Antibiotic Use in Term and Near-Term Newborns.

OBJECTIVES: We aimed to study whether national and local antibiotic stewardship projects have reduced the antibiotic use in newborns and to monitor potential changes in adverse outcomes. METHODS: In a nationwide, population-based study from Norway, we included all hospital live births from 34 weeks' gestation (n = 282 046) during 2015 to 2019. The primary outcome was the proportion of newborns treated with antibiotics from 0 to 28 days after birth. The secondary outcomes were the overall duration of antibiotic treatment and by categories: culture-positive sepsis, clinical sepsis, and no sepsis. RESULTS: A total of 7365 (2.6%) newborns received intravenous antibiotics during the period, with a reduction from 3.1% in 2015 to 2.2% in 2019 (30% decrease; P < .001). Hospitals with antibiotic stewardship projects experienced the largest reduction (48% vs 23%; P < .001). We found a small decrease in the median duration of antibiotic treatment in newborns without sepsis from 2.93 to 2.66 days (P = .011), and geographical variation was reduced during the study period. The overall number of days with antibiotic treatments was reduced by 37% from 2015 to 2019 (119.1 of 1000 vs 75.6 of 1000; P < .001). Sepsis was confirmed by blood culture in 206 newborns (incidence rate: 0.73 cases per 1000 live births). We found no increase in sepsis with treatment onset >72 hours of life, and sepsis-attributable deaths remained at a low level. CONCLUSIONS: During the study period, a substantial decrease in the proportion of newborns treated with antibiotics was observed together with a decline in treatment duration for newborns without culture-positive sepsis.

[Evaluation of the practice of prescribing oral chemotherapy type "Capecitabine" by medical oncologist: A first study from Morocco]. / Évaluation de la pratique de prescription d'une chimiothérapie orale type « capécitabine ¼. Résultats de la première enquête auprès des oncologues médicaux marocains.

INTRODUCTION: Oral anticancer therapy is becoming increasingly developed; their prescription has become a common practice in oncology. However, there is a variability and diversity in prescription practice. Its magnitude has been very little studied in scientific literature. To our knowledge, this is the first study in Morocco and North Africa to evaluate the practice of prescribing oral chemotherapy. METHODS: The authors conducted a national exhaustive cross-sectional survey, to evaluate the practice of the oral chemotherapy "Capecitabine" type prescription by Moroccan oncologists and to identify strategies to promote an adherence to oral anti-neoplasic therapy. RESULTS: Ninety-one medical oncologists answered out of 118, from public oncology centres (29.7%), Hospital University (58.2%), and private sector (12.1%). Thirty-four of the oncologists replied by email, 33 through phone conversation and 24 by filling paper questionnaires. In total, 32% of the cases were handwritten prescriptions, and 51.6% electronically generated. Forty-six percent of medical oncologists dedicated more time to the oral chemotherapy type Capecitabine prescription versus its intravenous equivalent 5FU. However, 33% medical oncologists take less time to this prescription, and 20.9% of them take the same time. Adherence to oral chemotherapy was evaluated by simply questioning of patients in most of the cases (94%) and 4% of medical oncologist declared that they did not evaluate this adherence. In total, 87.9% of Moroccan medical oncologists revealed that they have not received any specific training in the therapeutic education of the patient with oral anti-cancer treatment. CONCLUSION: In Morocco, there is a great variability in prescription and follow-up practice for patients receiving oral chemotherapy. There is a lack of a national standardization with regards to the procedures of prescribing and monitoring patients to ensure the quality and safety of the oral chemotherapy prescription.

Association of the incidence of venous air embolism on coronary computed tomography angiography with the intravenous access route preparation process.

Venous air embolism (VAE) can be observed in the right heart system on contrast-enhanced computed tomography (CT), following injection of contrast media with a power injector system. Although most VAEs are mostly asymptomatic, they may result in paradoxical air embolism (PAE).To evaluate whether the incidence of VAE on coronary CT angiography is associated with the process of preparation of the intravenous access route.We retrospectively evaluated 692 coronary CT examinations at 3 institutions. Trained CT nurses placed an intravenous cannula in the forearm. Tubes connected to the cannula were prepared in the following ways: A, using an interposed three-way cock and a 20-mL syringe filled with normal saline to collect air contamination in the tube; B, through direct connection to the power injector system without the interposed 3-way cock; and C, using an interposed three-way cock and a 100-mL normal saline drip infusion bottle system to keep the tube patent. The incidence and location of VAE and preparation of intravenous injection were assessed.The overall incidence of VAE was 55.3% (383/692), most frequently observed in the right atrium (81.5%, 312/383). Its incidence varied significantly across the 3 techniques (A: 21.6% (35/162), B: 63.2% (237/375) and C: 71.6% (111/155); P < .001). No patient demonstrated any symptom associated with VAE.Using a 3-way cock with syringe demonstrated the lowest incidence of VAE on coronary CT angiography. It is thus recommended to reduce potential complication risks related to intravenous contrast media injection.

Reducing injection intensity is associated with decreased risk for invasive bacterial infection among high-frequency injection drug users.

BACKGROUND: Bacterial infection is a major cause of morbidity and mortality for persons who inject drugs (PWID). Injection cessation may help abrogate such infections, but maintaining complete cessation is challenging. Limited data exists on the role of reduced injection intensity on invasive bacterial infection risk. We sought to evaluate decreased risk for bacterial infections following cessation and substantive reduction in the injection intensity. METHODS: Participants were persons in the AIDS Linked to the Intravenous Experience (ALIVE) cohort with initial high-frequency injection drug use (> 1 daily). Pooled logistic regression with generalized estimating equations was used to estimate risk for invasive bacterial infection (pneumonia, endocarditis, or sepsis) among participants achieving complete injection cessation or reduced injection intensity relative to those with sustained high-frequency use. RESULTS: Of 2247 study participants with 12,469 paired study visits, complete injection cessation was achieved at 13.5% and reduced injection intensity at 25.5% of study visits. Adjusting for sociodemographics and HIV status, injection cessation was associated with a 54% reduction of bacterial infection at 3 months (odds ratio [OR] 0.46, 95% CI 0.25-0.84) and a 46% reduction at 6 months (OR 0.54, 95% CI 0.36-0.81). Reduced injection intensity was associated with a 36% reduction of infection at 3 months (OR 0.64, 95% CI 0.43-0.96) and a 26% reduction at 6 months (OR 0.74, 95% CI 0.56-0.98). CONCLUSIONS: Both complete cessation and reduced injection frequency demonstrate substantial benefit in reducing invasive bacterial infection risk among PWID. With high rates of relapse into injection use, targeting sustained reductions in drug use intensity may be a key harm reduction modality for improving clinical outcomes in this population.

Predictors of Drug Injection in High-Risk Populations of Prisoners with a History of Tattooing: A Cross-Sectional Study.

BACKGROUND: Transmitting blood-borne diseases is alarming in places with high prevalence of people who inject drugs. This study aimed to determine the prevalence of drug injection and its related predictors among prisoners with a history of tattooing in Iran. STUDY DESIGN: Cross-sectional study. METHODS: By using a census sampling, 5493 prisoners with a history of tattooing of 11988 prisoners participated for hepatitis B and C bio-behavioral surveillance surveys (BSS) in prisons of Iran, during 2015-2016 from 55 prisons in 19 provinces were assessed. The data for the BSS were collected using face-to-face checklist-based interviews. Weighted prevalence and the association between variables and history of drug injection were determined using Chi-square test and adjusted odds ratio (AOR) was estimated through multivariate logistic regression test using survey package. RESULTS: The mean age of participants was 33.9 ±8.3 yr. Most of them were male (96.4%) and had a history of drug use (85.4%). The prevalence of drug injection among drug users was 20.2%, of which 33.9% had a history of shared injection. The prevalence of drug injection among prisoners with a history of tattooing is associated with male gender (P=0.047), age ≥35 yr (P<0.001), being single (P=0.002), being divorced/widow (P=0.039), and a history of imprisonment (P<0.001). CONCLUSION: The prevalence of drug injection increases in the presence of other high-risk behaviors. It is necessary to initiate harm reduction programs and preventive interventions in groups with multiple high-risk behaviors.

[Intravenous chemotherapy at home: A pediatric monocentric experience]. / Chimiothérapie intraveineuse à domicile en cancérologie pédiatrique : une expérience monocentrique.

INTRODUCTION: Our home care unit (HCU) developed the administration of IV chemotherapy at home for some pediatric oncologic patients. METHODS: We conducted a retrospective monocentric analysis, leading to identify patients with at least one sequence of chemotherapy at home in 2015. RESULTS: Two hundred and forty four sequences of home chemotherapy have been administered in 2015. We identified two situations for home IV chemotherapy. Pediatric oncologist of day hospital prescribes the sequence. The chemotherapy is delivered at hospital for the first day. HCU takes over for the next days at home. For a sequence replacing a conventional hospitalization, the attending physician examines the patient, and confirm the clinical validation. The pediatric oncologist of HCU checks lab exams, and prescribes the chemotherapy. For both situations, IV chemotherapy is prepared by our hospital pharmacy, delivers at home or at day hospital, and HCU team manages home material and organizes hospitalization. CONCLUSIONS: This kind of organization allows setting up home IV CT for more and more patients. It allows to limit daily hospitalization for some patients living far from the hospital, and whose therapies lead to several hospitalizations.

A Comparison of Error Rates Between Intravenous Push Methods: A Prospective, Multisite, Observational Study.

OBJECTIVES: Current literature estimates the error rate associated with the preparation and administration of all intravenous (IV) medications to be 9.4% to 97.7% worldwide. This study aims to compare the number of observed medication preparation and administration errors between the only commercially available ready-to-administer product (Simplist) and IV push traditional practice, including a cartridge-based syringe system (Carpuject) and vials and syringes. METHODS: A prospective, multisite, observational study was conducted in 3 health systems in various states within the United States between December 2015 and March 2016 to observe IV push medication preparation and administration. Researchers observed a ready-to-administer product and IV push traditional practice using a validated observational method and a modified data collection sheet. All observations were reconciled to the original medication order to determine if any errors occurred. RESULTS: Researchers collected 329 observations (ready to administer = 102; traditional practice = 227) and observed 260 errors (ready to administer = 25; traditional practice = 235). The overall observed error rate for ready-to-administer products was 2.5%, and the observed error rate for IV push traditional practice was 10.4%. CONCLUSIONS: The ready-to-administer group demonstrated a statistically significant lower observed error rate, suggesting that use of this product is associated with fewer observed preparation and administration errors in the clinical setting. Future studies should be completed to determine the potential for patient harm associated with these errors and improve clinical practice because it relates to the safe administration of IV push medications.

[Observational study of outpatient unit duration of stay depending on the route of administration (intravenous vs subcutaneous) for a targeted therapy]. / Étude observationnelle du temps passé en hôpital de jour selon la voie d'administration (intraveineuse vs sous-cutanée) d'une thérapie ciblée.

New routes of administration available for some targeted therapies, especially subcutaneous injections, have an impact not only on the patients' daycare experience, but also on the unit's organization. This observational study conducted on 48 voluntary patients at the Institut universitaire du cancer Toulouse-Oncopole shows that the mean duration of the outpatient unit stay is diminished by one hour when a subcutaneous injection is used instead of an intravenous route. This duration decrease is mainly caused by an 82% average reduction in treatment duration. However, the waiting times before and after the treatment itself are not significantly impacted. Organizational methods related to the treatment prescription and preparation remain indeed the same. Anticipated prescription is not noticeably impacted either. This reduction of the duration of stay will truly be obtained if the whole unit's organization is adapted.

Abuse liability of intravenous buprenorphine vs. buprenorphine/naloxone: Importance of absolute naloxone amount.

BACKGROUND: This study sought to determine the relative importance of a range of Bup/Nx doses compared to Bup alone in producing subjective and reinforcing effects. METHODS: Heroin-using volunteers (n=13) were transitioned onto daily oral hydromorphone (40mg). Laboratory sessions assessed the reinforcing and subjective effects of intravenous (IV) doses of Bup (1.51, 2.16, 6.15, and 8.64mg) and Bup/Nx (1.51/0.44, 2.16/0.61, 6.15/1.71, and 8.64/2.44mg). Placebo (Pbo), heroin (25mg) and Nx (0.3mg) were tested as neutral, positive, and negative controls, respectively. RESULTS: IV Bup alone was self-administered substantially less than IV heroin, though the two largest doses of Bup produced positive subjective effects, drug "Liking" (0-100mm), which were comparable to heroin (mean difference: Heroin vs Bup 6.15mg: -3.4mm, Heroin vs Bup 8.64mg: -11.3mm). All indicators of abuse potential seen with IV Bup alone were substantially decreased with the addition of Nx. All Bup/Nx combinations produced ratings of aversive effects, "Bad", which were comparable to, or greater than IV, Nx. On three of the four measures of aversive effects, the largest difference is seen with the 8.64 vs 8.64/2.44 condition. CONCLUSIONS: This study further demonstrates the ability of the Bup/Nx combination to deter IV use. Although none of the Bup/Nx combinations showed indications of abuse potential, formulations with larger absolute Nx, may be less abusable as they precipitate a greater degree of withdrawal.

Comparative Safety of Morphine Delivered via Intravenous Route vs. Patient-Controlled Analgesia Device for Pediatric Inpatients.

CONTEXT: Although patient-controlled analgesia (PCA) is an effective pain control modality, there is a lack of large studies on PCA safety in pediatric patients. OBJECTIVES: This study compared the delivery of morphine either via intravenous route (morphine IV) or via PCA device (morphine PCA) on risk of cardiopulmonary resuscitation (CPR) and mechanical ventilation (MV) using a large administrative database. METHODS: We assembled a retrospective cohort of pediatric inpatients between five and 21 years old in 42 children's hospitals between 2007 and 2011 from the Pediatric Health Information System database. After propensity score matching, we created matched cohorts of morphine PCA and morphine IV patients, in both surgical and nonsurgical samples, who were similar on demographic, clinical, and hospital-level factors. We examined if PCA administration was associated with greater likelihood of CPR or MV up to two days after drug administration. RESULTS: Surgical and nonsurgical patients administered morphine PCA generally had lower odds of having MV on the baseline day and up to two days after PCA exposure, although these estimates were not statistically significant. Similarly, PCA exposure was associated with about 20%-44% lower odds of same day CPR in both surgical and nonsurgical patients, with a slightly greater reduction in the odds of CPR in the surgical patients. CONCLUSION: In this large pediatric inpatient population, morphine administered via PCA device for surgical and nonsurgical pain was not associated with an increased risk of receiving CPR or MV, and was associated with slightly better safety outcomes than intravenous morphine.

Power Injection Through Ultrasound-Guided Intravenous Lines: Safety and Efficacy Under an Institutional Protocol.

BACKGROUND: After an index case of contrast-associated compartment syndrome, an urban hospital instituted a protocol limiting high-speed injection to intravenous (IV) lines started proximal to the forearm and testing those lines before contrast injection. OBJECTIVE: In this article, we estimate the safety and efficacy of high-speed injection using this protocol in patients with IV lines inserted under ultrasound guidance. METHODS: In an ambispective study, we enrolled prospective cohorts of ED patients requiring high-speed radiographic contrast media injection (≥3.5 mL/sec) into two groups: those with IV lines placed under ultrasound guidance and those with IV lines placed using traditional inspection and palpation. We also performed a retrospective review involving those groups. In addition, we reviewed hospital records for all patients with compartment syndrome between January 2010 and December 2011. We calculated 95% confidence intervals using normal approximation or exact calculation. RESULTS: Between November 2013 and August 2014, the ED referred 32 patients to the Department of Radiology for computed tomography angiography involving high-speed contrast injection through ultrasound-guided IV lines. Of these, 25 of 32 (78%) had successful injection (7 failed in the Department of Radiology) vs. 26 of 27 (96%) with catheters inserted using traditional methods (risk difference 0.18 [95% confidence interval -0.01 to 0.38]). Based on retrospective records, we estimated 79 additional cases. We found no cases of compartment syndrome during either period, for an incidence estimate of 0 per 100 cases (95% confidence interval 0-3). CONCLUSION: A hospital policy for high-speed contrast injection through ultrasound-guided IV lines has a safe record. However, 22% of patients with ultrasound-guided IV lines were refused for CT.

Iron deficiency in cancer patients

ABSTRACT Anemia is a frequent complication in cancer patients, both at diagnosis and during treatment, with a multifactorial etiology in most cases. Iron deficiency is among the most common causes of anemia in this setting and can develop in nearly half of patients with solid tumors and hematologic malignancies. Surprisingly, this fact is usually neglected by the attending physician in a way that proper and prompt investigation of the iron status is either not performed or postponed. In cancer patients, functional iron deficiency is the predominant mechanism, in which iron availability is reduced due to disease or the therapy-related inflammatory process. Hence, serum ferritin is not reliable in detecting iron deficiency in this setting, whereas transferrin saturation seems more appropriate for this purpose. Besides, lack of bioavailable iron can be further worsened by the use of erythropoiesis stimulating agents that increase iron utilization in the bone marrow. Iron deficiency can cause anemia or worsen pre-existing anemia, leading to a decline in performance status and adherence to treatment, with possible implications in clinical outcome. Due to its frequency and importance, treatment of this condition is already recommended in many specialty guidelines and should be performed preferably with intravenous iron. The evidences regarding the efficacy of this treatment are solid, with response gain when combined with erythropoiesis stimulating agents and significant increments in hemoglobin as monotherapy. Among intravenous iron formulations, slow release preparations present more favorable pharmacological characteristics and efficacy in cancer patients.

Is the recent emergence of mephedrone injecting in the United Kingdom associated with elevated risk behaviours and blood borne virus infection?

The recent, and rapid, emergence of injection of the short-acting stimulant mephedrone (4-methylmethcathione) has resulted in concerns about increased infection risks among people who inject drugs (PWID). Data from the bio-behavioural surveillance of PWID in the United Kingdom were analysed to examine the impact of mephedrone injection on infections among PWID. During the year preceding the survey, 8.0% of PWID (163/2,047) had injected mephedrone. In multivariable analyses, those injecting mephedrone were younger, less likely to have injected opiates, and more likely to have injected cocaine or amphetamines, used needle/syringe programmes or sexual health clinics, been recruited in Wales and Northern Ireland or shared needles/syringes. There were no differences in sexual risks. Those injecting mephedrone more often had hepatitis C antibodies (adjusted odds ratio (AOR) = 1.51; 95% confidence interval (CI): 1.08-2.12), human immunodeficiency virus (AOR = 5.43; 95% CI: 1.90-15.5) and overdosed (AOR = 1.70; 95% CI: 1.12-2.57). There were no differences in the frequency of injecting site infections or prevalence of hepatitis B. The elevated levels of risk and infections are a concern considering its recent emergence. Mephedrone injection may currently be focused among higher-risk or more vulnerable groups. Targeted responses are needed to prevent an increase in harm.

Off-Label Use of Ultrasound Contrast Agents for Intravenous Applications in Children: Analysis of the Existing Literature.

OBJECTIVES: The purpose of this study was to collect and analyze the published data related to intravenous (IV) use of ultrasound (US) contrast agents in children. METHODS: We searched the literature to collect all of the published studies reporting the IV administration of a second-generation US contrast agent in children. RESULTS: We analyzed 9 case series and 5 case reports, as well as 5 individual cases, of pediatric contrast-enhanced US use reported in a study group that also included adults. We found that 502 children underwent contrast-enhanced US examinations (mean age, 9.7 years; range, 1 day-18 years). Most patients (89%) were injected with the sulfur hexafluoride contrast agent SonoVue (Bracco SpA, Milan, Italy). The mean dose used was 1.5 mL (range, 0.1-9.6 mL). Only 10 patients (2%) had adverse reactions related to the contrast agent administration: 1 life-threatening anaphylactic shock and 9 mild transitory adverse effects. We additionally found 38 papers in which the study groups included at least 1 child; thus, we obtained a total of 540 reported cases of off-label use of IV US contrast agents in children. The most frequent target organ was the liver, and most indications were related to space-occupying lesion characterization and abdominal evaluations after blunt trauma. Some studies also evaluated the diagnostic performance of contrast-enhanced US in different clinical scenarios and found very good accuracy. Concordance between contrast-enhanced US imaging and the respective reference-standard imaging methods ranged between 83% and 100% in different studies. CONCLUSIONS: Our results support the idea that the IV use of US contrast agents in children is safe, feasible, diagnostically robust, and effective.

Acute Flaccid Myelitis of Unknown Etiology in California, 2012-2015.

IMPORTANCE: There has been limited surveillance for acute flaccid paralysis in North America since the regional eradication of poliovirus. In 2012, the California Department of Public Health received several reports of acute flaccid paralysis cases of unknown etiology. OBJECTIVE: To quantify disease incidence and identify potential etiologies of acute flaccid paralysis cases with evidence of spinal motor neuron injury. DESIGN, SETTING, AND PARTICIPANTS: Case series of acute flaccid paralysis in patients with radiological or neurophysiological findings suggestive of spinal motor neuron involvement reported to the California Department of Public Health with symptom onset between June 2012 and July 2015. Patients meeting diagnostic criteria for other acute flaccid paralysis etiologies were excluded. Cerebrospinal fluid, serum samples, nasopharyngeal swab specimens, and stool specimens were submitted to the state laboratory for infectious agent testing. MAIN OUTCOMES AND MEASURES: Case incidence and infectious agent association. RESULTS: Fifty-nine cases were identified. Median age was 9 years (interquartile range [IQR], 4-14 years; 50 of the cases were younger than 21 years). Symptoms that preceded or were concurrent included respiratory or gastrointestinal illness (n = 54), fever (n = 47), and limb myalgia (n = 41). Fifty-six patients had T2 hyperintensity of spinal gray matter on magnetic resonance imaging and 43 patients had cerebrospinal fluid pleocytosis. During the course of the initial hospitalization, 42 patients received intravenous steroids; 43, intravenous immunoglobulin; and 13, plasma exchange; or a combination of these treatments. Among 45 patients with follow-up data, 38 had persistent weakness at a median follow-up of 9 months (IQR, 3-12 months). Two patients, both immunocompromised adults, died within 60 days of symptom onset. Enteroviruses were the most frequently detected pathogen in either nasopharynx swab specimens, stool specimens, serum samples (15 of 45 patients tested). No pathogens were isolated from the cerebrospinal fluid. The incidence of reported cases was significantly higher during a national enterovirus D68 outbreak occurring from August 2014 through January 2015 (0.16 cases per 100,000 person-years) compared with other monitoring periods (0.028 cases per 100,000 person-years; P <.001). CONCLUSIONS AND RELEVANCE: In this series of patients identified in California from June 2012 through July 2015, clinical manifestations indicated a rare but distinct syndrome of acute flaccid paralysis with evidence of spinal motor neuron involvement. The etiology remains undetermined, most patients were children and young adults, and motor weakness was prolonged.

Incidence of nonconfounded post-computed tomography acute kidney injury in hospitalized patients with stable renal function receiving intravenous iodinated contrast material.

OBJECTIVE: The purpose of our investigation was to determine the frequency of proximate acute and chronic confounding risk factors for acute kidney injury (AKI) in a cohort of adult hospitalized patients with stable renal function who developed AKI following an intravenous (IV) contrast-enhanced computed tomography (CT) examination. MATERIALS AND METHODS: Institutional review board approval was obtained for this retrospective, Health Insurance Portability and Accountability Act-compliant investigation. Overall, 100 adult inpatients (50 males [mean age = 61 years, range: 24-94 years] and 50 females [mean age = 60 years, range: 20-95 years]) with stable pre-CT renal function who developed post-CT AKI using the Acute Kidney Injury Network (AKIN) laboratory criteria following an IV contrast-enhanced CT examination comprised the study population. Electronic International Classification of Disease-9 analysis followed by a comprehensive manual electronic medical record review was systematically performed by 5 radiologists to identify known acute (n = 24, within 5 days before or 3 days after CT) and chronic (n = 21) risk factors for AKI other than contrast material administration that might confound a diagnosis of contrast-induced nephrotoxicity. Descriptive statistics were performed. RESULTS: Of 100 inpatients with post-CT AKI, 99 (99%) had 1 or more acute risk factor(s) for AKI other than contrast material administration (median = 3 risk factors, range: 0-8) and 86 (86%) had one or more chronic risk factor(s) for AKI (median = 2 risk factors, range: 0-7). The median number of risk factors (acute or chronic) per patient was 5 (range: 1-13). Only 1 inpatient (1%) developed post-CT AKI without a confounding acute risk factor (estimated glomerular filtration rate = 62-71 mL/min/1.73 m(2), 4 chronic risk factors, and CT 7 days after pancreaticoduodenectomy). The most common acute risk factors were nephrotoxic medications (83%) and parenteral blood product administration (30%). The most common chronic risk factors were hypertension (59%) and chronic kidney disease (56%). CONCLUSION: Nonconfounded post-CT AKI is rare in hospitalized adults with stable renal function who have been exposed to IV low- or iso-osmolality iodinated contrast material.

Contrast induced nephropathy in patients undergoing intravenous (IV) contrast enhanced computed tomography (CECT) and the relationship with risk factors: a meta-analysis.

PURPOSE: To summarize the incidence of contrast-induced nephropathy (CIN) and associations between CIN incidence and risk factors in patients undergoing intravenous contrast-enhanced computed tomography (CECT) with low- or iso-osmolar iodinated contrast medium. METHODS: This review is performed in accordance with the preferred reporting items in systematic reviews and meta-analysis (PRISMA) guidelines. We searched the MEDLINE, EMBASE and Cochrane databases from 2002 till November 2012. Two reviewers included papers and extracted data. The pooled data were analysed by either fixed or random-effects approach depending on heterogeneity defined as the I(2) index. RESULTS: 42 articles with 18,790 patients (mean age 61.5 years (range: 38-83 years)) were included. The mean baseline eGFR was 59.8 mL/min and ranged from 4 to 256 mL/min. Of all patients 45.0% had an estimated glomerular filtration rate (eGFR)<60 mL/min, 55.2% had hypertension; 20.2% had diabetes mellitus (DM) and 6.5% had congestive heart failure (CHF). The overall pooled CIN incidence, defined as a SCr increase of ≥ 25% or ≥ 0.5mg/dL, was 4.96% (95%CI: 3.79-6.47). Data analysis showed associations between CIN and the presence of renal insufficiency, DM, malignancy, age>65 years and use of non-steroidal anti-inflammatory drugs (NSAID's) with odds ratios of 1.73 (95%CI: 1.06-2.82), 1.87 (95%CI: 1.55-2.26), 1.79 (95%CI: 1.03-3.11), 1.95 (95%CI: 1.02-3.70) and 2.32 (95%CI: 1.04-5.19), respectively while hypertension, anaemia and CFH were not associated (p=0.13, p=0.38, p=0.40). CONCLUSION: The mean incidence of CIN after intravenous iodinated CECT was low and associated with renal insufficiency, diabetes, presence of malignancy, old age and NSAID's use.

Contrast material-induced nephrotoxicity and intravenous low-osmolality iodinated contrast material: risk stratification by using estimated glomerular filtration rate.

PURPOSE: To determine the effect of intravenous (IV) low-osmolality iodinated contrast material (LOCM) on the development of post-computed tomography (CT) acute kidney injury (AKI), stratified by pre-CT estimated glomerular filtration rate (eGFR), in patients with stable renal function. MATERIALS AND METHODS: Institutional review board approval was obtained and patient consent waived for this HIPAA-compliant, retrospective study. CT examinations performed over a 10-year period on unique adult inpatients with sufficient serum creatinine (SCr) data and stable renal function (difference between baseline and pre-CT SCr within 0.3 mg/dL and 50% of baseline) were identified. A 1:1 propensity score matched cohort analysis with multivariate analysis of effects was performed with post-CT AKI as the primary outcome measure (8826 nonenhanced and 8826 IV contrast agent-enhanced CT studies in 17 652 patients). Propensity matching was performed with respect to likelihood of receiving IV contrast material (19 tested covariates). Post-CT AKI with Acute Kidney Injury Network SCr criteria was the primary endpoint. A stepwise multivariate conditional logistic regression model was performed to identify the effect of IV LOCM on post-CT AKI. RESULTS: After 1:1 propensity matching, IV LOCM had a significant effect on the development of post-CT AKI (P = .04). This risk increased with decreases in pre-CT eGFR (≥ 60 mL/min/1.73 m(2): odds ratio, 1.00; 95% confidence interval: 0.86, 1.16; 45-59 mL/min/1.73 m(2): odds ratio, 1.06; 95% confidence interval: 0.82, 1.38; 30-44 mL/min/1.73 m(2): odds ratio, 1.40; 95% confidence interval: 1.00, 1.97; <30 mL/min/1.73 m(2): odds ratio, 2.96; 95% confidence interval: 1.22, 7.17). CONCLUSION: IV LOCM is a nephrotoxic risk factor in patients with a stable eGFR less than 30 mL/min/1.73 m(2), with a trend toward significance at 30-44 mL/min/1.73 m(2). IV LOCM does not appear to be a nephrotoxic risk factor in patients with a pre-CT eGFR of 45 mL/min/1.73 m(2) or greater.

Home care use of intravenous and subcutaneous immunoglobulin for primary immunodeficiency in the United States.

PURPOSE: Utilization reports on immunoglobulin (Ig) use for immunodeficiency in the United States (U.S.) have focused on prescribing practices in hospitals. There have been no large-scale reports on Ig use for immune deficiency in the home. We investigated the use of Ig in 3,187 subjects diagnosed with primary immunodeficiency. METHODS: Cross-sectional data on 4,580 subjects in the U.S. receiving Ig in 2011 was obtained from a major home care provider. Demographics, route, dose, and frequency of Ig use by subjects with ICD-9 coded primary immunodeficiencies were analyzed. RESULTS: Of 4,580 subjects, 3,187 had ICD-9 codes suggesting primary immunodeficiencies; 1,939 (60.8 %) were females and 1,248 (39.2 %) were males, with age ranging from 0 to 95 years. The predominant diagnoses were: common variable immunodeficiency (279.06; n=1,764; 55.3 %), hypogammaglobulinemia (279.00; n=635; 19.9 %), unspecified immunity deficiency (279.3; n=286; 9 %), other selective Ig deficiencies (279.03; n=171; 5.4 %), and agammaglobulinemia (279.04; n=127; 4 %). 54 % of subjects received Ig by the subcutaneous (SC) route, and 46 % by intravenous (IV) route, with more SC use by older subjects. The mean dose prescribed was 483 mg/kg/month, but less Ig was ordered for subjects on SCIg (409 mg/kg/month), as compared to subjects on IVIg (568 mg/kg/month). A highly significant inverse correlation between increasing age and dosage of Ig ordered was found (P= <.0001). CONCLUSION: Analysis of home care use of Ig in primary immune deficiency revealed that the SC route was prescribed more than the IV route, especially for older patients. By either method of administration, less immunoglobulin was prescribed for older subjects.