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Comparison of efficacy and safety of atorvastatin (80 mg) to simvastatin (20 to 40 mg) in patients aged <65 versus >or=65 years with coronary heart disease (from the Incremental DEcrease through Aggressive Lipid Lowering [IDEAL] study).

Am J Cardiol. 2009 Mar 1;103(5):577-82

Authors: Tikkanen MJ, Holme I, Cater NB, Szarek M, Faergeman O, Kastelein JJ, Olsson AG, Larsen ML, Lindahl C, Pedersen TR,

The efficacy and safety of atorvastatin (80 mg/day) versus simvastatin (20 to 40 mg/day) in older (age >or=65 years) versus younger (<65 years) patients were assessed in a prespecified secondary analysis of the 8,888 patients with myocardial infarction in the IDEAL trial, a randomized open-label study. Several cardiovascular end points were evaluated, including the occurrence of a first major coronary event (MCE; nonfatal myocardial infarction, coronary heart disease death, or resuscitated cardiac arrest), the primary end point of the trial, and occurrence of any cardiovascular event (MCE, stroke, revascularization, unstable angina, congestive heart failure, and peripheral artery disease). Although there were no significant interactions between age and treatment, the magnitude of effect in favor of atorvastatin was higher in younger versus older patients (occurrence of first MCE, hazard ratio [HR] 0.80, 95% confidence interval [CI] 0.66 to 0.98; and HR 0.95, 95% CI 0.80 to 1.15, respectively; occurrence of any cardiovascular (CV) event, HR 0.80, 95% CI 0.71 to 0.89; and HR 0.88, 95% CI 0.79 to 0.99, respectively). These results were likely influenced by adherence, which was lower in older patients and those receiving atorvastatin compared with those receiving simvastatin. Rates of any reported serious adverse event were higher in older patients, but did not differ between the 2 statin groups. In conclusion, except for any CV events in the older group, significant reductions in primary and secondary end points were observed only in patients <65 years of age. The safety of atorvastatin (80 mg) and simvastatin (20 to 40 mg) was similar in patients aged <65 and >65 years with stable coronary disease.

PMID: 19231315 [PubMed - indexed for MEDLINE]

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Legionella bacteria in shower aerosols increase the risk of Pontiac fever among older people in retirement homes.

J Epidemiol Community Health. 2008 Oct;62(10):913-20

Authors: Bauer M, Mathieu L, Deloge-Abarkan M, Remen T, Tossa P, Hartemann P, Zmirou-Navier D

BACKGROUND: 828 elderly subjects residing in nursing homes were followed up during 4 months to ascertain incidence of symptoms associated with Pontiac fever (PF) in a non-epidemic setting. METHODS: The exposure situation was inhalation of Legionella bacteria while showering. An audit of the hot water system in all institutions allowed ascribing each subject to a water quality area wherefrom one shower was sampled for Legionella assays at the end of the follow-up period. Legionella were detected in water and aerosols using the culture (CFU, colony forming units) and in situ hybridization (FISH) techniques. RESULTS: Among 32 Pontiac-like episodes, 29 cases complied with the operational definition of PF elaborated for this study. Incidence density was 0.11 case/person-year (95% CI 0.07 to 0.15). Water concentrations greater than 105 Legionella FISH/l and 104 Legionella CFU/l were associated with an increased risk of PF (respectively RR 2.23, p = 0.05 and RR 2.39, p = 0.11, with significant dose-response patterns: p for trend <0.04). The condition also seems associated with aerosol concentrations above 103 Legionella FISH/l of air. A significantly higher risk of Pontiac-like episodes (RR 6.24, 95% CI 2.12 to 18.38) was seen for elderly subjects receiving corticosteroid therapy. CONCLUSION: The water and threshold values identified in this research could be used to inform guidance measures aimed at protecting institutionalised older people from Legionnaires' disease. Immunosuppressive therapy in the same population group can significantly enhance susceptibility to Legionella bacteria.

PMID: 18791050 [PubMed - indexed for MEDLINE]

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Tigecycline: in community-acquired pneumonia.

Drugs. 2008;68(18):2633-44

Authors: McKeage K, Keating GM

Tigecycline is a first-in-class glycylcycline, broad-spectrum, intravenous antibacterial developed to overcome the two major mechanisms of tetracycline resistance (ribosomal protection and efflux). The drug has been in use since 2005 for complicated intra-abdominal infections, and complicated skin and soft tissue structure infections, but is currently being assessed in the US for community-acquired pneumonia (CAP) in adults. In vitro, tigecycline had good activity against a range of Gram-positive, Gram-negative and atypical community-acquired respiratory tract pathogens implicated in CAP. Compared with other antibacterials, tigecycline has a prolonged post-antibiotic effect against key bacteria and a long serum elimination half-life in humans. The drug effectively penetrates lung tissue. The combined results of two well designed, phase III studies demonstrated that tigecycline 100 mg initially, followed by 50 mg every 12 hours for 7-14 days was not inferior to recommended dosages of levofloxacin in the treatment of hospitalized patients with CAP. Clinical cure rates were 89.7% versus 86.3% in the clinically evaluable population and 81.0% versus 79.7% in the clinical modified intent-to-treat population. Tigecycline was generally well tolerated in patients with CAP.

PMID: 19093704 [PubMed - indexed for MEDLINE]

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Proton pump inhibitor use and enteric infections.

Am J Gastroenterol. 2009 Mar;104(2 Suppl):S10-6

Authors: Dial MS

Proton pump inhibitors (PPIs) and H2 receptor antagonists (H2RAs) are very commonly prescribed drugs and are routinely used in the chronic management of gastro-esophageal reflux disease. Concerns have been raised about the possible association of PPIs with enteric infections. This article reviews the studies that have examined the associations of proton pump inhibitors in particular, and enteric infections.

PMID: 19262540 [PubMed - indexed for MEDLINE]

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Acid inhibition and infections outside the gastrointestinal tract.

Am J Gastroenterol. 2009 Mar;104(2 Suppl):S17-20

Authors: Vakil N

Acid-inhibitory agents can alter the flora of the stomach, and epidemiologic studies suggest an association between the use of these agents and the development of pneumonia. Microbiologic studies suggest that a causal association may be biologically plausible because gastric colonization with organisms can occur in patients taking acid suppressive agents. In mechanically ventilated patients, colonization of the oropharynx and stomach may predispose to Gram-negative pneumonias. Despite the associations between acid inhibitor use and pneumonia shown in some studies, the data on community-acquired pneumonias are not conclusive. In clinical practice, prudence would dictate that the need for acid inhibition with histamine-2 receptor antagonists or proton pump inhibitors should be carefully considered in patients who are at risk for pneumonias (elderly patients with chronic lung disease who are on immunosuppressive drugs or corticosteroids and patients with recurrent lung infections requiring frequent antibiotic therapy).

PMID: 19262541 [PubMed - indexed for MEDLINE]

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Glucose control in the intensive care unit.

Crit Care Med. 2009 Mar 25;

Authors: Fahy BG, Sheehy AM, Coursin DB

OBJECTIVE:: Hyperglycemia, be it secondary to diabetes, impaired glucose tolerance, impaired fasting glucose, or stress-induced is common in the critically ill. Hyperglycemia and glucose variability in intensive care unit (ICU) patients has some experts calling for routine administration of intensive insulin therapy to normalize glucose levels in hyperglycemic patients. Others, however, have raised concerns over the optimal glucose level, the accuracy of measurements, the resources required to attain tight glycemic control (TGC), and the impact of TGC across the heterogeneous ICU population in patients with diabetes, previously undiagnosed diabetes or stress-induced hyperglycemia. Increased variability in glucose levels during critical illness and the therapeutic intervention thereof have recently been reported to have a deleterious impact on survival, particularly in nondiabetic hyperglycemic patients. The incidence of hypoglycemia (<40 mg/dL or 2.2 mmol) associated with TGC is reported to be as high as 18.7%, by Van den Berghe in a medical ICU, although application of various approaches and computer-based algorithms may improve this. The impact of hypoglycemia, particularly in patients with septic shock and those with neurologic compromise, warrants further evaluation. This review briefly discusses the epidemiology of hyperglycemia in the acutely ill and glucose metabolism in the critically ill. It comments on present limitations in glucose monitoring, outlines current glucose management approaches in the critically ill, and the transition from the ICU to the intermediate care unit or ward. It closes with comment on future developments in glycemic care of the critically ill. METHODS:: The awareness of the potential deleterious impact of hyperglycemia was heightened after Van den Berghe et al presented their prospective trial in 2001. Therefore, source data were obtained from PubMed and Cochrane Analysis searches of the medical literature, with emphasis on the time period after 2000. Recent meta-analyses were reviewed, expert editorial opinion collated, and the website of the Normoglycemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation Trial investigated. SUMMARY AND CONCLUSIONS:: Hyperglycemia develops commonly in the critically ill and impacts outcome in patients with diabetes but, even more so, in patients with stress-induced hyperglycemia. Despite calls for TGC by various experts and regulatory agencies, supporting data remain somewhat incomplete and conflicting. A recently completed large international study, Normoglycemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation, will hopefully provide information to further guide best practice. This concise review interprets the current state of adult glycemic management guidelines to provide a template for care as new information becomes available.

PMID: 19325461 [PubMed - as supplied by publisher]

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Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock*

Crit Care Med. 2009 Mar 25;

Authors: Mikkelsen ME, Miltiades AN, Gaieski DF, Goyal M, Fuchs BD, Shah CV, Bellamy SL, Christie JD

PRINCIPLE:: Serum lactate is a potentially useful biomarker to risk-stratify patients with severe sepsis; however, it is plausible that elevated serum lactate is simply a manifestation of clinically apparent organ dysfunction and/or shock (i.e., refractory hypotension). OBJECTIVE:: To test whether the association between initial serum lactate level and mortality in patients presenting to the emergency department (ED) with severe sepsis is independent of organ dysfunction and shock. DESIGN:: Single-center cohort study. The primary outcome was 28-day mortality and the risk factor variable was initial venous lactate (mmol/L), categorized as low (<2), intermediate (2-3.9), or high (>/=4). Potential covariates included age, sex, race, acute and chronic organ dysfunction, severity of illness, and initiation of early goal-directed therapy. Multivariable logistic regression analyses were stratified on the presence or absence of shock. SETTING:: The ED of an academic tertiary care center from 2005 to 2007. PATIENTS:: Eight hundred thirty adults admitted with severe sepsis in the ED. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: Mortality at 28 days was 22.9% and median serum lactate was 2.9 mmol/L. Intermediate (odds ratio [OR] = 2.05, p = 0.024) and high serum lactate levels (OR = 4.87, p < 0.001) were associated with mortality in the nonshock subgroup. In the shock subgroup, intermediate (OR = 3.27, p = 0.022) and high serum lactate levels (OR = 4.87, p = 0.001) were also associated with mortality. After adjusting for potential confounders, intermediate and high serum lactate levels remained significantly associated with mortality within shock and nonshock strata. CONCLUSIONS:: Initial serum lactate was associated with mortality independent of clinically apparent organ dysfunction and shock in patients admitted to the ED with severe sepsis. Both intermediate and high serum lactate levels were independently associated with mortality.

PMID: 19325467 [PubMed - as supplied by publisher]

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Use of corticosteroids in acute lung injury and acute respiratory distress syndrome: A systematic review and meta-analysis*

Crit Care Med. 2009 Mar 25;

Authors: Tang BM, Craig JC, Eslick GD, Seppelt I, McLean AS

OBJECTIVE:: Controversy remains as to whether low-dose corticosteroids can reduce the mortality and morbidity of acute lung injury (ALI) or the acute respiratory distress syndrome (ARDS) without increasing the risk of adverse reactions. We aimed to evaluate all studies investigating prolonged corticosteroids in low-to-moderate dose in ALI or ARDS. DATA SOURCES:: MEDLINE, EMBASE, Current Content, and Cochrane Central Register of Controlled Trials, and bibliographies of retrieved articles. STUDY SELECTION:: Randomized controlled trials (RCTs) and observational studies reported in any language that used 0.5-2.5 mg.kg.d of methylprednisolone or equivalent to treat ALI/ARDS. DATA EXTRACTION:: Data were extracted independently by two reviewers and included study design, patient characteristics, interventions, and mortality and morbidity outcomes. DATA SYNTHESIS:: Both cohort studies (five studies, n = 307) and RCTs (four trials, n = 341) showed a similar trend toward mortality reduction (RCTs relative risk 0.51, 95% CI 0.24-1.09; p = 0.08; cohort studies relative risk 0.66, 95% CI 0.43-1.02; p = 0.06). The overall relative risk was 0.62 (95% CI 0.43-0.91; p = 0.01). There was also improvement in length of ventilation-free days, length of intensive care unit stay, Multiple Organ Dysfunction Syndrome Score, Lung Injury Scores, and improvement in Pao2/Fio2. There was no increase in infection, neuromyopathy, or any major complications. There was significant heterogeneity in the pooled studies. Subgroup and meta-regression analyses showed that heterogeneity had minimal effect on treatment efficacy; however, these findings were limited by the small number of studies used in the analyses. CONCLUSION:: The use of low-dose corticosteroids was associated with improved mortality and morbidity outcomes without increased adverse reactions. The consistency of results in both study designs and all outcomes suggests that they are an effective treatment for ALI or ARDS. The mortality benefits in early ARDS should be confirmed by an adequately powered randomized trial.

PMID: 19325471 [PubMed - as supplied by publisher]

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Usefulness of the “Candida score” for discriminating between Candida colonization and invasive candidiasis in non-neutropenic critically ill patients: A prospective multicenter study.

Crit Care Med. 2009 Mar 25;

Authors: León C, Ruiz-Santana S, Saavedra P, Galván B, Blanco A, Castro C, Balasini C, Utande-Vázquez A, González de Molina FJ, Blasco-Navalproto MA, López MJ, Charles PE, Martín E, Hernández-Viera MA,

OBJECTIVE:: To assess the usefulness of the "Candida score" (CS) for discriminating between Candida species colonization and invasive candidiasis (IC) in non-neutropenic critically ill patients. A rate of IC <5% in patients with CS <3 was the primary end point. DESIGN:: Prospective, cohort, observational study. SETTING:: Thirty-six medical-surgical intensive care units of Spain, Argentina, and France. PATIENTS:: A total of 1,107 non-neutropenic adult intensive care unit patients admitted for at least 7 days between April 2006 and June 2007. MEASUREMENTS AND MAIN RESULTS:: Clinical data, surveillance cultures for fungal growth, and serum levels of (1-3)-beta-d-glucan and anti-Candida antibodies (in a subset of patients) were recorded. The CS was calculated as follows (variables coded as absent = 0, present = 1): total parenteral nutrition x1, plus surgery x1, plus multifocal Candida colonization x1, plus severe sepsis x2. A CS >/=3 accurately selected patients at high risk for IC. The colonization index was registered if >/=0.5. The rate of IC was 2.3% (95% confidence interval [CI] 1.06-3.54) among patients with CS <3, with a linear association between increasing values of CS and IC rate (p </= 0.001). The area under the receiver operating characteristic curve for CS was 0.774 (95% CI 0.715-0.832) compared with 0.633 (95% CI 0.557-0.709) for CI. (1-3)-Beta-d-glucan was also an independent predictor of IC (odds ratio 1.004, 95% CI 1.0-1.007). The relative risk for developing IC in colonized patients without antifungal treatment was 6.83 (95% CI 3.81-12.45). CONCLUSIONS:: In this cohort of colonized patients staying >7 days, with a CS <3 and not receiving antifungal treatment, the rate of IC was <5%. Therefore, IC is highly improbable if a Candida-colonized non-neutropenic critically ill patient has a CS <3.

PMID: 19325481 [PubMed - as supplied by publisher]

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The Sequential Organ Failure Assessment score for predicting outcome in patients with severe sepsis and evidence of hypoperfusion at the time of emergency department presentation*

Crit Care Med. 2009 Mar 25;

Authors: Jones AE, Trzeciak S, Kline JA

OBJECTIVES:: Organ failure worsens outcome in sepsis. The Sequential Organ Failure Assessment (SOFA) score numerically quantifies the number and severity of failed organs. We examined the utility of the SOFA score for assessing outcome of patients with severe sepsis with evidence of hypoperfusion at the time of emergency department (ED) presentation. DESIGN:: Prospective observational study. SETTING:: Urban, tertiary ED with an annual census of >110,000. PATIENTS:: ED patients with severe sepsis with evidence of hypoperfusion. Inclusion criteria: suspected infection, two or more criteria of systemic inflammation, and either systolic blood pressure <90 mm Hg after a fluid bolus or lactate >4 mmol/L. Exclusion criteria: age <18 years or need for immediate surgery. INTERVENTIONS:: SOFA scores were calculated at ED recognition (T0) and 72 hours after intensive care unit admission (T72). The primary outcome was in-hospital mortality. The area under the receiver operating characteristic curve was used to evaluate the predictive ability of SOFA scores at each time point. The relationship between Delta SOFA (change in SOFA from T0 to T72) was examined for linearity. RESULTS:: A total of 248 subjects aged 57 +/- 16 years, 48% men, were enrolled over 2 years. All patients were treated with a standardized quantitative resuscitation protocol; the in-hospital mortality rate was 21%. The mean SOFA score at T0 was 7.1 +/- 3.6 points and at T72 was 7.4 +/- 4.9 points. The area under the receiver operating characteristic curve of SOFA for predicting in-hospital mortality at T0 was 0.75 (95% confidence interval 0.68-0.83) and at T72 was 0.84 (95% confidence interval 0.77-0.90). The Delta SOFA was found to have a positive relationship with in-hospital mortality. CONCLUSIONS:: The SOFA score provides potentially valuable prognostic information on in-hospital survival when applied to patients with severe sepsis with evidence of hypoperfusion at the time of ED presentation.

PMID: 19325482 [PubMed - as supplied by publisher]

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Evolving role of early antifungals in the adult intensive care unit.

Crit Care Med. 2009 Mar 25;

Authors: Lam SW, Eschenauer GA, Carver PL

OBJECTIVE:: Invasive candidiasis (IC) is associated with significant morbidity and mortality in critically ill patients. This, in conjunction with difficulties in diagnosis, underscores the need for novel treatment strategies based on the identification of significant risk factors for IC. To review the evidence surrounding the use of early antifungals in critically ill adult patients and to present concise and specific recommendations for different early treatment strategies for IC. DATA SOURCES AND DATA EXTRACTION:: Pubmed search from 1966 to July 2008 using the search terms “antifungals, critical care, prophylaxis, preemptive therapy, and empiric therapy.” Examined all relevant peer-reviewed original articles, meta-analyses, guidelines, consensus statements, and review articles. CONCLUSION:: The use of early antifungal therapy should be reserved for patients with a high risk (10% to 15%) of developing IC. Despite a large number of articles published on this topic, there is no single predictive rule that can adequately forecast IC in critically ill patients. Until further prospective validation of existing data is completed, clinicians should assess patients on a case-by-case basis and determine the need for early antifungal treatment strategies based on frequent evaluations of risk factors and clinical status.

PMID: 19325484 [PubMed - as supplied by publisher]

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Benefit of antiretroviral therapy on survival of human immunodeficiency virus-infected patients admitted to an intensive care unit.

Crit Care Med. 2009 Mar 25;

Authors: Croda J, Croda MG, Neves A, Dos Santos SD

OBJECTIVE:: To evaluate the impact of antiretroviral therapy (ART) and the prognostic factors for in-intensive care unit (ICU) and 6-month mortality in human immunodeficiency virus (HIV)-infected patients. DESIGN:: A retrospective cohort study was conducted in patients admitted to the ICU from 1996 through 2006. The follow-up period extended for 6 months after ICU admission. SETTING:: The ICU of a tertiary-care teaching hospital at the Universidade de São Paulo, Brazil. PARTICIPANTS:: A total of 278 HIV-infected patients admitted to the ICU were selected. We excluded ICU readmissions (37), ICU admissions who stayed less than 24 hours (44), and patients with unavailable medical charts (36). OUTCOME MEASURE:: In-ICU and 6-month mortality. MAIN RESULTS:: Multivariate logistic regression analysis and Cox proportional hazards models demonstrated that the variables associated with in-ICU and 6-month mortality were sepsis as the cause of admission (odds ratio [OR] = 3.16 [95% confidence interval [CI] 1.65-6.06]); hazards ratio [HR] = 1.37 [95% CI 1.01-1.88]), an Acute Physiology and Chronic Health Evaluation II score >19 [OR = 2.81 (95% CI 1.57-5.04); HR = 2.18 (95% CI 1.62-2.94)], mechanical ventilation during the first 24 hours [OR = 3.92 (95% CI 2.20-6.96); HR = 2.25 (95% CI 1.65-3.07)], and year of ICU admission [OR = 0.90 (95% CI 0.81-0.99); HR = 0.92 [95% CI 0.87-0.97)]. CD4 T-cell count <50 cells/mm was only associated with ICU mortality [OR = 2.10 (95% CI 1.17-3.76)]. The use of ART in the ICU was negatively predictive of 6-month mortality in the Cox model [HR = 0.50 (95% CI 0.35-0.71)], especially if this therapy was introduced during the first 4 days of admission to the ICU [HR = 0.58 (95% CI 0.41-0.83)]. Regarding HIV-infected patients admitted to ICU without using ART, those who have started this treatment during ICU stay presented a better prognosis when time and potential confounding factors were adjusted for [HR 0.55 (95% CI 0.31-0.98)]. CONCLUSIONS:: The ICU outcome of HIV-infected patients seems to be dependent not only on acute illness severity, but also on the administration of antiretroviral treatment.

PMID: 19325488 [PubMed - as supplied by publisher]

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Epidemiology and outcome of nosocomial bloodstream infection in elderly critically ill patients: A comparison between middle-aged, old, and very old patients*

Crit Care Med. 2009 Mar 25;

Authors: Blot S, Cankurtaran M, Petrovic M, Vandijck D, Decruyenaere J, Danneels C, Vandewoude K, Piette A, Verschraegen G, Van Den Noortgate N, Peleman R, Vogelaers D

BACKGROUND:: We investigated the epidemiology of nosocomial bloodstream infection in elderly intensive care unit (ICU) patients. METHODS:: In a single-center, historical cohort study (1992-2006), we compared middle-aged (45-64 years; n = 524), old (65-74 years; n = 326), and very old ICU patients (>/=75 years; n = 134) who developed a nosocomial bloodstream infection during their ICU stay. RESULTS:: Although the total number of ICU admissions (patients aged >/=45 years) decreased by approximately 10%, the number of very old patients increased by 33% between the periods 1992-1996 and 2002-2006. The prevalence of bloodstream infection (per 1,000 ICU admissions) increased significantly over time among old (p = 0.001) and very old patients (p = 0.002), but not among middle-aged patients (p = 0.232). Yet, this trend could not be confirmed with the incidence data expressed per 1,000 patient days (p > 0.05). Among patients with bloodstream infection, the proportion of very old patients increased significantly with time from 7.2% (1992-1996) to 13.5% (1997-2001) and 17.4% (2002-2006) (p < 0.001). The incidence of bloodstream infection (per 1000 patient days) decreased with age: 8.4 per thousand in middle-aged, 5.5 per thousand in old, and 4.6 per thousand in very old patients (p < 0.001). Mortality rates increased with age: 42.9%, 49.1%, and 56.0% for middle-aged, old, and very old patients, respectively (p = 0.015). Regression analysis revealed that the adjusted relationship with mortality was borderline significant for old age (hazard ratio, 1.2; 95% confidence interval, 1.0-1.5) and significant for very old age (hazard ratio, 1.8; 95% confidence interval, 1.4-2.4). CONCLUSION:: Over the past 15 years, an increasing number of elderly patients were admitted to our ICU. The incidence of nosocomial bloodstream infection is lower among very old ICU patients when compared to middle-aged and old patients. Yet, the adverse impact of this infection is higher in very old patients.

PMID: 19325489 [PubMed - as supplied by publisher]

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Diagnosis and treatment of primary hypothyroidism.

BMJ. 2009;338:b725

Authors: Allahabadia A, Razvi S, Abraham P, Franklyn J

PMID: 19325179 [PubMed - indexed for MEDLINE]

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Low Sensitivity of Rapid Diagnostic Test for Influenza.

Clin Infect Dis. 2009 Mar 26;

Authors: Uyeki TM, Prasad R, Vukotich C, Stebbins S, Rinaldo CR, Ferng YH, Morse SS, Larson EL, Aiello AE, Davis B, Monto AS

The QuickVue Influenza A+B Test (Quidel) was used to test nasal swab specimens obtained from persons with influenza-like illness in 3 different populations. Compared with reverse-transcriptase polymerase chain reaction, the test sensitivity was low for all populations (median, 27%; range, 19%-32%), whereas the specificity was high (median, 97%; range, 96%-99.6%).

PMID: 19323628 [PubMed - as supplied by publisher]

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