Background Invasive pneumococcal disease declined among children and adults after the introduction of the pediatric heptavalent pneumococcal conjugate vaccine (PCV7) in 2000, but its effect on pneumococcal meningitis is unclear. Methods We examined trends in pneumococcal meningitis from 1998 through 2005 using active, population-based surveillance data from eight sites in the United States. Isolates were grouped into PCV7 serotypes (4, 6B, 9V, 14, 18C, 19F, and 23F), PCV7-related serotypes (6A, 9A, 9L, 9N, 18A, 18B, 18F, 19B, 19C, 23A, and 23B), and non-PCV7 serotypes (all others). Changes in the incidence of pneumococcal meningitis were assessed against baseline values from 1998–1999. Results We identified 1379 cases of pneumococcal meningitis. The incidence declined from 1.13 cases to 0.79 case per 100,000 persons between 1998–1999 and 2004–2005 (a 30.1% decline, P<0.001). Among persons younger than 2 years of age and those 65 years of age or older, the incidence decreased during the study period by 64.0% and 54.0%, respectively (P<0.001 for both groups). Rates of PCV7-serotype meningitis declined from 0.66 case to 0.18 case (a 73.3% decline, P<0.001) among patients of all ages. Although rates of PCV7-related–serotype disease decreased by 32.1% (P = 0.08), rates of non-PCV7–serotype disease increased from 0.32 to 0.51 (an increase of 60.5%, P<0.001). The percentages of cases from non-PCV7 serotypes 19A, 22F, and 35B each increased significantly during the study period. On average, 27.8% of isolates were nonsusceptible to penicillin, but fewer isolates were nonsusceptible to chloramphenicol (5.7%), meropenem (16.6%), and cefotaxime (11.8%). The proportion of penicillin-nonsusceptible isolates decreased between 1998 and 2003 (from 32.0% to 19.4%, P = 0.01) but increased between 2003 and 2005 (from 19.4% to 30.1%, P = 0.03). Conclusions Rates of pneumococcal meningitis have decreased among children and adults since PCV7 was introduced. Although the overall effect of the vaccine remains substantial, a recent increase in meningitis caused by non-PCV7 serotypes, including strains nonsusceptible to antibiotics, is a concern.
A strategy of trimethoprim-sulfamethoxazole prophylaxis and antiretroviral therapy, with the use of clinical criteria alone or in combination with CD4 testing to guide the timing of treatment, is an economically attractive health investment in settings with limited resources.
We provide a tutorial on the construction and evaluation of Markov decision processes (MDPs), which are powerful analytical tools used for sequential decision making under uncertainty that have been widely used in many industrial and manufacturing applications but are underutilized in medical decision making (MDM). We demonstrate the use of an MDP to solve a sequential clinical treatment problem under uncertainty. Markov decision processes generalize standard Markov models in that a decision process is embedded in the model and multiple decisions are made over time. Furthermore, they have significant advantages over standard decision analysis. We compare MDPs to standard Markov-based simulation models by solving the problem of the optimal timing of living-donor liver transplantation using both methods. Both models result in the same optimal transplantation policy and the same total life expectancies for the same patient and living donor. The computation time for solving the MDP model is significantly smaller than that for solving the Markov model. We briefly describe the growing literature of MDPs applied to medical decisions.
Introduction: The medical community recognizes the importance of confronting structural racism and implicit bias to address health inequities. Several curricula aimed at teaching trainees about these issues are described in the literature. However, few curricula exist that engage faculty members as learners rather than teachers of these topics or target interdisciplinary audiences. Methods: We developed a longitudinal case conference curriculum called Health Equity Rounds (HER) to discuss and address the impact of structural racism and implicit bias on patient care. The curriculum engaged participants across training levels and disciplines on these topics utilizing case-based discussion, evidence-based exercises, and two relevant conceptual frameworks. It was delivered quarterly as part of a departmental case conference series. We evaluated HER's feasibility and acceptability by tracking conference attendance and administering postconference surveys. We analyzed quantitative survey data using descriptive statistics and qualitatively reviewed free-text comments. Results: We delivered seven 1-hour HER conferences at our institution from June 2016 to June 2018. A mean of 66 participants attended each HER. Most survey respondents (88% or more) indicated that HER promoted personal reflection on implicit bias, and 75% or more indicated that HER would impact their clinical practice. Discussion: HER provided a unique forum for practitioners across training levels to address structural racism and implicit bias. Our aim in dissemination is to provide meaningful tools for others to adapt at their own institutions, recognizing that HER should serve as a component of larger, multifaceted efforts to decrease structural racism and implicit bias in health care.
Objective-To determine the feasibility of high-fidelity simulation for studying variation in ICU admission decision making for critically ill elders with end-stage cancer.Design-Mixed qualitative and quantitative analysis of physician subjects participating in a simulation scenario using a hospital set, actors, medical chart, and vital signs tracings. The simulation depicted a 78 year-old man with metastatic gastric cancer, life-threatening hypoxia most likely attributable to cancer progression, and stable preferences to avoid ICU admission and intubation. Two independent raters assesed the simulations and subjects completed a post-simulation web-based survey and debriefing interview. Setting-Peter M. Winter Institute for Simulation Education and Research at the University of Pittsburgh.Subjects-27 hospital-based attending physicians, including 6 emergency physicians, 13 hospitalists, and 8 intensivists.Measurements and Main Results-Outcomes included qualitative report of clinical verisimilitude during the debriefing interview, survey-reported diagnosis and prognosis, and observed treatment decisions. Independent variables included physician demographics, risk attitude, and reactions to uncertainty. All (100%) reported that the case and simulation were highly realistic, and their diagnostic and prognostic assessments were consistent with our intent. Eight (29.6%) physicians admitted the patient to the ICU. Among the 8 physicians who admitted the patient to the ICU, 3 (37%) initiated palliation, 2 (25%) documented the patient's code status (DNI/DNR), and 1Address for correspondence (reprints will not be ordered): Amber E. Barnato, MD, MPH, MS, 200 Meyran, Suite 200, Pittsburgh, PA 15221, Phone: 412-692-4875, Fax: 412-246-6954, aeb2@pitt.edu. NIH Public Access Author ManuscriptCrit Care Med. Author manuscript; available in PMC 2010 April 12. Published in final edited form as:Crit Care Med. The purpose of the current study was to assess whether simulation is a feasible way of studying variation in ICU admission decision making for a critically and terminally ill patient. Simulation offers several strengths over naturalistic observation of "real-world" decision making, including efficiency and automated data capture; avoiding patient privacy violations and complexities of consent during critical illness; and standardizing the clinical and psychosocial aspects of a case in order to isolate physician-specific determinants. The use of standardized patients and clinical simulation for education and evaluation are well-established methods for the assessment of simple communication tasks, like taking a history or breaking bad news, and time-pressured technical skills, such as running a code or intubating a difficult airway [19,20]. However, simulation has not previously been used to study the time-pressured communication and decision scenario of ICU triage for a critically and terminally ill patient.To simulate this context, we augmented simulation technology with trained actors. This study reports qualitative as...
IMPORTANCE In the US, federal value-based incentive programs are more likely to penalize safety-net institutions than non-safety-net institutions. Whether these programs differentially change the rates of targeted health care-associated infections in safety-net vs non-safety-net hospitals is unknown. OBJECTIVE To assess the association of Hospital-Acquired Condition Reduction Program (HACRP) and Hospital Value-Based Purchasing (HVBP) implementation with changes in rates of targeted health care-associated infections and disparities in rates among safety-net and non-safety-net hospitals. DESIGN, SETTING, AND PARTICIPANTS This interrupted time series included all US acute care hospitals enrolled in the Preventing Avoidable Infectious Complications by Adjusting Payment study that participated in mandatory reporting to the
These results suggest that ART must be accompanied by effective HIV-related risk reduction interventions. Programs that target prevention to decrease further HIV transmission are crucial to epidemic control.
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