2011 April 16

Acute upper gastrointestinal bleeding in the UK: patient characteristics, diagnoses and outcomes in the 2007 UK audit.

Apr 162011

Acute upper gastrointestinal bleeding in the UK: patient characteristics, diagnoses and outcomes in the 2007 UK audit.

Gut. 2011 Apr 13;

Authors: Hearnshaw SA, Logan RF, Lowe D, Travis SP, Murphy MF, Palmer KR

Objective To describe the patient characteristics, diagnoses and clinical outcomes of patients presenting with acute upper gastrointestinal bleeding (AUGIB) in the 2007 UK Audit. Design Multi-centre survey. Setting All UK hospitals admitting patients with AUGIB. Participants All adults (>16 years) presenting in or to UK hospitals with AUGIB between 1 May and 30 June 2007. Results Data on 6750 patients (median age 68 years) was collected from 208 participating hospitals. New admissions (n=5550) were younger (median age 65 years) than inpatients (n=1107, median age 71 years), with less co-morbidity (any co-morbidity 46% vs 71%, respectively). At presentation 9% (599/6750) had known cirrhosis, 26% a history of alcohol excess, 11% were taking non-steroidal anti-inflammatory drugs and 28% aspirin. Peptic ulcer disease accounted for 36% of AUGIB and bleeding varices 11%. In 13% there was evidence of further bleeding after the first endoscopy. 1.9% underwent surgery and 1.2% interventional radiology for AUGIB. Median length of stay was 5 days. Overall mortality in hospital was 10% (675/6750, 95% CI 9.3 to 10.7), 7% in new admissions and 26% among inpatients. Mortality was highest in those with variceal bleeding (15%) and with malignancy (17%). Conclusions AUGIB continues to result in substantial mortality although it appears to be lower than in 1993. Mortality is particularly high among inpatients and those bleeding from varices or upper gastrointestinal malignancy. Surgical or radiological interventions are little used currently.

PMID: 21490373 [PubMed - as supplied by publisher]

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Aliskiren-based stepped-care treatment algorithm provides effective blood pressure control.

Int J Clin Pract Start a Discussion »

Apr 162011

Aliskiren-based stepped-care treatment algorithm provides effective blood pressure control.

Int J Clin Pract. 2011 May;65(5):613-623

Authors: Richter D, Mickel C, Acharya S, Brunel P, Militaru C

Aims:? Recent guidelines for the management of hypertension recommend an individualised stepped-care treatment approach in mild-to-moderate hypertensive patients, to achieve blood pressure (BP) goals. This study evaluated the probability of patients achieving BP targets with an aliskiren-based stepped-care treatment regimen. Methods:? This was a 24-week, open-label, non-comparator study design that included six sequential 4-week treatment periods in patients with mild-to-moderate hypertension. Over the potential 24?weeks of active treatment, incremental therapy included the following add-on therapies at 4-week intervals: aliskiren 150-300?mg once daily, hydrochlorothiazide (HCTZ) 12.5-25?mg once daily, and finally amlodipine 5-10?mg once daily, as needed to achieve target BP. Subjects achieving BP targets following any given 4?weeks of therapy were considered study completers, while subjects not achieving their clinical BP target entered into the next step of incremental therapy. The primary efficacy end-point was the estimated cumulative probability of patients achieving BP target. Results:? Of 256 patients treated, 232 (90.6%) completed the study. Baseline mean sitting BP was 155.7/91.7?mmHg. At study end-point, the estimated cumulative probability of reaching BP target was 86.12%. The stepped-care treatment regimen was well tolerated at the maximal recommended doses of all the individual complimentary therapies. Conclusion:? An aliskiren-based stepped-care treatment regimen that subsequently included both HCTZ and amlodipine is effective in achieving BP goals in approximately 90% of patients with mild-to-moderate hypertension.

PMID: 21489085 [PubMed - as supplied by publisher]

Link to Article at PubMed

Efficacy of statin pretreatment for the prevention of contrast-induced nephropathy: a meta-analysis of randomised controlled trials.

Int J Clin Pract Start a Discussion »

Apr 162011

Efficacy of statin pretreatment for the prevention of contrast-induced nephropathy: a meta-analysis of randomised controlled trials.

Int J Clin Pract. 2011 May;65(5):624-630

Authors: Zhang L, Zhang L, Lu Y, Wu B, Zhang S, Jiang H, Ge J, Chen H

Contrast-induced nephropathy (CIN) is a common cause of acute kidney injury. Whether additional benefits can be achieved with the use of statin in decreasing the risk of CIN remains undetermined. The purpose of this meta-analysis is to evaluate the effects of statin pretreatment for the prevention of CIN. PubMed, MEDLINE, Web of Science, EMBASE and EBM Reviews databases were searched for randomised controlled trials comparing statin pretreatment with non-statin pretreatment for the prevention of CIN. Two reviewers independently assessed studies and performed data extraction. Risk ratio (RR) or weighted mean differences (WMD) with 95% confidence intervals (CI) were calculated using random-effects models. Four trials with 751 subjects were included. Pooled analyses showed that the incidence of CIN was not significantly lower in statin pretreatment group, as compared with control group (RR?=?0.76, 95% CI 0.44-1.29, p?=?0.30). Similarly, none of 276 patients in statin pretreatment group needed renal replacement therapy (RRT), which was not significantly less than 2 of 275 patients assigned to control group during 1-month follow up (RR?=?0.33, 95% CI 0.03-3.17, p?=?0.34). Moreover, statin pretreatment was associated with mild reduction of serum creatinine (SCr) (WMD?=?-0.06?mg/dl, 95% CI -0.12 to 0.00?mg/dl, p?=?0.05). The current cumulative evidence suggests that statin pretreatment may neither prevent CIN nor reduce the need for RRT. However, it may slightly decrease the level of SCr.

PMID: 21489086 [PubMed - as supplied by publisher]

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Anticoagulant Options – Why the FDA Approved a Higher but Not a Lower Dose of Dabigatran.

N Engl J Med Start a Discussion »

Apr 162011

Anticoagulant Options - Why the FDA Approved a Higher but Not a Lower Dose of Dabigatran.

N Engl J Med. 2011 Apr 13;

Authors: Beasley BN, Unger EF, Temple R

On October 19, 2010, the Food and Drug Administration (FDA) approved dabigatran for the reduction of the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. Approval was based on a multicenter, active-control trial, the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY),(1) in which patients were randomly assigned to receive 150 mg of dabigatran, 110 mg of dabigatran, or warfarin. Dabigatran was given twice daily; warfarin was titrated to achieve an international normalized ratio (INR) of 2.0 to 3.0. Assignment to warfarin or dabigatran treatment was unblinded; assignment to a specific dabigatran dose was double-blind. RE-LY was . . .

PMID: 21488759 [PubMed - as supplied by publisher]

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Intervention to Reduce Transmission of Resistant Bacteria in Intensive Care.

N Engl J Med Start a Discussion »

Apr 162011

Intervention to Reduce Transmission of Resistant Bacteria in Intensive Care.

N Engl J Med. 2011 Apr 14;364(15):1407-1418

Authors: Huskins WC, Huckabee CM, O'Grady NP, Murray P, Kopetskie H, Zimmer L, Walker ME, Sinkowitz-Cochran RL, Jernigan JA, Samore M, Wallace D, Goldmann DA,

Background Intensive care units (ICUs) are high-risk settings for the transmission of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE). Methods In a cluster-randomized trial, we evaluated the effect of surveillance for MRSA and VRE colonization and of the expanded use of barrier precautions (intervention) as compared with existing practice (control) on the incidence of MRSA or VRE colonization or infection in adult ICUs. Surveillance cultures were obtained from patients in all participating ICUs; the results were reported only to ICUs assigned to the intervention. In intervention ICUs, patients who were colonized or infected with MRSA or VRE were assigned to care with contact precautions; all the other patients were assigned to care with universal gloving until their discharge or until surveillance cultures obtained at admission were reported to be negative. Results During a 6-month intervention period, there were 5434 admissions to 10 intervention ICUs, and 3705 admissions to 8 control ICUs. Patients who were colonized or infected with MRSA or VRE were assigned to barrier precautions more frequently in intervention ICUs than in control ICUs (a median of 92% of ICU days with either contact precautions or universal gloving [51% with contact precautions and 43% with universal gloving] in intervention ICUs vs. a median of 38% of ICU days with contact precautions in control ICUs, P<0.001). In intervention ICUs, health care providers used clean gloves, gowns, and hand hygiene less frequently than required for contacts with patients assigned to barrier precautions; when contact precautions were specified, gloves were used for a median of 82% of contacts, gowns for 77% of contacts, and hand hygiene after 69% of contacts, and when universal gloving was specified, gloves were used for a median of 72% of contacts and hand hygiene after 62% of contacts. The mean (±SE) ICU-level incidence of events of colonization or infection with MRSA or VRE per 1000 patient-days at risk, adjusted for baseline incidence, did not differ significantly between the intervention and control ICUs (40.4±3.3 and 35.6±3.7 in the two groups, respectively; P=0.35). Conclusions The intervention was not effective in reducing the transmission of MRSA or VRE, although the use of barrier precautions by providers was less than what was required. (Funded by the National Institute of Allergy and Infectious Diseases and others; STAR*ICU ClinicalTrials.gov number, NCT00100386 .).

PMID: 21488763 [PubMed - as supplied by publisher]

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Veterans Affairs Initiative to Prevent Methicillin-Resistant Staphylococcus aureus Infections.

N Engl J Med Start a Discussion »

Apr 162011

Veterans Affairs Initiative to Prevent Methicillin-Resistant Staphylococcus aureus Infections.

N Engl J Med. 2011 Apr 14;364(15):1419-1430

Authors: Jain R, Kralovic SM, Evans ME, Ambrose M, Simbartl LA, Obrosky DS, Render ML, Freyberg RW, Jernigan JA, Muder RR, Miller LJ, Roselle GA

Background Health care-associated infections with methicillin-resistant Staphylococcus aureus (MRSA) have been an increasing concern in Veterans Affairs (VA) hospitals. Methods A "MRSA bundle" was implemented in 2007 in acute care VA hospitals nationwide in an effort to decrease health care-associated infections with MRSA. The bundle consisted of universal nasal surveillance for MRSA, contact precautions for patients colonized or infected with MRSA, hand hygiene, and a change in the institutional culture whereby infection control would become the responsibility of everyone who had contact with patients. Each month, personnel at each facility entered into a central database aggregate data on adherence to surveillance practice, the prevalence of MRSA colonization or infection, and health care-associated transmissions of and infections with MRSA. We assessed the effect of the MRSA bundle on health care-associated MRSA infections. Results From October 2007, when the bundle was fully implemented, through June 2010, there were 1,934,598 admissions to or transfers or discharges from intensive care units (ICUs) and non-ICUs (ICUs, 365,139; non-ICUs, 1,569,459) and 8,318,675 patient-days (ICUs, 1,312,840; and non-ICUs, 7,005,835). During this period, the percentage of patients who were screened at admission increased from 82% to 96%, and the percentage who were screened at transfer or discharge increased from 72% to 93%. The mean (±SD) prevalence of MRSA colonization or infection at the time of hospital admission was 13.6±3.7%. The rates of health care-associated MRSA infections in ICUs had not changed in the 2 years before October 2007 (P=0.50 for trend) but declined with implementation of the bundle, from 1.64 infections per 1000 patient-days in October 2007 to 0.62 per 1000 patient-days in June 2010, a decrease of 62% (P<0.001 for trend). During this same period, the rates of health care-associated MRSA infections in non-ICUs fell from 0.47 per 1000 patient-days to 0.26 per 1000 patient-days, a decrease of 45% (P<0.001 for trend). Conclusions A program of universal surveillance, contact precautions, hand hygiene, and institutional culture change was associated with a decrease in health care-associated transmissions of and infections with MRSA in a large health care system.

PMID: 21488764 [PubMed - as supplied by publisher]

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