Entries from March 2008
Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy.
Circulation. 2008 Mar 11;117(10):1283-91
Authors: Shaw LJ, Berman DS, Maron DJ, Mancini GB, Hayes SW, Hartigan PM, Weintraub WS, O’Rourke RA, Dada M, Spertus JA, Chaitman BR, Friedman J, Slomka P, Heller GV, Germano G, Gosselin G, Berger P, Kostuk WJ, Schwartz RG, Knudtson M, Veledar E, Bates ER, McCallister B, Teo KK, Boden WE,
BACKGROUND: Extent and severity of myocardial ischemia are determinants of risk for patients with coronary artery disease, and ischemia reduction is an important therapeutic goal. The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) nuclear substudy compared the effectiveness of percutaneous coronary intervention (PCI) for ischemia reduction added to optimal medical therapy (OMT) with the use of myocardial perfusion single photon emission computed tomography (MPS). METHODS AND RESULTS: Of the 2287 COURAGE patients, 314 were enrolled in this substudy of serial rest/stress MPS performed before treatment and 6 to 18 months (mean=374+/-50 days) after randomization using paired exercise (n=84) or vasodilator stress (n=230). A blinded core laboratory analyzed quantitative MPS measures of percent ischemic myocardium. Moderate to severe ischemia encumbered > or = 10% myocardium. The primary end point was > or = 5% reduction in ischemic myocardium at follow-up. Treatment groups had similar baseline characteristics. At follow-up, the reduction in ischemic myocardium was greater with PCI+OMT (-2.7%; 95% confidence interval, -1.7%, -3.8%) than with OMT (-0.5%; 95% confidence interval, -1.6%, 0.6%; P<0.0001). More PCI+OMT patients exhibited significant ischemia reduction (33% versus 19%; P=0.0004), especially patients with moderate to severe pretreatment ischemia (78% versus 52%; P=0.007). Patients with ischemia reduction had lower unadjusted risk for death or myocardial infarction (P=0.037 [risk-adjusted P=0.26]), particularly if baseline ischemia was moderate to severe (P=0.001 [risk-adjusted P=0.08]). Death or myocardial infarction rates ranged from 0% to 39% for patients with no residual ischemia to > or = 10% residual ischemia on follow-up MPS (P=0.002 [risk-adjusted P=0.09]). CONCLUSIONS: In COURAGE patients who underwent serial MPS, adding PCI to OMT resulted in greater reduction in ischemia compared with OMT alone. Our findings suggest a treatment target of > or = 5% ischemia reduction with OMT with or without coronary revascularization.
PMID: 18268144 [PubMed - indexed for MEDLINE]
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Tags: Circulation
Poor communication, poor training, and chaotic drug rounds contribute to drug errors.
BMJ. 2008 Mar 15;336(7644):581
Authors: Tonks A
PMID: 18340065 [PubMed - indexed for MEDLINE]
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Tags: BMJ
Don’t add aspirin for associated stable vascular disease in a patient with atrial fibrillation receiving anticoagulation.
BMJ. 2008 Mar 15;336(7644):614-5
Authors: Lip GY
PMID: 18340078 [PubMed - indexed for MEDLINE]
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Tags: BMJ
Prescribing for older people.
BMJ. 2008 Mar 15;336(7644):606-9
Authors: Milton JC, Hill-Smith I, Jackson SH
PMID: 18340075 [PubMed - indexed for MEDLINE]
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Tags: BMJ
Hospital-based study of viridans streptococcal bacteraemia in children and adults.
J Infect. 2008 Feb;56(2):103-7
Authors: Tan LK, Lacey S, Mandalia S, Melzer M
OBJECTIVES: To assess the proportion and clinical significance of bacteraemia caused by viridans streptococci (VS) in immunocompetent adults and children. METHODS: Over a 25-month period, we collected data on all patients with VS bacteraemia at a UK district general hospital. RESULTS: VS caused 50/723 (6.9%) adult and 13/106 (12.3%) paediatric community-acquired bacteraemias. Of the 43 adult and 12 paediatric patient notes reviewed, 26 (47.3%) cultures were of ‘definite’ or ‘probable’ clinical significance. No patients were neutropenic and overall penicillin resistance was 11/55 (20.0%). Amongst adults, there were five (11.6%) confirmed or suspected cases of infective endocarditis compared to none in the paediatric cohort. Similar proportions of adults (16.3%) and children (16.7%) had lower respiratory tract infections. Among non-significant cultures, a history of seizures was observed in one (1.3%) adult and four (33.3%) children (p=0.008). Thirty-day mortality was 7.3%. No children and four adults died, one directly attributable to infection. Median adult inpatient stay was 11 days compared to 2 days in the paediatric population (p=0.003). CONCLUSION: Despite cases of infective endocarditis and an incidence of penicillin resistance of 20%, mortality directly attributable to VS infection in immunocompetent adults and children was rare.
PMID: 18068805 [PubMed - indexed for MEDLINE]
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Tags: J Infect
Differences between low-molecular-weight and unfractionated heparin for venous thromboembolism prevention following ischemic stroke: a metaanalysis.
Chest. 2008 Jan;133(1):149-55
Authors: Shorr AF, Jackson WL, Sherner JH, Moores LK
BACKGROUND: Venous thromboembolism (VTE) remains a major cause of morbidity following stroke. The optimal form of pharmacologic prophylaxis following stroke is unknown. METHODS: We identified randomized trials comparing unfractionated heparin (UFH) to low-molecular-weight heparin (LMWH) for VTE prevention in ischemic stroke patients. We focused on the risk for VTE, pulmonary embolism (PE), bleeding, and mortality as a function of the type of agent used for prophylaxis. Findings were pooled with a random-effects model. RESULTS: We identified three trials including 2,028 patients. Two of the studies were blinded, two studies relied on enoxaparin, while one study utilized certoparin. In two studies, UFH was administered three times a day, while it was administered twice daily in the remaining study. The use of LMWH was associated with a significant risk reduction for any VTE (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.41 to 0.70; p < 0.001). Limiting the analysis to proximal VTEs also indicated that LMWHs were superior (OR with LMWH vs UFH, 0.53; 95% CI, 0.37 to 0.75; p < 0.001). LMWH use led to fewer PEs as well (OR, 0.26; 95% CI, 0.07 to 0.95; p = 0.042). There were no differences in rates of overall bleeding, intracranial hemorrhage, or mortality based on the type of agent employed. Restricting the analysis to the reports employing enoxaparin did not alter our findings. CONCLUSIONS: The prophylactic use of LMWH compared to UFH following ischemic stroke is associated with a reduction in both VTE and PE. This benefit is not associated with an increased incidence of bleeding. Broader use of LMWH for VTE prevention after ischemic stroke is warranted.
PMID: 17925410 [PubMed - indexed for MEDLINE]
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Tags: Chest
Pharmacotherapy of asthma: what do the 2007 NAEPP guidelines say?
Allergy Asthma Proc. 2007 Nov-Dec;28(6):628-33
Authors: Schatz M
The purpose of this article is to review the recommendations for pharmacotherapy in the new National Asthma Education and Prevention Program (NAEPP) guidelines. There are four main changes regarding pharmacotherapy in the updated guidelines. First, the recommendations for three age groups (0-4 years, 5-11 years, and > or =12 years) are presented separately. Second, the steps of therapy have been expanded from 4 steps to 6 steps to simplify the action within each step. Third, medium dose inhaled corticosteroids (ICS) or low-dose ICS plus add-on therapy are recommended for patients 5 years of age and older who are not controlled on low dose ICS. Finally, consideration of omalizumab is recommended for allergic patients 12 years of age and older who are not controlled on medium dose ICS plus long-acting beta agonists. For all age groups, the first step of therapy is inhaled short-acting beta agonists as needed and the second step is low dose ICS. Oral corticosteroids are part of step 6 therapy for all age groups. In patients not already on long-term control medications, the step of initiation of therapy is based on the assessment of severity. In patients on long-term control medications, therapy is adjusted based on the level of asthma control. If the patient is not well controlled, therapy is usually advanced one step. If the patient is very poorly controlled, consider stepping up two steps, a course of oral corticosteroids, or both. It is hoped that the updated NAEPP guidelines will lead to improved quality of life for patients with asthma.
PMID: 18201425 [PubMed - indexed for MEDLINE]
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Tags: Allergy Asthma Proc
Uncomplicated urinary tract infection in adults including uncomplicated pyelonephritis.
Urol Clin North Am. 2008 Feb;35(1):1-12, v
Authors: Nicolle LE
Acute uncomplicated urinary tract infection and acute pyelonephritis are very common infections affecting many women throughout their lives. The determinants of infection have been well described and current strategies to prevent recurrent infections are highly effective. While antimicrobial management is straightforward for most episodes, the evolution of antimicrobial susceptibility of E. coli in community-acquired infection requires continuing re-evaluation of appropriate empiric therapy.
PMID: 18061019 [PubMed - indexed for MEDLINE]
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Tags: Urol Clin North Am
Catastrophic antiphospholipid syndrome: report of 4 cases.
J Nephrol. 2007 Nov-Dec;20(6):739-44
Authors: Sinico RA, Di Toma L, Sabadini E, Renoldi P, Li Vecchi M
Catastrophic antiphospholipid syndrome (CAPS), described by Asherson in 1992, is a rare form of antiphospholipid syndrome resulting in multiorgan failure with a mortality rate of about 50%. The syndrome occurs in patients with either systemic lupus erythematosus and other rheumatic diseases (systemic sclerosis, rheumatoid arthritis, primary Sjogren syndrome) or alone. Whereas in “classic” antiphospholipid syndrome (APS), medium-large vessels are involved, a diffuse small vessel ischemia and thrombosis (microangiopathic disease) leading to a severe multiorgan dysfunction is predominant in CAPS. “Trigger” factors have been demonstrated in 45% of patients, but in the majority, they remain unknown. Not infrequently, CAPS arises in patients without any previous thrombotic history. The kidney is the organ most commonly affected, followed by the lung, the central nervous system, the heart and the skin. Disseminated intravascular coagulation occurs in approximately 13% of patients. The present study reports the clinical and serological features of 4 patients affected by this rare form of antiphospholipid syndrome. Nephrologists should be aware of the possibility of this syndrome as a cause of multiorgan failure since prompt recognition is essential for effective treatment.
PMID: 18046677 [PubMed - indexed for MEDLINE]
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Tags: J Nephrol
Vitamin D and cardiovascular disease risk.
Curr Opin Clin Nutr Metab Care. 2008 Jan;11(1):7-12
Authors: Michos ED, Melamed ML
PURPOSE OF REVIEW: Despite our understanding of how to prevent and treat traditional cardiovascular risk factors, cardiovascular disease remains the leading cause of death of both men and women in the US. Thus, there is widespread interest in a number of emerging nontraditional risk factors for the detection of early cardiovascular disease in order to implement aggressive preventive therapies. 25-Hydroxyvitamin D deficiency has been identified as a potential novel cardiovascular disease risk factor. This review outlines what is known about the association of 25-hydroxyvitamin D levels and cardiovascular disease risk. RECENT FINDINGS: Low 25-hydroxyvitamin D levels have been associated with the cardiovascular disease risk factors of hypertension, obesity, diabetes mellitus and the metabolic syndrome, as well as cardiovascular disease events including stroke and congestive heart failure. Studies suggest vitamin D deficiency may be a contributor to the development of cardiovascular disease potentially through associations with diabetes or hypertension. SUMMARY: Vitamin D deficiency is easy to screen for and easy to treat with supplementation. Further larger observational studies and randomized clinical trials are, however, needed to determine whether vitamin D supplementation could have any potential benefit in reducing future cardiovascular disease events and mortality risk.
PMID: 18090651 [PubMed - indexed for MEDLINE]
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Tags: Curr Opin Clin Nutr Metab Care
Antifungal management in cancer patients.
Wien Med Wochenschr. 2007;157(19-20):503-10
Authors: Staber P, Langner S, Dornbusch HJ, Neumeister P
Invasive fungal infections (IFI) are a major cause of morbidity and mortality in cancer patients receiving myelotoxic chemotherapy. Established risk factors are previous fungal infection, neutropenia exceeding 10 days, older age, active cancer, corticosteroid therapy, administration of broad spectrum antibiotics, allogeneic HSCT, central venous catheter and organ dysfunction. The strategies to manage IFI comprise chemoprophylaxis, preemptive, empirical and directed antifungal therapy. Benefit of antifungal prophylaxis has been proven for fluconazole (400 mg/d) in allogeneic transplant recipients, and for posaconazole (600 mg/d) in patients during AML/MDS induction chemotherapy as well as in patients with GvHD. Pre-emptive therapy based on sensitive diagnostic non-culture methods needs further validation in larger randomized studies before becoming a standard. Empirical antifungal therapy is well established and should consist of either liposomal amphotericin B, itraconazole, voriconazole, or caspofungin. In patients with documented invasive aspergillosis, therapy with voriconazole is the treatment of choice. Liposomal amphotericin B is a good alternative candidate and caspofungin is reserved for salvage treatment. Invasive candidiasis should be treated with caspofungin or one of the lipid based amphotericin B formulations. Since non-albicans species are increasingly observed, the use of fluconazole is reserved for “stable”, non-neutropenic patients.
PMID: 18030555 [PubMed - indexed for MEDLINE]
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Tags: Wien Med Wochenschr
An evidence-based approach to the first seizure.
Epilepsia. 2008;49 Suppl 1:50-7
Authors: Wiebe S, Téllez-Zenteno JF, Shapiro M
Evidence-based care (EBC) is an explicit approach to applying the best evidence to the care of individual patients. We outline the basic principles of EBC and apply them to various clinical questions pertaining to a patient presenting with a first seizure, providing a summary of the best available evidence for each question. Depending on the question at hand, the evidence derives from retrospective, prospective, and randomized controlled studies in children and adults. There is solid evidence that early seizure recurrence is reduced by early initiation of AEDs. A meta-analysis of six randomized trials revealed an average absolute risk reduction of 34% (95% CI 15-52) with AED therapy. However, the prognosis for the development of epilepsy is not altered by early intervention. EEG epileptiform abnormalities, family history of epilepsy, imaging lesions, and remote symptomatic seizures increase the risk of recurrence, and impact the risk-benefit ratio of treatment after a single event. In the end, clinicians must evaluate patients with a first unprovoked seizure on a case-by-case basis to determine the appropriateness of treatment with a given AED.
PMID: 18184156 [PubMed - indexed for MEDLINE]
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Tags: Epilepsia
Management of a first seizure. Special problems: adults and elderly.
Epilepsia. 2008;49 Suppl 1:45-9
Authors: Stephen LJ, Brodie MJ
A first seizure out of a clear blue sky can be a major life-changing event. Careful history-taking and appropriate investigation together with a clear explanation provided to patient and family are an essential requirement. Although for most patients, pharmacotherapy can be withheld and events awaited, there are circumstances where introduction of antiepileptic drug (AED) therapy should be considered. Medical causes of seizures should also be sought and treated. In addition, a first seizure in HIV-positive patients and in those with underlying neurocysticercosis should usually provoke the introduction of AED therapy. Particular problems can occur in patients with a single episode of provoked status epilepticus, a first tonic-clonic seizure during pregnancy and, particularly, an unprovoked event in older and learning disabled people. Treatment following a first seizure should balance risk factors for recurrence with the informed opinion of the patients and their family.
PMID: 18184155 [PubMed - indexed for MEDLINE]
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Tags: Epilepsia
First seizure: EEG and neuroimaging following an epileptic seizure.
Epilepsia. 2008;49 Suppl 1:19-25
Authors: Pohlmann-Eden B, Newton M
An early EEG (within 48 h) and high-resolution magnetic resonance imaging (hr_MRI) are the methods of choice for an accurate diagnosis after a first seizure presentation. Together with a careful history and examination, they will allow definition of the epilepsy syndrome in two-thirds of patients and help assess the individual risk for seizure recurrence, which is determined by the specific syndrome and is highest with focal epileptiform activity on EEG. Despite the heterogeneity of first seizure studies, EEG and etiology are consistently found to be the best predictors for seizure recurrence and prognosis. The additional yield of sleep-deprived EEG and sleep EEG is uncertain; yet MRI is essential for detecting brain tumors and other structural bases for new epilepsy. The rate occurrence of remote symptomatic seizures increases significantly with age and the most common etiology in the elderly with a first seizure is stroke; however, its exact relevance to epileptogenicity is yet to be defined. There is a striking lack of systematic studies using early EEG and hr_MRI in order to better characterize epileptogenic areas and elucidate the mechanisms of seizure provocation.
PMID: 18184150 [PubMed - indexed for MEDLINE]
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Tags: Epilepsia
Risk of recurrence after a first unprovoked seizure.
Epilepsia. 2008;49 Suppl 1:13-8
Authors: Berg AT
The risk of recurrence after a first unprovoked seizure has been examined in numerous observational studies and two large, high-quality randomized trials. Overall, in untreated individuals, 40-50% can expect a recurrence within 2 years of the initial seizure. Treatment may reduce this risk by as much as half. Those at the greatest risk of recurrence have either an abnormal EEG or an identifiable neurological condition or symptoms consistent with one (“symptomatic”). Status epilepticus and a history of febrile seizures may be associated with an increased risk of recurrence in individuals with symptomatic seizures. The great majority of people (approximately 90%) who are seen for a first unprovoked seizure attain a one to two year remission within 4 or 5 years of the initial event.
PMID: 18184149 [PubMed - indexed for MEDLINE]
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Tags: Epilepsia
