米卡芬净在儿童恶性血液病患者合并肺部真菌感染中的临床应用

目的 探讨米卡芬净治疗儿童恶性血液病并侵袭性肺部真菌感染的疗效及安全性.方法 选取柘城县人民医院血液/肿瘤病区治疗恶性血液病合并肺部真菌感染患儿51例,随机分为两组,分别给予米卡芬净与伏立康唑治疗,比较两组的治疗有效率、痊愈率和不良反应发生率.结果 两组患儿在有效率和痊愈率方面比较差异无统计学意义（P〉0.05）,但在不良反应发生率方面,米卡芬净组患儿低于伏立康唑组患儿,差异有统计学意义（P〈0.05）.结论 米卡芬净与伏立康唑对儿童恶性血液病侵袭性肺部真菌感染均具有良好的疗效,但米卡芬净具有更好的安全性.     

Clinical outcomes of lung-transplant recipients treated by voriconazole and caspofungin combination in aspergillosis

Background and objective: Invasive pulmonary aspergillosis (IPA) is a serious cause of death among immune‐compromised patients such as organ‐transplant recipients. Recently, voriconazole has been approved for first‐line therapy in IPA. Theoretically, optimal voriconazole blood level (superior to 1 mg/L according to recent studies) should be reached within 24 h. In practice, a significantly longer time seems to be needed in lung‐transplant recipients. Therefore, caspofungin is now used in combination with voriconazole to provide cover against Aspergillus spp. infection during this gap. The first aim of this study was to investigate Aspergillus spp. infection treated with this combination and the atter’s tolerability. The median time for attainment of apparently active blood levels in lung transplant recipients were compared between those with cystic fibrosis and those without. Methods: Lung‐transplant recipients who received a combination of voriconazole and caspofungin between 2002 and 2008 as primary therapy were identified retrospectively. The median number of days to reach active voriconazole blood levels was compared between cystic fibrosis and other patients by Student’s t‐test. Statistical significance was defined by P‐value <0·05. Results: Four patients were treated for Aspergillus colonization before transplantation and their culture were negative at 90 days. Eleven patients were treated for proven or probable invasive aspergillosis and 14 of them had a complete response. Hallucinations (n = 2) and significant hepatic toxicity (n = 2) were reported. Among the 15 studied transplant recipients, a median of 12·3 days was observed for active voriconazole blood levels to be reached. With cystic fibrosis patients, time tended to be longer than with other recipients (14·9 days vs. 8·3 days). Tacrolimus blood levels (between 5 and 15 ng/mL) may have been increased by voriconazole. Conclusion: This retrospective study describes practical experience in the management of this rare and severe disease in a referral centre for cystic fibrosis lung transplantation. Voriconazole and caspofungin combination was acceptably safe and was associated with good clinical outcomes in almost all patients. We showed that in 15 lung‐transplant recipients a median of 12·3 days was required for voriconazole to reach high enough blood levels. Caspofungin in combination with voriconazole provides cover against Aspergillus infection during the period when voriconazole may be at subtherapeutic levels with good tolerability.     

米卡芬净与伏立康唑联合治疗侵袭性真菌感染的临床研究

目的评价米卡芬净静脉注射后口服伏立康唑治疗ICU侵袭性真菌感染(IFI)疗效及安全性。方法将侵袭性真菌感染患者,根据不同抗真菌治疗方法分成两组,A组(16例)采用米卡芬净静注后伏立康唑口服联合疗法;B组(16例),米卡芬净组静脉滴注米卡芬净(100 mg/d),观察两组患者的疗效和不良反应。结果 A组的总有效率为87.5%(14/16),药物相关的不良反应发生率6.3%(1/16);B组的总有效率56.3%(9/16),药物相关的不良反应发生率为25%(4/16)。两组总有效率较高,但有显著性差异(P0.05),A组不良反应率显著低于B组。结论两种方案对侵袭性真菌感染的患者均有效,米卡芬净联合伏立康唑疗法比单独应用米卡芬净更具有疗效优势,且安全性好,不良反应少,有显著性差异(P0.05)。     

Effect of plasma uric acid on pharmacokinetics of cyclosporine A in living‐related renal transplant recipients and pharmacokinetic study in rats with experimental hyperuricaemia

Objectives: Renal transplant recipients are thought to have an increased risk of hyperuricaemia (HU); therefore, the effects of plasma uric acid (UA) on the pharmacokinetics (PK) of cyclosporine A (CyA), an immunosuppressant, in renal transplant recipients and experimental animals were investigated. Methods: An open‐label, non‐randomized, retrospective study was performed in renal transplant recipients. Data from 76 subjects who received a renal transplantation with CyA medication were included. We compared the PK of CyA of recipients showing a high UA level with the other recipients. In addition, PK studies were performed using hyperuricaemic‐model rats (HU rats) prepared by subcutaneous injection of the uricase inhibitor, potassium oxonate and intraperitoneal injection of UA. Results: The area under the blood concentration vs. time curve (AUC) up to 9 h, the blood level at 2 h after dose and peak level in high UA recipients (UA > 7·0 mg/dL) was significantly lower (about 10–16%) than that in the other recipients, although there were no differences in dose, and the trough blood level. On the contrary, there were no differences in PK parameters after intravenous administration of CyA between HU and control rats; however, AUC, peak level and bioavailability in HU rats (2·01 ± 0·56 μg h/mL, 0·47 ± 0·26 μg/mL and 0·186 ± 0·05, respectively) after oral administration were significantly lower than in the control animals (6·13 ± 0·97 μg h/mL, 0·82 ± 0·17 μg/mL and 0·458 ± 0·07 μg/mL, respectively). In addition, the absorptions of CyA and midazolam, an ideal probe for CYP3A, from the intestinal loop in HU rats were significantly less (about 50% and 37%, respectively) than in the controls. Conclusions: The absorption of CyA was affected by plasma UA in transplant recipients and experimental rats. The contribution of intestinal metabolism by CYP3A to decreasing CyA absorption in HU rats was significant. These results suggest that transplant recipients with high UA may have poor absorption of CyA.     

The depression status of patients with end‐stage renal disease in different renal replacement therapies

Depression is a common emotional problem among end‐stage renal disease (ESRD) patients, but there is a paucity of research comparing the prevalence of depression between patients in different types of renal replacement therapies in Taiwan. The purpose of this study was to describe the prevalence of depression among ESRD patients in Taiwan who received different treatment regimens, and to determine the factors related to depression among these participants across various treatment regimens. A convenience sample of 342 participants was recruited from two medical centres. Participants were diagnosed with ESRD and received one of three renal replacement therapies, and screened for depression using the Taiwanese Depression Questionnaire (TDQ). The prevalence of depression (defined as TDQ score above 19) varied by treatment type: 36·3% (27/102) among peritoneal dialysis (PD) patients, 18·5% (17/92) among haemodialysis (HD) patients and 14·8% (21/142) among transplant patients. There were significant differences in the TDQ scores between the three treatment types (p < 0·001), indicating that participants' depression status varied by treatment type. Prevalence of depression among PD patients was higher than among HD and transplant patients. Logistic regression analysis revealed that treatment duration (p < 0·01) was a predictor of PD patients' depression, whereas self‐reported health status was a predictor of depression among both HD patients (p < 0·01) and transplant patients (p < 0·05). Screening for and treatment of depression should be important parts of the standard care of ESRD patients. Pre‐ and post‐therapy counselling by nurses and early recognition of emotional difficulties may also help these patients adapt to psychosocial stressors.     

In vitro interaction of micafungin with conventional and new antifungals against clinical isolates of Trichosporon, Sporobolomyces and Rhodotorula

OBJECTIVES: The infections caused by basidiomycetous yeasts are often difficult to resolve. Combined therapy might be useful in those severe cases where a monotherapy was ineffective. The aim of this study was to evaluate the in vitro activity of combinations of micafungin with amphotericin B or fluconazole, itraconazole, voriconazole and ravuconazole against isolates of Trichosporon, Rhodotorula and Sporobolomyces. METHODS: Twenty-seven clinical isolates were tested, i.e. 10 of Trichosporon asahii, two of Trichosporon mucoides, five of Sporobolomyces salmonicolor and 10 of Rhodotorula glutinis. Drug interactions were assessed by the chequerboard technique using the NCCLS microdilution method (M27-A2). The fractional inhibitory concentration index (FICI) was used to classify drug interactions. Results were interpreted as follows: synergy (FICI < or =0.5), no interaction (FICI >0.5 and < or =4.0), or antagonism (FICI >4.0). RESULTS: Micafungin combined with amphotericin B showed the highest percentage of synergic interactions (78%) followed by micafungin/ravuconazole and micafungin/itraconazole (48% for each), and micafungin/fluconazole and micafungin/voriconazole (34% for each). Antagonism was not observed in any case. CONCLUSIONS: Some of the combinations tested, especially micafungin/amphotericin B, have potential for the treatment of basidiomycetous yeast infections.     

Treatment of severe neutropenic sepsis with granulocyte transfusion in the current era – experience from an adult haematology unit in Singapore

Objectives: Granulocyte transfusion's (GT) efficacy among adult severe neutropenic sepsis (SNS) patients remains uncertain. We assessed GT's efficacy and its determinants among SNS patients in an adult haematology unit. The feasibility and safety of granulocyte donation (GD) and determinants of granulocyte yield were also evaluated. Methods: Retrospective analysis of granulocyte donors and recipients from March 2008 to October 2009. Results: Donors: Sixty GDs with a median WBC yield (WBCY) of 65·49 (31·30–131·72) × 10⁹ were collected from 48 donors (9 repeat donors) using hydroxyethyl starch and intermittent flow centrifugation aphaeresis after receiving 8 mg dexamethasone and 300 mcg granulocyte colony‐stimulating factor, with no serious adverse reactions (SAR). Six donations were urgently collected <3 h after pre‐medication, the median WBCY of which was not significantly different from donations collected >12 h after pre‐medication [59·18 (45·68–62·90) × 10⁹ vs 67·45 (31·30–131·72) × 10⁹, P = 0·140]. Only pre‐GD absolute neutrophil count (ANC) correlated with WBCY. Patients: Fifteen patients (12 acute leukaemias, 1 severe AA, 1 myelodysplastic syndrome and 1 lymphoma) received median 3 (2–9) ABO/RhD‐matched GTs over 2–24 (median 7) days at 3–61 (median 28) days from severe neutropenia (SN) onset without SAR. They received intensive chemotherapies (N = 9), allogeneic transplant (N = 3), autologous stem cell rescue (N = 1) or immunosuppressants (N = 2). Fourteen had bacterial (N = 1) infections, fungal (N = 3) infections or both (N = 10) and one had severe viral pneumonitis; 63·6 and 30·8% of bacterial and fungal infections responded, respectively. Median ANC increase (ANC_increase) was 1·26 (0–9·25) × 10⁹ at 5–20 (median 11) h post‐GT. On multivariate analysis, each patient's median ANC_increase only significantly correlated positively with median WBC dose/kg (P = 0·013). Five (33·3%) patients survived to discharge; the rest had infection‐related mortality (IRM). IRM was significantly associated with inotropic requirement (P = 0·004), ventilatory requirement (P = 0·017) and persistent SN (P = 0·007). Conclusion: GD is safe and feasible with good WBCY obtainable using our protocol. The effect of shortening pre‐medication interval on WBCY which may prevent delay in initiating GT is worth evaluating. GT most likely benefits SNS patients with prospects of neutrophil recovery before haemodynamic deterioration. Large randomised trials investigating the role and timing of GT among such patients are required.     

Comparison of SSRIs and SNRIs in major depressive disorder: a meta‐analysis of head‐to‐head randomized clinical trials

Context: Controversy exists whether serotonin–norepinephrine reuptake inhibitors (SNRIs) have improved efficacy compared with selective serotonin reuptake inhibitors (SSRIs). Objective: To compare clinical outcomes of adults treated with SSRIs or SNRIs for major depressive disorder (MDD) under ideal clinical condition, research design, and outcome measure. Data sources: Electronic databases searched were Medline, Embase and Cochrane Library from inception to July 2007. Study selection: Included studies were those head‐to‐head randomized trials comparing remission (HAMD‐17 ≤7–8, MADRS ≤10–12) after 8–12 weeks of therapeutic doses of SSRIs or SNRIs in patients diagnosed with MDD were targeted for analysis. Reviews, letters, commentaries, economic studies, etc. were excluded. Studies were reviewed by two independent researchers. Where disagreements occurred in study selection, a consensus approach was used. Data extraction and analysis: Targeted outcome data included number of patients achieving remission, withdrawing from therapy due to lack of efficacy (LoE) and/or adverse drug reactions (ADRs), and total patients in trial. A random effects model combined intent‐to‐treat (ITT) and per‐protocol (PP) odds ratio (OR), and remission and dropout rates. Chi‐square assessed heterogeneity. Quality assessment was done using Downs‐Black checklist. Results: Thirty‐three studies were identified; 18 were rejected (patients had co‐morbidities in 7, outcomes differed in 5, different follow‐up in 3, and three reviews). Fifteen head‐to‐head trials of 3094 patients, average age was 41·9 ± 11·9 years (for SNRIs) and 41·6 ± 12·1 years (for SSRIs), P = 0·941. All analyses displayed non‐heterogeneity (P > 0·05). The OR (under ITT) was 1·27 (1·06–1·52 95% CI) favoring SNRIs. Meta‐analytic remission rates were 48·5 ± 3·2% and 41·9 ± 4·2% for SNRIs and SSRIs, respectively. The meta‐analytic difference in remission rates between drugs was 5·7% (P = 0·007). Dropout rates due to ADRs were higher with SNRIs than SSRIs (3·2% difference, P < 0·001). Dropout rates due to LoE were non‐significant between studied groups (P > 0·05). Conclusions: Serotonin and norepinephrine reuptake inhibitors showed statistical but not clinical significance when compared with SSRIs in treating MDD.     

Renal artery stenosis predicts adverse cardiovascular and renal outcome in patients with peripheral artery disease

Background Patients with symptomatic peripheral artery disease (PAD) are considered cardiovascular high‐risk patients. Our aim was to investigate whether incidental renal artery stenosis (RAS) increases the risk for adverse cardiovascular and renal outcomes in these patients. Materials and methods We prospectively enrolled 487 consecutive patients admitted for revascularization of symptomatic PAD and performed a renal overview angiogram categorizing RAS as absent (0–29%), moderate (30–59%) and severe (≥ 60%) respectively. Clinical follow‐up was for median 15 months (IQR 12–22) for the occurrence of major adverse events [MAE: composite of death, myocardial infarction (MI), stroke, percutaneous coronary intervention, coronary bypass surgery, amputation and kidney failure]. Glomerular filtration rates (GFR) were obtained at 12 months to quantify the course of renal function. Results A severe RAS was found in 76 patients (15·6%). Overall MAE occurred in 121 patients (24·8%), the composite endpoint of MI, stroke, amputation and death occurred in 101 patients (20·7%). Patients with a severe RAS had a 1·87‐fold increased adjusted risk for MAE (95% CI 1·12–3·12, P = 0·017), a 2·51‐fold increased adjusted risk for occurrence of the composite endpoint of MI, stroke, amputation and death (95% CI 1·45–4·34, P = 0·001) and a 2·93‐fold increased risk for death (95% CI 1·41–6·08, P = 0·004), compared to those of patients without RAS respectively. We observed a significant association between the decrease of GFR over the 12‐month follow‐up period and the severity of RAS by multivariable analysis (P = 0·044). Conclusion Severe RAS in patients with symptomatic PAD is an independent predictor of major adverse cardiovascular events, adverse renal outcome and mortality.     

卡泊芬净与米卡芬净治疗重症侵袭性真菌感染的临床疗效与药物利用评价

目的探讨卡泊芬净和米卡芬净治疗重症侵袭性真菌感染（invasive fungal infections,IFI）患者的临床疗效,评价药物利用。方法随机抽取四川省人民医院2009年1月至2011年12月分别经卡泊芬净和米卡芬净治疗的IFI病例各40例,分析评价卡泊芬净和米卡芬净治疗IFI的疗效、不良反应及药物利用情况。结果治疗总有效率卡泊芬净组为57.5%,米卡芬净组为55.0%,差异无统计学意义（P〉0.05）;两组首选治疗有效率均远高于三唑类（如氟康唑、伊曲康唑）、多烯类（如两性霉素B及其脂质体）治疗无效或不能耐受而进行的挽救治疗有效率,差异有统计学意义（P〈0.05）;不良反应发生率卡泊芬净组高于米卡芬净组,但差异无统计学意义（P〉0.05）;药物利用指数（DUI）卡泊芬净为0.985,米卡芬净为1.000,使用基本合理;日用药金额卡泊芬净为1942.04元/天,米卡芬净为1260.00元/天。结论卡泊芬净和米卡芬净治疗重症IFI的疗效相当,首选二者治疗的有效率均高于挽救治疗;二者不良反应发生率相近;DUI≤1.0,为合理用药。二者在疗效和不良反应相当的情况下,从经济学角度考虑米卡芬净更具优势。     

Infectious complications in using mofetil micofenolate in patients with renal allotransplant

AIM: To study infectious complications in renal transplant recipients receiving mycophenolate mofetil (MMF) for prevention of acute transplant rejection or treatment of chronic allograft nephropathy (CAN). MATERIAL AND METHODS: A group of renal transplant recipients (n=47) receiving 1.0-2.0 g/day MMF with cyclosporine A (CsA) and steroids as maintaining immunosuppression was compared to a group (n=47) taking triple immunosuppressive therapy which included azathioprine (Aza). Separate group of patients (n=9) received MMF for treatment of CAN. In all groups etiology and incidence of infections were evaluated. RESULTS: During 2 years various posttransplant infections developed in 72.3% patients on MMF and 93.6% on Aza. The incidence of viral infections was 53.2% in MMF and 59.6% in Aza group, the incidence of bacterial infection--55.3 and 70.2%, respectively. Among 9 recipients with CAN the infections occurred in five. There were two cases of active tuberculosis in Aza group, one--in MMF group and one in patients with CAN. CONCLUSION: We suggest that MMF in the dose 1-2 g/day does not increase infection rates in renal transplant recipients comparing Aza.     

The efficacy and toxicity of two dosing-regimens of amikacin in neonates with sepsis

What is known and objective: Neonatal sepsis is one of the most common reasons for admission to neonatal units in developing countries. Aminoglycosides widely used in its treatment are usually administered two or three times a day. Less frequent doing may be more convenient and as effective. We aim to compare the efficacy and safety (nephrotoxicity) of once daily vs. twice daily dosing of amikacin in neonates with suspected or proven sepsis and report on the drug’s pharmacokinetics in these subjects. Methods: Thirty neonates of gestational age ≥36 weeks and body weight ≥2500 g with suspected or proven sepsis were randomized to receive amikacin either at a dose of 15 mg/kg once per day; group I (n = 15), or a dose of 7·5 mg/kg twice per day, group II (n = 15). All neonates received classical treatment of sepsis including antibiotics, hemodynamic support, inotropic support based on blood pressure levels and size of the heart in chest X‐ray, if needed. Amikacin was infused over 1 h. Peak and trough serum samples for amikacin were measured for all infants at steady state. Nephrotoxicity was assessed by serum creatinine and urinary N‐acetyl β‐d ‐glucosaminidase before and 7 days after therapy. Clinical efficacy was compared using both observation of clinical status and normalization of laboratory tests. Results: All the patients in group I had achieved a trough level <10 μg/mL and two patients had trough concentration >10 μg/mL in group II. No significant difference between group I and group II in either baseline or day 7 serum creatinine was demonstrated (P > 0·05). No significant difference was found between the two groups in clinical efficacy or renal toxicity. The calculated pharmacokinetic parameters were in group I and II, respectively: clearance =63·8 ± 15·9 mL/kg/h and 73·5 ± 18·1 mL/kg/h; volume of distribution =0·54 ± 0·09 L/kg and 0·61 ± 0·13 L/kg, half‐life =6·1 ± 1·0 h and 5·95 ± 1·1 h. What is new and conclusion: As expected, amikacin given once every 24 h to septic neonates of ≥36 weeks of gestation achieved higher peak levels and lower trough concentrations than the twice daily regimen. Treatment with once daily regimen did not lead to more nephrotoxicity than with a twice‐daily regimen, and showed comparable efficacy.     

Antifungal prophylaxis among allogeneic hematopoietic stem cell transplant recipients: current issues and new agents

Invasive candidiasis and invasive mold infections cause significant morbidity and mortality in the hematopoietic stem cell transplant population, in particular in recipients of allografts. The introduction of a variety of new antifungal compounds over the past decade has focused attention on prophylactic strategies as a means to decrease the burden of invasive fungal infections (IFIs). Until recently, fluconazole has been the standard agent for prophylaxis before and after engraftment. In 2005, the echinocandin micafungin received US FDA approval for prophylaxis against IFIs in stem cell transplant recipients during the neutropenic period prior to engraftment. In patients with substantial risk for invasive mold infection, many centers now use a mold-active antifungal agent (e.g., a triazole such as itraconazole, voriconazole or posaconazole, or an echinocandin) as prophylaxis after engraftment. Several recent studies have highlighted the efficacy of these newer agents in preventing IFIs in these highly immunocompromised patients. This review will discuss current issues in IFI and new agents available for prophylaxis in allogeneic hematopoietic stem cell transplant recipients.     

Antifungal prophylaxis among allogeneic hematopoietic stem cell transplant recipients: current issues and new agents

Invasive candidiasis and invasive mold infections cause significant morbidity and mortality in the hematopoietic stem cell transplant population, in particular in recipients of allografts. The introduction of a variety of new antifungal compounds over the past decade has focused attention on prophylactic strategies as a means to decrease the burden of invasive fungal infections (IFIs). Until recently, fluconazole has been the standard agent for prophylaxis before and after engraftment. In 2005, the echinocandin micafungin received US FDA approval for prophylaxis against IFIs in stem cell transplant recipients during the neutropenic period prior to engraftment. In patients with substantial risk for invasive mold infection, many centers now use a mold-active antifungal agent (e.g., a triazole such as itraconazole, voriconazole or posaconazole, or an echinocandin) as prophylaxis after engraftment. Several recent studies have highlighted the efficacy of these newer agents in preventing IFIs in these highly immunocompromised patients. This review will discuss current issues in IFI and new agents available for prophylaxis in allogeneic hematopoietic stem cell transplant recipients.     

Therapeutic drug monitoring of tobramycin: once-daily versus twice-daily dosage schedules

Objective: To evaluate the effect of dosage regimen (once-daily vs. twice-daily) of tobramicyn on steady-state serum concentrations and toxicity. Materials and methods: Patients undergoing treatment with iv tobramycin (4 mg/kg/day) were randomised to two groups. Group OD ( n=22) received a once-daily dose of tobramycin and group TD (n=21) received the same dose divided into two doses daily. Tobramycin serum concentrations (peak and trough) were measured by enzyme multiplied immunoassay. The renal and auditorory functions of the patients were monitored before, during and immediately after treatment. Results: The two groups were comparable with respect to sex, age, body weight and renal function. No statistically significant differences were found in mean daily dose, duration of treatment, or cumulative dose. Trough concentrations were < 2 μg/ml in the two groups (100%). Peak concentrations were > 6 μg/ml in 100% of the OD group and in 67% of the TD group ( P< 0·01). Mean peak concentrations were markedly different: 11·00±2·89 μg/ml in OD vs. 6·53±1·45 μg/ml in TD ( P< 0·01). The pharmacokinetics parameters were: K_e, (0·15±0·03/h in OD vs. 0·24±0·06/h in TD), t_1/2, (4·95±1·41 h in OD vs. 3·07±0·71 h in TD), V_d (0·35±0·11 l/kg in OD vs. 0·33±0·09 l/kg in TD), Cl (0·86±0·29 ml/min/kg in OD vs. 1·28±0·33 ml/min/kg in TD). Increased serum creatinine was observed in 73% of patients in OD versus 57% of patients in TD, without evidence of nephrotoxicity. In TD group, three patients developed decreased auditory function, of which one presented with an auditory loss of –30 dB, whereas in the OD group only one patient presented decreased auditory function. Conclusion: This small study suggests that a once-daily dosing regimen of tobramycin is at least as effective as and is no more and possibly less toxic than the twice-daily regimen. Using a single-dose therapy, peak concentration determination is not necessary, only trough samples should be monitored to ensure levels below 2 μg/ml.     

Assessment of hypnotic effects and patient satisfaction in empirical use of sleep medicines

Objective: We assessed the hypnotic effects of and patient satisfaction with three types of hypnotics prescribed empirically: ultra‐short‐acting (US‐a), short‐acting (S‐a), and intermediate‐ and long‐acting (IL‐a) agents. Methods: We studied 310 insomniac patients (age 60·5 ± 15·0 years) treated with US‐a (n = 124), S‐a (n = 149) or IL‐a (n = 37) agents. Patients were interviewed to evaluate individual satisfaction and drug efficacy. Efficacy, as assessed by total sleep time (TST) and sleep latency time (SLT), was compared between satisfied and dissatisfied patient groups. Nocturnal awaking curve for each hypnotic was used for comparing the effects between satisfied and dissatisfied patient groups in each type of hypnotics. Results: Thirty‐two patients (25·8%) were dissatisfied with US‐a, 35 (23·5%) with S‐a and 11 (29·7%) with IL‐a. TST differed significantly between satisfied and dissatisfied groups: 424 ± 88 vs. 345 ± 101 min for US‐a (P < 0·001), 440 ± 84 vs. 359 ± 111 min for S‐a (P < 0·001) and 453 ± 96 vs. 345 ± 125 min for IL‐a (P < 0·01), respectively. With IL‐a agents, the SLT of dissatisfied patients was longer than in satisfied ones (81 ± 52 vs. 33 ± 22 min, P < 0·05). Twenty (62·5%) dissatisfied patients taking US‐a agents awoke before 05:00 hours – a rate significantly higher than satisfied patients (n = 23, 25·0%, P < 0·001). These characteristics of dissatisfied patients were reflected by the patterns of nocturnal awaking curves, although the patterns for satisfied patients were similar among the three types of hypnotics. Conclusion: Between 24% and 30% of patients were dissatisfied with their hypnotics. Shorter TST was common in dissatisfied patients receiving any agent, for reasons differing among hypnotics (longer SLT with IL‐a agents and early awakening with US‐a). Drug efficacy and patient satisfaction in empirical use of hypnotics can be assessed by nocturnal awaking curves for each hypnotic.     

Subcutaneous versus intravenous insulin therapy for glucose control in non‐diabetic trauma patients. A randomized controlled trial

What is known and Objective:  Hyperglycaemia in trauma patients admitted to the intensive care unit (ICU) is associated with increased morbidity and mortality. Our pilot study is a prospective randomized controlled trial comparing the impact of two glucose control regimens on outcomes in non‐diabetic trauma patients admitted with hyperglycaemia to the ICU. Methods:  Trauma patients with blood glucose levels (BGLs) ≥7·8 mm within the first 48 h of the hospital admission were randomized to receive intermittent SQ or continuous IV insulin to maintain BGLs between 4·4 and 6·1 mm. We excluded diabetics on the basis of history, or a glycosylated haemoglobin ≥6% on admission. We compared the effect of SQ vs. IV insulin therapy on the ICU length of stay (ILOS). Results and Discussion:  A total of 58 patients were included in the study. The SQ and IV groups were comparable in terms of age, gender, injury severity, revised trauma, Glasgow coma scores and type of trauma (blunt vs. penetrating). There was no significant difference between the two treatment groups in the ILOS (3 vs. 2 days, P = 0·084), hospital length of stay (8 vs. 6, P = 0·09), ventilator support days (6 vs. 3, P = 0·98), requirement for blood transfusion (P = 0·66), rates of infections (P = 0·70), acute kidney injury (P = 0·99) and mortality (P = 0·61). What is new and Conclusion:  There was no difference between SQ and IV insulin therapy in the ILOS in non‐diabetic trauma patients.     

Effect of health on knowledge,self‐efficacy and health behaviours of women with urinary tract infection

Urinary tract infection (UTI) is one of the most common bacterial infections affecting about 40% of women in some points in their lives. UTI can cause serious potential consequences such as life‐threatening sepsis, if it is not treated by primary health care providers. Health behaviours play an important role in causing UTI. Self‐efficacy, as an important moderator of the relationship between knowledge and behaviour, is an important prerequisite for behaviour change. The aim of this study is to investigate the effect of health education on knowledge, self‐efficacy and health behaviours of women with UTI. This is a quasi‐experimental study of the intervention and comparison groups, with pre‐test and post‐test design, conducted with 170 married women with UTI; referred to selected hospital laboratories in Tehran. The data collection tool was a self‐made questionnaire which was answered by both groups, prior to the intervention and 12 weeks thereafter. The intervention was performed on the intervention group samples. On the basis of the study results, after the intervention the average score of the knowledge (p = 0·002), self‐efficacy (p < 0·001) and health behaviours (p < 0·001) of the intervention group had significantly increased compared to the comparison group. The findings showed that health education was effective in promotion of the knowledge, self‐efficacy and health behaviours of women with UTI.     

Incidence and risk factors of catheter‐associated urinary tract infection in Yazd – Iran

Catheter‐associated urinary tract infection (CAUTI) is the most common nosocomial infection, accounting for more than 1 million cases each year in the US hospitals and nursing homes. The significant number of infections and dissemination of resistant bacteria in hospitals make it important to find ways to decrease their incidence. The aim of the study was to describe the incidence and risk factors of CAUTIs. A cohort study was conducted from 2003 to 2008 on every patient who became catheterized consecutively. Variables included age, sex, indications for catheterization, antimicrobials usage, duration of catheterization and hospital stay, and type and colony count of microorganism. The incidence was 21·8%, the risk factor identified was duration of catheterization [relative risk 1·213, 95% CI (1·053–1·398)] while usage of antimicrobials was protective [relative risk 0·433, 95% CI (0·237–0·792)]. Organisms isolated were: Esherichia coli 23%, Enterobacter 8·1%, Staphylococcus aureus 10·8%, Pseudomonas aeuroginosa 5·4%, coagulase negative Staphylococcus 9·4%, klebsiella 4%, Proteus mirabilis 2·8%, yeasts 9·46%, Enterococcus 4%, Acinetobacter 1·4% and mixed growth of bacteria 21·6%. The incidence of CAUTI was slightly higher than in the studies from the developing countries. Daily monitoring to decrease duration of catheterization is reemphasized.