Short vs long-course antibiotic therapy in pyelonephritis: a comparison of systematic reviews and guidelines for the SIMI choosing wisely campaign.

BACKGROUND: The Italian Society of Internal Medicine (SIMI) Choosing Wisely Campaign has recently proposed, among its five items, to reduce the prescription of long-term intravenous antibiotics if not indicated. The aim of our study was to assess the available evidences on optimal duration of antibiotic treatment in pyelonephritis through a systematic review of secondary studies. MATERIALS AND METHODS: We searched for all guidelines on pyelonephritis and systematic reviews assessing the optimal duration of antibiotic therapy in this type of infection. We compared the recommendations of the three most cited and recent guidelines on the topic of interest. We extracted data of non-duplicated RCT from the selected systematic reviews and performed meta-analyses for clinical and microbiological failure. A trial sequential analysis (TSA) was also achieved to identify the need for further evidence. RESULTS: We identified 4 systematic reviews, including data from 10 non-duplicated RCTs (1536 patients). The meta-analysis showed a higher rate of clinical cure for short-course antibiotic treatment (RR for clinical failure 0.70, 95% CI [0.53-0.94]). No significant difference in the rate of microbiological failure (RR 1.06, 95% CI [0.75-1.49]) was observed. In terms of clinical cure, the TSA suggests that current evidence is sufficient to consider short course at least as effective as long-course treatment. Selected guidelines recommend considering shorter courses, but do not cite most of the published RCTs. CONCLUSIONS: Short-course antibiotic treatment is at least as effective as longer courses for both microbiological and clinical success in the treatment of acute uncomplicated pyelonephritis.

Diagnostic accuracy of transthoracic echocardiography to identify native valve infective endocarditis: a systematic review and meta-analysis.

Infective endocarditis (IE) is a serious and potentially life-threatening disease, and accurate diagnosis is essential. We performed a systematic review and meta-analysis to assess the diagnostic accuracy of transthoracic echocardiography (TTE), with transesophageal echocardiography (TEE) as the reference standard, in patients with suspected IE of the native valves. We performed a systematic search in MEDLINE, EMBASE and Cochrane Library searching for studies that enrolled adult patients with suspected native valves IE where data about both TTE and TEE could be extracted. We included 11 studies, for a total of 2209 patients. The overall sensitivity, specificity, negative and positive likelihood ratios (LR) of TTE are 0.71 (95% CI 0.56-0.82), 0.80 (95% CI 0.58-0.92), 0.37 (95% CI 0.20-0.68) and 3.56 (95% CI 1.3-9.72), respectively. The subgroup analyses of the studies considering different cut-off levels show that the strict negative criteria (i.e., managing indeterminate results as positive) have the highest sensitivity and the lowest LR-. On the contrary, when managing indeterminate results as negative (standard criteria), the specificity and LR+ are the highest. We observed no differences between the studies performed with older and more recent technologies. In conclusion, our study results support the use of a negative TTE as a single rule-out test in patients with a low pre-test probability. In selected cases, the use of strict negative criteria might exclude IE in intermediate-risk patients, and a positive TTE might be considered as a single rule-in test with no need for TEE if TEE results would not change the patient's management.

Diagnostic accuracy of ICD-9 code 780.2 for the identification of patients with syncope in the emergency department.

PURPOSE: Syncope is a common condition that affects individuals of all ages and is responsible for 1-3% of all emergency department (ED) visits. Prospective studies on syncope are often limited by the exiguous number of subjects enrolled. A possible alternative approach would be to use of hospital discharge diagnoses from administrative databases to identify syncope subjects in epidemiological observational studies. We assessed the accuracy of the International Classification of Diseases, Ninth Revision (ICD-9) code 780.2 "syncope and collapse" to identify patients with syncope. METHODS: Patients in two teaching hospitals in Milan, Italy with a triage assessment for ED access that was possibly related to syncope were recruited in this study. We considered the index test to be the attribution of the ICD-9 code 780.2 at ED discharge and the reference standard to be the diagnosis of syncope by the ED physician. RESULTS: The sensitivity, specificity, positive and negative predictive values of the ICD-9 code 780.2 to identify patients with syncope were 0.63 (95% confidence interval [CI] 0.58-0.67), 0.98 (95% CI 0.98-0.99), 0.83 (95% CI 0.79-0.87) and 0.95 (95% CI 0.94-0.95), respectively. CONCLUSIONS: The moderate sensitivity of ICD-9 code 780.2 should be considered when the code is used to identify patients with syncope through administrative databases.

An Unusual Coexistence of Primary Central Nervous System Non-Hodgkin's Lymphoma and Acute Promyelocytic Leukemia.

Acute promyelocytic leukemia and primary central nervous system lymphoma are uncommon hematological malignancies. The co-occurrence of acute myeloid leukemia with various lymphoproliferative diseases is an extremely rare condition, especially in the absence of previous chemotherapy or radiotherapy. Herein, we provide a comprehensive characterization of a patient with concomitant diagnosis of extranodal high-grade non-Hodgkin B-cell neoplasm confined to the central nervous system and acute promyelocytic leukemia. We describe the efficacy and feasibility of the consecutive use of all-trans retinoic acid and arsenic trioxide-containing regimen for the treatment of promyelocytic leukemia and high-dose methotrexate plus cytarabine to treat lymphoproliferative involvement of the central nervous system.

Variability of adverse events in the public health-care service of the Tuscany region.

The objective of the study is to analyze the variation of adverse events (AEs) according to the different structure of hospitals. The study is a multicenter, retrospective study. It involves 4 teaching hospitals (THs) and 32 community hospitals, distributed in 12 local trusts (LTs), of the Tuscany Regional Healthcare Service (RHS). A random sample of the clinical records of patients admitted in LTs and THs in 2008 was selected from the database of the hospital discharge records of the centers. Among 11,293 clinical records included, a total of 354 adverse events were identified. There was a significant higher incidence of AEs in the male and elderly (>65 years) population, and the incidence of AEs was more relevant in the THs (5.3, 95% CI 4.7-6.1) than in the LTs (1.8, 95% CI 1.5-2.2). AEs related to falls were significantly more preventable in THs (OR 19.22, 95% CI 2.45-151.02), while in LTs, AEs related to infections were the most preventable (OR 6.22, 95% CI 1.35-28.67). Concerning the consequence of AE, death is significantly more probable for AEs related to unexpected cardiac arrest in LTs, while disability and prolongation of the stay are significantly more probable consequences associated with re-admission in THs, and to transfer to ICU or HDU in LTs. Re-interventions, surgical complications and falls are the factors more correlated with AEs. In conclusion, the study shows a higher risk of incurring adverse events for the THs compared to the LTs, presumably connected with a major complexity of the clinical cases. Furthermore, the preventability of AEs is higher in the LTs (56.1 vs 42.2%), and this might be associated with lower expertise in managing complications in these settings. Concerning specialties, there are no significant differences in AEs distribution.

Syncope recurrence and mortality: a systematic review.

AIMS: Data on adverse events and death rates following syncope are heterogeneous among studies, and knowledge of syncope prognosis could help to better define the correct management of patients. METHODS AND RESULTS: We performed a systematic review of literature by searching for prospective observational studies enrolling consecutive patients presenting to the Emergency Department because of syncope. The outcomes considered were syncope recurrence and short- and long-term mortality. Morbidity and a composite of morbidity and mortality were also assessed. Pooled event rates and 95% confidence intervals (CI) were calculated for each outcome using the random effects model. Twenty-five studies (11 158 patients) were included. The incidence of syncope relapse linearly increased from 0.3% at 30 days to 22% at 2 years follow-up. One-year mortality rate varied between 5.7 and 15.5%; the pooled estimate was 8.4% (95% CI: 6.7-10.2%). The incidence of adverse events (morbidity) varied between 6.1 and 25.2% at 10 days and 2 years, respectively. The short-term (10 days) pooled incidence of the composite of morbidity and mortality was 9.1% (95% CI: 6.6-12.5%). We found a high statistical heterogeneity between studies. CONCLUSION: This meta-analysis of prospective observational studies shows that the chance of being asymptomatic linearly progressively decreased over time after the first syncope. Short-term (10-30 days) mortality after syncope was <2% and that the overall 10-day rate of the composite endpoint of death and major events was ∼9%. The knowledge of syncope prognosis could help clinicians to understand syncope patients' prognosis and researchers to design future studies.

Errors in medical literature: not a question of impact.

The editorial and peer-review processes should guarantee readers as to the reliability of published data. The first step of these processes is to check for errors. The aim of our study was to look for the presence of objective errors in consecutive articles published on three of the most authoritative clinical journals. Two reviewers evaluated the presence of any error in 200 consecutive original articles containing at least two tables, allowing a reanalysis of the data, published between October 2010 and April 2011. Error was considered any action different from what was planned. Errors were listed as: methodological, numerical and slips. They were considered as severe if numbers in the abstract were completely different from numbers reported in the full text. Among the 125 articles included in the study, 102 (82 %, 95 % CI 74-88 %) contained some kind of error, even multiple. Nine articles (7 %, 95 % CI 3-13 %) contained one slip, 92 articles (74 %, 95 % CI 65-81 %) contained at least one numerical error, and 22 articles (18 %, 95 % CI 11-25 %) contained one methodological error. Five articles (4 %, 95 % CI 1-9 %) contained one serious error. None of the errors retrieved (0 %, 95 % CI 0-2 %) would have changed the results of the studies. Most of the articles published in the most important medical journals present mistakes. Our results could be a clue to editorial and peer review systems system weaknesses. A debate within the scientific medical community about these systems, and possible alternative adjustments are needed.

Is magnetic resonance safe in implanted cardiac devices patients?

Nazarian et al. [1] evaluate in a prospective non-randomized trial the safety of a 1.5 T MRI protocol for patients with implanted cardiac devices (ICD and PM). 438 participants (54 % with PM and 46 % with ICD implanted, respectively,after the 1998 and 2000) were enrolled and underwent 555MRI examinations. Patients with a recent implant(\6 weeks), those with abandoned or epicardiac leads, and PM-dependent patients with an ICD were excluded.According to the experimental protocol, an asynchronous pacing mode (VOO/DOO) was programmed in the pacemaker-dependent patients, while an inhibited pacing mode(VVI/DDI) was used for the other patients. The ICD function of non-PM-dependent patients was disabled. During the MRI examination, blood pressure, electrocardiography, pulse oximetry and symptoms were monitored by a nurse with experience in cardiac life support and device programming who had an immediate backup from an electrophysiologist.Device variables including sensing, impedance, capture threshold and battery voltage were evaluated before MRI examination, immediately after MRI and after 3­6 months.Variations exceeding 30, 40 and 50 %for, respectively, lead impedance, sensing and capture threshold were considered as significant changes in lead performance.Baseline and immediate follow-up interrogations were performed in all 438. Long-term follow-up device variables were available for 266 patients (61 %). 3 of 438 patients(0.7 %) experienced acute power-on-reset events. None of them had device dysfunction during long-term follow-up(3­6 months). Right ventricular sensing and atrial, right and left ventricular impedances were reduced immediately after MRI. At long-term follow-up in 61 % of the patients,decreased right ventricular (RV) sensing and lead impedance,increased RV capture threshold and decreased battery voltage were noted. The observed changes did not require device revision or reprogramming. The distributions of changes in device variables were within the 20 % at baseline for most participants. Thoracic MRI sequences had a greater effect on device variables and were more likely to result in artifacts (for instance, image distortion,signal voids or bright areas and poor fat suppression).