Estacionalidad de las bacteriemias en urgencias / Seasonality of bacteremia cases in an emergency department

Objetivo. Valorar la variabilidad de la estacionalidad en los episodios de bacteriemia. Método. Estudio de cohortes retrospectivo de las bacteriemias significativas de los hemocultivos extraídos en un servicio de urgencias. Se analizó la incidencia, etiología, rentabilidad y pronóstico, así como las variaciones en función de las estaciones del año. Resultados. Se realizaron 4.384 solicitudes de hemocultivos, que representó una tasa de solicitud del 4,1%. La rentabilidad diagnóstica fue del 12,2%. La incidencia de bacteriemia fue de 490 episodios por cada 100.000 atenciones. En invierno, respecto a la media del resto de estaciones, resultaron significativos el incremento en la solicitud de hemocultivos (4,6% frente a 3,8%, p < 0,001), el descenso de la rentabilidad diagnóstica (10,2% frente a 13%, p = 0,01), el incremento en la tasa de contaminación (4,9 % frente a 3,8%, p = 0,02), una menor frecuencia de aislamientos de Escherichia coli (36,4% frente a 46,9%, p = 0,03) y mayor de Streptococcus pneumoniae (14,5% frente a 5,9%, p = 0,001). Conclusiones. Se identifica una variabilidad significativa en cuanto al perfil microbiológico, rentabilidad y contaminantes en los hemocultivos obtenidos durante la estación invernal

Objective. To assess seasonal variation in episodes of bacteremia. Methods. Retrospective cohort study of cases of significant bacteremia found in blood cultures ordered in a hospital emergency department. The incidence, etiology, diagnostic and prognostic yield were analyzed for each season of the year. Results. A total of 4384 blood cultures were ordered in 4.1% of the emergency patients attended. The diagnostic yield was 12.2% (incidence, 490 cases per 100 000 cases attended). Cultures were ordered more often in winter (in 4.6% of the patients vs in 3.8% in the other seasons on average, P<.001). The diagnostic yield was lower in winter than in the other seasons (10.2% vs 13%, P=.01), and the contamination rate was higher (4.9% vs 3.8%, P=.02). Escherichia coli was isolated in fewer cultures in winter than in other seasons (36.4% vs 46.9%, P=.03), and Streptococcus pneumoniae was isolated in more (14.5% vs 5.9%, P=.001). Conclusions. The microbiological profile of blood cultures, their diagnostic yield, and rate of contamination differ greatly in winter

Seasonality of bacteremia cases in an emergency department. / Estacionalidad de las bacteriemias en urgencias.

OBJECTIVES: To assess seasonal variation in episodes of bacteremia. MATERIAL AND METHODS: Retrospective cohort study of cases of significant bacteremia found in blood cultures ordered in a hospital emergency department. The incidence, etiology, diagnostic and prognostic yield were analyzed for each season of the year. RESULTS: A total of 4384 blood cultures were ordered in 4.1% of the emergency patients attended. The diagnostic yield was 12.2% (incidence, 490 cases per 100 000 cases attended). Cultures were ordered more often in winter (in 4.6% of the patients vs in 3.8% in the other seasons on average, P<.001). The diagnostic yield was lower in winter than in the other seasons (10.2% vs 13%, P=.01), and the contamination rate was higher (4.9% vs 3.8%, P=.02). Escherichia coli was isolated in fewer cultures in winter than in other seasons (36.4% vs 46.9%, P=.03), and Streptococcus pneumoniae was isolated in more (14.5% vs 5.9%, P=.001). CONCLUSION: The microbiological profile of blood cultures, their diagnostic yield, and rate of contamination differ greatly in winter.

OBJETIVO: Valorar la variabilidad de la estacionalidad en los episodios de bacteriemia. METODO: Estudio de cohortes retrospectivo de las bacteriemias significativas de los hemocultivos extraídos en un servicio de urgencias. Se analizó la incidencia, etiología, rentabilidad y pronóstico, así como las variaciones en función de las estaciones del año. RESULTADOS: Se realizaron 4.384 solicitudes de hemocultivos, que representó una tasa de solicitud del 4,1%. La rentabilidad diagnóstica fue del 12,2%. La incidencia de bacteriemia fue de 490 episodios por cada 100.000 atenciones. En invierno, respecto a la media del resto de estaciones, resultaron significativos el incremento en la solicitud de hemocultivos (4,6% frente a 3,8%, p < 0,001), el descenso de la rentabilidad diagnóstica (10,2% frente a 13%, p = 0,01), el incremento en la tasa de contaminación (4,9 % frente a 3,8%, p = 0,02), una menor frecuencia de aislamientos de Escherichia coli (36,4% frente a 46,9%, p = 0,03) y mayor de Streptococcus pneumoniae (14,5% frente a 5,9%, p = 0,001). CONCLUSIONES: Se identifica una variabilidad significativa en cuanto al perfil microbiológico, rentabilidad y contaminantes en los hemocultivos obtenidos durante la estación invernal.

Ability of retinopathy to predict cardiovascular disease in patients with type 2 diabetes mellitus.

It is important identify patients with very high cardiovascular risk to intensify their therapy. Our aim was to assess the association between retinopathy and incident cardiovascular events (cardiovascular disease [CVD]) in patients with type 2 diabetes mellitus (DM). Patients were included if they had type 2 DM and a visible fundus. Baseline clinical and biochemical variables, including urinary albumin excretion rate, were collected. Clinical end points were nonfatal or fatal cardiovascular events (unstable angina including revascularization, nonfatal or fatal myocardial infarction, transient ischemic attack, nonfatal or fatal stroke, lower-leg amputation, terminal chronic heart failure, sudden death). Cox multivariate regression models were used to evaluate the risk associated with each variable and the independent contribution of baseline retinopathy. A total of 458 patients were included, with mean follow-up time of 6.7 +/- 2.6 years. Incident CVD rates were 30.7 per 1,000 patient-years in patients with a normal fundus, 56.7 in patients with nonproliferative retinopathy, and 90.7 in patients with proliferative retinopathy (p <0.0001). In multivariate analysis, nonproliferative retinopathy (hazard ratio 1.71, 95% confidence interval 1.1 to 2.66, p = 0.017) and proliferative retinopathy (hazard ratio 2, 95% confidence interval 1.1 to 3.56, p = 0.019) were significantly associated with incident CVD. In conclusion, retinopathy proved to be an independent risk marker for CVD in patients with type 2 DM.

[Microalbuminuria accounts for the increased vascular disease risk in diabetic patients with metabolic syndrome]. / La microalbuminuria explica el incremento de riesgo vascular en pacientes con diabetes y síndrome metabólico.

The aim of this study was to determine the impact of the metabolic syndrome on vascular disease risk in patients with type-2 diabetes. A prospective cohort study was carried out. The main dependent variable was the combination of coronary disease, stroke and lower leg amputation. Cox regression modeling was used. In total, 317 patients were followed for a mean of 7.7 years. The prevalence of metabolic syndrome was 87%. Multivariate analysis identified the following as predictors of incident vascular disease: age (relative risk [RR] =1.06, 95% confidence interval [CI], 1.02-1.1; P=.0003), baseline cardiovascular disease (RR=1.8; 95% CI, 1.1-3.0; P=.017), and the simultaneous presence of four metabolic risk factors (RR=5.8; 95% CI, 1.8-18; P=.003). The most predictive factor was microalbuminuria (chi2=5.9; P=.015). Microalbuminuria accounts for the increased risk of vascular disease in patients with metabolic syndrome. In evaluating vascular disease risk in patients with type-2 diabetes, it is more important to consider the total number of metabolic risk factors than the presence of metabolic syndrome alone.

La microalbuminuria explica el incremento de riesgo vascular en pacientes con diabetes y síndrome metabólico / Microalbuminuria accounts for the increased vascular disease risk in diabetic patients with metabolic syndrome

El objetivo fue evaluar la importancia pronóstica del síndrome metabólico (SM) en el riesgo vascular en diabetes mellitus tipo 2 (DM2). Se realizó estudio de cohortes prospectivo. La variable dependiente, enfermedad cardiovascular (ECV), fue una combinación de eventos coronarios, cerebrovasculares y amputación de extremidades inferiores. Se utilizó modelo de regresión de Cox. Se incluyó a 317 pacientes seguidos durante 7,7 años. La prevalencia de SM fue del 87%. Los predictores de ECV incidente en análisis multivariable fueron: edad (riesgo relativo [RR] = 1,06; intervalo de confianza [IC] del 95%, 1,02-1,1; p = 0,0003), ECV prevalente (RR = 1,8; IC del 95%, 1,1-3; p = 0,017), y presentar simultáneamente 4 factores de riesgo metabólicos (RR = 5,8; IC del 95%, 1,8-18; p = 0,003). El componente más predictivo fue la microalbuminuria (χ2 = 5,9; p = 0,015). La microalbuminuria explica el poder predictivo del SM para la aparición de ECV. Es más importante considerar el número de factores de riesgo metabólico que el SM al evaluar el riesgo vascular del paciente con DM2 (AU)

The aim of this study was to determine the impact of the metabolic syndrome on vascular disease risk in patients with type-2 diabetes. A prospective cohort study was carried out. The main dependent variable was the combination of coronary disease, stroke and lower leg amputation. Cox regression modeling was used. In total, 317 patients were followed for a mean of 7.7 years. The prevalence of metabolic syndrome was 87%. Multivariate analysis identified the following as predictors of incident vascular disease: age (relative risk [RR] =1.06, 95% confidence interval [CI], 1.02-1.1; P=.0003), baseline cardiovascular disease (RR=1.8; 95% CI, 1.1-3.0; P=.017), and the simultaneous presence of four metabolic risk factors (RR=5.8; 95% CI, 1.8-18; P=.003). The most predictive factor was microalbuminuria (χ2=5.9; P=.015). Microalbuminuria accounts for the increased risk of vascular disease in patients with metabolic syndrome. In evaluating vascular disease risk in patients with type-2 diabetes, it is more important to consider the total number of metabolic risk factors than the presence of metabolic syndrome alone (AU)

Microalbuminuria presents the same vascular risk as overt CVD in type 2 diabetes.

OBJECTIVES: We attempted to assess whether microalbuminuria conferred the same cardiovascular risk as overt CVD in type 2 diabetic patients. MATERIAL AND METHODS: A prospective cohort study including 436 type 2 diabetic patients (64.8+/-9.2 years old) without proteinuria, with follow-up until any cardiovascular event occurred, was performed. Patients were classified into four groups: group 0, non baseline CVD and normoalbuminuria; group 1, non baseline CVD and microalbuminuria; group 2, baseline CVD and normoalbuminuria; group 3, baseline CVD and microalbuminuria. Cox's multivariate regression models were used to assess the risk ratio (RR) associated with each variable. RESULTS: The median follow-up time was 7.6 years. Incidence rates of cardiovascular events per 1000 patient-years increased from groups 0 to 3 (23.8, 63.4, 74.1, 85.6; p<0.0001). Multivariate RR for incident CVD in groups 1, 2 and 3 in relation to group 0 were 2.8 (95% confidence interval (CI) 1.7-4.6; p<0.0001), 2.7 (95% CI 1.6-4.6; p<0.0001) and 2.9 (95% CI 1.6-5.4; p=0.001), respectively. No significant differences were seen between groups 1 and 2. CONCLUSIONS: We suggest that patients with microalbuminuria are at very high vascular risk and should share the same objectives of a vascular risk-factor control as patients with overt CVD.

Mild renal insufficiency as a cardiovascular risk factor in non-proteinuric type II diabetes.

OBJECTIVES: To evaluate cardiovascular risk according to baseline renal function in a group of non-proteinuric type II diabetic patients. MATERIAL AND METHODS: Prospective study with a follow-up of 423 non-proteinuric type II diabetic patients with creatinine <150 micromol/l for an average of 4.7 years (S.D. 1.55). Creatinine clearance (CC) was estimated using the Cockcroft-Gault formula and expressed in millilitre per minute. The hazard ratio (HR) associated with each millilitre per minute decrease in baseline CC on fatal or non-fatal cardiovascular events and total mortality was evaluated using the Cox regression model. RESULTS: Baseline creatinine was 89 micromol/l (S.D. 15.9) and CC was 69.5 ml/min (S.D. 20). There were 63 cardiovascular events (15 unstable angina, 10 non-fatal myocardial infarctions, 25 non-fatal strokes, two amputations, nine fatal myocardial infarctions and two fatal strokes) and 39 total deaths (11 for cardiovascular causes). The cardiovascular event rate was 31.7/1000 patient-years and the total mortality rate was 19.6/1000 patient-years. The independent predictors of cardiovascular events were: CC (HR=1.035; confidence interval (CI) 95% 1.02-1.05; P<0.0001), total cholesterol/HDL cholesterol ratio (HR=1.25; CI 95% 1.1-1.4; P=0.0008), baseline coronary heart disease (HR=2.05; CI 95% 1.07-3.9; P=0.04) and baseline microalbuminuria (HR=2.3; CI 95% 1.3-3.8; P=0.003). The independent total mortality predictors were: CC (HR=1.04; CI 95% 1.02-1.08; P<0.0001), male (HR=2.1; CI 95% 1.1-4; P=0.027) and baseline microalbuminuria (HR=2.1; CI 95% 1.1-4;P=0.03). CONCLUSIONS: Mild renal insufficiency increases cardiovascular risk in non-proteinuric patients with type II diabetes.

Fasting plasma glucose variability as a risk factor of retinopathy in Type 2 diabetic patients.

AIMS/HYPOTHESIS: The purpose of this study was to determine whether plasma glucose variability, irrespective of glycated hemoglobin (HbA1c), was able to predict the onset of retinopathy in Type 2 diabetic patients. METHODS: The study was based on a cohort of 130 Type 2 diabetic patients without retinopathy recruited from June 1994 to June 1998. The fundus was reexamined between November 2000 and June 2001, with a mean follow-up period of 5.2 years. Fasting plasma glucose (FPG) variability was measured by its variation coefficient (VC). Stratified and multivariate models were used to estimate the effect of FPG variability and mean HbA1c during follow-up on cumulative incidence (IP) of retinopathy. RESULTS: The IP of retinopathy was 36.2% and increased all along the quartiles of FPG variability (P=.001). In multivariate analyses, only the last quartile of the distribution of VC (OR=3.68; 95% confidence interval (CI) 1.01-13.4; P=.049) was significant. The term of interaction between mean HbA1c and VC was not significant. CONCLUSIONS/INTERPRETATION: FPG variability fulfills criteria to be considered a risk factor for retinopathy: A statistically significant association exists after adjustment for confounders, time sequence, dosage response gradient, and biological plausibility.