Bjug Borgundvaag

Community-associated methicillin-resistant Staphylococcus aureus: prevalence in skin and soft tissue infections at emergency departments in the Greater Toronto Area and associated risk factors.

OBJECTIVE Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA), which is caused primarily by the Canadian methicillin-resistant Staphylococcus aureus-10 (CMRSA-10) strain (also known as the USA300 strain) has emerged rapidly in the United States and is now emerging in Canada. We assessed the prevalence, risk factors, microbiological characteristics and outcomes of CA-MRSA in patients with purulent skin and soft tissue infections (SSTIs) presenting to emergency departments (EDs) in the Greater Toronto Area. METHODS Patients with Staphylococcus aureus SSTIs who presented to 7 EDs between Mar. 1 and Jun. 30, 2007, were eligible for inclusion in this study. Antimicrobial susceptibilities and molecular characteristics of MRSA strains were identified. Demographic, risk factor and clinical data were collected through telephone interviews. RESULTS MRSA was isolated from 58 (19%) of 299 eligible patients. CMRSA-10 was identified at 6 of the 7 study sites and accounted for 29 (50%) of all cases of MRSA. Telephone interviews were completed for 161 of the eligible patients. Individuals with CMRSA-10 were younger (median 34 v. 63 yr, p = 0.002), less likely to report recent antibiotic use (22% v. 67%, p = 0.046) or health care-related risk factors (33% v. 72%, p = 0.097) and more likely to report community-related risk factors (56% v. 6%, p = 0.008) than patients with other MRSA strains. CMRSA-10 SSTIs were treated with incision and drainage (1 patient), antibiotic therapy (3 patients) or both (5 patients), and all resolved. CMRSA-10 isolates were susceptible to clindamycin, tetracycline and trimethoprim-sulfamethoxazole. CONCLUSION CA-MRSA is a significant cause of SSTIs in the Greater Toronto Area, and can affect patients without known community-related risk factors. The changing epidemiology of CA-MRSA necessitates further surveillance to inform prevention strategies and empiric treatment guidelines.

Non-ST segment elevation acute coronary syndromes : A simplified risk-oriented algorithm

Non-ST segment elevation acute coronary syndromes (NSTE ACS) include a clinical spectrum that ranges from unstable angina to NSTE myocardial infarction. Management goals aim to prevent recurrent ACS and improve long-term outcomes by choosing a treatment strategy according to an estimate of the risk of an adverse outcome. Recent registry data suggest that patients with NSTE ACS frequently do not receive recommended treatment, and that risk stratification is not used to determine either the choice of treatment or the speed of access to coronary angiography. The present article evaluates the evidence for recommended treatment using information from recent trials and guidelines published by the major cardiac organizations in Europe and North America. Using this information, a multidisciplinary group developed a simplified algorithm that uses risk stratification to select an optimal early management strategy. Long-term outcomes are improved by a multi-faceted vascular protection strategy that is initiated at the time of hospitalization for NSTE ACS.

Opioid Prescribing for Opioid-Naive Patients in Emergency Departments and Other Settings: Characteristics of Prescriptions and Association With Long-Term Use

Study objective: We explore the emergency department (ED) contribution to prescription opioid use for opioid‐naive patients by comparing the guideline concordance of ED prescriptions with those attributed to other settings and the risk of patients’ continuing long‐term opioid use. Methods: We used analysis of administrative claims data (OptumLabs Data Warehouse 2009 to 2015) of opioid‐naive privately insured and Medicare Advantage (aged and disabled) beneficiaries to compare characteristics of opioid prescriptions attributed to the ED with those attributed to other settings. Concordance with Centers for Disease Control and Prevention (CDC) guidelines and rate of progression to long‐term opioid use are reported. Results: We identified 5.2 million opioid prescription fills that met inclusion criteria. Opioid prescriptions from the ED were more likely to adhere to CDC guidelines for dose, days’ supply, and formulation than those attributed to non‐ED settings. Disabled Medicare beneficiaries were the most likely to progress to long‐term use, with 13.4% of their fills resulting in long‐term use compared with 6.2% of aged Medicare and 1.8% of commercial beneficiaries’ fills. Compared with patients in non‐ED settings, commercial beneficiaries receiving opioid prescriptions in the ED were 46% less likely, aged Medicare patients 56% less likely, and disabled Medicare patients 58% less likely to progress to long‐term opioid use. Conclusion: Compared with non‐ED settings, opioid prescriptions provided to opioid‐naive patients in the ED were more likely to align with CDC recommendations. They were shorter, written for lower daily doses, and less likely to be for long‐acting formulations. Prescriptions from the ED are associated with a lower risk of progression to long‐term use.

Efficacy and Safety of a Routine Early Invasive Strategy in Relation to Time from Symptom Onset to Fibrinolysis (a Subgroup Analysis of TRANSFER-AMI)

The aim of this study was to assess the efficacy and safety of an early invasive strategy post-fibrinolysis in relation to time from symptom onset to fibrinolysis in patients with ST-elevation myocardial infarction (STEMI). The Trial of Routine Angioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI) randomized 1,059 patients receiving fibrinolysis for STEMI to an early invasive strategy versus standard therapy. The primary end point was the composite of death, reinfarction, recurrent ischemia, new or worsening heart failure, or cardiogenic shock at 30 days. In this post hoc subgroup analysis, we examined the effect of an early invasive strategy on efficacy and safety outcomes after stratification by time from symptom onset to fibrinolysis (<2 or ≥2 hours). Of 1,059 patients in TRANSFER-AMI, 557 (53%) received fibrinolysis <2 hours and 502 (47%) ≥2 hours after symptom onset. Compared to patients who received fibrinolysis within 2 hours of symptoms, patients who received fibrinolysis ≥2 hours after symptom onset had higher Global Registry of Acute Coronary Events risk scores (median 127 vs 122, p = 0.004). The effect of an early invasive strategy did not differ between symptom-to-fibrinolysis time strata for the primary efficacy end point (p-heterogeneity = 0.67), 30-day mortality, the composite of death or reinfarction at 30 days, 6 months, or 1 year, or bleeding (all p-heterogeneity >0.40). In conclusion, the efficacy and safety of an early invasive strategy in patients undergoing fibrinolysis for STEMI do not vary in relation to time (<2 or ≥2 hours) from symptom onset to fibrinolysis.

Efficacy of an early invasive strategy after fibrinolysis in ST-elevation myocardial infarction relative to the extent of coronary artery disease.

BACKGROUND A strategy of early transfer for coronary angiography and intervention is superior to a standard approach of delayed coronary angiography after fibrinolysis for ST-elevation myocardial infarction (STEMI). STEMI patients with lesions in noninfarct-related arteries have a worse prognosis compared with patients with single vessel disease. This study aimed to assess whether the benefits of an early invasive strategy differ in patients with single vessel and multivessel disease. METHODS The Trial of Routine ANgioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI) randomized STEMI patients receiving fibrinolysis to a strategy of early transfer and coronary angiography vs a standard approach. In this post hoc analysis, we stratified 992 patients into 2 groups according to the presence or absence of multivessel disease. We compared the 2 groups in terms of baseline characteristics, in-hospital management, and patient outcomes, and tested for treatment heterogeneity. RESULTS Multivessel disease was present in 369 (37%) patients. Patients with multivessel disease had a greater rate of the primary composite end point of in-hospital death, recurrence of infarction, recurrent ischemia, shock, or heart failure at 30 days (18.2% vs 10.8%; P < 0.001). An early invasive strategy was efficacious in both groups for the primary outcome. In multivariable analysis adjusting for Global Registry of Acute Coronary Events (GRACE) risk score, there was no significant treatment heterogeneity (all P interaction > 0.40) for the primary end point, or death/recurrence of infarction at 6 months and 1 year. CONCLUSIONS Multivessel disease is present in a significant proportion of STEMI patients treated with fibrinolysis and is associated with worse outcomes. A strategy of early transfer and coronary intervention after fibrinolysis was beneficial regardless of the presence or absence of multivessel disease.

EFFICACY OF AN EARLY INVASIVE STRATEGY FOLLOWING FIBRINOLYSIS IN ST-ELEVATION MYOCARDIAL INFARCTION IN RELATION TO THE ANGIOGRAPHIC EXTENT OF CORONARY ARTERY DISEASE

benefit as compared to mild therapeutic hypothermia by inhibiting multiple deleterious pathways. OBJECTIVE: We sought to determine the feasibility of cooling and maintaining comatose post-cardiac arrest patients with ROSC at a target temperature of 31 degrees Celsius over a 24 hour interval. The ability to achieve and maintain moderate therapeutic hypothermia (31 degrees Celsius) in a clinical setting has never been studied in post-cardiac arrest patients. METHODS: The University of Ottawa Heart Institute (UOHI) is currently conducting a randomized controlled therapeutic hypothermia trial, CAPITAL CHILL. Patients presenting with out-of-hospital cardiac arrest, whose treatment includes therapeutic hypothermia, are randomly allocated to mild (34 degrees Celsius) or moderate (31 degrees Celsius) hypothermia through the use of an endovascular cooling device. We identified the first 20 patients who were randomized to 31 degrees Celsius. We examined the ability to achieve and maintain a target temperature of 31 degrees Celsius during a 24 hour interval. RESULTS: Between August 2013 and April 2014, we identified the first 20 consecutive patients randomized to 31 degrees Celsius: the mean age was 60 16 yr. A complete temperature dataset was available on 18 patients, however, out of these patients, 2 expired 12 and 16 hrs following randomization. The figure depicts the mean temperatures with standard deviations evaluated during a 24 hour period at the following time points; 0, 2, 4, 8, 12, 16, 20 and 24 hours. The zero time point was defined as the temperature at randomization.