2011 November

Efficacy of corticosteroid therapy in patients with an acute exacerbation of chronic obstructive pulmonary disease receiving ventilatory support.

Nov 302011

Efficacy of corticosteroid therapy in patients with an acute exacerbation of chronic obstructive pulmonary disease receiving ventilatory support.

Arch Intern Med. 2011 Nov 28;171(21):1939-46

Authors: Alía I, de la Cal MA, Esteban A, Abella A, Ferrer R, Molina FJ, Torres A, Gordo F, Elizalde JJ, de Pablo R, Huete A, Anzueto A

Abstract
BACKGROUND: Randomized trials assessing the effect of systemic corticosteroids on chronic obstructive pulmonary disease (COPD) exacerbations excluded patients who were mechanically ventilated or admitted to the intensive care unit (ICU). Critically ill patients constitute a population of persons who are prone to develop complications that are potentially associated with the use of corticosteroids (eg, infections, hyperglycemia, ICU-acquired paresis) that could prolong the duration of mechanical ventilation and even increase mortality.
METHODS: A double-blind placebo-controlled trial was conducted to evaluate the efficacy and safety of systemic corticosteroid treatment in patients with an exacerbation of COPD who were receiving ventilatory support (invasive or noninvasive mechanical ventilation). A total of 354 adult patients who were admitted to the ICUs of 8 hospitals in 4 countries from July 2005 through July 2009 were screened, and 83 were randomized to receive intravenous methylprednisolone (0.5 mg/kg every 6 hours for 72 hours, 0.5 mg/kg every 12 hours on days 4 through 6, and 0.5 mg/kg/d on days 7 through 10) or placebo. The main outcome measures were duration of mechanical ventilation, length of ICU stay, and need for intubation in patients treated with noninvasive mechanical ventilation.
RESULTS: There were no significant differences between the groups in demographics, severity of illness, reasons for COPD exacerbation, gas exchange variables, and corticosteroid rescue treatment. Corticosteroid treatment was associated with a significant reduction in the median duration of mechanical ventilation (3 days vs 4 days; P = .04), a trend toward a shorter median length of ICU stay (6 days vs 7 days; P = .09), and significant reduction in the rate of NIV failure (0% vs 37%; P = .04).
CONCLUSION: Systemic corticosteroid therapy in patients with COPD exacerbations requiring mechanical ventilation is associated with a significant increase in the success of noninvasive mechanical ventilation and a reduction in the duration of mechanical ventilation Trial Registration clinicaltrials.gov Identifier: NCT01281748.

PMID: 22123804 [PubMed - in process]

Link to Article at PubMed

Risk of pulmonary embolism in patients with autoimmune disorders: a nationwide follow-up study from Sweden.

Lancet Start a Discussion »

Nov 292011

Risk of pulmonary embolism in patients with autoimmune disorders: a nationwide follow-up study from Sweden.

Lancet. 2011 Nov 25;

Authors: Zöller B, Li X, Sundquist J, Sundquist K

Abstract
BACKGROUND: Some autoimmune disorders have been linked to venous thromboembolism. We examined whether there is an association between autoimmune disorders and risk of pulmonary embolism. METHODS: We followed up all individuals in Sweden without previous hospital admission for venous thromboembolism and with a primary or secondary diagnosis of an autoimmune disorder between Jan 1, 1964, and Dec 31, 2008, for hospital admission for pulmonary embolism. We obtained data from the MigMed2 database, which has individual-level information about all registered residents of Sweden. The reference population was the total population of Sweden. We calculated standardised incidence ratios (SIRs) for pulmonary embolism, adjusted for individual variables, including age and sex. FINDINGS: 535?538 individuals were admitted to hospital because of an autoimmune disorder. Overall risk of pulmonary embolism during the first year after admission for an autoimmune disorder was 6·38 (95% CI 6·19-6·57). All the 33 autoimmune disorders were associated with a significantly increased risk of pulmonary embolism during the first year after admission. However, some had a particularly high risk-eg, immune thrombocytopenic purpura (10·79, 95% CI 7·98-14·28), polyarteritis nodosa (13·26, 9·33-18·29), polymyositis or dermatomyositis (16·44, 11·57-22·69), and systemic lupus erythematosus (10·23, 8·31-12·45). Overall risk decreased over time, from 1·53 (1·48-1·57) at 1-5 years, to 1·15 (1·11-1·20) at 5-10 years, and 1·04 (1·00-1·07) at 10 years and later. The risk was increased for both sexes and all age groups. INTERPRETATION: Autoimmune disorders are associated with a high risk of pulmonary embolism in the first year after hospital admission. Our findings suggest that these disorders in general should be regarded as hypercoagulable disorders. FUNDING: Swedish Research Council, Swedish Council for Working Life and Social Research, Swedish Research Council Formas, Region Skåne.

PMID: 22119579 [PubMed - as supplied by publisher]

Link to Article at PubMed

Outcomes of Drug-Eluting Stents for Protected Left Main Coronary Artery Disease (from the Multicenter, United States DEScover Registry).

Am J Cardiol Start a Discussion »

Nov 292011

Outcomes of Drug-Eluting Stents for Protected Left Main Coronary Artery Disease (from the Multicenter, United States DEScover Registry).

Am J Cardiol. 2011 Nov 23;

Authors: Leitner J, Vlachos HA, Selzer F, Jamal SM, Kip KE, Williams DO, Abbott JD

Abstract
Percutaneous coronary intervention (PCI) for protected left main coronary artery (PLM) disease is complex because of patient and lesion factors; however, limited data exist on the outcomes of drug-eluting stent (DES) use for this indication. DEScover is a prospective observational study that enrolled consecutive patients with PCI in 2005. In-hospital and 1-year statuses were analyzed for 6,172 patients treated with DES according to LM and coronary artery bypass grafting (CABG) statuses (PLM, n = 93; previous CABG native vessel non-LM, n = 722; no previous CABG, n = 5,357). Cumulative event rates were calculated by the Kaplan-Meier method. Cox proportional hazards regression was used for multivariable analysis of adverse events. Baseline clinical, angiographic, and procedural variables differed significantly among groups, with patients with previous CABG, PLM, and non-LM having higher risk characteristics. In patients with previous CABG, after adjustment with CABG non-LM as a reference group, there were no significant differences in 1-year risk of any adverse event except a trend toward a greater risk of myocardial infarction (MI) in patients with PLM (adjusted hazard ratio 2.4, confidence interval 0.95 to 6.2, p = 0.06). However, patients after CABG (PLM and non-LM) compared to patients without previous CABG had a similar adjusted risk of death, MI, and stent thrombosis; an increased risk of target lesion revascularization (adjusted hazard ratio 1.79, confidence interval 1.2 to 2.6, p = 0.003), target vessel revascularization and death/MI/target vessel revascularization; and a lower risk of CABG (adjusted hazard ratio 0.25, confidence interval 0.09 to 0.67, p = 0.006). In conclusion, status after CABG rather than PLM location increases the risk of repeat revascularization with PCI in DES-treated patients.

PMID: 22118825 [PubMed - as supplied by publisher]

Link to Article at PubMed

Rates and Implications for Hospitalization of Patients ?65 Years of Age With Atrial Fibrillation/Flutter.

Am J Cardiol Start a Discussion »

Nov 292011

Rates and Implications for Hospitalization of Patients ?65 Years of Age With Atrial Fibrillation/Flutter.

Am J Cardiol. 2011 Nov 23;

Authors: Naccarelli GV, Johnston SS, Dalal M, Lin J, Patel PP

Abstract
The responsibility of managing atrial fibrillation (AF) and atrial flutter (AFL) falls predominantly on the Medicare system. Patients with AF or AFL often have a range of cardiovascular (CV) co-morbidities and are frequently hospitalized for AF and other CV causes. The present retrospective cohort study used medical claims data to evaluate the rates of hospitalization and inpatient mortality in elderly (aged ?65 years) patients with AF or AFL with Medicare supplemental insurance. The data were extracted from the United States Thomson Reuters MarketScan Medicare Supplemental and Coordination of Benefits Database (January 2004 to December 2007). Patients aged ?65 years with ?1 inpatient or ?2 outpatient nondiagnostic claims for AF or AFL and ?12 months of continuous enrollment before their index AF or AFL diagnoses were identified. The frequencies of hospitalization and inpatient death were evaluated over the postindex study period (mean 24.3 months). Of an eligible study population of 55,774 patients with AF or AFL (mean age 77.9 years, 52.2% men), 28,939 patients (51.9%) were hospitalized (all causes) with nonfatal outcomes, 12,652 (22.7%) were rehospitalized, and 1,592 (2.9%) died in the hospital. Higher proportions of patients were hospitalized for non-CV than for CV causes (35.6% vs 27.2%). For CV hospitalizations culminating in inpatient death (n = 516), the most common admission diagnoses were major bleeding, stroke or transient ischemic attack, and congestive heart failure. In conclusion, elderly patients with AF or AFL undergo frequent hospitalization for CV and non-CV causes. Measures that lower inpatient admission rates, particularly readmission rates, may reduce the increasing cost of treating patients with AF or AFL with Medicare supplemental insurance.

PMID: 22118826 [PubMed - as supplied by publisher]

Link to Article at PubMed

Effect of Warfarin on Outcomes in Septuagenarian Patients With Atrial Fibrillation.

Am J Cardiol Start a Discussion »

Nov 292011

Effect of Warfarin on Outcomes in Septuagenarian Patients With Atrial Fibrillation.

Am J Cardiol. 2011 Nov 23;

Authors: Roy B, Desai RV, Mujib M, Epstein AE, Zhang Y, Guichard J, Jones LG, Feller MA, Ahmed MI, Aban IB, Love TE, Levesque R, White M, Aronow WS, Fonarow GC, Ahmed A

Abstract
Anticoagulation has been shown to decrease ischemic stroke in atrial fibrillation (AF). However, concerns remain regarding their safety and efficacy in those ?70 years of age who constitute most patients with AF. Of the 4,060 patients (mean age 65 years, range 49 to 80) in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial, 2,248 (55% of 4,060) were 70 to 80 years of age, 1,901 of whom were receiving warfarin. Propensity score for warfarin use, estimated for each of the 2,248 patients, was used to match 227 of the 347 patients not on warfarin (in 1:1, 1:2, or 1:3 sets) to 616 patients on warfarin who were balanced in 45 baseline characteristics. All-cause mortality occurred in 18% and 33% of matched patients receiving and not receiving warfarin, respectively, during up to 6 years (mean 3.4) of follow-up (hazard ratio [HR] when warfarin use was compared to its nonuse 0.58, 95% confidence interval [CI] 0.43 to 0.77, p <0.001). All-cause hospitalization occurred in 64% and 67% of matched patients receiving and not receiving warfarin, respectively (HR associated with warfarin use 0.93, 95% CI 0.77 to 1.12, p = 0.423). Ischemic stroke occurred in 4% and 8% of matched patients receiving and not receiving warfarin, respectively (HR associated with warfarin use 0.57, 95% CI 0.31 to 1.04, p = 0.068). Major bleeding occurred in 7% and 10% of matched patients receiving and not receiving warfarin, respectively (HR associated with warfarin use 0.73, 95% CI 0.44 to 1.22, p = 0.229). In conclusion, warfarin use was associated with decreased mortality in septuagenarian patients with AF but had no association with hospitalization or major bleeding.

PMID: 22118824 [PubMed - as supplied by publisher]

Link to Article at PubMed

Intensive glycaemic control for patients with type 2 diabetes: systematic review with meta-analysis and trial sequential analysis of randomised clinical trials.

BMJ 1 Response »

Nov 272011

Intensive glycaemic control for patients with type 2 diabetes: systematic review with meta-analysis and trial sequential analysis of randomised clinical trials.

BMJ. 2011;343:d6898

Authors: Hemmingsen B, Lund SS, Gluud C, Vaag A, Almdal T, Hemmingsen C, Wetterslev J

Abstract
Objective To assess the effect of targeting intensive glycaemic control versus conventional glycaemic control on all cause mortality and cardiovascular mortality, non-fatal myocardial infarction, microvascular complications, and severe hypoglycaemia in patients with type 2 diabetes. Design Systematic review with meta-analyses and trial sequential analyses of randomised trials. Data sources Cochrane Library, Medline, Embase, Science Citation Index Expanded, LILACS, and CINAHL to December 2010; hand search of reference lists and conference proceedings; contacts with authors, relevant pharmaceutical companies, and the US Food and Drug Administration. Study selection Randomised clinical trials comparing targeted intensive glycaemic control with conventional glycaemic control in patients with type 2 diabetes. Published and unpublished trials in all languages were included, irrespective of predefined outcomes. Data extraction Two reviewers independently assessed studies for inclusion and extracted data related to study methods, interventions, outcomes, risk of bias, and adverse events. Risk ratios with 95% confidence intervals were estimated with fixed and random effects models. Results Fourteen clinical trials that randomised 28?614 participants with type 2 diabetes (15?269 to intensive control and 13?345 to conventional control) were included. Intensive glycaemic control did not significantly affect the relative risks of all cause (1.02, 95% confidence interval 0.91 to 1.13; 28?359 participants, 12 trials) or cardiovascular mortality (1.11, 0.92 to 1.35; 28?359 participants, 12 trials). Trial sequential analyses rejected a relative risk reduction above 10% for all cause mortality and showed insufficient data on cardiovascular mortality. The risk of non-fatal myocardial infarction may be reduced (relative risk 0.85, 0.76 to 0.95; P=0.004; 28?111 participants, 8 trials), but this finding was not confirmed in trial sequential analysis. Intensive glycaemic control showed a reduction of the relative risks for the composite microvascular outcome (0.88, 0.79 to 0.97; P=0.01; 25?600 participants, 3 trials) and retinopathy (0.80, 0.67 to 0.94; P=0.009; 10?793 participants, 7 trials), but trial sequential analyses showed that sufficient evidence had not yet been reached. The estimate of an effect on the risk of nephropathy (relative risk 0.83, 0.64 to 1.06; 27?769 participants, 8 trials) was not statistically significant. The risk of severe hypoglycaemia was significantly increased when intensive glycaemic control was targeted (relative risk 2.39, 1.71 to 3.34; 27?844 participants, 9 trials); trial sequential analysis supported a 30% increased relative risk of severe hypoglycaemia. CONCLUSION: Intensive glycaemic control does not seem to reduce all cause mortality in patients with type 2 diabetes. Data available from randomised clinical trials remain insufficient to prove or refute a relative risk reduction for cardiovascular mortality, non-fatal myocardial infarction, composite microvascular complications, or retinopathy at a magnitude of 10%. Intensive glycaemic control increases the relative risk of severe hypoglycaemia by 30%.

PMID: 22115901 [PubMed - in process]

Link to Article at PubMed

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