2011 August 11

No Accumulation of the Peak Anti-Xa Activity of Tinzaparin in Elderly Patients with Moderate-to-Severe Renal Impairment: the IRIS Substudy.

Aug 112011

No Accumulation of the Peak Anti-Xa Activity of Tinzaparin in Elderly Patients with Moderate-to-Severe Renal Impairment: the IRIS Substudy.

J Thromb Haemost. 2011 Aug 5;

Authors: Siguret V, Gouin-Thibault I, Pautas E, Leizorovicz A

Background: In the elderly, concerns have been raised regarding the risk of accumulation with low molecular weight heparins due to their renal elimination. Although data exist for tinzaparin, they are observational. Objectives: To assess whether: (i)there was an accumulation of anti-Xa activity; (ii)there was any relationship between anti-Xa activity and age, weight, creatinine clearance or clinical outcomes in patients with moderate-to-severe renal impairment receiving tinzaparin (175 IU/kg/24h) for acute venous thromboembolism. Methods: In 38 centres participating in the IRIS trial, peak plasma anti-Xa activity was measured on Day2/Day3 and on Day5 or at visit S (end of tinzaparin treatment). Absence of accumulation was to be claimed if the 90% confidence interval (CI) of the (Anti-Xa-Day5/VS)/(Anti-Xa-Day2/3) ratio did not exceed the pre-defined limit of 1.25. Results: 87 patients, mean age 83±5 years (75-99 years), mean creatinine clearance (CrCl) 40.8 mL/min, 24.1% with severe renal impairment, were included. The mean duration of tinzaparin treatment was 8.4 days. No significant accumulation was detected: the mean accumulation ratio was 1.06 (90%CI:1.01-1.11). There was no correlation between the accumulation ratio and age, weight or CrCl. The mean anti-Xa activity did not differ significantly between the eight patients experiencing a clinical relevant bleeding and those who did not. Conclusion: No accumulation of anti-Xa activity was observed in elderly patients with renal impairment receiving therapeutic doses of tinzaparin, suggesting no need for systematic anti-Xa monitoring in these patients. The high proportion of high-molecular-weight moieties in tinzaparin may account for its reduced dependence on renal elimination.

PMID: 21819539 [PubMed - as supplied by publisher]

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Comparison of two Prognostic Models for Acute Pulmonary Embolism: clinical vs right Ventricular Dysfunction Guided Approach.

J Thromb Haemost Start a Discussion »

Aug 112011

Comparison of two Prognostic Models for Acute Pulmonary Embolism: clinical vs right Ventricular Dysfunction Guided Approach.

J Thromb Haemost. 2011 Aug 5;

Authors: Vanni S, Nazerian P, Pepe G, Baioni M, Michele R, Grifoni G, Viviani G, Grifoni S

Background: Recently, some prognostic models for acute Pulmonary Embolism (PE) have been proposed. We investigated whether the Pulmonary Embolism Severity Index (PESI) and the European Society of Cardiology (ESC) prognostic approach result in different prognostications. Methods: Consecutive adult patients with acute PE were included. According to the ESC guidelines, high-risk patients were identified by the presence of shock/hypotension, intermediate-risk patients by elevated Troponin I or RVD assessed by echocardiography, and low-risk patients by the absence of any of the above. In the PESI, eleven clinical variables, easily accessible at bedside, were used to generate three risk classes. Main outcomes were all-cause and PE-related in-hospital mortality. Results: Forty-one patients (8%,CI95% 5.8-10.8) out of 510 died. According to the ESC, 40% were at low, 54% at intermediate and 6% at high risk of short-term mortality. The distribution according to PESI was 31% (P<0.05 vs ESC), 49% and 20% (P<0.05 vs ESC) respectively. Mortality increased through the risk classes (P<0.01) without significant differences between the models. The ESC model identified with higher accuracy than the PESI both high-risk and low-risk patients (P<0.05 for both). When patients with shock/hypotension were excluded, the PESI stratified patients into classes with increasing PE-related mortality (0.7%,4.3%,11.6%, P<0.05). Troponin I and RVD added incremental prognostic value to the PESI, particularly in normotensive patients at intermediate-risk. Conclusions: The ESC model showed higher accuracy than the PESI in identifying high and low-risk patients. In normotensive patients, the PESI could guide clinical management as well as troponin I and echocardiography testing.

PMID: 21819540 [PubMed - as supplied by publisher]

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The Role of Functional Status in Discharge to Assisted Care Facilities and In-Hospital Death Among Dialysis Patients.

Am J Kidney Dis Start a Discussion »

Aug 112011

The Role of Functional Status in Discharge to Assisted Care Facilities and In-Hospital Death Among Dialysis Patients.

Am J Kidney Dis. 2011 Aug 4;

Authors: Sood MM, Rigatto C, Bueti J, Jassal V, Miller L, Verrelli M, Bohm C, Mojica J, Roberts D, Komenda P

BACKGROUND: Functional status is an important component in the assessment of hospitalized patients. We set out to determine the scope, severity, and prognostic significance of impaired functional status in acutely hospitalized dialysis patients. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 1,286 hospitalized dialysis patients admitted and discharged from 1 of 11 area hospitals in Manitoba, Canada, from September 2003 to September 2010 with an activity of daily living (ADL) assessment within 24 hours of admission. PREDICTOR: The 12-point ADL score assesses 6 domains (bathing, toileting, dressing, incontinence, feeding, and transferring) and scores them as independent or supervision only (score, 0), partial assistance (1), and full assistance (2). Thus, higher score indicates worse functional status. Parametric and nonparametric tests were used as appropriate to determine differences in baseline characteristics. OUTCOMES: Multivariable logistic regression and Cox proportional hazards assessed the association between functional status, in-hospital death, and discharge to an assisted care facility. RESULTS: During the study period, 250 (19.4%) and 72 (5.6%) patients experienced the outcomes of in-hospital death or discharge to an assisted care facility. Abnormalities in functional status were present in >70% of the cohort. ADL score within 24 hours of admission combined with age differentiated risks of death and discharge to an assisted care facility home, ranging from 4.8%-46.6% and 0.6%-17.8%, respectively. After adjustment, ORs of death and discharge to an assisted care facility were 1.16 (95% CI, 1.11-1.22; P < 0.001; C statistic = 0.79) and 1.25 (95% CI, 1.14-1.36; P < 0.001; C statistic = 0.91) per 1-point increase in ADL score, respectively. Findings were consistent after accounting for the competing outcomes of in-hospital death or discharge to an assisted care facility versus discharge to home. LIMITATIONS: A 1-time measurement of ADLs could not differentiate temporary from long-term deterioration in functional status. CONCLUSIONS: Impaired functional status is common at the time of admission in the dialysis population. A single ADL score measurement at admission combined with age is highly predictive of poor outcomes in the hospitalized dialysis population.

PMID: 21820221 [PubMed - as supplied by publisher]

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The survival of patients with heart failure with preserved or reduced left ventricular ejection fraction: an individual patient data meta-analysis.

Eur Heart J Start a Discussion »

Aug 112011

The survival of patients with heart failure with preserved or reduced left ventricular ejection fraction: an individual patient data meta-analysis.

Eur Heart J. 2011 Aug 6;

Authors:

Aims A substantial proportion of patients with heart failure have preserved left ventricular ejection fraction (HF-PEF). Previous studies have reported mixed results whether survival is similar to those patients with heart failure and reduced EF (HF-REF). Methods and results We compared survival in patients with HF-PEF with that in patients with HF-REF in a meta-analysis using individual patient data. Preserved EF was defined as an EF ? 50%. The 31 studies included 41 972 patients: 10 347 with HF-PEF and 31 625 with HF-REF. Compared with patients with HF-REF, those with HF-PEF were older (mean age 71 vs. 66 years), were more often women (50 vs. 28%), and have a history of hypertension (51 vs. 41%). Ischaemic aetiology was less common (43 vs. 59%) in patients with HF-PEF. There were 121 [95% confidence interval (CI): 117, 126] deaths per 1000 patient-years in those with HF-PEF and 141 (95% CI: 138, 144) deaths per 1000 patient-years in those with HF-REF. Patients with HF-PEF had lower mortality than those with HF-REF (adjusted for age, gender, aetiology, and history of hypertension, diabetes, and atrial fibrillation); hazard ratio 0.68 (95% CI: 0.64, 0.71). The risk of death did not increase notably until EF fell below 40%. Conclusion Patients with HF-PEF have a lower risk of death than patients with HF-REF, and this difference is seen regardless of age, gender, and aetiology of HF. However, absolute mortality is still high in patients with HF-PEF highlighting the need for a treatment to improve prognosis.

PMID: 21821849 [PubMed - as supplied by publisher]

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Hospital antibiotic consumption in Switzerland: comparison of a multicultural country with Europe.

J Hosp Infect Start a Discussion »

Aug 112011

Hospital antibiotic consumption in Switzerland: comparison of a multicultural country with Europe.

J Hosp Infect. 2011 Aug 3;

Authors: Plüss-Suard C, Pannatier A, Kronenberg A, Mühlemann K, Zanetti G

The consumption of antibiotics in the inpatient setting of Switzerland was assessed to determine possible differences between linguistic regions, and to compare these results with European results. Data on antibiotic consumption were obtained from a sentinel network representing 54% of the national acute care hospitals, and from a private drug market monitoring company. Aggregated data were converted into defined daily doses (DDD). The total consumption density in Switzerland was close to the median consumption reported in European surveys. Between 2004 and 2008, the total consumption of systemic antibiotics rose from 46.1 to 54.0 DDD per 100 occupied bed-days in the entire hospitals, and from 101.6 to 114.3 DDD per 100 occupied bed-days in the intensive care units. Regional differences were observed for total consumption and among antibiotic classes. Hospitals in the Italian-speaking region showed a significantly higher consumption density, followed by the French- and German-speaking regions. Hospitals in the Italian-speaking region also had a higher consumption of fluoroquinolones, in line with the reported differences between Italy, Germany and France. Antibiotic consumption in acute care hospitals in Switzerland is close to the European median with a relatively low consumption in intensive care units. Some of the patterns of variation in consumption levels noticed among European countries are also observed among the cultural regions of Switzerland.

PMID: 21820207 [PubMed - as supplied by publisher]

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Brain natriuretic peptide measurement in pulmonary medicine.

Respir Med Start a Discussion »

Aug 112011

Brain natriuretic peptide measurement in pulmonary medicine.

Respir Med. 2011 Aug 5;

Authors: Salerno D, Marik PE

Serum levels of natriuretic peptides are well established as important biomarkers in patients with cardiac disease. Less attention has been placed on the role of natriuretic peptides in patients with pulmonary conditions. In several well-defined groups of patients with pulmonary disease natriuretic peptides provide the clinician with clinically valuable information. A limitation of the interpretation of natriuretic peptides in pulmonary disease is the confounding effect of concurrent conditions such as heart failure, hypoxia, sepsis and renal failure. The present paper reviews the role of natriuretic peptides for diagnosis, risk stratification and prognosis of several pulmonary disorders.

PMID: 21821404 [PubMed - as supplied by publisher]

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