Spokane, WA, United States
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Yam P.,Providence St Mary Medical Center | Fales D.,Providence St Mary Medical Center | Jemison J.,Providence St Peter Hospital | Gillum M.,Providence Sacred Heart Medical Center | Bernstein M.,Providence St Mary Medical Center
American Journal of Health-System Pharmacy | Year: 2012

Purpose. The implementation of a pharmacy-directed antimicrobial stewardship (AMS) program involving the use of telemedicine technology is described. Summary. Pursuant to a gap analysis of AMS services at a rural hospital where physician specialists in infectious diseases (ID) or pharmacists with advanced ID training were not available, a multidisciplinary team was formed to implement a stewardship program targeting six antimicrobials with a high potential for misuse. A key part of the program was the participation of a remotely located ID physician specialist in weekly case review teleconferences. An evaluation of the first 13 months of the initiative (May 2010-June 2011) indicated that pharmacist-initiated AMS interventions increased dramatically after program implementation, from a baseline average of 2.1 interventions per week to an average of 6.8 per week; the rate of antimicrobial streamlining increased from 44%to an average of 96%. Due to inconsistent documentation, an increase in the rate of physician-pharmacist agreement could not be demonstrated; however, anecdotal evidence suggested an increase in physician requests for case reviews by the AMS team and enhanced interdisciplinary collaboration. An analysis of 2010 purchasing data demonstrated a decrease in annual antibiotic costs of about 28% from 2009 levels (and a further decrease of about 51% in the first two quarters of 2011). The rate of nosocomial Clostridium difficile infection decreased from an average of 5.5 cases per 10,000 patient-days to an average of 1.6 cases per 10,000 patient-days. Conclusion. Implementation of an AMS program at a rural hospital led to increases in pharmacist-recommended interventions and streamlining of antimicrobial therapy, as well as decreases in health care-associated C. difficile infections and antimicrobial purchasing costs. Copyright © 2012, American Society of Health-System Pharmacists, Inc. All rights reserved.


Grenache D.G.,University of Utah | Greene D.N.,University of Utah | Dighe A.S.,Harvard University | Fantz C.R.,Emory University | And 4 more authors.
Clinical Chemistry | Year: 2010

BACKGROUND: Earlier studies have shown that increased concentrations of certain human chorionic gonadotropin (hCG) variants can cause false-negative results in some qualitative hCG devices. The objective of this study was to determine if increased concentrations of hCGβ and hCGβ core fragment (hCGβcf) cause falsely decreased results on 9 commercially available quantitative hCG assays. METHODS: Several concentrations of purified hCGβ and hCGβcf were added to 2 sets of 6 serum samples with and without a fixed concentration of intact hCG. We examined 9 widely used immunoassays to measure immunoreactive hCG. Falsely decreased results were defined as those in which the measured hCG concentration was ≤50% of expected. RESULTS: High concentrations of hCGβ (≥240 000 pmol/L) produced falsely decreased hCG measurements in 2 assays known to detect this variant. Similarly, high concentrations of hCGβcf (≥63 000 pmol/L) produced falsely decreased hCG measurements in 3 assays that do not detect purified hCGβcf. Two assays were identified that detected both hCGβ and hCGβcf, and neither produced falsely decreased results in the presence of high concentrations of these variants. CONCLUSIONS: Extremely high concentrations of hCG variants can cause falsely decreased results in certain quantitative hCG assays. Of the 9 assays examined, none exhibited falsely decreased results in the presence of hCGβ concentrations typically associated with hCGβ-producing malignancies. Two assays exhibited decreased (>50%) hCG results in the presence of hCGβcf concentrations found during normal pregnancy. © 2010 American Association for Clinical Chemistry.


PubMed | Denver Medical Center, University of Colorado at Denver, National Partnership for Women and Families, University of California at Los Angeles and 9 more.
Type: Journal Article | Journal: Journal of the American College of Cardiology | Year: 2016

Public reporting of health care data continues to proliferate as consumers and other stakeholders seek information on the quality and outcomes of care. Medicares Hospital Compare website, the U.S. News & World Report hospital rankings, and several state-level programs are well known. Many rely heavily on administrative data as a surrogate to reflect clinical reality. Clinical data are traditionally more difficult and costly to collect, but more accurately reflect patients clinical status, thus enhancing the validity of quality metrics. We describe the public reporting effort being launched by the American College of Cardiology and partnering professional organizations using clinical data from the National Cardiovascular Data Registry (NCDR) programs. This hospital-level voluntary effort will initially report process of care measures from the percutaneous coronary intervention (CathPCI) and implantable cardioverter-defibrillator (ICD) registries of the NCDR. Over time, additional process, outcomes, and composite performance metrics will be reported.


Tran D.,University of Alberta | Cembrowski G.S.,University of Alberta | Shalapay C.,University of Alberta | Steele P.,Marshfield Laboratory | Wiley C.,Providence Sacred Heart Medical Center
Clinical Biochemistry | Year: 2011

Objectives: HbA1c has been recently recommended as the primary diagnostic test for diabetes. This study evaluated the positive predictive value (PPV) and negative predictive value (NPV) of HbA1c against the oral glucose tolerance test (OGTT) in three locations. Design and methods: Three years of data with concurrent OGTT and HbA1c tests were extracted from Laboratory Information Systems (LIS) and receiver operator (ROC) curves and positive and negative predictive values calculated comparing the OGTT with the HbA1c values using a 10% prevalence of diabetes. Results: The recommended threshold HbA1c value of 6.5% did not give the optimal combination of NPV (0.93 to 0.92) and PPV (0.40 to 0.61) compared to a threshold HbA1c value of 7.0% (NPV 0.91 to 0.92, PPV 0.61 to 0.73). Conclusion: The optimal HbA1c value for the diagnosis of diabetes is 7.0% but even at this HbA1c the PPV is suboptimal and may cause up to 12% of patients without diabetes, as defined by a normal OGTT, to be classified having diabetes mellitus. © 2011 The Canadian Society of Clinical Chemists.


Cochrane J.,Providence Sacred Heart Medical Center | Schlepp G.,Spokane Digestive Disease Center
Case Reports in Gastroenterology | Year: 2015

Metastatic breast cancer is typically identified in the bones, lymph nodes, lungs and liver. Rarely does metastatic breast cancer involve the common bile duct (CBD) without direct extension from liver metastasis into the CBD. We present a woman diagnosed with metastatic breast cancer in the CBD after presenting with obstructive jaundice. Patients with a history of primary breast cancer who present with obstructive jaundice secondary to CBD mass need identification of the mass in order to provide appropriate treatment. © 2015 S. Karger AG, Basel.


Wiley C.L.,Providence Sacred Heart Medical Center | Switzer S.P.,CentaCare Health System | Berg R.L.,Biomedical Informatics Research Center | Glurich I.,Marshfield Clinic Research Foundation | Dart R.A.,Marshfield Clinic
Clinical Medicine and Research | Year: 2010

Background: The causes of elevated B-Type natriuretic peptide (BNP) levels are multifactorial. Renal dysfunction has been shown to affect BNP levels in some studies and the diagnostic value of BNP levels in the presence of chronic kidney disease has been questioned. Prior studies have involved small patient populations with variable outcomes noted. This study evaluated the association of BNP levels with an estimated glomerular filtration rate (eGFR) and presence or absence of congestive heart failure (CHF). Methods: A retrospective, cross-sectional study in which medical records were electronically screened, identified patients with a BNP level and serum creatinine measurement on the same day between December 2002 and March 2006. Results: Of 1739 eligible patients, 537 were positive for CHF and 1202 were negative for CHF by our criteria. There was a clear trend for BNP to be higher with the advancement of CHF, as determined by New York Heart Association (NYHA) classification (P<0.001). Median BNP levels increased from 65 pg/mL in patients without CHF to 496 pg/mL in patients with NYHA class IV CHF (P <0.001), and there was a strong inverse association with eGFR (P <0.001). Conclusion: BNP levels show a strong inverse association with eGFR in both CHF and non-CHF patients. Currently best practice at most institutions involves use of BNP cutoff diagnostic levels not adjusted for eGFR. The data presented underlines that eGFR is a significant confounder of BNP measurement especially when renal status is compromised and interpretation of clinical significance in the presence of elevated BNP measures should take renal status into consideration. © 2010 Marshfield Clinic.


Mani D.,Providence Sacred Heart Medical Center | Haigentz Jr. M.,Yeshiva University | Aboulafia D.M.,Virginia Mason Medical Center | Aboulafia D.M.,University of Washington
Clinical Lung Cancer | Year: 2012

Lung cancer is the most prevalent nonAIDS-defining malignancy in the highly active antiretroviral therapy era. Smoking plays a significant role in the development of HIV-associated lung cancer, but the cancer risk is two to four times greater in HIV-infected persons than in the general population, even after adjusting for smoking intensity and duration. Lung cancer is typically diagnosed a decade or more earlier among HIV-infected persons (mean age, 46 years) compared to those without HIV infection. Adenocarcinoma is the most common histological subtype, and the majority of patients are diagnosed with locally advanced or metastatic carcinoma. Because pulmonary infections are common among HIV-infected individuals, clinicians may not suspect lung cancer in this younger patient population. Surgery with curative intent remains the treatment of choice for early-stage disease. Although there is increasing experience in using radiation and chemotherapy for HIV-infected patients who do not have surgical options, there is a need for prospective studies because this population is frequently excluded from participating in cancer trials. Evidence-based treatments for smoking-cessation with demonstrated efficacy in the general population must be routinely incorporated into the care of HIV-positive smokers. © 2012 Elsevier Inc. All Rights Reserved.


Puhlman M.,Providence Sacred Heart Medical Center
AACN Advanced Critical Care | Year: 2012

Left ventricular assist devices (LVADs) have become accepted as treatment for heart failure as a result of improvements in diagnosing and treating left ventricular failure and limited donor availability. In the Pivotal Study of the HeartMate II in the bridge to transplantation population, the incidence of right ventricular failure without the implantation of a right ventricular assist device was 14%, with an additional 6% of the participants ill enough that they required implantation of a right ventricular assist device. This complication increases mortality, cost, and length of stay. This article reviews the screening of LVAD candidates for the probability of right ventricular failure postoperatively, the evaluation of right ventricular function in LVAD candidates, and the optimal management of the right ventricle during the perioperative care of LVAD patients. Copyright © 2012 American Association of Critical-Care Nurses.


Saha S.A.,Providence Sacred Heart Medical Center | Saha S.A.,University of Washington | Arora R.R.,Administration Medical Center
Current Opinion in Lipidology | Year: 2011

Purpose of Review: Fibrates continue to be a viable treatment option for mixed atherogenic dyslipidemia, and recent reports from clinical studies have shed new light on the therapeutic utility of fibrates for the prevention of microvascular and macrovascular disease, especially in combination with statins. Recent Findings: Data from randomized placebo-controlled trials have shown that fibrates reduce nonfatal coronary events but do not confer any benefit on mortality or other adverse cardiovascular outcomes. The ACCORD Lipid trial studied the additive effect of fenofibrate therapy along with low-dose simvastatin therapy in 5518 patients with type 2 diabetes mellitus, and found that fenofibrate did not affect any of the adverse cardiovascular outcomes, either individually or as part of a composite outcome, after 4.7 years of follow-up. An a priori subgroup analysis showed a significant benefit from fenofibrate-simvastatin combination therapy over simvastatin alone in participants with moderate hypertriglyceridemia and low HDL-cholesterol on major cardiovascular events, consistent with post-hoc analyses of previous fibrate trials. The ACCORD-Eye study adds to the sparse clinical data on the effect of fenofibrate on diabetic retinopathy, and showed that fenofibrate may be used to reduce the risk of progression of diabetic retinopathy even in patients with established disease. The combination of statin and fibrate was well tolerated. Summary: Fibrate therapy does not reduce mortality but may reduce nonfatal coronary events in patients at risk for cardiovascular disease, including those with type 2 diabetes. The ACCORD Lipid study shows that the combination of low-dose simvastatin and fenofibrate is well tolerated, and is potentially cardioprotective in patients with atherogenic 'mixed' dyslipidemia. © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.


Lehur P.-A.,University of Nantes | McNevin S.,Providence Sacred Heart Medical Center | Buntzen S.,Aarhus University Hospital | Mellgren A.F.,Colon and Rectal Surgery Associates | And 2 more authors.
Diseases of the Colon and Rectum | Year: 2010

BACKGROUND: Magnetic sphincter augmentation, a successful treatment of gastroesophageal reflux disease, has been applied to treat fecal incontinence. The purpose of this feasibility study was to understand the safety profile as well as the potential benefit of this new device when it is implanted in patients with fecal incontinence. METHODS: A magnetic anal sphincter device was surgically implanted in candidates with documented fecal incontinence of more than 2 episodes per week at 3 investigational centers in Europe and the United States following ethics/institutional review board approval. The magnetic anal sphincter device was placed around the anal canal via a single anterior incision. All data were collected prospectively. The primary outcome measure was the reduction of incontinent episodes based on a daily continence diary. RESULTS: To date 14 patients have been implanted with the device (all female; mean age, 62.8 y; range, 41-74 y) with a median follow-up of 6 months. There have been no intraoperative complications. Mean hospital stay was 3 days; range, 1 to 7 days. Adverse events were observed in 7 patients. Three patients are no longer implanted with a device; 2 devices were removed and one passed spontaneously following a separation at the suture connection. Five patients with 6-month follow-up demonstrated a mean reduction in the number of average weekly incontinence episodes from 7.2 to 0.7 (90.9%) and a mean reduction in Wexner Continence Score from 17.2 to 7.8 (54.7%). Compared with baseline, quality of life improved in all 4 domains of the fecal incontinence quality of life (FIQoL) scoring system. No patients have reported that their condition has worsened. Two patients at 1-year follow-up both reported perfect continence. CONCLUSION: This preliminary study describes the use of a new device to treat fecal incontinence. Compared with existing devices, implantation is simple and it requires no adjustments from the physician or patient once the device is implanted. Initial assessment with a small number of patients shows promising outcomes with a limited incidence of complications and good restoration of continence. © The ASCRS 2010.

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