomes among women with antiphospholipid syndrome of the addition of intravenous immune globulin to a heparin and low-dose aspirin regimen. STUDY DESIGN: This multicenter, randomized, double-blind pilot study compared treatment with heparin and low-dose aspirin plus intravenous immune globulin with heparin and low-dose aspirin plus placebo in a group of women who met strict criteria for antiphospholipid syndrome. All patients had lupus anticoagulant, medium to high levels of immunoglobulin G anticardiolipin antibodies, or both. Patients with a single live intrauterine fetus at

Serologic and virologic evidence for frequent intrauterine transmission of human parvovirus B19 with a primary maternal infection during pregnancy.

OBJECTIVE: To define the intrauterine viral transmission rate during primary maternal parvovirus B19 infection and identify factors that may influence this rate. METHODS: Forty-three pregnant women at two medical centers were identified with a primary B19 infection and followed to delivery. At delivery maternal and infant (umbilical cord) blood was obtained for B19 serologic and virologic PCR testing. RESULTS: All of the women delivered healthy infants at term and none was hydropic. Overall 22 (51%) of the 43 infants had some evidence of a congenital B19 infection. B19-specific IgM was detected in 11 infants at delivery, B19 IgA was detected in 10 and B19 DNA was detectable by PCR in 11 infants. One infant was negative at birth but became positive for IgM, IgA and PCR at 6 weeks of age. No association was found between the likelihood of intrauterine infection and: maternal age; symptomatic maternal infection; method of delivery; maternal IgG titer at delivery; maternal IgG avidity at delivery; or maternal viremia at delivery. Intrauterine infection was associated with maternal IgM positivity at delivery; this association may have been a result of maternal infection occurring later in gestation. CONCLUSION: Although the incidence of intrauterine hydrops and fetal demise after maternal infection is low, there is a high rate of intrauterine viral infection that occurs throughout gestation and yields newborns who, although infected in utero, are asymptomatic at birth.

Prospective evaluation of 618 pregnant women exposed to parvovirus B19: risks and symptoms.

OBJECTIVE: To assess the risk of maternal parvovirus B19 infection from exposure to various sources and the fetal morbidity of those infections. METHODS: We obtained demographic and occupational information about pregnant women exposed to sources of B19 and about the nature and duration of the exposures. We performed serologic testing 10-14 days after exposure using an indirect capture enzyme-linked immunosorbent assay. Women with immunoglobulin (Ig) M were examined with weekly ultrasound until 12 weeks after exposure, and the outcome of the pregnancy was ascertained from interviews with patients and their obstetricians. Logistic regression analysis was used to determine risk factors for maternal immunity and infection by B19. RESULTS: Of 618 pregnant women exposed, 307 (49.7%) were immune to B19, 259 remained susceptible after exposure, and 52 (16.7% of all susceptibles) contracted B19 infection. None of the 52 fetuses of infected women developed nonimmune hydrops, and there were no fetal deaths attributable to B19 in this group. The relative risk of maternal B19 infection was 2.8 if the source was a related child living in the household (95% confidence interval 1.7, 4.6; P < .001). No significant differences were found for maternal B19 infection in eight categories of maternal occupation. Maternal symptoms of polyarthralgia (46%), fever (19%), and nonspecific rash (38%) were significantly more common (P < .001) in IgM-positive patients than in noninfected women (4.1%, 2.8%, and 5.7%, respectively). Only 17 (33%) of the IgM-positive women were entirely asymptomatic. CONCLUSION: The risk of maternal B19 infection in pregnancy could not be predicted by a gravida's occupation, but it was significantly higher when the source of exposure was her own child. The fetal risk of nonimmune hydrops after maternal B19 infection must be very low. As a consequence, exclusion of pregnant women from the workplace during endemic periods with seasonal clusters of cases is not justified. Weekly fetal ultrasound evaluation in these cases carries a low yield.

Low-dose aspirin and prednisone treatment of pregnancy loss caused by lupus anticoagulants.

The objective of this study was to ascertain the complications and the efficacy of low-dose aspirin (LDA) and prednisone therapy in women with pregnancy loss and "lupus anticoagulants" (LAC). During the period 1985 to 1993, 255 patients with two or more pregnancy losses (RPL) were tested for LAC with an activated partial thromboplastin time (aPTT) and a tissue thromboplastin inhibition index (TTI, normal value < 1.3). The diagnosis of LAC was established if two TTI values were > or = 1.3 or if a prolonged aPTT was measured in the patient's plasma that did not correct to normal by 1:1 mixing with normal plasma. We excluded patients with RPL who had only anticardiolipin antibodies. We treated 28 pregnancies in 21 women with LDA/prednisone for RPL associated with LAC. Therapy with LDA/prednisone was initiated as soon as a viable pregnancy was diagnosed. Therapy was continued until delivery in all but one case. Prednisone dose was minimized by measuring TTI and aPTT every 2 weeks and adjusting the dosage to maintain a TTI < or = 1.2 and to correct the aPTT to less than 36 seconds. Among the 28 pregnancies there were four (14%) first-trimester spontaneous abortions and four (14%) second-trimester fetal deaths. Of 20 surviving neonates (72%), seven were delivered after 37 weeks and 13 before 37 weeks (mean 35.9 +/- 2.3 weeks, range 31.5 to 40.4 weeks). Pre-term premature rupture of membranes occurred in three pregnancies, hypertensive disorders in six, and four small-for-gestational-age neonates were delivered (two stillborn). Mean birth weight of 20 surviving neonates was 2736 +/- 763 gm (range 900 to 3920 gm). Mean daily prednisone dose in 20 live births was 24.1 +/- 8.5 (SD) mg (range 11.3 to 49.3 mg/day) with mean duration of LDA/prednisone therapy of 185 +/- 40 days (range 97 to 223 days). Maximum prednisone dose was 60 mg/day (mean 36.8 +/- 12.7 mg/day). Only one serious maternal complication of LDA/prednisone therapy was observed. One neonate had talipes equinovarus that resolved without surgical therapy. LDA/prednisone therapy seemed effective and reasonably well tolerated in this population. These findings should be confirmed in a prospective, controlled investigation if such a trial can be organized and performed.

Association between familial autoimmune diseases and recurrent spontaneous abortions.

PROBLEM: To examine the aggregation of autoimmune disease in the families of women experiencing recurrent spontaneous abortions. METHOD: The 95 participants in this case-control study were recruited from Magee Womens Hospital, Pittsburgh, Pennsylvania from June 1988 to May 1991. The women having recurrent spontaneous abortions (N = 45) reported at least three early fetal losses, and the controls (N = 50) reported a minimum of three pregnancies with at least two live births and no more than one induced or involuntary pregnancy loss. Data from the participants and from their first-degree and second-degree relatives were obtained by questionnaire and verified by a repeated interview, if necessary. RESULTS: The prevalence of arthritis, thyroid disease, and diabetes mellitus was increased among the relatives of women having recurrent spontaneous abortions compared to normally fertile couples. Several autoimmune diseases occurred concurrently in family members of patients, but not in the family members of normally fertile couples. CONCLUSIONS: Autoimmune diseases occur more frequently in the families of women who have experienced recurrent spontaneous abortions. Both types of diseases involve genes in the class II region of the major histocompatibility complex.

Prevention of neonatal group B streptococcal infection.

The optimal clinical strategy to prevent neonatal group B streptococcal infection has not been established. The Maternal-Fetal Medicine Units Network assessed the feasibility of a randomized clinical trial to compare the effectiveness of two methods of prevention of streptococcal infection. The attack rates of early-onset group B streptococcal disease were estimated for the following: 1) a hypothetical program of universal prenatal screening and selective intrapartum chemoprophylaxis, and 2) a hypothetical program of selective intrapartum chemoprophylaxis based on clinical risk factors. Sample size requirements were calculated for a clinical trial to detect a significant difference in attack rates between the two hypothetical programs. Similar low attack rates using both strategies would require extremely large sample sizes to detect differences between programs. Until a satisfactory, rapid diagnostic test for intrapartum group B streptococcal carrier status is developed and clinical strategies are tested in populations with varying carriage frequencies, institutions will need to individualize their approaches to prevent early-onset neonatal group B streptococcal disease.

Early postpartum endometritis. Randomized comparison of ampicillin/sulbactam vs. ampicillin, gentamicin and clindamycin.

Seventy-six parturients with a clinical diagnosis of early postpartum endometritis were randomized to be treated with either standard therapy--ampicillin, gentamicin and clindamycin--or a new regimen, ampicillin/sulbactam. We deliberately chose to administer 1.5 g of ampicillin/sulbactam rather than a 3-g dose every six hours in order to accentuate any differences that might occur between the regimens. Failure rates, days of therapy and cost of treatment were compared. There was no statistically significant difference (P > .9) in the failure or recovery rates: 4 of 42 (9.5%) patients failed standard therapy vs. 6 of 34 (17.6%) patients in the ampicillin/sulbactam group. The times to recovery were 3.6 +/- 1.8 SD and 3.3 +/- 1.3 days, respectively. There was no difference in side effects or drug toxicity between the two groups. The cost of standard therapy was $355.32 for 3.6 days, whereas ampicillin/sulbactam cost $139.49 for 3.3 days. Therapy with ampicillin/sulbactam may be an equally effective and efficient way to treat patients with early postpartum endometritis.

Intrauterine parvovirus B19 infection may cause an asymptomatic or recurrent postnatal infection.

Although infection with parvovirus B19 (B19) during pregnancy may cause fetal demise, the true incidence of intrauterine infection is unknown. For 19 women with serologically confirmed B19 infections between 4 and 38 weeks of gestation, we performed follow-up examinations of their infants. Serial sonograms of the 19 fetuses showed that none developed hydrops. All 19 women delivered healthy term infants. Cord sera of four infants were tested for IgM to B19 and three were positive. Between 3 and 21 months of age, all 19 infants had normal physical examinations, developmental evaluations and hematocrits; and 16 lacked IgG to B19. One infant who was IgM-positive to B19 at birth was IgM-positive at age 7 months when he also had an IgG titer to B19 of 1:500,000 (mother's concurrent titer, 1:10,000), and had B19 DNA in serum detected by polymerase chain reaction. The other two infants who were IgM-positive at birth were IgM- and IgG-negative by 11 and 16 months of age. These results suggest that intrauterine B19 infection may be frequent and occasionally cause an asymptomatic postnatal infection.

Accuracy of the Papanicolaou smear in the diagnosis of asymptomatic infection with Trichomonas vaginalis.

OBJECTIVE: To assess the accuracy of Papanicolaou smears in reporting cytologic evidence of Trichomonas vaginalis in asymptomatic women attending a resident clinic. METHODS: In phase I of this study, we prospectively enrolled 100 asymptomatic gynecologic patients to be screened for vaginal trichomoniasis using wet preparation, vaginal culture, and Papanicolaou smear. During phase II, asymptomatic patients (40 gynecologic and 20 obstetric) whose screening Papanicolaou smears showed cytologic evidence of trichomoniasis returned for wet preparation, culture, and repeat Papanicolaou smear. Patients were considered infected with T vaginalis if either the wet preparation or culture was positive, and uninfected if both tests were negative. The cytopathologist was not informed of the patient's enrollment in this study or of the results of culture or wet preparation. RESULTS: The prevalence of asymptomatic trichomonas infection in gynecologic patients enrolled in phase I was 6%. In asymptomatic gynecologic patients enrolled in phase II, repeat Papanicolaou smear had a sensitivity and specificity of 86 and 83%, respectively, when diagnosing infection. Thirty percent of these patients would have been treated unnecessarily for trichomoniasis based upon screening Papanicolaou smear. In obstetric patients, the sensitivity of repeat Papanicolaou smear was 94% and specificity was 100%. Had therapy been initiated based on screening cytology, 20% of obstetric patients would have received unindicated therapy. The differences in sensitivity and specificity between the groups were statistically significant (P < .05). CONCLUSION: When a screening Papanicolaou smear reports cytologic evidence of T vaginalis infection in the asymptomatic patient, a confirmatory test should be performed before initiating therapy.

Comparison of two antigen assays for rapid intrapartum detection of vaginal group B streptococcal colonization.

As part of a clinical investigation evaluating the efficacy of intrapartum antigen detection for screening for heavy vaginal colonization with group B streptococci (GBS), we compared the performance of modified Bactigen and Directigen GBS latex particle agglutination (LPA) kits. Paired vaginal swabs obtained from women in labor were rapidly transported to the laboratory and used for culturing (both swabs) and LPA testing (one swab by each method). GBS growth was estimated semiquantitatively and further designated as light or heavy growth. Performance specifications for each method were determined by comparing LPA and culture results from the same swab. A total of 4,251 paired swabs were evaluated during the study period. The performance specifications for detecting GBS growth of any degree for Bactigen and Directigen, respectively, were as follows: sensitivity, 20 and 24%; specificity, 99 and 99%. The performance specifications for heavy colonization for Bactigen and Directigen, respectively, were as follows: sensitivity, 57 and 62%; specificity, 99 and 99%. Neither LPA kit was a sensitive indicator of vaginal colonization with GBS or neonatal infection.

Efficacy of hepatitis B screening in a private obstetrical population.

We sought to determine whether the recent Centers for Disease Control recommendation of universal prenatal screening for hepatitis B surface antigen (HBsAg) is necessary or cost-effective in a population of private patients. During the 21 months of our study there were 17,973 deliveries at Magee-Womens Hospital, the largest-volume private obstetrics service in the United States. We screened 12,377 of these patients for HBsAg. Only 11 patients, 0.09% of those screened (5 private and 6 clinic) tested positive. We administered questionnaires regarding historical risk factors for hepatitis B to all 11 patients testing positive for HBsAg and to 100 controls who tested negative for HBsAg. All private patients and 5 of 6 clinic patients testing positive for HBsAg had identifiable risk factors for hepatitis B. In addition, historical risk factors for hepatitis B were identified in 29% of the women testing negative for HBsAg. We found historical risk factors to be excellent predictors of the presence of HBsAg in our private patients. Our data indicate that universal screening for HBsAg is not necessary in private patients.