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Out-of-hospital thrombolysis during cardiopulmonary resuscitation in patients with high likelihood of ST-elevation myocardial infarction.

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Out-of-hospital thrombolysis during cardiopulmonary resuscitation in patients with high likelihood of ST-elevation myocardial infarction.

Resuscitation. 2008 Feb;76(2):180-4

Authors: Arntz HR, Wenzel V, Dissmann R, Marschalk A, Breckwoldt J, Müller D

Up to 90% of cardiac arrests are due to acute myocardial infarction or severe myocardial ischaemia. Thrombolysis is an effective treatment for ST-elevation myocardial infarction (STEMI), but there is no evidence or guideline to put forward a thrombolysis strategy during cardiopulmonary resuscitation (CPR). In two physician-manned emergency medical service (EMS) units in Berlin, Germany, using thrombolysis is based on an individual judgment of the EMS physician managing the CPR attempt. In this retrospective analysis over 3 years (total 22.164 scene calls), thrombolysis was started at the scene in 50 patients during brief intermittent phases of spontaneous circulation, and in 3 patients during ongoing CPR. On-scene diagnosis of myocardial infarction was established in 45 patients (85%) by a 12-lead ECG, 5 (9%) patients had a left bundle branch block. Sixteen patients (30%) died at the scene, 37 patients (70%) were admitted to a hospital. In-hospital mortality was 35% (13 of 37 patients), with cause of death being cardiogenic shock in nine patients, hypoxic cerebral coma in two and acute haemorrhage in two other patients. All 24 of 53 (45%) survivors were discharged with an excellent neurological recovery. CPR was started by an EMS physician in 18 of the 24 survivals (75%) and emergency medical technicians who arrived first in six (25%). Duration of CPR until return of spontaneous circulation was <10 min in 13 of 24 (54%) of the survivors. Thrombolysis was initiated during intermittent phases of spontaneous circulation in 50 (94%) of all patients and in 23 (96%) of the 24 survivors. In conclusion, this retrospective analysis shows excellent survival rates and neurological outcome in selected patients with a high likelihood of myocardial infarction, who develop cardiac arrest and are treated with thrombolysis.

PMID: 17728040 [PubMed – indexed for MEDLINE]

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Darbepoetin alpha for the treatment of anemia in patients with active cancer not receiving chemotherapy or radiotherapy: results of a phase III, multicenter, randomized, double-blind, placebo-controlled study.

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Darbepoetin alpha for the treatment of anemia in patients with active cancer not receiving chemotherapy or radiotherapy: results of a phase III, multicenter, randomized, double-blind, placebo-controlled study.

J Clin Oncol. 2008 Mar 1;26(7):1040-50

Authors: Smith RE, Aapro MS, Ludwig H, Pintér T, Smakal M, Ciuleanu TE, Chen L, Lillie T, Glaspy JA

PURPOSE: The efficacy and safety of darbepoetin alpha (DA) for treating patients with active cancer and anemia not receiving or planning to receive cytotoxic chemotherapy or myelosuppressive radiotherapy was evaluated. PATIENTS AND METHODS: Patients with active cancer and anemia not receiving or planning to receive chemotherapy or radiotherapy were enrolled onto a phase III, multicenter, randomized, placebo-controlled study and administered placebo or DA 6.75 microg/kg every 4 weeks (Q4W) for up to 16 weeks with a 2-year follow-up for survival. Patients who completed 16 weeks of treatment could receive the same treatment as randomized Q4W for an additional 16 weeks. The primary end point was all occurrences of transfusions from weeks 5 through 17; safety end points included incidence of adverse events and survival. RESULTS: The incidence of transfusions between weeks 5 and 17 was lower in the DA group but was not statistically significantly different from that of placebo. DA was associated with an increased incidence of cardiovascular and thromboembolic events and more deaths during the initial 16-week treatment period. Long-term survival data demonstrated statistically significantly poorer survival in patients treated with DA versus placebo (P = .022). This effect varied by baseline covariates including, sex, tumor type, and geographic region; statistical significance diminished (P = .12) when the analysis was adjusted for baseline imbalances or known prognostic factors. CONCLUSION: DA was not associated with a statistically significant reduction in transfusions. Shorter survival was observed in the DA arm; thus, this study does not support the use of erythropoiesis-stimulating agents in this subset of patients with anemia of cancer.

PMID: 18227526 [PubMed – indexed for MEDLINE]

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Effect of renin-angiotensin-aldosterone system triple blockade on non-diabetic renal disease: addition of an aldosterone blocker, spironolactone, to combination treatment with an angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker.

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Effect of renin-angiotensin-aldosterone system triple blockade on non-diabetic renal disease: addition of an aldosterone blocker, spironolactone, to combination treatment with an angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker.

Hypertens Res. 2008 Jan;31(1):59-67

Authors: Furumatsu Y, Nagasawa Y, Tomida K, Mikami S, Kaneko T, Okada N, Tsubakihara Y, Imai E, Shoji T

Although dual blockade of the renin-angiotensin-aldosterone system (RAAS) with the combination of an angiotensin-converting enzyme inhibitor (ACE-I) and angiotensin II receptor blocker (ARB) is generally well-established as a treatment for nephropathy, this treatment is not fully effective in some patients. Based on the recent evidence implicating aldosterone in renal disease progression, this study was conducted to examine the efficacy of blockade with three different mechanisms by adding an aldosterone blocker in patients who do not respond adequately to the dual blockade. A 1-year randomized, open-label, multicenter, prospective controlled study was conducted, in which 32 non-diabetic nephropathy patients with proteinuria exceeding 0.5 g/day were enrolled after more than 12 weeks of ACE-I (5 mg enalapril) and ARB (50 mg losartan) combination treatment. These patients were allocated into two groups of 16 patients each: a triple blockade group in which 25 mg of spironolactone daily was added to the ACE-I and ARB combination treatment, and a control group in which 1 mg of trichlormethiazide or 20 mg of furosemide was added to the combination treatment instead of spironolactone depending upon the creatinine level. After 1 year of treatment, the urinary protein level decreased by 58% (p<0.05) with the triple blockade but was unchanged in the controls. Furthermore, urinary type IV collagen level decreased by 40% (p<0.05) with the triple blockade but was unchanged in the controls. The decreases in urinary protein and urinary type IV collagen were not accompanied by a decrease in blood pressure. Mean serum creatinine, potassium and blood pressure did not change significantly by either treatment. In conclusion, triple blockade of the RAAS was effective for the treatment of proteinuria in patients with non-diabetic nephropathy whose increased urinary protein had not responded sufficiently to a dual blockade.

PMID: 18360019 [PubMed – indexed for MEDLINE]

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Role of erythropoietin in cancer-related anaemia: a double-edged sword?

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Role of erythropoietin in cancer-related anaemia: a double-edged sword?

J Int Med Res. 2008 Jan-Feb;36(1):1-8

Authors: Guan X, Chen L

Anaemia often occurs in cancer patients and its origin is multifactorial, resulting from either bone marrow infiltration of cancer cells or cytotoxic effects produced by chemotherapy and radiotherapy. Anaemia impacts significantly on quality of life and appears markedly to limit disease control. Erythropoietin stimulates erythrocyte formation and the human recombinant form is useful in treating anaemia in cancer patients. Over the past decade erythropoietin has been associated with amelioration of anaemia and reduced need for blood transfusions. Nevertheless, several pre-clinical and clinical trials, employing relatively high doses of erythropoietin, have been halted recently following increased mortality and morbidity, primarily due to thrombotic events and possible tumour growth stimulation. It is, therefore, too early to know whether erythropoietin is useful in controlling morbidity and mortality in cancer-related anaemia. The risk-benefit of erythropoietic agents should be studied in carefully controlled trials. This review discusses prevalent issues and addresses key questions concerning the use of erythropoietic agents for the treatment of cancer-related anaemia.

PMID: 18230261 [PubMed – indexed for MEDLINE]

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Statins for infection and sepsis: a systematic review of the clinical evidence.

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Statins for infection and sepsis: a systematic review of the clinical evidence.

J Antimicrob Chemother. 2008 Apr;61(4):774-85

Authors: Falagas ME, Makris GC, Matthaiou DK, Rafailidis PI

INTRODUCTION: Statins are currently used for hyperlipidaemia control and considered useful for protection from cardiovascular events. In addition, there is increasing evidence for the potential use of statins in preventing and treating infections. METHODS: We performed a systematic review of the literature that compared the outcome between statin and non-statin users among patients suffering from sepsis or other infections. The relevant studies were identified from searches of PubMed, Scopus and the Cochrane Library databases. RESULTS: Twenty studies were identified (13 of them were retrospective), out of which 9 examined the use of statins in patients with sepsis, bacteraemia or multiorgan dysfunction syndrome, 4 community-acquired pneumonia (CAP), 1 ICU infections, 2 other bacterial infections and 4 viral infections. Eleven studies had data regarding mortality as the main outcome: 8 showed decreased mortality in statin users (3 of them reported on patients with bacteraemia), 2 showed no difference in mortality and 1 reported an increased mortality in patients who received statins. Seven studies examined the risk of sepsis as the main outcome; six of these studies showed a decreased risk of sepsis in patients receiving statins, whereas one study found no difference. CONCLUSIONS: The majority of the studies suggest that statins may have a positive role in the treatment of patients with sepsis and infection. However, the majority of the reviewed studies have the inherent methodological limitations of retrospective studies. Conclusions regarding this important clinical question should wait for the results of ongoing relevant randomized controlled trials.

PMID: 18263570 [PubMed – indexed for MEDLINE]