2012 June 12

Antimicrobial stewardship at a large tertiary care academic medical center: cost analysis before, during, and after a 7-year program.

Infect Control Hosp Epidemiol Start a Discussion »

Jun 122012

Antimicrobial stewardship at a large tertiary care academic medical center: cost analysis before, during, and after a 7-year program.

Infect Control Hosp Epidemiol. 2012 Apr;33(4):338-45

Authors: Standiford HC, Chan S, Tripoli M, Weekes E, Forrest GN

Abstract
BACKGROUND: An antimicrobial stewardship program was fully implemented at the University of Maryland Medical Center in July 2001 (beginning of fiscal year [FY] 2002). Essential to the program was an antimicrobial monitoring team (AMT) consisting of an infectious diseases-trained clinical pharmacist and a part-time infectious diseases physician that provided real-time monitoring of antimicrobial orders and active intervention and education when necessary. The program continued for 7 years and was terminated in order to use the resources to increase infectious diseases consults throughout the medical center as an alternative mode of stewardship.
DESIGN: A descriptive cost analysis before, during, and after the program.
PATIENTS/SETTING: A large tertiary care teaching medical center.
METHODS: Monitoring the utilization (dispensing) costs of the antimicrobial agents quarterly for each FY.
RESULTS: The utilization costs decreased from $44,181 per 1,000 patient-days at baseline prior to the full implementation of the program (FY 2001) to $23,933 (a 45.8% decrease) by the end of the program (FY 2008). There was a reduction of approximately $3 million within the first 3 years, much of which was the result of a decrease in the use of antifungal agents in the cancer center. After the program was discontinued at the end of FY 2008, antimicrobial costs increased from $23,933 to $31,653 per 1,000 patient-days, a 32.3% increase within 2 years that is equivalent to a $2 million increase for the medical center, mostly in the antibacterial category.
CONCLUSIONS: The antimicrobial stewardship program, using an antimicrobial monitoring team, was extremely cost effective over this 7-year period.

PMID: 22418628 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Seasonal variation of venous thrombosis: a consecutive case series within studies from Leiden, Milan and Tromsø

J Thromb Haemost Start a Discussion »

Jun 122012

Seasonal variation of venous thrombosis: a consecutive case series within studies from Leiden, Milan and Tromsø

J Thromb Haemost. 2012 Jun 8;

Authors: Ribeiro DD, Bucciarelli P, Braekkan SK, Lijfering WM, Passamonti SM, Brodin EE, Rosendaal FR, Martinelli I, Hansen JB

Abstract
Circannual variability of venous thrombosis has been reported since 1939, but there is no definitive determination of whether it really exists. Although a recent meta-analysis on this topic, including 35 000 patients with venous thrombosis, has recently been published [1], and showed a similar existence of a seasonal variability in venous thrombosis as for arterial cardiovascular disease [2], there are some issues that preclude whether this meta-analysis found a true association between seasonal variability in the incidence of venous thrombosis. © 2012 International Society on Thrombosis and Haemostasis.

PMID: 22681473 [PubMed - as supplied by publisher]

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High sensitivity cardiac troponin T and interleukin-6 predict adverse cardiovascular events and mortality in anticoagulated patients with atrial fibrillation.

J Thromb Haemost Start a Discussion »

Jun 122012

High sensitivity cardiac troponin T and interleukin-6 predict adverse cardiovascular events and mortality in anticoagulated patients with atrial fibrillation.

J Thromb Haemost. 2012 Jun 8;

Authors: Roldán V, Marín F, Díaz J, Gallego P, Jover E, Romera M, Manzano-Fernández S, Casas T, Valdés M, Vicente V, Lip GY

Abstract
There are limited data on the prognostic role of biomarkers in anticoagulated patients with atrial fibrillation (AF). We evaluated the prognostic value of hsTnT and high sensitivity interleukin-6 (hsIL6) in a large cohort of AF patients taking oral anticoagulant therapy (OAC) as both biomarkers have been associated with adverse cardiovascular events. Methods: We studied 930 patients (51% male; median age 76) with permanent/ paroxysmal AF who were stabilised (for at least 6 months) on OAC (INRs 2.0-3.0). Plasma hsTnT and hsIL6 levels were quantified by electrochemiluminescense immunoassay at baseline. Patients were followed-up for up to 2 years, and adverse events (thrombotic and vascular events, mortality and major bleeding) were recorded. Results. At follow-up, 96 patients (3.97%/year) died whilst 107 had an adverse cardiovascular event (3.14%/year). On multivariate analysis, high hsTnT and high hsIL6 remained significantly associated with prognosis even after adjusting for CHADS(2) score, HR 2.21(1.46-3.35, p<0.001) for high hsTnT and 1.97(1.29-3.02, p=0.002) for high hsIL6, for adverse cardiovascular events. For all cause mortality, the HRs were 1.79(1.13-2.83, p=0.013) and 2.48(1.60-3.85, p<0.001), respectively. The integrated discrimination index (IDI) values of clinical scores (CHADS(2) and CHA(2) DS(2) -VASc) were improved by the addition of hsTnT and/or hsIL6 (all p<0.05). Conclusion. In a large 'real world' cohort of anticoagulated AF patients, both hsTnT and hsIL6 levels provided complementary prognostic information to clinical risk scores for prediction of long-term cardiovascular events and death, suggesting that these biomarkers may potentially be used to refine clinical risk stratification in AF. © 2012 International Society on Thrombosis and Haemostasis.

PMID: 22681487 [PubMed - as supplied by publisher]

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Prevalence, Clinical Phenotype, and Outcomes Associated With Normal B-Type Natriuretic Peptide Levels in Heart Failure With Preserved Ejection Fraction.

Am J Cardiol Start a Discussion »

Jun 122012

Prevalence, Clinical Phenotype, and Outcomes Associated With Normal B-Type Natriuretic Peptide Levels in Heart Failure With Preserved Ejection Fraction.

Am J Cardiol. 2012 Jun 6;

Authors: Anjan VY, Loftus TM, Burke MA, Akhter N, Fonarow GC, Gheorghiade M, Shah SJ

Abstract
B-type natriuretic peptide (BNP) is used widely to exclude heart failure (HF) in patients with dyspnea. However, most studies of BNP have focused on diagnosing HF with reduced ejection fraction (EF). The aim of this study was to test the hypothesis that a normal BNP level (?100 pg/ml) is relatively common in HF with preserved EF (HFpEF), a heterogenous disorder commonly associated with obesity. A total of 159 consecutive patients enrolled in the Northwestern University HFpEF Program were prospectively studied. All subjects had symptomatic HF with EF >50% and elevated pulmonary capillary wedge pressure. BNP was tested at baseline in all subjects. Clinical characteristics, echocardiographic parameters, invasive hemodynamics, and outcomes were compared among patients with HFpEF with normal (?100 pg/ml) versus elevated (>100 pg/ml) BNP. Of the 159 patients with HFpEF, 46 (29%) had BNP ?100 pg/ml. Subjects with normal BNP were younger, were more often women, had higher rates of obesity and higher body mass index, and less commonly had chronic kidney disease and atrial fibrillation. EFs and pulmonary capillary wedge pressures were similar in the normal and elevated BNP groups (62 ± 7% vs 61 ± 7%, p = 0.67, and 25 ± 8 vs 27 ± 9 mm Hg, p = 0.42, respectively). Elevated BNP was associated with enlarged left atrial volume, worse diastolic function, abnormal right ventricular structure and function, and worse outcomes (e.g., adjusted hazard ratio for HF hospitalization 4.0, 95% confidence interval 1.6 to 9.7, p = 0.003). In conclusion, normal BNP levels were present in 29% of symptomatic outpatients with HFpEF who had elevated pulmonary capillary wedge pressures, and although BNP is useful as a prognostic marker in HFpEF, normal BNP does not exclude the outpatient diagnosis of HFpEF.

PMID: 22681864 [PubMed - as supplied by publisher]

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A specific sign for differential diagnosis of atypical atrioventricular nodal reentrant tachycardia from atrial tachycardia.

Pacing Clin Electrophysiol Start a Discussion »

Jun 122012

A specific sign for differential diagnosis of atypical atrioventricular nodal reentrant tachycardia from atrial tachycardia.

Pacing Clin Electrophysiol. 2012 Feb;35(2):245-8

Authors: Hirai Y, Wen MS, Yeh SJ, Wu D

Abstract
Narrow QRS tachycardia with atrial activation occurring before ventricular activation was induced in a 34-year-old woman with dilated cardiomyopathy. During tachycardia late ventricular extrastimulus delivered when His bundle was refractory failed to reset the tachycardia while early ventricular extrastimulus caused paradoxical delay of the subsequent atrial response and terminated the tachycardia with a QRS not being followed by an atrial response. This is a rare but specific sign for excluding atrial reentry as the mechanism of tachycardia when P wave or atrial activation is registered before QRS response.

PMID: 22150931 [PubMed - indexed for MEDLINE]

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Corticosteroids and rituximab as adjunctive treatments for thrombotic thrombocytopenic purpura.

Am J Hematol Start a Discussion »

Jun 122012

Corticosteroids and rituximab as adjunctive treatments for thrombotic thrombocytopenic purpura.

Am J Hematol. 2012 May;87 Suppl 1:S88-91

Authors: George JN

Abstract
Although treatment with plasma exchange increased the survival of patients with thrombotic thrombocytopenia purpura to 80% in the 1980s, no further increase of survival occurred over the next 20 years. However, more consistent use of adjuvant treatment with corticosteroids and rituximab in recent years has begun to further increase survival as well as decrease the frequency of relapse. With adjuvant treatment, durable remissions can be achieved more quickly, requiring fewer days of plasma exchange. Fewer days of plasma exchange have resulted in fewer complications, such as central venous catheter-related systemic infections. Future potential options for adjuvant treatment, recombinant ADAMTS13 to correct severe ADAMTS13 deficiency, and agents to block von Willebrand factor-mediated platelet thrombosis are being investigated.

PMID: 22407740 [PubMed - indexed for MEDLINE]

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