Saturday, October 21, 2017

Cardiac manifestations of neuromuscular diseases


An AHA scientific statement. Free full text.

Friday, October 20, 2017

Discontinuation of low dose aspirin leads to increased cardiovascular events



Results: During a median of 3.0 years of follow-up, 62 690 cardiovascular events occurred. Patients who discontinued aspirin had a higher rate of cardiovascular events than those who continued (multivariable-adjusted hazard ratio, 1.37; 95% confidence interval, 1.34–1.41), corresponding to an additional cardiovascular event observed per year in 1 of every 74 patients who discontinue aspirin. The risk increased shortly after discontinuation and did not appear to diminish over time.

Conclusions: In long-term users, discontinuation of low-dose aspirin in the absence of major surgery or bleeding was associated with a greater than 30% increased risk of cardiovascular events. Adherence to low-dose aspirin treatment in the absence of major surgery or bleeding is likely an important treatment goal.

These were people who were on it for either primary or secondary prevention.

Thursday, October 19, 2017

Atrioesophageal fistula after atrial fibrillation ablation


This is frightening. Fortunately, quite rare.

From the paper:

Esophageal perforation is a dreaded complication of atrial fibrillation ablation that occurs in 0.1% to 0.25% of atrial fibrillation ablation procedures. Delayed diagnosis is associated with the development of atrial-esophageal fistula (AEF) and increased mortality. The relationship between the esophagus and the left atrial posterior wall is variable, and the esophagus is most susceptible to injury where it is closest to areas of endocardial ablation. Esophageal ulcer seems to precede AEF development, and postablation endoscopy documenting esophageal ulcer may identify patients at higher risk for AEF. AEF has been reported with all modalities of atrial fibrillation ablation despite esophageal temperature monitoring. Despite the name AEF, fistulas functionally act 1 way, esophageal to atrial, which accounts for the observed symptoms and imaging findings. Because of the rarity of AEF, evaluation and validation of strategies to reduce AEF remain challenging. A high index of suspicion is recommended in patients who develop constitutional symptoms or sudden onset chest pain that start days or weeks after atrial fibrillation ablation. Early detection by computed tomography scan with oral and intravenous contrast is safe and feasible, whereas performance of esophageal endoscopy in the presence of AEF may result in significant neurological injury resulting from air embolism. Outcomes for esophageal stenting are poor in AEF. Aggressive intervention with skilled cardiac and thoracic surgeons may improve chances of stroke-free survival for all types of esophageal perforation.

Wednesday, October 18, 2017

Neurotoxicity of cefepime in relation to plasma concentration



Methods

In this single-centre retrospective cohort study, we enrolled all adult hospitalized patients receiving cefepime and undergoing TDM from January 2013 through July 2016. The primary outcome was the incidence of clinical toxicity; a secondary outcome was clinical failure. Plasma samples were analysed via high-performance liquid chromatography with ultraviolet detection.

Results

A total of 161 cefepime concentrations were drawn from 93 patients. Roughly half (82/161, 51%) and one-third (49/161, 30%) were trough and steady-state levels from patients receiving intermittent and continuous infusions, respectively; median concentrations were 17.6 mg/L (IQR 9.7-35.2) and 29.2 mg/L (IQR 18.9-45.9). Ten patients (11%) experienced a neurologic event considered at least possibly related to cefepime; neurotoxicity was associated with poorer renal function (median creatinine clearance 54 (IQR 39-97) vs. 75 mL/min/1.732 (IQR 44-104)) and longer cefepime durations (mean 8.3 (SD±6.7) vs. 13.3 days (± 14.2), p = 0.071). Patients with trough levels greater than 20 mg/L had a fivefold higher risk for neurologic events (OR 5.05, 95% CI 1.3-19.8).

Conclusions

Neurotoxicity potentially related to cefepime occurred at plasma concentrations greater than 35 mg/L. For those receiving intermittent infusions, trough concentrations greater than 20 mg/L should be avoided until further information is available from prospective studies.

Tuesday, October 17, 2017

Which of the two popular regimens for community acquired pneumonia is best?



Objective

The best treatment option for hospitalized patients with community-acquired pneumonia (CAP) has not been defined. The effectiveness of β-lactam/fluoroquinolone (BLFQ) versus β-lactam/macrolide (BLM) combinations for the treatment of patients with CAP was evaluated.

Methods

PubMed, Scopus and the Cochrane Library were searched for observational cohort studies, non-randomized and randomized controlled trials providing data for patients with CAP receiving BLM or BLFQ. Mortality was the primary outcome. A meta-analysis was performed. MINORS and GRADE were used for data quality assessment.

Results

Seventeen studies (16 684 patients) were included. Randomized trials were not identified. A variety of β-lactams, fluoroquinolones and macrolides were used within and between the studies. Mortality was reported at different time points. The available body of evidence had very low quality. In the analysis of unadjusted data, mortality with BLFQ was higher than with BLM (risk ratio 1.33, 95% CI 1.15–1.54, I2 28%). BLFQ was associated with higher mortality regardless of the study design, mortality recording time, study period and study BLM group mortality. BLFQ was associated with higher mortality in American but not European studies. No difference was observed in patients with bacteraemia and septic shock. In the meta-analysis of adjusted mortality data, a non-significant difference between the two regimens was observed (eight studies, adjusted risk ratio 1.26, 95% CI 0.95–1.67, I2 43%).

Conclusion

In the absence of data from randomized controlled trials recommendations cannot be made for or against either of the studied regimens in this group of hospitalized patients with CAP. Well designed randomized controlled trials comparing the two regimens are warranted.

Of interest, they didn’t compare fluoroquinolone monotherapy which is also popular and endorsed by CAP guidelines.


Monday, October 16, 2017

Sunday, October 15, 2017

The coming microbial apocalypse: Staph aureus in retreat?


Twenty years ago the post antibiotic era was predicted for gram positive infections. Five years or so later CA-MRSA began to overtake HA-MRSA. The takeover is complete, with the result that today’s MRSA, though resistant to most beta lactam antibiotics, is sensitive to several older antimicrobial agents besides vancomycin, in contrast to the older traditional MRSA (HA-MRSA). In a new development, a goodly number of MSSA  infections show susceptibility to plain penicillin.