2011 August 16

Chronic kidney disease.

Aug 162011

Chronic kidney disease.

Lancet. 2011 Aug 12;

Authors: Levey AS, Coresh J

Chronic kidney disease is a general term for heterogeneous disorders affecting kidney structure and function. The 2002 guidelines for definition and classification of this disease represented an important shift towards its recognition as a worldwide public health problem that should be managed in its early stages by general internists. Disease and management are classified according to stages of disease severity, which are assessed from glomerular filtration rate (GFR) and albuminuria, and clinical diagnosis (cause and pathology). Chronic kidney disease can be detected with routine laboratory tests, and some treatments can prevent development and slow disease progression, reduce complications of decreased GFR and risk of cardiovascular disease, and improve survival and quality of life. In this Seminar we discuss disease burden, recommendations for assessment and management, and future challenges. We emphasise clinical practice guidelines, clinical trials, and areas of uncertainty.

PMID: 21840587 [PubMed - as supplied by publisher]

Link to Article at PubMed

Are family physicians using the CHADS2 score?: Is it useful for assessing risk of stroke in patients with atrial fibrillation?

Can Fam Physician Start a Discussion »

Aug 162011

Are family physicians using the CHADS2 score?: Is it useful for assessing risk of stroke in patients with atrial fibrillation?

Can Fam Physician. 2011 Aug;57(8):e305-9

Authors: Klein D, Levine M

Objective To assess whether family physicians are using the CHADS(2) (congestive heart failure, hypertension, age ? 75, diabetes mellitus, and stroke or transient ischemic attack) score in the decision to initiate warfarin therapy to prevent stroke in patients with atrial fibrillation. Design Retrospective analysis of the medical records of patients with atrial fibrillation. Setting Data were gathered from records at 3 clinics in a primary care network in Edmonton, Alta. Participants The medical records of patients with atrial fibrillation who were currently taking warfarin therapy. Main outcome measures Percentage of patients whose CHADS(2) scores indicated warfarin therapy for stroke prophylaxis compared with the actual percentage of patients taking warfarin therapy. Data on patients' age, number of medications, and number of comorbid conditions were also recorded. Results Among these patients, 7% had a CHADS(2) score of 0, for which no warfarin therapy was indicated; 21% had a score of 1, for which either acetylsalicylic acid or warfarin was indicated; and 72% had a score of 2 or greater, for which warfarin therapy was indicated. About 80% of patients were taking medication to control their heart rate. Conclusion The CHADS(2) score is not being used in all cases to assess the need for warfarin therapy for preventing stroke in patients with atrial fibrillation. The CHADS(2) score might be of limited use because it is not sensitive enough to stratify patients clearly into high-, intermediate-, and low-risk groups. Although guidelines for stroke prevention should be followed, the CHADS(2) portion of the guidelines might not be the most effective way to assess patients' risk of stroke.

PMID: 21841094 [PubMed - in process]

Link to Article at PubMed

Post-bronchoscopy sputum: Improving the diagnostic yield in smear negative pulmonary TB.

Respir Med Start a Discussion »

Aug 162011

Post-bronchoscopy sputum: Improving the diagnostic yield in smear negative pulmonary TB.

Respir Med. 2011 Aug 12;

Authors: George PM, Mehta M, Dhariwal J, Singanayagam A, Raphael CE, Salmasi M, Connell DW, Molyneaux P, Wickremasinghe M, Jepson A, Kon OM

INTRODUCTION: Patients with suspected active Pulmonary Tuberculosis (PTB) who are Acid-Fast Bacilli (AFB) smear negative or non-productive of sputum may undergo bronchoalveolar lavage. However, post-bronchoscopy sputum (PBS) sampling is not routine. The aim of this study was to establish the potential diagnostic value of PBS sampling. METHODS: A retrospective study of patients attending a London University hospital with microbiologically confirmed PTB between January 2004 and December 2010. Patients who were AFB smear negative or non-productive of sputum were eligible if sputum sampling was performed within 7 days of bronchoscopy. RESULTS: Over the study period, 236 patients had microbiologically confirmed smear negative PTB of which 57 patients were eligible for the study. 15 patients (26.3%) were infected with HIV. 19 patients (33.3%) converted to AFB sputum smear positivity post-bronchoscopy and 5 patients (8.8%) were exclusively AFB sputum smear positive on PBS microscopy. Mycobacterium tuberculosis was cultured from the PBS of 43 patients (75.4%) and of these, 4 (7.0%) were exclusively PBS culture positive. CONCLUSION: PBS analysis can provide a simple method of rapidly diagnosing pulmonary tuberculosis. In this cohort, M. tuberculosis culture yield was increased by 7% through PBS sampling. This study has important infection control implications with nearly one third of patients becoming more infectious after bronchoscopy.

PMID: 21840695 [PubMed - as supplied by publisher]

Link to Article at PubMed

Association Between Statins Given in Hospital and Mortality in Pneumonia Patients.

J Gen Intern Med Start a Discussion »

Aug 162011

Association Between Statins Given in Hospital and Mortality in Pneumonia Patients.

J Gen Intern Med. 2011 Aug 13;

Authors: Rothberg MB, Bigelow C, Pekow PS, Lindenauer PK

BACKGROUND: Statins are prescribed to lower cholesterol, but also have anti-inflammatory properties. Some observational studies suggest that statins may reduce mortality from sepsis. METHODS: Using a highly detailed administrative database, we conducted an observational cohort study of all patients aged ?18 years who received a discharge diagnosis of pneumonia from 2003-2005 at 376 hospitals. Patients with contraindications to statins, and those unable to take oral medications or discharged within 2 days were excluded. We used multivariable logistic regression and propensity matching to compare mortality among patients who did and did not receive statins on hospital day 1 or 2. RESULTS: Of the 121,254 patients who met the inclusion criteria, median age was 74; 56% were female and 70% were white; 19% received a statin on day 1 or 2. Compared to patients who did not receive statins, statin-treated patients were less likely to be admitted to intensive care (15.7% vs 18.1%, p?<?0.001), require mechanical ventilation (6.9% vs. 9.3%, p?<?0.001), or die in hospital (3.9% vs 5.7%, p?<?0.001). After multivariable adjustment, including the propensity for statin treatment and severity at presentation, mortality was lower in statin-treated patients [OR for propensity-adjusted 0.86 (95% CI 0.79 to 0.93) OR for propensity-matched 0.90, (0.82 to 0.99)]. For patients admitted to intensive care the adjusted odds ratio for mortality with statins was 0.93 (95% CI 0.81 to 1.06), whereas outside intensive care it was 0.79 (95% CI 0.71 to 0.87). CONCLUSIONS: Inpatient treatment with statins is associated with a modest reduction in pneumonia mortality outside of intensive care.

PMID: 21842322 [PubMed - as supplied by publisher]

Link to Article at PubMed

Very Low Risk of Thromboembolic Events in Patients Undergoing Successful Catheter Ablation of Atrial Fibrillation with a CHADS2 <=3: A Long Term Outcome Study.

Circ Arrhythm Electrophysiol Start a Discussion »

Aug 162011

Very Low Risk of Thromboembolic Events in Patients Undergoing Successful Catheter Ablation of Atrial Fibrillation with a CHADS2 <=3: A Long Term Outcome Study.

Circ Arrhythm Electrophysiol. 2011 Aug 13;

Authors: Saad EB, d'Avila A, Costa IP, Aryana A, Slater C, Costa RE, Inácio LA, Maldonado P, Neto DM, Camiletti A, Camanho LE, Polanczyk CA

BACKGROUND: -Long term cessation of oral anticoagulation (OAC) following catheter ablation of atrial fibrillation (AF) has been deemed controversial. The safety of this management strategy in patients without recurrent AF, with historically elevated risks for thromboembolism, remains largely unknown. In this study, we sought to evaluate the long term results of OAC cessation following successful catheter ablation of AF. METHODS AND RESULTS: -OAC and antiarrhythmic drugs (AADs) were discontinued irrespective of AF type or baseline CHADS(2) risk score in 327 patients (mean age: 63 ± 13 years, 79% males) with drug-refractory AF following catheter ablation (mean CHADS2 score: 1.89 ± 0.95; median: 2.0). Patients with a CHADS(2) score of 2 (45.4%) and 3 (23.2%) accounted for 68.8% of this cohort. In patients with high risk of recurrence or prior thromboembolic complications, OAC was continued for up to 6-12 months post-ablation, while antiplatelet therapy was administered to all other patients who maintained sinus rhythm. After a follow up of 46 ± 17 months (range: 13-82) 82% remained AF-free (off AADs). Significant predictors of late AF recurrence (p<0.05) were non-paroxysmal AF (HR: 1.83), female gender (HR: 2.19), age ?60 years (HR: 1.81), LA size >40mm (HR: 3.52), CHADS(2) ? 2 (HR: 1.81) and early recurrences (HR: 5.52). No symptomatic ischemic cerebrovascular events were detected during follow-up despite interruption of OAC in 298 patients (91%) and AADs in 293 patients (89%). CONCLUSIONS: -No significant thromboembolic-related morbidity is observed when AADs and OAC are discontinued following successful catheter ablation of AF in patients with a CHADS(2) score ?3 maintained on antiplatelet therapy during long term follow-up.

PMID: 21841192 [PubMed - as supplied by publisher]

Link to Article at PubMed

Intraventricular Conduction Delay in a Standard 12-Lead Electrocardiogram as a Predictor of Mortality in General Population.

Circ Arrhythm Electrophysiol Start a Discussion »

Aug 162011

Intraventricular Conduction Delay in a Standard 12-Lead Electrocardiogram as a Predictor of Mortality in General Population.

Circ Arrhythm Electrophysiol. 2011 Aug 13;

Authors: Aro AL, Anttonen O, Tikkanen JT, Junttila MJ, Kerola T, Rissanen HA, Reunanen A, Huikuri HV

BACKGROUND: -Prolonged duration of QRS complex (QRSd) in a 12-lead electrocardiogram (ECG) is associated with adverse prognosis in patients with cardiac disease, but its significance is not well established in general population. In particular, there is paucity of data on the prognostic significance of nonspecific intraventricular conduction delay (IVCD) in apparently healthy subjects. METHODS AND RESULTS: -We evaluated the 12-lead ECGs of 10899 Finnish middle-aged subjects from the general population (52% males, mean age 44±8.5 years) between 1966 and 1972 and followed them for 30±11 years. Primary end points were all-cause mortality, cardiac mortality, and arrhythmic death. Prolonged QRSd was defined as QRS ? 110 ms and IVCD as QRS ? 110 ms without the criteria of complete or incomplete bundle branch block. QRSd ? 110 ms was present in 1.3% (N=147) and IVCD in 0.6% (N=67) of the subjects. Prolonged QRSd predicted all-cause mortality (multivariate adjusted relative risk [RR] 1.48; 95% confidence interval [CI] 1.22-1.81; P<0.001), cardiac mortality (RR 1.94; CI 1.44-2.63; P<0.001), and sudden arrhythmic death (RR 2.14; CI 1.38-3.33; P=0.002). Subjects with IVCD had increased all-cause mortality (RR 2.01; CI 1.52-2.66; P<0.001), cardiac mortality (RR 2.53; CI 1.64-3.90; P<0.001), and an elevated risk of arrhythmic death (RR 3.11; CI 1.74-5.54; P=0.001). LBBB also weakly predicted arrhythmic death (P=0.04), but RBBB was not associated with increased mortality. CONCLUSIONS: -Prolonged QRSd in a standard 12-lead ECG is associated with increased mortality in general population, IVCD being most strongly associated with an increased risk of arrhythmic death.

PMID: 21841194 [PubMed - as supplied by publisher]

Link to Article at PubMed

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