Complications of seasonal and pandemic influenza.

Crit Care Med. 2009 Nov 23;

Authors: Rothberg MB, Haessler SD

Influenza is a seasonal viral infection associated with significant morbidity and mortality. In 2009, a novel H1N1 influenza A virus emerged and has been classified as a pandemic. In contrast to seasonal influenza, severe disease from pandemic H1N1 seems concentrated in older children and young adults, with almost no cases reported in patients older than 60 yrs. Although patients with underlying cardiopulmonary disease remain at risk, most complications have occurred among previously healthy individuals, with obesity and respiratory disease as the strongest risk factors. Pulmonary complications are common. Primary influenza pneumonia occurs most commonly in adults and may progress rapidly to acute lung injury requiring mechanical ventilation. Secondary bacterial infection is more common in children. Staphylococcus aureus, including methicillin-resistant strains, is an important cause of secondary bacterial pneumonia with a high mortality rate. Treatment of pneumonia should include empirical coverage for this pathogen. Neuromuscular and cardiac complications are unusual but may occur.

PMID: 19935413 [PubMed - as supplied by publisher]

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Spontaneous bacterial peritonitis: A severe complication of liver cirrhosis.

World J Gastroenterol. 2009 Nov 28;15(44):5505-5510

Authors: Lata J, Stiburek O, Kopacova M

This report presents a survey of current knowledge concerning one of the relatively frequent and severe complications of liver cirrhosis and associated ascites-spontaneous bacterial peritonitis. Epidemiology, aetiology, pathogenesis, clinical manifestation, diagnosis and present possibilities of treatment are discussed.

PMID: 19938187 [PubMed - as supplied by publisher]

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‘Bare below the elbows’ and quality of hand washing: a randomised comparison study.

J Hosp Infect. 2009 Nov 19;

Authors: Farrington RM, Rabindran J, Crocker G, Ali R, Pollard N, Dalton HR

PMID: 19931939 [PubMed - as supplied by publisher]

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BNP Testing and the Accuracy of Heart Failure Diagnosis in the Emergency Department.

Circ Heart Fail. 2009 Nov 20;

Authors: Lokuge A, Lam LL, Cameron P, Krum H, Smit DV, Bystrzycki A, Naughton MT, Eccleston D, Flannery G, Federman J, Schneider HG

BACKGROUND: -It is often difficult to diagnose heart failure (HF) accurately in patients presenting with dyspnoea to the emergency department (ED). This study assessed whether B-type Natriuretic Peptide (BNP) testing in these patients improved the accuracy of HF diagnosis. METHODS AND RESULTS: -Patients presenting to The Alfred and The Northern Hospital EDs with a chief complaint of dyspnoea were enrolled prospectively from August 2005 to April 2007. Patients were randomly allocated to have BNP levels tested or not. The diagnostic “gold” standard for HF was determined by one cardiologist and one emergency or respiratory physician who, blinded to the BNP result, independently reviewed all available information. The ED diagnosis of HF in the non BNP group, showed a sensitivity, specificity and accuracy of 65%, 92% and 81% respectively. The BNP group had a similar sensitivity, specificity and accuracy of 66%, 90% and 78% respectively for the diagnosis of HF in the ED. There was no significant difference between the BNP and non BNP groups in any of the measures of diagnostic accuracy for HF. CONCLUSIONS: -In the clinical setting of emergency departments, availability of BNP levels did not significantly improve the accuracy of a diagnosis of HF.

PMID: 19933409 [PubMed - as supplied by publisher]

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Biphasic insulin aspart in the treatment of type 2 diabetes mellitus.

Expert Opin Pharmacother. 2009 Dec;10(17):2905-11

Authors: Cucinotta D, Russo GT

Background: Initiating and implementing insulin treatment in type 2 diabetic subjects is a major challenge in diabetes clinical practice. Although simple regimens, such as the combination of a once-daily basal insulin + oral agents, are widely used, they often are not able to achieve an adequate glycemic control, especially in the postprandial period. Biphasic insulin analogues are a valid tool to start and to improve insulin treatment in type 2 diabetes. Biphasic insulin aspart (BIAsp) is available in three different mixtures (30, 50 and 70% of rapid-acting insulin, respectively), which allows insulin treatment to be individualized. Objective/methods: To review recent published papers concerning pharmacological properties and clinical use of BIAsp in type 2 diabetes. Results/conclusion: BIAsp seems to have some advantages over biphasic human insulins, especially for its practical pre- or post-meal administration and lesser hypoglycemic risk. Against basal insulins once daily, BIAsp twice daily seems to perform better in achieving the glucose targets and, even when compared with the more complex basal-bolus regimens, a BIAsp-based treatment using the different available mixtures is at least non-inferior. Side effects are no more frequent than with other insulins; more hypoglycemic episodes of low severity have been sometimes reported, but only in comparison with basal insulin.

PMID: 19929709 [PubMed - in process]

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A randomised controlled comparison of early post-pyloric versus early gastric feeding to meet nutritional targets in ventilated intensive care patients.

Crit Care. 2009 Nov 25;13(6):R187

Authors: White H, Sosnowski K, Tran K, Reeves A, Jones M

ABSTRACT: INTRODUCTION: To compare outcomes from early post-pyloric to gastric feeding in ventilated, critically ill patients in a medical intensive care unit (ICU). METHODS: Prospective randomized study. Ventilated patients were randomly assigned to receive enteral feed via a nasogastric or a post-pyloric tube. Post-pyloric tubes were inserted by the bedside nurse and placement was confirmed radiographically. RESULTS: A total of 104 patients were enrolled, 54 in the gastric group and 50 in the post-pyloric group. Bedside post-pyloric tube insertion was successful in 80% of patients. Patients who failed post-pyloric insertion were fed via the nasogastric route, but were analysed on an intent-to treat basis. A per protocol analysis was also performed. Baseline characteristics were similar for all except Acute Physiology and Chronic Health Evaluation II (APACHE II) score, which was higher in the post-pyloric group. There was no difference in length of stay or ventilator days. The gastric group was quicker to initiate feed 4.3 hours (2.9 – 6.5 hours) as compared to post-pyloric group 6.6 hours (4.5 – 13.0 hours) (P = 0.0002). The time to reach target feeds from admission was also faster in gastric group: 8.7 hours (7.6 – 13.0 hours) compared to 12.3 hours (8.9 – 17.5 hours). The average daily energy and protein deficit were lower in gastric group 73 Kcal (2 – 288 Kcal) and 3.5 g (0 – 15 g) compared to 167 Kcal (70 – 411 Kcal) and 6.5 g (2.8 – 17.3 g) respectively but was only statistically significant for the average energy deficit (P = 0.035). This difference disappeared in the per protocol analysis. Complication rates were similar. CONCLUSIONS: Early post-pyloric feeding offers no advantage over early gastric feeding in terms of overall nutrition received and complications Clinical Trial: anzctr.org.au:ACTRN12606000367549.

PMID: 19930728 [PubMed - as supplied by publisher]

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Pulmonary artery catheters in acute heart failure: end of an era?

Crit Care. 2009 Nov 11;13(6):1003

Authors: Vernon C, Phillips CR

ABSTRACT: Whereas the pulmonary artery catheter (PAC) is still widely used in guiding assessment and treatment of heart failure, controversy surrounding its safety and efficacy has prompted development of newer, less invasive techniques. For these purposes, the transpulmonary thermodilution technique allows assessment of preload, cardiac output, filling volumes, and metrics of contractility without the need to pass a catheter through the right heart. In a previous issue of Critical Care, Ritter and colleagues compare metrics of transpulmonary thermodilution with the PAC in patients with acute heart failure and severe sepsis. The results add to a growing body of evidence that the PAC adds little to information attainable by less invasive methods in many conditions, including acute heart failure. Whether newer devices improve outcome needs to be tested in well-controlled prospective trials.

PMID: 19930618 [PubMed - as supplied by publisher]

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Daptomycin Versus Other Antimicrobial Agents for the Treatment of Skin and Soft Tissue Infections: A Meta-Analysis(January).

Ann Pharmacother. 2009 Nov 24;

Authors: Bliziotis IA, Plessa E, Peppas G, Falagas ME

BACKGROUND: Skin and soft tissue infections (SSTIs) are common in everyday clinical practice. Daptomycin has been shown to achieve very good concentrations in skin and soft tissues. OBJECTIVE: To compare the effectiveness and toxicity of daptomycin with that of other antimicrobials for the treatment of SSTIs. METHODS: PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched for articles published up to March 2009. Comparative studies in which daptomycin was used in the intervention group were included in this meta-analysis. The primary outcome of interest was clinical success; secondary outcomes were microbiologic success, clinical success in subsets with complicated SSTIs (cSSTIs) or infections due to methicillin-resistant Staphylococcus aureus (MRSA), clinical success of daptomycin- versus vancomycin-treated patients, time to clinical cure, treatment-related adverse events, withdrawal from treatment due to toxicity, all-cause mortality, and development of resistance. RESULTS: Four studies were included in the analysis (3 were randomized controlled trials [RCTs]). Vancomycin and semisynthetic penicillins were used in the comparator arm. Three studies reported on patients with cSSTIs. The intention-to-treat (ITT) population was 1557 patients. No statistically significant difference between daptomycin and comparators was found regarding clinical success in clinically evaluable (OR 0.89; 95% CI 0.63 to 1.25 in the 3 RCTs and OR 1.34; 95% CI 0.38 to 4.66 with all 4 studies included), ITT, MRSA-infected patients, and those with cSSTIs. Two studies reported that significantly fewer patients with cSSTIs required prolonged treatment in the daptomycin arm and that clinical cure was faster than with comparators. No difference between the compared regimens was found in other outcomes. CONCLUSIONS: Daptomycin is effective and safe for the treatment of SSTIs. Studies evaluating the optimal duration of daptomycin therapy for cSSTIs, comparing daptomycin with new agents, and focusing on proven MRSA SSTIs will be helpful for the further evaluation of the drug.

PMID: 19934396 [PubMed - as supplied by publisher]

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Intensification with prandial insulin.

Int J Clin Pract. 2009 Oct;63(s164Insulin Intensification Summit):11-14

Authors: Pfützner A, Forst T

Aims: Many patients with type 2 diabetes will ultimately need insulin therapy to maintain their target for glycaemic control. This review considers how best to achieve the target for glycaemic control in primary care. Methods: Literature review and workshop discussions among participants at the Insulin Intensification Summit. Results: Treatment aimed at reducing postprandial glucose is more effective in improving glycaemic control near target levels. Adding prandial doses of a short-acting insulin is superior to switching to a twice-daily premixed insulin. Short-acting analogue insulins offer advantages over animal insulins for intensification of basal insulin therapy, which can be achieved either by sequentially adding prandial doses or immediate introduction of three-times daily prandial dose. Each approach has benefits depending on the health care system and can be supported in primary care by a simple algorithm. Conclusion: Intensification of basal insulin therapy is most effectively achieved by adding a prandial short-acting insulin analogue, using a simple clinical algorithm. The regimen should be selected according to local needs.

PMID: 19930415 [PubMed - as supplied by publisher]

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Persistence of Skin Contamination and Environmental Shedding of Clostridium difficile during and after Treatment of C. difficile Infection.

Infect Control Hosp Epidemiol. 2009 Nov 23;

Authors: Sethi AK, Al-Nassir WN, Nerandzic MM, Bobulsky GS, Donskey CJ

Background. Current guidelines for control of Clostridium difficile infection (CDI) suggest that contact precautions be discontinued after diarrhea resolves. However, limited information is available regarding the frequency of skin contamination and environmental shedding of C. difficile during and after treatment. Design. We conducted a 9-month prospective, observational study involving 52 patients receiving therapy for CDI. Stool samples, skin (chest and abdomen) samples, and samples from environmental sites were cultured for C. difficile before, during, and after treatment. Polymerase chain reaction ribotyping was performed to determine the relatedness of stool, skin, and environmental isolates. Results. Fifty-two patients with CDI were studied. C. difficile was suppressed to undetectable levels in stool samples from most patients during treatment; however, 1-4 weeks after treatment, 56% of patients who had samples tested were asymptomatic carriers of C. difficile. The frequencies of skin contamination and environmental shedding remained high at the time of resolution of diarrhea (60% and 37%, respectively), were lower at the end of treatment (32% and 14%, respectively), and again increased 1-4 weeks after treatment (58% and 50%, respectively). Skin and environmental contamination after treatment was associated with use of antibiotics for non-CDI indications. Ninety-four percent of skin isolates and 82% of environmental isolates were genetically identical to concurrent stool isolates. Conclusions. Skin contamination and environmental shedding of C. difficile often persist at the time of resolution of diarrhea, and recurrent shedding is common 1-4 weeks after therapy. These results provide support for the recommendation that contact precautions be continued until hospital discharge if rates of CDI remain high despite implementation of standard infection-control measures.

PMID: 19929371 [PubMed - as supplied by publisher]

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Clinical findings and demographic factors associated with intensive care unit admission in Utah due to 2009 novel influenza A (H1N1) infection.

Chest. 2009 Nov 20;

Authors: Miller RR, Markewitz BA, Rolfs RT, Brown SM, Dascomb KK, Grissom CK, Friedrichs MD, Mayer J, Hirshberg EL, Conklin J, Paine R, Dean NC

BACKGROUND: Novel influenza A H1N1 2009 (novel H1N1) infection has significantly affected intensive care units (ICU). We sought to characterize our region's clinical findings and demographic associations with ICU admission due to novel H1N1. METHODS: Observational study from May 19, 2009 to June 30, 2009 of descriptive clinical course, inpatient mortality, financial data, and demographic characteristics of an ICU cohort. Case-control study comparing the ICU cohort to Salt Lake County residents. RESULTS: The ICU cohort of 47 influenza patients had a median age of 34, APACHE II score of 21, and body mass index (BMI) of 35. Mortality was 17% (8/47). All 8 deaths occurred among the 64% of patients (n=30) with acute respiratory distress syndrome, twenty-six (87%) of whom also developed multiorgan failure. Compared to the Salt Lake County population, novel H1N1 patients were more likely to be obese (22% versus 74%; p<0.001), medically uninsured (14% versus 45%; p<0.001), and Hispanic (13% versus 23%; p<0.01) or Pacific Islander (1% versus 26%; p<0.001). Observed ICU admissions were 15-fold greater than expected for those with BMI >/=40 (SMR 15.8, 95% CI 8.3, 23.4) and 1.5-fold greater among those with BMI 30-39 than expected for age- and sex-adjusted rates for Salt Lake County. CONCLUSION: Severe ARDS with multiorgan dysfunction in the absence of bacterial infection was a common clinical presentation. In this cohort, young non-whites without medical insurance were disproportionately likely to require ICU care. Obese patients were particularly susceptible to critical illness due to novel H1N1 infection.

PMID: 19933372 [PubMed - as supplied by publisher]

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Pulmonary/renal interaction.

Curr Opin Crit Care. 2009 Nov 20;

Authors: Ricci Z, Ronco C

PURPOSE OF REVIEW: Acute kidney injury contributes to the development of acute lung injury and vice-versa. Volume overload that may occur during renal impairment increases pulmonary capillary hydrostatic pressure. However, experimental evidence clearly shows that lung damage occurs even in the absence of positive fluid balance. However, acute lung injury with its attendant hypoxemia, hypercapnia and mechanical ventilation worsens renal hemodynamics and function. RECENT FINDINGS: An increasing body of evidence suggests that kidney and lung interact (crosstalk) during severe insults, such as shock, trauma, and sepsis, due to a loss of the normal balance of immune, inflammatory and soluble mediators. Kidney-lung crosstalk in the critically ill constitutes a possibility to analyze mechanisms of multiple organ failure in which the kidney and the lung can play an important role. Consequently, on the clinical side, specific therapeutic options can be hypothesized for kidney/lung dysfunction. SUMMARY: Fluid management optimization and prevention of inflammation and lung stretching are currently recommended for the treatment of acute lung and renal injury. Extracorporeal CO2 removal and renal replacement associated with extracorporeal membrane oxygenation might be interesting options for a future approach to pulmonary/renal syndrome.

PMID: 19935063 [PubMed - as supplied by publisher]

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Related Articles

Venous thromboembolism prophylaxis and treatment in cancer: a consensus statement of major guidelines panels and call to action.

J Clin Oncol. 2009 Oct 10;27(29):4919-26

Authors: Khorana AA, Streiff MB, Farge D, Mandala M, Debourdeau P, Cajfinger F, Marty M, Falanga A, Lyman GH

PURPOSE: Venous thromboembolism (VTE) is an increasingly frequent complication of cancer and its treatments, and is associated with worsened mortality and morbidity in patients with cancer. DESIGN: The Italian Association of Medical Oncology, the National Comprehensive Cancer Network, the American Society of Clinical Oncology, the French National Federation of the League of Centers Against Cancer, and the European Society of Medical Oncology have recently published guidelines regarding VTE in patients with cancer. This review, authored by a working group of members from these panels, focuses on the methodology and areas of consensus and disagreement in the various clinical guidelines as well as directions for future research. RESULTS: There is broad consensus regarding the importance of thromboprophylaxis in hospitalized patients with cancer, including prolonged prophylaxis in high-risk surgical patients. Prophylaxis is not currently recommended for ambulatory patients with cancer (with exceptions) or for central venous catheters. All of the panels agree that low molecular weight heparins are preferred for the long-term treatment of VTE in cancer. Areas that warrant further research include the benefit of prophylaxis in the ambulatory setting, the risk/benefit ratio of prophylaxis for hospitalized patients with cancer, an understanding of incidental VTE, and the impact of anticoagulation on survival. CONCLUSION: We call for a sustained research effort to investigate the clinical issues identified here to reduce the burden of VTE and its consequences in patients with cancer.

PMID: 19720907 [PubMed - indexed for MEDLINE]

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2009 ACCF/AHA Focused Update on Perioperative Beta Blockade.

J Am Coll Cardiol. 2009 Nov 24;54(22):2102-2128

Authors: , , , , , , , , , Fleischmann KE, Beckman JA, Buller CE, Calkins H, Fleisher LA, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Robb JF, Valentine RJ

PMID: 19926021 [PubMed - as supplied by publisher]

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Transesophageal Echocardiography Before Atrial Fibrillation Ablation Looking Before Cooking.

J Am Coll Cardiol. 2009 Nov 24;54(22):2040-2042

Authors: Knight BP

PMID: 19926010 [PubMed - as supplied by publisher]

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