Oral hygiene and infective endocarditis: a case control study.

OBJECTIVE: To determine if oral hygiene is associated with infective endocarditis (IE) among those at moderate risk for IE. STUDY DESIGN: This is a case control study of oral hygiene among hospitalized patients with IE (cases) and outpatients with heart valve disease but without IE (controls). The primary outcome was the mean dental calculus index. Secondary outcomes included other measures of oral hygiene and periodontal disease (e.g., dental plaque, gingivitis) and categorization of blood culture bacterial species in case participants. RESULTS: The 62 case participants had 53% greater mean dental calculus index than the 119 control participants (0.84, 0.55, respectively; difference = 0.29, 95% CI: 0.11, 0.48; P = .002) and 26% greater mean dental plaque index (0.88, 0.70, respectively; difference = 0.18, 95% CI: 0.01.0.36; P = .043). Overall, cases reported fewer dentist and dental hygiene visits (P = .013) and fewer dental visits in the 12 weeks before enrollment than controls (P = .007). Common oral bacteria were identified from blood cultures in 27 of 62 cases (44%). CONCLUSIONS: These data provide evidence to support and strengthen current American Heart Association guidance that those at risk for IE can reduce potential sources of IE-related bacteremia by maintaining optimal oral health through regular professional dental care and oral hygiene procedures.

Association of race and acute kidney injury among patients admitted with Coronavirus disease of 2019 (COVID-19).

BACKGROUND: COVID-19 is a multi-organ system disease, and rates of acute kidney injury (AKI) have varied significantly. Our objective was to evaluate the prevalence of AKI among hospitalized COVID-19-positive patients in a large hospital system in the Southeast of the USA. MATERIALS AND METHODS: This was a cohort study of admitted patients discharged between March 1, 2020 and April 30, 2020 at Atrium Health who had tested positive for COVID-19 by polymerase chain reaction testing of a nasopharyngeal swab. The positive test had been within 2 weeks prior to or after admission. AKI was defined and staged using the Kidney Disease Improving Global Outcomes (KDIGO) 2012 AKI criteria. Patient-level data including demographic characteristics, Charlson Comorbidity Index, and other comorbidities were also obtained. RESULTS: Of the admitted patients with COVID-19, 74 of 254 (29.1%, 95% CI 23.6 - 35.1%) had AKI. Participants with AKI compared to those without AKI tended to be ≥ 65 years of age (57 vs. 39%; p = 0.01), male (62 vs. 46%; p = 0.02), African American (70 vs. 45%; p < 0.01), have a diagnosis of chronic kidney disease (28 vs. 15%; p = 0.01), and a higher median Charlson Comorbidity Index score (6.5 vs. 4.0; p < 0.01). After adjusting for other factors, African Americans had three times the odds of developing AKI compared to other racial groups among patients admitted with a COVID-19 diagnosis (OR 3.09; 95% CI 1.49 - 6.41). CONCLUSION: Among the 254 patients hospitalized with COVID-19, we observed a high prevalence of AKI. However, a majority of survivors demonstrated renal recovery at the time of discharge. African American race was strongly associated with development of AKI and portended a poor prognosis.

Impact of Point-of-Care Platelet Function Testing Among Patients With and Without Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention With Drug-Eluting Stents (from the ADAPT-DES Study).

We sought to examine if the risk conferred by high on-treatment platelet reactivity (HPR) varies based upon clinical presentation. We examined the relation between HPR (P2Y12 reaction units >208) and adverse ischemic and bleeding events among patients with and without acute coronary syndromes (ACS) from ADAPT-DES; 51.7% of patients had ACS. After clopidogrel loading, ACS patients had higher P2Y12 reaction units and a greater prevalence of HPR based on VerifyNow P2Y12 assay. Of 92 definite or probable stent thrombosis (ST) events at 2 years, 65.2% occurred among patients with ACS. HPR was independently associated with ST in ACS patients (adjusted hazard ratio 2.29, 95% confidence interval 1.32 to 3.98) but not with clinically relevant bleeding. Although no statistical interactions between ACS status and these associations were observed, non-ACS patients exhibited an attenuated association between HPR and ST, and an inverse association between HPR and clinically relevant bleeding. HPR was similarly associated with myocardial infarction, but not with overall mortality in ACS and non-ACS patients. In conclusion, the majority of ST events in the 2 years after drug-eluting stent placement occurred in ACS patients; HPR was strongly associated with ST in these patients. These data support current recommendations for using more potent antiplatelet therapies in ACS patients.

Impact of Timely Treatment Intensification on Glycemic Goal Achievement in Patients With Type 2 Diabetes Failing Metformin Monotherapy.

Purpose The purpose of the study was to examine the association between timely treatment intensification (TTI) and glycemic goal achievement in patients with type 2 diabetes (T2D) failing metformin monotherapy (MM). Methods This study was set at a large integrated health care system in the United States. The study cohort included T2D patients aged 18 to 85 years who were on MM between January 2009 and September 2013 and had an uncontrolled glycated hemoglobin (A1C) reading (≥8%) after at least 3 months of MM (corresponding date was index date). Secondary analyses were performed using A1C <7% as T2D control. TTI was defined as receipt of an add-on therapy within 180 days after the index date. Impact of TTI on glycemic goal achievement was determined using multivariate Cox proportional hazards regression. Patients were censored at their last A1C reading or health care visit during 2 years after the index date. Results The study cohort consisted of 996 patients, ~58% male and ~59% Caucasian, with a mean age of ~54 (±12) years. TTI was observed in 50.2% of the patients. The rate of glycemic goal achievement was higher in patients with TTI compared with patients without TTI (hazards ratio = 1.632, 95% confidence interval = 1.328-2.006). The results for the secondary analyses were largely consistent with the primary findings. Conclusions TTI positively affected glycemic goal achievement among T2D patients failing MM and could be a useful strategy to increase the currently low proportion of patients with their T2D controlled in the United States.

Patient and Provider Factors Affecting Clinical Inertia in Patients With Type 2 Diabetes on Metformin Monotherapy.

PURPOSE: Our aim was to determine the extent of clinical inertia and the associated patient and provider factors in patients with type 2 diabetes on metformin monotherapy (MM) at a large integrated health care system in the United States. METHODS: The study cohort included patients with type 2 diabetes aged 18 to 85 years, on MM between January 2009 and September 2013, who experienced MM failure (had an uncontrolled glycosylated hemoglobin [HbA1c] reading (≥8.0% [64 mmol/mol]) after at least 90 days of MM). Clinical inertia was defined as absence of treatment intensification with an add-on therapy within 180 days after the MM failure (index date). The impact of patient and provider factors on clinical inertia was determined using generalized estimating equations. FINDINGS: The study cohort consisted of 996 patients; 58% were men and 59% were white, with a mean age of 53 (11.8) years. Of these, 49.8% experienced clinical inertia. Lower HbA1c at index date, absence of liver diseases, absence of renal diseases, and greater provider age were associated with clinical inertia. The clinical inertia rate in a secondary analysis considering HbA1c <7.0% (53 mmol/mol) as glycemic control was 67.9%. Greater patient age, lower HbA1c at index date, greater provider age, and being a primary care physician were associated with clinical inertia. IMPLICATIONS: Considerable clinical inertia rates were observed in our real-world patient population, suggesting the need of interventions to reduce clinical inertia in clinical practice. Information about patient and provider factors affecting clinical inertia provided by this study could help healthcare policymakers plan and implement such interventions.

Retrospective Analysis of Catheter-Acquired Urinary Tract Infection: Relationship to Stroke Diagnosis.

AIMS: The objective of this study was to determine if a diagnosis of stroke was associated with a higher incidence of catheter-associated urinary tract infections (CAUTIs). Secondary aims included examining the effect of healthcare-related variables including antibiotic and steroid use, length of stay before catheter insertion, and duration of catheter use on the incidence of CAUTI in stroke patients. DESIGN: This was a retrospective chart review analysis set in a large teaching hospital in the Southeastern United States. METHODS: A total of 300 patients with indwelling urinary catheter use who also had a stroke diagnosis were randomly selected and matched (on age, gender, race, and admission date) to 300 randomly selected patients with indwelling urinary catheter use and without stroke. Bivariate statistical tests included Wilcoxon signed-rank test and McNemar's test, whereas the multivariate test consisted of generalized estimating equations. RESULTS: The incidence of CAUTIs in stroke patients was significantly higher than that in nonstroke patients (6.0% vs 1.7%, P = .005). In the multivariable generalized estimating equations analysis, stroke patients were found to be approximately 3.5 times more likely to experience CAUTI compared with nonstroke patients (odds ratio = 3.53; 95% confidence interval, 1.24-10.03; P = .018). The proportion of patients who used steroids was greater among stroke patients who experienced CAUTI compared with those who did not experience CAUTI (55.6% vs 24.5%, P = .004). CONCLUSION: Stroke patients were more likely to develop CAUTI compared with nonstroke patients. These patients should be considered as key targets when implementing interventions aimed at reducing CAUTIs. Use of steroids may be associated with a higher likelihood of CAUTI in stroke patients. IMPLICATIONS: Clinical nurse specialists are directly influential in preventing CAUTIs. This study provides evidence regarding the association between stroke and CAUTI to clinical nurse specialists to help them plan CAUTI prevention initiatives.