Comparison of antibiotic dosing recommendations for neonatal sepsis from established reference sources

Background Incorrect dosing is the most frequent prescribing error in neonatology, with antibiotics being the most frequently prescribed medicines. Computer physician order entry and clinical decision support systems can create consistency contributing to a reduction of medication errors. Although evidence-based dosing recommendations should be included in such systems, the evidence is not always available and subsequently, dosing recommendations mentioned in guidelines and textbooks are often based on expert opinion. Objective To compare dosage recommendations for antibiotics in neonates with sepsis provided by eight commonly used and well-established international reference sources. Setting An expert team from our Dutch tertiary care neonatal intensive care unit selected eight well-established international reference sources. Method Daily doses of the seven most frequently used antibiotics in the treatment of neonatal sepsis, classified by categories for birth weight and gestational age, were identified from eight well-respected reference sources in neonatology/pediatric infectious diseases. Main outcome measure Standardized average daily dosage. Results A substantial variation in dosage recommendations of antibiotics for neonatal sepsis between the reference sources was shown. Dosage recommendations of ampicillin, ceftazidime, meropenem and vancomycin varied more than recommendations for benzylpenicillin, cefotaxime and gentamicin. One reference source showed a larger variation in dosage recommendations in comparison to the average recommended daily dosage, compared to the other reference sources. Conclusion Antibiotic dosage recommendations for neonates with sepsis can be derived from important reference sources and guidelines. Further exploration to overcome variation in dosage recommendations is necessary to obtain standardized dosage regimens.     

Unintended consequences of policy change to watchful waiting for asymptomatic inguinal hernias

Introduction

In 2009 the Department of Health instructed McKinsey & Company to provide advice on how commissioners might achieve world class National Health Service productivity. Asymptomatic inguinal hernia repair was identified as a potentially cosmetic procedure, with limited clinical benefit. The Birmingham and Solihull primary care trust cluster introduced a policy of watchful waiting for asymptomatic inguinal hernia, which was implemented across the health economy in December 2010. This retrospective cohort study aimed to examine the effect of a change in clinical commissioning policy concerning elective surgical repair of asymptomatic inguinal hernias.

Methods

A total of 1,032 patients undergoing inguinal hernia repair in the 16 months after the policy change were compared with 978 patients in the 16 months before. The main outcome measure was relative proportion of emergency repair in groups before and after the policy change. Multivariate binary logistic regression was used to adjust the main outcome for age, sex and hernia type.

Results

The period after the policy change was associated with 59% higher odds of emergency repair (3.6% vs 5.5%, adjusted odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.03–2.47). In turn, emergency repair was associated with higher odds of adverse events (4.7% vs 18.5%, adjusted OR: 3.68, 95% CI: 2.04–6.63) and mortality (0.1% vs 5.4%, p<0.001, Fisher’s exact test).

Conclusions

Introduction of a watchful waiting policy for asymptomatic inguinal hernias was associated with a significant increase in need for emergency repair, which was in turn associated with an increased risk of adverse events. Current policies may be placing patients at risk.     

Hospital variation in combined liver resection and thermal ablation for colorectal liver metastases and impact on short-term postoperative outcomes: a nationwide population-based study

BackgroundCombining resection and thermal ablation can improve short-term postoperative outcomes in patients with colorectal liver metastases (CRLM). This study assessed nationwide hospital variation and short-term postoperative outcomes after combined resection and ablation.MethodsIn this population-based study, all CRLM patients who underwent resection in the Netherlands between 2014 and 2018 were included. After propensity score matching for age, ASA-score, Charlson-score, diameter of largest CRLM, number of CRLM and earlier resection, postoperative outcomes were compared. Postoperative complicated course (PCC) was defined as discharge after 14 days or a major complication or death within 30 days of surgery.ResultsOf 4639 included patients, 3697 (80%) underwent resection and 942 (20%) resection and ablation. Unadjusted percentage of patients who underwent resection and ablation per hospital ranged between 4 and 44%. Hospital variation persisted after case-mix correction. After matching, 734 patients remained in each group. Hospital stay (median 6 vs. 7 days, p = 0.011), PCC (11% vs. 14.7%, p = 0.043) and 30-day mortality (0.7% vs. 2.3%, p = 0.018) were lower in the resection and ablation group. Differences faded in multivariable logistic regression due to inclusion of major hepatectomy.ConclusionSignificant hospital variation was observed in the Netherlands. Short-term postoperative outcomes were better after combined resection and ablation, attributed to avoiding complications associated with major hepatectomy.     

Addition of felodipine to metoprolol vs replacement of metoprolol by felodipine in patients with angina pectoris despite adequate beta-blockade: Results of the Felodipine ER and Metoprolol CR in Angina (FEMINA) Study

AIMS: The study aimed to compare the addition of felodipine to metoprolol,and of the replacement of metoprolol by felodipine, with continuationof metoprolol, in patients with angina pectoris despite optimalbeta-blockade. METHODS AND RESULTS: The study was double-blind, parallel, randomized and controlled,and comprised 363 patients from 27 outpatient cardiology clinicsin the Netherlands. The patients had angina and positive bicycleexercise tests despite optimal beta-blockade (resting heartrate <65 beats . min^–1). Randomization was to threetreatment groups: continuation of metoprolol (control), additionof felodipine to metoprolol, and replacement of metoprolol byfelodipine. Exercise tests were repeated after 2 and 5 weeks.The main outcome measure was: exercise result after 5 weeks,compared with baseline, between-group comparison of changesvs control. There were no significant differences in exerciseduration and onset of chest pain vs control. The addition offelodipine increased time until 1 mm ST depression (43 s, 95%confidence interval 20–65 s), and decreased both ST depressionat highest comparable work load (0·46 mm, 95% confidenceinterval 0·19–0·72), and maximal ST depression(0·49 mm, 95% confidence interval 0·23–0·74).Exercise results after replacement of metoprolol by felodipinewere not different from control, apart from a significant increasein rate pressure product. Significantly more patients experiencedadverse events in the felodipine monotherapy group. CONCLUSION: Combination of metoprolol and felodipine is to be preferredto felodipine monotherapy in patients who have signs and symptomsof myocardial ischaemia despite optimal beta-blockade.     

Limited predictive value of inducible sustained ventricular tachycardia for future occurrence of spontaneous ventricular tachycardia in patients with coronary artery disease and relatively preserved cardiac function

To evaluate the significance of inducible sustained ventricular tachycardia (VT) in patients with coronary artery disease and relatively preserved cardiac function, 33 patients who met the following criteria were studied; documented nonsustained VT but no history of life-threatening arrhythmia, inducible sustained VT at electrophysiologic study, and implantation of a cardioverter-defibrillator. Eighteen patients developed clinical sustained VT within 2 years. By univariate analysis, left ventricular ejection fraction (EF) and the cycle length of induced VT were associated with clinical VT occurrence. By multivariate analysis, however, EF was the only independent predictor. Among 23 patients with EF 40% (P <.01). In coronary artery disease patients with relatively preserved EF, the incidence of clinical VT is considerably low even though sustained VT is inducible. Inducible VT is therefore not appropriate for risk stratification in this patient population.     

Mortality, reinfarction, left ventricular ejection fraction and costs following reperfusion therapies for acute mvocardial infarction

The comparative efficacy of thrombolytic drugs and primary angioplastyfor acute myocardial infarction have recently been studied,but long-term follow-up data have not yet been reported. Weconducted a randomized trial involving 301 patients with acutemyocardial infarction; 152 patients were randomized to primaryangioplasty and 149 to intravenous streptokinase. Left ventricularfunction was assessed with a radionuclide technique both athospital discharge and at the end of the follow-up period. Follow-updata were collected after a mean (± SD) of 31 ±9 months. Total medical costs were calculated. At the end ofthe follow-up period, 5% of the angioplasty patients had diedfrom a cardiac cause compared to 11% of the patients randomizedto intravenous streptokinase, P=0·031. Cardiac deathor a non-fatal reinfarction occurred in 7% of angioplasty patientscompared to 28% of streptokinase patients, P0·001. Therewas a sustained benefit of angioplasty compared to streptokinaseon left ventricular function. The total medical costs in thetwo groups were similar. Coronary anatomy (patency and singleor multivessel disease), infarct location and previous myocardialinfarction were important determinants of clinical outcome andcosts. After 31±9 months of follow-up, primary angioplasty comparedto intravenous streptokinase results in a lower rate of cardiacdeath and reinfarction, a better left ventricular ejection fraction,and no increase in total medical costs. (Eur Heart J 1996; 17: 382–387)