Entries from June 2008
Acute nonvariceal upper gastrointestinal bleeding: endoscopic diagnosis and therapy.
Med Clin North Am. 2008 May;92(3):511-50, vii-viii
Authors: Cappell MS, Friedel D
Acute upper gastrointestinal bleeding is a relatively common,potentially life-threatening condition that causes more than 300,000 hospital admissions and about 30,000 deaths per annum in America. Esophagogastroduodenoscopy is the procedure of choice for the diagnosis and therapy of upper gastrointestinal bleeding lesions. Endoscopic therapy is indicated for lesions with high risk stigmata of recent hemorrhage, including active bleeding, oozing, a visible vessel, and possibly an adherent clot. Endoscopic therapies include injection therapy, such as epinephrine or sclerosant injection; ablative therapy, such as heater probe or argon plasma coagulation; and mechanical therapy, such as endoclips or endoscopic banding. Endoscopic therapy reduces the risk of rebleeding,the need for blood transfusions, the requirement for surgery, and patient morbidity.
PMID: 18387375 [PubMed - indexed for MEDLINE]
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Tags: Med Clin North Am
Portal hypertension and variceal hemorrhage.
Med Clin North Am. 2008 May;92(3):551-74, viii
Authors: Toubia N, Sanyal AJ
Portal hypertension, a major hallmark of cirrhosis, is defined as a portal pressure gradient exceeding 5 mm Hg. In portal hypertension, porto-systemic collaterals decompress the portal circulation and give rise to varices. Successful management of portal hypertension and its complications requires knowledge of the underlying pathophysiology, the pertinent anatomy, and the natural history of the collateral circulation, particularly the gastroesophageal varices.
PMID: 18387376 [PubMed - indexed for MEDLINE]
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Tags: Med Clin North Am
Mechanical obstruction of the small bowel and colon.
Med Clin North Am. 2008 May;92(3):575-97, viii
Authors: Cappell MS, Batke M
Mechanical obstruction of the small bowel and colon is moderately common, accounting for several hundred thousand admissions per year in the United States. Patients generally present with abdominal pain, nausea and emesis, abdominal distention, and progressive obstipation. Clinical findings of high fever, localized severe abdominal tenderness, rebound tenderness, severe leukocytosis, or metabolic acidosis suggest possible complications of bowel necrosis, bowel perforation, or generalized peritonitis. Differentiation of total mechanical obstruction from partial mechanical obstruction and pseudo-obstruction is important because total mechanical obstruction is generally treated surgically,whereas the other two entities are usually treated medically. Mechanical obstruction is usually suggested by plain abdominal radiographs, and confirmed by small bowel follow through,abdominal CT, or CT enteroclysis.
PMID: 18387377 [PubMed - indexed for MEDLINE]
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Tags: Med Clin North Am
Gastrointestinal perforation and the acute abdomen.
Med Clin North Am. 2008 May;92(3):599-625, viii-ix
Authors: Langell JT, Mulvihill SJ
The acute abdomen accounts for up to 40% of all emergency-surgical hospital admissions and is considered in the differential in the more than 7 million visits to the emergency department annually for abdominal pain in the United States. A large percentage of these cases are secondary to perforation or impending gastrointestinal perforation. Gastrointestinal perforation causes considerable mortality and usually requires emergency surgery.Rapid diagnosis and treatment of these conditions is essential to reduce the high morbidity and mortality of late-stage presentation. Successful treatment requires a thorough understanding of the anatomy, microbiology, and pathophysiology of this disease process and in-depth knowledge of the therapy, including resuscitation,antibiotics, source control, and physiologic support.
PMID: 18387378 [PubMed - indexed for MEDLINE]
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Tags: Med Clin North Am
Acute abdominal vascular emergencies.
Med Clin North Am. 2008 May;92(3):627-47, ix
Authors: Shanley CJ, Weinberger JB
Abdominal vascular emergencies are relatively uncommon, frequently catastrophic, and highly lethal. Despite improved understanding of the pathophysiology and natural history of these disorders, delays in diagnosis and treatment remain the most important factors contributing to the observed high mortality. A high index of clinical suspicion together with a sound understanding of the clinical presentation, natural history, and management of these disorders are critical to improving outcomes. This article focuses on abdominal vascular emergencies presenting with acute visceral ischemia or catastrophic intra-abdominal hemorrhage.
PMID: 18387379 [PubMed - indexed for MEDLINE]
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Tags: Med Clin North Am
Adynamic ileus and acute colonic pseudo-obstruction.
Med Clin North Am. 2008 May;92(3):649-70, ix
Authors: Batke M, Cappell MS
Ileus and colonic pseudo-obstruction cause functional obstruction of intestinal transit, without mechanical obstruction, because of uncoordinated or attenuated intestinal muscle contractions. Ileus usually arises from an exaggerated intestinal reaction to abdominal surgery that is often exacerbated by numerous other conditions. Colonic pseudo-obstruction is induced by numerous metabolic disorders, drugs that inhibit intestinal motility, severe illnesses, and extensive surgery. It presents with massive colonic dilatation with variable, moderate small bowel dilatation. Both conditions are initially treated with supportive measures that include intravenous rehydration, correction of electrolyte abnormalities, discontinuation of antikinetic drugs, and treatment of other contributing disorders. Specific therapies for colonic pseudo-obstruction include neostigmine (an anticholinesterase) for pharmacologic colonic decompression and colonoscopic decompression.
PMID: 18387380 [PubMed - indexed for MEDLINE]
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Tags: Med Clin North Am
Severe complications of inflammatory bowel disease.
Med Clin North Am. 2008 May;92(3):671-86, ix
Authors: Marrero F, Qadeer MA, Lashner BA
Patients who have inflammatory bowel disease occasionally develop severe complications or emergency situations that require expert and expedited medical care, including toxic colitis, fistulas, abdominal abscesses, malignancy, primary sclerosing cholangitis, and pouchitis. Morbidity and mortality rates of Crohn’s disease and ulcerative colitis are increased over the expected rates in the unaffected population. Knowledge of the presenting features, natural history, and treatment of these complications should to lead to early and effective therapy and better outcomes.
PMID: 18387381 [PubMed - indexed for MEDLINE]
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Tags: Med Clin North Am
Epidemiology, imaging, and treatment of giant cell arteritis.
Joint Bone Spine. 2008 May;75(3):267-72
Authors: Devauchelle-Pensec V, Jousse S, Destombe C, Saraux A
Giant cell arteritis (GCA) is the most common vasculitis, and epidemiological data indicate a further increase in incidence over the last two decades. The disease predominates in individuals from Scandinavia and other Northern European countries. The impact of GCA on mortality remains unclear, although an increased risk of cardiovascular events has been reported. Most of the complications are related to the use of glucocorticoids to treat the disease. Recently introduced tools for diagnosing GCA include high-resolution Doppler ultrasonography and magnetic resonance imaging (MRI), whose performance remains to be determined. Glucocorticoids constitute the mainstay of the treatment of GCA. Other drugs have been evaluated, including dapsone, hydroxychloroquine, methylprednisolone pulse therapy, azathioprine, cyclosporine, cyclophosphamide, and methotrexate; however, the studies were methodologically flawed and produced conflicting results. No drug has been found effective in reducing glucocorticoid requirements. The role for biotherapies remains unclear, as the promising results obtained in open-label studies were not borne out by controlled trials.
PMID: 18378179 [PubMed - indexed for MEDLINE]
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Tags: Joint Bone Spine
Predictors of early re-bleeding and mortality after acute variceal haemorrhage in patients with cirrhosis.
Gut. 2008 Jun;57(6):814-20
Authors: Bambha K, Kim WR, Pedersen R, Bida JP, Kremers WK, Kamath PS
BACKGROUND AND AIMS: Risk factors for mortality and re-bleeding following acute variceal haemorrhage (AVH) are incompletely understood. The aim of this study was to determine risk factors for 6-week mortality, and re-bleeding within 5 days in patients with cirrhosis and AVH. METHODS: Kaplan-Meier and Cox proportional hazards regression analyses were used to determine risk factors among 256 patients with AVH entered into a randomised, prospective trial. RESULTS: Thirty-five patients (14%) died within 6 weeks of AVH; 14 deaths (40%) occurred within 5 days. Only the Model for End-stage Liver Disease (MELD) score and units of packed red blood cells (PRBCs) transfused in the first 24 h were associated with 6-week mortality univariately (HR 1.11, p < 0.001; HR 1.22, p < 0.001) and bivariately (HR MELD = 1.10, p < 0.001; HR per unit of PRBCs transfused = 1.15, p = 0.005). Re-bleeding within 5 days occurred in 37 patients (15%); MELD score (p = 0.01) and a clot on a varix (p = 0.05) predicted re-bleeding. Patients with a MELD score > or = 18; both MELD score > or = 18 and > or = 4 units of PRBCs transfused; both MELD score > or = 18 and active bleeding at index endoscopy; and variceal re-bleeding had increased risk of death 6 weeks post-AVH (HR = 7.4, p < 0.001; 11.3, p < 0.001; 9.9, p < 0.001; 10.2, p < 0.001 respectively). CONCLUSIONS: Patients with AVH and MELD score > or = 18, requiring > or = 4 units of PRBCs within the first 24 h or with active bleeding at endoscopy are at increased risk of dying within 6 weeks. MELD score > or = 18 is also a strong predictor of variceal re-bleeding within the first 5 days.
PMID: 18250126 [PubMed - indexed for MEDLINE]
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Tags: Gut
Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial.
JAMA. 2008 May 28;299(20):2413-22
Authors: Parienti JJ, Thirion M, Mégarbane B, Souweine B, Ouchikhe A, Polito A, Forel JM, Marqué S, Misset B, Airapetian N, Daurel C, Mira JP, Ramakers M, du Cheyron D, Le Coutour X, Daubin C, Charbonneau P,
CONTEXT: Based on concerns about the risk of infection, the jugular site is often preferred over the femoral site for short-term dialysis vascular access. OBJECTIVE: To determine whether jugular catheterization decreases the risk of nosocomial complications compared with femoral catheterization. DESIGN, SETTING, AND PATIENTS: A concealed, randomized, multicenter, evaluator-blinded, parallel-group trial (the Cathedia Study) of 750 patients from a network of 9 tertiary care university medical centers and 3 general hospitals in France conducted between May 2004 and May 2007. The severely ill, bed-bound adults had a body mass index (BMI) of less than 45 and required a first catheter insertion for renal replacement therapy. INTERVENTION: Patients were randomized to receive jugular or femoral vein catheterization by operators experienced in placement at both sites. MAIN OUTCOME MEASURES: Rates of infectious complications, defined as catheter colonization on removal (primary end point), and catheter-related bloodstream infection. RESULTS: Patient and catheter characteristics, including duration of catheterization, were similar in both groups. More hematomas occurred in the jugular group than in the femoral group (13/366 patients [3.6%] vs 4/370 patients [1.1%], respectively; P = .03). The risk of catheter colonization at removal did not differ significantly between the femoral and jugular groups (incidence of 40.8 vs 35.7 per 1000 catheter-days; hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.62-1.16; P = .31). A prespecified subgroup analysis demonstrated significant qualitative heterogeneity by BMI (P for the interaction term < .001). Jugular catheterization significantly increased incidence of catheter colonization vs femoral catheterization (45.4 vs 23.7 per 1000 catheter-days; HR, 2.10; 95% CI, 1.13-3.91; P = .017) in the lowest tercile (BMI <24.2), whereas jugular catheterization significantly decreased this incidence (24.5 vs 50.9 per 1000 catheter-days; HR, 0.40; 95% CI, 0.23-0.69; P < .001) in the highest tercile (BMI >28.4). The rate of catheter-related bloodstream infection was similar in both groups (2.3 vs 1.5 per 1000 catheter-days, respectively; P = .42). CONCLUSION: Jugular venous catheterization access does not appear to reduce the risk of infection compared with femoral access, except among adults with a high BMI, and may have a higher risk of hematoma. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00277888.
PMID: 18505951 [PubMed - indexed for MEDLINE]
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Tags: JAMA
Methylnaltrexone for opioid-induced constipation in advanced illness.
N Engl J Med. 2008 May 29;358(22):2332-43
Authors: Thomas J, Karver S, Cooney GA, Chamberlain BH, Watt CK, Slatkin NE, Stambler N, Kremer AB, Israel RJ
BACKGROUND: Constipation is a distressing side effect of opioid treatment. As a quaternary amine, methylnaltrexone, a mu-opioid-receptor antagonist, has restricted ability to cross the blood-brain barrier. We investigated the safety and efficacy of subcutaneous methylnaltrexone for treating opioid-induced constipation in patients with advanced illness. METHODS: A total of 133 patients who had received opioids for 2 or more weeks and who had received stable doses of opioids and laxatives for 3 or more days without relief of opioid-induced constipation were randomly assigned to receive subcutaneous methylnaltrexone (at a dose of 0.15 mg per kilogram of body weight) or placebo every other day for 2 weeks. Coprimary outcomes were laxation (defecation) within 4 hours after the first dose of the study drug and laxation within 4 hours after two or more of the first four doses. Patients who completed this phase were eligible to enter a 3-month, open-label extension trial. RESULTS: In the methylnaltrexone group, 48% of patients had laxation within 4 hours after the first study dose, as compared with 15% in the placebo group, and 52% had laxation without the use of a rescue laxative within 4 hours after two or more of the first four doses, as compared with 8% in the placebo group (P<0.001 for both comparisons). The response rate remained consistent throughout the extension trial. The median time to laxation was significantly shorter in the methylnaltrexone group than in the placebo group. Evidence of withdrawal mediated by central nervous system opioid receptors or changes in pain scores was not observed. Abdominal pain and flatulence were the most common adverse events. CONCLUSIONS: Subcutaneous methylnaltrexone rapidly induced laxation in patients with advanced illness and opioid-induced constipation. Treatment did not appear to affect central analgesia or precipitate opioid withdrawal. (Clinical Trials.gov number, NCT00402038 [ClinicalTrials.gov].).
PMID: 18509120 [PubMed - indexed for MEDLINE]
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Tags: N Engl J Med
Acute mortality in hospitalized patients undergoing echocardiography with and without an ultrasound contrast agent: results in 18,671 consecutive studies.
J Am Coll Cardiol. 2008 Apr 29;51(17):1704-6
Authors: Kusnetzky LL, Khalid A, Khumri TM, Moe TG, Jones PG, Main ML
OBJECTIVES: We sought to define acute mortality in hospitalized patients undergoing clinically indicated echocardiography with and without use of an ultrasound contrast agent. BACKGROUND: The U.S. Food and Drug Administration recently issued a boxed warning and new contraindications for the perflutren-containing ultrasound contrast agents following post-marketing reports of 4 patient deaths that were temporally related to Definity (Bristol-Myers Squibb Medical Imaging, Billerica, Massachusetts) administration. To appreciate the incremental risk of any medical procedure, the ambient risk of untoward outcome in the population in question must first be defined. There are no published data on short-term major adverse cardiac events in hospitalized patients undergoing echocardiography, either with or without administration of an ultrasound contrast agent. METHODS: A retrospective analysis of hospitalized patients undergoing clinically indicated echocardiography between January 2005 and October 2007, within Saint Luke’s Health System, Kansas City, Missouri, was performed. Studies were separated into 2 groups, those performed without contrast enhancement (n = 12,475) and those performed with Definity (n = 6,196). Vital status within 24 h of the echocardiographic study was available for all patients using a combination of the Social Security Death Master File and Saint Luke’s Health System medical records. Incidence of death within 24 h was compared by chi-square test between Definity and unenhanced procedures. RESULTS: Of the 18,671 patient events, 72 patients died within 24 h. Of those that underwent unenhanced echocardiography, 46 died within 24 h (0.37%). Of patients receiving Definity during the echocardiogram, 26 died within 24 h (0.42%). There was no statistical difference between these 2 groups (p = 0.60). No patient died within 1 h of the echocardiographic study. In a random sampling from the unenhanced (n = 201) and Definity groups (n = 202), patients who underwent Definity-enhanced echocardiography exhibited higher clinical acuity, and more significant comorbidities. CONCLUSIONS: Approximately 0.4% of hospitalized patients die within 24 h of echocardiography. There is no increased mortality risk associated with Definity-enhanced examinations, despite evidence for higher clinical acuity and more comorbid conditions in patients undergoing contrast studies.
PMID: 18436124 [PubMed - indexed for MEDLINE]
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Tags: J Am Coll Cardiol
Long-term prognosis of acute kidney injury after acute myocardial infarction.
Arch Intern Med. 2008 May 12;168(9):987-95
Authors: Parikh CR, Coca SG, Wang Y, Masoudi FA, Krumholz HM
BACKGROUND: Acute kidney injury (AKI) is a common complication during hospitalization and is an accepted risk factor for in-hospital mortality. However, the association of severity of AKI with the long-term risk of death is not well defined. METHODS: To examine the independent effect of the severity of AKI on long-term risk of death following acute myocardial infarction (AMI), we performed an observational study of 147007 elderly Medicare patients admitted for AMI from January 1994 through February 1996 as a part of the Cooperative Cardiovascular Project. We evaluated the association between AKI and all-cause mortality. We defined AKI as absolute changes in serum creatinine level, categorized as none (creatinine level increase, < or =0.2 mg/dL), mild (0.3-0.4 mg/dL increase), moderate (0.5-0.9 mg/dL increase), and severe (> or =1.0 mg/dL increase). RESULTS: Overall, 19.4% of the patients had AKI, including 7.1% with mild AKI, 7.1% with moderate AKI, and 5.2% with severe AKI. Less than 10% of patients who had severe AKI were alive at 10 years compared with 12.2%, 21.1%, and 31.7% patients with moderate, mild, and no AKI, respectively. The adjusted hazard ratio for death for in-hospital survivors at 10 years was 1.15 (95% confidence interval [CI], 1.12-1.18) for mild AKI, 1.23 (95% CI, 1.20-1.26) for moderate AKI, and 1.33 (95% CI, 1.28-1.38) for severe AKI. Similar results were obtained in several secondary analyses that included inpatient mortality, excluded mortality in the first 3 years, and stratified by some specified high-risk groups. Moderate or severe AKI were comparable in strength with other known correlates of cardiovascular mortality. CONCLUSIONS: Acute kidney injury has an independent and graded association with long-term mortality. These results should stimulate additional mechanistic and interventional studies and plans for follow-up of patients with AKI after discharge.
PMID: 18474763 [PubMed - indexed for MEDLINE]
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Tags: Arch Intern Med
Antibiotics in the management of hepatic encephalopathy: an evidence-based review.
Rev Gastroenterol Disord. 2005;5 Suppl 3:26-35
Authors: Rothenberg ME, Keeffe EB
Hepatic encephalopathy (HE) is an increasingly prevalent and debilitating condition that occurs in functional hepatic insufficiency. It is marked by fluctuating neuropsychiatric and cognitive impairment, which can be severe and life threatening. Hepatic encephalopathy is a diagnosis of exclusion; thus, it is challenging to diagnose definitively and to investigate in clinical trials. High response rates in the placebo arms of well-conducted studies demonstrate that the most effective treatment for HE is the correction of known precipitating triggers. However, pharmacological therapies may also be helpful. Although the precise pathogenesis remains unknown, bacterially derived neurotoxins from enteric flora likely play an important role. Based on this hypothesis and on accumulating clinical experience documented in randomized trials, oral antibiotics have emerged as an important treatment adjunct. This article addresses the qualities of an ideal antibiotic and reviews the literature on 4 antibiotics used to treat HE: neomycin, metronidazole, vancomycin, and rifaximin, with the most promising of these drugs appearing to be rifaximin. Unfortunately, most studies of the treatment of HE are difficult to interpret due to small sample sizes, methodological flaws, vulnerability to bias, and the intrinsic challenges of studying HE. Many studies have erroneously concluded that treatments are equivalent simply because no significant difference between treatment arms was detected. Consequently, the literature generally lacks definitive data from large, randomized, placebo-controlled trials. Nevertheless, the data suggest that minimally absorbed antibiotics are emerging as a safe and effective approach for the treatment of HE.
PMID: 17713457 [PubMed - indexed for MEDLINE]
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Tags: Rev Gastroenterol Disord
The history of 0.9% saline.
Clin Nutr. 2008 Apr;27(2):179-88
Authors: Awad S, Allison SP, Lobo DN
BACKGROUND & AIMS: We aimed to trace the historical origins of 0.9% saline, how it came to be used so commonly today, and to consider whether its continued use can be justified. METHODS: We searched the Medline, Science Citation Index, ScienceDirect and Google databases using the key words saline, physiological, salt solution, sodium chloride, 0.9%, intravenous, injection, fluid, cholera, resuscitation, parenteral, history, historical and origins. RESULTS: The use of 0.9% saline is believed to have originated during the cholera pandemic that swept across Europe in 1831. However, an examination of the composition of the fluids used by the pioneering physicians of that era reveals solutions that bear no resemblance to 0.9% or so-called 'normal' saline which appears to have very little scientific or historical basis for its routine use, except for Hamburger's in vitro studies of red cell lysis. CONCLUSIONS: The currently used 0.9% saline solution is without convincing historical basis. Given that the composition of 0.9% sodium chloride is dissimilar to most solutions used in the past, and is in no way 'normal' or 'physiological', our current practice may be based on historical fallacy and misconception.
PMID: 18313809 [PubMed - indexed for MEDLINE]
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Tags: Clin Nutr
