The American journal of the medical sciences最新文献

Cefepime, a fourth-generation cephalosporin, has traditionally been administered via 30-minute standard infusions. However, an extended infusion of cefepime, administered over 3-4 h, has demonstrated improved pharmacodynamic target attainment. This narrative review evaluates the clinical impact of extended infusion cefepime across diverse infections and patient populations. While retrospective studies suggest improved outcomes, such as reduced mortality and faster defervescence in patients with Pseudomonas aeruginosa infections or febrile neutropenia, prospective trials have not consistently shown significant benefits, particularly in mortality reduction. Potential risks of extended infusions, including neurotoxicity and complications from increased IV access, remain under-researched, especially in adult populations. Overall, the extended infusion is non-inferior to the standard infusion length and may be superior to the standard infusion in certain contexts. Further prospective, controlled studies are warranted to determine the clinical efficacy and safety of EI cefepime in comparison to standard infusion in various patient populations.

Background: Lipoprotein (a) [Lp (a)] may confer pro-thrombotic potential, and high concentrations may be an independent risk for MI. This systematic review sought to investigate the association of Lp (a) levels with post-revascularization Major Adverse Cardiac Events (MACE) in patients with CAD, ACS, and DM.

Methods: A systematic literature search for original investigations was performed using PubMed/MEDLINE, Embase, Scopus, and Google Scholar, searching for articles (meeting inclusion criteria) focusing on the relationship between Lp(a), DM, and PCI in patients with ACS, MI, or IHD and the impact on cardiovascular outcomes. The data was abstracted and descriptively summarized.

Results: The systematic review selected four relevant articles: 3 prospective Konishi et al., (2016); Silverio et al., (2022); and Li et al., (2023) and one retrospective (Takahashi et al., 2020). Total population: 4624, total males: 3719. Konishi et al. (2016) concluded that an elevated Lp(a) is an independent risk factor for cardiac death and/or ACS recurrence in diabetics undergoing PCI. The adjusted OR for cardiac death and ACS in the high Lp(a) group vs. the low Lp(a) group was 1.20 (CI 1.00-1.42), p = 0.04. Takahashi et al. (2020) showed that after adjusting for clinical covariates, high Lp(a) was independently associated with a higher frequency of MACE and poorer long-term outcomes compared to low Lp(a). The adjusted OR for the risk of MACE in patients with high Lp (a) vs. low Lp (a) was 1.83 (CI 1.16-2.95), p = 0.009. Silverio et al. (2022) showed that while there was an increased risk of recurrent MI in this patient population without DM, it was not confirmed in patients with DM. Compared with the lowest Lp (a) category, non-DM patients with very high Lp (a) >70 mg/dl vs. low Lp (a) showed a higher risk of recurrent MI and all-cause death; adjusted OR 2.839 (CI 1.382-5.832), p = 0.005. In diabetics, high Lp (a) vs. low Lp (a) = 1.115 (CI 0.405-3.071), p = 0.833.

Conclusions: There is some evidence that Lp (a) levels are an independent risk factor for MACE in patients who underwent PCI for CAD. There is also some evidence that elevated Lp (a) levels are associated with a worse prognosis in patients with DM after PCI, but this association is not consistent in the literature. Further prospective multicenter studies are required in order to elucidate this association.

Background: Distinguishing between viral and bacterial pneumonia is paramount for antimicrobial stewardship. The biomarker procalcitonin has shown potential-its serum levels rise with bacterial infection and remain normal in its absence. Yet its application in medical practice remains controversial. Not using antibiotics based on procalcitonin-driven guidelines can be considered as a legal liability. Since the USA features more aggressive medical litigation practices compared with Europe, we hypothesized that there should also be an intercontinental difference for the use of procalcitonin.

Methods: Systematic review of original research on procalcitonin used for pneumonia in the USA and Europe, identified via PubMed and Medline covering 2013-2024. PRISMA flow diagram and risk bias assessment were applied.

Results: Thirty reports met our inclusion and exclusion criteria (17 from Europe, 12 from the USA, and 1 mixed, 24 covered adults, 6 were pediatric). For adults, the vast majority of European and all US-based studies demonstrated an association between higher procalcitonin levels and bacterial pneumonia. Regarding children, all European studies demonstrated correlation while in the USA the results were mixed. The effect of procalcitonin-based guidelines on antibiotic use yielded mixed results among adults in both Europe and the USA, with about half of the studies showing antibiotic stewardship benefit. There were too few pediatric studies covering this research end point to allow for comparison.

Conclusions: Procalcitonin proved a useful tool for differentiating bacteria from viral pneumonia in both Europe and the USA. No consistent intercontinental differences were identified regarding the application of procalcitonin-driven antibiotics stewardship for pneumonia.

Background: Long COVID presents a substantial and evolving challenge to individuals and health systems. Despite growing interest in interdisciplinary care models, empirical evidence on their structure, utilization, and effectiveness remains limited. This study examined the delivery and outcomes of specialized outpatient programs for long COVID in Alberta, Canada, focusing on: (a) patterns of program utilization; (b) patient-reported health outcomes; and (c) impacts on healthcare system utilization and costs.

Methods: A retrospective observational study was conducted using administrative health records, electronic medical records, and patient-reported outcome measures (PROMs) between April 2022 and September 2023. Adults (≥18 years) with persistent symptoms ≥12 weeks post-infection were included. Healthcare utilization and costs were assessed over 180-day pre- and post-enrollment periods. Cost-effectiveness was evaluated using the incremental cost-effectiveness ratio (ICER).

Results: Of 2819 referrals, 81% (n = 2287) were accepted. Most patients were female (68%), aged 48.2 years on average, and referred by community physicians. Site-level differences were observed in staffing models, care delivery modalities, and wait times. Following enrollment, patients reported small but statistically significant improvements in functional status and quality of life. Symptoms of depression, as measured by the PHQ-9, decreased by an average of 0.9 points (p < 0.05), though below thresholds for clinical significance. Anxiety levels, assessed by the GAD-7, did not change significantly. EQ-5D VAS scores improved by 4.6 points (p = 0.003). Modest reductions in inpatient, ambulatory, and physician service costs were observed. The ICER was $31,140 per quality-adjusted life year (QALY), approaching the Canadian cost-effectiveness threshold.

Conclusions: In this observational analysis, program participation was associated with small improvements in patient-reported health status and modest cost patterns. Because natural recovery, regression to the mean, and concurrent system changes may also explain these trends, the findings should be interpreted as preliminary associations rather than causal effects. Prospective controlled studies are needed to confirm effectiveness and economic value.

Background: Sex, racial, and ethnic disparities have been documented in survival after cardiac arrest. Whether knowledge of these disparities has led to their mitigation remains unclear. We evaluated trends in sex and racial disparities in cardiac arrest mortality over a 22-year period.

Methods: Crude death rates (CDRs) for cardiac arrest per 100,000 individuals aged ≥15 years were obtained from the CDC WONDER database from 1999 through 2020. Inferential statistics and linear regression were performed to assess average annual percentage change (AAPC).

Results: Among 364,531 cardiac arrest deaths (CDR of 6.7 per 100,000; 95 % confidence interval [CI] 6.7-6.8), mortality declined significantly from 1999 through 2020 (slope -0.1, 95 % CI -0.14 to -0.05; p < 0.001). No difference was noted in CDR between Women and Men (6.59 vs 6.97; p = 0.117). By race, African Americans had the highest CDR (8.68), and Native Americans had the lowest (2.32), with significant differences across races (p < 0.001). Hispanics had a significantly lower CDR (1.38) than non-Hispanics (7.64; p < 0.001). Trend analysis showed a significant decline in CDR (AAPC -1.4, 95 % CI -1.4 to -1.7), with women experiencing a greater reduction (-2.1) than men (-0.88). Whites had the largest AAPC decline (-1.6; p < 0.001), while African Americans had the smallest (-0.6; p = 0.04). Hispanics showed a non-significant AAPC increase (0.77; p = 0.28).

Conclusions: Cardiac arrest mortality declined over two decades, but the decline was not equal across sexes, races, and ethnicities. Further work is required to develop interventions to address these disparities.

Stercoral colitis is an underrecognized, life-threatening complication of refractory constipation. We systematically reviewed Embase, PubMed/MEDLINE, Web of Science, and CINAHL for presentation, imaging, management, and outcomes. Fifty-three studies (58 patients) met inclusion. Mean age was 55.8 years (range 9-94); 62.1% were female. Chronic constipation (75.9%) and opioid exposure (13.8%) were common. CT was used in 86.2%, showing fecaloma and wall thickening (65.5%); perforation occurred in 29.3% and ischemic colitis in 44.8%. Conservative measures, manual disimpaction, enemas, laxatives, were common; endoscopic disimpaction was rare; surgery was reserved for deterioration, peritonitis, or perforation. Overall in-hospital/30-day mortality was 22.4% (operative 26.9% vs non-operative 0.0%). SC should be suspected in at-risk patients with refractory constipation; only 75.9% had abdominal pain, so its absence does not exclude disease. Early CT, especially with elevated WBC, CRP, or lactate, and severity-guided escalation to conservative therapy or timely surgery are essential; standardized criteria and prospective studies are needed.

Acute kidney injury (AKI) is common both general population and in hospitalized patients. Previously, AKI was considered reversible condition without long-term adverse impacts, but it is now recognized that AKI predicts future adverse clinical outcomes such as chronic kidney disease, cerebrovascular disease and heart disease. In addition, recent studies showed that future cognitive dysfunction and dementia risk are increased after AKI. Although the mechanisms regarding acute cognitive dysfunction during AKI are considerably understood, the underlying pathologies causing chronic cognitive dysfunction and increased long term dementia risk after AKI are not well elucidated. Potential culprits include persistent systemic inflammation and structural brain alterations after AKI. In this review, we first summarized the studies investigating the impact of AKI on future dementia risk and cognitive function. Then, we highlighted the mechanisms regarding acute cognitive decline during AKI, and also discuss potential mechanisms regarding chronic cognitive decline after AKI. Lastly, we discussed potential therapeutic options to mitigate future cognitive decline after AKI.