Geneva College

BACKGROUND:These recommendations provide guidance on the optimal duration of antibiotics in patients with complicated urinary tract infection (cUTI), especially in presence of associated Gram-negative bacteremia. METHODS:The panel's recommendations are based upon evidence derived from systematic literature reviews which focused on comparative benefits and harms of shorter (5-7 days) vs prolonged (10-14 days) duration of antibiotics, including publications since 2000. These recommendations adhere to a standardized methodology for rating the certainty of evidence and strength of recommendation according to the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. RESULTS:The guidelines panel suggests that patients with cUTI who are improving on effective therapy can be treated with shorter duration of antimicrobials (either 5-7 days of a fluoroquinolone or 7 days of a non-fluoroquinolone) rather than longer courses of antibiotics, regardless of the presence of associated Gram-negative bacteremia. An effective antimicrobial agent achieves therapeutic levels in the urine and relevant tissue and is active against the causative pathogen. However, men with febrile UTI in whom acute bacterial prostatitis is suspected may benefit from a longer treatment duration (10-14 days), and a short courses of oral beta lactams may require higher doses for efficacy. CONCLUSIONS:Shorter durations of antibiotics for cUTI provide similar efficacy as longer courses, except in men with febrile UTI in whom acute bacterial prostatitis is suspected. This recommendation places a high value on antibiotic stewardship considerations as well as reducing the burden of antimicrobial administration from a healthcare perspective and reducing the burden of taking antibiotics from a patient perspective.

BACKGROUND:Apixaban and rivaroxaban are the oral anticoagulants most frequently used to treat acute venous thromboembolism. However, uncertainty remains about the difference in bleeding risk between the two medications. METHODS:In an international trial with a prospective, randomized, open-label, blinded end-point design, we assigned, in a 1:1 ratio, eligible patients with acute symptomatic pulmonary embolism or proximal deep-vein thrombosis to receive apixaban or rivaroxaban for 3 months. Apixaban was given at a dose of 10 mg twice daily for 7 days followed by 5 mg twice daily, and rivaroxaban was given at a dose of 15 mg twice daily for 21 days followed by 20 mg daily. The primary outcome was clinically relevant bleeding, a composite of major bleeding or clinically relevant nonmajor bleeding, as defined according to the International Society on Thrombosis and Haemostasis, during the 3-month trial period. Secondary outcomes included death from any cause. RESULTS:A total of 2760 patients underwent randomization: 1370 to the apixaban group and 1390 to the rivaroxaban group. A primary-outcome event occurred in 44 of 1345 patients (3.3%) in the apixaban group and 96 of 1355 patients (7.1%) in the rivaroxaban group (relative risk, 0.46; 95% confidence interval [CI], 0.33 to 0.65; P<0.001). Death from any cause occurred in 1 patient (0.1%) in the apixaban group and in 4 patients (0.3%) in the rivaroxaban group (relative risk, 0.25; 95% CI, 0.03 to 2.26). Serious adverse events unrelated to bleeding or venous thrombosis occurred in 36 patients (2.7%) in the apixaban group and in 30 patients (2.2%) in the rivaroxaban group. CONCLUSIONS:Among patients with acute venous thromboembolism, the risk of clinically relevant bleeding was significantly lower with apixaban than with rivaroxaban during the 3-month treatment period. (Funded by the Canadian Institutes of Health Research and others; COBRRA ClinicalTrials.gov number, NCT03266783.).

AIMS:We aimed to develop the European Society of Cardiology (ESC) quality indicators (QIs) for myocardial infarction (MI), from 1 year after hospital discharge, corresponding to transition to the chronic coronary syndrome phases. METHODS AND RESULTS:We collaborated with the European Association of Preventive Cardiology (EAPC) and developed QIs for the long-term management of patients following MI. We applied the ESC methodology for QI development by (i) determining key domains of post-MI care; (ii) developing candidate QIs by performing a systematic review of the literature, and (iii) selecting the final set of QIs using a modified Delphi approach. In total, 18 QIs were identified across seven domains of care including (i) structural framework, (ii) risk assessment and follow-up, (iii) pharmacological management, (iv) rehabilitation, behavioural, and preventive interventions, (v) coronary revascularization, (vi) clinical outcomes, and (vii) patient-reported outcomes. CONCLUSION:We present the ESC QIs from 1 year after hospitalization for MI, to standardize and address gaps in care for this high-risk group. These QIs are supported by evidence from contemporary literature, endorsed by expert consensus, and aligned with the 2024 ESC guidelines on the management of chronic coronary syndromes. LAY SUMMARY:Measures to evaluate and improve the long-term management of patients following a heart attack are needed. In this paper, we identified key aspects of care that can help clinicians, decision-makers and patients improve the quality of care, from one year after a heart attack onwards, and help address inequalities and variations in clinical practice.

Recent literature has assessed Jonathan Edwards's theology of creation, particularly of creation's beauty, as one that provides the resources for environmental ethics. Understood as a communication of God's glory, creation in all its beauty becomes a crucial means of human knowledge and sense of divine beauty. However, these accounts neglect Edwards's eschatology in its exclusion of the non-human creation from redemption, an exclusion that results from Edwards's definition of secondary beauty. The telos of the creation as a whole becomes subservient to the telos of humanity, and thus, once humanity's goal of union with God is achieved, the creation serves no other purpose. This article explores these weaknesses of Edwards's eschatology and offers a revision of Edwards that seeks to read with the grain of his theology of beauty and his Reformed emphasis on the orientation of all creation towards divine glory.

BACKGROUNDNeonates and infants are among the most vulnerable populations to undergo procedures necessitating general anaesthesia and are at risk for postoperative neurological complications. The objective of this study was to assess the association between interventions for intra-operative physiologic instability and the development of postoperative neurological complications in a cohort of neonates and infants undergoing operative and nonoperative procedures.METHODSData for this study were extracted from the NECTARINE study: a prospectively collected cohort of neonates and infants receiving anaesthesia for operative and nonoperative procedures from 165 participating hospitals in 31 countries.In a multivariable logistic regression model predicting the development of a neurologic complication up to 30 days postoperatively, exposures of interest were binary indicators of unexpected intra-operative instability of systemic homeostasis necessitating a corrective action (based on blood pressure, heart rate, end-tidal and/or blood CO2, glucose and sodium).METHODSData for this study were extracted from the NECTARINE study: a prospectively collected cohort of neonates and infants receiving anaesthesia for operative and nonoperative procedures from 165 participating hospitals in 31 countries.In a multivariable logistic regression model predicting the development of a neurologic complication up to 30 days postoperatively, exposures of interest were binary indicators of unexpected intra-operative instability of systemic homeostasis necessitating a corrective action (based on blood pressure, heart rate, end-tidal and/or blood CO2, glucose and sodium).RESULTSOne hundred and forty out of 5504 (2.5%) neonates and infants developed a postoperative neurologic complication. No statistically significant association was found between interventions for intra-operative physiologic instability and the development of a postoperative neurologic complication.CONCLUSIONIn this secondary analysis of neonates and infants undergoing cardiac and noncardiac procedures, we found a higher rate of neurologic complications compared to adult populations undergoing noncardiac surgery. There was no association between unexpected intra-operative instability of systemic homeostasis necessitating a corrective action and subsequent neurologic complications; however, these findings do not necessarily indicate the absence of any effect of physiological disturbances on neurologic outcomes.