2011 December 01

Risk factors for invasive fungal disease in critically ill, adult patients: a systematic review.

Dec 012011

Risk factors for invasive fungal disease in critically ill, adult patients: a systematic review.

Crit Care. 2011 Nov 29;15(6):R287

Authors: Muskett H, Shahin J, Eyres G, Harvey S, Rowan K, Harrison D

Abstract
ABSTRACT: INTRODUCTION: Over 5,000 cases of invasive Candida species infections occur in the UK each year and around 40% of these occur in critical care units. Invasive fungal disease (IFD) in critically-ill patients is associated with increased morbidity and mortality at a cost to both the individual and the health service. This paper reports the results of a systematic review performed to identify and summarise the important risk factors from published multivariable analyses, risk prediction models and clinical decision rules, for IFD in critically ill, adult patients to inform the primary data collection for the Fungal Infection Risk Evaluation (FIRE) Study. METHODS: An electronic search was performed to identify articles which investigated risk factors, risk prediction models or clinical decisions rules for IFD in critically ill, adult patients. Eligible articles were identified in a staged process and were assessed by two investigators, independently. The methodological quality of the reporting of the eligible articles was assessed using a set of questions addressing both general and statistical methodology. RESULTS: Thirteen articles met the inclusion criteria, of which eight articles examined risk factors, four developed a risk prediction model or clinical decision rule, and one evaluated a clinical decision rule. Studies varied in terms of objectives, risk factors, definitions and outcomes. The following risk factors were found in multiple studies to be significantly associated with IFD: surgery, total parenteral nutrition, fungal colonisation, renal replacement therapy, infection/sepsis, mechanical ventilation, diabetes, and APACHE II or APACHE III score. Several other risk factors were also found to be statistically significant in single studies only. Risk factor selection process and modelling strategy also varied across studies, and sample sizes were inadequate for obtaining reliable estimates. CONCLUSION: This review has shown a number of risk factors to be significantly associated with the development of IFD in critically ill adults. Methodological limitations were identified in the design and conduct of studies in this area, and caution should be used in their interpretation.

PMID: 22126425 [PubMed - as supplied by publisher]

Link to Article at PubMed

Provider-Directed Imaging Stress Testing Reduces Health-Care Expenditures in Lower-Risk Chest Pain Patients Presenting to the Emergency Department.

Circ Cardiovasc Imaging Start a Discussion »

Dec 012011

Provider-Directed Imaging Stress Testing Reduces Health-Care Expenditures in Lower-Risk Chest Pain Patients Presenting to the Emergency Department.

Circ Cardiovasc Imaging. 2011 Nov 29;

Authors: Miller CD, Hoekstra JW, Lefebvre C, Blumstein H, Hamilton CA, Harper EN, Mahler S, Diercks DB, Neiberg R, Hundley WG

Abstract
BACKGROUND: -Among intermediate to high-risk patients with chest pain, we have shown that a cardiac magnetic resonance (CMR) stress-test strategy implemented in an observation unit (OU) reduces 1-year healthcare costs compared to inpatient care. In this study, we compare two OU strategies to determine among lower-risk patients if a mandatory CMR stress test strategy was more effective than a physicians' ability to select a stress test modality. METHODS AND RESULTS: -Upon ED arrival and referral to the OU for management of low to intermediate-risk chest pain, 120 individuals were randomized to receive an a) CMR stress imaging test (n=60), or b) a provider selected stress test (n=60: stress echo [62%], CMR (32%), cardiac catheterization (3%), nuclear (2%), and coronary CT [2%]). No differences were detected in length of stay (median CMR = 24.2 hours vs 23.8 hours, p=0.75), catheterization without revascularization (CMR=0% vs 3%), appropriateness of admission decisions (CMR 87% vs 93%, p=0.36), or 30-day ACS (both 3%). Median cost was higher among those randomized to the CMR mandated group ($2005 vs $1686, p<0.001). CONCLUSIONS: -In patients with lower-risk chest pain receiving ED-directed OU care, the ability of a physician to select a cardiac stress imaging modality (including echocardiography, CMR, or radionuclide testing) was more cost effective than a pathway that mandates a CMR stress test. Contrary to prior observations in individuals with intermediate to high-risk chest pain, in those with lower risk chest pain, these results highlight the importance of physician-related choices during ACS diagnostic protocols. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00869245.

PMID: 22128195 [PubMed - as supplied by publisher]

Link to Article at PubMed

Vasopressin for treatment of vasodilatory shock: an ESICM systematic review and meta-analysis.

Intensive Care Med Start a Discussion »

Dec 012011

Vasopressin for treatment of vasodilatory shock: an ESICM systematic review and meta-analysis.

Intensive Care Med. 2011 Nov 30;

Authors: Polito A, Parisini E, Ricci Z, Picardo S, Annane D

Abstract
OBJECTIVE: To examine the benefits and risks of vasopressin or its analog terlipressin for patients with vasodilatory shock. DATA SOURCE: We searched the CENTRAL, MEDLINE, EMBASE, and LILACS databases (up to March 2011) as well as reference lists of articles and proceedings of major meetings; we also contacted trial authors. We considered randomized and quasirandomized trials of vasopressin or terlipressin versus placebo or supportive treatment in adult and pediatric patients with vasodilatory shock. The primary outcome for this review was short-term all-cause mortality. STUDY SELECTION: We identified 10 randomized trials (1,134 patients). Six studies were considered for the main analysis on mortality in adults. DATA EXTRACTION AND SYNTHESIS: The crude short-term mortality was 206 of 512 (40.2%) in vasopressin/terlipressin-treated patients and 198 of 461 (42.9%) in controls [six trials, risk ratio (RR) = 0.91; 95% confidence interval (CI) 0.79-1.05; P = 0.21; I (2) = 0%]. There were 49 of 463 (10.6%) patients with serious adverse events in the vasopressin/terlipressin arm and 51 of 431 (11.8%) in the control arm (four trials, RR = 0.90; 95% CI 0.49-1.67; P = 0.75; I (2) = 26%). Metaregression analysis showed negative correlation between vasopressin dose and norepinephrine dose (P = 0.03). CONCLUSIONS: Overall, use of vasopressin or terlipressin did not produce any survival benefit in the short term in patients with vasodilatory shock. Physicians may value the sparing effects of vasopressin/terlipressin on norepinephrine requirement given its apparent safe profile.

PMID: 22127480 [PubMed - as supplied by publisher]

Link to Article at PubMed

Management of severe hypertriglyceridemia in the hospital: A review.

J Hosp Med Start a Discussion »

Dec 012011

Management of severe hypertriglyceridemia in the hospital: A review.

J Hosp Med. 2011 Nov 29;

Authors: Schaefer EW, Leung A, Kravarusic J, Stone NJ

Abstract
For hospitalists, hypertriglyceridemia (HTG) is more than cardiovascular risk. Severe HTG occurs when serum triglycerides rise above 1000 mg/dL, and it carries a risk of abdominal pain and pancreatitis. The etiology of severe HTG is usually a combination of genetic and secondary factors. A detailed history with attention to family history, medications, and alcohol consumption can often lead to the cause. Physical examination findings may stretch across multiple organ systems. Patients with severe HTG should be admitted to the hospital for aggressive medical therapy if they develop symptoms such as abdominal pain or pancreatitis. Asymptomatic patients with severe HTG who have significant short-term risk for developing symptoms require urgent consultation that may lead to a brief hospitalization to address exacerbating factors. Treatment of severe HTG includes a combination of pharmacologic agents and a restriction on dietary triglyceride intake. If oral medications fail to adequately lower triglyceride levels, intravenous insulin and in rare cases therapeutic plasma exchange may be required. To prevent recurrent severe HTG, the patient should be counseled about adherence to long-term medications and lifestyle changes. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine.

PMID: 22128096 [PubMed - as supplied by publisher]

Link to Article at PubMed

Thromboprophylaxis in patients receiving inpatient palliative care: a survey of present practice in Austria.

Support Care Cancer Start a Discussion »

Dec 012011

Thromboprophylaxis in patients receiving inpatient palliative care: a survey of present practice in Austria.

Support Care Cancer. 2011 Nov 26;

Authors: Gartner V, Kierner KA, Namjesky A, Kum-Taucher B, Hammerl-Ferrari B, Watzke HH, Stabel C,

Abstract
BACKGROUND: There is limited data on the use of thromboprophylaxis in patients with advanced cancer. We therefore aimed to study the practice of thromboprophylaxis in palliative care units in Austria. METHODS: We monitored use, indication, and contraindications to thromboprophylaxis in 134 patients hospitalized in 21 palliative care units in a prospective, cross-sectional study. RESULTS: Forty-seven percent of patients were on low molecular weight heparin on the day of the study for primary or secondary thromboembolism. Thromboprophylaxis had been withdrawn in 18% of the patients upon admission to the palliative care unit. Contraindications for thromboprophylaxis were present in 27% of all patients. Cancer was present in 86% of the patients. The use of thromboprophylaxis was similar in cancer patients and in non-cancer patients (49% vs. 42%). Contraindications for thromboprophylaxis were present in 24% of all cancer patients. Significantly more bedridden cancer patients had contraindications for prophylaxis when compared with mobile cancer patients (35% vs. 16%; p?=?0.03). Low performance status was by far the most frequent contraindication among these patients (89%). Seventy-one percent of all bedridden cancer patients were treated in accordance with common guidelines for thromboprophylaxis when contraindications were taken into account. Eighty-seven percent of patients who had been involved in decision making opted for getting prophylaxis. CONCLUSIONS: Our data reveal that about half of all cancer patients in palliative care units are treated with thromboprophylaxis. Low performance status was the most frequent contraindication for thromboprophylaxis.

PMID: 22119936 [PubMed - as supplied by publisher]

Link to Article at PubMed

December 2011
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