Elpidoforos S. Soteriades

Continuous versus intermittent intravenous administration of antibiotics: a meta-analysis of randomised controlled trials

Intermittent intravenous administration of antibiotics is the first-line approach in the management of severe infections worldwide. However, the potential benefits of alternate modes of administration of antibiotics, including continuous intravenous infusion, deserve further evaluation. We did a meta-analysis of randomised controlled trials comparing continuous intravenous infusion with intermittent intravenous administration of the same antibiotic regimen. Nine randomised controlled trials studying beta-lactams, aminoglycosides, and vancomycin were included. Clinical failure was lower, although without statistical significance, in patients receiving continuous infusion of antibiotics (pooled OR 0.73, 95% CI 0.53-1.01); the difference was statistically significant in a subset of randomised controlled trials that used the same total daily antibiotic dose for both intervention arms (0.70, 0.50-0.98, fixed and random effects models). Regarding mortality and nephrotoxicity, no differences were found (mortality 0.89, 0.48-1.64; nephrotoxicity 0.91, 0.56-1.47). In conclusion, the data suggest that the administration of the same total antibiotic dose by continuous intravenous infusion may be more efficient, with regard to clinical effectiveness, compared with the intermittent mode. In an era of gradually increasing resistance among most pathogens, the potential advantages of continuous intravenous administration of antibiotics on several clinical outcomes should be further investigated.

Combination Therapy with Intravenous Colistin for Management of Infections Due to Multidrug-Resistant Gram-Negative Bacteria in Patients without Cystic Fibrosis

ABSTRACT Colistin, an antibiotic almost abandoned for intravenous administration for many years due to its reported toxicity, has been recently reintroduced in clinical practice due to the emergence of multidrug-resistant gram-negative bacteria and the lack of development of new antibiotics to combat them. To assess the safety and effectiveness of intravenous colistin, in combination with other antimicrobial agents, in the treatment of serious infections in patients without cystic fibrosis, a retrospective cohort study in a 450-bed tertiary-care hospital in Athens, Greece, was performed. Patients who were hospitalized from 1 October 2000 to 31 January 2004 and received intravenous colistin for more than 72 h were further analyzed. The primary outcome measure was the in-hospital mortality; secondary end points were the clinical outcome of the infections and the occurrence of colistin toxicity. Fifty patients received intravenous colistin with a median (mean) daily dose of 3 (4.5) million IU for 16.5 (21.3) days for the management of 54 episodes of infections due to multidrug-resistant gram-negative bacteria. The predominant infections were pneumonia (33.3%), bacteremia (27.8%), urinary tract infection (11.1%), and intra-abdominal infection (11.1%). The responsible pathogens were Acinetobacter baumannii (51.9%), Pseudomonas aeruginosa (42.6%), and Klebsiella pneumoniae (3.7%) strains (no pathogen was isolated from one case). In-hospital mortality was 24% (12/50 patients). Clinical response (cure or improvement) of the infection was observed in 66.7% of episodes (36/54). In the studied group, serum creatinine levels were decreased, at the end of colistin treatment, by an average of 0.2 ± 1.3 mg/dl compared to baseline levels. Deterioration of renal function during colistin therapy was observed in 4/50 patients (8%). Coadministration of other antimicrobial agents with spectrum against gram-negative microorganisms and the absence of a control group constitute the major limitations of this study. The use of intravenous colistin for the treatment of infections due to multidrug-resistant gram-negative bacteria appears to be safe and effective.

Parent’s Socioeconomic Status, Adolescents’ Disposable Income, and Adolescents’ Smoking Status in Massachusetts

OBJECTIVES This study examined the association between parental socioeconomic status (SES) and adolescent smoking. METHODS We conducted telephone interviews with a probability sample of 1308 Massachusetts adolescents aged 12 to 17 years. We used multiple-variable-adjusted logistic regression models. RESULTS The risk of adolescent smoking increased by 28% with each step down in parental education and increased by 30% for each step down in parental household income. These associations persisted after adjustment for age, sex, race/ethnicity, and adolescent disposable income. Parental smoking status was a mediator of these associations. CONCLUSIONS Parental SES is inversely associated with adolescent smoking. Parental smoking is a mediator but does not fully explain the association.

Firefighters and on-duty deaths from coronary heart disease: a case control study

BackgroundCoronary heart disease (CHD) is responsible for 45% of on-duty deaths among United States firefighters. We sought to identify occupational and personal risk factors associated with on-duty CHD death.MethodsWe performed a case-control study, selecting 52 male firefighters whose CHD deaths were investigated by the National Institute for Occupational Safety and Health. We selected two control populations: 51 male firefighters who died of on-duty trauma; and 310 male firefighters examined in 1996/1997, whose vital status and continued professional activity were re-documented in 1998.ResultsThe circadian pattern of CHD deaths was associated with emergency response calls: 77% of CHD deaths and 61% of emergency dispatches occurred between noon and midnight. Compared to non-emergency duties, fire suppression (OR = 64.1, 95% CI 7.4–556); training (OR = 7.6, 95% CI 1.8–31.3) and alarm response (OR = 5.6, 95% CI 1.1–28.8) carried significantly higher relative risks of CHD death. Compared to the active firefighters, the CHD victims had a significantly higher prevalence of cardiovascular risk factors in multivariate regression models: age ≥ 45 years (OR 6.5, 95% CI 2.6–15.9), current smoking (OR 7.0, 95% CI 2.8–17.4), hypertension (OR 4.7, 95% CI 2.0–11.1), and a prior diagnosis of arterial-occlusive disease (OR 15.6, 95% CI 3.5–68.6).ConclusionsOur findings strongly support that most on-duty CHD fatalities are work-precipitated and occur in firefighters with underlying CHD. Improved fitness promotion, medical screening and medical management could prevent many of these premature deaths.

Blood Pressure in Firefighters, Police Officers, and Other Emergency Responders

Elevated blood pressure is a major risk factor for cardiovascular morbidity and mortality. Increased risk begins in the prehypertensive range and increases further with higher pressures. The strenuous duties of emergency responders (firefighters, police officers, and emergency medical services (EMS) personnel) can interact with their personal risk profiles, including elevated blood pressure, to precipitate acute cardiovascular events. Approximately three-quarters of emergency responders have prehypertension or hypertension, a proportion which is expected to increase, based on the obesity epidemic. Elevated blood pressure is also inadequately controlled in these professionals and strongly linked to cardiovascular disease morbidity and mortality. Notably, the majority of incident cardiovascular disease events occur in responders who are initially prehypertensive or only mildly hypertensive and whose average premorbid blood pressures are in the range in which many physicians would hesitate to prescribe medications (140-146/88-92). Laws mandating public benefits for emergency responders with cardiovascular disease provide an additional rationale for aggressively controlling their blood pressure. This review provides a background on emergency responders, summarizes occupational risk factors for hypertension and the metabolic syndrome, their prevalence of elevated blood pressure, and evidence linking hypertension with adverse outcomes in these professions. Next, discrepancies between relatively outdated medical standards for emergency responders and current, evidence-based guidelines for blood pressure management in the general public are highlighted. Finally, a workplace-oriented approach for blood pressure control among emergency responders is proposed, based on the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

Comparison of amount of biomedical research originating from the European Union and the United States

Abstract Objective To examine and compare the research productivity of the European Union, the four “candidate” countries (those currently waiting to join the EU), and the United States in several fields of biomedical sciences. Design A retrospective observational study—bibliometric analysis. Data sources Manuscripts published by authors from each country separately and from each group of countries for the period 1994 to 2004 and included in the Essential Science Indicators database of the Institute of Scientific Information. Main outcome measures Number of published articles and number of citations, adjusted for gross domestic product and population size. Results 1 485 749 articles were published by authors from the EU compared with 1 356 805 from the US. The research productivity of the first 15 countries to join the EU, adjusted for population, was lower (76%) than that of the US—and even lower (66%) when the 10 newest EU countries were included in the analysis. Conclusion The newest EU members and the EU candidate countries need further help and resources to increase their productivity, thereby improving the productivity of the EU as a whole.

Antifungal prophylaxis with azoles in high-risk, surgical intensive care unit patients: A meta-analysis of randomized, placebo-controlled trials*

Objective:The use of antifungal prophylaxis remains controversial in most populations including surgical intensive care unit patients. A meta-analysis of randomized controlled trials was performed to evaluate the safety and effectiveness of azoles as antifungal prophylaxis in high-risk patients receiving treatment in the surgical intensive care unit. Data Source:Data were obtained from PubMed, Current Contents, Cochrane central register of controlled trials, and references from relevant articles. Study Selection:Randomized controlled trials using azoles as antifungal prophylaxis vs. placebo were included in the study. Data Extraction:Two independent reviewers extracted data concerning the development of fungal infections (superficial or invasive), adverse effects, and mortality. Synthesis:Six randomized controlled trials were included in the main analysis. Publication bias and statistically significant heterogeneity were not observed among the analyzed studies. Patients receiving antifungal prophylaxis developed fewer episodes of candidemia (odds ratio [OR] = 0.28, 95% confidence interval [CI] 0.09–0.86), nonbloodstream invasive fungal infections (OR = 0.26, 95% CI 0.12–0.53), and noninvasive (superficial) fungal infections (OR = 0.22, 95% CI 0.11–0.43), respectively. No reduction in mortality was observed among patients who received azole prophylaxis (OR = 0.74, 95% CI 0.52–1.05). There was no significant difference in reported adverse effects (OR = 1.28, 95% CI 0.82–1.98). Conclusions:Despite its limitations, our meta-analysis suggests that the prophylactic use of azoles in high-risk surgical intensive care unit patients is associated with a reduction of fungal infections but not in all-cause mortality. However, although not noted in the analyzed randomized controlled trials, there is concern about the use of azoles due to possible shift toward non-albicans species and development of resistance to azoles.

A bibliometric analysis in the fields of preventive medicine, occupational and environmental medicine, epidemiology, and public health

BackgroundResearch in the fields of Preventive Medicine, Occupational/Environmental Medicine, Epidemiology and Public Health play an important role in the advancement of knowledge. In order to map the research production around the world we performed a bibliometric analysis in the above fields.MethodsAll articles published by different world regions in the above mentioned scientific fields and cited in the Journal Citation Reports (JCR) database of the Institute for Scientific Information (ISI) during the period 1995 and 2003, were evaluated. The research production of different world regions was adjusted for: a) the gross domestic product in 1995 US dollars, and b) the population size of each region.ResultsA total of 48,861 articles were retrieved and categorized. The USA led the research production in all three subcategories. The percentage of articles published by USA researchers was 43%, 44% and 61% in the Preventive Medicine, Epidemiology, and Public Health subcategories, respectively. Canada and Western Europe shared the second position in the first two subcategories, while Oceania researchers ranked second in the field of Public Health.ConclusionUSA researchers maintain a leadership position in the production of scientific articles in the fields of Preventive Medicine, Occupational/Environmental Medicine and Epidemiology, at a level similar to other scientific disciplines, while USA contribution to science in the field of Public Health is by all means outstanding. Less developed regions would need to support their researchers in the above fields in order to improve scientific production and advancement of knowledge in their countries.

Tobacco use among students aged 13–15 years in Greece: the GYTS project

BackgroundData on the prevalence of tobacco use among teenagers in Greece are limited. We examined the prevalence of smoking among middle-school students in Greece using the Global Youth Tobacco Survey (GYTS).MethodsThe Global Youth Tobacco Survey was implemented in Greece during the academic year 2004 – 2005 by the University of Thessaly and the National School of Public Health. Data were collected using the GYTS self-administered anonymous questionnaire, which was distributed by specifically trained field workers to a nationally representative sample of middle-school students aged 13–15 years (through randomly selected schools and classes), randomly selected through a two-stage cluster sample design. Data processing and statistical analyses were performed at the Centers for Disease Control and Prevention (CDC).ResultsAbout one third of the students 32.1% (29.4 – 35.0) reported that they had tried tobacco in the past, while 16.2% (14.3 – 18.4) reported being current users of tobacco products. In addition, 1 in 4 of ever smokers reported that they began smoking before the age of 10 years old. Almost 1 in 5 never smokers reported being susceptible to initiate smoking in the next year and about 89.8% (88.3 – 91.1) of the respondents were exposed to environmental tobacco smoke in their homes and 94.1% (93.2 – 94.9) in public places. Finally, a strikingly high number of students 95% (89.5 – 97.7) reported that they were able to buy their own cigarettes without restrictions.ConclusionThe results of the GYTS show that the prevalence of smoking in middle-school children is alarmingly high in Greece. Smoking among young people constitutes a significant problem that is destined to worsen in the absence of any comprehensive efforts focused on strict anti-smoking legislation, policies and tobacco control interventions targeting children at a young age.

Obesity and risk of job disability in male firefighters

BACKGROUND Obesity is a major public health problem and a workplace epidemic in Western societies. However, little is known about the association between obesity and job disability in specific occupational groups. AIM To examine the association between obesity and risk of job disability among firefighters. METHODS A prospective cohort study design was employed in following 358 Massachusetts firefighters enrolled in a statewide medical surveillance program. We prospectively evaluated time to development of adverse employment outcomes >6 years of follow-up. RESULTS In multivariable-adjusted Cox proportional hazard models, we found that every one-unit increase in body mass index (BMI) was associated with a 5% increased risk of job disability. Compared to firefighters in the lowest tertile of BMI (BMI < 27.2), those in the highest tertile (BMI >or= 30.2) had a significantly increased risk of an adverse employment event with a multivariable-adjusted hazard ratio (HR) of 1.98 (95% CI 1.06-3.72). There was also a significant dose-response relationship of increasing risk across tertiles, as well as a significant trend: HR 1.39 (95% CI 1.04-1.86). The highest categories of BMI had a 60-90% increased risk of job disability compared to the lowest or normal-weight categories, respectively. CONCLUSIONS Obesity is associated with higher risk of job disability in firefighters. Additional research is needed to further explore our findings. Our study may have economic and public health implications in other occupational settings.