The effect of fluoroquinolone use on the susceptibility of Pseudomonas aeruginosa to fluoroquinolones in U.S. hospitals was studied. Benchmarking surveys were sent annually to pharmacists practicing in U.S. hospitals from 1993 to 1999. Data collected included hospital characteristics, antimicrobial expenditures and use, antimicrobial stewardship activities, and bacterial susceptibilities. Antimicrobial expenditures were normalized for the number of occupied beds (OBs) per year. General linear modeling and repeated-measures mixed-effects modeling were used to determine factors predictive of P. aeruginosa susceptibility to fluoroquinolones. A total of 174 hospitals provided data for fluoroquinolone expenditures and susceptibility of P. aeruginosa; the median number of years of data was 3 (range, 1-6), representing 416 hospital years. Community hospitals contributed a majority of the data. Median fluoroquinolone expenditures increased gradually from $230 per OB in 1993 to $400 per OB in 1998. A 55% increase to $620 per OB occurred in 1999, largely because of increased spending on levofloxacin. Susceptibility to ciprofloxacin was commonly used to assess fluoroquinolone susceptibility. The median susceptibility of P. aeruginosa to ciprofloxacin decreased from 84% to 71%. Increasing expenditures for ofloxacin and levofloxacin, but not ciprofloxacin, were associated with decreasing P. aeruginosa susceptibility to ciprofloxacin. In the final multivariable model, each study year after 1993 and every increase in ofloxacin expenditure of $100 per OB were associated with decreases in P. aeruginosa susceptibility. Data from a benchmarking survey of U.S. hospitals for 1993-1999 revealed increases in levofloxacin expenditures, total fluoroquinolone expenditures, expenditures for nonfluoroquinolone antipseudomonal antimicrobials, and total antimicrobial expenditures in 1999. Increases in expenditures for levofloxacin and ofloxacin were associated with a significant decrease in P. aeruginosa susceptibility to ciprofloxacin.
An estimated 400,000 coronary artery bypass graft operations are performed annually in the United States. Saphenous vein grafts are the most commonly used conduits; however, graft failure is common. In contrast, left internal mammary artery grafts have more favorable long-term patency rates. Guidelines recommend aggressive secondary prevention. In the 2 decades following surgery, 16% of patients require repeat revascularization, and percutaneous coronary intervention accounts for 98% of procedures performed. Post-coronary artery bypass graft patients presenting with symptoms of acute coronary syndrome or progressive heart failure should undergo early coronary angiography given the high likelihood that such a presentation represents graft failure. Percutaneous coronary intervention in degenerated saphenous vein grafts is associated with embolization that may cause the “no-reflow phenomenon,” which can be avoided with the use of embolic protection devices. Hybrid revascularization procedures are a promising emerging strategy to avoid the placement of vein grafts.
in identifying the presence of needle shaped crystals confirmed by cytopathology and non-inferior in determining the absence of needle shaped crystals in synovial fluid confirmed by cytopathology.Analysis by a rheumatology trainee was significantly quicker (p < 0.0001) compared with formal laboratory analysis.
Abstract : The development of an ambient noise model for use in ice-covered Arctic waters is the primary goal of this research. The generation of ambient noise is considered to originate from large scale deformation of the ice cover (pressure ridge formation) which is caused on a synoptic scale by convergence of the ice cover due to wind stress/speed associated with the passage of Arctic storms. The Arctic Storm Noise Model (ASNM) has been developed as a dynamic model to predict the occurrence of extreme noise events. The emphasis is on accurately predicting the large increases or decreases in ambient noise, which observations have shown to be in the order of 20 to 30 dB over a matter of hours. ASNM was adapted from the Ambient Noise Directional Estimation System (ANDES) for use under the Arctic pack ice. ASNM predictions are compared quantitatively to noise measurements made by ice-mounted drifting buoys in the Arctic basin during the early 1990's. Results showed that for extreme events ( 95th percentile) ASNM is accurate in predicting both the level of ambient noise and the large increases in the noise record. Due to the encouraging results further improvements are recommended to increase the robustness of the model for potential tactical use by submarine units operating under the Arctic pack ice.
OBJECTIVE: The Diabetes Prevention Program (DPP) is a 27-center randomized clinical trial designed to evaluate the safety and efficacy of interventions that may delay or prevent development of diabetes in people at increased risk for type 2 diabetes. RESEARCH DESIGN AND METHODS: Eligibility requirements were age > or = 25 years, BMI > or = 24 kg/m2 (> or = 22 kg/m2 for Asian-Americans), and impaired glucose tolerance plus a fasting plasma glucose of 5.3-6.9 mmol/l (or < or = 6.9 mmol for American Indians). Randomization of participants into the DPP over 2.7 years ended in June 1999. Baseline data for the three treatment groups--intensive lifestyle modification, standard care plus metformin, and standard care plus placebo--are presented for the 3,234 participants who have been randomized. RESULTS: Of all participants, 55% were Caucasian, 20% were African-American, 16% were Hispanic, 5% were American Indian, and 4% were Asian-American. Their average age at entry was 51 +/- 10.7 years (mean +/- SD), and 67.7% were women. Moreover, 16% were < 40 years of age, and 20% were > or = 60 years of age. Of the women, 48% were postmenopausal. Men and women had similar frequencies of history of hypercholesterolemia (37 and 33%, respectively) or hypertension (29 and 26%, respectively). On the basis of fasting lipid determinations, 54% of men and 40% of women fit National Cholesterol Education Program criteria for abnormal lipid profiles. More men than women were current or former cigarette smokers or had a history of coronary heart disease. Furthermore, 66% of men and 71% of women had a first-degree relative with diabetes. Overall, BMI averaged 34.0 +/- 6.7 kg/m2 at baseline with 57% of the men and 73% of women having a BMI > or = 30 kg/m2. Average fasting plasma glucose (6.0 +/- 0.5 mmol/l) and HbA1c (5.9 +/- 0.5%) in men were comparable with values in women (5.9 +/- 0.4 mmol/l and 5.9 +/- 0.5%, respectively). CONCLUSIONS: The DPP has successfully randomized a large cohort of participants with a wide distribution of age, obesity, and ethnic and racial backgrounds who are at high risk for developing type 2 diabetes. The study will examine the effects of interventions on the development of diabetes.
Society of Critical Care Medicine; 28th Educational and Scientific Symposium; San Francisco, California, USA; January 23-27, 1999: Poster Presentations: Poster Hall
Background: Patients with RA have an increased prevalence of cardiovascular disease (CVD). This is due to increased traditional risk factors and the effect of chronic inflammation. TNF antagonists are potent suppressors of inflammation and may reduce the risk of CVD. We performed a systematic literature review to determine whether TNF antagonists affect the risk of clinical CVD events in RA. Methods: We searched Medline, Embase, Cochrane database, DARE, HTA and Science Citation Index from 1980-2008. Papers were included if they assessed the relationship between the use of TNF antagonists and clinical CVD outcomes in RA. All articles were assessed for study quality. Results: 1840 abstracts were identified. Two reviewers independently assessed each title and abstract. 20 studies fulfilled the inclusion criteria: 1 RCT, 11 cohorts, 7 case-controls and 1 cross-sectional study(Table to be included in a poster). 7 studies considered all CVD events, 4 demonstrating a significant decreased CVD risk and 3 no change in risk. 7 studies assessed the association of TNF antagonists and MI; 2 demonstrated a significant decreased risk and 5 no difference. The study with the lowest risk of bias, showed a significantly lower risk of MI in TNF responders compared with non-responders. 3 studies considered stroke and TNF antagonists, two demonstrated no change in risk and 1 a reduced risk after 6 months of treatment. 6 studies considered heart failure (HF): 1 demonstrated a significantly increased risk of HF in elderly RA patients, 3 no difference in risk and 2 a significantly decreased risk of HF. In the study with the lowest risk of bias, a non-significant increased risk of HF was considered to be offset by the efficacy of TNF antagonists. Conclusions: For all CVD events there may be a decreased risk associated with use of TNF antagonists. For specific events, e.g. MI and HF the effect is less clear. Atherosclerosis is an inflammatory process, TNF antagonists would be expected to reduce the risk of CVD by decreasing the burden of systemic inflammation. There are several reasons this may not be apparent. Firstly, TNF antagonists may have adverse effects on traditional risk factors (lipids, etc.). Secondly MTX reduces the risk of CVD events, it is commonly used in combination with TNF antagonists and in some of the studies was used by controls. TNF antagonists may therefore have no additional benefit to MTX. In contrast to MTX, TNF antagonists are often used late in the disease when significant irreversible damage has occurred. Finally the effect on CVD may depend on response to treatment as some of the studies demonstrated a lower risk of CVD events in responders compared with non-responders. To determine the true effect of TNF antagonists on CVD risk future studies should publish data on CVD risk factors and clinical events, this is particularly important in studies of early disease when the burden of inflammation has not been realised. Disclosure statement: E.C., Abbott, Allergan, Boehringer, Ingelheim, Chelsa Therapeutica, Eli Lilly, GSK, Jazz Pharmaceuticals, Merrimack Pharmaceutical, MSD, Pfizer, Pierre Fabre Medicament, Roche, Schering Plough, UCB, Celltech and Wyeth - Research grants and honoraria for advisory boards, consultancy and speaker bureaus. C.J.E., Abbott, Roche, wyeth, Schering-Plough and UCB-Pharma - Advisory fees, speaker fees and unrestricted educational grant. A.J.O., Roche, Chugai, Schering-Plough, Abbott, Wyeth, BMS, GSK, MerckSorono and UCB - Support and Consultant. M.Q., Abbott and Schering-Plough - Speaker fees, Abbott, Schering-Plough and UCB - Advisory board, Abbott - Research grants. All other authors have declared no conflicts of interest.
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