Pretransplant cachexia and morbid obesity are predictors of increased mortality after heart transplantation

BACKGROUND

Extremes in body weight are a relative contraindication to cardiac transplantation.

METHODS

We retrospectively reviewed 474 consecutive adult patients (377 male, 97 female, mean age 50.3+/-12.2 years), who received 444 primary and 30 heart retransplants between January of 1992 and January of 1999. Of these, 68 cachectic (body mass index [BMI]<20 kg/m2), 113 overweight (BMI=>27-30 kg/m2), and 55 morbidly obese (BMI>30 kg/m2) patients were compared with 238 normal-weight recipients (BMI=20-27 kg/m2). We evaluated the influence of pretransplant BMI on morbidity and mortality after cardiac transplantation. Kaplan-Meier survival distribution and Cox proportional hazards model were used for statistical analyses.

RESULTS

Morbidly obese as well as cachectic recipients demonstrated nearly twice the 5-year mortality of normal-weight or overweight recipients (53% vs. 27%, respectively, P=0.001). An increase in mortality was seen at 30 days for morbidly obese and cachectic recipients (12.7% and 17.7%, respectively) versus a 30-day mortality rate of 7.6% in normal-weight recipients. Morbidly obese recipients experienced a shorter time to high-grade acute rejection (P=0.004) as well as an increased annual high-grade rejection frequency when compared with normal-weight recipients (P=0.001). By multivariable analysis, the incidence of transplant-related coronary artery disease (TCAD) was not increased in morbidly obese patients but cachectic patients had a significantly lower incidence of TCAD (P=0.05). Cachectic patients receiving oversized donor hearts had a significantly higher postoperative mortality (P=0.02).

CONCLUSIONS

The risks of cardiac transplantation are increased in both morbidly obese and cachectic patients compared with normal-weight recipients. However, the results of cardiac transplantation in overweight patients is comparable to that in normal-weight patients. Recipient size should be kept in mind while selecting patients and the use of oversized donors in cachectic recipients should be avoided.

Complicated UTI. Effective treatment in the long-term care setting

Diagnosis and treatment of complicated urinary tract infection (UTI) in older persons in the long-term care setting presents practitioners with special clinical challenges and is a more complex proposition than management of UTIs that commonly arise in younger persons. Effective care is a function of consideration and understanding of several key issues relating to urinalysis, antibiotic therapy, duration of therapy, and the route of drug administration. Typical diagnostic and management hurdles include collecting a clean specimen; dealing effectively with asymptomatic bacteriuria, a benign condition that often precipitates unnecessary treatment; and appreciation that diagnosis should not be made based solely on a positive culture result.

Antibiotic use in the elderly: issues and nonissues

Despite the well-recognized increase in mortality and morbidity due to infections in the elderly, antibiotics may, in most cases, be used in a manner similar to that in younger patients. The decreased lean body weight and reduced renal function typical of elderly patients, however, require consideration of reduced doses and longer dosing intervals, especially for renally excreted antibiotics. Length of therapy should be conservative because underlying anatomic or functional predispositions to infections tend to complicate treatment. Oral antibiotics are equally well absorbed in the elderly and younger patients and may be used for the same indications as for younger patients. A notable, important difference in the choice of antibiotics for serious infections in older versus younger patients is that empirical therapy should be broader in spectrum for elderly patients, and especially for elderly long-term residents, since the variety of infecting bacteria tends to be greater and polymicrobial infections tend to be common.

Antibiotic resistance: why is it increasing in nursing homes?

Causes of the apparent increase in antibiotic resistance in the bacterial flora of nursing homes are multifactorial. Today's nursing home patients are older, in poorer health, and less able to function independently than has been true in the past. Infection and antibiotic use in this population may increase selective pressure for the emergence of resistant strains. The efficient transfer to nursing homes of patients from acute-care settings also contributes to the increase in colonization or infection with highly resistant bacteria. Prudent restraint in the use of antibiotics and better infection control in nursing homes may reduce or retard the increase or spread in resistant infections.

Denying the dying. Advance directives and dialysis discontinuation

A structured interview was administered to a sample of patients on maintenance dialysis and their attending physicians to obtain information on the documentation of their end-of-life treatment preferences. The majority of the patients reported never having considered stopping dialysis, or having discussed with their nephrologist or family the circumstances in which treatment should be discontinued. Only 7 patients (6%) had completed an advance directive; these patients were all men (P = 0.01) and tended to be better educated (P = 0.02). Only one of the nine physicians had completed an advance directive. In most cases, the dialysis patients and their treatment team staff were preoccupied with the struggles of daily life and had avoided or denied considerations of terminal illness and death. The literature on denial, medical illness, and dying is also reviewed as it relates to dialysis patients, end-of-life treatment, and terminal care.

Safety of antihistamines in the treatment of allergic rhinitis in elderly patients

Elderly patients may be more susceptible than younger persons to the sedating and anticholinergic effects of first-generation antihistamines. Second-generation antihistamines, such as loratadine, astemizole, and terfenadine, cause minimal sedation and little if any impairment in cognitive and psychomotor activity in healthy nonelderly patients. Although less extensively studied in elderly patients, it is probable that second-generation antihistamines are also less likely to induce the adverse central nervous system effects in older patients that are characteristic of the first-generation antihistamines. Toxic effects to the cardiovascular system, an issue of greater concern among elderly patients who may have subclinical heart disease, has not been observed with first-generation antihistamines. Among the second-generation antihistamines, however, astemizole and terfenadine, but not loratadine, can cause serious cardiovascular adverse effects, including death, when taken in high doses or coadministered with ketoconazole, itraconazole, or macrolide antibiotics.

The naturalness of dying

Evidence that dying occurs as a natural, final event in the wholeness of human life is culturally, artistically, and scientifically persuasive. Very elderly patients eventually undergo a process of functional declines, progressive apathy, and loss of willingness to eat and drink that culminates in death, even in the absence of acute illness or severe chronic disease. Despite clinical resemblances to depression and dementia, aging itself and a loss of will to live are the most probable explanations for natural dying. Acceptance of the naturalness of dying, however, directly conflicts with the medicalization and legalization of death that characterizes modern society's treatment of dying elderly patients. We prefer instead to believe that dying results from disease and injury, which may yield to advances in medical technology. The progressive move of the dying out of the home and into acute and long-term care facilities suggests that medicalization may be an irreversible process. Viewing dying as an independent diagnosis in patients who are obviously undergoing terminal declines from aging and chronic diseases can facilitate communication about spiritual and palliative care needs, which tend to be neglected in the medicalized view of dying. Physicians and nurses may need to assume the role of medical stewardship to help prevent the overtreatment and overtesting of modern medicine's approach to the dying. The emotional burdens of caring for the dying elderly, however, must be addressed openly through collaborative work, institutional policies on limitation of treatment, and support building among physicians and other caregivers.

Addressing the service versus education conflicts created by residency training in ambulatory care settings

Much of the tension and conflict that result from the competing demands of work and learning during residency training--the service versus education conflict--can be addressed by mutual adherence to fundamental guidelines of fairness and personal responsibility by residents and their employers, mentors, and teachers. Residents should be recognized by their employers as professionals and by their teachers as colleagues. Because residency is postgraduate professional education for medical school graduates, the content of resident education must be primarily determined by the educational needs of maturing physicians. The greatest value of residents' services for their employing institutions remains in the inpatient setting where they work as inexpensive professional labor, working long and unattractive patient care shifts providing acute care. In the ambulatory setting, they are less efficient, work ordinary hours, and require real-time on-site supervision. Nevertheless, it is clear that the opportunities for medical education are rapidly shifting from the inpatient setting to ambulatory settings--locations in which there is less experience in proven techniques in medical education.

Complicated, recurrent, and geriatric UTI

If the patient is older or has certain underlying diseases, urinary tract infection can persist or recur, and unusual pathogens may be at work. Consider broader-spectrum coverage and a longer treatment course.

Dialysis discontinuation. A 'good' death?

BACKGROUND

Approximately 10% of the deaths of patients receiving long-term dialysis for end-stage renal disease are preceded by discontinuation of dialysis. We prospectively studied the decision to discontinue dialysis and whether, as is often stated, these patients have a prompt, predictable, and comfortable death.

METHODS

All patients receiving hemodialysis in a hospital-based and a freestanding unit whose long-term dialysis was discontinued in 1990 were included in the study. Patients, providers, and families of prospectively enrolled cases were interviewed to determine the reasons for discontinuation; the patients' terminal courses were reviewed daily to collect information describing their quality of death. Retrospectively enrolled cases were studied by chart review and interviews of providers. The reasons for discontinuation of dialysis and a rating of the quality of their deaths (for prospectively studied patients only) were determined by interdisciplinary team consensus. Quality of death was rated on scales of 1 (worst) to 5 (best) according to duration of dying, discomfort, and psychosocial circumstances.

RESULTS

Eighteen patients discontinued dialysis after a mean duration of 43.6 months of hemodialysis, and they lived a mean of 9.6 days after termination. The quality of death of the 11 patients who were enrolled prospectively was subjectively assessed as "good" (> 10 of a possible 15 points) for seven patients and "poor" for four patients. A good quality of death was more likely if dialysis was discontinued because of medical deterioration from progressive chronic disease (P = .009); none of the three patients whose dialysis was discontinued for other reasons had a good death (P = .024).

CONCLUSIONS

A majority of the prospective cohort of patients who discontinued dialysis experienced a good death by our largely subjective criteria. Improved palliative therapy for some of these dying patients, however, could have ameliorated prolonged suffering, delirium, and inadequately treated pain that led to a poor quality of death.

Rationale for the use of oral fluoroquinolones as empiric treatment of nursing home infections

Despite relatively limited clinical data in nursing home patients, studies in non-nursing home settings indicate that the systemic fluoroquinolones offer a spectrum of activity against typical gram-negative bacillary nursing home pathogens that is unavailable with other oral antimicrobials, offer excellent pharmacokinetics in the elderly, and have few adverse effects. When ofloxacin and ciprofloxacin have been compared with standard empiric intravenous or oral regimens in the hospitalized elderly in the treatment of the types of complicated urinary tract infections, pneumonia, and skin and soft-tissue infections that may be encountered in nursing homes, clinical efficacy has been at least equivalent. Although not similarly tested in nursing home settings, lomefloxacin, enoxacin, and fleroxacin have given clinical results at least comparable to control oral regimens for complicated urinary tract infection in the elderly.

Do clinical and formal assessments of the capacity of patients in the intensive care unit to make decisions agree?

BACKGROUND

The complex environment and technology of intensive care unit (ICU) care may impair the ability of patients to participate in medical decision making or give informed consent. We studied the agreement of the intuitive assessments of residents and nurses of ICU patients' cognition, judgment, and decision-making capacity, and whether those assessments agreed with abbreviated formal mental status testing.

METHODS

Using a prospective survey case study, we assessed 200 English-speaking patients within 24 hours of their ICU admission. Formal assessment of cognition, judgment, and insight was performed by a research assistant. We obtained independent intuitive ratings by nurses and residents of patient cognition, judgment, and ability to participate in medical decision making or give informed consent.

RESULTS

Residents' and nurses' assessment of cognition and judgment showed a high degree of agreement with weighted ks of greater than 0.76. Assessments of cognition by residents and nurses agreed with Folstein Mini-Mental State Examination in 70% and 73.6% of cases, respectively. Forty percent of the population had an unimpaired Mini-Mental State Examination score of greater than 23, and an additional 12% of the subjects were mildly impaired with scores of 20 to 23. When asked whether they would approach patient or family for consent for an invasive procedure, nurses and physicians said they would request informed consent from 66% and 62% of the patients, respectively.

CONCLUSIONS

Residents and nurses caring for patients newly admitted to the ICU agree in their assessment of cognition, judgment, and capacity to participate in medical decision making, and are not unduly influenced by ventilator status. Their assessments correlate highly with abbreviated formal mental status testing.

Pneumonia in the elderly. Special considerations in a special population

Bacterial infections of the lower respiratory tract in the elderly may not be as atypical in presentation as traditional wisdom once held. Recent studies indicate that more than one in three elderly patients have fever, cough, and leukocytosis; nevertheless, some elderly patients present with none of the features typically associated with pneumonia. An important and consistent clinical difference between younger and older patients is the broader range of bacterial respiratory pathogens found in the elderly, including gram-negative bacilli such as Haemophilus influenzae, Proteus mirabilis, and Moraxella catarrhalis. Little is gained by the initial use of narrow-spectrum antibiotic therapy, and much may be lost. Parenteral third-generation cephalosporins and oral fluoroquinolones are active against the major pathogens and can be used for empirical broad-spectrum therapy. Recent trials indicate that results are equally good with agents of either type. Perhaps a third of elderly patients with pneumonia do not require or benefit from hospitalization. The availability of excellent new broad-spectrum oral antimicrobial agents makes treatment at home or in a nursing home an attractive way to avoid the costs and many complications of hospitalization for acute care of these frail patients.

Patient attitudes and psychological considerations in dialysis discontinuation

The authors surveyed 36 adult patients who were maintained with chronic renal dialysis concerning their attitudes about dialysis discontinuation. Few subjects reported having ever considered stopping the life-support treatment. When asked to consider 12 hypothetical scenarios in which they might consider stopping treatment (e.g., onset of dementia or blindness), most subjects would still not consider discontinuation. Consideration of dialysis discontinuation was directly correlated with the patient's educational level. Follow-up after 1 year underscored the substantial differences between the responses the subjects gave to the 12 hypothetical scenarios and their real-life responses when they were later faced with decisions to actually terminate treatment. Psychiatrists have an opportunity to participate in the complex clinical and ethical decisions associated with advance directives and patients' right to refuse life-support treatment.

Urinary tract infections in the elderly

Urinary tract infection (UTI) is the most common infectious disease of the elderly and is especially prevalent in debilitated, institutionalized older individuals. Unlike UTI in younger women, which tends to be related to frequency of sexual intercourse and is uncomplicated, in the elderly it is more difficult to treat and its pathogenesis is related to abnormal bladder function, bladder outlet obstruction, vaginal and urethral atrophy, use of long-term indwelling catheters, and puddling related to bed rest. The spectrum of organisms causing infection relates to the ecology of the patients' environments; those residing in nursing homes and especially with permanent indwelling catheters tend to have a greater variety of pathogenic organisms, many of which may be relatively antibiotic resistant. Short-course antibiotic therapy is less effective in older patients, and relapse or recurrence is more common regardless of the duration of treatment. Asymptomatic bacteriuria is common in older patients with abnormal bladder function. The clinical significance of asymptomatic bacteriuria generally is minor, and treatment is not beneficial.

Antimicrobial therapy

Antibiotic dosing is not influenced by age as much as by the weight loss and loss of renal function that occurs with advanced age. The chronic diseases that afflict the frail, elderly person, however, exert a profound influence on the types of infections and the variety of organisms that must be considered in empiric therapy choices. Safety, efficacy, and cost favor the choice of broad-spectrum oral antimicrobials or the newer quinolones for initial treatment of moderately severe, urinary, respiratory, or skin and soft-tissue infections. When parenteral empiric therapy is needed, the third-generation cephalosporins are preferable to multi-drug or narrow-spectrum regimens. To avoid adverse reactions, the frail, elderly patient generally should be given somewhat lower doses at longer dose intervals compared with younger patients.

Oral antibiotics: practical prescribing rules for practitioners

Oral antibiotics are frequently prescribed for older patients for the treatment of such common bacterial infections as upper respiratory and urinary tract infections. Six practical prescribing rules can help control the cost of therapy. 1) Oral antimicrobials used to prevent hospitalization are always cost-effective. 2) Oral antimicrobials are always less expensive than parenteral antimicrobials. 3) Generic antimicrobials are not always less expensive than proprietary antimicrobials. 4) The best drug for the infection is usually the most cost-effective in the long run, regardless of cost. 5) The use of antimicrobials for marginal indications is almost always cost-ineffective. 6) The simplest regimens are often the most cost-effective.

Alcohol and other substance abuse and impairment among physicians in residency training

Substance abuse and impairment are serious societal problems. Physicians have historically had high rates of substance abuse, which has been viewed as an occupational hazard. Most authorities agree that the rate of alcoholism among practicing physicians is similar to that among control populations and that the rates of other substance abuse are greater, although some studies have shown no difference. Data about substance abuse among residents in training are limited but suggest that the use of benzodiazopines is greater than that among age-matched peers, whereas the use of alcohol is similar between the two groups. Medical institutions, including those with teaching programs, have legal and ethical responsibilities concerning substance abuse among current and future physicians. Many training programs, however, do not provide educational programs on this subject, do not have faculty trained in substance abuse medicine, and do not have a formal system to address the problem of residents who are suspected or known to be substance abusers. This position paper examines the extent of substance abuse, including alcohol abuse, among physicians in residency training. It outlines approaches to the problem and delineates responsibilities of institutions and residency program directors. Recommendations are made to establish an informational program and a clearly defined, organized process to address the problems of substance abuse among residents. Careful and humane approaches can be used to identify and treat residents with substance abuse problems and thus allowing them to complete their training as competent and drug-free professionals.

A stress management workshop improves residents' coping skills

We describe the effectiveness of a stress management workshop designed for physicians. Of the 64 medicine, pediatrics, and medicine-pediatrics residents who agreed to participate in the workshop, the 43 who could be freed from clinical responsibilities constituted the intervention group; the 21 residents who could not be freed from clinical responsibilities were asked to be the nonintervention group. The ESSI Stress Systems Instrument and Maslach Burnout Inventory were administered to control subjects and workshop participants 2 weeks before and 6 weeks after the workshop. The half-day workshops taught management of the stresses of medical practice through: (1) learning and practicing interpersonal skills that increase the availability of social support; (2) prioritization of personal, work, and educational demands; (3) techniques to increase stamina and attend to self-care needs; (4) recognition and avoidance of maladaptive responses; and (5) positive outlook skills. Overall, the ESSI Stress Systems Instrument test scores for the workshop participants improved (+1.27), while the nonintervention group's mean scores declined (-0.65). All 21 individual ESSI Stress Systems Instrument scale items improved for the workshop, compared with eight of 21 items for the nonintervention group. The workshop group improved in the Maslach Burnout Inventory emotional exhaustion scale and deteriorated less than the nonintervention group in the depersonalization scale. We conclude that a modest, inexpensive stress management workshop was received positively, and can lead to significant short-term improvement in stress and burnout test scores for medicine and pediatrics residents.

Drug interchanges at the pharmacy: safe for cardiovascular disease?

With the development of sustained-release formulations for various chronic diseases, long-standing questions about the "interchangeability" of drugs have acquired new pertinence. A case in point is provided by verapamil.

Acute psychoses associated with the use of ciprofloxacin and trimethoprim-sulfamethoxazole

Although adverse drug reactions are a well-recognized cause of mental status changes in the elderly, antimicrobials are rarely implicated. Three patients with serious organic brain disease developed paranoid psychosis after therapy with trimethoprim-sulfamethoxazole or ciprofloxacin was begun. One of the patients was accidently rechallenged and again developed a psychotic reaction. The acute psychoses did not improve with moderate doses of major tranquilizers but resolved completely with drug discontinuation.

Residents' views of the value of moonlighting

The opportunity for residents to moonlight is threatened by legal liability concerns and legislation designed to limit the duration of workdays and workweeks. We sought the opinion of all 40 second- or third-year residents and fellows in a hybrid university/community hospital internal medicine residency program regarding their motivation to moonlight and the value of their experiences. Sixty-five percent were moonlighters; moonlighters had a higher average debt ($41 644) than nonmoonlighters ($32 917). Residents viewed moonlighting as a positive educational experience that helped them with career decisions. They believed they acquired important skills and knowledge not learned elsewhere, and that moonlighting did not interfere with their job and educational responsibilities. A program in operation for 10 years that was designed to control, monitor, and facilitate moonlighting experiences is described. We believe our residents' positive views may be in part a result of the supervision and integration of moonlighting in a residency training program with a controlled workload.

Evaluation and management of vaginitis. An update for primary care practitioners

There are three major causes of vaginitis symptoms that primary care practitioners should be able to diagnose and treat expertly. Recent investigations have shown that bacterial vaginosis, the most common cause of vaginitis symptoms in patients not seen in sexually transmitted disease clinics, has a multifactorial etiology: Gardnerella vaginalis is universally present but is not, per se, the etiologic agent. Diagnosis and treatment are based, therefore, on evidence of a disturbed bacterial ecology as well as the presence of "clue" cells that indicate the presence of Gardnerella. Trichomonas vaginitis is usually easy to diagnose, but treatment failures occasionally occur. Some strains of Trichomonas vaginalis may be relatively resistant to metronidazole, and short-course therapy may lead to reinfection from sexual partners. Candida vulvovaginitis, the third major type of vaginitis, is not a sexually transmitted disease and should be viewed as vaginal "thrush." Earlier treatment regimens have been simplified by the introduction of more potent antifungals.

The residency-practice training mismatch. A primary care education dilemma

Primary care practice requires clinical skills and knowledge that differ greatly from those required for successful completion of residency training. Discrepant clinical settings and physician responsibilities have thus created a mismatch between the educational content of residency training and the content of clinical practice, which may result in suboptimal preparation of internists, family practitioners, and pediatricians for patient care. Of equal concern, the psychosocial environment of residency does not prepare physicians for their future community and personal adult roles. Barriers to correcting this worsening mismatch include the following: (1) economic pressures to use house staff to meet service needs of hospitals, (2) changes in patient demographics and the focus of hospital-based medicine that are making hospitals progressively more unsuitable as the principal training site for primary care physicians, (3) the deemphasis of practicing physicians as role models and teachers in postgraduate training, and (4) the often heated disagreement among medical educators regarding the purpose and content of residency training. Efforts to resolve this mismatch should include the following: reexamining the educational objectives of the current system of postgraduate training, better counseling of physicians in training regarding career goals, and emphasizing the primary care physician as role models and faculty.

Gram-negative bacillary bacteremia in the elderly: incidence, ecology, etiology, and mortality

The incidence, ecology, and mortality of gram-negative bacillary bacteremia in elderly patients were studied in an analysis of 334 episodes over a four-year-period in a 489-bed North Carolina community teaching hospital, 135 (40.4%) of which occurred in patients 70 years of age or older. The bacteremia rate per 1000 hospital admissions increased sharply with increasing age. The ecology and in vitro antimicrobial susceptibilities of the bacterial isolates were strongly influenced by community v hospital acquisition, but not by age. Urosepsis was significantly more likely to be the underlying source of hospital-acquired bacteremia in patients 70 years or older (P less than 0.01). Total bacteremia-related mortality did not increase with increasing age; in the group of patients aged 70 years or older with nonfatal/ultimately fatal underlying diseases (NF/UFUD), however, mortality was 9.1% compared to 2.9% in the younger age group (P less than 0.001). Significantly increased bacteremia-related mortality was also noted in the older patients with NF/UFUD admitted from nursing homes (P less than 0.05) and those not treated with an appropriate antimicrobial agent within 24 hours (P less than 0.01). Overall, the older patients with hospital-acquired bacteremia, neutropenia-associated infection, those bacteremic from a nonurinary source of infection, and those treated with multiple-drug regimens had higher mortality (P less than 0.05). Gram-negative bacteremia is much more common in patients 70 years of age or older and compared with younger patients mortality appears to be significantly increased for the important subgroup of older patients with nonfatal or ultimately fatal underlying diseases.

The effect of oral cimetidine on total and unbound serum lidocaine concentrations in patients with suspected myocardial infarction

In this study, we prospectively evaluated the effect of oral cimetidine on serum lidocaine concentrations in 6 patients with suspected myocardial infarction. Compared to baseline lidocaine levels, total lidocaine concentrations increased by 8.2 +/- 7.8% at 6 hours, 16.4 +/- 9.0% at 12 hours and 27.9 +/- 9.4% at 24 hours after two doses of oral cimetidine. Unbound lidocaine concentrations increased by 14.3 +/- 4.1% at 6 hours, and 18.3 +/- 10.3% at 24 hours after cimetidine. In patients with myocardial infarction (3), total lidocaine concentrations increased by 24.2 +/- 10.4%, whereas unbound lidocaine increased by 8.9 +/- 10.2% at 24 hours. Therefore, increases in total lidocaine concentrations after cimetidine administration were considerably less than those previously reported and empiric dosage reductions of lidocaine in patients receiving cimetidine may not be appropriate.

Urinary tract infection and dysuria. Cost-conscious evaluation and antibiotic therapy

Recent research into the pathogenesis and treatment of urinary tract infection (UTI) clearly indicates that our traditional approach has overestimated the need for extensive evaluation and prolonged antibiotic therapy. The great majority of UTIs can be managed adequately with urinalysis and single-dose or three-day antibiotic regimens; only complicated UTIs or those occurring in unusual hosts require cultures and longer courses of treatment.

P&T Committee guidelines for antibiotic cost comparisons

P & T Committees are focusing much effort and attention on controlling the costs of antibiotic therapy in their hospitals. In their efforts, committee members must understand not only the basic costs of acquisition in determining cost-effective therapy, but also the many expenses involved with dosing and administration. The author provides guidelines for assessing the various costs involved with antibiotic therapy based on his observations of hospitals' attempts to control costs. Suggestions of ways to make most effective use of the formulary and staff resources are presented.

Working with contagious patients

Infectious diseases ranging from hepatitis to tuberculosis can be transmitted or contracted by physicians, nurses, or laboratory personnel during the performance of their ordinary patient care activities. But by acquiring a basic knowledge of how infections are transmitted, complying with infection-control guidelines, taking necessary precautions for patient isolation, and receiving proper immunization, you can protect your patients, hospital staff members, and yourself from unnecessary risk.

Physicians' opinions of the accuracy, accessibility, and frequency of use of ten sources of new drug information

We surveyed internists, surgeons, and general practitioners in a six-county area of North Carolina to determine how accurate and accessible they believed ten sources of new drug information to be and how frequently they used each of the sources. Evaluable questionnaires were returned by 119 of the 336 physicians. The majority indicated that all sources were accessible. Commercial sources were thought to be less accurate than noncommercial sources, but were used more frequently (P less than .0002), especially by physicians who had practiced more than 15 years (P less than .02). Written sources were thought to be more accurate (P less than .0001) and were preferred over oral sources of new drug information (P less than .0004). Pharmacists and pharmacology textbooks were believed to be both accurate and accessible, but were relatively infrequently used.

Hospital charges for antibiotics

Hospital charges for intravenous antibiotics were obtained in a survey of 71 hospitals in 25 U.S. cities. Only 56.3% of the hospitals used their actual drug acquisition cost to calculate patient charges; the remainder used a base price derived from one of the wholesale price guides, which often seriously overstate the cost of antibiotics. Sixty-eight percent added a markup, averaging 134.5%, and 63.4% added a dispensing fee, averaging $5.47. A relatively high-dose, single-antibiotic regimen costs patients $50-$150 per day, independent of dose-preparation charges (average, $9.09 per dose) for a piggyback-type system or intravenous line-related charges. Antibiotics were least expensive in large hospitals and in those located in the northeastern United States. Charges for antibiotics are often inconsistently calculated, vary enormously among hospitals, and may be unfair to patients and confusing to physicians. Cost-conscious prescribing of antibiotics by physicians would be facilitated by a more consistent relationship between charges and true costs.

Improved mortality in gram-negative bacillary bacteremia

From 1979 to 1982, the four years of this study, episodes of gram-negative bacillary bacteremia occurred in a 489-bed community teaching hospital--an increase of 15.9%. Mortality related to bacteremia was 19.4% overall and only 3.2% for the 158 episodes involving nonfatal underlying illnesses, lower figures than those reported in the past. The severity of underlying illnesses in bacteremic patients dominated all other clinical variables that were studied as prognostic factors for the outcome of the episode. The same bacteremia-related mortality was seen in patients who had empirically received (1) multiple-antibiotic regimens in which one or more drugs were active against the pathogenic organism(s), (2) either an appropriate aminoglycoside or beta-lactam antibiotic alone, or (3) both an aminoglycoside antibiotic and a beta-lactam antibiotic active against the pathogenic organism(s).

Influence of medical and premedical education on important personal qualities of physicians

Three interrelated personal qualities of physicians are believed important for sensitive patient care and optimal individual adjustment to the stresses of medical practice: maturity, social competence, and moderation in aggressive competitive (exaggerated "type A" behavior). Despite widespread recognition of the importance of these qualities by patients and physicians alike, they have commonly been neglected in favor of scientific and scholastic excellence in the selection process for medical schools. In addition, some aspects of premedical and medical education may actually have an adverse influence on these personal qualities of future physicians. More emphasis in premedical and medical education on the importance of physicians' noncognitive abilities, and more individualized feedback to students and residents on the interactions between their personal qualities and their success and happiness as physicians, are needed.

Cefoxitin resistance in community-acquired gram-negative bacillary bacteremia. Associated clinical risk factors

Among 185 patients with nonneutropenic, community-acquired gram-negative bacillary bacteremias, clinical risk factors for cefoxitin resistance included any antibiotic taken within the last three weeks (25.6% cefoxitin resistance), long-term bladder catheterization or surgical urinary diversion (23.3%), hospitalization within the last 30 days (22.9%), and nursing home residence before admission (20.8%). Patients with none of these risk factors were less likely to have cefoxitin-resistant bacteremias (0.9%). When these risk factors were examined in the subgroups of urinary tract and non-urinary tract sources of community-acquired gram-negative bacillary bacteremia, they were also helpful in predicting sensitivity to trimethoprim-sulfamethoxazole and gentamicin. The presence of one or more of the risk factors identified may be a useful adjunct in determining initial empiric antimicrobial therapy for community-acquired gram-negative bacillary bacteremia.