2012 January 11

Combined use of exercise electrocardiography, coronary calcium score and cardiac CT angiography for the prediction of major cardiovascular events in patients presenting with stable chest pain.

Jan 112012

Combined use of exercise electrocardiography, coronary calcium score and cardiac CT angiography for the prediction of major cardiovascular events in patients presenting with stable chest pain.

Int J Cardiol. 2012 Jan 5;

Authors: Versteylen MO, Joosen IA, Winkens MH, Laufer EM, Snijder RJ, Wildberger JE, Crijns HJ, Narula J, Hofstra L

Abstract
BACKGROUND: The usual diagnostic work-up of chest pain patients includes clinical risk profiling and exercise-ECG, possibly followed by additional tests. Recently cardiac computed tomographic angiography (CCTA) has been employed. We evaluated the prognostic value of the combined use of exercise-ECG and CCTA for the development of cardiovascular endpoints. METHODS: In 283 patients (143 male, mean age 54±10years) with intermediate pre-test probability for coronary artery disease presenting with stable chest pain, exercise-ECG, CCTA and calcium score were performed. Patients were followed-up for combined endpoint of acute coronary syndrome (ACS) and revascularization. RESULTS: After a median follow-up of 769days (interquartile range 644-1007), 6 ACS and 9 revascularizations were recorded. A positive exercise-ECG predicted for the combined endpoint, [hazard ratio (HR) 5.14 (95% confidence interval (CI) 1.64-16.13), p=0.005], as well as a positive calcium score [HR 4.59 (95% CI 1.30-16.28), p=0.02] and a ?50% stenosis on CCTA [HR 45.82 (95% CI 6.02-348.54), p<0.001]. ROC-analysis showed an area under the curve (AUC) of 0.79 (95% CI 0.67-0.90) for exercise-ECG, which increased significantly when CCTA was added: 0.91 (95% CI; 0.86-0.97; p=0.006). Multivariable Cox regression showed exercise-ECG predicted independently [HR 3.6, (95% CI 1.1-11.2), p=0.03], as well as CCTA [HR 31.4 (95% CI 4.0-246.6), p=0.001], but not calcium score [HR 0.6 (95% CI 0.2-2.3), p=0.5]. CONCLUSIONS: The combined subsequent use of exercise-ECG for functional information and CCTA for anatomical information provides a high diagnostic yield in stable chest pain patients with an intermediate pre-test probability for coronary artery disease.

PMID: 22225760 [PubMed - as supplied by publisher]

Link to Article at PubMed

Early initiation of low-dose corticosteroid therapy in the management of septic shock: a retrospective observational study.

Crit Care Start a Discussion »

Jan 112012

Early initiation of low-dose corticosteroid therapy in the management of septic shock: a retrospective observational study.

Crit Care. 2012 Jan 7;16(1):R3

Authors: Park HY, Suh GY, Song JU, Yoo H, Jo IJ, Shin TG, Lim SY, Woo S, Jeon K

Abstract
ABSTRACT: INTRODUCTION: The use of low-dose steroid therapy in the management of septic shock has been extensively studied. However, the association between the timing of low-dose steroid therapy and the outcome has not been evaluated. Therefore, we evaluated whether early initiation of low-dose steroid therapy is associated with mortality in patients with septic shock. METHODS: We retrospectively analyzed the clinical data of 178 patients who received low-dose corticosteroid therapy for septic shock between January 2008 and December 2009. Time-dependent Cox regression models were used to adjust for potential confounding factors in the association between the time to initiation of low-dose corticosteroid therapy and in-hospital mortality. RESULTS: The study population consisted of 107 men and 71 women with a median age of 66 (interquartile range, 54-71) years. The 28-day mortality was 44% and low-dose corticosteroid therapy was initiated within a median of 8.5 (3.8-19.1) hours after onset of septic shock-related hypotension. Median time to initiation of low-dose corticosteroid therapy was significantly shorter in survivors than in non-survivors (6.5 hours vs. 10.4 hours; P = 0.0135). The mortality rates increased significantly with increasing quintiles of time to initiation of low-dose corticosteroid therapy (P = 0.0107 for trend). Other factors associated with 28-day mortality were higher Simplified Acute Physiology Score (SAPS) 3 (P < 0.0001) and Sequential Organ Failure Assessment (SOFA) scores (P = 0.0007), dose of vasopressor at the time of initiation of low-dose corticosteroid therapy (P < 0.0001), need for mechanical ventilation (P = 0.0001) and renal replacement therapy (P < 0.0001), while the impaired adrenal reserve did not affect 28-day mortality (81% vs. 82%; P = 0.8679). After adjusting for potential confounding factors, the time to initiation of low-dose corticosteroid therapy was still significantly associated with in-hospital mortality (adjusted OR 1.025, 95% CI 1.007-1.044, P = 0.0075). The early therapy group (administered within 6 hours after the onset of septic shock, n = 66) had a 37% lower mortality rate than the late therapy group (administered after 6 hours after the onset of septic shock, n = 112) (32% vs. 51%, P = 0.0132). CONCLUSIONS: Early initiation of low-dose corticosteroid therapy was significantly associated with decreased mortality.

PMID: 22226237 [PubMed - as supplied by publisher]

Link to Article at PubMed

Three-year mortality among alcoholic patients after intensive care: A population-based cohort study.

Crit Care Start a Discussion »

Jan 112012

Three-year mortality among alcoholic patients after intensive care: A population-based cohort study.

Crit Care. 2012 Jan 8;16(1):R5

Authors: Christensen S, Johansen MB, Pedersen L, Jensen R, Larsen KM, Larsson A, Tonnesen E, Christiansen CF, Sorensen HT

Abstract
ABSTRACT: BACKGROUND: Alcoholic patients comprise a large proportion of patients in intensive care units (ICUs). However, data are limited on the impact of alcoholism on mortality following intensive care. METHODS: We conducted a cohort study among 16,848 first-time ICU patients between 2001 and 2007 to examine 30-day and 3-year mortality among alcoholic patients. Alcoholic patients with and without complications of alcohol misuse (e.g., alcoholic liver disease) were identified from previous hospital contacts for alcoholism-related conditions or redemption of a prescription for alcohol deterrents. Data on medication use, demographics, hospital diagnoses, and comorbidity were obtained from medical databases. We computed 30-day and 3-year mortality and mortality rate ratios (MRR) using Cox regression analysis, controlling for covariates. RESULTS: A total of 1,229 (7.3%) ICU patients were current alcoholics. Among alcoholic patients without complications of alcoholism (n=785, 4.7% of the cohort), 30-day mortality was 15.9% compared with 19.7% among non-alcoholic patients. Compared with non-alcoholic patients, the adjusted 30-day MRR was 1.04 (95% confidence interval (CI): 0.87-1.25). Three-year mortality was 36.2% compared with 40.9% among non-alcoholic patients, corresponding to an adjusted 3-year MRR of 1.16 (95% CI: 1.03-1.31). For alcoholic patients with complications (n=444, 2.6% of the cohort), 30-day mortality was 33.6% and 3-year mortality was 64.5%, corresponding to adjusted MRRs, with non-alcoholics as the comparator, of 1.64 (95% CI: 1.38-1.95) and 1.67 (95% CI: 1.48-1.90), respectively. CONCLUSION: Alcoholic ICU patients with chronic complications of alcoholism have substantially increased 30-day and three year mortality. In contrast, alcoholics without complications have no increased 30-day and only slightly increased three year mortality.

PMID: 22226344 [PubMed - as supplied by publisher]

Link to Article at PubMed

Plasma neutrophil gelatinase-associated lipocalin for the prediction of acute kidney injury in acute heart failure.

Crit Care Start a Discussion »

Jan 112012

Plasma neutrophil gelatinase-associated lipocalin for the prediction of acute kidney injury in acute heart failure.

Crit Care. 2012 Jan 7;16(1):R2

Authors: Breidthardt T, Socrates T, Drexler B, Noveanu M, Heinisch C, Arenja N, Klima T, Zusli C, Reichlin T, Potocki M, Twerenbold R, Steiger J, Mueller C

Abstract
ABSTRACT: INTRODUCTION: The accurate prediction of acute kidney injury (AKI) in patients with acute heart failure (AHF) is an unmet clinical need. Neutrophil gelatinase-associated lipocalin (NGAL) is a novel sensitive and specific marker of AKI. METHODS: A total of 207 consecutive patients presenting to the emergency department with AHF were enrolled. Plasma NGAL was measured in a blinded fashion at presentation and serially thereafter. The potential of plasma NGAL levels to predict AKI was assessed as the primary endpoint. We defined AKI according to the AKI Network classification. RESULTS: Overall 60 patients (29%) experienced AKI. These patients were more likely to suffer from pre-existing chronic cardiac or kidney disease. At presentation, creatinine (median 140 [IQR, 91-203] umol/l vs. 97 [76-132] umol/l, p<0.01) and NGAL (114.5 [67.1-201.5] ng/ml vs. 74.5 [60-113.9] ng/ml, p<0.01) levels were significantly higher in AKI compared to Non-AKI patients. The prognostic accuracy for measurements obtained at presentation, as quantified by the area under the receiver operating characteristic curve was mediocre and comparable for the two markers (creatinine 0.69; 95%CI 0.59-0.79 vs. NGAL 0.67; 95%CI 0.57-0.77). Serial measurements of NGAL did not further increase the prognostic accuracy for AKI. Creatinine, but not NGAL, remained an independent predictor of AKI (HR 1.15; 95%CI 1.01-1.31; p=0.04) in multivariable regression analysis. CONCLUSION: Plasma NGAL levels do not adequately predict AKI in patients with AHF.

PMID: 22226205 [PubMed - as supplied by publisher]

Link to Article at PubMed

Pulmonary thromboembolism in an East African tertiary referral hospital.

J Thromb Thrombolysis Start a Discussion »

Jan 112012

Pulmonary thromboembolism in an East African tertiary referral hospital.

J Thromb Thrombolysis. 2011 Oct;32(3):386-91

Authors: Ogeng'o JA, Obimbo MM, Olabu BO, Gatonga PM, Ong'era D

Abstract
Pulmonary thromboembolism (PTE) is a frequent cause of mortality in Kenya, but its characteristics are hardly reported in Subsaharan Africa. To describe the pattern of PTE among black Africans, in a Kenyan referral hospital. Retrospective study at Kenyatta National Hospital (KNH), Nairobi, Kenya. Records of patients seen between January 2005 and December 2009 were examined for mode of diagnosis, comorbidities, age, gender, treatment and outcome. Data were analyzed using SPSS version 15.0 and are presented in tables and bar charts. One hundred and twenty-eight (60 male; 68 female) cases were analyzed. Diagnosis was made by clinical evaluation, a Well's score of >4.0, high D-dimer levels and ultrasound demonstration of a proximal deep venous thrombosis (DVT, 35.9%), lung spiral computer tomography (CT, 50%), multidetector CT (7.8%) and angiography (6.3%). Most frequent comorbidities included DVT (36%); hypertension (18.8%); pulmonary tuberculosis (PTB, 12.5%); HIV infection (10.9%), pueperium, diabetes mellitus and cigarette smoking (9.4% each). Mean age was 40.8 years (range 5-86 years) with a peak between 30 and 50 years. Over 46% of patients were aged 40 years and less. Male:female ratio was 1:1.13. All the patients were treated with anticoagulants and thrombolytics with only one having embolectomy. Ninety-two patients (71.9%) recovered, 18.8% of them with cor pulmonale, while 28.1% died. PTE is not uncommon in Kenya. It affects many individuals below 40 years without a gender bias, and carries high morbidity and mortality. Associated comorbidities include venous thrombosis, lifestyle conditions and communicable diseases. Control measures targeting both are recommended.

PMID: 21674133 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Advance care directives: realities and challenges in Central California.

j clin ethics Start a Discussion »

Jan 112012

Advance care directives: realities and challenges in Central California.

J Clin Ethics. 2011;22(3):239-48

Authors: Tunzi M

Abstract
PURPOSE: To discover where patients with advance directives (ADs) obtain them and to learn what patients' understanding is of how ADs function.
METHODS: Adult patients with ADs admitted to the four acute-care hospitals in Monterey County, California, were asked to participate in a survey during the study period 1 July to 8 September 2009.
RESULTS: Of 5,811 total admissions, 455 patients (7 percent) had an AD. Of these 455 patients, 204 (45 percent) completed our survey. Participants included 146 patients with a power of attorney for healthcare (72 percent), and 21 patients who were unable to identify the type of AD they had (10 percent). Attorneys provided ADs to 99 participants (49 percent) and personal physicians provided ADs to 12 participants (6 percent). Most participants (181, or 89 percent) had spoken to their family about their AD; fewer (131, or 65 percent) to their physician. Of the 146 participants with a power of attorney, only 73 (50 percent) said they had spoken specifically to their agent. Family members (38 percent) and attorneys (35 percent) were seen as helpful in completing ADs; physicians (1 percent) were not.
CONCLUSIONS: Few study participants had advance directives, and attorneys provided and discussed ADs with study participants more than physicians did. Because many patients with ADs seem not to fully understand them, new approaches to advance planning education must be developed.

PMID: 22167986 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

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