Relationship between antibiotic consumption, oropharyngeal colonization, and ventilator-associated pneumonia by Staphylococcus aureus in an intensive care unit of a Brazilian teaching hospital

INTRODUCTION: his study evaluated the consumption of major classes of antibiotics, the colonization of the oropharynx of patients on mechanical ventilation, and the risk of ventilator-associated pneumonia (VAP) caused by Staphylococcus aureus in an intensive care unit for adults. METHODS: A case-control study was carried out using colonized patients (cases) by oxacillin-resistant S. aureus (ORSA) and (controls) oxacillin-sensitive S. aureus (OSSA) from May 2009 to August 2010. The occurrence of VAP by S. aureus was also evaluated in the same period. Antibiotic consumption was expressed as the number of defined daily doses (DDD)/1,000 patient-days for glycopeptides, carbapenems, and extended-spectrum cephalosporins. RESULTS: Three hundred forty-six (56.1%) patients underwent mechanical ventilation with a frequency of oropharyngeal colonization of 36.4%, corresponding to 63.5% for ORSA and 36.5% for OSSA. The risk of illness for this organism was significant (p<0.05), regardless of whether colonization/infection was by ORSA or OSSA. The consumption of antibiotics was high, mainly for broad-spectrum cephalosporins (551.26 DDDs/1,000 patient-days). The high density of use of glycopeptides (269.56 DDDs/1,000 patient-days) was related to colonization by ORSA (Pearson r=0.57/p=0.02). Additionally, age >60 years, previous antibiotic therapy, and previous use of carbapenems were statistically significant by multivariate analysis. CONCLUSIONS: There was a significant relationship between the colonization of the oropharyngeal mucosa and the risk of VAP by both phenotypes. The use of glycopeptides was related to colonization by ORSA.

Nosocomial infections in a pediatric intensive care unit of a developing country: NHSN surveillance

INTRODUCTION: This study aimed to determine the epidemiology of the three most common nosocomial infections (NI), namely, sepsis, pneumonia, and urinary tract infection (UTI), in a pediatric intensive care unit (PICU) in a developing country and to define the risk factors associated with NI. METHODS: We performed a prospective study on the incidence of NI in a single PICU, between August 2009 and August 2010. Active surveillance by National Healthcare Safety Network (NHSN) was conducted in the unit and children with NI (cases) were compared with a group (matched controls) in a case-control fashion. RESULTS: We analyzed 172 patients; 22.1% had NI, 71.1% of whom acquired it in the unit. The incidence densities of sepsis, pneumonia, and UTI per 1,000 patients/day were 17.9, 11.4, and 4.3, respectively. The most common agents in sepsis were Enterococcus faecalis and Escherichia coli (18% each); Staphylococcus epidermidis was isolated in 13% of cases. In pneumonias Staphylococcus aureus was the most common cause (3.2%), and in UTI the most frequent agents were yeasts (33.3%). The presence of NI was associated with a long period of hospitalization, use of invasive devices (central venous catheter, nasogastric tube), and use of antibiotics. The last two were independent factors for NI. CONCLUSIONS: The incidence of NI acquired in this unit was high and was associated with extrinsic factors.

Prevalence rates of infection in intensive care units of a tertiary teaching hospital

OBJECTIVE: To determine the prevalence rates of infections among intensive care unit patients, the predominant infecting organisms, and their resistance patterns. To identify the related factors for intensive care unit-acquired infection and mortality rates. DESIGN: A 1-day point-prevalence study. SETTING:A total of 19 intensive care units at the Hospital das Clínicas - University of São Paulo, School of Medicine (HC-FMUSP), a teaching and tertiary hospital, were eligible to participate in the study. PATIENTS: All patients over 16 years old occupying an intensive care unit bed over a 24-hour period. The 19 intensive care unit s provided 126 patient case reports. MAIN OUTCOME MEASURES: Rates of infection, antimicrobial use, microbiological isolates resistance patterns, potential related factors for intensive care unit-acquired infection, and death rates. RESULTS: A total of 126 patients were studied. Eighty-seven patients (69%) received antimicrobials on the day of study, 72 (57%) for treatment, and 15 (12%) for prophylaxis. Community-acquired infection occurred in 15 patients (20.8%), non- intensive care unit nosocomial infection in 24 (33.3%), and intensive care unit-acquired infection in 22 patients (30.6%). Eleven patients (15.3%) had no defined type. The most frequently reported infections were respiratory (58.5%). The most frequently isolated bacteria were Enterobacteriaceae (33.8%), Pseudomonas aeruginosa (26.4%), and Staphylococcus aureus (16.9%; [100% resistant to methicillin]). Multivariate regression analysis revealed 3 risk factors for intensive care unit-acquired infection: age > 60 years (p = 0.007), use of a nasogastric tube (p = 0.017), and postoperative status (p = 0.017). At the end of 4 weeks, overall mortality was 28.8%. Patients with infection had a mortality rate of 34.7%. There was no difference between mortality rates for infected and noninfected patients (p=0.088). CONCLUSION: The rate of nosocomial infection is high in intensive care unit patients, especially for respiratory infections. The predominant bacteria were Enterobacteriaceae, Pseudomonas aeruginosa, and Staphylococcus aureus (resistant organisms). Factors such as nasogastric intubation, postoperative status, and age ³60 years were significantly associated with infection. This study documents the clinical impression that prevalence rates of intensive care unit-acquired infections are high and suggests that preventive measures are important for reducing the occurrence of infection in critically ill patients.

Prevalencia de Trastornos Mentales en consultantes de Centros de Atención Primaria de la Ciudad de Córdoba, Argentina.Prevalence of Mental Disorders among Consultants in Primary Health Care Centers of the City of Córdoba, Argentina

El informe de la Organización Mundial de la Salud (2001), refiere que en un plazo de 20 años los trastornos mentales pasarán a ser la segunda causa dentro de la carga de morbilidad a nivel mundial, y en la actualidad una de cada cuatro personas padece de algún trastorno mental en alguna etapa de su vida. Los estudios realizados en diversos países revelan que una proporción importante de los consultantes de la atención primaria en salud presentan algún tipo de trastornos mentales. Desde esta perspectiva, la atención primaria de la salud ofrece una oportunidad de intervenir en el manejo de los trastornos mentales de forma temprana y eficaz. En Argentina, es limitada la información acerca del registro epidemiológico en salud mental, no contando con estudios abordados desde la Atención Primaria en la provincia de Córdoba. El objetivo general del proyecto es estimar la prevalencia de trastornos mentales entre los consultantes de atención primaria por problemas de salud general. Para ello se propone: Estimar la prevalencia de trastornos mentales en una muestra representativa de consultantes adultos por problemas de salud general, de centros de atención primaria de la ciudad de Córdoba, identificar y describir los tipos de trastornos mentales que presentan estos consultantes adultos de centros de atención primaria y analizar la prevalencia de los trastornos mentales por sexo y edad de la población en estudio. Metodología: el estudio se realizará en consultorios de Atención Primaria de Salud distribuídos en todo el éjido de la ciudad, teniendo en cuenta la representación de las 12 zonas de CPC. La muestra es probabilística, estratificada, polietápica de pacientes que consultan en el primer nivel de atención. Se entrevistarán 1200 pacientes utilizando la versión computorizada del CIDI 3.0, que proporciona diagnóstico de acuerdo a la DSM IV y la CIE-10. La confiabilidad y la validez del instrumento ha sido ampliamente documentada y la traducción de la encuesta al español fue realizada conforme a las recomendaciones de la OMS. El análisis efectuado será de prevalencia de Trastornos Mentales y del Comportamiento (TMC),asociación entre factores sociodemográficos y TCM estimados calculando las razones de disparidad (odds ratio), regresión logística a fin de ajustar los resultados por la posible interacción entre variables, análisis de la asociación de todas las variables con los TMC, análisis univariado de la asociación de cada variable con los TMC, controlando sexo y edad, se construirá un modelo de regresión logística. En todos los casos el nivel de significación será de 0,05. El equipo de trabajo, de cooperación internacional entre profesionales de la UNC y de la Universidad de Chile, y con la participación en colaboración de los profesionales dependientes de la Secretaría de Salud de la municipalidad de Córdoba, representa un avance para trabajar en los centros de salud de esta ciudad, constituyéndose en un avance, cualitativo y cuantitativo de la actividad científica en Atención Primaria en salud mental con abordaje epidemiológico. Se espera contribuir al conocimiento acerca de la prevalencia de los problemas de salud mental de esta población en la ciudad de Córdoba, proporcionando información a los funcionarios y responsables por la gestión de las áreas vinculadas a la salud mental, aportando conocimiento que promueva una temprana identificación de riesgos iniciales en salud mental y conductas de cuidado en la población como potencial de bienestar.Así mismo, se espera sistematizar una experiencia que pueda ser replicada en otros sitios geográficos. Por todo lo anterior, esta propuesta permitirá conocer por primera vez en la ciudad de Córdoba la frecuencia y características de los problemas de salud mental entre consultantes de Atención Primaria, información fundamental para el desarrollo posterior de estrategias que busquen mejorar la detección y el tratamiento de estos problemas. According to the WHO Report (2001), in 20 years, mental health disorders (MHDs) will be the world’s second most frequent cause of morbidity. Primary care offers the opportunity to handle MHDs efficiently at an early stage. In Argentina, the epidemiologic data on mental health (MH) is limited, and there are no records for Córdoba. The aim of this project is to assess the prevalence of MHDs among consultants who resort to primary health centers (PHCCs) in the city of Córdoba for common health problems, by using a representative sample of adult consultants, identifying and describing the types of MHDs evinced, and analysing prevalence by sex and age group under study. Methodology:the study will be carried out in PHCCs located in the municipal area of Córdoba, covering the 12 zones corresponding to the CPCs (municipal branch offices for each zone). A multi-stage stratified random sample of 1200 patients will be interviewed using the program CIDI 3.0 to produce a diagnostic according to DSM IV and CIE-10, a tool with proven reliability and validity.The aspects to be analysed are prevalence of mental and behavior disorders, their association with socio-demographic factors estimated by odds ratios, logistic regression for adjustment of potential interaction among variables, association with all variables, and univariate analysis for association with each variable. Significance level will be 0.05 in all cases. The international teamwork including professionals from the Universities of Córdoba, Chile and the Public Health Department of the Municipality of Córdoba constitutes a qualitative and quantitative step forward in the field of primary health care studies with an epidemiologic approach. This project aims at providing administrators in the MH area with data for the early detection of initial risks in MH and the promotion of prevention habits. This will be the first study conducted in Córdoba, and is aimed at facilitating replication in other geographical areas.

The Cost of ownership in the governance of interfirm collaborations

This paper investigates the selection of governance forms in interfirm collaborations taking into account the predictions from transaction costs and property rights theories. Transaction costs arguments are often used to justify the introduction of hierarchical controls in collaborations, but the ownership dimension of going from “contracts” to “hierarchies” has been ignored in the past and with it the so called “costs of ownership”. The theoretical results, tested with a sample of collaborations in which participate Spanish firms, indicate that the cost of ownership may offset the benefits of hierarchical controls and therefore limit their diffusion. Evidence is also reported of possible complementarities between reputation effects and forms of ownership that go together with hierarchical controls (i.e. joint ventures), in contrast with the generally assumed substitutability between the two.

The Total fiscal cost of indirect taxation: an approximation using Catalonia's recent input-output table

In this note we quantify to what extent indirect taxation influences and distorts prices. To do so we use the networked accounting structure of the most recent input-output table of Catalonia, an autonomous region of Spain, to model price formation. The role of indirect taxation is considered both from a classical value perspective and a more neoclassical flavoured one. We show that they would yield equivalent results under some basic premises. The neoclassical perspective, however, offers a bit more flexibility to distinguish among different tax figures and hence provide a clearer disaggregate picture of how an indirect tax ends up affecting, and by how much, the cost structure.

On the cost of rent-seeking by government bureaucrats in a Real-Business-Cycle framework

This paper studies the wasteful e ffect of bureaucracy on the economy by addressing the link between rent-seeking behavior of government bureaucrats and the public sector wage bill, which is taken to represent the rent component. In particular, public o fficials are modeled as individuals competing for a larger share of those public funds. The rent-seeking extraction technology in the government administration is modeled as in Murphy et al. (1991) and incorporated in an otherwise standard Real-Business-Cycle (RBC) framework with public sector. The model is calibrated to German data for the period 1970-2007. The main fi ndings are: (i) Due to the existence of a signi ficant public sector wage premium and the high public sector employment, a substantial amount of working time is spent rent-seeking, which in turn leads to signifi cant losses in terms of output; (ii) The measures for the rent-seeking cost obtained from the model for the major EU countries are highly-correlated to indices of bureaucratic ineffi ciency; (iii) Under the optimal scal policy regime,steady-state rent-seeking is smaller relative to the exogenous policy case, as the government chooses a higher public wage premium, but sets a much lower public employment, thus achieving a decrease in rent-seeking.

Agency cost of government ownership: a study of voluntary audit comitte formation in China

In this paper, we investigate the agency costs of government ownership and their impact on corporate governance and firm value. China is used as a laboratory because of the prevalent state shareholdings in exchange-listed firms. In this context, we specifically consider the trade-offs involved in the voluntary formation of an audit committee when the controlling shareholder is the state. The decision to improve corporate governance (in this case, introduce an audit committee) is shown to be value relevant and a function of existing agency relationships and non-trivial implementation costs. Our findings are robust to the level of pyramid groups, the ownership-control wedge, and financial leverage. The research adds to the debate regarding the effect of government shareholdings on corporate culture and performance - a topic that hastaken on renewed importance in recent times.

The Complementarity between segment disclosure and earnings quality, and its effect on cost of capital

We investigate the role of earnings quality in determining the levels of segment disclosure, and whether and how better quality earnings and segment disclosure influences cost of capital. Using a large US sample for the period 2001-2006, we find a positive relation between earnings quality and levels of segment disclosures. We also find that firms providing better quality segment information, contingent upon good earnings quality, enjoy lower cost of capital. We base our empirical tests on a self created index of segment disclosure. Our results contribute to a better understanding of (1) the incentives for providing segment disclosures, and (2) how accounting quality (quality of segment information and earnings quality) is related to the cost of capital.

The Political cost of reforms

This paper formalizes in a fully-rational model the popular idea that politicians perceive an electoral cost in adopting costly reforms with future benefits and reconciles it with the evidence that reformist governments are not punished by voters. To do so, it proposes a model of elections where political ability is ex-ante unknown and investment in reforms is unobservable. On the one hand, elections improve accountability and allow to keep well-performing incumbents. On the other, politicians make too little reforms in an attempt to signal high ability and increase their reappointment probability. Although in a rational expectation equilibrium voters cannot be fooled and hence reelection does not depend on reforms, the strategy of underinvesting in reforms is nonetheless sustained by out-of-equilibrium beliefs. Contrary to the conventional wisdom, uncertainty makes reforms more politically viable and may, under some conditions, increase social welfare. The model is then used to study how political rewards can be set so as to maximize social welfare and the desirability of imposing a one-term limit to governments. The predictions of this theory are consistent with a number of empirical regularities on the determinants of reforms and reelection. They are also consistent with a new stylized fact documented in this paper: economic uncertainty is associated to more reforms in a panel of 20 OECD countries.

Cost of Illness and Contingent Valuation : Controlling for the Motivations of Expressed Preferences in an Attempt to Avoid Double-Counting

This paper addresses the issue of double counting of health impacts in the context of cost of illness valuation. Double counting occurs when estimates are jointly used, which rely on valuation techniques that overlap. As a solution, we propose to limit the scope of each of the valuation method to a specific range of impacts. In order to limit the contingentvaluation method to the exclusive valuation of intangible costs, we propose a three steps approach : (1) leave the respondents free to valuate the consequences which matter to them, (2) elicit respondent's motivations, (3) control for the influence motivations have on elicited values. This procedure was applied in a Swiss contingent-valuation. An econometric treatment was applied in order to limit the scope of the estimates of the contingent valuation method to intangibles,therefore the possibility to a combination of methods with the risk of double-counting and underestimating costs being kept to a minimum.

Counting the Cost of Diabetes on the Island of Ireland

A new report published by the Institute of Public Health in Ireland (IPH) and released on Monday 9 July 2007, predicts a 26% increase in diabetes in Northern Ireland and a 37% increase in the Republic over the ten year period (2005-2015). The new report entitled, Making Diabetes Count: What does the future hold? is the second such report from the authors - The Irish Diabetes Prevalence Working Group.

HSS (F)2004 04/04 - Revised Cost of Capital Rate in Fees and Charges Recovery Policy (PDF 51 KB)

HSS (F)2004 04/04 - Revised Cost of Capital Rate in Fees and Charges Recovery Policy

Best Practice - Best Care - Summary of Responses to the Consultation (PDF 318KB)

A Framework for Setting Standards, Delivering Services and Improving Monitoring and Regulation in the HPSS