2012 February 14

Frequency, determinants and outcome of elevated troponin in acute ischemic stroke patients.

Feb 142012

Frequency, determinants and outcome of elevated troponin in acute ischemic stroke patients.

Int J Cardiol. 2012 Feb 10;

Authors: Scheitz JF, Endres M, Mochmann HC, Audebert HJ, Nolte CH

Abstract
BACKGROUND: Myocardial injury indicated by elevation of cardiac troponins (cTnT) can be observed in acute ischemic stroke patients. Frequency, determinants and prognostic value are still unsettled. METHODS: We performed a retrospective analysis including all consecutive ischemic stroke patients admitted to our stroke unit within 72h after symptom onset in a one-year period. Multivariable logistic regression analyses were conducted to identify determinants of cTnT elevation and to detect factors independently associated with unfavorable short-term outcome (modified Rankin scale >2), major neurologic improvement (improvement of NIHSS>=8 or NIHSS 0-1) and in-hospital mortality. RESULTS: Admission cTnT levels were measured in 715 ischemic stroke patients. Frequency of cTnT elevation was 14% (n=103). Factors independently associated with increased cTnT were higher stroke severity (p=0.04), renal insufficiency (p<0.001), pre-existing coronary artery disease (p=0.03), hypercholesterolemia (p=0.02) and insular cortex involvement (p<0.001). After exclusion of patients with renal insufficiency and coronary artery disease frequency of cTnT elevation was 10% (n=44) and only insular cortex involvement remained significantly associated. Increased cTnT on admission was an independent predictor of unfavorable outcome (adjusted odds ratio 2.65 [95% confidence interval 1.29-5.46]) and in-hospital mortality (4.51 [1.93-10.57]). There was a trend towards a negative association of cTnT elevation with major neurologic improvement (0.54 [0.27-1.07]). CONCLUSIONS: Elevation of cTnT occurs in every seventh patient with acute ischemic stroke and is independently associated with poor short-term outcome and mortality. Patients with strokes affecting the insular cortex are particularly prone to myocardial injury justifying intensive cardiac monitoring.

PMID: 22326514 [PubMed - as supplied by publisher]

Link to Article at PubMed

The impact of the heparin-induced thrombocytopenia (HIT) computerized alert on provider behaviors and patient outcomes.

J Am Med Inform Assoc Start a Discussion »

Feb 142012

The impact of the heparin-induced thrombocytopenia (HIT) computerized alert on provider behaviors and patient outcomes.

J Am Med Inform Assoc. 2011 Nov-Dec;18(6):783-8

Authors: Austrian JS, Adelman JS, Reissman SH, Cohen HW, Billett HH

Abstract
OBJECTIVE: The aim of this study was to measure the effect of an electronic heparin-induced thrombocytopenia (HIT) alert on provider ordering behaviors and on patient outcomes.
MATERIALS AND METHODS: A pop-up alert was created for providers when an individual's platelet values had decreased by 50% or to <100,000/mm(3) in the setting of recent heparin exposure. The authors retrospectively compared inpatients admitted between January 24, 2008 and August 24, 2008 to a control group admitted 1 year prior to the HIT alert. The primary outcome was a change in HIT antibody testing. Secondary outcomes included an assessment of incidence of HIT antibody positivity, percentage of patients started on a direct thrombin inhibitor (DTI), length of stay and overall mortality.
RESULTS: There were 1006 and 1081 patients in the control and intervention groups, respectively. There was a 33% relative increase in HIT antibody test orders (p=0.01), and 33% more of these tests were ordered the first day after the criteria were met when a pop-up alert was given (p=0.03). Heparin was discontinued in 25% more patients in the alerted group (p=0.01), and more direct thrombin inhibitors were ordered for them (p=0.03). The number who tested HIT antibody-positive did not differ, however, between the two groups (p=0.99). The length of stay and mortality were similar in both groups.
CONCLUSIONS: The HIT alert significantly impacted provider behaviors. However, the alert did not result in more cases of HIT being detected or an improvement in overall mortality. Our findings do not support implementation of a computerized HIT alert.

PMID: 21712374 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Comparison of post-dural puncture headache and low back pain between 23 and 25 gauge Quincke spinal needles in patients over 60 years: randomized, double-blind controlled trial.

Int J Nurs Stud Start a Discussion »

Feb 142012

Comparison of post-dural puncture headache and low back pain between 23 and 25 gauge Quincke spinal needles in patients over 60 years: randomized, double-blind controlled trial.

Int J Nurs Stud. 2011 Nov;48(11):1315-22

Authors: Kim M, Yoon H

Abstract
BACKGROUND: Even though the use of a 25 gauge or smaller Quincke needle is recommended for spinal anesthesia to reduce post-dural puncture headache in Korea, lumbar puncture in older patients using a 25 gauge or smaller Quincke needle can be difficult. However, most previous studies concerning post-dural puncture headache have chosen children, parturients, and young adults as study participants.
OBJECTIVES: The study compared post-dural puncture headache, post-operative back pain, and the number of lumbar puncture attempts using a 23 or 25 gauge Quincke needle for spinal anesthesia of Korean patients >60-years-of-age.
DESIGN: Randomized, double-blinded controlled trial.
PARTICIPANTS: The 53 participants who underwent orthopedic surgery under spinal anesthesia were recruited by informed notices from December 2006 through August 2007 at a 200-bed general hospital located in Kyunggido. Inclusion criteria were an age >60 years, ASA I-II, and administration of patient controlled analgesia for the first 48 h post-operatively.
METHODS: The 53 patients were randomly allocated to either the experimental (23 gauge Quincke needle) or control group (25 gauge Quincke needle). All patients had 24 h bed rest post-operatively. Post-dural puncture headache was assessed by the Dittmann Scale and post-operative back pain was assessed by a visual analogue scale at 24, 48, and 72 h post-operatively. The statistical methods included the Mann-Whitney U-test and Spearman correlation.
RESULTS: There were no differences in post-dural puncture headache, and post-operative back pain at 24, 48, and 72 h post-operatively, and no differences in the number of lumbar punctures, with the 23 and 25 gauge Quincke needle. Forty-eight hour post-operative back pain was positively associated with the number of lumbar punctures (p=.036) and age (p=.040). There were no statistically significant associations among post-dural puncture headache, the number of lumbar punctures, and 48 h post-operative back pain. Pre-operative back pain was positively associated with 48 h post-operative back pain (p<.001).
CONCLUSIONS: The choice of a 23 or 25 gauge Quincke needle for spinal anesthesia has no significant influence on post-dural puncture headache and post-operative back pain for Korean patients greater than 60-years-of-age. The 23 gauge Quincke needle is an option for lumbar punctures in this patient population.

PMID: 21561619 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

A negative nares screen in combination with absence of clinical risk factors can be used to identify patients with very low likelihood of methicillin-resistant Staphylococcus aureus infection in a Veterans Affairs hospital.

Am J Infect Control Start a Discussion »

Feb 142012

A negative nares screen in combination with absence of clinical risk factors can be used to identify patients with very low likelihood of methicillin-resistant Staphylococcus aureus infection in a Veterans Affairs hospital.

Am J Infect Control. 2012 Feb 9;

Authors: Jinno S, Chang S, Donskey CJ

Abstract
BACKGROUND: Screening for nares carriage of methicillin-resistant Staphylococcus aureus (MRSA) could be used to identify patients at reduced risk for MRSA infection. However, recent studies suggest that negative results of nares surveillance testing are not reliable to predict a low risk for MRSA infection. METHODS: To derive a clinical prediction rule, logistic regression was performed to identify predictors of MRSA infection in patients with negative nares surveillance results. To validate the prediction rule and modifications of the rule, the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated in a prospective cohort of inpatients receiving empiric vancomycin. RESULTS: A prediction rule that included 8 clinical risk factors and nares surveillance results was sensitive with NPV of 99.9%. In the validation cohort, 43 of 451 (10%) patients receiving empiric vancomycin had MRSA infection. In comparison with nares surveillance results (sensitivity, 72%; NPV, 96%), the prediction rule was more reliable for prediction of low risk for MRSA infection (sensitivity, 93%; NPV, 98%). A modified rule that included additional indications for empiric MRSA coverage based on practice guidelines reliably predicted MRSA infection (sensitivity, 100%) while excluding those at low risk (NPV, 100%). CONCLUSION: Negative nares screening results in combination with absence of certain clinical risk factors or syndromes could provide a useful strategy to predict patients with low likelihood of MRSA infection.

PMID: 22325726 [PubMed - as supplied by publisher]

Link to Article at PubMed

Prevalence of potentially inappropriate prescribing in an acutely ill population of older patients admitted to six European hospitals.

Eur J Clin Pharmacol Start a Discussion »

Feb 142012

Prevalence of potentially inappropriate prescribing in an acutely ill population of older patients admitted to six European hospitals.

Eur J Clin Pharmacol. 2011 Nov;67(11):1175-88

Authors: Gallagher P, Lang PO, Cherubini A, Topinková E, Cruz-Jentoft A, Montero Errasquín B, Mádlová P, Gasperini B, Baeyens H, Baeyens JP, Michel JP, O'Mahony D

Abstract
PURPOSE: Potentially inappropriate prescribing is common in older people presenting to hospital with acute illness in Ireland. The aim of this study was to determine if this phenomenon is unique to Ireland or whether it is a more widespread problem in hospitals across Europe.
METHODS: Prospective data were collected from 900 consecutive older patients admitted to six university teaching hospitals (150 patients per centre) in Geneva (Switzerland), Madrid (Spain), Oostende (Belgium), Perugia (Italy), Prague (Czech Republic) and Cork (Ireland). Age, gender, comorbidity, cognitive status, prescription medicines taken before admission and baseline haematological, biochemical and electrocardiographic data were recorded. STOPP and Beers' criteria were applied to detect potentially inappropriate medicines (PIMs). START criteria were applied to detect potentially inappropriate prescribing omissions (PPOs).
RESULTS: The overall PIM prevalence rate was 51.3% using STOPP criteria, varying from 34.7% in Prague to 77.3% in Geneva, and 30.4% using Beer's criteria, varying from 22.7% in Prague to 43.3% in Geneva. Using START criteria, the overall PPO prevalence rate was 59.4%, ranging from 51.3% in Cork to 72.7% in Perugia. Polypharmacy predicted the presence of PIMs using STOPP criteria [with?>10 medications: odds ratio (OR)??7.22, 95% confidence interval (CI) 4.30-12.12, p?<?0.001] and Beers' criteria (with?>10 medications: OR?4.87, 95% CI 3.00-7.90, p?<?0.001). Increasing co-morbidity (Charlson Index??2) and age??85 years significantly predicted PPOs.
CONCLUSION: Potentially inappropriate drug prescribing and the omission of beneficial drugs are highly prevalent in acutely ill hospitalized older people in six European centres.

PMID: 21584788 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Determining vancomycin clearance in an overweight and obese population.

Am J Health Syst Pharm Start a Discussion »

Feb 142012

Determining vancomycin clearance in an overweight and obese population.

Am J Health Syst Pharm. 2011 Apr 1;68(7):599-603

Authors: Leong JV, Boro MS, Winter M

Abstract
PURPOSE: Two methods of calculating vancomycin clearance were compared to determine the best body weight measure to use when dosing vancomycin for overweight and obese patients.
METHODS: Hospitalized veterans weighing more than 120% of their ideal body weight (IBW) with serum vancomycin concentrations (SVCs) drawn between January 1, 2003, and June 30, 2005, were eligible for study inclusion. Exclusion criteria included weight of more than 300% the IBW, unstable renal function, dialysis, uncertain vancomycin dosing or sampling times, and distribution-phase sampling. Data from January 1 through December 31, 2003 (phase 1) determined the best-fit weight for vancomycin clearance for the Leonard and Boro method. The bias and precision of the modified Leonard and Boro method using the best-fit weight for vancomycin clearance were then compared with those of the Rushing and Ambrose method for predicting SVCs from January 1, 2004, through June 30, 2005 (phase 2).
RESULTS: Forty-eight patients were included in phase 1, with 67 SVCs for analysis. During phase 1, adjusted body weight (ABW), using the Leonard and Boro method, was superior in predicting vancomycin clearance and the resultant SVCs. A total of 96 patients were included in phase 2 of the study, with 160 SVCs for analysis. The modified Leonard and Boro method was significantly more precise than the Rushing and Ambrose method in predicting vancomycin clearance.
CONCLUSION: Use of ABW proved to be superior compared with total body weight when estimating vancomycin clearance in overweight and obese patients. While there was no difference in bias between methods, the modified Leonard and Boro method was significantly more precise than the Rushing and Ambrose method in predicting SVCs when dosing vancomycin for obese patients.

PMID: 21411801 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

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