2011 November 15

Systematic review: the treatment of noncardiac chest pain.

Aliment Pharmacol Ther Start a Discussion »

Nov 152011

Systematic review: the treatment of noncardiac chest pain.

Aliment Pharmacol Ther. 2011 Nov 13;

Authors: Hershcovici T, Achem SR, Jha LK, Fass R

Abstract
Background? Treatment of noncardiac chest pain (NCCP) remains a challenge. This is in part due to the heterogenous nature of this disorder. Several conditions are associated with NCCP including gastro-oesophageal reflux disease (GERD), oesophageal dysmotility, oesophageal hypersensitivity as well as others. Aim To determine the currently available therapeutic modalities for NCCP. Methods? We performed a systematic review of the literature that was published between January, 1980 and March, 2011. We identified 734 studies; 68 of them met entry criteria. Results? Patients with GERD-related NCCP should receive proton pump inhibitors (PPI) twice daily for at least 8?weeks. Smooth muscle relaxants are only recommended for temporary relief of NCCP with motility disorders. Botulinum toxin injection of the distal oesophagus may be effective in the treatment of NCCP and spastic oesophageal motility disorders. Studies assessing the value of tricyclic antidepressants, trazodone and selective serotonine reuptake inhibitors in NCCP are relatively small, but suggest an oesophageal analgesic effect in NCCP patients that is limited by their side effects profile. The usage of theophylline to treat patients with non-GERD-related NCCP should be weighed against its potential toxicity. Use of complementary medicine has been scarcely studied in NCCP. Patients with coexisting psychological morbidity or those not responding to any medical therapy should be considered for psychological intervention. Cognitive behavioural therapy and hypnotherapy may be useful in the treatment of NCCP. Conclusions? Patients with GERD-related noncardiac chest pain should be treated with at least double dose PPI. The primary treatment for non-GERD-related noncardiac chest pain, regardless if oesophageal dysmotility is present, is pain modulators.

PMID: 22077344 [PubMed - as supplied by publisher]

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Comparison of bleeding complications and one-year survival of low molecular weight heparin versus unfractioned heparin for acute myocardial infarction in elderly patients. The FAST-MI registry.

Int J Cardiol Start a Discussion »

Nov 152011

Comparison of bleeding complications and one-year survival of low molecular weight heparin versus unfractioned heparin for acute myocardial infarction in elderly patients. The FAST-MI registry.

Int J Cardiol. 2011 Nov 10;

Authors: Puymirat E, Aïssaoui N, Collet JP, Chaib A, Bonnet JL, Bataille V, Drouet E, Mulak G, Ferrières J, Blanchard D, Simon T, Danchin N

Abstract
BACKGROUND: There are limited data on the safety and efficacy of low molecular weight heparin (LMWH) in elderly patients with acute myocardial infarction (AMI). METHODS: We aimed to compare LMWH with unfractioned heparin (UFH) in the management of AMI in elderly patients. FAST-MI is a nationwide registry carried out over a 1-month period in 2005, including consecutive patients with AMI admitted to intensive care unit <48h from symptom onset in 223 participating centers. We assessed the impact of LMWH on bleeding, the need for blood transfusion and one-year survival in elderly patients (?75years). RESULTS: 963 patients treated with heparin were included (mean age 82±5years; 51% women; 42.5% ST-elevation myocardial infarction). Major bleeding (2.4% vs. 6.1%, P=0.004) and blood transfusions (4.6% vs. 9.7%, P=0.002) were significantly less frequent with LMWH compared with the UFH, a difference that persisted after multivariate adjustment (OR=0.41, 95% CI: 0.20-0.83 and OR=0.49, 95% CI: 0.28-0.85, respectively). One-year survival and stroke and reinfarction-free survival were also significantly higher with LMWH compared with UFH (OR=0.66, 95% CI: 0.50-0.85 and OR=0.71, 95% CI: 0.56-0.91, respectively). In two cohorts of patients matched on a propensity score for getting LMWH and with similar baseline characteristics (328 patients per group), major bleeding and transfusion were significantly lower while one-year survival was significantly higher in patients receiving LMWH. CONCLUSIONS: The present data show that in elderly patients admitted for AMI, use of LMWH is associated with less bleeding, less need for transfusion, and higher survival, compared with the use of UFH.

PMID: 22078393 [PubMed - as supplied by publisher]

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SvO2 to monitor resuscitation of septic patients: let’s just understand the basic physiology.

Crit Care Start a Discussion »

Nov 152011

SvO2 to monitor resuscitation of septic patients: let's just understand the basic physiology.

Crit Care. 2011 Nov 7;15(6):1005

Authors: Teboul JL, Hamzaoui O, Monnet X

Abstract
ABSTRACT: Real-time monitoring of mixed venous oxygen blood saturation (SvO2) or of central venous oxygen blood saturation is often used during resuscitation of septic shock. However, the meaning of these parameters is far from straightforward. In the present commentary, we emphasize that SvO2 - a global marker of tissue oxygen balance - can never be simplistically used as a marker of preload responsiveness, which is an intrinsic marker of cardiac performance. In some septic shock patients, because of profound hypovolemia or myocardial dysfunction, SvO2 can be low but obviously cannot alone indicate whether a fluid challenge would increase cardiac output. In other patients, because of a profound impairment of oxygen extraction capacities, SvO2 can be abnormally high even in patients who are still able to respond positively to fluid infusion. In any case, other reliable dynamic parameters can help to address the important question of fluid responsiveness/unresponsiveness. However, whether fluid administration in fluid responders and high SvO2 would be efficacious to reduce tissue dysoxia in the most injured tissues is still uncertain.

PMID: 22078239 [PubMed - as supplied by publisher]

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Computerized lung sound analysis as diagnostic aid for the detection of abnormal lung sounds: a systematic review and meta-analysis.

Respir Med Start a Discussion »

Nov 152011

Computerized lung sound analysis as diagnostic aid for the detection of abnormal lung sounds: a systematic review and meta-analysis.

Respir Med. 2011 Sep;105(9):1396-403

Authors: Gurung A, Scrafford CG, Tielsch JM, Levine OS, Checkley W

Abstract
RATIONALE: The standardized use of a stethoscope for chest auscultation in clinical research is limited by its inherent inter-listener variability. Electronic auscultation and automated classification of recorded lung sounds may help prevent some of these shortcomings.
OBJECTIVE: We sought to perform a systematic review and meta-analysis of studies implementing computerized lung sound analysis (CLSA) to aid in the detection of abnormal lung sounds for specific respiratory disorders.
METHODS: We searched for articles on CLSA in MEDLINE, EMBASE, Cochrane Library and ISI Web of Knowledge through July 31, 2010. Following qualitative review, we conducted a meta-analysis to estimate the sensitivity and specificity of CLSA for the detection of abnormal lung sounds.
MEASUREMENTS AND MAIN RESULTS: Of 208 articles identified, we selected eight studies for review. Most studies employed either electret microphones or piezoelectric sensors for auscultation, and Fourier Transform and Neural Network algorithms for analysis and automated classification of lung sounds. Overall sensitivity for the detection of wheezes or crackles using CLSA was 80% (95% CI 72-86%) and specificity was 85% (95% CI 78-91%).
CONCLUSIONS: While quality data on CLSA are relatively limited, analysis of existing information suggests that CLSA can provide a relatively high specificity for detecting abnormal lung sounds such as crackles and wheezes. Further research and product development could promote the value of CLSA in research studies or its diagnostic utility in clinical settings.

PMID: 21676606 [PubMed - indexed for MEDLINE]

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Evaluation of therapeutic anticoagulation with enoxaparin and associated anti-Xa monitoring in patients with morbid obesity: a case series.

J Thromb Thrombolysis Start a Discussion »

Nov 152011

Evaluation of therapeutic anticoagulation with enoxaparin and associated anti-Xa monitoring in patients with morbid obesity: a case series.

J Thromb Thrombolysis. 2011 Aug;32(2):188-94

Authors: Deal EN, Hollands JM, Riney JN, Skrupky LP, Smith JR, Reichley RM

Abstract
Our purpose was to describe anti-Xa levels, dosage requirements, and complications associated with enoxaparin treatment doses in patients with morbid obesity. Inpatients with a BMI >40 kg/m(2) at an academic medical center prescribed therapeutic enoxaparin from 2004 to 2010 who also had an associated anti-Xa level were included in this retrospective evaluation. Twenty-six patients were identified having median weight of 162 kg (range 106-243), median BMI of 49.5 kg/m(2) (range 40.1-98.1), and median enoxaparin duration of 4 days (range 1-32). Venous thromboembolism was the most common reason for anticoagulation (n = 19, 73%). The median starting dose was 0.8 mg/kg actual body weight (range 0.51-1; absolute dose 80-150 mg) every 12 h. Twelve patients (46%) achieved a goal anti-Xa level, 10 (38%) were above goal and 4 (15%) were uninterpretable. Among the 10 patients with anti-Xa levels above goal, the median initial dose was 0.85 mg/kg (range 0.75-1) versus 0.74 mg/kg (range 0.51-1) for patients at goal with similar median peak serum creatinine (PSCr) values between these two groups (P > 0.05). No bleeding events occurred in patients achieving goal anticoagulation versus 4/10 (40%) with high anti-Xa levels (P = 0.033) with similar median PSCr between these groups. No thrombotic events occurred while on therapy. The majority in this cohort with morbid obesity achieved anti-Xa levels at or above goal at doses less than the recommended 1 mg/kg every 12 h. Bleeding events were more frequent among patients with anti-Xa levels above goal, despite similar PSCr values.

PMID: 21465129 [PubMed - indexed for MEDLINE]

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Current Status and Trends in the Treatment of Acute Pulmonary Thromboembolism.

Circ J Start a Discussion »

Nov 152011

Current Status and Trends in the Treatment of Acute Pulmonary Thromboembolism.

Circ J. 2011 Nov 10;

Authors: Yamada N, Nakamura M, Ito M

Abstract
Untreated acute pulmonary thromboembolism (APTE) is associated with high mortality, which is reduced by prompt treatment. Anticoagulation is fundamental in the treatment of APTE and should be initiated from suspicion. The efficacy and safety of novel anticoagulant drugs, such as oral anti-Xa and anti-IIa inhibitors, are topics in the treatment of APTE and are now under investigation. Thrombolytic therapy is a widely accepted treatment strategy for massive APTE, but its use for submassive APTE is controversial. Catheter intervention, percutaneous cardiopulmonary support and surgical embolectomy are also necessary and effective for some patients with APTE. A retrievable inferior vena cava filter is preferred for transient protection against APTE. Some studies have demonstrated the feasibility of outpatient treatment in patients with APTE after risk stratification.

PMID: 22076423 [PubMed - as supplied by publisher]

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