Hemodynamic Adverse Effects of Dexmedetomidine and Propofol in a Critically Ill Trauma and Surgical Population: A Retrospective Cohort.

BACKGROUND: Propofol and dexmedetomidine may cause hemodynamic adverse effects (AEs) and more data are needed in a trauma and surgical population. OBJECTIVE: The objective of this study was to evaluate the rate of hemodynamic AEs requiring an intervention between dexmedetomidine and propofol in a critically ill trauma and surgical population. METHODS: This was a retrospective cohort study at a Level 1 trauma center. Intensive care unit patients admitted from October 1, 2017, through October 31, 2018, were divided into two groups: dexmedetomidine or propofol. The primary end point was the proportion of patients who required a therapeutic intervention for a hemodynamic AE within the first 24 hr of initiation of dexmedetomidine or propofol. RESULTS: A total of 800 charts were reviewed and 85 patients (dexmedetomidine [n = 35] and propofol [n = 50]) were included. The study population consisted of Caucasian (86%) males (61%) with a median age of 61 [interquartile range-IQR 48, 72], and 18% and 24% required antihypertensive and vasopressor agents, respectively. No difference in the primary outcome was observed (17 [49%] vs. 27 [54%], p = .624). There was no difference in the overall incidence of hemodynamic AE (18 [51%] vs. 30 [60%], p = .433). Dexmedetomidine patients had a greater decrease in median heart rate (HR) compared with the propofol (23 [IQR 16, 41] vs. 14 [IQR 5, 24] beats/min, p = .002). CONCLUSIONS: The rate of hemodynamic AEs requiring therapeutic interventions was similar between dexmedetomidine and propofol in a critically ill trauma and surgical population; however, dexmedetomidine may be associated with a larger decrease in HR.

Suspected gonorrhea and chlamydia: Incidence and utilization of empiric antibiotics in a health system emergency department.

BACKGROUND: In the ED, patients are treated empirically for suspected gonorrhea and/or chlamydia (GC). Limited studies have evaluated the treatment of sexually transmitted diseases (STDs) in conjunction with predictor variables. This study will allow providers to better identify patients with potential GC to streamline antibiotic treatment. OBJECTIVES: The primary objective was to determine the incidence of positive assay in patients that underwent GC screening. The secondary objectives included the proportion of patients assayed that received empiric therapy and the predictive value of risk factors to identify positive assays. METHODS: This retrospective cohort study included adult patients who presented to the health-system EDs and underwent GC screening. Subjects were excluded if they were victims of sexual assault, left AMA or eloped. RESULTS: A total of 490 assayed patients were included, of which 84 (17%) were found to be positive for GC assay. Of the 278 patients treated empirically, 74% had a negative assay. Of the entire sample (n = 490), risk factors found to predict a positive assay (p < 0.05) included male, women <25 years of age, concomitant bacterial vaginosis, pelvic inflammatory disease or trichomonas, penile discharge, inconsistent condom use, previous/coexisting STDs, and uninsured. CONCLUSIONS: Compared to previous reports, this study found a higher incidence of positive GC assays for patients with suspected infection. This is the first study to evaluate GC testing in both men and women in the ED, and risk factors not previously reported by the CDC were identified.

Evaluation of factors associated with achieving glycemic control in a pharmacist-managed diabetes clinic.

The aim of this study was to identify factors that are associated with patients achieving goal A1c after 6 months in a pharmacist-managed diabetes clinic. This study is a descriptive, retrospective chart review of patients with type 2 diabetes enrolled in a pharmacist-managed diabetes clinic. The primary endpoint was the odds of each identified factor being associated with achievement of goal A1c after 6 months of enrollment. The factors were also evaluated within 2 subgroups: those with a baseline A1c >7% and those with a baseline A1c >9%. Of 112 patients enrolled, 58 were included in the analysis. There was a positive association with reaching goal for patients who had <1 failure to show (FTS) to office visits in 6 months [odds ratio (OR) 8.10, 95% confidence interval (CI) 1.47-58.65], had canceled or FTS to <50% of office visits (OR 10.0, 95% CI 1.8-72.79), and brought >75% of blood glucose logs to their office visits (OR 7.36, 95% CI 1.87-30.88). There was a negative association with reaching the goal for patients with documented social worker involvement (OR 0.22, 95% CI 0.04-0.99) and noninsulin or insulin dose increases at >50% of office visits (OR 0.10, 95% CI 0.01-0.55). Overall, this analysis found that patients who had <1 FTS, had canceled or FTS to <50% of office visits, or who brought >75% logs to office visits were more likely to achieve goal A1c, whereas patients with social work assistance or dose increases at >50% of office visits were less likely to reach goal A1c.

Utilization of a reminder mailing to improve blood glucose log reporting in an outpatient diabetes clinic.

Self-monitored blood glucose (SMBG) offers a strategy used to achieve glycemic control in diabetic patients. However, if SMBG readings are unavailable to clinicians, this strategy will have a limited effect. This study assessed the impact of a reminder mailing on response rates to requests for SMBG logs. Patients were asked to mail completed SMBG logs to the clinic in 2 weeks. For the intervention, a reminder mailing was sent to each patient 1 week before SMBG logs were to be returned. Compliance rates pre and postinterventions were compared. The primary outcome was the percentage of all SMBG logs returned on time. Secondary outcomes included the percentage of SMBG logs returned, percentage fulfilled, percentage of clinic appointments kept, percentage of SMBG logs brought to follow-up appointments, and number of interventions made to antidiabetic therapy. Twenty SMBG requests were made in the preintervention cohort versus 19 in postintervention cohort. A trend toward more on time and fulfilled SMBG requests was observed post vs. preintervention. Overall return rates were similar between groups. A nonsignificant increase in clinic appointments kept and a nonsignificant decrease in interventions made were observed postintervention. Receipt of a reminder mail was not a significant predictor of patients bringing an SMBG log to follow-up appointments. In conclusion, the use of a reminder mail was not associated with an increase in the return rate of SMBG logs, although there were nonsignificant trends toward more on time and fulfilled SMBG logs received during the postintervention period.

Cinacalcet for the treatment of primary hyperparathyroidism.

The objective of this article is to review the literature regarding the treatment of primary hyperparathyroidism (PHPT) with a focus on cinacalcet. A MEDLINE (1965-June 2009) and bibliographic search of the English-language literature was conducted using the search terms cinacalcet, calcimimetics, primary hyperparathyroidism, and treatment. All articles identified in the search were included. Parathyroidectomy is curative for patients with PHPT; however, there are few options for patients who are not surgical candidates, who refuse surgery, or those with refractory PHPT after parathyroidectomy. Possible treatment options include estrogens, raloxifene, bisphosphonates, calcitonin, and cinacalcet. Cinacalcet has been shown to decrease serum calcium and parathyroid hormone serum levels in patients with PHPT. These trials, however, have not studied the effect of cinacalcet on patient-oriented outcomes such as bone mineral density, nephrolithiasis, or other complications of PHPT. Cinacalcet may be considered to reduce serum calcium and parathyroid hormone serum levels in patients with PHPT who cannot or will not undergo surgery and those with refractory PHPT after parathyroidectomy. Because the effects of cinacalcet on bone mineral density are uncertain, more frequent monitoring of bone mineral density may be required along with a medication proven to improve bone mineral density. Future studies should evaluate the effect of cinacalcet on complications of PHPT.

Comparison of short-acting intramuscular antipsychotic medication: impact on length of stay and cost.

A retrospective cohort study was conducted to determine if there is an association between short-acting intramuscular (SAIM) antipsychotics used for acute agitation and length of stay (LOS). Patients with a diagnosis of schizophrenia or schizoaffective disorder who were dispensed at least one dose of a SAIM antipsychotic were divided into groups based on the initial SAIM antipsychotic received once admitted to a psychiatric unit. Electronic records were used to gather demographic information, LOS, and number of injections received during an admission. Cost was calculated from the number of injections received. One-hundred and thirty-six patients were enrolled. When comparing the haloperidol group to the second generation antipsychotic group, there was no statistically significant difference, in LOS 16.98 ± 9.56 days versus 17.59 ± 11.52 days (P = 0.75), respectively. There was a statistically significant difference in both cost and number of injections between groups, favoring the haloperidol group. Ziprasidone was associated with a shorter LOS compared with olanzapine, 13.57 and 19.10 days, respectively (P = 0.026). Patient characteristics should be evaluated when determining an agent for acute agitation. However, because literature indicates second generation SAIM antipsychotics are only noninferior to haloperidol; other factors should also be evaluated; including impact on LOS and impact on hospital resources. This study indicates use of a second generation SAIM antipsychotic for acute agitation is more costly, requires more injections, and was not associated with a shorter length of stay when compared with SAIM haloperidol.

Pharmacy-facilitated medication history program at a community teaching hospital: A pre-post study in an emergency department.

PURPOSE: A study was conducted to compare the accuracy of medication histories compiled by pharmacy technicians with histories obtained through the usual multidisciplinary process. METHODS: A retrospective cohort study was conducted at a community teaching hospital from January 2017 through February 2018. Inclusion criteria included patient age of at least 18 years, use of 1 or more medications at the time of admission, and hospital admission through the emergency department. Each electronically documented medication history was assessed for accuracy. The objective was to compare the accuracy of pharmacy technician-collected medication histories to those obtained through the usual multidisciplinary process. RESULTS: Of 215 patients screened, 183 were included in the study: 91 patients whose medication histories were obtained through the usual multidisciplinary process and 92 whose medication histories were collected by pharmacy technicians. Overall, documentation for 1,773 medications listed in medication histories was reviewed. The primary outcome of medication history accuracy occurred 38% of the time with the usual multidisciplinary process and 70% of the time with pharmacy technician collection of medication histories (P < 0.001). CONCLUSION: The study showed that the accuracy of medication histories was improved when histories were obtained by pharmacy technicians instead of via the usual multidisciplinary process.

Anticholinergic therapy for lower urinary tract symptoms associated with benign prostatic hyperplasia.

Lower urinary tract symptoms (LUTS) are commonly associated with benign prostatic hyperplasia (BPH). The LUTS-BPH complex consists of both voiding and storage symptoms that may overlap with overactive bladder symptoms. Drug therapy for men with LUTS may include alpha1-antagonists, 5-alpha-reductase inhibitors, combination therapy, and over-the-counter phytotherapy. Anticholinergic agents are effective in relieving overactive bladder symptoms in patients without bladder outlet obstruction. However, anticholinergic therapy has historically been contraindicated in patients with LUTS associated with BPH because of concerns for developing acute urinary retention. To assess the safety and efficacy of anticholinergic therapies for LUTS associated with BPH, a MEDLINE search and a bibliographic search of the English-language literature were conducted. Two nonrandomized, open-label studies; two randomized trials that assessed anticholinergic therapy alone; and eight trials that assessed anticholinergic therapy in combination with an alpha1-antagonist were identified. Trials were of short duration (6-12 wks) and included only men with low postvoid residual volumes at baseline. Small nonsignificant changes were seen in objective measures of urinary function. Several trials demonstrated an increase in postvoid residual with anticholinergic therapy, which was statistically significant in two trials. Despite the increase in postvoid residual, rates of acute urinary retention were low and the drugs were well tolerated. Of the five trials that used a validated symptom scoring scale, two demonstrated subjective improvement in urinary function. Men with symptomatic overactive bladder and BPH who are not adequately relieved with alpha1-antagonists may benefit from the addition of an anticholinergic agent. Before starting therapy, however, a postvoid residual volume should be measured to measure to rule out baseline urinary retention.

Retrospective evaluation of a method to predict fresh-frozen plasma dosage in anticoagulated patients.

In the United States, fresh-frozen plasma (FFP) is commonly used for urgent reversal of warfarin; however, dosage recommendations are difficult to find. If validated, a proposed method that uses a nonlinear relationship between international normalized ratio (INR) and clotting factor activity (CFa) would be useful. This study retrospectively evaluated a proposed equation with adult medical inpatients who received FFP for warfarin reversal. For each patient the equation was used to predict the dose of FFP required to achieve the observed change in INR, which was then compared to the actual dose. The equation was considered successful if the predicted dose was within +/-20% of the actual dose. Subgroup analyses included subjects who received concomitant vitamin K; subjects with supratherapeutic INRs (>3); and subjects with significantly elevated INRs (>5). Of the 209 patients screened, 91 met criteria for inclusion in the study. Use of the equation to calculate the predicted dose of FFP was successful in 11 patients (12.1%) with use of actual body weight for prediction and in 23 patients (25.3%) with use of ideal body weight (P = 0.02). The equation performed similarly in all subgroups analyzed. The mean predicted FFP dose was significantly greater than the actual dose in all patients when actual body weight was used (925.2 mL vs. 620.6 mL; P < 0.001). Least-squares regression modeling of repeat INR (converted to CFa) produced a model that accounted for 57% of the variance in repeat INR. The value predicted from the model was closer to the actual CFa than was the value predicted from the published equation in every comparison, but it was statistically different only when actual body weight was used. This study revealed that a published equation for calculation of FFP dose to reverse oral anticoagulation resulted in doses that were significantly higher than the actual dose. Use of ideal body weight improved accuracy but was still not successful for the majority of patients. Until trials are able to prospectively demonstrate the accuracy of a dose-prediction model for FFP, dosing will remain largely empiric.

Use of intravenous valproic acid for acute migraine.

OBJECTIVE: To review the literature regarding the use of intravenous valproic acid in aborting an acute migraine attack. DATA SOURCES: A MEDLINE (1967-June 2007) and bibliographic search of the English-language literature was conducted using the search terms valproic acid and migraine disorders. STUDY SELECTION AND DATA EXTRACTION: All articles identified through the search were included. DATA SYNTHESIS: Divalproex sodium is approved by the Food and Drug Administration for the prevention of migraine headaches. The use of intravenous valproic acid has been studied as a possible treatment for acute migraine. Available studies are small, mostly open-label and non-placebo-controlled, and used variable doses. Valproic acid has not been shown to be superior to comparator drugs and was inferior to prochlorperazine in one trial. CONCLUSIONS: Intravenous valproic acid has not been proven effective for acute migraine treatment. Future trials should be larger, placebo-controlled, and use a standardized dose and outcome measures.

Antibiotic Dosing in Sustained Low-Efficiency Dialysis in Critically Ill Patients.

PURPOSE OF REVIEW: Sustained low-efficiency dialysis (SLED) is increasingly used as a renal replacement modality in critically ill patients with acute kidney injury (AKI) and hemodynamic instability. There is, therefore, a greater need for the understanding of the antibiotic dosage and pharmacokinetics in these patients, to provide them with optimal therapy. SOURCES OF INFORMATION: PubMed/Medline, Embase, and Google Scholar. METHODS: PubMed/Medline, Embase, and Google Scholar databases were searched using a combination of key words: dialysis, end stage renal disease, renal failure, sustained low efficiency dialysis, extended daily dialysis, prolonged intermittent renal replacement therapy (PIRRT), and antibiotic dosing. Studies that investigated antibiotic dosing and pharmacokinetics during SLED/extended daily dialysis/PIRRT were selected for this review. KEY FINDINGS: Eleven studies met inclusion criteria and selected for data extraction. The data with regard to dialysis specifications, type of antibiotic including dosages, drug clearances, and dosage recommendations are summarized in Table 1. It is a challenge to find therapeutic doses for antibiotics during SLED therapy because, in general, only aminoglycosides and vancomycin can be assayed in clinical laboratories. LIMITATIONS: Although current studies on antibiotic dosing in SLED are limited due to diverse and undersized patient populations, antibiotic dosage adjustments for patients receiving SLED discussed here will serve as a valuable guide. Future large-scale research should focus on establishing guidelines for antibiotic dosage in SLED. IMPLICATIONS: Pharmacokinetic principles should be taken into consideration for the appropriate dosing of drugs during SLED, yet it is vital to monitor response to drug to make sure therapeutic goals are achieved. Antibiotic dosing and timing relative to the initiation of SLED may be important to maximize either the time above the minimum inhibitory concentration (MIC) (time-dependent) or the peak to MIC ratio (concentration-dependent), balancing efficacy and toxicity concerns. Critical care physicians should liaise with nephrologists to make decisions regarding appropriate antibiotic dosing in patients undergoing SLED.

JUSTIFICATION: On recourt de plus en plus à l'hémodialyse prolongée à faible efficacité (SLED ­ sustained low-efficiency dialysis) comme thérapie de remplacement rénal chez les patients gravement malades présentant une insuffisance rénale aiguë (IRA) et une instabilité hémodynamique. Dès lors, il devient impératif de se pencher sur la posologie des antibiotiques et leur pharmacocinétique chez ces patients de façon à leur offrir le meilleur traitement possible. SOURCES: Les bases de données PubMed/Medline, Embase et Google Scholar. MÉTHODOLOGIE: Nous avons épluché les bases de données PubMed/Medline, Embase et Google Scholar à l'aide d'une combinaison de mots-clés : dialysis (dialyse), end stage renal disease (insuffisance rénale terminale), renal failure (insuffisance rénale), sustained low efficiency dialysis (hémodialyse prolongée à faible efficacité), extended daily dialysis (dialyse quotidienne prolongée), prolonged intermittent renal replacement therapy ou PIRRT (thérapie de remplacement rénal intermittente prolongée) et antibiotic dosing (posologie des antibiotiques). Ont été retenues pour cette revue les études qui exploraient la posologie des antibiotiques et leur pharmacocinétique dans les contextes de la SLED, de la dialyse quotidienne prolongée et de la PIRRT. CONSTATS: Onze études répondaient à nos critères d'inclusion. Les données obtenues sur les caractéristiques de la dialyse, de même que sur le type d'antibiotique, sa posologie, sa clairance et les doses recommandées sont résumées dans le Tableau 1. L'établissement de la dose thérapeutique d'antibiotique durant la SLED pose un défi puisque, généralement, seuls les aminoglycosides et la vancomycine peuvent être dosés en laboratoire clinique. LIMITES: Bien que la fiabilité d'études traitant de la posologie des antibiotiques utilisés durant la SLED soit limitée, en raison notamment d'échantillons de sujets faibles et hétérogènes, les ajustements posologiques pour les patients traités par SLED discutés ci-après constitueront des balises utiles. De futurs essais à plus grande échelle devraient se concentrer sur l'établissement de lignes directrices concernant les doses thérapeutiques d'antibiotiques à administrer pendant la SLED. CONCLUSION: Les principes pharmacocinétiques devraient être pris en compte pour établir la posologie d'antibiotique appropriée pendant la SLED. Il demeure toutefois crucial de surveiller la réponse au médicament pour s'assurer que les objectifs thérapeutiques sont atteints. La posologie d'antibiotiques et le moment d'initiation de la SLED pourraient s'avérer importants pour maximiser soit le temps au-dessus de la concentration minimale inhibitrice (en fonction du temps), soit le rapport entre le pic et cette même concentration (en fonction de la concentration), de façon à établir un équilibre entre les préoccupations liées à l'efficacité et celles relatives à la toxicité. Les médecins des unités de soins intensifs et les néphrologues devraient coopérer pour prendre des décisions conjointes quant à la posologie d'antibiotique appropriée pour les patients traités par SLED.

Update on prostate cancer chemoprevention.

BACKGROUND: Prostate cancer is the most common type of cancer and the second leading cause of cancer-related deaths in American men. Its high rate of occurrence and long lead time to clinically significant disease make prostate cancer an ideal disease for pharmacologic or nutritional chemoprevention. METHODS: To identify the various chemoprevention strategies for prostate cancer, a MEDLINE search (from 1967-2005) and bibliographic search of the English-language literature were conducted. RESULTS: Epidemiologic and retrospective studies have assessed the effect of carotenoids (e.g., lycopene), vitamins, selenium, and nonsteroidal antiinflammatory drugs (NSAIDs) on the rate of occurrence of prostate cancer. The few published prospective trials evaluated prostate cancer as a secondary end point. Lycopene (as beta-carotene) and selenium supplementation have been associated with a reduced risk of prostate cancer in nested case-control studies, but only in subgroups of men with low baseline plasma lycopene (or beta-carotene) and selenium levels respectively. The Prostate Cancer Prevention Trial prospectively evaluated finasteride, a 5-alpha-reductase inhibitor, as chemoprevention. The results showed a 25% relative risk reduction in prostate cancer, albeit at an increased risk of invasive tumors. CONCLUSION: Data regarding lycopene, vitamin E, and selenium as chemoprevention for prostate cancer appear promising. Prospective trials such as the Selenium and Vitamin E Cancer Prevention Trial (SELECT) will clarify the role of these agents in prostate cancer prevention. The role of NSAIDs is unclear, and the long-term toxicity associated with NSAIDs may limit their usefulness. Although finasteride has decreased overall prostate cancer occurrence, the risk of invasive tumors may outweigh the benefit of this agent. The continuing Reduction by Dutasteride of Prostate Cancer Events (REDUCE) trial may help define a role for the 5-alpha-reductase inhibitors in cancer chemoprevention. At this time, nothing has been proven effective as chemoprevention against clinically significant prostate cancer.

Erythromycin in the Treatment of Diabetic Gastroparesis.

The macrolide antibiotic erythromycin has been known to be associated with increased gastrointestinal motility since its introduction more than 35 years ago. Investigators have, thus, sought to take advantage of this side effect in patients with gastric stasis secondary to long-standing insulin-dependent diabetes mellitus (IDDM). The hormone motilin induces phase 3 contractions of the migrating motor complex (MMC) to induce peristalsis and facilitate gastric emptying in normal subjects. Patients with diabetic gastroparesis lack adequate phase 3 activity to effectively empty gastric contents. Exogenous motilin administered to animals and patients with diabetic gastroparesis has proven useful for promoting gastric emptying. However, motilin is expensive to produce and must be given intravenously. Erythromycin has been shown to induce premature phase 3 activity via stimulation of motilin receptors, so investigators evaluated its efficacy for the treatment of diabetic gastroparesis. Early studies in animals with experimental gastroparesis indicated that erythromycin may be a useful prokinetic agent. Human studies of both intravenous erythromycin and chronic oral erythromycin in patients with diabetic gastroparesis resistant to other prokinetic agents showed that gastric retention was indeed reduced and symptomatic improvement achieved. Even though erythromycin lost some of its prokinetic activity with chronic oral dosing, gastric retention was still significantly reduced compared to placebo or baseline. Although prokinetic agents like metoclopramide, domperidone and cisapride are effective for the treatment of patients with diabetic gastroparesis, tachyphylaxis and adverse effects are obstacles to their use. Erythromycin appears to be both effective and well tolerated in clinical studies. At this time it should be reserved for the treatment of patients with diabetic gastroparesis who are resistant to or intolerant of other prokinetic agents. Future research on erythromycin's long-term safety and comparative efficacy will further define its role.

Screening for nephropathy and antiangiotensin use among diabetic patients in an academic community medical center.

The American Diabetes Association recommends routine screening for albuminuria to detect early nephropathy in all patients with diabetes mellitus. If nephropathy is identified, treatment with an antiangiotensin agent decreases progression and improves renal outcomes. Concordance with guidelines for nephropathy screening and antiangiotensin therapy among diabetic patients in a primary care setting of an academic community medical center was evaluated. Medical charts of adult patients with diabetes mellitus from February 2000 through January 2003 were retrospectively reviewed. In part 1 of the study, whether patients were screened for nephropathy at least once was recorded. In part 2 of the study, antiangiotensin prescribing was assessed in all patients and in subgroups stratified by screening. In both parts of the study, patient characteristics and comorbidities were assessed using multivariate analysis to determine their impact on the odds that a patient was screened and that antiangiotensin therapy was prescribed. Among the 329 patients included, 182 patients (55.3%) were screened for nephropathy. Patients who were screened were younger (OR=0.83 for 10-year increase, 95% CI: 0.69-0.99), less likely to have congestive heart failure (OR=0.42, 95% CI: 0.20-0.90), and more likely to be cared for by a resident physician directly supervised by an attending physician (OR=3.03; 95% CI: 1.82-5.03). A total of 215 patients (65.3%) were prescribed antiangiotensin therapy. Hypertension was a predictor of antiangiotensin therapy among all patients who were screened (OR=10.34, 95% CI: 4.45-24.01), those who were screened and negative (OR=15.46, 95% CI: 5.56-42.98), and those who were not screened (OR=10.79, 95% CI: 4.39-26.52). Among patients screened for nephropathy, coronary artery disease (OR=3.01, 95% CI: 1.05-8.63), and the presence of proteinuria (OR=4.26, 95% CI: 1.61-11.24) were predictors of antiangiotensin use. This study found that the likelihood of screening for nephropathy among diabetic patients was inversely associated with a diagnosis of congestive heart failure and increasing age. Conversely, care by a resident physician directly supervised by an attending physician increased the odds that patients would be screened. A diagnosis of hypertension and the presence of albuminuria were each associated with increased use of an antiangiotensin agent.

Long-term prophylaxis of spontaneous bacterial peritonitis in patients with cirrhosis.

OBJECTIVE: To review the literature regarding long-term prophylaxis of spontaneous bacterial peritonitis (SBP) in patients with cirrhosis. DATA SOURCES: A MEDLINE (1967-September 2004) and bibliographic search of the English-language literature was conducted using the search terms spontaneous bacterial peritonitis, cirrhosis, antimicrobial, and prophylaxis. DATA SYNTHESIS: Long-term antimicrobial prophylaxis has been shown to decrease recurrent SBP in cirrhotics with a prior episode. Prophylaxis in patients with low ascitic fluid protein has also been shown to reduce the incidence of SBP; however, studies are too in-homogeneous to identify subgroups that benefit the most. CONCLUSIONS: Long-term antimicrobial therapy should be considered for secondary prophylaxis of SBP. Studies should be done to confirm this benefit and identify subsets of patients with low ascitic fluid protein who clearly benefit.

Retrospective comparison of nebulized levalbuterol and albuterol for adverse events in patients with acute airflow obstruction.

The objective of this study was to retrospectively compare the mean change in heart rate (HR) of patients with acute airflow obstruction treated with nebulized levalbuterol vs. albuterol. The study was conducted at the Akron General Medical Center, a 537-bed adult tertiary care teaching and research medical center. The participants were patients (> or = 18 years old) presenting to the emergency department with acute airflow obstruction. This was a retrospective chart review. Treatment groups received either levalbuterol (0.63 mg) or albuterol (2.5 mg). Respiratory care notes record HRs before and after nebulization of levalbuterol or albuterol. Primary analysis was conducted on days 1 and 3 of therapy to determine whether there is a difference between levalbuterol and albuterol with regard to mean change in HR with each treatment. In the primary analysis data, 35 subjects in each treatment group were compared. The mean age (+/- SD) was 65 +/- 16.4 and 68 +/- 16.5 for levalbuterol and albuterol, respectively. On day 1 of therapy, the difference in the mean change in HR with albuterol compared with levalbuterol was 1.0 bpm (95% CI, -1.6 to 3.7). On day 3, a statistically significant difference occurred in mean change in HR between treatment groups at 2.7 bpm (95% CI, 0.02 to 5.4). An increase in HR of 2.7 bpm by albuterol compared with levalbuterol on day 3 of therapy was the only significant finding among the analyses. However, this finding did not demonstrate dangerous elevations in HR following treatment with albuterol. Even the upper end of the confidence interval range at 5.4 bpm does not support a clinically significant difference in tachycardia with the pure isomer compared with the racemic mixture during acute airway obstruction.

Duration of anticoagulant therapy after initial idiopathic venous thromboembolism.

OBJECTIVE: To review the literature investigating the duration of oral anticoagulant therapy following a first event of idiopathic venous thromboembolism (VTE). DATA SOURCE: MEDLINE (1967-April 2003) and bibliographic searches of the English-language literature pertaining to the duration of oral anticoagulant therapy following a first event of idiopathic VTE was conducted. Search terms included venous thromboembolism, anticoagulation, duration of treatment, warfarin, and idiopathic. STUDY SELECTION AND DATA EXTRACTION: The results of all trials and meta-analyses that were obtained are reviewed and critiqued. DATA SYNTHESIS: The risk of recurrent VTE following a first idiopathic event is similar to the risk in patients with a permanent risk factor. Conventional-intensity oral anticoagulant therapy reduces this risk by 80-90%, but at an annual risk of bleeding of approximately 2-3%. According to the PREVENT trial, low-intensity anticoagulation also affords protection against VTE recurrence, but at a lower risk of bleeding. Older trials indicated that longer therapy was superior to shorter therapy; however, data from recent trials have demonstrated that the benefit was maintained only while receiving therapy. CONCLUSIONS: Patients with a first episode of idiopathic proximal VTE should be considered for indefinite anticoagulant therapy. The appropriate intensity of anticoagulation is still controversial; however, it appears that low-intensity treatment would be appropriate in most patients. For patients who will not continue therapy indefinitely, there does not appear to be any long-term benefit to extending the duration of therapy from 3 to 6 months.

Management of asymptomatic bacteriuria in patients with diabetes mellitus.

OBJECTIVE: To review the literature regarding the management of asymptomatic bacteriuria (ASB) in patients with diabetes mellitus. DATA SOURCES: A MEDLINE (1967-June 2003) and bibliographic search of the English-language literature was conducted using the search terms diabetes mellitus, asymptomatic, bacteriuria, and urinary tract infection. DATA SYNTHESIS: ASB occurs in diabetic women more commonly than in non-diabetics and is associated with an increased risk of symptomatic urinary tract infection (UTI) among patients with type 2 diabetes. Symptomatic UTIs tend to follow a more complicated course in diabetics. Despite these independent observations, antimicrobial therapy has not been shown to reduce symptomatic UTIs, pyelonephritis, or hospitalization for UTI. CONCLUSIONS: Available evidence does not support antimicrobial treatment of ASB among patients with diabetes mellitus.