The American journal of medicine
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Multicenter Study
Variation in length of hospital stay in patients with community-acquired pneumonia: are shorter stays associated with worse medical outcomes?
To assess the variation in length of stay for patients hospitalized with community-acquired pneumonia and to determine whether patients who are treated in hospitals with shorter mean stays have worse medical outcomes. ⋯ We observed substantial interhospital variation in the lengths of stay for patients hospitalized with community-acquired pneumonia. The finding that medical outcomes were similar in patients admitted to the hospital with the shortest length of stay and those admitted to hospitals with longer mean lengths of stay suggests that hospitals with longer stays may be able to reduce the mean duration of hospitalization for this disease without adversely affecting patient outcomes.
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This review provides a practical, simple, and logical approach to the diagnosis and management of patients with acute infectious diarrhea, one of the most common diagnoses in clinical practice. Diarrhea in the immunocompromised host, traveler's diarrhea, and diarrhea in the hospitalized patient are also discussed. Most episodes of acute diarrhea are self-limited, and investigations should be performed only if the results will influence management and outcome. ⋯ The most useful agents are opiate derivatives and bismuth subsalicylate. Antibiotic therapy is not required in most patients with acute diarrheal disorders. Guidelines for their use are presented.
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Acute uncomplicated urinary tract infection is a common and costly disorder in women. To reduce potentially unnecessary expense and inconvenience, a large staff-model health maintenance organization instituted a telephone-based clinical practice guideline for managing presumed cystitis in which women 18 to 55 years of age who met specific criteria were managed without a clinic visit or laboratory testing. We sought to evaluate the effects of the guideline. ⋯ Guideline use decreased laboratory utilization and overall costs while maintaining or improving the quality of care for patients who were presumptively treated for acute uncomplicated cystitis.
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Although the prevalence of nephrotoxicity in patients treated with nonsteroidal anti-inflammatory drugs (NSAIDs) is relatively low, the extensive use profile of these agents implies that many persons are at risk. At basal states of normal renal function, the role of renal prostaglandin production for maintenance of stable renal hemodynamic function is relatively limited. Nonetheless, in the clinical setting of reduced renal perfusion as seen in various forms of cardio-renal disease, dehydration, and the aging kidney, the adequacy of renal prostaglandin production mediated predominantly by cyclooxygenase-1 (COX-1) and, potentially, by COX-2 enzyme activity becomes of major significance in the activation of compensatory renal hemodynamics. ⋯ This is a matter of considerable public health concern, in that some 12 million US citizens are concurrently treated with NSAIDs and antihypertensive drugs. Finally, the risk of congestive heart failure is significantly increased when NSAIDs are given to patients receiving diuretic therapy who have cardiovascular risk factors. Physiologic factors, clinical presentations, diagnostic modalities, and clinical management strategies appropriate to these NSAID-induced renal syndromes are described.
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Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of nosocomial infections. Healthcare professionals in the United States should develop programs to prevent transmission of this organism within their institutions. Aggressive control efforts are justified for several reasons: (1) the incidence of nosocomial MRSA reflects the general effectiveness of infection control practice; (2) MRSA do not replace susceptible strains but instead increase the overall rate of nosocomial S. aureus infections; (3) MRSA infections cause substantial morbidity and mortality; (4) serious MRSA infections must be treated with vancomycin. ⋯ Staff should choose a control method based on the prevalence of MRSA in their institution and in their referring facilities, the rate of nosocomial transmission of MRSA in their hospital, the risk factors present in their patient population, the reservoirs and modes of transmission specific to their hospital, and their resources. Any MRSA control plan must stress adherence to basic infection control measures, such as hand washing and contact isolation precautions. In addition, decolonization of patients and staff, control of antimicrobial use, surveillance cultures, and molecular typing may be helpful adjuncts.