RESUMO
BACKGROUND: N-terminal fragment B-type natriuretic peptide (NT-proBNP) prognostic utility is commonly determined post hoc by identifying a single optimal discrimination threshold tailored to the individual study population. The authors aimed to determine how using these study-specific post hoc thresholds impacts meta-analysis results. METHODS: The authors conducted a systematic review of studies reporting the ability of preoperative NT-proBNP measurements to predict the composite outcome of all-cause mortality and nonfatal myocardial infarction at 30 days after noncardiac surgery. Individual patient-level data NT-proBNP thresholds were determined using two different methodologies. First, a single combined NT-proBNP threshold was determined for the entire cohort of patients, and a meta-analysis conducted using this single threshold. Second, study-specific thresholds were determined for each individual study, with meta-analysis being conducted using these study-specific thresholds. RESULTS: The authors obtained individual patient data from 14 studies (n = 2,196). Using a single NT-proBNP cohort threshold, the odds ratio (OR) associated with an increased NT-proBNP measurement was 3.43 (95% CI, 2.08 to 5.64). Using individual study-specific thresholds, the OR associated with an increased NT-proBNP measurement was 6.45 (95% CI, 3.98 to 10.46). In smaller studies (<100 patients) a single cohort threshold was associated with an OR of 5.4 (95% CI, 2.27 to 12.84) as compared with an OR of 14.38 (95% CI, 6.08 to 34.01) for study-specific thresholds. CONCLUSIONS: Post hoc identification of study-specific prognostic biomarker thresholds artificially maximizes biomarker predictive power, resulting in an amplification or overestimation during meta-analysis of these results. This effect is accentuated in small studies.
Assuntos
Cardiopatias/sangue , Cardiopatias/diagnóstico , Peptídeo Natriurético Encefálico/sangue , Fragmentos de Peptídeos/sangue , Biomarcadores/sangue , Humanos , PrognósticoRESUMO
OBJECTIVES: To quantify the occurrence of myocardial infarction (MI) occurring in the early postoperative period after surgical hip fracture repair and estimate the effect on 1-year mortality. DESIGN: A population-based, historical cohort study of individuals who underwent surgical repair of a hip fracture that used the computerized medical record linkage system of the Rochester Epidemiology Project. SETTING: Academic and community hospitals, outpatient offices, and nursing homes in Olmsted County, Minnesota. PARTICIPANTS: Over the 15-year study period (1988-2002), 1,116 elderly adults underwent surgical repair of a hip fracture. MEASUREMENTS: At the end of the first 7 days after hip fracture repair, participants were classified into one of three groups: clinically verified MI (cv-MI), subclinical myocardial ischemia, and no myocardial ischemia. One-year mortality was compared between these groups. Multivariate models assessed risk factors for early postoperative cv-MI and 1-year mortality. RESULTS: Within the first 7 days after hip fracture repair, 116 (10.4%) participants experienced cv-MI and 41 (3.7%) subclinical myocardial ischemia. Overall 1-year mortality was 22%, with no difference between those with subclinical myocardial ischemia and those with no myocardial ischemia. One-year mortality for those with cv-MI (35.8%) was significantly higher than for the other two groups. Occurrence of early postoperative cv-MI, male sex, and history of heart failure or dementia were independently associated with greater 1-year mortality, whereas prefracture home residence and preoperative higher hemoglobin were protective. CONCLUSION: Rates of early postoperative, cv-MI after hip fracture repair exceed rates after other major orthopedic surgeries and are independently associated with greater 1-year mortality.
Assuntos
Fraturas do Quadril/cirurgia , Infarto do Miocárdio/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Infarto do Miocárdio/mortalidade , Taxa de SobrevidaRESUMO
This study considered if N-terminal prohormone brain natriuretic peptide (NT-proBNP) is associated with increased risk for postoperative cardiac events in high-risk patients undergoing noncardiac surgery. In addition, this report describes how levels of NT-proBNP are affected by noncardiac surgery. The study design was a prospective cohort study that enrolled 83 patients age > or =50 years with > or =1 risk factor for coronary artery disease having intermediate or high-risk noncardiac surgery. NT-proBNP levels were measured preoperatively and on postoperative days 1 and 3. During the month following surgery, 25 patients (33%) had a combined 37 postoperative cardiac events including 15 episodes of heart failure (20%), 12 episodes of new dysrhythmia (16%), 7 myocardial infarctions (9%), and 3 cardiac arrests (4%). Preoperative NT-proBNP level > or =457 pg/ml was significantly associated with occurrence of a postoperative cardiac event (odds ratio 10.5, 95% confidence interval 1.9 to 56.6, p = 0.006). After surgery, 64 of 72 patients (89%) had an increase in NT-proBNP from their preoperative level. In conclusion, this study determined there was a significant association between elevated preoperative NT-proBNP and occurrence of a postoperative cardiac event. In addition, increased NT-proBNP after noncardiac surgery is not uncommon even in the absence of clinically identifiable heart failure.
Assuntos
Doença da Artéria Coronariana/sangue , Peptídeo Natriurético Encefálico/sangue , Fragmentos de Peptídeos/sangue , Complicações Pós-Operatórias/sangue , Idoso , Biomarcadores/sangue , Estudos de Coortes , Intervalos de Confiança , Doença da Artéria Coronariana/etiologia , Feminino , Humanos , Masculino , Razão de Chances , Complicações Pós-Operatórias/etiologia , Prognóstico , Estudos Prospectivos , Curva ROC , Medição de Risco , Fatores de Risco , Sensibilidade e Especificidade , Fatores de TempoRESUMO
BACKGROUND: We previously demonstrated that a hospitalist service created to medically manage patients with hip fracture reduced time to surgery and length of hospital stay, with no difference in inpatient mortality, compared with patients who received standard care. Whether this improved efficiency affects long-term mortality is unknown. OBJECTIVE: This study examined the effects of this hospitalist service versus standard care on mortality up to 1 year and identified predictors of mortality in patients with hip fracture. DESIGN: Retrospective cohort study. SETTING: Tertiary care center. PATIENTS: Four hundred and sixty-six consecutive patients admitted for surgical repair of a hip fracture in 2000-2002 with 93% 1-year follow-up. RESULTS: There was no significant difference in survival of the patients between those on the hospitalist care service and those on the standard care service (70.5% [CI: 64.8%, 76.7%] vs. 70.6% [CI: 64.9%, 76.8%]; P = .36), despite the shortened time to surgery and decreased length of stay in the hospitalist group. Predictors of mortality included: admission from a nursing home (hazard ratio [HR] 2.24, [CI: 1.73, 2.90]); age at admission (HR 1.17 [CI: 0.99, 1.38]); inpatient complications, including ICU admission, myocardial infarction, or acute renal failure (HR 1.85 [CI: 1.45, 2.35]); and ASA class III or IV compared with ASA class II (HR 4.20 [CI: 2.21, 7.99]). CONCLUSIONS: The improved efficiency in reducing length of stay and time to surgery in the hospitalist group did not adversely affect long-term mortality of this patient population.
Assuntos
Fraturas do Quadril/mortalidade , Médicos Hospitalares , Idoso , Idoso de 80 Anos ou mais , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Assistência Perioperatória , Complicações Pós-Operatórias , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Análise de Sobrevida , Fatores de TempoRESUMO
OBJECTIVE: To report a case of organizing pneumonia with pulmonary eosinophilic infiltrates in a patient receiving daptomycin. CASE SUMMARY: An 84-year-old man developed bilateral, irregularly shaped nodules and infiltrates in the mid and peripheral lung and multiple mediastinal lymph nodes following treatment with intravenous daptomycin for infection of his left knee prosthesis. His other symptoms included decreased appetite, weight loss (6.8 kg over 4-6 wk), malaise, and generalized weakness after 4 weeks of daptomycin therapy. Transthoracic needle biopsy revealed organizing pneumonia with scattered eosinophils. His symptoms and results of computed tomography (CT) scan improved in the month following discontinuation of daptomycin. The Naranjo probability scale indicated a probable reaction to daptomycin. DISCUSSION: Pulmonary reactions have been reported with numerous drugs and have a wide range of clinical and radiographic presentations. Clinical trials have shown that daptomycin is well tolerated and has an adverse effect profile similar to that of vancomycin and the semisynthetic penicillins. This case report suggests that chronic use of daptomycin caused organizing pneumonia with eosinophilic infiltrates in a patient treated for an infected knee prosthesis. A definite mechanism for this reaction is not known. We speculate that the chronic administration of daptomycin allowed drug accumulation in surfactant in the alveolar spaces. This may result in higher concentrations of drug near the alveolar epithelial surface, which could injure the epithelium, resulting in organizing pneumonia. CONCLUSIONS: Development of new pulmonary infiltrates in patients treated with chronic daptomycin therapy should alert healthcare workers to this potential association.
Assuntos
Antibacterianos/efeitos adversos , Daptomicina/efeitos adversos , Eosinofilia/induzido quimicamente , Pneumonia/induzido quimicamente , Idoso de 80 Anos ou mais , Eosinofilia/complicações , Humanos , Masculino , Pneumonia/complicaçõesRESUMO
We describe the clinical presentation and diagnostic tests of a patient with regional transient osteoporosis (RTO) of the foot. This patient presented with a 4-month history of left-foot pain, nonpitting edema, and brownish discolorations of both feet. He had a history of tobacco abuse, alcohol abuse, and malnutrition. Radiological studies revealed severe osteopenia in the feet, and a MRI revealed bone marrow edema. The bone biopsy was consistent with RTO. This patient also had vitamin C deficiency. This case suggests a link between vitamin C deficiency and RTO, a hypothesis supported by our review of relevant literature on osteoporosis and vitamin C.
Assuntos
Deficiência de Ácido Ascórbico/complicações , Ácido Ascórbico/uso terapêutico , Suplementos Nutricionais , Osteoporose/etiologia , Deficiência de Ácido Ascórbico/fisiopatologia , Doenças Ósseas Metabólicas , Ossos do Pé/diagnóstico por imagem , Ossos do Pé/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Osteoporose/diagnóstico por imagem , Osteoporose/fisiopatologia , RadiografiaRESUMO
The clinical presentation of West Nile virus (WNV) can be severe in immunosuppressed patients. A 65-year-old with steroid-dependent rheumatoid arthritis on infliximab and methotrexate presented with meningitis and profound muscular weakness. Serum WNV IgM and IgG antibody were positive. WNV should be included in the differential diagnosis of neurological symptoms in peak months.
Assuntos
Artrite Reumatoide/imunologia , Hospedeiro Imunocomprometido , Meningite Viral/imunologia , Febre do Nilo Ocidental/imunologia , Idoso , Animais , Anticorpos Monoclonais/uso terapêutico , Antirreumáticos/uso terapêutico , Artrite Reumatoide/tratamento farmacológico , Humanos , Imunossupressores/uso terapêutico , Infliximab , Masculino , Meningite Viral/diagnóstico , Meningite Viral/virologia , Metotrexato/uso terapêutico , Febre do Nilo Ocidental/diagnóstico , Vírus do Nilo OcidentalRESUMO
Spontaneous intracranial hypotension is an increasingly recognized disorder, often, although not always, characterized by the triad of low-opening cerebrospinal fluid pressure on lumbar puncture, postural headache, and diffuse parenchymal meningeal enhancement on magnetic resonance imaging of the head. We describe an unusual case of a patient with spontaneous intracranial hypotension presenting with postural headache and tinnitus, aggravated at high altitudes.
Assuntos
Doença da Altitude/complicações , Cefaleia/etiologia , Hipotensão Intracraniana/complicações , Idoso , Feminino , Humanos , Zumbido/etiologiaRESUMO
BACKGROUND: Hospitalists' increased role in perioperative medicine allows for examination of their effects on surgical patients. This study examined the effects of a hospitalist service created to medically manage elderly patients with hip fracture. METHODS: During a 2-year historical cohort study of 466 patients 65 years or older admitted for surgical repair of hip fracture, we examined outcomes 1 year prior to and subsequent to the change from the standard to the hospitalist model. RESULTS: The mean (SD) time to surgery (38 [47] vs 25 [53] hours; P<.001), time from surgery to dismissal (9 [8] vs 7 [5] days; P = .04), and length of stay (10.6 [9] vs 8.4 [6] days; P<.001) were shorter in the hospitalist group. Predictors of shorter time to surgery were care by the hospitalist group (P = .002), older age (P = .01), and fall as the mechanism of fracture (P<.001), while American Society of Anesthesia scores of 3 and 4 were associated with increased time to surgery (P<.001). Receiving care by the hospitalist group (P<.001) and diagnosis of delirium (P<.001) were associated with increased chance of earlier dismissal, while admission to the intensive care unit decreased this chance (P<.001). Diagnosis of delirium was more frequent in the hospitalist group (74 [32.2%] of 230 vs 42 [17.8%] of 236; P<.001). There were no differences in inpatient deaths or 30-day readmission rates. CONCLUSION: In elderly patients with hip fracture, a hospitalist model decreased time to surgery, time from surgery to dismissal, and length of stay without adversely affecting inpatient deaths or 30-day readmission rates.
Assuntos
Fraturas do Quadril/cirurgia , Médicos Hospitalares , Tempo de Internação , Assistência Perioperatória , Complicações Pós-Operatórias , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Estudos Retrospectivos , Fatores de TempoRESUMO
OBJECTIVES: To determine whether the level of presence of faculty in the afternoon or evening influences residents' perception of learning, "autonomy," or satisfaction, and if so whether the effect is positive or negative. SUBJECTS AND METHODS: A survey of internal medicine residents was conducted from January 1 through June 30, 1999. Primary outcome was residents' satisfaction and its relationship to the degree of (resident-observed) faculty presence. RESULTS: A total of 156 (86.7%) of the 180 surveys distributed were returned. Residents rated the individual faculty members' frequency of afternoon or evening presence as "most/all of the time" (47%), "occasionally" (32%), or "never/rarely" (21%). Increased faculty presence was positively associated with higher resident "satisfaction with faculty" (P < .001), "educational value of time spent with the faculty member" (P = .001), "team dynamics" (P = .002), "(quality of) overall medical care provided" (P = .03), and "sufficient autonomy" (P = .04). Residents were less likely to report concerns (difficulties) with teaching (P < .001) and efficiency (P = .008) of faculty whose level of presence was increased. CONCLUSION: Contrary to some concerns expressed, increased faculty presence is associated with higher resident satisfaction and a more favorable learning experience.