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The effect of bedrails on falls and injury: a systematic review of clinical studies.

Age Ageing. 2008 Jul;37(4):368-78

Authors: Healey F, Oliver D, Milne A, Connelly JB

BACKGROUND: around one-fourth of all falls in healthcare settings are falls from bed. The role of bedrails in falls prevention is controversial, with a prevailing orthodoxy that bedrails are harmful and ineffective. OBJECTIVE: to summarise and critically evaluate evidence on the effect of bedrails on falls and injury DESIGN: systematic literature review using the principles of QuoRoM guidance. Setting and SUBJECTS: adult healthcare settings Review METHODS: using the keyword, bedrail, and synonyms, databases were searched from 1980 to June 2007 for direct injury from bedrails or where falls, injury from falls, or any other effects were related to bedrail use. RESULTS: 472 papers were located; 24 met the criteria. Three bedrail reduction studies identified significant increases in falls or multiple falls, and one found that despite a significant decrease in falls in the discontinue-bedrails group, this group remained significantly more likely to fall than the continue-bedrails group; one case-control study found patients who had their bedrails raised significantly less likely to fall; one retrospective survey identified a significantly lower rate of injury and head injury in falls with bedrails up. Twelve papers described direct injury from bedrails. DISCUSSION: it is difficult to perform conventional clinical trials of an intervention already embedded in practice, and all included studies had methodological limitations. However, this review concludes that serious direct injury from bedrails is usually related to use of outmoded designs and incorrect assembly rather than being inherent, and bedrails do not appear to increase the risk of falls or injury from falls.

PMID: 18495686 [PubMed - indexed for MEDLINE]

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Risk prediction with procalcitonin and clinical rules in community-acquired pneumonia.

Ann Emerg Med. 2008 Jul;52(1):48-58.e2

Authors: Huang DT, Weissfeld LA, Kellum JA, Yealy DM, Kong L, Martino M, Angus DC,

STUDY OBJECTIVE: The Pneumonia Severity Index and CURB-65 predict outcomes in community-acquired pneumonia but have limitations. Procalcitonin, a biomarker of bacterial infection, may provide prognostic information in community-acquired pneumonia. Our objective is to describe the pattern of procalcitonin in community-acquired pneumonia and determine whether procalcitonin provides prognostic information beyond the Pneumonia Severity Index and CURB-65. METHODS: We conducted a multicenter prospective cohort study in 28 community and teaching emergency departments. Patients presenting with a clinical and radiographic diagnosis of community-acquired pneumonia were enrolled. We stratified procalcitonin levels a priori into 4 tiers: I: less than 0.1; II: greater than 0.1 to less than 0.25; III: greater than 0.25 to less than 0.5; and IV: greater than 0.5 ng/mL. Primary outcome was 30-day mortality. RESULTS: One thousand six hundred fifty-one patients formed the study cohort. Procalcitonin levels were broadly spread across tiers: 32.8% (I), 21.6% (II), 10.2% (III), and 35.4% (IV). Used alone, procalcitonin had modest test characteristics: specificity (35%), sensitivity (92%), positive likelihood ratio (1.41), and negative likelihood ratio (0.22). Adding procalcitonin to the Pneumonia Severity Index in all subjects minimally improved performance. Adding procalcitonin to low-risk Pneumonia Severity Index subjects (classes I to III) provided no additional information. However, subjects in procalcitonin tier I had low 30-day mortality, regardless of clinical risk, including those in higher risk classes (1.5% versus 1.6% for those in Pneumonia Severity Index classes I to III versus classes IV/V). Among high-risk Pneumonia Severity Index subjects (classes IV/V), one quarter (126/546) were in procalcitonin tier I, and the negative likelihood ratio of procalcitonin tier I was 0.09. Procalcitonin tier I was also associated with lower burden of other adverse outcomes. Similar results were observed with CURB-65 stratification. CONCLUSION: Selective use of procalcitonin as an adjunct to existing rules may offer additional prognostic information in high-risk patients.

PMID: 18342993 [PubMed - indexed for MEDLINE]

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Positive-end expiratory pressure reduces incidence of ventilator-associated pneumonia in nonhypoxemic patients.

Crit Care Med. 2008 Aug;36(8):2225-31

Authors: Manzano F, Fernández-Mondéjar E, Colmenero M, Poyatos ME, Rivera R, Machado J, Catalán I, Artigas A

OBJECTIVE: To analyze the effect on clinical outcomes of prophylactic positive end expiratory pressure in nonhypoxemic ventilated patients. DESIGN: Multicenter randomized controlled clinical trial. SETTING: One trauma and two general intensive care units in two university hospitals. PATIENTS: One hundred thirty-one mechanically ventilated patients with normal chest radiograph and PaO2/FiO2 above 250. INTERVENTIONS: Patients were randomly allocated to receive mechanical ventilation with 5-8 cm H2O of positive end-expiratory pressure (PEEP) (PEEP group, n = 66) or no-PEEP (control group, n = 65). MEASUREMENTS AND MAIN RESULTS: Primary end-point variable was hospital mortality. Secondary outcomes included microbiologically confirmed ventilator-associated pneumonia, acute respiratory distress syndrome, barotrauma, atelectasis, and hypoxemia (PaO2/FiO2 <175). Both groups were similar at randomization in demographic characteristics, intensive care unit admission diagnoses, severity of illness, and risk factors for ventilator-associated pneumonia. Hospital mortality rate was similar (p = 0.58) between PEEP (29.7%) and control (25.4%) groups. Ventilator-associated pneumonia was detected in 16 (25.4%) patients in the control group and 6 (9.4%) in the PEEP group (relative risk, 0.37; 95% confidence interval = 0.15-0.84; p = 0.017). The number of patients who developed hypoxemia was significantly higher in the control group (34 of 63 patients, 54%) than in the PEEP group (12 of 64, 19%) (p < 0.001), and the hypoxemia developed after a shorter period (median [interquartile range]) in the control group than in the PEEP group (38 [20-70] hrs vs. 77 [32-164] hrs, p < 0.001). Groups did not significantly differ in incidence of acute respiratory distress syndrome (14% in controls vs. 5% in the PEEP group, p = 0.08), barotrauma (8% vs. 2%, respectively, p = 0.12), or atelectasis (27% vs. 19%, respectively, p = 0.26). CONCLUSIONS: These findings indicate that application of prophylactic PEEP in nonhypoxemic ventilated patients reduces the number of hypoxemia episodes and the incidence of ventilator-associated pneumonia.

PMID: 18664777 [PubMed - in process]

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The association between nighttime transfer from the intensive care unit and patient outcome.

Crit Care Med. 2008 Aug;36(8):2232-7

Authors: Hanane T, Keegan MT, Seferian EG, Gajic O, Afessa B

OBJECTIVE: To determine the impact of nighttime transfer of patients from the intensive care unit (ICU) on clinical outcome. DESIGN: Retrospective, observational. SETTING: Three intensive care units of a tertiary care medical center. PATIENTS: We used prospectively collected information from the Acute Physiology and Chronic Health Evaluation III database of 11,659 patients transferred from the ICU to the regular ward. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Based on the time of transfer, patients who were transferred from the ICU to the regular ward were categorized into daytime (7:00 am-6:59 pm) and nighttime (7:00 pm-6:59 am) transfers. Patients who were transferred to other ICUs or other facilities, died in the ICU, were discharged home, or did not authorize their medical records to be reviewed for research were excluded. Only the first ICU admission of each patient was considered for outcome analysis. Of the 11,659 study patients, 418 (3.6%) were transferred at night. The first ICU day predicted mortality rate and the last ICU day Acute Physiology Score and Acute Physiology and Chronic Health Evaluation III scores in the nighttime transfer group were higher compared with the daytime transfers. The hospital mortality rate of the nighttime transfers was 5.3% compared with 4.5% of the daytime transfers (p = 0.478). There was no statistically significant difference between the two groups in severity adjusted hospital mortality rate. The ICU readmission rate of the nighttime transfers was higher (12.2% compared with 9.0%, p = 0.027) and the median (interquartile range) hospital length of stay longer (8 [5-15] vs. 7 [4-13] days, p = 0.013) compared with the daytime transfer group. CONCLUSIONS: Our study did not find an association between nighttime ICU discharge and hospital mortality. However, the ICU readmission rate was higher and the hospital length of stay longer in the nighttime transfer group.

PMID: 18664778 [PubMed - in process]

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Early predictors of outcome in comatose survivors of ventricular fibrillation and non-ventricular fibrillation cardiac arrest treated with hypothermia: A prospective study.

Crit Care Med. 2008 Aug;36(8):2296-2301

Authors: Oddo M, Ribordy V, Feihl F, Rossetti AO, Schaller MD, Chioléro R, Liaudet L

OBJECTIVES:: Current indications for therapeutic hypothermia (TH) are restricted to comatose patients with cardiac arrest (CA) due to ventricular fibrillation (VF) and without circulatory shock. Additional studies are needed to evaluate the benefit of this treatment in more heterogeneous groups of patients, including those with non-VF rhythms and/or shock and to identify early predictors of outcome in this setting. DESIGN:: Prospective study, from December 2004 to October 2006. SETTING:: 32-bed medico-surgical intensive care unit, university hospital. PATIENTS:: Comatose patients with out-of-hospital CA. INTERVENTIONS:: TH to 33 +/- 1 degrees C (external cooling, 24 hrs) was administered to patients resuscitated from CA due to VF and non-VF (including asystole or pulseless electrical activity), independently from the presence of shock. MEASUREMENTS AND MAIN RESULTS:: We hypothesized that simple clinical criteria available on hospital admission (initial arrest rhythm, duration of CA, and presence of shock) might help to identify patients who eventually survive and might most benefit from TH. For this purpose, outcome was related to these predefined variables. Seventy-four patients (VF 38, non-VF 36) were included; 46% had circulatory shock. Median duration of CA (time from collapse to return of spontaneous circulation [ROSC]) was 25 mins. Overall survival was 39.2%. However, only 3.1% of patients with time to ROSC >25 mins survived, as compared to 65.7% with time to ROSC </=25 mins. Using a logistic regression analysis, time from collapse to ROSC, but not initial arrest rhythm or presence of shock, independently predicted survival at hospital discharge. CONCLUSIONS:: Time from collapse to ROSC is strongly associated with outcome following VF and non-VF cardiac arrest treated with therapeutic hypothermia and could therefore be helpful to identify patients who benefit most from active induced cooling.

PMID: 18664785 [PubMed - as supplied by publisher]

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Parenteral Polymyxin B Use in Patients with Multidrug-Resistant Gram-Negative Bacteremia and Urinary Tract Infections: A Retrospective Case Series (September).

Ann Pharmacother. 2008 Jul 29;

Authors: Pastewski AA, Caruso P, Parris AR, Dizon R, Kopec R, Sharma S, Mayer S, Ghitan M, Chapnick EK

BACKGROUND: Parenteral polymyxin use declined after the 1960s, due to safety concerns. An increase in multidrug-resistant (MDR) gram-negative infections and a shortage of new agents have prompted increased use of parenteral polymyxin. OBJECTIVE: To describe our clinical experience with parenteral polymyxin B for MDR gram-negative bacteremia and urinary tract infection (UTI). METHODS: Paper pharmacy records were used to identify patients aged 18 years or older, presence of MDR gram-negative bacteremia or UTI, and use of parenteral polymyxin B for at least 48 hours. Electronic and paper patient records were then retrospectively reviewed. Polymyxin B susceptibility was evaluated using the Kirby-Bauer method. MDR isolates were defined as resistant to at least 3 antimicrobial classes, excluding polymyxin B. Microbiologic clearance was defined by 1 repeat urine or 2 repeat blood cultures that were sterile or growing different organisms. Secondary outcomes included hospital mortality and nephrotoxicity, defined as an increase in serum creatinine of 0.5 mg/dL or more, or a 50% reduction in creatinine clearance. RESULTS: Seventeen infections in 16 patients were treated with polymyxin B (1 pt. had 2 infections that were analyzed separately). Microbiologic clearance occurred in 14 of 16 (88%) cases of MDR gram-negative bacteremia or UTI in which repeat cultures were done. Ten of 16 patients died (all-cause mortality 63%). Five patients required hemodialysis prior to polymyxin B use. Six (55%) of the remaining 11 patients with baseline renal insufficiency developed nephrotoxicity, and none of them required hemodialysis. The mean +/- SD number of days from the initiation of therapy to the onset of nephrotoxicity was 7.5 +/- 2.3 (range 4-10) days. Three (50%) of 6 patients with nephrotoxicity died. CONCLUSIONS: Our data suggest that polymyxin B may be effective for MDR gram-negative infections in patients with limited therapeutic options, but precautions should be taken to avoid toxicity.

PMID: 18664609 [PubMed - as supplied by publisher]

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A Clinical Decision Rule to Aid Ordering of Serum and Urine Protein Electrophoresis for Case-Finding of Paraproteins in Hospitalized Inpatients.

J Gen Intern Med. 2008 Jul 30;

Authors: Thakkinstian A, Tran H, Reeves G, Murch S, Attia J

OBJECTIVE: To develop a simple clinical decision rule that could increase the yield of serum and urine protein electrophoresis (SPE/UPE) without loss of sensitivity. DESIGN: A cross-sectional study of inpatients with a SPE/UPE performed over a 5-year period (2001-2006) with complete data on electrolytes, globulins, full blood count, creatinine, age, and gender. SETTING: A tertiary-care general teaching hospital serving the Hunter Valley in New South Wales, with a referral population of over 1 million. PARTICIPANTS: A total of 14,374 adult patients admitted between January 2001-November 2006. MAIN OUTCOME MEASURES: Paraprotein on serum and/or urine protein electrophoresis (SPE/UPE). RESULTS: Five points were assigned for globulin >41 g/l, 3 points for age >/=60, 2 points for each of hemoglobin <121 and male gender, and 1 point for estimated glomerular filtration rate (eGFR) <60. Total scores of 0-5, 6-10, and >/=11 corresponded to positive likelihood ratios of an abnormal SPE/UPE of 1, 2.5, and 6.6, respectively. The predictive ability of this model was strong, with an area under the curve of approximately 0.8. Results in the validation set were almost identical. CONCLUSION: A clinical decision rule using simple clinical variables has the potential to improve the yield of SPE/UPE. This rule however needs to be verified prospectively.

PMID: 18665429 [PubMed - as supplied by publisher]

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The risk of acute renal failure in patients with chronic kidney disease.

Kidney Int. 2008 Jul;74(1):101-7

Authors: Hsu CY, Ordoñez JD, Chertow GM, Fan D, McCulloch CE, Go AS

Few studies have defined how the risk of hospital-acquired acute renal failure varies with the level of estimated glomerular filtration rate (GFR). It is also not clear whether common factors such as diabetes mellitus, hypertension and proteinuria increase the risk of nosocomial acute renal failure independent of GFR. To determine this we compared 1,746 hospitalized adult members of Kaiser Permanente Northern California who developed dialysis-requiring acute renal failure with 600,820 hospitalized members who did not. Patient GFR was estimated from the most recent outpatient serum creatinine measurement prior to admission. The adjusted odds ratios were significantly and progressively elevated from 1.95 to 40.07 for stage 3 through stage 5 patients (not yet on maintenance dialysis) compared to patients with estimated GFR in the stage 1 and 2 range. Similar associations were seen after controlling for inpatient risk factors. Pre-admission baseline diabetes mellitus, diagnosed hypertension and known proteinuria were also independent risk factors for acute kidney failure. Our study shows that the propensity to develop in-hospital acute kidney failure is another complication of chronic kidney disease whose risk markedly increases even in the upper half of stage 3 estimated GFR. Several common risk factors for chronic kidney disease also increase the peril of nosocomial acute kidney failure.

PMID: 18385668 [PubMed - indexed for MEDLINE]

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Atypical pneumonias: current clinical concepts focusing on Legionnaires’ disease.

Curr Opin Pulm Med. 2008 May;14(3):183-94

Authors: Cunha BA

PURPOSE OF REVIEW: This review provides clinicians with an overview of the clinical features of the atypical pneumonias. Atypical community-acquired pneumonia pathogens cause systemic infections with pneumonia. The key to the clinical diagnosis of atypical pneumonias depends on recognizing the characteristic pattern of extrapulmonary organ involvement different for each pathogen. As Legionella is likely to present as severe pneumonia and does not respond to beta-lactams, it is important to presumptively diagnose Legionnaires’ disease clinically so that Legionella coverage is included in empiric therapy. This study reviews the clinical features and nonspecific laboratory markers of atypical pathogens, focusing on Legionnaires’ disease. RECENT FINDINGS: Case reports/outbreaks increase our understanding of Legionnaires’ disease transmission. Both Mycoplasma pneumoniae and Chlamydophilia pneumoniae may cause asthma. Antimicrobial therapy of Chlamydophilia pneumoniae/Mycoplasma pneumoniae is important to decrease person-to-person spread and to decrease potential long-term sequelae. SUMMARY: Atypical pulmonary pathogens cause systemic infections accompanied by a variety of characteristic extrapulmonary features. Clinically, it is possible to differentiate Legionnaires’ disease from the other typical/atypical pneumonias. Rapid clinical diagnosis of atypical pathogens, particularly Legionnaires’ disease, is important in selecting effective empiric therapy and prompting definitive laboratory testing.

PMID: 18427241 [PubMed - indexed for MEDLINE]

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Clinical features, pathogenesis and immunobiology of severe acute respiratory syndrome.

Curr Opin Pulm Med. 2008 May;14(3):241-7

Authors: Hui DS, Chan PK

PURPOSE OF REVIEW: Severe acute respiratory syndrome coronavirus is a novel virus responsible for the major pandemic in 2003, and it re-emerged in China in late 2003 and 2004 following resumption of wild animal trading activities. Over the past few years, research work has looked into factors that may lead to super-spreading events, clinical/laboratory parameters that may differentiate severe acute respiratory syndrome from other causes of community-acquired pneumonia, the origin of severe acute respiratory syndrome, reservoir host distribution and transmission routes. A better understanding of these issues may help prevent and control future outbreaks of severe acute respiratory syndrome. RECENT FINDINGS: Bats are natural reservoirs of severe acute respiratory syndrome like coronaviruses. The human and civet isolates of severe acute respiratory syndrome coronavirus nestle phylogenetically within the spectrum of severe acute respiratory syndrome like coronaviruses. Severe acute respiratory syndrome has the potential of being converted from droplet to airborne transmission. When evaluating epidemiologically high-risk patients with community-acquired pneumonia and no immediate alternative diagnosis, a low absolute neutrophil count on presentation, along with poor responses after 72 h of antibiotic treatment, may raise the index of suspicion for severe acute respiratory syndrome. SUMMARY: The presence of severe acute respiratory syndrome like coronaviruses in horseshoe bats raises the possible role of bats in previous and potentially future severe acute respiratory syndrome outbreaks in human. Healthcare workers should take adequate respiratory protection in addition to strict contact and droplet precautions when managing patients with severe acute respiratory syndrome.

PMID: 18427248 [PubMed - indexed for MEDLINE]

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Signs and symptoms in diagnosing acute myocardial infarction and acute coronary syndrome: a diagnostic meta-analysis.

Br J Gen Pract. 2008 Feb;58(547):105-11

Authors: Bruyninckx R, Aertgeerts B, Bruyninckx P, Buntinx F

BACKGROUND: Prompt diagnosis of acute myocardial infarction or acute coronary syndrome is very important. AIM: A systematic review was conducted to determine the accuracy of 10 important signs and symptoms in selected and non-selected patients. DESIGN OF STUDY: Diagnostic meta-analysis. METHOD: Using MEDLINE, CINAHL, EMBASE, tracing references, and by contacting experts, studies were sought out that described one of the 10 signs and symptoms on one or both conditions. Studies were excluded if they were not based on original data. Validity was assessed using QUADAS and all data were pooled using a random effects model. RESULTS: Sixteen of the 28 included studies were about patients who were non-selected. In this group, absence of chest-wall tenderness on palpation had a pooled sensitivity of 92% (95% confidence interval [CI] = 86 to 96) for acute myocardial infarction and 94% (95% CI = 91 to 96) for acute coronary syndrome. Oppressive pain followed with a pooled sensitivity of 60% (95% CI = 55 to 66) for acute myocardial infarction. Sweating had the highest pooled positive likelihood ratio (LR+), namely 2.92 (95% CI = 1.97 to 4.23) for acute myocardial infarction. The other pooled LR+ fluctuated between 1.05 and 1.49. Negative LRs (LR-) varied between 0.98 and 0.23. Absence of chest-wall tenderness on palpation had a LR- of 0.23 (95% CI = 0.18 to 0.29). CONCLUSIONS: Based on this meta-analysis it was not possible to define an important role for signs and symptoms in the diagnosis of acute myocardial infarction or acute coronary syndrome. Only chest-wall tenderness on palpation largely ruled out acute myocardial infarction or acute coronary syndrome in low-prevalence settings.

PMID: 18307844 [PubMed - indexed for MEDLINE]

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Early diagnosis of lower respiratory tract infections (point-of-care tests).

Curr Opin Pulm Med. 2008 May;14(3):176-82

Authors: Charles PG

PURPOSE OF REVIEW: Respiratory tract infections are a common reason for prescribing antibiotics, although not all of these infections require such therapy. Rapid diagnosis of etiology using point-of-care tests is a potentially useful way of reducing prescriptions of both unnecessary and unnecessarily broad-spectrum antibiotics. This can also lead to the facilitation of appropriate infection control measures to prevent spread of respiratory viruses within institutions. RECENT FINDINGS: Point-of-care tests are available for diagnosing influenza, respiratory syncytial virus, Streptococcus pneumoniae, and Legionella infections using easily obtainable specimens. Their main benefit is that results can be obtained in about 15 min with reasonable accuracy. In many situations, however, it is still important to confirm diagnosis with more accurate but slower tests such as bacterial cultures with antibacterial susceptibility testing or viral polymerase chain reaction testing. SUMMARY: Although the sensitivities of many of the rapid diagnostic tests are moderate, when used at the time of initial consultation, they have the potential to reduce costs, length of stay, secondary spread of respiratory viruses, and inappropriate antibiotic prescribing.

PMID: 18427240 [PubMed - indexed for MEDLINE]

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High-dose amphotericin B with flucytosine for the treatment of cryptococcal meningitis in HIV-infected patients: a randomized trial.

Clin Infect Dis. 2008 Jul 1;47(1):123-30

Authors: Bicanic T, Wood R, Meintjes G, Rebe K, Brouwer A, Loyse A, Bekker LG, Jaffar S, Harrison T

BACKGROUND: The standard therapy for human immunodeficiency virus (HIV)-associated cryptococcal meningitis of amphotericin B (AmB; 0.7 mg/kg per day) plus flucytosine frequently takes >2 weeks to sterilize the cerebral spinal fluid, and acute mortality remains high. A dosage range for AmB of 0.7-1 mg/kg per day is noted in current guidelines, but there are no data comparing 0.7 mg/kg per day with 1 mg/kg per day. METHODS: Sixty-four HIV-seropositive, antiretroviral therapy-naive patients in Cape Town, South Africa, who experienced their first episode of cryptococcal meningitis during the period May 2005-June 2006 were randomized to receive either (1) AmB, 0.7 mg/kg per day, plus flucytosine, 25 mg/kg 4 times per day (group 1; 30 patients); or (2) AmB, 1 mg/kg per day, plus flucytosine, 25 mg/kg 4 times per day (group 2; 34 patients). Regimens were given for 2 weeks, followed by treatment with oral fluconazole. The primary outcome measure was early fungicidal activity, as determined by results of serial, quantitative cerebral spinal fluid cryptococcal cultures. Secondary outcome measures were safety and mortality. The median duration of follow-up was 1 year. RESULTS: Early fungicidal activity was significantly greater for group 2 than for group 1 (mean +/- SD, -0.56 +/- 0.24 vs. -0.45 +/- 0.16 log cfu/mL of cerebral spinal fluid per day; P = .02). The incidence of renal impairment did not significantly differ between the 2 groups. Anemia was associated with female sex and, less strongly, with membership in group 2. Renal impairment and anemia reversed after the regimen was switched to fluconazole. Two- and 10-week mortality rates were 6% and 24%, respectively, with no difference between groups. CONCLUSIONS: AmB, 1 mg/kg per day, plus flucytosine is more rapidly fungicidal than is standard-dose AmB plus flucytosine. Because of its size, this study provides limited data on any difference in toxicity between the regimens, but toxicities were manageable and reversible. CLINICAL TRIALS REGISTRATION NUMBER: ISRCTN68133435 (http://www.controlled-trials.com).

PMID: 18505387 [PubMed - indexed for MEDLINE]

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The PREDICT study: a randomized double-blind comparison of contrast-induced nephropathy after low- or isoosmolar contrast agent exposure.

AJR Am J Roentgenol. 2008 Jul;191(1):151-7

Authors: Kuhn MJ, Chen N, Sahani DV, Reimer D, van Beek EJ, Heiken JP, So GJ

OBJECTIVE: The objective of the PREDICT (patients with renal impairment and diabetes undergoing computed tomography) study was to compare the incidence of contrast-induced nephropathy (CIN) after administration of low-osmolar (iopamidol 370, 796 mOsm/kg) or isoosmolar (iodixanol 320, 290 mOsm/kg) contrast medium in patients with diabetes and chronic kidney disease undergoing CT. SUBJECTS AND METHODS: Two hundred sixty-three patients with moderate to severe chronic kidney disease (estimated glomerular filtration rate [GFR] = 20-59 mL/min/1.73 m(2)) and diabetes mellitus were randomized to receive at least 65 mL of iopamidol 370 or iodixanol 320 for a CT procedure. Serum creatinine levels were measured at baseline and 48-72 hours after contrast administration. CIN was defined as an increase in the serum creatinine level after contrast administration of >or= 25% from the baseline level. The incidence of CIN in the total study population and the incidence of CIN in patients at increased risk for CIN were compared using Fisher's exact test. RESULTS: Two hundred forty-eight patients were included in the CIN analysis: 125 receiving iopamidol 370 and 123 receiving iodixanol 320. Study population demographics were comparable, as was baseline renal function (estimated GFR = 47.6 mL/min/1.73 m(2) for the iopamidol 370 group vs 49.9 mL/min/1.73 m(2) for the iodixanol 320 group; p = 0.16). Increases in the serum creatinine value of >or= 25% occurred in seven patients (5.6%) receiving iopamidol 370 and in six patients (4.9%) receiving iodixanol 320 (95% CI, -4.8% to 6.3%; p = 1.0). The mean serum creatinine change from the baseline level was 0.04 mg/dL in both groups (analysis of covariance, p = 0.80). In patients with a baseline serum creatinine value of >or= 2.0 mg/dL, baseline estimated GFR of <or= 40 mL/min/1.73 m(2), or those receiving > 140 mL of contrast medium, the incidence of CIN was low and comparable between the two study groups (p = 1.0 in all instances). CONCLUSION: The incidence of CIN in patients with diabetes and chronic kidney disease receiving IV contrast medium was not significantly different after CT using iopamidol 370 or iodixanol 320.

PMID: 18562739 [PubMed - indexed for MEDLINE]

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Importance of low-grade albuminuria.

Mayo Clin Proc. 2008 Jul;83(7):806-12

Authors: Danziger J

The well-described association between chronic kidney disease and cardiovascular disease is typically thought to originate from loss of renal function, as estimated by the glomerular filtration rate. However, recent data suggest that urinary albumin excretion has an important role in this association. Albuminuria is a marker of underlying vascular dysfunction and has been correlated with structural and functional integrity of the vasculature. Although the traditional upper limit of normal daily albumin excretion has been 30 mg/d, recent epidemiologic data suggest that levels in the general population are actually much lower. Further, within this range of low-grade albuminuria (LGA), increasing excretion rates are associated with increasing risk of cardiovascular disease. This association is independent of renal function, and in the earliest stages of chronic kidney disease, LGA seems to be a more important determinant than the glomerular filtration rate. This emerging association underscores the complexity of albumin excretion, in which subtle changes in albumin excretion reflect widespread vascular processes. Using the key words albuminuria, low-grade albuminuria, and microalbuminuria in a PubMed search of literature from January 1, 1995, to February 29, 2008, this review summarizes the most recent data on LGA and its association with cardiovascular and renal disease.

PMID: 18613997 [PubMed - indexed for MEDLINE]

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