University-based Tertiary Hospital Research Articles

Absence of Association Between TNF α Polymorphysm and Cerebral Large Vessel Abnormalities in Adults with Sickle Cell Anemia

Purpose: Stroke is a common and serious complication of sickle cell disease (SCD) affecting children as well as adults. Recent reports suggested that promoter region polymorphism in the tumour necrosis factor alpha (TNF-α) gene at position −308 is an important risk factor for large vessel stroke in children with SCD. The role of TNF-α polymorphism in the frequency of magnetic resonance angiography (MRA) abnormalities in adults with SCD is still uncertain. Our objective was to evaluate TNF-α polymorphism in adults with SCD from a tertiary University-based hospital in Sao Paulo, Brazil and correlate them to brain magnetic resonance imaging (MRI) and MRA findings.Casuistic and Methods: The determination of the G-308A polymorphism of the TNF-α gene was performed in forty-nine adult patients with SCD followed in our outpatient clinic. All subjects were evaluated with brain MRI and MRA to determine the presence of previous stroke, arterial tortuosity and intracranial stenosisResults: Thirty-three patients (67.3%) had abnormal brain MRA scans (intracranial stenosis or arterial tortuosity). Eight patients (16.3%) had intracranial stenosis on MRA and 29 (59.2%) showed arterial tortuosity. Forty one patients (83.7%) had the GG TNF-α (−308) genotype and eight had the GA genotype. There were no cases of AA genotype. There was no correlation between homozygosis for the TNF-α (−308) G allele and MRA abnormalities.Conclusion: Although TNF-α (−308) polymorphism has been considered a potential predictor of genetic risk for stroke in children with SCA, we found no association between the polymorphism and large vessel abnormalities in adults with sickle cell disease. (FAPESP: 04/04498-4)

Vancomycin Concentrations in Necrotic Pancreatic Tissue: A Pilot Study

Purpose: To determine vancomycin concentrations in necrotic pancreatic tissue of intensive care unit (ICU) patients with acute necrotizing pancreatitis. Methods: The prospective, observational pilot study was conducted at a university-based tertiary hospital. The patient population consisted of 11 patients with necrotizing pancreatitis receiving vancomycin and undergoing necrosectomy. Tissue samples taken during surgical debridement were assayed for vancomycin by immunoassay. Patients were divided into steady state and nonsteady-state groups. Two patients were excluded because necrosectomy was not performed, and one tissue sample could not be assayed because of contamination. Results: The mean tissue concentration was 5.84 mcg/mL (ranging from 3.1 mcg/mL to 8.94 mcg/mL). Four patients in the nonsteady-state group, who each received a single dose of vancomycin, had a mean tissue concentration of 4.5 ± 1.68 mcg/mL, compared with 7.76 ± 1.05 mcg/mL for the four steady-state patients. Conclusion: The data shows that vancomycin is detectable in necrotic pancreas tissue but possibly not in concentrations sufficient to prevent or treat bacterial contamination in patients with pancreatic necrosis.

Physicians’ recommendations to patients for use of antibiotic prophylaxis to prevent endocarditis

The American Heart Association recommendations for infectious endocarditis (IE) prophylaxis, published in June 1997, sought to improve patient and physician compliance by simplifying the dosing regimen and clarifying endocarditis risk. (Ophthalmic procedures were not addressed in this 1997 document but are not generally considered to require prophylaxis). Adherence to these updated recommendations in patients with echocardiographic verification of their endocarditis risk profile is unknown. The authors sought to determine the recommended and actual use of IE prophylaxis as reported by patients undergoing echocardiography. All patients who underwent outpatient transthoracic echocardiography at a university-based tertiary hospital in Boston during December 1997 were contacted 6 to 9 months later to respond to a survey, completed by 218 (80%) eligible subjects. One hundred eight patients (49.5%) had clinical or echocardiographic findings for which prophylaxis was indicated. Of these 108 patients, 71 (65.7%) reported that they were instructed to take IE prophylaxis. Sixteen high-risk patients (88.9%) but only 55 moderate-risk patients (61.1%) reported that they were instructed to take prophylaxis. Among the 110 negligible-risk patients, 29 (26.4%) reported that they had been instructed to take IE prophylaxis. Overall, 100 patients (45.9%) reported that they received physician instructions to take IE prophylaxis. Of those who subsequently underwent a procedure for which IE prophylaxis was indicated (n = 68), 9 (13.2%) elected not to follow their physician’s advice to take prophylaxis. The authors conclude that although most patients reported receiving instructions for IE prophylaxis use consistent with American Heart Association guidelines, IE prophylaxis overuse among negligible-risk patients and underuse among moderate-risk patients was common. Continued physician and patient education may lead to improved adherence to the current American Heart Association recommendations.—Thomas J. Liesegang

Physicians' recommendations to patients for use of antibiotic prophylaxis to prevent endocarditis.

The American Heart Association recommendations for infectious endocarditis (IE) prophylaxis, published in June 1997, sought to improve patient and physician compliance by simplifying the dosing regimen and clarifying endocarditis risk. Adherence to these updated recommendations in patients with echocardiographic verification of their endocarditis risk profile is unknown. To determine the recommended and actual use of IE prophylaxis as reported by patients undergoing echocardiography. All patients who underwent outpatient transthoracic echocardiography at a university-based tertiary hospital in Boston, Mass, during December 1997 were contacted 6 to 9 months later to respond to a survey, completed by 218 (80%) eligible subjects. Patients' report of their physicians' instructions on actual use of IE prophylaxis in accordance with patient risk category, determined by echocardiographic data. One hundred eight patients (49.5%) had clinical or echocardiographic findings for which prophylaxis was indicated. Of these 108 patients, 71 (65.7%) reported that they were instructed to take IE prophylaxis. Sixteen high-risk patients (88. 9%) but only 55 moderate-risk patients (61.1%) reported that they were instructed to take prophylaxis. Among the 110 negligible-risk patients, 29 (26.4%) reported that they had been instructed to take IE prophylaxis. Overall, 100 patients (45.9%) reported that they received physician instructions to take IE prophylaxis. Of those who subsequently underwent a procedure for which IE prophylaxis was indicated (n=68), 9 (13.2%) elected not to follow their physician's advice to take prophylaxis. We found that although most patients reported receiving instructions for IE prophylaxis use consistent with American Heart Association guidelines, IE prophylaxis overuse among negligible-risk patients and underuse among moderate-risk patients was common. Continued physician and patient education may lead to improved adherence to the current American Heart Association recommendations. JAMA. 2000;284:68-71