Vincent A. DeBari

Statins may reduce episodes of exacerbation and the requirement for intubation in patients with COPD : evidence from a retrospective cohort study

Introduction:  Statins have diverse anti‐inflammatory effects in addition to their lipid‐lowering ability. This study assesses the rate of chronic obstructive pulmonary disease (COPD) exacerbation and intubations in patients taking statins.

Chronic kidney disease as a risk factor for Clostridium difficile infection

Introduction:  Clostridium difficile‐associated diarrhoea (CDAD) is the most common cause of nosocomial diarrhoea in the USA. In this study, we sought to determine the association between chronic kidney disease (CKD) and CDAD.

Levalbuterol Versus Racemic Albuterol in the Treatment of Acute Exacerbation of Asthma in Children

Objective: To compare levalbuterol and racemic albuterol for the treatment of acute exacerbation of asthma in pediatric population. Design: Prospective, double-blind, randomized research trial in a pediatric emergency department of an urban tertiary care hospital. Participants: Children 5 to 21 years with a history of asthma presenting to the emergency department in acute exacerbation. Interventions: As per a computer-generated randomization sequence, patients received either 1.25 mg of levalbuterol or albuterol 2.5 mg via nebulization along with ipratropium hydrochloride. Patients received 3 back-to-back treatments as needed every 20 minutes, maximum of 3; 2 mg/kg of oral prednisone was administered to the patients after the second treatment. Baseline respiratory parameters such as oxygen saturations, respiratory rates, and peak flow rates were measured and repeated after every treatment. The decision for further treatments and or hospitalization was made by the treating emergency department physician as per his/her clinical judgement of the respiratory parameters at the end of 3 treatments. Results: Seventy patients completed the study. Most of the patients were in moderate severity of asthma exacerbation. All patients in both groups showed improvement in oxygen saturations, respiratory rates, and peak flow rates. However, no statistically significant difference was observed in the 2 groups regarding the respiratory parameters (P > 0.05). Conclusion: Levalbuterol is not more efficacious than racemic albuterol in improving respiratory parameters in children presenting with acute exacerbation of asthma.

Diabetes mellitus as a risk factor for recurrence of Clostridium difficile infection in the acute care hospital setting

BACKGROUND Clostridium difficile-associated diarrhea (CDAD) is increasingly encountered in the acute care setting with rates of infection increasing dramatically since 2001. Reoccurring episodes are being seen with increasing frequency. The purpose of this study was to examine risk factors specifically associated with CDAD recurrence in an urban medical center. METHODS This study was conducted in a 651-bed, acute care teaching hospital in an urban community in northeastern New Jersey. We examined the medical records of subjects discharged from the institution with a diagnosis of CDAD over the 6-year period January 1, 2003, to December 31, 2008. Inclusion in the study required clinical signs and symptoms of CDAD and the presence of C difficile toxins A/B. This cohort of 247 subjects was divided into 2 groups: those who were not readmitted with CDAD within 6 months (n = 171) and those who required readmission for CDAD within 6 months of discharge from their last admission (n = 76). RESULTS Both hypoalbuminemia (odds ration [OR], 1.74, 95% confidence interval [CI]: 1.10-2.77; P = .02) and diabetes (P < .0001; OR, 3.04; 95% CI: 1.84-5.03; P < .0001) were considered as independent risk factors. After adjustment for potential confounders, hypoalbuminemia was found to be race dependent (OR, adjusted for black race: 1.62; 95% CI: 0.93-2.82; P = .09); however, diabetes was found to be a significant independent risk factor for CDAD recurrence (adjusted OR ranged from 3.79 to 5.46, minimum lower 95% confidence level: 2.01, all P values <.0001). CONCLUSION We have demonstrated that diabetes is an important risk factor for recurrence of CDAD. Although previous have concluded that hypoalbuminemia is associated with CDAD recurrence, our data suggest that this association may have some dependence on race or ethnicity.

Is There a Clinical Role For Smartphone Sleep Apps? Comparison of Sleep Cycle Detection by a Smartphone Application to Polysomnography

STUDY OBJECTIVES Several inexpensive, readily available smartphone apps that claim to monitor sleep are popular among patients. However, their accuracy is unknown, which limits their widespread clinical use. We therefore conducted this study to evaluate the validity of parameters reported by one such app, the Sleep Time app (Azumio, Inc., Palo Alto, CA, USA) for iPhones. METHODS Twenty volunteers with no previously diagnosed sleep disorders underwent in-laboratory polysomnography (PSG) while simultaneously using the app. Parameters reported by the app were then compared to those obtained by PSG. In addition, an epoch-by-epoch analysis was performed by dividing the PSG and app graph into 15-min epochs. RESULTS There was no correlation between PSG and app sleep efficiency (r = -0.127, p = 0.592), light sleep percentage (r = 0.024, p = 0.921), deep sleep percentage (r = 0.181, p = 0.444) or sleep latency (rs = 0.384, p = 0.094). The app slightly and nonsignificantly overestimated sleep efficiency by 0.12% (95% confidence interval [CI] -4.9 to 5.1%, p = 0.962), significantly underestimated light sleep by 27.9% (95% CI 19.4-36.4%, p < 0.0001), significantly overestimated deep sleep by 11.1% (CI 4.7-17.4%, p = 0.008) and significantly overestimated sleep latency by 15.6 min (CI 9.7-21.6, p < 0.0001). Epochwise comparison showed low overall accuracy (45.9%) due to poor interstage discrimination, but high accuracy in sleep-wake detection (85.9%). The app had high sensitivity but poor specificity in detecting sleep (89.9% and 50%, respectively). CONCLUSIONS Our study shows that the absolute parameters and sleep staging reported by the Sleep Time app (Azumio, Inc.) for iPhones correlate poorly with PSG. Further studies comparing app sleep-wake detection to actigraphy may help elucidate its potential clinical utility. COMMENTARY A commentary on this article appears in this issue on page 695.

Predictors and outcomes of pneumonia in patients with spontaneous intracerebral hemorrhage.

Objectives. Pneumonia is an important complication of spontaneous intracerebral hemorrhage (sICH). The purpose of this study was to determine the predictors and outcomes of the development of pneumonia in patients with sICH. Methods. In total, 290 consecutive patients with sICH admitted within 24 hours of stroke onset were investigated in a single center, retrospective study from January 2006 to July 2009. Clinical, biochemical, and imaging variables were registered. Stroke severity and functional outcomes were evaluated with the Glasgow Coma Scale (GCS) and modified Rankin Scale (mRS). Baseline variables that predicted pneumonia were investigated and outcomes were assessed. Results. The association of our primary exposure variables, such as mechanical ventilation, tube feeding, dysphagia, and tracheostomy, with pneumonia was highly significant (P < .0001, for each variable). For mechanical ventilation, we observed an odds ratio (OR; 95% confidence interval [CI]) of 9.42 (4.24-20.9); for tube feeding, OR = 22.3 (8.91-55.8); for dysphagia, OR = 13.1 (4.66-36.7); and for tracheostomy, OR = 26.8 (8.02-89.3). After adjustment of potential confounders including GCS and mRS on admission, the use of angiotensin-converting enzyme inhibitors, proton pump inhibitors, and H2 blockers, all the adjusted OR (ORa) remained significant. For mechanical ventilation, the minimum ORa was 3.72 (95% CI: 1.68-8.26) when adjusted for GCS. For both dysphagia and tracheostomy, mRS reduced OR to 7.46 (95% CI: 3.34-10.6) in the case of dysphagia with an ORa of 16.2 (95% CI: 4.98 to 52.8) for tracheostomy. For tube feeding, both GCS and mRS reduced ORa; the former to 14.7 (95% CI: 6.16-35.0) and the latter to 15.7 (95% CI: 6.63-37.0). Pneumonia shows a significant effect on the morbidity (P = .003), length of stay (P < .0001), and mortality (P = .041) rate of the patients. Conclusion. Mechanical ventilation, tube feeding, dysphagia, and tracheostomy are exposures associated with increased risk of the development of pneumonia in patients with sICH. Pneumonia is associated with an increase in morbidity, length of stay, and mortality among patients with sICH.

An emergency physician activated protocol, ‘Code STEMI’ reduces door‐to‐balloon time and length of stay of patients presenting with ST‐segment elevation myocardial infarction

Introduction:  National consensus guidelines recommend that ST‐segment elevation myocardial infarction (STEMI) patients achieve a door‐to‐balloon time of < 90 min. We sought to determine if emergency physician initiated simultaneous activation of the cardiac catheterisation laboratory team and the on‐call interventional cardiologist has any impact on reducing door‐to‐balloon‐times at our hospital.

Acute ST-segment elevation myocardial infarction in young adults: who is at risk?

ObjectiveLess than 10% of patients presenting with acute myocardial infarction (AMI) are young adults. The primary objective of this study was to provide an overview of similarities and dissimilarities among younger and older patients presenting with AMI with the expectation of using the information as an aid in primary and secondary preventions in the future. MethodsFrom the database of 3527 patients with AMI admitted from January 2001 to December 2008, young adults aged 21–40 years (n=43) who were diagnosed with ST-segment elevation myocardial infarction were identified. They were then compared with their older counterparts who were admitted from January 2007 to December 2008 subdivided into age groups of 41–60 (n=86) and 61–80 years (n=51). Data on clinical cardiovascular risk factors, demographic features, and angiographic findings were gathered and analyzed. ResultsOnly 2.58% of ST-segment elevation myocardial infarction patients who were admitted to our hospital over an 8-year period were less than 40 years. Young adults were found to be predominantly male patients (P=0.04) and had positive family history for coronary artery disease (P=0.0005). Diabetes and hypertension were less prevalent in the younger group (P=0.048 and 0.078). Analysis of lipid profile showed comparatively higher total cholesterol, low-density lipoprotein and high-density lipoprotein values in the younger group (⩽P=0.004). Angiographically, youngsters had propensity toward single-vessel involvement (P=0.0001). ConclusionThe risk factor profile and the angiographic involvement differ considerably in the high-risk younger adults and substantiate the need for an aggressive approach directed toward primary and secondary preventions of premature cardiovascular disease.

Cardiac troponin I levels and alveolar-arterial oxygen gradient in patients with community-acquired pneumonia.

BACKGROUND Patients with community-acquired pneumonia (CAP) appear to have cardiac stress as demonstrated by elevated B-type natriuretic peptide (BNP). We hypothesised that myocardial stress and decrease in oxygenation might also lead to elevations of cardiac troponin I (cTnI) levels in serum. OBJECTIVE The aim of this study was to see if cTnI was associated with the alveolar-arterial oxygen gradient (DeltaA-a), a marker of severity in CAP. METHODS Retrospective cohort study of 901 CAP patients with no evidence of acute coronary syndrome presenting to a large, tertiary-care, urban teaching hospital over a 3-year period. RESULTS A strong linear trend between log(10)cTnI and DeltaA-a was observed (r(2)=0.76) with a statistically significant Spearman correlation coefficient (r(s)=0.75; p<0.0001) between cTnI and DeltaA-a. A cTnI value of 0.5 ng/ml discriminated mild CAP from moderate-severe CAP with an OR=208 (95% CI: 50.5-408; p<0.0001). CONCLUSIONS These data suggest that decreased blood O(2) levels as suggested by elevated DeltaA-a may lead to acute myocardial damage and that cTnI may be useful as a biomarker to stratify risk in subjects with CAP.

Percutaneous Coronary Interventions in Nonagenarians: In‐Hospital Mortality and Outcome at One Year Follow‐up

Limited information is available regarding outcome of very elderly patients referred for percutaneous coronary intervention (PCI).