Alex Kiss

Randomized Controlled Trial of Chlorhexidine Gluconate for Washing, Intranasal Mupirocin, and Rifampin and Doxycycline Versus No Treatment for the Eradication of Methicillin-Resistant Staphylococcus aureus Colonization

BACKGROUND Eradication of methicillin-resistant Staphylococcus aureus (MRSA) carriage may reduce the risk of MRSA infection and prevent transmission of the organism to other patients. METHODS To determine the efficacy of decolonization therapy, patients colonized with MRSA were randomized (3:1 allocation) to receive treatment (2% chlorhexidine gluconate washes and 2% mupirocin ointment intranasally, with oral rifampin and doxycycline for 7 days), or no treatment. Follow-up samples for MRSA culture were obtained from the nares, perineum, skin lesions, and catheter exit sites monthly for up to 8 months. The primary outcome measure was detection of MRSA at 3 months of follow-up. Univariate and multivariable analyses were performed to identify variables associated with treatment failure. RESULTS Of 146 patients enrolled in the study, 112 patients (87 treated; 25 not treated) were followed up for at least 3 months. At 3 months of follow-up, 64 (74%) of those treated had culture results negative for MRSA, compared with 8 (32%) of those not treated (P=.0001). This difference remained significant at 8 months of follow-up, at which time, 54% of those treated had culture results negative for MRSA (chi2=64.4; P<.0001, by log-rank test). The results of the multivariable analysis indicated that having a mupirocin-resistant isolate at baseline was associated with treatment failure (relative risk, 9.4; 95% confidence interval, 2.8-31.9; P=.0003), whereas decolonization therapy was protective (relative risk, 0.1; 95% confidence interval, 0.04-0.4; P=.0002). Mupirocin resistance emerged in only 5% of follow-up isolates. CONCLUSIONS Treatment with topical mupirocin, chlorhexidine gluconate washes, oral rifampin, and doxycycline for 7 days was safe and effective in eradicating MRSA colonization in hospitalized patients for at least 3 months.

Neuropsychological tests accurately predict incident Alzheimer disease after 5 and 10 years

Objective: To determine whether neuropsychological tests accurately predict incident Alzheimer disease (AD) after 5 and 10 years in participants of the Canadian Study of Health and Aging (CSHA) who were initially nondemented. Methods: The CSHA was conducted in three waves: CSHA-1 (1991 to 1992), CSHA-2 (1996 to 1997), and CSHA-3 (2001 to 2002). The 10-year prediction study included those who completed neuropsychological testing at CSHA-1 and received a diagnostic assessment at CSHA-3 (n = 263). The 5-year prediction study included those who completed neuropsychological testing at CSHA-2 and received a diagnostic assessment at CSHA-3 (n = 551). The diagnostic workup for dementia at CSHA-3 was formulated without knowledge of neuropsychological test performance at CSHA-1 or CSHA-2. The authors excluded cases with a baseline diagnosis of dementia or a prior history of any condition likely to affect the brain. Age and education were included in all analyses as covariates. Results: In the 10-year follow-up study, only one test (short delayed verbal recall) emerged from the forward regression analyses. The model with this test and two covariates was significant, χ2 (3) = 31.61, p < 0.0001 (sensitivity = 73%, specificity = 70%). In the 5-year follow-up study, three tests (short delayed verbal recall, animal fluency, and information) emerged from the forward logistic regression analyses. The model was significant, χ2 (5) = 91.34, p < 0.0001 (sensitivity = 74%, specificity = 83%). Both models were supported with bootstrapping estimates. Conclusions: In a large epidemiologic sample of nondemented participants, neuropsychological tests accurately predicted conversion to Alzheimer disease after 5 and 10 years.

Diabetic status and the relation of the three domains of glycemic control to mortality in critically ill patients: an international multicenter cohort study.

IntroductionHyperglycemia, hypoglycemia, and increased glycemic variability have each beenindependently associated with increased risk of mortality in critically illpatients. The role of diabetic status on modulating the relation of these threedomains of glycemic control with mortality remains uncertain. The purpose of thisinvestigation was to determine how diabetic status affects the relation ofhyperglycemia, hypoglycemia, and increased glycemic variability with the risk ofmortality in critically ill patients.MethodsThis is a retrospective analysis of prospectively collected data involving 44,964patients admitted to 23 intensive care units (ICUs) from nine countries, betweenFebruary 2001 and May 2012. We analyzed mean blood glucose concentration (BG),coefficient of variation (CV), and minimal BG and created multivariable models toanalyze their independent association with mortality. Patients were stratifiedaccording to the diagnosis of diabetes.ResultsAmong patients without diabetes, mean BG bands between 80 and 140 mg/dl wereindependently associated with decreased risk of mortality, and mean BG bands> 140 mg/dl, with increased risk of mortality. Among patients withdiabetes, mean BG from 80 to 110 mg/dl was associated with increased risk ofmortality and mean BG from 110 to 180 mg/dl with decreased risk of mortality. Aneffect of center was noted on the relation between mean BG and mortality.Hypoglycemia, defined as minimum BG <70 mg/dl, was independently associatedwith increased risk of mortality among patients with and without diabetes andincreased glycemic variability, defined as CV > 20%, was independentlyassociated with increased risk of mortality only among patients without diabetes.Derangements of more than one domain of glycemic control had a cumulativeassociation with mortality, especially for patients without diabetes.ConclusionsAlthough hyperglycemia, hypoglycemia, and increased glycemic variability is eachindependently associated with mortality in critically ill patients, diabeticstatus modulates these relations in clinically important ways. Our findingssuggest that patients with diabetes may benefit from higher glucose target rangesthan will those without diabetes. Additionally, hypoglycemia is independentlyassociated with increased risk of mortality regardless of the patients diabeticstatus, and increased glycemic variability is independently associated withincreased risk of mortality among patients without diabetes.See related commentary by Krinsley,http://ccforum.com/content/17/2/131See related commentary by Finfer and Billot,http://ccforum.com/content/17/2/134

Significant regional variation in adequacy of lymph node assessment and survival in gastric cancer.

Lymph node (LN) status is a major determinant of prognosis and treatment of gastric adenocarcinoma. The 1997 American Joint Commission on Cancer/Union Internationale Contre le Cancer guidelines were revised, requiring examination of ≥15 LN for staging.

Does inclusion of a placebo arm influence response to active antidepressant treatment in randomized controlled trials? Results from pooled and meta-analyses.

OBJECTIVE To determine if the inclusion of a placebo arm and/or the number of active comparators in antidepressant trials influences the response rates of the active medication and/or placebo. DATA SOURCES Searches of MEDLINE, PsycINFO, and pharmaceutical Web sites for published trials or trials conducted but unpublished between January 1996 and October 2007. STUDY SELECTION 2,275 citations were reviewed, 285 studies were retrieved, and 90 were included in the analysis. Trials reporting response and/or remission rates in adult subjects treated with an antidepressant monotherapy for unipolar major depression were included. DATA EXTRACTION The primary investigator recorded the number of responders and/or remitters in the intent-to-treat population of each study arm or computed these numbers using the quoted rates. DATA SYNTHESIS Poisson regression analyses demonstrated that mean response rate for the active medication was higher in studies comparing 2 or more active medications without a placebo arm than in studies comparing 2 or more active medications with a placebo arm (65.4% vs 57.7%, P < .0001) or in studies comparing only 1 active medication with placebo (65.4% vs 51.7%, P = .0005). Mean response rate for placebo was significantly lower in studies comparing 1 rather than 2 or more active medications (34.3% vs 44.6%, P = .003). Mean remission rates followed a similar pattern. Meta-analysis confirmed results from the pooled analysis. CONCLUSIONS These data suggest that antidepressant response rates in randomized control trials may be influenced by the presence of a placebo arm and by the number of treatment arms and that placebo response rates may be influenced by the number of active treatment arms in a study.

Universal Health Insurance and Health Care Access for Homeless Persons

OBJECTIVES We examined the extent of unmet needs and barriers to accessing health care among homeless people within a universal health insurance system. METHODS We randomly selected a representative sample of 1169 homeless individuals at shelters and meal programs in Toronto, Ontario. We determined the prevalence of self-reported unmet needs for health care in the past 12 months and used regression analyses to identify factors associated with unmet needs. RESULTS Unmet health care needs were reported by 17% of participants. Compared with Torontos general population, unmet needs were significantly more common among homeless individuals, particularly among homeless women with dependent children. Factors independently associated with a greater likelihood of unmet needs were younger age, having been a victim of physical assault in the past 12 months, and lower mental and physical health scores on the 12-Item Short Form Health Survey. CONCLUSIONS Within a system of universal health insurance, homeless people still encounter barriers to obtaining health care. Strategies to reduce nonfinancial barriers faced by homeless women with children, younger adults, and recent victims of physical assault should be explored.

The effect of traumatic brain injury on the health of homeless people

Background: We sought to determine the lifetime prevalence of traumatic brain injury and its association with current health conditions in a representative sample of homeless people in Toronto, Ontario. Methods: We surveyed 601 men and 303 women at homeless shelters and meal programs in 2004–2005 (response rate 76%). We defined traumatic brain injury as any self-reported head injury that left the person dazed, confused, disoriented or unconscious. Injuries resulting in unconsciousness lasting 30 minutes or longer were defined as moderate or severe. We assessed mental health, alcohol and drug problems in the past 30 days using the Addiction Severity Index. Physical and mental health status was assessed using the SF-12 health survey. We examined associations between traumatic brain injury and health conditions. Results: The lifetime prevalence among homeless participants was 53% for any traumatic brain injury and 12% for moderate or severe traumatic brain injury. For 70% of respondents, their first traumatic brain injury occurred before the onset of homelessness. After adjustment for demographic characteristics and lifetime duration of homelessness, a history of moderate or severe traumatic brain injury was associated with significantly increased likelihood of seizures (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.8 to 5.6), mental health problems (OR 2.5, 95% CI 1.5 to 4.1), drug problems (OR 1.6, 95% CI 1.1 to 2.5), poorer physical health status (–8.3 points, 95% CI –11.1 to –5.5) and poorer mental health status (–6.0 points, 95% CI –8.3 to –3.7). Interpretation: Prior traumatic brain injury is very common among homeless people and is associated with poorer health.

Validation of a universal prehospital termination of resuscitation clinical prediction rule for advanced and basic life support providers

BACKGROUND Prehospital termination of resuscitation rules have been derived for Emergency Medical Technician-Paramedics providing advanced life support care and defibrillation-only Emergency Medical Technicians providing basic life support care. We sought to externally validate each rule on a prospective cohort of prehospital cardiac arrest patients to determine if either rule could be proposed as a universal prehospital termination of resuscitation rule. METHODS Investigators at the University of Toronto performed a secondary cohort analysis of data prospectively collected for the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest trial from 1 April 2006 to 1 April 2007 by one site. The diagnostic test characteristics and predicted transportation rate were calculated for each rule. RESULTS Of the 2415 patients with cardiac arrest of presumed cardiac etiology, the advanced life support rule recommended termination of resuscitation for 743 patients. No survivors were identified in this group. It had a specificity of 100% for recommending transport of potential survivors, a positive predictive value of 100% for death and a predicted transport rate of 69%. The basic life support rule recommended termination of resuscitation for 1302 patients, with no survivors. This rule had a specificity of 100%, a positive predictive value of 100% and a predicted transport rate of 46%. CONCLUSIONS Implementing the basic life support rule as a universal termination of resuscitation clinical prediction rule would result in a lower overall transport rate without missing any potential survivors. The universal rule would recommend termination of resuscitation when there was no return of spontaneous circulation prior to transport, no shock was given and the arrest was not witnessed by Emergency Medical Services personnel. This rule may be useful for emergency medical services systems with mixed levels of providers responding to cardiac arrest patients.

Surgical Management of Intrahepatic Cholangiocarcinoma - A Population-Based Study

BackgroundCholangiocarcinoma (CCA) is associated with poor survival and therapeutic nihilism. To date, there has not been an examination of the surgical management of CCA at a population level.MethodsUsing the Surveillance, Epidemiology and End Results (SEER) database, we identified all patients with intrahepatic CCA diagnosed between 1988 and 2003. Tumors categorized as a single, unilobar lesion with no evidence of vascular invasion were defined as localized. It was then determined whether patients received cancer directed surgery (CDS). Multivariable logistic regression was used to evaluate factors associated with CDS in patients with localized disease. The influence of CDS on overall survival (OS) was evaluated using Kaplan–Meier curves and Cox proportional hazards modeling.ResultsOnly 446 (12%) of 3,756 patients with intrahepatic CCA underwent CDS. On multivariable analysis, non-Klatskin tumor (p < 0.01) and younger age (p = 0.02) was associated with CDS. Localized disease was strongly associated with CDS (p < 0.01); however, only 91 (37%) of these 248 patients underwent CDS. Of patients with localized disease, those who had CDS had significantly better survival than those who did not (p < 0.01), with median overall survival (OS) of 44 months versus 8 months, and five-year OS of 42% versus 4%, respectively.ConclusionsPatients with localized CCA who are selected for CDS are strongly associated with improved survival, with rates approaching that found in single institution studies. However, many patients with localized tumors do not receive potentially curative cancer-directed surgery. Further study is warranted to address the barriers to the delivery of appropriate care to these patients.

Multidimensional Social Support and the Health of Homeless Individuals

Homeless individuals often suffer from serious health problems. It has been argued that the homeless are socially isolated, with low levels of social support and social functioning, and that this lack of social resources contributes to their ill health. These observations suggest the need to further explore the relationship between social networks, social support, and health among persons who are homeless. The purpose of this study was to examine the association between multidimensional (cognitive/perceived and behavioral/received) social support and health outcomes, including physical health status, mental health status, and recent victimization, among a representative sample of homeless individuals in Toronto, Canada. Multivariate regression analyses were performed on social support and health outcome data from a subsample of 544 homeless adults, recruited from shelters and meal programs through multistage cluster sampling procedures. Results indicated that participants perceived moderately high levels of access to financial, emotional, and instrumental social support in their social networks. These types of perceived social supports were related to better physical and mental health status and lower likelihood of victimization. These findings highlight a need for more services that encourage the integration of homeless individuals into social networks and the building of specific types of social support within networks, in addition to more research into social support and other social contextual factors (e.g., social capital) and their influence on the health of homeless individuals.