Aug 212014
 
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Use of clarithromycin and roxithromycin and risk of cardiac death: cohort study.

BMJ. 2014;349:g4930

Authors: Svanström H, Pasternak B, Hviid A

Abstract
OBJECTIVE: To assess the risk of cardiac death associated with the use of clarithromycin and roxithromycin.
DESIGN: Cohort study.
SETTING: Denmark, 1997-2011.
PARTICIPANTS: Danish adults, 40-74 years of age, who received seven day treatment courses with clarithromycin (n=160 297), roxithromycin (n=588 988), and penicillin V (n=4 355 309).
MAIN OUTCOME MEASURES: The main outcome was risk of cardiac death associated with clarithromycin and roxithromycin, compared with penicillin V. Subgroup analyses were conducted according to sex, age, risk score, and concomitant use of drugs that inhibit the cytochrome P450 3A enzyme, which metabolises macrolides.
RESULTS: A total of 285 cardiac deaths were observed. Compared with use of penicillin V (incidence rate 2.5 per 1000 person years), use of clarithromycin was associated with a significantly increased risk of cardiac death (5.3 per 1000 person years; adjusted rate ratio 1.76, 95% confidence interval 1.08 to 2.85) but use of roxithromycin was not (2.5 per 1000 person years; adjusted rate ratio 1.04, 0.72 to 1.51). The association with clarithromycin was most pronounced among women (adjusted rate ratios 2.83 (1.50 to 5.36) in women and 1.09 (0.51 to 2.35) in men). Compared with penicillin V, the adjusted absolute risk difference was 37 (95% confidence interval 4 to 90) cardiac deaths per 1 million courses with clarithromycin and 2 (-14 to 25) cardiac deaths per 1 million courses with roxithromycin.
CONCLUSIONS: This large cohort study found a significantly increased risk of cardiac death associated with clarithromycin. No increased risk was seen with roxithromycin. Given the widespread use of clarithromycin, these findings call for confirmation in independent populations.

PMID: 25139799 [PubMed - in process]

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Aug 212014
 
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PROF-ETEV study: prophylaxis of venous thromboembolic disease in critical care units in Spain.

Intensive Care Med. 2014 Aug 20;

Authors: García-Olivares P, Guerrero JE, Galdos P, Carriedo D, Murillo F, Rivera A

Abstract
PURPOSE: Venous thromboembolic disease (VTE) in critically ill patients has a high incidence despite prophylactic measures. This fact could be related to an inappropriate use of these measures due to the absence of specific VTE risk scores. To assess the current situation in Spain, we have performed a cross-sectional study, analyzing if the prophylactic measures were appropriate to the patients' VTE risk.
METHODS: Through an electronic questionnaire, we carried out a single day point prevalence study on the VTE prophylactic measures used in several critical care units in Spain. We performed a risk stratification for VTE in three groups: low, moderate-high, and very high risk. The American College of Chest Physicians guidelines were used to determine if the patients were receiving the recommended prophylaxis.
RESULTS: A total of 777 patients were included; 62 % medical, 30 % surgical, and 7 % major trauma patients. The median number of the risk factors for VTE was four. According to the proposed VTE risk score, only 2 % of the patients were at low risk, whereas 83 % were at very high risk. Sixty-three percent of patients received pharmacological prophylaxis, 12 % mechanical prophylaxis, 6 % combined prophylaxis, and 19 % did not receive any prophylactic measure. According to criteria suggested by the guidelines, 23 % of medical, 71 % of surgical, and 70 % of major trauma patients received an inappropriate prophylaxis.
CONCLUSIONS: Most critically ill patients are at high or very high risk of VTE, but there is a low rate of appropriate prophylaxis. The efforts to improve the identification of patients at risk, and the implementation of appropriate prevention protocols should be enhanced.

PMID: 25138229 [PubMed - as supplied by publisher]

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Aug 212014
 
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Secretoneurin as a marker for hypoxic brain injury after cardiopulmonary resuscitation.

Intensive Care Med. 2014 Aug 20;

Authors: Hasslacher J, Lehner GF, Harler U, Beer R, Ulmer H, Kirchmair R, Fischer-Colbrie R, Bellmann R, Dunzendorfer S, Joannidis M

Abstract
PURPOSE: The neuropeptide secretoneurin (SN) shows widespread distribution in the brain. We evaluated whether SN is elevated after cardiopulmonary resuscitation (CPR) and could serve as a potential new biomarker for hypoxic brain injury after CPR.
METHODS: This was a prospective observational clinical study. All patients admitted to a tertiary medical intensive care unit after successful CPR with expected survival of at least 24 h were consecutively enrolled from September 2008 to April 2013. Serum SN and neuron-specific enolase were determined in 24 h intervals starting with the day of CPR for 7 days. Neurological outcome was assessed with the Cerebral Performance Categories Scale (CPC) at hospital discharge.
RESULTS: A total of 134 patients were included with 49 % surviving to good neurological outcome (CPC 1-2). SN serum levels peaked within the first 24 h showing on average a sixfold increase above normal. SN levels were significantly higher in patients with poor (CPC 3-5) than in patients with good neurological outcome [0-24 h: 75 (43-111) vs. 38 (23-68) fmol/ml, p < 0.001; 24-48 h: 45 (24-77) vs. 23 (16-39) fmol/ml, p < 0.001]. SN determined within the first 48 h showed a receiver operating characteristic (ROC) area under the curve (AUC) of 0.753 (0.665-0.841). NSE in the first 72 h had a ROC-AUC of 0.881 (0.815-0.946). When combining the two biomarkers an AUC of 0.925 (0.878-0.972) for outcome prediction could be reached.
CONCLUSIONS: SN is a promising early biomarker for hypoxic brain injury. Further studies will be required for confirmation of these results.

PMID: 25138227 [PubMed - as supplied by publisher]

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Aug 212014
 
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Weaning from Mechanical Ventilation.

Semin Respir Crit Care Med. 2014 Aug;35(4):451-468

Authors: Shaikh H, Morales D, Laghi F

Abstract
For many critically ill patients admitted to an intensive care unit, the insertion of an endotracheal tube and the initiation of mechanical ventilation (MV) can be lifesaving procedures. Subsequent patient care often requires intensivists to manage the complex interaction of multiple failing organ systems. The shift in the intensivists' focus toward the discontinuation of MV can thus occur late in the course of critical illness. The dangers of MV, however, make it imperative to wean patients at the earliest possible time. Premature weaning trials, however, trigger significant respiratory distress, which can cause setbacks in the patient's clinical course. Premature extubation is also risky. To reduce delayed weaning and premature extubation, a three-step diagnostic strategy is suggested: measurement of weaning predictors, a trial of unassisted breathing (T-tube trial), and a trial of extubation. Since each step constitutes a diagnostic test, clinicians must not only command a thorough understanding of each test but must also be aware of the principles of clinical decision making when interpreting the information generated by each step. Many difficult aspects of pulmonary pathophysiology encroach on weaning management. Accordingly, weaning commands sophisticated, individualized care. Few other responsibilities of an intensivist require a more analytical effort and carry more promise for improving patient outcome than the application of physiologic principles in the weaning of patients.

PMID: 25141162 [PubMed - as supplied by publisher]

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Aug 212014
 
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Ebola 2014 - New Challenges, New Global Response and Responsibility.

N Engl J Med. 2014 Aug 20;

Authors: Frieden TR, Damon I, Bell BP, Kenyon T, Nichol S

Abstract
Since Ebola virus was first identified in 1976, no previous Ebola outbreak has been as large or persistent as the current epidemic, and none has spread beyond East and Central Africa.(1) To date, more than 1000 people, including numerous health care workers, have been killed by Ebola virus disease (EVD) in 2014, and the number of cases in the current outbreak now exceeds the number from all previous outbreaks combined. Indirect effects include disruption of standard medical care, including for common and deadly conditions such as malaria, and substantial economic losses, insecurity, and social disruption in countries that were already . . .

PMID: 25140858 [PubMed - as supplied by publisher]

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Aug 212014
 
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The International Ebola Emergency.

N Engl J Med. 2014 Aug 20;

Authors: Briand S, Bertherat E, Cox P, Formenty P, Kieny MP, Myhre JK, Roth C, Shindo N, Dye C

Abstract
On August 8, 33 weeks into the longest, largest, and most widespread Ebola outbreak on record, the World Health Organization (WHO) declared the epidemic to be a Public Health Emergency of International Concern (PHEIC). This declaration was not made lightly. A PHEIC is an instrument of the International Health Regulations (IHR) - a legally binding agreement made by 196 countries on containment of major international health threats. The August 8 statement made by WHO Director-General Margaret Chan followed advice from the independent IHR Emergency Committee. Reviewing all the available evidence, the committee concluded that further international spread of Ebola could . . .

PMID: 25140855 [PubMed - as supplied by publisher]

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