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(See the commentary by Van Schooneveld and Rupp, on pages1100–1102.)
Although prior authorization and prospective audit with feedback are both effective antimicrobial stewardship program (ASP) strategies, the relative impact of these approaches remains unclear. We compared these core ASP strategies at an academic medical center.
We compared antimicrobial use during the 24 months before and after implementation of an ASP strategy change. The ASP used prior authorization alone during the preintervention period, June 2007 through May 2009. In June 2009, many antimicrobials were unrestricted and prospective audit was implemented for cefepime, piperacillin/tazobactam, and vancomycin, marking the start of the postintervention period, July 2009 through June 2011. All adult inpatients who received more than or equal to 1 dose of an antimicrobial were included. The primary end point was antimicrobial consumption in days of therapy per 1,000 patient-days (DOT/1,000-PD). Secondary end points included length of stay (LOS).
In total, 55,336 patients were included (29,660 preintervention and 25,676 postintervention). During the preintervention period, both total systemic antimicrobial use (−9.75 DOT/1,000-PD per month) and broad-spectrum anti-gram-negative antimicrobial use (−4.00 DOT/1,000-PD) declined. After the introduction of prospective audit with feedback, however, both total antimicrobial use (+9.65 DOT/1,000-PD per month; P < .001) and broad-spectrum anti-gram-negative antimicrobial use (+4.80 DOT/1,000-PD per month; P < .001) increased significantly. Use of cefepime and piperacillin/tazobactam both significantly increased after the intervention (P = .03). Hospital LOS and LOS after first antimicrobial dose also significantly increased after the intervention (P = .016 and .004, respectively).
Significant increases in antimicrobial consumption and LOS were observed after the change in ASP strategy.
Infect Control Hosp Epidemiol 2014;35(9):1092-1099
Vascular anomalies consist of a diverse group of blood vessel disorders that typically present in childhood. Historically, the field is clouded by a confusing web of outdated and inappropriate terms that cross-medical disciplines and permeate the literature. For example, a venous malformation is often improperly referred to as a “cavernous hemangioma,” and “cystic hygroma” or “lymphangioma” is used to describe a lymphatic malformation. The suffix “oma”, when applied to malformations, incorrectly implies a disorder of endothelial proliferation and may overwhelm patients with fears of malignancy. Furthermore, clinicians might be tempted to “treat” these lesions with potent anti-angiogenic medications such as systemic steroids or interferon. Since these venous and lymphatic malformations are congenital, they will not respond to anti-angiogenic therapy. Patients are then placed at unnecessary risk of significant complications and side effects from these potent medications.
This confusion among patients and physicians led the International Society for the Study of Vascular Anomalies to adopt a general, biologic classification scheme (Table 63.1) for vascular anomalies based on physical findings, natural history, and cellular kinetics. In this system, vascular anomalies are described as either malformations or tumors. Vascular tumors exhibit abnormal endothelial cell proliferation while malformations are products of abnormal embryonic vessel development. This schema presents a useful framework for discussing the diagnosis and treatment of vascular anomalies. Although this standard system of nomenclature and classification exists, it is not consistently applied by physicians even in centers with an established vascular anomalies program.
While iron deficiency is regarded as the major cause of nutritional anaemia, changes in vitamins A, B12, C and E, folic acid and riboflavin status have also been linked to its development and control. This paper provides a systematic review of vitamin supplementation trials relating to the control of nutritional anaemia.
A MEDLINE search was used to find reports of vitamin supplementation trials that reported changes in anaemia or iron status.
Vitamin A can improve haematological indicators and enhance the efficacy of iron supplementation. Both folate and vitamin B12 can cure and prevent megaloblastic anaemia. Riboflavin enhances the haematological response to iron, and its deficiency may account for a significant proportion of anaemia in many populations. Vitamin C enhances the absorption of dietary iron, although population-based data showing its efficacy in reducing anaemia or iron deficiency are lacking. Vitamin E supplementation given to preterm infants has not reduced the severity of the anaemia of prematurity. Vitamin B6 effectively treats sideroblastic anaemia. Multivitamin supplementation may raise haemoglobin (Hb) concentration, but few studies have isolated the effect of multivitamins from iron on haematological status.
In general, the public health impact of vitamin supplementation in controlling anaemia is not clear. Neither are the complex interactions involving multiple vitamins in haematopoiesis sufficiently understood to explain the observed variability in haematological responses to vitamins by age, population, vitamin mixture and dosages. Further research is needed to understand the roles of individual and combined vitamin deficiencies on anaemia to design appropriate micronutrient interventions to prevent anaemia.
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