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OBJECTIVE: To determine whether caloric intake is associated with risk of nosocomial bloodstream infection in critically ill medical patients. DESIGN: Prospective cohort study. SETTING: Urban, academic medical intensive care unit. PATIENTS: Patients were 138 adult patients who did not take food by mouth for > or =96 hrs after medical intensive care unit admission. MEASUREMENTS: Daily caloric intake was recorded for each patient. Participants subsequently were grouped into one of four categories of caloric intake: <25%, 25-49%, 50-74%, and > or =75% of average daily recommended calories based on the American College of Chest Physicians guidelines. Simplified Acute Physiology Score II and serum albumin were measured on medical intensive care unit admission. Serum glucose (average value and maximum value each day) and route of feeding (enteral, parenteral, or both) were collected daily. Nosocomial bloodstream infections were identified by infection control surveillance methods. MAIN RESULTS: The overall mean (+/-sd) daily caloric intake for all study participants was 49.4 +/- 29.3% of American College of Chest Physicians guidelines. Nosocomial bloodstream infection occurred in 31 (22.4%) participants. Bivariate Cox analysis revealed that receiving > or =25% of recommended calories compared with <25% was associated with significantly lower risk of bloodstream infection (relative hazard, 0.24; 95% confidence interval, 0.10-0.60). Simplified Acute Physiology Score II also was associated with risk of nosocomial bloodstream infection (relative hazard, 1.27; 95% confidence interval, 1.01-1.60). Average daily serum glucose, admission serum albumin, time to initiating nutritional support, and route of nutrition did not affect risk of bloodstream infection. After adjustment for Simplified Acute Physiology Score II in a multivariable analysis, receiving > or =25% of recommended calories was associated with a significantly lower risk of bloodstream infection (relative hazard, 0.27; 95% confidence interval, 0.11-0.68). CONCLUSIONS: In the context of reducing risk of nosocomial bloodstream infections, failing to provide > or =25% of the recommended calories may be harmful. Higher caloric goals may be necessary to achieve other clinically important outcomes. [ABSTRACT FROM AUTHOR]

Study Objectives: To determine whether distraction therapy with nature sights and sounds during flexible bronchoscopy (FB) reduces pain and anxiety.Design: Randomized controlled trial.Setting: Teaching hospital in Baltimore, MD.Patients: Consecutive adult patients (n = 80) undergoing FB with conscious sedation.Intervention: Nature scene murals were placed at the bedside, and patients were provided a tape of nature sounds to listen to before, during, and after the procedure. Patients assigned to the control group were not offered either the nature scene or the sounds.Measurements and Results: The primary outcomes were patient ratings of pain control (a 5-point scale ranging from poor to excellent) and anxiety. In a multivariate ordinal logistic regression model, the odds of better pain control were greater in the intervention patients than in the control patients (odds ratio [OR], 4.76; 95% confidence interval [CI], 1.35 to 16.7), after adjustment for age, gender, race, education, health status, and dose of narcotic medication. Older patients and patients with better health status reported significantly less pain. There was no difference in patient-reported anxiety between the two groups (OR, 0.87; 95% CI, 0.39 to 1.96).Conclusions: Distraction therapy with nature sights and sounds significantly reduces pain in patients undergoing FB. Although the precise mechanism of this beneficial effect requires further investigation, clinicians should consider this nonintrusive strategy in addition to standard analgesic medications in patients undergoing painful, invasive procedures. [ABSTRACT FROM AUTHOR]

Background: Although outdoor particulate matter (PM) has been linked to mortality and asthma morbidity, the impact of indoor PM on asthma has not been well established. Objective: This study was designed to investigate the effect of in-home PM on asthma morbidity. Methods: For a cohort of 150 asthmatic children (2-6 years of age) from Baltimore, Maryland, a technician deployed environmental monitoring equipment in the children's bedrooms for 3-day intervals at baseline and at 3 and 6 months. Caregivers completed questionnaires and daily diaries during air sampling. Longitudinal data analyses included regression models with generalized estimating equations. Results: Children were primarily African Americans (91%) from lower socioeconomic backgrounds and spent most of their time in the home. Mean (± SD) indoor PM2.5-10 (PM with aerodynamic diameter 2.5-10 µm) and PM2.5 (aerodynamic diameter < 2.5 µm) concentrations were 17.4 ± 21.0 and 40.3 ± 35.4 µg/m3. In adjusted models, 10-µg/m3 increases in indoor PM2.5-10 and PM2.5 were associated with increased incidences of asthma symptoms: 6% [95% confidence interval (CI) , 1 to 12%] and 3% (95% CI, -1 to 7%) , respectively ; symptoms causing children to slow down: 8% (95% CI, 2 to 14%) and 4% (95% CI, 0 to 9%) , respectively ; nocturnal symptoms: 8% (95% CI, 1 to 14%) and 6% (95% CI, 1 to 10%) , respectively ; wheezing that limited speech: 11% (95% CI, 3 to 19%) and 7% (95% CI, 0 to 14%) , respectively ; and use of rescue medication: 6% (95% CI, 1 to 10%) and 4% (95% CI, 1 to 8%) , respectively. Increases of 10 µg/m3 in indoor and ambient PM2.5 were associated with 7% (95% CI, 2 to 11%) and 26% (95% CI, 1 to 52%) increases in exercise-related symptoms, respectively. Conclusions: Among preschool asthmatic children in Baltimore, increases in in-home PM2.5-10 and PM2.5 were associated with respiratory symptoms and rescue medication use. Increases in in-home and ambient PM2.5 were associated with exercise-related symptoms. Although reducing PM outdoors may decrease asthma morbidity, reducing PM indoors, especially in homes of inner-city children, may lead to improved asthma health. [ABSTRACT FROM AUTHOR]

BACKGROUND: COPD is a significant cause of morbidity and mortality. Guidelines recommend the confirmation of a COPD diagnosis with spirometry. Limited evidence exists, however, documenting the frequency of spirometry use in clinical practice. METHODS: The National Committee for Quality Assurance recruited five health plans to determine the proportion of patients >/= 40 years old with a new diagnosis of COPD who had received spirometry during the interval starting 720 days prior to diagnosis and ending 180 days after diagnosis. Patients were identified via International Classification of Diseases, Ninth Revision diagnostic codes for encounters during the period July 1, 2002, through June 30, 2003. For each patient, the participating plans provided patient demographic and claims data from administrative data systems. RESULTS: Participating health plans covered 1,597,749 members with a total of 5,039 eligible COPD patients identified. Patients in the 40 to 64 age range had the highest percentage of new COPD diagnoses. Women were also slightly more likely to undergo spirometry (33.5% vs 29.4%, p = 0.001). Approximately 32% of patients with a new diagnosis of COPD had undergone spirometry in the specified interval. Spirometry frequency was lowest in older patients, with the lowest frequency in those >/= 75 years old. CONCLUSIONS: Our study suggests that approximately 32% of a broad range of patients with a new COPD diagnosis had undergone spirometry within the previous 2 years to 6 months following diagnosis. In addition, spirometric testing appeared to decrease with increasing age. As opposed to a prior report, women were not less likely to have undergone spirometry. This study shows that spirometry is infrequently used in clinical practice for diagnosis of COPD and suggests opportunities for practice improvement. [ABSTRACT FROM AUTHOR]

Objectives. To develop a propensity score-based risk adjustment method to estimate the performance of 20 physician groups and to compare performance rankings using our method to a standard hierarchical regression-based risk adjustment method.Data Sources/Study Setting. Mailed survey of patients from 20 California physician groups between July 1998 and February 1999.Study Design. A cross-sectional analysis of physician group performance using patient satisfaction with asthma care. We compared the performance of the 20 physician groups using a novel propensity score-based risk adjustment method. More specifically, by using a multinomial logistic regression model we estimated for each patient the propensity scores, or probabilities, of having been treated by each of the 20 physician groups. To adjust for different distributions of characteristics across groups, patients cared for by a given group were first stratified into five strata based on their propensity of being in that group. Then, strata-specific performance was combined across the five strata. We compared our propensity score method to hierarchical model-based risk adjustment without using propensity scores. The impact of different risk-adjustment methods on performance was measured in terms of percentage changes in absolute and quintile ranking (AR, QR), and weighted of agreement on QR.Results. The propensity score-based risk adjustment method balanced the distributions of all covariates among the 20 physician groups, providing evidence for validity. The propensity score-based method and the hierarchical model-based method without propensity scores provided substantially different rankings (75 percent of groups differed in AR, 50 percent differed in QR, weighted =0.69).Conclusions. We developed and tested a propensity score method for profiling multiple physician groups. We found that our method could balance the distributions of covariates across groups and yielded substantially different profiles compared with conventional methods. Propensity score-based risk adjustment should be considered in studies examining quality comparisons. [ABSTRACT FROM AUTHOR]

STUDY OBJECTIVES: Despite curative therapy, mortality remains high for hospitalized patients with tuberculosis (TB) in the United States. The purpose of this study was to describe the characteristics of hospitalized patients with TB and to identify patient characteristics associated with in-hospital mortality. DESIGN, SETTING, AND PATIENTS: Using the 2000 Nationwide Inpatient Sample, representing 20% of US hospital admissions, we identified 2,279 hospital admissions with a primary diagnosis of TB (International Classification of Diseases, ninth revision, codes, 010.xx to 018.xx). MEASUREMENTS AND RESULTS: Mortality was the main outcome measure. Logistic regression analyses were performed including age, gender, race, insurance status, income, Deyo-adapted Charlson comorbidity index (DCI), HIV status, hospital admission source, and hospital characteristics as explanatory variables. A disproportionate number of patients hospitalized with TB were men (64%), nonwhite (72%), lived in areas with median incomes of < $35,000 (50%), and had publicly funded health insurance (49%) or no health insurance (17%). The mortality rate for patients hospitalized for TB was greater than that for non-TB hospital admissions (4.9% vs 2.4%, respectively; p < 0.001). Patients with TB who died during hospitalization were older (mean age, 65.1 vs 49.4 years, respectively; p < 0.001), had greater comorbid illness (DCI, 1.1 vs 0.55, respectively; p < 0.001), required longer hospitalizations (19.9 vs 13.9 days, respectively; p < 0.001), and accumulated substantially higher charges ($79,585 vs $31,610, respectively; p < 0.001) than did patients with TB who were alive at hospital discharge. In a multivariable analysis, older age, comorbid illnesses, and emergency department admissions were independently associated with mortality. The total charges for TB hospitalizations in the United States in 2000 exceeded $385 million. CONCLUSIONS: Despite public health efforts, patients who are hospitalized with TB are frequently admitted through emergency care settings, have a high risk of in-hospital mortality, and incur substantial hospital charges. To improve TB health outcomes, more vigorous clinical management and prevention strategies should especially target older patients and those with comorbid medical conditions. [ABSTRACT FROM AUTHOR]

Study Objectives: To assess the consistency of caloric intake with American College of Chest Physicians (ACCP) recommendations for critically ill patients and to evaluate the relationship of caloric intake with clinical outcomes.Design: Prospective cohort study.Setting: Adult ICUs at two teaching hospitals.Participants: Patients with an ICU length of stay of at least 96 h.Measurements and Results: On ICU admission, severity of illness (ie, simplified acute physiology score II) and markers of nutritional status (ie, serum albumin level and body mass index) were recorded. The route of feeding (ie, enteral or parenteral), actual caloric intake (ie, percentage of ACCP recommendations: 0 to 32% [tertile I]; 33 to 65% [tertile II]; >/==" BORDER="0"> 66% [tertile III]), and evidence of GI intolerance (ie, gastric aspirate levels, >/==" BORDER="0"> 100 mL) were recorded daily. The following outcomes were assessed: status on hospital discharge (alive vs dead); spontaneous ventilation before ICU discharge (yes vs no); and ICU discharge without developing nosocomial sepsis (yes vs no). The average caloric intake among 187 participants was 50.6% of the ACCP targets and was similar in both hospitals. Caloric intake was inversely related to the mean number of gastric aspirates >/==" BORDER="0"> 100 mL/d (Spearman rho = -0.04; p = 0.06), but not to severity of illness, nutritional status, or route of feeding. After accounting for the number of gastric aspirates >/==" BORDER="0"> 100 mL, severity of illness, nutritional status, and route of feeding, tertile II of caloric intake (vs tertile I) was associated with a significantly greater likelihood of achieving spontaneous ventilation prior to ICU discharge. Tertile III of caloric intake (vs tertile I) was associated with a significantly lower likelihood of both hospital discharge alive and spontaneous ventilation prior to ICU discharge.Conclusions: Study participants were underfed relative to ACCP targets. These targets, however, may overestimate needs, since moderate caloric intake (ie, 33 to 65% of ACCP targets; approximately 9 to 18 kcal/kg per day) was associated with better outcomes than higher levels of caloric intake. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Factors predictive of future asthma must be identified among young inner-city children, who suffer disproportionately from asthma. We investigated whether current asthma control predicts future asthma-related health care use among inner-city preschool-aged children with asthma. METHODS: A total of 150 inner-city preschool-aged children with asthma were followed prospectively for 6 months. At baseline, symptom frequency and reliever-medication use were assessed to classify children into National Asthma Education and Prevention Program-derived control categories. Long-term controller-medication use was also assessed, as well as asthma-related health care use at baseline and at 3 and 6 months. RESULTS: The mean age was 4.4 years, 92% were black, and 39% reported long-term controller use. At baseline, 37% were classified as having mild-intermittent, 17% had mild-persistent, 21% had moderate-persistent, and 25% had severe-persistent asthma control. Significant changes in asthma control were observed over time, including 46% of children originally categorized with mild-intermittent asthma who had worsened asthma control by 3 months. Asthma control significantly predicted future health care use 3 months later but not 6 months later. Multivariate analyses showed that, once control status was known, reported use of long-term controller medication added little additional predictive value. CONCLUSIONS: Among inner-city preschool-aged children, significant fluctuations in asthma control occur as early as 3 months after assessment. Poor control but not long-term controller-medication use is an independent predictor of future asthma-related health care use at 3 months but is not significantly predictive of 6-month outcomes. Therefore, clinicians caring for inner-city children with asthma should consider reassessing asthma control at least every 3 months to identify those at highest future risk and to provide early interventions. [ABSTRACT FROM AUTHOR]