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In Australia, 18F-fluorodeoxyglucose positron emission tomography with low-dose computed tomography (FDG-PET/CT) is currently only funded for cancer staging-related indications. A recent multicenter randomized trial demonstrated that FDG-PET/CT, compared with standard of care computed tomography (CT) imaging, improved antimicrobial management and the outcomes of patients with persistent and recurrent neutropenic fever. There is potential value in expanding the use of FDG-PET/CT as a diagnostic tool for this high-risk population. We conducted an economic evaluation from a healthcare perspective alongside the randomized trial and compared FDG-PET/CT with standard CT up to 6 months after the scans.
Methods
Case report forms were used to collect resource utilization data and length of hospitalization. Effectiveness was measured as the number of patients with antimicrobial rationalization and quality-adjusted life-years (QALYs) derived from patient-reported trial-based health-related quality of life. Generalized linear models (GLM) were used to analyze costs and outcomes. Incremental cost-effectiveness ratios (ICERs) for each of the outcomes were calculated and interpreted as the cost per patient with antimicrobial rationalization and cost per QALY gained. To account for sampling, we performed bootstrapping with 1,000 replications using the recycled predictions method.
Results
The adjusted healthcare costs were lower in the FDG-PET/CT group (mean AUD49,563, 95% confidence interval [CI]: 36,867, 65,133; equivalent to USD34,268, 95% CI: 25,490, 45,033) compared with the standard CT group (mean AUD57,574, 95% CI: 44,837, 73,347; equivalent to USD39,807, 95% CI: 31,000, 50,712). The magnitude of differences in QALYs between the two groups was small (0.001; 95% CI: -0.001, -0.001). When simulated 1,000 times, our analysis showed that across both outcomes FDG-PET/CT was the dominant strategy as it was cheaper and had better outcomes than standard CT in 74 percent of simulations.
Conclusions
FDG-PET/CT is cost effective when compared with standard CT for investigating persistent or recurrent neutropenic fever in high-risk patients. Aligning economic evaluations with clinical studies is key to an integrated evidence generation approach for supporting funding for FDG-PET/CT in this patient group.
To evaluate the effects of handshake antimicrobial stewardship on medicine floors at a large tertiary care hospital.
Design:
Retrospective observational study.
Setting:
1,278-bed academic hospital.
Patients:
Adults admitted to non-ICU medicine services.
Interventions:
A handshake stewardship team consisting of an infectious diseases (ID) physician and pharmacist reviewed charts of patients receiving antimicrobials on medicine floors without a formal ID consult. Recommendations were communicated in-person to providers and acceptance rates were examined with descriptive statistics. Additional data regarding program perception among providers were obtained via surveys. Antibiotic usage trends were extracted from National Healthcare Safety Network Antimicrobial Use option data and evaluated using an interrupted time-series analysis pre- and post-intervention.
Results:
The overall acceptance rate of interventions was 80%, the majority being recommendations either to discontinue (37%) or de-escalate therapy (28%). Medical residents and hospitalists rated the intervention favorably with 90% reporting recommendations were helpful all or most of the time. There was a statistically significant decrease in vancomycin (78 vs 70 DOT/1,000 d present (DP), p = 0.002) and meropenem (24 vs 17 DOT/1,000 DP, p = 0.007) usage and a statistically significant increase in amoxicillin-clavulanate usage (11 vs 15 DOT/1,000 DP, p < 0.001). Overall antibiotic usage remained unchanged by the intervention, though pre-intervention there was a nonsignificant overall increasing trend while post-intervention there was a nonsignificant decreasing trend in overall usage. There was no change in in-hospital mortality.
Conclusion:
The addition of handshake stewardship with adult medicine services was favorably viewed by participants and led to shifts in antibiotic usage.
Chapter 5 begins with a review and critique of the classic, natural kinds, account of emotional experience and communication.It summarizes LeDoux’s research on survival circuits, then Barrett’s theory of cultural construction of emotions.It discusses research on alternative theories, including self-attribution, excitation transfer, and facial feedback, and emotion as part of communication strategy.It discusses Damasio’s evidence that emotion plays a vital role in reasoning.It closes with the role of signals and metaphors in communicating emotion.
The introduction briefly summarizes the contrasts between traditional views about mind and communication, including the computer and code metaphors.It summarizes the central perspective of the book, that human communication is embodied in a biological sense, as well as in a social and cultural sense, and briefly explains the meaning of these terms. It presents a case for conceptual clarity as a basis for critiquing conventional terminology based on computer and code metaphors, and proposes a more direct and accurate set of terms.
Chapter 13 begins with a definition of story and a brief overview of past theory and research.Then story structure, master-plots, and themes are discussed, using examples from well-known literature as well as from actual discourse.Different forms and uses of stories in conversation are discussed, including retold stories and stories that express or celebrate group identity.
Chapter 8 discusses the processes involved in building and maintaining satisfactory relationships.It covers politeness theory, facework, morality, and how these contribute to relationship homeostasis.
Chapter 3 summarizes recent and current theories of how language and conversation may have evolved and the nature of language.Chapter 3 includes discussion of animal signaling and the role of complex social organization, collaboration, imitation, and play in language evolution.It summarizes and critiques the contributions of meme theory to the social evolution account of language development, and closes with a discussion of how language extends and contributes to individual and group homeostasis.
Chapter 9 begins with a review of the contribution of talk to maintaining homeostasis through “small talk” and other forms of “grooming,” both as a response to complex social structure and in facilitating social cooperation.It discusses the role of talk in forward projection of group-level representations, and the role of forward projection of a conversation topic in sustaining and managing conversations.It discusses the role of both physical constraints and social constraints such as politeness norms and facework in shaping the structure of conversation practices.It discusses the fine structure of conversation, in which the interpretations of utterances are confirmed or revised by subsequent utterances and the macro-structure of conversation (beginnings, turn-taking, topics, and closure).
Chapter 4 begins with a discussion of consciousness, then summarizes and critiques the computer metaphor for thinking.It summarizes the role of perceptual and motor simulation in thinking and communication, along with some of the key research on simulation.It shows how simulations, semantic connections, and metaphors may be merged into a unified account of thinking and language use.
Chapter 2 introduces and explains the concept of homeostasis, and other concepts central to the evolution of the neural system, brain, and signaling.It describes key communication-related features of the evolving brain and contrasts them with digital computers as a basis for criticizing the computer metaphor and associated terminology.It introduces crucial concepts, including theory of mind, identity, and consciousness.
Chapter 12 begins with an overview, and a distinction among various categories of humor, followed by a summary and critique of conventional humor theories, using common examples.It then turns to a discussion of humor in contribution, its effects on bonding and group solidarity, and its functions in maintaining group homeostasis.Then coping humor is discussed, followed by an extended discussion of irony and the potential persuasive effects of humor.
Chapter 7 provides a detailed discussion of cognitive context, communication context, and how they interact in conversation.It covers framing and relevance theory, and introduces politeness and facework.
Chapter 14 begins with a general discussion of how the affordances and constraints of media affect their adoption and use, and conversely how they affect social interaction, language use, culture, and social structure.It then discusses the particular affordances, constraints, and effects of classes of media, beginning with language itself.
Chapter 6 begins with an extended discussion of intentionality and pattern, and applies it to distinguishing the concepts of signal, cue, and incidental behavior.These concepts are then applied to a more precise definition of communication.There follows a detailed discussion of signals, signaling systems, and language. Then Chapter 6 covers the role of signals in conversation and in relationship.Finally, the chapter takes up the topic of ad hoc signals, and the question, whether communicative signals are analog or digital.