Utilization of hepatitis B core antibody-positive donor liver grafts

Background

The inclusion of hepatitis B core antibody-positive (HBcAb+) liver donors is a strategy utilized to increase organ availability. This study examined HBcAb+ transplantation practices to identify specific factors influencing outcomes.

Methods

Twenty-five HBcAb+ liver transplants were identified retrospectively among 868 adult transplants performed between 1 January 1997 and 31 December 2009. Twelve (48%) recipients had hepatitis C and five (20%) had hepatitis B. Patient and donor demographics, preoperative morbidity, transplant data and outcomes were examined. Statistical analysis was completed using Student''s t-test or the Kaplan–Meier method. A P-value of <0.05 was considered significant.

Results

There was no difference in age, body mass index or comorbidities between HBcAb+ liver recipients and control subjects. Model for End-stage Liver Disease (MELD) scores of >30 were significantly more frequent in HBcAb+ liver recipients (32% vs. 15%; P = 0.04). All patients received immunoglobulin and longterm antiviral therapy as prophylaxis against graft hepatitis B resurgence. No patients who received HBcAb+ livers developed hepatitis B infection on follow-up. Overall survival at 30 days, 1 year and 5 years in HBcAb+ liver recipients was 92%, 74% and 74%, respectively, compared with 96%, 89% and 76%, respectively, in the control group (P = not significant, log-rank test). All except one of the deaths in the HBcAb+ liver recipient group occurred within 90 days postoperatively and in patients with MELD scores >30.

Conclusions

The practice of transplanting HBcAb+ grafts incurs low risk for infection using current methods of prophylaxis. The highest mortality risk was in the early postoperative period, specifically in patients with very high MELD scores. This probably reflects the practice of using positive serology grafts in emergent situations.     

Sex, drugs, bugs, and age: rational selection of empirical therapy for outpatient urinary tract infection in an era of extensive antimicrobial resistance

BackgroundOptimal empirical therapy of urinary tract infection requires accurate knowledge of local susceptibility patterns, which may vary with organism and patient characteristics.MethodsAmong 9,798 consecutive, non-duplicate, community-source urine isolates from ambulatory patients ≥ 13 years old, from clinical laboratory and an academic medical center in Curitiba, Brazil (May 1^st to December 1^st, 2009), susceptibility data for ampicillin, nitrofurantoin, trimethoprim-sulfamethoxazole, gentamicin, fluoroquinolones, and ceftriaxone/cefotaxime were compared with organism and patient gender and age.ResultsThe female-to-male ratio decreased with age, from 28.1 (among 20–29 year-olds) to 3.3 (among > 80 year-olds). Overall, susceptibility prevalence varied widely by drug class, from unacceptably low levels (53.5% and 61.1%: ampicillin and trimethoprimsulfamethoxazole) to acceptable but suboptimal levels (81.2% to 91.7%: fluoroquinolones, ceftriaxone, nitrofurantoin, and gentamicin). E. coli isolates exhibited higher susceptibility rates than other isolates, from 3–4% higher (fluoroquinolones, gentamicin) to ≥ 30% (nitrofurantoin, ceftriaxone). Males exhibited lower susceptibility rates than females. Within each gender, susceptibility declined with increasing age. For females, only nitrofurantoin and gentamicin were suitable for empirical therapy (≥ 80% susceptibility) across all age cohorts; fluoroquinolones were suitable only through age 60, and ceftriaxone only through age 80. For males, only gentamicin yielded ≥ 80% susceptibility in any age cohort.ConclusionFew suitable empirical treatment options for community-source urinary tract infection were identified for women aged over 60 years or males of any age. Empirical therapy recommendations must consider the patient's demographic characteristics. Site-specific, age and gender-stratified susceptibility surveillance involving all uropathogens is needed.     

Metformin therapy in patients with chronic kidney disease

Metformin therapy is limited in patients with chronic kidney disease (CKD) due to the potential risk of lactic acidosis. This open‐label observational study investigated metformin and lactate concentrations in patients with CKD (n = 22; creatinine clearances 15–40 ml/min) and in two dialysed patients. Patients were prescribed a range of metformin doses (250–2000 mg daily) and metformin concentrations were compared with data from healthy subjects (scaled to 1500 mg twice daily). A subset of patients (n = 7) was controlled on low doses of metformin (250 or 500 mg daily). No correlation between metformin and lactate concentrations was observed. Three patients had high lactate concentrations (>2.7 mmol/l) and two had high metformin concentrations (3–5 mg/l), but none had any symptoms of lactic acidosis. Reducing metformin dosage and monitoring metformin concentrations will allow the safe use of metformin in CKD, provided that renal function is stable.     

A systematic mapping review of Randomized Controlled Trials (RCTs) in care homes

ABSTRACT: BACKGROUND: A thorough understanding of the literature generated from research in care homes is required to support evidence-based commissioning and delivery of healthcare. So far this research has not been compiled or described. We set out to describe the extent of the evidence base derived from randomized controlled trials conducted in care homes. METHODS: A systematic mapping review was conducted of the randomized controlled trials (RCTs) conducted in care homes. Medline was searched for "Nursing Home", "Residential Facilities" and "Homes for the Aged"; CINAHL for "nursing homes", "residential facilities" and "skilled nursing facilities"; AMED for "Nursing homes", "Long term care", "Residential facilities" and "Randomized controlled trial"; and BNI for "Nursing Homes", "Residential Care" and "Long-term care". Articles were classified against a keywording strategy describing: year and country of publication; randomization, stratification and blinding methodology; target of intervention; intervention and control treatments; number of subjects and/or clusters; outcome measures; and results. RESULTS: 3226 abstracts were identified and 291 articles reviewed in full. Most were recent (median age 6 years) and from the United States. A wide range of targets and interventions were identified. Studies were mostly functional (44 behaviour, 20 prescribing and 20 malnutrition studies) rather than disease-based. Over a quarter focussed on mental health. CONCLUSIONS: This study is the first to collate data from all RCTs conducted in care homes and represents an important resource for those providing and commissioning healthcare for this sector. The evidence-base is rapidly developing. Several areas - influenza, falls, mobility, fractures, osteoporosis - are appropriate for systematic review. For other topics, researchers need to focus on outcome measures that can be compared and collated.     

Evidence-based hypertension treatment in patients with diabetes

J Clin Hypertens (Greenwich). 2011;00:00–00. ©2011 Wiley Periodicals, Inc. Both impaired glucose tolerance and diabetes are associated with substantially increased prevalence of hypertension, cardiovascular and renal disease. The goal for hypertension treatment in diabetic patients is in evolution, because of recent clinical trials. For example, the results of the recent Action to Control Cardiovascular Risk in Diabetes—BP Arm (ACCORD BP) trial failed to show an additional benefit on cardiovascular event reduction at a mean systolic BP of 119 mm Hg. A post hoc analysis of 6,400 patients with type 2 diabetes from the International Verapamil‐Trandolapril Study (INVEST) also failed to show additional cardiovascular risk reduction among patients who achieved a BP <130/80 mm Hg. While the evidence fails to support a lower BP goal to reduce coronary events, there was a risk reduction in stroke events both in ACCORD and the Appropriate Blood Pressure Control in NIDDM (ABCD) trial. A number of other clinical trials also demonstrate that when systolic pressures fall to less than 130 mm Hg, a reduction in stroke but not coronary disease events occurs. Thus, the precise BP goal for diabetic patients remains unresolved. We would posit that a BP goal of 135/85 mm Hg may be a reasonable compromise when viewing the impact of BP reduction on composite stroke and coronary artery disease in extant trials.