Baseline resistance and virological outcome in patients with virological failure who start a regimen containing abacavir: EuroSIDA study

OBJECTIVES: To investigate the ability of several HIV-1 drug-resistance interpretation systems, as well as the number of pre-specified combinations of abacavir-related mutations, to predict virological response to abacavir-containing regimens in antiretroviral therapy-experienced, abacavir-naive patients starting an abacavir-containing regimen in the EuroSIDA cohort. PATIENTS AND METHODS: A total of 100 HIV-infected patients with viral load (VL) >500 copies/ml who had a plasma sample available at the time of starting abacavir (baseline) were included. Resistance to abacavir was interpreted by using eight different commonly used systems that consisted of rules-based algorithms or tables of mutations. Correlation between baseline abacavir-resistance mutations and month 6 virological response was performed on this population using a multivariable linear regression model accounting for censored data. RESULTS: The baseline VL was 4.36 log10 RNA copies/ml [interquartile range (IQR): 3.65-4.99 log10 RNA copies/ml] and the median CD4 cell count was 210 cells/microl (IQR: 67-305 cells/microl). Our patients were pre-exposed to a median of seven antiretrovirals (2-12) before starting abacavir therapy. The median (range) number of abacavir mutations (according to the International AIDS Society-USA) detected at baseline was 3.5 (0-8). Overall, the Kaplan-Meier estimate of the median month 6 VL decline was 0.86 log10 RNA copies/ml [95% confidence intervals (95% CI): 0.45-1.24]. The VL in those patients (n=31) who intensified treatment by adding only abacavir decreased by a median 0.20 log10 RNA copies/ml (95% CI: -0.18; +0.94). The proportion of patients who harboured viruses fully resistant to abacavir among the eight genotypic resistance interpretation algorithms ranged from 12% [Agence Nationale de Recherches sur le SIDA (ANRS)] to 79% [Stanford HIV RT and PR Sequence Database (HIVdb)]. Some interpretation systems showed statistically significant associations between the predicted resistance status and the virological response while others showed no consistent association. The number of active drugs in the regimen was associated with greater virological suppression (additional month 6 VL reduction per additional sensitive drug=0.51, 95% CI: 0.15-0.88, P=0.006); baseline VL was also weakly associated (additional month 6 VL reduction per log10 higher=0.30, 95% CI: -0.02; +0.62, P=0.06). In contrast, the number of drugs previously received was associated with diminished viral reduction (additional month 6 VL reduction per additional drug=-0.14, 95% CI: -0.28; 0.00, P=0.05). CONCLUSIONS: Our results revealed a high degree of variability among several genotypic resistance interpretation algorithms currently in use for abacavir. Therefore, the interpretation of genotypic resistance for predicting response to regimens containing abacavir remains a major challenge.     

A randomized study comparing a three- and four-drug HAART regimen in first-line therapy (QUAD study)

BACKGROUND: Evidence from randomized controlled trials supports the use of triple therapy. Research is required on the effectiveness of quadruple therapy in comparison to this and the relative effectiveness of specific highly active antiretroviral therapy (HAART) combinations. METHODS: Antiretroviral-naive individuals (n = 53) with an HIV-1 viral load >100 000 copies/mL were randomized to receive three-drug HAART with zidovudine/lamivudine (Combivir) and efavirenz or quadruple therapy with zidovudine/lamivudine/abacavir (Trizivir) and efavirenz (quad regimen). Patients continued on HAART for 48 weeks with regular clinical and immunological assessment. Standard and ultrasensitive (<5 copies/mL) viral load testing was carried out. RESULTS: A DAVG (difference in averages) analysis of the fall in viral load and increase in CD4 count showed no significant differences between regimens. Triple therapy resulted in a -4.17 log change (95% CI, -4.48 to -3.85) and quadruple therapy in a -4.36 log change (95% CI, -4.68 to -4.03) in viral load. For CD4 counts, the triple therapy arm increased by 164 cells/mm(3) (95% CI 112-217) and the quadruple arm by 185 (95% CI, 133-237). In an intent-to-treat analysis, 77% of patients in the triple therapy group reached an undetectable viral load (<50 copies/mL) compared with 84.2% of the quadruple therapy group. For ultrasensitive viral load testing, 23% and 18% of each group, respectively, reached undetectable viral loads. The hazard ratio for attaining a viral load of <5 copies/mL was 0.59 (95% CI, 0.26-1.33) for quadruple versus triple therapy. Three individuals in the triple therapy arm and nine in the quadruple therapy arm discontinued treatment. CONCLUSIONS: No differences in any analyses were observed between a standard of care regimen (zidovudine/lamivudine and efavirenz) and the quad regimen (zidovudine/lamivudine/abacavir and efavirenz).     

Motorcycle‐related major trauma: On‐road versus off‐road incidence and profile of cases

Objective: To describe and compare the incidence and profile of on‐ and off‐road motorcycle‐related major trauma (including death) cases across a statewide population. Methods: A review of prospectively collected data on adult, motorcycle‐related major trauma cases from 2001 to 2008 was conducted. Major trauma survivors were identified from the population‐based Victorian State Trauma Registry, and deaths were extracted from the National Coroners Information System. Poisson regression was used to test for increasing incidence using two measures of exposure: population of Victoria aged ≥16 years, and registered motorcycles. Results: There were 1157 major trauma survivors and 344 deaths with motorcycle‐related injuries over the study period. There was no change in the incidence of motorcycle‐related major trauma (both survivors plus deaths) (Incident Rate ratio [IRR]= 1.14, 95% confidence interval [CI] 0.94–1.37) over the study period. Similarly, there was no change over time in the incidence of on‐road motorcycle‐related injury (survivors plus deaths) per 100 000 population (IRR = 1.03, 95% CI 0.84–1.27). However, the incidence of off‐road motorcycle‐related injury (survivors plus deaths) increased over the study period (IRR = 1.69, 95% CI 1.10–2.60). Among survivors and deaths, 882 (76%) and 301 (87.5%) cases, respectively, occurred on road. Conclusions: Off‐road motorcycle‐related major trauma has increased and this has not been targeted in injury prevention campaigns in Australia. The incidence of on‐road motorcycle‐related death in adults has decreased. Preventive strategies to address on‐road injuries have been enforced and these are expected to lead to further reduction of on‐road motorcycle crashes in the future.     

Risk of discontinuation of nevirapine due to toxicities in antiretroviral-naive and -experienced HIV-infected patients with high and low CD4+ T-cell counts

INTRODUCTION: It is unknown whether the increased risk of toxicities in antiretroviral-naive HIV-infected patients initiating nevirapine-based (NVPc) combination antiretroviral therapy (cART) with high CD4+ T-cell counts is also observed when NVPc is initiated in cARTexperienced patients. PATIENTS AND METHODS: 1,571 EuroSIDA patients started NVPc after 1/1/1999, with CD4+ T-cell counts and viral load measured in the 6 months before starting treatment, and were stratified into four groups based on CD4+ T-cell counts at initiation of NVPc (high [H], > 400/mm3 or > 250/mm3 for male or female, respectively, or low [L], < or = 400/mm3 or 5250/mm3 for male or female) and prior antiretroviral experience (antiretroviral-naive [N] or -experienced [E]). Cox proportional hazards models compared the risks of discontinuation of nevirapine due to toxicities or patient/physician choice (TOXPC). RESULTS: After adjustment, there was a significantly lower risk of discontinuation of nevirapine due to TOXPC in the HE group (n = 588; proportion discontinued by 3/12 months: 10/17%, respectively) than in HN (n = 62; 21/32% respectively; overall relative hazard [RH]: 0.56; 95% confidence interval [CI]: 0.34-0.94; P = 0.027). This difference was most pronounced during the first 3 months of NVPc (RH: 0.44; 95% CI: 0.23-0.87; P = 0.017). There were no deaths in the 6 months after starting NVPc resulting from exposure to < 3 months of NVPc exposure within the HE group (incidence: 0; per 1,000 person-years follow up; 95% CI: 0-6.9). After adjustment, there were no differences between the HE and HN groups in discontinuation due to TOXPC in patients starting efavirenz-based cART (RH: 0.91; 95% CI: 0.60-1.38; P = 0.66) or protease-inhibitor-based cART (RH: 1.13; 95% CI: 0.77-1.66; P = 0.52). CONCLUSIONS: Results from this non-randomized study suggest that NVPc might be safer to initiate in antiretroviral-experienced than in antiretroviral-naive patients with high CD4+ T-cell counts.     

The management of hepatitis B virus/HIV-1 co-infected patients starting their first HAART regimen. Treating two infections for the price of one drug?

We examined the impact of a lamivudine-containing highly active antiretroviral therapy (HAART) regimen on 164 hepatitis B virus/HIV co-infected individuals starting their first HAART. Lamivudine-treated patients (accounting for 73% of the study population) showed a significantly lower level of alanine aminotransferase over follow-up [-81.1 mU/ml mean difference; 95% confidence intervals (95% CI): -30.3; -131.7, P=0.003] and a significantly reduced risk of liver-related morbidity/mortality [Relative hazard (RH)=0.07; 95% CI: 0.01-0.38, P=0.002] than those starting a lamivudine sparing-regimen.     

Life-long morbidity among Danes with poliomyelitis

OBJECTIVE: To estimate long-term morbidity in a cohort of Danish poliomyelitis patients. DESIGN: A historical prospective cohort study of 27,047 persons. SETTING: Denmark. PARTICIPANTS: A total of 5421 persons hospitalized for poliomyelitis between 1919 to 1954 in Copenhagen, Denmark, and 21,626 age- and gender-matched Danes. Participants were followed up on average for 20.6 years, yielding a total of 555,884 person-years of follow-up. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The exposed (poliomyelitis) cohort and the unexposed (control) cohort were followed up for somatic hospitalization from 1977 to 1999 in the Danish Hospital Discharge Register. The incidence rate ratio (IRR) was calculated as the ratio between the incidence rate of disease in the exposed and unexposed cohorts. RESULTS: Overall, polio patients had a 1.2- to 1.3-fold increased risk of being hospitalized with pulmonary diseases, heart diseases, gastrointestinal disorders, or diseases of the locomotive apparatus. Among paralytic polio patients, long-term morbidity seems to be associated with the acute severity of poliomyelitis, as well as young age at infection. Paralytic patients, who contracted respiratory polio under the age of 5, had the highest risk of being hospitalized with lung diseases (IRR=7.26; 95% confidence interval [CI], 3.06-18.33), diseases of the locomotive apparatus (IRR=4.05; 95% CI, 1.66-9.86), heart diseases (IRR=1.70; 95% CI, 0.65-3.98), and diseases of the digestive system (IRR= 2.23; 95% CI, 1.03-4.62). Surprisingly, patients without paralyses, especially women, also had an increased morbidity. CONCLUSIONS: Overall, a history of poliomyelitis was associated with a slightly increased morbidity measured by hospitalizations. Long-term morbidity was highest among respiratory polio patients; however, patients presumably left without any residual symptoms also had an increased morbidity.     

The impact of trauma exposure and post-traumatic stress disorder on healthcare utilization among primary care patients

BACKGROUND: Trauma exposure and post-traumatic stress disorder (PTSD) increase healthcare utilization in veterans, but their impact on utilization in other populations is uncertain. OBJECTIVES: To examine the association of trauma exposure and PTSD with healthcare utilization, in civilian primary care patients. RESEARCH DESIGN: Cross-sectional study. SUBJECTS: English speaking patients at an academic, urban primary care clinic. MEASURES: Trauma exposure and current PTSD diagnoses were obtained from the Composite International Diagnostic Interview. Outcomes were nonmental health outpatient and emergency department visits, hospitalizations, and mental health outpatient visits in the prior year from an electronic medical record. Analyses included bivariate unadjusted and multivariable Poisson regressions adjusted for age, gender, income, substance dependence, depression, and comorbidities. RESULTS: Among 592 subjects, 80% had > or =1 trauma exposure and 22% had current PTSD. In adjusted regressions, subjects with trauma exposure had more mental health visits [incidence rate ratio (IRR), 3.9; 95% confidence interval (CI), 1.1-14.1] but no other increased utilization. After adjusting for PTSD, this effect of trauma exposure was attenuated (IRR, 3.2; 95% CI, 0.9-11.7). Subjects with PTSD had more hospitalizations (IRR, 2.2; 95% CI, 1.4-3.7), more hospital nights (IRR, 2.6; 95% CI, 1.4-5.0), and more mental health visits (IRR, 2.2; 95% CI, 1.1-4.1) but no increase in outpatient and emergency department visits. CONCLUSIONS: PTSD is associated with more hospitalizations, longer hospitalizations, and greater mental healthcare utilization in urban primary care patients. Although trauma exposure is independently associated with greater mental healthcare utilization, PTSD mediates a portion of this association.     

Clinical Outcomes in Neurogenic Claudication Using a Multimodal Program for Lumbar Spinal Stenosis: A Study of 49 Patients With Prospective Long-term Follow-up

ObjectiveThe purpose of this study was to assess long-term outcomes of a 6-week multimodal program (manual therapy, exercises, and self-management strategies) in patients with neurogenic claudication due to degenerative lumbar spinal stenosis.MethodsThis study evaluated 49 patients with neurogenic claudication who completed a 6-week multimodal program between 2010 and 2013. Outcomes included Oswestry Disability Index (ODI), Zurich Claudication Questionnaire (ZCQ), and Numeric Rating Scale. Mean differences, paired t tests, and the Wilcoxon rank-sum test were used to compare outcomes at baseline, 6 weeks, and long-term follow-up.ResultsTwenty-three patients completed the follow-up questionnaire (47% response rate). Median follow-up was 3.6 years (interquartile range: 3.3-4.6). The mean age was 73.5 years (standard deviation: 8.5). Between baseline and long-term follow-up, there were statistically significant and clinically important improvements in disability (ODI: -23.7 [95% confidence interval (CI): -15.7 to -31.6]; ODI walking item: -1.96 [95% CI: -1.34 to -2.57]; ZCQ function scale: -0.42 [95% CI: -0.10 to -0.70]) and pain (leg pain: -3.53 [95% CI: -1.80 to -5.20]; ZCQ symptom scale: -0.71 [95% CI: -0.30 to -1.10]), but not low back pain (Numeric Rating Scale: -1.03 [95% CI: -1.00 to 3.10]). There was no statistically significant change in any outcomes between 6 weeks and long-term follow-up.ConclusionIn a sample of patients with neurogenic claudication participating in a 6-week multimodal program, clinically important improvements in leg pain and disability, but not low back pain while walking, were maintained in the long term (median duration of 3.6 years) when compared to baseline.     

Ventilator-associated pneumonia caused by multidrug-resistant organisms or Pseudomonas aeruginosa: prevalence, incidence, risk factors, and outcomes

PURPOSE: The aim of this study was to clarify the prevalence and incidence of, risk factors for, and outcomes from suspected ventilator-associated pneumonia (VAP) associated with the isolation of either Pseudomonas or multidrug-resistant (MDR) bacteria ("high risk" pathogens) from respiratory secretions. MATERIALS AND METHODS: Data were collected as part of a large, multicentered trial of diagnostic and therapeutic strategies for patients (n = 739) with suspected VAP. RESULTS: At enrollment, 6.4% of patients had Pseudomonas species, and 5.1% of patients had at least 1 MDR organism isolated from respiratory secretions. Over the study period, the incidence of Pseudomonas and MDR organisms was 13.4% and 9.2%, respectively. Independent risk factors for the presence of these pathogens at enrollment were duration of hospital stay >or=48 hours before intensive care unit (ICU) admission (odds ratio, 2.37 [95% CI, 1.40-4.02]; P = .001] and prolonged duration of ICU stay before enrollment (odds ratio, 1.50 [95% CI, 1.17-1.93]; P = .002] per week. Fewer patients whose specimens grew either Pseudomonas or MDR organisms received appropriate empirical antibiotic therapy compared to those without these pathogens (68.5% vs 93.9%, P < .001). The isolation of high risk pathogens from respiratory secretions was associated with higher 28-day (relative risk, 1.59 [95% CI, 1.07-2.37]; P = .04] and hospital mortality (relative risk, 1.48 [95% CI, 1.05-2.07]; P = .05), and longer median duration of mechanical ventilation (12.6 vs 8.7 days, P = .05), ICU length of stay (16.2 vs 12.0 days, P = .05), and hospital length of stay (55.0 vs 41.8 days, P = .05). CONCLUSIONS: In this patient population, the incidence of high-risk organisms newly acquired during an ICU stay is low. However, the presence of high risk pathogens is associated with worse clinical outcomes.     

Incidence of abacavir hypersensitivity and its relationship with HLA-B*5701 in HIV-infected patients in Taiwan

OBJECTIVES: To describe the incidence of hypersensitivity to abacavir and frequency of human leucocyte antigen (HLA)-B*5701 in HIV-infected Taiwanese persons. METHODS: Medical records of 337 HIV-infected Taiwanese in whom abacavir-containing combination antiretroviral therapy (CART) was prescribed from 1 May 2001 to 31 December 2006 were reviewed, and HLA typing of the patients was performed in 320 patients (232 receiving abacavir and 88 not receiving abacavir) with available blood samples. HLA class I and II polymorphisms were determined by PCR with specific primers. HLA-B*5701 was further confirmed by sequence-based typing. RESULTS: Of the 337 patients, median CD4 count was 166.5 cells/mm3 (range, 1.0-1914.0) and 83 patients (24.6%) had AIDS-defining opportunistic infections. Thirty-eight patients (11.3%) discontinued abacavir within 6 weeks of starting abacavir-containing CART. Among them, 10 patients had successful abacavir re-challenge and another 11 patients had other specific reasons for abacavir discontinuation. Therefore, 14 patients (4.2%) were classified as cases in whom abacavir hypersensitivity could not be excluded, and 3 patients (0.9%) met the criteria of abacavir hypersensitivity. Of the 320 patients undergoing HLA typing, HLA-A02 was the most common allele and only one individual (0.3%) expressed HLA-B*5701. Along with some differences in allele distributions, there was a significant difference in the genetic frequency of HLA-B57 in our patients compared with those of previous studies in other Chinese populations. CONCLUSIONS: Abacavir hypersensitivity was less frequently encountered in HIV-infected Taiwanese initiating abacavir-containing CART than in Caucasians, which might be explained by the low frequency of the HLA-B*5701 allele.     

Risk factor analysis of hypersensitivity reactions to abacavir

BACKGROUND: A hypersensitivity reaction to abacavir has been known to occur in approximately 4% of patients treated with the drug. OBJECTIVE: The goal of this study was to determine risk factors associated with the development of hypersensitivity reactions to abacavir. METHODS: We constructed an analysis population from all protocols conducted by GlaxoSmithKline that involved at least 24 weeks of abacavir exposure with a quality-assured or validated clinical database by June 30, 2000. Demographic, clinical, and laboratory characteristics of patients who developed a hypersensitivity reaction to abacavir were compared with those of patients who did not. Univariate and multivariate logistic regression models were fit to understand the predictive ability of each potential risk factor. Odds ratios (ORs) and 95% Wald CIs were computed. RESULTS: A total of 5332 patients exposed to abacavir were included in this analysis; 197 cases of hypersensitivity reaction were reported (3.7%). In univariate models, several associations were noted, but most subgroups produced rates within the expected range of 3% to 6%. The multivariate model using all demographic data available (Model 1) indicated that the risk of hypersensitivity reaction among black patients (3% hypersensitivity reaction) was lower (OR = 0.59; 95% CI, 0.38-0.91) compared with other ethnic groups. In addition, a lower rate of hypersensitivity reaction was observed in patients who received previous therapy for HIV-1 infection with other antiretroviral agents (3% hypersensitivity reaction) compared with those receiving therapy for the first time (OR = 0.58; 95% CI, 0.44-0.78). CONCLUSIONS: The only characteristics identified as prognostic factors for hypersensitivity reaction to abacavir were antiretroviral treatment status (ie, treatment experience) and black race, each resulting in a lower rate compared with the expected incidence.     

Long-term opioid therapy for chronic noncancer pain: a systematic review and meta-analysis of efficacy and safety

Opioid therapy for chronic noncancer pain (CNCP) is controversial due to concerns regarding long-term efficacy and adverse events (including addiction). We systematically reviewed the clinical evidence on patients treated with opioids for CNCP for at least six months. Of 115 studies identified by our search of eleven databases (through April 7, 2007), 17 studies (patients [n]=3,079) met inclusion criteria. Studies evaluated oral (studies [k]=7; n=1,504), transdermal (k=3; n=1, 993), and/or intrathecal (k=8; n=177) opioids. Many patients withdrew from the clinical trials due to adverse effects (oral: 32.5% [95% confidence interval (CI), 26.1%-39.6%]; intrathecal: 6.3% [95% CI, 2.9%-13.1%]; transdermal: 17.5% [95% CI, 6.5%-39.0%]), or due to insufficient pain relief (oral: 11.9% [95% CI, 7.8%-17.7%]; intrathecal: 10.5% [95% CI, 3.5%-27.4%]; transdermal: 5.8% [95% CI, 4.2%-7.3%]). Signs of opioid addiction were reported in only 0.05% (1/2,042) of patients and abuse in only 0.43% (3/685). There was an insufficient amount of data on transdermal opioids to quantify pain relief. For patients able to remain on oral or intrathecal opioids for at least six months, pain scores were reduced long-term (oral: standardized mean difference [SMD] 1.99, 95% CI, 1.17-2.80; intrathecal: SMD 1.33, 95% CI, 0.97-1.69). We conclude that many patients discontinue long-term opioid therapy due to adverse events or insufficient pain relief; however, weak evidence suggests that oral and intrathecal opioids reduce pain long-term in the relatively small proportion of individuals with CNCP who continue treatment.     

Long-term lamivudine treatment is associated with a good maintained response in severe acute exacerbation of chronic HBeAg-negative hepatitis B

Hepatitis B e antigen (HBeAg)-negative chronic hepatitis B is difficult to treat and there is little long-term data for lamivudine treatment of severe acute exacerbation. We report a prospective, consecutive cohort of severe acute exacerbation of HBeAg-negative chronic hepatitis B patients treated by lamivudine between 1999 and 2004. All patients had respectively increased alanine aminotransferase and serum bilirubin to at least 10 and 2 times the upper limit of laboratory normal. Thirty-two patients were treated with lamivudine for 130 +/- 58 (range 48-217) weeks. Five patients had evidence of virological breakthrough (HBV DNA >10,000 copies/ml) during lamivudine treatment. The cumulative probability of maintained response without any virological breakthrough was 94% (95% confidence interval [CI], 86-100%) at year 1, 94% (95% CI, 82-100%) at year 2 and 71% (95% CI, 41-100%) at year 3. At the last follow-up visit, 31 (97%) lamivudine patients had HBV DNA <10,000 copies/ml. The prevalence of lamivudine resistance mutation was 1 in 32 patients (3%; 95% CI, 0-9%) at year 1, 1 in 17 patients (6%; 95% CI, 0-17%) at year 2, 1 in 9 patients (11%, 95% CI, 0-32%) at year 3 and 1 in 4 patients (25%; 95% CI, 0-67%) at year 4 of lamivudine treatment. In conclusion, extended lamivudine treatment is associated with a high maintained virological response and a low rate of drug resistance in severe acute exacerbation of HBeAg-negative chronic hepatitis B.     

早期心脏康复程序对经皮冠状动脉介入术后患者有效性与安全性的Meta分析

目的通过Meta分析的方法评价早期心脏康复程序应用于经皮冠状动脉介入术(Percutaneous Coronary Intervention,PCI)后患者的有效性与安全性。方法计算机检索Cochrane Library、PubMed、EMbase、clinical trials、中国生物医学文献(CBM)、知网(CNKI)、维普(VIP)、万方等数据库,收集所有关于早期心脏康复程序对急性心肌梗死PCI术后患者的随机对照试验。2名研究者根据纳入和排除标准独立检索、筛选文献,并评价文献资料,提取资料,使用RevMan 5.3软件进行统计处理。结果共纳入11篇随机对照试验,816例样本。Meta分析结果显示,早期心脏康复程序可提高PCI术后患者的射血分数[MD=3.60,95%CI(2.73,4.47),P<0.00001],增加峰值摄氧量[MD=1.67,95%CI(0.50,2.84),P=0.005],增加6 min步行距离[MD=102.15,95%CI(11.57,192.73),P=0.03],缩短住院时长[MD=-3.40,95%CI(-5.91,-0.90),P=0.008];对不良心血管事件的发生率无影响[MD=0.41,95%CI(0.15,1.08),P=0.07]。进一步亚组分析显示,实验组在心律失常、心力衰竭的发生率方面低于对照组(P<0.05),在复发心梗、心绞痛、死亡的发生率方面差异无统计学意义(P>0.05)。结论早期心脏康复程序能有效改善PCI术后患者心肺功能,提高其运动耐量,促进机体康复且不会增加不良心血管事件(MACE)的发生率。     

The Effect of Exit-Site Antibacterial Honey Versus Nasal Mupirocin Prophylaxis on the Microbiology and Outcomes of Peritoneal Dialysis-Associated Peritonitis and Exit-Site Infections: A Sub-Study of the Honeypot Trial

♦ Background:

The HONEYPOT study recently reported that daily exit-site application of antibacterial honey was not superior to nasal mupirocin prophylaxis for preventing overall peritoneal dialysis (PD)-related infection. This paper reports a secondary outcome analysis of the HONEYPOT study with respect to exit-site infection (ESI) and peritonitis microbiology, infectious hospitalization and technique failure.

♦ Methods:

A total of 371 PD patients were randomized to daily exit-site application of antibacterial honey plus usual exit-site care (N = 186) or intranasal mupirocin prophylaxis (in nasal Staphylococcus aureus carriers only) plus usual exit-site care (control, N = 185). Groups were compared on rates of organism-specific ESI and peritonitis, peritonitis- and infection-associated hospitalization, and technique failure (PD withdrawal).

♦ Results:

The mean peritonitis rates in the honey and control groups were 0.41 (95% confidence interval [CI] 0.32 – 0.50) and 0.41 (95% CI 0.33 – 0.49) episodes per patient-year, respectively (incidence rate ratio [IRR] 1.01, 95% CI 0.75 – 1.35). When specific causative organisms were examined, no differences were observed between the groups for gram-positive (IRR 0.99, 95% CI 0.66 – 1.49), gram-negative (IRR 0.71, 95% CI 0.39 – 1.29), culture-negative (IRR 2.01, 95% CI 0.91 – 4.42), or polymicrobial peritonitis (IRR 1.08, 95% CI 0.36 – 3.20). Exit-site infection rates were 0.37 (95% CI 0.28 – 0.45) and 0.33 (95% CI 0.26 – 0.40) episodes per patient-year for the honey and control groups, respectively (IRR 1.12, 95% CI 0.81 – 1.53). No significant differences were observed between the groups for gram-positive (IRR 1.10, 95% CI 0.70 – 1.72), gram-negative (IRR: 0.85, 95% CI 0.46 – 1.58), culture-negative (IRR 1.88, 95% CI 0.67 – 5.29), or polymicrobial ESI (IRR 1.00, 95% CI 0.40 – 2.54). Times to first peritonitis-associated and first infection-associated hospitalization were similar in the honey and control groups. The rates of technique failure (PD withdrawal) due to PD-related infection were not significantly different between the groups.

♦ Conclusion:

Compared with standard nasal mupirocin prophylaxis, daily topical exit-site application of antibacterial honey resulted in comparable rates of organism-specific peritonitis and ESI, infection-associated hospitalization, and infection-associated technique failure in PD patients.     

Disaster and subsequent healthcare utilization: a longitudinal study among victims, their family members, and control subjects

BACKGROUND: The impact of disasters on primary healthcare utilization is largely unknown. Moreover, it is often overlooked how disaster affects those closest to the primary victims, their family members. OBJECTIVE: The objective of this study was to examine the long-term effects of a catastrophic fire on primary healthcare utilization. RESEARCH DESIGN: We conducted a prospective, population-based cohort study covering 1 year pre- and 3 years postfire. Utilization data were extracted from primary care records. SUBJECTS: Subjects consisted of 286 disaster victims, 802 family members of disaster victims, 3722 community control subjects, and 10,230 patients from a national reference population. MEASURES: As outcome measures, we studied 1) the annual number of contacts in primary care and 2) the annual number of contacts for problems related to mental health. Determinants are injury characteristics of victims and bereavement. All analyses control for age, gender, and insurance status. RESULTS: Being an uninjured victim who witnessed the disaster increases the number of contacts by a factor of 1.55 during the first year postfire (95% confidence interval [CI], 1.35-1.78). Uninjured victims contact the family practitioner more often for mental health-related problems than adolescent community control subjects (incidence rate ratio [IRR], 4.54; 95% CI, 1.69-12.20). In adult family members, the loss of a child predicts overall utilization (IRR, 1.88; 95% CI, 1.35-2.63) and utilization for mental health (IRR, 8.69; 95% CI, 2.10-35.92) during the first year postfire. CONCLUSION: Attention should be paid to the primary care needs of bereaved individuals and those who have witnessed the disaster.     

Tram‐related trauma in Melbourne,Victoria

Objectives: To establish the incidence and pattern of injuries in patients presenting to hospital with tram‐related injuries. Methods: Data on tram‐related injury pertaining to 2001–2008 calendar years were extracted from three datasets: the population‐based Victorian State Trauma Registry for major trauma cases, the Victorian Emergency Minimum Dataset for ED presentations and the National Coroners' Information System for deaths. Incidence rates adjusted for the population of Melbourne, and trends in the incidence of tram‐related ED presentations and major trauma cases, were analysed and presented as incidence rate ratios (IRR). Results: There were 1769 patients who presented to ED after trauma related to trams in Melbourne during the study period. Of these, 107 patients had injuries classified as major trauma. There was a significant increase in the rate of ED presentations (IRR 1.03, P= 0.010) with falls (46%) the most commonly reported mechanism. Most falls occurred inside the trams. There was also a significant increase in the incidence rates of major trauma cases (IRR 1.12, P= 0.006) with pedestrians accounting for most major trauma cases. Conclusions: Most cases of trauma related to trams have minor injuries and are discharged following ED management. Primary prevention of falls in trams and the separation of pedestrians from trams are key areas requiring immediate improvement. In the face of increasing trauma associated with trams, continuing safety surveillance and targeted public safety messages are important to sustain trams as safe and effective mode of transport.     

Racial disparities in length of stay in hospice care by tumor stage in a large elderly cohort with non-small cell lung cancer

This study examined whether there are racial disparities for length of stay in hospice for patients with non-small cell lung cancer (NSCLC).We studied 53,626 deceased patients aged ≥66 years diagnosed with American Joint Committee on Cancer stages I-IV NSCLC identified from the Surveillance, Epidemiology, and End Results-Medicare linked data who used hospice services in the last six months before death, and died between 1 January 1991 and 31 December 2005. Median time (days) and percent length of stay in hospice, and multivariate incidence rate ratios (IRRs) with 95% confidence intervals (CIs) using zero-truncated negative binomial regression described relationships. In 2000-2005, most patients (64.1%) had <30 days, including those (30.2%) with <7 days length of stay in hospice care. After adjusting for confounders, the IRR for length of stay in hospice compared to whites was 38% increased for blacks (IRR = 1.38; 95% CI: 1.01-1.89), and almost three-fold increased for Hispanics (IRR = 2.91;95% CI: 1.15-7.37) at stages I-II. However, blacks at stages III-IV had slightly decreased use of hospice services (IRR = 0.91; 95% CI: 0.85-0.97). Length of stay decreased slightly among blacks diagnosed with late stage (III-IV) NSCLC in 2000-2005.The gap in disparity for length of stay in hospice has narrowed for ethnic minorities compared to whites, while some ethnic minorities had greater length of stay at early disease stage.     

Neighborhood Poverty and 9-1-1 Ambulance Contacts

Background: Neighborhood poverty is positively associated with frequency of 9-1-1 ambulance utilization, but it is unclear whether this association remains significant when accounting for variations in the severities and types of ambulance contacts. Methods: We merged EMS ambulance contact records in a single California county (n = 88,027) with data from the American Community Survey at the census tract level (n = 300). Using tract as a proxy for neighborhood and negative binomial regression as an analytical tool, we predicted 16 outcomes: any ambulance contacts, ambulance contacts stratified by three intervention severities, and ambulance contacts varied by 12 primary impression categories. For each model, we estimated the incident rate ratios for 10 percentage point increases in tract-level poverty while controlling for geographic patterns in race, citizenship, gender, age, emergency department proximity, population density, and population size. Results: Our study produced three major findings. First, tract-level poverty was positively associated with ambulance contacts (incident rate ratio [IRR] 1.45; 95% confidence interval [CI] 1.34 to 1.57). Second, poverty was positively associated with low severity contacts (IRR 1.48; 95% CI 1.35 to 1.61), medium severity contacts (IRR 1.38; 95% CI 1.28 to 1.49), and high severity contacts (IRR 1.40; 95% CI 1.30 to 1.51). Third, poverty was positively associated with 12 primary impression categories: abdominal (IRR 1.48; 95% CI 1.36 to 1.61), altered level of consciousness (IRR 1.37; 95% CI 1.25 to 1.50), cardiac (IRR 1.28; 95% CI 1.14 to 1.42), overdose/intoxication (IRR 1.59; 95% CI 1.40 to 1.81), pain (IRR 1.56; 95% CI 1.41 to 1.73), psych/behavioral (IRR 1.50; 95% CI 1.34 to 1.67), respiratory (IRR 1.42; 95% CI 1.29 to 1.56) seizure (IRR 1.52; 95% CI 1.38 to 1.68), stroke (IRR 1.14; 95% CI 1.01 to 1.28), syncope/near syncope (IRR 1.23; 95% CI 1.12 to 1.36), trauma (IRR 1.44; 95% CI 1.31 to 1.58), and general weakness (IRR 1.31; 95% CI 1.20 to 1.42). Conclusion: Our study suggests poverty is a positive, strong, and enduring predictor of ambulance contacts at the neighborhood level. The relationship between neighborhood poverty and ambulance utilization should be considered at multiple levels of EMS decision making