Background Sepsis is a leading cause of morbidity, mortality, and health care costs worldwide. Methods We conducted a multi-center, prospective cohort study evaluating the yield of blood cultures drawn before and after empiric antimicrobial administration among adults presenting to the emergency department with severe manifestations of sepsis (ClinicalTrials.gov: NCT01867905). Enrolled patients who had the requisite blood cultures drawn were followed for 90 days. We explored the independent association between blood culture positivity and its time to positivity in relation to 90-day mortality. Findings 325 participants were enrolled; 90-day mortality among the 315 subjects followed-up was 25·4% (80/315). Mortality was associated with age (mean age in those who died was 72·5 ±15·8 vs. 62·9 ±17·7 years among survivors, p<0·0001), greater Charlson Comorbidity Index (2 (IQR 1,3) vs. 1 (IQR 0,3), p=0·008), dementia (13/80 (16·2%) vs. 18/235 (7·7%), p=0·03), cancer (27/80 (33·8%) vs. 47/235 (20·0%), p=0·015), positive qSOFA score (57/80 (71·2%) vs. 129/235 (54·9%), p=0·009), and normal white blood cell counts (25/80 (31·2%) vs. 42/235 (17·9%), p=0·02). The presence of bacteremia, persistent bacteremia after antimicrobial infusion, and shorter time to blood culture positivity were not associated with mortality. Neither the source of infection nor pathogen affected mortality. Interpretation Although severe sepsis is an inflammatory condition triggered by infection, its 90-day survival is not influenced by blood culture positivity nor its time to positivity. Funding Vancouver Coastal Health; St-Paul’s Hospital Foundation Emergency Department Support Fund; the Fonds de Recherche Santé – Québec (CPY); Intramural Research Program of the NIH, Clinical Center (AL); the Maricopa Medical Foundation
SummaryBackgroundPatients with cirrhosis are at risk of developing cirrhotic cardiomyopathy. This syndrome is unique to cirrhosis and is generally defined as subnormal cardiac function in the absence of prior heart disease. There is no systematic or comprehensive review of cirrhotic cardiomyopathy to date.AimsTo comprehensively review the literature on the definition, pathogenic mechanisms, diagnostic criteria, prevalence, management and influence on liver transplantation including reversibility of cirrhotic cardiomyopathy.MethodsElectronic searches of the EMBASE, MEDLINE, EBM Reviews—Cochrane Central Register of Controlled Trials, EBM Reviews—Cochrane Database of Systematic Reviews and Google Scholar databases were conducted. MeSH terms focused on cirrhosis, cardiomyopathy, medication classes and epidemiology. Literature up to August 2020 was reviewed.ResultsNew diagnostic criteria for the definition of cirrhotic cardiomyopathy have recently been published, consisting of systolic and diastolic dysfunction parameters as assessed by echocardiographic methods. The roles of electrocardiographic disturbances and biomarkers in the definition criteria remain unclear. Pathogenic mechanisms underlying cirrhotic cardiomyopathy are likely related to the inflammatory phenotype of cirrhosis. Prevalence rates of 26%‐81% in cirrhotic patients are reported. Several medical therapies have been proposed, but none with clear evidence of efficacy. The presence of cirrhotic cardiomyopathy complicates the liver transplantation process with a higher risk of adverse cardiovascular events post‐transplant. Complete reversibility of the syndrome after transplantation remains controversial but most studies suggest that it does not occur at least within the first post‐operative year.ConclusionsCirrhotic cardiomyopathy is a clinically relevant syndrome that affects morbidity and mortality in patients with cirrhosis.
Background Of all microbiological tests performed, blood cultures have the most impact on patient care. Timely results are essential, especially in the management of sepsis. While there are multiple available blood culture systems on the market, they have never been compared in a prospective study in a critically ill population. Methods We performed an analysis of the FABLED study cohort to compare culture results and time to positivity (TTP) of two widely used blood culture systems: BacT/Alert and BACTEC. In this multi-site prospective study, patients with severe manifestations of sepsis had cultures drawn prior to antibiotics using systematic enrolment criteria and blood drawing methodology allowing for minimization of pre-analytical biases. Results We enrolled 315 patients; 144 had blood cultures (47 positive) with BacT/Alert, and 171 with BACTEC (53 positive). Patients whose blood cultures were processed using the BacT/Alert system were younger (median 64 vs 70 years, p=0.003), had a higher proportion of HIV (9.03% vs 1.75% p=0.008), and a lower qSOFA (p=0.003). There were no statistically significant differences in the most commonly identified bacterial species. TTP was faster for BACTEC (median 12.5 hours, IQR 10-14) compared to BacT/Alert (median 17 hours, IQR 14-21) (p&0.0001). Conclusion This is the only large-scale study comparing the two blood culture systems in a prospective manner, on patients with severe manifestations of sepsis, and using a rigorous pre-analytical methodology. The BACTEC system provided culture results 4.5 hours earlier than BacT/Alert. More research is needed to determine the clinical importance of this finding.
Background. Colonoscopy is widely used for the diagnosis and management of colorectal disease and requires adequate bowel preparation. Ischemic colitis is a form of intestinal ischemia that presents with abdominal pain, diarrhea, and hematochezia. Risk factors include advanced age, cardiovascular disease, and diabetes. Both colonoscopy and bisacodyl bowel preparation have been described as rare causes of ischemic colitis with less than 35 cases collectively in the literature. Our review found that of these cases, there exists significant heterogeneity within individual patient characteristics. The majority of the cases are managed conservatively without complications or sequela. Due to the risk of ischemic colitis, the FDA has withdrawn bisacodyl bowel preparations from use in the USA. Bisacodyl bowel preparations are still used in Canada. Cases. Here, we present two cases of ischemic colitis in previously healthy women aged 57 and 69 who underwent screening colonoscopy using bisacodyl bowel preparation. Both were treated conservatively without complications. Conclusion. Thus far, there has been one documented case of ischemic colitis following colonoscopy with bisacodyl bowel preparation; here, we present two additional cases with one case occurring without the presence of known risk factors for ischemic colitis. Our literature review finds that there is limited evidence surrounding bisacodyl as a causative agent of ischemic colitis. Cases often contain confounding variables such as the presence of known risk factors for ischemic colitis. Our report aims to highlight the need for a more comprehensive analysis evaluating the safety of bowel preparations as well as increasing the clinical awareness surrounding the rare risk of colonoscopy-induced ischemic colitis.
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