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Locey KJ, Webb TA, Weinstein RA, Hota B, Stein BD. Random variation drives a critical bias in the comparison of healthcare-associated infections. Infect Control Hosp Epidemiol 2023; 44:1396-1402. [PMID: 36896667 DOI: 10.1017/ice.2022.288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
OBJECTIVE To evaluate random effects of volume (patient days or device days) on healthcare-associated infections (HAIs) and the standardized infection ratio (SIR) used to compare hospitals. DESIGN A longitudinal comparison between publicly reported quarterly data (2014-2020) and volume-based random sampling using 4 HAI types: central-line-associated bloodstream infections, catheter-associated urinary tract infections, Clostridioides difficile infections, methicillin-resistant Staphylococcus aureus infections. METHODS Using 4,268 hospitals with reported SIRs, we examined relationships of SIRs to volume and compared distributions of SIRs and numbers of reported HAIs to the outcomes of simulated random sampling. We included random expectations into SIR calculations to produce a standardized infection score (SIS). RESULTS Among hospitals with volumes less than the median, 20%-33% had SIRs of 0, compared to 0.3%-5% for hospitals with volumes higher than the median. Distributions of SIRs were 86%-92% similar to those based on random sampling. Random expectations explained 54%-84% of variation in numbers of HAIs. The use of SIRs led hundreds of hospitals with more infections than either expected at random or predicted by risk-adjusted models to rank better than other hospitals. The SIS mitigated this effect and allowed hospitals of disparate volumes to achieve better scores while decreasing the number of hospitals tied for the best score. CONCLUSIONS SIRs and numbers of HAIs are strongly influenced by random effects of volume. Mitigating these effects drastically alters rankings for HAI types and may further alter penalty assignments in programs that aim to reduce HAIs and improve quality of care.
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Affiliation(s)
- Kenneth J Locey
- Center for Quality, Safety and Value Analytics, Rush University Medical Center, Chicago, Illinois
| | - Thomas A Webb
- Center for Quality, Safety and Value Analytics, Rush University Medical Center, Chicago, Illinois
| | - Robert A Weinstein
- Division of Infectious Diseases, Rush Medical College, Chicago, Illinois
| | - Bala Hota
- Tendo Systems, Inc, Hinsdale, Illinois
| | - Brian D Stein
- Center for Quality, Safety and Value Analytics, Rush University Medical Center, Chicago, Illinois
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Lin MY, Stein BD, Kothadia SM, Blank S, Schoeny ME, Tomich A, Hayden MK, Segreti J. Impact of Mandatory Infectious Disease Specialist Approval on Hospital-Onset Clostridioides difficile Infection Rates and Testing Appropriateness. Clin Infect Dis 2023; 77:346-350. [PMID: 37157903 DOI: 10.1093/cid/ciad250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 04/12/2023] [Accepted: 04/21/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Inappropriate Clostridioides difficile testing is common in the hospital setting, leading to potential overdiagnosis of infection when single-step nucleic acid amplification testing is used. The potential role of infectious diseases (ID) specialists in enforcing appropriate C. difficile testing is unclear. METHODS At a single 697-bed academic hospital, we performed a retrospective study from 1 March 2012 to 31 December 2019 comparing hospital-onset C. difficile infection (HO-CDI) rates during 3 consecutive time periods: baseline 1 (37 months, no decision support), baseline 2 (32 months, computer decision support), and intervention period (25 months, mandatory ID specialist approval for all C. difficile testing on hospital day 4 or later). We used a discontinuous growth model to assess the impact of the intervention on HO-CDI rates. RESULTS During the study period, we evaluated C. difficile infections across 331 180 admission and 1 172 015 patient-days. During the intervention period, a median of 1 HO-CDI test approval request per day (range, 0-6 alerts/day) was observed; adherence by providers with obtaining approval was 85%. The HO-CDI rate was 10.2, 10.4, and 4.3 events per 10 000 patient-days for each consecutive time period, respectively. In adjusted analysis, the HO-CDI rate did not differ significantly between the 2 baseline periods (P = .14) but did differ between the baseline 2 period and intervention period (P < .001). CONCLUSIONS An ID-led C. difficile testing approval process was feasible and was associated with a >50% decrease in HO-CDI rates, due to enforcement of appropriate testing.
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Affiliation(s)
- Michael Y Lin
- Departments of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Brian D Stein
- Departments of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Sonya M Kothadia
- Departments of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Samantha Blank
- Departments of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Alexander Tomich
- Infection Prevention and Control, Rush University Medical Center, Chicago, Illinois, USA
| | - Mary K Hayden
- Medicine and Pathology, Rush University Medical Center, Chicago, Illinois, USA
| | - John Segreti
- Departments of Medicine, Rush University Medical Center, Chicago, Illinois, USA
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Jacob JT, Baker JM, Fridkin SK, Lopman BA, Steinberg JP, Christenson RH, King B, Leekha S, O’Hara LM, Rock P, Schrank GM, Hayden MK, Hota B, Lin MY, Stein BD, Caturegli P, Milstone AM, Rock C, Voskertchian A, Reddy SC, Harris AD. Risk Factors Associated With SARS-CoV-2 Seropositivity Among US Health Care Personnel. JAMA Netw Open 2021; 4:e211283. [PMID: 33688967 PMCID: PMC7948059 DOI: 10.1001/jamanetworkopen.2021.1283] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
IMPORTANCE Risks for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among health care personnel (HCP) are unclear. OBJECTIVE To evaluate the risk factors associated with SARS-CoV-2 seropositivity among HCP with the a priori hypothesis that community exposure but not health care exposure was associated with seropositivity. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study was conducted among volunteer HCP at 4 large health care systems in 3 US states. Sites shared deidentified data sets, including previously collected serology results, questionnaire results on community and workplace exposures at the time of serology, and 3-digit residential zip code prefix of HCP. Site-specific responses were mapped to a common metadata set. Residential weekly coronavirus disease 2019 (COVID-19) cumulative incidence was calculated from state-based COVID-19 case and census data. EXPOSURES Model variables included demographic (age, race, sex, ethnicity), community (known COVID-19 contact, COVID-19 cumulative incidence by 3-digit zip code prefix), and health care (workplace, job role, COVID-19 patient contact) factors. MAIN OUTCOME AND MEASURES The main outcome was SARS-CoV-2 seropositivity. Risk factors for seropositivity were estimated using a mixed-effects logistic regression model with a random intercept to account for clustering by site. RESULTS Among 24 749 HCP, most were younger than 50 years (17 233 [69.6%]), were women (19 361 [78.2%]), were White individuals (15 157 [61.2%]), and reported workplace contact with patients with COVID-19 (12 413 [50.2%]). Many HCP worked in the inpatient setting (8893 [35.9%]) and were nurses (7830 [31.6%]). Cumulative incidence of COVID-19 per 10 000 in the community up to 1 week prior to serology testing ranged from 8.2 to 275.6; 20 072 HCP (81.1%) reported no COVID-19 contact in the community. Seropositivity was 4.4% (95% CI, 4.1%-4.6%; 1080 HCP) overall. In multivariable analysis, community COVID-19 contact and community COVID-19 cumulative incidence were associated with seropositivity (community contact: adjusted odds ratio [aOR], 3.5; 95% CI, 2.9-4.1; community cumulative incidence: aOR, 1.8; 95% CI, 1.3-2.6). No assessed workplace factors were associated with seropositivity, including nurse job role (aOR, 1.1; 95% CI, 0.9-1.3), working in the emergency department (aOR, 1.0; 95% CI, 0.8-1.3), or workplace contact with patients with COVID-19 (aOR, 1.1; 95% CI, 0.9-1.3). CONCLUSIONS AND RELEVANCE In this cross-sectional study of US HCP in 3 states, community exposures were associated with seropositivity to SARS-CoV-2, but workplace factors, including workplace role, environment, or contact with patients with known COVID-19, were not. These findings provide reassurance that current infection prevention practices in diverse health care settings are effective in preventing transmission of SARS-CoV-2 from patients to HCP.
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Affiliation(s)
- Jesse T. Jacob
- School of Medicine, Emory University, Atlanta, Georgia
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Julia M. Baker
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Scott K. Fridkin
- School of Medicine, Emory University, Atlanta, Georgia
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | | | | | - Brent King
- University of Maryland School of Medicine, Baltimore
| | - Surbhi Leekha
- University of Maryland School of Medicine, Baltimore
| | | | - Peter Rock
- University of Maryland School of Medicine, Baltimore
| | | | | | - Bala Hota
- Rush University Medical Center, Chicago, Illinois
| | | | | | | | | | - Clare Rock
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Sujan C. Reddy
- US Centers for Disease Control and Prevention, Atlanta, Georgia
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Abstract
Background: Coronavirus disease 2019 (COVID-19) has disrupted the delivery of health care services, including dental care. The objective of this study was to quantify and describe US adults who delayed dental care due to the COVID-19 pandemic. Methods: We analyzed cross-sectional responses collected from a nationally representative and long-running panel survey of US adults conducted in late May and early June 2020 (response rate = 70%). The survey included questions about dental care delayed due to the COVID-19 pandemic, purpose of the delayed dental visits, timing of future dental visits, and demographic information. Pearson’s chi-square tests were used to determine if rates of delayed dental care varied by subgroup. A multivariable regression model, adjusted for age, race, Hispanic ethnicity, census division, and rurality, was estimated to predict the odds of reporting delayed dental care. Results: Nearly half of respondents (46.7%) reported delaying going to the dentist or receiving dental care due to the COVID-19 pandemic. Among adults who reported delaying dental care due to the pandemic, 74.7% reported delaying a checkup, 12.4% reported delaying care to address something that was bothering them, and 10.5% reported delaying care to get planned treatment. About 44.4% of adults reported that they planned to visit the dentist within the next 3 mo. In the multivariable regression model, only living in an urban (vs. rural) area was associated with significantly higher odds of delayed dental care due to the pandemic (odds ratio: 1.5; 95% confidence interval: 1.1, 2.1). Conclusions: Nearly half of US adults reported delaying dental care due to the COVID-19 pandemic during the spring of 2020. Our results offer insight into the experiences of patients seeking dental care this spring and the economic challenges faced by dental providers due to the pandemic. Knowledge Transfer Statement: This article describes US adults who delayed dental care due to the COVID-19 pandemic. Results can be used by clinicians and policymakers to understand delayed care during the pandemic.
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Affiliation(s)
- A M Kranz
- RAND Corporation, Arlington, VA, USA
| | - G Gahlon
- RAND Corporation, Arlington, VA, USA
| | - A W Dick
- RAND Corporation, Boston, MA, USA
| | - B D Stein
- RAND Corporation, Pittsburgh, PA, USA
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Batist G, Michaud S, Richards DP, Servidio-Italiano F, Stein BD. Developing a model of a patient-group pathway to accessing cancer clinical trials in Canada. Curr Oncol 2018; 25:e597-e609. [PMID: 30607129 PMCID: PMC6291290 DOI: 10.3747/co.25.4213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Colorectal Cancer Canada, in partnership with a Scientific Advisory Committee, is developing a Canadian Patient Group Pathway to Accessing Cancer Clinical Trials ("Pathway"). A central element of the Pathway is presented here-namely, a set of recommendations and tools aimed at each stakeholder group. Methods A summary of the peer-reviewed and grey literature informed discussions at a meeting, held in June 2017, in which a cross-section of stakeholders reached consensus on the potential roles of patient groups in the cancer clinical trials process, barriers to accessing cancer clinical trials, best practice models for patient-group integration, and a process for developing the Pathway. Canadian recommendations and tools were subsequently developed by a small working group and reviewed by the Scientific Advisory Committee. Results The major output of the consensus conference was agreement that the Clinical Trials Transformation Initiative (ctti) model, successfully applied in the United States, could be adapted to create a Canadian Pathway. Two main differences between the Canadian and American cancer clinical research environments were highlighted: the effects of global decision-making and systems of regulatory and funding approvals. The working group modified the ctti model to incorporate those aspects and to reflect Canadian stakeholder organizations and how they currently interact with patient groups. Conclusions Developing and implementing a Canadian Pathway that incorporates the concepts of multi-stakeholder collaboration and the inclusion of patient groups as equal partners is expected to generate significant benefits for all stakeholders. The next steps to bring forward a proposed Pathway will involve engaging the broader cancer research community. Clinical trial sponsors will be encouraged to adopt a Charter recognizing the importance of including patient groups, and to support the training of patient groups through an independent body to ensure quality research partners. Integration of patient groups into the process of developing "real world" evidence will be advanced by a further consensus meeting being organized by Colorectal Cancer Canada for 6-7 November 2018.
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Affiliation(s)
- G Batist
- McGill Centre for Translational Research in Cancer, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC
- Segal Cancer Centre, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC
- National Centre of Excellence in Personalized Medicine, Exactis Innovation, Montreal, QC
| | | | | | | | - B D Stein
- Colorectal Cancer Canada, Montreal, QC
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Alsomali HJ, Vines DL, Stein BD, Becker EA. Evaluating the Effectiveness of Written Dry Powder Inhaler Instructions and Health Literacy in Subjects Diagnosed With COPD. Respir Care 2016; 62:172-178. [PMID: 28028187 DOI: 10.4187/respcare.04686] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Improper inhaler use results in decreased drug deposition in the lungs. The impact of health literacy and poor vision on the patient's ability to learn inhaler technique by reading instructions has not been confirmed. This study evaluated the effectiveness of learning inhaler technique from written instructions and the impact of health literacy for patients diagnosed with COPD who used a dry powder inhaler (DPI). METHODS This pilot study recruited subjects diagnosed with COPD. A trained assessor scored subjects' inhaler technique before and after reading the appropriate American College of Chest Physicians handouts. Peak inspiratory flows (PIFs) were measured using an InCheck Dial. Health literacy was measured by the S-TOFHLA (Short Test of Functional Health Literacy in Adults), and visual acuity was measured by a Snellen chart. Associations between health literacy and visual acuity and changes in subjects' inhaler technique scores were assessed by Spearman's rho. Inhaler technique change scores were assessed by the Wilcoxon signed-rank test at P = .05. RESULTS Of the 24 participants enrolled, 63% were female, mean age was 65.6 y, and 83% were Global Initiative for Chronic Obstructive Lung Disease air-flow limitation 2 or 3. Wilcoxon scores were significant for improved total scores for both the Diskus and HandiHaler, with medians improving from 6.5 to 7.0 (interquartile range 6.0-7.8) (P = .047) and from 6.0 to 7.5 (interquartile range 7.0-9.0) (P = .002), respectively. The minimum required PIF was achieved by 93.8% of the Diskus and 94.4% of the HandiHaler groups. There were no associations detected between the handout intervention (Diskus and HandiHaler) and health literacy level and vision. CONCLUSIONS The educational handouts for DPIs helped participants already using a DPI to improve their inhaler technique. Stable participants diagnosed with COPD are able to generate appropriate PIFs to properly use DPIs. Neither vision nor health literacy was associated with the inability to learn inhaler technique from patient education inhaler device handouts.
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Affiliation(s)
- Hana J Alsomali
- Rush University, Chicago, Illinois. .,University of Dammam, Saudi Arabia
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Stein BD, Bautista A, Schumock GT, Lee TA, Charbeneau JT, Lauderdale DS, Naureckas ET, Meltzer DO, Krishnan JA. The validity of International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for identifying patients hospitalized for COPD exacerbations. Chest 2011; 141:87-93. [PMID: 21757568 DOI: 10.1378/chest.11-0024] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Acute exacerbations of COPD (AE-COPD) are a leading cause of hospitalizations in the United States. To estimate the burden of disease (eg, prevalence and cost), identify opportunities to improve care quality (eg, performance measures), and conduct observational comparative effectiveness research studies, various algorithms based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes have been used to identify patients with COPD. However, the validity of these algorithms remains unclear. METHODS We compared the test characteristics (sensitivity, specificity, positive predictive value, and negative predictive value) of four different coding algorithms for identifying patients hospitalized for an exacerbation of COPD with chart review (reference standard) using a stratified probability sample of 200 hospitalizations at two urban academic medical centers. Sampling weights were used when calculating prevalence and test characteristics. RESULTS The prevalence of COPD exacerbations (based on the reference standard) was 7.9% of all hospitalizations. The sensitivity of all ICD-9-CM algorithms was very low and varied by algorithm (12%-25%), but the negative predictive value was similarly high across algorithms (93%-94%). The specificity was > 99% for all algorithms, but the positive predictive value varied by algorithm (81%-97%). CONCLUSIONS Algorithms based on ICD-9-CM codes will undercount hospitalizations for AE-COPD, and as many as one in five patients identified by these algorithms may be misidentified as having a COPD exacerbation. These findings suggest that relying on ICD-9-CM codes alone to identify patients hospitalized for AE-COPD may be problematic.
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Affiliation(s)
- Brian D Stein
- Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, IL
| | - Adriana Bautista
- Center for Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL
| | - Glen T Schumock
- Center for Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL
| | - Todd A Lee
- Center for Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL; Center for Management of Complex Chronic Care, Hines VA Hospital, University of Chicago, Chicago, IL
| | - Jeffery T Charbeneau
- Department of Health Studies, Section of Pulmonary, University of Chicago, Chicago, IL
| | - Diane S Lauderdale
- Department of Health Studies, Section of Pulmonary, University of Chicago, Chicago, IL
| | | | - David O Meltzer
- Section of Hospital Medicine, University of Chicago, Chicago, IL
| | - Jerry A Krishnan
- Section of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois at Chicago, Chicago, IL.
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Stein BD, Charbeneau JT, Lee TA, Schumock GT, Lindenauer PK, Bautista A, Lauderdale DS, Naureckas ET, Krishnan JA. Hospitalizations for acute exacerbations of chronic obstructive pulmonary disease: how you count matters. COPD 2010; 7:164-71. [PMID: 20486814 DOI: 10.3109/15412555.2010.481696] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
ICD-9-CM diagnosis codes are increasingly used to estimate the burden of disease, as well as to evaluate the quality of care and outcomes of various conditions. Acute exacerbations of COPD (AE-COPD) are common and associated with substantial health and financial burden in the U.S. Whether published algorithms that employ different combinations of ICD-9-CM codes to identify patients hospitalized for AE-COPD yield similar or different estimates of disease burden is unclear. In this study, the Nationwide Inpatient Sample from years 2000-2006 was used to identify and compare the number of hospitalizations, healthcare utilization, and outcomes for patients hospitalized for AE-COPD in the U.S. AE-COPD was identified using five different published ICD-9-CM algorithms. Estimates of the annual number of hospitalizations for AE-COPD in the U.S. varied more than 2-fold (e.g., 421,000 to 870,000 in 2006). Outcomes and healthcare utilization of patients hospitalized for AE-COPD varied substantially, depending on the algorithm used (e.g., in-hospital mortality 2.0% to 5.1%, total hospital days 2.0 to 5.1 million in 2006). Observed trends in the number of hospitalizations over the 7-year period varied depending on which algorithm was used. In conclusion, the estimated health burden and trends in hospitalizations for AE-COPD in the United States differ, depending on which ICD-9-CM algorithm is used. To improve our understanding of the burden of AE-COPD and to ensure that quality of care initiatives are not misdirected, a validated approach to identifying patients hospitalized for AE-COPD is needed.
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Affiliation(s)
- Brian D Stein
- Rush University Medical Center, Section of Pulmonary and Critical Care Medicine, Chicago, Illinois, USA.
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9
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Davis SQ, Permutt Z, Permutt S, Naureckas ET, Bilderback AL, Rand CS, Stein BD, Krishnan JA. Perception of airflow obstruction in patients hospitalized for acute asthma. Ann Allergy Asthma Immunol 2009; 102:455-61. [PMID: 19558002 DOI: 10.1016/s1081-1206(10)60117-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Little is known about the perception of airflow obstruction in patients hospitalized for acute asthma. OBJECTIVES To evaluate patient perception of airflow obstruction at hospital discharge and at a 2-week follow-up visit and to determine whether symptom control and/or severity of airflow obstruction identified patients at risk for acute asthma after discharge. METHODS In a prospective cohort study of inner-city adults hospitalized for acute asthma from April 1, 2001, through October 31, 2002, symptom control (Asthma Control Questionnaire) and airflow obstruction (forced expiratory volume in 1 second [FEV1] percentage predicted) were evaluated at discharge and 2 weeks after discharge. We evaluated perception of airflow obstruction (symptom control vs FEV1 percentage predicted) and perception of change in airflow obstruction (change in symptom control vs percentage change in FEV1) between the 2 visits. Acute asthma after discharge was defined as an emergency department visit or hospitalization for asthma within 90 days of discharge. RESULTS In fifty-one participants, symptom control was not significantly associated with airflow obstruction at hospital discharge (P = .30), indicating poor perception of airflow obstruction. Among the 41 participants (80.4% of those enrolled) who completed the follow-up visit, change in symptom control was not significantly associated with change in airflow obstruction (P = .20), indicating poor perception of change in airflow obstruction. Greater airflow obstruction at follow-up (P = .02) and a smaller improvement in airflow obstruction (P = .03), but not symptom control, were associated with a higher risk of acute asthma after discharge. CONCLUSIONS Patients hospitalized for acute asthma have poor perception of airflow obstruction and change in airflow obstruction. Objective measurements of lung function should guide treatment decisions after discharge in this population.
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Affiliation(s)
- Steven Q Davis
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
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Schuster MA, Stein BD, Jaycox L, Collins RL, Marshall GN, Elliott MN, Zhou AJ, Kanouse DE, Morrison JL, Berry SH. A national survey of stress reactions after the September 11, 2001, terrorist attacks. N Engl J Med 2001; 345:1507-12. [PMID: 11794216 DOI: 10.1056/nejm200111153452024] [Citation(s) in RCA: 682] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND People who are not present at a traumatic event may also experience stress reactions. We assessed the immediate mental health effects of the terrorist attacks on September 11, 2001. METHODS Using random-digit dialing three to five days after September 11, we interviewed a nationally representative sample of 569 U.S. adults about their reactions to the terrorist attacks and their perceptions of their children's reactions. RESULTS Forty-four percent of the adults reported one or more substantial stress symptoms; 91 percent had one or more symptoms to at least some degree. Respondents throughout the country reported stress syndromes. They coped by talking with others (98 percent), turning to religion (90 percent), participating in group activities (60 percent), and making donations (36 percent). Eighty-five percent of parents reported that they or other adults in the household had talked to their children about the attacks for an hour or more; 34 percent restricted their children's television viewing. Thirty-five percent of children had one or more stress symptoms, and 47 percent were worried about their own safety or the safety of loved ones. CONCLUSIONS After the September 11 terrorist attacks, Americans across the country, including children, had substantial symptoms of stress. Even clinicians who practice in regions that are far from the recent attacks should be prepared to assist people with trauma-related symptoms of stress.
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Stein BD, Zima BT, Elliott MN, Burnam MA, Shahinfar A, Fox NA, Leavitt LA. Violence exposure among school-age children in foster care: relationship to distress symptoms. J Am Acad Child Adolesc Psychiatry 2001; 40:588-94. [PMID: 11349704 DOI: 10.1097/00004583-200105000-00019] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the amount and nature of violence exposure and examine the relationship between violence exposure and distress symptoms among children in foster care. METHOD Violence exposure and distress symptoms were evaluated in interviews, conducted between July 1996 and March 1998, of 300 children from Los Angeles County living in out-of-home placement. RESULTS Interviews were successfully completed in 91% of eligible children. The majority of children (85%) reported having been a witness to violence, and 51% had been a victim of violence during their lifetime. Of these youths, 54% and 41%, respectively, reported having been exposed to such violence in the past 6 months. Girls, victims of assaultive violence and weapon related violence, and those reporting exposure to mild violence were more likely (p < .05) to have higher levels of distress symptoms than those without such characteristics, after age was controlled for. CONCLUSIONS Children in foster care continue to have high levels of violence exposure, even after removal from their biological parents' home. The relationship between violence exposure and distress symptoms underscores the need for clinicians to inquire about multiple forms of violence exposure among children living in out-of-home placement.
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Stein BD, Myers D. Emotional sequelae of disasters: a primary care physician's guide. J Am Med Womens Assoc (1972) 1999; 54:60-4. [PMID: 10319593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Disasters are a common cause of psychological trauma and distress, especially for women victims, who are more likely to develop several types of psychological problems. This paper examines the important role of the primary care physician in addressing the emotional and psychological needs of disaster victims. The phases of a disaster are discussed, as are common disaster-related somatic complaints. The paper then outlines a brief intervention for use with disaster victims that can be performed in a primary care physician's office, addresses appropriate patient referral, and outlines the mental health resources commonly available after a disaster.
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Affiliation(s)
- B D Stein
- Department of General Medicine, University of California, Los Angeles, USA
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Lauerma AI, Stein BD, Homey B, Lee CH, Bloom E, Maibach HI. Topical FK506: suppression of allergic and irritant contact dermatitis in the guinea pig. Arch Dermatol Res 1994; 286:337-40. [PMID: 7526805 DOI: 10.1007/bf00402225] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Topical FK506 has recently been shown to have an anti-inflammatory effect in vivo in humans. In this study its effects in contact dermatitis were studied in the guinea pig model. Topical FK506 suppressed both irritant and allergic patch-test reactions. The most prominent suppressive effect was seen when skin sites were pretreated with FK506. Topical FK506 did not impair the induction of contact allergy as assessed by challenges, although it suppressed local lymph node cell accumulation during contact allergy induction. Topical FK506 may hold promise as a treatment for skin disorders that respond to oral FK506 or cyclosporin A.
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Affiliation(s)
- A I Lauerma
- Department of Dermatology, University of California, School of Medicine, San Francisco 94143-0989
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Affiliation(s)
- R J Wityk
- Johns Hopkins School of Medicine, Baltimore, Maryland
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Stein BD, Klomparens KL, Hammerschmidt R. Comparison of bromine and permanganate as ultrastructural stains for lignin in plants infected by the fungus Colletotrichum lagenarium. Microsc Res Tech 1992; 23:201-6. [PMID: 1282045 DOI: 10.1002/jemt.1070230302] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Transmission electron microscopy (TEM) and energy dispersive X-ray microanalysis (EDS) were used to localize manganese from KMnO4, and bromine, as ultrastructural stains for lignin in an herbaceous plant. The Spookie cultivar of pumpkin is susceptible to infection by the fungus Colletotrichum lagenarium and served as a model system to compare the Br and KMnO4 techniques. Bromine was used in a fixation/staining procedure, and in separate experiments, KMnO4 was used as either a fixative or as a postsection stain. The technique for using bromine was modified from the woody plant procedure by adding a paraformaldehyde prefixation step. With the bromine procedure, cell walls were well-preserved, but the cytoplasm was heavily extracted. The KMnO4 procedures produced well-fixed cytoplasm, but with some staining artifacts. With all procedures, EDS dot mapping demonstrated lignin deposition in the cell walls specifically associated with sites of fungal infection. Lignin was also localized in secondary walls of tracheary elements, sites known to be highly lignified. The bromine procedure provided the most specific localization of lignin with a minimum of artifact. The specific applications of these stains provided data on the ultrastructural localization of lignin which contributed to the elucidation of its role in the interactions between pathogenic fungi in both their resistant and susceptible plant hosts.
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Affiliation(s)
- B D Stein
- Department of Botany and Plant Pathology, Michigan State University, East Lansing 48824
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