2012 July 20

The CSF tap test in normal pressure hydrocephalus: evaluation time, reliability and the influence of pain.

Jul 202012

The CSF tap test in normal pressure hydrocephalus: evaluation time, reliability and the influence of pain.

Eur J Neurol. 2012 Feb;19(2):271-6

Authors: Virhammar J, Cesarini KG, Laurell K

Abstract

BACKGROUND: The cerebrospinal fluid tap test (TT) is a diagnostic tool used to select patients with idiopathic normal pressure hydrocephalus (iNPH) for shunt surgery. The procedure and the evaluation of the TT vary between centres. We aimed to describe the evaluation time after the TT, to assess the variability between repeated measurements, the interrater agreement of the gait tests chosen and finally to investigate whether pain affects the gait performance post-TT.

METHODS: Forty patients (21 men and 19 women) under evaluation for iNPH underwent a TT. Standardized gait analyses were performed before and 2, 4, 6, 8 and 24 h after the TT and repeated twice on every occasion. Independent of each other, two investigators evaluated the quality of gait. At each assessment time, the patients graded headache and back pain on a visual analogue scale.

RESULTS: Twenty-seven patients (15 men and 12 women) responded to TT. Improvements in gait speed and number of steps were significant at every assessment time post-TT. The variability between two measurements was low (Intra class correlation coefficient=0.97), and the inter-rater agreement was good with a ?=0.74. Pain correlated negatively with improvement in gait speed (r=-0.40, P<0.05).

CONCLUSIONS: We suggest that the TT can be evaluated at any time within the first 24 h and should be repeated if the patient does not initially improve. Gait analysis appears reliable between two evaluators. Further, it is indicated that post-lumbar puncture pain negatively affects the gait and should be minimized.

PMID: 21801282 [PubMed - indexed for MEDLINE]

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Serum Cystatin C- Versus Creatinine-Based Definitions of Acute Kidney Injury Following Cardiac Surgery: A Prospective Cohort Study.

Am J Kidney Dis Start a Discussion »

Jul 202012

Serum Cystatin C- Versus Creatinine-Based Definitions of Acute Kidney Injury Following Cardiac Surgery: A Prospective Cohort Study.

Am J Kidney Dis. 2012 Jul 16;

Authors: Spahillari A, Parikh CR, Sint K, Koyner JL, Patel UD, Edelstein CL, Passik CS, Thiessen-Philbrook H, Swaminathan M, Shlipak MG, TRIBE-AKI Consortium

Abstract

BACKGROUND: The primary aim of this study was to compare the sensitivity and rapidity of acute kidney injury (AKI) detection by cystatin C level relative to creatinine level after cardiac surgery. STUDY DESIGN: Prospective cohort study. SETTINGS & PARTICIPANTS: 1,150 high-risk adult cardiac surgery patients in the TRIBE-AKI (Translational Research Investigating Biomarker Endpoints for Acute Kidney Injury) Consortium. PREDICTOR: Changes in serum creatinine and cystatin C levels. OUTCOME: Postsurgical incidence of AKI. MEASUREMENTS: Serum creatinine and cystatin C were measured at the preoperative visit and daily on postoperative days 1-5. To allow comparisons between changes in creatinine and cystatin C levels, AKI end points were defined by the relative increases in each marker from baseline (25%, 50%, and 100%) and the incidence of AKI was compared based on each marker. Secondary aims were to compare clinical outcomes among patients defined as having AKI by cystatin C and/or creatinine levels. RESULTS: Overall, serum creatinine level detected more cases of AKI than cystatin C level: 35% developed a ?25% increase in serum creatinine level, whereas only 23% had a ?25% increase in cystatin C level (P < 0.001). Creatinine level also had higher proportions meeting the 50% (14% and 8%; P < 0.001) and 100% (4% and 2%; P = 0.005) thresholds for AKI diagnosis. Clinical outcomes generally were not statistically different for AKI cases detected by creatinine or cystatin C level. However, for each AKI threshold, patients with AKI confirmed by both markers had a significantly higher risk of the combined mortality/dialysis outcome compared with patients with AKI detected by creatinine level alone (P = 0.002). LIMITATIONS: There were few adverse clinical outcomes, limiting our ability to detect differences in outcomes between subgroups of patients based on their definitions of AKI. CONCLUSIONS: In this large multicenter study, we found that cystatin C level was less sensitive for AKI detection than creatinine level. However, confirmation by cystatin C level appeared to identify a subset of patients with AKI with a substantially higher risk of adverse outcomes.

PMID: 22809763 [PubMed - as supplied by publisher]

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Intussusception in adults: what radiologists should know.

Emerg Radiol Start a Discussion »

Jul 202012

Intussusception in adults: what radiologists should know.

Emerg Radiol. 2012 Apr;19(2):89-101

Authors: Baleato-González S, Vilanova JC, García-Figueiras R, Juez IB, Martínez de Alegría A

Abstract

Adult intussusception (AI) is a rare entity with an organic lesion within the intussusception in 70-90% of the cases. Intussusception is classified according to location, etiology, and to the presence or not of a lead point. We illustrate several causes of AI with a variety of radiological findings on plain film, ultrasonography, computed tomography, magnetic resonance, and endoscopy seen at our institution. Imaging plays a major role in their diagnosis and in determining the appropriate treatment.

PMID: 22200965 [PubMed - indexed for MEDLINE]

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2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.

J Am Coll Cardiol Start a Discussion »

Jul 202012

2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.

J Am Coll Cardiol. 2012 Jul 16;

Authors: American College of Emergency Physicians, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons, Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP

PMID: 22809746 [PubMed - as supplied by publisher]

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Effectiveness and safety of drotrecogin alfa (activated) for severe sepsis: a meta-analysis and metaregression.

Lancet Infect Dis Start a Discussion »

Jul 202012

Effectiveness and safety of drotrecogin alfa (activated) for severe sepsis: a meta-analysis and metaregression.

Lancet Infect Dis. 2012 Jul 16;

Authors: Kalil AC, Larosa SP

Abstract

BACKGROUND: Drotrecogin alfa (activated) was approved for use in severe sepsis in 2001 on the basis of the Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) trial, but controversies about its effectiveness remain. We aimed to assess effectiveness and safety of use of this drug in the past 10 years and compare them with the original PROWESS results. METHODS: We searched PubMed, Embase, Ovid, Cochrane Library, Evidence-Based Medicine, and the American College of Physicians Journal Club databases for experimental and analytical studies of drotrecogin alfa (activated) in adults with severe sepsis until Jan 31, 2012. We calculated adjusted risk ratios for effectiveness and safety outcomes with random-effects models. We did a metaregression to assess the effect of severity of illness on the risk of death and the risk of bleeding associated with drotrecogin alfa (activated). FINDINGS: We included nine controlled trials (41?401 patients) and 16 single-group studies (5822 patients) in effectiveness analyses and 20 studies (8245 patients) in safety analyses. Hospital mortality was reduced by 18% with drotrecogin alfa (activated) compared with controls (relative risk 0·822, 95% CI 0·779-0·867; p<0·0001; I(2)=40%). This mortality reduction was much the same as was noted in PROWESS (0·851, 0·740-0·979), but smaller than that of patients in PROWESS with high disease severity (0·708, 0·590-0·849). Propensity-adjusted studies also showed a significant mortality reduction with lower heterogeneity (0·844, 0·800-0·891; p<0·0001, I(2)=18%). These findings were not changed by the addition of PROWESS-SHOCK results. Metaregression showed greater benefits of drotrecogin alfa (activated) with increasing control mortality (p=0·01) and more severe disease (p=0·04). Hospital mortality for single-group studies of drotrecogin alfa (activated) was 41% (95% CI 35-48), and was higher than that noted in PROWESS at 31% (27-36; p<0·0001). The serious bleeding rate with drotrecogin alfa (activated) was 5·6% (4·5-6·9), which was higher than the 3·5% (2·5-5·0) noted in PROWESS (p=0·003), but similar to that reported in PROWESS high disease severity (p=0·073). INTERPRETATION: Real-life use of drotrecrogin alfa (activated) was associated with significant reduction in hospital mortality and increased rates of bleeding in patients with severe sepsis. Our effectiveness findings were in line with the PROWESS trial but not with the PROWESS-SHOCK trial. FUNDING: None.

PMID: 22809883 [PubMed - as supplied by publisher]

Link to Article at PubMed