Transcript surgical site infection - 埼玉医科大学総合医療センター 内分泌・糖尿病

Journal Club
Sussman JB, Kerr EA, Saini SD, Holleman RG, Klamerus ML, Min LC, Vijan S, Hofer
TP.
Rates of Deintensification of Blood Pressure and Glycemic Medication Treatment
Based on Levels of Control and Life Expectancy in Older Patients With Diabetes
Mellitus.
JAMA Intern Med. 2015 Oct 26:1-8. doi: 10.1001/jamainternmed.2015.5110.
Martin ET, Kaye KS, Knott C, Nguyen H, Santarossa M, Evans R, Bertran E, Jaber L.
Diabetes and Risk of Surgical Site Infection: A Systematic Review and Meta-analysis.
Infect Control Hosp Epidemiol. 2015 Oct 27:1-12.
2015年11月5日 8:30-8:55
８階 医局
埼玉医科大学 総合医療センター 内分泌・糖尿病内科
Department of Endocrinology and Diabetes,
Saitama Medical Center, Saitama Medical University
松田 昌文
Matsuda, Masafumi
1Department
of Veterans Affairs Center for Clinical Management Research, Ann
Arbor, Michigan
2Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
3Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor
JAMA Intern Med. Published online October 26, 2015. doi:10.1001/jamainternmed.2015.5110
Importance Older patients with diabetes mellitus
receiving medical treatment whose blood
pressure (BP) or blood glucose level are
potentially dangerously low are rarely
deintensified. Given the established risks of low
blood pressure and blood glucose, this is a major
opportunity to decrease medication harm.
Objective To examine the rate of BP- and blood
glucose–lowering medicine deintensification
among older patients with type 1 or 2 diabetes
mellitus who potentially receive overtreatment.
Design, Setting, and Participants Retrospective cohort study
conducted using data from the US Veterans Health Administration.
Participants included 211 667 patients older than 70 years with diabetes
mellitus who were receiving active treatment (defined as BP-lowering
medications other than angiotensin-converting enzyme inhibitors or
angiotensin receptor blockers, or glucose-lowering medications other
than metformin hydrochloride) from January 1 to December 31, 2012.
Data analysis was performed December 10, 2013, to July 20, 2015.
Exposures Participants were eligible for deintensification of treatment if
they had low BP or a low hemoglobin A1c (HbA1c) level in their last
measurement in 2012. We defined very low BP as less than 120/65
mm Hg, moderately low as systolic BP of 120 to 129 mm Hg or diastolic
BP (DBP) less than 65 mm Hg, very low HbA1c as less than 6.0%, and
moderately low HbA1c as 6.0% to 6.4%. All other values were not
considered low.
Main Outcomes and Measures Medication deintensification, defined
as discontinuation or dosage decrease within 6 months after the index
measurement.
Figure 3. Predicted Probability of Deintensification by Baseline Blood Pressure
(BP) and Hemoglobin A1c (HbA1c) Levels and Life Expectancy
Error bars indicate 95%CI.
Figure 3. Predicted Probability of Deintensification by Baseline Blood Pressure
(BP) and Hemoglobin A1c (HbA1c) Levels and Life Expectancy
Error bars indicate 95%CI.
Solid line with arrowhead
indicates standard vascular risk
control strategy. Dashed lines with
arrowheads indicate possible
vascular risk control strategies for
robust and vulnerable patients,
with question marks pointing out
the need for a choice. Gray box
presents the proposed approach
for vulnerable individuals. HbA1c
indicates hemoglobin A1c; RCTs,
randomized clinical trials; SBP,
systolic blood pressure; and
T2DM, type 2 diabetes mellitus.
To convert HbA1c to a proportion
of total hemoglobin, multiply by
0.01.
JAMA Intern Med. Published online October 26, 2015. doi:10.1001/jamainternmed.2015.5941
Results The actively treated BP cohort included 211 667
participants, more than half of whom had moderately or very low
BP levels. Of 104 486 patients with BP levels that were not low,
treatment in 15.1% was deintensified. Of 25 955 patients with
moderately low BP levels, treatment in 16.0% was deintensified.
Among 81 226 patients with very low BP levels, 18.8% underwent
BP medication deintensification. Of patients with very low BP
levels whose treatment was not deintensified, only 0.2% had a
follow-up BP measurement that was elevated (BP ≥140/90
mm Hg). The actively treated HbA1c cohort included 179 991
participants. Of 143 305 patients with HbA1c levels that were not
low, treatment in 17.5% was deintensified. Of 23 769 patients with
moderately low HbA1c levels, treatment in 20.9% was
deintensified. Among 12 917 patients with very low HbA1c levels,
27.0% underwent medication deintensification. Of patients with
very low HbA1c levels whose treatment was not deintensified,
fewer than 0.8% had a follow-up HbA1c measurement that was
elevated (≥7.5%).
Conclusions and Relevance Among older
patients whose treatment resulted in very low
levels of HbA1c or BP, 27% or fewer underwent
deintensification, representing a lost opportunity
to reduce overtreatment. Low HbA1c or BP
values or low life expectancy had little association
with deintensification events. Practice guidelines
and performance measures should place more
focus on reducing overtreatment through
deintensification.
Message
血糖の強化療法を緩和するという論文がついに
出てきた！
“Disintensification!”
そのうち糖尿病の専門家の言うことはほとんど
一般開業医には受け入れられなくなるかもしれ
ない。
1 Department
of Epidemiology, University of Michigan School of Public Health,
Ann Arbor, Michigan
2 Division of Infectious Diseases, Wayne State University and Detroit Medical
Center, Detroit, Michigan
3 Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy
and Health Sciences, Wayne State University, Detroit, Michigan
Infect Control Hosp Epidemiol. 2015 Oct 27:1-12. DOI: http://dx.doi.org/10.1017/ice.2015.249
OBJECTIVE To determine the independent
association between diabetes and surgical
site infection (SSI) across multiple surgical
procedures.
DESIGN Systematic review and meta-analysis.
METHODS Studies indexed in PubMed published
between December 1985 and through July 2015 were
identified through the search terms “risk factors” or
“glucose” and “surgical site infection.” A total of 3,631
abstracts were identified through the initial search terms.
Full texts were reviewed for 522 articles. Of these, 94
articles met the criteria for inclusion. Standardized data
collection forms were used to extract study-specific
estimates for diabetes, blood glucose levels, and body
mass index (BMI). A random-effects meta-analysis was
used to generate pooled estimates, and meta-regression
was used to evaluate specific hypothesized sources of
heterogeneity.
figure 2. Meta-analysis of diabetes and surgical site infection, by surgery type.
figure 2. Meta-analysis of diabetes and surgical site infection, by surgery type.
figure 2. Meta-analysis of diabetes and surgical site infection, by surgery type.
figure 2. Meta-analysis of diabetes and surgical site infection, by surgery type.
figure 2. Meta-analysis of diabetes and surgical site infection, by surgery type.
figure 2. Meta-analysis of diabetes and surgical site infection, by surgery type.
figure 2. Meta-analysis of diabetes and surgical site infection, by surgery type.
figure 3. Meta-analysis of pre-operative hyperglycemia and surgical site infection.
figure 4. Meta-analysis of post-operative hyperglycemia and surgical site infection.
RESULTS The primary outcome was SSI, as
defined by the Centers for Disease Control and
Prevention surveillance criteria. The overall effect
size for the association between diabetes and
SSI was odds ratio (OR)=1.53 (95% predictive
interval [PI], 1.11–2.12; I2, 57.2%). SSI class,
study design, or patient BMI did not significantly
impact study results in a meta-regression model.
The association was higher for cardiac surgery
2.03 (95% PI, 1.13–4.05) compared with
surgeries of other types (P=.001).
CONCLUSIONS These results support the
consideration of diabetes as an
independent risk factor for SSIs for multiple
surgical procedure types. Continued efforts
are needed to improve surgical outcomes
for diabetic patients.
Message
糖尿病で術後感染が増加することが再確認され
た。当然だと感じるが
しかし血糖をよくしたからと言ってよくなるか
は不明であるが。