Sex‐ and Gender‐specific Research Priorities in Cardiovascular Resuscitation: Proceedings from the 2014 Academic Emergency Medicine Consensus Conference Cardiovascular Resuscitation Research Workgroup

Significant sex and gender differences in both physiology and psychology are readily acknowledged between men and women; however, data are lacking regarding differences in their responses to injury and treatment and in their ultimate recovery and survival. These variations remain particularly poorly defined within the field of cardiovascular resuscitation. A better understanding of the interaction between these important factors may soon allow us to dramatically improve outcomes in disease processes that currently carry a dismal prognosis, such as sudden cardiac arrest. As part of the 2014 Academic Emergency Medicine consensus conference “Gender‐Specific Research in Emergency Medicine: Investigate, Understand, and Translate How Gender Affects Patient Outcomes,” our group sought to identify key research questions and knowledge gaps pertaining to both sex and gender in cardiac resuscitation that could be answered in the near future to inform our understanding of these important issues. We combined a monthly teleconference meeting of interdisciplinary stakeholders from largely academic institutions with a focused interest in cardiovascular outcomes research, an extensive review of the existing literature, and an open breakout session discussion on the recommendations at the consensus conference to establish a prioritization of the knowledge gaps and relevant research questions in this area. We identified six priority research areas: 1) out‐of‐hospital cardiac arrest epidemiology and outcome, 2) customized resuscitation drugs, 3) treatment role for sex steroids, 4) targeted temperature management and hypothermia, 5) withdrawal of care after cardiac arrest, and 6) cardiopulmonary resuscitation training and implementation. We believe that exploring these key topics and identifying relevant questions may directly lead to improved understanding of sex‐ and gender‐specific issues seen in cardiac resuscitation and ultimately improved patient outcomes.     

Funding Mechanisms for Gender‐specific Research: Proceedings from a Panel Discussion at the 2014 Academic Emergency Medicine Consensus Conference

As part of the 2014 Academic Emergency Medicine (AEM) consensus conference “Gender‐Specific Research in Emergency Care: Investigate, Understand, and Translate How Gender Affects Patient Outcomes,” we assembled a diverse panel of representatives from federal and nonfederal funding agencies to discuss future opportunities for sex‐ and gender‐specific research. The discussion revolved around the mission and priorities of each organization, as well as its interest in promoting sex‐ and gender‐specific research. The panelists were asked to provide specific examples of funding lines generated or planned for as pertinent to emergency care. Training opportunities for future researchers in this area were also discussed.     

Blastomycosis in solid organ transplant recipients

BACKGROUND: Blastomyces dermatitidis, the etiologic agent of blastomycosis, causes severe disease and substantial mortality in those immunocompromised by acquired immunodeficiency syndrome or malignancy. In solid organ transplant recipients, the epidemiology, clinical features, and outcomes have not been fully described. METHODS: We conducted a retrospective case-series at the University of Wisconsin Hospital and Clinics. Case patients were solid organ transplant recipients with blastomycosis. RESULTS: From 1986 to 2004, we identified 11 cases of post-transplant blastomycosis with 64% occurring between 2000 and 2004. Onset of infection occurred a median of 26 months post transplantation with near equal distribution before and after the first year of transplantation. Rejection did not precede any case of post-transplant blastomycosis. Opportunistic co-infections were common, occurring in 36% of patients. Pneumonia was the most common clinical presentation and was frequently complicated by acute respiratory distress syndrome (ARDS). Extrapulmonary disease predominantly involved the skin and spared the central nervous system. The overall mortality rate was 36%; however, this increased to 67% in those with ARDS. None of the surviving patients relapsed or received routine secondary antifungal prophylaxis. CONCLUSION: Blastomycosis is an uncommon infection following solid organ transplantation that is frequently complicated by ARDS, dissemination, and opportunistic co-infection. After cure, post-transplant blastomycosis may not require lifelong antifungal suppression.     

Effectiveness of preemptive barrier precautions in controlling nosocomial colonization and infection by methicillin-resistant Staphylococcus aureus in a burn unit

BACKGROUND: We report the effectiveness of preemptive enhanced barrier precautions in containing a methicillin-resistant Staphylococcus aureus (MRSA) outbreak in a university hospital burn unit and further controlling endemic nosocomial MRSA infection in the unit during the succeeding 27 months. METHODS: During a 6-month period, 12 patients in a 7-bed burn unit were found to be colonized (7) or infected (5) by MRSA. An epidemiologic study was undertaken. RESULTS: Seven of the 10 strains of MRSA from patients that were available for DNA typing were clonally identical. Early in the outbreak, a health care worker was found to be a concordant nasal carrier and was successfully decolonized with nasal mupirocin. However, despite stringent compliance with isolation of MRSA-positive patients (targeted precautions), new cases of MRSA colonization or infection continued to occur. The outbreak was rapidly terminated after implementing preemptive barrier precautions with all patients in the unit: a new, clean gown and gloves for any physical contact with the patient or their environment. Although 25% of all nosocomial S aureus isolates in our hospital are resistant to methicillin, the incidence of endemic MRSA colonization and infection in the burn unit has remained very low since implementing barrier precautions unit wide (baseline rate, 2.2 [95% CI: 1.0-4.2] cases per 1000 patient-days; outbreak rate, 7.2 [95% CI: 4.4-11.0] cases per 1000 patient-days; post-outbreak termination endemic rate, 1.1 (95% CI: 0.4-2.3) cases per 1000 patient-days). The rate ratio comparing the outbreak and the baseline period was 3.20 (95% CI: 1.40-7.95, P = .002); the rate ratio comparing the post-outbreak period with the baseline period was 0.48 (95% CI: 0.14-1.53, P = .10), and it has not been necessary to screen personnel for MRSA carriage to prevent nosocomial MRSA infections in this highly vulnerable population. CONCLUSION: Preemptive barrier precautions were highly effective in controlling the outbreak and, most notably, have also been highly effective in maintaining a very low incidence of nosocomial MRSA infection endemically in the succeeding 27 months of follow-up. Use of clean gloves, with or without a gown, bears consideration for all high-risk hospitalized patients to prevent cross transmission of all multiresistant nosocomial pathogens.     

A review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted,noncuffed central venous catheters: implications for preventive strategies

Strategies for preventing central venous catheter (CVC)-related bloodstream infection are most likely to be effective if guided by an understanding of the risk factors associated with these infections. In this critical review of published studies of risk factors for CVC-related bloodstream infection that were prospective and used multivariable techniques of data analysis or that were randomized trials of a preventive measure, a significantly increased risk of catheter-related bloodstream infection was associated with inexperience of the operator and nurse-to-patient ratio in the intensive care unit, catheter insertion with less than maximal sterile barriers, placement of a CVC in the internal jugular or femoral vein rather than subclavian vein, placement in an old site by guidewire exchange, heavy colonization of the insertion site or contamination of a catheter hub, and duration of CVC placement > 7 days. Prospective studies or randomized trials of control measures focusing on these risk factors have been shown to reduce risk significantly: formal training in CVC insertion and care, use of maximal sterile barriers at insertion, use of chlorhexidine rather than povidone-iodine for cutaneous antisepsis, applying a topical anti-infective cream or ointment or a chlorhexidine-impregnated dressing to the insertion site, and the use of novel catheters with an anti-infective surface or a contamination resistant hub. Better prospective studies of sufficient size to address all potential risk factors, including insertion site and hub colonization, insertion technique, and details of follow-up care, would enhance our understanding of the pathogenesis of CVC-related bloodstream infection and guide efforts to develop more effective strategies for prevention.     

Inhaled corticosteroids stabilize constrictive bronchiolitis after hematopoietic stem cell transplantation

Post transplantation constrictive bronchiolitis (PTCB) is the most common pulmonary complication among long-term survivors of allogeneic hematopoietic stem cell transplantation (HSCT). It is a late manifestation of GVHD. Its treatment with high-dose systemic corticosteroids and other immunosuppressive regimens is associated with multiple side effects. Topical corticosteroids are used for the treatment of other manifestations of GVHD to minimize these side effects. We conducted a retrospective analysis of a series of adult patients to evaluate the efficacy of high-dose inhaled corticosteroids in the treatment of PTCB. Seventeen patients with new-onset airflow obstruction were diagnosed with PTCB. Their forced expiratory volume in 1 s (FEV1) declined from a median of 84% (range, 56-119) before HSCT to 53% (26-82) after HSCT. All patients received inhaled fluticasone propionate 500-940 microg two times daily. Symptoms of airway obstruction improved and FEV1 stabilized 3-6 months after treatment. We conclude that high-dose inhaled corticosteroids may be effective in the treatment of PTCB and propose a plausible mechanism of its action. A prospective evaluation of its efficacy is warranted.     

Probiotics and prebiotics to combat enteric infections and HIV in the developing world: a consensus report

Infectious disease in the developing world continues to represent one of the greatest challenges facing humanity. Every year over a million children suffer and die from the sequela of enteric infections, while in 2008 it is estimated almost 2.7 million (UNAIDS 2009 update) adults and children became infected with human immunodeficiency virus (HIV). While oral rehydration therapy for diarrhea, and antiretrovirals (ARV) for HIV are critical, there is a place for adjunctive therapies to improve quality of life. The importance of the human microbiota in retaining health is now recognized, as is the concept of replenishing beneficial microbes through probiotic treatments. Studies have shown that probiotics can reduce the duration of diarrhea, improve gut barrier function, help prevent bacterial vaginosis (BV), and enhance immunity even in HIV-infected subjects. However, many issues remain before the extent of probiotic benefits can be verified, and their application to the developing world realised. This consensus report outlines the potential probiotic, and to a lesser extent prebiotic, applications in resource disadvantages settings, and recommends steps that could bring tangible relief to millions of people. The challenges to both efficacy and effectiveness studies in these settings include a lack of infrastructure and funding for scientists, students and research projects in developing countries; making available clinically proven probiotic and prebiotic products at affordable prices; and undertaking appropriately designed clinical trials. We present a roadmap on how efficacy studies may be conducted in a resource disadvantages setting among persons with chronic diarrhea and HIV. These examples and the translation of efficacy into effectiveness are described.     

Does Nonpayment for Hospital-Acquired Catheter-Associated Urinary Tract Infections Lead to Overtesting and Increased Antimicrobial Prescribing?

Background.?On 1 October 2008, in an effort to stimulate efforts to prevent catheter-associated urinary tract infection (CAUTI), the Centers for Medicare & Medicaid Services (CMS) implemented a policy of not reimbursing hospitals for hospital-acquired CAUTI. Since any urinary tract infection present on admission would not fall under this initiative, concerns have been raised that the policy may encourage more testing for and treatment of asymptomatic bacteriuria. Methods.?We conducted a retrospective multicenter cohort study with time series analysis of all adults admitted to the hospital 16 months before and 16 months after policy implementation among participating Society for Healthcare Epidemiology of America Research Network hospitals. Our outcomes were frequency of urine culture on admission and antimicrobial use. Results.?A total of 39 hospitals from 22 states submitted data on 2?362?742 admissions. In 35 hospitals affected by the CMS policy, the median frequency of urine culture performance did not change after CMS policy implementation (19.2% during the prepolicy period vs 19.3% during the postpolicy period). The rate of change in urine culture performance increased minimally during the prepolicy period (0.5% per month) and decreased slightly during the postpolicy period (-0.25% per month; P?相似文献