2012 August 11

Prevention of Venous Thromboembolism with New Oral Anticoagulants versus Standard Pharmacological Treatment in Acute Medically Ill Patients: A Systematic Review and Meta-Analysis.

Aug 112012

Prevention of Venous Thromboembolism with New Oral Anticoagulants versus Standard Pharmacological Treatment in Acute Medically Ill Patients: A Systematic Review and Meta-Analysis.

Drugs. 2012 Aug 9;

Authors: Albertsen IE, Larsen TB, Rasmussen LH, Overvad TF, Lip GY

Abstract

Introduction: Venous thromboembolism (VTE) is a common and potentially avoidable cause of morbidity and mortality in patients hospitalized for acute medical illness. Objective: Our objective was to conduct a systematic review of studies that assessed the efficacy and safety of new oral anticoagulant (OAC) drugs versus standard pharmacological drugs and/or placebo in prevention of VTE in acute medically ill patients. Methods: PubMed.org and ClinicalTrials.gov databases were searched to identify studies that evaluated the efficacy and safety of a new OAC versus the standard pharmacological treatment and/or placebo in the prevention of VTE in medically ill patients. Relative risks (RR), weighted means and 95% CIs were calculated. Statistical heterogeneity was evaluated using Chi2 and I2 statistics. Two studies were included in the meta-analysis. The primary outcome in both studies was the composite of VTE-related death, symptomatic non-fatal pulmonary embolism (PE), symptomatic deep venous thrombosis (DVT) and asymptomatic proximal DVT. Both studies compared a factor (F)Xa inhibitor with enoxaparin in standard short-term thromboprophylaxis followed by a period where the FXa inhibitor was compared with placebo as prolonged thromboprophylaxis in medically ill patients. The primary major safety outcome in both studies was a composite of treatment-related major bleeding and clinically relevant non-major bleeding. A total of 14?629 patients were randomized. Results: Compared with subjects treated with enoxaparin followed by placebo, the RR of the primary outcome during the prolonged treatment period was 0.79 (95% CI 0.66, 0.94), the RR for the primary outcome during the first short-term treatment period was 1.03 (95% CI 0.81, 1.31). For major bleeding during the prolonged treatment period, the RR was 2.69 (95% CI 1.65, 4.39) for patients treated with an FXa inhibitor compared with enoxaparin/placebo. For major bleeding during the shorter treatment period, the RR was 2.01 (95% CI 1.10, 3.65) in favour of enoxaparin. Conclusion: In acute medically ill patients, prolonged thromboprophylaxis with an oral FXa inhibitor is more protective than regular short-term treatment with enoxaparin. However, treatment with FXa inhibitors is significantly associated with major bleeding, both in long- and short-term treatment compared with enoxaparin.

PMID: 22876779 [PubMed - as supplied by publisher]

Link to Article at PubMed

Non-adherence to guidelines for preoperative testing in a secondary care hospital in Austria: the economic impact of unnecessary and double testing.

Eur J Anaesthesiol Start a Discussion »

Aug 112012

Non-adherence to guidelines for preoperative testing in a secondary care hospital in Austria: the economic impact of unnecessary and double testing.

Eur J Anaesthesiol. 2011 Dec;28(12):867-73

Authors: Flamm M, Fritsch G, Seer J, Panisch S, Sönnichsen AC

Abstract

CONTEXT: Preoperative evaluation is aimed at prevention of complications and risk stratification. Routine testing should be abandoned in favour of selective ordering according to contemporary guidelines. This study was conducted to calculate the possible economic impact of a Web-based preoperative diagnostic guideline prior to its implementation in the state of Salzburg, Austria.

DESIGN: Prospective observational cohort study.

SETTING: The study was carried out in a secondary care hospital in Salzburg (Schwarzach). PARTICIPANTS AND MAIN OUTCOME MEASURES: Data from 1363 consecutive patients scheduled for elective surgery from 1 September to 30 November 2007 were collected: demographic data, medical history, surgical procedure, preoperative tests and findings. The data were entered into the preoperative diagnostic guideline software and the guideline-adherent recommendations were compared with the investigations performed, with special attention to duplicate examinations.

RESULTS: A total of 5879 tests were documented and analysed. In 65.6% of patients, guideline-adherent evaluation would have indicated only basic requirements, but 3380 additional tests were carried out. In all, 81.7% of tests were identified as nonadherent based on the preoperative diagnostic guideline software and 226 duplicate tests were performed. Possible savings per 1000 patients would be €26? 287 if preoperative diagnostic guideline recommendations were followed exactly and €1076 if duplicated tests were avoided. According to a generalised linear model (Gamma model), an increase of 1 year of age leads to an increase of costs by a factor of 1.020.

CONCLUSION: These data indicate a considerable potential for improvement in process quality and cost reduction by using structured preoperative assessment with computer-assisted implementation of a guideline.

PMID: 21968636 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

In-hospital mortality among patients with takotsubo cardiomyopathy: A study of the National Inpatient Sample 2008 to 2009.

Am Heart J Start a Discussion »

Aug 112012

In-hospital mortality among patients with takotsubo cardiomyopathy: A study of the National Inpatient Sample 2008 to 2009.

Am Heart J. 2012 Aug;164(2):215-21

Authors: Brinjikji W, El-Sayed AM, Salka S

Abstract

BACKGROUND: Takotsubo cardiomyopathy is characterized by acute, reversible left ventricular apical ballooning. Little is known about the characteristics of patients with takotsubo cardiomyopathy who have in-hospital mortality. We sought to determine in-hospital mortality rate, complication rate, and characteristics of patients with in-hospital mortality related to takotsubo cardiomyopathy.

METHODS: Patients diagnosed with takotsubo cardiomyopathy in the National Inpatient Database Samples 2008 to 2009 using International Classification of Diseases, Ninth Revision, code 42983 were included in this study. Our primary outcome was in-hospital mortality. In patients with takotsubo cardiomyopathy, we assessed demographic factors, the prevalence and associated mortality of underlying critical illnesses (acute ischemic stroke, sepsis, acute renal failure, respiratory insufficiency, and noncardiac surgery), and acute complications (acute congestive heart failure, respiratory insufficiency with congestive heart failure, cardiogenic shock, ventricular fibrillation/cardiac arrest, and intraaortic balloon pump placement).

RESULTS: A total of 24,701 patients with takotsubo cardiomyopathy were identified. In-hospital mortality rate was 4.2%. A total of 21,994 patients (89.0%) were female. Male patients had a higher mortality rate than females (8.4% vs 3.6%, P < .0001). Age and race were not associated with mortality. Of patients with in-hospital mortality, 81.4% had underlying critical illnesses. Male patients with takotsubo had higher incidence of underlying critical illnesses than their female counterparts (36.6% vs 26.8%, P < .0001).

CONCLUSIONS: The presence of underlying critical illness was the main driver of mortality, as these patients comprised >80% of patients with in-hospital mortality. Male patients, who were significantly more likely to have underlying critical illness, had significantly higher mortality rates than female patients. The presence of underlying critical illness likely explains the higher mortality rate among male patients.

PMID: 22877807 [PubMed - in process]

Link to Article at PubMed

High-sensitivity C-reactive protein as an independent predictor of progressive myocardial functional deterioration: The multiethnic study of atherosclerosis.

Am Heart J Start a Discussion »

Aug 112012

High-sensitivity C-reactive protein as an independent predictor of progressive myocardial functional deterioration: The multiethnic study of atherosclerosis.

Am Heart J. 2012 Aug;164(2):251-8

Authors: Choi EY, Yan RT, Fernandes VR, Opdahl A, Gomes AS, Almeida AL, Wu CO, Liu K, Carr JJ, McClelland RL, Bluemke DA, Lima JA

Abstract

BACKGROUND: Systemic inflammation has been linked to the development of heart failure in population studies including Multi-Ethnic Study of Atherosclerosis (MESA), but little evidence exists regarding potential mechanism of this relationship. In this study, we used longitudinal magnetic resonance imaging follow-up analysis to examine whether C-reactive protein (CRP) levels relate to progressive myocardial functional deterioration as a potential mechanism of incident heart failure.

METHODS: Regional myocardial functional data from MESA participants who had baseline CRP measurement and also underwent tagged cardiac magnetic resonance imaging both at baseline and at 5-year follow-up were analyzed. Left ventricular midwall and midslice peak circumferential strain (Ecc), of which a more negative value denotes stronger regional myocardial function, was measured. Circumferential strain change was calculated as the difference between baseline and follow-up Ecc.

RESULTS: During the follow-up period, participants (n = 785) with elevated CRP experienced a decrease in strain, independent of age, gender, and ethnicity (B = 0.081, ?Ecc change per 1 mg/L CRP change, 95% CI 0.036-0.126, P < .001, model 1) and, additionally, beyond systolic blood pressure, heart rate, diabetes, smoking status, body mass index, current medication, and glomerular filtration rate (B = 0.099, 0.052-0.145, P < .001, model 2). The relationship remained statistically significant after further adjustment for left ventricular mass, coronary calcium score, and interim clinical coronary events (B = 0.098, 0.049-0.147, P < .001, model 3).

CONCLUSION: Higher CRP levels are related to progressive myocardial functional deterioration independent of subclinical atherosclerosis and clinical coronary events in asymptomatic individuals without previous history of heart disease.

PMID: 22877812 [PubMed - in process]

Link to Article at PubMed

Usefulness of high-sensitivity troponin T for the evaluation of patients with acute chest pain and no or minimal myocardial damage.

Am Heart J Start a Discussion »

Aug 112012

Usefulness of high-sensitivity troponin T for the evaluation of patients with acute chest pain and no or minimal myocardial damage.

Am Heart J. 2012 Aug;164(2):194-200.e1

Authors: Sanchis J, Bardají A, Bosch X, Loma-Osorio P, Marín F, Sánchez PL, Núñez J, Carratalá A, Barrabés JA

Abstract

BACKGROUND: Although high-sensitivity troponins allow early diagnosis of acute myocardial infarction, their role for identification of acute coronary syndrome in patients with normal conventional troponin remains unclear.

METHODS AND RESULTS: A total of 446 patients presenting to the emergency department with chest pain and normal troponin (common practice assays) in 2 serial samples were included. Both samples were also centrally analyzed for high-sensitivity troponin T (hs-TnT) (Roche Diagnostics, Basel, Switzerland). Detection (>3 ng/L) and 99th percentile (?14 ng/L) cutoffs of the maximum hs-TnT levels (hs-TnTmax) were considered. The end points were acute coronary syndrome diagnosis and the composite of in-hospital revascularization or 30-day cardiac events.

RESULTS: Acute coronary syndrome was adjudicated to 84 patients (19%), and 62 (14%) had the composite end point. In univariate setting, hs-TnTmax >3 ng/L exhibited high sensitivity (87% and 92%, respectively) and negative predictive value (93% and 97%) for both end points, whereas hs-TnTmax ?14 ng/L provided high specificity (90% and 89%), although low positive predictive values (40% and 33%). After adjusting for clinical (pain characteristics and risk factors) and electrocardiographic data, there was a stepped increase of risk across hs-TnTmax categories (?3, >3 but <14, and ?14 ng/L) for both end points; however, the discriminative capacity added was marginal (integrated discrimination improvement of 2.6% and 3.5%, respectively).

CONCLUSIONS: Clinical and electrocardiographic data remain the most important tools for the evaluation of patients with chest pain and with no or minimal myocardial damage. The main contribution of hs-TnT is the high negative predictive value of undetectable levels (?3 ng/L).

PMID: 22877804 [PubMed - in process]

Link to Article at PubMed

Reduction of Peripherally Inserted Central Catheter Associated Deep Venous Thrombosis.

Chest Start a Discussion »

Aug 112012

Reduction of Peripherally Inserted Central Catheter Associated Deep Venous Thrombosis.

Chest. 2012 Aug 1;

Authors: Evans RS, Sharp JH, Linford LH, Lloyd JF, Woller SC, Stevens SM, Elliott CG, Tripp JS, Jones SS, Weaver LK

Abstract

ABSTRACT BACKGROUND: As peripherally inserted central catheter (PICC) use has increased, so has the upper extremity deep venous thrombosis (DVT) rate. PICC diameter may pose the most modifiable risk for PICC-associated DVT. METHODS: A three year prospective observational study of all PICC insertions by a specially trained and certified team using a consistent and replicable approach was conducted at a 456-bed, level-one trauma and tertiary referral hospital during January 1, 2008 through December 31, 2010. An intensified effort by the PICC team in 2010 was introduced to discuss and reach interdisciplinary consensus on the need for each lumen of the PICC and a change to smaller diameter 5F triple-lumen PICC. RESULTS: Significantly more 4F single-lumen PICC were used during 2010 (n = 470) compared to 2008 and 2009 (n = 338, 382; p < 0.0001). 5F triple-lumen PICC used in 2010 were found to have similar DVT rates as 5F double-lumen and lower rates than 6F triple-lumen catheters used in 2008 and 2009. The PICC-associated DVT rate was significantly lower (1.9% vs. 3.0%,; p < 0.04) in 2010 compared to 2008 and 2009. The cost and length of stay attributable to PICC-associated DVT was $15,973 and 4.6 days. CONCLUSIONS: A significant increase in the use of single lumen PICC in addition to the institutional adoption of smaller 5F triple lumen PICC was associated with a significant decrease in the rate of PICC-associated DVT.1Medical Informatics, Intermountain Healthcare;2Biomedical Informatics, University of Utah School of Medicine;3Nutrition Support Service/PICC Team, Intermountain Medical Center;4Department of Medicine, Intermountain Medical Center;5Department of Medicine, University of Utah School of Medicine;6RAND,7Hyperbaric Medicine, Intermountain Medical Center and LDS Hospital; Salt Lake City, UTCorresponding author: R. Scott Evans, Medical Informatics, LDS Hospital, 8th Avenue and C Street, Salt Lake City, Utah 84143, rscott.evans@imail.org.

PMID: 22878346 [PubMed - as supplied by publisher]

Link to Article at PubMed

Older Entries

August 2012
M	T	W	T	F	S	S
« Jul				Sep »
		1	2	3	4	5
6	7	8	9	10	11	12
13	14	15	16	17	18	19
20	21	22	23	24	25	26
27	28	29	30	31