Factors Associated With Prolonged Antibiotic Use in the Setting of Suspected Pneumonia and Negative Bronchoalveolar Lavage Cultures.

Diagnostic criterion for pneumonia includes clinical data and bronchoalveolar lavage cultures (BALCx) to identify pathogens. Although ~60% of BALCx are negative, there may be reluctance to discontinue antibiotics, leading to prolonged antibiotic use (PAU). The purpose of this study is to compare outcomes of subjects with negative BALCx with PAU versus without prolonged antibiotic use (nPAU).

7 Strategies for Improving Drug Utilization.

When new pharmaceutical products enter the market, the lack of real-world experience with these drugs creates quandaries for payers and providers alike. Often, all there is to go on is the minimum required for FDA approval-non-inferiority to a comparator product in terms of efficacy and safety. Here are a few promising strategies to end this ambiguity.

Enhancing insulin-use safety in hospitals: Practical recommendations from an ASHP Foundation expert consensus panel.

Purpose: Consensus recommendations to help ensure safe insulin use in hospitalized patients are presented.

Summary: Insulin products are frequently involved in medication errors in hospitals, and insulin is classified as a high-alert medication when used in inpatient settings. In an initiative to promote safer insulin use, the American Society of Health-System Pharmacists (ASHP) Research and Education Foundation convened a 21-member panel representing the fields of pharmacy, medicine, and nursing and consumer advocacy groups for a three-stage consensus-building initiative.

Use of a furosemide drip does not improve earlier primary fascial closure in the open abdomen.

Background: The furosemide drip (FD), in addition to improving volume overload respiratory failure, has been used to decrease fluid in attempts to decrease intra-abdominal and abdominal wall volumes to facilitate fascial closure. The purpose of this study is to evaluate the FD and the associated rate of primary fascial closure following trauma damage control laparotomy (DCL).

Materials And Methods: From January 2004 to September 2008, a retrospective review from a single institution Trauma Registry of the American College of Surgeons dataset was performed.

Clinically significant psychotropic drug-drug interactions in the primary care setting.

In recent years, the growing numbers of patients seeking care for a wide range of psychiatric illnesses in the primary care setting has resulted in an increase in the number of psychotropic medications prescribed. Along with the increased utilization of psychotropic medications, considerable variability is noted in the prescribing patterns of primary care providers and psychiatrists. Because psychiatric patients also suffer from a number of additional medical comorbidities, the increased utilization of psychotropic medications presents an elevated risk of clinically significant drug interactions in these patients.

Increasing blood glucose variability heralds hypoglycemia in the critically ill.

Background: Control of hyperglycemia improves outcomes, but increases the risk of hypoglycemia. Recent evidence suggests that blood glucose variability (BGV) is more closely associated with mortality than either isolated or mean BG. We hypothesized that differences in BGV over time are associated with hypoglycemia and can be utilized to estimate risk of hypoglycemia (<50 mg/dL).

Glucose metabolism, not obesity, predicts mortality in critically ill surgical patients.

Our hypothesis was to determine if insulin resistance and hyperglycemia, rather than obesity, are predictive of mortality in the surgically critically ill. An observational study of an automated protocol in surgical and trauma intensive care units was performed. Two groups were created based on body mass index (BMI): Obese (OB) defined as BMI > or = 30 (n = 338) and nonobese defined as BMI < 30 (n = 885).

Failure to achieve euglycemia despite aggressive insulin control signals abnormal physiologic response to trauma.

Purpose: We hypothesize that a failure to normalize a patient's glucose on an automated euglycemia protocol signals an adverse response after trauma and that this response can identify patients with an increased mortality.

Materials And Methods: There were 1246 ventilated, critically ill trauma patients who were placed on an automated euglycemia. All glucose values collected both by laboratory serum measurements and by bedside arterial samples were included in the analysis.

Infection reduction strategies including antibiotic stewardship protocols in surgical and trauma intensive care units are associated with reduced resistant gram-negative healthcare-associated infections.

Background: Resistance to broad-spectrum antibiotics by gram-negative organisms is increasing. Resistance demands more resource utilization and is associated with patient morbidity and death. We describe the implementation of infection reduction protocols, including antibiotic stewardship, and assess their impact on multi-drug-resistant (MDR) healthcare-acquired gram-negative infections.

Severe hypoglycemia while on intensive insulin therapy is not an independent predictor of death after trauma.

Background: Fear of the adverse effects of hypoglycemia has limited the widespread application of intensive insulin therapy (goal, 80-110 mg/dL) in the trauma population. We hypothesized that severe hypoglycemia (SH;
Methods: An analysis of critically ill trauma patients treated with intensive insulin therapy from November 2005 to May 2008 was performed.

Insulin resistance heralds positive cultures after severe injury.

Background: Insulin resistance and hyperglycemia are common in acutely injured patients, and associated with poor outcomes. In the era of tight glucose control, measures of insulin responsiveness (IR) may provide a better indicator of patient status than does the serum glucose concentration. We hypothesized that measures of IR during tight glycemic control protocols are associated with infection and may be more predictive than the serum glucose concentration.

Risk factors for treatment failure in patients receiving vancomycin for hospital-acquired methicillin-resistant Staphylococcus aureus pneumonia.

Background: The rate of vancomycin failure in patients with hospital-acquired pneumonia (HAP) caused by methicillin-resistant Staphylococcus aureus (MRSA) has exceeded 40% in several studies. This observation was attributed initially to the lack of weight-based dosing and targeting of lower trough concentrations. However, a subsequent study demonstrated no additional benefit in patients who achieved trough vancomycin concentrations >15 mg/L compared with patients with concentrations between 5 and 15 mg/L.

Insulin resistance despite tight glucose control is associated with mortality in critically ill surgical patients.

Background: The hyperglycemic state following trauma and surgery is related partially to insulin resistance (IR). The objective is to determine if critically ill surgical patients vary in their extent of IR and is IR associated with mortality.

Methods: Prospective observational study in trauma and surgical intensive care units.

Stress insulin resistance is a marker for mortality in traumatic brain injury.

Background: Both hyper- and hypoglycemia have been associated with poor outcome in traumatic brain injury (TBI). Neither the risks nor benefit of tight glucose control (goal range, 80-110 mg/dL) have been documented in the TBI population.

Objective: To analyze whether densely collected blood glucose data, using a computerized algorithm, to maintain tight glycemic control will reveal significant differences in blood glucose control between survivors and nonsurvivors in patients with TBI.

Intensive insulin therapy in practice: can we do it?

Background: Intensive insulin therapy (IIT) is the standard of care in the ICU, but precise implementation of insulin protocols has been difficult in clinical practice. The authors' objective was to quantify adherence to an IIT protocol in a practice setting, and to describe how adherence impacts overall blood glucose (BG) control.

Methods: A retrospective analysis of a cohort of critically ill patients treated with IIT was performed.

Blood glucose variability is associated with mortality in the surgical intensive care unit.

Intensive insulin therapy has widely and rapidly been adopted as the standard of care for the treatment of hyperglycemia in the intensive care unit (ICU). Variability in blood glucose is increasingly recognized as an important factor in outcomes in the chronic diabetic in addition to hemoglobin A1C. We tested the hypothesis that measures of blood glucose variability would be associated with mortality in the surgical ICU.

A computerized insulin infusion titration protocol improves glucose control with less hypoglycemia compared to a manual titration protocol in a trauma intensive care unit.

Background: Previous studies reflect reduced morbidity and mortality with intensive blood glucose control in critically ill patients. Unfortunately, implementation of such protocols has proved challenging. This study evaluated the degree of glucose control using manual paper-based vs computer-based insulin protocols in a trauma intensive care unit.

Migraine headache misconceptions: barriers to effective care.

Migraine headaches affect 12% of the adult population in the United States and cause a significant economic loss due to decreased workplace productivity Although interactions between pharmacists and individuals with headache are common, few pharmacists receive adequate training regarding migraine therapy. We refute several misconceptions that hinder effective care, such as that migraine is a vascular disease, triptans cause rampant cardiacrelated morbidity and even mortality, a best oral triptan exists, sinus and tension headaches are prevalent, and migraine is a minor economic problem. Our pathophysiologic understanding demonstrates that migraine is a neurologic process of the trigeminovascular system, of which vascular effects are secondary.