Staphylococcus aureus infections after liver transplantation

Background

More data on the risk factors and outcomes after Staphylococcus aureus infections in liver transplantation are needed.

Methods

Liver recipients with S. aureus infections (cases) were retrospectively identified and compared to gender-, age-, and transplant type-matched (1:2) non-S. aureus-infected controls. Risk factors associated with S. aureus infections were identified by conditional logistic regression analysis.

Results

We evaluated 51 patients (median age 52?years). First S. aureus infections developed at a median time of 29?days after transplantation, with 52.94% of them in the first month; 88.24% were nosocomial, 41.18% were polymicrobial, and 47.06% were caused by methicillin-resistant S. aureus (MRSA). Surgical site infections represented 58.82% and bacteremia 23.53%. By univariate analysis, patients with S. aureus infections were intubated more frequently (odds ratio [OR] 26.92, 95% confidence interval [CI] 3.23?C3,504.15, p?=?0.0006), had a central line (OR 11.69, 95% CI 1.42?C95.9, p?=?0.02), or recent surgery (OR 26.92, 95% CI 3.23?C3,504.15, p?=?0.0006) compared with controls. By multivariate analysis, subjects who underwent surgery within 2?weeks prior to infection had a 26.9 times higher risk of developing S. aureus infection (95% CI 3.23?C3,504.15, p?=?0.0006); these results were adjusted for matched criteria. S. aureus infections did not affect graft or patient survival, but the study was not powered for such outcomes.

Conclusion

Only recent surgical procedure was found to be a significant independent risk factor for S. aureus infections after liver transplantation.     

Pathogen-Specific Risk of Celiac Disease Following Bacterial Causes of Foodborne Illness: A Retrospective Cohort Study

Background

The US CDC recently estimated over 2 million foodborne illnesses annually are caused by 4 major enteropathogens: non-typhoid Salmonella spp., Campylobacter spp., Shigella spp., and Yersinia enterocolitica. While recent data suggest functional gastrointestinal disorders are associated with these infections, studies linking foodborne illness to celiac disease (CD) are limited. We utilized a US Department of Defense medical encounter database to evaluate the risk of CD following select foodborne infections.

Methods

We identified subjects with acute gastroenteritis between 1998 and 2009 attributed to Salmonella (nontyphoidal) spp., Shigella spp., Campylobacter spp., or Y. enterocolitica and matched each with up to 4 unexposed subjects. Exposed and unexposed subjects were followed for incident CD diagnosis for their entire military record duration (or a minimum of 1 year). Relative risks were calculated using modified Poisson regression to determine the relationship between pathogen-attributable gastroenteritis and CD while controlling for covariates.

Results

A total of 1,753 pathogen-specific gastroenteritis cases (Campylobacter: 738; Salmonella: 624; Shigella: 376; Yersinia: 17) were identified and followed for a median of 3.8 years. The incidence (per 100,000 person-years) of CD was 0.05. We found a suggested risk of CD after Campylobacter, but not other foodborne infection etiologies.

Conclusions

These data support a previous study demonstrating increased risk of CD following Campylobacteriosis and highlight the need for additional research into how infections might trigger CD in susceptible individuals.     

The Influence of Etiologic Factors on Clinical Outcome in Patients with Peptic Ulcer Bleeding

Background

Peptic ulcer bleeding remains an important cause of morbidity and mortality.

Aim

The aim of this study was to evaluate the prevalence of non-steroidal anti-inflammatory drugs (NSAID) use, Helicobacter pylori infection and non-H. pylori?Cnon-NSAIDs causes of peptic ulcer bleeding and to identify the predictive factors influencing the rebleeding rate and in-hospital mortality in patients with bleeding peptic ulcer.

Methods

A total of 1,530 patients with endoscopically confirmed peptic ulcer bleeding were evaluated consecutively between January 2005 and December 2009. The 30-day mortality and clinical outcome were related to patient??s demographic data, endoscopic and clinical characteristics.

Results

The age-standardized 1-year cumulative incidence for peptic ulcer bleeding was 40.4 cases/100,000 people. The proportion of patients over 65?years increased from 45.7?% in 2005 to 61.4?% in 2009 (p?=?0.007). Overall 30-day mortality rate was 4.6?%, not significantly different for conservatively and surgically treated patients (4.9 vs. 4.1?%, p?=?0.87). Mortality was significantly higher in patients over 65?years of age and those with in-hospital bleeding recurrence. Patients with non-H. pylori?Cnon-NSAID idiopathic ulcers had significantly higher 30-day mortality rate than those with H. pylori ulcers and NSAID?CH. pylori ulcers (7.1 vs. 0 vs. 0.8?%, p?=?0.001 and p?=?0.007, respectively). There was no statistically significant difference between patients with NSAID ulcers and non-H. pylori?Cnon-NSAID idiopathic ulcers in terms of 30-day mortality rate (5.3 vs. 7.1?%, p?=?0.445).

Conclusion

The incidence of peptic ulcer bleeding has not changed over a 5-year observational period. The overall 30-day mortality was positively correlated to older age, underlying comorbid illnesses, in-hospital bleeding recurrence and the absence of H. pylori infection.     

Early Oral Antibiotic Switch Compared with Conventional Intravenous Antibiotic Therapy for Acute Cholangitis with Bacteremia

Background

Biliary decompression with antibiotic therapy is the mainstay treatment for acute cholangitis with bacteremia. A few studies have been conducted to investigate the optimal duration and route of antibiotic therapy in biliary tract infection with bacteremia.

Methods

Patients with acute cholangitis with bacteremia who achieved successful biliary drainage were randomly assigned to an early oral antibiotic switch group (group A, n = 29) and a conventional intravenous antibiotics group (group B, n = 30). Patients were discharged when they were afebrile over 2 days after oral antibiotic switch and showed consecutive improvement in the laboratory index. They were followed up and assessed at 30 days after diagnosis to evaluate the eradication of bacteria, recurrence of acute cholangitis, and 30-day mortality rate.

Results

There were no statistically significant differences between the two groups in baseline characteristics, clinical and laboratory index, severity of acute cholangitis, bacteria isolated from blood cultures, and clinical outcomes. The rate of eradication of bacteria was 93.1 % in group A and 93.3 % in group B, respectively (p = 0.97). Using non-inferiority tests, the rate of eradication of bacteria in group A was not inferior to that in group B (95 % CI ?0.13 to 0.14, p = 0.97). There was no statistically significant difference in the recurrence of acute cholangitis and a 30-day mortality rate between the two groups.

Conclusions

Early switch to oral antibiotic therapy following adequate biliary drainage for treatment of acute cholangitis with bacteremia was not inferior to conventional 10-day intravenous antibiotic therapy.     

Prevalence of syphilis infection in different tiers of female sex workers in China: implications for surveillance and interventions

Background

Streptococcus pneumoniae is a leading cause of invasive infection in young children causing morbidity and mortality. Active surveillance systems of invasive pneumococcal disease (IPD) are recommended worldwide. The aim of this study was to estimate the current incidence of IPD and to describe the serotype distribution and the antimocrobial susceptibility of S. pneumoniae isolates in children aged less than 5?years residing in North-West Lombardy, Italy.

Methods

A twelve-month prospective active surveillance system recruited all children aged less than 5?years admitted for suspicion of IPD at emergency room of ten hospitals located in the monitored area. Blood samples were taken in all participants for confirmation of IPD based on isolation of S. pneumoniae from blood. Pneumococcal meningitis and sepsis were additionally confirmed by cerebrospinal fluid analysis. Serotyping and antimicrobial susceptibility testing were performed on isolates from blood.

Results

A total of 15 confirmed cases of IPD were detected among 135 recruited children, including pneumonia (n?=?8), bacteremia (n?=?4), sepsis (n?=?2) and meningitis (n?=?1). The annual IPD incidence rate was 50.0/100,000 (95%CI, 30.5-82.5/100,000). Incidence was 58.3/100,000 (28.8-120.1/100,000) among children aged less than 2?years and 44.4/100,000 (22.9-87.5/100,000) among children aged 2?C4?years. Thirteen isolates were typified. The most common serotype was 19A (23.1%) that together with serotypes 1, 7F and 19F accounted for 69.2% of typified isolates. Serotypes 14, 23F, 12B and 15C were also identified. The 7- and 13-valent pneumococcal conjugate vaccines covered respectively 30.8% and 84.6% of typified IPD cases. One isolate (serotype 15C) was penicillin-resistant and caused meningitis.

Conclusions

The inclusion of the 13-valent pneumococcal conjugate vaccine in immunization programs of young children might be considered to reduce incidence and morbidity of invasive pneumococcal disease in this surveilled population.     

Cryptosporidium gastroenteritis in Egyptian children with acute lymphoblastic leukemia: magnitude of the problem

Purpose

Cryptosporidium species is considered to be an important cause of significant morbidity in immunocompromised individuals. A prospective case?Ccontrol study of sporadic diarrhea due to Cryptosporidium infection was conducted on children with acute lymphoblastic leukemia (ALL).

Methods

Forty children with ALL on maintenance chemotherapy according to the Berlin?CFrankfurt?CMunster (BFM-90) protocol and 45 sex- and age-matched controls were studied. The ALL group included 25 patients with acute diarrhea and 15 without diarrhea, and the control group included 30 children with acute diarrhea and 15 without. Collected stool specimens were examined using modified Ziehl?CNeelsen (MZN) and modified trichrome stains. Serum Cryptosporidium Parvum immunoglobulin G (IgG) antibodies were detected by enzyme-linked immunosorbent assay.

Results

Cryptosporidium oocysts, pathogenic Gram-negative organisms, Giardia lamblia, and Entamoeba histolytica were identified in the stool samples (fecal specimens) of six (24%), eight (32%), four (16%), and two (8%), respectively, of the 25 patients with ALL and actute diarrhea and in one (3%), two (6.5%), six (20%), and five (16.5%), respectively, of the 30 control patients with diarrhea. Serum IgG antibodies were positive in four of the six ALL patients and in one of the control group patients with Cryptosporidium diarrhea who tested positive for oocysts in the stool. Diarrhea duration and severity were greater in ALL patients with stool-positive Cryptosporidium oocysts than in those with non-Cryptosporidium-positive diarrhea (p?<?0.000).

Conclusions

Cryptosporidium infection should be considered in children with ALL presenting with prolonged or severe watery diarrhea during chemotherapy, especially those treated with methotrexate and 6-mercaptopurine. Since Cryptosporidium is not routinely tested for in stool examination, a MZN stain is recommended.     

Sleep of children living in institutional care facilities

Purpose

To describe sleep patterns and problems among institutionalized children.

Methods

In this cross-sectional study, the caregivers of 118 children, aged 4?C12?years from six institutional care facilities completed the Children??s Sleep Habits Questionnaire (CSHQ).

Results

The mean (±SD) of night bedtime was 21:05?±?2:52, mean morning wake-up time was 06:58?±?0:31, mean total sleep duration was 10?±?1.1?h, and mean night-sleep duration was 9.5?±?0.9?h. The percentage of children who took a daytime nap was 34.7% (n?=?41) and the mean duration of nap was 0.5?±?0.7?h. The most frequently reported sleep problems were bedtime resistance, daytime sleepiness and night awakening. Children with bedtime at or after 9?PM, night-sleep duration less than 10?h and daytime napping had more disturbed sleep.

Conclusions

Sleep problems are common among this sample of institutionalized children.     

Levels and Variation in Overuse of Fecal Occult Blood Testing in the Veterans Health Administration

BACKGROUND

Policy-makers have called for efforts to reduce overuse of cancer screening tests, including colorectal cancer screening (CRCS). Overuse of CRCS tests other than colonoscopy has not been well documented.

OBJECTIVE

To estimate levels and correlates of fecal occult blood test (FOBT) overuse in a national Veterans Health Administration (VHA) sample.

DESIGN

Observational

PARTICIPANTS

Participants included 1,844 CRCS-eligible patients who responded to a 2007 CRCS survey conducted in 24 VHA facilities and had one or more FOBTs between 2003 and 2009.

MAIN MEASURES

We combined survey data on race, education, and income with administrative data on region, age, gender, CRCS procedures, and outpatient visits to estimate overuse levels and variation. We coded FOBTs as overused if they were conducted <10?months after prior FOBT, <9.5?years after prior colonoscopy, or <4.5?years after prior barium enema. We used multinomial logistic regression models to examine variation in overuse by reason (sooner than recommended after prior FOBT; sooner than recommended after colonoscopy, barium enema, or a combination of procedures), adjusting for clustering of procedures within patients, and patients within facilities.

KEY RESULTS

Of 4,236 FOBTs received by participants, 885 (21?%) met overuse criteria, with 323 (8?%) sooner than recommended after FOBT, and 562 (13?%) sooner than recommended after other procedures. FOBT overuse varied across facilities (9?C32?%, p?<?0.0001) and region (12?C23?%, p?<?.0012). FOBT overuse after prior FOBT declined between 2003 and 2009 (8?%?C5?%, p?=?.0492), but overuse after other procedures increased (11?C19?%, p?=?.0002). FOBT overuse of both types increased with number of outpatient visits (OR 1.15, p?<?0.001), but did not vary by patient demographics. More than 11?% of overused FOBTs were followed by colonoscopy within 12?months.

CONCLUSIONS

Many FOBTs are performed sooner than recommended in the VHA. Variation in overuse by facility, region, and outpatient visits suggests addressing FOBT overuse will require system-level solutions.     

Pharyngeal airway in children with sleep-disordered breathing in relation to head posture

Purpose

The aim of this study was to compare the pharyngeal airway size in different cranio-cervical postures in children with sleep-disordered breathing (SDB) and asymptomatic control children. We tested the hypothesis that the site of the most constricted pharyngeal airway in SDB children is not affected by head posture.

Methods

The study group comprised 29 children (14 boys, 15 girls, mean age 7.3?±?1.37?years, range 4.8?C9.8?years) with SDB. A control group of 29 age- and gender-matched healthy children was recruited. The pharyngeal airway of the children was imaged with a low-field 0.23-T open-configuration magnetic resonance imaging scanner in three different head postures: neutral, extension, and flexion. Inter-group differences in pharyngeal variables were analyzed using two-sided paired t test and intra-group differences using Bonferroni and ?idak correlations for multiple comparisons.

Results

Nasopharyngeal airway was not affected by head posture. Head extension had no significant effect on the most constricted retropalatal airway in the SDB group, but it increased the hypopharyngeal airway (P?=?0.000) significantly when compared to neutral head posture. The hypopharyngeal airway increased more in the SDB group than in the asymptomatic children (P?=?0.031). The retropalatal oropharynx was on the whole significantly narrower in the SDB children compared with the controls in all head postures (neutral P?=?0.000, extended P?=?0.001, flexed P?=?0.000).

Conclusions

Head posture is an important factor in maintaining airway patency. We suggest that the effectiveness of neuromuscular compensation may be compromised in constricted retropalatal airways. Instead, the hypopharyngeal airway is enlarged suggesting possible neuromuscular compensation for oropharyngeal narrowing in children with SDB.     

Serial interferon-gamma release assays after chemoprophylaxis in a tuberculosis outbreak cohort

Purpose

Interferon-gamma release assay (IGRA) results have been suggested as a surrogate marker of treatment response in latent tuberculosis infection (LTBI). However, data have not been consistent, and most previous studies focused on participants taking isoniazid prophylaxis. The aim of this study was to elucidate the changes in the IGRA results in patients who underwent chemoprophylaxis with isoniazid and rifampicin daily for 3?months.

Methods

In a TB outbreak cohort, 26 asymptomatic close contacts with normal chest radiographs and positive QuantiFERON-TB Gold In-Tube assay (QFT-GIT) results were recruited. These patients were treated with isoniazid and rifampicin daily for 3?months. The QFT-GIT was repeated at 3 and 6?months following treatment initiation.

Results

Compared with the initial QFT-GIT results (3.59?±?3.39?IU/mL), the interferon-gamma (IFN-??) levels had decreased significantly at 6?months (0.84?±?1.14?IU/mL; P?=?0.005), but not at 3?months (3.58?±?3.64?IU/mL; P?=?0.98). Reversions occurred in seven (26.9?%) patients at 3?months and in an additional two participants at 6?months; a total of nine participants (34.6?%) had reversions. Recent conversion was associated with reversion of the test results (odds ratio?26.3, 95?% confidence interval?3.04?C226.6).

Conclusion

Chemoprophylaxis with isoniazid and rifampicin generally decreased IFN-?? levels among tuberculosis contacts. However, only a small portion of participants achieved reversion.     

Updated survival analysis in patients with stage IIIB or IV non-small-cell lung cancer receiving BLP25 liposome vaccine (L-BLP25): phase IIB randomized, multicenter, open-label trial

Purpose

To present an updated survival analysis of an open-label, parallel-group, phase IIB trial of BLP25 liposome vaccine (L-BLP25) in patients with stage IIIB or IV non-small-cell lung cancer (NSCLC).

Methods

Patients were randomized to either L-BLP25 plus best supportive care (BSC) or BSC alone. Patients in the L-BLP25 arm received subcutaneous vaccinations of L-BLP25 930???g weekly for 8?weeks, followed by maintenance vaccinations at 6-week intervals.

Results

Median survival time was 4.2?months longer in patients receiving L-BLP25 plus BSC (n?=?88) than in those receiving BSC alone (n?=?83; 17.2?months vs. 13.0?months, respectively; hazard ratio [HR] 0.745, 95% confidence interval [CI] 0.533?C1.042). The 3-year survival rate was 31% in patients receiving L-BLP25 plus BSC and 17% in those receiving BSC (P?=?0.035). In the stratified subset of patients with stage IIIB loco-regional (LR) disease, median survival time was 17.3?months longer in patients receiving L-BLP25 plus BSC (n?=?35) than in those receiving BSC (n?=?30; 30.6?months vs. 13.3?months, respectively; HR 0.548, 95% CI 0.301?C0.999). In this subgroup, 3-year survival was 49% in patients receiving L-BLP25 plus BSC and 27% in those receiving BSC (P?=?0.070).

Conclusions

Confirming the initial results, further follow-up continues to show that survival time for patients with stage IIIB/IV NSCLC was longer with L-BLP25 plus BSC compared with BSC alone, with the greatest difference seen in patients with stage IIIB LR disease.     

Incidence of Bacteremia Following Bronchoscopy with Argon Plasma Coagulation: A Prospective Study

Background

This evaluation was undertaken to determine the incidence of bacteremia and infectious complications associated with argon plasma coagulation (APC) procedures.

Methods

Consecutive patients undergoing bronchoscopy with APC for treatment of endobronchial lesions were studied. Venesection was performed for blood cultures within 60 s of the APC procedure. APC catheter washings were cultured. Patients with positive blood cultures were reviewed immediately. All patients underwent clinical review 1 and 12 weeks after APC.

Results

Forty-two patients underwent 44 APC procedures. Their mean age was 66 ± 12 years. One case (2.3 %) had bacteremia with Acinetobacter lwolfii. APC catheter washing culture was positive in 14 (31.8 %) procedures. No patient had clinical features suggesting infection and there were no complications. Phone review after 1 week revealed no complications. After 3 months, 8 (18 %) had died, all related to advanced lung malignancy and not to the APC procedure.

Conclusions

APC does not appear to increase the risk of bacteremia compared to airway insertion of the bronchoscope. Although contamination of the APC catheter with oropharyngeal commensal bacteria is common, clinically significant infection following the APC procedure is rare.     

Association of exposure to diabetes in utero with adiposity and fat distribution in a multiethnic population of youth: the Exploring Perinatal Outcomes among Children (EPOCH) Study

Aims/hypothesis

To evaluate whether exposure to maternal gestational diabetes (GDM) is associated with adiposity and fat distribution in a multiethnic population of children.

Methods

Retrospective cohort study of 82 children exposed to maternal GDM and 379 unexposed youths 6?C13?years of age with measured BMI, waist circumference, skinfold thickness, and visceral and subcutaneous abdominal fat.

Results

Exposure to maternal GDM was associated with higher BMI (p?=?0.02), larger waist circumference (p?=?0.004), more subcutaneous abdominal fat (p?=?0.01) and increased subscapular to triceps skinfold thickness ratio (p?=?0.01) in models adjusted for age, sex, race/ethnicity and Tanner stage. Adjustment for socioeconomic factors, birthweight and gestational age, maternal smoking during pregnancy and current diet and physical activity did not influence associations; however, adjustment for maternal pre-pregnancy BMI attenuated all associations.

Conclusions/interpretation

Exposure to maternal GDM is associated with increased overall and abdominal adiposity, and a more central fat distribution pattern in 6- to 13-year-old youths from a multi-ethnic population, providing further support for the fetal overnutrition hypothesis.     

agr dysfunction and persistent methicillin-resistant Staphylococcus aureus bacteremia in patients with removed eradicable foci

Purpose

Persistent Staphylococcus aureus bacteremia (SAB) has been observed in patients with eradicated foci, but there are few studies of the risk factors and clinical outcomes of persistent bacteremia. This study determined the risk factors for persistent methicillin-resistant S. aureus (MRSA) bacteremia in patients without retained eradicable foci, including genotypic characteristics.

Methods

All adult SAB patients were investigated between 2008 and 2010. Persistent bacteremia was defined as bacteremia lasting >7 days after treatment and patients were monitored prospectively. The study included patients without retained eradicable foci, e.g., removed prosthetic devices and intravenous catheters removed after diagnosis, and those without metastatic infections.

Results

Persistent bacteremia occurred in 36 % (31/87) SAB patients with eradicated foci. There were no significant differences in successful defervescence (2.0 vs. 2.0 days, P = 0.55) and total length of hospital stay after bacteremia in the persistent bacteremia group and resolved bacteremia group (P = 0.32). The difference in MRSA bacteremia-related 30-day mortality with persistent bacteremia and resolved bacteremia was not significant (P = 0.12). However, agr dysfunction was higher in persistent bacteremia patients (94 %) than those with resolved bacteremia (75 %, P = 0.03). Multivariate analysis using a logistic regression model found that only agr dysfunction [odds ratio (OR) 4.83, 95 % confidence interval (CI) 1.02–22.89, P = 0.04] was an independent risk factor for persistent bacteremia.

Conclusions

This study suggests that persistent bacteremia with eradicated foci might not adversely affect the outcome for MRSA bacteremia patients. agr dysfunction in S. aureus was significantly associated with persistent bacteremia.     

Microvascular autoregulation in children and adolescents with type 1 diabetes mellitus

Aims/hypothesis

Deterioration of microvascular function may have an early onset in individuals with type 1 diabetes mellitus. We hypothesised that microvascular autoregulation is impaired in children with type 1 diabetes and can be detected non-invasively by postocclusive reactive hyperaemia (PORH).

Methods

Microvascular autoregulation was assessed in 58 children with type 1 diabetes and 58 age- and sex-matched healthy controls by PORH using laser Doppler fluxmetry. Baseline perfusion, biological zero (defined as a ‘no flow’ laser Doppler signal during suprasystolic occlusion), peak perfusion following occlusion, time to peak and recovery time (time until baseline perfusion is resumed) were recorded and compared between the groups.

Results

Peak perfusion was higher in children with type 1 diabetes than in healthy controls (1.7?±?0.93?AU [arbitrary units] vs 1.29?±?0.46?AU; p?=?0.004), and biological zero was lower in children with type 1 diabetes vs controls (0.14?±?0.04?AU vs 0.19?±?0.04?AU; p?Conclusions/interpretation PORH reveals impaired microvascular autoregulation in children with type 1 diabetes. The higher peak perfusion might reflect a decline in the vasoconstrictive ability of arteriolar smooth muscle cells upstream of capillary beds in children with type 1 diabetes.     

Long-term effectiveness of enzyme replacement therapy in Fabry disease: results from the NCS-LSD cohort study

Objectives

To determine the effectiveness of enzyme replacement therapy (ERT) for adults and children with Fabry disease.

Design

Cohort study including prospective and retrospective clinical data. Age- and gender-adjusted treatment effects were estimated using generalised linear mixed models. Treated patients contributed data before and during treatment and untreated patients contributed natural history data.

Participants

Consenting adults (N?=?289) and children (N?=?22) with a confirmed diagnosis of Fabry disease attending a specialist Lysosomal Storage Disorder treatment centre in England. At recruitment 211 adults and seven children were on ERT (range of treatment duration, 0 to 9.7 and 0 to 4.2 years respectively).

Outcome measures

Clinical outcomes chosen to reflect disease progression included left ventricular mass index (LVMI); proteinuria; estimated glomerular filtration rate (eGFR); pain; hearing and transient ischaemic attacks (TIA)/stroke.

Results

We found evidence of a statistically significant association between time on ERT and a small linear decrease in LVMI (p?=?0.01); a reduction in the risk of proteinuria after adjusting for angiotensin-converting enzyme inhibitors and angiotensin receptor blockers (p?p?=?0.01 and p?Conclusions These data provide some further evidence on the long-term effectiveness of ERT in adults with Fabry disease, but evidence of effectiveness could not be demonstrated in children.     

Impact of Information Leaflets on Behavior of Patients with Gastroenteritis or Tonsillitis: A Cluster Randomized Trial in French Primary Care

OBJECTIVE

To assess the impact of four patient information leaflets on patients’ behavior in primary care.

DESIGN

Cluster randomized multicenter controlled trial between November 2009 and January 2011.

PARTICIPANTS

French adults and children consulting a participating primary care physician and diagnosed with gastroenteritis or tonsillitis. Patients were randomized to receive patient information leaflets or not, according to the cluster randomization of their primary care physician.

INTERVENTION

Adult patients or adults accompanying a child diagnosed with gastroenteritis or tonsillitis were informed of the study. Physicians in the intervention group gave patients an information leaflet about their condition. Two weeks after the consultation patients (or their accompanying adult) answered a telephone questionnaire on their behavior and knowledge about the condition.

MAIN MEASURES

The main and secondary outcomes, mean behavior and knowledge scores respectively, were calculated from the replies to this questionnaire.

RESULTS

Twenty-four physicians included 400 patients. Twelve patients were lost to follow-up (3 %). In the group that received the patient information leaflet, patient behavior was closer to that recommended by the guidelines than in the control group (mean behavior score 4.9 versus 4.2, p?<?0.01). Knowledge was better for adults receiving the leaflet than in the control group (mean knowledge score 4.2 versus 3.6, p?<?0.01). There were fewer visits for the same symptoms by household members of patients given leaflets (23.4 % vs. 56.2 %, p?<?0.01).

CONCLUSION

Patient information leaflets given by the physician during the consultation significantly modify the patient’s behavior and knowledge of the disease, compared with patients not receiving the leaflets, for the conditions studied.     

Risk factors and consequences of excessive autonomic activation during sleep in children

Purpose

The aim of this study was to assess risk factors for excessive autonomic activation during sleep (EAAS) and its association with sleep problems, impaired behavior, and poor academic performance in primary school children.

Methods

Data from a community-based study on 997 primary school children were used. Based on nocturnal home pulse oximetry, autonomic activation during sleep was defined as a pulse rate increase by more than 20%. Children with ??35.9 autonomic activations per hour (i.e., ??the 95^th centile) were classified as suffering from EAAS and compared with controls. Sleep problems, impaired behavior, and academic performance were assessed by parental questionnaires and analysis of school reports.

Results

According to the abovementioned definition, EAAS was diagnosed in 52 children (67% male). Risk factors for EAAS were male gender (odds ratio [95% confidence interval]: 2.06 [1.14?C3.72]) and presence of symptoms of sleep-disordered breathing (3.48 [1.29?C9.43]). Children with EAAS had a higher prevalence of hyperactive behavior (39.2% vs. 26.0%; p?=?0.05) and enuresis (5.8% vs. 0.8%; p?=?0.017) but not of poor academic performance. The association with hyperactive behavior was confirmed in a subsample (n?=?119) using the Strengths and Difficulties Questionnaire. Mean (SD) score of the hyperactive?Cinattentive scale was 4.5 (2.8) for EAAS and 3.4 (2.7) for non-EAAS (p?=?0.04).

Conclusion

EAAS may be a marker of sleep disruption in children and may predict the occurrence of enuresis and hyperactive behavior.     

Tuberculosis mortality: patient characteristics and causes

Background

Resistance among Klebsiella pneumoniae to most antibiotics is on the rise. Tigecycline has been considered as one of the few therapeutic options available to treat multidrug-resistant bacteria. We investigated the clinical and microbiological characteristics of tigecycline non-susceptible K. pneumoniae bacteremia.

Methods

Adult patients with tigecycline non-susceptible K. pneumoniae bacteremia at a medical center in Taiwan over a 3-year period were enrolled. K. pneumoniae isolates were identified by the E-test using criteria set by the US Food and Drug Administration (FDA). Data on the clinical features of patients were collected from medical records. Genes for β-lactamases, antimicrobial susceptibilities and pulsed-field gel electrophoresis (PFGE) results were determined for all isolates.

Results

Of 36 patients, 27 had nosocomial bacteremia. Overall 28-day mortality was 38.9%. The MIC₅₀ and MIC₉₀ of tigecycline were 6 and 8 mg/L, respectively. No carbapenemase was detected among the 36 isolates. Twenty isolates carried extended spectrum β-lactamases and/or DHA-1 genes. No major cluster of isolates was found among the 36 isolates by PFGE. Intensive care unit onset of tigecycline non-susceptible Klebsiella pneumoniae bacteremia was the only independent risk factor for 28-day mortality.

Conclusions

The high mortality of patients with tigecycline non-susceptible K. pneumoniae bacteremia may suggest a critical problem. Further study to identify the possible risk factors for its development and further investigation of this type of bacteremia is necessary.