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Prognostic significance of increased serum bilirubin levels coincident with cardiac decompensation in chronic heart failure.

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Prognostic significance of increased serum bilirubin levels coincident with cardiac decompensation in chronic heart failure.

Circ J. 2008 Mar;72(3):364-9

Authors: Shinagawa H, Inomata T, Koitabashi T, Nakano H, Takeuchi I, Naruke T, Ohsaka T, Nishii M, Takehana H, Izumi T

BACKGROUND: The aim of this study was to analyze the relationship between abnormal liver function tests (LFTs) coincident with heart failure (HF) exacerbation and subsequent long-term outcome in patients with chronic HF. METHODS AND RESULTS: The study population consisted of 183 consecutive patients admitted for HF exacerbation with left ventricular ejection fraction < or =40%. Cox proportional hazard analysis revealed that serum total bilirubin (T-Bil) levels on admission (hazard ratio 1.896, p<0.001, 95% confidence interval 1.323-2.717), but not T-Bil at discharge or other LFTs, was an independent predictor of subsequent cardiac events after hospital discharge (cardiac death or readmission for HF exacerbation) The cardiac-event-free rates significantly decreased according to increasing tertiles of T-Bil stratified by the level of 0.7 and 1.2 mg/dl (p<0.001). T-Bil on admission had significant correlations with simultaneously-measured central venous pressure (CVP) (r=0.42, p<0.01) and cardiac index (CI) (r= -0.50, p<0.01). The patients demonstrating high CVP together with low CI showed significantly increased T-Bil compared with any other group. CONCLUSIONS: Increased T-Bil coincident with cardiac decompensation predicts a worse long-term prognosis of CHF, presumably through the potential liability to both congestion and tissue hypoperfusion simultaneously when HF deteriorates.

PMID: 18296830 [PubMed – indexed for MEDLINE]

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Management of acute decompensated heart failure in an evidence-based era: what is the evidence behind the current standard of care?

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Management of acute decompensated heart failure in an evidence-based era: what is the evidence behind the current standard of care?

Heart Lung. 2008 May-Jun;37(3):173-8

Authors: Fares WH

Despite the increased mortality and morbidity in patients with acute decompensated heart failure (ADHF), its management has been based primarily on anecdotal experiences and physiologic assumptions rather than on prospective randomized controlled trials. The data on diuretics have been conflicting. Routine use of inotropes in ADHF has been clearly associated with increased mortality and morbidity, although inotropes seem to cause short-term clinical improvement. The safety of the different vasoactive medications has never been adequately confirmed in prospective trials despite their use for a long time in heart failure. Good evidence that supports the safety and efficacy of the different medications that are routinely used in ADHF is lacking. Unless properly designed prospective clinical trials are done to evaluate the safety of the various ADHF regimens, clinicians might continue to be misguided by the beneficial short-term effects at the expense of long-term mortality and morbidity.

PMID: 18482628 [PubMed – indexed for MEDLINE]

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Three successful interventions in health care workers that improve compliance with hand hygiene: is sustained replication possible?

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Three successful interventions in health care workers that improve compliance with hand hygiene: is sustained replication possible?

Am J Infect Control. 2008 Jun;36(5):349-55

Authors: Whitby M, McLaws ML, Slater K, Tong E, Johnson B

BACKGROUND: Hand hygiene (HH) compliance by health care workers has been universally disappointing. Two major programs (Washington and Geneva) have demonstrated interventions that induce sustained improvement. The introduction of alcohol-based hand rub (AHR) together with education also has been reported to improve compliance. METHODS: These interventions were replicated concurrently for 2 years in selected wards of an 800-bed university teaching hospital, with compliance assessed only within, not between, programs. RESULTS: No significant improvement in HH compliance was observed after the introduction of AHR (incidence rate ratio [IRR] = 1.11; 95% confidence interval [CI] = 0.93 to 1.33; P = .238) or substitution of AHR for a similar product (IRR = 1.10; 95% CI = 0.91 to 1.32; P = .328) with concomitant education. The Washington program achieved a 48% (IRR = 1.48, 95% CI = 1.20 to 1.81; P < .001) improvement in compliance, sustained over 2 years. The Geneva program failed to induce a significant increase in HH compliance in 3 wards, but achieved a 56% (IRR = 1.56; 95% CI = 1.29 to 1.89; P < .001) improvement over the already high HH rate in 1 ward (infectious disease unit). CONCLUSIONS: The Washington program demonstrated effectiveness in achieving sustained improved HH compliance, whereas the effect of the Geneva program was limited in those wards without strong medical leadership. Introduction of AHR without an associated behavioral modification program proved ineffective.

PMID: 18538701 [PubMed – indexed for MEDLINE]

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Correlation between pretherapeutic d-dimer levels and response to neoadjuvant chemotherapy in patients with advanced esophageal cancer.

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Correlation between pretherapeutic d-dimer levels and response to neoadjuvant chemotherapy in patients with advanced esophageal cancer.

Dis Esophagus. 2008;21(4):281-7

Authors: Tomimaru Y, Yano M, Takachi K, Kishi K, Miyashiro I, Ohue M, Ohigashi H, Sasaki Y, Ishikawa O, Imaoka S

Neoadjuvant chemotherapy may improve survival of responders in esophageal cancer patients but is useless and harmful in non-responders. Thus, it is important to predict the effect of the chemotherapy, and that any predictor must be applicable clinically. The aim of this study is to examine the correlation between pretherapeutic hypercoagulopathy as determined by plasma d-dimer levels and response to chemotherapy. In 71 patients with esophageal cancer who underwent neoadjuvant chemotherapy (cisplatin, adriamycin and 5-fluorouracil) followed by surgery, plasma d-dimer levels were measured before chemotherapy and the clinical and pathological responses to chemotherapy were assessed at 4 weeks after therapy (after surgery). Pretherapeutic plasma d-dimer level was significantly lower in clinical responders (complete response/partial response [CR/PR]; 0.62 +/- 1.10 microg/mL, mean +/- SD) than in non-responders (no change/progressive disease [NC/PD]; 1.15 +/- 1.08 microg/mL, P = 0.0491), and in pathological responders (Grade 1b-3; 0.62 +/- 1.11 microg/mL) and non-responders (Grade 0-1a; 1.15 +/- 1.05 microg/mL, P = 0.0107). The optimal cut-off level of the plasma d-dimer levels for predicting clinical and pathological responses was 0.6 microg/mL. Then, sensitivity and specificity for the prediction of CR/PR were 68% and 73%, and those for Grade 1b-3 were 91% and 69%, respectively. Our results suggested that pretherapeutic plasma d-dimer level correlated significantly with clinical and pathological responses to chemotherapy. Pretherapeutic plasma d-dimer level can be used as a predictor for chemosensitivity.

PMID: 18477248 [PubMed – indexed for MEDLINE]

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Dysphagia: causes, assessment, treatment, and management.

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Dysphagia: causes, assessment, treatment, and management.

Geriatrics. 2008 May;63(5):15-20

Authors: White GN, O’Rourke F, Ong BS, Cordato DJ, Chan DK

Dysphagia, or difficulty in swallowing, is a condition with a strong age-related bias. Rates of dysphagia vary due to differences in method between studies; eg, clinical history of “swallowing difficulty,” evidence of aspiration, or dysphagia confirmed by swallowing investigations. In general, the rate is lower in the community than in nursing home facilities. The management and treatment of dysphagia among geriatric patients is complicated by cognitive decline, lowered immunity, malnutrition, and end-of-life decisions. This article reviews the current assessment, treatment, and management techniques for dysphagia; covers new developments in research and pilot studies; and reviews the ethical issues related to treatment when prognosis is poor.

PMID: 18447407 [PubMed – indexed for MEDLINE]

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Antibiotic resistance-What’s dosing got to do with it?

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Antibiotic resistance-What’s dosing got to do with it?

Crit Care Med. 2008 Jul 1;

Authors: Roberts JA, Kruger P, Paterson DL, Lipman J

OBJECTIVE:: This review seeks to identify original research articles that link antibiotic dosing and the development of antibiotic resistance for different antibiotic classes. Using this data, we seek to apply pharmacodynamic principles to assist clinical practice for suppressing the emergence of resistance. Concepts such as mutant selection window and mutant prevention concentration will be discussed. DATA SOURCES:: Pubmed, EMBASE and the Cochrane Controlled Trial Register. STUDY SELECTION:: All articles that related antibiotic doses and exposure to the formation of antibiotic resistance were reviewed. DATA SYNTHESIS:: The escalation of antibiotic resistance continues worldwide, most prominently in patients in intensive care units. Data are emerging from in vitro and in vivo studies that suggest that inappropriately low antibiotic dosing may be contributing to the increasing rate of antibiotic resistance. Fluoroquinolones have widely been researched and publications on other antibiotic classes are emerging. Developing dosing regimens that adhere to pharmacodynamic principles and maximize antibiotic exposure is essential to reduce the increasing rate antibiotic resistance. CONCLUSIONS:: Antibiotic dosing must aim to address not only the bacteria isolated, but also the most resistant subpopulation in the colony, to prevent the advent of further resistant infections because of the inadvertent selection pressure of current dosing regimens. This may be achieved by maximizing antibiotic exposure by administering the highest recommended dose to the patient.

PMID: 18596628 [PubMed – as supplied by publisher]