2011 December 27

?-Glucan Antigenemia Assay for the Diagnosis of Invasive Fungal Infections in Patients With Hematological Malignancies: A Systematic Review and Meta-Analysis of Cohort Studies From the Third European Conference on Infections in Leukemia (ECIL-3).

Dec 272011

?-Glucan Antigenemia Assay for the Diagnosis of Invasive Fungal Infections in Patients With Hematological Malignancies: A Systematic Review and Meta-Analysis of Cohort Studies From the Third European Conference on Infections in Leukemia (ECIL-3).

Clin Infect Dis. 2011 Dec 23;

Authors: Lamoth F, Cruciani M, Mengoli C, Castagnola E, Lortholary O, Richardson M, Marchetti O,

Abstract
Background.?Invasive fungal infections (IFIs) are life-threatening complications in patients with hemato-oncological malignancies, and early diagnosis is crucial for outcome. The compound 1,3-?-D-glucan (BG), a cell wall component of most fungal species, can be detected in blood during IFI. Four commercial BG antigenemia assays are available (Fungitell, Fungitec-G, Wako, and Maruha). This meta-analysis from the Third European Conference on Infections in Leukemia (ECIL-3) assessed the performance of BG assays for the diagnosis of IFI in hemato-oncological patients.Methods.?Studies reporting the performance of BG antigenemia assays for the diagnosis of IFI (European Organization for Research and Treatment of Cancer and Mycoses Study Group criteria) in hemato-oncological patients were identified. The analysis was focused on high-quality cohort studies with exclusion of case-control studies. Meta-analysis was performed by conventional meta-analytical pooling and bivariate analysis.Results.?Six cohort studies were included (1771 adult patients with 414 IFIs of which 215 were proven or probable). Similar performance was observed among the different BG assays. For the cutoff recommended by the manufacturer, the diagnostic performance of the BG assay in proven or probable IFI was better with 2 consecutive positive test results (diagnostic odds ratio for 2 consecutive vs one single positive results, 111.8 [95% confidence interval {CI}, 38.6-324.1] vs 16.3 [95% CI, 6.5-40.8], respectively; heterogeneity index for 2 consecutive vs one single positive results, 0% vs 72.6%, respectively). For 2 consecutive tests, sensitivity and specificity were 49.6% (95% CI, 34.0%-65.3%) and 98.9% (95% CI, 97.4%-99.5%), respectively. Estimated positive and negative predictive values for an IFI prevalence of 10% were 83.5% and 94.6%, respectively.Conclusions.?Different BG assays have similar accuracy for the diagnosis of IFI in hemato-oncological patients. Two consecutive positive antigenemia assays have very high specificity, positive predictive value, and negative predictive value. Because sensitivity is low, the test needs to be combined with clinical, radiological, and microbiological findings.

PMID: 22198786 [PubMed - as supplied by publisher]

Link to Article at PubMed

Outcomes of Patients Treated With Triple Antithrombotic Therapy After Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction (from the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction [HORIZONS-AMI] Trial).

Am J Cardiol Start a Discussion »

Dec 272011

Outcomes of Patients Treated With Triple Antithrombotic Therapy After Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction (from the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction [HORIZONS-AMI] Trial).

Am J Cardiol. 2011 Dec 21;

Authors: Nikolsky E, Mehran R, Dangas GD, Yu J, Parise H, Xu K, Pocock SJ, Stone GW

Abstract
In the setting of ST-segment elevation myocardial infarction (STEMI), patients at high risk of systemic emboli who undergo primary percutaneous coronary intervention (PCI) using stents might require triple antithrombotic therapy (a combination of aspirin, thienopyridine, and vitamin K antagonist [VKA]). The risks and benefits of such therapy in the setting of STEMI have been incompletely characterized. We, therefore, assessed the outcomes of patients who received triple therapy after primary PCI in the large-scale, contemporary Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction [HORIZONS-AMI] trial. Among the 3,320 patients triaged to primary PCI, 126 (3.8%) were prescribed triple therapy and 3,194 (96.2%) were prescribed dual antiplatelet therapy. The most frequent indications for VKA treatment were a severely reduced left ventricular ejection fraction with a large akinetic area, atrial fibrillation (23.8% each), and mural thrombus (23.0%). The assignment to triple therapy was associated with older age, female gender, rhythm disturbances, Killip class >1 on admission, lower left ventricular ejection fraction, left anterior descending artery territory infarcts, and Final Thrombolysis In Myocardial Infarction flow grade <3. Patients treated with triple versus dual therapy had comparable short- and long-term ischemic outcomes but had significantly increased rates of major bleeding during the index hospitalization (17.1% vs 6.5%, p <0.0001), resulting in premature VKA discontinuation in 14.3% of those patients. In conclusion, in the setting of STEMI treated with primary PCI, the combination of aspirin, thienopyridine, and VKA results in an excess of bleeding complications and premature discontinuation of VKA. The risk of adding oral anticoagulation to patients admitted for STEMI should be carefully considered before choosing drug-eluting or bare metal stents.

PMID: 22196778 [PubMed - as supplied by publisher]

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Effect of Timing of Chronic Preoperative Aspirin Discontinuation on Morbidity and Mortality in Patients Having Combined Coronary Artery Bypass Grafting and Valve Surgery.

Am J Cardiol Start a Discussion »

Dec 272011

Effect of Timing of Chronic Preoperative Aspirin Discontinuation on Morbidity and Mortality in Patients Having Combined Coronary Artery Bypass Grafting and Valve Surgery.

Am J Cardiol. 2011 Dec 21;

Authors: Jacob M, Smedira N, Blackstone E, Williams S, Cho L

Abstract
The objective of this study was to determine if late use of aspirin before coronary artery bypass grafting (CABG) with valve surgery affects bleeding events and major adverse cardiovascular events. Aspirin has been shown to decrease postoperative CABG mortality and ischemic events. There are no data on the time of aspirin discontinuation and its effect on CABG with valve surgery and bleeding complications. From January 1, 2002 to January 31, 2008, 1,963 patients undergoing nonurgent plus valve surgery at the Cleveland Clinic were on preoperative aspirin; 1,404 (72%) discontinued aspirin ?6 days before surgery (early discontinuation) and 559 (28%) continued aspirin within 5 days of surgery (late use). Propensity-score analysis and matching were employed for fair comparison of outcomes. There was no difference between early-discontinuation and late-use groups in the composite outcome of in-hospital mortality, myocardial infarction, and stroke (5.3% in the 2 groups). More patients in the late-use group received postoperative transfusions (49% vs 42%, p = 0.02). There was a trend toward increased reoperation for bleeding (6.1% vs 3.7%, p = 0.08) in the late-use group. In conclusion, in patients undergoing CABG with valve surgery, there was an increased use of postoperative red blood cell transfusion and a trend toward increased reoperation for bleeding in the late-use group. There was no difference in major adverse cardiac events between groups. Late use of aspirin in CABG with valve surgery must be weighed against an increased risk of bleeding.

PMID: 22196776 [PubMed - as supplied by publisher]

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Sex Differences in Management and Mortality of Patients With ST-Elevation Myocardial Infarction (from the Korean Acute Myocardial Infarction National Registry).

Am J Cardiol Start a Discussion »

Dec 272011

Sex Differences in Management and Mortality of Patients With ST-Elevation Myocardial Infarction (from the Korean Acute Myocardial Infarction National Registry).

Am J Cardiol. 2011 Dec 21;

Authors: Kang SH, Suh JW, Yoon CH, Cho MC, Kim YJ, Chae SC, Yoon JH, Gwon HC, Han KR, Kim JH, Ahn YK, Jeong MH, Kim HS, Choi DJ,

Abstract
There has been controversy over the disparity between men and women with regard to the management and prognosis of acute myocardial infarction. Analyzing nationwide multicenter prospective registries in Korea, the aim of this study was to determine whether female gender independently imposes a risk for mortality. Data from 14,253 patients who were hospitalized for ST-segment elevation myocardial infarction from November 2005 to September 2010 were extracted from registries. Compared to men, women were older (mean age 56 ± 12 vs 67 ± 10 years, p <0.001), and female gender was associated with a higher frequency of co-morbidities, including hypertension, diabetes, and dyslipidemia. Women had longer pain-to-door time and more severe hemodynamic status than men. All-cause mortality rates were 13.6% in women and 7.0% in men at 1 year after the index admission (hazard ratio for women 2.01, 95% confidence interval 1.80 to 2.25, p <0.001). The risk for death after ST-segment elevation myocardial infarction corresponded highly with age. Although the risk remained high after adjusting for age, further analyses adjusting for medical history, clinical performance, and hemodynamic status diminished the gender effect (hazard ratio 1.00, 95% confidence interval 0.86 to 1.17, p = 0.821). Propensity score matching, as a sensitivity analysis, corroborated the results. In conclusion, this study shows that women have a comparable risk for death after ST-segment elevation myocardial infarction as men. The gender effect was accounted for mostly by the women's older age, complex co-morbidities, and severe hemodynamic conditions at presentation.

PMID: 22196789 [PubMed - as supplied by publisher]

Link to Article at PubMed

Application of the Sequential Organ Failure Assessment score for predicting mortality in patients with acute myocardial infarction.

Resuscitation Start a Discussion »

Dec 272011

Application of the Sequential Organ Failure Assessment score for predicting mortality in patients with acute myocardial infarction.

Resuscitation. 2011 Dec 22;

Authors: Huang SS, Chen YH, Lu TM, Chen LC, Chen JW, Lin SJ

Abstract
BACKGROUND: Thrombolysis in Myocardial Infarction (TIMI) score and Global Registry of Acute Coronary Events (GRACE) score have been validated as predictors of death in patients with acute myocardial infarction (AMI). This study was undertaken to determine whether the Sequential Organ Failure Assessment (SOFA) score had good accuracy for predicting mortality in AMI patients, and to compare the discriminatory performance of the 3 risk scores (RSs). METHODS: This was a retrospective study. We calculated the TIMI RS, GRACE RS, and SOFA score for 726 consecutive AMI patients. The study endpoint was all-cause mortality. All patients were followed up for at least 3 years or until the occurrence of death. The area under the receiver operating characteristic curve (AUC) was used to evaluate the predictive ability of each score at different time points. RESULTS: For in-hospital death, the AUC were 0.67 for TIMI RS, 0.73 for GRACE RS, and 0.79 for SOFA score (P<0.001, respectively). However, the SOFA score and GRACE RS were significantly better for predicting the 1-year (P<0.001, respectively) and 3-year (P<0.001, respectively) mortality than the TIMI RS was. Multivariate Cox regression analysis revealed that the SOFA score was an independent predictor of long-term mortality in AMI patients [hazard ratio (HR), 1.313; 95% CI, 1.191-1.447]. CONCLUSIONS: The SOFA score provides potentially valuable prognostic information on clinical outcome when applied to patients with AMI. Compared with TIMI RS, both SOFA score and GRACE RS provide better discrimination for long-term mortality in patients presenting with AMI.

PMID: 22198421 [PubMed - as supplied by publisher]

Link to Article at PubMed

Skilled nursing facility referral and hospital readmission rates after heart failure or myocardial infarction.

Am J Med Start a Discussion »

Dec 272011

Skilled nursing facility referral and hospital readmission rates after heart failure or myocardial infarction.

Am J Med. 2012 Jan;125(1):100.e1-9

Authors: Chen J, Ross JS, Carlson MD, Lin Z, Normand SL, Bernheim SM, Drye EE, Ling SM, Han LF, Rapp MT, Krumholz HM

Abstract
BACKGROUND: Substantial hospital-level variation in the risk of readmission after hospitalization for heart failure (HF) or acute myocardial infarction (AMI) has been reported. Prior studies have documented considerable state-level variation in rates of discharge to skilled nursing facilities (SNFs), but evaluation of hospital-level variation in SNF rates and its relationship to hospital-level readmission rates is limited.
METHODS: Hospital-level 30-day all-cause risk-standardized readmission rates (RSRRs) were calculated using claims data for fee-for-service Medicare patients hospitalized with a principal diagnosis of HF or AMI from 2006-2008. Medicare claims were used to calculate rates of discharge to SNF following HF-specific or AMI-specific admissions in hospitals with ?25 HF or AMI patients, respectively. Weighted regression was used to quantify the relationship between RSRRs and SNF rates for each condition.
RESULTS: Mean RSRR following HF admission among 4101 hospitals was 24.7%, and mean RSRR after AMI admission among 2453 hospitals was 19.9%. Hospital-level SNF rates ranged from 0% to 83.8% for HF and from 0% to 77.8% for AMI. No significant relationship between RSRR after HF and SNF rate was found in adjusted regression models (P=.15). RSRR after AMI increased by 0.03 percentage point for each 1 absolute percentage point increase in SNF rate in adjusted regression models (P=.001). Overall, HF and AMI SNF rates explained <1% and 4% of the variation for their respective RSRRs.
CONCLUSION: SNF rates after HF or AMI hospitalization vary considerably across hospitals, but explain little of the variation in 30-day all-cause readmission rates for these conditions.

PMID: 22195535 [PubMed - in process]

Link to Article at PubMed

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