The utility of patient-completed and partner-completed Epworth Sleepiness Scale scores in the evaluation of obstructive sleep apnea.

PURPOSE: Excessive daytime sleepiness in obstructive sleep apnea (OSA) is often rated differently by patients and their partners. This cross-sectional study compared the utility of patient-completed and partner-completed Epworth Sleepiness Scale (ESS) scores in the evaluation of suspected OSA. METHODS: Eighty-five patient-partner pairs were enrolled, and 75 patients completed diagnostic sleep studies. The individual and combined utilities of patient-completed and partner-completed ESS scores in identifying OSA and predicting various sleep study-derived indicators of disease severity were determined. RESULTS: Mean partner-completed ESS scores were higher than patient-completed ESS scores (12.3 ± 4.2 vs. 9.4 ± 4.8, p < 0.0001); Bland-Altman plot showed significant bias (partner-completed ESS scores 33.5 % higher, SD ±55.2 %). Partner-completed and combined (but not patient-completed) ESS scores correlated weakly with the apnea-hypopnea index (AHI; partner-completed ESS score r s  = 0.25, p = 0.029; combined ESS score r s  = 0.29, p = 0.013) and oxygen desaturation index (partner-completed ESS score r s  = 0.26, p = 0.025; combined ESS score r s  = 0.23, p = 0.047). None of the ESS scores correlated with body mass index, arousal index, or other parameters of nocturnal oxygen desaturation. In OSA (AHI > 15/h) detection, partner-completed ESS scores had greater sensitivity than patient-completed ESS scores (76.9 vs. 46.2 %) but poorer specificity (39.1 vs. 65.2 %); sensitivity was greatest (82.7 %) when either patient-completed or partner-completed ESS score was 10 or higher, and specificity was greatest (80.8 %) when both scores were 10 or higher. CONCLUSIONS: Neither patient-completed nor partner-completed ESS scores by themselves have great utility in identifying OSA or predicting its severity. However, taking both scores into consideration together improves the sensitivity and specificity of the screening process.

Impact of routine methicillin-resistant Staphylococcus aureus (MRSA) surveillance and cohorting on MRSA-related bloodstream infection in neonatal intensive care unit.

OBJECTIVE: To study the impact of methicillin-resistant Staphylococcus aureus (MRSA) surveillance on the incidence of MRSA-related bloodstream infection (BSI) in neonatal intensive care unit (NICU) and to evaluate cost-effectiveness of MRSA surveillance. STUDY DESIGN: MRSA surveillance policy was introduced in our NICU in April 2008. Pre-MRSA surveillance period (P1, April 2006-March 2008) was compared with the surveillance period (P2, April 2008-April 2010) for MRSA-related BSI (MRSA BSI). RESULTS: During P1 and P2, 1,576 and 1,512 neonates were enrolled. Of these, 3.8/1,000 and 5.3/1,000 developed MRSA BSI, respectively. During P2, 100% MRSA-related BSI occurred in MRSA-colonized neonates, as compared with zero in noncolonized group (p < 0.0001). Overall, 7 (30%) of the 23 neonates colonized during hospitalization developed MRSA BSI as compared with 1 of the 31 (3%) neonates colonized at admission (p = 0.007). Direct screening cost was $208 per patient. Since 28 neonates had to be screened to detect one colonization, $5,824 estimated per detection, excluding indirect costs. CONCLUSIONS: MRSA surveillance may protect non-MRSA colonized neonates from becoming colonized. This is of considerable importance because the acquisition of colonization during hospitalization was associated with a 10-fold increase in risk of developing MRSA BSI. Cost-effectiveness of MRSA surveillance remains debatable and further studies are needed to delineate cost-benefit ratio.

The impact of Sleep Time-Related Information and Communication Technology (STRICT) on sleep patterns and daytime functioning in American adolescents.

This cross-sectional study explored the extent and impact of mobile device-based Sleep Time-Related Information and Communication Technology (STRICT) use among American adolescents (N = 3139, 49.3% female, mean age = 13.3 years). Nearly 62% used STRICT after bedtime, 56.7% texted/tweeted/messaged in bed, and 20.8% awoke to texts. STRICT use was associated with insomnia, daytime sleepiness, eveningness, academic underperformance, later bedtimes and shorter sleep duration. Moderation analysis demonstrated that the association between STRICT use and insomnia increased with age, the association between STRICT use and daytime sleepiness decreased with age, and the association between STRICT use and shorter sleep duration decreased with age and was stronger in girls. Insomnia and daytime sleepiness partially mediated the relationship between STRICT use and academic underperformance. Our results illustrate the adverse interactions between adolescent STRICT use and sleep, with deleterious effects on daytime functioning. These worrisome findings suggest that placing reasonable limitations on adolescent STRICT use may be appropriate.

Fluconazole prophylaxis is associated with a decreased rate of coagulase-negative Staphylococcal infections in a subset of extremely low birth weight neonates.

Fluconazole prophylaxis is being used efficaciously in the neonatal intensive care unit (NICU) for fungal prophylaxis in very low birth weight and extremely low birth weight (ELBW) neonates. Little is known about the effect of fluconazole prophylaxis on bacterial infections. The purpose of this study was to examine that issue in a subset of ELBW, those weighing ≤900 g at birth. This is a retrospective study conducted in a level III NICU at state-designated children hospital in New Jersey (USA). We examined the data from our records of neonates ≤ 900 g birth weight during the period March 1, 2007-February 28, 2011. Inclusion in the study was all infants ≤ 900 g before (n = 67) and after (n = 81) the institution of fluconazole prophylaxis. Fluconazole prophylaxis was accompanied by a significant decrease in both the rate and number of days of bacterial infections as well as co-infections. We found that the incidence of coagulase-negative Staphylococcus (CONS) decreased from 46.2 to 24.7 % (OR 2.63; 95 % CI 1.31-5.27). Similarly, days of infection also decreased significantly (p < 0.0001). These data suggest that fluconazole prophylaxis may be associated with a reduction in CONS infections in that subset of ELBW neonates.

Predictors and outcomes of pneumonia in patients with spontaneous intracerebral hemorrhage.

OBJECTIVES: Pneumonia is an important complication of spontaneous intracerebral hemorrhage (sICH). The purpose of this study was to determine the predictors and outcomes of the development of pneumonia in patients with sICH. METHODS: In total, 290 consecutive patients with sICH admitted within 24 hours of stroke onset were investigated in a single center, retrospective study from January 2006 to July 2009. Clinical, biochemical, and imaging variables were registered. Stroke severity and functional outcomes were evaluated with the Glasgow Coma Scale (GCS) and modified Rankin Scale (mRS). Baseline variables that predicted pneumonia were investigated and outcomes were assessed. RESULTS: The association of our primary exposure variables, such as mechanical ventilation, tube feeding, dysphagia, and tracheostomy, with pneumonia was highly significant (P < .0001, for each variable). For mechanical ventilation, we observed an odds ratio (OR; 95% confidence interval [CI]) of 9.42 (4.24-20.9); for tube feeding, OR = 22.3 (8.91-55.8); for dysphagia, OR = 13.1 (4.66-36.7); and for tracheostomy, OR = 26.8 (8.02-89.3). After adjustment of potential confounders including GCS and mRS on admission, the use of angiotensin-converting enzyme inhibitors, proton pump inhibitors, and H2 blockers, all the adjusted OR (ORa) remained significant. For mechanical ventilation, the minimum ORa was 3.72 (95% CI: 1.68-8.26) when adjusted for GCS. For both dysphagia and tracheostomy, mRS reduced OR to 7.46 (95% CI: 3.34-10.6) in the case of dysphagia with an ORa of 16.2 (95% CI: 4.98 to 52.8) for tracheostomy. For tube feeding, both GCS and mRS reduced ORa; the former to 14.7 (95% CI: 6.16-35.0) and the latter to 15.7 (95% CI: 6.63-37.0). Pneumonia shows a significant effect on the morbidity (P = .003), length of stay (P < .0001), and mortality (P = .041) rate of the patients. CONCLUSION: Mechanical ventilation, tube feeding, dysphagia, and tracheostomy are exposures associated with increased risk of the development of pneumonia in patients with sICH. Pneumonia is associated with an increase in morbidity, length of stay, and mortality among patients with sICH.

CT scanning in the evaluation of pulmonary hypertension.

BACKGROUND: Right-heart catheterization is currently the gold standard method for detecting pulmonary hypertension (PH) and grading its severity. Our study determined the utility of computerized tomography (CT) scans for detecting PH in patients with left-sided heart disease, thereby potentially avoiding the overuse of invasive right-heart catheterization. METHODS: A retrospective review was conducted on 40 patients with left-sided cardiac pathology who had undergone both right-heart catheterization and CT scanning of the chest. Mean pulmonary artery diameters (MPADs) were measured on CT scans and compared with pulmonary artery pressures measured by right-heart catheterization. RESULTS: Patients with mild-to-moderate PH had significantly greater CT-measured MPADs (34.89 ± 1.01) than patients without PH (controls) (27.36 ± 0.83, p < 0.001). Patients with severe PH had significantly greater MPADs (38.31 ± 0.88) than both mild-to-moderate PH patients (p < 0.01) and controls (p < 0.001). Receiver operating characteristic curve analysis showed that CT scanning predicted PH with an area under the curve of 0.95 (p < 0.0001). A cutoff MPAD of >33.3 mm had 100% specificity and 100% positive predictive value (N = 40, p < 0.0001), and a cutoff MPAD of <27.3 mm had 100% sensitivity with 100% negative predictive value (N = 40, p < 0.001). CONCLUSIONS: CT scanning correctly identified all patients with PH with MPADs >34 mm and excluded all patients without PH when MPADs were <27 mm. We advocate that the measurement of MPAD by CT scanning can be quickly and easily performed by the clinician to screen for the presence of PH.

Electrocardiographic abnormalities in patients presenting with intracranial parenchymal haemorrhage.

OBJECTIVES: The electrocardiographic abnormalities associated with ischaemic stroke and subarachnoid haemorrhage have been described frequently and studied systematically; however, these changes were not investigated thoroughly in patients with intracranial parenchymal haemorrhage (IPH). METHODS: We retrospectively reviewed the electrocardiograms (ECGs) and medical records of all patients who had been diagnosed with acute intraparynchemal haemorrhage (IPH) between 2006 and 2009. RESULTS: We included 160 patients (56% males). The median age was 71 years (interquartile range (IQR) 59 to 80) and 69% were above the age of 60 years. Most patients were hypertensive (81%).The majority of patients (86%) had at least one ECG abnormality. Sixty-eight (43%) patients had T-wave inversion and 65 (41%) had QTc interval prolongation. There was a significant association between QTc prolongation and the bleeding size and the presence of midline shift; odd ratios were 2.8 (CI 1.4 to 5.5; P 0.003) and 2.2 (CI 1.1 to 4.2; P 0.04), respectively. In addition, sinus tachycardia was found to be significantly associated with the presence of hydrocephalus (OR 4.1; CI 1.3 to 12.8; P 0.02). CONCLUSIONS: ECG abnormalities are a common finding in patients with IPH. Repolarizaion abnormalities occur the most frequently. QTc prolongation was associated with bleeding size and midline shift. Patients who had hydrocephalus were more likely to have sinus tachycardia at presentation.

The Interim Case Fatality Rate (ICFR) of the COVID-19 Pandemic for Europe and the United States from March 1, 2020 to August 15, 2021. Does the ICFR Regress to the Final CFR?

OBJECTIVE: The true case fatality rate (CFR) of a disease outbreak can only be ascertained after all cases and deaths have been tabulated at the end of the epidemic. We define a metric, the interim case fatality rate (ICFR) which is the incremental change in the ratio of cases to deaths. To examine longitudinal changes in the ICFR of the COVID-19 pandemic and to evaluate the likelihood that the ICFR can predict the final CFR. METHODS: Publicly available databases were used to gather data on the number of cases and deaths in Europe and the United States (USA). These data were gathered over the period from Mar.1, 2020 to Aug. 15, 2021, on four regions of the USA and four regions of Europe on a bi-weekly basis. Statistical methods were utilized to evaluate changes over the final month of the study (July 15, 2021 to August 15, 2021). Stability of the ICFR was based on acceptance of the null hypothesis that no significant difference (p>0.05) was observed over that period. RESULTS: In all regions studied, the early months of the pandemic were marked by very high ICFRs. By late 2020, these began to stabilize at levels well below 5%. During the final month of the study, only one (Northeast USA) of the eight regions evaluated showed a statistically significant difference in ICFR. Mean ICFR projections, based on weighted values of cases are 1.8% (95% CI: 1.2% to 2.3%) for the USA and 2.1% (95% CI: 1.5% 2.7% for Europe. CONCLUSION: After an early peak, very little change was observed in the ICFR, and by summer 2021, the rates had stabilized. Weighted ICFR for all regions may well reflect the final ICFR.

Viral load and CD4+ cell count as risk factors for prolonged QT interval in HIV-infected subjects: a cohort-nested case-control study in an outpatient population.

BACKGROUND: QTc interval prolongation is a serious ECG finding which has frequently been reported in HIV-infected patients, but associated risk factors have not been determined in this population. METHODS: Data were collected from the charts of a cohort of 135 consecutive HIV-infected patients from our HIV outpatient clinic. The cohort was divided into two groups, patients with prolonged QTc and those with normal QTc interval. Multiple variables and potential risk factors were analyzed, including the CD4+ cell count and viral load (VL), which were assessed on the same day or within several days of the initial ECG. RESULTS: 23 patients were found to have prolonged QTc (17%). No significant difference in baseline characteristics was observed between the groups; however, statistically significant differences were observed with regard to the CD4+ cell count and VL. CONCLUSION: A low CD4 cell count and a high VL may be risk factors potentially related to QT prolongation in HIV patients in the outpatient setting.

Chronic kidney disease as a risk factor for Clostridium difficile infection.

INTRODUCTION: Clostridium difficile-associated diarrhoea (CDAD) is the most common cause of nosocomial diarrhoea in the USA. In this study, we sought to determine the association between chronic kidney disease (CKD) and CDAD. METHODS: A case-control study was designed to determine the association between CKD and CDAD in an urban hospital. Over a 2-year period, all patients diagnosed with CDAD (n = 188) were included as cases and the prevalence of CKD was calculated. Age- and sex-matched patients without CDAD were considered as controls with a ratio of 2:1 controls to cases. The prevalence of different stages of advanced CKD (stages 3-5) was determined and compared between groups. Also the calculated odds ratios (OR) were adjusted for multiple possible confounding variables using logistic regression analysis. RESULTS: There was no significant difference in prevalence of advanced CKD between cases and controls (OR = 1.38, 95% confidence intervals (CI) = 0.90-2.12, P = 0.1365). The association between CKD and CDAD remained insignificant in subjects with CKD stages 3-5 who were not on dialysis (OR = 1.07, 95% CI = 0.65-1.77), P = 0.7970). However, the group with end-stage renal disease on dialysis showed a significant association (OR = 2.60, 95% CI = 1.25-5.41, P = 0.0165). Controlling for antibiotics as a possible confounding variable, yielded an OR that was not statistically significant (OR = 2.05, 95% CI = 0.94-4.47, P = 0.07), but still showing a trend towards increased risk. CONCLUSION: End-stage renal disease may increase the risk of acquiring CDAD through unknown mechanisms. This suggests implementing better surveillance strategies for these patients and eliminating the known risk factors for CDAD.

Importance of performing transesophageal echocardiography in acute stroke patients older than fifty.

BACKGROUND: The purpose of this study was to determine the value of transesophageal echocardiography (TEE) in determining the presence of cardiac manifestations that required anticoagulation in patients presenting with acute stroke. METHODS: Of 626 consecutive stroke patients who underwent TEE, 188 patients with no obvious etiology for stroke were subcategorized according to age. TEE results were analyzed for cardiac findings suggestive of a cause for embolic stroke, including complex atheromas in the arch/ascending aorta, patent foramen ovale (PFO), atrial septal aneurysm (ASA), and intracavitary thrombi. Data were analyzed using Fisher's exact test. RESULTS: Of 188 patients, 66% (125/188) were older than 50 years and 34% (63/188) were younger than 50 years. The incidence of complex atheroma was 12.8% (16/125) in patients older than 50 years as compared to 0% (0/63) in patients who were younger than 50 years (P = 0.002). In patients older than 50 years, findings that indicated a need for anticoagulation based on TEE results were found in 22.4% (28/125) (atheroma = 16, PFO = 12, ASA = 5, thrombus = 3, PFO + ASA = 1) compared to 14.3% (9/63) (atheroma = 0, PFO = 5, ASA = 2, thrombus = 2, PFO + ASA = 1) in patients younger than 50 years. CONCLUSIONS: TEE plays an important role in suspected embolic stroke patients of all age groups. Due to the higher incidence of complex atheromas in patients older than 50 years of age, TEE might be of added importance in identifying the candidates who may benefit from anticoagulation.

Cardiac troponin I levels and alveolar-arterial oxygen gradient in patients with community-acquired pneumonia.

BACKGROUND: Patients with community-acquired pneumonia (CAP) appear to have cardiac stress as demonstrated by elevated B-type natriuretic peptide (BNP). We hypothesised that myocardial stress and decrease in oxygenation might also lead to elevations of cardiac troponin I (cTnI) levels in serum. OBJECTIVE: The aim of this study was to see if cTnI was associated with the alveolar-arterial oxygen gradient (DeltaA-a), a marker of severity in CAP. METHODS: Retrospective cohort study of 901 CAP patients with no evidence of acute coronary syndrome presenting to a large, tertiary-care, urban teaching hospital over a 3-year period. RESULTS: A strong linear trend between log(10)cTnI and DeltaA-a was observed (r(2)=0.76) with a statistically significant Spearman correlation coefficient (r(s)=0.75; p<0.0001) between cTnI and DeltaA-a. A cTnI value of 0.5 ng/ml discriminated mild CAP from moderate-severe CAP with an OR=208 (95% CI: 50.5-408; p<0.0001). CONCLUSIONS: These data suggest that decreased blood O(2) levels as suggested by elevated DeltaA-a may lead to acute myocardial damage and that cTnI may be useful as a biomarker to stratify risk in subjects with CAP.

The association of D-dimer levels with clinical outcomes in patients presenting with acute pulmonary embolism.

The D-dimer fragment of fibrin degradation has been a useful adjunct in the diagnosis of venous thromboembolism (VTE). In conjunction with predictive algorithms, the high negative predictive value (NPV) of D-dimer measurements has provided this analyte with a prominent position in the diagnosis of pulmonary embolism (PE). The purpose of this study was to determine if D-dimer levels correlate with ventilation/perfusion (V/Q) derangements as assessed by the alveolar-arterial oxygen tension gradient (DeltaA-a) and to ascertain if quantitative measurements of D-dimer on admission have prognostic value in terms of during-admission mortality and recurrence over a 60-week period. The study utilized a retrospective cohort of 108 subjects admitted to a single institution and studied longitudinally. The cohort was divided into 4 groups representing degree of severity assessed by computed tomographic (CT) angiography: mild, moderate, severe, and very severe. Differences in D-dimer levels among these groups were strongly significant (P < .0001). A strong correlation was observed between D-dimer concentration and DeltaA-a (P < .0001). Logistic methods were used to calculate a "cut-off" level that would distinguish mild-moderate from severe-very severe PE. At a concentration of 12.35 mug/mL, this level yielded an odds ratio (OR) of 12.64 (P = .006) for during-admission mortality and a hazard ratio (HR) of 0.13 (P < .0001) for 60-week recurrence. These data suggest that D-dimer levels have utility beyond their NPV and should be considered as potential prognostic markers in subjects presenting with acute PE.

In-use comparison of blood pressure measurements from an automated blood pressure instrument with those from a mercury sphygmomanometer.

In addition to its ease of use and degree of independence from the subjectivity inherent in measurements made with the mercury sphygmomanometer (HgS), automated blood pressure measurement instruments (ABPMI) obviate the use of mercury-containing instrumentation and the attendant environmental issues. Thus, they have been widely used in healthcare facilities worldwide. Most evaluations of ABPMI have focused on their compliance with established international protocols, and there has been a paucity of studies examining their performance in actual use in healthcare facilities. The purpose of this study was to evaluate the ABPMI used in our institution--a large, urban, tertiary-care teaching hospital in the northeastern United States--under routine conditions. This device, the Dinamap ProCare 400 Monitor, was compared to HgS (considered the "gold standard" for non-invasive blood pressure measurement) with respect to key analytical variables, i.e., precision of measurements and correlation within a large (n=300) sample of patients. Several sources of observer bias with HgS were detected. Precision varied among parameter (systolic blood pressure [SBP]; diastolic blood pressure [DBP]; and mean arterial pressure [MAP]) and level (normotensive, moderately hypertensive, and severely hypertensive). Correlation and regression suggested a strong association between the methods and Bland-Altman analysis indicated an acceptably small systematic error (bias) but greater random error than that demonstrated by previous evaluations with international test protocols. We recommend that healthcare facilities evaluate ABPMI under actual conditions and that formal protocols be established for these evaluations under routine conditions of patient care.

Adherence to the United States Preventative Services Task Force Female Screening Guidelines: An Internal Medicine Residency Program Experience.

Background Various guidelines exist for female preventative screening tests and medical resident physician adherence to the United States Preventive Services Task Force (USPSTF) guidelines varies. National screening rates for breast cancer and osteoporosis have improved but they are still below the expected target. Material and methods Ambulatory medical clinic records of female patients from the period July 2015 to December 2017 were reviewed for breast cancer and osteoporosis screening. Resident performance and commitment with regards to ordering the aforementioned screening tests according to the USPSTF guidelines were compared to the most recent national screening rates for mammograms and dual-energy X-ray absorptiometry (DXA) scans. Results Of the 1327 charts reviewed, 1025 was included in the study. Of the 545 mammograms performed, 93% of them were indicated according to the USPSTF guidelines (P < 0.0001, 95% CI: 125.9-342.0). A total of 480 mammograms were not ordered, of which 6% were indicated and 93.9% were not indicated. Out of a total of 107 DXA scans performed, 88.7% were correctly indicated (P < 0.0001, 95% CI: 37.11-132.9). Conclusion Resident physician adherence to the USPSTF screening guidelines for breast cancer and DXA scans were higher than the national and state screening rates. Our well-structured educational project (strong faculty mentorship, resident to patient continuity of care and the reasonable resident-clinic load) resulted in higher screening rates.

Alveolar-arterial oxygen gradient, pneumonia severity index and outcomes in patients hospitalized with community acquired pneumonia.

The alveolar-arterial oxygen gradient (DeltaA-a) provides a useful assessment of ventilation/perfusion (V/Q) abnormalities. The objectives of the present study were to: (i) examine the correlation between the DeltaA-a and the pneumonia severity index (PSI); and (ii) determine whether these measures were comparable in predicting clinical outcomes. The present study was conducted at a 750-bed teaching hospital. It examined a retrospective cohort of 255 patients with community acquired pneumonia (CAP) over a 2 year period. Association between the CAP and DeltaA-a was investigated by regression models and correlation, as well as two logistic models for subjects bifurcated by low-risk/moderate-to-high risk. The decision levels (DL) for both PSI and DeltaA-a were then compared as predictors of both length of stay (LOS) and survival. The correlation between PSI and DeltaA-a was strong (rho = 0.76; P < 0.0001) and was best modelled by a curvilinear relationship. Both logistic models indicated a strong association (P < 0.001) between DeltaA-a and PSI and yielded an optimal DL for the DeltaA-a of < 89 mmHg. Inter-test agreement of DeltaA-a with PSI was 76.9% (kappa = 0.60; 95% confidence interval 0.47-0.72; P < 0.0001). At < 89 mmHg, the odds ratios for LOS were similar to those at PSI = 90 in predicting LOS in the range 3-7 days, inclusive. There was no significant difference in the ability of DeltaA-a and PSI to predict survival for either the low- or high-risk group (P = 0.363 and P = 0.951, respectively). The DeltaA-a correlates well with PSI and performs comparably in predicting two major outcomes in subjects hospitalized with CAP.

The relationships between improvements in daytime sleepiness, fatigue and depression and psychomotor vigilance task testing with CPAP use in patients with obstructive sleep apnea.

OBJECTIVE: The purpose of this study was to determine if the subjective improvements in daytime sleepiness, fatigue and depression experienced by patients with obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) therapy predict an objective improvement in vigilance, and whether patients with mild-to-moderate OSA differ from patients with severe OSA in this regard. METHODS: A total of 182 patients underwent psychomotor vigilance task (PVT) testing and measurements of subjective daytime sleepiness, fatigue and depression at baseline and after a minimum of one month of adherent CPAP use at an adequate pressure. RESULTS: Patients with both mild-to-moderate (n = 92) and severe (n = 90) OSA experienced improvements in subjective daytime sleepiness, fatigue and depression, but objective improvement in vigilance was only seen in patients with severe OSA. In patients with severe OSA, while a correlation was found between improvements in daytime sleepiness and some PVT parameters, changes in subjective daytime sleepiness, fatigue and depression scores were not predictive of objective improvement in vigilance while controlling for all these subjective symptoms and for age, gender, body mass index, apnea-hypopnea index/respiratory event index and total sleep time/total recording time with pulse oximetry below 90%. CONCLUSIONS: We found no predictive relationship between subjective improvements in daytime sleepiness, fatigue and depression and objective vigilance with CPAP use in patients with OSA. These results suggest that subjective complaints of daytime impairment and objective measures of vigilance in patients with OSA should be assessed separately while evaluating the efficacy of CPAP therapy on daytime functioning.

Laboratory evaluation of the antiphospholipid syndrome.

The antiphospholipid syndrome (APS) was first described in 1986. The original association of this hypercoagulable state with anticardiolipin antibodies (aCL) resulted from the synthesis of evidence stemming from laboratory findings in systemic lupus erythematosus (SLE), ie, the frequent occurrence of false-positive VDRL tests and the paradoxical observation of the so-called "lupus anticoagulant" (LA), an increase in phospholipid (PL)-dependent clotting times. By the early 1990s, it was clear that a co-factor was involved in the reaction of antibodies to PL (aPL) in SLE patients with secondary APS and that this was a hitherto-obscure protein, beta-2 glycoprotein I (beta2GPI). In the intervening years, it has been established that beta2GPI and other PL-binding proteins such as prothrombin (PT) are relevant antigens in APS and assays for these antigens have been developed, standardized, and applied to subjects with both primary and secondary APS. Measurement and confirmation of LA activity is based on a stepwise approach and should follow the recommendations of the International Society of Thrombosis and Haemostasis. Although antibodies to various PL-binding proteins have been suggested as diagnostic targets for APS, the current (2006) consensus guidelines recognize only LA, aCL, and anti-beta2GPI for the classification of APS.

Clostridium difficile infection in an urban medical center: five-year analysis of infection rates among adult admissions and association with the use of proton pump inhibitors.

C. difficile-associated diarrhea (CDAD) has become a major cause of morbidity in hospitalized patients. In this study of five-year (2001-2005, inclusive) trends of incidence of CDAD among adults in an inner-city medical center, the overall annual incidence increased from 5.08 to 8.42 cases/10(3) admissions (p = 0.0005). Age distribution remained fairly constant for 2001-2004 but decreased significantly in 2005 (p = 0.005); no significant change was observed for gender. During the five-year period, we observed a decline in the use of histamine type 2 receptor antagonists (H2A) with a concomitant increase in the use of proton pump inhibitors (PPI) as a prophylactic measure to prevent stress ulcers. The usage of PPI correlated exactly (r(s) = 1.0; p = 0.017) with the increase in CDAD incidence. A case (n = 122)-control (n = 244) study for the final year was conducted, examining the association of PPI and H2A with CDAD. After controlling for the effect of antibiotic use, PPI either pre- or during admission was associated with CDAD (odds ratio, OR (adjusted) = 2.75, 95% CI = 1.68 to 4.52; p = 0.0001); the association with H2A was not significant (OR (adjusted) = 0.95, 95% CI = 0.39 to 2.34; p = 0.9153). If only first-time use during hospital stay is considered, PPI were also strongly associated with CDAD (OR (adjusted) = 1.88, 95% CI: 1.07 to 3.31; p = 0.0283) and H2A were not associated with CDAD (OR (adjusted) = 0.73, 95%CI: 0.26 to 2.06; p = 0.5520). These data suggest that the widespread prescription of PPI for stress ulcer prophylaxis in acute care facilities may contribute to the increased incidence of CDAD.

A review of echocardiograms in hypertensive patients greater than 60 years in a community based family medicine program.

Background: Heart disease as a result of Hypertension is known to occur. Anatomical and functional changes of the heart can easily be detected by echocardiography, which is a safe and readily available study. Objectives: The aims of this study were to evaluate the prevalence of common echocardiographic changes in chronic hypertensive patients and to compare these changes in male and female populations. Design/methods: The study was a community-based cross-sectional study, on 227 hypertensive patients, 60 years and older, seen in St. Joseph's Family Medicine at Clifton, with integrated clinical and echocardiographic data. Results: Study population consisted of 227 hypertensive patients, over the age of 60 years who had echocardiography done. Overall 92.5% of the echocardiograms had abnormal findings including but not limited to TR, Diastolic dysfunction, MR, and LVH. There was significant difference between the rate of MR in male and female population. Conclusion: A variety of echocardiographic abnormalities can be found in hypertensive patients. Drug selection in hypertension should be driven by the underlying cardiac pathology. Certain drugs have more effectiveness for diastolic dysfunction, LVH, systolic dysfunction and pulmonary hypertension and are superior choices when these conditions are present. Echocardiogram is a non-invasive and easily available tool in order to help us to select the best treatment strategy to optimize hypertensive control in the challenging group of elderly patients. The results of our study should influence us to liberally use echocardiography in these patients to guide treatment decision and drug selection. Abbreviations: LVH: left ventricular hypertrophy; MR: mitral valve regurgitation; TR: tricuspidvalve regurgitation; LVD: left ventricular dilation; LVEF: left ventricular ejection fraction.