Central venous pressure after coronary artery bypass surgery: Does it predict postoperative mortality or renal failure?

Objective

Although hemodynamic monitoring is often performed after coronary artery bypass grafting (CABG), the role of monitoring postoperative central venous pressure (CVP) measurement as a predictor of clinical outcomes is unknown. As such, this study tests the hypothesis that postoperative CVP is predictive of operative mortality or renal failure.

Methods

This is an observational cohort study of detailed clinical data from 2390 randomly selected patients undergoing high-risk CABG or CABG/valve at 55 hospitals participating in the Society of Thoracic Surgeons' National Cardiac Surgery Database 2004-2005. Eligible patients underwent elective/urgent CABG with an ejection fraction less than 40% or elective/urgent CABG at 65 years or older with diabetes or a glomerular filtration rate less than 60 mL/min per 1.73 m². The exposure of interest is CVP monitoring in the intensive care unit after adult cardiac surgery. The primary outcome measure was correlation between postoperative CVP and inhospital/30-day mortality and renal failure, assessed as a continuous variable, both unadjusted and after adjusting for important clinical factors using logistic regression modeling.

Results

Mean age was 72 years, 54% of patients had diabetes mellitus, 49% were urgent procedures, and mean cardiopulmonary bypass time was 105 minutes. Patients' CVP 6 hours postoperation was strongly associated with inhospital and 30-day mortality: odds ratio (OR) of 1.5 (95% confidence interval [CI], 1.23-1.87) for every 5-mm Hg increase in CVP; P < .0001. This association remained significant after risk adjustment: adjusted OR of 1.44 (95% CI, 1.10-1.89); P < .01. A model adjusting for cardiac index also revealed increased incidence of mortality or renal failure: adjusted OR of 1.5 (95% CI, 1.28-1.86) for every 5-mm Hg increase in CVP; P < .0001.

Conclusions

Patients' CVP at 6 hours after CABG surgery was highly predictive of operative mortality or renal failure, independent of cardiac index and other important clinical variables. Future studies will need to assess whether interventions guided by postoperative CVP can improve patient outcomes.     

Comparison of intramuscular recombinant alpha interferon (rIFN-2A) with topical acyclovir for the treatment of first-episode herpes genitalis and prevention of recurrences.

Intramuscular recombinant alpha interferon (rIFN-2A; 9 million IU given for 5 days during a 9-day treatment period) was compared with topical acyclovir in a double-blind, placebo-controlled trial for the treatment of first-episode genital herpes simplex virus (HSV) infection and for subsequent alteration of the frequency of recurrences. rIFN-2A (within 96 h of onset of the first episode) was not superior to topical acyclovir in a well-matched group of 105 patients. The early use of rIFN-2A also did not alter the frequency or severity of genital HSV recurrences within either the first or second 6 months following therapy. Separate analyses by HSV type and by type of infection (primary versus nonprimary) did not change this conclusion. Furthermore, there was significant toxicity associated with rIFN-2A therapy. rIFN-2A is not indicated for the treatment of genital HSV infections.     

Incidence and repeat infection rates of Chlamydia trachomatis among male and female patients in an STD clinic: implications for screening and rescreening

BACKGROUND: Nucleic acid amplification tests permit widespread screening for Chlamydia trachomatis. However, the public health benefit of screening may be reduced by high chlamydia incidence and repeat infection rates. GOAL: To study chlamydia incidence and repeat infection among clients of a sexually transmitted disease (STD) clinic. STUDY DESIGN: A retrospective cohort study of all clients tested for chlamydia on two or more occasions during a 30-month period. RESULTS: Between January 1, 1997 and June 30, 1999, 3568 clients were tested on multiple occasions. Of these, 491 (13.8%) had positive test results at their first visit (baseline infections), and 385 (10.8%) had positive results at a subsequent visit (incident infections). The overall incidence was 11.7 per 100 person-years of follow-up evaluation (95% CI, 10.6-12.9). The incidence was significantly higher among those 25 years of age or younger (19.7/100 person-years; 95% CI, 17.3-22.2) than among older subjects (6.8/100 person-years, 95% CI, 5.7-7.9; relative hazard, 3.0; 95% CI, 2.5-3.7). The incidence of new infections among persons without a baseline infection was 10.0 per 100 person-years (95% CI, 8.8-11.2), whereas the incidence of repeat infections was 23.6 per 100 person-years (95% CI, 18.9-28.2; relative hazard, 2.4; 95% CI, 1.9-3.0), with repeat infections accounting for 26% of all incident infections. In the multivariate analysis, the factors associated with new infections included young age, black race, male gender, history of sexually transmitted disease, a new sex partner in the previous 30 days, and inconsistent condom use. The factors associated with repeat infection were younger age, nonuse of condoms, and no treatment after contact with a partner who had a diagnosis of chlamydia or a chlamydia-related condition, as measured at the initial visit. CONCLUSIONS: Among clients making multiple visits to the clinic, repeat infection rates were significantly higher than new infection rates, likely because of reexposure to untreated partners. These findings point to the need for more effective strategies to prevent chlamydia infection, including enhanced partner management services and rescreening.     

Comparative study of 5% permethrin cream and 1% lindane lotion for the treatment of scabies.

A multicenter, randomized, investigator-blind controlled trial was conducted to compare the safety and efficacy of a single, whole-body application of 5% permethrin cream with that of 1% lindane lotion for the treatment of scabies in 467 patients. At 14 +/- 3 days after treatment, the mean active lesion count decreased from pretreatment levels of 85 (range, 4 to 600) in both treatment groups to 14 (range, 0 to 133) in the permethrin group and to 15 lesions (range, 0 to 500) in the lindane group. At 28 +/- 7 days after treatment, complete resolution had occurred in 181 (91%) of 199 patients treated with permethrin and in 176 (86%) of 205 patients given lindane. Pruritis due to scabies persisted at 28 +/- 7 days in 14% of the permethrin group and in 25% of the lindane group. The most frequent adverse effects were new or increased pruritus and mild, transient burning or stinging; the latter was slightly more frequent following permethrin treatment and appeared to be related to severity of infestation. Because of a lower potential for neurologic toxicity, permethrin may be preferable to lindane for the treatment of scabies particularly in children.     

Anorectal gonorrhea in women. Is it more difficult to cure?

It is unclear whether anorectal gonorrhea in women is more difficult to cure than endocervical gonorrhea or whether anorectal test-of-cure cultures are always indicated. Using endocervical and anorectal test-of-cure cultures, the authors evaluated 1,124 women treated for culture-positive endocervical gonorrhea with a recommended regimen of ampicillin (n = 868), procaine penicillin G (n = 78), spectinomycin (n = 45), or tetracycline (n = 133). There were 35 failures (3.1%) among women with anogenital gonorrhea, including 11 (1.0%) among those with anorectal infection. Only eight failures (0.7%) were detected by anorectal culture alone. Although anorectal isolates of Neisseria gonorrhoeae obtained before treatment from women were significantly (P less than .05) less susceptible to tetracycline than were endocervical isolates (geometric mean MIC, 0.35 micrograms/ml vs. 0.21 micrograms/ml), there were no failures of treatment of anorectal infection when tetracycline was used. The authors conclude that anorectal infection in women is not more difficult to treat than endocervical infection. Because of the very high cost-per-case ratio, anorectal test-of-cure cultures in women should be accorded a low priority in a gonorrhea control program.     

Recent micturition does not affect the detection of urethral gonorrhoea

In 202 men with urethral gonorrhoea (176 symptomatic and 26 asymptomatic) who had modified Thayer-Martin cultures taken before and within five minutes after micturition there was complete agreement between results of the two cultures. Micturition did, however, temporarily eliminate the discharge in 100 (56.8%) and make interpretation of Gram-stained smears more laborious.     

Condyloma acuminatum of the oral cavity: a case report

A 24-year-old man developed condyloma acuminatum on his penis and on the upper lip of his mouth approximately three months after his girl friend was diagnosed and treated for vaginal warts. Cunnilingus was the postulated method of spread to the lip. Condyloma acuminatum should be considered among the many sexually transmitted infections that affect both anogenital and oral areas.