Prognostic value and diagnostic properties of the diastolic pulmonary pressure gradient in patients with pulmonary hypertension and left heart disease.

BACKGROUND: The use of the diastolic pressure gradient (DPG) for the diagnosis of combined post- and pre-capillary pulmonary hypertension (Cpc-PH) versus isolated post-capillary pulmonary hypertension (Ipc-PH) in patients with PH due to left heart disease (PH-LHD) remains controversial. We studied the incremental prognostic information provided by DPG and potential sources of disagreements between different hemodynamic criteria for Cpc-PH. METHODS: We studied 393 patients with PH-LHD who underwent right heart catheterization and were followed for hospitalizations and all-cause mortality for a median of 53 months. Patients were classified into Ipc-PH or Cpc-PH using DPG, pulmonary vascular resistance (PVR) or transpulmonary gradient (TPG)-based criteria. RESULTS: Classifying PH categories according to DPG alone was not associated with a significant difference in clinical outcomes between patients with Ipc-PH and Cpc-PH (P = 0.17). By contrast, PVR criteria alone were associated with a strong prognostic separation between Ipc-PH and Cpc-PH (P = 0.005). Adding DPG to the PVR-based classification contributed no additional prognostic information. Classifying PH using the cutoff of DPG >7 mmHg or TPG >15 mmHg, resulted in an almost perfect agreement (κ statistic 0.87; 93.4% agreement). However, in cases of disagreement, occurring with low or negative DPG values, the TPG-based classification was more likely to be correct. CONCLUSION: The DPG does not add incremental prognostic information beyond PVR. Using DPG/PVR criteria to differentiate between Ipc-PH and Cpc-PH is equivalent to using TPG/PVR criteria with a TPG threshold >15 mmHg. However, the use of DPG for diagnostic purposes may lead to misclassification of PH when DPG is low or negative.

Trimethoprim-sulfamethoxazole vs. colistin or ampicillin-sulbactam for the treatment of carbapenem-resistant Acinetobacter baumannii: A retrospective matched cohort study.

OBJECTIVES: This study aimed to assess the effectiveness of trimethoprim-sulfamethoxazole (TMP/SMX) as monotherapy for the treatment of carbapenem-resistant Acinobacter baumannii (A. baumannii) (CRAB) infections. METHODS: This retrospective cohort study included patients receiving TMP/SMX as the main treatment for severe infections caused by CRAB, who were matched with patients treated with colistin or ampicillin-sulbactam (AMP/SUL) by age, Charlson score, department, and source of infection. Outcomes were compared among all patients and in a subgroup of propensity-score (PS) matched patients. The PS matching was performed using a match tolerance of 0.15 with replacement. RESULTS: Fifty-three patients treated with TMP/SMX and 83 matched patients treated with colistin or AMP/SUL were included. Variables that were independently significantly associated with TMP/SMX treatment included admission for infection and septic shock, while abnormal cognition on admission and intensive care unit admission were associated with colistin or AMP/SUL treatment. All-cause 30-day mortality was lower with TMP/SMX compared with the comparator antibiotics among all patients (24.5%, 13 of 53 vs. 38.6%, 32 of 83, P=0.09) and in the PS-matched subgroup (29%, 9 of 31 vs. 55.2% 16 of 29, P=0.04). Treatment failure rates were not significantly different overall (34%, 18 of 53 vs. 42.4%, 35 of 83, P=0.339) and in the PS-matched subgroup (35.5%, 11 of 31 vs. 44.8%, 13 of 29, P=0.46). Time to clinical stability and hospitalization duration were significantly shorter with TMP/SMX. Patients treated with TMP/SMX probably had less severe infections than those treated with other antibiotics, even after matching. CONCLUSIONS: TMP/SMX might be a valuable treatment option for TMP/SMX-susceptible CRAB infections. Given the very limited available treatment options, further studies assessing its effectiveness and safety are necessary.