Mon2-monocytes and increased CD-11b expression before transcatheter aortic valve implantation are associated with earlier death.

BACKGROUND: In the first three months after Transcatheter aortic valve implantation (TAVI), a remarkable number of patients have an unfavorable outcome. An inflammatory response after TAVI is suspected to have negative effects. The exact mechanisms remain unclear. We examined the influence of monocyte subpopulations on the clinical outcome, along with the degree of monocyte activation and further parameters of inflammation and platelet activation. METHODS: Flow-cytometric quantification analyses of peripheral blood were done in 120 consecutive patients who underwent TAVI (one day before TAVI and on day 1 and 7 after TAVI). Monocyte-subsets were defined by their CD14 and CD16 expression, monocyte-platelet-aggregates (MPA) by CD14/CD41 co-expression. The extent of monocyte activation was determined by quantification of CD11b-expression (activation epitope). Additionally, pro-inflammatory cytokines such as interleukin (IL)-6, IL-8, C-reactive protein were measured with the cytometric bead array method or standard laboratory tests. RESULTS: Elevated Mon2 (CD14++CD16+) - monocytes (38 vs. 62 cells/µl, p < 0.001) and a high expression of CD11b prior to TAVI (MFI 50.1 vs. 84.6, p < 0.05) were independently associated with death 3 months after TAVI. Mon2 showed the highest CD11b-expression and CD11b correlated with platelet activation and markers of systemic inflammation. Even CRP and IL-8 before TAVI were associated with death after TAVI. In contrast, a systemic inflammation response shortly after TAVI was not associated with early death. CONCLUSIONS: Elevated Mon2-monocytes and a high level of monocyte activation before TAVI are associated with early mortality after TAVI. Chronic inflammation in aging patients seems to be an important risk factor after TAVI.

Evidence-based analysis of risk factors for postoperative nausea and vomiting.

BACKGROUND: /st> In assessing a patient's risk for postoperative nausea and vomiting (PONV), it is important to know which risk factors are independent predictors, and which factors are not relevant for predicting PONV. METHODS: /st> We conducted a systematic review of prospective studies (n>500 patients) that applied multivariate logistic regression analyses to identify independent predictors of PONV. Odds ratios (ORs) of individual studies were pooled to calculate a more accurate overall point estimate for each predictor. RESULTS: /st> We identified 22 studies (n=95 154). Female gender was the strongest patient-specific predictor (OR 2.57, 95% confidence interval 2.32-2.84), followed by the history of PONV/motion sickness (2.09, 1.90-2.29), non-smoking status (1.82, 1.68-1.98), history of motion sickness (1.77, 1.55-2.04), and age (0.88 per decade, 0.84-0.92). The use of volatile anaesthetics was the strongest anaesthesia-related predictor (1.82, 1.56-2.13), followed by the duration of anaesthesia (1.46 h(-1), 1.30-1.63), postoperative opioid use (1.39, 1.20-1.60), and nitrous oxide (1.45, 1.06-1.98). Evidence for the effect of type of surgery is conflicting as reference groups differed widely and funnel plots suggested significant publication bias. Evidence for other potential risk factors was insufficient (e.g. preoperative fasting) or negative (e.g. menstrual cycle). CONCLUSIONS: /st> The most reliable independent predictors of PONV were female gender, history of PONV or motion sickness, non-smoker, younger age, duration of anaesthesia with volatile anaesthetics, and postoperative opioids. There is no or insufficient evidence for a number of commonly held factors, such as preoperative fasting, menstrual cycle, and surgery type, and using these factors may be counterproductive in assessing a patient's risk for PONV.

Histological changes in a model of chronic heart failure induced by multiple sequential coronary microembolization in sheep.

AIM: Valuable models of chronic heart failure to perform histological studies are scarce. The authors aimed at investigating histological changes of the heart, lung, liver and kidneys in a stable and reproducible animal model of chronic heart failure in sheep. METHODS: In 8 sheep (N.=8, 77+/-2 kg) chronic heart failure was induced by multiple sequential microembolization through bolus injection of polysterol microspheres (90 microm, N=25 000) into the left main coronary artery. Microembolization (ME) was repeated up to three times in two to three week intervals until animals started to develop stable signs of heart failure. Therefore, clinical and hemodynamic parameters were measured (Troponin T, heart and respiratory rate, cardiac output) after each embolization. Clinical examination was carried out by a veterinarian. All animals were followed for 3 months after first microembolization and then euthanized for histological examination. Histological data of the heart, lung, liver and the kidneys were analyzed in hematoxylin-eosin (HE) stains (10x, 25x, 100x) at baseline (control group) and at 3 months after first ME. Additionally preparations of heart tissue were stained with Picro-Sirius-Red (PSR) for planimetric quantification. A score from 0 to 4 according to Rassler et al. (2005) was used to assess the degree of lung injury. RESULTS: All animals developed histological signs of heart failure as indicated by island-like, patchy fibrosis of the heart. Planimetric quantification (PSR stain) of the heart revealed a significant increase of the total amount of fibrosis from 8+/-2% (base) to 21+/-4% (3 months) (P<0.05), which was distributed homogeneously throughout the left ventricle (20+/-3% left ventricular [LV] anterior wall, 21+/-4% LV posterior wall, 20+/-4% septum). Histologic analysis of the lung demonstrated a moderate degree of interstitial edema and pronounced peribronchial processes of inflammation with beginning proliferation of fibrotic tissue. Liver tissue showed histological changes in terms of pericentral adiposis as sign of hypoxia in course of lacking perfusion. Signs of liver congestion could be detected histological in form of central-venous accumulation of erythrocytes and dissolution of liver tissue in proximity of the central veins. Kidney preparations illustrated loss of endothelial function and vascular occlusions, caused by microspheres, with decline of renal parenchyma particularly of the tubules. CONCLUSION: Multiple sequential intracoronary microembolization can effectively induce myocardial dysfunction with histological signs of chronic ischemic cardiomyopathy and pathological changes of lung, liver and kidney, which can directly be coursed by chronic heart failure. Thus, the present model may be suitable in experimental work on heart failure and LV assist devices, e.g. for studying the impact of mechanical unloading, mechanisms of recovery and reverse remodeling.

Vaginal douching as a risk factor for cervical Chlamydia trachomatis infection.

OBJECTIVE: To evaluate the association between vaginal douching and cervical Chlamydia trachomatis infection. METHODS: We analyzed cross-sectional data from a study conducted at Group Health Cooperative of Puget Sound, a nonprofit health maintenance organization in western Washington state. Participants were nonpregnant women Group Health enrollees between the ages of 18 and 34 years who were attending two primary care clinics either for nonurgent visits, primarily routine preventive health visits, or in response to an invitation from the study. Before the clinical examination, all completed a self-administered survey assessing demographic and behavioral characteristics, including the timing, frequency, products used, and reasons for douching. Chlamydial infection was ascertained via cell culture isolation of C trachomatis from endocervical specimens obtained at the same visit. RESULTS: Chlamydia trachomatis was isolated from cervical cultures in 58 (3.4%) of 1692 study participants. Women who reported douching in the 12 months before their clinic visit had an increased likelihood of chlamydial infection compared with women who did not douche (prevalence odds ratio [OR] 2.29, 95% confidence interval [CI] 1.22, 4.30, after adjusting for confounding factors). The likelihood was higher for women who reported douching more often: OR 2.60 (95% CI 1.29, 5.24) for women who douched one to three times per month, and OR 3.84 (95% CI 1.26, 11.70) for those douching four times or more per month. These associations were slightly stronger when women who reported douching because of an infection were excluded from the analysis. CONCLUSION: These results support the hypothesis that vaginal douching predisposes to acquisition of cervical chlamydial infection and are compatible with previous studies that report associations between douching and sequelae of chlamydial infection, including pelvic inflammatory disease, ectopic pregnancy, and infertility.

Successful implementation of an evidence-based clinical practice guideline: acute dysuria/urgency in adult women.

This paper describes the development and successful implementation of an evidence-based clinical practice guideline dealing with uncomplicated urinary tract infection in adult women (acute dysuria guideline). This guideline was based on an evaluation and synthesis of the medical literature using the best available evidence. Following guideline implementation, clinical practice changes recommended by the guideline were observed, including a significant decrease in laboratory testing and clinic visits for acute dysuria. Successful implementation of this guideline is attributed to the use of an explicit, evidence-based guideline development process, a combination of implementation strategies including decision support for providers, and a change in the roles of registered nurses.

Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection.

BACKGROUND: Chlamydia trachomatis is a frequent cause of pelvic inflammatory disease. However, there is little information from clinical studies about whether screening women for cervical chlamydial infection can reduce the incidence of this serious illness. METHODS: We conducted a randomized, controlled trial to determine whether selective testing for cervical chlamydial infection prevented pelvic inflammatory disease. Women who were at high risk for disease were identified by means of a questionnaire mailed to all women enrollees in a health maintenance organization who were 18 to 34 years of age. Eligible respondents were randomly assigned to undergo testing for C. trachomatis or to receive usual care; both groups were followed for one year. Possible cases of pelvic inflammatory disease were identified through a variety of data bases and were confirmed by review of the women's medical records. We used an intention-to-screen analysis to compare the incidence of pelvic inflammatory disease in the two groups of women. RESULTS: Of the 2607 eligible women, 1009 were randomly assigned to screening and 1598 to usual care. A total of 645 women in the screening group (64 percent) for chlamydia; 7 percent tested positive and were treated. At the end of the follow-up period, there had been 9 verified cases of pelvic inflammatory disease among the women in the screening group and 33 cases among the women receiving usual care (relative risk, 0.44; 95 percent confidence interval, 0.20 to 0.90). We found similar results when we used logistic-regression analysis to control for potentially confounding variables. CONCLUSIONS: A strategy of identifying, testing, and treating women at increased risk for cervical chlamydial infection was associated with a reduced incidence of pelvic inflammatory disease.

Contraceptive methods and the risk of Chlamydia trachomatis infection in young women.

To evaluate the relation between contraceptive methods and cervical Chlamydia trachomatis infection, the authors studied a population-based sample of 1,779 nonpregnant women aged 15-34 years who underwent cell culture diagnostic testing for the detection of C. trachomatis at a health maintenance organization. Barrier contraceptive method users were classified as those who reported using one of the following methods at time of testing: condom, diaphragm, cervical cap, spermicidal sponge, foam, or vaginal spermicidal suppositories. Barrier methods were associated with a reduction in the risk of chlamydial infection in women aged 25 years or older when compared with all other women in the same age category (adjusted prevalence odds ratio = 0.15, 95% confidence interval (CI) 0.04-0.66). When compared with only noncontracepting women, the adjusted prevalence odds ratio was 0.34 (95% CI 0.06-1.99). The protective effect of barrier methods was not evident in women younger than age 25 years. Oral contraceptive use was not associated with the risk of C. trachomatis infection using either referent group; the adjusted prevalence odds ratio was 0.99 (95% CI 0.57-1.73) compared with all other women, and 0.88 (95% CI 0.44-1.79) compared with noncontracepting women. These findings suggest that present patterns of use of barrier methods differ by age and afford only selective protection against cervical C. trachomatis infections.

PIP: Chlamydia trachomatis infection is among the most prevalent of sexually transmitted diseases in young women in the US. Approximately 2.6 million women are estimated to be infected annually in the country. The authors investigated the relation between contraceptive methods and cervical Chlamydia trachomatis infection in a population-based sample of 1779 nonpregnant women aged 15-34 years attending two primary care clinics at Group Health Cooperative of Puget Sound between January 1988 and June 1989. 3.8% of the women were infected with C. trachomatis. Cervical chlamydial infection occurred more often in women younger than age 25 years, of black race, low income level, single marital status, in nulliparous women, women having douched during the preceding year, and those having two or more sexual partners in the preceding year. Overall, the risk of cervical C. trachomatis infection among barrier method users was lower than among all other women. Condoms, diaphragms, cervical caps, spermicidal sponges, foam, and vaginal spermicidal suppositories are barrier contraceptives. The greatest protective effect among barrier method users was found in women aged 25 years or older. Overall, there was no association between the use of oral contraceptives and chlamydial infection. These findings therefore suggest that present patterns of use of barrier methods differ by age and afford only selective protection against cervical infection with C. trachomatis.

Selective screening for Chlamydia trachomatis infection in a primary care population of women.

The authors used cell cultures to assess the prevalence of cervical infection caused by Chlamydia trachomatis in a population-based sample of nonpregnant women aged 15 to 34 years who attended two primary care clinics at Group Health Cooperative of Puget Sound, Seattle, Washington, between January 1, 1988, and June 30, 1989. C. trachomatis was isolated from 67 of 1,804 women (3.7%), including 13% of those who were less than 20 years of age. Seven patient characteristics were independently predictive of chlamydial infection by stepwise multivariate logistic regression analysis: being unmarried, examination showing cervical ectopy, black race, douching, nulliparity, age of 24 years or less, and intercourse with two or more partners within the preceding year. Testing all women who had a score of 5 or more (28% of women) on a weighted index based on risk factors would detect 77% of all infections with a positive predictive value of 9%. These results suggest that it should be feasible to develop a risk factor-based program to screen for cervical infection with C. trachomatis in populations where its prevalence is low.

Diuretic drug use and the risk for hip fracture.

OBJECTIVE: To test the hypothesis that use of thiazide diuretics prevents hip fracture and to study the risk for hip fracture associated with furosemide use. DESIGN: A case-control study. SETTING: Hospitals owned by a health maintenance organization in Washington. PATIENTS: Elderly patients (n = 462) hospitalized because of a hip fracture between 1977 and 1983 and an equal number of age- and sex-matched population-based control patients. MEASUREMENTS: Use of thiazide diuretics and furosemide was ascertained from medical records and computerized pharmacy records. The relative risk for hip fracture associated with diuretic use was calculated and adjusted for the potentially confounding effects of nursing home residence; previous hospitalizations; a history of stroke, alcoholism, or the organic brain syndrome; body weight; leg paralysis; and use of phenobarbital, corticosteroids, or other diuretics. Current and former users of diuretics were analyzed separately. MAIN RESULTS: The adjusted risk for hip fracture was 1.6 (95% CI, 1.0 to 2.5) for current thiazide users. The adjusted risk for hip fracture for current furosemide use was 3.9 (CI, 1.5 to 10.4). CONCLUSIONS: According to this study, use of thiazide diuretics did not protect against hip fracture and cannot be recommended for fracture prevention. Current furosemide use was also associated with hip fracture.