Hospital-Onset Sepsis Warrants Expanded Investigation and Consideration as a Unique Clinical Entity.

Sepsis causes more than a quarter million deaths among hospitalized adults in the United States each year. Although most cases of sepsis are present on admission, up to one-quarter of patients with sepsis develop this highly morbid and mortal condition while hospitalized. Compared with patients with community-onset sepsis (COS), patients with hospital-onset sepsis (HOS) are twice as likely to require mechanical ventilation and ICU admission, have more than two times longer ICU and hospital length of stay, accrue five times higher hospital costs, and are twice as likely to die. Patients with HOS differ from those with COS with respect to underlying comorbidities, admitting diagnosis, clinical manifestations of infection, and severity of illness. Despite the differences between these patient populations, patients with HOS sepsis are understudied and warrant expanded investigation. Here, we outline important knowledge gaps in the recognition and management of HOS in adults and propose associated research priorities for investigators. Of particular importance are questions regarding standardization of research and clinical case identification, understanding of clinical heterogeneity among patients with HOS, development of tailored management recommendations, identification of impactful prevention strategies, optimization of care delivery and quality metrics, identification and correction of disparities in care and outcomes, and how to ensure goal-concordant care for patients with HOS.

Clinical Implications of Bronchodilator Testing: Diagnosing and Differentiating COPD and Asthma-COPD Overlap.

BACKGROUND: Bronchodilation testing is an important component of spirometry testing, and omitting this procedure has potential clinical implications toward diagnosing respiratory diseases. We aimed to estimate the impact of bronchodilator testing in accurately diagnosing COPD and differentiating COPD from asthma-COPD overlap (ACO). METHODS: The National Health and Nutrition Examination Survey data were analyzed from 2007-2012. Airflow limitation was defined by FEV1/FVC < 0.7. Subjects with pre-bronchodilator airflow limitation were classified into pre-but-not-post-bronchodilator airflow limitation and post-bronchodilator airflow limitation groups. Spirometry-confirmed COPD was defined by persistent airflow limitation on post-bronchodilator spirometry. The American Thoracic Society (ATS) and the Spanish Society of Pneumology and Thoracic Surgery (SEPAR) definitions were used to identify possible ACO subjects. RESULTS: We identified 11,763 subjects ≥ 40 y of age eligible for spirometry; 625 of them had a pre-bronchodilator FEV1/FVC < 0.7 and completed post-bronchodilator spirometry that met ATS spirometry quality standards. A total of 244 (39%) of these subjects had only pre-not-post-bronchodilator airflow limitation, thereby not meeting the definition of spirometrically confirmed COPD. The prevalence of ACO was 7.6% using the modified ATS definition and 19.8% using the modified SEPAR criteria. When bronchodilator testing-based criteria were excluded from ATS and SEPAR definitions, the number of ACO subjects decreased by 39.3% and 12.3%, respectively. CONCLUSIONS: Spirometry with bronchodilation is an important element in the accurate diagnosis of ACO and COPD. Spirometry performed without bronchodilator testing may lead to an estimated misclassification of ACO by 7.6% to 19.8% and overdiagnosis of COPD by 39%.

Significado del patrón serológico Anti-HBc Aislado determinado por la respuesta serológica a la vacunación contra Hepatitis B / Significance of the Isolated Anti-HBc serological pattern determined by the serological response to the vaccination against Hepatitis B

Con frecuencia se encuentran donantes de Banco de sangre con presencia en suero del anti-HBc total, en ausencia del Antígeno de superficie (HBsAg) y el anticuerpo contra el antígeno de superficie (Anti-HBs). Se diseñó el presente estudio para determinar la respuesta serológica a la vacunación contra el virus de la hepatitis B y evaluar la efectividad de la vacuna en dichos casos, considerando que los títulos protectores en Hepatitis B se miden en niveles superiores a 10 mUl/ml. Se incluyeron 31 pacientes con el patrón serológico HBsAg(-)/Anti-HBs(-)Anti-HBc(+). Se les administró 3 dosis de la vacuna ADN recombinante (Hepavax Gene 20 ug), siguiendo el esquema 0,1,2 meses. Se midieron los niveles de Anti-HBs 30 días después de la aplicación de la última dosis. Luego de las 3 dosis de vacuna los niveles de Anti-HBs fueron > 100 mUl/ml en el 89 por ciento, >500 en el 50 por ciento y >1000 en el 14,3 por ciento de los pacientes vacunados. Sólo 3 pacientes (9.7 por ciento) no presentaron respuesta serológica 30 días después de la aplicación de la última dosis de vacuna. En conclusión, se obtuvieron niveles de Anti-HBs, considerados protectores (>10 mUl/ml), en el 90 por ciento de pacientes con el patrón serológico HBsAg (-) Anti-HBs (-) Anti-HBc (+).