Study design: Prospective, randomized, open-blinded-endpoint trial.
Setting: Forty-nine UK National Institute for Health Research Stroke Centers.
Synopsis: From January 2003 and March 2009, 763 patients with pre-existing hypertension and diagnosis of mild to moderate acute stroke were recruited and assigned to continue or stop antihypertension drugs. The time limit for inclusion into the study was within 48 hours of the stroke and the endpoint was death or dependency (modified Rankin Scale >3) at the end of two weeks.
There was a statistically significant difference in the two groups at two weeks in both systolic and diastolic pressures, 13 mmHg and 8mmHg, respectively (P<0.0001). Seventy-two of 379 patients in the continuation group and 82 of 384 patients in the stop group reached the primary endpoint (P=0.3). The latter point is a major limitation to this trial, since it was underpowered because of early termination to detect differences in outcomes.
Bottom line: Antihypertensive therapy during the immediate post-stroke period did not reduce two-week death or dependency, cardiovascular event rate, or mortality at six months.
Citation: Robinson TG, Potter JF, Ford GA, et al. Effects of antihypertensive treatment after acute stroke in the continue or stop post-stroke antihypertensives collaborative study (COSSACS): a prospective, randomized, open, blinded-endpoint trial. Lancet Neurol. 2010;9:767-775.
All Lumens from Multi-Lumen Catheters Should Be Cultured to Diagnose Catheter-Related Bloodstream Infections
Clinical question: Do all lumens from multi-lumen catheters need to be cultured to best diagnose catheter-related bloodstream infections (CRBSIs)?
Background: The recent Infectious Diseases Society of America’s “Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infections” has not conclusively established the number of lumens to culture from multi-lumen catheters when attempting to diagnose CRBSIs.
Study design: Retrospective cohort study.
Setting: Large teaching institution in Spain.
Synopsis: From January 2003 until May 2009, 154 patients, mostly men, with a mean age of 58.1 years, were recruited to participate in the study. Of these, 171 episodes of proven CRBSIs were detected in 154 subjects. Of the 171 tested catheters (112 double lumen and 59 triple lumen), testing only one lumen from double catheters would have led to 27.2% of missed cases for CRBSIs. Additionally, testing only two or one lumen from triple lumen catheters would have led to 15.8% and 37.3% of missed cases for CRBSIs, respectively.
The study was limited by being conducted at a single test site and the need to withdraw catheters to perform endoluminal brushing and semi-quantitative techniques. Though diagnostic yield might significantly improve by culturing all multi-lumen sites, hospitalists should consider the time and cost expenditure for testing from more than one lumen.
Bottom line: Culturing all lumens from multi-lumen catheters could greatly increase diagnostic yield in CRBSIs.
Citation: Guembe M, Rodríguez-Créixems M, Sánchez-Carrillo C, Pérez-Parra A, Martín-Rabadán P, Bouza E. How many lumens should be cultured in the conservative diagnosis of catheter-related bloodstream infections? CID. 2010;50(12):1575-1579.
Early Anticoagulation Improves Survival after Acute PE
Clinical question: Does the timing of initial heparinization reduce mortality in patients with acute symptomatic PE?