Donna K. McClish

Nosocomial Bloodstream Infections in United States Hospitals: A Three-Year Analysis

Nosocomial bloodstream infections are important causes of morbidity and mortality. In this study, concurrent surveillance for nosocomial bloodstream infections at 49 hospitals over a 3-year period detected >10,000 infections. Gram-positive organisms accounted for 64% of cases, gram-negative organisms accounted for 27%, and 8% were caused by fungi. The most common organisms were coagulase-negative staphylococci (32%), Staphylococcus aureus (16%), and enterococci (11%). Enterobacter, Serratia, coagulase-negative staphylococci, and Candida were more likely to cause infections in patients in critical care units. In patients with neutropenia, viridans streptococci were significantly more common. Coagulase-negative staphylococci were the most common pathogens on all clinical services except obstetrics, where Escherichia coli was most common. Methicillin resistance was detected in 29% of S. aureus isolates and 80% of coagulase-negative staphylococci. Vancomycin resistance in enterococci was species-dependent--3% of Enterococcus faecalis strains and 50% of Enterococcus faecium isolates displayed resistance. These data may allow clinicians to better target empirical therapy for hospital-acquired cases of bacteremia.

Health related quality of life in sickle cell patients: The PiSCES project

BackgroundSickle cell disease (SCD) is a chronic disease associated with high degrees of morbidity and increased mortality. Health-related quality of life (HRQOL) among adults with sickle cell disease has not been widely reported.MethodsWe administered the Medical Outcomes Study 36-item Short-Form to 308 patients in the Pain in Sickle Cell Epidemiology Study (PiSCES) to assess HRQOL. Scales included physical function, physical and emotional role function, bodily pain, vitality, social function, mental health, and general health. We compared scores with national norms using t-tests, and with three chronic disease cohorts: asthma, cystic fibrosis and hemodialysis patients using analysis of variance and Dunnetts test for comparison with a control. We also assessed whether SCD specific variables (genotype, pain, crisis and utilization) were independently predictive of SF-36 subscales, controlling for socio-demographic variables using regression.ResultsPatients with SCD scored significantly worse than national norms on all subscales except mental health. Patients with SCD had lower HRQOL than cystic fibrosis patients except for mental health. Scores were similar for physical function, role function and mental health as compared to asthma patients, but worse for bodily pain, vitality, social function and general health subscales. Compared to dialysis patients, sickle cell disease patients scored similarly on physical role and emotional role function, social functioning and mental health, worse on bodily pain, general health and vitality and better on physical functioning. Surprisingly, genotype did not influence HRQOL except for vitality. However, scores significantly decreased as pain levels increased.ConclusionSCD patients experience health related quality of life worse than the general population, and in general, their scores were most similar to patients undergoing hemodialysis. Practitioners should regard their HRQOL as severely compromised. Interventions in SCD should consider improvements in health related quality of life as important outcomes.

Differences in initial treatment patterns and outcomes of lung cancer in the elderly

BACKGROUND Non-small cell lung cancer (NSCLC) accounts for substantial deaths and costs in the elderly greater than 65 years old. The current practice of NSCLC treatment in a Medicare population was examined to ascertain important areas of practice variation, and differences in clinical outcome and costs. METHODS Data from incident cases of NSCLC from the Virginia Cancer Registry (VCR), 1985-89, were matched with claims from Medicare Part A and B, census tract data and the Area Resource File. Multivariate models were created to include clinical data, demographics, and access information. RESULTS For patients with locoregional disease, increasing age was associated with lower likelihood of therapy (odds ratio (OR) 0.35; confidence intervals (CI) 0.29, 0.43), thoracotomy (OR 0.27; CI 0.21, 0.34), and more use of radiation therapy compared to surgery (OR 1.69; CI 1.39, 2.03). Low education levels were associated with less likelihood of treatment (OR 0.78; CI 0.66, 0.94), or radiation instead of surgery (OR 1.22; CI 1.05, 1.47). Patients in urban areas were less likely to receive therapy (OR 0.67; CI 0.49, 0.92). For distant disease, increasing age was also associated with lower likelihood of treatment (OR 0.48; CI 0.41, 0.56), as was increasing co-morbidity (OR 0.84; CI 0.75, 0.93). Distance to radiation oncologists made no difference in radiotherapy utilization. Two year survival according to therapy was surgery 66%, radiation 15%, no therapy 17%. CONCLUSIONS Patterns of care, and survival according to therapy, vary widely for elderly NSCLC patients. Age, low education, higher co-morbidity and urban residence all decrease the likelihood of surgical therapy for locoregional NSCLC. Despite the availability of coverage through the Medicare program, use of therapies and survival is not uniform for all beneficiaries. Possible discrimination by age, co-morbid illnesses not recorded in the Medicare files, or patient and provider choice could all be involved; administrative billing files cannot resolve these important differences.

Cigarette smoking and urinary incontinence in women

OBJECTIVE The goal of this case control study was to evaluate the relationship between smoking and female urinary incontinence. STUDY DESIGN The study included 606 women whose smoking histories were known; 322 were incontinent and 284 were continent. The condition(s) causing each subjects incontinence was determined by urodynamic testing; 40% of the continent subjects had the same testing. RESULTS There were highly significant overall differences (p = 0.000009) in the distribution of current, former, and never smokers between incontinent (35%, 16%, 49%) and continent (24%, 8%, 68%) groups. The odds ratio for genuine stress incontinence was 2.20 for former (95% confidence interval 1.18 to 4.11) and 2.48 for current smokers (95% confidence interval 1.60 to 3.84); for motor incontinence it was 2.92 for former (95% confidence interval 1.58 to 5.39) and 1.89 (95% confidence interval 1.19 to 3.02) for current smokers. Increasing daily and lifetime cigarette consumption was associated with an increasing odds ratio for genuine stress incontinence but not for motor incontinence. The increased risk for incontinence was not due to differences in age, parity, weight, or hypoestrogenic status. CONCLUSION The data establish a strong statistical relationship between current and former cigarette smoking and both stress and motor urinary incontinence in women.

A systematic review of the effects of estrogens for symptoms suggestive of overactive bladder

Objective.  To perform a systematic review of the effects of estrogen therapy on symptoms suggestive of overactive bladder (OAB) in postmenopausal women.

Prediction of survival of critically ill patients by admission comorbidity

The objective of this study was to determine how well the Charlson index of comorbidity would predict mortality of critically ill patients; and how the predictive ability of the index would compare with that of the comorbidity component (Chronic Health Points) of the APACHE II system. This prospective cohort study included in its setting an intensive care unit (ICU) and intermediate ICU (IICU) in a teaching hospital. Patients included a previously assembled inception cohort of 201 patients consecutively admitted to either unit, followed until death or discharge from the hospital, excluding patients admitted after coronary artery bypass grafting, for planned dialysis, or transferred to the IICU from another intensive care unit. Main outcome measures were recorded as death in hospital versus survival at discharge. For each patient we had prospectively obtained all data necessary to predict the probability of in-hospital death using the APACHE II system, and to classify comorbidity using the Charlson index. The Charlson index had significant ability to discriminate between patients who would live and who would die (ROC curve area = 0.67, SE = 0.05). The Chronic Health Points component of APACHE II had no significant discriminating ability (ROC area = 0.57, SE = 0.05), although the full APACHE II system was an excellent predictor (area = 0.87, SE = 0.04). Logistic regression analyses suggested that the Charlson index could contribute significant (p = 0.03) prognostic information to that obtained from the components of APACHE II other than Chronic Health, i.e., acute physiological derangement, age, and reason for admission, but the Chronic Health Points component of APACHE II could not so contribute to the rest of APACHE II (p = 0.19). Our conclusion is that use of the detailed information about comorbidity captured by the Charlson index could improve prognostic predictions even for critically ill patients.

Valsalva leak point pressures in women with genuine stress incontinence: Reproducibility, effect of catheter caliber, and correlations with other measures of urethral resistance

Abstract OBJECTIVES: The Valsalva leak point pressure has been promoted as an alternative to urethral pressure profilometry as a measure of urethral resistance in women with genuine stress incontinence. Our aims were to evaluate the reproducibility of the Valsalva leak point pressure, to assess the effect of catheter caliber on the Valsalva leak point pressure, and to compare vesical Valsalva leak point pressure to other measures of urethral resistance. STUDY DESIGN: Sixty consecutive women with genuine stress incontinence underwent duplicate Valsalva leak point pressure determinations by use of 8F and 3F vesical and 8F vaginal catheters. Subjects also underwent a standard resting urethral pressure profilometry, cough leak point pressure determinations, and pressure-flow micturition studies. RESULTS: Leakage was demonstrated on both Valsalva maneuvers in approximately 80% of subjects with both catheters. In subjects who leaked with both strains there was an extremely high correlation between the test-retest Valsalva leak point pressure within both catheters. The intercatheter correlation between the 8F and 3F Valsalva leak point pressures was significant but much weaker than the intracatheter correlations; 8F Valsalva leak point pressures were significantly higher than 3F Valsalva leak point pressures, although there were individual exceptions to this observation. Urethral pressure profilometry measures and micturition opening pressures were poorly correlated with Valsalva leak point pressure. Cough and vaginal Valsalva leak point pressures were significantly correlated with vesical Valsalva leak point pressure, but cough leak point pressures were significantly higher and vaginal Valsalva leak point pressures were significantly lower than the vesical Valsalva leak point pressure. CONCLUSIONS: Valsalva leak point pressure is a simple and reproducible technique for evaluating urethral resistance in women with genuine stress incontinence. However, variations in Valsalva leak point pressure measurement must be precisely described, standardized, and validated before a technique can be advocated for clinical use.

Depression and Anxiety in Adults With Sickle Cell Disease: The Pisces Project

Objective: Depression and anxiety are common in sickle cell disease (SCD) but relatively little is known about their impact on SCD adults. This study measured prevalence of depression and anxiety in SCD adults, and their effects on crisis and noncrisis pain, quality-of-life, opioid usage, and healthcare utilization. Methods: The Pain in Sickle Cell Epidemiology Study is a prospective cohort study in 308 SCD adults. Baseline variables included demographics, genotype, laboratory data, health-related quality-of-life, depression, and anxiety. Subjects completed daily diaries for up to 6 months, reporting sickle cell pain intensity, distress, interference, whether they were in a sickle cell crisis, as well as health care and opioid utilization. Results: Two hundred thirty-two subjects who completed at least 1 month of diaries were studied; 27.6% were depressed and 6.5% had any anxiety disorder. Depressed subjects had pain on significantly more days than nondepressed subjects (mean pain days 71.1% versus 49.6%, p < .001). When in pain on noncrisis days, depressed subjects had higher mean pain, distress from pain, and interference from pain. Both depressed and anxious subjects had poorer functioning on all eight SF-36 subscales, even after controlling for demographics, hemoglobin type, and pain. The anxious subjects had more pain, distress from pain, and interference from pain, both on noncrisis pain days and on crisis days, and used opioids more often. Conclusions: Depression and anxiety predicted more daily pain and poorer physical and mental quality-of-life in adults with SCD, and accounted for more of the variance in all domains of quality-of-life than hemoglobin type. SCD = sickle cell disease; PiSCES = Pain in Sickle Cell Epidemiology Study; ED = emergency department; PHQ = patient health questionnaire; MOS SF-36 = Medical Outcome Study 36 item Short Form-36; MMSE = mini mental status examination.

Predicting hospital rates of fluoroquinolone-resistant Pseudomonas aeruginosa from fluoroquinolone use in US hospitals and their surrounding communities.

Rates of fluoroquinolone resistance among Pseudomonas aeruginosa in hospitals are increasing, but interhospital variability is great. We sought to determine whether this variability correlated to fluoroquinolone use in hospitals and in the surrounding community. Hospital quinolone use in 1999 (24 hospitals) through 2001 (35 hospitals) was determined from billing records. The number of fluoroquinolone prescriptions within a 10-mile (approximately 16-km) radius of each hospital was determined for 1999 and 2000. Hospital fluoroquinolone use increased from 1999 through 2001, from 137 to 163 defined daily doses (DDD)/1000 patient-days (P=.01). The rate of community fluoroquinolone use also increased, from 2.3 to 2.8 DDD/1000 inhabitant-days (P<.001). Rates of fluoroquinolone-resistant P. aeruginosa increased from 29% in 1999 to 36% in 2001 (P=.003). Both community and hospital fluoroquinolone use were predictive of rates of fluoroquinolone-resistant P. aeruginosa. Levofloxacin was associated with resistance, but ciprofloxacin was not. Most of the variability in resistance rates is explained by volume of fluoroquinolone use, both in the hospital and the surrounding community.

FACTORS THAT DETERMINE THE TREATMENT FOR LOCAL AND REGIONAL PROSTATE CANCER

This article assesses the significance of comorbid and nonclinical factors in type of treatment received by elderly male patients with local-regional stage prostate cancer. Multivariate analysis of data from the Virginia Cancer Registry was linked to Medicare claim files, the Area Resource File, and 1990 Census Data. The type of initial treatment received was studied in 3117 men with local-regional staged prostate cancer diagnosed from 1985 to 1989. The frequency of surgical and radiation therapy for prostate cancer rose between 1985 and 1989 (12.5% to 18.5% for surgery, P < 0.001; 25% to 32% for radiation, P < 0.001). Age was the most important predictor of therapeutic choice; no therapy was given to 26% of men 65 to 69 years old versus 63% of men 85 years or older P < 0.001). Race, residence (rural versus urban), and comorbidity were also strong factors in predicting initial therapy. Using logistic regression, three treatment alternatives were evaluated. Age (odds ratio [OR] .51; 99% confidence interval [CI] = .43, .60), comorbidity (OR .72; 99% CI .63, .82), income (OR 1.14; 99% CI 1.01, 1.28), residence (OR .65; 99% CI .48, .87), diagnosis year (OR 1.15; 99% CI 1.07, 1.23) all were associated independently with treatment versus no treatment. For surgery versus radiation, age (OR .40; 99% CI .27, .57), race (OR 2.92; 99% CI 1.65, 5.15) and education (OR 1.75; 99% CI 1.31, 2.34) were significant factors. For hormonal/orchiectomy versus surgery/radiation, age (OR 5.19; 99% CI 3.84, 7.01), comorbidity (OR 1.28; 99% CI 1.03, 1.58), distance to radiation oncologist (OR .89; 99% CI .80, .99), and diagnosis year (OR .89; 99% CI .79, 1.00) were significant. The number of men receiving surgical and radiation treatments for prostate cancer increased between 1985 and 1989. During that period, age consistently played a significant role in all therapeutic decisions. Other factors, such as comorbidity, race, socioeconomic status, and distance, also were important considerations, depending on the treatment alternative.