Related Articles

Serum sodium as a risk factor for in-hospital mortality in acute unselected general medical patients.

QJM. 2009 Mar;102(3):175-82

Authors: Whelan B, Bennett K, O’Riordan D, Silke B

BACKGROUND: Serum sodium has been shown to predict mortality in heart and liver failure. AIM: To determine whether serum sodium independently predicts in-hospital mortality during any emergency medical admission. DESIGN: An analysis was performed of all emergency medical patients admitted to St James's Hospital (SJH), Dublin between 1 January 2002 and 31 December 2006, using the hospital inpatient enquiry (HIPE) system, linked to the patient administration system and laboratory datasets. Hospital mortality was obtained from a database of 20 deaths occurring during the same period under physicians participating in the 'on call' roster. METHODS: The serum sodium was determined at admission in all cases where it was deemed clinically necessary. Logistic regression was used to calculate crude and 25 adjusted odds ratios (ORs). Factors adjusted for included age, illness severity score (Modified Apache II score), major disease category, ICU stay, year effect, blood transfusion, gender and sepsis. RESULTS: A total of 14 239 patients (47.5% male) were included in the analysis. Mortality had a U-shaped distribution and was highest in patients whose sodium level was <125 or >140 mmol/l. The unadjusted OR of death within 30 days of admission was 3.36 (95% CI 2.59-4.36) and 4.07 (95% CI 2.95-5.63) with sodium level <125 and >140 mmol/l, respectively. Adjustment for all of the factors above reduced the mortality odds in all hyponatraemia groups but all remained significant predictors of mortality. After adjustment for illness severity score the OR ratio for death in the >140 mmol/l group fell to 1.41 (95% CI 0.97-2.07). DISCUSSION: The serum sodium is a powerful initial marker of likely mortality in unselected general medical patients. The increased death rate in hyponatraemic patients is independent of other clinical variables, whereas mortality in the hypernatraemic group is primarily a factor of illness severity.

PMID: 19106156 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Pain management for hepatobiliary cancer.

Curr Treat Options Oncol. 2008 Jun;9(2-3):234-41

Authors: Halpert D, Erdek MA

OPINION STATEMENT: Although many options exist to address hepatobiliary cancer-induced pain, it remains undertreated and has an adverse impact on quality of life. Fortunately, if addressed appropriately, the majority of patients can be treated successfully. This pain may be nociceptive, neuropathic, or a combination of the two. A multimodality approach including oral and intravenous opioid and non-opioid medications, and interventional approaches including celiac plexus blocks and implantation of drug delivery systems for intrathecal delivery of opioids can be considered and utilized as appropriate. We review the pathophysiology of pain, the approach to correctly diagnosing the different types of pain, the appropriate treatment recommendations, and how to avoid and address the common side effects resulting from these treatments.

PMID: 18712483 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Atypical presentations of thrombotic thrombocytopenic purpura: a review.

J Clin Apher. 2009;24(1):47-52

Authors: Sarode R

Thrombotic thrombocytopenic purpura (TTP) is diagnosed by the presence of microangiopathic hemolytic anemia and thrombocytopenia in a patient who frequently presents with central nervous system involvement and, to a lesser extent, renal dysfunction. Recent understanding of the pathophysiology of TTP due to severe deficiency of von Willebrand factor cleaving protease, known as ADAMTS13, has improved diagnosis of TTP. Once the diagnosis is suspected, life-saving therapeutic plasma exchange therapy is initiated. Occasionally, an unusual clinical presentation makes TTP diagnosis difficult, thus resulting in a delay in the management of TTP. This review highlights a variety of atypical TTP presentations described in the literature. It is intended to bring unusual scenarios to the clinician’s awareness, so that timely treatment can be delivered.

PMID: 19073011 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Moderate-severe renal insufficiency is a risk factor for sirolimus-eluting stent thrombosis. The RIFT study.

Cardiology. 2009;112(3):191-9

Authors: Zhu ZB, Zhang RY, Zhang Q, Zhang JS, Hu J, Yang ZK, Shen WF

OBJECTIVE: The RIFT study aimed to observe the impact of renal insufficiency (RI) on the incidence of stent thrombosis (ST) after percutaneous coronary intervention. METHODS: The RIFT study enrolled 1,174 patients undergoing revascularization exclusively with sirolimus-eluting stents. The occurrence of ST and major adverse cardiac events were compared between patients with (n = 309) and without (n = 865) RI, and independent predictors of ST were also identified. RESULTS: During follow-up (mean 18.9 +/- 9.2 months), the rate of ST was significantly higher in patients with than without RI [5.5% (n = 17) vs. 1.7% (n = 15), p < 0.001], and the presence of severe RI (estimated glomerular filtration rate <30 ml/min.1.73 m(2)) was an independent predictor of ST (odds ratio = 4.5, 95% confidence interval 1.4-15, p = 0.011). In patients with RI and diabetes or left ventricular ejection fraction (LVEF) <50%, the incidence of ST was significantly increased [13.0% (n = 10) vs. 3.6% (n = 7), p = 0.010; 11.6% (n = vs. 1.9% (n = 3), p = 0.004, respectively] compared to those with diabetes or LVEF <50% alone. The influence of RI on ST was not significant in patients with multivessel disease, calcified or bifurcation lesions, and target lesion revascularization. CONCLUSIONS: These findings substantiate the importance of long-term antiplatelet therapy for patients with RI after drug-eluting stent implantation.

PMID: 18682662 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Diagnostic capacity of 64-slice multidetector computed tomography for acute coronary syndrome in patients presenting with acute chest pain.

Cardiology. 2009;112(3):211-8

Authors: Ueno K, Anzai T, Jinzaki M, Yamada M, Kohno T, Kawamura A, Yoshikawa T, Kuribayashi S, Ogawa S

BACKGROUND/AIMS: Early evaluations of patients presenting with acute chest pain remain difficult. We examined the diagnostic capacity of multidetector computed tomography (MDCT) for acute coronary syndrome (ACS) in patients presenting with acute chest pain. METHODS/RESULTS: We examined 36 consecutive patients presenting with acute chest pain with neither diagnostic ECG changes nor elevated biomarkers. 64-slice MDCT was performed, and we evaluated the presenceof significant coronaryartery stenosis (>50% reduction in lumen diameter). Significant stenosis was detected in 15 patients by MDCT. Among them, 11 patients were diagnosed as having ACS based on the findings of coronary angiography or myocardial perfusion single photon emission computed tomography (positive predictive value 73%). All 21 patients without significant stenosis by MDCT, except only one, were regarded as not having ACS (negative predictive value 95%). Sensitivity and specificity were 92 and 83%, respectively. In patients without a history of coronary artery disease (CAD), both the specificity and positive predictive value improved to 100% (sensitivity 90%; negative predictive value 95%). In patients with neither a history of CAD nor coronary calcification, the diagnostic accuracy of MDCT was 100%. CONCLUSIONS: MDCT has high diagnostic capacity for the early evaluation of ACS, especially in patients without a history of CAD or coronary calcification.

PMID: 18682665 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Emergency surgery for complicated acute diverticulitis.

Colorectal Dis. 2009 Feb;11(2):198-202

Authors: Issa N, Dreznik Z, Dueck DS, Arish A, Ram E, Kraus M, Gutman M, Neufeld D

AIM: Antecedent attacks of diverticulitis are thought to increase the risk of complicated diverticulitis, and unless elective surgery is performed, a high proportion of patients with recurrent symptoms will require emergency operations for complicated diverticulitis with its associated morbidity. In this multicentre study, we aim to assess impact of previous attacks of diverticulitis on patients requiring an emergency surgical intervention. METHOD: All patients operated on as an emergency for complicated diverticulitis were retrospectively analysed. Patients were separated into two groups: group A included patients without previous history of diverticular disease, and group B those with previous attacks of diverticulitis. RESULTS: A total of 96 patients were included in the study. Group A included 68 (70.8%) patients, and group B 28 (29.2%) patients. Generalized peritonitis was the reason for operation in 50 (73.5%) patients in-group A and only four (14%) patients in group B. Perforated diverticulitis occurred more often in group A, whereas pericolonic abscess and phlegmon formation occurred more commonly in group B. Resection was performed in all patients in group B; 50% had a Hartmann’s procedure, and the other 50% patients had primary anastomosis. Hartmann’s procedure was performed in 52 patients (76.5%) in group A, and 8 patients (11.7%) had resection and primary anastomosis. No difference in postoperative complications was identified between the groups. CONCLUSION: Multiple attacks of diverticulitis are not associated with an increased risk of complicated diverticulitis. Recurrent episodes of diverticulitis are not associated with a less favourable outcome or an increased risk of fatality if complications ensue.

PMID: 18462249 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Management of methicillin-resistant Staphylococcus aureus infections.

Clin Microbiol Infect. 2009 Feb;15(2):125-36

Authors: Garau J, Bouza E, Chastre J, Gudiol F, Harbarth S

This review addresses selected aspects of the management of severe healthcare-associated infections due to methicillin-resistant Staphylococcus aureus (MRSA), including the limitations of current therapy, potential alternative agents, new therapeutic options, clinical approaches to MRSA bacteraemia/endocarditis and ventilator-associated pneumonia, and strategies to improve outcomes in patients with severe MRSA infections.

PMID: 19291144 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Coma.

Ann N Y Acad Sci. 2009 Mar;1157:32-47

Authors: Young GB

Coma is a state of unarousable unconsciousness due to dysfunction of the brain’s ascending reticular activating system (ARAS), which is responsible for arousal and the maintenance of wakefulness. Anatomically and physiologically the ARAS has a redundancy of pathways and neurotransmitters; this may explain why coma is usually transient (seldom lasting more than 3 weeks). Emergence from coma is succeeded by outcomes ranging from the vegetative state to complete recovery, depending on the severity of damage to the cerebral cortex, the thalamus, and their integrated function. The clinical and laboratory assessments of the comatose patient are reviewed here, along with an analysis of how various conditions (structural brain lesions, metabolic and toxic disorders, trauma, infections, seizures, hypothermia, and hyperthermia) produce coma. Management issues include the determination of the cause and reversibility (prognosis) of neurological impairment, support of the patient, definitive treatment when possible, and the ethical considerations for those situations where marked disability is predicted with certainty.

PMID: 19351354 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Cardiac biomarkers for risk stratification in non-massive pulmonary embolism: a multicenter prospective study.

J Thromb Haemost. 2009 Mar;7(3):391-8

Authors: Vuilleumier N, Le Gal L, Verschuren F, Perrier A, Bounameaux H, Turck N, Sanchez JC, Mensi N, Perneger T, Hochstrasser D, Righini M

BACKGROUND: Troponins (cTnI and cTnT), N-terminal pro-Brain Natriuretic Peptide (NT-proBNP), myoglobin, heart-type fatty acid-binding protein (H-FABP) and fibrin D-Dimer are emergent candidates for risk stratification in pulmonary embolism (PE). OBJECTIVE: To compare the respective prognostic values of biomarker with non-massive PE to predict an adverse outcome at 3 months. PATIENTS/METHODS: One hundred and forty-six consecutive patients with non-massive PE were included in this multicenter prospective study. The combined outcome consisted of intensive care monitoring on admission, death or hospitalization attributable to either a PE-related complication [defined by PE/deep vein thrombosis (DVT) relapse or major bleeding under anticoagulation] or to dyspnoea with or without chest pain during follow-up. RESULTS: The outcome was met in 12% of patients. In univariate analysis, a NT-proBNP level above 300 pg/ml was the strongest predictor of unfavorable outcome with an odds ratio (OR) of 15.8 [95% confidence interval (CI): 2.05-122). ORs for the other variables were: 8.0 for D-dimer >2000 ng/ml (95% CI: 1.1-64), 4.7 for H-FABP >6 ng/ml (95% CI:1.5-14.8), 3.5 for cTnI >0.09 ng/ml (95% CI:1.2-9.7), 3.4 for myoglobin >70 ng/ml (95% CI:0.9-12.2). Receiver operating curve (ROC) analysis indicated that NT-proBNP was the best predictor [area under the curve (AUC) 0.84; 95%CI: 0.76-0.92; P < 0.0001] with a negative predictive value of 100% (95% CI: 91-100) at 300 pg/ml. At that cut-off, the true negative rate for NT-proBNP was 40%. In multivariate analysis, NT-proBNP was the only significant independent predictors. CONCLUSIONS: NT-proBNP appears to be a good risk stratification marker in identifying low-risk patients with non-massive PE who could be treated in an outpatient setting.

PMID: 19087222 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Formoterol and tiotropium compared with tiotropium alone for treatment of COPD.

COPD. 2009 Feb;6(1):17-25

Authors: Tashkin DP, Pearle J, Iezzoni D, Varghese ST

Combined use of beta(2)-agonists and anticholinergic bronchodilators may have complementary benefits in patients with chronic obstructive pulmonary disease (COPD). The objective of this study was to compare combination treatment with formoterol (FORM) plus tiotropium (TIO) versus treatment with TIO alone in patients with COPD. In this active-controlled, double-blind, multicenter trial, a total of 255 subjects with diagnosed COPD were randomized to 12 weeks of either a combination of FORM 12 microg twice-daily plus TIO 18 microg once-daily in the morning (QD AM) or monotherapy with TIO 18 microg QD AM. The primary efficacy variable was the area under the curve for forced expiratory volume in 1 second measured 0 to 4 hours after AM dosing (FEV(1) AUC(0-4h)). Significantly greater improvements in the FEV(1) AUC(0-4h) were seen with FORM + TIO (n = 116) versus TIO (n = 124) at all time points. The increase in FEV(1) 5 minutes after the first dose was 180 mL with FORM + TIO versus 40 mL with TIO (p < 0.001). At endpoint, FEV(1) AUC(0-4h) increased 340 mL with FORM + TIO versus 170 mL with TIO (p < 0.001). Improvements in trough FEV(1) with FORM + TIO versus TIO were 180 mL and 100 mL, respectively (p < 0.01). Significantly greater reductions from baseline in symptom scores (p < 0.05) and daytime albuterol use (p < 0.04) were seen at endpoint with combination FORM + TIO versus TIO monotherapy. Both treatments were well tolerated. This study demonstrated that concurrent treatment with FORM + TIO results in greater therapeutic benefits than TIO alone.

PMID: 19229704 [PubMed - indexed for MEDLINE]

[Read more →]

Venous thrombo-embolic disease.

Compr Ther. 2009;35(1):24-36

Authors: Shakoor H, Santacruz JF, Dweik RA

Venous thrombo-embolic disease carries a high mortality rate and sometimes difficulties in diagnosis. Conventional pulmonary angiography remains the gold standard diagnostic test for pulmonary embolism. While contrast venography remains the gold standard modality to diagnose deep venous thrombi, the highly sensitive and specific venous ultrasonography makes it the most common initial test. The management of below-the-knee deep vein thrombosis and the indications for thrombolysis in pulmonary embolism are among the controversies explored.

PMID: 19351102 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Necrotizing fasciitis.

J Am Acad Orthop Surg. 2009 Mar;17(3):174-82

Authors: Bellapianta JM, Ljungquist K, Tobin E, Uhl R

Necrotizing fasciitis is a rare but life-threatening soft-tissue infection characterized by rapidly spreading inflammation and subsequent necrosis of the fascial planes and surrounding tissue. Infection typically follows trauma, although the inciting insult may be as minor as a scrape or an insect bite. Often caused by toxin-producing, virulent bacteria such as group A streptococcus and associated with severe systemic toxicity, necrotizing fasciitis is rapidly fatal unless diagnosed promptly and treated aggressively. Necrotizing fasciitis is often initially misdiagnosed as a more benign soft-tissue infection. The single most important variable influencing mortality is time to surgical débridement. Thus, a high degree of clinical suspicion is necessary to avert potentially disastrous consequences. Orthopaedic surgeons are often the first to evaluate patients with necrotizing fasciitis and as such must be aware of the presentation and management of this disease. Timely diagnosis, broad-spectrum antibiotic therapy, and aggressive surgical débridement of affected tissue are keys to the treatment of this serious, often life-threatening infection.

PMID: 19264710 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Enterococcal-associated lower respiratory tract infections: a case report and literature review.

Infection. 2009 Feb;37(1):60-4

Authors: Grupper M, Kravtsov A, Potasman I

We report a rare case of bacteremic enterococcal pneumonia in an 81-year-old man, with an indolent disease course. We reviewed the literature concerning lower respiratory tract infections associated with enterococci for the burden, the pathogenesis and the clinical characteristics of these unusual infections.

PMID: 17973076 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Cardiovascular complications of cocaine: imaging findings.

Emerg Radiol. 2009 Jan;16(1):11-9

Authors: Restrepo CS, Rojas CA, Martinez S, Riascos R, Marmol-Velez A, Carrillo J, Vargas D

Cocaine is the second most commonly abused illicit drug in the US and the most common one involved in emergency department visits, the majority of which are related to the cardiovascular system. Cardiovascular complications related with cocaine abuse include myocardial ischemia and infarction, myocarditis, hypertrophic cardiomyopathy, dilated cardiomyopathy, aortic dissection, thrombosis, stroke and cerebral hemorrhage, and different forms of visceral ischemia, among others. In an era where cocaine use has reached epidemic proportions, it is necessary for the radiologist to understand the pathophysiology, clinical presentation, and imaging characteristics of its cardiovascular complications.

PMID: 18773229 [PubMed - indexed for MEDLINE]

[Read more →]

Related Articles

Recognizing the importance of respiratory syncytial virus in chronic obstructive pulmonary disease.

COPD. 2009 Feb;6(1):64-75

Authors: Ramaswamy M, Groskreutz DJ, Look DC

Acute exacerbations of chronic obstructive pulmonary disease (COPD) are responsible for a large proportion of the health care dollar expenditure, morbidity, and mortality related to COPD. Respiratory infections are the most common cause of acute exacerbations, but recent evidence indicates that the importance of respiratory syncytial virus (RSV) infection in COPD is under-appreciated. Improved detection of RSV using techniques based on the polymerase chain reaction accounts for much of the increased recognition of the importance of this virus in COPD patients. Furthermore, COPD patients may be more susceptible to RSV infection, possibly due to RSV-or immune response-induced pulmonary effects that are altered by age, environmental exposures, genetics, COPD itself, or a combination of these. However, although RSV infection occurs throughout life, viral and host factors that place COPD patients at increased risk are unclear. The complexities of RSV effects in COPD present opportunities for research with the goal of developing approaches to selectively modify damaging viral effects (e.g., altered airway function), while retaining beneficial immunity (e.g., clearance of virus) in COPD patients. This review explores the role RSV plays in acute exacerbations of COPD, the potential for RSV disease in chronic stable COPD, and newer concepts in RSV diagnosis, epidemiology, and host defense.

PMID: 19229710 [PubMed - indexed for MEDLINE]

[Read more →]