Nov 182014
 
Related Articles

Cystitis: antibiotic prescribing, consultation, attitudes and opinions.

Fam Pract. 2014 Apr;31(2):149-55

Authors: Willems CS, van den Broek D'Obrenan J, Numans ME, Verheij TJ, van der Velden AW

Abstract
BACKGROUND: Despite stable overall antibiotic use between 2007 and 2011 in The Netherlands, use of nitrofurantoin and trimethoprim increased by 32%. The background of this increased antibiotic use against uropathogens is unknown.
OBJECTIVES: To determine whether increased use of urinary tract infection antibiotics is caused by changes in patients' consultation or physicians' prescribing behaviour and to investigate attitudes and opinions of women with respect to cystitis management and antibiotics.
METHODS: Consultation and prescribing for International Classification of Primary Care (ICPC) codes U01 (dysuria), U02 (frequency), U05 (other urination problems), U70 (pyelonephritis) and U71 (cystitis) were determined from 2007 to 2010, using routinely collected primary health care data. Separately, behaviour of women with respect to managing cystitis, consultation and opinions towards (delayed) antibiotic treatment were studied using questionnaires in 2012.
RESULTS: Consultation for U02 and U71 significantly increased from 93 to 114/1000 patient-years from 2007 to 2010; proportion of episodes in which an antibiotic was prescribed remained constant. Questionnaires revealed that urination problems and pain were dominant complaints of cystitis; pain medication, however, was not adequately used. One-third of women directly consult upon first symptoms, whereas the majority awaits an average of 4 days. Sixty-six per cent of women report to be willing to postpone antibiotic use.
CONCLUSION: Increased use of urinary tract infection antibiotics may be caused by increased consultation for cystitis in primary care. Future research should focus on the outcomes of adequate pain medication, enhanced diagnostic procedures and of delaying antibiotic use in cystitis management.

PMID: 24317602 [PubMed - indexed for MEDLINE]

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Nov 182014
 

Cirrhotic cardiomyopathy: A cardiologist's perspective.

World J Gastroenterol. 2014 Nov 14;20(42):15492-15498

Authors: Gassanov N, Caglayan E, Semmo N, Massenkeil G, Er F

Abstract
Cardiac dysfunction is frequently observed in patients with cirrhosis, and has long been linked to the direct toxic effect of alcohol. Cirrhotic cardiomyopathy (CCM) has recently been identified as an entity regardless of the cirrhosis etiology. Increased cardiac output due to hyperdynamic circulation is a pathophysiological hallmark of the disease. The underlying mechanisms involved in pathogenesis of CCM are complex and involve various neurohumoral and cellular pathways, including the impaired β-receptor and calcium signaling, altered cardiomyocyte membrane physiology, elevated sympathetic nervous tone and increased activity of vasodilatory pathways predominantly through the actions of nitric oxide, carbon monoxide and endocannabinoids. The main clinical features of CCM include attenuated systolic contractility in response to physiologic or pharmacologic strain, diastolic dysfunction, electrical conductance abnormalities and chronotropic incompetence. Particularly the diastolic dysfunction with impaired ventricular relaxation and ventricular filling is a prominent feature of CCM. The underlying mechanism of diastolic dysfunction in cirrhosis is likely due to the increased myocardial wall stiffness caused by myocardial hypertrophy, fibrosis and subendothelial edema, subsequently resulting in high filling pressures of the left ventricle and atrium. Currently, no specific treatment exists for CCM. The liver transplantation is the only established effective therapy for patients with end-stage liver disease and associated cardiac failure. Liver transplantation has been shown to reverse systolic and diastolic dysfunction and the prolonged QT interval after transplantation. Here, we review the pathophysiological basis and clinical features of cirrhotic cardiomyopathy, and discuss currently available limited therapeutic options.

PMID: 25400434 [PubMed - as supplied by publisher]

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Nov 182014
 

Embolization of splenorenal shunt associated to portal vein thrombosis and hepatic encephalopathy.

World J Gastroenterol. 2014 Nov 14;20(42):15910-5

Authors: Franzoni Lde C, de Carvalho FC, Garzon RG, Yamashiro Fda S, Augusti L, Santos LA, Dorna Mde S, Baima JP, Lima TB, Caramori CA, Silva GF, Romeiro FG

Abstract
UNLABELLED: Hepatic encephalopathy (HE) is a cognitive disturbance characterized by neuropsychiatric alterations. It occurs in acute and chronic hepatic disease and also in patients with portosystemic shunts. The presence of these portosystemic shunts allows the passage of nitrogenous substances from the intestines through systemic veins without liver depuration. Therefore, the embolization of these shunts has been performed to control HE manifestations, but the presence of portal vein thrombosis is considered a contraindication. In this presentation we show a cirrhotic patient with severe HE and portal vein thrombosis who was submitted to embolization of a large portosystemic shunt.
CASE REPORT: a 57 years-old cirrhotic patient who had been hospitalized many times for persistent HE and hepatic coma, even without precipitant factors. She had a wide portosystemic shunt and also portal vein thrombosis. The abdominal angiography confirmed the splenorenal shunt and showed other shunts. The larger shunt was embolized through placement of microcoils, and the patient had no recurrence of overt HE. There was a little increase of esophageal and gastric varices, but no endoscopic treatment was needed. Since portosystemic shunts are frequent causes of recurrent HE in cirrhotic patients, portal vein thrombosis should be considered a relative contraindication to perform a shunt embolization. However, in particular cases with many shunts and severe HE, we found that one of these shunts can be safely embolized and this procedure can be sufficient to obtain a good HE recovery. In conclusion, we reported a case of persistent HE due to a wide portosystemic shunt associated with portal vein thrombosis. As the patient had other shunts, she was successfully treated by embolization of the larger shunt.

PMID: 25400477 [PubMed - in process]

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Nov 182014
 

Dual Antiplatelet Therapy after Drug-Eluting Stents - How Long to Treat?

N Engl J Med. 2014 Nov 16;

Authors: Colombo A, Chieffo A

Abstract
The rationale behind dual antiplatelet therapy after successful stenting is based upon two indications. First, the stented segment requires protection from stent thrombosis that occurs as a result of inflammation during healing. Second, the areas inside and outside the stented section require protection from the development of progressive atherosclerosis and plaque rupture. The first of these two problems is of less concern with drug-eluting stents, especially second- and third-generation drug-eluting stents.(1),(2) However, the second issue continues to be important. The most effective duration of dual antiplatelet therapy for preventing both stent thrombosis and spontaneous myocardial infarction, while limiting bleeding . . .

PMID: 25399657 [PubMed - as supplied by publisher]

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Nov 182014
 

Low-Dose Aspirin for Primary Prevention of Cardiovascular Events in Japanese Patients 60 Years or Older With Atherosclerotic Risk Factors: A Randomized Clinical Trial.

JAMA. 2014 Nov 17;

Authors: Ikeda Y, Shimada K, Teramoto T, Uchiyama S, Yamazaki T, Oikawa S, Sugawara M, Ando K, Murata M, Yokoyama K, Ishizuka N

Abstract
Importance: Prevention of atherosclerotic cardiovascular diseases is an important public health priority in Japan due to an aging population.
Objective: To determine whether daily, low-dose aspirin reduces the incidence of cardiovascular events in older Japanese patients with multiple atherosclerotic risk factors.
Design, Setting, and Participants: The Japanese Primary Prevention Project (JPPP) was a multicenter, open-label, randomized, parallel-group trial. Patients (N = 14 464) were aged 60 to 85 years, presenting with hypertension, dyslipidemia, or diabetes mellitus recruited by primary care physicians at 1007 clinics in Japan between March 2005 and June 2007, and were followed up for up to 6.5 years, with last follow-up in May 2012. A multidisciplinary expert panel (blinded to treatment assignments) adjudicated study outcomes.
Interventions: Patients were randomized 1:1 to enteric-coated aspirin 100 mg/d or no aspirin in addition to ongoing medications.
Main Outcomes and Measures: Composite primary outcome was death from cardiovascular causes (myocardial infarction, stroke, and other cardiovascular causes), nonfatal stroke (ischemic or hemorrhagic, including undefined cerebrovascular events), and nonfatal myocardial infarction. Secondary outcomes included individual end points.
Results: The study was terminated early by the data monitoring committee after a median follow-up of 5.02 years (interquartile range, 4.55-5.33) based on likely futility. In both the aspirin and no aspirin groups, 56 fatal events occurred. Patients with an occurrence of nonfatal stroke totaled 114 in the aspirin group and 108 in the no aspirin group; of nonfatal myocardial infarction, 20 in the aspirin group and 38 in the no aspirin group; of undefined cerebrovascular events, 3 in the aspirin group and 5 in the no aspirin group. The 5-year cumulative primary outcome event rate was not significantly different between the groups (2.77% [95% CI, 2.40%-3.20%] for aspirin vs 2.96% [95% CI, 2.58%-3.40%] for no aspirin; hazard ratio [HR], 0.94 [95% CI, 0.77-1.15]; P = .54). Aspirin significantly reduced incidence of nonfatal myocardial infarction (0.30 [95% CI, 0.19-0.47] for aspirin vs 0.58 [95% CI, 0.42-0.81] for no aspirin; HR, 0.53 [95% CI, 0.31-0.91]; P = .02) and transient ischemic attack (0.26 [95% CI, 0.16-0.42] for aspirin vs 0.49 [95% CI, 0.35-0.69] for no aspirin; HR, 0.57 [95% CI, 0.32-0.99]; P = .04), and significantly increased the risk of extracranial hemorrhage requiring transfusion or hospitalization (0.86 [95% CI, 0.67-1.11] for aspirin vs 0.51 [95% CI, 0.37-0.72] for no aspirin; HR, 1.85 [95% CI, 1.22-2.81]; P = .004).
Conclusions and Relevance: Once-daily, low-dose aspirin did not significantly reduce the risk of the composite outcome of cardiovascular death, nonfatal stroke, and nonfatal myocardial infarction among Japanese patients 60 years or older with atherosclerotic risk factors.
Trial Registration: clinicaltrials.gov Identifier: NCT00225849.

PMID: 25401325 [PubMed - as supplied by publisher]

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Nov 182014
 

Radiographic Imaging for Patients With Contagious Infectious Diseases: How to Acquire Chest Radiographs of Patients Infected With the Ebola Virus.

AJR Am J Roentgenol. 2014 Nov 17;:1-5

Authors: Auffermann WF, Kraft CS, Vanairsdale S, Lyon GM, Tridandapani S

Abstract
OBJECTIVE. Contagious infectious diseases add a new dimension to radiology and pose many unanswered questions. In particular, what is the safest way to image patients with contagious and potentially lethal infectious diseases? Here, we describe protocols used by Emory University to successfully acquire chest radiographs of patients with Ebola virus disease. CONCLUSION. Radiology departments need to develop new protocols for various modalities used in imaging patients with contagious and potentially lethal infectious diseases.

PMID: 25402496 [PubMed - as supplied by publisher]

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