Screening for vancomycin-resistant enterococci using stools sent for Clostridium difficile cytotoxin assay is effective: results of a survey of 300 Patients in a large Singapore Teaching Hospital.

Ann Acad Med Singapore. 2007 Nov;36(11):926-9

Authors: Tay JK, Bodle EE, Fisher DA, Lin RV, Kumarasinghe G, Tambyah PA

INTRODUCTION: To assess the efficacy of screening stools sent for Clostridium difficile cytotoxin assay (CDTA) for surveillance of vancomycin-resistant enterococci (VRE). MATERIALS AND METHODS: From April to May 2005, all stools submitted for CDTA were also cultured for VRE using vancomycin containing culture media. Isolates were identified to species level and vancomycin resistance confirmed, followed by polymerase chain reaction (PCR) for detection of vancomycin resistance genes and DNA fingerprinting. Over 2 consecutive days during that period, stool specimens or rectal swabs were also obtained from all patients in high-risk units (haematology, oncology, renal and intensive care). Fifty-one patients in each group were compared in terms of VRE risk factors previously identified. RESULTS AND DISCUSSION: The prevalence of VRE in both groups was similar [3/204 (1.5%) in the CDTA arm and 1/97 (1.0%) in the high-risk arm; P = 1.0, Fisher's exact test]. Prevalence of risk factors for VRE colonisation, including age, duration of hospitalisation, exposure to antibiotics, exposure to surgical procedures, presence of malignancy and diabetes mellitus was similar in both groups (P > 0.05). Only renal failure (P < 0.05) was more common in the high-risk group. All 4 isolates of VRE identified were genetically distinct by variable number tandem repeat (VNTR) typing; 3 were Enterococcus faecium (2 with the vanB gene, 1 with vanA) and one E. faecalis. CONCLUSION: Less than 2% of our high-risk patients are VRE carriers. In-hospital VRE screening using stools sent for CDTA is a simple, reasonable surrogate for screening individual high-risk patients as the patient risk profile is similar and the yield comparable in a low-prevalence setting.

PMID: 18071603 [PubMed - indexed for MEDLINE]

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Antipsychotic drug use and risk of pneumonia in elderly people.

J Am Geriatr Soc. 2008 Apr;56(4):661-6

Authors: Knol W, van Marum RJ, Jansen PA, Souverein PC, Schobben AF, Egberts AC

OBJECTIVES: To investigate the association between antipsychotic drug use and risk of pneumonia in elderly people. DESIGN: A nested case-control analysis. SETTING: Data were used from the PHARMO database, which collates information from community pharmacies and hospital discharge records. PARTICIPANTS: A cohort of 22,944 elderly people with at least one antipsychotic prescription; 543 cases of hospital admission for pneumonia were identified. Cases were compared with four randomly selected controls matched on index date. MEASUREMENTS: Antipsychotic drug use in the year before the index date was classified as current, recent, or past use. No prescription for an antipsychotic in the year before the index date was classified as no use. The strength of the association between use of antipsychotics and the development of pneumonia was estimated using multivariate logistic regression analysis and expressed as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: Current use of antipsychotics was associated with an almost 60% increase in the risk of pneumonia (adjusted OR=1.6, 95% CI=1.3-2.1). The risk was highest during the first week after initiation of an antipsychotic (adjusted OR=4.5, 95% CI=2.8-7.3). Similar associations were found after exclusion of elderly people with a diagnosis of delirium. Current users of atypical agents showed a higher risk of pneumonia (adjusted OR=3.1, 95% CI=1.9-5.1) than users of conventional agents (adjusted OR=1.5, 95% CI=1.2-1.9). There was no clear dose-response relationship. CONCLUSION: Use of antipsychotics in elderly people is associated with greater risk of pneumonia. This risk is highest shortly after the initiation of treatment, with the greatest increase in risk found for atypical antipsychotics.

PMID: 18266664 [PubMed - indexed for MEDLINE]

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Comparative efficacy and safety of aliskiren, an oral direct renin inhibitor, and ramipril in hypertension: a 6-month, randomized, double-blind trial.

J Hypertens. 2008 Mar;26(3):589-99

Authors: Andersen K, Weinberger MH, Egan B, Constance CM, Ali MA, Jin J, Keefe DL

OBJECTIVES: This double-blind study compared long-term efficacy, safety and tolerability of the oral direct renin inhibitor aliskiren and the angiotensin-converting enzyme inhibitor ramipril alone and combined with hydrochlorothiazide in patients with hypertension. METHODS: After a 2-4-week placebo run-in, 842 patients [mean sitting diastolic blood pressure (msDBP) 95-109 mmHg] were randomized to aliskiren 150 mg (n = 420) or ramipril 5 mg (n = 422). Dose titration (to aliskiren 300 mg/ramipril 10 mg) and subsequent hydrochlorothiazide addition (12.5 mg, titrated to 25 mg if required) were permitted at weeks 6, 12, 18 and 21 for inadequate blood pressure control. Patients completing the 26-week active-controlled treatment period were re-randomized to their existing regimen or placebo for a 4-week double-blind withdrawal phase. RESULTS: Six hundred and eighty-seven patients (81.6%) completed the active treatment period. At week 26, aliskiren-based therapy produced greater mean reductions in mean sitting systolic blood pressure (17.9 versus 15.2 mmHg, P = 0.0036) and msDBP (13.2 versus 12.0 mmHg, P = 0.025), and higher rates of systolic blood pressure control (< 140 mmHg; 72.5 versus 64.1%, P = 0.0075) compared with ramipril-based therapy. During withdrawal, blood pressure increased more rapidly after stopping ramipril than aliskiren-based therapy; median blood pressure reached 140/90 mmHg after 1 and 4 weeks, respectively. Blood pressure reductions were maintained with continued active treatment. Aliskiren therapy was well tolerated. Overall adverse event rates were similar with aliskiren (61.3%) and ramipril (60.4%); cough was more frequent with ramipril (9.5%) than aliskiren (4.1%). CONCLUSIONS: Aliskiren-based therapy was well tolerated and produced sustained blood pressure reductions in patients with hypertension over 6 months, greater than those with ramipril-based therapy.

PMID: 18300872 [PubMed - indexed for MEDLINE]

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Can the MELD score predict perioperative morbidity for patients with liver cirrhosis undergoing laparoscopic cholecystectomy?

Am Surg. 2008 Feb;74(2):156-9

Authors: Bingener J, Cox D, Michalek J, Mejia A

The Model for End Stage Liver Disease (MELD) score is a mortality predictor in patients awaiting liver transplantation. We evaluated the MELD score's ability to predict morbidity for patients with cirrhosis undergoing laparoscopic cholecystectomy. From March 1991 to February 2004, data of all patients undergoing laparoscopic cholecystectomy were prospectively collected. Data of patients with liver cirrhosis were reviewed. The MELD and Child scores were correlated with outcome variables. Of 7859 patients undergoing laparoscopic cholecystectomy, 99 patients (1.3%) exhibited liver cirrhosis, 44 women and 55 men. The mean age was 55 years (range, 28 to 92 years). The mortality rate was 6.3 per cent, morbidity rate 18 per cent, and conversion rate 11 per cent. Laboratory values on 55 patients were available to calculate MELD scores. The mean MELD score was 11 (range, 6 to 23). There was no significant variation in MELD scores with gender (P = 0.61) or cirrhosis etiology, alcoholic and nonalcoholic (P = 0.52). MELD and Child's score correlated well (P < 0.001); however, the risk of complication was not related to the MELD (P = 0.94) or Child-Pugh-Turcotte score (P = 0.26). Morbidity for patients with liver cirrhosis undergoing laparoscopic cholecystectomy remains high. The MELD score is useful for transplant risk stratification for but requires further investigation regarding morbidity prediction for laparoscopic cholecystectomy.

PMID: 18306870 [PubMed - indexed for MEDLINE]

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A comparative study of community-acquired pneumonia patients admitted to the ward and the ICU.

Chest. 2008 Mar;133(3):610-7

Authors: Restrepo MI, Mortensen EM, Velez JA, Frei C, Anzueto A

BACKGROUND: Limited information is available on the health-care utilization of hospitalized patients with community-acquired pneumonia (CAP) depending on the location of care. Our aim was to compare the clinical characteristics, etiologies, and outcomes of patients with CAP who were admitted to the ICU with those admitted who were to the ward service. METHODS: A retrospective cohort study, at two tertiary teaching hospitals, one of which was a Veterans Affairs hospital, and the other a county hospital. Eligible subjects had been admitted to the hospital with a diagnosis of CAP between January 1, 1999, and December 31, 2001, had a confirmatory chest radiograph, and a hospital discharge International Classification of Diseases, ninth revision, diagnosis of pneumonia. Subjects were excluded from the study if they had designated "comfort measures only" or had been transferred from another acute care hospital or were nursing home patients. Bivariate and multivariable analysis evaluated 30-day and 90-day mortality as the dependent measures. RESULTS: Data were abstracted on 730 patients (ICU, 145 patients; wards, 585 patients). Compared to ward patients, ICU patients were more likely to be male (p = 0.001), and to have congestive heart failure (p = 0.01) and COPD (p = 0.01). ICU patients also had higher mean pneumonia severity index scores (112 [SD, 35] vs 83 [SD, 30], respectively; p = 0.02). Patients admitted to the ICU had a longer mean length of hospital stay (12 days [SD, 10 days] vs 7 days [SD, 17 days], respectively; p = 0.07), and a higher 30-day mortality rate (23% vs 4%, respectively; p < 0.001) and 90-day mortality rate (28% vs 8%, respectively; p < 0.001) compared to ward patients. CONCLUSIONS: ICU patients present with more severe disease and more comorbidities. ICU patients stay longer in the hospital and have a much higher mortality rate when compared to ward patients. Management strategies should be designed to improve clinical outcomes in ICU patients.

PMID: 17989157 [PubMed - indexed for MEDLINE]

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Methicillin-resistant Staphylococcus epidermidis (MRSE) endocarditis treated with linezolid.

Scand J Infect Dis. 2008;40(1):67-73

Authors: Mancino P, Ucciferri C, Falasca K, Pizzigallo E, Vecchiet J

Linezolid is not yet recognized as a standard therapy for infective endocarditis but its use becomes a necessity when infection is due to multidrug-resistant microorganisms. This report describes 1 patient with endocarditis treated with linezolid and 45 similar cases from the medical literature.

PMID: 17852941 [PubMed - indexed for MEDLINE]

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Is hospital-in-the-home (HITH) treatment of bacterial endocarditis safe and effective?

Scand J Infect Dis. 2008;40(1):40-3

Authors: McMahon JH, O’keeffe JM, , Lindsay GM

Although serious infections such as bacterial endocarditis (BE) are being increasingly treated with parenteral antibiotics via Hospital-in-the-Home (HITH) programmes in Australia, there are few published data to confirm the safety and efficacy of this treatment modality, especially among patients with BE due to pathogens other than streptococci. In a 12-month prospective, multi-site study we assessed HITH treatment outcomes for all cases of BE. Among the 40 BE cases (29 ‘definite’, 11 ‘possible’; Duke criteria) caused by a range of pathogens (16 staphylococci spp., 11 streptococci, 4 other, 9 culture-negative), cure was achieved in 37 (93%) cases. BE due to Staphylococcus aureus was significantly associated with an inferior outcome (p =0.046). Adverse events were relatively common (9/40), but most were not severe and were managed with continuation of HITH care. BE can be safely managed via HITH, but particular care in patient selection is necessary, especially for cases due to S. aureus.

PMID: 17852904 [PubMed - indexed for MEDLINE]

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Phase II, randomized, multicenter, double-blind, placebo-controlled trial of a polyclonal anti-Staphylococcus aureus capsular polysaccharide immune globulin in treatment of Staphylococcus aureus bacteremia.

Antimicrob Agents Chemother. 2007 Dec;51(12):4249-54

Authors: Rupp ME, Holley HP, Lutz J, Dicpinigaitis PV, Woods CW, Levine DP, Veney N, Fowler VG

New treatment modalities are needed for the treatment of infections due to multidrug-resistant Staphylococcus aureus. S. aureus capsular polysaccharide immune globulin (Altastaph) is a polyclonal immune globulin preparation that is being developed as adjunctive therapy for persons with S. aureus infections complicated by bacteremia. In a phase II, multicenter, randomized, double-blind, placebo-controlled trial, 40 subjects with documented S. aureus bacteremia received standard therapy plus either Altastaph at 200 mg/kg of body weight in each of two infusions 24 h apart or placebo. During the 42-day observation period, antibody pharmacokinetics and safety were the primary characteristics studied. Information regarding the resolution of bacteremia and fever was also analyzed. Anti-type-5 and anti-type-8 capsular antibody levels peaked after the second infusion at 550 mug/ml and 419 mug/ml, respectively, and remained above 100 mug/ml at day 28. A total of 316 adverse events were noted in 39 of 40 subjects. Infusion-related adverse events in Altastaph recipients were infrequent and similar to those among recipients of commercial intravenously administered immunoglobulin G products. Five of 21 (23%) subjects in the Altastaph group died, whereas 2 of 18 (11%) subjects in the placebo group died (P = 0.42). Compared to the control patients, the Altastaph recipients had a shorter median time to the resolution of fever (2 days and 7 days, respectively; P = 0.09) and a shorter length of hospital stay (9 days and 14 days, respectively; P = 0.03). However, these findings are exploratory, and there were few differences in the other variables measured. High levels of opsonizing antibodies were maintained for the initial 4 weeks. Although the study was not powered to show efficacy, these preliminary findings and safety profile suggest that Altastaph may be an effective adjunct to antibiotics and warrants further investigation (ClinicalTrials.gov number NCT00063089).

PMID: 17893153 [PubMed - indexed for MEDLINE]

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Coccidioidomycosis.

Mayo Clin Proc. 2008 Mar;83(3):343-48; quiz 348-9

Authors: Parish JM, Blair JE

Coccidioidomycosis is a common infectious disease in the southwestern United States. Although Coccidioides species are not endemic in other areas of the country, the rapid population growth in the southwestern United States in recent decades and the increase in tourism mean that many people travel to the Southwest and return home before developing the clinical syndrome of coccidioidomycosis. In this respect, coccidioidomycosis is a disease of national importance. It can occur in various manifestations: acute pneumonia, chronic progressive pneumonia, pulmonary nodules and cavities, extrapulmonary nonmeningeal disease, and meningitis. The diagnosis is often made on the basis of serologic findings. Treatment is usually with an azole or amphotericin B, depending on the clinical manifestations and the immune status of the host. We discuss the most common clinical manifestations, the best way to make the diagnosis, and the treatment of common infections.

PMID: 18316002 [PubMed - indexed for MEDLINE]

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Peritoneal dialysis in refractory end-stage congestive heart failure: a challenge facing a no-win situation.

Nephrol Dial Transplant. 2005 Jul;20 Suppl 7:vii32-6

Authors: Gotloib L, Fudin R, Yakubovich M, Vienken J

BACKGROUND: Current medical therapeutic strategies for refractory congestive heart failure (CHF) in the population of 65 years and older with contraindications for heart transplantation are limited. Peritoneal dialysis applied to CHF patients with or without renal impairment showed clinical functional improvement. METHODS: A single centre, prospective but non-randomized study in 20 patients with severe congestive heart failure refractory to optimal pharmacological therapy [New York Heart Association (NYHA), class IV] was performed between 2000 and 2003. The mean age was 65.71+/-7.66 years. The patients had a baseline glomerular filtration rate of 14.84+/-3.8 ml/min. Fifteen patients were diabetics (type I, 10; type II, five). For all patients, the baseline ejection fraction was <35% (31.2+/-4.7%). The mean Charlson's co-morbidity index was 7.8+/-1.8. Patients were treated initially by 2-5 sessions of continuous veno-venous haemofiltration (CVVH) or sequential haemofiltration (SHF). Automated peritoneal dialysis (APD) was started after implantation of a Tenckhoff catheter. Three APD sessions/week (8 h each), with 15-20 l of dialysis fluid (PDF) per session (10.35+/-3.05 l of 1.5% lactated glucose and 8.95 +/-2.95 l of 4.25% glucose PDF), were performed. Total follow-up ranged between 7 and 35 months (mean 19.80+/-7.37). RESULTS: After 1 year of follow-up, all patients showed haemodynamic improvement: significant improvement of left cardiac work index (2.33+/-0.69 to 2.59+/-0.47 kg min/m(2)), reduction of the systolic times ratio (61.14+/-12.57 to 39.18+/-13.44%), lower thoracic fluid contents (0.04+/-0.005 to 0.003+/-0.0001 Omega) as well as a regression from NYHA class IV to class I. Need for hospitalization for CHF decreased from 157 to 13 days. CONCLUSIONS: Peritoneal dialysis appears to be a promising therapeutic tool for patients affected by refractory CHF. Clinical improvement of cardiac function may be related to clearing blood from middle molecular weight myocardial depressant substances, including atrial natriuretic peptide. Prospective multicentre trials are needed to confirm these encouraging results.

PMID: 16024831 [PubMed - indexed for MEDLINE]

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The role of peritoneal dialysis in the treatment of refractory heart failure.

Nephrol Dial Transplant. 2005 Jul;20 Suppl 7:vii28-31

Authors: Kagan A, Rapoport J

Heart failure (HF) refractory to conventional therapy is a major and increasing public health and financial problem. Refractory HF is associated with hypervolaemia due to sodium and fluid retention, and azotaemia due to renal hypoperfusion. There is extreme renal salt and water retention and marked secondary hyperaldosteronism. In this state, the kidneys are relatively resistant to diuretic therapy, and the use of very high doses of oral or parenteral diuretics only worsens the renal hypoperfusion, making the patient more azotaemic. A logical treatment for this ‘cardiorenal syndrome’ is the use of dialysis, which is efficient in treating both the hypervolaemia and azotaemia of refractory HF. Peritoneal dialysis (PD), haemodialysis or continuous veno-venous haemofiltration can and have been used, but the simplest long-term treatment is PD. We present several case reports of the successful use of PD in refractory heart failure. In our opinion, chronic PD is a highly effective mode of treatment for refractory HF, and should be more widely used in this condition.

PMID: 16024829 [PubMed - indexed for MEDLINE]

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Acute renal failure in patients with severe sepsis and septic shock–a significant independent risk factor for mortality: results from the German Prevalence Study.

Nephrol Dial Transplant. 2008 Mar;23(3):904-9

Authors: Oppert M, Engel C, Brunkhorst FM, Bogatsch H, Reinhart K, Frei U, Eckardt KU, Loeffler M, John S,

BACKGROUND: Sound data about the prevalence of acute renal failure (ARF) among patients with severe sepsis and septic shock are lacking. Further, it is not known whether ARF is an independent risk factor for mortality in septic patients or merely an indicator of disease severity. METHODS: A prospective cross-sectional one-day prevalence study was carried out in a representative sample of German ICUs, divided into five strata (< 200 beds; 201-400 beds; 401-600 beds; > 600 beds; university hospitals). 3877 patients were screened of whom 415 had severe sepsis and septic shock. RESULTS: Fourteen patients (3.4%) had chronic dialysis-dependent RF and were excluded from analysis. Of the remaining 401 patients, 166 (41.4%) had ARF, as defined by a rise in creatinine above twice the upper limit of normal and/or a drop in urine output to < 0.5 ml/kg bodyweight. Median APACHE II score was 22 in patients with ARF and 16 in patients without ARF (p< 0.0001). Patients with severe sepsis/septic shock had an overall hospital mortality of 55.2%. Hospital mortality in patients with ARF was 67.3% and without ARF 42.8% (p< 0.0001). After adjustment for APACHE II score and age, ARF remained a significant independent risk factor for death [odds ratio (OR) 2.11, 95% confidence interval (CI) 1.27-3.52]. Mortality in septic patients was not associated with pre-existing, non-dialysis-dependent chronic kidney disease, whereas in dialysis-dependent patients with sepsis mortality increased to 86%. CONCLUSION: In this representative survey in patients with severe sepsis/septic shock, prevalence of ARF is high with 41.4%. ARF represents a significant independent risk factor for mortality in these patients.

PMID: 18065435 [PubMed - indexed for MEDLINE]

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Haemodialysis clearance of baclofen.

Eur J Clin Pharmacol. 2007 Dec;63(12):1143-6

Authors: Brvar M, Vrtovec M, Kovac D, Kozelj G, Pezdir T, Bunc M

BACKGROUND: Baclofen is a centrally acting gamma-aminobutyric acid agonist used for spasticity of spinal origin and mainly excreted unchanged by the kidneys. We report haemodialysis clearance and the haemodialysis removal rate constant of baclofen in a comatose patient with baclofen overdose due to acute renal failure. CASE REPORT: A 60-year-old man with spastic tetraplegia on chronic baclofen therapy was admitted due to pneumonia and acute renal failure. The patient became comatose and, as a result of the baclofen dosage being left unchanged despite a deterioration leading to renal failure due to hypotension, the concentration of baclofen was determined to be in the toxic range (0.70 mg/L). During a 4-hour-long bicarbonate haemodialysis the patient woke up and became completely orientated and cooperative. Baclofen therapy was subsequently stopped, and the patient remained conscious. The pharmacokinetics calculations revealed a baclofen haemodialysis removal rate constant of 0.152 h(-1) and a haemodialysis clearance of 2.14 mL/s. CONCLUSIONS: Patients on a stable baclofen regime can develop baclofen toxicity due to acute renal failure. Haemodialysis removes baclofen as effectively as normal kidneys, and it would appear that haemodialysis is a reasonable treatment modality in patients with accidental baclofen overdose due to acute renal failure.

PMID: 17764008 [PubMed - indexed for MEDLINE]

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Potent anticoagulants are associated with a higher all-cause mortality rate after hip and knee arthroplasty.

Clin Orthop Relat Res. 2008 Mar;466(3):714-21

Authors: Sharrock NE, Gonzalez Della Valle A, Go G, Lyman S, Salvati EA

Anticoagulation for thromboprophylaxis after THA and TKA has not been confirmed to diminish all-cause mortality. We determined whether the incidence of all-cause mortality and pulmonary embolism in patients undergoing total joint arthroplasty differs with currently used thromboprophylaxis protocols. We reviewed articles published from 1998 to 2007 that included 6-week or 3-month incidence of all-cause mortality and symptomatic, nonfatal pulmonary embolism. Twenty studies included reported 15,839 patients receiving low-molecular-weight heparin, ximelagatran, fondaparinux, or rivaroxaban (Group A); 7193 receiving regional anesthesia, pneumatic compression, and aspirin (Group B); and 5006 receiving warfarin (Group C). All-cause mortality was higher in Group A than in Group B (0.41% versus 0.19%) and the incidence of clinical nonfatal pulmonary embolus was higher in Group A than in Group B (0.60% versus 0.35%). The incidences of all-cause mortality and nonfatal pulmonary embolism in Group C were similar to those in Group A (0.4 and 0.52, respectively). Clinical pulmonary embolus occurs despite the use of anticoagulants. Group A anticoagulants were associated with the highest all-cause mortality of the three modalities studied.

PMID: 18264861 [PubMed - indexed for MEDLINE]

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Orthostatic hypotension: a new classification system.

Europace. 2007 Oct;9(10):937-41

Authors: Deegan BM, O’Connor M, Donnelly T, Carew S, Costelloe A, Sheehy T, OLaighin G, Lyons D

AIMS: Orthostatic hypotension (OH) is a common condition, which is defined as a reduction in systolic blood pressure of >or=20 mmHg or diastolic blood pressure of >or=10 mmHg within 3 min of orthostatic stress. Utilizing total peripheral resistance (TPR) and cardiac output (CO) measurements during tilt-table testing (Modelflow method), we classified OH into three categories, namely arteriolar, venular, and mixed. The principle defect in arteriolar OH is impaired vasoconstriction after orthostatic stress, reflected by absence of the compensatory increase in TPR. In venular OH, the predominant defect is excessive reduction in venous return, reflected by a large drop in CO after orthostatic stress with marked tachycardia. Mixed OH is due to a combination of both these mechanisms. METHODS AND RESULTS: We analysed haemodynamic parameters of 110 patients with OH and categorized them as arteriolar, venular, or mixed. Significant differences between the groups were found for the magnitude and time to reach nadir of the systolic blood pressure drop post-head-up tilt. The mixed OH category had the largest systolic blood pressure reduction (42.5, 31.9, 53.3 mmHg, P < 0.001) and the longest nadir time (18.6, 20, 30.7 s, P = 0.002). CONCLUSION: This is a practical classification tool and when validated physiologically, this system could be useful in directing treatment of OH.

PMID: 17720979 [PubMed - indexed for MEDLINE]

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