Symptoms of cystitis probably caused by bacterial infection, even when tests are negative

The majority of women suffering with pain when urinating, or needing to urinate often or urgently probably do have a bacterial infection, even when nothing is detected by standard urine testing.

Symptoms of a urinary tract infection (UTI) such as cystitis are common in women but, in around a quarter of cases, no infection is found using standard testing.

However, new research published in Clinical Microbiology and Infection and using a more sensitive test, found evidence of bacterial infection in almost all women with UTI symptoms, including those where no bacteria were found with standard testing.

The study, led by Dr Stefan Heytens from University of Ghent, Belgium, supports the idea that testing is unnecessary for women with symptoms of an uncomplicated UTI.

UTI symptoms account for between two and five per cent of women’s GP appointments. In 60-80% of cases, urine testing reveals a bacterial infection.

Testing involves using laboratory techniques to detect bacteria in the urine.

These women may be offered antibiotics such as nitrofurantoin, trimethoprim or fosfomycin.

However, doctors have assumed that women with negative tests do not have a bacterial infection. In the past, this group of women may have been diagnosed with unexplained ‘urethral syndrome’, which some researchers have suggested could be psychosomatic.

Dr Heytens, who is a practicing GP and a researcher at the department of family medicine and primary health care at the University of Ghent, explained: “A substantial percentage of women visiting their GP with symptoms of a UTI, who test negative for a bacterial infection, are told they have no infection and sent home without treatment.

“On the other hand, women with a positive test might be given a short course of antibiotics to treat their infection.”

The new research involved 308 Belgian women, including 220 who were visiting their GP for UTI symptoms and 86 healthy volunteers. All the women gave urine samples.

Urine samples were tested in the standard way to see whether any bacteria grew. They were also tested using a technique called quantitative polymerase chain reaction, or qPCR. This technique is very sensitive and can be used to detect tiny quantities of DNA that come from bacteria which can cause UTIs, such as Escherichia coli (E. coli) and Staphloccocus saprophyticus (S. saphrophyticus).

Among the women with UTI symptoms, standard testing detected bacteria in 80.9% of urine samples. But the qPCR test found evidence of E. coli in 95.9% of samples and S. saphrophyticus in 8.6%. Combining the results of both tests found evidence of an infection in 98.2% of women with symptoms.

In the women without symptoms, standard testing picked up E. coli in 10.5% of samples and qPCR picked up E. coli in 11.6%.

Dr Heytens said: “In this study, we used a more sensitive test to look for bacteria that commonly cause UTIs. We found E. coli in nearly all women complaining of symptoms, even if they had a negative traditional urine culture. This suggests that if a woman has these symptoms, she probably does have a UTI.

“Our findings support previous research which indicates that traditional testing may not be helpful in uncomplicated UTIs. However, traditional urine culture tests may still have a role to play if treatment fails or if there are signs and symptoms of a more complicated UTI.

“What we don’t yet know is whether all women with these symptoms would benefit from a course of antibiotics.”

Dr Heytens says the findings need to be confirmed in further research. He and his colleagues also plan to investigate whether women with UTI symptoms but a negative urine test would benefit from treatment with antibiotics, and whether they can use qPCR to detect other types of bacteria which might be causing UTIs in rarer cases.

Tomado de: European Society of Clinical Microbiology and Infectious Diseases (ESCMID). (2017, April 28). Symptoms of cystitis probably caused by bacterial infection, even when tests are negative. ScienceDaily. Retrieved May 8, 2017 from http://www.sciencedaily.com/releases/2017/04/170428084433.htm

Oktoberfest: Downing Beers, Raising Heart Rates -Acute measurement in beer tents shows high rate of sinus tachycardia

Beer-fueled partying often led to pounding heart rates and other arrhythmia acutely, although the chronic impact appeared small, according to an observational study.

Among 3,028 attendees at the 2015 Munich Oktoberfest, smartphone-based ECG measurements turned up a 30.5% rate of cardiac arrhythmias.

The bulk of these cases involved sinus tachycardia (25.9%), Stefan Brunner, MD, and Moritz F. Sinner, MD, MPH, both of University Hospital Munich, and colleagues reported in the European Heart Journal.

On multivariable analysis, breath alcohol concentration (BAC) in the beer tent correlated with cardiac arrhythmia (OR 1.75 for each 1-unit change, 95% CI 1.50-2.05). This was largely driven by more sinus tachycardia (OR 1.96, 95% CI 1.66-2.31).

“Ours is the first large and prospective investigation to systematically analyze the immediate occurrence of arrhythmias under the influence of acute alcohol intake. We thus conclude that acute alcohol consumption leads to increased arrhythmia prevalence overall, with sinus tachycardia as the immediate main effect,” Brunner and Sinner’s group wrote.

But how applicable to clinical care are these finding? Not very, suggested Kenneth J. Mukamal, MD, MPH, of Beth Israel Deaconess Medical Center.

“We don’t treat heart rate as a condition per se, and this doesn’t address abnormal heart rhythms directly at all. So this does provide some interesting mechanistic insight into how alcohol influences risk of heart rhythm disturbances at high doses, but it does not otherwise identify new risks from drinking,” he commented to MedPage Today.

“One may argue that having a high heart rate during a festival like Oktoberfest is physiologically normal!” Daniel P. Morin, MD, of John Ochsner Heart and Vascular Institute in New Orleans, even said.

“I think the potential confounding of the party-type atmosphere of Oktoberfest, which may be expected to affect alcohol’s impact (on autonomic tone and otherwise), may make this less applicable to more sedate settings of alcohol intake,” commented Morin.

Oktoberfest attendees had a 22.2% rate of respiratory sinus arrhythmia, a measure of autonomic tone. “This partly reflects autonomic imbalance as assessed by significantly reduced respiratory sinus arrhythmia. Such imbalance might lead to sympathetically triggered atrial fibrillation [Afib] resembling the holiday heart syndrome,” the authors suggested.

The Oktoberfest enrollees reflected the festival’s international attendance with 69% being of German nationality. This acute alcohol cohort (average age 34.7 years, 29.9% women) had a mean 0.85 g/kg BAC.

Separately, Brunner and Sinner gathered data from the Survey S4 participants of the community-based Cooperative Health Research in the region of Augsburg (KORA S4) Study to analyze the relationship between chronic alcohol consumption and cardiac arrhythmias.

What they found was that chronic drinking was also tied to sinus tachycardia — albeit much more weakly than in the acute setting (OR 1.03 per 1 g/kg BAC, 95% CI 1.01-1.06). This was in a population of 4,131 German participants (mean age 49.1 years, 51.1% women) who averaged 15.8 g/day of alcohol consumption.

For the Oktoberfest analysis, researchers took 30-second ECG readings using the smartphone-based AliveCor device. Ten-second 12-lead ECGs were taken for the KORA S4 cohort using the Hannover ECG System after 10 minutes of rest in supine position. ECG analysis was performed in both cases by blinded interpreters.

“Given the public environment of our study, we were restricted in assessing personal questions and conducting physical examinations,” the investigators acknowledged. “Hence, several possible confounding factors remained unaddressed, including but not limited to the amount of alcohol consumption prior to BAC measurement, the participants’ common alcohol consumption behaviour, their use of recreational drugs, or their usual physical activity.”

“Due to our exclusion criteria, we were not able to study severely intoxicated individuals (BAC ≥3.00 g/kg). In KORA S4, chronic alcohol consumption was rather low compared with other community-based cohorts. We might thus have underestimated arrhythmia prevalence secondary to long-term alcohol use. Information on chronic alcohol consumption in our acute alcohol cohort was unavailable.”

Commenting to MedPage Today, however, T. Jared Bunch, MD, of Intermountain Medical Center in Murray, Utah, maintained that the study had some useful additions to the current literature.

“In this study, the authors found that alcohol altered the heart’s autonomic nervous system. Alterations of this nervous system have also been described as a cause of Afib,” he suggested. “This may be a newly discovered link into why alcohol is associated with Afib.”

Bunch emphasized that even light drinking is tied to an increase in the risk of Afib. “This level of drinking also can raise blood pressure and in people with a history of heart failure result in worsening symptoms and heart failure.”

If people choose to imbibe, he urged, “light drinking combined with other healthy lifestyle choices and monitoring of the heart rhythm and blood pressure is the best way to go.”

Tomado de medscape.com.  Nicole Lou  Reporter, MedPage Today/CRTonline.org

Primary Source

European Heart Journal

 Brunner S, et al “Alcohol consumption, sinus tachycardia, and cardiac arrhythmias at the Munich Oktoberfest: results from the Munich Beer Related Electrocardiogram Workup Study (MunichBREW)” Eur Heart J 2017; DOI: 10.1093/eurheartj/ehx156.

Physicians’ misunderstanding of genetic test results may hamper mastectomy decisions

A recent survey of over 2,000 women newly diagnosed with breast cancer found that half of those who undergo bilateral mastectomy after genetic testing don’t actually have mutations known to confer increased risk of additional cancers, according to a study by researchers at the Stanford University School of Medicine and four other U.S. medical centers.

Instead the women had what are known as variants of uncertain significance, or VUS, that are often eventually found to be harmless. A bilateral mastectomy is a surgical procedure in which both of a woman’s breasts are removed after a diagnosis of cancer in one breast.

The finding highlights the need for genetic counselors to help both patients and physicians better understand the results of genetic testing intended to determine a woman’s risk for cancer recurrence or for developing a separate cancer in her ovaries or unaffected breast.

“Our findings suggest a limited understanding among physicians and patients of the meaning of genetic testing results,” said Allison Kurian, MD, associate professor of medicine and of health research and policy at Stanford. “Clinical practice guidelines state that variants of uncertain significance should not be considered to confer high cancer risk, and that patients with these variants should be counseled similarly to a patient whose genetic test is normal. However, many of the physicians surveyed in our study stated that they manage these patients in the same way as they do patients with mutations known to increase a woman’s risk.”

Only about half of the surveyed women who received genetic testing ever discussed their test results with a genetic counselor, and between one-quarter and one-half of the surveyed breast cancer surgeons indicated they treat women with VUS no differently than women with known cancer-associated mutations, the researchers found. Furthermore, some women undergo surgery prior to receiving genetic testing or seeing the results.

Kurian is the lead author of the study, which will be published online in the Journal of Clinical Oncology. University of Michigan researchers Reshma Jagsi, MD, DPhil, and Steven Katz, MD, MPH, share senior authorship.

The need for genetic testing

The findings come on the heels of a February study by many of the same researchers showing that physicians often fail to recommend genetic testing for breast cancer patients at high risk for mutations in the BRCA1 or BRCA2 genes, which are strongly associated with ovarian and other cancers.

In this study, the researchers asked 2,502 women newly diagnosed with breast cancer whether they had received genetic testing, and if so, whether the testing and any discussion of results occurred before or after breast surgery.

They found that of the 666 women who had received testing, 59 percent were considered to have a high risk of a dangerous mutation in a cancer-associated gene. About one-quarter of these women had genetic testing only after surgery – meaning critical decisions were made about their care before information about their mutation status was available. Delays in testing were particularly pronounced in women who lacked private health insurance.

The researchers then polled the surgeons who treated the women in the survey. They found that, when compared with doctors who had treated 51 or more newly diagnosed breast cancer patients during the previous year, doctors who had treated fewer than 21 breast cancer patients were: less confident in discussing the results of genetic testing with patients, more likely to order the genetic test without referring women to a genetic counselor, less likely to delay surgery in order to have test results available for surgical decision-making and more likely to manage a patient with variants of uncertain significance in the same way they would manage patients with proven high-risk mutations in cancer-associated genes.

“Our findings suggest that we are not maximizing the benefit of genetic testing for our patients with breast cancer because of barriers related to timeliness of testing and lack of expertise necessary to incorporate results into treatment decisions,” said Katz, who is a professor of medicine and of health management and policy at the University of Michigan.

Expertise to interpret the results

Although genetic testing has become more common and less costly, it’s also become more confusing. The advent of multiplex gene panels that simultaneously test for mutations or variations in many different genes can render results that are difficult to interpret without the help of a trained genetic counselor. Uncertainties as to the meaning of test results may lead less-experienced surgeons to recommend aggressive treatment in the form of bilateral mastectomies, or cause women to opt for what they may feel is the safest option to manage their cancer.

Conversely, high-risk women who do carry dangerous mutations need this information to make informed decisions about their health care choices.

“The gaps identified in this study are striking,” said Jagsi, professor and deputy chair of radiation oncology at the University of Michigan. “It is critical to ensure that patients at high risk for known cancer-associated mutations are fully informed of the potential benefits of genetic testing, and counseled accurately about the meaning of test results.”

“We’re learning that clinicians’ knowledge of breast cancer genetics can be highly variable,” said Kurian, who is a member of the Stanford Cancer Institute. “It’s important for women at high risk of carrying a dangerous mutation to see someone with expertise in cancer genetics when planning their care. Unfortunately, in many cases genetic counselors may not be optimally integrated into the care of newly diagnosed cancer patients, making it difficult to rapidly triage these patients. Our study highlights the urgent need for improved patient access to cancer genetics experts, particularly genetic counselors, and for educating physicians about the appropriate use of genetic testing and interpretation of test results.”

The study was supported by the National Institutes of Health (grant P01CA163233), the California Department of Public Health and the Centers for Disease Control and Prevention.

Kurian has received research funding from Invitae, Myriad Genetics, Ambry Genetics, GenDx and Genomic Health.

Tomado de: http://www.medicalnewstoday.com. Stanford University School of Medicine. “Physicians’ misunderstanding of genetic test results may hamper mastectomy decisions.” Medical News Today. MediLexicon, Intl., 18 Apr. 2017. Web.
Articulo original: Gaps in Incorporating Germline Genetic Testing Into Treatment Decision-Making for Early-Stage Breast Cancer, Allison W. Kurian, Yun Li, Ann S. Hamilton, Kevin C. Ward, Sarah T. Hawley, Monica Morrow, M. Chandler McLeod, Reshma Jagsi, and Steven J. Katz, Journal of Clinical Oncology, doi: 10.1200/JCO.2016.71.6480, published online 12 April 2017.

Fecal Transplant Good For the Brain? (Small trial tests microbiome transfer in hepatic encephalopathy)

There is an old saying that brains are baffled by the end product of a bull’s digestion.

But a similar product, from carefully selected human donors, might reduce recurrent hepatic encephalopathy in liver disease patients and protect their brains, according to Jasmohan Bajaj, MD, of Virginia Commonwealth University in Richmond, Va.

In an early-stage randomized trial, fecal microbiota transplants were safe in patients with hepatic encephalopathy and reduced hospital readmissions, Bajaj told reporters at the International Liver Congress, the annual meeting of the European Association for the Study of the Liver (EASL).

The researchers also saw encouraging signs that the transplants reversed cognitive damage associated with the condition, Bajaj said.

The findings are “encouraging (and) open new avenues of research,” commented Tom Hemming Karlsen, MD, PhD, of Oslo’s University Hospital Rikshospitalet, who was not part of the study but who moderated a media briefing at which details were presented.

“This is the first randomized trial to show that fecal transplantation may be of benefit to patients with hepatic encephalopathy,” he said, although it remains to find out how best to manipulate the gut microbiota in patients with the condition.

The study also is “proof-of-concept for the likely beneficial impact of such interventions, adding to what is already known for non-absorbable antibiotics like rifaximin,” he said.

Hepatic encephalopathy occurs when the liver can’t clear some toxins, such as ammonia, which then build up and enter the brain, leading to confusion, an altered level of consciousness, and sometimes coma, Bajaj noted.

The condition is a leading cause of hospital admission for people with liver disease and the readmissions occur often in spite of standard care with lactulose and rifaximin (Xifaxan), he said. During their frequent hospital stays, patients are exposed to antibiotics, which upsets their gut microbiota and exacerbates the problem, Bajaj said.

“It’s a vicious circle,” he said.

He and colleagues hypothesized that restoring a healthy gut microbiome would reduce the rate of hospital readmission, cut recurrence of hepatic encephalopathy, and improve cognition.

To test the idea, they first compared gut microbes in patients with and without hepatic encephalopathy to see what bacterial classes were different. Then they asked a non-profit universal stool bank to find a donor whose microbiome would be best to restore the good bacteria in patients.

For the study, the researchers enrolled 20 patients with recurrent hepatic encephalopathy and randomly assigned them to get the transplant, delivered by enema, plus standard care or to get standard care alone. The 10 patients in the transplant arm were first conditioned with high doses of antibiotics to destroy their own gut microbiome.

After 150 days of follow-up, the researchers found:

  • There were 11 re-admissions in eight patients in the standard care arm, including six related to hepatic encephalopathy, compared with two in the transplant arm, neither related to encephalopathy.
  • There were no infections in the transplant arm and no variceal bleeding, compared with two cases each in the standard care arm.
  • On two measures of cognition, there was no change over time among the standard care patients, but most transplant patients improved.

During the antibiotic lead-in, the researchers observed a transient increase in MELD score, but the combination of fecal transplant plus antibiotic therapy restored antibiotic-associated changes in the gut microbes.

Bajaj noted that the study is small and was designated by the FDA as a phase I trial. He added that further studies are needed in women and people with more advanced disease, as well as trials to see what happened without the pre-treatment antibiotic blitz.

He told MedPage Today that future trials will use a capsule form of delivery for the transplant, rather than an enema.

Tomado de medpagetoday.com

by Michael Smith
North American Correspondent, MedPage Today