2012 June 28

Persistent hypocoagulability in patients with septic shock predicts greater hospital mortality: impact of impaired thrombin generation.

Jun 282012

Persistent hypocoagulability in patients with septic shock predicts greater hospital mortality: impact of impaired thrombin generation.

Intensive Care Med. 2012 Jun 27;

Authors: Massion PB, Peters P, Ledoux D, Zimermann V, Canivet JL, Massion PP, Damas P, Gothot A

Abstract

PURPOSE: Sepsis induces hypercoagulability, hypofibrinolysis, microthrombosis, and endothelial dysfunction leading to multiple organ failure. However, not all studies reported benefit from anticoagulation for patients with severe sepsis, and time courses of coagulation abnormalities in septic shock are poorly documented. Therefore, the aim of this prospective observational cohort study was to describe the coagulation profile of patients with septic shock and to determine whether alterations of the profile are associated with hospital mortality. METHODS: Thirty-nine patients with septic shock on ICU admission were prospectively included in the study. From admission to day 7, analytical coagulation tests, thrombin generation (TG) assays, and thromboelastometric analyses were performed and tested for association with survival. RESULTS: Patients with septic shock presented on admission prolongation of prothrombin time, activated partial thromboplastin time (aPTT), increased consumption of most procoagulant factors as well as both delay and deficit in TG, all compatible with a hypocoagulable state compared with reference values (PÃÂ <ÃÂ 0.001). Time courses revealed a persistent hypocoagulability profile in non-survivors as compared with survivors. From multiple logistic regression, prolonged aPTT (PÃÂ =ÃÂ 0.007) and persistence of TG deficit (PÃÂ =ÃÂ 0.024) on day 3 were strong predictors of mortality, independently from disease severity scores, disseminated intravascular coagulation score, and standard coagulation tests on admission. CONCLUSIONS: Patients with septic shock present with hypocoagulability at the time of ICU admission. Persistence of hypocoagulability assessed by prolonged aPTT and unresolving deficit in TG on day 3 after onset of septic shock is associated with greater hospital mortality.

PMID: 22735856 [PubMed - as supplied by publisher]

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Ischemic Preconditioning for Prevention of Contrast-Medium-Induced Nephropathy: Randomized Pilot RenPro-Trial (Renal Protection Trial).

Circulation Start a Discussion »

Jun 282012

Ischemic Preconditioning for Prevention of Contrast-Medium-Induced Nephropathy: Randomized Pilot RenPro-Trial (Renal Protection Trial).

Circulation. 2012 Jun 26;

Authors: Er F, Nia AM, Dopp H, Hellmich M, Dahlem KM, Caglayan E, Kubacki T, Benzing T, Erdmann E, Burst V, Gassanov N

Abstract

BACKGROUND: Contrast-medium-induced acute kidney injury is associated with substantial morbidity and mortality. The underlying mechanism has been partially attributed to ischemic kidney injury. The aim of this randomized, double-blind, sham-controlled trial was to assess the impact of remote ischemic preconditioning on contrast-medium-induced acute kidney injury. METHODS AND RESULTS: Patients with impaired renal function (serum creatinine >1.4 mg/dL and/or estimated glomerular filtration rate <60 mL/min/1.73 m(2)) undergoing elective coronary angiography were randomized in a 1:1 ratio to standard care with (n=50) or without ischemic preconditioning (n=50; intermittent arm ischemia through four cycles of 5-min inflation and 5-min deflation of a blood-pressure cuff). Overall, both study groups were at high risk to develop contrast-medium-induced acute kidney injury using Mehran risk score. The primary endpoint was the incidence of contrast-medium-induced kidney injury, defined as an increase of serum creatinine Ã¢ÂÂ¥ 25 % and/or Ã¢ÂÂ¥ 0.5 mg/dL above baseline at 48 hours after contrast-medium exposure. Contrast-medium-induced acute kidney injury occurred in 26 patients (26%), 20 (40%) in the control group and 6 (12%) in the remote ischemic preconditioning group (OR 0.21; 95% CI 0.07-0.57; P=0.002). No major adverse events were related to remote ischemic preconditioning. CONCLUSIONS: Remote ischemic preconditioning before contrast-medium use prevents contrast-medium-induced acute kidney injury in high risk patients. Our findings merit a larger trial to establish remote ischemic preconditioning on clinical outcomes. CLINICAL TRIAL REGISTRATION INFORMATION: www.germanctr.de; Identifier: U1111-1118-8098.

PMID: 22735306 [PubMed - as supplied by publisher]

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Limb Ischemia Protects Against Contrast-Induced Nephropathy.

Circulation Start a Discussion »

Jun 282012

Limb Ischemia Protects Against Contrast-Induced Nephropathy.

Circulation. 2012 Jun 26;

Authors: Bonventre JV

Abstract

Contrast-induced acute kidney injury (AKI), or nephropathy, (CIN) is frequently diagnosed in the setting of coronary angiography. The incidence varies in the literature partly related to the differences in diagnostic criteria used for CIN. In a recently published manuscript in Circulation Maioli et al.(1) used a definition of Ã¢ÂÂ¥ 0.5 mg/dl over baseline serum creatinine within 3 days of the administration of contrast medium and found an incidence of 12.1 % among 1490 patients who had an baseline estimated creatinine clearance of <60 ml/min. It has become increasingly recognized that even mild forms of AKI are associated with adverse short and long term outcomes including onset or progression of chronic kidney disease and more rapid progression to end stage kidney disease(2,3). Patients with CIN have an increase in short-term and long-term mortality, whether the renal dysfunction is acute or chronic and after adjustments for other comorbidities(4). While it has been concluded by many that the development of CIN may identify other comorbidities that are more responsible for the adverse outcomes, there are increasing data from randomized trials that CIN may directly contribute to the increased risk of cardiovascular and renal adverse outcomes(5). (SELECT FULL TEXT TO CONTINUE).

PMID: 22735307 [PubMed - as supplied by publisher]

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Physician-Reported Corticosteroid Therapy Practices in Certified Palliative Care Units in Japan: A Nationwide Survey.

J Palliat Med Start a Discussion »

Jun 282012

Physician-Reported Corticosteroid Therapy Practices in Certified Palliative Care Units in Japan: A Nationwide Survey.

J Palliat Med. 2012 Jun 26;

Authors: Matsuo N, Morita T, Iwase S

Abstract

Abstract Background: Although corticosteroids are commonly used for symptom relief in the treatment of patients with advanced cancer, few studies have addressed nationwide physician-reported practices and attitudes toward corticosteroid therapy in palliative care settings. Design and Subjects: To clarify physician-reported practices and attitudes toward corticosteroid therapy for anorexia, fatigue, and dyspnea, a 15-item questionnaire was mailed to all 178 certified palliative care units in Japan. Results: In total, 124 physicians returned questionnaires (response rate of 70%). The median percentage receiving corticosteroids among all terminally ill cancer inpatients was 80% (fatigue, 80%; anorexia, 80%; dyspnea, 80%). Physicians reported varying methods and attitudes regarding corticosteroid use in palliative care settings. Regarding withdrawal when patient death was imminent, 46% of respondents usually abruptly ceased corticosteroid use, while 33% reduced but did not stop administration, and 21% neither stopped nor reduced corticosteroids. As for dosage, 47% of physicians selected a minimum daily dose for fatigue <2Ã¢ÂÂmg, while 51% chose 2-4Ã¢ÂÂmg. As for administration period, 50% started administering corticosteroids for dyspnea regardless of the prognosis, while 30% regarded a predicted survival of less than 3 months to be an indication for corticosteroid treatment. For side effect management, 48% did not principally prescribe corticosteroids for patients with hyperactive delirium, while 44% cautiously prescribed corticosteroids. Conclusion: The use of corticosteroids is very common in Japanese palliative care units, but physicians reported varying practices and attitudes regarding administration protocols. Future studies are needed to determine the standard treatment protocol for corticosteroid use in the terminally ill.

PMID: 22734663 [PubMed - as supplied by publisher]

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Cost-effectiveness of dabigatran compared with warfarin for patients with atrial fibrillation in Sweden.

Eur Heart J Start a Discussion »

Jun 282012

Cost-effectiveness of dabigatran compared with warfarin for patients with atrial fibrillation in Sweden.

Eur Heart J. 2012 Jun 24;

Authors: Davidson T, Husberg M, Janzon M, Oldgren J, Levin LA

Abstract

AimsPatients with atrial fibrillation have a significantly increased risk of thromboembolic events such as ischaemic stroke, and patients are therefore recommended to be treated with anticoagulation treatment. The most commonly used anticoagulant consists of vitamin K antagonist such as warfarin. A new oral anticoagulation treatment, dabigatran, has recently been approved for stroke prevention among patients with atrial fibrillation. The purpose of this study was to estimate the cost-effectiveness of dabigatran as preventive treatment of stroke and thromboembolic events compared with warfarin in 65-year-old patients with atrial fibrillation in Sweden.Methods and resultsA decision analytic simulation model was used to estimate the long-term (20-year) costs and effects of the different treatments. The outcome measures are the number of strokes prevented, life years gained, and quality-adjusted life years (QALYs) gained. Costs and effect data are adjusted to a Swedish setting. Patients below 80 years of age are assumed to start with dabigatran 150 mg twice a day and switch to 110 mg twice a day at the age of 80 years due to higher bleeding risk. The price of dabigatran in Sweden is Ã¢ÂÂ¬2.82 (Swedish kronor 25.39) per day for both doses. The cost per QALY gained for dabigatran compared with warfarin is estimated at Ã¢ÂÂ¬7742, increasing to Ã¢ÂÂ¬12 449 if dabigatran is compared with only well-controlled warfarin treatment.ConclusionDabigatran is a cost-effective treatment in Sweden, as its incremental cost-effectiveness ratio is below the normally accepted willingness to pay limit.

PMID: 22733833 [PubMed - as supplied by publisher]

Link to Article at PubMed

June 2012
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