Effect of statins on atrial fibrillation: collaborative meta-analysis of published and unpublished evidence from randomised controlled trials.
BMJ. 2011;342:d1250
Authors: Rahimi K, Emberson J, McGale P, Majoni W, Merhi A, Ass…

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Comparative cardiovascular effects of thiazolidinediones: systematic review and meta-analysis of observational studies.
BMJ. 2011;342:d1309
Authors: Loke YK, Kwok CS, Singh S
To determine the comparative effects of the…

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Essential care after an inpatient fall: summary of a safety report from the National Patient Safety Agency.

BMJ. 2011;342:d329

Authors: Healey F, Darowski A, Lamont T, Panesar S, Poulton S, Treml J, Wiese M

PMID: 21278215 [PubMed - in process]

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Use of weaning protocols for reducing duration of mechanical ventilation in critically ill adult patients: Cochrane systematic review and meta-analysis.

BMJ. 2011;342:c7237

Authors: Blackwood B, Alderdice F, Burns K, Cardwell C, Lavery G, O’Halloran P

To investigate the effects of weaning protocols on the total duration of mechanical ventilation, mortality, adverse events, quality of life, weaning duration, and length of stay in the intensive care unit and hospital.

PMID: 21233157 [PubMed - in process]

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Phantom vibration syndrome among medical staff: a cross sectional survey.

BMJ. 2010;341:c6914

Authors: Rothberg MB, Arora A, Hermann J, Kleppel R, Marie PS, Visintainer P

To describe the prevalence of and risk factors for experiencing “phantom vibrations,” the sensory hallucination sometimes experienced by people carrying pagers or cell phones when the device is not vibrating.

PMID: 21159761 [PubMed - in process]

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Urine output on an intensive care unit: case-control study.

BMJ. 2010;341:c6761

Authors: Solomon AW, Kirwan CJ, Alexander ND, Nimako K, Jurukov A, Forth RJ, Rahman TM,

OBJECTIVE: To compare urine output between junior doctors in an intensive care unit and the patients for whom they are responsible. DESIGN: Case-control study. SETTING: General intensive care unit in a tertiary referral hospital. PARTICIPANTS: 18 junior doctors responsible for clerking patients on weekday day shifts in the unit from 23 March to 23 April 2009 volunteered as "cases." Controls were the patients in the unit clerked by those doctors. Exclusion criteria (for both groups) were pregnancy, baseline estimated glomerular filtration rate <15 ml/min/1.73 m(2), and renal replacement therapy. MAIN OUTCOME MEASURES: Oliguria (defined as mean urine output <0.5 ml/kg/hour over six or more hours of measurement) and urine output (in ml/kg/hour) as a continuous variable. RESULTS: Doctors were classed as oliguric and "at risk" of acute kidney injury on 19 (22%) of 87 shifts in which urine output was measured, and oliguric to the point of being "in injury" on one (1%) further shift. Data were available for 208 of 209 controls matched to cases in the data collection period; 13 of these were excluded because the control was receiving renal replacement therapy. Doctors were more likely to be oliguric than their patients (odds ratio 1.99, 95% confidence interval 1.08 to 3.68, P=0.03). For each additional 1 ml/kg/hour mean urine output, the odds ratio for being a case rather than a control was 0.27 (0.12 to 0.58, P=0.001). Mortality among doctors was astonishingly low, at 0% (0% to 18%). CONCLUSIONS: Managing our own fluid balance is more difficult than managing it in our patients. We should drink more water. Modifications to the criteria for acute kidney injury could be needed for the assessment of junior doctors in an intensive care unit.

PMID: 21156738 [PubMed - as supplied by publisher]

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Consultants should be available to admit patients to hospital 12 hours a day.

BMJ. 2010;341:c7021

Authors: White C

PMID: 21135000 [PubMed - as supplied by publisher]

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Thrombolysis in very elderly people: controlled comparison of SITS International Stroke Thrombolysis Registry and Virtual International Stroke Trials Archive.

BMJ. 2010;341:c6046

Authors: Mishra NK, Ahmed N, Andersen G, Egido JA, Lindsberg PJ, Ringleb PA, Wahlgren NG, Lees KR,

OBJECTIVE: To assess effect of age on response to alteplase in acute ischaemic stroke. DESIGN: Adjusted controlled comparison of outcomes between non-randomised patients who did or did not undergo thrombolysis. Analysis used Cochran-Mantel-Haenszel test and proportional odds logistic regression analysis. SETTING: Collaboration between International Stroke Thrombolysis Registry (SITS-ISTR) and Virtual International Stroke Trials Archive (VISTA). PARTICIPANTS: 23?334 patients from SITS-ISTR (December 2002 to November 2009) who underwent thrombolysis and 6166 from VISTA neuroprotection trials (1998-2007) who did not undergo thrombolysis (as controls). Of the 29?500 patients (3472 aged >80 ("elderly," mean 84.6), data on 272 patients were missing for baseline National Institutes of Health stroke severity score, leaving 29?228 patients for analysis adjusted for age and baseline severity. MAIN OUTCOME MEASURES: Functional outcomes at 90 days measured by score on modified Rankin scale. RESULTS: Median severity at baseline was the same for patients who underwent thrombolysis and controls (median baseline stroke scale score: 12 for each group, P=0.14; n=29?228). The distribution of scores on the modified Rankin scale was better among all thrombolysis patients than controls (odds ratio 1.6, 95% confidence interval 1.5 to 1.7; Cochran-Mantel-Haenszel P<0.001). The association occurred independently among patients aged ?80 (1.6, 1.5 to 1.7; P<0.001; n=25?789) and in those aged >80 (1.4, 1.3 to 1.6; P<0.001; n=3439). Odds ratios were consistent across all 10 year age ranges above 30, and benefit was significant from age 41 to 90; dichotomised outcomes (score on modified Rankin scale 0-1 v 2-6; 0-2 v 3-6; and 6 (death) v rest) were consistent with the results of the ordinal analysis. CONCLUSIONS: Outcome in patients with acute ischaemic stroke is significantly better in those who undergo thrombolysis compared with those who do not. Increasing age is associated with poorer outcome but the association between thrombolysis treatment and improved outcome is maintained in very elderly people. Age alone should not be a barrier to treatment.

PMID: 21098614 [PubMed - as supplied by publisher]

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Continuous positive airway pressure as treatment for systemic hypertension in people with obstructive sleep apnoea: randomised controlled trial.

BMJ. 2010;341:c5991

Authors: Durán-Cantolla J, Aizpuru F, Montserrat JM, Ballester E, Terán-Santos J, Aguirregomoscorta JI, Gonzalez M, Lloberes P, Masa JF, De La Peña M, Carrizo S, Mayos M, Barbé F,

OBJECTIVE: To assess the effect of continuous positive airway pressure (CPAP) on 24 hour ambulatory blood pressure monitoring values in a large number of patients with untreated systemic hypertension of new onset and obstructive sleep apnoea. DESIGN: Multicentre, double blind, randomised, placebo controlled trial. SETTING: Eleven general hospitals in Spain between 2004 and 2007. PARTICIPANTS: 340 patients recently diagnosed as having systemic hypertension by a general practitioner (systolic blood pressure ?140 mm Hg, diastolic blood pressure ?90 mm Hg, or both) and an apnoea-hypopnoea index per hour of sleep of >15 events/hour. INTERVENTION: Patients were assigned to CPAP (n=169) or sham CPAP (n=171) for three months. Main outcome measurements Net changes in the different 24 hour ambulatory blood pressure monitoring values from baseline to three months of optimal or sham CPAP. RESULTS: 277 (81%) of the 340 patients randomised were men; the patients had a mean age of 52.4 (SD 10.5) years, a body mass index of 31.9 (5.7), an Epworth sleepiness scale score of 10.1 (4.3), an apnoea-hypopnoea index of 43.5 (24.5). No differences between groups were seen at baseline. Compared with placebo and analysed by intention to treat, the mean 24 hour ambulatory blood pressure of the CPAP group decreased by 1.5 (95% confidence interval: 0.4 to 2.7) mm Hg (P=0.01). The mean 24 hour ambulatory blood pressure monitoring measures decreased by 2.1 mm Hg (0.4 to 3.7) mm Hg (P=0.01) for systolic pressure and 1.3 (0.2 to 2.3) mm Hg (P=0.02) for diastolic blood pressure. Mean nocturnal blood pressure decreased by 2.1 (0.5 to 3.6) mm Hg (P=0.01). CONCLUSIONS: CPAP produced a statistically significant reduction in blood pressure in patients with systemic hypertension and obstructive sleep apnoea. This reduction is small and did not achieve the 3 mm Hg drop in mean 24 hour ambulatory blood pressure that the trial was powered to detect. Consequently, these results may have uncertain clinical relevance. However, taking into account the prevalence of hypertension and the likelihood of comorbidities, the decrease in blood pressure, although minimal, may be beneficial. Trial registration Clinical trials NCT00202527.

PMID: 21106625 [PubMed - as supplied by publisher]

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Endobronchial intubation detected by insertion depth of endotracheal tube, bilateral auscultation, or observation of chest movements: randomised trial.

BMJ. 2010;341:c5943

Authors: Sitzwohl C, Langheinrich A, Schober A, Krafft P, Sessler DI, Herkner H, Gonano C, Weinstabl C, Kettner SC

OBJECTIVE: To determine which bedside method of detecting inadvertent endobronchial intubation in adults has the highest sensitivity and specificity. DESIGN: Prospective randomised blinded study. SETTING: Department of anaesthesia in tertiary academic hospital. PARTICIPANTS: 160 consecutive patients (American Society of Anesthesiologists category I or II) aged 19-75 scheduled for elective gynaecological or urological surgery. INTERVENTIONS: Patients were randomly assigned to eight study groups. In four groups, an endotracheal tube was fibreoptically positioned 2.5-4.0 cm above the carina, whereas in the other four groups the tube was positioned in the right mainstem bronchus. The four groups differed in the bedside test used to verify the position of the endotracheal tube. To determine whether the tube was properly positioned in the trachea, in each patient first year residents and experienced anaesthetists were randomly assigned to independently perform bilateral auscultation of the chest (auscultation); observation and palpation of symmetrical chest movements (observation); estimation of the position of the tube by the insertion depth (tube depth); or a combination of all three (all three). MAIN OUTCOME MEASURES: Correct and incorrect judgments of endotracheal tube position. RESULTS: 160 patients underwent 320 observations by experienced and inexperienced anaesthetists. First year residents missed endobronchial intubation by auscultation in 55% of cases and performed significantly worse than experienced anaesthetists with this bedside test (odds ratio 10.0, 95% confidence interval 1.4 to 434). With a sensitivity of 88% (95% confidence interval 75% to 100%) and 100%, respectively, tube depth and the three tests combined were significantly more sensitive for detecting endobronchial intubation than auscultation (65%, 49% to 81%) or observation(43%, 25% to 60%) (P<0.001). The four tested methods had the same specificity for ruling out endobronchial intubation (that is, confirming correct tracheal intubation). The average correct tube insertion depth was 21 cm in women and 23 cm in men. By inserting the tube to these distances, however, the distal tip of the tube was less than 2.5 cm away from the carina (the recommended safety distance, to prevent inadvertent endobronchial intubation with changes in the position of the head in intubated patients) in 20% (24/118) of women and 18% (7/42) of men. Therefore optimal tube insertion depth was considered to be 20 cm in women and 22 cm in men. CONCLUSION: Less experienced clinicians should rely more on tube insertion depth than on auscultation to detect inadvertent endobronchial intubation. But even experienced physicians will benefit from inserting tubes to 20-21 cm in women and 22-23 cm in men, especially when high ambient noise precludes accurate auscultation (such as in emergency situations or helicopter transport). The highest sensitivity and specificity for ruling out endobronchial intubation, however, is achieved by combining tube depth, auscultation of the lungs, and observation of symmetrical chest movements. Trial registration NCT01232166.

PMID: 21062875 [PubMed - in process]

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Tricyclic antidepressants and headaches: systematic review and meta-analysis.

BMJ. 2010;341:c5222

Authors: Jackson JL, Shimeall W, Sessums L, Dezee KJ, Becher D, Diemer M, Berbano E, O’Malley PG

OBJECTIVE: To evaluate the efficacy and relative adverse effects of tricyclic antidepressants in the treatment of migraine, tension-type, and mixed headaches. DESIGN: Meta-analysis. DATA SOURCES: Medline, Embase, the Cochrane Trials Registry, and PsycLIT. Studies reviewed Randomised trials of adults receiving tricyclics as only treatment for a minimum of four weeks. DATA EXTRACTION: Frequency of headaches (number of headache attacks for migraine and number of days with headache for tension-type headaches), intensity of headache, and headache index. RESULTS: 37 studies met the inclusion criteria. Tricyclics significantly reduced the number of days with tension-type headache and number of headache attacks from migraine than placebo (average standardised mean difference -1.29, 95% confidence interval -2.18 to -0.39 and -0.70, -0.93 to -0.48) but not compared with selective serotonin reuptake inhibitors (-0.80, -2.63 to 0.02 and -0.20, -0.60 to 0.19). The effect of tricyclics increased with longer duration of treatment (?=-0.11, 95% confidence interval -0.63 to -0.15; P<0.0005). Tricyclics were also more likely to reduce the intensity of headaches by at least 50% than either placebo (tension-type: relative risk 1.41, 95% confidence interval 1.02 to 1.89; migraine: 1.80, 1.24 to 2.62) or selective serotonin reuptake inhibitors (1.73, 1.34 to 2.22 and 1.72, 1.15 to 2.55). Tricyclics were more likely to cause adverse effects than placebo (1.53, 95% confidence interval 1.11 to 2.12) and selective serotonin reuptake inhibitors (2.22, 1.52 to 3.32), including dry mouth (P<0.0005 for both), drowsiness (P<0.0005 for both), and weight gain (P<0.001 for both), but did not increase dropout rates (placebo: 1.22, 0.83 to 1.80, selective serotonin reuptake inhibitors: 1.16, 0.81 to 2.97). CONCLUSIONS: Tricyclic antidepressants are effective in preventing migraine and tension-type headaches and are more effective than selective serotonin reuptake inhibitors, although with greater adverse effects. The effectiveness of tricyclics seems to increase over time.

PMID: 20961988 [PubMed - in process]

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Antipsychotic drugs and risk of venous thromboembolism: nested case-control study.

BMJ. 2010;341:c4245

Authors: Parker C, Coupland C, Hippisley-Cox J

OBJECTIVE: To determine whether antipsychotic drugs are associated with an increased risk of venous thromboembolism, and to examine risks by type of antipsychotic, potency, and dose. DESIGN: Population based nested case-control study. SETTING: The UK QResearch primary care database. PARTICIPANTS: Patients (cases) with a first ever record of venous thromboembolism between 1 January 1996 and 1 July 2007; each was matched with up to four controls by age, calendar time, sex, and practice. MAIN OUTCOME MEASURES: Odds ratios for venous thromboembolism associated with antipsychotic drugs adjusted for comorbidity; concomitant drug exposure. RESULTS: There were 25 532 eligible cases (15 975 with deep vein thrombosis and 9557 with pulmonary embolism) and 89 491 matched controls from a study population of 7 267 673. Individuals prescribed antipsychotic drugs in the previous 24 months had a 32% greater risk of venous thromboembolism than non-users, despite adjustment for potential risk factors (odds ratio 1.32, 95% confidence interval 1.23 to 1.42). Patients who had started a new drug in the previous three months had about twice the risk (1.97, 1.66 to 2.33). The risk was greater for individuals prescribed atypical rather than conventional drugs (adjusted odds ratio 1.73, 1.37 to 2.17, for atypical drugs; 1.28, 1.18 to 1.38, for conventional drugs). It also tended to be greater for patients prescribed low rather than high potency drugs (1.99, 1.52 to 2.62, for low potency; 1.28, 1.18 to 1.38, for high potency). The estimated number of extra cases of venous thromboembolism per 10 000 patients treated over one year was 4 (3 to 5) in patients of all ages and 10 (7 to 13) for patients aged 65 and over. CONCLUSIONS: There is an association between use of antipsychotic drugs and risk of venous thromboembolism in a large primary care population. The increased risk was more marked among new users and those prescribed atypical antipsychotic drugs.

PMID: 20858909 [PubMed - as supplied by publisher]

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Is there a role for revascularisation in asymptomatic carotid stenosis? Yes.

BMJ. 2010;341:c4898

Authors: Roffi M

PMID: 20843932 [PubMed - as supplied by publisher]

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Is there a role for revascularisation in asymptomatic carotid stenosis? No.

BMJ. 2010;341:c4900

Authors: Spence JD

PMID: 20843933 [PubMed - as supplied by publisher]

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Why many patients shouldn’t be in hospital.

BMJ. 2010;341:c4710

Authors: Patel K

PMID: 20810486 [PubMed - in process]

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