Oral versus intravenous clarithromycin in moderate to severe community-acquired pneumonia:an observational study

Objectives: British Thoracic Society guidelines recommend clarithromycin in addition to beta-lactam antibiotics for patients with community-acquired pneumonia and CURB-65 score 2-5. Intravenous therapy is commonly used but there are few data on whether oral therapy is equally effective.Methods: This observational study used propensity matching to compare two groups of patients with moderate to severe community-acquired pneumonia (CURB-65 score 2-5) treated with oral (n = 226) or intravenous (n = 226) clarithromycin on admission. Outcomes were 30-day mortality, intensive care unit admission, time to clinical stability, and length of hospital stay.Results: There was no significant difference in 30-day mortality (16.8% for intravenous [IV] group vs. 14.6% for oral group, hazard ratio for IV group 1.11 95% CI 0.70-1.78), ICU admission (10.6% in both groups) or complications (10.6% for IV group and 9.3% for oral group) between the groups. The time to clinical stability in both cohorts was a median of 5 days (interquartile range 3-7 days, p = 0.3). The median length of hospital stay was 8 days in the IV group (interquartile range 4-14 days) and 7 days in the oral group (interquartile range 4-13 days), p = 0.5. No other differences were observed between oral and IV groups.Conclusion: Where the oral route is not compromised, oral macrolides appear to be equivalent to IV in treating moderate to severe CAP.</p

High morbid-mortability and reduced level of osteoporosis diagnosis among elderly people who had hip fractures in São Paulo City

OBJECTIVE: To know the morbid-mortality following an osteoporotic hip fracture in elderly patients living in São Paulo. PATIENTS AND METHODS: This study evaluated prospectively all patient over 60 years admitted in 2 school-hospitals in the city of São Paulo in a following 6-month period due to a osteoporotic proximal femur fracture. All of them filled up the Health Assessment Questionnaire (HAQ) and had their chart reviewed. After 6 months they were re-interviewed. Linear regression analysis was utilized to determine the factors related to functional ability. RESULTS: 56 patients were included (mean age 80.7 ± 7.9 years old, 80.4% females). After the 6-month follow up the mortality rate was 23.2%. Only 30% of the patients returned to their previous activities, and 11.6% became totally dependent. Factors related to worse functional ability after fracture were HAQ before fracture, institutionalization after fracture and age (r² 0.482). The diagnosis of osteoporosis was informed only by 13.9% of them, and just 11.6% received any treatment for that. CONCLUSION: Our results showed the great impact of these fractures on mortality and in the functional ability of these patients. Nevertheless, many of our physicians do not inform the patients about the diagnosis of osteoporosis and, consequently, the treatment of this condition is jeopardized.As fraturas osteoporóticas de fêmur proximal trazem graves conseqüências quanto à morbimortalidade e à qualidade de vida, mas desconhece-se este impacto no Brasil. OBJETIVO: Conhecer a morbimortalidade decorrente deste tipo de fraturas em idosos na cidade de São Paulo. MÉTODOS: Foram incluídos todos os pacientes com mais de 60 anos internados por fraturas de fêmur proximal durante seis meses, em dois hospitais de São Paulo. Os pacientes preencheram o questionário de capacidade funcional (HAQ), tiveram seu prontuário examinado e foram reavaliados após seis meses. Utilizou-se a análise de regressão linear para determinar os fatores relacionados à capacidade funcional. RESULTADOS: Cinqüenta e seis pacientes foram incluídos no estudo (80,7 ± 7,9 anos; 80,4% mulheres). A mortalidade em seis meses foi de 23,2%. Apenas 30% retornaram plenamente às suas atividades prévias e 11,6% tornaram-se completamente dependentes. Os fatores que mais bem conseguiram prever pior capacidade funcional após a fratura foram HAQ pré-fratura, institucionalização pós-fratura e idade (r² 0,482). Somente 13,9% receberam o diagnóstico de osteoporose e 11,6% iniciaram algum tratamento. CONCLUSÕES: Os resultados do presente estudo demonstram o impacto deste tipo de fraturas sobre a mortalidade e a capacidade funcional. Entretanto, a falha médica no diagnóstico e na orientação de tratamento da osteoporose permanece elevada.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaSanta Casa de Misericórdia de São Paulo Departamento de OrtopediaUNIFESP-EPM EPMUNIFESP, EPM, EPMSciEL

Environmental enrichment reduces signs of boredom in caged mink

Animals housed in impoverished cages are often labelled 'bored'. They have also been called 'apathetic' or 'depressed', particularly when profoundly inactive. However, these terms are rarely operationally defined and validated. As a negative state caused by under-stimulation, boredom should increase interest in stimuli of all kinds. Apathy (lack of interest), by contrast, should manifest as decreased interest in all stimuli, while anhedonia (loss of pleasure, a depressive symptom) should specifically decrease interest in normally rewarding stimuli. We tested the hypotheses that mink, a model carnivore, experience more boredom, depression-like apathy, or anhedonia in non-enriched (NE) cages than in complex, enriched (E) cages. We exposed 29 subjects (13 E, 16 NE) to ten stimuli categorized a priori as aversive (e.g. air puffs), rewarding (e.g. evoking chasing) or ambiguous/neutral (e.g. candles). Interest in stimuli was assessed via latencies to contact, contact durations, and durations oriented to stimuli. NE mink contacted all stimuli faster (P = 0.003) than E mink, and spent longer oriented to/in contact with them, albeit only significantly so for ambiguous ones (treatment*type P<0.013). With stimulus category removed from statistical models, interest in all stimuli was consistently higher among NE mink (P<0.0001 for all measures). NE mink also consumed more food rewards (P = 0.037). Finally, we investigated whether lying down while awake and stereotypic behaviour (both increased by NE housing) predicted these responses. Lying awake positively co-varied with certain measures of increased exploration. In contrast, stereotypic 'scrabbling' or locomotion (e.g. pacing) did not. Overall, NE mink showed no evidence of apathy or depression, but instead a heightened investigation of diverse stimuli consistent with boredom. This state was potentially indicated by spending much time lying still but awake (although this result requires replication). Boredom can thus be operationalized and assessed empirically in non-human animals. It can also be reduced by environmental enrichment

Bilateral undisplaced insufficiency neck of femur fractures associated with short-term steroid use: a case report

<p>Abstract</p> <p>Introduction</p> <p>We present an interesting and unusual case of a 61-year-old woman with bilateral, undisplaced, stress neck of femur fractures associated with short-term steroid use. Insufficiency fractures of the neck of femur without preceding trauma have been described in the literature, although bilateral involvement is infrequent. These fractures have been associated with strenuous exercise, seizures, renal osteodystrophy, fluoride treatment, long-term corticosteroid use, amenorrhoea, abnormal anatomy and osteomalacia due to nutritional and/or hormonal factors.</p> <p>Case Presentation</p> <p>The case we present differs from other published reports, in that the patient's symptoms developed acutely after only a short course of steroids and with no associated trauma or strenuous exercise. It is also the only case described where no operative intervention was required.</p> <p>Conclusion</p> <p>Our case reiterates the importance of considering insufficiency or stress fractures in high-risk patients who present with musculoskeletal pain. Institution of bone protection should also be considered in these patients. Morbidity related to delayed treatment has been well documented, so a high level of clinical suspicion is imperative.</p

The integrated care pathway reduced the number of hospital days by half: a prospective comparative study of patients with acute hip fracture

BACKGROUND: The incidence of hip fracture is expected to increase during the coming years, demanding greater resources and improved effectiveness on this group of patients. The aim of the present study was to evaluate the effectiveness of an integrated care pathway (ICP) in patients with an acute fracture of the hip. METHODS: A nonrandomized prospective study comparing a consecutive series of patients treated by the conventional pathway to a newer intervention. 112 independently living patients aged 65 years or older admitted to the hospital with a hip fracture were consecutively selected. Exclusion criteria were pathological fracture and severe cognitive impairment. An ICP was developed with the intention of creating a care path with rapid pre-operative attention, increased continuity and an accelerated training programme based on the individual patient's prerequisites and was used as a guidance for each patient's tailored care in the intervention group (N = 56) The main outcome measure was the length of hospital stay. Secondary outcomes were the amount of time from the emergency room to the ward, to surgery and to first ambulation, as well as in-hospital complications and 30-day readmission rate. RESULTS: The intervention group had a significantly shorter length of hospital stay (12.2 vs. 26.3 days; p < 0.000), a shorter time to first ambulation (41 vs. 49 h; p = 0.01), fewer pressure wounds (8 vs. 19; p = 0.02) and medical complications (5 vs. 14; p = 0.003) than the comparison group. No readmissions occurred within 30 days post-intervention in either group. CONCLUSION: Implementing an ICP for patients with a hip fracture was found to significantly reduce the length of hospital stay and improve the quality of care

Moderation of the Association between Media Exposure and Youth Smoking Onset: Race/Ethnicity, and Parent Smoking

This study of youth smoking onset aims to replicate previously published media moderation effects for race/ethnicity in a national longitudinal multiethnic sample of U.S. adolescents. Previous research has demonstrated that associations between media and smoking during adolescence are greater for Whites than Hispanics or Blacks, and for youth living in non-smoking families. In this study, changes in smoking status over 24 months were assessed among 4,511 baseline never-smokers. The incidence of smoking onset was 14.3% by 24 months with no differences by race/ethnicity. Blacks had higher exposure to movie smoking and overall television viewing compared with Whites and Hispanics. Whites responded to movie smoking regardless of parent smoking but more strongly if their parents were non-smokers. In contrast, Black adolescents showed little behavioral response to any media, regardless of parent smoking. Hispanic adolescents responded only to TV viewing and only when their parents did not smoke. In an analysis assessing the influence of the race of smoking characters on smoking behavior of White and Black adolescents, Whites responded to both White and Black movie character smoking, whereas Blacks responded only to smoking by Black movie characters. Taken as a whole, the findings replicate and extend previous findings, suggesting media factors are more influential among adolescents at low to moderate overall risk for smoking. We draw analogies between these low-moderate risk adolescents and “swing voters” in national elections, suggesting that media effects are more apt to influence an adolescent in the middle of the risk spectrum, compared with his peers at either end of it

Harmonic publication and citation counting: sharing authorship credit equitably – not equally, geometrically or arithmetically

Bibliometric counting methods need to be validated against perceived notions of authorship credit allocation, and standardized by rejecting methods with poor fit or questionable ethical implications. Harmonic counting meets these concerns by exhibiting a robust fit to previously published empirical data from medicine, psychology and chemistry, and by complying with three basic ethical criteria for the equitable sharing of authorship credit. Harmonic counting can also incorporate additional byline information about equal contribution, or the elevated status of a corresponding last author. By contrast, several previously proposed counting schemes from the bibliometric literature including arithmetic, geometric and fractional counting, do not fit the empirical data as well and do not consistently meet the ethical criteria. In conclusion, harmonic counting would seem to provide unrivalled accuracy, fairness and flexibility to the long overdue task of standardizing bibliometric allocation of publication and citation credit