Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial

Jean-Jacques Parienti, MD, DTM&H; Marina Thirion, MD; Bruno Mégarbane, MD, PhD; Bertrand Souweine, MD, PhD; Abdelali Ouchikhe, MD; Andrea Polito, MD; Jean-Marie Forel, MD; Sophie Marqué, MD; Benoît Misset, MD; Norair Airapetian, MD; Claire Daurel, MD; Jean-Paul Mira, MD, PhD; Michel Ramakers, MD; Damien du Cheyron, MD, PhD; Xavier Le Coutour, MD; Cédric Daubin, MD; Pierre Charbonneau, MD; for Members of the Cathedia Study Group

JAMA. 2008;299(20):2413-2422.

Context  Based on concerns about the risk of infection, the jugular site is often preferred over the femoral site for short-term dialysis vascular access.

Objective  To determine whether jugular catheterization decreases the risk of nosocomial complications compared with femoral catheterization.

Design, Setting, and Patients  A concealed, randomized, multicenter, evaluator-blinded, parallel-group trial (the Cathedia Study) of 750 patients from a network of 9 tertiary care university medical centers and 3 general hospitals in France conducted between May 2004 and May 2007. The severely ill, bed-bound adults had a body mass index (BMI) of less than 45 and required a first catheter insertion for renal replacement therapy.

Intervention  Patients were randomized to receive jugular or femoral vein catheterization by operators experienced in placement at both sites.

Main Outcome Measures  Rates of infectious complications, defined as catheter colonization on removal (primary end point), and catheter-related bloodstream infection.

Results  Patient and catheter characteristics, including duration of catheterization, were similar in both groups. More hematomas occurred in the jugular group than in the femoral group (13/366 patients [3.6%] vs 4/370 patients [1.1%], respectively; P = .03). The risk of catheter colonization at removal did not differ significantly between the femoral and jugular groups (incidence of 40.8 vs 35.7 per 1000 catheter-days; hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.62-1.16; P = .31). A prespecified subgroup analysis demonstrated significant qualitative heterogeneity by BMI (P for the interaction term < .001). Jugular catheterization significantly increased incidence of catheter colonization vs femoral catheterization (45.4 vs 23.7 per 1000 catheter-days; HR, 2.10; 95% CI, 1.13-3.91; P = .017) in the lowest tercile (BMI <24.2), whereas jugular catheterization significantly decreased this incidence (24.5 vs 50.9 per 1000 catheter-days; HR, 0.40; 95% CI, 0.23-0.69; P < .001) in the highest tercile (BMI >28.4). The rate of catheter-related bloodstream infection was similar in both groups (2.3 vs 1.5 per 1000 catheter-days, respectively; P = .42).

Conclusion  Jugular venous catheterization access does not appear to reduce the risk of infection compared with femoral access, except among adults with a high BMI, and may have a higher risk of hematoma.

Trial Registration  clinicaltrials.gov Identifier: NCT00277888

     

Pediatricians' Perspectives on Indoor Tanning

This report presents results from an online survey of New York State pediatricians regarding their counseling habits and attitudes toward indoor tanning among adolescents, as well as their awareness of current legislation that restricts youth access to tanning beds.     

Falsely elevated intraocular pressure due to increased central corneal thickness

· Purpose: To evaluate whether ocular hypertensive subjects have a higher central corneal thickness than other individuals. · Methods: In this prospective study, 48 subjects with ocular hypertension, 63 patients with open-angle glaucoma, 56 nonglaucomatous patients with diabetes mellitus, and 106 control subjects were evaluated. Corneal thickness was measured by ultrasound pachymetry, and intraocular pressure was determined by Goldmann applanation tonometry. · Results: Central corneal thickness was significantly higher in the ocular hypertensive subjects, mean ±S.D., 592±39 μm, than in the patients with glaucoma (536±34 μm), the nonglaucomatous patients with diabetes mellitus (550±31 μm), and the normal subjects (545±33 μm), P<0.001. The three latter groups did not vary significantly in central corneal thickness, P>0.05. · Conclusion: In some individuals with increased transcorneal measurements of intraocular pressure, the cornea is thicker than in subjects with normal intraocular pressure readings or patients with glaucoma. It suggests that in ocular hypertensive subjects, corneal pachymetry should be performed to rule out an abnormally thick cornea as a reason for falsely high measurements of intraocular pressure. Received: 14 April 1998 Revised version received: 10 July 1998 Accepted: 23 July 1998     

Intermittent oral cyclosporin for recurrent herpes simplex-associated erythema multiforme

Recurrent erythema multiforme is one of three distinct clinical subtypes of erythema multiforme. We present a 42-year-old man with a 10-year history of recurrent herpes simplex virus-induced erythema multiforme. Our patient was debilitated by the frequency of his attacks and the associated pain, for which he often required leave from work. The frequency, duration and morbidity of the attacks were poorly controlled using oral prednisone and oral aciclovir. Three episodes of his recurrent herpes simplex virus-induced erythema multiforme were treated with intermittent oral cyclosporin. Oral cyclosporin rapidly reduced his symptoms and led to rapid resolution of his erythema multiforme, provided the cyclosporin was commenced on day 1 or 2 of the erythema multiforme episode. Consequently, his quality of life has dramatically improved. We recommend the use of intermittent oral cyclosporin for recurrent, debilitating episodes of erythema multiforme.     

Therapeutic Options for the Treatment of Tinea Capitis Caused by Trichophyton Species: Griseofulvin Versus the New Oral Antifungal Agents, Terbinafine, Itraconazole, and Fluconazole

Tinea capitis is a relatively common fungal infection of childhood. Griseofulvin has been the mainstay of management. However, newer oral antifungal agents are being used more frequently. A multicenter, prospective, randomized, single-blinded, non-industry-sponsored study was conducted in centers in Canada and South Africa to determine the relative efficacy and safety of griseofulvin, terbinafine, itraconazole, and fluconazole in the treatment of tinea capitis caused by Trichophyton species. The regimens for treating tinea capitis were griseofulvin microsize 20 mg/kg/day x 6 weeks, terbinafine [> 40 kg, one 250 mg tablet; 20-40 kg, 125 mg (half of a 250 mg tablet); < 20 kg, 62.5 mg (one-quarter of a 250 mg tablet)] x 2-3 weeks, itraconazole 5 mg/kg/day x 2-3 weeks, and fluconazole 6 mg/kg/day x 2-3 weeks. Patients were asked to return at weeks 4, 8, and 12 from the start of the study. Griseofulvin was administered for 6 weeks and the final evaluation was at week 12. Terbinafine, itraconazole, and fluconazole were administered for 2 weeks and the patient evaluated 4 weeks from the start of therapy. At this time, if clinically indicated, one extra week of therapy was given. There were 200 patients randomized to four treatment groups (50 in each group). At the final evaluation at week 12, the number of evaluable patients were griseofulvin, 46; terbinafine, 48; itraconazole, 46; and fluconazole, 46. Patients who discontinued therapy or were lost to follow-up were griseofulvin, 1/3; itraconazole, 0/4; terbinafine, 0/4; and fluconazole, 0/4. The causative organisms were Trichophyton tonsurans and T. violaceum species. Patients were regarded as effectively treated at week 12 if there was mycologic cure and either clinical cure or only a few residual symptoms. Effective treatment was recorded in, intention to treat, griseofulvin (46 of 50, 92.0%), terbinafine (47 of 50, 94.0%), itraconazole (43 of 50, 86.0%), and fluconazole (42 of 50, 84.0%) (p=0.33). Adverse effects were reported only in the griseofulvin group (gastrointestinal effects in six patients). Discontinuation from therapy due to adverse effects occurred only in the griseofulvin group (nausea in one patient). For the treatment of tinea capitis caused by the Trichophyton species, in this study, griseofulvin given for 6 weeks is similar in efficacy to terbinafine, itraconazole, and fluconazole given for 2-3 weeks. Each of the agents has a favorable adverse-effects profile.     

Starch digestibility modulation significantly improves glycemic variability in type 2 diabetic subjects: A pilot study

Background and aimsIn type 2 diabetes (T2D) patients, the reduction of glycemic variability and postprandial glucose excursions is essential to limit diabetes complications, beyond HbA1c level. This study aimed at determining whether increasing the content of Slowly Digestible Starch (SDS) in T2D patients’ diet could reduce postprandial hyperglycemia and glycemic variability compared with a conventional low-SDS diet.Methods and resultsFor this randomized cross-over pilot study, 8 subjects with T2D consumed a controlled diet for one week, containing starchy products high or low in SDS. Glycemic variability parameters were evaluated using a Continuous Glucose Monitoring System.Glycemic variability was significantly lower during High-SDS diet compared to Low-SDS diet for MAGE (Mean Amplitude of Glycemic Excursions, p < 0.01), SD (Standard Deviation, p < 0.05), and CV (Coefficient of Variation, p < 0.01). The TIR (Time In Range) [140–180 mg/dL[ was significantly higher during High-SDS diet (p < 0.0001) whereas TIRs ≥180 mg/dL were significantly lower during High-SDS diet. Post-meals tAUC (total Area Under the Curve) were significantly lower during High-SDS diet.ConclusionOne week of High-SDS Diet in T2D patients significantly improves glycemic variability and reduces postprandial glycemic excursions. Modulation of starch digestibility in the diet could be used as a simple nutritional tool in T2D patients to improve daily glycemic control.Registration numberin clinicaltrials.gov: NCT 03289494.     

Focal nodular hyperplasia occurring after blunt abdominal trauma

Focal nodular hyperplasia of the liver is a benign neoplasm. The pathogenesis is unknown, but it was hypothesized that focal nodular hyperplasia may be a response to a vascular abnormality. We report on a case of focal nodular hyperplasia that developed in a young patient 1 year after a blunt hepatic injury.