Rate and predictors of blood culture positivity after antibiotic administration: a prospective single-center study.

PURPOSE: Blood culture obtainment prior to antibiotic administration, in patients with suspected infection, is considered the best practice in international guidelines. However, there is little data regarding the effect of a single dose of antibiotics on blood culture sterilization. METHODS: We conducted a prospective study, enrolling consecutive patients with suspected infection, hospitalized in an internal medicine ward between December 2019 and January 2023. Included patients had a positive blood culture prior to antibiotic administration and a set of blood cultures taken within 24 h after a single dose of antibiotics. The rate of patients with pathogen isolation after antibiotic administration was assessed. Logistic regression was performed to examine factors associated with blood culture positivity. RESULTS: A total of 155 patients were recruited for the study of which 131 (50.8% female 77.5 ± 13.4 years) met the inclusion criteria. The overall rate of patients with a positive blood culture after a single dose of antibiotics was 42.0% (55/131 patients). Increasing time between antibiotic administration and post-antibiotic culture was an independent predictor for blood culture sterilization (odds ratio 0.89 [95% confidence interval, 0.83-0.97; p = 0.006] for every 60 min). Blood culture volume was an independent predictor for blood culture positivity in a sensitivity analysis which included 82 patients (OR = 1.26 [95% CI 1.03-1.57] for every 1 ml increase; p = 0.024). CONCLUSION: Blood culture positivity is reduced by antimicrobial therapy but remains high after a single dose of antibiotics. If cultures are not obtained prior to antibiotic administration, they should be obtained as soon as possible afterwards.

Lowering the upper limit of serum alanine aminotransferase levels may reveal significant liver disease in the elderly.

This study sought to determine the prevalence of significant liver disease in those subjects with serum alanine aminotransferase levels in the range between the current and the newly suggested upper limit of normal (termed the delta range). The files of the previous study subjects (who underwent at least one alanine aminotransferase measurement in 2002 and followed to 2012) were reviewed for a diagnosis of chronic liver disease; aspartate aminotransferase/platelet ratio index, FIB-4 and alanine aminotransferase/aspartate aminotransferase ratio were used to evaluate liver fibrosis. The prevalence of significant liver disease, by diagnoses and fibrosis scores was compared between subjects with alanine aminotransferase levels in the delta range (men, 42-45 IU/L; women, 26-34 IU/L) and in the newly suggested normal range (men, 15-42 IU/L; women, 10-26 IU/L). The cohort included 49,634 subjects (41% male, mean age 83±6 years) of whom 2022 were diagnosed with chronic liver disease including 366 with cirrhosis. Compared to subjects with alanine aminotransferase levels in the newly suggested normal range, subjects with alanine aminotransferase levels in the delta range had a significantly higher rate of chronic liver disease (men, 15.3% vs. 4.9%; women, 7.8% vs. 3.3%) and of cirrhosis specifically (men, 4.2% vs. 0.9%; women, 1.5% vs. 0.4%) and also had higher mean fibrosis scores (P <0.001 for all). Lowering the current upper limit of normal of serum alanine aminotransferase may help to identify elderly patients at risk of significant liver disease.

Increasing Serum Albumin Level Shortly After Gastrostomy Tube Insertion Predicts Longer Survival in Elderly Patients With Dementia.

GOAL: To identify factors influencing survival after percutaneous endoscopic gastrostomy (PEG) tube insertion in elderly patients with severe dementia. BACKGROUND: Use of PEG in patients with dementia raises medical and ethical questions. STUDY: The cohort included 189 patients aged ≥64 years with severe dementia who underwent PEG tube insertion in 2002 to 2011 at a tertiary hospital and were followed through 2014. Data were collected on background diseases, laboratory tests conducted 14 (±10) days before and 90 (±10) days after PEG, and date of death. Multivariate Cox regression analysis was performed and cumulative survival curves plotted. RESULTS: Mean baseline serum albumin level was significantly lower in patients who died ≤30 days after PEG (n=32, 16.9%) than patients who survived longer (2.9±0.5 vs. 3.3±0.5 g/dL, P<0.001), and significantly higher in patients who survived 1 year after PEG (n=96, 50.8%) than patients who died earlier (3.4±0.5 vs. 3.1±0.5 g/dL, P=0.002). No significant differences were found for the other laboratory parameters. After adjustment for background diseases, serum albumin level above the median (3.3 g/dL) was the only predictor of survival (hazard ratio 0.51; 95% confidence interval, 0.37-0.72; P<0.001). Patients with stable/increased serum albumin levels at 90 days after PEG (n=80, 42.3%) survived longer than patients with decreased levels. The only predictor of survival after adjustment for age and background diseases was a stable/increased albumin level at 90 days (hazard ratio 0.59; 95% confidence interval, 0.42-0.85; P=0.004). CONCLUSIONS: Survival after PEG tube insertion is associated with a higher serum albumin level at baseline and a stable/increased serum albumin level during follow-up.

Inter-arm blood pressure difference in hospitalized elderly patients--is it consistent?

Inter-arm blood pressure difference (IAD) is recognized as a risk factor for cardiovascular mortality. Its reproducibility in the elderly is unknown. The authors determined the prevalence and reproducibility of IAD in hospitalized elderly patients. Blood pressure was measured simultaneously in both arms on two different days in elderly individuals hospitalized in a geriatric ward. The study included 364 elderly patients (mean age, 85±5 years). Eighty-four patients (23%) had systolic IAD >10 and 62 patients (17%) had diastolic IAD >10 mm Hg. A total of 319 patients had two blood pressure measurements. Systolic and diastolic IAD remained in the same category in 203 (64%) and 231 (72%) patients, respectively. Correlations of systolic and diastolic IAD between the two measurements were poor. Consistency was not affected by age, body mass index, comorbidities, or treatment. IAD is extremely common in hospitalized elderly patients, but, because of poor consistency, its clinical significance in this population is uncertain.

Inter-arm blood pressure differences in young, healthy patients.

The prevalence and magnitude of inter-arm BP difference (IAD) in young healthy patients is not well characterized. Flight academy applicants and designated aviators undergo annual evaluation that includes blood pressure (BP) measurement on both arms. All BP measurements performed from January 1, 2012, to April 30, 2012, were recorded and IAD was calculated. Results were compared between patients in whom BP was initially measured in the right arm (group 1), those in whom BP was initially measured in the left arm (group 2), and those in whom the arm in which BP was initially measured was not recorded (group 3). A total of 877 healthy patients had BP measured during the study period. In the entire group, mean systolic BP was the same in both arms. Absolute IAD was 5.6±5.5 mm Hg for systolic and 4.7±4.5 mm Hg for diastolic BP. IAD >10 mm Hg was recorded in 111 (12.6%) and 77 (8.8%) patients for systolic and diastolic BP, respectively. IAD was the same in the 3 groups and was unrelated to age, body mass index, and heart rate, but was related to systolic BP. IAD is common in young healthy patients, is not dependent on which arm was measured first, and unrelated to age, body mass index, and heart rate.

Progression of coronary artery calcification is associated with long-term cardiovascular events in hypertensive adults.

OBJECTIVES: Coronary artery calcification (CAC) is an independent predictor of cardiovascular (CV) events in hypertensive adults. However, the additive value of serial CAC measurements for risk stratification is unclear. The aim of the present study was to find whether CAC progression predicts long-term CV events in hypertensive patients. METHODS: The study group included 210 patients (mean age 64 ± 5.6 years, 54% men), a subgroup of 544 participants in the calcification side arm of the INSIGHT (International Nifedipine Study Intervention as Goal for Hypertension Therapy). All were free of symptoms or known CV disease, had at least two CT scans 1 year apart, and had available long-term follow-up. Progression of CAC was defined as the absolute change in CAC score between maximal score during follow-up and baseline score. The endpoint was the first CV event after the last CT scan. Three categories of CAC progression were defined. Zero progression was defined as 'nonprogressors', and progression below and above the median of maximal progression were defined as 'slow progressors' and 'rapid progressors', respectively. RESULTS: During 15 years of follow-up (mean 11.4 ± 4.4), 83 patients experienced a first CV event. The rate of events was higher in rapid (29/59, 49%), and slow (36/78 46%) than in nonprogressors (18/73 25%); (P=0.005). Compared with nonprogressors, the adjusted hazard ratio for CV events was 1.91 [95% confidence interval (95% CI); 1.05-3.47] in the slow, and 2.13 (95% CI; 1.12-4.03) in the rapid progressors. CONCLUSION: In hypertensive patients, progression of CAC is associated with long-term CV events.

Relation of serum lactate dehydrogenase to coronary artery disease.

Serum lactate dehydrogenase (LDH) is known pathologic marker for a diversity of diseases, including myocardial ischemia. Strenuous and enduring physical activity can transiently induce a greater total LDH level, still within its normal range. To date, however, it has not been determined whether normal-range LDH might be inversely associated with coronary artery disease (CAD) in the low-cardiovascular-risk, physically active, adult population. We conducted a retrospective cohort analysis. A total of 5,519 healthy adults aged 34 to 86 years were followed up for a mean period of 4.2 years. The cohort incidence of CAD was 6.1% (338 cases) from 2001 to 2009. In the present cohort, greater mean LDH levels were significantly associated with a greater number of years, days/week, and minutes/week of leisure time activity (p = 0.02, p = 0.04, and p = 0.01, respectively). These associations were externally validated successfully by analysis of all 5,064 healthy participants aged ≥40 years with normal-range LDH from the 2007 to 2010 National Health and Nutrition Examination Surveys combined. For instance, the mean LDH level was significantly greater in those engaged in 6 to 7 versus 1 to 5 days/wk of vigorous-intensity work activity (138.0 ± 20.7 IU/L vs 133.3 ± 21.7 IU/L, respectively, p = 0.007). In our cohort, the hazard ratio for CAD according to the normal total serum LDH tertiles, adjusted for multiple risk and protective CAD factors in a Cox proportional hazards model, was 0.70 (95% confidence interval 0.54 to 0.92) in the greater versus lower tertile (p for trend = 0.01). In conclusion, we suggest that increased normal-range total serum LDH is associated with reduced short-term risk of CAD outcome in this low-risk, physically active population.

Relation of coronary artery calcium to cardiovascular risk in patients with combined diabetes mellitus and systemic hypertension.

Certain patients with type 2 diabetes mellitus (DM) do not have increased cardiovascular (CV) risk. The aim of the present study was to stratify hypertensive adults with DM into those with low or high CV risk according to the absence or presence of coronary artery calcium (CAC). The study group included 423 patients, a subgroup of the 544 participants in the calcification side arm of the International Nifedipine Study: Intervention as Goal for Hypertension Therapy. All underwent a baseline computed tomography scan with an unenhanced dual-detector spiral computed tomography scan for CAC measurements. All were free of CV disease and completed 3 years (short-term) of follow-up. A total of 268 patients were included in the 15-year (long-term) follow-up period. The study group was divided into 4 subgroups according to the presence or absence of DM and CAC and was analyzed for a first CV event. Of the 423 patients, 164 (39%) had DM. Cardiovascular events occurred in 41 patients during the first 3 years and in 111 of 268 patients during the long-term follow-up. The rate of CV events was greater in the patients with DM with CAC than in those without (15% vs 7% after 3 years and 52% vs 32% after 15 years). Compared to those without DM without CAC, the short-term adjusted hazard ratio for CV event in those with DM with and without CAC was 6.6 (95% confidence interval 1.4 to 30.5) and 3.9 (95% confidence interval 0.7 to 22.6), respectively. A similar trend was seen in the long-term follow-up study. In conclusion, patients with hypertension and DM can be stratified into a lower CV risk in the absence of CAC.

Coronary artery calcification predicts long-term mortality in hypertensive adults.

BACKGROUND: Coronary artery calcification (CAC) predicts mortality in normotensive individuals. We hypothesized that CAC has an impact on long-term mortality in hypertensive patients. METHODS: We followed 423 participants of the INSIGHT (International Nifedipine Study Intervention as Goal for Hypertension Therapy) calcification substudy, for the incidence of mortality as a function of CAC. All patients were hypertensive (mean age 64 ± 6 years, 48% male), without coronary artery or peripheral vascular disease, aged >55 years and with at least one more major cardiovascular (CV) risk factor. All underwent a baseline computed tomography (CT) (Dual slice) to determine the calcification score and were followed for a mean period of 14 ± 0.5 years. Mortality and the cause of death were derived from the registry of the Ministry-of-Interior Affairs. RESULTS: During the follow-up, 94 patients died; 27 from CV causes, 54 from non-CV causes and 13 of undefined causes. The prevalence of calcification at baseline was 59% (195/329) among the survivors compared to 82% (77/94) in participants who died and 96.7% (26/27) among those who died of CV causes. The incidence of CV death was 14 times higher among those with than those without CAC (9.6% (26/272) vs. 0.7% (1/151); P < 0.01). After adjusting for age, gender, left ventricular hypertrophy, proteinuria, duration of hypertension, and renal function the presence of calcification predicted all cause mortality with a hazard ratio (HR) of 1.8 (95% confidence interval (CI) 1.04-3.07). CONCLUSIONS: CAC is associated with long-term mortality in asymptomatic hypertensive adults.

Coronary calcium by spiral computed tomography predicts cardiovascular events in high-risk hypertensive patients.

OBJECTIVE: The ability of coronary artery calcium (CAC) to predict coronary events has been shown in several studies. We aimed to investigate the hypothesis that CAC as assessed by dual slice spiral computed tomography (DSCT), is an independent risk factor for cardiovascular events in hypertensive patients. METHODS: We followed 446 participants of INSIGHT (International Nifedipine Study Intervention as Goal for Hypertension Therapy) calcification study, for the incidence of cardiovascular events as a function of CAC and other factors. All were hypertensive, without coronary artery disease (CAD), ages > 55 years and with at least one more major cardiovascular risk factor. All underwent a baseline DSCT and were followed for a mean period of 3.8 +/- 0.4 years. All events were documented while the scheduled visits and confirmed by the INSIGHT critical event committee. RESULTS: Follow-up was conducted on all participants. 294 patients (66%) had CAC at baseline. Forty-seven patients experienced a first cardiovascular event: acute myocardial infarction (MI), 16; sudden cardiac death, two; unstable angina resulting in revascularization, 14; stroke, 15. The incidence of first cardiovascular events was 3.7 times higher among those who had CAC at baseline than among those who had no CAC (14.5% (41 of 294) versus 3.9% (6 of 152)). Patients who experienced an event were more likely to be males, had had higher prevalence of peripheral vascular disease, longer duration of hypertension, and had higher levels of systolic blood pressure (SBP), glucose, creatinine and uric acid. Adjusting for these covariates, CAC (total coronary calcium score (TCS) > 0) independently predicted cardiovascular events with an odds ratio (OR) of 2.76 [95% confidence interval (CI) 1.09-6.99, P = 0.032]. CONCLUSION: The presence of CAC predicts cardiovascular events in high-risk asymptomatic hypertensive patients.