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1.
Hosp Pract (1995) ; 47(3): 123-129, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31177865

RESUMO

Clostridium difficile (CD) is the most common cause of nosocomial diarrhea. We aim to highlight practice measures for controlling and preventing Clostridium difficile infections (CDI) in the hospital setting. Electronic databases including PubMed, MEDLINE, Google Scholar, ClinicalTrials.gov, and Cochrane Databases were searched for human studies that assessed strategic measures for the prevention of CDI. Bundled interventions can effectively reduce the rates of CDI. Current evidence support the implementation antibiotic stewardship programs, hygiene enhancement, dietary management with probiotics, use of copper surfaces, and the cautious use of PPIs. However, current guidelines do not advocate the use of copper, probiotics, or the discontinuation of PPIs as a means for reducing CDI. We review these practical and evidence-based approaches.


Assuntos
Gestão de Antimicrobianos , Infecções por Clostridium/prevenção & controle , Clostridium difficile , Infecção Hospitalar/prevenção & controle , Hospitais , Humanos , Higiene
2.
J Intensive Care Med ; 31(5): 333-7, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-24916754

RESUMO

BACKGROUND: The utilization of imaging procedures is under scrutiny due to high costs and radiation exposure to patients and staff associated with some radiologic procedures. Within our institution's intensive care unit (ICU), it is common for patients to undergo chest radiography (CR) not only immediately following tracheostomy tube placement but also on a daily basis, irrespective of the patient's clinical status. We hypothesize that the clinical utility of performing routine daily CR on patients with tracheostomy tubes is low and leads to unnecessary financial cost. METHODS: A retrospective medical chart review was done on 761 CRs performed on 79 ICU patients with tracheostomy from April 2010 to July 2011. We searched the radiology reports of the 761 CRs for the presence of new radiographically detected complications and reviewed medical records to determine which complications were clinically suspected and which radiology reports led to changes in patient management. RESULTS: Of the 761 CRs, only 18 (2.3%) radiographs revealed new complications. All complications were clinically suspected prior to imaging. Only 5 (0.7%) complications resulted in a management change. The most common management changes were a change in antibiotic regimen (0.3%) and ordering of diuretics (0.3%). CONCLUSIONS: Routine daily imaging of patients with tracheostomy in an ICU provides little clinical utility, and CR in this population should be performed selectively based on the patient's clinical status.


Assuntos
Cuidados Críticos , Estado Terminal/terapia , Unidades de Terapia Intensiva , Radiografia Torácica , Traqueostomia , Procedimentos Desnecessários , Análise Custo-Benefício , Cuidados Críticos/economia , Estado Terminal/economia , Humanos , Unidades de Terapia Intensiva/economia , Cuidados Pós-Operatórios , Exposição à Radiação , Radiografia Torácica/efeitos adversos , Radiografia Torácica/economia , Radiografia Torácica/estatística & dados numéricos , Estudos Retrospectivos , Procedimentos Desnecessários/economia
3.
J Intensive Care Med ; 30(5): 303-7, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-24671004

RESUMO

Norethindrone acetate/ethinyl estradiol (Estrostep; Warner Chilcott, Rockaway, New Jersey) is an "estrophasic" type of oral contraceptive, which combines a continuous low progestin dose with a gradually increasing estrogen dose. In clinical trials, this medication failed to produce clinically significant changes in serum lipid levels. We report a case of severe hypertriglyceridemia-induced acute pancreatitis in a 24-year-old woman caused by Estrostep, occurring nearly 10 years after she began using the drug. The patient was admitted to the medical intensive care unit (ICU) for aggressive volume resuscitation and management of severe electrolyte abnormalities. Laboratory studies obtained on admission indicated severe hypertriglyceridemia (2,200 mg/dL), hyponatremia (120 mEq/L), and hypocalcemia (0.78 mmol/L). Amylase and lipase levels were also elevated (193 and 200 U/L, respectively). Ranson score calculated after 48 hours of admission was 4, and her Acute Physiology and Chronic Health Evaluation (APACHE) IV score was 35. Treatment included an insulin infusion, ω-3 fatty acid esters, and gemfibrozil. The insulin infusion reduced serum triglyceride levels by 50% after 1 day of treatment and to 355 mg/dL by day 7 of her ICU course. We believe that this is the first reported case of severe, acute hypertriglyceridemia-induced pancreatitis caused by this medication.


Assuntos
Anticoncepcionais Orais Hormonais/efeitos adversos , Etinilestradiol/efeitos adversos , Hipertrigliceridemia/induzido quimicamente , Noretindrona/efeitos adversos , Pancreatite/induzido quimicamente , Combinação de Medicamentos , Feminino , Humanos , Adulto Jovem
4.
J Intensive Care Med ; 30(6): 358-64, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-24603677

RESUMO

BACKGROUND: Many terminally ill patients experience an increasing intensity of medical care, an escalation frequently not consistent with their preferences. In 2009, formal palliative care consultation (PCC) was integrated into our medical intensive care unit (ICU). We hypothesized that significant differences in clinical and economic outcomes exist between ICU patients who received PCC and those who did not. METHODS: We reviewed ICU admissions between July and October 2010, identified 41 patients who received PCC, and randomly selected 80 patients who did not. We measured clinical outcomes and economic variables associated with patients' ICU courses. RESULTS: Patients in the PCC group were older (average 64 years, standard deviation [SD] 19.2 vs 55.6 years, SD 14.5; P = .021) and sicker (median Acute Physiology and Chronic Health Evaluation IV score 85.5, interquartile range [IQR] 60.5-107.5 vs 60, IQR 39.2-74.75; P < .001) than the non-PCC controls. PCC patients received significantly more total days of ICU care on average (8 days, IQR 4-15 vs 4 days, IQR 2-7; P < .001), had more ICU admissions, and were more likely to die during their ICU stay (64.3% vs 12.5%, P < .001). Median total hospital charges per patient attributable to ICU care were higher in the PCC group than in the controls (US$315,493, IQR US$156,470-US$486,740 vs US$116,934, IQR US$54,750-US$288,660; P < .001). After we adjusted for ICU length of stay, we found that median ICU charges per day per patient did not differ significantly between the groups (US$37,463, IQR US$27,429-US$56,230 vs US$41,332, IQR US$30,149-US$63,288; P = .884). Median time to PCC during the ICU stay was 7 days (IQR 2-14.5 days). CONCLUSIONS: Patients who received PCC had higher disease acuity, longer ICU lengths of stay, and higher ICU mortality than controls. "Trigger" programs in the ICU may improve utilization of PCC services, improve patient comfort, and reduce invasive, often futile end-of-life care.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Assistência à Saúde/métodos , Unidades de Terapia Intensiva/estatística & dados numéricos , Cuidados Paliativos/estatística & dados numéricos , Melhoria de Qualidade , APACHE , Idoso , Cuidados Críticos/economia , Cuidados Críticos/normas , Assistência à Saúde/economia , Assistência à Saúde/normas , Feminino , Preços Hospitalares/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/economia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Cuidados Paliativos/economia , Cuidados Paliativos/normas
5.
J Intensive Care Med ; 30(1): 49-57, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-24212597

RESUMO

Cocaine use continues to be a major public health problem in the United States. Although many of the initial signs and symptoms of cocaine intoxication result from increased stimulation of the sympathetic nervous system, this condition can present as a spectrum of acuity from hypertension and tachycardia to multiorgan system failure. Classic features of acute intoxication include tachycardia, arterial vasoconstriction, enhanced thrombus formation, mydriasis, psychomotor agitation, and altered level of consciousness. At the extreme end of this toxidrome is a rare condition known as cocaine-induced agitated delirium. This syndrome is characterized by severe cardiopulmonary dysfunction, hyperthermia, and acute neurologic changes frequently leading to death. We report a case of cocaine-induced agitated delirium in a man who presented to our institution in a paradoxical form of circulatory shock. Rapid evaluation, recognition, and proper management enabled our patient not only to survive but also to leave the hospital without neurologic sequelae.


Assuntos
Transtornos Relacionados ao Uso de Cocaína/diagnóstico , Delírio/induzido quimicamente , Febre/induzido quimicamente , Intubação Intratraqueal , Agitação Psicomotora/etiologia , Cateterismo Urinário , Acetilcisteína/administração & dosagem , Antibacterianos/administração & dosagem , Transtornos Relacionados ao Uso de Cocaína/complicações , Transtornos Relacionados ao Uso de Cocaína/terapia , Cuidados Críticos/métodos , Diagnóstico Precoce , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
6.
J Clin Neurol ; 8(1): 75-8, 2012 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-22523517

RESUMO

BACKGROUND: Malignant peripheral nerve sheath tumors (MPNSTs), sarcomas originating from tissues of mesenchymal origin, are rare in patients without a history of neurofibromatosis. CASE REPORT: We report a case of an MPNST of the spinal accessory nerve, unassociated with neurofibromatosis, which metastasized to the brain. The tumor, originating in the intrasternomastoid segment of the spinal accessory nerve, was removed. Two years later, the patient presented with focal neurological deficits. Radiographic findings revealed a well-defined 2.2×2.2×2.2 cm, homogeneously enhancing mass in the left parieto-occipital region of the brain surrounded by significant vasogenic edema and mass effect, culminating in a 1-cm midline shift to the right. The mass was surgically removed. The patient had nearly complete recovery of vision, speech, and memory. CONCLUSIONS: To our knowledge, this is the first documented case of an MPNST arising from an extracranial segment of the spinal accessory nerve and metastasizing to the brain.

7.
Crit Care Res Pract ; 2011: 170814, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-22110908

RESUMO

The Affordable Care Act signed into law by President Obama, with its value-based purchasing program, is designed to link payment to quality processes and outcomes. Treatment of critically ill patients represents nearly 1% of the gross domestic product and 25% of a typical hospital budget. Data suggest that high-intensity staffing patterns in the intensive care unit (ICU) are associated with cost savings and improved outcomes. We evaluate the literature investigating the cost-effectiveness and clinical outcomes of high-intensity ICU physician staffing as recommended by The Leapfrog Group (a consortium of companies that purchase health care for their employees) and identify ways to overcome barriers to nationwide implementation of these standards. Hospitals that have implemented the Leapfrog initiative have demonstrated reductions in mortality and length of stay and increased cost savings. High-intensity staffing models appear to be an immediate cost-effective way for hospitals to meet the challenges of health care reform.

8.
Health Policy ; 102(2-3): 223-8, 2011 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-21439669

RESUMO

The field of critical care has changed markedly in recent years to accommodate a growing population of chronically critically ill patients. New administrative structures have evolved to include divisions, departments, and sections devoted exclusively to the practice of critical care medicine. On an individual level, the ability to manage complex multisystem critical illnesses and to introduce invasive monitoring devices defines the intensivist. On a systems level, critical care services managed by an intensivist-led multidisciplinary team are now recognized by their ability to efficiently utilize hospital resources and improve patient outcomes. Due to the numerous cost and quality issues related to the delivery of critical care medicine, intensive care unit physician staffing (IPS) has become a charged subject in recent years. Although the federal government has played a large role in regulating best practices by physicians, other third parties have entered the arena. Perhaps the most influential of these has been The Leapfrog Group, a consortium representing 130 employers and 65 Fortune 500 companies that purchase health care for their employees. This group has proposed specific regulatory guidelines for IPS that are purported to result in substantial cost containment and improved quality of care. This narrative review examines the impact of The Leapfrog Group's recommendations on critical care delivery in the United States.


Assuntos
Cuidados Críticos , Estado Terminal , Unidades de Terapia Intensiva , Admissão e Escalonamento de Pessoal/normas , Médicos/provisão & distribução , Humanos , Unidades de Terapia Intensiva/economia , Modelos Econômicos , Inovação Organizacional , Admissão e Escalonamento de Pessoal/economia , Guias de Prática Clínica como Assunto , Qualidade da Assistência à Saúde , Gestão de Riscos , Estados Unidos , Recursos Humanos
9.
Med Hypotheses ; 76(3): 328-31, 2011 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-21106301

RESUMO

Results of epidemiological studies suggest that, after one controls for the number of cigarettes smoked, women have a three times higher risk of getting lung cancer than men. Although the mechanism(s) explaining this gender-dependent difference in lung cancer risk is not known, it is thought that endocrine factors may play an important role. Normal human bronchial epithelial cells contain estrogen receptors and synthesize 17ß-estradiol (E(2)) and estrone (E(1)), which can undergo further metabolism into the catechol estrogens, 4-hydroxyestradiol (4-OHE(2)) and 4-hydroxyestrone (4-OHE(1)), respectively. Catechol estrogens are formed from E(2) by the actions of cytochrome p450 1B1 (CYP1B1). CYP1B1 is present in normal human bronchial epithelial) cells, and its activity is increased by cigarette smoking. Both 4-OHE(1) and 4-OHE(2) are mutagenic and carcinogenic and may exert their biological effects by inducing DNA adducts in cancer-related genes, including the tumor suppressor gene p53 and the proto-oncogene K-ras. Women with lung cancer have a different p53 mutational spectrum and a higher frequency of K-ras mutations than do men with lung cancer. Both clinical and basic research studies support the hypothesis that E(2) and cigarette smoking are cofactors in lung carcinogenesis in women. More specifically, cigarette smoke stimulates metabolism of E(2) into the genotoxic metabolites, 4-OHE(1) and 4-OHE(2,) which interact with DNA in cancer-related genes, including the tumor suppressor gene, p53, and the proto-oncogene K-ras, two genes frequently mutated in patients with lung cancer. E(2) may stimulate cellular proliferation and enhance tumor growth.


Assuntos
Estradiol/metabolismo , Estrogênios/metabolismo , Neoplasias Pulmonares/epidemiologia , Fumar/efeitos adversos , Adenocarcinoma/epidemiologia , Adenocarcinoma de Pulmão , Animais , Carcinógenos/farmacologia , Sistema Enzimático do Citocromo P-450/farmacologia , Adutos de DNA/farmacologia , Estradiol/farmacologia , Feminino , Terapia de Reposição Hormonal/efeitos adversos , Humanos , Masculino , Camundongos , Proto-Oncogenes/genética , Fatores de Risco , Fatores Sexuais
10.
J Crit Care ; 25(2): 282-6, 2010 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-19592210

RESUMO

BACKGROUND: A nationwide increase in the rate and severity of Clostridium difficile-associated disease may reflect infection with a virulent strain characterized by polymerase chain reaction as ribotype 027 (NAP1/B1). HYPOTHESIS: The high prevalence of ribotype 027 at our institution would allow investigation of the risk of mortality and admission to the intensive care unit (ICU) associated with C difficile infection. METHODS: In a retrospective cohort study, we identified 108 patients with positive enzyme-linked immunosorbant assay tests for C difficile toxins over a 6-month period and compared them to 108 patients who were suspected to have C difficile but with negative toxin assays. Proportions of all-cause mortality and ICU admission were compared using chi(2), and odds ratios (ORs) were estimated using logistic regression to adjust for potential confounders. Mean log lengths of stay were compared using t test. RESULTS: Comparing patients with C difficile to those without, mortality (20% vs 8%) and ICU admission (32% vs 17%) were significantly higher (P = .02 for both), whereas log length of stay was not (P = .29). Adjusting for potential confounders, the OR for mortality was 6.8 (95% confidence interval, 1.8-25.4; P = .01), whereas for ICU admission, the association was no longer observed (OR, 1.0; 95% confidence interval, 0.4-2.5; P = .97). CONCLUSION: C difficile infection was associated with increased all-cause mortality. An observed association with ICU admission and C difficile infection was identified through univariate analysis but was not significant in multivariate analysis. Although we did not strain-type isolates for patients infected with C difficile, the institutional prevalence of ribotype 027 C difficile infection was known to be high. These results document a strong association between ribotype 027 C difficile infection and mortality and underscore the need to identify effective C difficile preventive strategies.


Assuntos
Infecções por Clostridium/mortalidade , Clostridium difficile/isolamento & purificação , Unidades de Terapia Intensiva/estatística & dados numéricos , Idoso , Toxinas Bacterianas/isolamento & purificação , Distribuição de Qui-Quadrado , Infecções por Clostridium/microbiologia , Infecções por Clostridium/terapia , Clostridium difficile/classificação , Estudos de Coortes , Ensaio de Imunoadsorção Enzimática , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Retrospectivos , Ribotipagem , Risco
12.
Liver Int ; 27(8): 1148-51, 2007 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-17845545

RESUMO

Dengue infections are caused by a single-stranded RNA virus, which has four serotypes (DEN 1-4); mosquitoes of the genus Aedes serve as vectors of transmission. Risk factors for dengue infection are related to both the host and virus. Age, gender, immune status, and genetic background of the host all contribute to the severity of dengue infection. Recently, international travel to endemic areas has also been identified as a major risk factor for both primary and secondary dengue infection. Dengue remains a diagnostic challenge, given its protean nature, ranging from mild febrile illness to profound shock. The most severe manifestation of dengue infection is dengue shock syndrome, which has an estimated mortality rate close to 50%. Dengue shock syndrome typically presents with increased anion gap metabolic acidosis, disseminated intravascular coagulation, severe hypotension, and jaundice. Liver involvement appears to occur more frequently when infections involve DEN-3 and DEN-4 serotypes. While hepatocellular damage has been reported previously in dengue infection, acute liver failure is an extremely rare occurrence in adults. We report a patient with dengue shock syndrome who presented with acute liver failure and hepatic encephalopathy after recent travel to an endemic area.


Assuntos
Encefalopatia Hepática/virologia , Falência Hepática Aguda/virologia , Fígado/virologia , Dengue Grave/diagnóstico , Viagem , Idoso , Feminino , Encefalopatia Hepática/patologia , Humanos , Fígado/patologia , Falência Hepática Aguda/patologia , Necrose , Dengue Grave/complicações , Dengue Grave/patologia , Dengue Grave/virologia
14.
Clin Lung Cancer ; 5(6): 353-9, 2004 May.
Artigo em Inglês | MEDLINE | ID: mdl-15217534

RESUMO

Although lung cancer is the leading cause of cancer death among men and women in the United States, female smokers appear to be at increased risk. After controlling for the number of cigarettes smoked, female sex imparts a significant, independent risk for most histologic types of lung cancer. Cigarette smoking, genetics, and endocrine factors may interact to contribute to the disparity in lung cancer risk between the sexes. Estrogens have direct and indirect actions in the lung, and estrogen has been implicated in lung carcinogenesis in female smokers. This review of the literature will focus on endocrine factors and tobacco carcinogens as risk factors for lung cancer in women.


Assuntos
Estrogênios/farmacologia , Neoplasias Pulmonares/etiologia , Fumar/efeitos adversos , Carcinógenos/efeitos adversos , Sistema Endócrino/fisiologia , Estrogênios/metabolismo , Feminino , Humanos , Masculino , Fatores de Risco , Fatores Sexuais
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