Elena Shleyfer

Nasopharyngeal versus oropharyngeal sampling for isolation of potential respiratory pathogens in adults

ABSTRACT The optimal methodology for the identification of colonization by potential respiratory pathogens (PRP) in adults is not well established. The objectives of the present study were to compare the sensitivities of sampling the nasopharynx and the oropharynx for identification of PRP colonization and to compare the sensitivities of samples from the nasopharynx by swab and by washing for the same purpose. The study included 500 participants with a mean age of 65.1 ± 17.8 years. Of these, 300 patients were hospitalized for acute febrile lower respiratory tract infection and 200 were controls. Each participant was sampled by oropharyngeal swab (OPS), nasopharyngeal swab (NPS), and nasopharyngeal washing (NPW). The samples were tested by conventional bacteriological methods to identify Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. OPS detected colonization by S. pneumoniae in 30% of the subjects compared with 89% by NPS and NPW (P < 0.000001). The corresponding rates for H. influenzae were 49% and 64%, respectively (no significant difference [NS]), and for M. catarrhalis were 72% and 46%, respectively (P < 0.0004). NPS identified 61% of the cases of colonization with S. pneumoniae, compared with 76% by NPW (NS). The corresponding rates for H. influenzae were 31% and 56%, respectively (P < 0.04), and for M. catarrhalis were 39% and 33%, respectively (NS). We conclude that the sensitivities of nasopharyngeal and oropharyngeal sampling for identification of PRP colonization in adults are different for each of the three bacteria in this category. The combined results of sampling from both sites are necessary to obtain a true picture of the rate of colonization. NPW is superior to NPS.

Comparison of Diabetic Ketoacidosis in Patients With Type-1 and Type-2 Diabetes Mellitus

Background:Diabetic ketoacidosis (DKA) occurs most often in patients with type 1 diabetes, however patients with type 2 diabetes are also susceptible to DKA under stressful conditions. The aims of our study were to evaluate and compare the clinical and biochemical characteristics and outcomes of type 1 versus type 2 diabetes mellitus (DM) patients with DKA. Methods:A retrospective cohort study of adult patients hospitalized with DKA between January 1, 2003, and January 1, 2010. The clinical and biochemical characteristics of DKA patients with type-1 DM were compared with those of patients with type-2 DM. The primary outcome was in-hospital all-cause mortality. Results:The study cohort included 201 consecutive patients for whom the admission diagnosis was DKA: 166 patients (82.6%) with type-1 DM and 35 patients (17.4%) with type-2 DM. The patients with DKA and type-2 DM were significantly older than patients with type-1 DM (64.3 versus 37.3, P < 0.001). Significantly more patients with severe forms of DKA were seen in the group with type-2 DM (25.7% versus 9.0%, P = 0.018). The total in-hospital mortality rate of patients with DKA was 4.5%. The primary outcome was significantly worse in the group of patients with type-2 DM. Conclusions:DKA in patients with type-2 DM is a more severe disease with worse outcomes compared with type-1 DM. Advanced age, mechanical ventilation and bed-ridden state were independent predictors of 30-day mortality.

Gender-related differences in clinical characteristics and outcomes in patients with diabetic ketoacidosis.

BACKGROUND Diabetic ketoacidosis (DKA) is 1 of the most common and serious complications of diabetes, and is a significant cause of morbidity and mortality. There is a paucity of data regarding gender-related differences in clinical characteristics and outcomes of patients hospitalized for DKA. OBJECTIVE The purpose of this study was to assess whether gender plays a role in clinical characteristics and outcome of DKA. METHODS We performed a retrospective cohort study of patients hospitalized with DKA between January 1, 2003 and January 1, 2010. The outcomes of male and female patients were compared. The primary outcome was in-hospital all-cause mortality. The secondary outcomes were 30-day all-cause mortality and rate of complications: sepsis, respiratory failure, multiple organ failure, stroke, and myocardial infarction. RESULTS Eighty-nine men and 131 women with DKA were included in the study. Male patients had higher rates of chronic renal failure compared with women (16.9% vs 3.1%; P = 0.001), whereas more women than men received oral hypoglycemic therapy (19.8% vs 9.0%; P = 0.046); women also had higher glycosated hemoglobin levels before admission (11.9% [1.7%] vs 9.9% [2.2%]; P = 0.025). The in-hospital mortality rate was not significantly different for both genders (4.5% in the male group vs 3.8% in the female group; P = 1.0). We did not find significant differences between the 2 groups in the 30-day mortality rate (4.5% vs 6.1%; P = 0.7) or the rate of complications (5.6% vs 6.9%; P = 0.9). Advanced age, mechanical ventilation, and bedridden state were independent predictors of 30-day mortality. CONCLUSIONS In our study we did not find statistically significant differences in the in-hospital mortality, 30-day all-cause mortality, or rate of complications between men and women hospitalized with DKA. However, women with poorly controlled type 2 diabetes mellitus receiving oral hypoglycemic therapy required particular attention and might benefit from earlier introduction and intensification of insulin therapy to avoid DKA.

Mixing of nasopharyngeal and oropharyngeal samples to identify potential respiratory pathogens in adults.

A mixed culture of oropharyngeal swabs, nasopharyngeal swabs and nasopharyngeal washings, taken from 400 patients, was compared to separate cultures of the same samples. The mixed culture identified Streptococcus pneumoniae in 37 of 40 (93%) patients with positive samples, Hemophilus influenzae in 28 of 29 (97%), and Moraxella catarrhalis in 94 of 94 (100%). These sensitivity rates clearly justify the use of mixed cultures instead of separate cultures for clinical and epidemiological purposes. The reduction in costs stemming from the use of mixed cultures may have a decisive influence when considering this test for extensive clinical and epidemiological purposes.

Is It Possible to Shorten Ambulatory Blood Pressure Monitoring

The aim of this investigation was to find a time segment in which average blood pressure (BP) has the best correlation with 24‐hour BP control. A total of 240 patients with full ambulatory BP monitoring (ABPM) were included; 120 had controlled BP (systolic BP [SBP] ≤135 mm Hg and diastolic BP [DBP] ≤85 mm Hg) and 120 had uncontrolled BP (SBP >135 mm Hg and/or DBP >85 mm Hg). Each ABPM was divided into 6‐ and 8‐hour segments. Evaluation for correlation between mean BP for each time segment and 24‐hour BP control was performed using receiver operating characteristic curve analysis and Youdens index for threshold with the best sensitivity and specificity. The mean BP in the following segments showed the highest area under the curve (AUC) compared with average controlled 24‐hour BP: SBP 2 am to 8 am (AUC, 0.918; threshold value of 133.5 mm Hg, sensitivity−0.752 and specificity−0.904); SBP 2 pm to 10 pm (AUC, 0.911; threshold value of 138.5 mm Hg, sensitivity−0.803 and specificity−0.878); and SBP 6 am to 2 pm (AUC, 0.903; threshold value of 140.5 mm Hg, sensitivity−0.778 and specificity−0.888). The time segment 2 pm to 10 pm was shown to have good correlation with 24‐hour BP control (AUC >0.9; sensitivity and specificity >80%). This time segment might replace full ABPM as a screening measure for BP control or as abbreviated ABPM for patients with difficulty in performing full ABPM.

Dabigatran-induced nephropathy and its successful treatment with Idarucizumab - case report and literature review

BACKGROUND Anticoagulant induced renal injury has been previously described with Warfarin treatment. In the last decade direct oral anticoagulants (DOAC) were introduced. They include direct inhibitors of factor Xa (Rivaroxaban, Apixaban, Edoxaban) and a thrombin inhibitor (Dabigatran). There are isolated reports describing acute kidney injury (AKI) due to the use of DOACs. CASE REPORT We report a clinical case of an 80-year-old patient recently started on Dabigatran for new onset atrial fibrillation. She presented with AKI and hematuria, urine specimen showed RBC casts, and a working diagnosis of anticoagulant nephropathy due to Dabigatran was made. During hospitalization she was treated with Idarucizumab with a full recovery of renal function. To the best of our knowledge, there are 4 published case reports describing kidney injury produced by Dabigatran. CONCLUSION The use of DOACs is increasing rapidly, with increasing concern about its safety profile and, in particular, its potential harmful effect on renal function. As described in our case, treatment with Praxbind for Dabigatran induced kidney injury may be an acceptable management strategy that may obviate the need for urgent dialysis in selected cases by complete reversal of the AKI.

Glatiramer Acetate-associated Refractory Immune Thrombocytopenic Purpura

We present a case of glatiramer acetate-associated refractory immune thrombocytopenic purpura (ITP) in a female patient with multiple sclerosis. A search of MEDLINE/PubMed did not find any connection between glatiramer acetate and thrombocytopenia, specifically ITP. The autoimmune reaction was resistant to conservative ITP treatment, and was eventually managed only by splenectomy. To the best of our knowledge, this is the first report of glatiramer acetate-associated ITP. Physicians should be aware of this condition, and consider performing routine blood counts at the beginning of glatiramer acetate treatment. LEARNING POINTS We present a unique case of glatiramer acetate-associated refractory immune thrombocytopenic purpura (ITP) in a female patient with multiple sclerosis, which was eventually managed only by splenectomy. Although glatiramer acetate is known for its immunomodulatory effect, a literature search did not reveal any reports of an association with ITP. Physicians should be aware of this condition, and consider performing routine blood counts at the beginning of and during glatiramer acetate treatment.