A comparative study of propofol alone and propofol combined with midazolam for dental treatments in special needs patients

Although dental treatment with sedation is performed increasingly in special needs patients, data on adding midazolam to intravenous propofol sedation are very limited for this group. The purpose of this study was to identify the factors and procedure time associated with the use of intravenous sedation with propofol alone or propofol combined with midazolam in dental patients with special needs.This was a retrospective data analysis. The sedation medications and relevant covariates, including demographic parameters, disability levels, oral health conditions, dental procedures, treatment time, and side effects, of 718 patients with special needs were collected between April 2013 and September 2014. The unfavorable side effects by sedation types were reported. Factors associated with procedure time and the sedation medications were assessed with multiple logistic regression analyses.Of 718 patients, 8 patients experienced unfavorable side effects (vomiting, sleepiness, or emotional disturbance) after the dental procedures; the rate was 0.6% in the 509 patients who received propofol only. In 209 patients who received propofol and midazolam, 2.4% experienced the side effects. Sedation time was associated with body mass index (BMI) < 25 (adjusted odds ratio [aOR] = 1.45, 95% confidence interval [CI]: 1.04–2.04) and the performance of multiple dental procedures (aOR = 1.44, 95% CI: 1.06–1.97) but not associated with the sedation types. A significant odds ratio for the combined use of propofol and midazolam was shown for adolescents (aOR = 2.22, 95% CI: 1.28–3.86), men (aOR = 2.05, 95% CI: 1.41–2.98), patients with cognitive impairment (aOR = 1.99, 95% CI: 1.21–3.29), and patients undergoing scaling procedures (aOR = 1.64, 95% CI: 1.13–2.39).With the acceptable side effects of the use of propofol alone and propofol combined with midazolam, multiple dental procedures increase the sedation time and the factors associated with the combined use of propofol and midazolam are younger age, male sex, recognition problems, and the type dental procedure in the dental treatment of patients with special needs.     

Dental procedures in children with severe congenital heart disease: a theoretical analysis of prophylaxis and non-prophylaxis procedures

OBJECTIVE—To estimate the cumulative exposure to bacteraemia from dental procedures currently recommended for antibiotic prophylaxis and compare this with cumulative exposure from dental procedures not recommended for prophylaxis.
DESIGN—Retrospective analysis.
SETTING—University and teaching hospital maxillofacial and dental department.
PATIENTS—136 children with severe congenital cardiac disease attending for dental treatment between 1993 and 1998 and for whom full records were available. Each dental procedure was tallied.
MAIN OUTCOME MEASURES—Cumulative exposure per annum to "non-prophylaxis procedures"; cumulative exposure per annum to "prophylaxis procedures".
RESULTS—Cumulative exposure to bacteraemia from prophylaxis procedures was not significantly greater than from non-prophylaxis procedures.
CONCLUSIONS—The data raise important questions about the appropriateness of current guidelines for antibiotic prophylaxis of bacterial endocarditis.


Keywords: congenital heart disease; dental treatment; cumulative risk; endocarditis     

Infective endocarditis and the new AHA guideline

Infective endocarditis (IE) is becoming a disease of the elderly because of the aging process and increased use of intravascular devices. If undetected, IE has a poor prognosis. Previous guidelines had become cumbersome, and with unintended consequences, ie, excess antibiotic use, potential risk for acquisition of multiple-drug-resistant organisms and adverse drug reactions. The newest American Heart Association guideline severely restricts antibiotic prophylaxis, recommending it only for cardiac conditions with the greatest risks for complications and for dental procedures that involve perforation of oral mucosa, manipulation of gingival tissue or periapical region of the teeth. Routine prophylaxis for genitourinary and gastrointestinal procedures is no longer recommended.     

New French recommendations for the prophylaxis of infectious endocarditis

New French recommendations on infective endocarditis (IE) prevention were recently published and mark a turning point in the history of antibiotic prophylaxis. Endocarditis is an evolving disease, and its clinical and microbiological profile dramatically changes over time. The French surveys that were conducted in 1991 and 1999 showed variations in underlying heart disease with a decrease in native valvular disease and an increase of IE in patients without previously known heart disease. Moreover, the distribution of responsible microorganisms dramatically changed over time, with a marked decrease of oral streptococci. In addition, some dogmas are now challenged. First of all, the part of responsibility of dental procedures is debated, as dental bacteraemia possibly responsible of endocarditis are more likely due to daily manoeuvres such as tooth brushing or chewing gum than to occasional dental procedures. Moreover, as suggested by case-control studies, efficacy--or lack of efficacy--of antibiotic prophylaxis is far from being clinically proved. For all these reasons, the proportion of theoretically avoidable endocarditis seems very low, and the benefit of largely and systematically applied antibiotic prophylaxis may be discussed, not only in terms of financial cost but also in terms of microbiological threat of emergence of antibiotic resistant bacteria. So, the general idea of those new recommendations was to maintain the principle and the modalities of antibiotic prophylaxis, but to limit its indications to situations at high benefit to risk ratio, i.e. procedures at high risk in patients at high risk. Depending on the situation, antibiotic prophylaxis may be either recommended or become optional and decision-making factors are defined. Furthermore, the importance of general prophylaxis was emphasised, concerning more specifically oral and cutaneous hygiene, and patients and practitioners' education, such as, for example, recommendations on blood cultures to be performed before any antibiotic treatment in case on fever occurring in a patient at risk during the 3 months following a procedure at risk.     

The risk of gastrointestinal hemorrhage with non-vitamin K antagonist oral anticoagulants: A network meta-analysis

Background:Non-vitamin K antagonist oral anticoagulants (NOACs) have been widely used for stroke prevention in atrial fibrillation (AF) and the treatment and prevention of venous thromboembolism. There is an issue with safety, especially in clinically relevant bleeding. We performed a network meta-analysis to evaluate the risk of major gastrointestinal (GI) bleeding associated with NOACs.Methods:Interventions were warfarin, enoxaparin, apixaban, dabigatran, edoxaban, and rivaroxaban. The primary outcome was the incidence of major GI bleeding. A subgroup analysis was performed according to the following indications: AF, deep venous thrombosis/pulmonary embolism, and postsurgical prophylaxis.Results:A total of 29 randomized controlled trials (RCTs) and 4 large observation population studies were included. Compared with warfarin, apixaban showed a decreased the risk of major GI bleeding (relative risk [RR] 0.54, 95% confidence interval [CI] 0.25–0.76), and rivaroxaban tended to increase this risk (RR 1.40, 95% CI 1.06–1.85). Dabigatran (RR 1.25, 95% CI 0.98–1.60), edoxaban (RR 1.07, 95% CI 0.69–1.65), and enoxaparin (RR 1.24, 95% CI 0.63–2.43) did not significantly increase the risk of GI bleeding than did warfarin. In the subgroup analysis, according to indications, apixaban showed a decreased risk of major GI bleeding (RR 0.50, 95% CI 0.34–0.74) than did warfarin in AF studies. Dabigatran (RR 2.36, 95% CI 1.55–3.60, and rivaroxaban (RR 1.75, 95% CI 1.10–6.41) increased the risk of major GI bleeding than did apixaban. An analysis of studies on venous thromboembolism or pulmonary embolism showed that no individual NOAC or enoxaparin was associated with an increased risk of major GI bleeding compared to warfarin.Conclusion:Individual NOACs had varying profiles of GI bleeding risk. Results of analyses including only RCTs and those including both RCTs and population studies showed similar trends, but also showed several differences.     

Psychosocial risk factors associated with esophageal cancer in Chinese cohort: A systematic review and meta-analysis

Previous studies were controversial about the role of psychosocial factors in the pathogenesis of esophageal cancer (EC). This study aimed to systematically evaluate the effect size of psychosocial risk factors for EC in Chinese cohort.A literature search was conducted in both English and Chinese databases, and odds ratios (OR) with the corresponding 95% confidence intervals (CI) were pooled using a random-effects model.28 studies were identified with a total of 6951 EC cases and 7469 controls. The meta-analysis indicated a higher risk of EC among the individuals with psychological trauma (OR: 2.36, 95% CI: 1.71–3.26), Type A behavior (OR: 1.40, 95% CI: 1.17–1.67), depression (OR: 4.00, 95% CI: 2.44–6.55), melancholy (OR: 2.06, 95% CI: 1.32–3.20), always in sulks (OR: 2.49, 95% CI: 1.21–5.12), and irritable personality (OR: 2.13, 95% CI: 1.58–2.89). A lower EC risk was found in the individuals with good interpersonal relationship (OR: 0.35, 95% CI: 0.17–0.70) and outgoing personality (OR: 0.39, 95% CI: 0.19–0.78).This meta-analysis suggested a potential association between psychosocial factors and EC risk. For the individuals with psychosocial risk factors, physicians should pay more attention to EC screening.     

Network Meta-Analysis of Randomized Controlled Trials: Efficacy and Safety of UDCA-Based Therapies in Primary Biliary Cirrhosis

Major ursodeoxycholic acid (UDCA)-based therapies for primary biliary cirrhosis (PBC) include UDCA only, or combined with either methotrexate (MTX), corticosteroids (COT), colchicine (COC), or bezafibrate (BEF). As the optimum treatment regimen is unclear and warrants exploration, we aimed to compare these therapies in terms of patient mortality or liver transplantation (MOLT) and adverse events (AE).PubMed, the Cochrane Library, and Scopus were searched for randomized controlled trials up to August 31, 2014. We estimated the hazard ratios (HRs) for MOLT and odds ratios (ORs) for AE. A sensitivity analysis based on the dose of UDCA was also executed.Thirty-one eligible articles were included. Compared with COT plus UDCA, UDCA (HR 0.38, 95% confidence interval [CI] 0.09–1.39), BEF plus UDCA (HR 0.29, 95% CI 0.02–4.83), COC plus UDCA (HR 0.39, 95% CI 0.07–2.25), MTX plus UDCA (HR 0.28, 95% CI 0.05–1.63), or OBS (HR 0.49, 95% CI 0.11–2.01) all provided an increased risk of MOLT. With respect to drug AE profile, although not differing appreciably, BEF plus UDCA was associated with more AEs compared with UDCA (OR 3.16, 95% CI 0.59–20.67), COT plus UDCA (OR 2.27, 95% CI 0.15–33.36), COC plus UDCA (OR 1.00, 95% CI 0.09–12.16), MTX plus UDCA (OR 2.03, 95% CI 0.23–17.82), or OBS (OR 3.00, 95% CI 0.53–20.75). The results of sensitivity analyses were highly consistent with previous analyses.COT plus UDCA was the optimal UDCA-based regimen for both MOLT and AEs. BEF plus UDCA was most likely to cause AEs, whereas monotherapy with UDCA and coadministriation of COT plus UDCA appeared to be associated with the fewest AEs for PBC treatment.     

Stroke Event Rates and the Optimal Antithrombotic Choice of Patients With Paroxysmal Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The risks of stroke or systemic embolism and major bleeding are considered similar between paroxysmal and sustained atrial fibrillation (AF), and warfarin has demonstrated superior efficacy to aspirin, irrespective of the AF type. However, with the advent of novel oral anticoagulants (NOACs) and antiplatelet agents, the optimal antithrombotic prophylaxis for paroxysmal AF remains unclear.We searched Medline, Embase, CENTRAL, and China Biology Medicine up to October week 1, 2015. Randomized controlled trials of AF patients assigned to NOACs, warfarin, or antiplatelets, with reports of outcomes stratified by the AF type, were included. A fixed-effects model was used if no statistically significant heterogeneity was indicated; otherwise, a random-effects model was used.Six studies of 69,990 nonvalvular AF patients with ≥1 risk factor for stroke were included. Postantithrombotic treatment, paroxysmal AF patients showed lower risks of stroke (risk ratio [RR], 0.72; 95% confidence interval [CI], 0.59–0.87), stroke or systemic embolism (RR, 0.74; 95% CI, 0.63–0.86), and all-cause mortality (RR, 0.75; 95% CI, 0.67–0.83), while the major bleeding risk was comparable (RR, 0.96; 95% CI, 0.85–1.08). We were unable to detect the superiority of anticoagulation over antiplatelets for paroxysmal AF (RR, 0.72; 95% CI, 0.43–1.23), while it was more effective than antiplatelets for sustained AF (RR, 0.42; 95% CI, 0.33–0.54). NOACs showed superior efficacy over warfarin and trended to show reduced major bleeding irrespective of the AF type.The AF type is a predictor for thromboembolism, and might be helpful in stroke risk stratification model in combination with other risk factors. With the appearance of novel anticoagulant and antiplatelet agents, the best antithrombotic choice for paroxysmal AF needs further exploration.     

Meta-analysis of patent foramen ovale closure versus medical therapy for prevention of recurrent ischemic neurological events: Impact of medication type

BackgroundThe optimal treatment strategy for patent foramen ovale (PFO) patients with cryptic stroke remains controversial. We performed this meta-analysis to evaluate the effect of PFO closure versus different types of medical therapy.MethodsWe searched PubMed, Embase, and Cochrane databases. The primary efficacy endpoints were the composite outcome of recurrent stroke and/or transient ischemic attack (TIA). Secondary efficacy endpoints included separate stroke and TIA. Safety endpoints included new-onset atrial fibrillation (AF)/atrial flutter and bleeding.ResultsCompared with antiplatelet therapy, PFO closure significantly reduced the risk of composite outcome (odds ratio [OR] 0.37, 95% confidence interval [CI] 0.27–0.51), stroke (OR 0.22, 95% CI 0.13–0.36], and TIA (OR 0.57, 95% CI 0.34–0.98); Compared with the mixed medical therapy group (consist of antiplatelet therapy, anticoagulant therapy, or both), PFO closure still showed some benefits, but the effect was not as significant as that of antiplatelet therapy (composite outcome: OR 0.53, 95% CI 0.41–0.69; stroke: OR 0.48, 95% CI 0.34–0.68; TIA: OR 0.69, 95% CI 0.50–0.96); Compared with anticoagulant therapy, PFO closure showed no benefit (composite outcome: OR 0.77, 95% CI 0.46–1.28; stroke: OR 0.59, 95% CI 0.28–1.25; TIA: OR 1.01, 95% CI 0.50–2.04). In terms of safe endpoints, compared with antiplatelet therapy and anticoagulant therapy, PFO closure increased the risk of AF/atrial flutter (OR 9.56, 95% CI 2.85–32.06; OR 18.96, 95% CI 1.11–323.8, respectively) and reduced the risk of bleeding (OR 0.50, 95% CI 0.24–1.05; OR 0.13, 95% CI 0.04–0.46, respectively); compared with mixed medical therapy, PFO closure increased the risk of AF/atrial flutter (OR 4.40,95% CI 2.24–8.67), but there was no difference in bleeding (OR 0.97, 95% CI 0.56–1.68).ConclusionsWith the addition of anticoagulants, the benefit of PFO closure decreased gradually. Patient groups that adopt individualized medical therapy strategies may benefit more.     

Value of Quantitative and Qualitative Analyses of Circulating Cell-Free DNA as Diagnostic Tools for Hepatocellular Carcinoma: A Meta-Analysis

Qualitative and quantitative analyses of circulating cell-free DNA (cfDNA) are potential methods for the detection of hepatocellular carcinoma (HCC). Many studies have evaluated these approaches, but the results have been variable. This meta-analysis is the first to synthesize these published results and evaluate the use of circulating cfDNA values for HCC diagnosis.All articles that met our inclusion criteria were assessed using QUADAS guidelines after the literature research. We also investigated 3 subgroups in this meta-analysis: qualitative analysis of abnormal concentrations of circulating cfDNA; qualitative analysis of single-gene methylation alterations; and multiple analyses combined with alpha-fetoprotein (AFP). Statistical analyses were performed using the software Stata 12.0. We synthesized these published results and calculated accuracy measures (pooled sensitivity and specificity, positive/negative likelihood ratios [PLRs/NLRs], diagnostic odds ratios [DORs], and corresponding 95% confidence intervals [95% CIs]). Data were pooled using bivariate generalized linear mixed model. Furthermore, summary receiver operating characteristic curves and area under the curve (AUC) were used to summarize overall test performance. Heterogeneity and publication bias were also examined.A total of 2424 subjects included 1280 HCC patients in 22 studies were recruited in this meta-analysis. Pooled sensitivity and specificity, PLR, NLR, DOR, AUC, and CIs of quantitative analysis were 0.741 (95% CI: 0.610–0.840), 0.851 (95% CI: 0.718–0.927), 4.970 (95% CI: 2.694–9.169), 0.304 (95% CI: 0.205–0.451), 16.347 (95% CI: 8.250–32.388), and 0.86 (95% CI: 0.83–0.89), respectively. For qualitative analysis, the values were 0.538 (95% CI: 0.401–0.669), 0.944 (95% CI: 0.889–0.972), 9.545 (95% CI: 5.298–17.196), 0.490 (95% CI: 0.372–0.646), 19.491 (95% CI: 10.458–36.329), and 0.87 (95% CI: 0.84–0.90), respectively. After combining with AFP assay, the values were 0.818 (95% CI: 0.676–0.906), 0.960 (95% CI: 0.873–0.988), 20.195 (95% CI: 5.973–68.282), 0.190 (95% CI: 0.100–0.359), 106.270 (95% CI: 22.317–506.055), and 0.96 (95% CI: 0.94–0.97), respectively.The results in this meta-analysis suggest that circulating cfDNA have potential value for HCC diagnosis. However, it would not be recommended for using independently, which is based on the nonrobust results. After combining with AFP, the diagnostic performance will be improved. Further investigation with more data is needed.     

The risk factors of children acquiring refractory mycoplasma pneumoniae pneumonia: A meta-analysis

Objectives:Refractory mycoplasma pneumoniae pneumonia (RMPP) in children has been increasing worldwide. In this study, we conducted a meta-analysis to generate large-scale evidence on the risk factors of RMPP to provide suggestions on prevention and controlling for children.Methods:Web of Science, PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, and Wanfang (Chinese) were searched to identify relevant articles. All analyses were performed using Stata 14.0.Results:We conducted a meta-analysis of 15 separate studies. Fever for more than 10 days (odds ratio [OR] 3.965, 95% confidence interval [CI] 2.109–7.456), pleural effusion (OR 6.922, 95% CI 2.058–23.282), extra-pulmonary complications (OR 17.762, 95% CI 11.146–28.305), pulmonary X-ray consolidation ≥2/3 (OR 8.245, 95% CI 1.990–34.153), CRP >40 mg/L (OR 4.975, 95% CI 2.116–11.697) were significantly related to the risk of RMPP. We did not find an association between male sex (OR 0.808, 95% CI 0.548–1.189), LDH >410IU/L (OR 1.033, 95% CI 0.979–1.091) and the risk of RMPP.Conclusions:Fever for more than 10 days, pleural effusion, extra-pulmonary complications, pulmonary X-ray consolidation≥ 2/3 and CRP >40 mg/L are risk factors for early evaluation of RMPP.     

Impact of Coexisting Pulmonary Diseases on Survival of Patients With Lung Adenocarcinoma: A STROBE-Compliant Article

Asthma, chronic obstructive pulmonary disease (COPD), and pulmonary tuberculosis (TB) are common pulmonary diseases associated with lung cancer. Besides, smoking is more prevalent in Taiwanese men. This study evaluated gender disparities in coexisting pulmonary diseases on survival of patients with lung adenocarcinoma.Patients newly diagnosed with lung cancer between 2003 and 2008 were identified from Taiwan National Health Insurance Research Database. Cases with lung adenocarcinoma were further confirmed using the Cancer Registry Database and followed up until the end of 2010. Cox proportional hazard regression was used to calculate the hazard ratio (HR) of coexisting asthma, COPD, and/or TB to estimate all-cause mortality risk.During the study period, 13,399 cases of lung adenocarcinoma were identified. The HRs of adenocarcinoma in men and women were 1.20 (95% confidence interval [CI], 1.10–1.30) and 1.05 (95% CI, 0.95–1.16), respectively, for individuals with asthma, 1.32 (95% CI, 1.16–1.51) and 0.97 (95% CI, 0.89–1.05), respectively, for COPD, and 0.99 (95% CI, 0.93–1.06) and 1.06 (95% CI, 0.86–1.32), respectively, for individuals with TB. Specifically, among men with coexisting pulmonary diseases, the HRs were 1.63 (95% CI, 1.25–2.13), 1.31 (95% CI, 1.08–1.59), and 1.23 (95% CI, 1.11–1.36) for individuals with asthma + COPD + TB, asthma + COPD, and COPD + TB, respectively. However, there was no increase risk of mortality among women with coexisting pulmonary diseases.Coexisting pulmonary diseases are at an elevated risk of mortality among male patients with lung adenocarcinoma. Such patients deserve greater attention while undergoing cancer treatment.     

Prevalence and Risk Factors of Toxoplasmosis among Pregnant Women in Fortaleza,Northeastern Brazil

We determined the seroprevalence of Toxoplasma gondii and associated risk factors among 963 pregnant women attending an obstetric hospital in Fortaleza, Brazil. Seroprevalences of IgG and IgM against T. gondii were 68.6% (95% confidence interval [CI] = 65.6–71.6%) and 0.5% (95% CI = 0.06–1.0%), respectively. Seroprevalence of IgG was high in women less than 25 years of age (91.7%) and in low-income women (odds Ratio [OR] = 1.40, 95% CI = 1.02–1.90). Multivariate regression analysis showed that consumption of homemade water ice (adjusted OR = 1.49, 95% CI = 1.09–2.04), vegetables washed with untreated water (adjusted OR = 1.43, 95% CI = 1.05–1.94), consumption of chicken (adjusted OR = 1.49, 95% CI = 1.12–2.0), and dog ownership (adjusted OR= 1.46, 95% CI = 1.07–1.98) were factors associated with IgG seropositivity. Young women in northeastern Brazil living under poor socioeconomic conditions are at highest risk for acquiring infection with T. gondii. Oocyst contamination of water and soil must be addressed in future prevention strategies.     

Persistent Staphylococcus aureus Bacteremia: A Prospective Analysis of Risk Factors,Outcomes, and Microbiologic and Genotypic Characteristics of Isolates

Persistent Staphylococcus aureus bacteremia (SAB) that fails to respond to appropriate antibiotic therapy is associated with poor outcomes. Comprehensive prospective studies on risk factors and outcomes of persistent bacteremia are limited. We investigated outcomes and risk factors encompassing clinical, pharmacokinetic, microbiologic, and genotypic characteristics associated with persistent bacteremia using a case-control study nested in a prospective cohort of patients with SAB at a tertiary-care hospital from August 2008 through September 2010. We compared the clinical characteristics, management, and outcomes of patients with persistent bacteremia (≥7 d) with controls with resolving bacteremia (<3 d). To detect associations between microbiologic and genotypic characteristics of methicillin-resistant S. aureus (MRSA) isolates and persistent bacteremia, we determined the heteroresistance phenotype, SCCmec type, agr genotype and functionality, multilocus sequence typing, and presence of 41 virulence genes. Our cohort consisted of 483 patients; 76 (15.7%) had persistent bacteremia, 212 (43.5%) had resolving bacteremia. In the multivariate analysis, independent risk factors associated with persistent bacteremia were community-onset bacteremia (odds ratio [OR], 2.91; 95% confidence interval [CI], 1.24–6.87), bone and joint infection (OR, 5.26; 95% CI, 1.45–19.03), central venous catheter-related infection (OR, 3.36; 95% CI, 1.47–7.65), metastatic infection (OR, 36.22; 95% CI, 12.71–103.23), and methicillin resistance (OR, 16.99; 95% CI, 5.53–52.15). For patients with eradicable foci, delay (>3 d) in the removal of the infection focus was significantly associated with persistent bacteremia (OR, 2.18; 95% CI, 1.05–4.55). There were no significant associations of persistent bacteremia with high vancomycin minimal inhibitory concentration, vancomycin heteroresistance, and microbiologic/genotypic characteristics of MRSA isolates. However, initial vancomycin trough level <15 mg/L was an independent risk factor for persistent MRSA bacteremia (OR, 4.25; 95% CI, 1.51–11.96) in the multivariate analysis. Clinical outcomes were significantly worse for patients with persistent bacteremia. Relapse of bacteremia and attributable mortality within 12 weeks after SAB were significantly higher in patients with persistent bacteremia than in those with resolving bacteremia (9.2% [7/76] vs. 2.4% [5/212], p = 0.02 and 21.1% [16/76] vs. 9.4% [20/212], p = 0.009, respectively).In conclusion, patients with SAB should be given early aggressive treatment strategies, including early source control and maintenance of a vancomycin trough level ≥15 mg/L, to reduce the risk of persistent bacteremia.     

Bullying,Depression, and Suicidal Ideation Among Adolescents in the Fujian Province of China: A Cross-sectional Study

The relationship of bullying with suicidal ideation among adolescents is controversial. Although depression has been related to bullying and suicidal ideation, little is known about the combined impacts of depression and bullying on suicidal ideation.A sample of 20,509 high school students from Fujian Province were selected randomly by multistage stratified sampling. All participants completed an adolescent health status questionnaire. Three categories of bullying were assessed: perpetration, victimization, and both (victimization and perpetration). The associations of these 3 categories of bullying with depression and their interaction with suicidal ideation were examined in logistic models.After adjustment for potential confounders, all 3 categories of bullying (perpetration, victimization, and both) were related to increased risk of suicidal ideation with odds ratios (ORs) of 1.66 (95% confidence interval [CI] 1.20–2.30), 2.74 (95% CI 2.29–3.29), and 2.83 (95% CI 2.27–3.52), respectively. There was an interaction between depression and bullying (P = 0.001). Subgroup analyses showed a stronger association between perpetration and suicidal ideation in students with depression (odds ratio [OR] 2.97; 95% CI 1.44–6.09) than in those without depression (OR 1.65; 95% CI 1.19–2.28). The association between victimization and suicidal ideation was weaker in students with depression (OR 1.49; 95% CI 1.07–2.07) than in those without (OR 2.69; 95% CI 2.24–3.23). The association of both victimization and perpetration with suicidal ideation was weaker in students with depression (OR 2.22, 95% CI 1.43–3.47) than those without (OR 2.78; 95% CI 2.23–3.47).We observed an independent association of bullying with increased risk of suicidal ideation among adolescent students, and this association was affected by depression. Prospective studies should be conducted to confirm these findings.     

Relationship Between Myo-Inositol Supplementary and Gestational Diabetes Mellitus: A Meta-Analysis

To determine whether myo-inositol supplement will increase the action of endogenous insulin, which is mainly measured by markers of insulin resistance such as homeostasis model assessment of insulin resistance.PubMed, Cochrane Library, Embase, and web of science were comprehensively searched using “gestational diabetes mellitus” and “myo-inositol” to identify relevant studies. Both subject headings and free texts were adopted. The methodological quality of the included studies were assessed and pooled analyzed by the methods recommended by the Cochrane collaboration.A total of 5 trials containing 513 participants were included. There was a significant reduction in aspects of gestational diabetes incidence (risk ratio [RR], 0.29; 95% confidence interval (95% CI), 0.19–0.44), birth weight (mean difference [MD], −116.98; 95% CI, −208.87 to −25.09), fasting glucose oral glucose tolerance test (OGTT) (MD, −0.36; 95% CI, −0.51 to −0.21), 1-h glucose OGTT (MD, −0.63; 95% CI, −1.01 to −0.26), 2-h glucose OGTT (MD, −0.45; 95% CI, −0.75 to −0.16), and related complications (odds ratio [OR], 0.28; 95% CI 0.14–0.58).On the basis of current evidence, myo-inositol supplementation reduces the development of gestational diabetes mellitus (GDM), although this conclusion requires further evaluation in large-scale, multicenter, blinded randomized controlled trials.     

Determinants of Mortality from Severe Dengue in Brazil: A Population-Based Case-Control Study

Although increases in severity of mortality from dengue infection have been observed in Brazil, their determinants are not fully known. A case–control study was conducted by using the National Notifiable Diseases Surveillance System, including patients with severe dengue during 2000–2005. Cases were defined as patients that died and controls were those who survived. Hierarchical multivariate logistic regression was performed. During the study period, there were 12,321 severe cases of dengue and 1,062 deaths. Factors independently associated with death included age ≥ 50 years (odds ratio [OR] = 2.29, 95% confidence interval [CI] = 1.59–3.29), < 4 years of schooling (OR = 1.83, 95% CI = 1.47–2.28), a rural area (OR =2.84, 95% CI = 2.19–3.69), hospitalization (OR = 1.42, 95% CI = 1.17–1.73), and a high hematocrit (OR = 2.46, 95% CI = 1.85–3.28). Factors associated with a lower chance of dying were female sex (OR = 0.76, 95% CI = 0.67–0.87), history of previous dengue (OR = 0.78, 95% CI = 0.62–0.99), positive tourniquet test result (OR = 0.47, 95% CI = 0.33–0.66), laboratory diagnosis of dengue (OR = 0.75, 95% CI = 0.61–0.92), and a platelet count of 50,000–100,000 cells/mm³ (OR = 0.56, 95% CI = 0.36–0.87). The risk profile identified in this study should serve to direct public health interventions to minimize deaths.     

Prophylaxis against wound infection following herniorrhaphy or breast surgery.

The effect of perioperative antibiotic prophylaxis on definite wound infections was assessed for 3202 herniorrhaphies or selected breast surgery procedures. Patients were identified preoperatively and monitored for greater than or equal to 4 weeks. Thirty-four percent of patients (1077/3202) received prophylaxis at the discretion of the surgeon; 86 definite wound infections (2.7%) were identified. Prophylaxis recipients were at higher risk for infection, with a higher proportion of mastectomies, longer procedures, and other factors. Patients who received prophylaxis experienced 41% fewer definite wound infections (odds ratio [OR], 0.59; 95% confidence interval [CI], 0.35-0.99; P = .04) and 65% fewer definite wound infections requiring parenteral antibiotic therapy (OR, 0.35; 95% CI, 0.15-0.88; P = .02) after adjustment for duration of surgery and type of procedure. Additional adjustment for age, body mass index, the presence of drains, diabetes, and exposure to corticosteroids did not change the magnitude of this effect meaningfully. The effect of prophylaxis was similar for all procedures studied. In the absence of formal guidelines, surgeons at these institutions administered prophylaxis preferentially to patients at highest risk.     

A Single Center Experience for Antifungal Prophylaxis in Patients with Acute Myelogenous Leukemia

We aimed to provide real-life information about the effectivity of different types of primary antifungal prophylaxis (AFP) in patients with acute myeloid leukemia (AML). Records of AML patients who received remission-induction chemotherapy between June 2010 and February 2013 were retrospectively reviewed. A total of 85 AML remission-induction chemotherapy cycles were identified in 80 patients. Fluconazole prophylaxis (FP) was administered in 29 cycles, and posaconazole prophylaxis was given in 56 cycles. Failure in the AFP was observed in 45 (57.9 %) out of 85 cycles. Any type of invasive fungal diseases were detected in 15 (26.8 %) out of 56 cycles receiving posaconazole and 15 (51.7 %) out of 29 cycles receiving fluconazole (p = 0.023). Relapsing or refractory AML, longer duration of neutropenia and FP were more common in patients with AFP failure. Multivariate logistic regression analysis showed that type of AFP (odds ratio (OR) 3.63; 95 % confidence interval (CI) 1.19–11.07), presence of neutropenia longer than 21 days (OR 3.96; 95 % CI 1.36–11.46), and refractory or relapsing AML (OR 6.09; 95 % CI 2.09–17.73) were independent factors associated with failure of AFP. We observed superiority of posaconazole on fluconazole in the prophylaxis of AML patients receiving remission-induction chemotherapy.