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Drugs for hypertension.

Treat Guidel Med Lett. 2009 Jan;7(77):1-10; quiz 2 p

Authors:

PMID: 19107095 [PubMed - indexed for MEDLINE]

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Patient perception of osteopathic manipulative treatment in a hospitalized setting: a survey-based study.

J Am Osteopath Assoc. 2008 Nov;108(11):665-8

Authors: Pomykala M, McElhinney B, Beck BL, Carreiro JE

CONTEXT: Although many studies on the effects of osteopathic manipulative treatment (OMT) have been published, few examine its role in treating hospitalized patients. OBJECTIVE: To determine patient perception of receiving OMT while hospitalized. METHODS: Patients were referred to receive OMT through a consultation service and were separated into four groups: medical, musculoskeletal, obstetric, or postsurgical. The same osteopathic physician treated each patient and used various OMT techniques as needed. High-velocity, low-amplitude was not used. Patient perceptions were assessed 24 hours after treatment using a 10-question survey. Main outcome measures included pain, need for pain medication, anxiety about hospitalization, and overall comfort level. RESULTS: Of the 195 hospitalized patients who received OMT, 160 (82%) returned the survey. Of these patients, 43% reported a decreased need for pain medication, 74% indicated a decrease in pain, 90% had reduced anxiety, and 98% reported that OMT improved their overall comfort level. In addition, 94% of patients felt OMT was helpful for their recovery, and 98% would recommend OMT for other hospitalized patients. CONCLUSION: Osteopathic manipulative treatment may be of tremendous benefit to hospitalized patients, regardless of their diagnoses.

PMID: 19011230 [PubMed - indexed for MEDLINE]

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Single-step EUS-guided endoscopic treatment for sterile pancreatic collections: a single-center experience.

Dig Dis. 2008;26(4):370-6

Authors: Ardengh JC, Coelho DE, Coelho JF, de Lima LF, dos Santos JS, Módena JL

BACKGROUND AND AIMS: Endoscopic ultrasound (EUS) is useful for the treatment of sterile pancreatic fluid collections (PFC), either by means of transmural drainage or by complete aspiration. The aim of this study was to evaluate the efficacy and safety of single-step EUS-guided endoscopic approaches for treatment of sterile PFC. PATIENTS AND METHODS: During a 3-year period, 77 consecutive patients with symptomatic, persistent sterile PFC were evaluated and treated with the linear EUS. We excluded patients with grossly purulent collections, chronic pseudocyst and those whose cytology diagnostic was neoplastic cyst of pancreas. 44 patients received a single 10-Fr plastic straight stent under EUS or fluoroscopic control (group I) and 33 of these underwent a single-step complete aspiration with a 19-gauge needle (group II). RESULTS: The mean size of the sterile PFC was 48 mm in group I and 28 mm in group II (p < 0.001). Overall, endoscopic treatment was successful in 70 (90.9%) patients. The mean volume aspirated was 25 (18-65) ml. The total number of procedures was 50 in group I and 41 punctures in group II. After a mean follow-up of 64 +/- 15.6 weeks there were 6 complications (13.6%): 2 recurrences (referred to surgery), 2 developing abscesses (submitted a new EUS-guided endoscopic drainage with success), 1 perforation that died (2.2%), and 1 case of bleeding (sent to surgery) in group I. In group II there were only 6 (18.1%) recurrences (submitted a new EUS-guided aspiration). None of the patients undergoing single-step aspiration developed infections, perforation or hemorrhage. CONCLUSION: The recurrence of pancreatic pseudocysts after endoscopic treatment was similar, either by means of plastic stents or by complete single-step aspiration.

PMID: 19188730 [PubMed - indexed for MEDLINE]

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Therapeutic challenges in the era of antibiotic resistance.

Int J Antimicrob Agents. 2008 Dec;32 Suppl 4:S197-9

Authors: Lee C

Multidrug microbial resistance poses major challenges to the management of infection, particularly with the paucity of new drugs with activity against these bacteria. Since the turn of this century a few new antibiotics have been licensed, including linezolid, daptomycin and tigecycline. This supplement reports data presented at the 13th International Congress of Infectious Diseases held in Kuala Lumpur in June 2008. Dr R. Isturiz reviews the data on global resistance trends and the potential impact on empirical therapy; Dr J.-H. Song reviews new agents on the antimicrobial horizon; and the final paper in the supplement, by Dr L.R. Peterson, reviews the role of tigecycline in the management of complicated intra-abdominal and skin and soft tissue infections.

PMID: 19134519 [PubMed - indexed for MEDLINE]

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What’s new on the antimicrobial horizon?

Int J Antimicrob Agents. 2008 Dec;32 Suppl 4:S207-13

Authors: Song JH

The antimicrobial era is threatened by high levels of antibiotic resistance, the limited number and disparate availability of effective antibiotics against diverse bacterial species, and reduced involvement by the pharmaceutical industry in the development of new anti-infectives. For the treatment of resistant Gram-positive coccal infections, particularly methicillin-resistant staphylococcal infections, vancomycin has long been the mainstay antimicrobial agent due to its safety, durability against resistance, and lack of other approved alternatives. However, the efficacy and safety of vancomycin for the treatment of many serious infections has been called into question. Promising results from clinical trials suggest that five new antimicrobials could offer safe and effective alternatives to vancomycin. With regard to resistant Gram-negative infections, new carbapenems and some other options will be available. This paper reviews the safety and efficacy of these new antimicrobial agents against resistant bacterial pathogens.

PMID: 19134521 [PubMed - indexed for MEDLINE]

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A review of tigecycline–the first glycylcycline.

Int J Antimicrob Agents. 2008 Dec;32 Suppl 4:S215-22

Authors: Peterson LR

The dawn of a troubling post-antibiotic era likely is on the horizon, fuelled by a rise in bacterial resistance to existing antibiotic therapy alongside a waning pipeline of novel antibacterial agents. Tigecycline, a new glycylcycline with an expanded broad spectrum of in vitro activity, was recently approved for the treatment of complicated skin and soft tissue infections (cSSTIs) and complicated intra-abdominal infections (cIAIs). This review will examine how tigecycline evades the common mechanisms of antibiotic resistance, the metabolism and pharmacokinetics of tigecycline, and its spectrum of in vitro activity. The results of randomized clinical trials for the treatment of cSSTIs and cIAIs with tigecycline are also described, as is the patient safety and tolerability observed during these studies. Tigecycline monotherapy has been shown to be as effective as its comparators and, against a backdrop of rising bacterial resistance, the role for tigecycline in monotherapy of infections from Gram-positive, Gram-negative and anaerobic bacteria is a meaningful development.

PMID: 19134522 [PubMed - indexed for MEDLINE]

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Outcomes of volume-overloaded cardiovascular patients treated with ultrafiltration.

J Card Fail. 2008 Aug;14(6):515-20

Authors: Jaski BE, Romeo A, Ortiz B, Hoagland PM, Stone M, Glaser D, Thomas L, Walsh C, Smith SC

BACKGROUND: Ultrafiltration (UF) can rapidly and predictably remove extracellular and intravascular fluid volume. To date, assessment of UF in patients with cardiovascular disease has been confined to short- and medium-term studies in patients with a principal diagnosis of acute heart failure. METHODS: In-hospital and long-term outcomes were reviewed from consecutive patients with cardiovascular disorders and recognized pulmonary and systemic volume overload treated with a simplified UF system with the capability for peripheral venovenous access. Trained abstractors reviewed both paper and electronic medical records. Patients with a principal diagnosis of heart failure versus other primary hospital discharge diagnoses were identified according to International Classification of Diseases, 9th Revision standards by independent coders. RESULTS: For a period of 43 months, 100 patients (76 male/24 female, 65 +/- 14.0 years of age, systolic dysfunction 64%) were treated with UF during 130 hospitalizations. Baseline systolic blood pressure was 119 +/- 23 mm Hg. Before UF, 53% were receiving intravenous vasoactive therapy. By using UF, 7.1 +/- 3.9 L of ultrafiltrate were removed during 2.0 +/- 1.2 treatments per hospitalization. Baseline creatinine was 1.8 +/- 0.8 and 1.9 +/- 1.2 (not significant) at discharge. Of the 15 in-hospital deaths, 14 occurred during the initial hospitalization. Left ventricular dysfunction was related to 13 (87%) of the 15 deaths; no deaths were related to UF use. In hospitalizations with a principal diagnosis of heart failure (n = 79), in-hospital mortality was 7.6% compared with an ADHERE risk tree estimated mortality of 7.5%. Multivariate logistic regression identified a trend for decreased systolic blood pressure to predict patient initial hospitalization mortality (P = .06). Kaplan-Meier survivals for all patients were 71% at 1 year and 67% at 2 years. Cox regression found decreased systolic blood pressure as a predictor of long-term mortality (P = .025). Total volume of ultrafiltrate removed, ejection fraction, history of coronary artery disease, creatinine clearance, gender, age, and principal diagnosis of heart failure were not significantly associated with long-term mortality. CONCLUSION: This series extends the spectrum of patients previously reported to be treated with UF. Despite marked volume overload, UF-treated patients with a principal diagnosis of heart failure had inpatient outcomes similar to the ADHERE registry. UF should be considered for a broad range of patients who present with volume overload.

PMID: 18672200 [PubMed - indexed for MEDLINE]

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Intravenous azithromycin plus ceftriaxone followed by oral azithromycin for the treatment of inpatients with community-acquired pneumonia: an open-label, non-comparative multicenter trial.

Braz J Infect Dis. 2008 Jun;12(3):202-9

Authors: Rubio FG, Cunha CA, Lundgren FL, Lima MP, Teixeira PJ, Oliveira JC, Golin V, Mattos WL, Mählmann HK, Moreira ED, Jardim JR, Silva RL, Silva PH

Community-Acquired Pneumonia (CAP) is a major public health problem. In Brazil it has been estimated that 2,000,000 people are affected by CAP every year. Of those, 780,000 are admitted to hospital, and 30,000 have death as the outcome. This is an open-label, non-comparative study with the purpose of evaluating efficacy, safety, and tolerability levels of IV azithromycin (IVA) and IV ceftriaxone (IVC), followed by oral azithromycin (OA) for the treatment of inpatients with mild to severe CAP. Eighty-six patients (mean age 56.6 +/- 19.8) were administered IVA (500 mg/day) and IVC (1g/day) for 2 to 5 days, followed by AO (500 mg/day) to complete a total of 10 days. At the end of treatment (EOT) and after 30 days (End of Study–EOS) the medication was evaluated clinically, microbiologically and for tolerability levels. Out of the total 86-patient population, 62 (72.1%) completed the study. At the end of treatment, 95.2% (CI95: 88.9% – 100%) reported cure or clinical improvement; at the end of the study, that figure was 88.9% (CI95: 74.1% – 91.7%). Out of the 86 patients enrolled in the study, 15 were microbiologically evaluable for bacteriological response. Of those, 6 reported pathogen eradication at the end of therapy (40%), and 8 reported presumed eradication (53.3%). At end of study evaluation, 9 patients showed pathogen eradication (50%), and 7 showed presumed eradication (38.89%). Therefore, negative cultures were obtained from 93.3% of the patients at EOT, and from 88.9% at the end of the study. One patient (6.67% of patient population) reported presumed microbiological resistance. At study end, 2 patients (11.11%) still reported undetermined culture. Uncontrollable vomiting and worsening pneumonia condition were reported by 2.3% of patients. Discussion and Conclusion Treatment based on the administration of IV azithromycin associated to ceftriaxone and followed by oral azithromycin proved to be efficacious and well-tolerated in the treatment of Brazilian inpatients with CAP.

PMID: 18833404 [PubMed - indexed for MEDLINE]

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Complications of endotracheal intubation in the critically ill.

Intensive Care Med. 2008 Oct;34(10):1835-42

Authors: Griesdale DE, Bosma TL, Kurth T, Isac G, Chittock DR

OBJECTIVE: Assess the risk of complications during endotracheal intubation (ETI) and their association with the skill level of the intubating physician. DESIGN: Prospective cohort study of 136 patients intubated by the intensive care team during a 5-month period. Standardized data forms were used to collect detailed information on the intubating physicians, supervisors, techniques, medications and complications. SETTING: Canadian academic intensive care unit. MEASUREMENTS AND RESULTS: All intubations were successful and there were no deaths during intubation. Non-experts were supervised in 92% of procedures. Expert operators were successful within two attempts in 94%, compared to only 82% of non-experts (P = 0.03), with 13.2% of all intubations requiring > or =3 attempts. Furthermore, 10.3% of intubations required 10 or more minutes. Difficult intubation (3 or more attempts by an expert) occurred in 6.6%. Overall risk of complications was 39%, including: severe hypoxemia (19.1%), severe hypotension (9.6%), esophageal intubation (7.4%) and frank aspiration (5.9%). ICU and hospital mortality were 15.4 and 29.4%, respectively. Compared with non-expert intubating physicians, propensity score-adjusted odds ratios (95% confidence interval) for expert physicians were 0.92 (95% CI: 0.28, 3.05, P = 0.89) for any complication, 0.45 (95% CI: 0.09, 2.20, P = 0.32) for ICU mortality and 0.47 (95% CI: 0.13, 1.70, P = 0.25) for hospital mortality. Two or more attempts at ETI was independently associated with an increased risk of severe complications (OR 3.31, 95% CI: 1.30, 8.40, P = 0.01). CONCLUSIONS: These prospective data show a high risk of serious complications, and difficult intubations, that are associated with ETI of the critically ill. DESCRIPTOR: Artificial airways and complications.

PMID: 18604519 [PubMed - indexed for MEDLINE]

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Primary Budd-Chiari syndrome.

J Hepatol. 2009 Jan;50(1):195-203

Authors: Valla DC

Primary Budd-Chiari syndrome is characterized by a blocked hepatic venous outflow tract at various levels from small hepatic veins to inferior vena cava, resulting from thrombosis or its fibrous sequellae. This rare disease affects mainly young adults. Multiple risk factors have been identified and are often combined in the same patient. Myeloproliferative diseases of atypical presentation account for nearly 50% of patients; their diagnosis can be made by showing the V617F mutation in Janus tyrosine kinase-2 gene of peripheral blood granulocytes and, should this mutation be absent, by showing clusters of dystrophic megacaryocytes at bone marrow biopsy. Presentation and manifestations are extremely varied, so that the diagnosis must be considered in any patient with acute or chronic liver disease. Doppler-ultrasound, computed tomography or magnetic resonance imaging of hepatic veins and inferior vena cava are usually successful in demonstrating non-invasively the obstacle or its consequences, the collaterals to hepatic veins or inferior vena cava. The disease is considered to be spontaneously lethal within 3 years of first symptoms. A therapeutic strategy has been proposed where anticoagulation, correction of risk factors, diuretics and prophylaxis for portal hypertension are used first; then angioplasty for short-length venous stenoses; then TIPS; and ultimately liver transplantation. Treatment progression is dictated by the response to previous therapy. This strategy has achieved 5-year survival rates approaching 90%. Medium-term prognosis depends on the severity of liver disease. Long-term outcome might be jeopardized by transformation of underlying conditions and hepatocellular carcinoma.

PMID: 19012988 [PubMed - indexed for MEDLINE]

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Perspective: Limiting Resident Work Hours Is a Moral Concern.

Acad Med. 2009 Mar;84(3):310-314

Authors: Higginson JD

The author outlines the cross-cultural and widespread expectation that the moral character of physicians is built on dual possession of skill and compassion. The details of the moral makeup of physicians are often hotly debated in the biomedical literature. Despite a lack of consensus regarding the required aspects of character, the author demonstrates that little debate exists that at a minimum physicians should possess not only knowledge but also a willingness to care for and comfort patients. The primacy of the patient in the physician’s life is reflected in the panoply of oaths taken by new physicians despite great variability in other aspects of these oaths. The author details recent worrisome reports demonstrating the erosion of medical trainees’ empathy and compassion by long work hours. Further, the continued linkage of these attitude changes and fatigue to poor medical outcomes is a call to action. Changes enacted by the Accreditation Council for Graduate Medical Education to reduce resident work hours are insufficient to achieve the goal of improved patient care while promoting moral development among resident physicians. The debate regarding resident work hours is often framed as an idealistic discussion of placing patients first. However, residents are used as an inexpensive labor force, and efforts to curtail this usage would have a significant economic impact. Economic concerns play a larger part in decision making than is generally discussed. The author calls for further alterations of resident work schedules to improve patient care and ensure the preservation of the moral ethos of medicine.

PMID: 19240435 [PubMed - as supplied by publisher]

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A Structured Handoff Program for Interns.

Acad Med. 2009 Mar;84(3):347-352

Authors: Chu ES, Reid M, Schulz T, Burden M, Mancini D, Ambardekar AV, Keniston A, Albert RK

PURPOSE: To develop, teach, and supervise a structured process for handing off patient care and to evaluate its effect on interns' knowledge, skills, and attitudes toward handoffs. METHOD: The authors developed a formal process for interns on the medicine ward services to hand off patient care at their teaching hospital. In July 2006, attending physicians began to teach and supervise the process. To evaluate the entire structured handoff program (the process, teaching, and supervision), interns were surveyed on the first day and during the last week of each of their month long rotations. RESULTS: From June through December 2006, the authors obtained 137 of 144 surveys (95% response) they had administered to 72 consecutive interns rotating through the hospital. During the first three months of the academic year, first-year interns had little confidence in their ability to hand off patients, make contingency plans, or perform read-backs when they began their rotations, but after exposure to the handoff program, their perceptions of these abilities increased (all P < .05). Eighty-five percent of the interns felt that attending supervision of the handoff process was useful or extremely useful, but only 51% viewed the lecture/small-group session about handoffs as useful. CONCLUSIONS: The structured handoff program improved the participating interns' perceptions of their knowledge of the handoff process and their ability to transfer the care of their patients effectively. The formal program for teaching handoffs, that included attendings' supervision of the process, was well received.

PMID: 19240442 [PubMed - as supplied by publisher]

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Does advanced medical technology encourage hospitalist use and their direct employment by hospitals?

Health Econ. 2009 Feb;18(2):237-47

Authors: David G, Helmchen LA, Henderson RA

In the United States, inpatient medical care increasingly encompasses the use of expensive medical technology and, at the same time, is coordinated and supervised more and more by a rapidly growing number of inpatient-dedicated physicians (hospitalists). In the production of inpatient care services, Hospitalist services can be viewed as complementary to sophisticated and expensive medical equipment in the provision of inpatient medical care. We investigate the causal relationship between a hospital’s access to three types of sophisticated diagnostic and therapeutic medical equipment – intensity-modulated radiation therapy, gamma knife, and multi-slice computed tomography – and its likelihood of using hospitalists. To rule out omitted variables bias and reverse causality, we use technology-specific Certificate of Need regulation to predict technology use. We find a strong positive association, yet no causal link between access to medical technology and hospitalist use. We also study the choice of employment modality among hospitals that use hospitalists, and find that access to expensive medical technology reduces the hospital’s propensity to employ hospitalists directly.

PMID: 18470953 [PubMed - indexed for MEDLINE]

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Hospital-wide impact of a standardized order set for the management of bacteremic severe sepsis.

Crit Care Med. 2009 Mar;37(3):819-24

Authors: Thiel SW, Asghar MF, Micek ST, Reichley RM, Doherty JA, Kollef MH

OBJECTIVE: To evaluate the hospital-wide impact of a standardized order set for the management of bacteremic severe sepsis on processes of medical care and patient outcomes. DESIGN: Retrospective, before and after study design. SETTING: Barnes-Jewish Hospital, a 1200-bed academic medical center. PATIENTS: Bacteremic patients with severe sepsis (200 from the 18-month before period and 200 from the 18-month after period). INTERVENTIONS: Hospital-wide implementation of a standardized order set for the management of bacteremic severe sepsis. MEASUREMENTS AND MAIN RESULTS: A total of 400 patients with bacteremia and severe sepsis were selected at random within the specified time periods. Patients in the after group received more intravenous fluids in the first 12 hours after onset of hypotension (1627 +/- 1862 mL vs. 2054 +/- 2237 mL; p = 0.04) and were more likely to receive appropriate initial antibiotic therapy (53.0% vs. 65.5%, p = 0.01). In-hospital mortality was statistically decreased in the after group (55.0% vs. 39.5%, p < 0.01), as was the hospital length of stay (28.7 +/- 30.1 days vs. 22.4 +/- 20.9 days; p = 0.02). Compared with the before group, the after group had reduced occurrence of renal failure (49.0% vs. 36.0%, p < 0.01), cardiovascular failure (70.5% vs. 57.0%, p < 0.01), and were less likely to require vasopressors after initial fluid resuscitation (68.5% vs. 52.5%, p < 0.01). CONCLUSIONS: The implementation of a hospital-wide standardized order set for the management of bacteremic severe sepsis was associated with greater fluid administration, improved antibiotic therapy, decreased incidence of organ failure, and improved survival.

PMID: 19237883 [PubMed - in process]

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Predictors of Initial Nontherapeutic Anticoagulation With Unfractionated Heparin in ST-Segment Elevation Myocardial Infarction.

Circulation. 2009 Feb 23;

Authors: Cheng S, Morrow DA, Sloan S, Antman EM, Sabatine MS

BACKGROUND: -Although weight-based nomograms have improved the efficacy and safety of dosing unfractionated heparin in ST-segment elevation myocardial infarction, achieving therapeutic anticoagulation in practice remains challenging. Methods and Results-In the Enoxaparin and Thrombolysis in Reperfusion for Acute Myocardial Infarction Treatment-Thrombolysis in Myocardial Infarction (ExTRACT-TIMI) 25 study, 20 506 patients with ST-segment elevation myocardial infarction were randomized to enoxaparin or unfractionated heparin, the latter dosed according to the American College of Cardiology/American Heart Association weight-based nomogram with centrally monitored activated partial thromboplastin times (aPTTs). A total of 6055 patients received study unfractionated heparin and a fibrin-specific lytic and had an initial aPTT drawn within 4 to 8 hours of starting therapy. Despite close adherence to recommended dosing, only 33.8% of initial aPTTs were therapeutic (1.50 to 2.00 times control); 13.2% were markedly low (<1.25 times); and 16.3% were markedly high (>/=2.75 times). Markedly high aPTTs were more likely in patients who were older (adjusted risk ratio [RRadj], 1.14 per decade; P=0.001), were female (RRadj, 1.46; P<0.001), were of lower weight (RRadj, 1.19 per 10-kg decrease; P<0.001) or had renal dysfunction (RRadj, 1.08 per 0.2-mg/dL increase in serum creatinine; P=0.006). Markedly high aPTTs were associated with increased risk of TIMI major or minor bleeding by 48 hours (odds ratio, 2.11; P=0.004); markedly low aPTTs tended to be associated with increased risk of fatal or nonfatal reinfarction by 48 hours (odds ratio, 2.19; P=0.057). Conclusions-Despite the use of a standard weight-based unfractionated heparin nomogram in ST-segment elevation myocardial infarction, nontherapeutic anticoagulation is frequent and more likely among certain vulnerable patient groups, with excess anticoagulation associated with increased bleeding and inadequate anticoagulation associated with reinfarction. These findings should be considered when dosing unfractionated heparin in support of fibrinolytic therapy.

PMID: 19237657 [PubMed - as supplied by publisher]

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