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Nikolaos J. Skubas, MD, FASE
Bivariate tests between those who did and did not receive antidepressants and between racial categories medicine dosage chart purchase trileptal 300mg on line. Covariates included age symptoms 5 weeks pregnant buy generic trileptal 150 mg on line, gender treatment 1 degree burn trileptal 150mg online, Medicaid eligibility status medications qt prolongation buy trileptal 150mg, year of initial depression, if initial care received 44% of whites and 27. Whites were more likely to receive antidepressants than black patients (odds ratio = 0. Blacks were less likely than whites to -Racial/ethnic groups other than African Americans and whites not assessed. More psychiatric medications were prescribed to African Americans than other patients (= 0. The 24hour dosage of antipsychotic medication given to African Americans was significantly higher than for other patients (= 862, p < 0. Models predicting number of medications, number of oral and injected antipsychotic and 24-hour dosage became non-significant. Analysis of covariance models constructed using least-squares regression or logistic regression to assess the influence of race on five prescription practice indicators. Findings No significant differences were found among blacks, whites and Hispanics in the probability of a psychiatric hospitalization or in number of inpatient psychiatric days. Logistic regression to assess odds of amputation and surgery for black relative to white patients, controlling for case-mix, region, and hospital characteristics. Black patients were more likely to undergo all forms of amputation than were white patients (unadjusted odds ratio = 1. Among patients with diabetes, black patients were 58% more likely than white patients to undergo above the knee amputation (adjusted odds ratio = 1. Black patients who did not have diabetes were twice as likely to undergo the procedure (adjusted odds ratio = 2. Among those who did not have diabetes, black patients were 71% less likely to undergo angioplasty (adjusted odds ratio = 0. Limitations Generalized linear model to assess relationship between racial/ethnic composition of neighborhoods and opioid supplies of pharmacies. Analyses controlled for proportion of elderly persons at census-block level and crime rates at the precinct level. Overall, two-thirds of pharmacies that did not carry any opioids were in predominantly nonwhite neighborhoods. After adjustment pharmacies in predominantly nonwhite neighborhoods (< 40% of residents white) were significantly less likely to have adequate opioid supplies than were pharmacies in predominantly white neighborhoods (at least 80% residents white) (odds ratio = 0. Among 176 pharmacies with inadequate stock, reasons were as follows: 54%-little demand for medications, 44%-concern about disposal, 20%-fear of fraud and illicit drug use, 19% -fear of robbery, 7%-other. Analyses Weisse, Sorum, Sanders, and Syat, 2001 Racial and gender differences in pain management. Responding physicians asked if they would recommend transplantation given presence of certain criteria. Multiple logistic regression to assess independent effect of nephrologist and patient factors on decision to recommend transplantation. Analyses adjust for patient and neurologist demographics, clinical characteristics, nephrologist training, and organizational affiliations. Analysis of variance to assess impact of patient gender and race on treatment decision (hydrocodone dosage). Findings Limitations Kidney stone pain: Decision to treat with hydrocodone did not vary by race. Among physicians who opted to treat with medication, dose of hydrocodone selected did not differ by patient race (white = 308 mg, African American = 271 mg), patient gender, or physician gender. Male physicians prescribed higher doses to white patients than to African Americans, while female physicians prescribed higher doses to African-American patients. Similarly, dose selected did not differ by patient race (white 188 = mg, African American = 233 mg), patient gender, or physician gender. Sinus Infection: Decision to treat with antibiotic did not differ by patient race or gender. Physicians were less likely to recommend cardiac catheterization for women than men (odds ratio = 0. Analysis of race-sex interaction revealed that AfricanAmerican women were significantly less likely to be referred for catheterization than white men (odds ratio = 0. Records of 187,900 hip fracture patients (94% white, 4% African American, 3% "other") derived from Medicare administrative databases. Findings At higher levels of back pain, nonwhite patients received more spine films than did white patients (74% vs. Among patients with positive straight leg raising test, nonwhite patients had more spine films than white patients (23% vs. After controlling for clinical characteristics, race was no longer an independent predictor of lumbar spine radiograph use. Independent variables included age, gender, comorbidity index, surgery type, fracture type, urinary incontinence, and hospital characteristics. African-American patients were less likely than whites to receive acute physical therapy only (b/w odds ratio = 0. Logistic regression to predict utilization of physical and occupational therapy by race. Analyses Renal Care and Transplantation Ayanian, Cleary, Weissman, and Epstein, 1999 Effect of patient preferences on access to renal transplantation. Findings After controlling for clinical factors, African-American patients (odds ratio = 1. Measures included interviews and data from the renal networks and the United Network for Organ Sharing. Logistic regression to estimate: 1) the adjusted relative odds of referral for evaluation at a transplant center; and 2) placement on a waiting list for a transplant or receipt of transplant within 18 months after start of dialysis, for AfricanAmerican and white men and women. Analyses control for patient preference and expectations, perceptions of care, region, age, education, income, insurance, employment, marital status, car ownership, type facility, cause of renal failure, health status, and co-morbidities. African-American patients were slightly less likely than white patients to report wanting a kidney transplant (76. However, compared to preferences, African-American patients were much less likely than white patients to have been referred to a transplant center for evaluation (50. Independent predictors of listing before dialysis included being African American (odds ratio = 0. African Americans were 57% less likely than whites to be initially treated with peritoneal dialysis (odds ratio = 0. Logistic regression (backward stepwise procedure) to assess relationship between ethnicity and initial dialysis modality, controlling for patient characteristics. Analysis included logistic regression for inpatient mortality and Cox Proportional hazard models for 30-day and 6-month mortality to estimate the Mortality at 30 days was 4. In the waiver county, 3,490 adults and 3,414 children from pre-period (12 months prior to enrollment); 4,082 adults and 3,834 children in post-period. In nonwaiver county, 2,087 adults and 2,093 children in preperiod and 1,200 adults and 1,200 children in post-period. Andrews and Elixhauser, 2000 Ethnic differences in receipt of major therapeutic procedures during hospitalization. Data from 1993 discharge abstracts from Healthcare Cost and Utilization Project State Inpatient Database for California, Florida, and New York. Weinick, Zuvekas, and Cohn, 2000 Racial and ethnic magnitude of disparities in use of health care services from 1977 to 1996. Data from three national databases (1977 National Medical Care Expenditure Survey, 1987 National Medical Expenditure Survey, 1996 Medical Expenditure Panel Survey). Services assessed include physician visits, emergency department visits, and inpatient admissions. Difference-in difference method used to identify the program effect of mandatory enrollment in managed care on use of services. African-American beneficiaries had fewer visits to physicians than white beneficiaries after mandatory enrollment. Increases in emergency department visits for African-American children not evident.
Moreover symptoms 2dpo buy trileptal 150mg low price, the chronicle of African Americans medications causing thrombocytopenia 150mg trileptal for sale, alongside Native Americans medications zanaflex 150mg trileptal amex, epitomizes the depth symptoms pneumonia buy 600 mg trileptal with visa, breadth, and intensity of the American racial and ethnic minority experience (Burns and Ades, 1995; Byrd and Clayton, 2000, 2001a, 2002; Feagin and Feagin, 1999; Outlaw, 1990; Smedley, 1999; Stuart, 1987). Though viewed by many as recent occurrences, racial- and ethnicbased health disparities are centuries-old phenomena. They are outcomes that reflect medical-social values and policies in Western (and later U. Could it be that these differences, and the biases and discrimination they both generated and reflected, have dictated or even distorted how the U. What are the origins, bases, and evolution of the biases and inequities that contribute to persistent racial and ethnic health and healthcare disparities? As we acquire the knowledge to begin answering these questions, we can start to understand the nature of the problems, to perform objective analyses, and, eventually, to craft fact-based, logical interventions and solutions for the problems (Byrd and Clayton, 2000, 2001a, 2002; Feagin and Feagin, 1999; Section of House Committee Report to Accompany H. A brief examination of racial and ethnic relations in this country from its colonial past to the present provides the context for the larger examination of health and healthcare as social processes and problems. An examination of the intricacies of the process, its standardization, and its evolutionary phases is both a prerequisite and a necessity, especially as it has related to health and healthcare. A factual chronology about data and its collection is provided in order to appreciate and learn from the past experiences, to dispel assumptions and mythologies, and as a preparation for future fact-based policy-making. This lends a broader and much needed health policy perspective on where we have been and where we need to go. For example, as racial and ethnic minorities become larger percentages of our total population, the health and healthcare of minority Americans become national public policy issues of the first rank-in both relative and absolute terms. Obtaining a background regarding the roles of race, ethnicity, gender, culture, and class in U. In order to acquire a deeper understanding of the present racial and ethnic health and healthcare disparities, one must gain an understanding of the origins, evolution, and perpetuation of racial and ethnic bias, inequities, and disparities in health and healthcare in the United States and its earlier Western predecessor cultures. Moreover, racial and ethnic relations have always been tumultuous in the United States. The use of terms such as dominant group and subordinate group in the study of American racial and ethnic relations suggest-and has often been linked to-racial and ethnic hierarchy, stratification and substantial inequality among groups. Disparate outcomes between European Americans and racial and ethnic minority Americans in many spheres of social life, health, and healthcare-as all are viewed as social processes-are not new and should not be unexpected (Byrd and Clayton, 2000, 2001a, 2002; Feagin and Feagin, 1999; Jaco, 1979; Kosa and Zola, 1975; Pedraza and Rumbaut, 1996; Smedley, 1999). Founded more than 200 years ago after a revolution that cut colonial ties with Europe, the creation of the United States was based on Enlightenment principles of freedom and equality. However, racial and ethnic prejudices, biases, oppression, and conflict were embedded in the colonial antecedents, the founding period, and central documents of the new republic (Brinkley, 1993; Feagin, 2000; Omi and Winant, 1994). The European (predominantly English) colonists often took land from Native Americans (American Indians) by force or collusion. By the late-seventeenth century, the colonists had established an economy strongly based in African-American chattel slavery in the South and on the slave trade in the North. Moreover, throughout succeeding centuries a tradition of oppressing non-English. As Flexner observed, "Whatever their social station, Copyright National Academy of Sciences. Conflict between Anglo-Protestant Americans and Indians varied from outright warfare to separate coexistence. Though the promotion of nonEnglish immigration had coincided with English mercantile and colonial aims and intensified in the nineteenth century, new white immigrants ("foreigners") often met hostility and found themselves less than equal socially or under law. Racial tension and conflict was a constant between Anglo-Protestant Americans and African Americans under 246 years of brutal and exploitive chattel slavery, followed by 100 years of social segregation, physical oppression, political subjugation, and economic exploitation. As English domination was modified over the next two centuries by the challenges and occasional ascendancy of other northern Europeans, southern, and eastern Europeans as well as other non-European groups trying to move up socially, economically, and politically, the United States became an unprecedented and uneasy mix of diverse peoples (Brinkley, 1993; Burns and Ades, 1995; Feagin, 2000; Feagin and Feagin, 1999; Omi and Winant, 1994; Shipler, 1997; Stuart, 1987). Basic documents of the new republic reflect its patterns of racial subordination, ethnic discrimination, and gender difference. Neither the Articles of Confederation, nor the Declaration of Independence, nor the Naturalization Law of 1790 extended the doctrines of freedom and equality to African Americans (Brinkley, 1993; Feagin and Feagin, 1999; Omi and Winant, 1994). One provision of the Naturalization Law of 1790 was that only "white" persons could become citizens (Takaki, 1993, 273). Women were not allowed suffrage until 1920, Native Americans until 1924, and most African Americans until 1965. Slavery was not only legal with blacks designated as chattel, the slave trade was allowed to continue until 1808, and a fugitive slave provision was incorporated by the 1850s that required the return of runaways to their owners. The Alien, Sedition, and Naturalization Acts compromised the rights and citizenship status of immigrants as early as the late 1700s and early 1800s. The Page Act of 1875 restricted the immigration of Chinese women, while the Chinese Exclusion Act of 1882 pro- Copyright National Academy of Sciences. By adopting the English language and accommodating to Englishoriented institutions, white non-British immigrant groups have gained substantial power and status in the United States. However, voluntary and involuntary immigrants from Africa, Asia, and Latin America, as well as Native Americans have remained subordinate to white Americans in political, cultural, and in most instances, economic terms. For example, despite their arrival as agricultural laborers recruited in the 1880s, Japanese Americans could not become naturalized citizens until the passage of the McCarran-Walter Act of 1952 (Omi and Winant, 1994, 81). Though racial and ethnic diversity, inequality, and oppression continue to be part of the foundation of U. Likewise, the poor health status and outcomes of African American and other minority populations are inextricably linked to historical racial and ethnic discrimination (Byrd and Clayton, 2000, 2001b, 2002; Stuart, 1987; Williams, 1999). If current demographic trends continue and people of color become the majority of the U. As will be discussed later, attempts at categorization are further complicated by the complex histories and chronologic layers of definitions and classifications related to racial and ethnic concepts in Western culture (Byrd and Clayton, 2000, 2002; Smedley, 1999). Imprecise and changing definitions of race and ethnicity emanating from the federal government, anthropologists and other social scientists further complicate the issue of definitive categories or classifications (American Anthropological Association, 1997; Thernstrom, Orlov, and Handlin, 1980; Zenner, 1996). Nevertheless, in order to assess the health status, outcomes, and services utilization of vari- Copyright National Academy of Sciences. Although current data collection systems are both imprecise and do not adequately collect data for all the important U. The five racial and two ethnic categories are: American Indian or Alaskan Native, Asian, Native Hawaiian or Pacific Islander, Black, White, Hispanic or Latino, Not Hispanic or Latino [Box 1-1, Introduction, this volume], and originate from a 1977 Office of Management report (Haynes and Smedley, 1999). Depending on the data source, these racial or ethnic classifications are based on self-classification or on observation by an interviewer or other person filling out the questionnaire (National Center for Health Statistics, 2000). Before 1980, the National Vital Statistics System for newborn infants and fetal deaths tabulated the race of the fetus or newborn according to the race of both parents. If the parents were of different races and one parent was White, the child was classified according to the race of the other parent. Since 1989, newborn infants and fetal deaths are tabulated according to the race of the mother (National Center for Health Statistics, 1998a). In spite of these efforts, most existing sources of health data, with the exception of those derived from the census and from the vital registration system (birth and death certificates), permit examination of only the three largest racial and ethnic categories: non-Hispanic White persons, non-Hispanic Black persons, and persons of Hispanic or Mexican origin (National Center for Health Statistics, 2000). Race has been such an important characteristic in this country that census takers have tallied the racial composition of the population since the first U. Whites were normally distinguished from nonwhites" (Thernstrom, Orlov, and Handlin, 1980, 869). However, "[t]he racial categories used in census enumeration have varied widely from decade to decade" (Omi and Winant, 1994, 3). Until the 1850 census, African Americans were tabulated as either "Slave" or Copyright National Academy of Sciences. Though the 1850 and 1860 censuses collected data for free persons in "White," "Black," or "Mulatto" categories, the main tables continued to designate the overall population as "White," "Slave," and "Free Colored. In 1870, Japanese were added, and the "Civilized Indian" category was divided into "Pure Indians" and "Half-breeds" designations. The first reliable statistics tabulated for Native Americans "are those for 1890, the year in which the Bureau of the Census and Bureau of Indian Affairs made a concerted effort to report accurately the Indian population and the occurrence of vital events" (Stuart, 1987, 96). Census Bureau officials grouped mulattos with Negroes under "Colored" in 1880, but made finer distinctions in 1890, counting 6. Finally admitting these divisions were valueless for analytical purposes, they grouped them all together with the Chinese, Japanese, and Indians under the general heading "Colored" (Thernstrom, Orlov, and Handlin, 1980).
Purpose of these guidelines is to: a) establish guidance for agencies that collect or use aggregate data on race symptoms non hodgkins lymphoma purchase trileptal 300 mg mastercard, and b) establish guidance for the allocation of multiple race responses for use in civil rights monitoring and enforcement symptoms 9 weeks pregnancy buy cheap trileptal 150 mg line. The guidelines do not mandate the collection of race data symptoms 3 weeks into pregnancy buy discount trileptal 150mg on line, but standardize its collection if agencies choose to gather it symptoms vaginal cancer cheap 300 mg trileptal overnight delivery. This initiative began in 1999 with $156 million and 384 Copyright National Academy of Sciences. The funds are distributed in the following areas: 1) providing technical assistance and infrastructure support, 2) increasing access to prevention and care, and 3) building stronger linkages to address the needs of specific populations. Grants are provided to community-based organizations, research institutions, minority-serving colleges and universities, healthcare organizations, and state and local health departments. The partnership includes a three-phase plan to develop guidelines for collaboration to develop a detailed, comprehensive national plan, and to implement the plan by 2002. The first goal of Healthy People 2010 is to help individuals of all ages increase life expectancy and improve their quality of life. The second goal of Healthy People 2010 is to eliminate health disparities among different segments of the population. Products of the initiative include, for example, the publication A Community Planning Guide Using Healthy People 2010, a guide for building community coalitions, creating a vision, measuring results, and creating partnerships dedicated to improving the health of a community. This program facilitates cultural competency training for providers and medical staff, interpreter training for community interpreters and bilingual healthcare workers, outreach to underrepresented communities, community-based research, interpreter services, translation services, and publications and videos relating to cross-cultural healthcare. Office for Civil Rights the Office has engaged in a number of efforts related to disparities in care. It has addressed redlining issues (limiting or eliminating services in Copyright National Academy of Sciences. The New York Regional Office is also investigating allegations of racial disparities in the provision of healthcare services by some healthcare providers in two counties in New York. In addition, Region V (Chicago) has conducted investigations focused on disparities in kidney transplant programs. Agency for Healthcare Research and Quality Measures of Quality of Care for Vulnerable Populations. This initiative will develop and test new quality measures for use in the purchase or improvement of healthcare services for priority populations. For example, one such project will develop a quality of care measure for hypertension in a population of Hmong refugees and pilot test the instrument. A recently funded study will create a partnership of six health providers to evaluate the effectiveness of nurse management compared to usual care for congestive heart failure patients in Harlem. Initiated in 1999, this funding is aimed at generating knowledge about approaches that effectively promote the use of empirically derived evidence in clinical settings that will lead to improved healthcare practice and sustained practitioner behavior change. Understanding and Eliminating Minority Health Disparities Initiative will support the development of Centers of Excellence that will conduct research to provide information on factors that influence quality, outcomes, costs, and access to healthcare for minority populations. This five-year demonstration project seeks to eliminate disparities in health in Copyright National Academy of Sciences. The two-phase project will support community coalitions in the design, implementation, and evaluation of community-driven strategies to eliminate health disparities. Phase I is a 12-month planning period during which needs assessments and action plans are developed. This program provides funding to states/territories to enhance existing registries and create new registries. Alaska Native Colorectal Cancer Education Project is being developed and will involve screening tests and the provision of specific language to Alaska Natives for use with healthcare providers when discussing colorectal cancer. Hispanic Colorectal Cancer Outreach and Education Project is a partnership with the National Alliance for Hispanic Health to increase awareness and screening for colorectal cancer. The program works to ensure that women receive screening services, needed follow-up, and assurance that tests are preformed in accordance with current guidelines. National Training Center initiative trains providers serving AmericanIndian women to enhance cultural sensitivity and client-provider interactions. Research on prostate cancer screening behaviors among African-American men, in collaboration with Loma Linda University, will examine the relationship between what primary care providers report telling their patients about prostate cancer and how the men perceive the messages. Centers for Medicare and Medicaid Services Reducing Health Care Disparities National Project. Its objectives are to improve health status and outcomes in racial/ethnic populations and reduce disparity between healthcare received by beneficiaries who are members of a targeted racial and ethnic group and all other beneficiaries living in each state. For example, projects involve topics such as racial and ethnic variations in medical interactions, improving the delivery of effective care to minorities, and understanding and reducing native elder health disparities. Health Resources and Services Administration Measuring Cultural Competence in Health Care Delivery Settings. This Project in coordination with the Lewin Group seeks to develop a measurement model of cultural competence for healthcare delivery settings. The objectives are to advance the conceptualization of measurement of cultural competence in healthcare settings, identify specific indicators and measures that can be used to assess cultural competence in healthcare, and assess the feasibility and practical application of these measures. Products of the project will include: a framework for measuring cultural competence in healthcare settings; a synthesis and assessment of existing measures; and a report recommending domains, indicators, measures, measurement uses, and data sources regarding competence measurement. A new application competition in the fall of 2001 will support 40 more communities. The Guide emerged out of the Quality Center of the Bureau of Primary Health Care and was developed by Management Sciences for Health, a nonprofit organization focused on the improvement of global health. The goals of the initiative are to: a) integrate dental health activities within the two agencies; b) partner with public agencies and private dental professional educational and advocacy organizations; and c) promote the application of dental science and technology to reduce disparities. Indian Health Service the Indian Health Service has a number of programs in place to improve healthcare access and quality, as well as increase community awareness of disease prevention and treatment. For example, the Southwest Native American Cardiology Program was developed in 1993. This program was developed to provide direct cardiovascular care to Native Americans at reservation clinics within the Navajo, Phoenix, and Tucson Areas as well as provide tertiary care for complex cardiovascular disease in Tucson. The National Diabetes Program was initiated to develop, document, and sustain a public health effort to prevent and control diabetes in American Indian and Alaska Native communities. Other programs, such as the Elder Care Initiative, serve to promote the development of high-quality care for American Indian and Alaska Native elders. The activities of the initiative are focused on information and referral, technical assistance and education, and advocacy. This is accomplished in partnership with a variety of tribal, state, federal, and academic programs. The objectives of the working group are to: develop a five-year Strategic Research Agenda; recruit and train minority investigators to advance community outreach activities; form new and enhance current partnerships with minority and other organizations that have similar goals to close health gaps; define, code, track, analyze, and evaluate progress more uniformly across the agency; and enhance public awareness. The new Center will conduct and support research, training, dissemination of information, and other programs about minority health conditions and about populations with health disparities. The goals of the Center are to assist in the development of an integrated cross-discipline national health research agenda; to promote and facilitate the creation of a robust minority health research environment; and to promote, assist, and support research capacity building activities in the minority and medically underserved communities. Substance Abuse and Mental Health Services Administration Community Action Grant Program-Hispanic priority. Awards are made to Hispanic community-based organizations to support the development and implementation of substance abuse prevention, addictions treatment, and mental health services for Hispanic adults and adolescents. For example, among the new grants is a program that is working toward a specialized dual-diagnosis model for Hispanic/Latino clients with cooccurring mental and addictive disorders. Physicians and nurses serving these communities are being trained at regional meetings, an effort coordinated by the Interamerican College of Physician Surgeons. The panel developed a report that includes Standards from the Consumer Perspective, Clinical Guidelines for Providers, and Provider and System Competencies for Training. The standards are being piloted to develop performance indicators and best practices. Activities of the Special Programs Development Branch have included: the collection of data on access to and quality of mental health services within ethnic and minority communities; working with representatives of consumer, advocacy, professional, and provider organizations serving minority communities to improve mental health treatment; developing guidelines and measures to assist state and local governments in making services and systems of care responsive to diverse cultural needs; and examining the impact of managed care on access, quality, and cost of mental health services for ethnic and minority populations. For example, the Centers for Excellence in Hepatitis C, Treatment and Prevention have been established in California and Florida. The Center has developed culturally sensitive literature on hepatitis C for distribution in minority communities and has been translated into Spanish, Cherokee, and Navajo. The Department has initiated several investigations to examine disparities in care in areas including prostate cancer, cardiac procedures, osteoarthritis care, and delivery of care to American Indians and Hispanic Americans. The communities serviced by the Alliance have large and diverse minority populations, with 26% of residents living below 200% of the federal poverty line.
Syndromes
However facial treatment trileptal 150mg line, pleural fluid should be aspirated for culture whenever technically feasible atlas genius - symptoms buy 300mg trileptal overnight delivery, unless the effusion is too small or there is fast clinical recovery medications used for fibromyalgia discount trileptal 600 mg on line. It may be applied to specimens from respiratory secretions treatment jock itch generic trileptal 300mg with amex, lung aspirate samples, or blood. It is a good diagnostic tool in research and can be used by clinicians in special situations, but it does not differentiate carrier state from disease. More details of these and other tests for viral detection can be found in other chapters. In the early stages, bacterial pneumonia not uncommonly presents with normal chest radiographs. There is also significant variation in interpretation of these radiographs in children. Specificity ranges from 42% to 100% in different studies because of varying definitions of pneumonia. In a study by Bachur and colleagues, 26% of the patients younger than 5 years of age who presented to the emergency department with fever, leukocytosis greater than 20,000 cells/mm3, and no clinical findings suggestive of pneumonia actually had a confirmed diagnosis of pneumonia on radiograph. Although alveolar pneumonia is usually more frequently observed in infections by typical bacteria, compared with interstitial pneumonia (which occurs more frequently in viral pneumonias and after Mycoplasma or Chlamydia infections), it is usually impossible to make an etiologic diagnosis solely on the basis of chest radiogra phs. Food and Drug Administration approved a rapid immunochromatographic test for pneumococcal antigen detection. The sensitivity and specificity are, respectively, 86% and 94% in urine for adult patients. One possible advantage of antigen detection methods is that they do not depend on bacterial viability. In children younger than 6 months of age, there is only a weak immunologic response to capsular bacterial antigens, making this test less useful. It is responsible for more than one half of the cases requiring hospital admissions. Various pneumococcus serotypes have been implicated, with distinct prevalence rates in different parts of the world. It can be very low or higher than 50%, as reported in case series from Africa and Asia. Antibiotic resistance is usually associated with changes in the penicillin-binding sites of the transpeptidases of the bacteria. In 1997, in the United States alone, 92% of resistant pneumococcus strains were from serogroups 23, 6, 9, 19, and 14, which are covered by the current available conjugated vaccines. Resistance to macrolides (which has increased lately) is associated with the alteration of the 50S ribosomal binding site, preventing the drug from inhibiting protein synthesis or the presence of efflux pumps to macrolides. Macrolide resistance is more likely to occur with the widespread use of this class of antibiotics in the community. The most common mode of transmission is direct contact with respiratory secretions. The radiologic findings vary from linear infiltrates and hyperinflation to bronchopneumonia. Pneumonia is not the leading presentation of group A streptococcal infections, with bacteremia and scarlet fever being common, and most significantly among small children. Measles, varicella, and influenza are also associated with co-infections from group A streptococcus since they seem to transiently affect host defenses and open room for commensal bacteria. Staphylococcus Aureus Staphylococcus aureus is secondary to inhalation of the infecting agent. In rare cases, it can be the result of bacteremic spread, usually in situations in which a predisposing factor is present. Radiologic findings include bronchopneumonia with alveolar infiltrates, which is more commonly unilateral. The infiltrates may coalesce and evolve to large areas of consolidation and cavitation. Destruction of bronchial walls may lead to air trapping and pneumatocele formation in at least 50% of cases. It is 466 Infections of the Respiratory Tract effusion and empyema are found in as many as 90% of cases. An increase in white blood cell count is usual but is not sufficiently sensitive or specific to suggest the etiologic diagnosis. Although the appearance of staphylococcal pneumatoceles may be dramatic, usually once the infection is under control, the pneumatoceles resolve completely in the next few months. However, therapeutic decisions can be difficult because most tests do not adequately differentiate viral from bacterial infection in an individual child. An additional issue is the fact that some patients harbor mixed viral and bacterial agents. It is believed that less antibiotic pressure limits the emergence of bacterial resistance. Although no recent studies have addressed the issue, it is common sense to use them whenever bacterial pneumonia is the most probable diagnosis. Few studies compare, in a well-designed fashion, different classes of antimicrobials for the treatment of childhood pneumonia. Since most children from affluent communities do well with very conservative treatment approaches, randomized controlled studies would have to involve large numbers of patients to be able to detect significant differences between treatments. Of note were a low prevalence of positive radiographic findings (14%) and a relatively high rate (20%) of treatment failure. Community-Associated Methicillin-Resistant Staphylococcus Aureus In recent years, community-associated Methicillinresistant S. In this situation, the child usually should be re-examined within 48 hours after beginning treatment. According to the British Thoracic Society guidelines, an Sao2 of 92% or less, cyanosis, respiratory rate greater than 70 breaths per minute, difficulty breathing, intermittent apnea, grunting, inability to feed, and a family incapable of providing appropriate observation or supervision are all indicators for hospital admission among infants. A Canadian board of experts includes also age younger than 6 months as lowering the threshold for admission. Fluid intake should be carefully monitored because pneumonia can be complicated by hyponatremia secondary to the syndrome of inappropriate antidiuretic hormone secretion. The benefit of nasogastric tube feeding should be weighed against its potential for respiratory compromise due to obstruction of a nostril, or by worsening gastroesophageal reflux by interference with lower esophageal sphincter function. Some studies have even shown increase in fever duration with the use of this practice. Though not a common feature, pneumococcus resistance rates of a specific locale should play importantly in the decisionmaking process. As mentioned previously, in real-life situations, causative agents are rarely identified. In these cases, a model associating age and clinical presentation is probably the best guide. Additional studies are required to determine at what level of penicillin resistance there should be a change in therapeutic strategy. One of the reasons for the better response in pneumonia may be the increased blood perfusion in alveoli as compared with those organs. For symptomatic children between 3 weeks and 3 months of age with interstitial infiltrates visible on chest radiograph, a macrolide should be used to cover for agents such as C. Lately, pneumococci have become increasingly macrolide resistant, so it is our suggestion to leave macrolides as a second-line treatment for situations in which atypical infections are either probable or confirmed by laboratory tests. The addition of a beta-lactamase inhibitor does not confer additional coverage for pneumococcus because this is not its resistance-associated mechanism. Atypical bacteria are not common agents in infancy and early childhood and should be considered only for unresponsive cases. Vancomycin or teicoplanin should be reserved for severely ill patients, when coverage for high-resistant pneumococcus is desired, because overuse may lead to increased resistance from other pathogens. If the clinical and radiologic findings suggest the possibility of an atypical agent, then a macrolide is the first choice, and a beta-lactam will be added in cases of poor response. Comparisons between different drug dosages of amoxicillin at either 45 or 90 mg/kg/day did not show significant changes in outcomes. When amoxicillin fails to improve pneumonia, high-dose amoxicillin (8090 mg/kg per day) with clavulanic acid in order to cover S. Cefuroxime and cefixime are reasonable options and could be taken into account whenever cost is not a main issue. The role of azithromycin, clarithromycin, and erythromycin is limited to extending the antimicrobial spectrum to atypical organisms, because these agents are relatively inactive against H. Thus, such choices should be tailored to treat organisms that fail first-line therapy.
Effective trileptal 600mg. Long QT Syndrome.