New therapeutic option for thromboembolism–dabigatran etexilate.

Expert Opin Pharmacother. 2008 Oct;9(14):2509-17

Authors: Nishio H, Ieko M, Nakabayashi T

BACKGROUND: Thrombin plays a key role in blood coagulation and haemostasis; thus its inhibition has been identified as a reasonable target to block the coagulation cascade. Direct thrombin inhibitors are potential prophylactic agents for venous thromboembolism and arterial thrombosis, which often accompany operative procedures and cardiac disease, especially orthopedic surgery and atrial fibrillation, respectively. New orally available anticoagulant agents with a wide therapeutic window are keenly anticipated because warfarin and heparins have some disadvantages, and recent progress in pharmaceutical techniques has led to the development of orally administered direct thrombin inhibitors. Objectives: In this review, we discuss the usefulness of dabigatran etexilate as a new therapeutic option for preventing thromboembolism, including chemistry, pharmacokinetics, and pharmacodynamics, from the results of recent clinical studies. METHODS: We systematically focused on relevant published studies, as data from recent clinical studies were difficult to obtain owing to their ongoing status. CONCLUSIONS: Dabigatran etexilate is a promising new oral anticoagulant that offers greatly expanded therapeutic options for both patients and physicians.

PMID: 18778188 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Drug treatment of delirium: past, present and future.

J Psychosom Res. 2008 Sep;65(3):273-82

Authors: Bourne RS, Tahir TA, Borthwick M, Sampson EL

OBJECTIVE: The aim of this review was to summarize and critically evaluate the current literature regarding the safety and efficacy of drug therapy in delirium. We also identified recent research developments and highlighted some ongoing clinical trials to explore future directions in drug treatment and prevention of delirium. METHODS: We conducted a literature search of Medline, Embase, PsychInfo, and Cochrane Review databases, which included both prospective and retrospective clinical trials and case studies on delirium and drug therapy in adult patients up to March 2008. Abstracts from recent topical conferences were also reviewed. Ongoing delirium drug studies were identified via the WHO International Clinical Trials Registry Platform Search Portal, accessed March 12, 2008. RESULTS: The evidence base for effective drug treatment of delirium is restricted by limitations in many of the studies conducted to date. However, there has been an increase in the quantity and quality of delirium drug studies in recent years; preliminary reports and ongoing studies add to this trend. Although efficacy rates between typical and atypical antipsychotic agents are similar, the latter are associated with fewer extrapyramidal side effects. Prophylactic interventions with antipsychotic and cholinesterase inhibitors in high-risk patients provide an opportunity to improve postoperative patient care. Alternative techniques and medication opportunities could be explored in attempts to minimize drug induced delirium potential. CONCLUSIONS: Appropriate drug therapy should be considered part of systematic approaches to delirium treatment and prevention. There is a need for well-designed randomized, double-blind placebo-controlled trials investigating the drug management of various aspects of delirium, including delineating treatment by delirium subtype, dose ranging studies, and optimal duration of therapy.

PMID: 18707951 [PubMed - indexed for MEDLINE]

[Read more →]

Elevated white blood cell count and outcome in cancer patients with venous thromboembolism. Findings from the RIETE Registry.

Thromb Haemost. 2008 Nov;100(5):905-11

Authors: Trujillo-Santos J, Di Micco P, Iannuzzo M, Lecumberri R, Guijarro R, Madridano O, Monreal M,

A significant association between elevated white blood cell (WBC) count and mortality in patients with cancer has been reported, but the predictive value of elevated WBC on mortality in cancer patients with acute venous thromboembolism (VTE) has not been explored. RIETE is an ongoing registry of consecutive patients with acute VTE. We compared the three-month outcome of cancer patients with acute VTE according to their WBC count at baseline. As of May 2007, 3805 patients with active cancer and acute VTE had been enrolled in RIETE. Of them, 215 (5.7%) had low- (<4,000 cells/microl), 2,403 (63%) normal- (4,000-11,000 cells/microl), 1,187 (31%) elevated (>11,000 cells/microl) WBC count. During the study period 190 patients (5.0%) had recurrent VTE, 156 (4.1%) major bleeding, 889 (23%) died (399 of disseminated cancer, 113 of PE, 46 of bleeding. Patients with elevated WBC count at baseline had an increased incidence of recurrent VTE (odds ratio [OR]: 1.6; 95% confidence interval [CI]: 1.2-2.2), major bleeding (OR: 1.5; 95% CI: 1.1-2.1) or death (OR: 2.7; 95% CI: 2.3-3.2). Most of the reported causes of death were significantly more frequent in patients with elevated WBC count. Multivariate analysis confirmed that elevated WBC count was independently associated with an increased incidence of all three complications. In conclusion, cancer patients with acute VTE and elevated WBC count had an increased incidence of VTE recurrences, major bleeding or death. This worse outcome was consistent among all subgroups and persisted after multivariate adjustment.

PMID: 18989537 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Update on nephrogenic systemic fibrosis.

Magn Reson Imaging Clin N Am. 2008 Nov;16(4):551-60, vii

Authors: Thomsen HS, Marckmann P, Logager VB

Gadolinium-based contrast agents were for many years considered safe, but this is no longer the case. The least stable agents may trigger the development of nephrogenic systemic fibrosis (NSF), a generalized fibrotic disorder, in renal failure patients. The use of gadodiamide and gadopentetate dimeglumine is now contraindicated in Europe and Japan in patients who have a glomerular filtration rate less than 30 mL/min/1.73 m(2), including those on dialysis. The fear of NSF, however, should not lead to an enhanced MR imaging examination being denied when there is a good clinical indication to give a gadolinium-based contrast agent.

PMID: 18926421 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Predisposing and precipitating factors for delirium in a frail geriatric population.

J Psychosom Res. 2008 Sep;65(3):249-54

Authors: Laurila JV, Laakkonen ML, Laurila JV, Timo SE, Tilvis RS, Reijo TS, Pitkala KH

OBJECTIVE: The aim of this study was to assess the possible predisposing aetiologic and short-term precipitating factors for delirium in acutely ill hospital patients with a heavy burden of comorbidities and medications. METHODS: Eighty-seven consecutive patients with acute delirium admitted to a general medicine unit were thoroughly examined, and the predisposing and precipitating factors of their delirium were assessed. RESULTS: In this population, an average of 5.2 predisposing factors and 3.0 potential precipitating factors for delirium was revealed, meaning an average of over eight possible aetiological causes for each patient. The most common precipitating factors were infections (n=72), metabolic abnormalities (n=52), adverse drug effects (n=41), and cardiovascular events (n=38). In addition, a number of very rare conditions were diagnosed after thorough assessments. CONCLUSION: Geriatric patients with acute delirium typically present with several concomitant predisposing factors for delirium exposing them to high vulnerability for the syndrome. In most patients, a number of possible etiological causes for delirium can be identified after a careful assessment, but their true pathogenetic pathway to the syndrome is unclear.

PMID: 18707947 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Accuracy of chest radiographs in the emergency diagnosis of heart failure.

Eur Radiol. 2008 Aug;18(8):1644-52

Authors: Studler U, Kretzschmar M, Christ M, Breidthardt T, Noveanu M, Schoetzau A, Perruchoud AP, Steinbrich W, Mueller C

The purpose of this study was to determine the diagnostic accuracy of chest radiographic findings of heart failure (HF) in current patients presenting with dyspnea in the emergency department. In a secondary analysis of the BASEL study, initial chest radiographs of 277 patients with acute dyspnea were evaluated by two radiologists blinded to the adjudicated diagnosis (56% had the final diagnosis of HF). Predefined radiographic criteria of HF were used. Statistical analysis included receiver-operating characteristic (ROC) analysis and calculation of a logistic regression model including B-type natriuretic peptide (BNP) levels. The reader’s overall impression showed the highest area under the ROC curve for the diagnosis of HF in both supine and erect patient positions (0.855 and 0.857). Among individual radiographic findings, peribronchial cuffing in the supine position (0.829) showed the highest accuracies. The lowest accuracy was found for the vascular pedicle width in the supine position (0.461). Logistic regression analysis showed no significant differences between the reader’s overall impression, the radiographic model, and BNP testing. In our study, the combination of radiographic features provided valuable information and was of comparable accuracy as BNP-testing for the diagnosis of HF.

PMID: 18369631 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Oral steroids in initial treatment of acute sciatica.

J Am Board Fam Med. 2008 Sep-Oct;21(5):469-74

Authors: Holve RL, Barkan H

OBJECTIVE: Many physicians use prednisone to treat acute sciatica with the hope of speeding recovery. There is little clinical evidence to support this practice. Our objective was to determine whether early administration of oral prednisone affects parameters related to recovery from acute sciatica. METHODS: In this double-blind, controlled clinical trial, 27 patients were sequentially assigned to receive either a 9-day tapering course of prednisone (n = 13) or placebo (n = 14) within 1 week of developing sciatic symptoms. Patients and investigators were blinded to the drug administered. Follow-up assessment was done weekly for 1 month and then monthly for 5 months. RESULTS: Prednisone and control groups showed no statistically significant differences in physical findings, use of nonsteroidal anti-inflammatory drugs or narcotic medications, or rates of patients returning to work at any time interval studied. Compared with controls, patients who received prednisone had more rapid rates of improvement from baseline in pain, mental well-being, and disability scores. These changes were subtle but statistically significant. Patients who received prednisone tended to receive fewer epidural injections for pain. CONCLUSIONS: Early administration of oral steroid medication in patients with acute sciatica had no significant effect on most parameters studied. It did, however, lead to slightly more rapid rates of improvement in pain, mental well-being, and disability scores. The impact of oral steroids on other outcomes is suggested by this study, but its small sample size limited its statistical power.

PMID: 18772303 [PubMed - indexed for MEDLINE]

[Read more →]

Study of anemia in long-term care (SALT): prevalence of anemia and its relationship with the risk of falls in nursing home residents.

Curr Med Res Opin. 2008 Aug;24(8):2139-49

Authors: Pandya N, Bookhart B, Mody SH, Funk Orsini PA, Reardon G

OBJECTIVE: The objectives of the current study were twofold. First, this study examined the prevalence of anemia in nursing home residents in the USA and its relationship with key resident characteristics and medical conditions. Second, the study explored whether an association between anemia and falls is evident in this same population. RESEARCH DESIGN AND METHODS: Chart review was conducted in 40 nursing homes across the USA. Residents were randomly sampled and considered eligible if they: were > or =18 years of age; had > or =1 hemoglobin (Hb) level reported during the data uptake period of 1/1/04-2/1/05 (first occurrence defined as index Hb); had a recorded serum creatinine level; maintained residency in the facility; and did not receive dialysis during the 6-month post-index follow-up period. Resident demographics, laboratory values, comorbid conditions, medication regimens, falling events, physical functioning measures, and hospitalizations were obtained from chart data. The relationship between selected resident characteristics and comorbidities was explored with index Hb level, using multiple linear regression. Logistic regression was used to analyze the relationship between falling and recurrent falls with anemia (index Hb < 13 g/dL and < 12 g/dL in men and women > or =15 years, respectively) adjusting for selected variables presumed to be related to falls. LIMITATIONS: Study limitations include the retrospective design and limited follow-up, potential for biased selection of relevant covariates, gaps in time between index Hb levels and falling events, non-random selection of nursing homes, limits to quality and detail in data extracted from residents' medical charts, and confounding of anemia therapy with index hemoglobin level. RESULTS: A total of 564 sampled residents met the criteria for data completeness and were retained for analysis; of these, 70% were female. Mean age was 81 +/- 12.3 years (+/-SD). Mean index Hb level was 11.9 +/- 1.8 g/dL (12.2 +/- 2.0 for males, 11.7 +/- 1.6 for females). Of all residents studied, 56% were identified as anemic (64% males, 53% females) from index Hb level. In all, 53% of anemic residents were receiving an identified therapy, with 72% of these treated residents receiving iron. None received an erythropoietic-stimulating agent (ESA). For index Hb level, the regression coefficient was significant for female (p = 0.002), African-American race (p = 0.012), glomerular filtration rate (GFR) < 60 mL/min/1.73 m(2) (p < 0.001), diabetes (p = 0.004), cancer (p < 0.001), asthma (p = 0.002), GI bleeding (p = 0.012), and inflammatory disease (p = 0.039). Except for asthma, these factors were associated with a decrease in Hb. In the regression model for the dependent variable of falling, anemia (OR = 2.26, p = 0.001), psychoactive medication use (OR = 2.18, p = 0.001), and age 85+ years (OR = 2.08, p = 0.016) were associated with more than twice the risk of falling. CONCLUSIONS: Anemia in nursing home residents appears to be under-recognized. For residents over 70 years, the prevalence of anemia in both male and female residents was approximately four times the rate reported in a study of older community dwellers (Salive et al., 1992). Both anemia and the use of psychoactive medications are potentially modifiable factors strongly associated with falling. Since falls and related fractures are events associated with high morbidity and mortality, each of these factors deserves special consideration for potentially reducing the risk of such events in the nursing home.

PMID: 18561876 [PubMed - indexed for MEDLINE]

[Read more →]

RSVP: a system for communication of deterioration in hospital patients.

Br J Nurs. 2008 Jul 10-23;17(13):860-4

Authors: Featherstone P, Chalmers T, Smith GB

Communication failures are a prime cause of patient safety incidents. In a medical emergency, patient survival often depends on ward staff making an early and effective call for help. To improve communication with senior colleagues, ward staff need to create a picture that efficiently and reliably conveys their concerns so that they get the help that they need without delay. This can best be achieved though a structured call for help. The Reason-Story-Vital Signs-Plan system, used in the Acute Life-threatening Events–Recognition and Treatment (ALERT) course, is easy to remember in an emergency and includes the essential information enabling an experienced clinician to respond appropriate to a call for help from ward staff. The use of such a structured call for help could improve patient safety.

PMID: 18856152 [PubMed - indexed for MEDLINE]

[Read more →]

Shared by Robert Mahoney

Link: http://linkinghub.elsevier.com/retrieve/pii/S000293430800497X
Related Articles
Should a Hand-carried Ultrasound Machine Become Standard Equipment for Every Internist?
Am J Med. 2009 Jan;122(1):1-3
…

[Read more →]

Acute forms of tuberculosis in adults.

Am J Med. 2009 Jan;122(1):12-7

Authors: Jacob JT, Mehta AK, Leonard MK

Although typically considered a chronic disease, tuberculosis (TB) has protean acute manifestations, the major forms of which are reviewed in this article. The pathogenesis of acute TB, although still incompletely understood, may be related to both epidemiologic and genetic host factors. Miliary TB manifests as a nonspecific clinical syndrome with a high mortality rate. The most well-known form of acute TB is meningitis, characterized by fever, nuchal rigidity, and a lymphocytic pleocytosis of the cerebrospinal fluid. Acute abdominal TB may present with obstruction or less commonly as perforated viscus or peritonitis. Critically ill patients may have acute respiratory distress syndrome, shock, or disseminated intravascular coagulopathy. The spectrum of disease makes diagnosis of acute TB difficult unless clinical suspicion of disease is high, but the high mortality mandates its consideration. Early initiation of therapy is crucial to optimize clinical outcome.

PMID: 19114163 [PubMed - in process]

[Read more →]

Shared by Robert Mahoney

Link: http://www.bmj.com/cgi/content/extract/337/dec29_1/a3154
Related Articles
Hospitals struggle to find enough junior doctors to fill rotas.
BMJ. 2008;337:a3154
Authors: Torjesen I

…

[Read more →]

Related Articles

Increased splanchnic oxygen extraction because of routine nursing procedures.

Crit Care Med. 2009 Dec 26;

Authors: Jakob SM, Parviainen I, Ruokonen E, Hinder R, Uusaro A, Takala J

OBJECTIVE:: Multiple organ failure is a common complication of acute circulatory and respiratory failure. We hypothesized that therapeutic interventions used routinely in intensive care can interfere with the perfusion of the gut and the liver, and thereby increase the risk of mismatch between oxygen supply and demand. DESIGN:: Prospective, observational study. SETTING:: Interdisciplinary intensive care unit (ICU) of a university hospital. PATIENTS:: Thirty-six patients on mechanical ventilation with acute respiratory or circulatory failure or severe infection were included. INTERVENTIONS:: Insertion of a hepatic venous catheter. MEASUREMENTS AND MAIN RESULTS:: Daily nursing procedures were recorded. A decrease of >/=5% in hepatic venous oxygen saturation (Sho2) was considered relevant. Observation time was 64 (29-104) hours (median [interquartile range]). The ICU stay was 11 (8-15) days, and hospital mortality was 35%. The number of periods with procedures/patient was 170 (98-268), the number of procedure-related decreases in Sho2 was 29 (13-41), and the number of decreases in Sho2 unrelated to procedures was 9 (4-19). Accordingly, procedure-related Sho2 decreases occurred 11 (7-17) times per day. Median Sho2 decrease during the procedures was 7 (5-10)%, and median increase in the gradient between mixed and hepatic venous oxygen saturation was 6 (4-9)%. Procedures that caused most Sho2 decreases were airway suctioning, assessment of level of sedation, and changing patients' position. Sho2 decreases were associated with small but significant increases in heart rate and intravascular pressures. Maximal Sequential Organ Failure Assessment scores in the ICU correlated with the number of Sho2 decreases (r: .56; p < 0.001) and with the number of procedure-related Sho2 decreases (r: .60; p < 0.001). CONCLUSIONS:: Patients are exposed to repeated episodes of impaired splanchnic perfusion during routine nursing procedures. More research is needed to examine the correlation, if any, between nursing procedures and hepatic venous desaturation.

PMID: 19114883 [PubMed - as supplied by publisher]

[Read more →]

Related Articles

The clinical effectiveness of central venous catheters treated with anti-infective agents in preventing catheter-related bloodstream infections: A systematic review.

Crit Care Med. 2009 Dec 26;

Authors: Hockenhull JC, Dwan KM, Smith GW, Gamble CL, Boland A, Walley TJ, Dickson RC

OBJECTIVES:: To assess the clinical effectiveness of central venous catheters (CVCs) treated with anti-infective agents (AI-CVCs) in preventing catheter-related bloodstream infections (CRBSI). DATA SOURCES:: MEDLINE (OVID), EMBASE, SCI//Web of Science, SCI/ISI Proceedings, and the Cochrane Library. STUDY SELECTION:: A systematic review of the literature was conducted using internationally recognized methodology. All included articles were reports of randomized controlled trials comparing the clinical effectiveness of CVCs treated with AI-CVCs with either standard CVCs or another anti-infective treated catheter. Articles requiring in-house preparation of catheters or that only reported interim data were excluded. DATA EXTRACTION:: Data extraction was carried out independently and crosschecked by two reviewers using a pretested data extraction form. DATA SYNTHESIS:: Meta-analyses were conducted to assess the effectiveness of AI-CVCs in preventing CRBSI, compared with standard CVCs. Results are presented in forest plots with 95% confidence intervals. RESULTS:: Thirty-eight randomized controlled trials met the inclusion criteria. Methodologic quality was generally poor. Meta-analyses of data from 27 trials assessing CRBSI showed a strong treatment effect in favor of AI-CVCs (odds ratio 0.49 (95% confidence interval 0.37-0.64) fixed effects, test for heterogeneity, chi-square = 28.78, df = 26, p = 0.321, I = 9.7). Results subgrouped by the different types of anti-infective treatments generally demonstrated treatment effects favoring the treated catheters. Sensitivity analyses investigating the effects of methodologic differences showed no differences to the overall conclusions of the primary analysis. CONCLUSION:: AI-CVCs appear to be effective in reducing CRBSI compared with standard CVCs. However, it is important to establish whether this effect remains in settings where infection-prevention bundles of care are established as routine practice. This review does not address this question and further research is required.

PMID: 19114884 [PubMed - as supplied by publisher]

[Read more →]

Related Articles

Influence of vasopressor agent in septic shock mortality. Results from the Portuguese Community-Acquired Sepsis Study (SACiUCI study).

Crit Care Med. 2009 Dec 26;

Authors: Póvoa PR, Carneiro AH, Ribeiro OS, Pereira AC,

OBJECTIVE:: Guidelines for the adrenergic support of septic shock are controversial. In patients with community-acquired septic shock, we assessed the impact of the choice of vasopressor support on mortality. DESIGN:: Cohort, multiple center, observational study. SETTING:: Seventeen Portuguese intensive care units (ICUs). PATIENTS:: All adult patients admitted to a participating ICU between December 2004 and November 2005. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: Patients were followed up during the first five ICU days, the day of discharge or death, and hospital outcome. Eight hundred ninety-seven consecutive patients with community-acquired sepsis (median age, 63 years; 577 men; and hospital mortality, 38%) were studied. Of the 458 patients with septic shock, 73% received norepinephrine and 50.5% dopamine. The norepinephrine group had a higher hospital mortality (52% vs. 38.5%, p = 0.002). A Kaplan-Meier survival curve showed diminished 28-day survival in the norepinephrine group (log-rank = 22.6, p < 0.001). A Cox proportional hazard analysis revealed that the administration of norepinephrine was associated with an increased risk of death (adjusted hazard ratio, 2.501; 95% confidence interval, 1.413-4.425; p = 0.002). In a multivariate analysis with ICU mortality as the dependent factor, Simplified Acute Physiology Score II and norepinephrine administration were independent risk factors for ICU mortality in patients with septic shock. CONCLUSIONS:: In patients with community-acquired septic shock, our data suggest that norepinephrine administration could be associated with worse outcome.

PMID: 19114885 [PubMed - as supplied by publisher]

[Read more →]