2011 July 29

Outcomes of Moderate-to-Severe Pneumocystis Pneumonia Treated with Adjunctive Steroid in Non-HIV-Infected Patients.

Antimicrob Agents Chemother Start a Discussion »

Jul 292011

Outcomes of Moderate-to-Severe Pneumocystis Pneumonia Treated with Adjunctive Steroid in Non-HIV-Infected Patients.

Antimicrob Agents Chemother. 2011 Jul 25;

Authors: Moon SM, Kim T, Sung H, Kim MN, Kim SH, Choi SH, Jeong JY, Woo JH, Kim YS, Lee SO

While it is well-known that adjunctive corticosteroid use improves the outcome of moderate-to-severe Pneumocystis jirovecii pneumonia (PcP) in patients with human immunodeficiency virus (HIV), there is limited data on its efficacy in non-HIV-infected patients with PcP. Patients undergoing fiberoptic bronchoscopy with bronchoalveolar lavage for suspected PcP from January 2007 through December 2010 were reviewed retrospectively. We compared demographics, clinical characteristics, and outcomes in 88 non-HIV infected patients with moderate-to-severe PcP with (n = 59) and without (n = 29) adjunctive corticosteroid use. Outcomes of PcP were assessed by respiratory failure and 30-day and 90-day all-cause mortality. Survival curves were analyzed by the Kaplan-Meier method and estimated by the log-rank test. All cause mortality of moderate-to-severe PcP at 90 days was lower in the solid organ transplant recipients than in all other patients (6/26 [23%] vs. 34/62 [55%]; P = 0.006), and mortality at 30 days was lower in patients with hematologic malignancies (4/26 [15%] vs. 24/62 [39%]; P = 0.03). The outcomes of PcP were not significantly different in moderate-to-severe PcP patients with and without adjunctive corticosteroid use, regardless of recent corticosteroid use. Survival analysis of PcP patients with and without corticosteroid use by the Kaplan-Meier method also did not reveal any difference (log-rank test, P = 0.81). There was again no difference within the subgroup of PcP patients with solid organ transplants. Adjunctive corticosteroid use may not improve the outcome of moderate-to-severe PcP in non-HIV infected patients.

PMID: 21788460 [PubMed - as supplied by publisher]

Link to Article at PubMed

Diagnostic accuracy in patients admitted to hospitals with cellulitis.

Uncategorized Start a Discussion »

Jul 292011

Diagnostic accuracy in patients admitted to hospitals with cellulitis.

Dermatol Online J. 2011;17(3):1

Authors: David CV, Chira S, Eells SJ, Ladrigan M, Papier A, Miller LG, Craft N

Misdiagnosis of non-infectious conditions such as cellulitis is a common error and can result in unnecessary hospitalization and antibiotic use. We sought to prospectively determine the misdiagnosis rate of cellulitis among hospitalized patients and to determine if a visually-based computerized diagnostic decision support system (VCDDSS, also named VisualDx) could generate an improved differential diagnosis (DDx) for misdiagnosed patients. In two separate institutions, attending dermatologists or infectious disease specialists evaluated all consecutive patients hospitalized for "cellulitis" by the emergency department. Among 145 subjects enrolled, misdiagnosis occurred in 41 (28%) patients. The diagnosis most commonly mistaken as cellulitis was stasis dermatitis (37%). At one center, in cases that were misdiagnosed by the emergency department, the VCDDSS included the correct diagnosis in the DDx more frequently than the admitting team (18/28 cases (64%) compared to 4/28 cases (14%), p=0.0003). These results demonstrate the capability of this VCDDSS to assist primary care physicians with generating a more accurate DDx when confronted with patients presenting with possible skin infections. Misdiagnoses may result in a significant source of healthcare costs and misdiagnosis-related patient harm. Inclusion of decision support tools early in the diagnostic workflow may reduce misdiagnosis and result in more efficient healthcare management.

PMID: 21426867 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Increasing outpatient treatment of mild community-acquired pneumonia: systematic review and meta-analysis.

Eur Respir J Start a Discussion »

Jul 292011

Increasing outpatient treatment of mild community-acquired pneumonia: systematic review and meta-analysis.

Eur Respir J. 2011 Apr;37(4):858-64

Authors: Chalmers JD, Akram AR, Hill AT

In order to identify, synthesise and interpret the evidence relating to strategies to increase the proportion of low-risk patients with community-acquired pneumonia treated in the community, we conducted a systematic review of intervention studies conducted between 1981-2010. Articles were included if they compared strategies to increase outpatient care with usual care. Outcomes were: the proportion of patients treated as outpatients, mortality, hospital readmissions, health related quality of life, return to usual activities and patient satisfaction with care. The main analysis included six studies. The interventions in these studies were generally complex, but all involved the use of a severity score to identify low-risk patients. Overall, a significantly larger numbers of patients were treated in the community with these interventions (OR 2.31, 95% CI 2.03-2.63). The interventions appear safe, with no significant differences in mortality (OR 0.83, 95% CI 0.59-1.17), hospital readmissions (OR 1.08, 95% CI 0.82-1.42) or patient satisfaction with care (OR 1.21, 95% CI 0.97-1.49) between the intervention and control groups. There was insufficient data regarding quality of life or return to usual activities. All studies had significant limitations. The available evidence suggests that interventions to increase the proportion of patients treated in the community are safe, effective and acceptable to patients.

PMID: 20729221 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Differentiating ST-Elevation Myocardial Infarction from Nonischemic ST-Elevation in Patients With Chest Pain.

Am J Cardiol Start a Discussion »

Jul 292011

Differentiating ST-Elevation Myocardial Infarction from Nonischemic ST-Elevation in Patients With Chest Pain.

Am J Cardiol. 2011 Jul 24;

Authors: Tran V, Huang HD, Diez JG, Kalife G, Goswami R, Paniagua D, Jneid H, Wilson JM, Sherron SR, Birnbaum Y

Current guidelines state that patients with compatible symptoms and ST-segment elevation (STE) in ?2 contiguous electrocardiographic leads should undergo immediate reperfusion therapy. Aggressive attempts at decreasing door-to-balloon times have led to more frequent activation of primary percutaneous coronary intervention (pPCI) protocols. However, it remains crucial to correctly differentiate STE myocardial infarction (STEMI) from nonischemic STE (NISTE). We assessed the ability of experienced interventional cardiologists in determining whether STE represents acute STEMI or NISTE. Seven readers studied electrocardiograms of consecutive patients showing STE. Patients with left bundle branch block or ventricular rhythms were excluded. Readers decided if, based on electrocardiographic results, they would have activated the pPCI protocol. If NISTE was chosen, readers selected from 12 possible explanations as to why STE was present. Of 84 patients, 40 (48%) had adjudicated STEMI. The percentage for which readers recommended pPCI varied (33% to 75%). Readers' sensitivity and specificity ranged from 55% to 83% (average 71%) and 32% to 86% (average 63%), respectively. Positive and negative predictive values ranged from 52% to 79% (average 66%) and 67% to 79% (average 71%), respectively. Broad inconsistencies existed among readers as to the chosen reasons for NISTE classification. In conclusion, we found wide variations in experienced interventional cardiologists in differentiating STEMI with a need for pPCI from NISTE.

PMID: 21791329 [PubMed - as supplied by publisher]

Link to Article at PubMed

Relation of Homocysteinemia to Contrast-Induced Nephropathy in Patients Undergoing Percutaneous Coronary Intervention.

Am J Cardiol Start a Discussion »

Jul 292011

Relation of Homocysteinemia to Contrast-Induced Nephropathy in Patients Undergoing Percutaneous Coronary Intervention.

Am J Cardiol. 2011 Jul 24;

Authors: Kim SJ, Choi D, Ko YG, Kim JS, Han SH, Kim BK, Kang SW, Hong MK, Jang Y, Choi KH, Yoo TH

Hyperhomocysteinemia induces oxidative stress and endothelial dysfunction, which share the proposed pathophysiologic mechanisms of contrast-induced nephropathy (CIN). However, no study has investigated the relation between hyperhomocysteinemia and CIN. The aim of the present study was to evaluate the effects of hyperhomocysteinemia on CIN in patients undergoing percutaneous coronary intervention. This was an observational cohort study that included 572 patients who underwent percutaneous coronary intervention. CIN was defined as an absolute ?0.5 mg/dl or a relative ?25% increase in the serum creatinine level at 48 hours after the procedure. The incidence of CIN was significantly greater in patients in the third homocysteine tertile (from lowest to highest, 4.7%, 7.3%, and 24.2%, p <0.001). Furthermore, the homocysteine levels were significantly greater in patients with CIN than in those without CIN (16.9 ± 4.9 vs 13.5 ± 4.2 ?mol/L, p <0.001). In multiple logistic regression models, hyperhomocysteinemia was an independent risk factor for CIN (per the SD change in the plasma homocysteine level [4.44 ?mol/L], odds ratio 1.70, 95% confidence interval 1.07 to 2.71, p = 0.025) after adjusting for major risk factors such as age, diabetes, and baseline cardiac and renal function. In subgroup analyses according to diabetes, acute coronary syndrome, or baseline estimated glomerular filtration rate, significant, graded associations were found between the homocysteine level and the incidence of CIN. In conclusion, hyperhomocysteinemia is independently associated with a greater risk of CIN in patients undergoing percutaneous coronary intervention.

PMID: 21791335 [PubMed - as supplied by publisher]

Link to Article at PubMed

Approach to the Evaluation of a Patient With an Increased Serum Osmolal Gap and High-Anion-Gap Metabolic Acidosis.

Am J Kidney Dis Start a Discussion »

Jul 292011

Approach to the Evaluation of a Patient With an Increased Serum Osmolal Gap and High-Anion-Gap Metabolic Acidosis.

Am J Kidney Dis. 2011 Jul 26;

Authors: Kraut JA, Xing SX

An increase in serum osmolality and serum osmolal gap with or without high-anion-gap metabolic acidosis is an important clue to exposure to one of the toxic alcohols, which include methanol, ethylene glycol, diethylene glycol, propylene glycol, or isopropanol. However, the increase in serum osmolal gap and metabolic acidosis can occur either together or alone depending on several factors, including baseline serum osmolal gap, molecular weight of the alcohol, and stage of metabolism of the alcohol. In addition, other disorders, including diabetic or alcoholic ketoacidosis, acute kidney injury, chronic kidney disease, and lactic acidosis, can cause high-anion-gap metabolic acidosis associated with an increased serum osmolal gap and therefore should be explored in the differential diagnosis. It is essential for clinicians to understand the value and limitations of osmolal gap to assist in reaching the correct diagnosis and initiating appropriate treatment. In this teaching case, we present a systematic approach to diagnosing high serum osmolality and increased serum osmolal gap with or without high-anion-gap metabolic acidosis.

PMID: 21794966 [PubMed - as supplied by publisher]

Link to Article at PubMed

July 2011
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