Entries from March 2008
Effectiveness of ezetimibe alone or in combination with twice a week Atorvastatin (10 mg) for statin intolerant high-risk patients.
Am J Cardiol. 2008 Feb 15;101(4):483-5
Authors: Athyros VG, Tziomalos K, Kakafika AI, Koumaras H, Karagiannis A, Mikhailidis DP
This study was undertaken to investigate the effect of ezetimibe (10 mg/day) alone or in combination with atorvastatin (10 mg twice a week) on hypercholesterolemia in 56 high-risk patients intolerant to daily statin use. Ezetimibe monotherapy was well tolerated (2 withdrawals) and induced a mean reduction in low-density lipoprotein (LDL) cholesterol of 20% (p <0.05) at the third month. However, of the 54 patients still taking ezetimibe, only 5 (9%) were at their LDL cholesterol targets. Atorvastatin 10 mg twice a week was then added to ezetimibe and was well tolerated (3 withdrawals). This combination reduced LDL cholesterol (in a treatment-based analysis) by 37% compared with baseline (p <0.001), with 43 (84%) patients reaching their LDL cholesterol goals. When patients (n = 34, 25 men) with baseline serum creatinine values in the upper 2 tertiles were analyzed separately, there was a significant (p = 0.041) decrease in serum creatinine levels after 6 months of treatment. In conclusion, the combination of ezetimibe plus atorvastatin 10 mg twice a week might be a therapeutic option for high-risk patients intolerant to daily statin monotherapy.
PMID: 18312762 [PubMed - indexed for MEDLINE]
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Tags: Am J Cardiol
Efficacy and tolerability of fluvastatin XL 80 mg alone, ezetimibe alone, and the combination of fluvastatin XL 80 mg with ezetimibe in patients with a history of muscle-related side effects with other statins.
Am J Cardiol. 2008 Feb 15;101(4):490-6
Authors: Stein EA, Ballantyne CM, Windler E, Sirnes PA, Sussekov A, Yigit Z, Seper C, Gimpelewicz CR
Although statin treatment is generally well tolerated, it is estimated that 5% to 10% of patients develop muscle-related side effects (MRSEs), resulting in less effective nonstatin alternatives or cessation of lipid-lowering therapy completely. This study was designed to assess the efficacy and tolerability of extended-release fluvastatin (fluvastatin XL) and ezetimibe alone or in combination in patients with previous MRSEs with other statins. This was a double-blinded, double-dummy trial of 199 mostly moderate- or high-risk dyslipidemic patients randomized to fluvastatin XL 80 mg/day (n = 69), ezetimibe 10 mg/day (n = 66), or fluvastatin XL 80 mg/day plus ezetimibe 10 mg/day (n = 64) for 12 weeks. Fluvastatin XL lowered low-density lipoprotein (LDL) cholesterol by 32.8% compared with 15.6% with ezetimibe (between-group difference -17.1%, 95% confidence interval -23.6 to -10.7, p <0.0001); the fluvastatin XL/ezetimibe combination lowered LDL cholesterol by 46.1% (between-group difference vs ezetimibe -30.4%, 95% confidence interval -37.0 to -23.8, p <0.0001). Proportions of patients achieving their National Cholesterol Education Program Adult Treatment Panel III target LDL cholesterol were 84% with the fluvastatin XL/ezetimibe combination, 59% with fluvastatin XL, and 29% with ezetimibe (p <0.001 for fluvastatin XL monotherapy or combination therapy vs ezetimibe monotherapy). Incidences of MRSEs were 24% in the ezetimibe group, 17% in the fluvastatin XL group, and 14% in the combination group. There were no instances of creatine kinase increases >or=10 times upper limit of normal. In conclusion, in patients with a history of statin-associated MRSEs, fluvastatin XL alone or in combination with ezetimibe offers an effective and well-tolerated lipid-lowering option.
PMID: 18312764 [PubMed - indexed for MEDLINE]
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Tags: Am J Cardiol
Emerging options for the management of fecal incontinence in hospitalized patients.
J Wound Ostomy Continence Nurs. 2008 Jan-Feb;35(1):104-10
Authors: Wishin J, Gallagher TJ, McCann E
Fecal incontinence is a common problem among hospitalized patients. It predisposes them to complications such as infections and pressure ulcers, resulting in added morbidity and increased length of stay. Despite the prevalence and clinical implications of fecal incontinence, relatively few well-designed studies have been completed assisting clinicians to determine which management strategies prevent complications most effectively. This article will review the prevalence and consequences of fecal incontinence in hospitalized patients and will provide practical suggestions for the management of fecal incontinence, including both traditional care according to clinical guidelines and the role of newer fecal collection devices.
PMID: 18199946 [PubMed - indexed for MEDLINE]
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Tags: J Wound Ostomy Continence Nurs
Managing an acute pain crisis in a patient with advanced cancer: “this is as much of a crisis as a code”.
JAMA. 2008 Mar 26;299(12):1457-67
Authors: Moryl N, Coyle N, Foley KM
The assessment and management of an acute pain crisis in the setting of advanced illness is challenging. Using the case of Mr X, a 33-year-old man with advanced metastatic mucinous adenocarcinoma of the appendix and “15 out of 10″ pain, we explore the issues of acute pain and its management. We define a pain crisis as an event in which the patient reports pain that is severe, uncontrolled, and causing distress for the patient, family members, or both. Our management strategy focuses on making a pain diagnosis, differentiating reversible from intractable causes of pain, and making decisions about further workup; selecting the opioid and monitoring and treating opioid adverse effects; titrating and rotating opioid and coanalgesics; consulting experts to treat a pain crisis as quickly as possible to prevent unnecessary suffering; and co-opting the available institutional resources. The timely intervention of a palliative care team and its expertise can provide the staff, patients, and their families the benefit of an interdisciplinary approach and help the patients address goals of care; understand the benefits and risks of treatment decisions; and meet the psychological, social, and existential needs of the patient and the family commonly seen in this setting.
PMID: 18364488 [PubMed - indexed for MEDLINE]
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Tags: JAMA
Usefulness of preoperative oral glucose tolerance testing for perioperative risk stratification in patients scheduled for elective vascular surgery.
Am J Cardiol. 2008 Feb 15;101(4):526-9
Authors: Dunkelgrun M, Schreiner F, Schockman DB, Hoeks SE, Feringa HH, Goei D, Schouten O, Welten GM, Vidakovic R, Noordzij PG, Boersma E, Poldermans D
Patients scheduled for major vascular surgery are screened for cardiac risk factors using standardized risk indexes, including diabetes mellitus (DM). Screening in patients without a history of DM includes fasting glucose measurement. However, an oral glucose tolerance test (OGTT) could significantly improve the detection of DM and impaired glucose tolerance (IGT) and the prediction of perioperative cardiac events. In a prospective study, 404 consecutive patients without signs or histories of IGT or DM were included and subjected to OGTT. The primary study end point was the composite of perioperative myocardial ischemia, assessed by 72-hour Holter monitoring using ST-segment analysis and troponin release. The primary end point was noted in 21% of the patients. IGT was diagnosed in 104 patients (25.7%), and new-onset DM was detected in 43 patients (10.6%). The OGTT detected 75% of the patients with IGT and 72% of the patients with DM. Preoperative glucose levels significantly predicted the risk for perioperative cardiac ischemia; odds ratios for DM and IGT were, respectively, 3.2 (95% confidence interval 1.3 to 8.1) and 1.4 (95% confidence interval 0.7 to 3.0). In conclusion, the prevalence of undiagnosed IGT and DM is high in vascular patients and is associated with perioperative myocardial ischemia. Therefore, an OGTT should be considered for all patients who undergo elective vascular surgery.
PMID: 18312771 [PubMed - indexed for MEDLINE]
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Tags: Am J Cardiol
Vascular dementia.
Top Stroke Rehabil. 2008 Jan-Feb;15(1):22-6
Authors: Schneck MJ
Vascular dementia (VaD) is the second most common form of dementia after Alzheimer’s dementia (AD). It is characterized by loss of executive function with milder memory loss as compared with AD and is associated with cerebral brain infarction or hemorrhage. Treatment is predominantly focused on cardiovascular risk factor reduction, but anticholinesterase inhibitors and memantine may play a role. The data is most robust for donepezil.
PMID: 18250070 [PubMed - indexed for MEDLINE]
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Tags: Top Stroke Rehabil
Acinetobacter infection.
N Engl J Med. 2008 Mar 20;358(12):1271-81
Authors: Munoz-Price LS, Weinstein RA
PMID: 18354105 [PubMed - indexed for MEDLINE]
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Tags: N Engl J Med
New directions in Medicaid payment for hospital care.
Health Aff (Millwood). 2008 Jan-Feb;27(1):269-80
Authors: Quinn K
Medicaid now pays for 20 percent of all inpatient stays and plays an especially important role in funding obstetric, pediatric, and mental health care. In coming years, policy decisions on inpatient payment may be the most consequential since diagnosis-related groups (DRGs) were introduced two decades ago. This study describes Medicaid’s growing role in purchasing inpatient care, reports Medicaid-specific results from an evaluation of three DRG algorithms, provides a case study of a new payment method designed in Mississippi, and summarizes recent developments in paying for quality.
PMID: 18180503 [PubMed - indexed for MEDLINE]
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Tags: Health Aff (Millwood)
Prophylactic antibiotics cannot reduce infected pancreatic necrosis and mortality in acute necrotizing pancreatitis: evidence from a meta-analysis of randomized controlled trials.
Am J Gastroenterol. 2008 Jan;103(1):104-10
Authors: Bai Y, Gao J, Zou DW, Li ZS
BACKGROUND: There is no agreement whether intravenous prophylactic antibiotics can reduce infected pancreatic necrosis and mortality in acute necrotizing pancreatitis (ANP). We performed a meta-analysis comparing intravenous antibiotics with placebo or no treatment in randomized controlled trials (RCTs). METHODS: Databases including MEDLINE, EMBASE, the Cochrane controlled trials register, the Cochrane Library, and Science Citation Index were searched to find relevant trials. Outcome measures were infected necrosis and mortality. RESULTS: Seven trials involving 467 patients were included. Analysis suggested infected pancreatic necrosis rates were not significantly different (antibiotics 17.8%, controls 22.9%), RR 0.81 (95% CI 0.54-1.22). There was nonsignificantly decreased mortality with antibiotics (9.3%) versus controls (15.2%), RR 0.70 (95% CI 0.42-1.17). Subsequent subgroup analysis confirmed antibiotics were not statistically superior to controls in reduction of infected necrosis and mortality. CONCLUSIONS: Prophylactic antibiotics cannot reduce infected pancreatic necrosis and mortality in patients with ANP.
PMID: 17925000 [PubMed - indexed for MEDLINE]
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Tags: Am J Gastroenterol
Prolonged cholestasis following successful removal of common bile duct stones: beware patients on estrogen therapy.
World J Gastroenterol. 2007 Dec 14;13(46):6277-80
Authors: Dunn JM, McNair A
There are various well described forms of chronic cholestatic jaundice in adults, such as autoimmune cholangitis, drug-induced cholangitis and intrahepatic cholestasis of pregnancy. We present two cases of prolonged cholestasis following removal of gallstones at endoscopic retrograde cholangiopancreatography (ERCP) and subsequent clear cholangiography. Both patients were taking oral estrogens at the time of presentation, which were subsequently withdrawn. The first case responded rapidly to corticosteroid treatment, and the second case had a much slower resolution with ursodeoxycholic acid. Both cases highlighted the significance of estrogen-induced cholestasis in female patients with protracted jaundice following ERCP and removal of intra-ductal stones. After oral estrogens are discontinued, a short course of steroids needs to be considered.
PMID: 18069774 [PubMed - indexed for MEDLINE]
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Tags: World J Gastroenterol
Independent prognostic value of C-reactive protein and coronary artery disease extent in patients affected by unstable angina.
Atherosclerosis. 2008 Feb;196(2):779-85
Authors: Niccoli G, Biasucci LM, Biscione C, Fusco B, Porto I, Leone AM, Bona RD, Dato I, Liuzzo G, Crea F
BACKGROUND: Previous studies have reported conflicting results on the association between C-reactive protein (CRP) and extent of atherosclerosis, suggesting that the association between CRP and outcome in patients with acute coronary syndromes is independent of coronary artery disease extent. We tested this hypothesis in a selected population of patients with unstable angina undergoing coronary angiography. METHODS: Ninety-seven consecutive patients with unstable angina were enrolled in this single-centre study. All patients underwent coronary angiography. CRP was measured by an ultrasensitive nephelometric method. We also measured serum levels of soluble CD40 ligand by ELISA and plasma fibrinogen levels by use of the Clauss method. Atherosclerotic disease severity and extent were assessed by angiography using the Bogaty score. The extent index refers to the proportion of the coronary tree affected by detectable atheroma on angiography. The primary end-point at 6 months was a composite of: (a) death, (b) myocardial infarction, and (c) recurrence of unstable angina requiring hospitalization. Cardiac death was the secondary end-point. RESULTS: No significant correlation was found between baseline CRP serum levels and angiographic measures of atherosclerotic disease severity and extent, whereas a trend for a significant correlation was found between soluble CD40 ligand and extent index (p=0.06). Diabetic patients exhibited a higher extent index compared to non-diabetic patients (0.94+/-0.1 versus 0.7+/-0.04, p=0.04). Predictors of primary end-point at both univariate and multivariate analysis were: extent index (p=0.04 and 0.04, respectively), CRP levels (p=0.05 and 0.02, respectively), and lack of revascularization (p=0.03 and 0.02, respectively). Fibrinogen levels were the only independent predictor of cardiac death at follow-up (p=0.04). CONCLUSION: In this study we demonstrate that in patients with unstable angina, CRP serum levels and coronary atherosclerosis are not correlated, but both are independently associated with a worse outcome at 6-month follow-up.
PMID: 17306806 [PubMed - indexed for MEDLINE]
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Tags: Atherosclerosis
Metabolic syndrome and risk of development of atrial fibrillation: the Niigata preventive medicine study.
Circulation. 2008 Mar 11;117(10):1255-60
Authors: Watanabe H, Tanabe N, Watanabe T, Darbar D, Roden DM, Sasaki S, Aizawa Y
BACKGROUND: The metabolic syndrome consists of a cluster of atherosclerotic risk factors, many of which also have been implicated in the genesis of atrial fibrillation (AF). However, the precise role of the metabolic syndrome in the development of AF is unknown. METHODS AND RESULTS: This prospective, community-based, observational cohort study was based on an annual health check-up program in Japan. We studied 28 449 participants without baseline AF. We used 2 different criteria for the metabolic syndrome–the guidelines of the National Cholesterol Education Program Third Adult Treatment Panel (NCEP-ATP III) and those of the American Heart Association/National Heart, Lung, and Blood Institute (AHA/NHLBI)–to study the risk of development of new-onset AF. The metabolic syndrome was present in 3716 subjects (13%) and 4544 subjects (16%) using the NCEP-ATP III and AHA/NHLBI definitions, respectively. During a mean follow-up of 4.5 years, AF developed in 265 subjects (105 women). Among the metabolic syndrome components, obesity (age- and sex-adjusted hazard ratio [HR], 1.64), elevated blood pressure (HR, 1.69), low high-density lipoprotein cholesterol (HR, 1.52), and impaired insulin tolerance (HR, 1.44 [NCEP-ATP III] and 1.35 [AHA/NHLBI]) showed an increased risk for AF. The association between the metabolic syndrome and AF remained significant in subjects without treated hypertension or diabetes by the NCEP-ATP III definition (HR, 1.78) but not by the AHA/NHLBI definition (HR, 1.28). CONCLUSIONS: The metabolic syndrome was associated with increased risk of AF. The metabolic derangements of the syndrome may be important in the pathogenesis of AF.
PMID: 18285562 [PubMed - indexed for MEDLINE]
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Tags: Circulation
Radiofrequency ablation of renal tumors.
Tech Vasc Interv Radiol. 2007 Jun;10(2):132-9
Authors: Stone MJ, Venkatesan AM, Locklin J, Pinto P, Linehan M, Wood BJ
Radiofrequency ablation (RFA) of renal tumors is a promising technique that plays a unique and increasingly important role in urologic oncology practices. RFA is appealing as a minimally invasive therapy that may be performed on an outpatient basis. It enables treatment of an area 3 to 5 cm in diameter, with relatively low morbidity and mortality rates. Most interventional radiologists (IRs) are familiar with RFA of liver tumors, and several principles and techniques used in the liver may be extrapolated for use in the kidney. However, it is crucial to bear in mind that local tumor ablation in the kidney presents unique challenges, secondary to the kidney’s unique anatomic and physiologic features. Clinical and technical considerations, risks, and complications pertaining to RFA of renal tumors are reviewed here, including approaches commonly used in our practice.
PMID: 18070691 [PubMed - indexed for MEDLINE]
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Tags: Tech Vasc Interv Radiol
Statins and sepsis.
Br J Anaesth. 2008 Mar;100(3):288-98
Authors: Gao F, Linhartova L, Johnston AM, Thickett DR
Severe sepsis and septic shock is common and frequently fatal. Over the last few years, the primary treatments demonstrated to improve outcome from several major clinical trials have finally emerged. However, translating these recent therapeutic advances to routine clinical practice has proven controversial, and new approaches of additional strategies are continued to be developed. Given their pleiotropic effects related to many pathophysiological determinants of sepsis, statin therapy could be the next step in the search for adjuvant therapy. A future challenge may be to test both the efficacy and the safety by large randomized controlled clinical trials ascertaining the effects of statins administered at the onset of sepsis and in patients with severe sepsis or septic shock admitted into intensive care units.
PMID: 18276651 [PubMed - indexed for MEDLINE]
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Tags: Br J Anaesth
Invasive pulmonary aspergillosis in neutropenic patients and the influence of hospital renovation.
Mycoses. 2008 Mar;51(2):117-22
Authors: Pini G, Faggi E, Donato R, Sacco C, Fanci R
To evaluate the effects of airborne Aspergillus contamination during and after the renovation work of a Florentine haematology unit, we conducted (November 2003-January 2005) a strict programme of environmental fungal surveillance. Air samples were taken from patients’ rooms, along the corridors inside the wards, along the corridor between wards and outside the building. The concentration of Aspergillus fumigatus was high along the corridor between the two haematology wards (2.98 CFU m(-3)), lower in the non-neutropenic patients’ rooms and outside the hospital building (1.53 and 1.42 CFU m(-3), respectively), very low in the neutropenic patients’ rooms (0.09 CFU m(-3)). During this period, three proven cases (A. fumigatus), two probable ones and two possible cases of invasive pulmonary aspergillosis were documented in 97 patients with acute leukaemia (7%). The three cases of proven aspergillosis coincided with the period of renovation work and with the period in which we have found the maximum concentration of A. fumigatus along the corridor. These data suggest a possible relationship between environmental fungal contamination and the incidence of invasive aspergillosis, and underline the importance of environmental surveillance.
PMID: 18254747 [PubMed - indexed for MEDLINE]
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Tags: Mycoses
