Early switch from intravenous to oral antibiotics: guidelines and implementation in a large teaching hospital.
In recent years 'switch therapy' has been advocated: short intravenous antibiotic therapy, for 2-3 days, followed by oral treatment for the remainder of the course. Little is known about the number of patients that could benefit from early switch therapy and the consequences of introducing this strategy in everyday practice. We prospectively registered all antibiotic courses on wards for Internal Medicine, Surgery, and Pulmonology during a 2 month period, before (n = 362, inventorial phase) and after (n = 281, implementation phase) the introduction of guidelines for switching therapy. Approximately 40% of all patients who started on iv antibiotics were candidates for an early iv-oral switch. During the inventorial phase, 54% (52/97) of eligible patients were switched to oral treatment, after a median of 6 days (range 2-28 days). After implementation of the guidelines, this percentage rose to 83% (66/80) (difference 29%, 95% CI 16-42%; P < 0.001). Therapy was also switched earlier, after a median of 4 days (range 2 to 16 days). In the 6 weeks after completion of the oral course, recurrence of infections, or readmissions due to reinfections did not occur. Compared with the inventorial phase, 43% of iv administrations could be avoided, that is >6000 per year. This means a potential annual reduction of dfl.60,000 (c. US$30,000) of administration costs. The potential savings in purchase costs of the antibiotics were dfl.54,000 (US$27,000) annually. In conclusion, a substantial number of patients starting on iv antibiotics were candidates for an early iv-oral switch. The guidelines were well accepted by the physicians and substantial savings in costs and nursing time were achieved. (+info)
Problem Knowledge Couplers: reengineering evidence-based medicine through interdisciplinary development, decision support, and research.
The rapid growth of medical knowledge is creating a demand for new ways of providing information in support of evidence-based medical practice. Problem Knowledge Couplers are a clinical decision support software tool that offer a new approach to this growing problem. Couplers are developed through a collaboration among clinicians, informaticians, and librarians. They recognize that functionality must be predicated upon combining unique patient information, gleaned through relevant structured question sets, with the appropriate knowledge found in the world's peer-reviewed medical literature. Two pilot studies indicate that couplers can meet the gold standards of decision making within both a primary care and a specialty practice. Issues remain about how to best integrate Problem Knowledge Couplers into clinical practice and whether large-scale outcomes research will support the findings of pilot studies. However, Problem Knowledge Couplers represent a promising approach that might portend a new model for health care delivery in the next millennium. (+info)
Clinical tumour size and prognosis in lung cancer. Bronchogenic Carcinoma Cooperative Group of the Spanish Society of Pneumology and Thoracic Surgery (GCCB-S).
In the staging of lung cancer (LC), tumour size is a variable that can be used to separate primary tumour, regional nodes, metastasis (TNM), stages T1 and T2 (<3 or >3 cm). The objective of this study was to evaluate the prognostic value of tumour size before thoracotomy and to determine whether tumour size can be used to classify LC as T3. This multi-institutional cooperative longitudinal prospective study in Spanish hospitals located throughout the country, with a broad range of activity levels, included all consecutive cases of LC treated surgically from October 1993 to September 1996 (n=2,361). Four prognostic groups, characterized by tumour size, were identified according to the Schoenfeld procedure: a) 0-2 cm (n=173); b) 2.1-4 cm (n=542); c) 4.1-7 cm (n= 413); and d) >7 cm (n=77). The 2-yr survival rates by group were a=0.78 (95% confidence interval (CI) 0.71-0.84); b=0.67 (95% CI 0.62-0.71); c=0.58 (95% CI 0.53-0.63); d=0.41 (95% CI 0.29-0.52). The log-rank comparisons of the survival curves were significant for the four groups (a versus b=0.0008, b versus c=0.003, c versus d=0.016). The clinical tumour size of lung cancer defined four prognostic groups (0-2 cm, 2.1-4 cm, 4.1-7 cm; and >7 cm). Lung cancer with a diameter >7 cm had a prognosis similar to that of stage T3 or stage IIB. (+info)
How the measurement of residual volume developed after Davy (1800).
H. Davy measured the residual volume of his own lungs in 1800, by inhaling a hydrogen mixture contained in a mercurial air holder. Using the same principle, Nestor Grehant determined the functional residual capacity, and the volume of the dead space, in 1864. Both used a forced breathing method, that was substituted by a prolonged dilution method by D.D. Van Slyke and C.A.L. Binger in 1923. It was in 1941 that G.R. Meneely and M.L. Kaltreider replaced hydrogen with helium. The open circuit nitrogen washout method was proposed by R.E. Darling, A. Cournand and D.W. Richards in 1940, and the body plethysmograph by A.B. DuBois et al. in 1956. So the three methods, still in common use today for measuring the static lung volumes, had been described by the mid-1950s. (+info)
The pulmonary physician in critical care: towards comprehensive critical care?
This overview of intensive care medicine in Europe and the United States is an introduction to the review series on "The pulmonary physician in critical care" which starts in this issue of Thorax. (+info)
Combined effects of inhaled nitric oxide and a recruitment maneuver in patients with acute respiratory distress syndrome.
Nitric oxide (NO) inhalation therapy has been employed in the management of acute respiratory distress syndrome (ARDS), in order to improve oxygenation. Several factors have been implicated as being responsible for the action of inhaled NO. Alveolar recruitment methods, such as prone positioning and a sufficient positive end expiratory pressure (PEEP), have been identified as having a positive impact on the NO response. A Recruitment maneuver (RM) was introduced for the treatment of ARDS, along with a lung protective strategy. Here, we hypothesized that a RM may further augment the oxygenation of patients treated with NO inhalation. Therefore, the effects of the inhalation of NO, either in combination with a RM, or separately, were evaluated on patients with ARDS for their enhancing action. 23 patients with ARDS were enrolled, and divided into three groups. The patients in group 1 (n=11) were treated with 5 ppm NO via inhalation, followed by a RM, applying a sustained inflation pressure of 30 - 35 cmH2O for 30 seconds. Group 2 (n=6) received a RM alone, while group 3 (n=3) was treated with NO inhalation alone. The oxygenation and hemodynamic parameters were obtained prior to, and 2, 12, and 24 h after, the respective treatment procedures. For group 1, the PaO2/FiO2 increased from its initial value of 171.8 +/- 67.8 to 203.2 +/- 90.0 2 h after NO inhalation. Further improvement was noted with the continual application of the RM reaching, 215.5 +/- 74.6 (p=0.05) and 254.2 +/- 109.5 (p < 0.05), after 12 and 24 h, respectively. Initially 7 of the subjects did not respond to NO inhalation, but 3 of these non-responders changed into responders 12 h after the RM. The changes in the PaO2/FiO2 from baseline at each time period were greater in group 1 than in the other groups, but with no statistical significance. The hemodynamics of the patients was not significantly altered during the entire study period. We conclude that the combined application of NO inhalation and a RM could be beneficial and safe for patients with ARDS, showing an enhancing effect in improvement of oxygenation. (+info)
Lung cancer: the importance of seeing a respiratory physician.
Patients with lung cancer present to and are managed by a variety of clinicians. In this study the effect of involvement by a respiratory physician on the diagnosis, staging, treatment and survival of a large unselected group of lung cancer patients was investigated. The study population was derived from the Scottish Cancer Registry. A total of 3,855 patients diagnosed during 1995 with lung cancer were studied. The data were validated and supplemented by references to medical records. The study found that a respiratory physician had been involved in the initial management of 2,901 (75.3%) patients. These patients were found more likely to have had the cancer diagnosis confirmed by histological methods and to have received active treatment with surgery, radiotherapy or chemotherapy. Survival, 1 yr after diagnosis was higher in patients who saw a respiratory physician (24.4 versus 11.1%) and benefit was found to have remained 3 yrs after diagnosis (8.1 versus 3.7%). Although the patients who had not seen a respiratory physician were generally older, and had more extensive disease, after correcting for age, stage and other prognostic factors, the relative hazard ratio of death for those not managed by a respiratory physician was 1.44. The data from this study supports the recommendations of recent lung cancer guidelines for the early involvement by a respiratory physician. (+info)
Guidelines and shared care for asthma and COPD.
Shared-care constructions between general practitioners and pulmonary physicians are seemingly attractive for asthma and COPD patients. Thus they have to be implemented in further guidelines. However, anticipation that rapid changes will occur in treatment options towards optimal disease management justifies rapid adjustments in these strategies and requires investigations as to their ultimate benefit in disease outcome. (+info)