Samuel R. Kaufman

Medical therapy to facilitate urinary stone passage: a meta-analysis

BACKGROUND Medical therapies to ease urinary-stone passage have been reported, but are not generally used. If effective, such therapies would increase the options for treatment of urinary stones. To assess efficacy, we sought to identify and summarise all randomised controlled trials in which calcium-channel blockers or alpha blockers were used to treat urinary stone disease. METHODS We searched MEDLINE, Pre-MEDLINE, CINAHL, and EMBASE, as well as scientific meeting abstracts, up to July, 2005. All randomised controlled trials in which calcium-channel blockers or alpha blockers were used to treat ureteral stones were eligible for inclusion in our analysis. Data from nine trials (number of patients=693) were pooled. The main outcome was the proportion of patients who passed stones. We calculated the summary estimate of effect associated with medical therapy use using random-effects and fixed-effects models. FINDINGS Patients given calcium-channel blockers or alpha blockers had a 65% (absolute risk reduction=0.31 95% CI 0.25-0.38) greater likelihood of stone passage than those not given such treatment (pooled risk ratio 1.65; 95% CI 1.45-1.88). The pooled risk ratio for alpha blockers was 1.54 (1.29-1.85) and for calcium-channel blockers with steroids was 1.90 (1.51-2.40). The proportion of heterogeneity not explained by chance alone was 28%. The number needed to treat was 4. INTERPRETATION Although a high-quality randomised trial is necessary to confirm its efficacy, our findings suggest that medical therapy is an option for facilitation of urinary-stone passage for patients amenable to conservative management, potentially obviating the need for surgery.

Preventing Hospital-Acquired Urinary Tract Infection in the United States: A National Study

BACKGROUND Although urinary tract infection (UTI) is the most common hospital-acquired infection in the United States, to our knowledge, no national data exist describing what hospitals in the United States are doing to prevent this patient safety problem. We conducted a national study to examine the current practices used by hospitals to prevent hospital-acquired UTI. METHODS We mailed written surveys to infection control coordinators at a national random sample of nonfederal US hospitals with an intensive care unit and >or=50 hospital beds (n=600) and to all Veterans Affairs (VA) hospitals (n=119). The survey asked about practices to prevent hospital-acquired UTI and other device-associated infections. RESULTS The response rate was 72%. Overall, 56% of hospitals did not have a system for monitoring which patients had urinary catheters placed, and 74% did not monitor catheter duration. Thirty percent of hospitals reported regularly using antimicrobial urinary catheters and portable bladder scanners; 14% used condom catheters, and 9% used catheter reminders. VA hospitals were more likely than non-VA hospitals to use portable bladder scanners (49% vs. 29%; P=.001), condom catheters (46% vs. 12%; P=.001), and suprapubic catheters (22% vs. 9%; P=.001); non-VA hospitals were more likely to use antimicrobial urinary catheters (30% vs. 14%; P=.001). CONCLUSIONS Despite the strong link between urinary catheters and subsequent UTI, we found no strategy that appeared to be widely used to prevent hospital-acquired UTI. The most commonly used practices--bladder ultrasound and antimicrobial catheters--were each used in fewer than one-third of hospitals, and urinary catheter reminders, which have proven benefits, were used in <10% of US hospitals.

Condom Versus Indwelling Urinary Catheters: A Randomized Trial

OBJECTIVES: To compare condom and indwelling urinary catheters in terms of infection risk and patient satisfaction.

Rates of infection for single-lumen versus multilumen central venous catheters: a meta-analysis.

ObjectiveSince the introduction of multilumen central venous catheters two decades ago, there has been controversy whether the additional lumens place patients with these catheters at higher risk for infection. Our objective was to determine the risk of catheter-related bloodstream infection (CRBSI) and catheter colonization in multilumen catheters compared with single-lumen catheters. Data SourceStudies were identified by a computerized search of MEDLINE, EMBASE, CINAHL, Current Contents, and PREMEDLINE databases and by review of bibliographies and expert consultation. Studies comparing the prevalence of CRBSI or catheter colonization among single-, double-, and triple-lumen central venous catheters were included. We excluded studies if they included central venous catheters that were long-term, cuffed, tunneled, or coated with antibiotic or antiseptic agents. Data AbstractionTwo independent reviewers abstracted data on: 1) risk factors for CRBSI and colonization, 2) outcome definitions used, 3) the absolute prevalence of CRBSI and catheter colonization, and 4) study design and quality. Data SynthesisA total of 15 studies met inclusion criteria. Summary odds ratios were calculated using a random-effects model. Although CRBSI was more common in multilumen catheters (summary odds ratios, 2.15; 95% confidence interval, 1.00–4.66), catheter colonization was not (summary odds ratios, 1.78; 95% confidence interval, 0.92–3.47). Tests for heterogeneity, however, suggested substantial variation by study. When only studies of higher quality were included, multilumen catheters were found not to be associated with a significant increase in CRBSI prevalence (summary odds ratios, 1.30; 95% confidence interval, 0.50–3.41). ConclusionsMultilumen central venous catheters may be associated with a slightly higher risk of infection when compared with single-lumen catheters; however, this relationship diminishes when only high-quality studies that control for patient differences are considered. The slight increase in infectious risk when using multilumen catheters is likely offset by their improved convenience, thereby justifying the continued use of multilumen vascular catheters.

Use of urinary collection devices in skilled nursing facilities in five states.

OBJECTIVES: To assess use of urinary collection devices (external, intermittent, and indwelling catheters; pads or briefs) and examine predictors of indwelling catheters in skilled nursing facilities (SNFs).

Preventing Ventilator-Associated Pneumonia in the United States: A Multicenter Mixed-Methods Study

OBJECTIVE To determine what practices are used by hospitals to prevent ventilator-associated pneumonia (VAP) and, through qualitative methods, to understand more fully why hospitals use certain practices and not others. DESIGN Mixed-methods, sequential explanatory study. METHODS We mailed a survey to the lead infection control professionals at 719 US hospitals (119 Department of Veterans Affairs [VA] hospitals and 600 non-VA hospitals), to determine what practices are used to prevent VAP. We then selected 14 hospitals for an in-depth qualitative investigation, to ascertain why certain infection control practices are used and others not, interviewing 86 staff members and visiting 6 hospitals. RESULTS The survey response rate was 72%; 83% of hospitals reported using semirecumbent positioning, and only 21% reported using subglottic secretion drainage. Multivariable analyses indicated collaborative initiatives were associated with the use of semirecumbent positioning but provided little guidance regarding the use of subglottic secretion drainage. Qualitative analysis, however, revealed 3 themes: (1) collaboratives strongly influence the use of semirecumbent positioning but have little effect on the use of subglottic secretion drainage; (2) nurses play a major role in the use of semirecumbent positioning, but they are only minimally involved with the use of subglottic secretion drainage; and (3) there is considerable debate about the evidence supporting subglottic secretion drainage, despite a meta-analysis of 5 randomized trials of subglottic secretion drainage that generally supported this preventive practice, compared with only 2 published randomized trials of semirecumbent positioning, one of which concluded that it was ineffective at preventing the development of VAP. CONCLUSION. Semirecumbent positioning is commonly used to prevent VAP, whereas subglottic secretion drainage is used far less often. We need to understand better how evidence related to prevention practices is identified, interpreted, and used to ensure that research findings are reliably translated into clinical practice.

Review of Clinical Trials of Skin Antiseptic Agents Used to Reduce Blood Culture Contamination

False-positive blood culture results may lead to prolonged hospitalization, inappropriate antibiotic administration, and increased healthcare costs. We conducted a review of the literature to assess the effect of skin antiseptic agents on the rate of false-positive blood culture results. We found no clear evidence to suggest which antiseptic should be used to prevent false-positive results. Studies suggest, however, a possible benefit from the use of prepackaged skin antiseptic kits and alcohol-containing antiseptics.

The Quality and Impact of Risk Factor Control in Patients With Stable Claudication Presenting for Peripheral Vascular Interventions

Background—Peripheral arterial disease is a manifestation of systemic atherosclerosis and is predictive of future cardiovascular events. Clinical trial data have demonstrated that medical therapy can attenuate cardiovascular morbidity and mortality in patients with peripheral arterial disease. The utilization and impact of recommended medical therapy in a contemporary population of patients who undergo percutaneous interventions for lifestyle-limiting peripheral arterial disease is unknown. Methods and Results—Using the Blue Cross Blue Shield of Michigan Cardiovascular Consortium Peripheral Vascular Intervention (BMC2 PVI) database, we identified 1357 peripheral vascular intervention encounters between January 2007 and December 2009 for the purpose of treating claudication. Before the intervention, 85% of these patients used aspirin, 76% used statin, 65% abstained from smoking, and 47% did all 3. There was no difference in cardiovascular events among those taking an aspirin and a statin on admission and those who were not. However, in both an unadjusted and a multivariable analysis, the odds of an adverse peripheral vascular outcome (repeat peripheral intervention, amputation, or limb salvage surgery) within 6 months decreased by more than half in patients receiving aspirin and statin therapy before peripheral vascular intervention as compared with those who received neither (odds ratio, 0.45; 95% CI, 0.29–0.71). Conclusions—The fundamental elements of medical therapy in patients with lifestyle-limiting claudication are often underutilized before referral for revascularization. Appropriate medical therapy before percutaneous revascularization is associated with fewer peripheral vascular events at 6 months.

Improving healthcare worker hand hygiene adherence before patient contact: a before-and-after five-unit multimodal intervention in Tuscany

Background: Despite the importance of hand hygiene in reducing infection, healthcare worker compliance with hand hygiene recommendations remains low. In a previous study, we found a generally low level of compliance at baseline, with substantial differences between doctors and nurses and between hospital units. We describe here the results of our multimodal intervention intended to improve levels of healthcare worker hand hygiene. Methods: A 6-month, before-and-after, multimodal interventional study in five hospital units in Florence, Italy. We used direct observation to assess hand hygiene rates for doctors and nurses, focusing on hygiene before touching the patient. We explored reasons for unit variability via interviews of doctor and nurse leaders on the units. Results: Overall healthcare worker hand hygiene increased from 31.5% to 47.4% (p<0.001). Hand hygiene adherence among nurses increased from 33.7% to 47.9% (p<0.001); adherence among doctors increased from 27.5% to 46.6% (p<0.001). Improvement was statistically significant in three out of five units, and units differed in the magnitude of their improvement. Based on the interviews, variability appeared related to the “champion” on each unit, as well as the level of motivation each physician leader exhibited when the preintervention results were provided. Conclusions: Although overall healthcare worker adherence with hand hygiene procedures before patient contact substantially increased after the multimodal intervention, considerable variability—for both nurses and doctors and across the 5 units—was seen. Although adherence substantially increased, overall hand hygiene in these units could still be greatly improved.

What Effect Does Inpatient Physician Specialty and Experience Have on Clinical Outcomes and Resource Utilization on a General Medical Service

AbstractOBJECTIVE: To examine the effects of internal medicine specialty and physician experience on inpatient resource use and clinical outcomes on an academic general medicine service. DESIGN: A 1-year retrospective cohort study. SETTING: The University of Michigan Hospitals, Ann Arbor, Michigan. PATIENTS: Two thousand six hundred seventeen admissions to the general medicine service from July 2001 to June 2002, excluding those for whom data were incomplete (n=18). MEASUREMENTS AND MAIN RESULTS: Length of stay (LOS) and total hospital costs were used to measure resource utilization. Hospital mortality and 14-day and 30-day readmission rates were used to measure clinical outcomes. Adjusted mean LOS was significantly greater for rheumatologists (0.56 days greater; P=.002) and endocrinologists (0.38 days greater; P=.03) compared to general internists. Total costs were lower for general internists compared to endocrinologists (