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Author(s): Paul E. Marik [sup.1], Walter T. Linde-Zwirble [sup.2], Edward A. Bittner [sup.3], Jennifer Sahatjian [sup.4], Douglas Hansell [sup.3] [sup.4] Author Affiliations: (1) grid.255414.3, 0000 0001 2182 3733, Division of [...], Purpose The optimal strategy of fluid resuscitation in the early hours of severe sepsis and septic shock is controversial, with both an aggressive and conservative approach being recommended. Methods We used the 2013 Premier Hospital Discharge database to analyse the administration of fluids on the first ICU day, in 23,513 patients with severe sepsis and septic shock, who were admitted to an ICU from the emergency department. Day 1 fluid was grouped into categories 1 L wide, starting with 1-1.99 L up to [greater than or equal to]9 L, to examine the effect of day 1 fluids on patient mortality. We built binary response models for hospital mortality and the propensity for receiving more than 5 L of fluids on day 1, using patient age and acute conditions present on admission. Patients were grouped by the requirement for mechanical ventilation and the presence or absence of shock. We assessed trends in the difference between actual and expected mortality, in the low fluid range (1-5 L day 1 fluids) and the high fluid range (5 to [greater than or equal to]9 L day 1 fluids) categories, using weighted linear regression controlling for the effects of sample size and variation within the day 1 fluid category. Results Day 1 fluid administration averaged 4.4 L being lowest in the group with no mechanical ventilation and no shock (3.6 L) and highest (5.4 L) in the group receiving mechanical ventilation and in shock. The administration of day 1 fluids was remarkably consistent on the basis of hospital size, teaching status, rural/urban location, and region of the country. The hospital mortality in the entire cohort was 25.8%, with a mean ICU and hospital length of stay of 5.1 and 9.1 days, respectively. In the entire cohort, low volume resuscitation (1-4.99 L) was associated with a small but significant reduction in mortality, of -0.7% per litre (95% CI -1.0%, -0.4%; p = 0.02). However, in patients receiving high volume resuscitation (5 to [greater than or equal to]9 L), the mortality increased by 2.3% (95% CI 2.0, 2.5%; p = 0.0003) for each additional litre above 5 L. Total hospital cost increased by $999 for each litre of fluid above 5 L (adjusted R.sup.2 = 92.7%, p = 0.005). Conclusion The mean amount of fluid administered to patients with severe sepsis and septic shock in the USA during the first ICU day is less than that recommended by the Surviving Sepsis Campaign guidelines. The administration of more than 5 L of fluid during the first ICU day is associated with a significantly increased risk of death and significantly higher hospital costs.

Introduction Although influenza has been widely studied in developed countries, little is known about its epidemiology, seasonality and burden in developing countries. (1-6) The epidemiology of influenza and the hospitalization [...], Objective To estimate the burden and age-specific rates of influenza-associated hospitalization in rural western Kenya. Methods All 3924 patients with respiratory illness (defined as acute cough, difficulty in breathing or pleuritic chest pain) who were hospitalized between June 2007 and May 2009 in any inpatient health facility in the Kenyan district of Bondo were enrolled. Nasopharyngeal and oropharyngeal swabs were collected and tested for influenza viruses using real-time reverse transcriptase polymerase chain reaction (RT-PCR). In the calculation of annual rates, adjustments were made for enrolled patients who did not have swabs tested for influenza virus. Findings Of the 2079 patients with tested swabs, infection with influenza virus was confirmed in 204 (10%); 176, 27 and 1 were found to be RT-PCR-positive for influenza A virus only, influenza B virus only, and both influenza A and B viruses, respectively. Among those tested for influenza virus, 6.8% of the children aged < 5 years and 14.0% of the patients aged > 5 years were found positive. The case-fatality rate among admitted patients with PCR-confirmed infection with influenza virus was 2.0%. The annual rate of hospitalization (per 100 000 population) was 699.8 among patients with respiratory illness and 56.2 among patients with influenza (with 143.7, 18.8, 55.2, 65.1 and 57.3 hospitalized patients with influenza virus per 100 000 people aged < 5, 5-19, 20-34, 35-49 and [greater than or equal to] 50 years, respectively). Conclusion In a rural district of western Kenya, the rate of influenza-associated hospitalization was highest among children aged less than 5 years. [TEXT NOT REPRODUCIBLE IN ASCII.] Objectif Estimer les taux specifiques par age et par charge de l'hospitalisation liee a la grippe dans les regions rurales de l'ouest du Kenya. Methodes Tous les 3924 patients souffrant de maladie respiratoire (definies comme toux aigue, difficulte respiratoire ou douleur de poitrine pleuretique) qui ont ete hospitalises entre juin 2007 et mai 2009 dans tous les etablissements hospitaliers du district du Bondo, au Kenya, ont ete inscrits. Des prelevements nasopharynges et oropharynges ont ete rassembles et testes pour les virus de la grippe au moyen d'une transcription inverse et amplification en chaine par polymerase en temps reel (RT-PCR). Dans le calcul des taux annuels, des ajustements ont ete faits pour les patients inscrits qui n'ont pas eu de prelevements testes pour le virus de la grippe. Resultats Des 2079 patients avec prelevements testes, l'infection au virus de la grippe a ete confirmee dans 204 (10%) des cas; 176, 27 et 1 cas se sont reveles RT-PCR positifs pour, respectivement, le virus de la grippe A uniquement, le virus de la grippe B uniquement, les virus des deux grippes A et B. Parmi les personnes testees pour le virus de la grippe, 6,8% des enfants ages de < 5 ans et 14,0% des patients ages de 5 ans ou plus se sont reveles positifs. Le taux de Ietalite parmi les patients admis avec infection confirmee PCR au virus de la grippe etait de 2.0%. Le taux annuel d'hospitalisation (par 100 000 habitants) etait de 699,8 parmi les patients souffrant de maladie respiratoire et de 56,2 parmi les patients souffrant de la grippe (avec 143,7, 18,8, 55,2, 65,1 et 57,3 des patients hospitalises avec le virus de la grippe par 100 000 personnes ages de respectivement Conclusion Dans une region rurale de l'ouest du Kenya, le taux d'hospitalisation liee a la grippe etait plus eleve parmi les enfants ages de moins de 5 ans. [TEXT NOT REPRODUCIBLE IN ASCII.] Objetivo Calcular la carga y las tasas por edades de las hospitalizaciones asociadas a la gripe en el oeste rural de Kenya. Metodos Se inscribieron los 3924 pacientes con enfermedades respiratorias (definidas como tos aguda, dificultad para respirar o dolor toracico pleuritico) hospitalizados entre junio de 2007 y mayo de 2009 en cualquier centro sanitario hospitalario del distrito keniata de Bodo. Se recogieron frotis nasofaringeos y bucofaringeos y se comprobo la presencia de virus de la gripe mediante una reaccion en cadena de la polimerasa dirigida por ARN (transcriptasa inversa) (RT-PCR). Se llevaron a cabo ajustes para aquellos pacientes inscritos para cuyos frotis no se habia realizado la prueba del virus de la gripe para realizar el calculo de las tasas anuales. Resultados Se confirmo la presencia de una infeccion por virus de la gripe en 204 (10%) de los 2079 pacientes cuyos frotis se sometieron a prueba;176, 27 y 1 casos dieron positivo en la prueba de la RT-PCR solo para el virus gripal A, solo para el virus gripal By para ambos virus gripales A y B, respectivamente. El 6,8% de los ninos menores de 5 anos y el 14,0% de los pacientes mayores de 5 anos entre los que se realizo la prueba para el virus gripal dio positivo. La tasa de letalidad entre los pacientes admitidos con una infeccion por el virus gripal confirmada por la prueba de la PCR fue del 2,0% La tasa anual de hospitalizaciones (por cada 100 000 habitantes) fue de 699,8 entre pacientes con enfermedades respiratorias y de 56,2 entre los pacientes con gripe (con 143,7,18,8, 55,2, 65,1 y 57,3 pacientes hospitalizados con virus gripal por cada 100 000 habitantes con edades menores de 5, comprendidas entre 5-19, 20-34, 35-49 y mas de 50 anos, respectivamente). Conclusion En un distrito rural del oeste de Kenya, la tasa de hospitalizaciones asociadas a la gripe fue mas alta entre los ninos menores de 5 anos.

Introduction Vesicoureteral reflux (VUR), the retrograde flow of urine from the bladder into the ureter, is the most common congenital abnormality of the urinary tract in children [1, 2]. The [...], This study evaluates the impact of vesicoureteral reflux (VUR) on the economy and inpatient healthcare utilization in the USA. A retrospective analysis was performed on children ≤ 18 years of age, hospitalized with the principal discharge diagnosis of VUR between 2000 and 2006, using the Healthcare Cost and Utilization Project Kids' Inpatient Database. The results are stratified as follows. First, by hospitalizations: between 2000 and 2006, 6,655 ± 720 (standard error) children/year were hospitalized with VUR. Since 2003, both the length of each hospitalization and the number of hospitalizations have decreased. Second, by related procedures/diagnoses: ureteral reimplantation was the most common procedure, accounting for 89% of hospitalizations. Congenital genitourinary anomalies, disorders of the kidney/ureter/bladder, and urinary tract infections (UTI) were the most common related diagnoses. Thirdly, by hospital economics: since 2000, hospital charges for VUR increased despite decreased lengths of hospitalization. By 2006, hospital charges rose to $18,798/hospitalization, and aggregate national charges exceeded $100 million. Our results indicate that fewer children with VUR are requiring inpatient management. Children with VUR are often hospitalized for ureteral reimplantation or the management of related diagnoses. Since 2000, hospital charges for inpatient VUR management have increased. More efforts are needed to evaluate cost-effective strategies for the evaluation and management of VUR. Keywords Vesicoureteral reflux * Pediatrics * Urinary tract infection * Epidemiology * Economics

Summary Most diabetes services that conduct oral glucose tolerance tests provide little information to patients about their potential condition and what they can do to ameliorate it. A community service [...]

Prompt and aggressive initiation of antimicrobial therapy is the mainstay of treatment for patients with blood-stream infections (BSIs). (1-3) Moreover, increasing rates of drug resistance have forced clinicians to expose [...], Context.--Early diagnosis of gram-negative bloodstream infections, prompt identification of the infecting organism, and appropriate antibiotic therapy improve patient care outcomes and decrease health care expenditures. In an era of increasing antimicrobial resistance, methods to acquire and rapidly translate critical results into timely therapies for gram-negative bloodstream infections are needed. Objective.--To determine whether mass spectrometry technology coupled with antimicrobial stewardship provides a substantially improved alternative to conventional laboratory methods. Design.--An evidence-based intervention that integrated matrix-assisted laser desorption and ionization time-off-light mass spectrometry, rapid antimicrobial susceptibility testing, and near-real-time antimicrobial stewardship practices was implemented. Outcomes in patients hospitalized prior to initiation of the study intervention were compared to those in patients treated after implementation. Differences in length of hospitalization and hospital costs were assessed in survivors. Results.--The mean hospital length of stay in the preintervention group survivors (n = 100) was 11.9 versus 9.3 days in the intervention group (n = 101; P = .01). After multivariate analysis, factors independently associated with decreased length of hospitalization included the intervention (hazard ratio, 1.38; 95% confidence interval, 1.01-1.88) and active therapy at 48 hours (hazard ratio, 2.9; confidence interval, 1.15-7.33). Mean hospital costs per patient were $45 709 in the preintervention group and $26 162 in the intervention group (P = .009). Conclusions.--Integration of rapid identification and susceptibility techniques with antimicrobial stewardship significantly improved time to optimal therapy, and it decreased hospital length of stay and total costs. This innovative strategy has ramifications for other areas of patient care. (Arch Pathol Lab Med. 2013;137:1247-1254; doi: 10.5858/arpa.2012-0651-OA)