Entries Tagged as 'Pol Arch Med Wewn'
Practical implications of the revised guidelines for inpatient glycemic control.
Pol Arch Med Wewn. 2009 Dec;119(12):801-9
Authors: Reider J, Donihi A, Korytkowski MT
Substantial observational data has linked hyperglycemia in hospitalized patients with poor patient outcomes. While early studies suggested improved clinical outcomes with interventions targeting near euglycemia, more recent studies have yielded inconsistent results, with the suggestion of harm with more severe hypoglycemia. The American Association of Clinical Endocrinologists and American Diabetes Association published a revised consensus statement on inpatient glycemic management that takes into account this recent evidence. This statement identifies reasonable, achievable, and safe glycemic targets and describes protocols, procedures, and system improvements necessary to achieve these effectively. These modified glycemic targets promote a rational approach to inpatient glycemic management that minimizes risks associated with uncontrolled hyperglycemia and hypoglycemia. Intravenous insulin infusions are recommended for critically ill patients who experience blood glucose (BG) levels above 140 mg/dl with a target of 140 to 180 mg/dl. Lower BG targets (i.e., 110-140 mg/dl) may be appropriate for patients following cardiac or vascular surgical procedures. In noncritically ill patients, scheduled subcutaneous basal:bolus insulin is the preferred therapy for achieving fasting and preprandial BG below 140 mg/dl and random BG values below 180 mg/dl, with consideration of more or less stringent targets based on a patient’s clinical status. Prolonged use of correctional insulin as monotherapy is discouraged. Oral and injectable noninsulin glucose-lowering agents have a limited role for hospital use but may be appropriate for selected noncritically ill patients. Educating personnel about appropriate inpatient glycemic management practices, obtaining reliable and reproducible measures of BG, and careful implementation of standardized protocols can help to ensure patient safety.
PMID: 20010466 [PubMed - indexed for MEDLINE]
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The effect of an antibiotic policy on the control of vancomycin-resistant enterococci outbreak and on the resistance patterns of bacteria isolated from the blood of patients in a hematology unit.
Pol Arch Med Wewn. 2009 Nov;119(11):712-8
Authors: Ozorowski T, Kawalec M, Zaleska M, Konopka L, Hryniewicz W
INTRODUCTION: Antibiotic resistance has become one of the main medical problems worldwide. This is mainly due to an overuse and misuse of antibiotics. OBJECTIVES: The aim of the study was to assess the effect of an antibiotic policy and enhanced infection control on the occurrence of epidemic strains of vancomycin-resistant enterococci (VRE) and resistance patterns of bacteria isolated from the blood of patients hospitalized in two departments of a hematology center in Poland. PATIENTS AND METHODS: Antibiotic use was calculated in daily defined doses (DDD) per 100 patient-days during the two 5-month periods, before and after the introduction of the policy. Infection control measures included a 1-week screening for VRE rectal carriage and contact isolation. RESULTS: Antibiotic consumption decreased from 82.1 to 57.3 DDD per 100 patient-days, mainly because of a decrease in the use of co-trimoxazole, other antimicrobials active against anaerobes, and cephalosporins. A significant change in antibiotic resistance patterns was observed and in vitro efficacy of antibiotics against bacteria isolated from the blood increased remarkably. We managed to eradicate the outbreak of VRE. CONCLUSIONS: The introduction of antibiotic policy and enhanced infection control measures may prove efficacious in VRE control.
PMID: 19920795 [PubMed - indexed for MEDLINE]
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Noninvasive positive pressure ventilation: effect on mortality in acute cardiogenic pulmonary edema: a pragmatic meta-analysis.
Pol Arch Med Wewn. 2009 Jun;119(6):349-53
Authors: Potts JM
INTRODUCTION: In contrast to a series of recent meta-analyses (MAs), the 3CPO (Three Interventions in Cardiogenic Pulmonary Oedema) randomized controlled trial (RCT) reported in 2008 did not find a significant mortality benefit of noninvasive positive pressure ventilation (NPPV) in acute cardiogenic pulmonary edema (ACPE). OBJECTIVES: This paper combines data collected in the 3CPO trial together with data from recent MAs and calculates a revised risk ratio for NPPV in ACPE. Reasons for the discrepancy in mortality estimates are identified and discussed through contrasting the methodology and results of the 3CPO trial with previous RCTs. PATIENTS AND METHODS: Patients included adults with ACPE secondary to a variety of insults such as hypertension, acute coronary syndromes, dietary indiscretion, arrhythmias and valvular lesions and assessed by clinical parameters (respiratory rate, crackles, oxygen saturation) and chest radiograph. Data was collected from MAs published after 2005 and their respective RCTs. As opinions regarding RCTs worthy of inclusion in the analyses were varied, 3 sets of RCTs were combined with the 3CPO data. The first set of data duplicated the RCTs chosen in the Cochrane; the second set, a comprehensive set, included all RCTs cited in any of the MAs reviewed; and the third set, a high quality RCT set, assessed data from only those RCTs included in at least 4 out of the 5 MAs reviewed. Data were analyzed with both fixed and variable effect modes using Revman software. RESULTS: All combinations of RCTs and modes of analysis predict a significant mortality benefit. The combined data predicts a risk ratio for mortality using NPPV of 0.75 (95% CI: 0.61-0.92). CONCLUSIONS: An analysis of the existing RCT data, inclusive of the 3CPO trial, predicts a continued and significant mortality benefit of NPPV in ACPE.
PMID: 19694215 [PubMed - indexed for MEDLINE]
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Should D-dimer testing be used to predict the risk of recurrence after discontinuation of anticoagulant therapy for a first unprovoked episode of venous thromboembolism?
Pol Arch Med Wewn. 2009 Apr;119(4):225-30
Authors: Wu C, Bates SM
Recurrent venous thromboembolism carries significant risks of morbidity and mortality. Although recurrence can be prevented by ongoing anticoagulant therapy, treatment is inconvenient and associated with risks of major bleeding. As a consequence, the decision as to whether or not to continue anticoagulants after the first three months of treatment must take into account both potential benefits and potential risks. For patients who have developed unprovoked venous thromboembolism, these are often closely balanced and the optimal duration of anticoagulant therapy remains controversial. Recent publications suggest that D-dimer testing may be helpful in stratifying these individuals into higher and lower risks groups for recurrence after anticoagulant discontinuation. This paper reviews recent data surrounding the use of D-dimer to predict the risk of recurrent venous thromboembolism and how this test may help streamline decisions regarding duration of therapy.
PMID: 19413181 [PubMed - indexed for MEDLINE]
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Hand hygiene in the intensive care unit: prospective observations of clinical practice.
Pol Arch Med Wewn. 2008 Oct;118(10):543-7
Authors: Qushmaq IA, Heels-Ansdell D, Cook DJ, Loeb MB, Meade MO
INTRODUCTION: Adherence to hand hygiene recommendations in the intensive care unit (ICU) is variable and moderate, at best. OBJECTIVES: To measure adherence to hand hygiene recommendations among ICU clinicians in a prospective observational study in 6 multidisciplinary ICUs among 4 hospitals. PATIENTS AND METHODS: We observed 115 clinicians (64 nurses, 21 respiratory therapists, 18 residents and 12 physicians) during 1 patient encounter, each. Clinicians were unaware that they were under observation. We documented use of gloves, soap, and alcohol solution before and after patient encounters for purposes of physical examination or patient care. RESULTS: The rate of adherence to current recommendations was 20% (95% CI 13.7-28.2). All 23 clinicians adhering to recommendations used gloves followed by washing with soap or alcohol solution. 57.4% (95% CI 48.3-66.0) of clinicians used some form of hand hygiene without fully adhering to recommendations, whereas 42.6% did not appear to attend to hand hygiene at all during observation. By univariate analysis, with nurses as the reference group, we found trends suggesting lowest adherence rates among residents (odds ratio [OR] 0.32, 95% CI 0.11-0.96) and intensivists (OR 0.46, 95% CI, 0.13-1.60), and highest adherence among respiratory therapists (OR 2.05, 95% CI 0.67-6.30). We also observed a center effect (p = 0.04). However, multivariate analysis showed no relationship of hand hygiene to clinician group (p = 0.06) nor ICU (p = 0.05). CONCLUSIONS: Multidisciplinary, multimethod approaches to improving hand hygiene are likely necessary to improve the modest adherence to hand hygiene that we observed.
PMID: 19112814 [PubMed - indexed for MEDLINE]
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Venous thromboembolism risk and prophylaxis in the acute hospital care setting–results of the ENDORSE study in Poland.
Pol Arch Med Wewn. 2008 Oct;118(10):555-61
Authors: Musia? J, Sydor WJ,
INTRODUCTION: Venous thromboembolism (VTE) is the most common preventable cause of in-hospital death. However, the risk of VTE and prophylaxis practices in Polish hospitals are not known. OBJECTIVES: The ENDORSE study in Poland was part of the global cross-sectional Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting survey with the objective to assess the prevalence of VTE risk in acutely ill medical and surgical patients and to determine the proportion of at-risk patients who receive recommended prophylaxis. PATIENTS AND METHODS: In 10 non-academic Polish hospitals, a chart review was performed in all inpatients aged 40 or older admitted to medical wards, and in patients at the age of > or = 18 admitted to surgical wards. The VTE risk and recommended prophylaxis were assessed according to the 2004 American College of Chest Physicians (ACCP) guidelines. RESULTS: The study enrolled 2673 patients (1092 in surgical wards, 1581 in medical wards). Out of these, 1111 were judged to be at risk for VTE (597 surgical patients, 514 medical patients). Only 51.8% of all at-risk patients received ACCP-recommended VTE prophylaxis (54.7% of surgical patients, 32.5% of medical patients). CONCLUSIONS: In Polish hospitals more than 40% of patients hospitalized for acute illness are at risk of VTE, but only a small proportion of them receives appropriate prophylaxis. These results call for decisive actions to ensure that at-risk patients receive recommended VTE prophylaxis.
PMID: 19112816 [PubMed - indexed for MEDLINE]
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