2012 January 18

Effects of Fractionated Plasma Separation and Adsorption on Survival in Patients with Acute-On-Chronic Liver Failure.

Jan 182012

Effects of Fractionated Plasma Separation and Adsorption on Survival in Patients with Acute-On-Chronic Liver Failure.

Gastroenterology. 2012 Jan 13;

Authors: Kribben A, Gerken G, Haag S, Herget-Rosenthal S, Treichel U, Betz C, Sarrazin C, Hoste E, Van Vlierberghe H, Escorsell A, Hafer C, Schreiner O, Galle PR, Mancini E, Caraceni P, Karvellas CJ, Salmhofer H, Knotek M, Ginès P, Kozik-Jaromin J, Rifai K,

Abstract
BACKGROUND & AIMS: Fractionated plasma separation and adsorption (FPSA) is an extracorporeal procedure that supports liver function by removing endogenous toxins that cause complications from acute-on-chronic liver failure (AOCLF). We performed a randomized trial to investigate survival of patients with AOCLF treated with FPSA. METHODS: Patients with AOCLF were randomly assigned to groups given a combination of FPSA and standard medical therapy (SMT) (FPSA group, n=77) or only SMT (n=68). The Prometheus® liver support system was used to provide 8-11 rounds of FPSA (minimum of 4 h each) for 3 weeks. Primary endpoints were survival probabilities at days 28 and 90, irrespective of liver transplantation. RESULTS: Baseline clinical parameters and number of transplanted patients were similar between study arms. Serum bilirubin decreased significantly in the FPSA group but not in the SMT group. In an intention-to-treat analysis, the probabilities of survival on day 28 were 66% in the FPSA group and 63% in the SMP group (p=0.70); on day 90, they were 47% and 38%, respectively (p=0.35). Baseline factors independently associated with poor prognosis were high SOFA score, bleeding, female sex, spontaneous bacterial peritonitis, intermediate increases in serum creatinine concentration, and combination of alcoholic and viral etiology of liver disease. There were no differences between the two groups in the incidence of side effects. CONCLUSIONS: Among all patients with AOCLF, extracorporeal liver support with FPSA does not increase the probability of survival. Further studies are needed to assess whether therapy might be beneficial in specific subsets of patients.

PMID: 22248661 [PubMed - as supplied by publisher]

Link to Article at PubMed

Endoscopic Ultrasound-Guided Transmural and Percutaneous Transhepatic Gallbladder Drainage are Comparable for Acute Cholecystitis.

Gastroenterology Start a Discussion »

Jan 182012

Endoscopic Ultrasound-Guided Transmural and Percutaneous Transhepatic Gallbladder Drainage are Comparable for Acute Cholecystitis.

Gastroenterology. 2012 Jan 11;

Authors: Jang JW, Lee SS, Song TJ, Hyun YS, Park DH, Seo DW, Lee SK, Kim MH, Yun SC

Abstract
BACKGROUND & AIMS: Endoscopic ultrasound (EUS)-guided transmural gallbladder drainage (EUS-GBD) is an alternative to percutaneous transhepatic gallbladder drainage (PTGBD) for patients with acute, high-risk, or advanced-stage cholecystitis who do not respond to initial medical treatment and cannot undergo emergency cholecystectomy. However, the technical feasibility, efficacy, and safety of EUS-GBD and PTGBD have not been compared. METHODS: Fifty-nine patients with acute cholecystitis, who did not respond to initial medical treatment and were unsuitable for an emergency cholecystectomy, were randomly chosen to undergo EUS-GBD (n=30) or PTGBD (n=29). The technical feasibility, efficacy, and safety of EUS-GBD and PTGBD were compared. RESULTS: EUS-GBD and PTGBD showed similar technical (97%, 29/30 vs 97%, 28/29; 95% 1-sided confidence interval [CI] lower limit, -7%; P=.001 for non-inferiority margin of 15%) and clinical (100%, 29/29 vs 96%, 27/28; 95% 1-sided CI lower limit, -2%; P=.0001 for non-inferiority margin of 15%) success rates, and similar rates of complications (7%, 2/30 vs 3%, 1/29; P=.492 in Fisher's exact test) and conversions to open cholecystectomy (9%, 2/23 vs 12%, 3/26; P=.999 in Fisher's exact test). The median post-procedure pain score was significantly lower after EUS-GBD than after PTGBD (1 vs 5; P<.001 in the Mann-Whitney U-test). CONCLUSIONS: EUS-GBD is comparable to PTGBD in terms of the technical feasibility and efficacy; there were no statistical differences in the safety. EUS-GBD is a good alternative for high-risk patients with acute cholecystitis who cannot undergo an emergency cholecystectomy.

PMID: 22245666 [PubMed - as supplied by publisher]

Link to Article at PubMed

The association between plasma D-dimer levels and community-acquired pneumonia.

Clinics (Sao Paulo) Start a Discussion »

Jan 182012

The association between plasma D-dimer levels and community-acquired pneumonia.

Clinics (Sao Paulo). 2010 Jun;65(6):593-7

Authors: Arslan S, Ugurlu S, Bulut G, Akkurt I

Abstract
BACKGROUND: Plasma D-dimer levels are directly related to the intra- and extra-vascular coagulation that occurs in acute and chronic lung damage in patients with community-acquired pneumonia (CAP).
OBJECTIVES: This study examines the relationship between the severity of community-acquired pneumonia and D-dimer levels. In addition, the study examines the correlations among community-acquired pneumonia, the radiological extent of the disease and mortality.
METHODS: The Pneumonia Severity Index was used to classify patients into five groups. Patients were treated at home or in the hospital according to the guidelines for community-acquired pneumonia. Blood samples were taken from the antecubital vein with an injector and placed into citrated tubes. After they were centrifuged, the samples were evaluated with the quantitative latex method.
RESULTS: The study included 60 patients who had been diagnosed with community-acquired pneumonia (mean age 62.5 +/- 11.7) and 24 healthy controls (mean age 59.63 +/- 6.63). The average plasma D-dimer levels were 337.3 +/- 195.1ng/mL in the outpatient treatment group, 691.0 +/- 180.5 in the inpatient treatment group, 1363.2 +/- 331.5 ng/mLin the intensive care treatment group and 161.3 +/- 38.1ng/mL in the control group (p<0.001). The mean D-dimer plasma level was 776.1 +/- 473.5ng/mL in patients with an accompanying disease and 494.2 +/- 280.1 ng/mL in patients without an accompanying disease (p<0.05).
CONCLUSIONS: Plasma D-dimer levels were increased even in community-acquired pneumonia patients who did not have an accompanying disease that would normally cause such an increase.

PMID: 20613935 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

U.K. National COPD Resources and Outcomes Project 2008: patients with chronic obstructive pulmonary disease exacerbations who present with radiological pneumonia have worse outcome compared to those with non-pneumonic chronic obstructive pulmonary disease exacerbations.

Respiration Start a Discussion »

Jan 182012

U.K. National COPD Resources and Outcomes Project 2008: patients with chronic obstructive pulmonary disease exacerbations who present with radiological pneumonia have worse outcome compared to those with non-pneumonic chronic obstructive pulmonary disease exacerbations.

Respiration. 2011;82(4):320-7

Authors: Myint PK, Lowe D, Stone RA, Buckingham RJ, Roberts CM

Abstract
BACKGROUND: Limited comparative data exist on the outcomes of patients presenting with chronic obstructive pulmonary disease (COPD) exacerbations with or without radiological pneumonia. Objective: To examine the outcome differences amongst these patients.
METHODS: We analysed 2008 U.K. National COPD audit data to examine the characteristics, management and outcomes, inpatient- and 90-day mortality and length of stay of patients admitted with COPD exacerbations.
RESULTS: Of 9,338 admissions, 16% (1,505) had changes consistent with pneumonia indicated on the admission chest X-ray. They tended to be older (mean ages 75 vs. 72 years), male (53 vs. 50%), more likely to come from care homes, with more disability, higher BMI and co-morbidity, lower albumin but higher urea levels, and less likely to be current smokers. COPD exacerbations with pneumonia were associated with worse outcomes: inpatient mortality was 11 and 7% and 90-day mortality was 17 and 13% for pneumonia and non-pneumonia patients, respectively (p < 0.001). After adjusting for factors that are significantly different between the 2 groups, including age, sex, place of residence, level of disability, co-morbidity, albumin and urea levels, estimated risk ratios for inpatient and 90-day mortality for pneumonia compared to non-pneumonia cases in this series were 1.19 (1.01,1.42) and 1.09 (0.96,1.23), respectively. The adjusted risk ratio of a prolonged acute hospital stay of more than 7 days was 1.15 (1.07, 1.23).
CONCLUSIONS: Patients who present with radiological pneumonia have worse outcomes compared to those admitted without pneumonia in exacerbation of COPD.

PMID: 21597277 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Pyoderma gangrenosum requiring inpatient management: a report of 26 cases with follow up.

australas j dermatol Start a Discussion »

Jan 182012

Pyoderma gangrenosum requiring inpatient management: a report of 26 cases with follow up.

Australas J Dermatol. 2011 Aug;52(3):218-21

Authors: Saracino A, Kelly R, Liew D, Chong A

Abstract
We present a case series of inpatients with pyoderma gangrenosum (PG), an ulcerative neutrophilic skin condition of unknown aetiology. Twenty-six patients were admitted with PG, nine men and 17 women. At the time of the chart review, seven patients (26.9%) had died. Patients had a mean of 2.0 active ulcerative lesions and 22 patients' ulcers (84.6%) were on the lower limb. Systemic diseases were coexistent in 15 patients (57.7%), the most common being rheumatoid arthritis (19.2%). Thirty-eight wound cultures were taken and were positive for Staphylococcus aureus in 22 cases (57.8%) and Pseudomonas aeruginosa in 20 (52.6%). After prednisolone, cyclosporin was the next most commonly prescribed systemic therapy (34.6%). Surgical debridement was undertaken in seven cases (26.9%) and two patients had skin grafts. Upon discharge from hospital, 21 patients' ulcers (80.8%) had improved. At 6 months 50% showed complete ulcer healing. Our results highlight the potential severity of PG requiring hospital admission, the need for aggressive therapy and the overall high associated morbidity and mortality.

PMID: 21834821 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Impact of an assisted reassessment of antibiotic therapies on the quality of prescriptions in an intensive care unit.

Med Mal Infect Start a Discussion »

Jan 182012

Impact of an assisted reassessment of antibiotic therapies on the quality of prescriptions in an intensive care unit.

Med Mal Infect. 2011 Sep;41(9):480-5

Authors: Bornard L, Dellamonica J, Hyvernat H, Girard-Pipau F, Molinari N, Sotto A, Roger PM, Bernardin G, Pulcini C

Abstract
OBJECTIVES: The study's objective was to assess the impact of a professional multifaceted intervention designed to improve the quality of inpatient empirical therapeutic antibiotic courses at the time of their reassessment, i.e. 24 to 96 hours after treatment initiation.
DESIGN: We conducted a 5-month prospective pre- and post-intervention study in a medical Intensive Care Unit (ICU) in a teaching hospital, using time-series analysis. The intervention was a multifaceted professional intervention combining systematic 3-weekly visits of an infectious diseases specialist to discuss all antibiotic therapies, interactive teaching courses, and daily contact with a microbiologist.
RESULTS: Eighty-one antibiotic prescriptions were assessed, 37 before and 44 after the intervention. The prevalence of adequate antibiotic prescriptions was high and not statistically different before and after the intervention (73% vs. 80%, P=0.31), both for sudden change (P=0.67) and linear trend (P=0.055), using interrupted time-series analysis. The intervention triggered a more frequent reassessment of the diagnosis between day 2 and day 4 (11% vs. 32%, P=0.02) and slightly improved the adaptation of antibiotic therapies to positive microbiology (25% before vs. 50% after, P=0.18).
CONCLUSIONS: Our multifaceted intervention may have improved the quality of antibiotic therapies around day 3 of prescription, but the difference did not reach statistical significance, possibly because of a ceiling effect.

PMID: 21778026 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

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