In an influenza pandemic, the benefit of vaccines and antiviral medications will be constrained by limitations on supplies and effectiveness. Non-pharmaceutical public health interventions will ...therefore be vital in curtailing disease spread. However, the most comprehensive assessments of the literature to date recognize the generally poor quality of evidence on which to base non-pharmaceutical pandemic planning decisions. In light of the need to prepare for a possible pandemic despite concerns about the poor quality of the literature, combining available evidence with expert opinion about the relative merits of non-pharmaceutical interventions for pandemic influenza may lead to a more informed and widely accepted set of recommendations. We evaluated the evidence base for non-pharmaceutical public health interventions. Then, based on the collective evidence, we identified a set of recommendations for and against interventions that are specific to both the setting in which an intervention may be used and the pandemic phase, and which can be used by policymakers to prepare for a pandemic until scientific evidence can definitively respond to planners' needs.
Building on reviews of past pandemics and recent historical inquiries, we evaluated the relative merits of non-pharmaceutical interventions by combining available evidence from the literature with qualitative and quantitative expert opinion. Specifically, we reviewed the recent scientific literature regarding the prevention of human-to-human transmission of pandemic influenza, convened a meeting of experts from multiple disciplines, and elicited expert recommendation about the use of non-pharmaceutical public health interventions in a variety of settings (healthcare facilities; community-based institutions; private households) and pandemic phases (no pandemic; no US pandemic; early localized US pandemic; advanced US pandemic).
The literature contained a dearth of evidence on the efficacy or effectiveness of most non-pharmaceutical interventions for influenza. In an effort to inform decision-making in the absence of strong scientific evidence, the experts ultimately endorsed hand hygiene and respiratory etiquette, surveillance and case reporting, and rapid viral diagnosis in all settings and during all pandemic phases. They also encouraged patient and provider use of masks and other personal protective equipment as well as voluntary self-isolation of patients during all pandemic phases. Other non-pharmaceutical interventions including mask-use and other personal protective equipment for the general public, school and workplace closures early in an epidemic, and mandatory travel restrictions were rejected as likely to be ineffective, infeasible, or unacceptable to the public.
The demand for scientific evidence on non-pharmaceutical public health interventions for influenza is pervasive, and present policy recommendations must rely heavily on expert judgment. In the absence of a definitive science base, our assessment of the evidence identified areas for further investigation as well as non-pharmaceutical public health interventions that experts believe are likely to be beneficial, feasible and widely acceptable in an influenza pandemic.
Background There is a growing use of procalcitonin (PCT) to facilitate the diagnosis and management of severe sepsis. We investigated the impact of one to two PCT determinations on ICU day 1 on ...health-care utilization and cost in a large research database. Methods A retrospective, propensity score-matched multivariable analysis was performed on the Premier Healthcare Database for patients admitted to the ICU with one to two PCT evaluations on day 1 of ICU admission vs patients who did not have PCT testing. Results A total of 33,569 PCT-managed patients were compared with 98,543 propensity score-matched non-PCT patients. In multivariable regression analysis, PCT utilization was associated with significantly decreased total length of stay (11.6 days 95% CI, 11.4 to 11.7 vs 12.7 days 95% CI, 12.6 to 12.8; 95% CI for difference, 1 to 1.3; P < .001) and ICU length of stay (5.1 days 95% CI, 5.1 to 5.2 vs 5.3 days 95% CI, 5.3 to 5.4; 95% CI for difference, 0.1 to 0.3; P < .03), and lower hospital costs ($30,454 95% CI, 29,968 to 31,033 vs $33,213 95% CI, 32,964 to 33,556); 95% CI for difference, 2,159 to 3,321; P < .001). There was significantly less total antibiotic exposure (16.2 days 95% CI, 16.1 to 16.5 vs 16.9 days 95% CI, 16.8 to 17.1; 95% CI for difference, –0.9 to 0.4; P = .006) in PCT-managed patients. Patients in the PCT group were more likely to be discharged to home (44.1% 95% CI, 43.7 to 44.6 vs 41.3% 95% CI, 41 to 41.6; 95% CI for difference, 2.3 to 3.3; P = .006). Mortality was not different in an analysis including the 96% of patients who had an independent measure of mortality risk available (19.1% 95% CI, 18.7 to 19.4 vs 19.1% 95% CI, 18.9 to 19.3; 95% CI for difference, –0.5 to 0.4; P = .93). Conclusions Use of PCT testing on the first day of ICU admission was associated with significantly lower hospital and ICU lengths of stay, as well as decreased total, ICU, and pharmacy cost of care. Further elucidation of clinical outcomes requires additional data.
Purpose
Many patients with suspected meningitis do not require hospitalization yet are admitted, often resulting in unnecessary care and additional cost. We assessed the possible economic impact of a ...rapid multiplex test for suspected adult community-acquired meningitis/encephalitis.
Methods
A model simulated diagnosis, clinical decisions, resource use/costs of standard of care (SOC) and two cerebrospinal fluid (CSF) testing strategies using the FDA-cleared BioFire® FilmArray® System (FA) which provides results in approximately one hour.
Results
Pathogens detected by FA caused approximately 74% of cases, 97% of which would be accurately diagnosed with FA. False positives and false negatives more often led to extended/unnecessary admission than inappropriate discharge/missed admission. Mean cost per case ranged from 16829 to 20791. A strategy of testing all suspected cases yielded greater savings (2213/case) than testing only those with abnormal CSF (812/case) and both were less expensive than SOC.
Conclusion
This economic analysis demonstrates that FA can inform more appropriate clinician decisions resulting in cost savings with greater economic benefits achievable with syndromic testing of all cases, rather than SOC or targeted syndromic testing.
Antiretroviral therapy has dramatically reduced the morbidity and mortality of infection due to HIV. The emergence of drug-resistant virus has limited the usefulness of many drugs.
To determine the ...prevalence of HIV drug resistance in the population of adults receiving care in the United States.
HIV drug susceptibility assays were performed on plasma virus from a random sample representative of the 132500 HIV-infected American adults who had received medical care in early 1996 yet were viremic with > 500 copies/ml of HIV RNA in late 1998. A blood sample was obtained from 1797 patients who comprised a representative sample of the 208900 adults receiving urban care for HIV infection in early 1996 who survived to late 1998. The sampling procedure permitted weighting each evaluated patient to reflect demographic and other characteristics of the target population.
We estimated that 132500 (63%) of the target population had HIV viremia of > 500 copies/ml. Among viremic patients, an estimated 76% had resistance to one or more antiretroviral drugs. The odds of resistance were significantly higher in patients with a history of antiretroviral drug use, advanced HIV disease, higher plasma HIV viral load and lowest CD4 cell count by self-report.
The frequent selection for drug-resistant virus among viremic patients during the first 3 years of widespread use of potent antiretroviral combination therapy has significant implications for HIV treatment and transmission.
We assessed the possible economic impact of a rapid test in pediatric patients with suspected community-acquired meningitis/encephalitis.
Modeling simulated diagnosis, clinical decisions, resource ...use/costs of standard of care (SOC) and two cerebrospinal fluid testing strategies using FilmArray
(FA), a US FDA-cleared system that provides results in approximately 1 h.
Pathogens detected by FA caused approximately 75% of cases, 97% of which would be accurately diagnosed with FA. Mean cost/case ranged from $17,599 to $22,025. Syndromic testing is less expensive than SOC. Testing all suspected cases yielded greater savings ($3481/case) than testing only those with abnormal cerebrospinal fluid ($2157/case).
Greater economic benefits are achievable with syndromic testing of all cases, rather than SOC or targeted syndromic testing.
•A randomized clinical trial was conducted on patients hospitalized with COVID-19.•The patient's clinical status was assessed daily on an 8-point ordinal scale.•Infliximab accelerated improvement and ...reduced deterioration of clinical status.•Abatacept was also beneficial.•Cenicriviroc was not beneficial.
A randomized, double-blind, placebo-controlled clinical trial was conducted to investigate the efficacy of infliximab, abatacept, and cenicriviroc in treating patients hospitalized with COVID-19. The patient's clinical status was assessed daily on an 8-point ordinal scale. We evaluated the totality of evidence on the efficacy of the 3 immunomodulators by considering all possible changes in the clinical status of each patient over time. We demonstrated that infliximab accelerated improvement and reduced deterioration of clinical status when added to standard of care. There was also evidence for the benefit of abatacept. There was no evidence for the benefit of cenicriviroc.
There is concern that, with prolonged survival, patients with human immunodeficiency virus (HIV) infection may be at risk for cardiovascular and cerebrovascular disease due to HIV infection itself ...and to the effects of antiretroviral drugs. This retrospective study, involving a large population of veterans, dispels this concern.
In a large population there was no increase in the rate of cardiovascular disease.
Widespread use of potent combination antiretroviral therapy dramatically improves survival among patients infected with the human immunodeficiency virus (HIV) but introduces questions about long-term management.
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HIV-associated abnormalities of lipid and insulin metabolism have been recognized, and there is an increasing prevalence of fat redistribution, frank diabetes, and hyperlipidemia.
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There are reports of premature cardiovascular and cerebrovascular disease and of endothelial dysfunction, possibly linked to both effects of the drugs and HIV infection itself.
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These reports have aroused concern about highly active antiretroviral therapy.
We used anonymous data bases of the Department of Veterans Affairs (VA) to construct . . .
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