Mar 032015
 
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Evaluation of anamnestic criteria for the identification of patients with acute community onset viral gastroenteritis in the emergency department--A prospective observational study.

Scand J Infect Dis. 2014 Aug;46(8):561-5

Authors: Andreasson T, Gustavsson L, Lindh M, Bergbrant IM, Raner C, Ahrén C, Westin J, Andersson LM

Abstract
BACKGROUND: To our knowledge no clinical criteria for the identification of community onset viral gastroenteritis in individual patients have been evaluated systematically with modern PCR-based diagnostic assays as gold standard.
OBJECTIVE: The aim of this study was to identify factors independently associated with the detection of virus by PCR in rectal swab samples from patients with acute community onset gastroenteritis.
METHODS: A prospective observational study was conducted from December 2010 through March 2011 at the emergency department (ED) of a large teaching hospital. All patients who reported vomiting and/or diarrhoea up to 48 h prior to their visit to the ED were asked to participate. A rectal swab sample was obtained from each patient. Symptoms, date of onset, and epidemiological data were recorded. Samples were analysed with a multiple real-time PCR targeting 6 viral agents (astrovirus, adenovirus, rotavirus, sapovirus, and norovirus GI and GII).
RESULTS: Two hundred and five patients fulfilled the inclusion criteria, of whom 66 agreed to participate; their median (IQR) age was 65 (38-84) y and 43 (65%) were females. Thirty-one (47%) were positive by PCR for at least 1 of the agents examined (26 norovirus, 2 sapovirus, 2 rotavirus, and 1 adenovirus). Diarrhoea and a short duration of symptoms (≤ 2 days) were independently associated with a positive rectal swab sample, with odds ratios of 7.5 (95% confidence interval (CI) 2.0-28) and 10.4 (95% CI 1.9-56), respectively (p < 0.01 for both). A multivariate model including these 2 variables had a sensitivity of 81% (25/31) and a specificity of 69% (24/35).
CONCLUSIONS: Diarrhoea and a short duration of symptoms were the only anamnestic criteria independently associated with acute community onset viral gastroenteritis confirmed by PCR.

PMID: 24832849 [PubMed - indexed for MEDLINE]

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Mar 032015
 
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Risk factors and clinical impact of levofloxacin or cefazolin nonsusceptibility or ESBL production among uropathogens in adults with community-onset urinary tract infections.

J Microbiol Immunol Infect. 2014 Jun;47(3):197-203

Authors: Wu YH, Chen PL, Hung YP, Ko WC

Abstract
BACKGROUND: Gram-negative bacilli causing community-onset urinary tract infections (CoUTIs) are getting increasingly resistant to antimicrobial agents. Clinical significance and risk factors of the acquisition of antimicrobial-nonsusceptible pathogens are still under investigation.
METHODS: A prospective study was performed in the medical wards of two hospitals in southern Taiwan between August 2009 and January 2012. Patients were enrolled if they were aged >18, admitted through the emergency department, and had CoUTI due to Enterobacteriaceae isolates.
RESULTS: Overall 136 adults with CoUTI were enrolled. Their mean age was 67 years and females were predominant (68.4%). Comorbidities, such as diabetes mellitus (30.1%) and hypertension (54.4%), were common. Escherichia coli (111, 81.6%) was the predominant species, followed by Klebsiella pneumoniae (11, 8.1%), and Proteus mirabilis (7, 5.1%). Nine (8.0%) of E. coli isolates and 5 (45%) of K. pneumoniae isolates had extended-spectrum β-lactamase (ESBL) production. Out of 122 non-ESBL producing isolates, 35 (28.7%) and 31 (25.4%) were nonsusceptible to levofloxacin and cefazolin, respectively. In the multivariate analysis, several clinical characters were found to be independently associated with CoUTIs due to levofloxacin-nonsusceptible (i.e. males, recent hospitalization, underlying old stroke, diabetes mellitus, and altered consciousness, or absence of chills, pyuria, or tachycardia), cefazolin-nonsusceptible (i.e. males, recent hospitalization, underlying old stroke, absence of fever or chills), or ESBL-producing isolates (i.e. recent hospitalization or antimicrobial therapy). All patients survived and discharged. However, the patients with CoUTIs due to levofloxacin-nonsusceptible (16.1 vs. 7.5 days, p < 0.01), cefazolin-nonsusceptible (15.4 vs. 8.4 days, p < 0.01) or ESBL-producing (16.7 vs. 9.6 days; p < 0.01) pathogens had a longer hospitalization stay than those due to their susceptible comparators.
CONCLUSION: Several host factors were recognized to be independently associated with the acquisition of UTIs due to levofloxacin- or cefazolin- nonsusceptible, or ESBL-producing Gram-negative bacilli. The clinical impact of UTIs due to nonsusceptible uropathogens is that they result in the prolongation of hospital stays.

PMID: 23063776 [PubMed - indexed for MEDLINE]

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Mar 032015
 

Prognostic significance of serum creatinine and its change patterns in patients with acute coronary syndromes.

Am Heart J. 2015 Mar;169(3):363-70

Authors: Marenzi G, Cabiati A, Cosentino N, Assanelli E, Milazzo V, Rubino M, Lauri G, Morpurgo M, Moltrasio M, Marana I, De Metrio M, Bonomi A, Veglia F, Bartorelli A

Abstract
BACKGROUND: In acute coronary syndromes (ACS), serum creatinine (sCr) levels have short- and long-term prognostic value. However, it is possible that repeated evaluations of sCr during hospitalization, rather than measuring sCr value at admission only, might improve risk assessment. We investigated the relationship between sCr baseline value, its changes, and in-hospital mortality in patients hospitalized with ACS.
METHODS: In 2,756 ACS patients, sCr was measured at hospital admission and then daily, until discharge from coronary care unit. Patients were grouped according to the maximum sCr change observed: <0.3 mg/dL change from baseline (stable renal function [SRF] group), ≥0.3 mg/dL decrease (improved renal function [IRF] group), and ≥0.3 mg/dL increase (worsening renal function [WRF] group).
RESULTS: Of the 2,756 patients, 2,163 (78%) had SRF, 292 (11%) had IRF, and 301 (11%) had WRF. In-hospital mortality in the 3 groups was 0.5%, 2%, and 14% (P < .001), respectively. Peak sCr value was a more powerful predictor of mortality (area under the curve 0.86, 95% CI 0.81-0.92) than the initial sCr value (area under the curve 0.69, 95% CI 0.63-0.77; P < .001). When sCr and its change patterns during coronary care unit stay were evaluated together, improved mortality risk stratification was found.
CONCLUSIONS: In ACS patients, daily sCr value and its change pattern are stronger predictors of in-hospital mortality than the initial sCr value only; thus, their combined evaluation provides a more accurate and dynamic stratification of patients' risk. Finally, the intermediate mortality risk of IRF patients possibly reflects acute kidney injury started before hospitalization.

PMID: 25728726 [PubMed - in process]

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Mar 032015
 

A reappraisal of loop diuretic choice in heart failure patients.

Am Heart J. 2015 Mar;169(3):323-333

Authors: Buggey J, Mentz RJ, Pitt B, Eisenstein EL, Anstrom KJ, Velazquez EJ, O'Connor CM

Abstract
The health and economic burden of heart failure is significant and continues to grow each year. Loop diuretics are an integral part of symptom management in heart failure. Furosemide is used disproportionately compared with other loop diuretics, and there is currently no guidance for physicians regarding which agent to choose. However, there exist pharmacologic differences as well as other mechanistic differences that appear to favor torsemide use over furosemide. Compared with furosemide, torsemide improves surrogate markers of heart failure severity such as left ventricular function, plasma brain natriuretic peptide levels, and New York Heart Association functional class and may also reduce hospitalizations, readmissions, and mortality. Data suggest that these benefits could be mediated through torsemide's ability to positively affect the renin-angiotensin-aldosterone system. Specifically, torsemide has been shown to inhibit aldosterone secretion, synthesis, and receptor binding in vitro, as well as decrease transcardiac extraction of aldosterone, myocardial collagen production, and cardiac fibrosis in patients with heart failure. We identified pertinent literature using keyword MEDLINE searches and cross-referencing prior bibliographies. We summarize the available data suggesting potential benefits with torsemide over furosemide, and call attention to the need for a reappraisal of diuretic use in heart failure patients and also for a well-powered, randomized control trial assessing torsemide versus furosemide use.

PMID: 25728721 [PubMed - as supplied by publisher]

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Mar 032015
 

Continuous Proton Pump Inhibitor Therapy and the Associated Risk of Recurrent Clostridium difficile Infection.

JAMA Intern Med. 2015 Mar 2;

Authors: McDonald EG, Milligan J, Frenette C, Lee TC

Abstract
Importance: Clostridium difficile infection (CDI) is associated with significant morbidity, mortality, and a high risk of recurrence. Proton pump inhibitor (PPI) use is associated with an initial episode of CDI, and PPIs are frequently overprescribed. For many, the use of PPIs could likely be discontinued before CDI recurrence.
Objectives: To determine whether PPI use was associated with a risk of initial CDI recurrence, to assess what proportion of patients who developed CDI were taking a PPI for a non-evidence-based indication, and to evaluate whether physicians discontinued unnecessary PPIs in the context of CDI.
Design, Setting, and Participants: We conducted a retrospective cohort study of incident health care-associated CDI cases to determine the association between continuous PPI use and CDI recurrence within 90 days. The setting was 2 university-affiliated hospitals, the 417-bed Montreal General Hospital (Montreal, Quebec, Canada) and the 517-bed Royal Victoria Hospital (Montreal, Quebec, Canada). The cohort consisted of 754 patients who developed health care-associated CDI between January 1, 2010, and January 30, 2013, and who survived for a minimum of 15 days after their initial episode of nosocomial CDI.
Exposure: Continuous PPI use.
Main Outcomes and Measures: Recurrence of CDI within 15 to 90 days of the initial episode.
Results: Using a multivariable Cox proportional hazards model, the cause-specific hazard ratios for recurrence were 1.5 (95% CI, 1.1-2.0) for age older than 75 years, 1.5 (95% CI, 1.1-2.0) for continuous PPI use, 1.003 (95% CI, 1.002-1.004) per day for length of stay, and 1.3 (95% CI, 0.9-1.7) for antibiotic reexposure. The use of PPIs was common (60.7%), with only 47.1% of patients having an evidence-based indication. Proton pump inhibitors were discontinued in only 3 patients with CDI.
Conclusions and Relevance: After adjustment for other independent predictors of recurrence, patients with continuous PPI use remained at elevated risk of CDI recurrence. We suggest that the cessation of unnecessary PPI use should be considered at the time of CDI diagnosis.

PMID: 25730198 [PubMed - as supplied by publisher]

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Mar 032015
 

Effects of Low Blood Pressure in Cognitively Impaired Elderly Patients Treated With Antihypertensive Drugs.

JAMA Intern Med. 2015 Mar 2;

Authors: Mossello E, Pieraccioli M, Nesti N, Bulgaresi M, Lorenzi C, Caleri V, Tonon E, Cavallini MC, Baroncini C, Di Bari M, Baldasseroni S, Cantini C, Biagini CA, Marchionni N, Ungar A

Abstract
Importance: The prognostic role of high blood pressure and the aggressiveness of blood pressure lowering in dementia are not well characterized.
Objective: To assess whether office blood pressure, ambulatory blood pressure monitoring, or the use of antihypertensive drugs (AHDs) predict the progression of cognitive decline in patients with overt dementia and mild cognitive impairment (MCI).
Design, Setting, and Participants: Cohort study between June 1, 2009, and December 31, 2012, with a median 9-month follow-up of patients with dementia and MCI in 2 outpatient memory clinics.
Main Outcomes and Measures: Cognitive decline, defined as a Mini-Mental State Examination (MMSE) score change between baseline and follow-up.
Results: We analyzed 172 patients, with a mean (SD) age of 79 (5) years and a mean (SD) MMSE score of 22.1 (4.4). Among them, 68.0% had dementia, 32.0% had MCI, and 69.8% were being treated with AHDs. Patients in the lowest tertile of daytime systolic blood pressure (SBP) (≤128 mm Hg) showed a greater MMSE score change (mean [SD], -2.8 [3.8]) compared with patients in the intermediate tertile (129-144 mm Hg) (mean [SD], -0.7 [2.5]; P = .002) and patients in the highest tertile (≥145 mm Hg) (mean [SD], -0.7 [3.7]; P = .003). The association was significant in the dementia and MCI subgroups only among patients treated with AHDs. In a multivariable model that included age, baseline MMSE score, and vascular comorbidity score, the interaction term between low daytime SBP tertile and AHD treatment was independently associated with a greater cognitive decline in both subgroups. The association between office SBP and MMSE score change was weaker. Other ambulatory blood pressure monitoring variables were not associated with MMSE score change.
Conclusions and Relevance: Low daytime SBP was independently associated with a greater progression of cognitive decline in older patients with dementia and MCI among those treated with AHDs. Excessive SBP lowering may be harmful for older patients with cognitive impairment. Ambulatory blood pressure monitoring can be useful to help avoid high blood pressure overtreatment in this population.

PMID: 25730775 [PubMed - as supplied by publisher]

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