Risk Factors for Nosocomial Gastrointestinal Bleeding and Use of Acid-Suppressive Medication in Non-Critically Ill Patients

BACKGROUND

It is unknown whether there exist certain subsets of patients outside of the intensive care unit in whom the risk of nosocomial gastrointestinal bleeding is high enough that prophylactic use of acid-suppressive medication may be warranted.

OBJECTIVE

To identify risk factors for nosocomial gastrointestinal bleeding in a cohort of non-critically ill hospitalized patients, develop a risk scoring system, and use this system to identify patients most likely to benefit from acid suppression.

DESIGN

Cohort study.

PATIENTS

Adult patients admitted to an academic medical center from 2004 through 2007. Admissions with a principal diagnosis of gastrointestinal bleeding or a principal procedure code for cardiac catheterization were excluded.

MAIN MEASURES

Medication, laboratory, and other clinical data were obtained through electronic data repositories maintained at the medical center. The main outcome measure—nosocomial gastrointestinal bleeding occurring outside of the intensive care unit—was ascertained via ICD-9-CM coding and confirmed by chart review.

KEY RESULTS

Of 75,723 admissions (median age = 56 years; 40 % men), nosocomial gastrointestinal bleeding occurred in 203 (0.27 %). Independent risk factors for bleeding included age > 60 years, male sex, liver disease, acute renal failure, sepsis, being on a medicine service, prophylactic anticoagulants, and coagulopathy. Risk of bleeding increased as clinical risk score derived from these factors increased. Acid-suppressive medication was utilized in > 50 % of patients in each risk stratum. Our risk scoring system identified a high risk group in whom the number-needed-to-treat with acid-suppressive medication to prevent one bleeding event was < 100.

CONCLUSIONS

In this large cohort of non-critically ill hospitalized patients, we identified several independent risk factors for nosocomial gastrointestinal bleeding. With further validation at other medical centers, the risk model derived from these factors may help clinicians to direct acid-suppressive medication to those most likely to benefit..     

Features of High Quality Discharge Planning for Patients Following Acute Myocardial Infarction

BACKGROUND

Hospital discharge planning is required as a Medicare Condition of Participation (CoP), and is essential to the health and safety for all patients. However, there have been no studies examining specific hospital discharge processes, such as patient education and communication with primary care providers, in relation to hospital 30-day risk standardized mortality rates (RSMRs) for patients with acute myocardial infarction (AMI).

OBJECTIVE

To identify hospital discharge processes that may be associated with better performance in hospital AMI care as measured by RSMR.

DESIGN

We conducted a qualitative study of U.S. Hospitals, which were selected based on their RSMR reported by the Centers for Medicare & Medicaid Services (CMS) Hospital Compare website for the most recent data available (January 1, 2005 – December 31, 2007). We selected hospitals that ranked in the top 5 % and the bottom 5 % of RSMR for the two consecutive years. We focused on hospitals at the extreme ends of the range in RSMR, known as deviant case sampling. We excluded hospitals that did not have the ability to perform percutaneous coronary intervention in order to decrease the heterogeneity in our sample.

PARTICIPANTS

Participants included key hospital clinical and administrative staff most involved in discharge planning for patients admitted with AMI.

METHODS

We conducted 14 site visits and 57 in-depth interviews using a standard discussion guide. We employed a grounded theory approach and used the constant comparative method to generate recurrent and unifying themes.

KEY RESULTS

We identified five broad discharge processes that distinguished higher and lower performing hospitals: 1) initiating discharge planning upon patient admission; 2) using multidisciplinary case management services; 3) ensuring that a follow-up plan is in place prior to discharge; 4) providing focused education sessions for both the patient and family; and 5) contacting the primary care physician regarding the patient’s hospitalization and follow-up care plan.

CONCLUSION

Comprehensive and more intense discharge processes that start on admission continue during the patient’s hospital stay, and follow up with the primary care physician within 2 days post-discharge, may be critical in reducing hospital RSMR for patients with AMI.     

Unilateral pulmonary artery branch stenosis: Diastolic prolongation of forward flow appears to maintain flow to the affected lung if the pulmonary valve is competent

Background

We sought to improve understanding of the diastolic prolongation of forward flow seen through a unilateral branch pulmonary artery (PA) stenosis.

Methods and Results

Of patients studied by cardiovascular magnetic resonance (CMR) for congenital heart disease, we reviewed right and left PA flow to find 10 cases with a diastolic prolongation of flow in a stenosed branch PA. They were aged 20 years (median, range = 14–40 years, 7 males). Seven had transposition of the great arteries corrected by arterial switch (TGA-AS) and 3 had repaired tetralogy of Fallot (rToF). All had at least moderate unilateral stenosis and competent pulmonary valves. For comparison, we identified 10 patients with unilateral stenosis and at least moderate pulmonary regurgitation, 9 rTOF and 1 TGA-AS, aged 23.5 years (range = 14–42 years, 6 males). Flow in each PA was measured, and in 10 healthy volunteers aged 27 years (range = 20–42 years, 5 males). The curves of flow through stenosed and non-stenosed arteries were averaged for each patient group and compared with those from controls. In competent pulmonary valve patients, the minimum diameters of the stenosed versus non-stenosed branches were as follows (median [range]): 4 [3–8] mm versus 13.5 [10–28] mm, p < 0.001, although their flows differed a little: 2.5 [1.5–6.8] L/min versus 3.2 [1.2–8.8] L/min, p = 0.6. No diastolic tail was identifiable in the patients with unilateral PA stenosis and pulmonary regurgitation, where stenosed versus non-stenosed diameters were 7 [4–12] mm versus 20.5 [13–33] mm, p < 0.001, and flows differed: 1.3 [0.4–2.9] L/min versus 3.8 [3.0–5.0] L/min, p < 0.001. No controls showed stenosis or diastolic tail.

Conclusions

Beyond a competent pulmonary valve, flow through a unilateral PA stenosis, although limited in systole, can continue into diastole, maintaining flow to the lung.     

Changes of calretinin,calbindin D28K and parvalbumin-immunoreactive neurons in the superficial layers of the hamster superior colliculus following monocular enucleation

We studied the effects of monocular enucleation on the patterned distribution of calretinin-, calbindin D28K- and parvalbumin-immunoreactive (IR) neurons in the superficial layers of the hamster superior colliculus (SC). The calcium-binding proteins were localized using antibody immunocytochemistry. Almost complete depletion of the calretinin-IR fibers in the superficial layers of the contralateral SC was found following unilateral enucleation. Quantitative analysis showed that on the experimental side of the SC, an enormous number of calretinin-IR cells newly appeared (716%). On the experimental side of the SC, the number of parvalbumin-IR cells also increased (32%). By contrast, on the experimental side of the SC, the number of calbindin D28K-IR cells exhibited a reduction (43%). Two-color immunofluorescence revealed that none of the newly appeared calretinin-IR cells were labeled with antibodies to calbindin D28K or parvalbumin. The present results demonstrate that retinal projection may control the activity of the expression of these calcium-binding proteins in the hamster SC but in different manners. The results also show that the patterned change of calretinin and parvalbumin in the hamster SC is comparable with other animals, but the change of calbindin D28K is not identical.     

Identification of an anticancer compound against HT-29 cells from Phellinus linteus grown on germinated brown rice

Objective

To isolate and identify the anticancer compound against proliferation of human colon cancer cells from ethyl acetate (EtOAC) extract of Phellinus linteus grown on germinated brown rice (PB).

Methods

EtOAC extract of PB was partitioned with n-hexane, EtOAC, and water-saturated n-butanol. Anticancer compound of n-hexane layer was isolated and identified by HPLC and NMR, respectively. Cytotoxicity against HT-29 cells was tested by SRB assay.

Results

The n-hexane layer obtained after solvent fractionation of PB EtOAC extracts showed a potent anticancer activity against the HT-29 cell line. Atractylenolide I, a eudesmane-type sesquiterpene lactone, a major anticancer substance of PB, was isolated from the n-hexane layer by silica gel column chromatography and preparative-HPLC. This structure was elucidated by one- and two-dimensional NMR spectroscopic data. Atractylenolide I has not been reported in mushrooms or rice as of yet. The isolated compound dose-dependently inhibited the growth of HT-29 human colon cancer cells.

Conclusions

Atractylenolide I might contribute to the anticancer effect of PB.     

Benidipine has effects similar to losartan on the central blood pressure and arterial stiffness in mild to moderate essential hypertension

Background Central blood pressure (BP) is pathophysiologically more important than peripheral BP for the pathogenesis of cardiovascular disease.Arterial stiffness is also a good predictor of cardiovascular morbidity and mortality.The effects of benidipine,a unique dual L-/T-type calcium channel blocker,on central BP have not been reported.This study aimed to compare the effect of benidipine and losartan on the central BP and arterial stiffness in mild to moderate essential hypertensives.Methods This 24 weeks,multi-center,open label,randomized,active drug comparative,parallel group study was designed as a non-inferiority study.The eligible patients (n=200) were randomly assigned to receive benidipine (n=101)or losartan (n=99).Radial artery applanation tonometry and pulse wave analysis were used to measure the central BP,pulse wave velocity (PWV) and augmentation index (Alx).We also measured the metabolic and inflammatory markers.Results After 24 weeks,the central BP decreased significantly from baseline by (16.8+14.0/10.5+9.2) mmHg (1mmHg =0.133 kPa) (systolic/diastolic BP; P ＜0.001) in benidipine group and (18.9+14.7/12.1+10.2) mmHg (P ＜0.001)in losartan group respectively.Both benidipine and losartan groups significantly lowered peripheral BP (P ＜0.001) and Alx (P ＜0.05),but there were no significant differences between the two groups.The mean aortic,brachial and femoral PWV did not change in both groups after 24-week treatment.There were no significant changes of the blood metabolic and inflammatory biomarkers in each group.Conclusion Benidipine is as effective as losartan in lowering the central and peripheral BP,and improving arterial stiffness.     

Phospholipid micelle-based magneto-plasmonic nanoformulation for magnetic field-directed,imaging-guided photo-induced cancer therapy

We present a magnetoplasmonic nanoplatform combining gold nanorods (GNR) and iron-oxide nanoparticles within phospholipid-based polymeric nanomicelles (PGRFe). The gold nanorods exhibit plasmon resonance absorbance at near infrared wavelengths to enable photoacoustic imaging and photothermal therapy, while the Fe₃O₄ nanoparticles enable magnetophoretic control of the nanoformulation. The fabricated nanoformulation can be directed and concentrated by an external magnetic field, which provides enhancement of a photoacoustic signal. Application of an external field also leads to enhanced uptake of the magnetoplasmonic formulation by cancer cells in vitro. Under laser irradiation at the wavelength of the GNR absorption peak, the PGRFe formulation efficiently generates plasmonic nanobubbles within cancer cells, as visualized by confocal microscopy, causing cell destruction. The combined magnetic and plasmonic functionalities of the nanoplatform enable magnetic field-directed, imaging-guided, enhanced photo-induced cancer therapy.From the Clinical EditorIn this study, a nano-formulation of gold nanorods and iron oxide nanoparticles is presented using a phospholipid micelle-based delivery system for magnetic field-directed and imaging-guided photo-induced cancer therapy. The gold nanorods enable photoacoustic imaging and photothermal therapy, while the Fe₃O₄ nanoparticles enable magnetophoretic control of the formulation. This and similar systems could enable more precise and efficient cancer therapy, hopefully in the near future, after additional testing.     

Protective effect of a marine polyphenol,dieckol against carbon tetrachloride-induced acute liver damage in mouse

In this study, the hepatoprotective effect of dieckol on carbon tetrachloride (CCl₄) induced hepatic damages in ICR mice liver was investigated. Mice were randomly divided into 4 groups such as saline treated (negative control), CCl₄ treated (positive control), CCl₄ + dieckol (5 mg/kg mouse) and CCl₄ + dieckol (25 mg/kg mouse), respectively. The body weights and survival rates of mice, followed by dieckol treatments were significantly increased compared to the positive control. The level of GOT, GPT and MDA in the serum of the dieckol treated groups were reduced dose dependently than the control, significantly. The antioxidant enzymes including CAT, and GSH-px levels were increased significantly compared to the positive control. However, no significant differences were observed on hepatic histophathological analysis in dieckol treated groups dose dependently. Down-regulation of Bax and up-regulation of Bcl-xl protein expressions were observed in liver tissues of the dieckol administered groups. These results suggested that, dieckol can be developed as a therapeutic agent for liver disease by oxidative stress.