Urinary tract infection in male veterans

JC on 22/2/13

JAMA Intern Med. 2013 Jan 14;173(1):62-8. doi: 10.1001/2013.jamainternmed.829.

Urinary tract infection in male veterans: treatment patterns and outcomes.

Drekonja DM, Rector TS, Cutting A, Johnson JR.

Source

Minneapolis Veterans Affairs Health Care System, Minneapolis, MN 55417, USA. drek0002@umn.edu

Abstract

BACKGROUND:

Lengthier antimicrobial therapy is associated with increased costs, antimicrobial resistance, and adverse drug events. Therefore, establishing minimum effective antimicrobial treatment durations is an important public health goal. The optimal treatment duration and current treatment patterns for urinary tract infection (UTI) in men are unknown. We used Veterans Affairs administrative data to study male UTI treatment and outcomes.

METHODS:

Male UTI episodes in the Veterans Affairs system (fiscal year 2009) were identified by combining International Classification of Diseases, Ninth Revision codes with UTI-relevant antimicrobial prescriptions. Episodes were categorized as index, early recurrence (<30 days), or late recurrence (≥30 days) cases. Drug name, treatment duration, and outcomes (recurrence and Clostridium difficile infection during 12 months) were recorded for index cases. Demographic, clinical, and treatment characteristics were assessed for associations with outcomes in univariate and multivariate analyses.

RESULTS:

Among 4 854 765 outpatient male veterans, 39 149 UTI episodes involving 33 336 unique patients were identified, including 33 336 index cases (85.2%), 1772 early recurrences (4.5%), and 4041 late recurrences (10.3%). Highest-use antimicrobial agents were ciprofloxacin (62.7%) and trimethoprim-sulfamethoxazole (26.8%); 35.0% of patients received shorter-duration treatment (≤7 days), and 65.0% of patients received longer-duration treatment (>7 days). Of the index cases, 4.1% were followed by early recurrence and 9.9% by late recurrence. Longer-duration treatment was not associated with a reduction in early or late recurrence but was associated with increased late recurrence compared with shorter-duration treatment (10.8% vs 8.4%, P < .001), including in multivariate analysis (odds ratio, 1.20; 95% CI, 1.10-1.30). In addition, C difficile infection risk was significantly higher with longer-duration vs shorter-duration treatment (0.5% vs 0.3%, P = .02) and exhibited a similar suggestive trend in multivariate analysis (odds ratio, 1.42; 95% CI, 0.97-2.07).

CONCLUSION:

Longer-duration treatment (>7 days) for male UTI in the outpatient setting was associated with no reduction in early or late recurrence.


http://www.ncbi.nlm.nih.gov/pubmed/23212273 

Benefits of β blockers in patients with heart failure and reduced ejection fraction

Journal club on 22/3/2013

Abstract

Objective To clarify whether any particular β blocker is superior in patients with heart failure and reduced ejection fraction or whether the benefits of these agents are mainly due to a class effect.

Design Systematic review and network meta-analysis of efficacy of different β blockers in heart failure.

Data sources CINAHL(1982-2011), Cochrane Collaboration Central Register of Controlled Trials (-2011), Embase (1980-2011), Medline/PubMed (1966-2011), and Web of Science (1965-2011).

Study selection Randomized trials comparing β blockers with other β blockers or other treatments.

Data extraction The primary endpoint was all cause death at the longest available follow-up, assessed with odds ratios and Bayesian random effect 95% credible intervals, with independent extraction by observers.

Results 21 trials were included, focusing on atenolol, bisoprolol, bucindolol, carvedilol, metoprolol, and nebivolol. As expected, in the overall analysis, β blockers provided credible mortality benefits in comparison with placebo or standard treatment after a median of 12 months (odds ratio 0.69, 0.56 to 0.80). However, no obvious differences were found when comparing the different β blockers head to head for the risk of death, sudden cardiac death, death due to pump failure, or drug discontinuation. Accordingly, improvements in left ventricular ejection fraction were also similar irrespective of the individual study drug.

Conclusion The benefits of β blockers in patients with heart failure with reduced ejection fraction seem to be mainly due to a class effect, as no statistical evidence from current trials supports the superiority of any single agent over the others.

http://www.bmj.com/content/346/bmj.f55 

Drug regimen changes after discharge

On 30th November 2012:

BMJ Open. 2012 Nov 19;2(6). pii: e001461. doi: 10.1136/bmjopen-2012-001461. Print 2012.

How are drug regimen changes during hospitalisation handled after discharge: a cohort study.

Viktil KK, Blix HS, Eek AK, Davies MN, Moger TA, Reikvam A.

Source

Diakonhjemmet Hospital Pharmacy, Diakonhjemmet Hospital, Oslo, Norway.

Abstract

OBJECTIVES:

To investigate drug regimen changes during hospitalisation and explore how these changes are handled after patients are transferred back into the care of their general practitioners (GPs).

DESIGN:

Cohort study.

SETTING:

Patients in this multicentre study had undergone at least one change in their drug regimens at discharge from the general medicine departments at six hospitals in Norway. These changes were altered doses, discontinuation of drugs or start of new drugs. Clinical pharmacists visited the patients' GPs 4-5 months after patient discharge and recorded any additional drug regimen changes.

RESULTS:

In total, 105 patients (mean age 76.1 years, 54.3% women) completed the study. On average, they used 5.6 drugs at admission (range 0-16) and 7.6 drugs at discharge (range 1-17). On average, 4.4 drug changes per patient (SD 2.7, range 1-16) were made at the hospital, and 3.4 drug changes per patient (SD 2.9, range 0-14) within 4-5 months of discharge. Of the 465 drug changes made in hospital, 153 were changed again after discharge (mean 1.5 per patient, SD 1.8, range 0-13). The drug regimens of 90 of these 105 patients were changed after discharge. The OR for extensive drug changes after discharge (≥ 4 changes) increased significantly with the number of drugs used at discharge from hospital (OR=1.29, 95% CI 1.04 to 1.59). Only 68 of 105 discharge notes contained complete drug lists, and only 24 of the discharge notes were received by the GPs within 7 days.

CONCLUSIONS:

In addition to the extensive changes in drug regimens during hospitalisation, almost equally extensive changes were made in the initial months after discharge. Surveillance of drug regimens is particularly necessary in the period immediately after hospital discharge.

Altering microRNA in colorectal cancer with histone deacetylase inhibitors

On 23rd November 2012

“Altering microRNA in colorectal cancer with histone deacetylase inhibitors”

Low sodium diet significantly increases morbidity and mortality in systolic HF

Discussed on 9th November 2012

Heart. 2012 Aug 21. [Epub ahead of print]

Low sodium versus normal sodium diets in systolic heart failure: systematic review and meta-analysis.

Dinicolantonio JJ, Pasquale PD, Taylor RS, Hackam DG.

Source

Ithaca, New York, USA.

Abstract

CONTEXT:

A low sodium diet has been proposed to reduce the risk of heart failure (HF) hospitalisations and is currently advocated in consensus guidelines, yet some evidence suggests adverse neurohumoral activation for sodium restriction in the HF setting.

OBJECTIVES:

To evaluate the effects of a restricted sodium diet in patients with systolic HF.

DATA SOURCES:

A systematic review and meta-analysis of randomised trials OVID MEDLINE, PubMed, Excerpta Medica (Embase), the Cochrane Controlled Trials Register, Scopus, Web of Science and Google Scholar were searched up to April 2012.

STUDY SELECTION:

Two independent reviewers selected studies for inclusion on the basis of a randomised controlled trial design that included adults with systolic HF receiving a restricted salt diet or control diet and reporting mortality (all-cause, sudden death or HF-related) and HF-related hospitalisations.

DATA EXTRACTION AND ANALYSIS:

Descriptive and quantitative information was extracted from included studies. A random-effects model was used to compute pooled risk ratios (RR) for mortality and morbidity outcomes.

RESULTS:

Six randomised trials comparing low sodium diets (1.8 g/day) with normal sodium diets (2.8 g/d) in 2747 patients with systolic HF were identified. Compared with a normal sodium diet, a low sodium diet significantly increased all cause mortality (RR 1.95, 95% CI 1.66 to 2.29), sudden death (RR 1.72, 95% CI 1.21 to 2.44), death due to HF (RR 2.23, 95% CI 1.77 to 2.81) and HF readmissions (RR 2.10, 95% CI 1.67 to 2.64).

CONCLUSION:

Compared with a normal sodium diet, a low sodium diet significantly increases morbidity and mortality in systolic HF.

Fish consumption, long chain omega 3 fatty acids, and risk of cerebrovascular disease

 Journal club on 2nd November 2012

 

BMJ. 2012 Oct 30;345:e6698. doi: 10.1136/bmj.e6698.

Association between fish consumption, long chain omega 3 fatty acids, and risk of cerebrovascular disease: systematic review and meta-analysis.

Chowdhury R, Stevens S, Gorman D, Pan A, Warnakula S, Chowdhury S, Ward H, Johnson L, Crowe F, Hu FB, Franco OH.

Source

Department of Public Health and Primary Care, University of Cambridge, UK.

Abstract

OBJECTIVE:

To clarify associations of fish consumption and long chain omega 3 fatty acids with risk of cerebrovascular disease for primary and secondary prevention.

DESIGN:

Systematic review and meta-analysis.

DATA SOURCES:

Studies published before September 2012 identified through electronic searches using Medline, Embase, BIOSIS, and Science Citation Index databases. ELIGIBILITY CRITERIA: Prospective cohort studies and randomised controlled trials reporting on associations of fish consumption and long chain omega 3 fatty acids (based on dietary self report), omega 3 fatty acids biomarkers, or supplementations with cerebrovascular disease (defined as any fatal or non-fatal ischaemic stroke, haemorrhagic stroke, cerebrovascular accident, or transient ischaemic attack). Both primary and secondary prevention studies (comprising participants with or without cardiovascular disease at baseline) were eligible.

RESULTS:

26 prospective cohort studies and 12 randomised controlled trials with aggregate data on 794 000 non-overlapping people and 34 817 cerebrovascular outcomes were included. In cohort studies comparing categories of fish intake the pooled relative risk for cerebrovascular disease for 2-4 servings a week versus ≤1 servings a week was 0.94 (95% confidence intervals 0.90 to 0.98) and for ≥5 servings a week versus 1 serving a week was 0.88 (0.81 to 0.96). The relative risk for cerebrovascular disease comparing the top thirds of baseline long chain omega 3 fatty acids with the bottom thirds for circulating biomarkers was 1.04 (0.90 to 1.20) and for dietary exposures was 0.90 (0.80 to 1.01). In the randomised controlled trials the relative risk for cerebrovascular disease in the long chain omega 3 supplement compared with the control group in primary prevention trials was 0.98 (0.89 to 1.08) and in secondary prevention trials was 1.17 (0.99 to 1.38). For fish or omega 3 fatty acids the estimates for ischaemic and haemorrhagic cerebrovascular events were broadly similar. Evidence was lacking of heterogeneity and publication bias across studies or within subgroups.

CONCLUSIONS:

Available observational data indicate moderate, inverse associations of fish consumption and long chain omega 3 fatty acids with cerebrovascular risk. Long chain omega 3 fatty acids measured as circulating biomarkers in observational studies or supplements in primary and secondary prevention trials were not associated with cerebrovascular disease. The beneficial effect of fish intake on cerebrovascular risk is likely to be mediated through the interplay of a wide range of nutrients abundant in fish.

JC on 19th October 2012

Cochrane Database Syst Rev. 2012 Apr 18;4:CD003040.

Angiotensin receptor blockers for heart failure.

Heran BS, Musini VM, Bassett K, Taylor RS, Wright JM.

Source

Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, Canada. bsheran@ti.ubc.ca

Abstract

BACKGROUND:

Chronic heart failure (HF) is a prevalent world-wide. Angiotensin receptor blockers (ARBs) are widely prescribed for chronic HF although their role is controversial.

OBJECTIVES:

To assess the benefit and harm of ARBs compared with ACE inhibitors (ACEIs) or placebo on mortality, morbidity and withdrawals due to adverse effects in patients with symptomatic HF and left ventricular systolic dysfunction or preserved systolic function.

SEARCH METHODS:

Clinical trials were identified by searching CENTRAL, HTA, and DARE , (The Cochrane Library 2010 Issue 3), as well as MEDLINE (2002 to July 2010), and EMBASE (2002 to July 2010). Reference lists of retrieved articles and systematic reviews were checked for additional studies not identified by the electronic searches.

SELECTION CRITERIA:

Double blind randomised controlled trials in men and women of all ages who have symptomatic (NYHA Class II to IV) HF and: 1) left ventricular systolic dysfunction, defined as left ventricular ejection fraction (LVEF) ≤40%; or 2) preserved ejection fraction, defined as LVEF >40%.

DATA COLLECTION AND ANALYSIS:

Two authors independently assessed risk of bias and extracted data from included studies.

MAIN RESULTS:

Twenty two studies evaluated the effects of ARBs in 17,900 patients with a LVEF ≤40% (mean 2.2 years). ARBs did not reduce total mortality (RR 0.87 [95% CI 0.76, 1.00]) or total morbidity as measured by total hospitalisations (RR 0.94 [95% CI 0.88, 1.01]) compared with placebo.Total mortality (RR 1.05 [95% CI 0.91, 1.22]), total hospitalisations (RR 1.00 [95% CI 0.92, 1.08]), MI (RR 1.00 [95% CI 0.62, 1.63]), and stroke (RR 1.63 [0.77, 3.44]) did not differ between ARBs and ACEIs but withdrawals due to adverse effects were lower with ARBs (RR 0.63 [95% CI 0.52, 0.76]). Combinations of ARBs plus ACEIs increased the risk of withdrawals due to adverse effects (RR 1.34 [95% CI 1.19, 1.51]) but did not reduce total mortality or total hospital admissions versus ACEI alone.Two placebo-controlled studies evaluated ARBs in 7151 patients with a LVEF >40% (mean 3.7 years). ARBs did not reduce total mortality (RR 1.02 [95% CI 0.93, 1.12]) or total morbidity as measured by total hospitalisations (RR 1.00 [95% CI 0.97, 1.05]) compared with placebo. Withdrawals due to adverse effects were higher with ARBs versus placebo when all patients were pooled irrespective of LVEF (RR 1.06 [95% CI 1.01, 1.12]).

AUTHORS' CONCLUSIONS:

In patients with symptomatic HF and systolic dysfunction or with preserved ejection fraction, ARBs compared to placebo or ACEIs do not reduce total mortality or morbidity. ARBs are better tolerated than ACEIs but do not appear to be as safe and well tolerated as placebo in terms of withdrawals due to adverse effects. Adding an ARB in combination with an ACEI does not reduce total mortality or total hospital admission but increases withdrawals due to adverse effects compared with ACEI alone.

Pubmed