Aug 312014
 
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Different clinical presentation of community-onset bacteremia among human immunodeficiency virus-infected and human immunodeficiency virus-uninfected adults in the ED.

Am J Emerg Med. 2014 Aug 2;

Authors: Lee CC, Chu FY, Ko WC, Chi CH

Abstract
OBJECTIVES: The objective of this study is to analyze the differences in clinical presentation and outcome of community-onset bacteremia between human immunodeficiency virus (HIV)-infected adults and HIV-uninfected adults visiting the emergency department (ED).
METHODS: A multicenter, case-control study with a ratio of 1:4 was conducted retrospectively over an 8-year period. Demographic characteristics, severity of illness, and clinical outcomes determined from chart records were analyzed.
RESULTS: In total, 74 HIV-infected adults (case patients) and 288 HIV-uninfected adults (control patients) were examined. Significant differences in clinical presentation, severity, and the source of bacteremia as well as bacteremia-causing microorganisms between the case patients and control patients were observed by univariate analyses. Using multivariate analyses, the following variables were positively associated with case patients: male sex (odds ratio [OR], 3.42; P = .01), bacteremia due to endocarditis (OR, 7.68; P = .007), bacteremia due to Salmonella enteritidis (OR, 4.29; P = .03), and comorbidity with chronic hepatitis (OR, 5.65; P < .001). Moreover, several independent risk factors of 28-day mortality were discovered, including inappropriate empirical antibiotic therapy after the ED visit (OR, 9.01; P < .001), an initial syndrome with septic shock (OR, 5.37; P < .001); a Pittsburgh bacteremia score greater than or equal to 4 points at the ED (OR, 4.28; P = .002), severe underlying disease based on McCabe classification (rapid and ultimately fatal; OR, 3.31; P = .002), and bacteremia due to pneumonia (OR, 2.66; P = .03). Of note, HIV infection was not a significant factor affecting 28-day mortality.
CONCLUSIONS: This study demonstrated that the clinical characteristics, the severity, and the character of bacteremia in HIV-infected and uninfected patients varied among community-onset bacteremic patients visiting the ED, despite the limited impact of HIV infection on short-term outcomes.

PMID: 25171801 [PubMed - as supplied by publisher]

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Aug 302014
 
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Accuracy of Statin Assignment Using the 2013 AHA/ACC Cholesterol Guideline Versus the 2001 NCEP ATP III Guideline: Correlation With Atherosclerotic Plaque Imaging.

J Am Coll Cardiol. 2014 Sep 2;64(9):910-9

Authors: Johnson KM, Dowe DA

Abstract
BACKGROUND: Accurate assignment of statin therapy is a major public health issue.
OBJECTIVES: The American Heart Association and the American College of Cardiology released a new guideline on the assessment of cardiovascular risk (GACR) to replace the 2001 National Cholesterol Education Program (NCEP) Adult Treatment Panel III recommendations. The aim of this study was to determine which method more accurately assigns statins to patients with features of coronary imaging known to have predictive value for cardiovascular events and whether more patients would be assigned to statins under the new method.
METHODS: The burden of coronary atherosclerosis on computed tomography angiography was measured in several ways on the basis of a 16-segment model. Whether to assign a given patient to statin therapy was compared between the NCEP and GACR guidelines.
RESULTS: A total of 3,076 subjects were studied (65.3% men, mean age 55.4 ± 10.3 years, mean age of women 58.9 ± 10.3 years). The probability of prescribing statins rose sharply with increasing plaque burden under the GACR compared with the NCEP guideline. Under the NCEP guideline, 59% of patients with ≥50% stenosis of the left main coronary artery and 40% of patients with ≥50% stenosis of other branches would not have been treated. The comparable results for the GACR were 19% and 10%. The use of low-density lipoprotein targets seriously degraded the accuracy of the NCEP guideline for statin assignment. The proportion of patients assigned to statin therapy was 15% higher under the GACR.
CONCLUSIONS: The new American Heart Association/American College of Cardiology guideline matches statin assignment to total plaque burden better than the older guidelines, with only a modest increase in the number of patients who were assigned statins.

PMID: 25169177 [PubMed - in process]

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Aug 302014
 
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Comparison of Mortality in Patients With Acute Myocardial Infarction Accidentally Admitted to Non-cardiology Departments Versus That in Patients Admitted to Coronary Care Units.

Am J Cardiol. 2014 Jul 30;

Authors: D'Souza M, Saaby L, Poulsen TS, Diederichsen AC, Hosbond S, Diederichsen SZ, Larsen TB, Schmidt H, Gerke O, Hallas J, Gislason G, Thygesen K, Mickley H

Abstract
The aim of this study was to prospectively investigate the clinical characteristics including symptoms and long-term mortality in patients with acute myocardial infarction (AMI) accidentally admitted to non-cardiology departments (NCDs). For comparison, similar observations in patients admitted to the coronary care unit (CCU) were collected. During a 1-year period, consecutive patients having cardiac troponin I measured at the Odense University Hospital were considered. The hospital has 27 clinical departments. Patients were classified as having an AMI if the diagnostic criteria of the universal definition were met. Follow-up was at least 1 year with mortality as the clinical end point. Of 3,762 consecutive patients, an AMI was diagnosed in 479, of whom 114 patients (24%) were hospitalized in NCDs and 365 (76%) in the CCU. Chest pain or chest discomfort more frequently occurred in patients from the CCU (83%) than in patients from the NCDs (45%, p <0.0001). At median follow-up of 2.1 years, 150 patients had died: 73 (64%) of patients from the NCDs and 77 (21%) of the patients from the CCU. In the multivariable Cox regression analysis, the adjusted hazard ratio of mortality for patients from the NCDs versus CCU was 2.0 (95% confidence interval 1.3 to 3.2). In conclusion, chest pain/discomfort was absent in more than half of the patients with AMI admitted to NCDs, and admission to NCDs was an independent predictor of a 2 times higher long-term mortality in comparison with admission to the CCU.

PMID: 25169985 [PubMed - as supplied by publisher]

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Aug 302014
 
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Mortality following acute pancreatitis: social deprivation, hospital size and time of admission: record linkage study.

BMC Gastroenterol. 2014 Aug 28;14(1):153

Authors: Roberts SE, Thorne K, Evans PA, Akbari A, Samuel DG, Williams JG

Abstract
BACKGROUND: Very little is known about whether mortality following acute pancreatitis may be influenced by the following five factors: social deprivation, week day of admission, recruitment of junior doctors in August each year, European Working Time Directives (EWTDs) for junior doctors' working hours and hospital size. The aim of this study was to establish how mortality following acute pancreatitis may be influenced by these five factors in a large cohort study.
METHODS: Systematic record linkage of inpatient, mortality and primary care data for 10 589 cases of acute pancreatitis in Wales, UK (population 3.0 million), from 1999 to 2010. The main study outcome measure was mortality at 60 days following the date of admission.
RESULTS: Mortality was 6.4% at 60 days. There was no significant variation in mortality according to social deprivation or the week day of admission. There was also no significant variation according to calendar month for acute pancreatitis overall or for gallstone aetiology, but for alcoholic acute pancreatitis, mortality was increased significantly by 93% for admissions during the months of August and September and 102% from August to October when compared with all other calendar months. Mortality was increased significantly for alcoholic aetiology in August 2004, the official month that the first EWTD was implemented, but there were no other increases following the first or second EWTDs. There were also indications of increased mortality in large hospitals when compared with small hospitals, for acute pancreatitis overall and for gallstone aetiology but not for alcoholic acute pancreatitis, although these increases in mortality were of quite marginal significance.
CONCLUSIONS: Although we found some evidence of increased mortality for patients admitted with alcoholic acute pancreatitis during August to October, in August 2004, and in large hospitals for acute pancreatitis overall and for gallstone aetiology, the study factors had limited impact on mortality following acute pancreatitis and no significant impact when adjusted for multiple comparisons.

PMID: 25168857 [PubMed - as supplied by publisher]

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Aug 302014
 
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International normalized ratio stabilization in newly initiated warfarin patients with nonvalvular atrial fibrillation.

Curr Med Res Opin. 2014 Aug 29;:1-21

Authors: Nelson WW, Desai S, Damaraju CV, Lu L, Fields LE, Wildgoose P, Schein JR

Abstract
Abstract Background-Warfarin is effective for stroke prevention in patients with atrial fibrillation (AF), but international normalized ratio (INR) levels fluctuate and frequent monitoring is necessary. Methods-This study used data from a large anticoagulation management service database to analyze the relationship between INR stabilization and warfarin utilization for >1 year in patients with nonvalvular AF (NVAF). Anticoagulation records from a large United States (US) electronic database collected from 2006 to 2010 were analyzed. Results-Patients with NVAF and ≥3 INR values in the dataset were identified (n=15,276). INR stabilization was defined as the first three consecutive INR values between 2.0 and 3.0 after warfarin initiation. One quarter of patients (n=3809) failed to reach INR stabilization. After initial stabilization, 30% of subsequent INR values were out of range. The mean (± standard deviation [SD]) follow-up time from stabilization to the end of study for these patients was 494.2±418.1 days. Age ≥75 years (odds ratio [OR]=1.17, 95% confidence interval [CI]=1.08-1.27), hypertension (OR=1.19, 95% CI=1.10-1.29), or prior stroke (OR=1.29, 95% CI=1.04-1.61) were positively associated with achieving stabilization; heart failure was negatively associated with stabilization (OR=0.78, 95% CI=0.70-0.87). Male gender (p<0.0001) and hypertension were associated with earlier stabilization (p=0.0013); heart failure was associated with later stabilization (p=0.0098). Patients who achieved INR stabilization within 1 year were 10 times more likely to remain on warfarin than patients who did not achieve it. Limitations-Observational data may contain incomplete records. Data on adherence, concurrent medications, vitamin K intake, genotype, reasons for discontinuation of monitoring, and patient outcomes were not available in the dataset. The study findings were generalizable only to patients with AF who were managed by anticoagulation clinics. Conclusion-Given the importance of stroke prevention among patients with AF, the potential for unpredictable INR patterns should be carefully considered during clinical decision-making.

PMID: 25170587 [PubMed - as supplied by publisher]

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Aug 302014
 
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Hyperglycemia in the intensive care unit: is insulin the only option?

Crit Care. 2013 Nov 13;17(6):1012

Authors: Dungan KM

Abstract
Current guidelines advocate the use of insulin for the management of hyperglycemia in the hospital setting. However, insulin is limited by a narrow therapeutic window, frequent errors, a need for expertise and systems-based monitoring, and lack of specificity for metabolic abnormalities that occur during critical illness. As a result, non-insulin alternatives have garnered increasing interest for managing hyperglycemia in the hospital. However, non-insulin therapies have had safety and tolerability concerns, patients may still need insulin for glycemic control, and there have been limited outcomes data supporting their use. In the study by Christiansen and colleagues in the previous issue of Critical Care, pre-admission metformin therapy was associated with reduced mortality in critically ill patients with type 2 diabetes. The mortality benefit persisted after controlling for other variables, and was particularly prominent when metformin was continued during admission. Furthermore, the reduction in mortality was observed despite a slightly increased prevalence of lactic acidosis in metformin users. The protective effects of metformin are purported to be related to pleiotropic, possibly anti-inflammatory mechanisms, raising the question of benefit in patients without diabetes. Thus, the findings warrant a re-appraisal of the risks and benefits of metformin use during critical illness. However, in order to justify the revision of multiple guidelines and changes in product labeling, clinical trials in carefully selected patient populations are indicated.

PMID: 25169675 [PubMed - as supplied by publisher]

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