2012 August 03

Treatment of antineutrophil cytoplasmic antibody-associated vasculitis.

Aug 032012

Treatment of antineutrophil cytoplasmic antibody-associated vasculitis.

Curr Opin Pulm Med. 2012 Sep;18(5):447-54

Authors: Rich EN, Brown KK

Abstract

PURPOSE OF REVIEW: The primary idiopathic small-vessel vasculitis syndromes include granulomatosis with polyangiitis, Churg-Strauss syndrome, and microscopic polyangiitis. These disorders are commonly referred to as antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides and prominently affect the pulmonary vasculature. Although significant progress has been made in the management of these disorders, they continue to carry substantial morbidity and mortality as a result of both the underlying vasculitis as well as complications of its immunosuppressive therapy. This review will focus on the recent advances in the management and longitudinal monitoring of ANCA-associated vasculitis.

RECENT FINDINGS: Cyclophosphamide and glucocorticoids are standard therapy, but carry measureable risk of treatment-related toxicity. The search for alternative therapies that are less toxic but similarly efficacious is continuing. Recent investigations suggest rituximab may be a well tolerated alternative to cyclophosphamide for the induction of remission, treatment of disease relapse, and as maintenance therapy.

SUMMARY: The ANCA-associated vasculitides are a group of disorders that commonly affect the pulmonary vasculature and represent a diagnostic and therapeutic challenge to the pulmonary clinician. Recent findings have expanded our ability to diagnose and treat these disorders with a focus on limiting treatment-related toxicity while inducing and maintaining remission.

PMID: 22854508 [PubMed - in process]

Link to Article at PubMed

Effect of closed-loop order processing on the time to initial antimicrobial therapy.

Am J Health Syst Pharm Start a Discussion »

Aug 032012

Effect of closed-loop order processing on the time to initial antimicrobial therapy.

Am J Health Syst Pharm. 2012 Aug 15;69(16):1423-6

Authors: Panosh N, Rew R, Sharpe M

Abstract

Purpose The results of a study comparing the average time to initiation of i.v. antimicrobial therapy with closed-versus open-loop order entry and processing are reported. Methods A retrospective cohort study was performed to compare order-to-administration times for initial doses of i.v. antimicrobials before and after a closed-loop order-processing system including computerized prescriber order entry (CPOE) was implemented at a large medical center. A total of 741 i.v. antimicrobial administrations to adult patients during designated five-month preimplementation and postimplementation study periods were assessed. Drug-use reports generated by the pharmacy database were used to identify order-entry times, and medication administration records were reviewed to determine times of i.v. antimicrobial administration. Results The mean ± S.D. order-to-administration times before and after the implementation of the CPOE system and closed-loop order processing were 3.18 ± 2.60 and 2.00 ± 1.89 hours, respectively, a reduction of 1.18 hours (p < 0.0001). Closed-loop order processing was associated with significant reductions in the average time to initiation of i.v. therapy in all patient care areas evaluated (cardiology, general medicine, and oncology). The study results suggest that CPOE-based closed-loop order processing can play an important role in achieving compliance with current practice guidelines calling for increased efforts to ensure the prompt initiation of i.v. antimicrobials for severe infections (e.g., sepsis, meningitis). Conclusion Implementation of a closed-loop order-processing system resulted in a significant decrease in order-to-administration times for i.v. antimicrobial therapy.

PMID: 22855110 [PubMed - in process]

Link to Article at PubMed

A Systemic Approach to Containing Health Care Spending.

N Engl J Med Start a Discussion »

Aug 032012

A Systemic Approach to Containing Health Care Spending.

N Engl J Med. 2012 Aug 1;

Authors: Emanuel E, Tanden N, Altman S, Armstrong S, Berwick D, de Brantes F, Calsyn M, Chernew M, Colmers J, Cutler D, Daschle T, Egerman P, Kocher B, Milstein A, Lee EO, Podesta JD, Reinhardt U, Rosenthal M, Sharfstein J, Shortell S, Stern A, Orszag PR, Spiro T

Abstract

In this election year, U.S. national spending on health care will reach $2.8 trillion, or about 18% of total spending on all goods and services. This high level of spending reduces our ability to invest in other important parts of the economy and also adds to our unsustainable national debt. There is wide agreement that we must find ways to bend the health care cost curve. Taking different approaches, the two Sounding Board articles, by Emanuel et al. and Antos et al., present a range of options, including reducing both the prices and quantity of services for public and private payers, reducing administrative costs, implementing new market-based incentives, . . .

PMID: 22852883 [PubMed - as supplied by publisher]

Link to Article at PubMed

Perioperative management of patients on chronic antithrombotic therapy.

Blood Start a Discussion »

Aug 032012

Perioperative management of patients on chronic antithrombotic therapy.

Blood. 2012 Aug 1;

Authors: Ortel TL

Abstract

Perioperative management of antithrombotic therapy is a situation that occurs frequently and requires consideration of the patient, the procedure, and an expanding array of anticoagulant and antiplatelet agents. Preoperative assessment must address the individual patient's risk for thromboembolic events, balanced against the risk for perioperative bleeding. Procedures can be separated into those with a low bleeding risk, which generally do not require complete reversal of the antithrombotic therapy, and those associated with an intermediate or high bleeding risk. For patients who are receiving warfarin who need interruption of the anticoagulant, consideration must be given to whether simply withholding the anticoagulant is the optimal approach, or whether a perioperative 'bridge' with an alternative agent, typically a low-molecular weight heparin, should be used. The new oral anticoagulants dabigatran and rivaroxaban have shorter effective half-lives, but they introduce other concerns for perioperative management, including prolonged drug effect in patients with renal insufficiency, limited experience with clinical laboratory testing to confirm lack of residual anticoagulant effect, and lack of a reversal agent. Antiplatelet agents must also be considered in the perioperative setting, with particular consideration given to the potential risk for thrombotic complications in patients with coronary artery stents who have antiplatelet therapy withheld.

PMID: 22855600 [PubMed - as supplied by publisher]

Link to Article at PubMed

Incidence and Predictors of 30-Day Hospital Readmission Rate Following Percutaneous Coronary Intervention (from the National Heart, Lung, and Blood Institute Dynamic Registry).

Am J Cardiol Start a Discussion »

Aug 032012

Incidence and Predictors of 30-Day Hospital Readmission Rate Following Percutaneous Coronary Intervention (from the National Heart, Lung, and Blood Institute Dynamic Registry).

Am J Cardiol. 2012 Jul 30;

Authors: Ricciardi MJ, Selzer F, Marroquin OC, Holper EM, Venkitachalam L, Williams DO, Kelsey SF, Laskey WK

Abstract

Postdischarge outcomes after percutaneous coronary intervention (PCI) are important measurements of quality of care and complement in-hospital measurements. We sought to assess in-hospital and postdischarge PCI outcomes to (1) better understand the relation between acute and 30-day outcomes, (2) identify predictors of 30-day hospital readmission, and (3) determine the prognostic significance of 30-day hospital readmission. We analyzed in-hospital death and length of stay (LOS) and nonelective cardiac-related rehospitalization after discharge in 10,965 patients after PCI in the Dynamic Registry. From 1999 to 2006 in-hospital death rate and LOS decreased. Thirty-day cardiac readmission rate was 4.6%, with considerable variability over time and among hospitals. Risk of rehospitalization was greater in women and those with congestive heart failure, unstable angina, multiple lesions, and emergency PCI. Conversely, a lower risk of rehospitalization was associated with a larger number of treated lesions. Patients readmitted within 30 days had higher 1-year mortality than those free from hospital readmission. In conclusion, although in-hospital mortality and LOS after PCI have decreased over time, the observed 30-day cardiac readmission rate was highly variable and risk of readmission was more closely associated with underlying patient characteristics than procedural characteristics.

PMID: 22853982 [PubMed - as supplied by publisher]

Link to Article at PubMed

Nurse staffing, burnout, and health care-associated infection.

Am J Infect Control Start a Discussion »

Aug 032012

Nurse staffing, burnout, and health care-associated infection.

Am J Infect Control. 2012 Aug;40(6):486-90

Authors: Cimiotti JP, Aiken LH, Sloane DM, Wu ES

Abstract

BACKGROUND: Each year, nearly 7 million hospitalized patients acquire infections while being treated for other conditions. Nurse staffing has been implicated in the spread of infection within hospitals, yet little evidence is available to explain this association.

METHODS: We linked nurse survey data to the Pennsylvania Health Care Cost Containment Council report on hospital infections and the American Hospital Association Annual Survey. We examined urinary tract and surgical site infection, the most prevalent infections reported and those likely to be acquired on any unit within a hospital. Linear regression was used to estimate the effect of nurse and hospital characteristics on health care-associated infections.

RESULTS: There was a significant association between patient-to-nurse ratio and urinary tract infection (0.86; P = .02) and surgical site infection (0.93; P = .04). In a multivariate model controlling for patient severity and nurse and hospital characteristics, only nurse burnout remained significantly associated with urinary tract infection (0.82; P = .03) and surgical site infection (1.56; P < .01) infection. Hospitals in which burnout was reduced by 30% had a total of 6,239 fewer infections, for an annual cost saving of up to $68 million.

CONCLUSIONS: We provide a plausible explanation for the association between nurse staffing and health care-associated infections. Reducing burnout in registered nurses is a promising strategy to help control infections in acute care facilities.

PMID: 22854376 [PubMed - in process]

Link to Article at PubMed

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