2012 April 19

Macrolide-Based Regimens and Mortality in Hospitalized Patients with Community-Acquired Pneumonia: A Systematic Review and Meta-Analysis.

Apr 192012

Macrolide-Based Regimens and Mortality in Hospitalized Patients with Community-Acquired Pneumonia: A Systematic Review and Meta-Analysis.

Clin Infect Dis. 2012 Apr 16;

Authors: Asadi L, Sligl WI, Eurich DT, Colmers IN, Tjosvold L, Marrie TJ, Majumdar SR

Abstract
BackgroundMacrolides are used to treat pneumonia despite increasing antimicrobial resistance. However, the immunomodulatory properties of macrolides may have a favorable effect on pneumonia outcomes. Therefore, we systematically reviewed all studies of macrolide use and mortality among patients hospitalized with community-acquired pneumonia (CAP).MethodsAll RCTs and observational studies comparing macrolides to other treatment regimens in adults hospitalized with CAP were identified through electronic databases and grey literature searches. Primary analysis examined any macrolide use and mortality; secondary analysis compared IDSA/ATS guideline-concordant macrolide/beta-lactam combinations vs. respiratory fluoroquinolones. Random effects models were used to generate pooled risk ratios (RR) and evaluate heterogeneity (I(2)).ResultsWe included 23 studies and 137,574 patients. Overall, macrolide use was associated with a statistically significant mortality reduction compared with non-macrolides (3.7% [1738 of 47071] vs. 6.5% [5861 of 90503]; RR 0.78; 95%CI 0.64-0.95; p=0.01; I(2)=85%). There was no survival advantage and heterogeneity was reduced when analyses were restricted to RCTs (4.6% [22 of 479] vs. 4.1% [25 of 613]; RR 1.13; 95%CI 0.65-1.98); p=0.66; I(2)=0%) or to patients treated with guideline-concordant antibiotics (macrolide/beta-lactam 5.3% [297 of 5574] vs. respiratory fluoroquinolones 5.8% [408 of 7050]; RR 1.17; 95%CI 0.91-1.50; p=0.22; I(2)=43%).ConclusionsIn hospitalized patients with CAP, macrolide-based regimens were associated with a significant 22% reduction in mortality compared to non-macrolides; however, this benefit did not extend to patients studied in RCTs or patients that received guideline-concordant antibiotics. Our findings suggest guideline-concordance is more important than choice of antibiotic when treating CAP.

PMID: 22511553 [PubMed - as supplied by publisher]

Link to Article at PubMed

Delayed and Unsuccessful Endoscopic Retrograde Cholangiopancreatography are Associated with Worse Outcomes in Patients with Acute Cholangitis.

Clin Gastroenterol Hepatol Start a Discussion »

Apr 192012

Delayed and Unsuccessful Endoscopic Retrograde Cholangiopancreatography are Associated with Worse Outcomes in Patients with Acute Cholangitis.

Clin Gastroenterol Hepatol. 2012 Apr 13;

Authors: Khashab MA, Tariq A, Tariq U, Kim K, Ponor L, Lennon AM, Canto MI, Gurakar A, Yu Q, Dunbar K, Hutfless S, Kalloo AN, Singh VK

Abstract
BACKGROUND & AIMS: Acute ascending cholangitis is usually treated with antibiotics and biliary drainage by endoscopic retrograde cholangiopancreatography (ECRP). We investigated the effects of the timing of ERCP on outcomes of patients with acute cholangitis factors that predict prolonged hospital stays, increased costs of hospitalization, and composite clinical outcomes (death, persistent organ failure, and admission to the intensive care unit). METHODS: We performed a retrospective analysis of data from 90 patients (mean age 60 y, 48% female) admitted to Johns Hopkins Hospital from January 1994 to June 2010 who were diagnosed with acute cholangitis and underwent ERCP. A delayed ERCP was defined as one performed more than 72 h after admission. Electronic and paper medical records were reviewed and relevant data was abstracted. RESULTS: ERCP was performed successfully in 92% of the patients, at a mean time period of 38 h after admission (14% of ERCPs were delayed). Factors that were independently associated with prolonged length of hospital stay (top 10%) included unsuccessful ERCP (odds ratio [OR]=52.5;P =.002) and delayed ERCP (OR=19.8;P =.008). Factors associated with increased hospitalization cost (top 10%) included unsuccessful ERCP (OR=33.8;P =.004) and delayed ERCP (OR=11.3;P =.03). Factors associated with composite clinical outcome included age (OR=1.1;P =.01), total level of bilirubin (OR=1.36;P =.002), and delayed ERCP (OR=7.8;P =.04). CONCLUSIONS: Delayed and failed ERCP are associated with prolonged hospital stays and increased costs of hospitalization. Delayed ERCP is associated with composite clinical outcome (death, persistent organ failure, and/or ICU stay). Older age and higher levels of bilirubin are also associated with patients' composite end point.

PMID: 22507875 [PubMed - as supplied by publisher]

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Low-molecular-weight heparin prophylaxis does not affect mortality in acutely ill medical patients at low risk for venous thromboembolism.

evid based med Start a Discussion »

Apr 192012

Low-molecular-weight heparin prophylaxis does not affect mortality in acutely ill medical patients at low risk for venous thromboembolism.

Evid Based Med. 2012 Apr 17;

Authors: Själander A

PMID: 22511642 [PubMed - as supplied by publisher]

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Optimal insertion depth of central venous catheters–is a formula required? A prospective cohort study.

Injury Start a Discussion »

Apr 192012

Optimal insertion depth of central venous catheters--is a formula required? A prospective cohort study.

Injury. 2012 Jan;43(1):38-41

Authors: Kim WY, Lee CW, Sohn CH, Seo DW, Yoon JC, Koh JW, Kim W, Lim KS, Hong SB, Lim CM, Koh Y

Abstract
INTRODUCTION: To determine the optimal length for initial insertion of central venous catheters (CVCs) and to evaluate whether a recommended depth predicted optimal positioning of CVCs.
MATERIALS AND METHODS: All patients who were CVC-cannulated and who underwent chest computed tomography (CT) during a 10-month period were included. We measured the distance from catheter insertion to the superior vena cava/right atrium (SVC/RA) junction and calculated a recommended insertion depth. We compared the accuracy of the recommended depth with that suggested by the formula of Peres for predicting optimal positioning of a CVC.
RESULTS: Of the 1238 patients who were CVC-cannulated over 10 months, 106 underwent chest CT. Based on the mean distance from the CVC insertion point to the distal SVC, we determined that the recommended depth of insertion should be 14 cm for the right subclavian vein, 15 cm for the right internal jugular vein, 17 cm for the left subclavian vein and 18 cm for left internal jugular vein. Using these guidelines, initial placement of a CVC in the distal SVC was more accurate than when the Peres formula was used (91.5% vs. 77.4%, p<0.05).
CONCLUSIONS: For Asian populations, we found that these guidelines are more accurate than those derived from the Peres formulae and more simple to use, thus increasing the likelihood of optimal tip location within the SVC on the first attempt and eliminating the need for later repositioning.

PMID: 21377676 [PubMed - indexed for MEDLINE]

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Prothrombinex-VF use in warfarin reversal and other indications.

Med J Aust Start a Discussion »

Apr 192012

Prothrombinex-VF use in warfarin reversal and other indications.

Med J Aust. 2012 Apr 16;196(7):462-5

Authors: Kruger PC, Le Viellez AS, Herrmann RP

Abstract
OBJECTIVE: To assess the use of Prothrombinex-VF powder for injection (PTX-VF) @Royal Perth Hospital and analyse the efficacy and safety profile of PTX-VF.
DESIGN, SETTING AND PATIENTS: A prospective observational audit of PTX-VF use, conducted by reviewing medical records and laboratory and imaging results for all patients prescribed PTX-VF from 1 November 2009 to 1 May 2010.
MAIN OUTCOME MEASURES: Data on indication, diagnosis, comorbidities, dose of PTX-VF, fresh frozen plasma (FFP) and vitamin K, coagulation parameters before and after PTX-VF administration, and adverse effects.
RESULTS: 334 vials of PTX-VF were administered to 84 patients over 107 prescriptions. Indications were warfarin reversal, intraoperative bleeding and coagulopathy (66, 20 and 21 prescriptions, respectively). PTX-VF with FFP was compared with PTX-VF alone for warfarin reversal and there was a significant decrease in international normalised ratio (INR) th@was independent of group (P < 0.001). Lower doses of PTX-VF (< 25 IU/kg) were compared with higher doses (25-50 IU/kg) for warfarin reversal and decrease in INR was significant, independent of group (P = 0.002). PTX-VF was administered for intraoperative bleeding in 18 patients who had not been treated with warfarin. No hypersensitivity reactions, thrombotic complications or worsening of disseminated intravascular coagulation occurred during 7-day follow-up.
CONCLUSION: For warfarin reversal, lower doses of PTX-VF (< 25 IU/kg) and PTX-VF without FFP were effective. PTX-VF was also used in intraoperative bleeding and non-warfarin coagulopathy. No adverse events were associated with PTX-VF.

PMID: 22509878 [PubMed - in process]

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A Randomized Controlled Trial of Telemonitoring in Older Adults With Multiple Health Issues to Prevent Hospitalizations and Emergency Department Visits.

Arch Intern Med Start a Discussion »

Apr 192012

A Randomized Controlled Trial of Telemonitoring in Older Adults With Multiple Health Issues to Prevent Hospitalizations and Emergency Department Visits.

Arch Intern Med. 2012 Apr 16;

Authors: Takahashi PY, Pecina JL, Upatising B, Chaudhry R, Shah ND, Van Houten H, Cha S, Croghan I, Naessens JM, Hanson GJ

Abstract
BACKGROUND: Efficiently caring for frail older adults will become an increasingly important part of health care reform; telemonitoring within homes may be an answer to improve outcomes. This study sought to assess differences in hospitalizations and emergency department (ED) visits among older adults using telemonitoring vs usual care. METHODS: A randomized controlled trial was performed among adults older than 60 years at high risk for rehospitalization. Participants were randomized to telemonitoring (with daily input) or to patient-driven usual care. Telemonitoring was accomplished by daily biometrics, symptom reporting, and videoconference. The primary outcome was a composite end point of hospitalizations and ED visits in the 12 months following enrollment. Secondary end points included hospitalizations, ED visits, and total hospital days. Intent-to-treat analysis was performed. RESULTS: Two hundred five participants were enrolled, with a mean age of 80.3 years. The primary outcome of hospitalizations and ED visits did not differ between the telemonitoring group (63.7%) and the usual care group (57.3%) (P = .35). No differences were observed in secondary end points, including hospitalizations, ED visits, and total hospital days. No significant group differences in hospitalizations and ED visits were found between the preenrollment period vs the postenrollment period. Mortality was higher in the telemonitoring group (14.7%) than in the usual care group (3.9%) (P = .008). CONCLUSIONS: Among older patients, telemonitoring did not result in fewer hospitalizations or ED visits. Secondary outcomes demonstrated no significant differences between the telemonitoring group and the usual care group. The cause of greater mortality in the telemonitoring group is unknown. Trial Registration clinicaltrials.gov Identifier: NCT01056640.

PMID: 22507696 [PubMed - as supplied by publisher]

Link to Article at PubMed

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