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The role of proton pump inhibitors in the management of upper gastrointestinal bleeding.

Gastroenterol Clin North Am. 2009 Jun;38(2):199-213

Authors: Leontiadis GI, Howden CW

Pre-endoscopic administration of PPIs in patients with nonvariceal upper GI bleeding is still of controversial efficacy. It downstages the severity of the endoscopic signs of recent bleeding and may reduce the requirement for endoscopic hemostatic therapy at index endoscopy. However, there is no evidence of an effect on mortality, rebleeding, or surgical intervention rates. In contrast, the efficacy of PPIs in endoscopically diagnosed peptic ulcer bleeding is supported by high-quality evidence from numerous RCTs and meta-analyses of RCTs. PPIs compared with H2RAs or placebo consistently reduce rebleeding rates regardless of dose, route of administration, application or not of endoscopic hemostatic treatment, and geographic location. Surgical intervention rates and the need for further endoscopic hemostatic treatment are also reduced by PPI treatment, although the results are not as robust as those for rebleeding. There is no evidence of an overall effect of PPI treatment on all-cause mortality. However, all-cause mortality is reduced among patients with high-risk endoscopic signs and among trials that had been conducted in Asia. The optimal dose and route of PPI administration has yet to be determined.

PMID: 19446254 [PubMed - indexed for MEDLINE]

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Management of massive peptic ulcer bleeding.

Gastroenterol Clin North Am. 2009 Jun;38(2):231-43

Authors: Cheung FK, Lau JY

Massive bleeding from a peptic ulcer remains a challenge. A multidisciplinary team of skilled endoscopists, intensive care specialists, experienced upper gastrointestinal surgeons, and intervention radiologists all have a role to play. Endoscopy is the first-line treatment. Even with larger ulcers, endoscopic hemostasis can be achieved in the majority of cases. Surgery is clearly indicated in patients in whom arterial bleeding cannot be controlled at endoscopy. Angiographic embolization is an alternate option, particularly in those unfit for surgery. In selected patients judged to belong to the high-risk group–ulcers 2 cm or greater in size located at the lesser curve and posterior bulbar duodenal, shock on presentation, and elderly with comorbid illnesses–a more aggressive postendoscopy management is warranted. The optimal course of action is unclear. Most would be expectant and offer medical therapy in the form of acid suppression. Surgical series suggest that early elective surgery may improve outcome. Angiography allows the bleeding artery to be characterized, and coil embolization of larger arteries may further add to endoscopic hemostasis. The role of early elective surgery or angiographic embolization in selected high-risk patients to forestall recurrent bleeding remains controversial. Prospective studies are needed to compare different management strategies in these high-risk ulcers.

PMID: 19446256 [PubMed - indexed for MEDLINE]

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Predicting poor outcome from acute upper gastrointestinal hemorrhage.

Gastroenterol Clin North Am. 2009 Jun;38(2):215-30

Authors: Chiu PW, Ng EK

In conclusion, numerous prediction models identified pre-endoscopic and endoscopic risk factors for adverse clinical outcomes in patients with acute upper GI hemorrhage. The risk factors for mortality are different from those of rebleeding. Predictors for rebleeding are usually related to the severity of the bleeding and characteristics of the ulcer, whereas advanced age, physical status of the patient, and comorbidities are important predictors for mortality in addition to those for rebleeding. Future studies should focus on validation of these predictors in a prospective cohort and application of these prediction models to guide clinical management in patients with acute upper GI hemorrhage.

PMID: 19446255 [PubMed - indexed for MEDLINE]

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Treatment options for hyponatremia in heart failure.

Heart Fail Rev. 2009 Jun;14(2):65-73

Authors: Goldsmith SR

Hyponatremia is independently associated with adverse outcomes in patients with congestive heart failure (CHF). The primary cause of hyponatremia in CHF is the inappropriate secretion of the antidiuretic hormone, arginine vasopressin (AVP). The binding of AVP to V(2) receptors in the renal collecting duct promotes water retention, a process that can lead to dilutional hyponatremia as well as increased ventricular preload. AVP could also exacerbate the course of CHF by interacting with V(1A) receptors on vascular smooth muscle cells and myocytes. Conventional treatment of hyponatremia in CHF is based largely on water restriction, which is neither effective nor well tolerated. Current research is exploring V(2)- and dual V(1A)/V(2)-receptor antagonism for the treatment of hyponatremia, as well as for the congestion and edema associated with CHF, since AVP-receptor antagonists may offer benefits in comparison to conventional loop diuretics. Clinical trials in patients with hyponatremia and CHF using both selective and nonselective vasopressin antagonists have demonstrated the effectiveness of these agents in correcting this common electrolyte abnormality.

PMID: 18777208 [PubMed - indexed for MEDLINE]

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Hyponatremia in heart failure.

Heart Fail Rev. 2009 Jun;14(2):59-63

Authors: Farmakis D, Filippatos G, Parissis J, Kremastinos DT, Gheorghiade M

Hyponatremia is the most common electrolyte abnormality found in hospitalized patients with heart failure. It may occur in patients who have hypovolemic, hypervolemic, or euvolemic state. It is usually not corrected by available therapies. It is a major predictor of prognosis, and correction of hyponatremia can be effectively accomplished by vasopressin antagonists. However, it still remains to be seen whether the normalization of serum sodium with vasopressin antagonists will also lead to an improved long-term prognosis.

PMID: 18758941 [PubMed - indexed for MEDLINE]

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Cluster-randomized controlled trial of oscillometric vs. manual sphygmomanometer for blood pressure management in primary care (CRAB).

Am J Hypertens. 2009 Jun;22(6):598-603

Authors: Nelson MR, Quinn S, Bowers-Ingram L, Nelson JM, Winzenberg TM

BACKGROUND: Although mercury sphygmomanometers are seen as the gold standard instrument for blood pressure (BP) measurement, they are being withdrawn due to safety concerns. CRAB was a cluster-randomized controlled trial in 24 family practices in Tasmania, Australia, which aimed to determine the effect of an oscillometric device on BP management. METHODS: Cluster-randomized controlled trial. Intervention practices were supplied with automated monitors and control (usual care) practices used mercury or aneroid sphygmomanometers. They were subsequently audited by a research nurse. Usual care practice audit periods were matched to intervention practices. All analyses were intention-to-treat and adjusted for potential clustering. Differences in BP were analyzed using generalized estimating equations. All other outcomes were analyzed using multilevel mixed-effects Poisson regression. Post hoc analyses were performed to determine the mediators of changes in prescribing behavior. RESULTS: A total of 3,355 records were reviewed (828 visits had BP recordings). The percentage of BP recordings ending in "0" was significantly lower in intervention vs. usual care practices (systolic BP (SBP) 18% (107/587) vs. 71% (233/329), diastolic BP (DBP) 20% (119/584) vs. 70% (229/328), P < 0.001). The mean of SBP recordings in the intervention group was 7.5 mm Hg (95% confidence interval (CI) 5.2, 9.9 mm Hg, P < 0.001) higher than in the usual care group. Patients taking BP lowering drugs were more likely (incidence rate ratio (IRR) 1.3, 95% CI 1.1, 1.7, P = 0.01) to have a BP lowering drug prescribed if they were in the intervention compared to the usual care. CONCLUSIONS: Although digit preference was largely eliminated by oscillometric measurement, prescribing behavior was mediated by SBP.

PMID: 19300424 [PubMed - indexed for MEDLINE]

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Impaired orthostatic response in patients with type 2 diabetes mellitus after 48 hours of bed rest.

Endocr Pract. 2009 Mar-Apr;15(2):104-10

Authors: Schneider SM, Robergs RA, Amorim FT, de Serna DG, Duran-Valdez EE, Schade DS

OBJECTIVE: To compare the effect of bed rest on orthostatic responses of patients with type 2 diabetes mellitus and nondiabetic control subjects. METHODS: Six patients with type 2 diabetes and 6 non-diabetic control subjects underwent 48 hours of bed rest and 48 hours of ambulatory activity in randomized order. A 10-minute tilt test was conducted before and after each period of hospitalization, and cardiovascular responses to 80 degrees head-up tilt were analyzed with use of a 2-factorial (study group and bed rest condition) analysis of variance design. We hypothesized that patients with diabetes would experience more severe changes in orthostatic response after bed rest. RESULTS: No significant differences in orthostatic responses were observed before bed rest between control subjects and patients with diabetes. After bed rest, control subjects had a greater (P = .01) increase in heart rate during tilt in comparison with before bed rest (before versus after bed rest, 9 +/- 4 versus 24 +/- 7 beats/min) and maintained their blood pressure during tilt. After bed rest, patients with diabetes did not have a compensatory increase in heart rate and had a greater (P = .02) decline in systolic blood pressure during tilt in comparison with before bed rest (before versus after bed rest, -7 +/- 10 versus -21 +/- 11 mm Hg). Their arm and leg skin vasomotor responses (laser Doppler flowmetry) during tilt were not altered after bed rest and were similar to those in control subjects before and after bed rest. CONCLUSION: Cardiac neuropathy in patients with type 2 diabetes may prevent a compensatory heart rate response after bed rest deconditioning and result in a more severe orthostatic response. A greater decrease in blood pressure with upright tilt is evident after a relatively short period of bed rest.

PMID: 19289319 [PubMed - indexed for MEDLINE]

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Enteral tube feeding for older people with advanced dementia.

Cochrane Database Syst Rev. 2009;(2):CD007209

Authors: Sampson EL, Candy B, Jones L

BACKGROUND: The use of enteral tube feeding for patients with advanced dementia who have poor nutritional intake is common. In one US survey 34% of 186,835 nursing home residents with advanced cognitive impairment were tube fed. Potential benefits or harms of this practice are unclear. OBJECTIVES: To evaluate the outcome of enteral tube nutrition for older people with advanced dementia who develop problems with eating and swallowing and/or have poor nutritional intake. SEARCH STRATEGY: The Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS were searched in April 2008. Citation checking was undertaken. Where it was not possible to accept or reject, the full text of the citation was obtained for further evaluation. SELECTION CRITERIA: Randomized controlled trials (RCTs), controlled clinical trials, controlled before and after studies and interrupted time series studies that evaluated the effectiveness of enteral feeding via a nasogastric tube or via a tube passed by percutaneous endoscopic gastrostomy (PEG) were planned to be included. In addition, controlled observational studies were included. The study population comprised adults aged 50 and over (either sex), with a diagnosis of primary degenerative dementia made according to validated diagnostic criteria such as DSM-IV or ICD-10 (APA 1994; WHO 1993) and with advanced cognitive impairment defined by a recognised and validated tool or by clinical assessment and had poor nutrition intake and/or develop problems with eating and swallowing. Where data were limited we also considered studies in which the majority of participants had dementia. DATA COLLECTION AND ANALYSIS: Data were independently extracted and assessed by one reviewer, checked by a second and if necessary, in the case of any disagreement or discrepancy it was planned that it would be reviewed by the third reviewer. Where information was lacking, we attempted contact with authors. It was planned that meta-analysis would be considered for RCTs with comparable key characteristics. The primary outcomes were survival and quality of life (QoL). MAIN RESULTS: No RCTs were identified. Seven observational controlled studies were identified. Six assessed mortality. The other study assessed nutritional outcomes. There was no evidence of increased survival in patients receiving enteral tube feeding. None of the studies examined QoL and there was no evidence of benefit in terms of nutritional status or the prevalence of pressure ulcers. AUTHORS’ CONCLUSIONS: Despite the very large number of patients receiving this intervention, there is insufficient evidence to suggest that enteral tube feeding is beneficial in patients with advanced dementia. Data are lacking on the adverse effects of this intervention.

PMID: 19370678 [PubMed - indexed for MEDLINE]

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Treatment for femoral pseudoaneurysms.

Cochrane Database Syst Rev. 2009;(2):CD004981

Authors: Tisi PV, Callam MJ

BACKGROUND: Femoral pseudoaneurysms may complicate up to 8% of vascular interventional procedures. Small pseudoaneurysms can spontaneously clot, but sometimes definitive treatment is needed. Surgery has traditionally been considered the ‘gold standard’ treatment, although it is not without risk in patients with severe cardiovascular disease. Less invasive treatment options such as Duplex ultrasound-guided compression and percutaneous thrombin injection are available, however, evidence of their efficacy is limited. This is an update of a Cochrane review first published in 2006. OBJECTIVES: To assess the effects of different treatments for femoral pseudoaneurysms resulting from endovascular procedures, specifically assessing less invasive treatment options such as blind manual or mechanical compression, ultrasound-guided compression, or percutaneous thrombin injection. SEARCH STRATEGY: The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (last searched December 2008) and the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 4). Additional searches were also made of the bibliographies of papers found through the electronic searches, and by handsearching relevant journals. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing two treatments for femoral pseudoaneurysms following vascular interventional procedures were considered for inclusion in the review. DATA COLLECTION AND ANALYSIS: Four studies were included in the analyses comparing: manual compression versus ultrasound-guided compression; ultrasound-guided application of a mechanical device (FemoStop) versus blind application; and ultrasound-guided compression versus percutaneous thrombin injection (two studies). There were no studies with a surgical intervention arm. Data were extracted independently by both authors. MAIN RESULTS: Compression (manual or FemoStop) was effective in achieving pseudoaneurysm thrombosis although ultrasound-guided application failed to confer any benefit (risk ratio (RR) 0.96; 95% confidence interval (CI) 0.88 to 1.04).Percutaneous thrombin injection was more effective than a single session of ultrasound-guided compression in achieving primary pseudoaneurysm thrombosis within individual RCTs but merged data failed to show statistical significance (RR 2.81; 95% CI 0.44 to 18.13). There was no statistically significant difference in the length of hospital stay between the two groups and no complications were reported apart from one deep vein thrombosis in the compression group. AUTHORS’ CONCLUSIONS: The limited evidence base appears to support the use of thrombin injection as an effective treatment for femoral pseudoaneurysm. A pragmatic approach may be to use compression (blind or ultrasound-guided) as first-line treatment, reserving thrombin injection for those in whom the compression procedure fails.

PMID: 19370614 [PubMed - indexed for MEDLINE]

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How to perform ultrasound-guided injections.

Best Pract Res Clin Rheumatol. 2009 Apr;23(2):269-79

Authors: Bruyn GA, Schmidt WA

Among the most important reasons for the increased use of ultrasound by rheumatologists is its feasibility to guide injections. Correct positioning of the needle in the targeted structure occurs much more frequently with ultrasound guidance than with conventional positioning without imaging. The sonographer can mark the skin above the structure, using ultrasound to localize this point and to estimate the depth of the structure. Alternatively, the sonographer might introduce the needle under direct sonographic visualisation, holding the probe in one hand and the needle in the other. The needle can be longitudinally parallel to the probe, with an angle of about 45 degrees to the probe. It can be introduced close to the middle of the probe or opposite the probe; the needle can be also depicted transversely. Ultrasound allows needle guidance in nearly all important structures of shoulders, elbows, hand, hips, knees and feet. Education involves training to coordinate probe and needle in sponges, chicken, cheese and other objects. Knowledge of anatomy, probe positioning and the ability to coordinate probe and needle are necessary when injecting patients with sonographic guidance. The rheumatologist might start with easy approaches in which the needle is parallel to the probe.

PMID: 19393570 [PubMed - indexed for MEDLINE]

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How to perform local soft-tissue glucocorticoid injections.

Best Pract Res Clin Rheumatol. 2009 Apr;23(2):193-219

Authors: Jacobs JW

Inflammation of periarticular soft-tissue structures such as tendons, tendon sheaths, entheses, bursae, ligaments and fasciae are the hallmark of many inflammatory rheumatic diseases, but inflammation – or rather irritation – of these structures also occurs in the absence of an underlying rheumatic disease. In both these primary and secondary soft-tissue lesions, local glucocorticoid injection often is beneficial, although evidence in literature is limited. This chapter reviews local injection therapy for these lesions and for nerve compression syndromes.

PMID: 19393566 [PubMed - indexed for MEDLINE]

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Proton pump inhibitors as a treatment method for type II diabetes.

Med Hypotheses. 2009 Jul;73(1):29-32

Authors: Mefford IN, Wade EU

Recent reports have hypothesized a role for exogenously administered gastrin in regulating beta cell function or activity. We surmised that a class of agents, proton pump inhibitors (omeprazole, esomeprazole, pantoprazole, rabeprazole, lansoprazole), known to increase serum gastrin levels could have such an effect, and that data might be available in our database which could address such an effect. We examined our electronic database to obtain glycohemoglobin (HgbA1c) levels measured in the past two years from all type II diabetics and extracted from those diabetics who were concurrently taking a proton pump inhibitor. A comparison of these groups showed an average HgbA1c of 7.6% for type II diabetics not taking a proton pump inhibitor (n=282) and an average HgbA1c of 7.0% for type II diabetics concurrently taking a proton pump inhibitor (n=65), T=-3.61, p=0.002. These data support the hypothesis that proton pump inhibitors can be used to treat type II diabetes.

PMID: 19304401 [PubMed - indexed for MEDLINE]

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Relationship of carbapenem restriction in 22 university teaching hospitals to carbapenem use and carbapenem-resistant Pseudomonas aeruginosa.

Antimicrob Agents Chemother. 2009 May;53(5):1983-6

Authors: Pakyz AL, Oinonen M, Polk RE

Many hospital antimicrobial stewardship programs restrict the availability of selected drugs by requiring prior approval. Carbapenems may be among the restricted drugs, but it is unclear if hospitals that restrict availability actually use fewer carbapenems than hospitals that do not restrict use. Nor is it clear if restriction is related to resistance. We evaluated the relationship between carbapenem restriction and the volume of carbapenem use and both the incidence rate and proportion of carbapenem-resistant Pseudomonas aeruginosa isolates from 2002 through 2006 in a retrospective, longitudinal, multicenter analysis among a consortium of academic health centers. Carbapenem use was measured from billing records as days of therapy per 1,000 patient days. Hospital antibiograms were used to determine both the incidence rate and proportion of carbapenem-resistant P. aeruginosa isolates. A survey inquired about restriction policies for antibiotics, including carbapenems. General linear mixed models were used to examine study outcomes. Among 22 hospitals with sufficient data for analysis, overall carbapenem use increased significantly over the 5 years of study (P < 0.0001), although overall carbapenem resistance in P. aeruginosa did not change. Hospitals that restricted carbapenems (n = 8; 36%) used significantly fewer carbapenems (P = 0.04) and reported lower incidence rates of carbapenem-resistant P. aeruginosa (P = 0.01) for all study years. Fluoroquinolone use was a potential confounder of these relationships, but hospitals that restricted carbapenems actually used fewer fluoroquinolones than those that did not. Restriction of carbapenems is associated with both lower use and lower incidence rates of carbapenem resistance in P. aeruginosa.

PMID: 19273670 [PubMed - indexed for MEDLINE]

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Antibiotic prophylaxis for spontaneous bacterial peritonitis in cirrhotic patients with ascites, without gastro-intestinal bleeding.

Cochrane Database Syst Rev. 2009;(2):CD004791

Authors: Cohen MJ, Sahar T, Benenson S, Elinav E, Brezis M, Soares-Weiser K

BACKGROUND: Spontaneous bacterial peritonitis is frequent among cirrhotic patients, associated with significant morbidity and mortality. Selective intestinal decontamination employing antibiotics is a proposed prophylactic measure. While data regarding this modality among cirrhotic patients with gastrointestinal bleeding exist, there is insufficient data synthesis regarding cirrhotic patients with ascites and no gastrointestinal bleeding. OBJECTIVES: To assess whether antibiotic prophylaxis decreases spontaneous bacterial peritonitis and mortality among cirrhotic patients with ascites and no gastrointestinal bleeding. SEARCH STRATEGY: We identified relevant randomised trials by searching trial registries of The Cochrane Hepato-Biliary Group and The Cochrane Collaboration, medical literature search engines, and reviewing all literature we found on the topic until February 2009. SELECTION CRITERIA: We searched for randomised clinical trials assessing prophylactic treatment among adult cirrhotic patients with ascites and no gastrointestinal bleeding, comparing antibiotic therapy with no intervention, placebo, or with another antibiotic regimen. DATA COLLECTION AND ANALYSIS: Three independent authors searched for and collected the trials and extracted relevant data. Four other independent authors validated the findings and assessed them. The studies were assessed for design, patient and intervention characteristics, and quality. A meta-analysis was performed to estimate measures of association between antibiotic prophylaxis and spontaneous bacterial peritonitis or mortality. MAIN RESULTS: Nine trials were included in the review. Seven trials, comparing antibiotics to placebo or no treatment, were meta-analysed. Systematic bias in design or publication is suggested by trial results. The randomisation results suggest that the probability that true randomisation took place in all trials is very small and the report of most trials regarding design was poor. The proportion of participants with spontaneous bacterial peritonitis varied between the trials from 15% to 50%. The calculated relative risks (95% confidence interval) of spontaneous bacterial peritonitis and mortality among patients treated with antibiotics compared with no treatment/placebo were 0.20 (0.11 to 0.37) and 0.61 (0.43 to 0.87). There were very few reports of adverse events. AUTHORS’ CONCLUSIONS: The pooled estimates suggest that antibiotic prophylaxis might be prudent among cirrhotic patients with ascites and no gastrointestinal bleeding. However, poor trial methodology and report coupled with findings suggesting systematic bias in publication and design reflect the fragility of these findings. Potential hazard to society and the patients themselves from resistant pathogens should be considered when promoting long-lasting antibiotic prophylaxis. It seems that recommending antibiotic prophylaxis is still far from being a substantiated prevention strategy. Trials of better design, well reported, and of longer follow-up are greatly needed.

PMID: 19370611 [PubMed - indexed for MEDLINE]

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Myopathic complications of medical disease.

Semin Neurol. 2009 Apr;29(2):163-80

Authors: Soni M, Amato AA

Disorders of muscle may be primary or acquired secondary to an underlying medical condition. Clinical presentations range from asymptomatic elevations in creatine kinase to fatal rhabdomyolysis. Recognition of the underlying precipitant is imperative to effectively institute treatment for a potentially reversible process. The focus of this article is to review complications of systemic illness that result in signs and symptoms of muscle dysfunction. Myopathic complications of endocrinopathy, metabolic abnormalities, medications, critical illness, organ transplantation, infection, autoimmune conditions, malignancy, and toxin exposure are discussed, with an emphasis on the clinical features, electromyography, and muscle biopsy findings.

PMID: 19370496 [PubMed - indexed for MEDLINE]

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