Levetiracetam for Status Epilepticus in Adults: A Systematic Review.

BACKGROUND: Status epilepticus (SE) is a neurologic emergency with potential for substantial mortality and morbidity. Parenteral benzodiazepine is the established first-line treatment but fails to control SE in about one-third of patients. Levetiracetam may be used for SE that is refractory to benzodiazepine therapy. OBJECTIVE: To examine, by means of a systematic review, the role of IV levetiracetam for the treatment of SE in adults. DATA SOURCES: MEDLINE, Embase, CENTRAL, and CINAHL databases were searched, from inception to August 18, 2020. STUDY SELECTION AND DATA EXTRACTION: Included in this review were prospective randomized controlled trials comparing levetiracetam with another antiepileptic drug, given with or after a benzodiazepine, in adult patients with SE. The primary outcome was cessation of SE. Quality of evidence was assessed with the Cochrane risk-of-bias tool. Characteristics of the included studies were reported using descriptive statistics. DATA SYNTHESIS: Five studies compared IV levetiracetam with valproic acid, phenytoin (or its prodrug fosphenytoin), or both. All 5 studies found no statistically significant differences in efficacy or safety end points. There were numerically more cases of hypotension and respiratory failure with phenytoin, and more cases of psychiatric adverse effects (e.g., post-ictal psychosis) with levetiracetam. CONCLUSIONS: Available evidence suggests that levetiracetam is as effective as valproic acid or phenytoin for the cessation of SE in adults. Other factors should therefore dictate the choice of antiepileptic drug for patients with SE, such as adverse effect profile, logistics of administration, drug cost, inclusion on hospital formularies, and drug availability.

CONTEXTE: L'état de mal épileptique (EME) est une urgence neurologique qui s'accompagne d'un potentiel important de mortalité et de morbidité. La benzodiazépine parentérale est le traitement de première ligne établi, mais ne parvient pas à contrôler l'EME chez environ un tiers des patients. Le lévétiracétam peut s'utiliser pour les EME réfractaires au traitement par les benzodiazépines. OBJECTIF: Examiner, au moyen d'une revue systématique, le rôle du lévétiracétam IV pour le traitement de l'EME chez l'adulte. SOURCES DES DONNÉES: Les bases de données MEDLINE, Embase, CENTRAL et CINAHL ont fait l'objet d'une recherche, depuis leur création jusqu'au 18 août 2020. SÉLECTION DES ÉTUDES ET EXTRACTION DES DONNÉES: Cette revue comprenait des essais contrôlés randomisés prospectifs comparant le lévétiracétam à un autre médicament antiépileptique, administré avec ou après une benzodiazépine, chez des patients adultes atteints d'EME. Le critère de jugement principal était l'arrêt de l'EME. La qualité des preuves a été évaluée avec l'outil de risque de biais Cochrane. Les caractéristiques des études incluses ont été rapportées à l'aide de statistiques descriptives. SYNTHÈSE DES DONNÉES: Cinq études ont comparé le lévétiracétam IV avec l'acide valproïque, la phénytoïne (ou son promédicament, la fosphénytoïne), ou les deux. Les 5 études n'ont trouvé aucune différence statistiquement significative en termes d'efficacité ou d'innocuité. Numériquement, les cas d'hypotension et d'insuffisance respiratoire avec la phénytoïne étaient plus élevés, et les cas d'effets indésirables psychiatriques (par exemple, psychose post-critique) étaient plus élevés avec le lévétiracétam. CONCLUSIONS: Les preuves disponibles suggèrent que le lévétiracétam est aussi efficace que l'acide valproïque ou la phénytoïne pour l'arrêt de l'EME chez l'adulte. D'autres facteurs devraient donc dicter le choix du médicament antiépileptique pour les patients atteints d'EME, tels que le profil des effets indésirables, la logistique d'administration, le coût du médicament, l'inscription sur les formulaires hospitaliers et la disponibilité des médicaments.

Colchicine for Secondary Cardiovascular Prevention: A Systematic Review.

Despite advancements in medical and interventional therapy, patients with cardiovascular disease (CVD) continue to have residual risk for recurrent cardiovascular events. Colchicine has a unique antiinflammatory mechanism that has generated interest in its potential use as a secondary cardiovascular preventive therapy. The objective of this systematic review was to evaluate the evidence for long-term (6 months or more) colchicine therapy in patients with established CVD. A search of Medline and Embase from inception to February 2020 was performed. Included were randomized controlled trials (RCTs) or propensity score-matched observational studies that compared colchicine (at any dose) with placebo or no treatment. Outcomes of interest included any major adverse cardiovascular event, cardiovascular hospitalization, coronary artery restenosis, cardiovascular death, or all-cause death. Five RCTs were included. The dose of colchicine ranged from 0.5 mg/day to 0.6 mg twice/day, and follow-up ranged from ~6-36 months. Two trials (one double blind and one single blind) showed a reduction in composite outcomes of major adverse cardiovascular events. One study failed to demonstrate a benefit with colchicine in restenosis or recurrent ischemia after angioplasty; however, it was conducted before the routine use of modern percutaneous coronary intervention and medical therapies. In contrast, a more recent trial found that colchicine reduced the rate of in-stent restenosis in patients who received a bare metal stent. Finally, one trial in patients with heart failure with reduced ejection fraction did not observe a benefit in death or heart failure hospitalization with colchicine despite a reduction in inflammatory markers. No trial demonstrated a reduction in cardiovascular or all-cause death, and most trials showed an increase in the rate of diarrhea with colchicine. Overall, colchicine has demonstrated promising results for the secondary prevention of CVD; however, further studies are required to confirm these findings before colchicine can be routinely recommended in practice.

Investigation into the cleaning methods of smartphones and wearables from infectious contamination in a patient care environment (I-SWIPE).

BACKGROUND: Many health care workers are using smartphones and wearable devices without an enforced cleaning standard to prevent the spread of bacteria to patients. To our knowledge, no real-world trials have been performed to date, examining bacterial elimination on these devices in a hospital setting. The primary objective was to determine if ultraviolet wavelength C (UV-C) was more effective at eliminating bacteria on smartphones and wearable devices when compared with usual care. METHODS: This prospective before-and-after study included clinicians who used smartphones or wearable devices during their daily clinical practice. Devices underwent two 30-second UV-C disinfection cycles, at the beginning and end of clinician shifts. Swabs were collected at predetermined intervals both prior to and following a UV-C disinfection cycle to determine the extent of bacterial growth. RESULTS: Following a run-in period of twice-daily UV-C disinfection, 20% of devices grew pathogenic bacteria prior to UV-C use. Comparatively, only 4% of devices grew bacteria post-UV-C; therefore, the decrease in bacterial growth was statistically significant (P = .002). CONCLUSIONS: UV-C appears to be more effective at eliminating bacteria on smartphones and wearable devices when compared with usual care and is a useful disinfection device in a hospital setting. Further studies are needed to determine the interval at which UV-C should be used to prevent bacterial growth and spread.

Quinolone-resistant gyrase mutants demonstrate decreased susceptibility to triclosan.

Objectives: Cross-resistance between antibiotics and biocides is a potentially important driver of MDR. A relationship between susceptibility of Salmonella to quinolones and triclosan has been observed. This study aimed to: (i) investigate the mechanism underpinning this; (ii) determine whether the phenotype is conserved in Escherichia coli; and (iii) evaluate the potential for triclosan to select for quinolone resistance. Methods: WT E. coli, Salmonella enterica serovar Typhimurium and gyrA mutants were used. These were characterized by determining antimicrobial susceptibility, DNA gyrase activity and sensitivity to inhibition. Expression of stress response pathways (SOS, RpoS, RpoN and RpoH) was measured, as was the fitness of mutants. The potential for triclosan to select for quinolone resistance was determined. Results: All gyrase mutants showed increased triclosan MICs and altered supercoiling activity. There was no evidence for direct interaction between triclosan and gyrase. Identical substitutions in GyrA had different impacts on supercoiling in the two species. For both, there was a correlation between altered supercoiling and expression of stress responses. This was more marked in E. coli, where an Asp87Gly GyrA mutant demonstrated greatly increased fitness in the presence of triclosan. Exposure of parental strains to low concentrations of triclosan did not select for quinolone resistance. Conclusions: Our data suggest gyrA mutants are less susceptible to triclosan due to up-regulation of stress responses. The impact of gyrA mutation differs between E. coli and Salmonella. The impacts of gyrA mutation beyond quinolone resistance have implications for the fitness and selection of gyrA mutants in the presence of non-quinolone antimicrobials.

Improving the documentation of the daily review of patients in general intensive care.

Following the daily review of patients on the general intensive care unit (GICU), ongoing issues are addressed and a management plan formulated. Within our unit, the documentation of this daily review is freehand and should include all items covered within the local GICU daily review checklist. However, an initial audit of the daily review demonstrated an average completion rate of only 57%, with several aspects of care consistently missed, most notably: eye and mouth care in ventilated patients (44% and 40%, respectively), glucose control (33%), stress ulcer prophylaxis (54%), and inspection and need for peripheral and central lines (24%). The current system relied on doctors learning the requirements for the clerking and remembering to document them all. It is known that there is a low level of reliability in successfully applying proven medical evidence; this is partly explained by dependence on vigilance and hard work by the clinician, and absence of checklists and protocols to reduce the impact of human factors on results. The majority of doctors on the unit believe they consistently record all items of this checklist, highlighting the gap between the ideal that clinicians strive towards and the outcome. An abbreviated daily review checklist was therefore implemented in the form of a laminated bookmark into the medical notes, to act as a reminder of the items that should be considered in the daily review and prompt subsequent documentation. Bookmarks were implemented over two PDSA cycles and medical notes re-audited. Post-intervention, the documentation of the daily review improved to an overall completion rate of >77%, with notable improvements in eye and mouth care in ventilated patients (89%, 95% respectively), glucose control (67%), stress ulcer prophylaxis (100%), and inspection and need for peripheral and central lines (43%). The daily review checklist concisely summarised onto bookmarks were cheap and simple to create, durable and easy to use, and improved the overall documentation of the daily review. The effect of this outcome remains untested.

What stops children with a chronic illness accessing health care: a mixed methods study in children with Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME).

BACKGROUND: Paediatric Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) is relatively common and disabling with a mean time out of school of more than one academic year. NICE guidelines recommend referral to specialist services immediately if severely affected, within 3 months if moderately affected and within 6 months if mildly affected. However, the median time-to-assessment by a specialist service in the UK is 18 months. This study used a mixed-methods approach to examine factors associated with time taken to access specialist services. METHODS: Time-to-assessment was analysed as a continuous "survival-time" variable in Cox regression models using data from self-completed assessment forms for children attending a regional specialist CFS/ME service between January 2006 and December 2009. Semi-structured interviews about barriers experienced in accessing healthcare for their child were conducted with nine parents of children aged < 17 years (8 individual and one parent couple). Interviews were digitally recorded and analysed using "thematic analysis". RESULTS: 405 children were assessed between 2006 and 2009 and information on school attendance was available on 388. Only 1/125 with severe CFS/ME and 49/263 (19%) with mild to moderate CFS/ME were seen within NICE recommended timeframe. Increased fatigue was associated with shorter time to assessment (HR = 1.15; 95% CI 1.03, 1.29 per unit increase in Chalder fatigue score; P = 0.01). Time-to-assessment was not associated with disability, mood, age or gender. Parents described difficulties accessing specialist services because of their own as well as their GP's and Paediatrician's lack of knowledge. They experienced negative attitudes and beliefs towards the child's condition when they consulted GPs, Paediatricians and Child Psychiatrists. Parents struggled to communicate an invisible illness that their child and not themselves were experiencing. CONCLUSIONS: GPs, Child Psychiatrists and Paediatricians need more knowledge about CFS/ME and the appropriate referral pathways to ensure timeliness in referral to specialist services.