Blood samples drawn for culture as a surrogate marker for case-mix adjustment of hospital antibiotic use

Résumé de l'étude La surveillance de la prescription des antibiotiques en milieu hospitalier est une des mesures recommandées pour prévenir l'émergence de bactéries résistantes. La consommation d'antibiotiques est généralement exprimée en termes de DDD (defined daily dose) rapporté au taux d'occupation (jours patients). Cette mesure ne tient cependant pas compte de la variation de la casuistique d'un service au cours du temps. La consommation d'antibiotiques est influencée par l'incidence des infections, qui peut être saisonnière ou varier selon les circonstances épidémiologiques, ainsi que par les habitudes des médecins en termes de prescription. Une échelle de mesure adaptée à ces paramètres est donc capitale pour rendre compte de la consommation d'antibiotiques au sein d'un service et identifier de possibles dérivations dans les habitudes de prescriptions. Nous avons émis l'hypothèse que le nombre de demandes d'hémocultures pouvait servir d'indicateur de la charge infectieuse d'un service. Une analyse préliminaire a permis d'établir une bonne relation entre ce paramètre et l'incidence d'événements infectieux en comparaison à d'autres paramètres testés (nombre de prélèvements microbiologiques provenant de sites stériles ou nombre total de prélèvements microbiologiques). Sur la base de cette hypothèse, nous avons analysé la consommation d'antibiotiques d'une unité de médecine générale (Service de Médecine Interne du CHUV) sur seize trimestres consécutifs en comparant deux échelles de mesures : la méthode standard en DDD par jours patients et une échelle ajustée à la charge infectieuse (DDD par nombre de demandes d'hémocultures). L'échelle ajustée aux hémocultures a permis d'identifier trois trimestres avec une consommation anormalement élevée qui n'avaient pas été classés comme tels par l'échelle standard (consommation dans les normes en DDD par jours patients). Une analyse détaillée d'un de ces trimestres a confirmé une incidence d'infections moins élevée en comparaison à un trimestre de référence (proche de la norme selon les deux échelles), alors que la corrélation entre infections et demandes d'hémocultures était similaire pour les deux périodes. De même, l'échelle ajustée ä la charge infectieuse a démontré une consommation dans la norme pour un trimestre avec une consommation en apparence trop élevée selon l'échelle standard en raison d'une incidence d'infections plus élevée pour cette période. Cette étude a donc permis une identification plus performante et plus précise de périodes avec des dérivations dans la pratique de la prescription des antibiotiques en utilisant une échelle de mesure ajustée à la charge infectieuse d'un service au cours du temps. Nous avons démontré que le nombre d'hémocultures prélevées était un indicateur stable de la charge infectieuse dans un service de médecine générale. Ceci ne permet cependant pas de généraliser l'usage de cet indicateur pour tous les types de service. La pratique des hémocultures peut, en effet, varier d'une unité à l'autre, ou entres différentes institutions. ll convient donc de tester la validité de ce paramètre dans un service avant de l'appliquer.

Policy for Accommodating and Adjustment of Utilities on the Primary Road System, 2012

This chapter covers initial placement, adjustment, and maintenance of utility facilities in, on, above or below the right-of-way of primary highways, including attachments to primary highway structures. It embodies the basic specifications and standards needed to ensure the safety of the highway user and the integrity of the highway. (2012 revision to 2005 policy.)

Policy for Accommodating and Adjustment of Utilities on the Primary Road System, 2005

This chapter covers initial placement, adjustment, and maintenance of utility facilities in, on, above or below the right-of-way of primary highways, including attachments to primary highway structures. It embodies the basic specifications and standards needed, to ensure the safety of the highway user and the integrity of the highway. (2005 revision to 1992 policy.)

Road Profile Adjustment Computer Program, HR-143, 1969

A computer program to adjust roadway profiles has been developed to serve as an aid to the county engineers of the State of Iowa. Many hours are spent reducing field notes and calculating adjusted roadway profiles to prepare an existing roadway for paving that will produce a high quality ride and be as maintenance free as possible. Since the computer is very well adapted to performing long tedious tasks; programming this work for a computer would result in freeing the engineer of these tasks. Freed from manual calculations, the engineer is able to spend more time in solving engineering problems. The type of roadway that this computer program is designed to adjust is a road that at sometime. in its history was graded to a finished subgrade. After a period of time, this road is to receive a finished paved surface. The problem then arises whether to bring the existing roadway up to the de signed grade or to make profile adjustments and comprise between the existing and the design profiles. In order to achieve the latter condition using this program, the engineer needs to give the computer only a minimum amount of information.

Agents anti-infectieux et fonction réna!e: vers des posologies sur mesure [Antimicrobial agents and renal elimination: towards individual dosage adjustment?].

The efficacy and safety of anti-infective treatments are associated with the drug blood concentration profile, which is directly correlated with a dosing adjustment to the individual patient's condition. Dosing adjustments to the renal function recommended in reference books are often imprecise and infrequently applied in clinical practice. The recent generalisation of the KDOQI (Kidney Disease Outcome Quality Initiative) staging of chronically impaired renal function represents an opportunity to review and refine the dosing recommendations in patients with renal insufficiency. The literature has been reviewed and compared to a predictive model of the fraction of drug cleared by the kidney based on the Dettli's principle. Revised drug dosing recommendations integrating these predictive parameters are proposed.

Associations between mood, anxiety or substance use disorders and inflammatory markers after adjustment for multiple covariates in a population-based study.

Inflammation is one possible mechanism underlying the associations between mental disorders and cardiovascular diseases (CVD). However, studies on mental disorders and inflammation have yielded inconsistent results and the majority did not adjust for potential confounding factors. We examined the associations of several pro-inflammatory cytokines (IL-1β, IL-6 and TNF-α) and high sensitive C-reactive protein (hsCRP) with lifetime and current mood, anxiety and substance use disorders (SUD), while adjusting for multiple covariates. The sample included 3719 subjects, randomly selected from the general population, who underwent thorough somatic and psychiatric evaluations. Psychiatric diagnoses were made with a semi-structured interview. Major depressive disorder was subtyped into "atypical", "melancholic", "combined atypical-melancholic" and "unspecified". Associations between inflammatory markers and psychiatric diagnoses were assessed using multiple linear and logistic regression models. Lifetime bipolar disorders and atypical depression were associated with increased levels of hsCRP, but not after multivariate adjustment. After multivariate adjustment, SUD remained associated with increased hsCRP levels in men (β = 0.13 (95% CI: 0.03,0.23)) but not in women. After multivariate adjustment, lifetime combined and unspecified depression were associated with decreased levels of IL-6 (β = -0.27 (-0.51,-0.02); β = -0.19 (-0.34,-0.05), respectively) and TNF-α (β = -0.16 (-0.30,-0.01); β = -0.10 (-0.19,-0.02), respectively), whereas current combined and unspecified depression were associated with decreased levels of hsCRP (β = -0.20 (-0.39,-0.02); β = -0.12 (-0.24,-0.01), respectively). Our data suggest that the significant associations between increased hsCRP levels and mood disorders are mainly attributable to the effects of comorbid disorders, medication as well as behavioral and physical CVRFs.

Feasibility of Therapeutic Drug Monitoring (TDM) for Imatinib: Preliminary considerations on the dosage adjustment approach for CML patients enrolled in the Imatinib Concentration Monitoring (I-COME) study

Background: As imatinib pharmacokinetics are highly variable, plasma levels differ largely between patients under the same dosage. Retrospective studies in chronic myeloid leukemia (CML) patients showed significant correlations between low levels and suboptimal response, and between high levels and poor tolerability. Monitoring of plasma levels is thus increasingly advised, targeting trough concentrations of 1000 μg/L and above. Objectives: Our study was launched to assess the clinical usefulness of systematic imatinib TDM in CML patients. The present preliminary evaluation questions the appropriateness of dosage adjustment following plasma level measurement to reach the recommended trough level, while allowing an interval of 4-24 h after last drug intake for blood sampling. Methods: Initial blood samples from the first 9 patients in the intervention arm were obtained 4-25 h after last dose. Trough levels in 7 patients were predicted to be significantly away from the target (6 <750 μg/L, and 1 >1500 μg/L with poor tolerance), based on a Bayesian approach using a population pharmacokinetic model. Individual dosage adjustments were taken up in 5 patients, who had a control measurement 1-4 weeks after dosage change. Predicted trough levels were confronted to anterior model-based extrapolations. Results: Before dosage adjustment, observed concentrations extrapolated at trough ranged from 359 to 1832 μg/L (median 710; mean 804, CV 53%) in the 9 patients. After dosage adjustment they were expected to target between 720 and 1090 μg/L (median 878; mean 872, CV 13%). Observed levels of the 5 recheck measurements extrapolated at trough actually ranged from 710 to 1069 μg/L (median 1015; mean 950, CV 16%) and had absolute differences of 21 to 241 μg/L to the model-based predictions (median 175; mean 157, CV 52%). Differences between observed and predicted trough levels were larger when intervals between last drug intake and sampling were very short (~4 h). Conclusion: These preliminary results suggest that TDM of imatinib using a Bayesian interpretation is able to bring trough levels closer to 1000 μg/L (with CV decreasing from 53% to 16%). While this may simplify blood collection in daily practice, as samples do not have to be drawn exactly at trough, the largest possible interval to last drug intake yet remains preferable. This encourages the evaluation of the clinical benefit of a routine TDM intervention in CML patients, which the randomized Swiss I-COME study aims to.

Workplace adjustment of an expatriate manager: identifying key components from a social capital perspective

Perustaen tutkimuksen kansainvälisen sopeutumisen teoreettiselle rungolle täydentäen sitä sosiaalisen pääoman teorialla, tämä tutkielma tutkii kuinka johtoasemassa oleva ulkosuomalainen luo hyvin toimivan sosiaalisen verkoston hong kongilaisella työpaikallansa. Tutkielma lähestyy aihetta Nahapietin ja Ghoshalin (1998) kehittämän sosiaalisen pääoman kolmen ulottuvuuden mallin avulla. Tutkielmassa kirjallisuudesta haettua teoriaa käytetään tutkimustavarten tehtyjen haastattelujen analysointiapuna. Tutkimalla sosiaalista pääomaa, kansainvälisen sopeutumisen kirjallisuutta, ekspatriootin perinteisiä menestystekijöitä ja guanxia (kiinalaisten henkilökohtaisia siteitä) tämän tutkimuksen teoriaosuus implikoi, että sosiaalisella pääomalla tulisi olla täydentävä rooli kansainvälisen sopeutumisen kirjallisuudessa. Sosiaalisen pääoman kolmen ulottuvuuden mallia käytetään pohjana empiirisen datan analysointiin. Tutkielman empiiriset tulokset osoittavat, että työpaikan sosiaaliseen verkostoon sopeutuminen liittyy exspatriootin kykyyn käsitellä estäviä ja mahdollistajia sosiaalisen pääoman luontiin vaikuttavia tekijöitä. Lisäksi sopeutuminen vaatii exspatriootin tunnistavan kohdemaalle tyypillisiä exspatriootin menestystekijöitä ja ekspatriootinomia tärkeitä henkilökohtaisia ominaisuuksia.

How Party Linkages Shape Austerity Politics: Clientelism and Fiscal Adjustment in Greece and Portugal during the Eurozone Crisis

Drawing on an analysis of austerity reforms in Greece and Portugal during the sovereign debt crisis from 2009 onwards, we show how the nature of the linkages between parties and citizens shapes party strategies of fiscal retrenchment. We argue that parties which rely to a greater extent on the selective distribution of state resources to mobilize electoral support (clientelistic linkages) are more reluctant to agree to fiscal retrenchment because their own electoral survival depends on their ability to control state budgets to reward clients. In Greece, where parties relied extensively on these clientelistic linkages, austerity reforms have been characterized by recurring conflicts and disagreements between the main parties, as well as a fundamental transformation of the party system. By contrast, in Portugal, where parties relied less on clientelistic strategies, austerity reforms have been more consensual because fiscal retrenchment challenged to a lesser extent the electoral base of the mainstream parties.

Method adjustment and equation set of maximum rainfall intensity, duration and frequency in the Mato Grosso do Sul State

Due to the lack of information concerning maximum rainfall equations for most locations in Mato Grosso do Sul State, the alternative for carrying out hydraulic work projects has been information from meteorological stations closest to the location in which the project is carried out. Alternative methods, such as 24 hours rain disaggregation method from rainfall data due to greater availability of stations and longer observations can work. Based on this approach, the objective of this study was to estimate maximum rainfall equations for Mato Grosso do Sul State by adjusting the 24 hours rain disaggregation method, depending on data obtained from rain gauge stations from Dourado and Campo Grande. For this purpose, data consisting of 105 rainfall stations were used, which are available in the ANA (Water Resources Management National Agency) database. Based on the results we concluded: the intense rainfall equations obtained by pluviogram analysis showed determination coefficient above 99%; and the performance of 24 hours rain disaggregation method was classified as excellent, based on relative average error WILMOTT concordance index (1982).

Comparison of diffusion models for description of osmotic dehydration of radish slices dipped in brine

ABSTRACT This paper aims at describing the osmotic dehydration of radish cut into cylindrical pieces, using one- and two-dimensional analytical solutions of diffusion equation with boundary conditions of the first and third kind. These solutions were coupled with an optimizer to determine the process parameters, using experimental data. Three models were proposed to describe the osmotic dehydration of radish slices in brine at low temperature. The two-dimensional model with boundary condition of the third kind well described the kinetics of mass transfers, and it enabled prediction of moisture and solid distributions at any given time.