2012 February 02

Present and future of prophylactic antibiotics for severe acute pancreatitis.

World J Gastroenterol Start a Discussion »

Feb 022012

Present and future of prophylactic antibiotics for severe acute pancreatitis.

World J Gastroenterol. 2012 Jan 21;18(3):279-84

Authors: Jiang K, Huang W, Yang XN, Xia Q

Abstract
AIM: To investigate the role of prophylactic antibiotics in the reduction of mortality of severe acute pancreatitis (SAP) patients, which is highly questioned by more and more randomized controlled trials (RCTs) and meta-analyses.
METHODS: An updated meta-analysis was performed. RCTs comparing prophylactic antibiotics for SAP with control or placebo were included for meta-analysis. The mortality outcomes were pooled for estimation, and re-pooled estimation was performed by the sensitivity analysis of an ideal large-scale RCT.
RESULTS: Currently available 11 RCTs were included. Subgroup analysis showed that there was significant reduction of mortality rate in the period before 2000, while no significant reduction in the period from 2000 [Risk Ratio, (RR) = 1.01, P = 0.98]. Funnel plot indicated that there might be apparent publication bias in the period before 2000. Sensitivity analysis showed that the RR of mortality rate ranged from 0.77 to 1.00 with a relatively narrow confidence interval (P < 0.05). However, the number needed to treat having a minor lower limit of the range (7-5096 patients) implied that certain SAP patients could still potentially prevent death by antibiotic prophylaxis.
CONCLUSION: Current evidences do not support prophylactic antibiotics as a routine treatment for SAP, but the potentially benefited sub-population requires further investigations.

PMID: 22294832 [PubMed - in process]

Link to Article at PubMed

Acute Hyperglycemia in Patients With Acute Myocardial Infarction.

Circ J Start a Discussion »

Feb 022012

Acute Hyperglycemia in Patients With Acute Myocardial Infarction.

Circ J. 2012 Jan 27;

Authors: Ishihara M

Abstract
Acute hyperglycemia is a common feature during the early phase after acute myocardial infarction (AMI), regardless of diabetes status. Numerous studies have demonstrated that patients with AMI and hyperglycemia on admission have high rates of mortality. It has been reported that there is a linear positive relation between admission blood glucose levels and mortality after AMI. However, recent studies showed that the relationship is U-shaped in patients with a history of diabetes. Diabetic patients with moderate hyperglycemia (glucose 9-11mmol/L) had the lowest mortality and not only severe hyperglycemia (glucose ?11mmol/L) but also euglycemia (glucose <7mmol/L) was associated with higher mortality. Although it has been debated whether acute hyperglycemia is causally related to adverse outcomes after AMI or is simply an epiphenomenon of severely damaged myocardium, multiple physiological studies have demonstrated that hyperglycemia has a direct detrimental effect on ischemic myocardium through several mechanisms, including oxidative stress, inflammation, apoptosis, endothelial dysfunction, hypercoagulation, platelet aggregation and impairment of ischemic preconditioning. Current guidelines recommend the use of an insulin-based regimen to achieve and maintain glucose levels <10.0mmol/dl, and emphasize the avoidance of hypoglycemia. However, the optimal management goal of glucose levels for patients with acute hyperglycemia remains uncertain. Further studies are warranted into the appropriate management in patients with AMI and acute hyperglycemia.

PMID: 22293452 [PubMed - as supplied by publisher]

Link to Article at PubMed

Value of venous color flow duplex scan as initial screening test for geriatric inpatients with clinically suspected pulmonary embolism.

Vasc Health Risk Manag Start a Discussion »

Feb 022012

Value of venous color flow duplex scan as initial screening test for geriatric inpatients with clinically suspected pulmonary embolism.

Vasc Health Risk Manag. 2011;7:585-9

Authors: Kreidy R, Stephan E, Salameh P, Waked M

Abstract
AIM: The contribution of lower extremity venous duplex scan to the diagnostic strategy for pulmonary embolism has been demonstrated by many authors. However, the positive diagnostic value of this noninvasive test in clinically suspected pulmonary embolism is not very high (10% - 18%). Since thromboembolic risks increase considerably in hospitalized patients with advanced age, this study aims to determine the importance of lower extremity venous color flow duplex scan in this particular subgroup of patients with clinically suspected pulmonary embolism. The effects of clinical presentation and risk factors on the results of duplex scan have been also studied.
METHODS: Between July 2007 and January 2010, 95 consecutive Lebanese geriatric (? 60 years of age) inpatients with clinically suspected pulmonary embolism assessed in an academic tertiary-care center for complete lower extremity venous color flow duplex scan were retrospectively reviewed. Age varied between 60 and 96 years (mean, 79.9 years). Forty patients were males and 55 females. Absence of compressibility was the most important criteria for detecting acute venous thrombosis.
RESULTS: Out of 95 patients, 33 patients (34.7%) were diagnosed with recent deep venous thrombosis of lower extremities (14 proximal and 19 distal) using complete venous ultrasound. Nine of these 33 patients (27.2%) had a history of venous thromboembolism and eleven (33.3%) presented with edema of lower extremities. A total of 28 patients (84.8%) with positive duplex scan had associated risk factors for venous thromboembolism.
CONCLUSION: Lower extremity venous color flow duplex scan appears to be a reasonable initial screening test in the diagnostic algorithm of pulmonary embolism in geriatric inpatients with clinically suspected pulmonary embolism. This is particularly true in patients with a history of venous thromboembolism, in patients with a clinical presentation suggesting venous thrombosis, in uremic patients and in patients with altered general and mental status who are not candidates for chest computed tomography.

PMID: 21966223 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Functional Status Does Not Predict Complicated Clinical Course in Older Adults in the Emergency Department with Infection.

J Am Geriatr Soc Start a Discussion »

Feb 022012

Functional Status Does Not Predict Complicated Clinical Course in Older Adults in the Emergency Department with Infection.

J Am Geriatr Soc. 2012 Jan 27;

Authors: Caterino JM, Murden RA, Stevenson KB

Abstract
OBJECTIVES: To identify the relationship between functional status and complicated clinical course in older adults in the emergency department (ED) with suspected infection and to identify other independent predictors of complicated clinical course. DESIGN: A prospective observational cohort study. SETTING: An academic, tertiary care ED with 70,000 visits per year. PARTICIPANTS: Aged 65 and older, blood cultures obtained in the ED, and final ED physician diagnosis of acute infection. MEASUREMENTS: Functional status was obtained using the Older Americans Resources Scale (OARS). Complicated clinical course was defined as in-hospital mortality, need for intensive care unit (ICU)-level care, or worsening in sepsis criteria within 48 hours. Analysis was performed using multivariable logistic regression. RESULTS: One hundred five participants were enrolled, 34 with the primary outcome. OARS was not predictive of complicated clinical course in univariate (P = .13) or multivariable (P = .90) models. An OARS score of 25 or less was also not significant (P = .22). Independent predictors were immunosuppression (odds ratio (OR) = 3.45, 95% confidence interval (CI) = 1.06-11.20), systolic blood pressure (OR = 0.98, 95% CI = 0.96-1.00), pulse (OR = 1.03, 95% CI = 1.00-1.06), metabolic acidosis (OR = 3.46, 95% CI = 1.08-11.09), severe sepsis or septic shock (OR = 10.24, 95% CI = 1.44-72.79), and suspected bloodstream infection (OR = 3.56, 95% CI = 1.13-11.16). CONCLUSION: For older adults admitted to the ED with infection, functional status did not predict complicated clinical course, but several other variables were predictive, including immunosuppression, several variables associated with hypoperfusion, and suspected bloodstream infection. Emergency physicians could consider these variables as potential indicators of complicated clinical course when making disposition decisions for this population.

PMID: 22283695 [PubMed - as supplied by publisher]

Link to Article at PubMed

Mortality and associated risk factors in consecutive patients admitted to a UK NHS trust with community acquired bacteraemia.

Postgrad Med J Start a Discussion »

Feb 022012

Mortality and associated risk factors in consecutive patients admitted to a UK NHS trust with community acquired bacteraemia.

Postgrad Med J. 2011 Nov;87(1033):757-62

Authors: Hounsom L, Grayson K, Melzer M

Abstract
PURPOSE: Within the UK, there is lack of contemporary data on clinical outcomes in patients admitted to hospital with severe community acquired infection. The purpose of this study was to determine outcomes and risk factors associated with mortality in consecutive patients admitted to a UK NHS trust with community acquired infections that cause bacteraemia.
METHODS: From September 2007 to August 2008, demographic, clinical and microbiological data were collected on patients with laboratory confirmed bacteraemia. Multivariate logistic regression was used to determine the association between predicted variables and likelihood of death.
RESULTS: 686 bacteraemic episodes occurred in 681 patients. The most common sites of infection were non-catheter associated urinary tract infections (140, 20.4%) and biliary tract infections (62, 9.1%). The most common organisms were Escherichia coli (238, 34.7%), Staphylococcus aureus (84, 12.2%) and Streptococcus pneumoniae (40, 5.8%). Of the E coli infections, extended spectrum ?-lactamase (ESBL) producers accounted for 21/238 (8.8%), and of the S aureus infections, methicillin resistant S aureus (MRSA) accounted for 14/84 (16.7%). 124 (18.2%, 95% CI 15.3% to 21.1%) people died within 7 days and 170 (25.0%, 95% CI 21.7% to 28.2%) within 30 days. Age (OR 2.17, 95% CI 1.54 to 3.06), Charlson comorbidity index (OR 1.21, 95% CI 1.10 to 1.34), and Pitt score (OR 1.49, 95% CI 1.32 to 1.67) were highly significantly associated with 30 day mortality (p<0.001). Delay in appropriate antibiotic treatment (OR 1.35, 95% CI 1.05 to 1.75) and an undefined site of infection (OR 2.05, 95% CI 1.19 to 3.53) were less significantly associated with 30 day mortality (p<0.05).
CONCLUSION: The 30 day mortality rate in consecutive patients with community acquired bacteraemic infection was 25.0%. These figures could be used as performance indicators to compare outcomes in different UK NHS trusts. With the exception of delay in appropriate antibiotic treatment, predictors of mortality at 30 days were non-modifiable.

PMID: 21798969 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

The ability of a behaviour-specific patient questionnaire to identify poorly performing doctors.

BMJ Qual Saf Start a Discussion »

Feb 022012

The ability of a behaviour-specific patient questionnaire to identify poorly performing doctors.

BMJ Qual Saf. 2011 Oct;20(10):885-93

Authors: Fossli Jensen B, Dahl FA, Safran DG, Garratt AM, Krupat E, Finset A, Gulbrandsen P

Abstract
BACKGROUND: Doctors' ability to communicate with patients varies. Patient questionnaires are often used to assess doctors' communication skills.
OBJECTIVE: To investigate whether the Four Habits Patient Questionnaire (4HPQ) can be used to assess the different skill levels of doctors.
DESIGN: A cross-sectional study of 497 hospital encounters with 71 doctors. Encounters were videotaped and patients completed three post-visit questionnaires.
SETTING: A 500-bed general teaching hospital in Norway.
MAIN OUTCOME: The proportion of video-observed between-doctor variance that could be predicted by 4HPQ.
RESULTS: There were strong correlations between all patient-reported outcomes (range 0.71-0.80 at the doctor level, p < 0.01). 4HPQ correlated significantly with video-observed behaviour at the doctor level (Pearson's r = 0.42, p<0.01) and the encounter level (Pearson's r = 0.27, p < 0.01). The proportion of between-doctor variance not detectable by 4HPQ was 88%. The reason for this discordance was large within-doctor between-encounter variance observed in the videos, and small between-patient variance in patient reports. The maximum positive predictive value for the identification of poorly performing doctors (92%) was achieved with a cut-off score for 4HPQ of 82% (ie, patient assessments were concordant with expert observers for these doctors).
CONCLUSION: Using a patient-reported questionnaire of doctors' communication skills, favourable assessments of doctors by patients were mostly discordant with the views of expert observers. Only very poor performance identified by patients was in agreement with the views of expert observers. The results suggest that patient reports alone may not be sufficient to identify all doctors whose communication skills need improvement training.

PMID: 21849336 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

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