The neutrophil-lymphocyte count ratio (NLCR) has been identified as a predictor of bacteremia in medical emergencies. The aim of this study was to investigate the value of the NLCR in patients with ...community-acquired pneumonia (CAP).
Consecutive adult patients were prospectively studied. Pneumonia severity (CURB-65 score), clinical characteristics, complications and outcomes were related to the NLCR and compared with C-reactive protein (CRP), neutrophil count, white blood cell (WBC) count. The study cohort consisted of 395 patients diagnosed with CAP. The mean age of the patients was 63.4 ± 16.0 years. 87.6% (346/395) of the patients required hospital admission, 7.8% (31/395) patients were admitted to the Intensive Care Unit (ICU) and 5.8% (23/395) patients of the study cohort died. The NLCR was increased in all patients, predicted adverse medical outcome and consistently increased as the CURB-65 score advanced. NLCR levels (mean ± SD) were significantly higher in non-survivors (23.3 ± 16.8) than in survivors (13.0 ± 11.4). The receiver-operating characteristic (ROC) curve for NLCR predicting mortality showed an area under the curve (AUC) of 0.701. This was better than the AUC for the neutrophil count, WBC count, lymphocyte count and CRP level (0.681, 0.672, 0.630 and 0.565, respectively).
Admission NLCR at the emergency department predicts severity and outcome of CAP with a higher prognostic accuracy as compared with traditional infection markers.
CONTEXT Reduction of gastric acid secretion by acid-suppressive therapy allows
pathogen colonization from the upper gastrointestinal tract. The bacteria
and viruses in the contaminated stomach have ...been identified as species from
the oral cavity. OBJECTIVE To examine the association between the use of acid-suppressive drugs
and occurrence of community-acquired pneumonia. DESIGN, SETTING, AND PARTICIPANTS Incident acid-suppressive drug users with at least 1 year of valid database
history were identified from the Integrated Primary Care Information database
between January 1, 1995, and December 31, 2002. Incidence rates for pneumonia
were calculated for unexposed and exposed individuals. To reduce confounding
by indication, a case-control analysis was conducted nested in a cohort of
incident users of acid-suppressive drugs. Cases were all individuals with
incident pneumonia during or after stopping use of acid-suppressive drugs.
Up to 10 controls were matched to each case for practice, year of birth, sex,
and index date. Conditional logistic regression was used to compare the risk
of community-acquired pneumonia between use of proton pump inhibitors (PPIs)
and H2-receptor antagonists. MAIN OUTCOME MEASURE Community-acquired pneumonia defined as certain (proven by radiography
or sputum culture) or probable (clinical symptoms consistent with pneumonia). RESULTS The study population comprised 364 683 individuals who developed
5551 first occurrences of pneumonia during follow-up. The incidence rates
of pneumonia in non–acid-suppressive drug users and acid-suppressive
drug users were 0.6 and 2.45 per 100 person-years, respectively. The adjusted
relative risk for pneumonia among persons currently using PPIs compared with
those who stopped using PPIs was 1.89 (95% confidence interval, 1.36-2.62).
Current users of H2-receptor antagonists had a 1.63-fold increased
risk of pneumonia (95% confidence interval, 1.07-2.48) compared with those
who stopped use. For current PPI users, a significant positive dose-response
relationship was observed. For H2-receptor antagonist users, the
variation in dose was restricted. CONCLUSION Current use of gastric acid–suppressive therapy was associated
with an increased risk of community-acquired pneumonia.
Over the last decades important risk factors for gastrointestinal symptoms have shifted, which may have changed its population prevalence. The aim of this study was to assess the current prevalence ...of gastrointestinal symptoms, appraise associated factors and assess health-related quality of life in the general population.
A total of 51,869 questionnaires were sent to a representative sample of the Dutch adult general population in December 2008. Demographic characteristics, gastrointestinal symptoms, health-related quality of life, medication use and co-morbidity were reported. We used multivariable logistic regression analysis to determine factors associated with gastrointestinal symptoms.
A total of 18,317 questionnaires were returned, and 16,758 were eligible for analysis. Prevalence of gastrointestinal symptoms was 26%. Most frequent symptoms were bloating (63%), borborygmi (60%) and flatulence (71%). Female gender (adjusted OR (aOR) 1.59, 95% CI 1.43-1.77), asthma/COPD (aOR 1.47, 95% CI 1.21-1.79), use of paracetamol (aOR 1.33, 95% CI 1.20-1.47), antidepressants (aOR 1.56, 95% CI 1.22-2.00) and acid-suppressive medication were independently associated with presence of gastrointestinal symptoms. Age over 65 years (aOR 0.75, 95% CI 0.65-0.87), and use of statins (aOR 0.75, 95% CI 0.61-0.93) were associated with a lower prevalence of gastrointestinal symptoms. Respondents with gastrointestinal symptoms had a lower mean health-related quality of life of 0.81 (SD = 0.21) compared to 0.92 (SD = 0.14) for persons without gastrointestinal symptoms (P<0.01).
Prevalence of gastrointestinal symptoms in the Dutch community is high and associated with decreased health-related quality of life.
To evaluate which parameters of dynamic magnetic resonance (MR) imaging and T2 relaxation rate would result in optimal discrimination of prostatic carcinoma from normal peripheral zone (PZ) and ...central gland (CG) tissues and to correlate these parameters with tumor stage, Gleason score, patient age, and tumor markers.
Of 58 patients with prostatic carcinoma, 36 were included for analysis. Patients underwent MR imaging at 1.5 T with an endorectal-pelvic phased-array coil and subsequently underwent prostatectomy. A T2-weighted turbo spin-echo sequence, an intermediate-weighted sequence, and a fast T1-weighted gradient-echo sequence (seven sections in 2.03 seconds) during bolus injection of 0.1 mmol gadopentetate dimeglumine per kilogram of body weight were performed. Contrast agent concentration-time curves were obtained for prostatic carcinoma and normal PZ and CG tissue by using whole-mount sections to guide placement of regions of interest. Onset time, time to peak, peak enhancement, relative peak enhancement, washout, and T2 relaxation rates were calculated. Multivariate receiver operating characteristic analysis was performed with and without relative peak enhancement.
Results of multivariate receiver operating characteristic analysis showed that relative peak enhancement demonstrated the highest area under the receiver operating characteristic curve (AUC) in the PZ and the CG (AUC = 0.93, 0.82). Results of multivariate analysis without relative peak enhancement showed that relative peak enhancement in the PZ and washout in the CG demonstrated the highest AUC (AUC = 0.9, 0.81). Pearson correlation coefficients between the dynamic parameters or T2 relaxation rates in carcinoma and the tumor stage, Gleason score, patient age, and tumor markers ranged between 0.02 and 0.44.
The optimal parameter for discrimination of prostatic carcinoma in the PZ and CG was relative peak enhancement. If relative peak enhancement was not used, then peak enhancement was optimal in the PZ, and washout was optimal in the CG. Poor-to-moderate correlation was present between the dynamic parameters or T2 relaxation rate in carcinoma and the tumor stage, Gleason score, patient age, tumor volume, and prostate-specific antigen.
Abstract
Background
Patients with inflammatory bowel disease (IBD) treated with immunomodulators or biologic therapy are at increased risk of infections. Malnutrition and vitamin or mineral ...deficiencies are common among patients with IBD. The results of various studies have indicate that vitamin deficiencies might increase the risk of infections. To evaluate the efficacy of a multivitamin and mineral supplement on the incidence of infections in patients with IBD treated with immunomodulators, biologic therapy, or combination therapy.
Methods
This was a single-center, randomized, double-blind, placebo-controlled clinical trial to compare a multivitamin and mineral supplement (supplemented group) vs identical-in-appearance placebo (placebo group) in a total of 320 non–vitamin-deficient patients with IBD (Crohn’s disease or ulcerative colitis) in remission with immunomodulators, biologic therapy, or combination therapy. Participants were asked to take a daily multivitamin and mineral supplement or placebo and report the occurrence of infections during a 24-week period of follow-up.
Results
Treatment arms consisted of 162 and 158 patients for the supplement and placebo, respectively. In both treatment groups, 107 patients reported an infection during the 24-week follow-up period (unadjusted odds ratio, 0.93; 95% confidence interval, 0.56-1.48). In the supplemented group, 32 patients received antibiotics for an infection compared with 21 patients in the placebo group (unadjusted odds ratio, 1.61; 95% confidence interval, 0.88-2.93).
Conclusions
An over-the-counter multivitamin and mineral supplement did not reduce the risk of infection for patients with IBD in remission with immunomodulators, biologic therapy, or combination therapy.
Background: Although breast cancer screening is recommended to start at a younger age for women with a hereditary risk of breast cancer, the sensitivity of mammography for these women is reduced. We ...compared magnetic resonance imaging (MRI) with mammography to determine which is more sensitive and whether MRI could play a role in the early detection of breast cancer for these women. Methods: We constructed a retrospective cohort of all breast MRI and mammography surveillance reports made in our department from November 1994 to February 2001. All of the 179 women in the cohort had received biannual palpation in addition to annual imaging by MRI, mammography, or both. The 258 MRI images and the 262 mammograms were classified with the use of the BI-RADSTM (i.e., Breast Imaging Reporting and Data System) scoring system, which has five categories to indicate the level of suspicion of a lesion. Receiver operator characteristic curves were generated for MRI and mammography, and the area under each curve (AUC) was assessed for the entire cohort of 179 women and for a subset of 75 women who had received both an MRI and a mammographic examination within a 4-month period. All statistical tests were two-sided. Results: In the cohort of 179 women, we detected 13 breast cancers. Seven cancers were not revealed by mammography, but all were detected by MRI. For the entire cohort, the AUC for mammography was 0.74 (95% confidence interval CI = 0.68 to 0.79), and the AUC for MRI was 0.99 (95% CI = 0.98 to 1.0). For the subset of women who had both examinations, the AUC for mammography was 0.70 (95% CI = 0.60 to 0.80), and the AUC for MRI was 0.98 (95% CI = 0.95 to 1.0). Conclusion: MRI was more accurate than mammography in annual breast cancer surveillance of women with a hereditary risk of breast cancer. Larger prospective studies to examine the role of MRI in screening programs are justified.
Mucosal healing has become the treatment goal in patients with ulcerative colitis (UC) and Crohn's disease (CD). Whether low fecal calprotectin levels and histological healing combined with mucosal ...healing is associated with a further reduced risk of relapses is unknown.
Patients with CD, UC or inflammatory bowel disease-unclassified (IBD-U) scheduled for surveillance colonoscopy collected a stool sample prior to bowel cleansing. Only patients with mucosal healing (MAYO endoscopic score of 0) were included. Fecal calprotectin was measured using a quantitative enzyme-linked immunosorbent assay (R-Biopharm, Germany). Biopsies were obtained from four colonic segments, and histological disease severity was assessed using the Geboes scoring system. Patients were followed until the last outpatient clinic visit or the development of a relapse, which was defined as IBD-related hospitalization, surgery or step-up in IBD medication.
Of the 164 patients undergoing surveillance colonoscopy, 92 patients were excluded due to active inflammation or missing biopsies. Of the remaining 72 patients (20 CD, 52 UC or IBD-U), six patients (8%) relapsed after a median follow-up of 11 months (range 5-15 months). Median fecal calprotectin levels at baseline were significantly higher for patients who relapsed compared with patients who maintained remission (284 mg/kg vs. 37 mg/kg. p < 0.01). Fecal calprotectin below 56 mg/kg was found to optimally predict absence of relapse during follow-up with 64% sensitivity, 100% specificity, 100% negative predictive value and 20% positive predictive value. The presence or absence of active inflammation determined by Geboes cut-off score of 3.1 was less strongly associated with the risk of relapse (64% sensitivity, 33% specificity, 9% negative predictive value and 92% positive predictive value.
Low calprotectin levels identify IBD patients who remain in stable remission during follow-up.
Gastrointestinal angiodysplasias are vascular anomalies that may result in transfusion-dependent anemia despite endoscopic therapy. An individual patient data meta-analysis of cohort studies suggests ...that octreotide decreases rebleeding rates, but component studies possessed a high risk of bias. We investigated the efficacy of octreotide in reducing the transfusion requirements of patients with angiodysplasia-related anemia in a clinical trial setting.
The study was designed as a multicenter, open-label, randomized controlled trial. Patients with angiodysplasia bleeding were required to have had at least 4 red blood cell (RBC) units or parental iron infusions, or both, in the year preceding randomization. Patients were allocated (1:1) to 40-mg octreotide long-acting release intramuscular every 28 days or standard of care, including endoscopic therapy. The treatment duration was 1 year. The primary outcome was the mean difference in the number of transfusion units (RBC + parental iron) between the octreotide and standard of care groups. Patients who received at least 1 octreotide injection or followed standard of care for at least 1 month were included in the intention-to-treat analyses. Analyses of covariance were used to adjust for baseline transfusion requirements and incomplete follow-up.
We enrolled 62 patients (mean age, 72 years; 32 men) from 17 Dutch hospitals in the octreotide (n = 31) and standard of care (n = 31) groups. Patients required a mean number of 20.3 (standard deviation, 15.6) transfusion units and 2.4 (standard deviation, 2.0) endoscopic procedures in the year before enrollment. The total number of transfusions was lower with octreotide (11.0; 95% confidence interval CI, 5.5–16.5) compared with standard of care (21.2; 95% CI, 15.7–26.7). Octreotide reduced the mean number of transfusion units by 10.2 (95% CI, 2.4–18.1; P = .012). Octreotide reduced the annual volume of endoscopic procedures by 0.9 (95% CI, 0.3–1.5).
Octreotide effectively reduces transfusion requirements and the need for endoscopic therapy in patients with angiodysplasia-related anemia. ClinicalTrials.gov, NCT02384122.
Display omitted
Octreotide treatment was compared with standard of care in an adequately powered randomized controlled trial, which established that octreotide significantly reduces transfusion requirements and endoscopic procedures in patients with angiodysplasia-related anemia.
PDF
