2012 May 05

Lifetime Analysis of Hospitalizations and Survival of Patients Newly-Admitted with Heart Failure.

May 052012

Lifetime Analysis of Hospitalizations and Survival of Patients Newly-Admitted with Heart Failure.

Circ Heart Fail. 2012 May 2;

Authors: Chun S, Tu JV, Wijeysundera HC, Austin PC, Wang X, Levy D, Lee DS

Abstract
BACKGROUND: -Hospital readmissions for heart failure (HF) contribute to increased morbidity and resource burden. Predictors of hospitalization and patterns of cardiovascular events over the lifetime of HF patients have not been elucidated. METHODS AND RESULTS: -We examined recurrent hospitalizations, cardiovascular events, and survival among patients newly-discharged (April 1999-March 2001) with HF in the Enhanced Feedback For Effective Cardiac Treatment Phase 1 study. During 10-year follow-up, we examined all new cardiovascular hospitalizations and selected predictors of readmission. Among 8543 patients (mean age 77.4 ± 10.5 years, 51.6% women) followed for 22,567 person-years, 60.7% were ischemic etiology and HFrEF (left ventricular ejection fraction ?45% vs. >45% [HFpEF]) was present in 67.3%. Overall 10-year mortality was 98.8%, with 35,966 hospital readmissions occurring over the cohort's lifetime. Adjusted hazards ratios (HR) for first cardiovascular hospitalization were 1.36 for ischemic HF (95%CI; 1.28-1.44, p<0.001), 1.10 for HFrEF (95%CI; 1.00-1.20, p=0.045), and 1.00 for men (95%CI; 0.94-1.06, p=0.979). On repeated events time-to-event analysis, ischemic HF was a predictor of cardiovascular (HR 1.24, 95%CI; 1.18-1.29), HF (HR 1.20, 95%CI; 1.13-1.27) and coronary heart disease (HR 2.01, 95%CI; 1.81-2.24) hospitalizations (all p<0.001). Of all recurrent HF hospitalizations, 26.8% occurred in the first and 39.8% in the last deciles of cohort survival duration. Similarly, 29.7% and 52.3% of all cardiovascular readmissions occurred in the first and last deciles of the cohort survival duration, respectively. CONCLUSIONS: -Among newly-discharged HF patients, cardiovascular events were clustered at early post-discharge and pre-fatal time periods, and were increased among those with ischemic etiology.

PMID: 22556322 [PubMed - as supplied by publisher]

Link to Article at PubMed

Identification and management of in-hospital drug-induced delirium in older patients.

Drugs Aging Start a Discussion »

May 052012

Identification and management of in-hospital drug-induced delirium in older patients.

Drugs Aging. 2011 Sep 1;28(9):737-48

Authors: Catic AG

Abstract
Delirium, an acute confusional state with changes in attention and cognition, is a common cause of morbidity and mortality among hospitalized elders. Medications are responsible for up to 39% of delirium cases in the elderly. The incidence of drug-induced delirium is particularly high in this population due to the altered pharmacokinetics and pharmacodynamics of aging, high prevalence of polypharmacy and occurrence of co-morbid disease. Although certain medications are more often associated with the development of delirium, including opioids, benzodiazepines, anticholinergics and antidepressants, any medication can cause delirium in the elderly. Evaluation of delirium should include a thorough medication history, which should determine if any new medications have been initiated, if medications have been discontinued, and the details of any recent dosage adjustments. It is important to understand the utility of medications in preventing and treating delirium in the elderly. Acetylcholinesterase inhibitors have not been found to reduce the incidence of delirium or length of hospitalization. Study results regarding the utility of antipsychotic medications in preventing delirium have been mixed. Haloperidol prophylaxis did not reduce the occurrence of delirium, but it did reduce the severity and duration. Olanzapine and risperidone were associated with a reduced incidence of delirium compared with placebo. Pharmacological therapy to treat delirium should be implemented only if patients pose a safety risk to themselves or others. Typical and atypical antipsychotics are effective in treating the symptoms of delirium, but it is important to note that they are not approved by the US FDA for this indication. Short-acting benzodiazepines are second-line therapy and are typically reserved for patients with sedative/alcohol withdrawal, Parkinson's disease or neuroleptic malignant syndrome. Study results regarding the utility of acetylcholinesterase inhibitors have been mixed.

PMID: 21913739 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Oral streptococcal bacteremia in hospitalized patients: taxonomic identification and clinical characterization.

J Clin Microbiol Start a Discussion »

May 052012

Oral streptococcal bacteremia in hospitalized patients: taxonomic identification and clinical characterization.

J Clin Microbiol. 2012 Mar;50(3):1039-42

Authors: Kitten T, Munro CL, Zollar NQ, Lee SP, Patel RD

Abstract
Oral streptococci have been associated with systemic diseases, including infective endocarditis and neutropenic bacteremia. We analyzed 58 recent oral streptococcal bloodstream isolates, and we obtained clinical and demographic data for source patients. The sodA gene was found to be a better target than the 16S-23S rRNA internal transcribed spacer for DNA sequence-based species identification. Together, Streptococcus mitis and Streptococcus oralis were significantly more likely than the 12 combined remaining species to be isolated from neutropenic patients.

PMID: 22189124 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

The clinical significance of peripherally inserted central venous catheter-related deep vein thrombosis.

Neurocrit Care Start a Discussion »

May 052012

The clinical significance of peripherally inserted central venous catheter-related deep vein thrombosis.

Neurocrit Care. 2011 Dec;15(3):454-60

Authors: Fletcher JJ, Stetler W, Wilson TJ

Abstract
BACKGROUND: Peripherally inserted central venous catheters (PICCs) are being increasingly utilized in hospitalized patients as alternatives to centrally inserted central venous catheters (CICVCs). However, concern exists over the risk of PICC-related large vein thrombosis (PRLVT). The incidence rate and significance of symptomatic PRLVT in critically ill patients admitted to the neurological intensive care unit (ICU) is not known.
METHODS: Retrospective descriptive study of consecutive PICCs placed in critically ill patients admitted to a tertiary care neurological ICU between March 2008 and February 2010. Symptomatic PRVLT was defined as an event that prompted Duplex ultrasound of the ipsilateral extremity in which an acute, proximal large vein thrombosis was confirmed in association with the PICC or confirmed within 5 days of PICC removal. Incidence rate of PRLVT and catheter-related complications were calculated per "line" (catheter). Descriptive statistics were performed with two-sample, and t-tests for age and categorical variables were assessed by Chi-square test or Fishers exact test as appropriate
RESULTS: Four hundred and seventy-nine lines were placed during the study period with 39 developing a symptomatic PRLVT (incidence rate = 8.1%). Male gender was associated with development of a thrombosis (P = 0.02), but size (P = 0.21) and location of catheter were not (P = 0.30). Median line dwell time was 12 days (IQR 16) with a dwell time of 8 days (IQR 9) until thrombosis diagnosis. Pulmonary embolus attributed to PRLVT occurred in 1.3% of line placements and 15% of symptomatic PRLVT. The majority of patients had their line removed. In addition, some patients also had anticoagulation initiated or a superior vena cava filter placed.
CONCLUSIONS: Symptomatic PRLVT is not uncommon in critically ill patients admitted to the neurological ICU. Future research should focus on indentifying modifiable risk factors for PRLVT and on comparing major cumulative complication rates between PICCs and CICVCs.

PMID: 21541826 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

How should long-term tunneled central venous catheters be managed in microbiology laboratories in order to provide an accurate diagnosis of colonization?

J Clin Microbiol Start a Discussion »

May 052012

How should long-term tunneled central venous catheters be managed in microbiology laboratories in order to provide an accurate diagnosis of colonization?

J Clin Microbiol. 2012 Mar;50(3):1003-7

Authors: Guembe M, Martín-Rabadán P, Echenagusia A, Camúñez F, Rodríguez-Rosales G, Simó G, Echenagusia M, Bouza E

Abstract
Guidelines recommend the roll-plate technique for short-term central venous catheter (CVC) tip cultures. However, the issue of whether the roll-plate technique is better than the sonication method for long-term CVCs remains unresolved. In addition, no data are available for predicting the value of direct Gram staining in anticipating catheter colonization or catheter-related bloodstream infection (CRBSI) in these long-term CVCs. Our objectives were to compare the roll-plate technique and the sonication method and to define the validity values of Gram staining for the prediction of colonization and CRBSI in patients with long-term tunneled CVCs. During the study period, all tunneled CVCs removed at our institution were prospectively and routinely sent to the microbiology laboratory for Gram staining (first) and tip culture (the Maki technique and sonication, in a random order). We received 149 tunneled CVCs, 39 (26.2%) of which were colonized and 11 (7.4%) of which were associated with CRBSI. Overall, the roll-plate method detected 94.9% of the colonized catheters, whereas sonication detected only 43.6% (P < 0.001). The validity values of Gram staining for the detection of colonization and CRBSI were as follows: a sensitivity of 35.9% to 60.0%, a specificity of 100% to 94.2%, a positive predictive value of 100% to 42.9%, and a negative predictive value of 81.5% to 97.0%. The roll-plate technique proved to be better than sonication for the detection of bacteria in long-term tunneled CVCs. Gram staining of the tips of tunneled CVCs can anticipate a positive culture and rule out CRBSI. In our opinion, direct Gram staining should be incorporated into routine microbiological assessments of long-term catheter tips.

PMID: 22170928 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

How long should peripherally inserted central catheterization be delayed in the context of recently documented bloodstream infection?

J Vasc Interv Radiol 1 Response »

May 052012

How long should peripherally inserted central catheterization be delayed in the context of recently documented bloodstream infection?

J Vasc Interv Radiol. 2012 Jan;23(1):123-5

Authors: Daneman N, Downing M, Zagorski BM

Abstract
The risk of relapsing bacteremia was assessed retrospectively among a cohort of 348 patients who underwent peripherally inserted central catheter (PICC) insertion within 6 weeks of a documented bacteremia. The overall risk of relapsing bacteremia was low (three of 348; 0.9%) when PICC insertion was performed in the context of a recent bloodstream infection. The relapse risk was higher when PICCs were inserted within 2 days (two of 31; 6.5%) versus at least 3 days (one of 317; 0.3%) after documentation of bacteremia (P = .02).

PMID: 22221476 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

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