2012 May 02

Nebulized anticoagulants for acute lung injury – a systematic review of pre-clinical and clinical investigations.

May 022012

Nebulized anticoagulants for acute lung injury - a systematic review of pre-clinical and clinical investigations.

Crit Care. 2012 Apr 30;16(2):R70

Authors: Tuinman PR, Dixon B, Levi M, Juffermans NP, Schultz MJ

Abstract
ABSTRACT: BACKGROUND: Data from interventional trials of systemic anticoagulation for sepsis inconsistently suggest beneficial effects in case of acute lung injury (ALI). Severe systemic bleeding due to anticoagulation may have offset the possible positive effects. Nebulization of anticoagulants may allow for improved local biological availability and as such may improve efficacy in the lungs and lower the risk of systemic bleeding complications. METHOD: We performed a systematic review of preclinical studies and clinical trials investigating the efficacy and safety of nebulized anticoagulants in the setting of lung injury in animals and ALI in humans. RESULTS: The efficacy of nebulized activated protein C, antithrombin, heparin and danaparoid has been tested in diverse animal models of direct (e.g., pneumonia-, intra-pulmonary lipopolysaccharide (LPS)-, and smoke inhalation-induced lung injury) and indirect lung injury (e.g., intravenous LPS- and trauma-induced lung injury). Nebulized anticoagulants were found to have the potential to attenuate pulmonary coagulopathy and frequently also inflammation. Notably, nebulized danaparoid and heparin but not activated protein C and antithrombin, were found to have an effect on systemic coagulation. Clinical trials of nebulized anticoagulants are very limited. Nebulized heparin was found to improve survival of patients with smoke inhalation-induced ALI. In a trial of in critically ill patients who needed mechanical ventilation for longer than two days, nebulized heparin was associated with a higher number of ventilator-free days. In line with results from preclinical studies, nebulization of heparin was found to have an effect on systemic coagulation, but without causing systemic bleedings. CONCLUSION: Local anticoagulant therapy through nebulization of anticoagulants attenuates pulmonary coagulopathy and frequently also inflammation in preclinical studies of lung injury. Recent human trials suggest nebulized heparin for ALI to be beneficial and safe, but data are very limited.

PMID: 22546487 [PubMed - as supplied by publisher]

Link to Article at PubMed

Outpatient laparoscopic appendectomy for acute appendicitis.

Am Surg Start a Discussion »

May 022012

Outpatient laparoscopic appendectomy for acute appendicitis.

Am Surg. 2012 Feb;78(2):213-5

Authors: Cash CL, Frazee RC, Smith RW, Davis ML, Hendricks JC, Childs EW, Abernathy SW

Abstract
Laparoscopic appendectomy is the widely accepted treatment for acute appendicitis. This approach offers the potential of less pain, shorter hospital stay, and quicker return to activities. Traditionally, patients are hospitalized for 24 hours after laparoscopic appendectomy. This practice can be questioned due to the good results of other outpatient laparoscopic surgery. A retrospective review of 119 patients undergoing laparoscopic appendectomy for uncomplicated acute appendicitis was undertaken from January through September 2009; outpatient and inpatient laparoscopic appendectomies were compared. Patients were selected for outpatient management based upon physician discretion and their clinical course in operation and recovery rooms. Forty-two patients were dismissed on the day of surgery and 77 were admitted for 1 to 5 days postoperatively. No significant differences in age, gender, and preoperative comorbidities between outpatient and inpatient groups were found. Postoperative complications occurred in 2.4 per cent of outpatients and 11.7 per cent of inpatients (P = 0.16). Complications included superficial wound infections, urinary retention, urinary tract infection, intra-abdominal bleeding, pneumonia, and infected hematoma. Based upon this study, outpatient laparoscopic appendectomy can be performed safely in selected patients. This study provides the background for the present prospective protocol for routine outpatient laparoscopic appendectomy at our institution.

PMID: 22369831 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Impact of cefepime therapy on mortality among patients with blood stream infections caused by extended spectrum ?-lactamase-producing Klebsiella pneumoniae and Escherichia coli.

Antimicrob Agents Chemother Start a Discussion »

May 022012

Impact of cefepime therapy on mortality among patients with blood stream infections caused by extended spectrum ?-lactamase-producing Klebsiella pneumoniae and Escherichia coli.

Antimicrob Agents Chemother. 2012 Apr 30;

Authors: Chopra T, Marchaim D, Veltman J, Johnson P, Zhao JJ, Tansek R, Hatahet D, Chaudhry K, Pogue JM, Rahbar H, Chen TY, Truong T, Rodriguez V, Ellsworth J, Bernabela L, Bhargava A, Yousuf A, Alangaden G, Kaye KS

Abstract
Background: Extended-spectrum beta lactamase (ESBL)-producing pathogens are associated with extensive morbidity, mortality, and rising healthcare costs. Scant data exist on the impact of antimicrobial therapy on clinical outcomes in patients with ESBL bloodstream infections (BSI) and no large studies have examined the impact of cefepime therapy. Methods: A retrospective 3 year study was performed at the Detroit Medical Center on adult patients with ESBL-producing K. pneumoniae or E. coli BSI. Data were collected from the medical records of study patients at five hospitals between January 2005 and December 2007. Multivariate analysis was performed using logistic regression. Results: One-hundred and forty-five patients with BSI due to ESBL-producing pathogens were studied, including K. pneumoniae (83%), and E. coli(16.5%). The mean age of the patients was 66 years, 51% were female and 79.3% were African-American. 53 patients (37%) died in the hospital and 92 survived to discharge. In bivariate analysis, the following variables were associated with mortality (p<0.05): presence of a rapidly fatal condition at the time of admission, use of gentamicin as a consolidative therapeutic agent, and presence of one or more of the following prior to culture date: mechanical ventilation, stay in the intensive care unit (ICU), and presence of a central venous catheter. In multivariate analysis, the predictors of in-hospital mortality included: intensive care unit stay (OR=2.17, 95% CI 0.98-4.78), presence of a central line prior to positive culture (OR=2.33, 95%CI 0.77-7.03) presence of a rapidly fatal condition at the time of admission (OR=5.13,95%CI 2.13-12.39) and recent prior hospitalization (OR=1.92,95%CI 0.83-4.09). When carbapenems were added as empiric therapy to the predictor model, there was a trend between empiric carbapenem therapy and decreased mortality (OR=0.61,95% CI 0.26-1.50). When added to the model, receipt of empiric cefepime alone (n=43) was associated with increased mortality, although this association did not reach statistical significance (OR= 1.66, 95% CI 0.71-3.87). Median length of hospital stay was shorter for patients receiving empiric cefepime and longer for those receiving empiric or consolidated carbapenem therapy. Conclusions: In multivariate analysis, empiric therapy with cefepime for BSI due to an ESBL-producing pathogen was associated with a trend towards an increased mortality risk and empiric carbapenem therapy was associated with a trend towards decreased mortality risk.

PMID: 22547616 [PubMed - as supplied by publisher]

Link to Article at PubMed

Hospital strategies for reducing risk-standardized mortality rates in acute myocardial infarction.

Ann Intern Med Start a Discussion »

May 022012

Hospital strategies for reducing risk-standardized mortality rates in acute myocardial infarction.

Ann Intern Med. 2012 May 1;156(9):618-26

Authors: Bradley EH, Curry LA, Spatz ES, Herrin J, Cherlin EJ, Curtis JP, Thompson JW, Ting HH, Wang Y, Krumholz HM

Abstract
Background: Despite recent improvements in survival after acute myocardial infarction (AMI), U.S. hospitals vary 2-fold in their 30-day risk-standardized mortality rates (RSMRs). Nevertheless, information is limited on hospital-level factors that may be associated with RSMRs. Objective: To identify hospital strategies that were associated with lower RSMRs. Design: Cross-sectional survey of 537 hospitals (91% response rate) and weighted multivariate regression by using data from the Centers for Medicare & Medicaid Services to determine the associations between hospital strategies and hospital RSMRs. Setting: Acute care hospitals with an annualized AMI volume of at least 25 patients. Participants: Patients hospitalized with AMI between 1 January 2008 and 31 December 2009. Measurements: Hospital performance improvement strategies, characteristics, and 30-day RSMRs. Results: In multivariate analysis, several hospital strategies were significantly associated with lower RSMRs and in aggregate were associated with clinically important differences in RSMRs. These strategies included holding monthly meetings to review AMI cases between hospital clinicians and staff who transported patients to the hospital (RSMR lower by 0.70 percentage points), having cardiologists always on site (lower by 0.54 percentage points), fostering an organizational environment in which clinicians are encouraged to solve problems creatively (lower by 0.84 percentage points), not cross-training nurses from intensive care units for the cardiac catheterization laboratory (lower by 0.44 percentage points), and having physician and nurse champions rather than nurse champions alone (lower by 0.88 percentage points). Fewer than 10% of hospitals reported using at least 4 of these 5 strategies. Limitation: The cross-sectional design demonstrates statistical associations but cannot establish causal relationships. Conclusion: Several strategies, which are currently implemented by relatively few hospitals, are associated with significantly lower 30-day RSMRs for patients with AMI. Primary Funding Source: The Agency for Healthcare Research and Quality, the United Health Foundation, and the Commonwealth Fund.

PMID: 22547471 [PubMed - in process]

Link to Article at PubMed

How I treat POEMS syndrome.

Blood Start a Discussion »

May 022012

How I treat POEMS syndrome.

Blood. 2012 Apr 30;

Authors: Dispenzieri A

Abstract
POEMS syndrome is a paraneoplastic syndrome whose acronym stands for less than half of the defining features of the disease, that is polyradiculoneuropathy, organomegaly, potentially including co-existing Castleman's disease, endocrinopathy, monoclonal plasma cell neoplasm, and skin changes. The other important features include papilledema, extravascular volume overload, sclerotic bone lesions, thrombocytosis, elevated VEGF, and abnormal pulmonary function. The diagnosis is based on having both the polyradiculoneuropathy and the monoclonal plasma cell disorder, and at least one of the other 3 major criteria (Castleman's disease, sclerotic bone lesions, or elevated VEGF) and at least one minor criterion. The diagnosis is often delayed with intervening incorrect diagnoses of chronic inflammatory demyelinating polyradiculoneuropathy, myeloproliferative disorder, and monoclonal gammopathy of undetermined significance. Prompt treatment directed at the underlying plasma cell clone produces dramatic responses in the majority of patients. Although there are no randomized clinical trial data to direct best therapy, for patients with disseminated disease high dose chemotherapy with peripheral blood transplantation has yielded durable benefit, while radiation therapy is typically effective for patients with a more localized presentation. More universal recognition of and more scientific inquiry into the underpinnings of the disease will provide direction towards the best treatment strategies in the future.

PMID: 22547581 [PubMed - as supplied by publisher]

Link to Article at PubMed

May 2012
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