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Table 2.

Cox proportional hazard ratios and 95% confidence intervals for incident hypertension according to baseline consumption of ultra-processed food (1999–2015)

Data are shown as Cox proportional hazard ratios and 95% confidence intervals.

Adjusted for age and sex.

Adjusted for sex, age, physical activity, hours of TV watching, baseline body mass index, smoking status, use of analgesics, following a special diet at baseline, family history of hypertension, hypercholesterolemia, and alcohol consumption.

Additionally adjusted for total energy intake, olive oil intake, and consumption of fruits and vegetables.

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Table 2.

Cox proportional hazard ratios and 95% confidence intervals for incident hypertension according to baseline consumption of ultra-processed food (1999–2015)

Data are shown as Cox proportional hazard ratios and 95% confidence intervals.

Adjusted for age and sex.

Adjusted for sex, age, physical activity, hours of TV watching, baseline body mass index, smoking status, use of analgesics, following a special diet at baseline, family history of hypertension, hypercholesterolemia, and alcohol consumption.

Additionally adjusted for total energy intake, olive oil intake, and consumption of fruits and vegetables.

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No significant interactions between UPF consumption and sex ( P interaction = 0.65), age ( P interaction = 0.32), and body mass index ( P interaction = 0.59) were observed. The results from the sensitivity analyses did not substantially change in any of the scenarios ( Table 3 ).

Table 3.

Sensitivity analyses of the hazard ratios (95% confidence intervals) for incident hypertension (1999–2015)

Abbreviations: DBP, diastolic blood pressure; SBP, systolic blood pressure.

Adjusted for sex, age, physical activity, hours of TV watching, baseline body mass index, smoking status, use of analgesics, following a special diet at baseline, family history of hypertension, hypercholesterolemia, alcohol consumption, total energy intake, olive oil intake, and consumption of fruits and vegetables.

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Table 3.

Sensitivity analyses of the hazard ratios (95% confidence intervals) for incident hypertension (1999–2015)

Abbreviations: DBP, diastolic blood pressure; SBP, systolic blood pressure.

Adjusted for sex, age, physical activity, hours of TV watching, baseline body mass index, smoking status, use of analgesics, following a special diet at baseline, family history of hypertension, hypercholesterolemia, alcohol consumption, total energy intake, olive oil intake, and consumption of fruits and vegetables.

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In this prospective study, higher baseline consumption of UPFs was associated with a higher risk of incident hypertension, even after adjustment for potential confounding factors. To our knowledge, this is the first epidemiologic study that has evaluated the association between UPFs, a new category of foods based on their degree of processing, and the risk of hypertension.

Table 3.

Summary of Available Tests for Infection, in Decreasing Order of Sensitivity

Must be combined with a toxin test.

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Table 3.

Summary of Available Tests for Infection, in Decreasing Order of Sensitivity

Must be combined with a toxin test.

View Large

The other reference method is the cell cytotoxicity neutralization assay (CCNA), which detects toxin directly in stool. This assay begins with preparation of a stool filtrate, which is applied to a monolayer of an appropriate cell line, such as Vero cells, or human fibroblasts, among others. Following incubation, the cells are observed for cytopathic effect (CPE); duplicate testing is usually carried out simultaneously with neutralizing antibodies to Clostridium sordellii or C. difficile toxin, to ensure that the observed CPE is truly caused by C. difficile toxins and not by other substances in the stool. Incubation continues for up to 48 hours, but the majority of positives are detected after overnight incubation. This method is cumbersome, time-consuming, and lacks standardization, although if optimized, it is one of the most sensitive and specific methods available for C. difficile toxin detection. As laboratories abandoned their viral cell culture facilities in favor of antigen and molecular tests, CCNA became less popular. Enzyme immunoassays, initially for toxin A detection alone, and later both toxins, became available and replaced the above reference methods for routine clinical testing in the late 1980s and early 1990s. EIAs use monoclonal or polyclonal antibodies to detect C. difficile toxins and there are numerous commercial assays available. Performance is variable and their overall poor performance sparked development of other methods such as GDH immunoassays and molecular tests for toxin gene detection [ 174 , 176 , 177 ]. While toxin EIAs remain insensitive in the detection of toxigenic C. difficile when compared with these successive technologies, sensitivities vary among available toxin EIA tests. Results across both sponsored and nonsponsored studies should be considered to select a relatively more sensitive EIA for general use [ 174 ]. Also, there is some evidence that newer EIAs have improved sensitivity compared with those examined in older studies [ 178 ].

Glutamate dehydrogenase immunoassays detect the highly conserved metabolic enzyme (common antigen) present in high levels in all isolates of C. difficile . Since this antigen is present in both toxigenic and nontoxigenic strains, GDH immunoassays lack specificity and must be combined with another (usually toxin) test. GDH testing is the initial screening step in 2- and 3-step algorithms that combine it with a toxin test and/or a molecular test for toxin gene detection. The combination has allowed for rapid results and improved sensitivity compared with toxin EIA testing alone, and can be economical [ 174 , 176 , 177 ].

Diabetic patients usually have extensive CAD and require multiple grafts. There is no direct randomized evidence regarding the use of only one vs. two ITA conduits in diabetic patients. Currently, only observational evidence suggests that using both arterial conduits improves outcomes, without compromising sternal stability [ 49 ]. A non-randomized comparison of bilateral ITA surgery with PCI in diabetic patients showed improved outcomes with the use of bilateral arterial grafts, though 5-year survival was not significantly different from that of PCI-treated patients [ 116 ]. Although diabetes is a risk factor for wound infection and mediastinitis, the impact of the use of bilateral ITA on these complications is debated.

There is no indication that antithrombotic pharmacotherapy should differ between diabetic vs. non-diabetic patients undergoing elective revascularization. In ACS trials, there is no indication that the antithrombotic regimen should differ between diabetic and non-diabetic patients [ 65 , 85 , 86 ]. Although an interaction between diabetic status and efficacy of GPIIb-IIIa inhibitors was noted in earlier trials without concomitant use of thienopyridines, this was not confirmed in the more recent Early-ACS trial [ 65 ]. In the current context of the use of high-dose oral antiplatelet agents, diabetic patients do not benefit from the routine addition of GPIIb-IIIa inhibitors.

There have been only a few specific trials of antidiabetic medications in patients undergoing myocardial revascularization.

Because of the risk of lactic acidosis in patients receiving iodinated contrast media, it is generally stated that metformin should be interrupted before angiography or PCI, and reintroduced 48 h later, only after assessment of renal function. However, there is no convincing evidence for such a recommendation. Checking renal function after angiography in patients on metformin and stopping metformin when renal function deteriorates might be an acceptable alternative to suspension of metformin in all patients. In patients with renal failure, metformin should preferably be stopped before the procedure.

Observational data have reported concern about the use of sulfonylureas in patients treated with primary PCI. This has not been confirmed with the use of newer pancreatic-specific sulfonylureas.

Thiazolidinediones may be associated with lower restenosis rates after PCI with BMS; however, they are associated with an increased risk of heart failure.

No trial has shown improved PCI outcome after STEMI with the administration of insulin or glucose insulin potassium (GIK) [ 117–119 ]. After CABG, the incidence of secondary endpoints, such as atrial fibrillation (AF), myocardial injury, wound infection, or hospital stay, was reduced after GIK infusion [ 120 , 121 ]. However, the NICE-SUGAR trial [ 122 ] assessed the impact of insulin therapy with tight blood glucose control in patients admitted to the intensive care unit for various clinical and surgical conditions. An increase in severe hypoglycaemic episodes was noted in the tighter blood glucose control arm of the trial, and 90-day mortality was increased.

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© 2018 Oxford University Press

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Abstract

A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.

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Summarized below are recommendations intended to improve the diagnosis and management of Clostridium difficile infection (CDI) in adults and children. CDI is defined by the presence of symptoms (usually diarrhea) and either a stool test positive for C. difficile toxins or detection of toxigenic C. difficile, or colonoscopic or histopathologic findings revealing pseudomembranous colitis. In addition to diagnosis and management, recommended methods of infection control and environmental management of the pathogen are presented. The panel followed a process used in the development of other Infectious Diseases Society of America (IDSA) guidelines, which included a systematic weighting of the strength of recommendation and quality of evidence using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system ( Figure 1 ). A detailed description of the methods, background, and evidence summaries that support each of the recommendations can be found in the full text of the guidelines. The extent to which these guidelines can be implemented is impacted by the size of the institution and the resources, both financial and laboratory, available in the particular clinical setting.

Figure 1.
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Approach and implications to rating the quality of evidence and strength of recommendations using the of Recommendations, Assessment, Development and Evaluation (GRADE) methodology (unrestricted use of this figure granted by the US GRADE Network) [ 1–4 ].

Figure 1.
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Approach and implications to rating the quality of evidence and strength of recommendations using the of Recommendations, Assessment, Development and Evaluation (GRADE) methodology (unrestricted use of this figure granted by the US GRADE Network) [ 1–4 ].

To increase comparability between clinical settings, use available standardized case definitions for surveillance of (1) healthcare facility-onset (HO) CDI; (2) community-onset, healthcare facility–associated (CO-HCFA) CDI; and (3) community-associated (CA) CDI (good practice recommendation ).

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