Uropathogen resistance complicates cystitis treatment
CYSTITIS treatment in adults is becoming increasingly difficult as uropathogens develop antibacterial resistance, a review published in JAMA has found. The authors included 27 clinical trials, 11 observational studies and six systematic reviews published to July 2014, which included more than 250 000 patients, in their assessment of the diagnosis and management of urinary tract infections (UTIs). Trimethoprim–sulfamethoxazole, nitrofurantoin and fosfomycin were all found to be appropriate first-line therapies for uncomplicated cystitis. The authors wrote that β-lactam agents such as amoxicillin–clavulanate were not as successful as empirical first-line therapies and that fluoroquinolones, while effective for clinical outcomes, “should be reserved for more invasive infections” The rate of resistance among Escherichia coli to fluoroquinolones was high and increasing, the authors wrote. They also found significant gaps in existing research on UTI treatment, with issues such as treatment for women with diabetes needing investigation. The authors wrote that while antibacterial resistance among uropathogens was rising, telephone management without an office visit was still an efficient approach for most women with uncomplicated cystitis. However, individualised assessment of possible risk factors for resistance was required, along with educating patients on the “need for reevaluation and urine culture if symptoms do not improve”, the authors wrote.

AAA surgical repair more risky in “real world”
MORTALITY rates in trials that compare open and endovascular repair of abdominal aortic aneurysms (AAA) may not be applicable to real-world surgical practice, research published in JAMA Surgery has found. The study compared the number of patient deaths recorded in the Open Vs Endovascular Repair (OVER) Veterans Affairs Cooperative randomised clinical trial (RCT), with deaths among 21 115 patients who had either endovascular or open repair surgery between 2005 and 2012 drawn from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Mortality rates within 30 days of surgery were higher in the NSQIP cohort than the OVER trial for both open and endovascular repair, which the authors wrote was due to the OVER trial’s exclusion of high-risk patients. Among the NSQIP cohort there was a 70% reduction in operative mortality after endovascular repair surgery compared with open repair. While increasing numbers of patients were offered endovascular repair surgery over the study period, there was no significant decrease in perioperative mortality. The authors said that this study supported “the need for individualized assessment of risk and treatment selection for patients with infrarenal AAA”.

Collaboration key to improving delivery room outcomes
A PROSPECTIVE pre–post intervention study of neonatal resuscitation practice has found collaboration between hospitals results in larger improvements to delivery room outcomes than individual efforts or non-participation. The research, published in Pediatrics, compared the outcomes and processes of 20 collaborative, 31 individual and 44 non-participant hospitals caring for 12 528 infants. The collaborative hospitals applied a collaborative quality improvement (QI) model, which brought together teams from different institutions and provided structured learning through face-to-face meetings, webcasts, electronic mailing lists and data sharing. The collaborative and individual groups participated in QI activities, which focused on reducing hypothermia and the need for invasive ventilatory support. Analysis showed a statistically significant reduction in the prevalence of hypothermia in each group from baseline to post-intervention; however, the collaborative hospitals had the largest and most statistically significant decrease, from 39% at baseline to 21% post-intervention (P < 0.001), compared with individual hospitals, where it dropped from 38% to 33% (P < 0.05), and non-participants, where it fell from 42% to 34% (P < 0.05).  Collaborative approaches were also associated with a greater decrease in delivery room intubation and surfactant administration, the authors wrote. They said that the sharing of information between the collaborative hospitals led to “measurable gains in outcomes” compared with sites that implemented a similar package but did not interact with other sites. The authors wrote that the collaborative model helped develop a community of practice, where hospitals were able to learn and adapt from the experience of teams in similar organisations, which led to better delivery room outcomes.

Hypertension targets being missed
GOALS for reducing the prevalence and improving the treatment of hypertension are not being achieved, according to an analysis published in Circulation. The goals, outlined in US health program Healthy People 2020, were assessed using data from the National Health and Nutrition Examination Surveys (NHANES) 1999‒2012. The study found prevalent hypertension varied within a narrow range of 30.1%–30.8% in the period, which was above the Healthy People 2020 target of 26.9%. The proportion of people with hypertension who were being treated rose from 59.8% to 74.7% and the proportion of treated adults whose hypertension was controlled rose from 53.3% to 68.9%. However, the goal to control high BP in 61.2% of all affected adults was not achieved, with this proportion reaching only 51.2% by 2011‒2012. Obesity, lack of access to health insurance and infrequent health care visits were associated with untreated hypertension, while treatment for hypercholesterolaemia, health insurance and more frequent health care visits were associated with controlled hypertension. Ongoing efforts, including encouraging more frequent health care visits, would “emerge as potentially useful solutions to reducing these critical gaps and attaining the Healthy People 2020 hypertension control goal”.

Link between bariatric surgery and severe headaches
BARIATRIC surgery is a potential risk factor for spontaneous intracranial hypotension, a study published in Neurology has found. The 10-year study compared 338 patients with spontaneous intracranial hypotension with a control group of 245 patients with unruptured intracranial aneurysms. Medical record data was used to assess which patients had a history of bariatric surgery. Eleven of the patients with spontaneous intracranial hypotension (3.3%) had a history of bariatric surgery, compared with two patients in the control group (0.8%) (P = 0.02). The study found that the time interval from bariatric surgery to the onset of severe headaches averaged 56.5 months. The authors wrote that although the mechanism which linked bariatric surgery to severe headaches remained unclear, there were several lines of evidence that explained the connection. For example, in previous studies, cerebrospinal fluid (CSF) pressure in obese patients was found to be chronically elevated, which resulted in a higher risk of spontaneous cerebrospinal fluid leakage. “Thus, the relationship of weight loss surgery and spontaneous intracranial hypotension can at least partially be explained mechanistically by the effect of weight loss on CSF pressure”, they wrote, saying further study was needed to find ways to prevent severe headache after bariatric surgery.

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