Statin use and infections in Veterans with cirrhosis.

BACKGROUND: Evidence about the beneficial effects of statins on reducing infections is accumulating. Identifying ways to reduce infection risk in patients with cirrhosis is important because of increased mortality risk and costs associated with infections. AIM: To estimate the extent to which statin use prolongs time to infection among patients with cirrhosis. METHODS: We identified Veterans with cirrhosis, but without decompensation (n = 19 379) using US Veterans Health Administration data from 2001 to 2009. New users of statins were identified and propensity matched to non-users and users of other cholesterol-lowering medications (1:1 matching). The cohort was followed up for hospitalisations with infections. Cox regression models with time-varying exposures provided estimates of adjusted hazard ratios (HR) and 95% confidence intervals (CI). RESULTS: New statin use was present among 13% of VA patients with cirrhosis without decompensation. Overall, 12.4% of patients developed a serious infection, and 0.1% of patients died. In the propensity-matched sample, statin users experienced hospitalisations with infections at a rate 0.67 less than non-users (95% Confidence Interval: 0.47-0.95). CONCLUSIONS: Infections are a major concern among cirrhotic patients and have the potential to seriously impact both life expectancy and quality of life. Statin use may potentially reduce the risk of infections among patients with cirrhosis.

Non-selective beta-blockers are not associated with serious infections in veterans with cirrhosis.

BACKGROUND: Studies evaluating outcomes associated with non-selective beta-blockers (NSBB) in cirrhosis have yielded mixed results. A major cause of death in decompensated cirrhosis is infection. AIM: To determine the effect of NSBB use on serious infections (requiring hospitalisation) in compensated and decompensated cirrhosis. METHODS: Using data from the US Veterans Health Administration from 2001-2009, we identified two cohorts: compensated cirrhotics (n = 12,656) and decompensated cirrhotics (n = 4834). From each cohort, we identified new NSBB users and propensity-matched them 1:1 to non-users (n = 1836 each in compensated users/non-users and n = 1462 each in decompensated users/non-users). They were followed up for serious infections (median time: 3.1 years), death and transplant. We estimated adjusted hazard ratios (HR) and 95% confidence intervals (CI) from Cox regression models. RESULTS: Death or transplantation occurred in 0.7% compensated and 2.7% of decompensated patients. Among decompensated cirrhotics, death (P = 0.0061) and transplantation (P = 0.0086) occurred earlier in NSBB users compared with non-users. Serious infections were observed in 4.8% of compensated cirrhotics and in 13.7% of decompensated cirrhotics. There was no difference in the rate of serious infection development in new NSBB users compared with non-users in the compensated (adjusted HR: 0.90, CI: 0.59-1.36) or in the decompensated group (adjusted HR: 1.10, CI: 0.96-1.25). CONCLUSION: The use of non-selective beta-blockers in U.S. veterans is not associated with an increased rate of serious infections in compensated or decompensated cirrhosis.

Association between duration and quality of sleep and the risk of pre-diabetes: evidence from NHANES.

AIMS: To examine the association between duration and quality of sleep and the prevalence of undiagnosed and clinically identified diabetes mellitus and pre-diabetes in a nationally representative sample. METHODS: Cross-sectional study of 2285 participants ≥ 30 years old and without diagnosed sleep disorders from the National Health and Nutrition Examination Survey (2005-2008). The primary exposures were sleep duration and quality. Sleep quality was assessed by questionnaire using trouble initiating sleep, trouble maintaining sleep, and waking up too early. The primary outcomes were clinically identified and undiagnosed pre-diabetes and diabetes as defined by the American Diabetes Association using fasting plasma glucose (5.6-6.9 mmol/l = pre-diabetes; ≥ 7.0 mmol/l = diabetes). Multivariate logistic regression was used to test the association between sleep quality, sleep duration and glycaemic status. RESULTS: After adjustment for socio-demographic characteristics and health behaviors, sleeping ≤ 5 h/night was associated with clinically identified pre-diabetes (odds ratio 2.06, 95% CI 1.00-4.22 vs. 7 h). Both trouble maintaining sleep ≥ 5 times/month (odds ratio 3.50, 95% CI 1.30-9.45) and waking up too early ≥ 5 times/month (odds ratio 2.69, 95% CI 1.21-5.98) were also significantly associated with increased risk of clinically identified pre-diabetes. Trouble initiating sleep and sleeping ≥ 9 h/night were not found to be associated with having diabetes. CONCLUSIONS: Only clinically identified pre-diabetes was associated with trouble maintaining sleep, waking up too early, and short sleep. No other relations were found to be significant. Findings suggest that poor sleep quality and short sleep duration were more strongly associated with clinically identified pre-diabetes than 7-8 hours per day.

Proton pump inhibitors are associated with a high rate of serious infections in veterans with decompensated cirrhosis.

BACKGROUND: There is increasing evidence that proton pump inhibitors (PPIs) increase the rate of infections in patients with decompensated cirrhosis. AIMS: To estimate the extent to which proton pump inhibitors (PPIs) increase the rate of infections among patients with decompensated cirrhosis. METHODS: We conducted a retrospective propensity-matched new user design using US Veterans Health Administration data. Only decompensated cirrhotic patients from 2001 to 2009 were included. New PPI users after decompensation (n = 1268) were 1:1 matched to those who did not initiate gastric acid suppression. Serious infections, defined as infections associated with a hospitalisation, were the outcomes. These were separated into acid suppression-related (SBP, bacteremia, Clostridium difficile and pneumonia) and non-acid suppression-related. Time-varying Cox models were used to estimate adjusted hazard ratios (HR) and 95% CIs of serious infections. Parallel analyses were conducted with H2 receptor antagonists (H2RA). RESULTS: More than half of persons with decompensated cirrhosis were new users of gastric acid suppressants, with most using PPIs (45.6%) compared with H2RAs (5.9%). In the PPI propensity-matched analysis, 25.3% developed serious infections and 25.9% developed serious infections in the H2RA analysis. PPI users developed serious infections faster than nongastric acid suppression users (adjusted HR: 1.66; 95% CI: 1.31­2.12). For acid suppression-related serious infections, PPI users developed the outcome at a rate 1.75 times faster than non-users (95% CI: 1.32­2.34). The H2RA findings were not statistically significant (HR serious infections: 1.59; 95% CI: 0.80­3.18; HR acid suppression-related infections: 0.92; 95% CI: 0.31­2.73). CONCLUSION: Among patients with decompensated cirrhosis, proton pump inhibitors but not H2 receptor antagonists increase the rate of serious infections.

SU-E-T-89: Characterization of Dental Restoration Material for Cs-137 Radiation Dosimetry.

PURPOSE: The purpose of this work is to characterize the radiation-induced thermoluminescence properties of a dental restoration material and to see if the material might be feasible for use in retrospective radiation dosimetry. METHODS: Retrospective, or accidental, dosimetry is the study of using nearby materials to measure radiation received by individuals. In this project we obtained samples of Ivoclar Vivadent e.max CAD material, a glass-ceramic used for making dental restorations such as full or partial crowns. The samples were machined into square chips .32 cm × .32 cm × .089 cm and annealed in the same furnace used by the dentist. The samples were exposed to a Cs-137 source using a PMMA source holder and then read in a Harshaw 3500 TLD reader. The samples were read without nitrogen gas flux using heating rates of 5 degrees C/s or 10 degrees C/s up to a maximum temperature of 400 degrees Celsius. The glow curves were analyzed using Systat PeakFIT peak-fitting software and Microsoft Excel spreadsheets. The authors gratefully thank Dr. Aaron Imdieke and the staff of River City Dental, St. Cloud, MN for the dental restoration materials and the use of their dental furnace. RESULTS: A sample subjected to a radiation exposure of .04 C/kg exhibits a glow curve with a prominent peak at approximately 140 degrees Celsius, which is well-modeled by the first order glow curve deconvolution formula developed by Kitis, Gomez-Ros, and Tuyn. The activation energy corresponding to this peak is approximately 1 eV. The thermoluminescent signal fades with time after exposure. CONCLUSIONS: Ivoclar Vivadent e.max CAD dental restoration material has the potential to be used as a material for retrospective Cs-137 radiation dosimetry. Future work could look at its thermoluminescent dosimetry properties in more detail and also at other dental restoration materials. The authors would like to thank Dr. Aaron Imdieke and the staff of River City Dental, St. Cloud, MN, for the donation of scrap dental restoration materials and the use of their dental furnace.

Waterfalls and geysers: the development of diversity awareness at Children's Hospital.

The development of diversity awareness at Children's Hospital in Columbus, Ohio, has been a work in progress since the early 1980s. The interface of administration and individual initiatives ("waterfalls" and "geysers") has resulted in projects ranging from major international exchange programs to noontime Spanish language classes. This article recounts the journey from a parochial focus to a consciousness of multiculturalism in virtually all aspects of hospital interaction.

Replica-plating virulence assay for Agrobacterium tumefaciens.

Replica plating onto wounded tobacco leaves provides a convenient method for screening for avirulent mutants of Agrobacterium tumefaciens.