Patient Outcomes Research Team Research Articles

A comparative study between curb-65 and psi/port score as predictors for ICU admission and mortality in community acquired pneumonia patients presenting to a tertiary care hospital

Despite recent advances in clinical medicine, mortality due to CAP has remained relatively the same. Therefore, early recognition for ICU admission plays a pivotal role in management of CAP. PSI/PORT (Pneumonia Severity Index/ Pneumonia Patient Outcome Research Team) score and CURB-65 (Confusion, Uremia, Respiratory rate, BP, Age > 65 years) are the two severity assessment scores that have extensively been used by the clinicians to distinguish between high risk and low risk patients. This study aims at comparing the predictive value of these two scores for ICU admission and mortality. The information required for calculating CURB-65 and PSI was extracted with careful history taking, patient assessment and necessary investigations. Patients with >18 years of age, diagnosed clinically and radiologically with CAP were included in the study.CURB-65 and PSI scores were determined in a total of 131 patients on admission. Based on careful clinical assessment and judgment of treating physician 60 patients were admitted in ICU whereas 71 patients were admitted in medical ward. Out of 60 patients admitted in ICU 23 died. The ability to predict ICU admission was almost similar for PSI/PORT score (AUC 0.9605; 95% CI 0.9277-0.9933) and CURB-65 (AUC 0.9694; 95% CI 0.9368-1.9714). The ability to predict mortality was almost similar for PSI/PORT score (AUC 0.9196; 95% CI 0.8670-0.9722) and CURB-65 (AUC 0.9214 95% CI 0.8696-0.9732). CURB-65 score was found almost similar in predicting ICU admission amongst patients coming with CAP to our hospital when compared to PSI/PORT score and when predicting mortality in patients with community-acquired pneumonia, CURB-65 and PSI/PORT score appear to have comparable specificity and sensitivity. Considering the simplicity, CURB-65 score could be preferred over PSI/PORT score. However, larger studies are required to know the exact Indian scenario. Despite of recent advances in the field of medical science the mortality due to CAP has remained relatively the same. Therefore, early diagnosis and admission to ICU with standard treatment play a pivot role in management of patients with CAP. Two scoring system, PSI/PORT score and CURB-65 score, are widely being used to differentiate between low risk and high risk patients. We undertook this study for comparing the predictive value of these two scores for ICU admission and mortality.

Understanding the provision of psychological interventions for psychosis in an Australian mental health service: a mixed methods study

ABSTRACT Objective To describe the provision of evidence-based psychological therapies for the treatment of psychosis in a large Australian mental health service; and to explore the barriers and facilitators to providing these therapies. Method Mixed-methods study including: 1) a retrospective audit of 100 clients with schizophrenia spectrum disorder to estimate adherence to guideline recommended psychological therapies; and 2) a cross-sectional survey of community based mental health practitioners, based on the Theoretical Domains Framework, to understand the barriers and facilitators to delivering psychological therapies to clients with psychosis. Results Twenty-five percent (25/100) of the audited sample engaged with psychological services. Of those who did, two received the recommended dose of evidence-based therapy. Thirty-three percent (37/112) of mental health practitioners completed the survey. Barriers to the delivery of psychological therapies related to perceived lack of knowledge, skills, and confidence with the therapies, and beliefs about who will (and will not) benefit. Other barriers included lack of time, demanding caseloads, and a culture of risk and crisis management. Conclusions People with psychosis have poor access to evidence-based psychological therapies. The barriers to providing psychological therapies are multifactorial and should be systematically addressed to improve health and quality of life outcomes for people living with psychosis. Abbreviations: CBT: Cognitive behaviour therapy; CBTp: cognitive behaviour therapy for psychosis; CRT: cognitive remediation therapy; FIp: family intervention for psychosis; PORT: Patient Outcomes Research Team; RANZCP: Royal Australian and New Zealand College of Psychiatrists; NICE: UK National Institute of Clinical Excellence; TDF: The Theoretical Domains Framework; HoNos: Health of the Nation Scale; EBPIs: Evidence Based Psychological Interventions; ACT: Acceptance and Commitment Therapy.

Decoding the Chronic Obstructive Pulmonary Disease (COPD) Puzzle: Investigating the Significance of Exacerbation Scores in Triage Decision-Making.

Chronic obstructive pulmonary disease (COPD) is a complex disease pathology of the lungs that has a significant impact on global health. It has been a major contributor toglobal mortality and morbidity, with COPD exacerbations posing a substantial economic burden on the healthcare systems. Appropriate triaging of patients with COPD exacerbation is crucial to reduce the burden of hospitalization, especially in the intensive care unit (ICU). Understanding the significance of exacerbation scores in triage decision-making is essential for improving outcomes and optimizing patient care.To aid this triage decision-making, several scoring systems have been developed. This review article aims to discuss the different scores, including assessment of Confusion, Urea, Respiratory rate, Blood pressure, and Age (≥65 years) (CURB-65); Dyspnoea, Eosinopenia, Consolidation, Acidaemia and atrial Fibrillation (DECAF), Neutrophil to lymphocyte ratio (NLR); Platelet-lymphocyte ratio (PLR); Pneumonia severity index/Pneumonia Patient Outcomes Research Team (PSI/PORT); and elevated BUN, Altered mental status, Pulse, Age (>65 years) (BAP-65), and their role in triaging COPD exacerbations. Proper triaging allows for the appropriate allocation of resources and timely interventions based on severity. Further research and validation are needed to establish the optimal use and integration of these scores in clinical practice, particularly in ICU settings.

Application of metagenomic next-generation sequencing in the diagnosis and resistome analysis of community-acquired pneumonia pathogens from bronchoalveolar lavage samples.

To perform a prospective diagnostic study exploring the clinical utility of metagenomic next-generation sequencing (mNGS) in diagnosing community-acquired pneumonia (CAP), and revealing resistome differences in bronchoalveolar lavage fluid (BALF) from CAP patients with varying severity of admission base on Pneumonia Patient Outcomes Research Team (PORT) risk classes. We compared the diagnostic performances of mNGS and conventional testing for the detection of pathogens in BALF from 59 CAP patients, and performed resistome differences analysis of metagenomic data from 59 BALF samples, namely, 25 from CAP patients with PORT score I (I group), 14 from CAP patients with PORT score II (II group), 12 from CAP patients with PORT score III (III group), and 8 from CAP patients with PORT score IV (IV group). The diagnostic sensitivities of mNGS and conventional testing for the detection of pathogens in BALF in patients with CAP were 96.6% (57/59) and 30.5% (18/59), respectively. There was a significant difference in the overall relative abundance of resistance genes between the four groups (P=0.014). The results of principal coordinate analysis based on Bray-Curtis dissimilarities showed that there were significant differences in the composition of resistance genes among the I, II, III, and IV groups (P=0.007). A large number of antibiotic resistance genes, such as those affiliated with multidrug, tetracycline, aminoglycoside, and fosfomycin resistance, were enriched in the IV group. In conclusion, mNGS has a high diagnostic value in CAP. There were significant differences present in microbiota resistance to antibiotics in BALF from CAP patients in different PORT risk classes, which should attract enough attention.

Psychological Treatments for Psychosis: History and Overview.

This article is part of the ISPS (International Society for the Psychological Treatment of the Schizophrenias and other Psychoses) task force report on the PORT (Patients Outcome Research Team) recommendations for treatment of schizophrenia. It reviews psychological treatment approaches in psychosis to date and assesses recent trends. The most influential therapies have been psychoanalytic/psychodynamic, cognitive behavioral (CBT), and supportive therapy.

Omadacycline vs moxifloxacin in adults with community-acquired bacterial pneumonia

ObjectiveCommunity-acquired bacterial pneumonia (CABP) is a major clinical burden worldwide. In the phase III OPTIC study (NCT02531438) in CABP, omadacycline was found to be non-inferior to moxifloxacin for investigator-assessed clinical response (IACR) at post-treatment evaluation (PTE, 5–10 days after last dose). This article reports the efficacy findings, as specified in the European Medicines Agency (EMA) guidance. MethodsPatients were randomized 1:1 to omadacycline 100 mg intravenously (every 12 h for two doses, then every 24 h) with optional transition to 300 mg orally after 3 days, or moxifloxacin 400 mg intravenously (every 24 h) with optional transition to 400 mg orally after 3 days. The total treatment duration was 7−14 days. The primary endpoint for EMA efficacy analysis was IACR at PTE in patients with Pneumonia Patient Outcomes Research Team (PORT) risk class III and IV. ResultsIn total, 660 patients were randomized as PORT risk class III and IV. Omadacycline was non-inferior to moxifloxacin at PTE. The clinical success rates were 88.4% and 85.2%, respectively [intent-to-treat population; difference 3.3; 97.5% confidence interval (CI) −2.7 to 9.3], and 92.5% and 90.5%, respectively (clinically evaluable population; difference 2.0; 97.5% CI 3.2–7.4). Clinical success rates with omadacycline and moxifloxacin were similar against identified pathogens and across key subgroups. ConclusionsOmadacycline was non-inferior to moxifloxacin for IACR at PTE, with high clinical success across pathogen types and patient subgroups.

Association of acute phase reactants with prognostic scores in community acquired pneumonia.

To investigate the association of C-reactive protein and procalcitonin with commonly used prognostic scoring systems, hospitalisation and mortality in cases of community-acquired pneumonia. The prospective study was conducted from April 2014 to April 2015 at the emergency department of Marmara University Pendik Research and Training Hospital, Turkey, and comprised community-acquired pneumonia patients diagnosed according to the British Thoracic Society criteria. Prognosis was estimated using confusion, urea, respiratory rate, blood pressure and age >65, Pneumonia Severity Index-Pneumonia Patient Outcome Research Team score, and severe community-acquired pneumonia scores. Data was analysed using MedCalc 15.8. Of the 203 patients assessed, community-acquired pneumonia was confirmed in 152(74.8%). Procalcitonin had moderate correlation with the three scales used (p<0.001), while C-reactive protein had weak correlation with them (p<0.004). Both procalcitonin and C-reactive protein levels were found to be correlated with prognostic risk scores.

Psychosocial interventions in schizophrenia: Focus on guidelines.

Schizophrenia is a lifelong condition with acute exacerbations and varying degrees of functional disability. Acute and long-term treatments are based on antipsychotic drugs, even if some domains of personal and social functioning are not addressed by psychopharmacotherapy. In fact, psychosocial interventions show a positive impact on patient's functioning and clinical outcome. In addition, psychosocial interventions are significantly associated with a lower number of relapses and hospitalizations in schizophrenia. An analytical review of the International Guidelines on Psychosocial Interventions in Schizophrenia has been performed; we included the National Institute for Health and Care Excellence (NICE) guidelines, the Scottish Intercollegiate Guidelines Network (SIGN) guidelines, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) guidelines, the Schizophrenia Patient Outcomes Research Team (PORT) guidelines and the American Psychiatric Association (APA) guidelines. The international guidelines recommend psychosocial interventions as supportive treatments alongside pharmaceutical or psychotherapeutic ones. More research studies need to be conducted and included in the updated version of the international guidelines to confirm the effectiveness of psychosocial interventions in the long-term outcome of schizophrenia.

Use of Evidence-Based Practices in Recreational Therapy for Schizophrenia Spectrum Disorder Recovery: A Descriptive Study of Current Practices

Schizophrenia spectrum disorder (SSD) represents a group of complex and chronic psychotic disorders affecting approximately 10.7% of the global population. Even though there is no cure for SSD, most symptoms can improve with active treatment. Effective interventions include pharmaceuticals and psychosocial treatments such as recreational therapy (RT). RT can provide effective and efficient care to individuals with SSD by grounding interventions in evidence-based practices indicated in the Mental Health Recovery Model (MHRM), as well as utilizing recommendations by the Schizophrenia Patient Outcome Research Team (PORT). A cross-sectional survey was used to identify awareness and utilization of MHRM principles and PORT recommendations in RT services for individuals with SSD. Data from 126 surveys completed by recreational therapists who currently or have previously provided treatment for individuals with SSD indicated discrepancies in awareness and utilization of MHRM principles and PORT recommendations. Implications for RT practice are discussed.Subscribe to TRJ

A quick scoping review of psychosocial treatment recommendations for African Americans with schizophrenia spectrum disorders

ABSTRACTObjective: To determine the generalizability of the Schizophrenia Patient Outcomes Research Team (PORT) 2009 treatment recommendations to African Americans. Methods: We examined inclusion of African Americans with schizophrenia spectrum disorders in 58 studies across seven interventions. Results: Evidence varied by intervention. Representation of African Americans ranged from 0% to 83%. The strongest evidence was found for assertive community treatment, supported employment, substance use disorder interventions, skills training, and weight management interventions. Conclusions: Future research should recruit samples that are representative of African Americans. We offer practice recommendations as well as recommendations for social work research to advance generalization of findings to African Americans.

Prognostic influence of toll-like receptor 4 gene polymorphism into community-acquired pneumonia course among young patients with cytomegalovirus persistence.

Objectives:The aim of this study was to determine the predictive role of TLR4 polymorphism in CAP course among young cytomegalovirus-positive patients.Subjects and Methods:One hundred and five patients with pneumonia (age range: 18–44 years) and 61 healthy respondents were observed clinically and specifically (by cytomegalovirus markers and TLR4 + 3725 G/C polymorphism).Results:Among CAP patients, there were 51 male (48.6%) and 54 female (51.4%), with average age 34.1 ± 0.8 years, and there were 19 (18.1%) patients with Pneumonia Patient Outcomes Research Team (PORT) I, 46 (43.8%) patients with PORT II, 31 (29.5%) patients with PORT III, and 9 (8.6%) patients with PORT IV. Cytomegalovirus persistence was detected in 80 (48.2%) patients and 34 (20.5%) healthy respondents (P = 0.003). G/G genotype of TLR4 signaling was found in 78 (74%) patients with pneumonia, G/C in 24 (23%) patients, and C/C in 3 (3%) patients. Among G/C patients, there were 16.2% cytomegalovirus-positive patients versus 6.7% negative patients (P < 0.05), as well as among G/G patients, and there were 59% versus 15,2%, accordingly (P < 0.01). The patients of the main group with G/G genotype were characterized by mostly mild (PORT I – 15 [14.3%]) and moderate pneumonia severity (PORT II – 32 [30.5%] and PORT III – 26 [24.8%] patients). The patients with G/C genotype were characterized by mostly PORT II (11 [10.5%] patients). All C/C genotype patients have PORT II (P < 0.05).Conclusions:Cytomegalovirus persistence worsens the pneumonia course. G/G and G/C TLR4 genotypes are associated with mild pneumonia severity.

2386. Efficacy of Lefamulin (LEF) vs. Moxifloxacin (MOX) Against Common Pathogens in Adults With Community-Acquired Bacterial Pneumonia (CABP): Results From the Phase 3 Lefamulin Evaluation Against Pneumonia (LEAP 1) Study

BackgroundNew CABP treatments with targeted activity and improved tolerability are needed. LEF, a novel pleuromutilin antibiotic that binds to a conserved region of the bacterial ribosome, is in development for IV or oral CABP treatment. This Phase 3 clinical study evaluated the efficacy of LEF vs. MOX in adults with CABP.MethodsIn this multicenter, randomized, double-blind study, 551 adult patients with CABP (Patient Outcomes Research Team Risk Class ≥III) were randomized to LEF 150 mg IV Q12 hours (n = 276) or MOX 400 mg IV Q24 hours (n = 275). After 6 IV doses, qualifying patients could be switched to oral therapy. Adjunctive linezolid was given with MOX for suspected methicillin-resistant S. aureus.Primary outcomes were early clinical response (ECR) in the intent-to-treat (ITT) population (FDA endpoint), and investigator assessment of clinical response (IACR) at test of cure in the modified ITT (mITT) and clinically evaluable (CE-TOC) populations (co-primary EMA endpoints). The microITT population included all patients with a baseline CABP pathogen detected by respiratory tract or blood culture, urinary antigen test, serology, and real-time PCR from sputum, oropharyngeal and nasopharyngeal swabs. The microITT2 population included patients with a CABP pathogen detected by methods excluding PCR. Confirmatory identification and susceptibility testing of isolates, serology, and PCR were performed by a central laboratory.ResultsLEF was noninferior to MOX for ECR and IACR (LEF 87.3% [ITT], 81.7% [mITT], 86.9% [CE-TOC]; MOX 90.2% [ITT], 84.2% [mITT], 89.4% [CE-TOC]). The most common pathogen identified was S. pneumoniae. In the microITT population (n = 159 per arm), LEF and MOX demonstrated similar ECR and IACR rates (figure). LEF was efficacious against S. pneumoniae (including resistant phenotypes), H. influenzae, M. catarrhalis, S. aureus, and atypical pathogens. In the microITT2 population, response rates remained similar across baseline pathogens but showed more variation likely due to smaller sample sizes.ConclusionIn this first Phase 3 clinical trial, LEF showed similar efficacy to MOX against the most commonly identified CABP pathogens. LEF demonstrates promise as a targeted monotherapy for the treatment of CABP in adults. Disclosures T. File, BioMerieux: Scientific Advisor, Consulting fee. Curetis: Scientific Advisor, Consulting fee. Melinta: Scientific Advisor, Consulting fee. Merck: Scientific Advisor, Consulting fee. MotifBio: Scientific Advisor, Consulting fee. Nabriva: Investigator and Scientific Advisor, Consulting fee and Research grant. Pfizer: Scientific Advisor, Consulting fee. Paratek: Scientific Advisor, Consulting fee. L. Goldberg, Nabriva: Employee, Employee Stock Options and Salary. S. Paukner, Nabriva: Employee and Shareholder, Salary. A. Das, Achaogen: Consultant, Consulting fee. Cempra: Consultant, Consulting fee. Contrafect: Consultant, Consulting fee. Paratek: Consultant, Consulting fee. Tetraphase: Consultant, Consulting fee. Wockhardt: Consultant, Consulting fee. Theravance: Consultant, Consulting fee. Zavante: Consultant, Consulting fee. UTILITY: Consultant, Consulting fee. S. P. Gelone, Nabriva Therapeutics: Employee, Equity, Shareholder and Salary. Achaogen: Shareholder, Equity, Shareholder. J. Saviski, Nabrica Therapeutics, plc: Employee, Salary. C. Sweeney, Nabriva: Employee, employee stock options and Salary. E. Seltzer, Nabriva (previous employee and salary): Employee and Shareholder, Salary. G. H. Talbot, Nabriva Therapeutics: Board Member, Consultant and Shareholder, Consulting fee and stock options, board fees. L. B. Gasink, Nabriva: Employee, Salary.

Transforming the Treatment of Schizophrenia in the United States: The RAISE Initiative

The schizophrenia spectrum disorders are neurodevelopmental illnesses with a lifetime prevalence near 1%, producing extensive functional impairment and low expectations for recovery. Until recently, treatment in the United States has largely attempted to stabilize individuals with chronic schizophrenia. The identification and promotion of evidence-based practices for schizophrenia via the Patient Outcomes Research Team, combined with international studies supporting the value of early intervention, provided the foundation for the Recovery After an Initial Schizophrenia Episode (RAISE) project. The RAISE studies further supported the value of reducing the duration of untreated psychosis and providing a multi-element treatment called coordinated specialty care (CSC) to improve outcomes for patients in usual treatment settings. Although CSC programs have proliferated rapidly in the United States, many challenges remain in the treatment and recovery of individuals with schizophrenia in the aftermath of RAISE.

Clinical Utility of Routine CBC Testing in Patients with Community-Acquired Pneumonia.

The goal of this study was to identify situations in which routine complete blood count (CBC) testing could be avoided in patients with community-acquired pneumonia (CAP). This was a retrospective study of 50 patients with CAP. Vital signs, lab results, assessment and plan data, and computerized provider order entry logs were collected to determine if a lab result or clinical finding changed clinical management. Clinical stability was defined based on Patient Outcomes Research Team study criteria. There were 94 CBCs obtained after admission, of which only 6 were associated with management changes. Only two of these instances involved management changes related to patients' pneumonia, while the other cases represented chronic illnesses. Among all patients, the positive likelihood ratio of a post-admission CBC predicting a change in clinical management was low (1.12 [95% confidence interval, 0.86-1.44]). Low utility of CBC testing after admission may represent an opportunity to improvethe value of care in CAP patients. Journal of Hospital Medicine 2017;12:336-338.

Beyond Psychopharmacology: Emerging Psychosocial Interventions for Core Symptoms of Schizophrenia

Psychiatrists who work with patients with severe mental illness often are more focused on diagnosis, medical management, and psychopharmacology than on psychosocial treatments. Furthermore, many psychosocial interventions that show great promise may not be available locally, making it harder for psychiatrists to recognize emerging trends. Finally, there has not been an update in the American Psychiatric Association's Practice Guideline for the Treatment of Schizophrenia for many years, and the most recent Patient Outcomes Research Team (PORT) review of evidence-based psychosocial treatments for schizophrenia was published eight years ago. This article reviews a selection of psychosocial interventions that have shown success in treating some of the more vexing and persistent core schizophrenia symptoms that often continue despite optimal pharmacologic treatment; formerly these had been considered too risky or out of reach for psychosocial intervention. The interventions reviewed include cognitive-behavioral therapy for psychosis (CBTp), which aims to reduce distress and disability from psychotic symptoms; CBT and other behavioral interventions focused for comorbid posttraumatic stress syndrome; cognitive training (remediation) interventions that use computerized training programs to reduce the severity and consequence of cognitive impairment associated with schizophrenia; clubhouse and peer support models that address the social alienation and social defeat endemic to persons with severe mental illness; and supported employment interventions that are effective in helping patients get back to work in a competitive job environment. The interventions are reviewed with the needs of the prescribing mental health clinician in mind. Each intervention's strengths and weaknesses are described, as well as their role in recovery-oriented treatment services.

Few states using clozapine to treat people with schizophrenia

Few states using clozapine to treat people with schizophrenia

Year in review 2014: Lung cancer, pleural diseases, respiratory infections and tuberculosis, bronchoscopic intervention and imaging.

Year in review 2014: Lung cancer, pleural diseases, respiratory infections and tuberculosis, bronchoscopic intervention and imaging.

CBT for psychotic disorders: beyond meta-analyses and guidelines - it is time to implement!

The treatment of psychotic disorders has considerably improved since the introduction of antipsychotic medication more than half a century ago, and there is no doubt that this medication can reduce psychotic symptoms and the risk of relapse 1. However, even though pharmacological treatment is significantly better than placebo, there are a number of patients who experience side effects which in some cases can be harmful, and a proportion of people who still experience psychotic symptoms in spite of antipsychotic treatment 2. There are also patients who refuse antipsychotics because of the risk of side effects, the belief that they are able to handle their difficulties without medication, or a fundamental disagreement with the clinician about the nature of their symptoms. In other words: there is room for improvement, and the use of approaches other than medication alone should be explored. There is clear evidence that cognitive behavior therapy (CBT) can reduce psychotic symptoms in schizophrenia when added to pharmacotherapy 1. Several meta-analyses have supported this conclusion, although many studies did not meet optimal standards for randomized controlled trials with regard to blinded measurement of outcome. The effect size in the most rigorously conducted trials is small 3, and evidence is lacking about the effectiveness of short versus long duration CBT 5. Few trials have directly compared CBT with other talking therapies 4, and it is possible, but not yet proven, that other therapies may also be effective. However, based on current evidence, it has not been established that psychodynamic therapy is better than treatment as usual 1. On this background, the American Schizophrenia Patient Outcomes Research Team (PORT) recommendations state that persons with schizophrenia who have persistent psychotic symptoms while receiving adequate pharmacotherapy should be offered adjunctive CBT to reduce the severity of symptoms 6, and the National Institute for Clinical Excellence (NICE) guidelines recommend to offer CBT to all people with psychosis or schizophrenia 7. In a recent paper, Morrison et al 8 presented data indicating that CBT can be effective even among patients who do not want to take antipsychotic medication. Whilst the sample size was small, this result is promising and warrants replication. Many CBT trials have focused on treatment resistant delusions, where the therapist and the patient will examine the basis and the likelihood of the delusional belief, exploring alternative explanations and identifying behavior that can reduce the stress related to the symptoms. Hallucinations can also be a target for CBT interventions. In a recently published multicenter trial, Birchwood et al 9 reported that CBT focusing on modifying conviction of beliefs linked to the construct of voice power, thereby challenging the omniscience and omnipotence of the voices, can successfully decrease compliance with command hallucinations. This finding is very important from a clinical point of view, as the patients were otherwise treatment resistant, and in many cases posed a significant danger to themselves or others. Hallucinations and delusions, however, are not the only symptoms in schizophrenia. For many patients, negative symptoms, depression, anxiety and low self-esteem are experienced as much more debilitating. CBT has been shown to be a promising intervention in reducing these phenomena. A more holistic approach to treatment, focusing not only on primary symptoms but also on the functional and psychological consequences of having a severe mental illness, is congruent with the current emphasis on factors that can facilitate recovery. In order to ensure that guidelines in different countries are actually rolled out, a carefully designed and closely monitored plan for implementation is required, including financial resources for educational material, training and supervision. Politicians and administrators should understand the need for a strong educational fundament. A continuing focus on intervention quality through skilled supervision is necessary to avoid “puppet on a string” therapists, who can only mechanically implement the intervention as taught in training courses without a clear understanding of what is needed in a specific clinical situation 10. The systematic evaluation of the implementation of CBT interventions in clinical settings can help build on the current evidence base and provide valuable information such as which subgroups may benefit from CBT, the acceptability of the intervention, the durability of treatment effects, and the meaningful outcomes which can be achieved.

Ceftobiprole medocaril: a review of its use in patients with hospital- or community-acquired pneumonia.

Ceftobiprole, the active metabolite of the prodrug ceftobiprole medocaril (Zevtera(®)), is a new generation broad-spectrum intravenous cephalosporin with activity against methicillin-resistant Staphylococcus aureus. Ceftobiprole exhibits potent in vitro activity against a number of Gram-positive and Gram-negative pathogens associated with hospital-acquired pneumonia (HAP) and community-acquired pneumonia (CAP). It is the first cephalosporin monotherapy approved in the EU for the treatment of both HAP (excluding ventilator associated-pneumonia [VAP]) and CAP. In phase III trials, ceftobiprole medocaril was noninferior, in terms of clinical cure rates at the test-of-cure visit, to ceftazidime plus linezolid in patients with HAP and to ceftriaxone±linezolid in patients with CAP severe enough to require hospitalization. In patients with HAP, noninferiority of ceftobiprole medocaril to ceftazidime plus linezolid was not demonstrated in a subset of patients with VAP. In patients with CAP, ceftobiprole medocaril was effective in those at risk for poor outcomes (pneumonia severity index ≥91, Pneumonia Patient Outcomes Research Team score IV-V or bacteraemic pneumonia). In the phase III trials, ceftobiprole medocaril was generally well tolerated, with ≈10% of patients discontinuing the treatment because of adverse events. The most common treatment-related adverse events occurring in ceftobiprole recipients in the trials in patients with HAP or CAP included nausea, diarrhoea, infusion site reactions, vomiting, hepatic enzyme elevations and hyponatraemia. Therefore, ceftobiprole medocaril monotherapy offers a simplified option for the initial empirical treatment of patients with HAP (excluding VAP) and in those with CAP requiring hospitalization.

Predictors of the pathogenicity of methicillin-resistant Staphylococcus aureus nosocomial pneumonia.

The clinical characteristics of patients with nosocomial pneumonia (NP) associated with methicillin-resistant Staphylococcus aureus (MRSA) infection are not well characterized. Three hundred and thirty-seven consecutive patients with MRSA isolation from respiratory specimens who attended our hospital between April 2007 and March 2011 were enrolled. Patients characteristics diagnosed with 'true' MRSA-NP were described with regards to clinical, microbiological features, radiological features and genetic characteristics of the isolates. The diagnosis of 'true' MRSA-NP was confirmed by anti-MRSA treatment effects, Gram-staining or bronchoalveolar lavage fluid culture. Thirty-six patients were diagnosed with 'true' MRSA-NP, whereas 34 were diagnosed with NP with MRSA colonization. Patients with a MRSA-NP had a Pneumonia Patient Outcomes Research Team score of 5 (58.3% vs 23.5%), single cultivation of MRSA (83.3% vs 38.2%), MRSA quantitative cultivation yielding more than 10(6) CFU/mL (80.6% vs 47.1%), radiological findings other than lobar pneumonia (66.7% vs 26.5%), and a history of head, neck, oesophageal or stomach surgery (30.6% vs 11.8%). These factors were shown to be independent predictors of the pathogenicity of 'true' MRSA-NP by multivariate analysis (P < 0.05). 'True' MRSA-NP shows distinct clinical and radiological features from NP with MRSA colonization.