Developing a risk prediction model for 30-day unplanned hospitalization in patients receiving outpatient parenteral antimicrobial therapy.

OBJECTIVES: Outpatient parenteral antimicrobial therapy (OPAT) is increasingly used to treat a wide range of infections. However, there is risk of hospital readmissions. The study aim was to develop a prediction model for the risk of 30-day unplanned hospitalization in patients receiving OPAT. METHODS: Using a retrospective cohort design, we retrieved data on 1073 patients who received OPAT over 2 years (January 2015 to January 2017) at a large teaching hospital in Sheffield, UK. We developed a multivariable logistic regression model for 30-day unplanned hospitalization, assessed its discrimination and calibration abilities, and internally them validated using bootstrap resampling. RESULTS: The 30-day unplanned hospitalization rate was 11% (123/1073). The main indication for hospitalization was worsening or nonresponse of infection (52/123, 42%). The final regression model consisted of age (adjusted odds ratio (aOR), 1.18 per decade; 95% confidence interval (CI), 1.04-1.34), Charlson comorbidity score (aOR, 1.11 per unit increase; 95% CI, 1.00-1.23), prior hospitalizations in past 12 months (aOR, 1.30 per admission; 95% CI, 1.17-1.45), concurrent intravenous antimicrobial therapy (aOR, 1.89; 95% CI, 1.03-3.47) and endovascular infection (aOR, 3.51; 95% CI, 1.49-8.28). Mode of OPAT treatment was retained in the model as a confounder. The model had adequate concordance (c-statistic 0.72; 95% CI 0.67-0.77) and calibration (Hosmer-Lemeshow p 0.546; calibration slope 0.99; 95% CI 0.78-1.21), and low degree of optimism (bootstrap optimism corrected c-statistic, 0.70). CONCLUSIONS: We identified a set of six important predictors of unplanned hospitalization based on readily available data. The prediction model may help improve OPAT outcomes through better identification of high-risk patients and provision of tailored care.

Classic congenital adrenal hyperplasia with virilisation and salt-wasting: from birth to the adult life.

AIM: Our objective was to show the way the classic CAH presents after birth as a severe condition and develops to the adult life, effecting growth, height and weight, appearance, fertility, relationships and quality of life. CASE: We report the case of a 23-years-old female with the classic Congenital Adrenal Hyperplasia (CAH) from birth, diagnosed due to genital pigmentation, clitoromegaly and salt-wasting crisis, treated with glucocorticoid replacement (hydrocortisone, fludrocortisone and NaCI), followed by genital surgery, until the adult life when she continues treatment with fludrocortisone and prednisolone. CONCLUSION: A treatment challenge is to effectively control the excess androgen symptoms by using the lowest possible glucocorticoid dose. Patients well-being can be accomplished by team work, adapted therapy, continues follow-up and patient's compliance (Ref. 15).

Complications in pregnancy after bariatric surgery.

INTRODUCTION: The application of bariatric surgery has recently spread among obese women including women of reproductive age. MATERIALS AND METHODS: We sought to present three cases of obese women undergoing bariatric surgery, their monitoring and complications during pregnancy. CONCLUSION: We suggest that conception should be postponed for at least 18 months after bariatric operation to avoid complications concerning both mother and fetus mainly associated with nutritional deficiencies due to the anatomical and physiological changes of such operations.

Quantitative detection of the M204V hepatitis B virus minor variants by amplification refractory mutation system real-time PCR combined with molecular beacon technology.

Mutations in the highly conserved tyrosine-methionine-aspartate-aspartate (YMDD) motif are frequently associated with resistance to antivirals and represent a major concern in the treatment of hepatitis B virus (HBV) infection. Conventional methods fail to detect minority populations of drug-resistant viral quasispecies if they represent less than 25% of the total sample virus population. The amplification refractory mutation system real-time PCR (ARMS RT-PCR) was combined with molecular beacon technology using the LightCycler system. The samples from HBV patients selected for assay evaluation included (i) 57 samples from treatment-naïve patients for biological discriminatory ability (cutoff) estimation, (ii) 12 samples from patients with treatment failure that were M204V positive by sequencing, and (iii) 13 samples from patients with treatment failure that were negative for mutation at codon 204 by sequencing. The discriminatory ability of the assay was 0.25% when tested with laboratory-synthesized DNA target sequences. The median mutant-to-wild-type ratio for samples from naive patients tested positive for the wild type and for mutant variants was 0.01% (5th and 95th percentiles = 0.0001 and 0.04%, respectively). A value of 0.04% was selected as the biological cutoff of the assay of clinical samples. In all samples M204V positive by sequencing (12/12), the mutant variant was detected as the predominant population (range, 82.76 to 99.43%). Interestingly, in 5 (38%) of 13 samples negative by sequencing, the M204V variant was detected at a ratio above the biological cutoff (0.05 to 28%). The assay represents an efficient technique for the early detection and quantification of M204V variants before mutant strains emerge to dominate the population.

Preeclampsia or initial diagnosis of chronic renal disease during pregnancy.

An unusual case of early nephrotic syndrome without hypertension which slightly resolved after delivery is documented. Renal biopsy was performed postpartum and the diagnosis was focal and segmental glomerulosclerosis with moderate chronic renal changes. It is questioned whether the case was due to preeclampsia or was the initial diagnosis of chronic renal disease which was made during pregnancy. The role of renal biopsy in such cases is briefly discussed (Tab. 2, Ref. 15). Full Text (Free, PDF) www.bmj.sk.

Matching criteria in case-control studies on postoperative infections.

Matching is commonly used in case-control studies to control for the effect of major confounding factors. We evaluated the available evidence from case-control studies regarding postoperative infections to identify how frequently matching was performed and with what specific variables. We searched for relevant case-control studies in PubMed until August 2006 and further evaluated those that used individual matching between cases and controls. We identified and evaluated 42 relevant studies. Age was used as a matching criterion in 27 of these 42 (64.3%) case-control studies. The specific type of surgical procedure was the second most commonly used criterion in 17 of 42 studies (40.5%). Gender was used in 14/42 studies (33.3%) as a matching criterion between case and control patients. The period at risk for development of surgical site and/or other postoperative infections, i.e. time from surgery to the diagnosis of infection, was used in nine of 42 studies (21.4%), as was date of operation, and the primary diagnosis that led the case and control patients to surgery. The same surgeon or surgical team was used in seven studies (16.7%); matching according to the National Nosocomial Infection Surveillance system risk score was performed in five studies (11.9%). The findings of our analysis suggest that various characteristics are used for matching in case-control studies of postoperative infections. A more consistent use of matching with the specific type of surgical procedure may help in increasing the internal validity of a case-control study in this field of clinical research.

Detection of large histiocytes in pap smears: role in the prediction of endometrial pathology?

OBJECTIVE: The objective of this study was to clarify the prognostic significance of large histiocytes in Papanicolaou smears. METHOD: During a 2-year period, 893 smears were assessed by the Cytology Laboratory of our Hospital. Twenty-one smears were reported including large histiocytes (2.4%). Colposcopy was also performed in all of these women. RESULTS: 9/21 of the women (43%) presented vaginocervicitis, whereas 3/21, 1/21, 1/21, 1/21 and 1/21 revealed endometrial polyps, complex hyperplasia with atypia, simple hyperplasia after tamoxifene use, submucosal myoma and endometrial carcinoma respectively. On the other hand, colposcopy revealed suspicious cervical areas in none of the patients. Therefore, the positive prognostic value for endometrial pathology was 7/21 (33.3%). DISCUSSION: Various forms of histiocytes are found in inflammatory processes in vaginal and cervical smears. According to our results, large histiocytes could be considered as an indicator for endometrial pathology but not for endometrial cancer. However, when histiocytes are found, further clinical evaluation and work up should be done. Finally, in the present study, the detection of large histiocytes seems to be a good prognostic factor for cervical pathology (Ref. 10).

The role of laboratory testing of free peritoneal fluid during an explorative laparotomy in the diagnosis of an extra-ovarian neoplasm.

We present a case in which the diagnosis of the ovarian carcinoma was made only by the free peritoneal fluid cytology as all the other specimens were negative for malignancy. We discuss the role of laboratory testing of the free peritoneal fluid even in small amounts or of the peritoneal drainage in cases of ovarian cystic neoplasms not only for the staging, but also for the diagnosis itself (Ref 16). Full Text (Free, PDF) www.bmj.sk.

Rifampin as adjuvant treatment of Gram-positive bacterial infections: a systematic review of comparative clinical trials.

We reviewed the bibliographic evidence from comparative trials regarding the role of rifampin as adjuvant treatment in the treatment of Gram-positive infections [PubMed (1/1950-7/2006)]. Only studies reporting comparative outcome data in patients treated with an antibiotic regimen with the addition or not of rifampin were included. Eight comparative studies were identified [all were randomized controlled trials (RCTs)], five reporting on infections caused by staphylococci (S. aureus in 97% of patients) and three by streptococci. There was no statistically significant difference in mortality between the treatment arms (with and without rifampin) in any of the included studies. Clinical cure was achieved more commonly (p < 0.05) in the rifampin treatment arm in 3/8 studies; in staphylococcal infections of orthopedic stable implants and in beta-hemolytic streptococcal pharyngitis in children (one RCT each), and in one RCT that reported on patients with various staphylococcal infections. However, no statistically significant difference in cure of the infection between the two groups was found after pooling data from two RCTs (121 patients) that reported on patients with various staphylococcal infections (odds ratio = 0.57; 95% confidence interval 0.27-1.17). No differences were noted between the two groups regarding relapse of infection or adverse events. There is only limited evidence from comparative trials regarding the role of rifampin as adjuvant therapeutic agent for infections caused by Gram-positive bacteria, not allowing for definitive conclusions on this important management question. More controlled trials are necessary for better evaluation of this practice.

Linezolid for the treatment of patients with [corrected] mycobacterial infections [corrected] a systematic review.

We searched PubMed and Cochrane databases to review the available evidence regarding the use of linezolid in combination with other drugs for the treatment of patients with mycobacterial infection. Case reports, case series, prospective and retrospective studies, and randomized controlled trials were eligible for inclusion in our systematic review if they evaluated the effectiveness and safety of linezolid for the treatment of patients with mycobacterial infection. Four studies were available, including 24 cases of patients with [corrected] mycobacterial infection. Cure of the infection, defined as sterilization of mycobacterial cultures or resolution of symptoms, was achieved in 15 of the 24 cases (62.5%) with mycobacterial infection (mainly tuberculosis). Sterile cultures were also achieved in three other cases, although the patients had stopped linezolid (two because of optic neuropathy and one due to economic reasons; all three continued on second-line therapy). On the other hand, serious adverse events were observed in the majority of patients with mycobacterial infection treated with combinations that included linezolid (18/24, 75%). Neuropathy (peripheral and/or optic) and anemia were reported in 11/24 (45.8%) and 10/24 (41.7%) cases, respectively. Although the limited evidence suggests that linezolid may be considered as a second-line agent for mycobacterial infections, any treatment with linezolid should be weighed against the risks associated with its long-term use.

Analysing the evolutionary history of HCV: puzzle of ancient phylogenetic discordance.

Though recombination is an important evolutionary strategy in RNA viruses, only two cases of HCV recombinant strains have been reported. Our objective was to analyze the evolutionary history of the HCV genotypes aiming to obtain evidence of significant phylogenetic discordance due to either recombination or selective forces leading to convergent/divergent evolution. The data support an evolutionary preservation of the interferon-resistance related genomic region (ISDR) for the genotypes 1 and 4. On the other hand, there was no evidence that recombination has occurred in the past with the possible exception of genotype 4. Moreover, it is evidenced that genotypes 3 and 10 split more recently than genotypes 6-9 and 11. This analysis reverberates a commonly found pattern in rapidly evolving viruses, that is the strongly disturbed evolutionary history which deforms the uniform distribution of the phylogenetic relationships across the genome, and introduces a conservative inference framework for approaching this kind of data.