Irene Alexandraki

Bacteremic and nonbacteremic pneumococcal pneumonia: a prospective study.

We prospectively identified cases of pneumococcal pneumonia and used stringent criteria to stratify them into bacteremic and nonbacteremic cases. Although patients were distributed among racial groups in proportion to all patients seen at this medical center, the proportion of African-Americans with bacteremic disease was significantly increased. All patients had at least 1 underlying condition predisposing to pneumococcal infection, and most had several. Although the mean number of predisposing factors was greater among bacteremic patients than nonbacteremic patients, only alcohol ingestion was significantly more common. Nearly one-third of patients had substantial anemia (hemoglobin < or = 10 g/dL) on admission, which may have predisposed to infection. In the case of other laboratory abnormalities, such as albumin, creatinine, and bilirubin, it was difficult to determine which abnormality might have predisposed to pneumococcal infection and which might have resulted from it. The radiologic appearance was varied. Airspace consolidation and air bronchogram on chest X-ray were highly associated with bacteremic disease, as was the presence of pleural effusion. Although the Pneumonia Patient Outcomes Research Team (PORT) risk score was a predictor of mortality, it did not help to predict the presence of bacteremia in an individual case. Most patients who died in the first week in hospital were bacteremic, and a high PORT risk score with bacteremia reliably predicted a high likelihood of a fatal outcome. Eleven patients had extrapulmonary disease with meningitis, empyema, and septic arthritis predominating; all of these patients were bacteremic. The antibiotic susceptibility of our strains correlated well with those that have been reported in the United States during the years of this study. The use of numerous antibiotics of different classes in many patients, especially those who were the most ill, precluded analysis of outcome based on antibiotic therapy. Only 17 patients had been vaccinated. Since nearly all patients had conditions for which pneumococcal vaccine is recommended and more than one-third had been hospitalized in the preceding 6 months, the low rate of vaccination can be regarded as a missed opportunity to administer a potentially beneficial vaccine.

Response of Human Immunodeficiency Virus–Infected Patients Receiving Highly Active Antiretroviral Therapy to Vaccination with 23-Valent Pneumococcal Polysaccharide Vaccine

Whether highly active antiretroviral therapy (HAART) impacts responses to 23-valent pneumococcal polysaccharide vaccine (PV) is not known. Immunoglobulin G (IgG) levels for 6 capsular polysaccharides in human immunodeficiency virus (HIV)-infected patients who had received > or =6 months of HAART were measured either after their first dose of PV (n=46) or after revaccination (n=41); control subjects had never received HAART and had received the first dose of PV (n=38). There were no significant differences in pre- or postvaccination IgG levels among these groups but for 1 capsular polysaccharide. The 3 groups had significant postvaccination increases in IgG levels to all capsular polysaccharides. The control group had a greater number of 2-fold responses than did the combined HAART groups (P<.05). Patients with a CD4 cell count of > or =200 cells/mm3 had a greater number of 2-fold responses than did those with a CD4 cell count of <200 cells/mm3 (P<.05). For revaccinated patients, postvaccination IgG levels were correlated with the CD4 cell count at the initial vaccination. The immunogenicity of PV among patients receiving long-term HAART is modest. It seems best to immunize HIV-infected patients early in the course of disease.

Barriers Related to Mammography Use for Breast Cancer Screening Among Minority Women

PURPOSE The purpose of this review was to better understand possible social, economic, cultural, behavioral, and systems barriers to breast cancer screening among minority women. METHODS Relevant manuscripts were identified through a MEDLINE/PubMed search for English-language literature from October 1971 through April 2009. The abstracts from a total of 515 manuscripts were reviewed. Only studies conducted among minority women in the United States and examining barriers related to screening mammography were considered. Of 64 relevant articles, 13 cross-sectional and 4 prospective studies met inclusion criteria. Study design; patient characteristics; outcomes regarding knowledge, attitudes and beliefs; social norms; accessibility; and cultural competence regarding breast cancer screening were abstracted. Studies were rated using a methodological quality score (MQS). RESULTS Pain and embarrassment associated with screening mammography, low income and lack of health insurance, poor knowledge about breast cancer screening, lack of physician recommendation, lack of trust in hospitals and doctors, language barriers, and lack of transportation were the most frequently identified barriers. The average MQS of the studies selected was 10.9 (SD = 3.25, range, 4-20). CONCLUSIONS Multiple barriers limit screening mammography among minority women. Recognizing predictors of screening among minority women and addressing culturally specific barriers may improve utilization of screening mammography among these women.

Blood Culture Isolates in Hemodialysis Vascular Catheter-Related Bacteremia

Hemodialysis requires reliable and recurrent access to the central circulation and arteriovenous fistulas or grafts are the preferred modes of vascular access. However, in many patients the use of external tunneled vascular catheters may be necessary. The major complication of tunneled catheters is infection. Understanding local epidemiologic patterns of dialysis catheter-related bacteremia may help in the management of these patients. To address this issue, we reviewed the 5-year microbiologic culture results from all bacteremic hemodialysis patients with tunneled catheters at our institution. During this period, there were 203 organisms isolated from 153 positive blood cultures. Gram-positive, Gram-negative, and fungal species represented 55.7%, 43.3%, and 1% of isolates, respectively. Positive blood cultures classified according to the presence of a single Gram-positive or single Gram-negative organism, single fungus, or polymicrobial organisms, accounted for 41.8%, 29.4%, 0.6% and 28.1% of infectious events. From 2000–2004, there was a numerical trend toward a decrease in Gram-positive infection (64.3% versus 34.8% respectively, P = 0.12) and a numerical trend toward an increase in Gram-negative and polymicrobial bacteremias (17.9 versus 21.7, P = 0.07 and 17.9 versus 43.5, P = 0.09, respectively). These data indicate that bacteremic events in hemodialysis patients with vascular catheters are commonly due to a single Gram-positive organism, but the incidence of Gram-negative and polymicrobial bacteremia may be increasing. If confirmed in a prospective trial, adjustment of empiric antibiotic regimens for suspected catheter-associated bacteremia may be indicated.

Increasing Access to Health Care Providers Through Medical Home Model May Abolish Racial Disparity in Diabetes Care: Evidence From a Cross-sectional Study

OBJECTIVES We hypothesized that the medical home model is an effective intervention to decreasing health care disparities in minority patients with diabetes. SETTING Set in a community-based health initiative in Jacksonville, Florida, the studys mission was to support and enhance the primary care infrastructure in an effort to improve quality of care and increase access while reducing costs. INTERVENTION We preformed a retrospective analysis of outcomes on 457 patients identified by registry specialists and enrolled in the diabetes rapid access program (DRAP). Data were obtained on 457 diabetic patients enrolled in the 6 clinic centers of the program between June 1, 2006, and December 31, 2009. MAIN OUTCOME MEASURES Improvements in hemoglobin A1c and proportion of patients with hemoglobin A1c of more than 8% according to gender, race, and clinic location. RESULTS The average hemoglobin A1c at the beginning of the study was 8.2% (+/-2.3), and decreased significantly by an average of 0.5% (p<.005). The mean improvement in hemoglobin A1c did not differ significantly by clinic location, race, or gender. Both African American and Caucasian patients as well as men and women with a hemoglobin A1c of at least 8% showed a significant improvement in their A1c after the intervention (p<.005). CONCLUSIONS The DRAP medical home model presents an opportunity to decrease disparities in care and improve diabetes care.

A comparative study of unscheduled hospital readmissions in a resident-staffed teaching service and a hospitalist-based service.

Background: The rate of unscheduled readmissions is an important quality indicator with financial implications for hospitals. Objective: To determine if resident-staffed services have more favorable outcomes compared to hospitalist services, predictors of readmissions were determined within an academic hospital. Methods: From November 1, 2006 to April 30, 2007, 5943 admissions were assigned to a resident-staffed teaching service (n = 2244) or to a hospitalist-based service (n = 3699). Data on age, race, sex, insurance status, case mix index (CMI), length of stay (LOS), and unscheduled hospital readmission within 30 days were analyzed. Results: Patients admitted to the hospitalist service were older and more likely to be female compared with those admitted to the teaching service. There were no significant differences in the health care insurance carrier of the patients admitted to the two services. The rate of unscheduled hospital readmissions within 30 days was significantly higher in the teaching service compared to the hospitalist service (14.1% vs 10.4%; P < 0.001). LOS was significantly higher (4.95 ± 7.77 vs 4.14 ± 5.95; P < 0.001), and the CMI was significantly lower (1.04 ± 0.94 vs 1.14 ± 1.02; P < 0.001) in the hospitalist service compared to the resident-staffed service. Probability of readmission was significantly reduced with increasing LOS and discharge home with self care. Conclusions: The modestly increased unscheduled readmission rate to the resident-staffed service compared to the hospitalist service may be related to lower LOS. Increased CMI of patients in the resident service may have contributed to the increased rate of readmissions.

Hepatitis C infection and the risk of bacteremia in hemodialysis patients with tunneled vascular access catheters.

Background: The major complication of tunneled vascular catheters in dialysis patients is infection. In preliminary work, an association was noted between hepatitis C virus (HCV) infection and bacteremia in these patients. On this basis, we theorized that HCV infection may be associated with bacteremia in dialysis patients with tunneled catheters. Methods: We conducted a two-phase clinical study to define the association between HCV infection and bacteremia in hemodialysis patients with catheters. Phase 1 was a cross-sectional study designed to assess the association between HCV serologic status and bacteremia. Phase 2 was a prospective study that examined the relationship between HCV viral load and bacteremia. Results: In Phase 1, HCV (+) patients had a significantly greater prevalence of bacteremia than HCV (−) patients (61 vs 7.7% respectively, P < 0.05). In Phase 2, the presence of detectable virus was associated with a numerical trend toward an increase in the incidence of bacteremia (40 vs 0% for patients with and without detectable virus, respectively, P = 0.09). Conclusion: These studies suggest that HCV infection may be associated with the development of bacteremia in hemodialysis patients with tunneled catheters.

Collet-sicard syndrome : An uncommon manifestation of metastatic prostate cancer

Metastatic spread of prostate adenocarcinoma to the temporal bone is very rare. Involvement of the jugular foramen may result in Collet-Sicard syndrome. This syndrome is characterized by paralysis of the lower four cranial nerves. A case of metastatic prostate adenocarcinoma involving the temporal bone causing Collet-Sicard syndrome is presented. This case highlights an uncommon manifestation of prostate adenocarcinoma causing symptoms referable to the occipital condyle of the temporal bone. Few cases have been reported in the literature of Collet-Sicard syndrome due to metastatic prostate cancer. This case reminds readers that awareness of atypical presentations may reduce diagnostic delay and expedite appropriate treatment.

Gram-negative versus Gram-positive bacteremia: what is more alarmin(g)?

Gram-negative bacteremia has been associated with severe sepsis, although the exact mechanism and pathophysiological differences among bacterial species are not well understood. In the previous issue of Critical Care, Abe and colleagues report results of a retrospective study that show a significantly higher incidence of Gram-negative bacteremia among adult intensive care unit patients with septic shock than in those with sepsis or severe sepsis. In this study, C-reactive protein and IL-6 levels were significantly higher in Gram-negative bacteremia than in Gram-positive bacteremia. These observations suggest a distinct immunopathophysiologic behavior of sepsis in patients with Gram-negative bacteremia that may influence clinical outcomes. Future research exploring new biomarkers and danger signals and further characterizing differences in the virulence mechanisms between Gram-negative and Gram-positive bacteria appears promising and could lead to new therapeutics and to improved clinical outcomes.

Relative Merits of Low-Carbohydrate Versus Low-Fat Diet in Managing Obesity.

Objectives Although low-fat diets (LFD) have been the cornerstone of dietary guidelines for weight reduction, low-carbohydrate diets (LCD) continue to gain attention and popularity. Which diet can achieve significant and sustainable weight loss in unclear, however. Our objective in this study was to compare LCDs with LFDs and their impact on weight loss. Methods We performed a MEDLINE/PubMed search for English-language articles of randomized controlled studies conducted with adults who were overweight or obese for at least 6 months for the time period of January 2001–October 2014. Two reviewers independently abstracted data, including participants’ characteristics, diet composition and duration, and change in weight from baseline at 6 and 12 months. Results A total of 17 studies were analyzed. At 6 months, the mean weight loss for participants on an LCD was −1.439 kg (95% confidence interval −2.319 to −0.558) compared with participants on an LFD (P < 0.001). At 12 months, the difference was smaller, −0.769 kg (95% confidence interval −1.361 to −0.178) but remained statistically significant (P < 0.010). The mean difference in the weight loss between the two diets was attenuated over time. Conclusions Reducing carbohydrate intake may help patients achieve weight loss. The mean difference in weight change between an LCD and an LFD was too small to have a meaningful impact on weight loss. More studies are needed to better elucidate the role of LCDs in weight loss efforts.