Search

This paper is part of a clinical practice guideline update on the risk assessment, diagnostic imaging, and microbiological evaluation of complicated intra-abdominal infections in adults, children, and pregnant people, developed by the Infectious Diseases Society of America (IDSA). In this paper, the panel provides recommendations for diagnostic imaging of suspected acute appendicitis. The panel's recommendations are based on evidence derived from systematic literature reviews and adhere to a standardized methodology for rating the certainty of evidence and strength of recommendation according to the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach., Competing Interests: Potential conflicts of interest. Evaluation of relationships as potential conflicts of interest (COIs) is determined by a review process. The assessment of disclosed relationships for possible COIs is based on the relative weight of the financial relationship (ie, monetary amount) and the relevance of the relationship (ie, the degree to which an association might reasonably be interpreted by an independent observer as related to the topic or recommendation of consideration). A. W. C. receives honoraria from UpToDate, Inc, and serves on an Agency for Healthcare Research and Quality technical expert panel for diagnosis of acute right lower quadrant abdominal pain (suspected acute appendicitis). J. R. B. serves as past president of the European Society of Clinical Microbiology and Infectious Diseases. M. S. E. receives royalties from UpToDate, Inc, as co-section editor of Pediatric Infectious Diseases. M. K. H. serves on the Society for Healthcare Epidemiology of America (SHEA) Board of Directors. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

This article is part of a clinical practice guideline update on the risk assessment, diagnostic imaging, and microbiological evaluation of complicated intra-abdominal infections in adults, children, and pregnant people, developed by the Infectious Diseases Society of America. In this guideline, the panel provides recommendations for obtaining blood cultures in patients with known or suspected intra-abdominal infection. The panel's recommendations are based on evidence derived from systematic literature reviews and adhere to a standardized methodology for rating the certainty of evidence and strength of recommendation according to the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach., Competing Interests: Potential conflicts of interest. Evaluation of relationships as potential conflicts of interest (COIs) is determined by a review process. The assessment of disclosed relationships for possible COIs is based on the relative weight of the financial relationship (ie, monetary amount) and the relevance of the relationship (ie, the degree to which an association might reasonably be interpreted by an independent observer as related to the topic or recommendation of consideration). A. W. C. receives honoraria from UpToDate, Inc; serves on an Agency for Healthcare Research and Quality technical expert panel for diagnosis of acute right lower quadrant abdominal pain (suspected acute appendicitis); and has served as an advisor for GenMark Diagnostics, Inc, on molecular diagnostics for gastrointestinal pathogens. J. R. B. serves as past president of ESCMID. M. S. E. receives royalties from UpToDate, Inc, as co–section editor of Pediatric Infectious Diseases. M. K. H. serves on the Society for Healthcare Epidemiology of America Board of Directors and has received free services from OpGen, Inc, for a research project. R. H. is an advisor for bioMérieux, Inc, and was previously an employee of Accelerate Diagnostics, Inc; has received research funding from bioMérieux, Inc; and has served as an advisor for Thermo Fisher Scientific, Inc. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

This paper is part of a clinical practice guideline update on the risk assessment, diagnostic imaging, and microbiological evaluation of complicated intra-abdominal infections in adults, children, and pregnant people, developed by the Infectious Diseases Society of America. In this paper, the panel provides a recommendation for risk stratification according to severity of illness score. The panel's recommendation is based on evidence derived from systematic literature reviews and adheres to a standardized methodology for rating the certainty of evidence and strength of recommendation according to the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach., Competing Interests: Potential conflicts of interest. Evaluation of relationships as potential conflicts of interest (COIs) is determined by a review process. The assessment of disclosed relationships for possible COIs is based on the relative weight of the financial relationship (ie, monetary amount) and the relevance of the relationship (ie, the degree to which an association might reasonably be interpreted by an independent observer as related to the topic or recommendation of consideration). A. W. C. receives honoraria from UpToDate, Inc. J. R. B. serves as past president of the European Society of Clinical Microbiology and Infectious Diseases. M. S. E. receives royalties from UpToDate, Inc. as co-section editor of Pediatric Infectious Diseases. M. K. H. serves on the Society for Healthcare Epidemiology of America Board of Directors. All other authors report no relevant disclosures. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

This paper is part of a clinical practice guideline update on the risk assessment, diagnostic imaging, and microbiological evaluation of complicated intra-abdominal infections in adults, children, and pregnant people, developed by the Infectious Diseases Society of America. In this paper, the panel provides recommendations for obtaining cultures of intra-abdominal fluid in patients with known or suspected intra-abdominal infection. The panel's recommendations are based on evidence derived from systematic literature reviews and adhere to a standardized methodology for rating the certainty of evidence and strength of recommendation according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach., Competing Interests: Potential conflicts of interest . Evaluation of relationships as potential conflicts of interest (COIs) is determined by a review process. The assessment of disclosed relationships for possible COIs is based on the relative weight of the financial relationship (ie, monetary amount) and the relevance of the relationship (ie, the degree to which an association might reasonably be interpreted by an independent observer as related to the topic or recommendation of consideration). A. W. C. receives honoraria from UpToDate, Inc.; serves on an Agency for Healthcare Research and Quality technical expert panel for diagnosis of acute right lower quadrant abdominal pain (suspected acute appendicitis); and has served as an advisor for GenMark Diagnostics, Inc. on molecular diagnostics for gastrointestinal pathogens. J. R. B. serves as past president of the European Society of Clinical Microbiology and Infectious Diseases. M. S. E. receives royalties from UpToDate, Inc. as co-section editor of Pediatric Infectious Diseases. M. K. H. serves on the Society for Healthcare Epidemiology of America (SHEA) Board of Directors and has received free services from OpGen, Inc. for a research project. R. H. is an advisor for bioMerieux, Inc. and was previously an employee of Accelerate Diagnostics, Inc.; has received research funding from bioMerieux, Inc.; and served as an advisor for Thermo Fisher Scientific, Inc. All other authors reported no relevant disclosures. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

As the first part of an update to the clinical practice guideline on the diagnosis and management of complicated intra-abdominal infections in adults, children, and pregnant people, developed by the Infectious Diseases Society of America, the panel presents 21 updated recommendations. These recommendations span risk assessment, diagnostic imaging, and microbiological evaluation. The panel's recommendations are based on evidence derived from systematic literature reviews and adhere to a standardized methodology for rating the certainty of evidence and strength of recommendation according to the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach., Competing Interests: Potential conflicts of interest. Evaluation of relationships as potential conflicts of interest (COIs) is determined by a review process. The assessment of disclosed relationships for possible conflicts of interest is based on the relative weight of the financial relationship (ie, monetary amount) and the relevance of the relationship (ie, the degree to which an association might reasonably be interpreted by an independent observer as related to the topic or recommendation of consideration). A. W. C. receives honoraria from UpToDate, Inc.; serves on an Agency for Healthcare Research and Quality technical expert panel for diagnosis of acute right lower quadrant abdominal pain (suspected acute appendicitis); and has served as an advisor for GenMark Diagnostics, Inc. on molecular diagnostics for gastrointestinal pathogens. J. R. B. serves as past president of the European Society of Clinical Microbiology and Infectious Diseases. M. S. E. receives royalties from UpToDate, Inc. as co-section editor of Pediatric Infectious Diseases. M. H. serves on the Society Healthcare Epidemiology of America Board of Directors and has received free services from OpGen, Inc. for a research project. R. H. is an advisor for bioMérieux, Inc. and was previously an employee of Accelerate Diagnostics, Inc.; has received research funding from bioMérieux, Inc.; and served as an advisor for Thermo Fisher Scientific, Inc. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Objectives: Frailty is associated with adverse outcomes among patients with vascular disease. Grip strength measurement is a comparatively simple, quick, and inexpensive screening test for weakness (a component of frailty) that is potentially applicable to clinical practice. We hypothesized that grip strength and categorical weakness are associated with clinical outcomes among patients with vascular disease. To test this hypothesis, we conducted a longitudinal cohort study evaluating associations between grip strength measured during outpatient clinic visits for vascular disease and clinical outcomes, including survival and perioperative outcomes., Methods: Adult patients recruited from outpatient vascular surgery and/or vascular medicine clinics underwent dominant hand grip strength measurement using a hand dynamometer. Participants were categorized as weak based on grip strength, sex, and body mass index. Multivariable logistic models were used to evaluate perioperative outcomes. Mortality was evaluated using Cox proportional hazards models adjusted for sex, age, and operative intervention during follow-up., Results: We enrolled 321 participants. The mean patients age was 69.0 ± 9.4 years, and 33% were women. Mean grip strength was 32.0 ± 12.1 kg, and 92 participants (29%) were categorized as weak. The median follow-up was 24.0 months. Adverse perioperative events occurred in 32 of 84 patients undergoing procedures. Grip strength was associated with decreased risk of perioperative adverse events (hazard ratio [HR], 0.41 per 12.7 kg increase; 95% confidence interval [CI], 0.20-0.85; P = .0171) in a model adjusted for open versus endovascular procedure (HR, 12.75 for open; 95% CI, 2.54-63.90; P = .0020) and sex (HR, 3.05 for male; 95% CI, 0.75-12.4; P = .120). Grip strength was also associated with a lower risk of nonhome discharge (HR, 0.34 per 12.7 kg increase; 95% CI, 0.14-0.82; P = .016) adjusted for sex (HR, 2.14 for male; 95% CI, 0.48-9.50; P = .31) and open versus endovascular procedure (HR, 10.36 for open; 95% CI, 1.20-89.47; P = .034). No associations between grip strength and length of stay were observed. Mortality occurred in 48 participants (14.9%) during follow-up. Grip strength was inversely associated with mortality (HR, 0.46 per 12.5 kg increase; 95% CI, 0.29-0.73; P = .0009) in a model adjusted for sex (HR, 5.08 for male; 95% CI, 2.1-12.3; P = .0003), age (HR, 1.04 per year; 95% CI, 1.01-1.08), and operative intervention during follow-up (HR, 1.23; 95% CI, 0.71-2.52). Categorical weakness was also associated with mortality (HR, 1.81 vs nonfrail; P = .048) in a model adjusted for age (HR, 1.06 per year; P = .002) and surgical intervention (HR, 1.36; 95% CI, 1.02-0.09; P = .331)., Conclusions: Grip strength is associated with all-cause mortality, perioperative adverse events, and nonhome discharge among patients with vascular disease. These observations support the usefulness of grip strength as a simple and inexpensive risk screening tool for patients with vascular disease., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Chagas disease is underappreciated as a health concern in the United States. Approximately 40 000 women of childbearing age living in the United States have chronic Chagas disease. Most of them are unaware that they have an infection that is transmissible to their offspring. The estimated US maternal-to-infant transmission rate of Trypanosoma cruzi is 1% to 5%. Ten percent to 40% of neonates with congenital T cruzi infection have clinical signs consistent with a congenital infection but no findings are unique to Chagas disease. If left untreated, 20% to 40% of infants with Chagas disease will later develop potentially fatal cardiac manifestations. Molecular testing can confirm the diagnosis in neonates. Treatment is well tolerated in infancy and usually results in cure. Screening of at-risk women during pregnancy can identify maternal infection and allow early assessment and treatment for congenital T cruzi infection., (© The Author(s) 2019. Published by Oxford University Press on behalf of The Journal of the Pediatric Infectious Diseases Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Group B streptococcal rectovaginal colonization prevalence in women of Indian descent living in the United States was 24.7% comparable with US rates but higher than rates reported from India. The capsular polysaccharide types were distinct in that type V was most common and 33% of group B streptococcal strains were nontypeable.

Background: A vaccine against group B streptococcus (GBS) that is intended for routine maternal immunization during pregnancy is in clinical development. Addition of vaccination to screening and intrapartum antibiotic prophylaxis (IAP) may further reduce the burden of GBS disease in infancy; its potential cost-effectiveness is unknown, however., Methods: We evaluated the cost-effectiveness of routine immunization at week 28 of pregnancy with the trivalent GBS (serotypes Ia, Ib and III) vaccine that is in clinical development. The vaccine was assumed to be used in addition to screening and IAP, and reduce the risk of invasive infection in infancy due to covered serotypes. We estimated the effectiveness of immunization in terms of additional cases of GBS disease prevented, deaths averted, life-years saved, and quality-adjusted life-years (QALYs) gained; potential reductions in prematurity and stillbirths were not considered. Costs considered included those of acute care for infants with GBS disease, and chronic care for those with long-term disability. The cost of immunization was assumed to be $100 per person., Results: Assuming 85% coverage, routine maternal immunization against GBS added to screening and IAP would prevent an additional 899 cases of GBS disease and an additional 35 deaths among infants in the US. The total annual cost of immunization would be $362.7 million; estimated cost savings from prevention of GBS disease in infancy would be $43.5 million. The cost-effectiveness of immunization was estimated to be $91,321 per QALY gained. Findings were sensitive to assumptions regarding vaccine efficacy and cost., Conclusions: Addition of a trivalent GBS maternal vaccine to screening and IAP might further reduce the burden of GBS disease among infants in the US, and may be comparable in cost-effectiveness to other vaccines recently approved for use in children and adolescents., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Nutrition is a recognized determinant in 3 (ie, diseases of the heart, malignant neoplasms, cerebrovascular diseases) of the top 4 leading causes of death in the United States. However, many health care providers are not adequately trained to address lifestyle recommendations that include nutrition and physical activity behaviors in a manner that could mitigate disease development or progression. This contributes to a compelling need to markedly improve nutrition education for health care professionals and to establish curricular standards and requisite nutrition and physical activity competencies in the education, training, and continuing education for health care professionals. This article reports the present status of nutrition and physical activity education for health care professionals, evaluates the current pedagogic models, and underscores the urgent need to realign and synergize these models to reflect evidence-based and outcomes-focused education.

Chagas disease, which is caused by the protozoan parasite Trypanosoma cruzi, can lead to severe cardiac and gastrointestinal disease. Most persons acquire this infection through contact with vector bugs carrying T. cruzi in endemic areas of Latin America. Infection can also be acquired by congenital, transfusion, transplantation, and foodborne transmission. Although an estimated 300,000 persons with Chagas disease live in the United States, little is known about the burden of chagasic heart disease. It is not known how often congenital or vector-borne transmission of T. cruzi occurs in the United States, although it is known that infected mothers and infected vector bugs are found in this country. Better diagnostic tests and treatment drugs are needed to improve patient care, and research is needed to define transmission risks and develop strategies to prevent new infections and reduce the burden of disease.

Purpose: Medication cost is a major factor associated with increasing health care costs in the United States. Expenditures for prescription drugs in 2013 are estimated to be $283.7 billion. Closed system transfer devices are widely used for preparation of hazardous drugs. Reports indicate the Phaseal(®) closed system transfer device maintains sterility in vials for 7 days, suggesting the unused portion of single-use vials could be salvaged. This study was done to determine whether using a closed system transfer device to extend the beyond-use date of single-use vials of antineoplastic medications would result in a measurable cost saving., Methods: A list of 25 drugs available in single-use vials, with a chemical stability of at least 48 hours, was compiled. Use of these agents was recorded during a 50-day period in April through June 2012. Use from a total of 296 vials of 21 antineoplastic agents was recorded. After allowing for the initial use of each vial, the mean potential percentage of drug waste was calculated to be 57.03%., Results: Actual savings during the study period was $96,348.70. The pharmacy avoided nearly half of the potential waste and saved a mean of 29% of each vial. The cost-saving during the study period represents a $703,047.67 annual saving; which more than offsets the $106,556.55 the pharmacy spent for the Phaseal(®) system in 2012., Conclusion: In addition to being a protective measure to reduce exposure to hazardous agents, use of the Phaseal(®) system results in a reduction in drug waste, and a noticeable cost saving for antineoplastic agents.

Background: Vancomycin treatment failures in adults with methicillin-resistant Staphylococcus aureus bacteremia are well documented despite established therapeutic monitoring consensus recommendations. Vancomycin use in children has unique challenges, and consensus guidelines are lacking. We evaluated trends in vancomycin monitoring in children and estimated the impact of adult guidelines on patterns of vancomycin use., Methods: A retrospective, descriptive study was designed. Data were obtained from the Pediatric Health Information System from 40 not-for-profit, tertiary care pediatric hospitals in the United States. Patients receiving vancomycin during hospitalizations ending July 1, 2007 through June 30, 2011 were included, and the number of vancomycin monitoring determinations per course of therapy was queried. Vancomycin utilization and monitoring practices were evaluated across institutions, age groups and time intervals., Results: A total of 104,586 patients met study criteria. The mean duration of vancomycin administration was 5 (median 3, range 1-257) days. A mean of 1 (median 1, range 0-186) serum vancomycin concentration was obtained per patient; 46% of patients had none. Eighty-one percent of those receiving vancomycin more than 3 days had monitoring performed at least once. Monitoring practices did not correlate with length of therapy (r² = 0.11). Monitoring frequency increased across all age groups (P < 0.05) after publication of adult guidelines in January 2009., Conclusions: Vancomycin monitoring practices are highly variable in children admitted to pediatric hospitals. The frequency with which serum vancomycin concentrations were monitored in children increased after the publication of the adult guidelines. Pediatric consensus guidelines should be developed to optimize patient care and resource utilization.

Object: Pediatric primary spinal cord tumors (PSCTs) are rare, with limited comprehensive data regarding incidence and patterns of diagnosis and treatment. The authors evaluated trends in the diagnosis and treatment of PSCTs using a nationwide database., Methods: The Surveillance, Epidemiology, and End Results (SEER) registry was queried for the years 1975-2007, evaluating clinical patterns in 330 patients 19 years of age or younger in whom a pediatric PSCT had been diagnosed. Histological diagnoses were grouped into pilocytic astrocytoma, other low-grade astrocytoma, ependymoma, and high-grade glioma. Patient demographics, tumor pathology, use of external beam radiation (EBR), and overall survival were analyzed., Results: The incidence of pediatric PSCT was 0.09 case per 100,000 person-years and did not change over time. Males were more commonly affected than females (58% vs 42%, respectively; p < 0.006). Over the last 3 decades, the specific diagnoses of pilocytic astrocytoma and ependymoma increased, whereas the use of EBR decreased (60.6% from 1975 to 1989 vs 31.3% from 1990 to 2007; p < 0.0001). The 5- and 10-year survival rates did not differ between these time periods., Conclusions: While the incidence of pediatric PSCT has not changed over time, the pattern of pathological diagnoses has shifted, and pilocytic astrocytoma and ependymoma have been increasingly diagnosed. The use of EBR over time has declined. Relative survival of patients with low-grade PSCT has remained high regardless of the pathological diagnosis.

Background: Deep vein thrombosis (DVT) is a quality measure recorded by initiatives such as the National Surgical Quality Improvement Program (NSQIP). However, because surveillance-detected DVT rates may be higher than symptomatic DVT rates, we examined how differences in the method of DVT detection may affect the use of this quality measure., Methods: Using the NSQIP database (2007-2009), we compared DVT rates of vascular (amputation, open aortic procedures, and lower extremity bypass) and nonvascular (prostatectomy, gastric bypass [GBP], and hip arthroplasty) operations. Using a predefined literature search strategy, we compared the incidence of DVT in NSQIP to the incidence of DVT reported in published literature, diagnosed by symptomatic status or by surveillance studies., Results: Within NSQIP, the overall incidence of postoperative DVT was 0.7%. This varied from 0.3% after GBP to 1.8% after open aortic surgery. Across all procedures except amputation, the incidence of DVT in NSQIP was similar to the incidence of DVT reported in our literature survey of "symptomatic" DVTs. The relative rate (RR) of literature-derived symptomatic DVTs to NSQIP ranged from 0.7 for aortic cases (95% confidence interval [CI], 0.3-1.7) to 1.4 (95% CI, .7-3.1) for GBP. Overall, surveillance studies had 11.6 higher RR of DVT compared to NSQIP (95% CI, 10.5-13), ranging from 2.6 for GBP (95% CI, 1.4-5) to 14 .5 for hip arthroplasty (95% CI, 10.5-20)., Conclusions: The incidence of DVT reported in NSQIP is similar to the reported incidence of symptomatic DVT for many high-risk procedures but is much lower than rates of DVT reported in surveillance studies. Clear delineation of symptomatic vs surveillance detection of DVT would improve the usefulness of this measurement in quality improvement registries., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Endovascular abdominal aortic aneurysm repair (EVAR) requires both endovascular and open surgical skills. Although usually performed by a single operating specialist, EVAR may alternatively involve multiple teams from different specialties performing separate procedural components. We examined the relative frequencies of single versus multi-specialty EVAR in the 2005 to 2008 American College of Surgeons National Surgical Quality Improvement Participant Use Datafile and explored the influence of multi-specialty EVAR on 30-day mortality. EVARs were identified and classified as single or multiple-specialty procedures based on Current Procedural Terminology codes. Baseline and procedural characteristics were compared using χ(2) or Fisher's exact test for categorical variables and t test for continuous variables. The association between multi-specialty EVAR and 30-day mortality was examined using a multivariate logistic regression model. Of 7269 EVAR patients identified, 7086 were single and 183 were multi-specialty. Multi-specialty patients had higher frequency of brachial or iliac artery exposure and longer operative times, but were otherwise similar in baseline and procedural characteristics. In the multivariate model, multi-specialty EVAR was associated with increased risk of 30-day mortality (odds ratio 2.35; 95% confidence interval 1.08-5.11; P value 0.031). Multi-specialty participation in EVAR procedures is associated with significantly higher 30-day mortality. Further research is warranted to determine whether multi-specialty participation reflects provider experience, institutional protocols, procedural complexity, non-surgical or other factors.

Objective: This study examined the national use of vena cava filters (VCFs) from 1998 to 2005., Methods: Methods for complex surveys were used to examine hospital discharge data from the Nationwide Inpatient Sample (NIS) to determine the use of VCFs for the years 1998 to 2005. VCF placement in the absence of deep venous thrombosis (DVT) or pulmonary embolus (PE) was categorized as prophylactic., Results: During the study period, the estimated rate of hospitalizations per year with a diagnosis of DVT (odds ratio [OR], 1.025; 95% confidence interval [CI], 1.019-1.032; P < .01) or PE (OR, 1.076; 95% CI, 1.069-1.083; P < .01) rose significantly. The estimated weighted frequency of VCF placement increased from 52,860 procedures in 1998 to 104,114 procedures in 2005 (0.15% and 0.27% of all discharges, respectively), representing an 80% increase. VCF placement significantly increased during hospitalizations with any diagnosis of DVT or PE, or both, and no DVT or PE (P < .01 for each). Logistic regression models revealed that the rate of prophylactic VCF placement increased at a significantly higher rate than VCF placement associated with DVT or PE (157% vs 42%; P < .01), after adjusting for age, gender, and hospital characteristics. Prophylactic VCF placement in the setting of morbid obesity (P < .01) and head injury (P = .03) rose significantly over time., Conclusions: From 1998 to 2005, the estimated rates of prophylactic VCF placement increased at a significantly higher rate than VCF placement in the setting of DVT or PE. Significant increases in the use of prophylactic VCFs were seen in the setting of morbid obesity and head injury., (Copyright (c) 2010. Published by Mosby, Inc.)

Object: Previous investigations of health outcome after spinal surgery for tethered cord syndrome (TCS) have been single-institution studies. The aim of this study was to report inpatient complications and outcomes on a nationwide level., Methods: The Nationwide Inpatient Sample (NIS) was used to identify patients who underwent spinal surgery for TCS in the US between 1993 and 2002. Patients who had a primary diagnosis of TCS (ICD-9 742.59) and also underwent spinal laminectomies were included in this study. Multivariate analysis was performed to analyze the effects of patient and hospital characteristics on variables such as mortality rate, nonfatal complications, LOS, and adverse outcomes in general (defined as death or discharge to an institution rather than home)., Results: The NIS sample included data on 9733 patients with TCS who underwent surgery. The means for mortality rate, complication rate, and LOS, respectively, were 0.0005%, 9.48%, and 5.6 days. Postoperative hemorrhages or hematomas (mean rate 2.3%) were the most common complications reported. Age and complications were the only significant predictors of adverse outcome on multivariate analysis. Patients older than 65 years had a threefold increase in risk of adverse outcome compared with patients 18 to 44 years of age. On average, one postoperative complication led to a 3-day increase in mean LOS and added more than $9000 to hospital charges., Conclusions: This study provides a national perspective on inpatient complications and outcomes after spinal surgery for TCS in the United States. The authors have demonstrated the impact of age, complications, and medical comorbidities on the outcome of surgery for patients with this common disorder.

Background: Changes in renal artery and renal parenchyma perfusion are believed to correlate with severity of hypertension and worsened renal function, but population-based studies of these associations are not available. This study examines relationships between parameters derived from renal duplex sonography (RDS), blood pressure (BP), and excretory renal function in a population-based cohort of elderly Americans., Methods: Through an ancillary study to the Cardiovascular Health Study, 758 participants (37% men; mean age, 77 years) underwent RDS in which flow velocities and frequency shifts were determined from spectral analysis of Doppler-shifted signals obtained from the renal artery and parenchyma. Associations of these duplex parameters with BP and inverse serum creatinine were examined by using multivariate regression techniques., Results: Main renal artery peak systolic flow velocity (PSV) showed independent associations with BP, with an SD increase in PSV (0.53 m/s) associated with a 3.3-mm Hg increase in systolic BP (SBP) and a 2.4-mm Hg decrease in diastolic BP (DBP). An SD decrease in end-diastolic frequency shift (EDF; 131 kHz) was associated with a 6.0-mm Hg increase in SBP, a 4.2-mm Hg decrease in DBP, and a significant 3.7% decrease in inverse serum creatinine., Conclusion: Increases in renal artery PSV and decreases in parenchymal EDF are associated with increased SBP and decreased DBP. Moreover, decreased parenchymal EDF showed significant associations with impaired excretory renal function. These results suggest that renal duplex parameters are associated with renal parenchymal changes caused by hypertension and progressive renal dysfunction in elderly people.

Context: Breast cancer mortality is higher among African American women than among white women in the United States, but the reasons for the racial difference are not known., Objective: To evaluate the influence of socioeconomic and cultural factors on the racial difference in breast cancer stage at diagnosis., Design: Case-control study of patients diagnosed as having breast cancer at the University Medical Center of Eastern Carolina from 1985 through 1992., Setting: The major health care facility for 2 rural counties in eastern North Carolina., Subjects: Five hundred forty of 743 patients with newly diagnosed breast cancer and 414 control women from the community matched by age, race, and area of residence., Main Outcome Measures: Breast cancer stage at diagnosis., Results: Of the 540 patients, 94 (17.4%) presented with TNM stage III or IV disease. The following demographic and socioeconomic factors were significant predictors of advanced stage: being African American (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.9-4.7); having low income (OR, 3.7; 95% CI, 2.1-6.5); never having been married (OR, 2.9; 95% CI, 1.4-5.9); having no private health insurance (OR, 2.5; 95% CI, 1.6-4.0); delaying seeing a physician because of money (OR, 1.6; 95% CI, 1.1-2.5); or lacking transportation (OR, 2.0; 95% CI, 1.2-3.6). Univariate analysis also revealed a large number of cultural beliefs to be significant predictors. Examples include the following beliefs: air causes a cancer to spread (OR, 2.8; 95% CI, 1.8-4.3); the devil can cause a person to get cancer (OR, 2.1; 95% CI, 1.2-3.5); women who have breast surgery are no longer attractive to men (OR, 1.9; 95% CI, 1.1-3.5); and chiropractic is an effective treatment for breast cancer (OR, 2.4; 95% CI, 1.4-4.4). When the demographic and socioeconomic variables were included in a multivariate logistic regression model, the OR for late stage among African Americans decreased to 1.8 (95% CI, 1.1 -3.2) compared with 3.0 (95% CI, 1.9-4.7) for race alone. However, when the belief measures were included with the demographic and socioeconomic variables, the OR for late stage among African Americans decreased further to 1.2 (95% CI, 0.6-2.5)., Conclusions: Socioeconomic factors alone were not sufficient to explain the dramatic effect of race on breast cancer stage; however, socioeconomic variables in conjunction with cultural beliefs and attitudes could largely account for the observed effect.

Delay in diagnosis of carcinoma of the breast is a significant cause of medical malpractice suits in the United States. Although less than one-third of the patients with carcinoma of the breast are less than 50 years of age, more than two-thirds of these suits involve women less than 50 years of age. To see whether or not there are medical factors that make diagnosis in young women more difficult, we reviewed all patient visits to the East Carolina University (ECU) Breast Clinic between 1 January 1988 and 30 June 1991. Women less than 50 years of age had many more patient visits (1,567 versus 838 visits) and many fewer carcinomas detected (38 versus 100 visits) than women who were more than 50 years old. The sensitivity and positive predictive value of mammography were significantly lower in young women than older women (68 versus 91 percent, p < 0.005, and 28 versus 53 percent, p < 0.001, respectively). Physical examination in young women was also less satisfactory. Tumors were more ill-defined and the percent that were easily palpable were significantly lower (45 versus 72 percent, p < 0.01). Furthermore, there was a basic difference in the reason tumors were not palpable in each age group. In older women, tumors were nonpalpable because they were small (mean size 1.0 versus 4.1 centimeters, p < 0.01), whereas in younger women, the non-palpable tumors were large (mean size 4.0 versus 3.4 centimeters), suggesting that they were not palpable because of background mammary density or diffuse growth pattern rather than size. Data from the Breast Cancer Detection Demonstration Project were analyzed and also suggested that carcinomas are more difficult to diagnose in young women. The percent of carcinomas that were not detectable by either mammogram or physical examination were inversely proportional to age and ranged from 36 percent at 40 years of age to 9 percent at 75 years of age. In addition, data from Blue Cross and Blue Shield and the ECU Breast Clinic indicated that it costs at least twice as much to diagnose each carcinoma in women less than 50 years of age. In conclusion, we believe that currently available techniques for diagnosis of carcinoma of the breast are not satisfactory for women less than 50 years of age and that this, rather than physician error, may account for the large number of malpractice suits in this age group.

At deployment plus 60 days, we were busy preparing for the possibility of war while simultaneously providing pharmaceutical service for more than 25,000 people. We were anticipating the arrival of a new Deployable Medical Systems hospital, increased automation in the form of the Tri-Service Micro Pharmacy Computer system, and various improvements in reference materials. Experiences similar to ours were occurring throughout Saudi Arabia. Army pharmacy had been challenged. The challenge was accepted, and viewed as an opportunity to excel, by providing the best possible pharmaceutical care to conserve the fighting strength of our armed forces.

A survey of dietitians at renal transplant centers in the United States was conducted to identify diet modifications currently used for nondiabetic adults after kidney transplantation. The survey focused on the diet recommended for the first 21 days after successful transplantation. Questionnaires were mailed to 100 centers randomly selected from a comprehensive list obtained through the Organ Transplant Coordinating Office of the Texas Medical Center, Houston. A 66% response rate was obtained. The results of the survey showed that dietitians were most frequently recommending 1.2 to 1.5 gm protein per kg body weight, 40% to 50% of total energy as carbohydrate, a fat intake of less than 30% of total energy, and an energy level consistent with achieving or maintaining desirable body weight. Sodium intake was most commonly restricted to 2 to 4 gm, whereas potassium and phosphorus intakes were individualized according to the patient's serum values. Comments on the returned questionnaires indicated that many institutions were reviewing and updating their transplant diet to include a polyunsaturated fat to saturated fat ratio and restrictions of cholesterol and simple sugars. The findings of the survey indicated that the renal transplant diet should focus on optimal protein and energy intake as well as restriction of simple sugars, total fat, cholesterol, and saturated fat to restore nitrogen balance and minimize clinical symptoms of post-transplant diabetes and hyperlipidemia.

Partial hospitalization programs evolved as a result of a variety of financial, social and therapeutic circumstances. At present, these programs can take one of several different forms. Of these, the most common ones are the three day programs--day hospital, day treatment, and day care. In theory, each of the three would serve a distinct population, have a clearly defined structure, and be administered in a predictable manner. This article contrasts theory with practice and makes an analysis of the actual and potential effectiveness such as demographics and economics are presented. Recommendations for the present and future follow from projected long range shifts and trends.