2012 March 16

Pulmonary Embolism in Sickle Cell Disease: A Case-Control Study.

Mar 162012

Pulmonary Embolism in Sickle Cell Disease: A Case-Control Study.

J Thromb Haemost. 2012 Mar 15;

Authors: Novelli EM, Huynh C, Gladwin MT, Moore CG, Ragni MV

Abstract
Introduction: Pulmonary embolism (PE) is a leading cause of mortality in hospitalized patients, yet the prevalence of PE in sickle cell disease (SCD) and its relation to disease severity or intrinsic hypercoagulability are not established. Methods: We estimated inpatient PE incidence and prevalence among SCD and non-SCD populations in Pennsylvania, and compared severity of illness and mortality, using Pennsylvania Health Care Cost Containment Council (PHC4) discharge data, 2001-2006. Risk factors for PE were assessed in a case-control study of discharges from the University of Pittsburgh Medical Archival Records System (MARS). Results: The incidence of inpatient PE was higher in the SCD PA population than in the non-SCD Pennsylvania population, 2001-2006. The PE prevalence among SCD discharges <50 years of age, 0.57%, was similar to that in non-SCD Pennsylvania discharges, 0.60%, and unchanged after adjustment for race. Among SCD discharges, those developing PE were significantly older, with longer length of stay, greater severity of illness, and higher mortality, p<0.001, than SCD without PE. Among PE discharges, SCD had similar severity of illness, p=0.77, and mortality, p=0.39, but underwent fewer computerized tomographic scans, p=0.006, than non-SCD with PE. In the local case-control study, no clinical or laboratory feature was associated with PE. Conclusions: The incidence of PE is higher and chest CT utilization is lower in SCD than non-SCD inpatients, suggesting that PE may be under-diagnosed. © 2012 International Society on Thrombosis and Haemostasis.

PMID: 22417249 [PubMed - as supplied by publisher]

Link to Article at PubMed

Thrombolytic therapy and outcome of patients with acute symptomatic pulmonary embolism.

J Thromb Haemost Start a Discussion »

Mar 162012

Thrombolytic therapy and outcome of patients with acute symptomatic pulmonary embolism.

J Thromb Haemost. 2012 Mar 15;

Authors: Riera-Mestre A, Jiménez D, Muriel A, Lobo JL, Moores L, Yusen RD, Casado I, Nauffal D, Oribe M, Monreal M,

Abstract
Background:?While the primary therapy for most patients with pulmonary embolism (PE) consists of anticoagulation, the efficacy of thrombolysis relative to standard therapy remains unclear. Methods:?In this retrospective cohort study of 15,944 patients with objectively confirmed symptomatic acute PE, identified from the multicenter, international, prospective, Registro Informatizado de la Enfermedad TromboEmbólica (RIETE registry), we aimed to assess the association between thrombolytic therapy and all-cause mortality during the first 3 months after the diagnosis of PE. After creating two subgroups, stratified by systolic blood pressure (SBP) (< 100 mm Hg vs. other), we used propensity score-matching for a comparison of patients who received thrombolysis to those who did not in each subgroup. Results: Patients who received thrombolysis had younger age, fewer comorbid diseases, and more signs of clinical severity compared to those who did not receive it. In the subgroup with systolic hypotension, analysis of propensity score-matched pairs (n = 94 pairs) showed a non-statistically significant but clinically relevant lower risk of death for thrombolysis compared with no thrombolysis (odds ratio [OR] 0.72; 95% CI, 0.36 to 1.46; P = 0.37). In the normotensive subgroup, analysis of propensity score-matched pairs (n = 217 pairs) showed a statistically significant and clinically meaningful increased risk of death for thrombolysis compared with no thrombolysis (OR 2.32; 95% CI, 1.15 to 4.68; P = 0.018). When we imputed data for missing values for echocardiography and troponin tests in the group of normotensive patients, we no longer detected the increased risk of death associated with thrombolytic therapy. Conclusions:?In normotensive patients with acute symptomatic PE, thrombolytic therapy is associated with a higher risk of death than no thrombolytic therapy. In haemodynamically unstable patients, thrombolytic therapy is possibly associated with a lower risk of death than no thrombolytic therapy. However, study design limitations do not imply a causal relationship between thrombolytics and outcome. © 2012 International Society on Thrombosis and Haemostasis.

PMID: 22417297 [PubMed - as supplied by publisher]

Link to Article at PubMed

Images in clinical medicine. Westermark sign in pulmonary embolism.

N Engl J Med Start a Discussion »

Mar 162012

Images in clinical medicine. Westermark sign in pulmonary embolism.

N Engl J Med. 2012 Mar 15;366(11):e16

Authors: Krishnan AS, Barrett T

PMID: 22417276 [PubMed - in process]

Link to Article at PubMed

Effect of a multidisciplinary intervention on central line utilization in an acute care hospital.

Am J Infect Control Start a Discussion »

Mar 162012

Effect of a multidisciplinary intervention on central line utilization in an acute care hospital.

Am J Infect Control. 2012 Mar 13;

Authors: Faruqi A, Medefindt J, Dutta G, Philip SA, Tompkins D, Carey J

Abstract
BACKGROUND: Many institutions that have adopted evidence-based infection prevention practices have achieved reductions in the rate of central line-associated bloodstream infection (CLABSI) in their intensive care units (ICUs). Few studies have investigated the impact of CLABSI prevention strategies in non-ICU settings, however. This study was conducted to assess whether a multifaceted educational initiative significantly improved health care workers' adherence to clinical practices that have been demonstrated to reduce CLABSI rates. METHODS: This prospective interventional study compared central line utilization and other variables in medical ICU (MICU) and non-ICU settings at an inner city community teaching hospital. The study included 3 phases: preintervention, intervention, and postintervention. RESULTS: A total of 128 central venous catheter (CVC) placements were reviewed. After the intervention, the proportion of patients transferred out of the MICU with a CVC in place decreased significantly (P = .05), and the percentage of patients transitioned from a CVC to a peripherally inserted venous catheter increased (P = .004). The mean duration of CVC use decreased from 8.2 days to 5.7 days (P = .004), which was confirmed by linear regression (P = .003). CONCLUSIONS: Our data indicate that multidisciplinary, evidenced-based educational interventions can significantly improve targeted measures of CVC use. Our program was successfully implemented with limited resources and should be reproducible at other hospitals.

PMID: 22418611 [PubMed - as supplied by publisher]

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Regular treatment with formoterol versus regular treatment with salmeterol for chronic asthma: serious adverse events.

Cochrane Database Syst Rev Start a Discussion »

Mar 162012

Regular treatment with formoterol versus regular treatment with salmeterol for chronic asthma: serious adverse events.

Cochrane Database Syst Rev. 2012;3:CD007695

Authors: Cates CJ, Lasserson TJ

Abstract
BACKGROUND: An increase in serious adverse events with both regular formoterol and regular salmeterol in chronic asthma has been demonstrated in previous Cochrane reviews.
OBJECTIVES: We set out to compare the risks of mortality and non-fatal serious adverse events in trials which have randomised patients with chronic asthma to regular formoterol versus regular salmeterol.
SEARCH METHODS: We identified trials using the Cochrane Airways Group Specialised Register of trials. We checked manufacturers' websites of clinical trial registers for unpublished trial data and also checked Food and Drug Administration (FDA) submissions in relation to formoterol and salmeterol. The date of the most recent search was January 2012.
SELECTION CRITERIA: We included controlled, parallel-design clinical trials on patients of any age and with any severity of asthma if they randomised patients to treatment with regular formoterol versus regular salmeterol (without randomised inhaled corticosteroids), and were of at least 12 weeks' duration.
DATA COLLECTION AND ANALYSIS: Two authors independently selected trials for inclusion in the review and extracted outcome data. We sought unpublished data on mortality and serious adverse events from the sponsors and authors.
MAIN RESULTS: The review included four studies (involving 1116 adults and 156 children). All studies were open label and recruited patients who were already taking inhaled corticosteroids for their asthma, and all studies contributed data on serious adverse events. All studies compared formoterol 12 ?g versus salmeterol 50 ?g twice daily. The adult studies were all comparing Foradil Aerolizer with Serevent Diskus, and the children's study compared Oxis Turbohaler to Serevent Accuhaler. There was only one death in an adult (which was unrelated to asthma) and none in children, and there were no significant differences in non-fatal serious adverse events comparing formoterol to salmeterol in adults (Peto odds ratio (OR) 0.77; 95% confidence interval (CI) 0.46 to 1.28), or children (Peto OR 0.95; 95% CI 0.06 to 15.33). Over a six-month period, in studies involving adults that contributed to this analysis, the percentages with serious adverse events were 5.1% for formoterol and 6.4% for salmeterol; and over a three-month period the percentages of children with serious adverse events were 1.3% for formoterol and 1.3% for salmeterol.
AUTHORS' CONCLUSIONS: We identified four studies comparing regular formoterol to regular salmeterol (without randomised inhaled corticosteroids, but all participants were on regular background inhaled corticosteroids). The events were infrequent and consequently too few patients have been studied to allow any firm conclusions to be drawn about the relative safety of formoterol and salmeterol. Asthma-related serious adverse events were rare and there were no reported asthma-related deaths.

PMID: 22419326 [PubMed - in process]

Link to Article at PubMed

Airway clearance techniques for chronic obstructive pulmonary disease.

Cochrane Database Syst Rev Start a Discussion »

Mar 162012

Airway clearance techniques for chronic obstructive pulmonary disease.

Cochrane Database Syst Rev. 2012;3:CD008328

Authors: Osadnik CR, McDonald CF, Jones AP, Holland AE

Abstract
BACKGROUND: Cough and sputum production are common in chronic obstructive pulmonary disease (COPD) and are associated with adverse clinical outcomes. Airway clearance techniques (ACTs) aim to remove sputum from the lungs, however evidence of their efficacy during acute exacerbations of COPD (AECOPD) or stable disease is unclear.
OBJECTIVES: To assess the safety and efficacy of ACTs for individuals with AECOPD and stable COPD.
SEARCH METHODS: We searched the Cochrane Airways Group Specialised Register of trials from inception to October 2011, and PEDro in October 2009.
SELECTION CRITERIA: We included randomised parallel trials and randomised cross-over trials which compared an ACT to no treatment, cough or sham ACT in participants with investigator-defined COPD, emphysema or chronic bronchitis.
DATA COLLECTION AND ANALYSIS: Two review authors independently conducted data extraction and assessed the risk of bias. We analysed data from studies of AECOPD separately from stable COPD, and classified the effects of ACTs as 'immediate' (less than 24 hours), 'short-term' (24 hours to eight weeks) or 'long-term' (greater than eight weeks). One subgroup analysis compared the effects of ACTs that use positive expiratory pressure (PEP) to those that do not.
MAIN RESULTS: Twenty-eight studies on 907 participants were included in the review. Study sample size was generally small (range 5 to 96 people) and overall quality was generally poor due to inadequate blinding and allocation procedures. Meta-analyses were limited by heterogeneity of outcome measurement and inadequate reporting of data.In people experiencing AECOPD, ACT use was associated with small but significant short-term reductions in the need for increased ventilatory assistance (odds ratio (OR) 0.21, 95% confidence interval (CI) 0.05 to 0.85; data from four studies on 171 people), the duration of ventilatory assistance (mean difference (MD) -2.05 days, 95% CI -2.60 to -1.51; mean duration for control groups seven days; data from two studies on 54 people) and hospital length of stay (MD -0.75 days, 95% CI -1.38 to -0.11; mean duration for control groups nine days; one study on 35 people). Data from a limited number of studies revealed no significant long-term benefits of ACTs on the number of exacerbations or hospitalisations, nor any short-term beneficial effect on health-related quality of life (HRQoL) as measured by the St. George's Respiratory Questionnaire (SGRQ) total score (MD -2.30, 95% CI -11.80 to 7.20; one study on 59 people).In people with stable COPD, data from single studies revealed no significant short-term benefit of ACTs on the number of people with exacerbations (OR 3.21, 95% CI 0.12 to 85.20; one study on 30 people), significant short-term improvements in HRQoL as measured by the SGRQ total score (MD -6.10, 95% CI -8.93 to -3.27; one study on 15 people) and a reduced long-term need for respiratory-related hospitalisation (OR 0.27, 95% CI 0.08 to 0.95; one study on 35 participants).The magnitude of effect of PEP-based ACTs on the need for increased ventilatory assistance and hospital length of stay was greater than for non-PEP ACTs, however we found no statistically significant subgroup differences. There was one report of vomiting during treatment with postural drainage and head-down tilt.
AUTHORS' CONCLUSIONS: Evidence from this review indicates that airway clearance techniques are safe for individuals with COPD and confer small beneficial effects on some clinical outcomes. Consideration may be given to the use of airway clearance techniques for patients with COPD in both acute and stable disease, however current studies suggest that the benefits achieved may be small.

PMID: 22419331 [PubMed - in process]

Link to Article at PubMed

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