Environmental contamination because of multidrug-resistant Acinetobacter baumannii surrounding colonized or infected patients.

BACKGROUND: Multidrug-resistant (MDR) Acinetobacter baumannii (MDR-AB) is an important nosocomial pathogen associated with significant morbidity and mortality. METHODS: We conducted a prospective cohort study of intensive care unit patients colonized or infected with MDR-AB at a tertiary care hospital from October 2008 to January 2009. For each patient, 10 surfaces in the patient room were sampled and evaluated for the presence of A baumannii. Pulsed-field gel electrophoresis was performed on all environmental isolates and a clinical isolate if available. RESULTS: Fifty rooms were sampled; 48% (24/50) were positive at 1 or more environmental sites. Supply carts (10/50, 20%), floors (8/50, 16%), infusion pumps (7/50, 14%), and ventilator touch pads (5/44, 11.4%) were most commonly contaminated. Patients with a recent history of MDR-AB were no more likely to contaminate their environment than patients with a remote history (51% vs 36%, respectively, P value = .50). In 85% (17/20) of cases, the environmental isolate was classified as genetically similar to the patient isolate. CONCLUSION: For patients with MDR-AB, the surrounding environment is frequently contaminated, even among patients with a remote history of MDR-AB. Surfaces often touched by health care workers during routine patient care are commonly contaminated and may be a source of nosocomial spread.

Antithrombotic therapies in patients with heart failure: hypothesis formulation from a research database.

PURPOSE: Heart failure is a significant public health problem. The present study is intended to explore in a research database whether antithrombotic therapies (ATTs) affect cardiovascular outcomes in patients with incident heart failure (IHF). METHODS: Using the United Kingdom Health Improvement Network research database, several multivariable models (including logistic and Cox's regression models, as well as propensity score methods) were used to examine all-cause mortality and clinical outcomes among five treatment groups. RESULTS: The cohort included 24,554 patients with IHF (50.2% men), with a mean age (standard deviation [SD]) of 76.4 (11.0) years. Nearly three-fourths of patients received at least one form of ATT. Patients receiving ATTs tended to be younger and more likely to be men, and had more cardiovascular comorbidities. During the 18-month follow-up period, the mortality rates were 11.1%, 14.6%, 17.8%, 19.5%, and 32.6% for warfarin combination therapy, warfarin alone, clopidogrel therapy, aspirin (ASA) alone, and no therapy, respectively, yielding odds ratios (95%confidence intervals [CI]) relative to no therapy of 0.28 (0.24, 0.33), 0.38 (0.34, 0.43), 0.46 (0.40, 0.52), and 0.49 (0.45, 0.53) for each therapy group, accordingly. The use of ATTs also appeared to be associated with a reduced risk for ischemic or thrombotic events. CONCLUSIONS: These data contribute to the formulation of the hypothesis that use of ATTs in clinical practice decreases the risk of morbidity and mortality in patients with IHF, although findings require further confirmative studies.

The role of patient-to-patient transmission in the acquisition of imipenem-resistant Pseudomonas aeruginosa colonization in the intensive care unit.

BACKGROUND: Imipenem-resistant Pseudomonas aeruginosa (IRPA) is an emerging problem. The causal role of antibiotic selective pressure versus patient-to-patient transmission has not been assessed using a large cohort. METHODS: Patients who were admitted to the medical and surgical intensive care units (ICUs) at the University of Maryland Medical Center from 2001 through 2006 had multiple perianal culture samples collected. Using pulsed-field gel electrophoresis (PFGE), the number of patients who acquired IRPA as a result of patient-to-patient transmission was determined. We also analyzed a subset of patients who had a previous surveillance culture that grew an imipenem-susceptible P. aeruginosa (ISPA) and a subsequent culture that grew IRPA. RESULTS: Our cohort consisted of 7071 patients. Three hundred patients were colonized with IRPA. 151 patients had positive culture findings at ICU admission, and 149 patients acquired an IRPA. Among the patients who acquired IRPA, 46 (31%) had a PFGE pattern similar to that for another isolate, and 38 (26%) were found to be colonized with an ISPA on the basis of earlier culture results. Of the 38-patient subset, 28 (74%) had identical PFGE patterns. CONCLUSIONS: Our data showed that, of those cases of IRPA acquisition, 46 (31%) were defined as cases of patient-to-patient transmission, and 28 (19%) were cases of acquisition by the patients' endogenous flora.

Prevention of erythropoietin-associated hypertension.

Hypertension is the most significant complication from treatment with erythropoietin (Epo). Can Epo-induced hypertension be eliminated? We examined systemic and local effects of our genetically engineered products, Epo-binding protein (Epo-bp) and anti-Epo-bp antibodies, on randomly assigned Sprague-Dawley rats at midnight, 4 am, 8 am, noon, 4 pm, and 8 pm. Blood pressure, hematocrit, and body weight were measured immediately before and after the completion of a 4-week, twice-weekly course of Epo (50 U/kg), Epo-bp, anti-Epo-bp antibodies, or physiological saline injections. Epo treatment increased hematocrit markedly overall as compared with the saline, Epo-bp, and anti-Epo-bp antibody groups (0.616 versus 0.427, 0.439, and 0.441, respectively) and at each of the 6 test times (all P<0.0001). Epo-bp and anti-Epo-bp antibody treatment with Epo had almost no effect on the Epo-induced hematocrit increase (0.616 versus 0.580 or 0.591, respectively). Circadian blood pressures for Epo versus saline, Epo-bp, and anti-Epo-bp antibody groups were 136.2+/-2.3 versus 116.2+/-1.7, 118.4+/-2.1, and 116.6+/-2.1 mm Hg, respectively (each P<0.0001). Significantly increased blood pressure was detected at noon, 4 pm, 8 pm, and midnight in Epo treatment. When Epo was given with Epo-bp or anti-Epo-bp antibodies, blood pressure was maintained at similar levels as in saline treatment (each P<0.0001) as compared with Epo treatment alone. Overall, body, brain, and heart weights were significantly lower in Epo treatment than those of other groups. Thus, Epo-bp and anti-Epo-bp antibodies eliminate Epo-induced hypertension without affecting hematocrit and blood volume.

About 7-day (circaseptan) and circadian changes in cold pressor test (CPT).

We assess circadian (CD) and circaseptan (CS) changes in the blood pressure (BP) response to a 1-min immersion of the hand into ice water, the cold pressor test (CPT). An about 8 mmHg BP increase in the CPT reported by others for health and an elevation >25 mmHg for patients with "hypertension" have been viewed as predisease, but variables related to the vascular system exhibit prominent CD, CS and circannuals, among other components of their genetically anchored time structure or chronome, and may also have to be considered. Hence, a 16-year-old adolescent (ML) immersed her hand into ice water every 2-4 h for 2 days and once daily in the morning thereafter for 1 week (N = 25), as did, only for <2 days (> or =24 h), four adults 20-66 years of age. BP and heart rate (HR) were monitored automatically around the clock at 15-min intervals and at 1-min intervals before and immediately after the CPT. Data were analyzed by cosinor. The difference between the first post-CPT BP value and the mean of the last seven values prior to the CPT was a measure of CPT response (at 1-min). Overall, ML's systolic (S) BP increased by 8.2 +/- 1.4 mmHg and her diastolic (D) BP by 6.2 +/- 0.9 mmHg (P < 0.001). Increases were found in 96% of the tests for SBP, 92% for DBP and 20% for HR. There was only one tie for HR (4%), resulting in a HR decrease in 76% of CPTs. The BP response to CPT at 1 min was CS-dependent. The CS double amplitudes are 12.5 +/- 4.1 for SBP (P = 0.019) and 7.8 +/- 2.8 mmHg for DBP (P = 0.030), with acrophases occurring on late Sunday, early Monday (at -50 degrees and -67 degrees from 00:00 h from Saturday to Sunday for SBP and DBP, respectively, with 360 degrees identical with 1 week). The response of HR did not allow the detection of a CS rhythm (P = 0.969). The CD response peaked in the early morning hours; with 24 h identical with 360 degrees and 0 degrees = local midnight, the acrophase (phi) for SBP is at -80 degrees and for DBP at -113 degrees, in keeping with earlier results from four adult subjects (SBP: -37 degrees; DBP: -42 degrees ), individual differences notwithstanding. The average timing of the largest overall response of BP to CPT coincides with the timing of the response to other stimuli. The CS acrophases coincide with the times of increased morbidity/mortality from vascular diseases. Chronomes, time structures broader than circadian, notably their about-weekly components, should be considered, not only at the extremes of life when the CS and about-half-weekly rhythms are particularly prominent in BP and HR but also in interpreting BP responses as a gauge of vascular disease status in adolescents.

Effects of diaphragmatic breathing on ambulatory blood pressure and heart rate.

Psychological procedures, such as self-hypnosis in the form of autogenic training, have been proposed for correcting a deviant, e.g., high blood pressure (BP). In view of the overwhelming evidence for the circadian (CD) stage dependence of any treatment effects, the CD stage dependence of the effects of diaphragmatic breathing (DB) on BP and heart rate (HR) was explored in data from a clinically healthy normotensive subject who, following 3 weeks of ambulatory monitoring as a reference standard, measured BP and HR with a manual monitor at 1-min intervals for 5 min before and after DB (three deep diaphragmatic breaths) and who performed DB for about 2 weeks at about 2-h intervals while awake. The 3-week data series were analyzed by cosinor, involving the least-squares fit of cosine curves with periods of 24, 12 and 168 h. A CD rhythm was detected for BP and HR (P < 0.001 in each case), peaking in the afternoon. Some about-weekly (circaseptan; CS) BP rhythms and 12-h (circasemidian) components were also statistically significant. DB was found to reduce systolic (S) BP. Overall, SBP decreased by 5.9 +/- 0.8 mmHg (P < 0.001) and diastolic (D) BP by 1.4 +/- 0.8 mmHg (P < 0.005), while HR remained at about the same average. The effect of DB on BP was CD-dependent, the largest response occurring in the afternoon, 2-3 h before the peaks in SBP and DBP found in the reference data of the same subject. There was also a 5-10% decrease in SBP around the weekend (Friday, Saturday and Sunday). The results on a single subject suggest the need to collect similar data on others for optimizing by clock-hour, day of the week, and eventually by the marker rhythms BP and/or HR the best times for DB and other procedures. The personalized best time for people on different work/rest schedules for relaxation may be several hours before their BP has reached its highest point in the 24-h span. HR may serve as a marker for DB timing, but the effect on HR of DB was only of borderline statistical significance in the subject investigated.