Impact of an oral theophylline loading dose pre-electroconvulsive therapy: a retrospective study in patients with missed or inadequate seizures.

OBJECTIVE: The aim of this study was to determine the safety and impact of an oral theophylline loading dose calculated to achieve a 10- to 15-mg/L plasma concentration when administered 1.5 hours before electroconvulsive therapy (ECT). METHODS: We conducted a retrospective study using inpatient hospital records between January 2007 and June 2012 at the Dr. Georges L. Dumont University Hospital Centre. Patients receiving a series of ECTs with a calculated theophylline loading dose were selected. Variables collected include ECT parameters for each ECT, medications received, and treatment-related side effects. RESULTS: We identified 35 patients and analyzed 14 who had no treatment modifications except for the addition of theophylline. The mean predicted theophylline plasma concentration was 12.99 (SD, 1.09) mg/L with dosages ranging from 260 to 600 mg. Eight patients (89%) with abortive seizures and 4 (80%) with missed seizures achieved a seizure duration of greater than 15 seconds with theophylline. Seizure duration increased by 165.6% (+21.3 seconds; P = 0.048) with theophylline, and all patients (N = 5) with a maximum sustained coherence of less than 92% achieved an increase after theophylline; however, the overall increase (+8.8%, P = 0.087) was not significant. No theophylline-related adverse events were documented in 128 ECTs with theophylline, and no seizure exceeded 120 seconds. CONCLUSIONS: A calculated theophylline loading dose before ECT is well tolerated and effective in prolonging seizure duration and aiding with seizure generation in patients who do not seize readily. Its positive impact in patients with lower maximum sustained coherence, in addition to the potential existence of a dose-response relationship, should be further investigated.

Effect of regenerative injection therapy on function and pain in patients with knee osteoarthritis: a randomized crossover study.

OBJECTIVE: We assessed the effectiveness of regenerative injection therapy (RIT) to relieve pain and restore function in patients with knee osteoarthritis. DESIGN: Crossover study where participants were randomly assigned to receive exercise therapy for 32 weeks in combination with RIT on weeks 0, 4, 8, and 12 or RIT on weeks 20, 24, 28, and 32. PATIENTS: Thirty-six patients with chronic knee osteoarthritis. INTERVENTIONS: RIT, which is made up of injections of 1 cc of 15% dextrose 0.6% lidocaine in the collateral ligaments and a 5 cc injection of 20% dextrose 0.5% lidocaine inside the knee joint. OUTCOME MEASURES: The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index of severity of osteoarthrosis symptoms (WOMAC) score (range: 0-96). RESULTS: Following 16 weeks of follow-up, the participants assigned to RIT presented a significant reduction of their osteoarthritis symptoms (mean ± standard deviation: -21.8 ± 12.5, P < 0.001). WOMAC scores in this group did not change further during the last 16 weeks of follow-up, when the participants received exercise therapy only (-1.2 ± 10.7, P = 0.65). WOMAC scores in the first 16 weeks did not change significantly among the participants receiving exercise therapy only during this period (-6.1±13.9, P=0.11). There was a significant decrease in this groups' WOMAC scores during the last 16 weeks when the participants received RIT (-9.3±11.4, P=0.006). After 36 weeks, WOMAC scores improved in both groups by 47.3% and 36.2%. The improvement attributable to RIT alone corresponds to a 11.9-point (or 29.5%) decrease in WOMAC scores. CONCLUSIONS: The use of RIT is associated with a marked reduction in symptoms, which was sustained for over 24 weeks.

Impact of a bloodstream infection stewardship program in hospitalized patients.

BACKGROUND: Bloodstream infections (BSIs) in hospitalized patients represent sentinel events requiring timely and responsive antimicrobial prescribing. These infections represent an attractive but seldom-evaluated stewardship opportunity. METHODS: Retrospective pre-post study design, with review of patient charts 18 months before and after initiation of a hospital Bloodstream Infection Stewardship Program (BSISP). Pre-intervention, the ward and attending physician were notified of all positive blood cultures. Post-intervention, an infectious disease (ID) pharmacist collaborating with an ID consultant was also notified. RESULTS: Two hundred twenty-six eligible BSIs were identified pre-intervention and 195 post-intervention. The urinary tract was the most common source of infection; most common bloodstream isolates were Escherichia coli, Staphylococcus aureus, beta-hemolytic streptococci, and Klebsiella pneumoniae; 71.7% of infections were community acquired. Empiric therapy was not given in 17.3% of cases and inadequate in 16.4% of patients. Therapy was altered on the basis of Gram stain results ('directed therapy') in 54.6% of episodes and was inadequate in 3.5%. Compared to pre-intervention, the post-intervention cohort received directed therapy on average 4.36 hours earlier (p = 0.003), was more likely to receive appropriate definitive therapy (99.0% post versus 79.1% pre, p <0.001), stepped down to oral therapy earlier (6.0 versus 8.0 days, p = 0.031), and received fewer directed prescriptions (214 per 100 cases post versus 260 per 100 cases pre; p = 0.001), including fewer prescriptions of quinolones and clindamycin. CONCLUSIONS: A BSISP could be an effective strategy for improving antimicrobial prescribing in hospitalized patients with a BSI.

HISTORIQUE: Chez les patients hospitalisés, les infections sanguines sont des événements sentinelles qui exigent des prescriptions antimicrobiennes opportunes et adaptées. Ces infections représentent une possibilité de gestion attrayante, mais rarement évaluée. MÉTHODOLOGIE: Les chercheurs ont utilisé une méthodologie d'étude avant-après comportant l'analyse des dossiers des patients 18 mois avant et après un programme de gestion des infections sanguines (PGIS) en milieu hospitalier. Avant l'intervention, le médecin du service a été avisé de toutes les cultures sanguines positives. Après l'intervention, un pharmacien infectiologue qui collaborait avec un consultant en infectiologie a également été avisé. RÉSULTATS: Au total, les chercheurs ont relevé 226 infections sanguines admissibles avant l'intervention et 195 après l'intervention. Les voies urinaires étaient la principale source d'infection et les principaux isolats sanguins, l'Escherichia coli, le Staphylococcus aureus, les streptocoques bêta-hémolytiques et le Klebsiella pneumoniae; 71,7 % des infections étaient d'origine communautaire. Dans 17,3 % des cas, les patients n'ont pas reçu de traitement empirique et chez 16,4 % des patients, le traitement n'était pas approprié. Il était modifié en fonction des résultats de la coloration de Gram de base (« thérapie dirigée ¼) dans 54,6 % des épisodes et n'était pas approprié dans 3,5 % des cas. Par rapport à celle d'avant l'intervention, la cohorte d'après l'intervention a reçu une thérapie dirigée en moyenne 4,36 heures plus tôt (p = 0,003) et était plus susceptible de recevoir un traitement définitif approprié (99,0 % après par rapport à 79,1 % avant, p <0,001), de passer à un traitement par voie orale plus rapidement (6,0 jours plutôt que 8,0, p = 0,031) et de recevoir moins d'ordonnances dirigées (214 sur 100 cas après, par rapport à 260 sur 100 cas avant; p = 0,001), y compris moins d'ordonnances de quinolones et de clindamycine. CONCLUSIONS: Un PGIS pourrait être une stratégie efficace pour améliorer les prescriptions d'antimicrobiens chez des patients hospitalisés atteints d'une infection sanguine.

The clinical impact of a urinary tract infection management bundle in a tertiary-care teaching hospital.

OBJECTIVE: The aim of this study was to assess the impact of a urinary tract infection (UTI) management bundle to reduce the treatment of asymptomatic bacteriuria (AB) and to improve the management of symptomatic UTIs. DESIGN: Before-and-after intervention study.SettingsTertiary-care hospital.PatientsConsecutive sample of inpatients with positive single or mixed-predominant urine cultures collected and reported while admitted to the hospital. METHODS: The UTI management bundle consisted of nursing and prescriber education, modification of the reporting of positive urine cultures, and pharmacists' prospective audit and feedback. A retrospective chart review of consecutive inpatients with positive urinary cultures was performed before and after implementation of the management bundle. RESULTS: Prior to the implementation of the management bundle, 276 patients were eligible criteria for chart review. Of these 276 patients, 165 (59·8%) were found to have AB; of these 165 patients with AB, 111 (67·3%) were treated with antimicrobials. Moreover, 268 patients met eligibility criteria for postintervention review. Of these 268, 133 patients (49·6%) were found to have AB; of these 133 with AB, 22 (16·5%) were treated with antimicrobials. Thus, a 75·5% reduction of AB treatment was achieved. Educational components of the bundle resulted in a substantial decrease in nonphysician-directed urine sample submission. Adherence to a UTI management algorithm improved substantially in the intervention period, with a notable decrease in fluoroquinolone prescription for empiric UTI treatment. CONCLUSIONS: A UTI management bundle resulted in a dramatic improvement in the management of urinary tract infection, particularly a reduction in the treatment of AB and improved management of symptomatic UTI.

Is there a link between postpartum anemia and discontinuation of breastfeeding?

PURPOSE: Factors associated with early cessation of breastfeeding were identified and patterns of infant feeding were examined. Feeding practices were compared with the 1998 guidelines in Nutrition for Healthy Term Infants and with recent Health Canada recommendations. METHODS: To recruit participants, a letter was sent to every mother (n=424) who gave birth at Dr. Georges-L. Dumont Regional Hospital in Moncton from April 1998 to February 1999. Eighty-five mothers agreed to participate with their infants. Information on infant feeding patterns and socioeconomic background was gathered with semi-structured questionnaires. Only healthy infants from singleton pregnancies were included in this study. RESULTS: At birth, almost 83% of infants were breastfed. The proportions of infants breastfed for at least four, six, and nine months were 43%, 22%, and 9%, respectively. As many as 34% of infants were introduced to baby cereals before age four months, and 21% were introduced to cow's milk before age nine months. Lower family income, lower level of parental education, and reduced postpartum hemoglobin level (below 95 g/L) were associated with discontinuation of breastfeeding before infants were four months old. CONCLUSIONS: Early postpartum nutrition interventions may be effective in ensuring follow-up care for mothers with compromised iron status, in supporting breastfeeding for at least six months, and in promoting better infant feeding practices.

[Factors associated with short- and long-term use of benzodiazepines in the elderly from Quebec]. / Facteurs associés à la consommation de courte et de longue durée des benzodiazépines chez les personnes âgées du Québec.

In Quebec, benzodiazepines are some of the most extensively used drugs by the elderly. The goal of this study was to identify factors associated with short- and long-term benzodiazepine use among 2,039 elderly persons having participated in the Quebec Health Survey conducted in 1998. Results of the multivariate, multinomial logistic regression showed that a higher number of chronic health problems, a higher number of physicians visited and general practitioners consulted were associated with short- and long-term use of benzodiazepines. Factors specifically associated with long-term use were female gender (OR = 1.84) and the presence of benzodiazepine users in the household (OR = 1.90). In this study, we were unable to show a difference between the two groups of users with regards to the risk factors studied. This result leads us to conclude that prevention of long-term use must be aimed at all new benzodiazepine users.

[Anxiolytic, sedative and hypnotic medication use in the elderly living in the community: Developing a conceptual framework]. / Utilisation des anxiolytiques, sédatifs et hypnotiques chez les personnes âgées vivant dans la communauté: construction d'un cadre conceptuel.

Inappropriate consumption of anxiolytic, sedative and hypnotic medication (ASH) in the elderly is an important public health issue. Almost 35 % of the elderly population living at home take these medications, approximately 206 days per year. According to Quebec data, people who are 65 and older take five times more ASH than people between 18 and 64. The use of ASH would not only be determined by the presence of symptoms, but also by psychosocial characteristics of the subjects. Moreover, several researchers have suggested that the family as well as the health system were environmental factors that could facilitate or inhibit consumption of these medications in the elderly. A conceptual framework is proposed to help specify more adequately the various explanatory hypotheses of this social health behavior and, consequently, better target interventions aiming at its modification.

Decolonization of methicillin-resistant Staphylococcus aureus during routine hospital care: Efficacy and long-term follow-up.

BACKGROUND/OBJECTIVE: Methicillin-resistant Staphylococcus aureus (MRSA) colonization is associated with a significant risk of subsequent MRSA infection in the hospital setting. The use of decolonization as an infection control strategy remains highly controversial despite publications evaluating more than 40 different decolonization regimens over the past 60 years. The present study describes the benefits and potential drawbacks of such an approach in the patient population. METHODS: A retrospective cohort study was performed to assess the efficacy and subsequent outcome for patients with newly identified MRSA colonization at the Horizon Health Network in Moncton, New Brunswick. RESULTS: A total of 241 patients with MRSA colonization or infection during the study period (2000 to 2005 inclusive) were identified. Eighty-nine MRSA-positive patients were decolonized according to a standardized regimen (hospital protocol group), and 98 received an alternative decolonization regimen (other treatment group). No attempt at decolonization was made for 54 patients (no treatment group). The hospital protocol group demonstrated superior overall successful decolonization compared with the other treatment group (67 of 84 [80%] versus 48 of 89 [54%]; OR 3.3; 95% CI 1.6 to 7.1; P=0.0004) and the no treatment group (four of 43 [9%]; OR 36.9; 95% CI 11.2 to 161.7; P<0.000001). The mean observed duration of culture negativity for the subgroup who remained MRSA culture negative over the long term was 419±398 days (range one to 1817 days). Successful decolonization occurred in 115 patients and permitted subsequent release from contact isolation for 4530 patient-days. The rate of clinical infection with MRSA was significantly lower in the hospital protocol group versus the other treatment group (16 of 89 [18%] versus 37 of 98 [38%]; OR 0.38; 95% CI 0.18 to 0.78; P=0.003). CONCLUSION: The present study supports recent reports indicating that MRSA decolonization can be successful using a multifactorial approach (chlorhexidine soap, enhanced hygiene/housekeeping and combination oral/topical antimicrobial therapy) in hospitalized patients, both over the short and long term. Unlike previous studies, decolonization appeared to be effective in a relatively unselected population, including patients with lines and catheters. Inability to decolonize was most closely associated with failure to use a standardized decolonization protocol.

Factors associated with long-term benzodiazepine use among elderly women and men in Quebec.

The goal of this study was to compare factors associated with long-term benzodiazepine use by elderly women and men (n = 1701) who participated in the Quebec Health Survey (QHS). Data from the 1998 QHS were linked with data from the administrative files of the Régie de l'assurance maladie du Québec. Results showed that elderly women were more at risk than men for long-term benzodiazepine use. Results of the multivariate logistic regression did not show a significant difference between women and men on any of the risk factors studied. Other factors such as elderly and physician attitudes deserve further study to explain differences in long-term benzodiazepine use between elderly women and men.

Consumption of psychotropic medication in the elderly: a re-evaluation of its effect on cognitive performance.

BACKGROUND: There have been few general population studies of the effects of psychotropic treatment on cognitive functioning in the elderly. Current evidence based on studies with numerous procedural shortenings supports the notion of the detrimental effect. OBJECTIVES: To examine changes in a wide range of specific cognitive abilities across time in a general population sample in order to establish a relationship between psychotropic drug use and cognitive performance, and to estimate to what extent such cognitive changes may be attributable to psychotropic use or other factors, notably age and co-morbidity. METHOD: We analysed the data from the Eugeria longitudinal study of cerebral ageing. Three hundred and seventy two subjects (263 female and 109 male) were visited at their place of residence and given a computerized cognitive examination. Depressive symptomatology and depressive episodes were defined according to ICD-9 criterias and medication use were established. Four categories of psychotropic consumers was differentiated. Using a logistic regression model, comparisons were made between consumers and non-consumers. RESULTS: A significant positive effect in chronic consumers was found on tests of secondary memory (delayed verbal recall: Odds Ratio (OR)=1.22; 95% Confidence Intervals (CI) [1.04-1.43]; p=0.013) and this effect is principally attributable to antidepressants with significant effects being shown for both verbal (OR=1.59; 95%CI [1.18-2.14]; p=0.002) and visual recall (OR=1.51; 95%CI [1.05-2.16]; p=0.025). No effect is found for benzodiazepines. CONCLUSIONS: Contrary to the common belief that psychotropic drug use has a detrimental effect on cognitive function of elderly people, even long term use is seen to be benign. We attest to the positive effects of antidepressant therapy on secondary memory.

Is serum ferritin an additional cardiovascular risk factor for all postmenopausal women?

BACKGROUND: Most of the studies on cardiovascular disease (CVD) risk factors in menopause have focused on serum lipid(lipoprotein) abnormalities and were conducted in populations which were not well controlled for several important influential factors. METHODS: Two homogenous groups of 30 apparently healthy Caucasian premenopausal women and 3-5 years postmenopausal women who were nonobese, nonsmoking and not using estrogen were compared in a well-controlled cross-sectional design. Fasting serum ferritin and plasma total homocysteine (tHcy) were evaluated concomitantly to classical serum lipid(lipoprotein) risk factors. Relationships between risk factors and the influence of other contributing variables such as diet and body weight were also examined. RESULTS: Serum total cholesterol (p < 0.01), low-density lipoproteins (LDL; p < 0.05) and triglycerides (p < 0.05) of postmenopausal women were greater than that of their menstruating counterparts, even though they ate a CVD-preventive diet, had similar body weight and body fat distribution. Their serum ferritin was almost 3-fold greater (p < 0.0001) but was still within normal limits, except for the 38.5% of postmenopausal women who exhibited values above the 80 mug/l limit that has been associated with sharp increases in the rate of heart disease in either gender. Serum ferritin was low in one third of the postmenopausal group (as low as in the premenopausal control group, whose dietary iron intake was slightly below the nutritional recommendation). The mean plasma tHcy of the postmenopausal group was almost twice as elevated (p < 0.0001). Both ferritin and tHcy were found to be linked to serum cholesterol. The correlation between tHcy and triglycerides was also significant. CONCLUSION: Early menopause is not associated with blood iron overload and CVD risk factor in an important proportion of women.