Hospital practice (1995)最新文献

Objective: Hospitalists have played a leading role in caring for hospitalized COVID-19 patients. Many clinical and administrative changes occurred in hospitals to meet the varied pandemic needs. We surveyed hospitalists to understand their perspective on pandemic-related changes in technology, models of care, administration and leadership, impact on personal lives, and which of these changes should be continued versus reverting to pre-pandemic practices.

Methods: A 30-question survey was distributed to hospitalists working across the United States between 6 April 2022 to 16 May 2022. Baseline demographics were measured, and post-pandemic perspectives related to changes were analyzed. Perspectives were measured using a 5-point Likert scale and responses were categorized into 'agree' and 'did not agree' for analysis. Variation was assessed using Chi-square or Fisher exact tests. Open-ended questions were reported following qualitative content analysis organized into themes and reported as frequency.

Results: 177 respondents (39%) completed the survey. Nearly three-fourths favored hybrid meetings, and two-thirds preferred to continue new models of care. Nearly 90% desired more family and leisure time, continued wellness, and support services, and resumption of social gatherings. No major differences in perspectives were noted between hospitalists at teaching facilities and non-teaching facilities except for resuming protected time for non-clinical activities in those from teaching facilities (83.0% vs 62.5%). Respondents less than age 50 were more likely to prefer virtual meetings (59.0% vs 31.3%). Content analysis of open-ended questions resulted in different themes for each question. Respondents favored more work-life balance and less administrative and logistical work burden.

Conclusions: Hospitalists preferred to continue the use of technology and new models of care even in the post-pandemic period and express a desire for more work-life balance and less administrative and logistical work burden.

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Objectives: Defensive medicine (DM) is the deviation of a physician from normal behavior or what is a good practice and is aimed at reducing or avoiding the risk of legal litigation from patients or their families. Therefore, this study aimed to determine DM-related behaviors and associated risk factors among Iranian surgeons.

Methods: In this cross-sectional study, 235 surgeons were selected using convenience sampling. The data gathering tool was a researcher-made questionnaire confirmed as a reliable and valid tool. Factors associated with DM-related behaviors were identified using logistic regression analysis.

Results: DM-related behaviors ranged from 14.9% to 88.9%. The most common positive DM-related behaviors, including unnecessary biopsy (78.7%), imaging and laboratory tests (72.4% and 70.6%), and refusing high-risk patients (61.7%), was the most common negative DM-related behavior. The likelihood of DM-related behaviors was more in younger and less experienced surgeons. Other variables, such as gender, specialty, and lawsuit history, positively affected some DM-related behaviors (p < 0.05).

Conclusion: This study showed that the proportion of surgeons who frequently performed DM-related behaviors was higher than those who rarely performed it. Therefore, strategies including reforming the rules and regulations for medical errors and litigations, developing and implementing medical guidelines and evidence-based medicine, and improving the medical liability insurance system can reduce DM-related behaviors.

The aim of the present study is to present a historical and unified perspective on the association of serum uric acid (SUA) in the cause of cardiovascular diseases (CVDs). The association of hyperuricemia (HUC) with CVD begun to be appreciated in the middle 1950s and early 1990s when clinical evidence was shown on the association of HUC with CVD. However, this association was disputed by several investigators including the Framingham group and by professional societies, like the American Heart Association and the American Society of Hypertension. This dispute was weakened or reversed by later studies, which showed a positive association of HUC with CVD, CHD, HF, CKD, and stroke, mediated by several risk factors, both molecular such as, oxidative stress, inflammatory stress, insulin resistance, and endothelial dysfunction, as well as clinical factors such as, atherosclerosis, hypertension, metabolic syndrome, and type 2 diabetes mellitus. The great majority of recent studies show a positive association of HUC with CVDs, and CKD. However, the cutoff of the damaging levels of SUA have not been established as yet. The European Society of Hypertension (ESH) Treatment Guidelines have proposed a cutoff level of SUA for CVD > 7 mg/dl for men and > 6 mg/dl for women. In contrast, the URRAH study has shown a SUA level of 4.7 mg/dl for all-cause mortality and 5.6 mg/dl for CV mortality. These levels are lower than the SUA levels proposed by the ESH, which are consistent with HUC. For a better understanding of this association, a Medline search of the English literature was conducted between 2015 and 2022 and 44 pertinent papers were selected. These papers together with collateral literature will be discussed in this review.

Introduction: A high vesicoureteral reflux (VUR) grade is among the specific risk factors for febrile urinary tract infection (febrile UTI) and renal scarring. The aim of this study was to examine the predictive value of some potential hematological parameters for high-grade VUR and renal scarring in children 2 to 24 months old with febrile UTI.

Methods: We retrospectively examined the clinical features, laboratory tests, and imaging studies of 163 children 2 to 24 months old with a diagnosis of febrile UTI. The hematological parameters based on the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and white blood cell count (WBC) were calculated using a receiver operating characteristic (ROC) analysis to select which one is suitable.

Results: Of the 163 children with febrile UTI, 57 patients (35%) exhibited high-grade VUR. Regarding the predictive power for high-grade VUR, the median area under the curve (AUC) was 0.692 for NLR (sensitivity 61.4%, specificity 69.8%, P < 0.001) and 0.681 for PLR (sensitivity 63.2%, specificity 62.3%, P < 0.001). White blood cell count demonstrated the highest area under the ROC curve for diagnosis of high-grade VUR (0.884, 95% confidence interval 0.834-0.934) and an optimal cutoff value of 13.5 (sensitivity 80.7%, specificity 80.2%, P < 0.001). White blood cell count, with the highest AUC of 0.892 while the sensitivity and specificity were 83.3% and 82.8, was the preferred diagnostic index for renal scarring screening.

Conclusions: White blood cell count, NLR, and PLR were useful biomarkers closely related to children with febrile UTI who are at risk for high-grade VUR can also act as a novel marker to accurate prediction of high-grade VUR and renal scarring. Also, NLR and PLR can serve as useful diagnostic biomarkers to distinguish high-grade VUR from low-grade VUR.

Background and aims: The purpose of this study was to investigate differences in the frequency of renally inappropriate medications (RIMs) in outpatient and inpatient among three institutions.

Methods: We collected prescription and renal function data for patients over 65 years of age from the drug department system. We selected 50 kinds of the most frequently used medicines which require dose adjustment according to a patient's renal function.

Results: Outpatient RIM was seen in 611 cases (6.17%), and inpatient prescription RIM was seen in 317 cases (5.29%), showing a significant difference between the groups (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.02-1.35). However, in a multivariate analysis, when the renal function was included, that difference between outpatients and inpatients became insignificant (OR 1.16, 95% CI 0.98-1.37). The distribution of prescription with or without RIM in outpatient and inpatient settings depended on the CKD stage. Outpatients with a better CKD stage (stage 1-3) had a higher rate of RIM than inpatients, while patients with a worse CKD stage (stage 4 or 5) had a higher rate of RIM than outpatients.

Conclusion: The rate of RIM in outpatients tends to be high, and attention should be paid to RIM in inpatients with a severe CKD stage.

Objectives: To determine the incidence of bacteremia in patients with DKA.

Methods: We conducted a cross-sectional study of patients aged 18 years and older with a principal diagnosis of DKA or hyperglycemic hyperosmotic syndrome (HHS) who presented to our community hospital between 2008 and 2020. Using medical records from initial visits, we retrospectively calculated the incidence of bacteremia. This was defined as the percentage of subjects with positive blood cultures except for those with contamination.

Results: Among 114 patients with hyperglycemic emergency, two sets of blood cultures were collected in 45 of 83 patients with DKA (54%), and 22 of 31 patients with HHS (71%). The mean age of patients with DKA was 53.7 years (19.1) and 47% were male, while the mean age of patients with HHS was 71.9 years (14.9) and 65% were male. The incidences of bacteremia and blood culture positivity were not significantly different between patients with DKA and those with HHS (4.8% vs. 12.9%, P = 0.21 and 8.9% vs. 18.2%, P = 0.42, respectively). Urinary tract infection was the most common concomitant infection of bacteria, with E. coli as the main causative organism.

Conclusion: Blood cultures were collected in approximately half of the patients with DKA, despite a nonnegligible number of them testing positive in blood culture. Promoting awareness of the need for taking blood culture is imperative for the early detection and management of bacteremia in patients with DKA.

Clinical trial registration: UMIN trial ID - UMIN000044097; jRCT trial ID - jRCT1050220185.

Objectives: Literature regarding clinical benefits of dornase alfa (DNase) in pediatric patients without cystic fibrosis is lacking. In December 2020, the study institution implemented restrictions to limit DNase use in this patient population. The primary objective was adherence to DNase ordering restrictions. Secondary objectives included length of stay, respiratory function, and use of inhaled mucolytic agents.

Methods: This single-center retrospective chart review included patients less than 18 years of age who received DNase one year prior to through one year after order restriction implementation. Data collected included patient demographics and respiratory clinical parameters. Dosing regimens for DNase, n-acetylcysteine, and hypertonic saline were collected, as well as changes in length of stay (LOS) and adherence to ordering restrictions.

Results: Of 101 total DNase orders, 45 were placed after implementation of ordering restrictions and 16 (36%) met all ordering criteria. Hospital and intensive care unit (ICU) LOS after implementation of restrictions were not significantly different (p = 0.767 and p = 0.219, respectively). There was no significant change in patients' mean oxygenation index (p = 0.252) or FiO2% (p = 0.113) 24 hours after DA administration.

Conclusion: Respiratory function did not significantly change after DNase administration. Implementing restrictions on DNase did not impact intensive care unit or hospital LOS. Adherence to DNase ordering restrictions could be improved.

Background: Nigeria is considering making Universal Health Coverage (UHC) a common policy goal to ensure that citizens have access to high-quality healthcare services without crippling debt. Globally, there is an acute shortage of human resources for Health (HRH), and the most significant burden is borne by low-income countries, especially in sub-Saharan Africa. This shortage has considerably constrained the achievement of health-related development goals and impeded accelerated progress toward universal health coverage. We examine the existing human resource capacity and the distribution of health facilities in Lagos state in this study, discussing the implications of our findings.

Methods: The study is descriptive using secondary data analysis. We leverage census-based primary data collected by NOIPoll on health facility assessments in Lagos state. The collected data was analyzed using counts, ratios, rates, and percentages.

Results: We observe a ratio of 5,014 people to 1 general medical doctor, 2,942 people to 1 specialist, 2,165 people to 1 nurse, and 5,117 people to 1 midwife, which are far higher than the WHO recommendation. We also observe that the ratio of nurses to general medical practitioners is 2.2:1 in urban areas and 2.7:1 in rural. In contrast, the ratio of nurses to specialist medical doctors is 1.3:1 in the urban area and 1.5:1 in the rural areas of Lagos state. The overall nurse per general medical practitioner ratio is 2.3:1 and 1.4:1 for specialist medical doctors. 77.2% of the health facilities surveyed were in the urban areas, with private-for-profit facilities accounting for 82.9%, government facilities accounting for 15.4%, and NGOs/faith clinics accounting for 1.7%. Primary healthcare facilities account for 75.3% of the facilities surveyed, secondary and tertiary facilities account for 24.6% and 0.08%, respectively. Alimosho LGA has the most health facilities (77.38% PHCs, and 22.62% SHCs) and staff strength specifically for general medical practitioners, specialists, nurses, and midwives (16.9%, 19.9%, 16.7%, 17.1%, respectively). Eti-Osa LGA has the best density ratio for generalist doctors, specialist doctors, and nurses per 10,000 (4.42, 12.96, and 11.34 respectively), while Ikeja has the best midwife population density ratio 5.46 per 10,000 population.

Conclusion: The distribution of health personnel and facilities in Lagos State is not equitable, with evident variation between rural and urban areas. This inequitable distribution could affect the physical distance of health facilities to residents, leading to decreased utilization, ultimately poor health outcomes, and impaired access. Much like child mortality, maternal mortality also exhibits a correlation with healthcare worker density. As the physician density increases linearly, the maternal mortality rate decreases exponentially. However, due to the low number of healthcare

Objectives: In the United States, approximately 18-25% of carotid duplex ultrasound (CUS) studies are ordered to assess patients with non-lateralizing neurological complaints such as syncope, blurry vision, lightheadedness, headache, and altered mental status. The purpose of this study is to evaluate the benefit of CUS in the evaluation of patients presenting with non-lateralizing signs or symptoms.

Materials and methods: We conducted a retrospective analysis to assess the degree and laterality of carotid stenosis among patients with non-lateralizing neurological complaints who underwent CUS interpreted by certified vascular neurologists over a period of 3 years. The primary endpoint was to identify the prevalence of moderate-to-severe carotid artery stenosis among 280 patients who met inclusion criteria.

Results: A total of 17.7% of CUS studies were ordered for non-lateralizing symptoms. Two hundred and sixty-one patients (93.21%) had either normal imaging or mild carotid stenosis of <50%. Nineteen patients (6.79%) were found to have stenosis of ≥50%. In this subgroup, age and known preexisting carotid artery atherosclerotic disease were the only variables found to have a statistically significant association with the level of stenosis found on CUS. Two patients with asymptomatic stenosis of >70% underwent a revascularization procedure.

Conclusion: At least 17.7% of CUS studies were completed for non-lateralizing symptoms. The study is of low-yield with the prevalence of moderate-to-severe stenosis being comparable to that in the general asymptomatic population. We conclude that there is minimal clinical value in the use of CUS to investigate non-lateralizing neurological complaints, resulting in unnecessary healthcare costs.