Safety and efficacy of outpatient parenteral antibiotic therapy in an academic infectious disease clinic

WHAT IS KNOWN AND OBJECTIVE

Outpatient parenteral therapy (OPAT) has become a safe and effective modality for patients requiring intravenous or prolonged antimicrobial therapy since the 1970s. It is being increasingly utilized in various settings; however, studies evaluating the safety and efficacy of clinic-based OPAT are limited. Since 2012, patients being considered for OPAT have required an infectious disease (ID) consultation at our institution. Candidates receiving once-daily antimicrobials who were ineligible for home infusion or nursing home placement as determined by their insurance companies and those who preferred the clinic over nursing home or home infusion were referred to the ID clinic. This study assessed the safety and outcome of patients receiving OPAT in an academic inner-city ID clinic in Detroit, Michigan.

METHODS

This was a retrospective cross-sectional study of electronic medical records of patients, identified through clinic records, who received at least 2 days of OPAT from December 2012 to December 2015. Demographics, types of infections, antimicrobial regimen used, adverse events and outcome were evaluated.

RESULTS

A total of 122 cases were identified during the study period. Mean age was 62 years with 55% male; 102 (84%) of 122 patients had peripherally inserted central catheter (PICC). Fifty-five per cent of patients participated in the clinic-based OPAT programme for insurance reasons, and 43% preferred the clinic over nursing home or home infusion. The most common infections were bone and joint (36%), followed by skin and soft tissue (18%) and urinary tract infections (12%). Ertapenem (44%) and daptomycin (41%) alone or in combination were used most frequently with 40% of patients receiving at least 4 weeks of treatment. Thirteen patients (11%) experienced one or more adverse drug events on daptomycin and/or ertapenem; of these, nine (69%) patients were receiving daptomycin monotherapy. Gastrointestinal symptoms (29%), cramping and myalgias (29%) and asymptomatic creatine phosphokinase (CPK) elevation (24%) were the most common adverse events. Three (3%) of 102 patients had PICC-related complications. Fourteen (88%) of 16 patients with adverse events or PICC-related complications required changing or stopping antibiotics; two (2%) had infection-related readmission. Conversely, 113 (93%) of 122 patients who completed treatment were considered cured and none had treatment failure at the end of 30 days of treatment. No patients died as a result of treatment or infection-related complications.

WHAT IS NEW AND CONCLUSION

Outpatient parenteral therapy in our academic ID clinic was a safe and effective alternative to home infusion or skilled nursing facilities for patients requiring long-term antibiotics with few adverse events and complications.

Biomarker discovery in serum from patients with carotid atherosclerosis

BACKGROUND

Blood-based biomarkers of atherosclerosis have been used to identify patients at high risk for developing stroke. We hypothesized that patients with carotid artery disease would have a distinctive proteomic signature in blood as compared to a healthy control population without carotid artery disease. In order to discover protein biomarkers associated with increased atherosclerotic risk, we used two different strategies to identify biomarkers from patients with clinically defined atherosclerosis who were undergoing endarterectomy for atherosclerotic carotid artery disease. These patients were compared with healthy matched controls.

METHODS

Serum was obtained from patients undergoing endarterectomy (EA; n = 38) and compared to a group of age-matched healthy controls (n = 40). Serum was fractionated using anion exchange chromatography and three different surface-enhanced laser desorption/ionization (SELDI) chip surfaces and then evaluated with mass spectrometry (MS) and two-dimensional difference gel electrophoresis (2D-DIGE).

RESULTS

A random forest (RF) analysis of the SELDI-MS protein peak data distinguished these two groups with 69.2% sensitivity and 73.2% specificity. Four unique SELDI peaks (4.2, 4.4, 16.7 and 28 kDa, all p< 0.01) showed the greatest influence in the RF model. The EA patients with a history of prior clinical atherosclerotic plaque rupture manifested as either stroke or transient ischemic attack (symptomatic; n = 16) were compared to patients with carotid atherosclerosis but no clinical evidence of plaque rupture (asymptomatic; n = 22). Analysis of the SELDI spectra did not separate these two patient subgroups. A subgroup analysis using 2D-DIGE images obtained from albumin-depleted serum comparing symptomatic (n = 10) to asymptomatic EA patients (n = 10) found 4 proteins that were differentially expressed (p < 0.01) in the symptomatic patients. These proteins were identified as α(1)-antitrypsin, haptoglobin and vitamin D binding protein that were downregulated and α(2)-glycoprotein precursor that was upregulated in the symptomatic EA group.

CONCLUSIONS

SELDI-MS data analysis of fractionated serum suggests that a distinct protein signature exists in patients with carotid atherosclerosis compared to age-matched healthy controls. Identification of 4 proteins in a subset of patients with symptomatic and asymptomatic carotid atherosclerosis suggests that these and other protein biomarkers may assist in identifying high-risk patients with carotid atherosclerosis.

An Open Access future? Report from the eurocancercoms project

In March 2011, as part of the background research to the FP7 Eurocancercoms project, the European Association for Cancer Research (EACR) conducted an online survey of its members working in Europe to discover their experiences of and attitudes to the issues surrounding academic publishing and Open Access. This paper presents the results from this survey and compares them to the results from a much larger survey on the same topic from the Study of Open Access Publishing (SOAP). The responses from both surveys show very positive attitudes to the Open Access publishing route; perhaps the most challenging statistic from the EACR survey is that 88% of respondents believe that publicly funded research should be made available to be read and used without access barriersAs a conclusion and invitation to further discussion, this paper also contributes to the debate around subscription and Open Access publishing, supporting the case for accelerating the progress towards Open Access publishing of cancer research articles as a particularly supportive way of assisting all researchers to make unhindered progress with their work.

Is the Internet useful for clinical practice?

BACKGROUND

Internet use in dentistry is increasing. The authors surveyed dentists to determine how they are using the Internet to support patient care and how useful they perceive the Internet to be.

MATERIALS AND METHODS

The authors sent a 25-question survey to 455 subscribers to the Internet Dental Forum, an Internet discussion list. Participants completed the survey through a Web page or by e-mail during an 18-day period in December 1998. The survey included questions about when they began using the Internet and their motivations for doing so, their positive and negative experiences, where they use the Internet and why, their use of information resources--including electronic information resources--and demographics.

RESULTS

The authors received 314 surveys from 438 participants, a 72 percent response rate. Participants reported demographic characteristics similar to national averages and were highly computer-literate. Most considered the Internet essential for their practice and had increased their Internet use for professional reasons over time. Ninety-seven percent of respondents used the Internet at home, and 68 percent used it in the office. Only 5 percent used the Internet in the treatment area. The primary reason cited by participants for using the Internet was to keep up in general, followed by to answer patient-specific questions and to provide patient education. Reduction of professional isolation was one of the most frequently cited advantages of using the Internet.

CONCLUSIONS

The authors found that some dentists use the Internet to support clinical practice and that it helped dentists adopt new techniques for patient treatment and obtain information on new materials or products.

CLINICAL IMPLICATIONS

The Internet appears to support clinical practice mostly indirectly, by helping users keep up in general, rather than by answering specific clinical questions.

Evidence that the high incidence of treatment failures in Indian kala-azar is due to the emergence of antimony-resistant strains of Leishmania donovani

The possibility that the high frequency of treatment failures in Indian kala-azar might be due to infection with antimony-resistant strains of Leishmania donovani has not been experimentally addressed. L. donovani isolates were obtained from splenic aspiration smears of 24 patients in Bihar, India, who either did not respond (15) or did respond (9) to 1 or more full courses of treatment with sodium antimony gluconate (SAG). A strong correlation (P<.001) between clinical response and SAG sensitivity in vitro was observed only when strains were assayed as intracellular amastigotes: responsive isolates ED50=2.4+/-2.6, ED90=6.4+/-7.8 microgram SAG/mL; unresponsive isolates ED50=7.4+/-3.7 microgram SAG/mL, ED90=29.1+/-11.1 SAG/mL. No correlation with clinical response was found by use of extracellular promastigotes (ED50=48+/-22 vs. 52+/-29 microgram/mL). The emergence of antimony-resistant L. donovani strains appears to be a cause of treatment failures in India.

Photoelastic stress patterns produced by implant-retained overdentures

STATEMENT OF PROBLEM

When 2 implants are used to support a removable overdenture, optimal stress distribution to minimize forces to the implants is desired.

PURPOSE

This study used photoelastic analysis to compare the stress patterns generated around implants with 2 retention mechanisms.

MATERIAL AND METHODS

Two root form implants were anchored in a photoelastic mandible and a removable overdenture was fabricated. The denture was lined with a resilient layer of impression material to simulate oral mucosa. Attachment of the denture to the implants was varied by using ball/O-ring and bar-clip attachments. Vertical and oblique occlusal forces from 10 to 200 lb were applied unilaterally to the right and left first molars. Resultant stress distributions in the photoelastic mandible were photographed and evaluated.

RESULTS

With vertical forces, the ball/O-ring attachment transferred minimal stress to both implants. Vertical forces applied to the bar-clip overdenture created immediate stress patterns of greater magnitude and concentration on both implants. A posterior oblique load resulted in similar stress patterns to both systems with slightly greater stress to the bar-clip overdenture.

CONCLUSIONS

Within the limits of this study, ball/O-ring attachments transferred less stress to implants than the bar-clip attachments when the photoelastic model was subjected to a posterior vertical load.

Typhlitis in a patient with acute lymphoblastic leukemia prior to the administration of chemotherapy

PATIENTS AND METHODS

A 3-year-old girl with acute lymphoblastic leukemia developed typhlitis immediately after diagnosis and before the institution of chemotherapy.

PURPOSE

Typhlitis is a necrotizing colitis that develops in immunodeficient patients with severe neutropenia. Most patients are leukemic children who are receiving or have received chemotherapy. Typhlitis in the absence of chemotherapy is rare. We report a fatal case of typhlitis in an untreated leukemic patient.

RESULTS

This case emphasizes the multifactorial pathogenesis of typhlitis, which may occur in the absence of chemotherapy.

CONCLUSIONS

Typhlitis should always be considered as a potential cause of acute sepsis and abdominal pain in a leukemic patient.

Carbohydrate utilization in exercising muscle in subtotally nephrectomized rabbits

Subtotally nephrectomized rabbits were compared with sham-operated controls. The isolated soleus muscle of one leg was exercised using controlled stimulus parameters at 1 Hz until the contraction tension (amplitude) was reduced by one half. The muscle was then quickly frozen in liquid nitrogen and analyzed for lactate, pyruvate, glycogen, alanine, glutamine and alpha-ketoglutarate. The resting leg was used as a control and similarly frozen and analyzed. The difference between resting and exercised muscle lactate and pyruvate concentration was significantly greater in experimental animals while muscle alanine and alpha-ketoglutarate concentrations were lower in the experimental animals. There was no difference in the time required to reach one half of the muscle contraction amplitude between experimental and control animals. Blood lactate levels rose in the experimental animals to a greater degree than in control animals, similar to that seen in human subjects with renal failure.

The effect of concurrent manual activity on the dichotic listening performance of boys with learning disabilities

Three groups of learning-disabled children, defined according to their Wechsler Intelligence Scale for Children (WISC) profiles, and one normal control group, were given both a standard dichotic listening task and a dichotic listening task performed concurrently with a manual tapping task. Learning-disabled children who showed no disparity in their verbal and performance subscale scores on the WISC demonstrated a right ear preference under standard testing and when tapping with the left hand, but not the right, which was nearly the same pattern as that obtained by the control group. Learning-disabled children whose verbal WISC score was at least 15 point lower than their performance demonstrated a right-ear preference only when tapping with their left hand. Finally, learning-disabled children who had high verbal, low performance WISC profiles showed no ear preference under any conditions. These results were interpreted as indicating that these three types of learning-disabled children are differentially lateralized and differentially affected by the facilitory-inhibitory effects of concurrent hemispheric activities.