Influenza Virus Resistance to Antiviral Agents: A Plea for Rational Use.

Clin Infect Dis. 2009 Mar 26;

Authors: Poland GA, Jacobson RM, Ovsyannikova IG

Although influenza vaccine can prevent influenza virus infection, the only therapeutic options to treat influenza virus infection are antiviral agents. At the current time, nearly all influenza A/H3N2 viruses and a percentage of influenza A/H1N1 viruses are adamantane resistant, which leaves only neuraminidase inhibitors available for treatment of infection with these viruses. In December 2008, the Centers for Disease Control and Prevention released new data demonstrating that a high percentage of circulating influenza A/H1N1 viruses are now resistant to oseltamivir. In addition, oseltamivir-resistant influenza B and A/H5N1 viruses have been identified. Thus, use of monotherapy for influenza virus infection is irrational and may contribute to mutational pressure for further selection of antiviral-resistant strains. History has demonstrated that monotherapy for influenza virus infection leads to resistance, resulting in the use of a new monotherapy agent followed by resistance to that new agent and thus resulting in a background of viruses resistant to both drugs. We argue that combination antiviral therapy, new guidelines for indications for treatment, point-of-care diagnostic testing, and a universal influenza vaccination recommendation are critical to protecting the population against influenza virus and to preserving the benefits of antiviral agents.

PMID: 19323631 [PubMed - as supplied by publisher]

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2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.

Circulation. 2009 Mar 26;

Authors: Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW

PMID: 19324966 [PubMed - as supplied by publisher]

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Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.

Circulation. 2009 Mar 26;

Authors: Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG, Konstam MA, Mancini DM, Rahko PS, Silver MA, Stevenson LW, Yancy CW

PMID: 19324967 [PubMed - as supplied by publisher]

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Clinical profile and outcomes of atrial fibrillation in elderly patients with acute myocardial infarction.

Chin Med J (Engl). 2008 Dec 5;121(23):2388-91

Authors: Li K, Huo Y, Ding YS

BACKGROUND: Atrial fibrillation (AF) occurs commonly in patients with acute myocardial infarction (MI) and is associated with an increased long-term mortality. This study aimed to investigate the clinical characteristics and outcomes of AF in in-hospital elderly Chinese patients with acute MI. METHODS: A total of 967 patients with acute MI, aged >/= 65 years, were categorized on the basis of the absence or presence of AF. Patients with documented AF were classified into two subgroups: the ongoing AF group and the new-onset AF group. We retrospectively evaluated the clinical profile, in-hospital outcomes, and effects of revascularization on the incidence of AF in elderly patients with acute MI. RESULTS: AF was documented in 100 (11.53%) patients and the incidence of new-onset AF was 6.51% during hospitalization. History of old MI and cerebrovascular events were more common in patients with AF than in those without AF (P < 0.001, P < 0.01, respectively). The incidence of AF was higher in patients with non-ST elevated MI (P = 0.014), inferior wall MI (P = 0.004) and cardiac function of Killip class III or IV (P = 0.008). Patients with AF had more complication of pneumonia (P = 0.003) and longer hospital stay. Left circumflex coronary artery involvement was more common in patients with AF (compared with patients without AF, P < 0.001). Percutaneous coronary intervention or coronary artery bypass grafting significantly decreased the incidence of new-onset AF from 7.97% to 3.82% (P = 0.017). AF depended to heart failure, increased the in-hospital mortality. CONCLUSIONS: AF is common in elderly patients with acute MI and is associated with poorer clinical outcomes. Revascularization reduces the incidence of AF and thus improves the clinical outcomes in these patients.

PMID: 19102954 [PubMed - indexed for MEDLINE]

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Communicating with seriously ill patients: better words to say.

JAMA. 2009 Mar 25;301(12):1279-81

Authors: Pantilat SZ

PMID: 19318656 [PubMed - in process]

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Nosocomial Pneumonia Risk and Stress Ulcer Prophylaxis: A Comparison of Pantoprazole vs Ranitidine in Cardiothoracic Surgery Patients.

Chest. 2009 Mar 24;

Authors: Miano TA, Reichert MG, Houle TT, Macgregor DA, Kincaid EH, Bowton DL

Background Stress ulcer prophylaxis (SUP) using ranitidine, a histamine H2 receptor antagonist, has been associated with an increased risk of ventilator-associated pneumonia. The proton-pump inhibitor pantoprazole is also commonly used for SUP. Proton-pump inhibitor use has been linked to an increased risk of community-acquired pneumonia. The objective of this study was to determine whether SUP with pantoprazole increases pneumonia risk compared to ranitidine in critically ill patients. Methods Our institution’s cardiothoracic surgery database was used to retrospectively identify all patients that received SUP with pantoprazole or ranitidine, without crossover between agents. 887 patients were identified from 01/01/04 – 03/31/07, with 53 being excluded (30 pantoprazole, 23 ranitidine). Our analysis compared the incidence of nosocomial pneumonia in 377 patients that received pantoprazole with 457 patients that received ranitidine. Results Nosocomial pneumonia developed in 35 of 377 (9.3%) of the patients receiving pantoprazole, as compared to 7 of 457 (1.5%) of the patients receiving ranitidine (OR 6.6; 95% CI, 2.9-14.9). Twenty-three covariates were used to estimate the probability of receiving pantoprazole as measured by propensity score (C-index 0.77). Using this score, pantoprazole and ranitidine patients were stratified according to their probability of receiving pantoprazole. After propensity adjusted, multivariable logistic regression, pantoprazole treatment was found to be an independent risk factor for nosocomial pneumonia (OR 2.7; 95% CI, 1.1-6.7, p = 0.034). Conclusion The use of pantoprazole for SUP was associated with a higher risk of nosocomial pneumonia compared to ranitidine. This relationship warrants further study in a randomized controlled trial.

PMID: 19318661 [PubMed - as supplied by publisher]

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Diagnosis and Management of Premature Ventricular Complexes-Associated Chronic Cough.

Chest. 2009 Mar 24;

Authors: Stec SM, Grabczak EM, Bielicki P, Zaborska B, Krenke R, Krynski T, Dabrowska M, Domagala-Kulawik J, Domeracka-Kolodziej A, Sikorska A, Kulakowski P, Chazan R

Background Chronic cough may frequently remain unexplained. Although various cardiac arrhythmias have already been reported as a cause of chronic cough, this phenomenon has not been evaluated prospectively. Therefore we studied the incidence and management of cough associated with premature ventricular complexes (PVC) in a population of patients with PVCs. Methods Patients without organic heart disease, referred for management of symptomatic PVC, were evaluated prospectively. PVC-associated cough was recognized if cough episodes occurred just after spontaneous or induced PVC, observed in ECG or a multichannel recording system including ECG. Differential diagnosis of cough was performed according to the guidelines on cough. Afterwards, antiarrhythmic therapy was instituted to achieve disappearance of PVC and cough. Results Of 120 patients referred for management of PVCs, 10 had a chronic cough. After extensive workup for the cause of chronic cough, the cough was thought to be solely due to PVCs in one, partially due to PVCs plus another cause in five, and not due to PVCs in four patients. In this last group, the cause of cough was nonasthamtic eosinophilic bronchitis, gastroesophageal reflux disease and chronic sinusitis. Patients with PVC-associated cough reported more severe perception of symptoms associated with arrhythmia as compared to patients without cough (Visual Analog Scale: 8.2 +/- 0.5 vs 5.7 +/- 1.6, p < 0.01). PVC-associated cough disappeared after antiarrhythmic treatment (radiofrequency ablation (n = 4), oral antiarrhythmic agent (n = 1)), or after spontaneous remission of PVC (n = 1). Conclusions PVC may be a cause of chronic cough. Interdisciplinary cooperation is warranted for proper diagnosis and management of PVC-associated cough.

PMID: 19318662 [PubMed - as supplied by publisher]

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Surrogate Decision Makers.

Chest. 2009 Mar 24;

Authors: Zier LS, Burack JH, Micco G, Chipman AK, Frank JA, White DB

Rationale Although the futility rationale is sometimes used by physicians to limit the use of life sustaining treatments, little is known about how surrogate decision-makers view the futility rationale. Objectives We sought to determine 1) the attitudes of surrogates of critically ill patients about whether physicians can predict futility and 2) whether these attitudes predict surrogates' willingness to discontinue life support when faced with predictions of futility. Design Multi-center, mixed qualitative and quantitative study at three California hospitals in from 2006 to 2007. Subjects Surrogate decision-makers of 50 incapacitated, critically ill patients. Methods We conducted semi-structured interviews with surrogates addressing their beliefs about medical futility and inductively developed an organizing framework to describe these beliefs. We used a hypothetical scenario with a modified time-tradeoff design to examine the relationship between a patient's prognosis and surrogates' willingness to withdraw life support. We used a mixed effects regression model to examine the association between surrogates' attitudes about futility and their willingness to limit life support in the face of a very poor prognosis. Validation methods included the use and integration of multiple data sources, multidisciplinary analysis, and member checking. Main results 64% (32/50; 95% CI: 49-77%) of surrogates expressed doubt about the accuracy of physicians' futility predictions. 32% (16/50; 95% CI: 20-47%) elected to continue life support with a < 1% survival estimate and 18% (9/50; 95% CI: 9-31%) elected to continue treatment when the physician felt there was no chance of survival. Surrogates with religious objections to the futility rationale (n = 18) were more likely to request continued life support (OR = 4; 95% CI: 1.2-14.0; p = 0.03), whereas those with secular or experiential objections (n = 15) were not (OR = 0.95; 95% CI: 0.3-3.4; p = 0.90). Conclusions Doubt about physicians' ability to predict medical futility is common among surrogate decision-makers. The nature of the doubt may have implications for responding to conflicts about futility in clinical practice.

PMID: 19318665 [PubMed - as supplied by publisher]

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Bile Acid Aspiration in Suspected Ventilator-Associated Pneumonia.

Chest. 2009 Mar 24;

Authors: Wu YC, Hsu PK, Su KC, Liu LY, Tsai CC, Tsai SH, Hsu WH, Lee YC, Perng DW

The aims of this study were to measure the levels of bile acids in patients with suspected ventilator-associated pneumonia (VAP) and provide a possible pathway for neutrophilic inflammation to explain its proinflammatory effect on the airway. Bile acid levels were measured by spectrophotometric enzymatic assay, and liquid chromatography mass spectrometry was used to quantify the major bile acids. Alveolar cells were grown on modified air-liquid interface culture inserts and bile acids were then employed to stimulate the cells. RT-PCR and western blots were used to determine the involved gene expression and protein levels. The mean concentration of total bile acids in tracheal aspirates was 6.2 +/- 2.1 and 1.1 +/- 0.4 muM/g sputum for patients with and without VAP, respectively (p < 0.05). The IL-8 level was significantly higher in the VAP group (p < 0.05). The major bile acid, chenodeoxycholic acid, stimulated alveolar epithelial cells to increase IL-8 production at both the messenger RNA and protein level through p38 and JNK kinase activation. The selective p38 and JNK inhibitors, as well as dexamethasone, successfully inhibited IL-8 production. These data suggest that early intervention to prevent bile acid aspiration may reduce the intensity of neutrophilic inflammation in intubated and mechanically-ventilated patients in the ICU.

PMID: 19318678 [PubMed - as supplied by publisher]

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The physician scientist training program in internal medicine at Washington University School of Medicine.

Acad Med. 2009 Apr;84(4):468-71

Authors: Muslin AJ, Kornfeld S, Polonsky KS

Physician scientists provide an invaluable resource in the pursuit of clinically relevant basic and translational research discoveries. The establishment of joint degree MD-PhD educational programs throughout the United States has helped to maintain a cohort of medical professionals who are well trained in both clinical medicine and biomedical research. However, professional development after graduation from a MD-PhD program until appointment as a faculty member has remained largely amorphous and unstructured. To fill this void in medical training and to promote the career development of talented individuals in academic medicine, the physician scientist training program (PSTP) was established at Washington University School of Medicine in St. Louis in 2000. This program provides training in general internal medicine and medical subspecialties, or in general dermatology, followed by research training leading to an appointment as a faculty member. In this article, the rationale for the development of the PSTP, its structure, and the initial outcomes of the program are described.

PMID: 19318780 [PubMed - in process]

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Challenges, duty hours, and metrics in the intensive care unit resident rotation.

Crit Care Med. 2009 Apr;37(4):1490-2

Authors: Thomas KW

PMID: 19318831 [PubMed - in process]

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Acute pancreatitis: etiology and common pathogenesis.

World J Gastroenterol. 2009 Mar 28;15(12):1427-30

Authors: Wang GJ, Gao CF, Wei D, Wang C, Ding SQ

Acute pancreatitis is an inflammatory disease of the pancreas. The etiology and pathogenesis of acute pancreatitis have been intensively investigated for centuries worldwide. Many causes of acute pancreatitis have been discovered, but the pathogenetic theories are controversial. The most common cause of acute pancreatitis is gallstone impacting the distal common bile-pancreatic duct. The majority of investigators accept that the main factors for acute billiary pancreatitis are pancreatic hyperstimulation and bile-pancreatic duct obstruction which increase pancreatic duct pressure and active trypsin reflux. Acute pancreatitis occurs when intracellular protective mechanisms to prevent trypsinogen activation or reduce trypsin activity are overwhelmed. However, little is known about the other acute pancreatitis. We hypothesize that acute biliary pancreatitis and other causes of acute pancreatitis possess a common pathogenesis. Pancreatic hyperstimulation and pancreatic duct obstruction increase pancreatic duct pressure, active trypsin reflux, and subsequent unregulated activation of trypsin within pancreatic acinar cells. Enzyme activation within the pancreas leads to auto-digestion of the gland and local inflammation. Once the hypothesis is confirmed, traditional therapeutic strategies against acute pancreatitis may be improved. Decompression of pancreatic duct pressure should be advocated in the treatment of acute pancreatitits which may greatly improve its outcome.

PMID: 19322914 [PubMed - in process]

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Risk of contrast-induced nephropathy in hospitalized patients with cirrhosis.

World J Gastroenterol. 2009 Mar 28;15(12):1459-64

Authors: Lodhia N, Kader M, Mayes T, Mantry P, Maliakkal B

AIM: To evaluate the incidence of contrast-induced nephropathy (CIN) in cirrhotic patients and to identify risk factors for the development of CIN. METHODS: We performed a retrospective review of 216 consecutive patients with cirrhosis who underwent computed tomography (CT) with intravenous contrast at the University of Rochester between the years 2000-2005. We retrospectively examined factors associated with a high risk for CIN, defined as a decrease in creatinine clearance of 25% or greater within one week after receiving contrast. RESULTS: Twenty-five percent of our patients developed CIN, and 74% of these patients had ascites seen on CT. Of the 75% of patients who did not develop CIN, only 46% had ascites. The presence of ascites was a significant risk factor for the development of CIN (P = 0.0009, OR 3.38, 95% CI 1.55-7.34) in multivariate analysis. Patient age, serum sodium, Model for End-stage Liver Disease score, diuretic use, and the presence of diabetes were not found to be significant risk factors for the development of CIN. Of the patients who developed CIN, 11% developed chronic renal insufficiency, defined as a creatinine clearance less than baseline for 6 wk. CONCLUSION: Our results suggest that in hospitalized cirrhotic patients, especially those with ascites, the risk of CIN is substantial.

PMID: 19322918 [PubMed - in process]

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Use of Electronic Health Records in U.S. Hospitals.

N Engl J Med. 2009 Mar 25;

Authors: Jha AK, Desroches CM, Campbell EG, Donelan K, Rao SR, Ferris TG, Shields A, Rosenbaum S, Blumenthal D

BACKGROUND: Despite a consensus that the use of health information technology should lead to more efficient, safer, and higher-quality care, there are no reliable estimates of the prevalence of adoption of electronic health records in U.S. hospitals. METHODS: We surveyed all acute care hospitals that are members of the American Hospital Association for the presence of specific electronic-record functionalities. Using a definition of electronic health records based on expert consensus, we determined the proportion of hospitals that had such systems in their clinical areas. We also examined the relationship of adoption of electronic health records to specific hospital characteristics and factors that were reported to be barriers to or facilitators of adoption. RESULTS: On the basis of responses from 63.1% of hospitals surveyed, only 1.5% of U.S. hospitals have a comprehensive electronic-records system (i.e., present in all clinical units), and an additional 7.6% have a basic system (i.e., present in at least one clinical unit). Computerized provider-order entry for medications has been implemented in only 17% of hospitals. Larger hospitals, those located in urban areas, and teaching hospitals were more likely to have electronic-records systems. Respondents cited capital requirements and high maintenance costs as the primary barriers to implementation, although hospitals with electronic-records systems were less likely to cite these barriers than hospitals without such systems. CONCLUSIONS: The very low levels of adoption of electronic health records in U.S. hospitals suggest that policymakers face substantial obstacles to the achievement of health care performance goals that depend on health information technology. A policy strategy focused on financial support, interoperability, and training of technical support staff may be necessary to spur adoption of electronic-records systems in U.S. hospitals. Copyright 2009 Massachusetts Medical Society.

PMID: 19321858 [PubMed - as supplied by publisher]

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Glucose Control in the ICU — How Tight Is Too Tight?

N Engl J Med. 2009 Mar 26;360(13):1346-1349

Authors: Inzucchi SE, Siegel MD

PMID: 19318385 [PubMed - as supplied by publisher]

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