Medicine News
Calcium supplements may raise risk of heart attack
Calcium supplements, which many people consume hoping to ward off osteoporosis, may increase the risk of heart attack by as much as 30 percent, researchers reported Friday. These tiny tablets which carry concentrated doses of calcium were also associated with higher incidences of stroke and death, but they were not statistically significant.
Predictive Value of Plasma Fibrinogen Levels in Patients Admitted for Acute Coronary Syndrome
In recent years, researchers have investigated the relationship between biological markers of inflammation and prognosis in patients who experience acute coronary syndromes; however, the association between plasma fibrinogen and coronary heart disease is still not clear. This article studied the prognostic value of fibrinogen, an acute-phase protein that is directly involved in thrombotic processes, by measuring plasma fibrinogen levels serially in 136 patients who had acute coronary syndromes, 142 patients who had stable coronary heart disease, and 82 healthy control participants. Plasma fibrinogen levels were significantly higher in the patients with acute coronary syndromes than in the patients with stable coronary heart disease and the control group. It was also found that significantly higher plasma fibrinogen levels in patients who developed clinical events than in those who did not, at 30 days and 2 years.
Early Outcomes of Radial Artery Use in All-Arterial Grafting of the Coronary Arteries in Patients 65 Years and Older
retrospectively evaluated early clinical results of coronary revascularization using none but arterial grafts in patients aged 65 years and older. The cases of 449 consecutive patients who had undergone isolated myocardial revascularization were divided into 2 groups: the arterial conduit group (n=107) received a left internal mammary artery (LIMA) graft and 1 or both radial arteries (RAs), while the mixed-conduit group (n=342) received a LIMA graft and 1 or more saphenous vein grafts (SVGs), with or without an RA. Overall myocardial revascularization using all arterial grafts (at least 50% RAs) in patients aged 65 years and older is safe and reliable, produces short-term results equal to those of saphenous vein grafting, and can reduce graft-harvest-site infections.
Stratification of the Risk Factors of Community-Acquired Methicillin-Resistant Staphylococcus Aureus Hand Infection
Several recent studies showed an increase in methicillin-resistant Staphylococcus aureus (MRSA) hand infections. The purpose of this study was to determine the prevalence of community-acquired MRSA hand infections in an urban setting and to determine independent risk factors for such infections. In the patients studied, only intravenous drug use correlated with community-acquired MRSA hand infections. Patient education about intravenous drug use and empiric treatment with MRSA-appropriate antibiotics for intravenous drug users presenting with hand infections are recommended.
FDA Finds Pneumonia Risk with Daptomycin
The FDA said that the intravenous antibiotic daptomycin (Cubicin) may be linked to an increased risk of eosinophilic pneumonia -- a rare but serious potential side effect -- and requested that a new drug label warning be added.
The agency reviewed the medical literature and adverse event reports for daptomycin and identified seven cases of eosinophilic pneumonia between 2004 and 2010 "that were most likely associated with Cubicin" on the basis of six criteria, the agency indicated in a Drug Safety Communication.
Major haemorrhagic complications of acute pancreatitis
Haemorrhage is a rare, potentially fatal complication in acute pancreatitis (AP). The aim was to investigate the incidence, management and outcome related to this complication.
Fourteen (1·0 per cent) of 1356 patients diagnosed with AP developed major haemorrhage. Angiography established the diagnosis in four of six patients. Embolization was successful in one patient. Surgery was performed in two patients. Sentinel bleeding occurred in three of four patients with major postoperative bleeding. The overall mortality rate was 36 per cent (5 of 14 patients). Haemorrhage presenting after more than 7 days was associated with a higher mortality rate of 80 per cent (4 of 5 patients). A fatal outcome was at least three times more likely in patients with severe AP and haemorrhagic complications than in those with severe AP but no bleeding.Concluding major haemorrhagic complications of AP are rare, but clinically important. Major postoperative bleeding is often preceded by sentinel bleeding. Intra-abdominal haemorrhage presenting more than 1 week after disease onset is a highly fatal complication.
Alcohol Use Lowers Rheumatoid Arthritis Risk
Alcohol consumption was associated with a significant reduction in susceptibility to rheumatoid arthritis (RA), a retrospective British study found.
Nondrinkers had an odds ratio for RA of 4.17 (95% CI 3.01 to 5.77) compared with those who consumed alcohol on more than ten days per month (P for trend <0.0001), James R. Maxwell, MBBS, and colleagues from the University of Sheffield, in England, reported online in Rheumatology.
Advisory panel votes to recommend FDA approval of ticagrelor
The FDA Cardiovascular and Renal Drugs Advisory Committee voted to recommend approval of antiplatelet drug ticagrelor (Brilinta, AstraZeneca) for preventing thrombotic events in patients with acute coronary syndrome. The panel voted seven to one in favor of approving the drug for patients with either ST-elevation-MI or unstable angina/non-ST-elevation MI who will be treated with PCI and then voted seven to one again in favor of STEMI/NSTEMI patients who will be treated with medical management.
Incidence of Delayed Intracranial Hemorrhage in Children After Uncomplicated Minor Head Injuries
This study sought to determine the incidence of delayed diagnosis of intracranial hemorrhage in the general population and the proportion of children who presented to emergency departments (EDs) with uncomplicated minor head injuries who received delayed diagnoses of intracranial hemorrhage. The proportions of children with uncomplicated minor head injuries with delayed diagnoses of intracranial hemorrhage with and without deterioration in level of consciousness were 0.00% (0 of 17 962 children [upper limit of 95% CI: 0.02%]) and 0.03% (5 of 17 962 children [95% CI: 0.01%–0.07%]), respectively. On the basis of population data for the Calgary Health Region, the incidences of delayed diagnosis of intracranial hemorrhage with and without deterioration in level of consciousness were 0.14 and 0.57 cases per 100 000 children per year, respectively. Overall the occurrence of delayed diagnosis of intracranial hemorrhage among children who present with uncomplicated minor head injuries is rare.
Measles-Mumps-Rubella-Varicella Combination Vaccine and the Risk of Febrile Seizures
In February 2008, we alerted the Advisory Committee on Immunization Practices to preliminary evidence of a twofold increased risk of febrile seizures after the combination measles-mumps-rubella-varicella (MMRV) vaccine when compared with separate measles-mumps-rubella (MMR) and varicella vaccines. Now with data on twice as many vaccine recipients, our goal was to reexamine seizure risk after MMRV vaccine. It was found that among 12- to 23-month-olds who received their first dose of measles-containing vaccine, fever and seizure were elevated 7 to 10 days after vaccination. Vaccination with MMRV results in 1 additional febrile seizure for every 2300 doses given instead of separate MMR + varicella vaccines. Providers who recommend MMRV should communicate to parents that it increases the risk of fever and seizure over that already associated with measles-containing vaccines.
Inappropriate Prehospital Ventilation in Severe Traumatic Brain Injury Increases In-Hospital Mortality
In the setting of acute brainstem herniation in traumatic brain injury (TBI), the use of hyperventilation to reduce intracranial pressure may be life-saving. However, undue use of hyperventilation is thought to increase the incidence of secondary brain injury through direct reduction of cerebral blood flow. This retrospective review determined the effect of prehospital hyperventilation on in-hospital mortality following severe TBI. Patients with normocarbia on presenting arterial blood gas testing had in-hospital mortality of 15%, significantly improved over patients presenting with hypocarbia (in-hospital mortality 77%) or hypercarbia (in-hospital mortality 61%). Although there are many reports of the negative impact of prophylactic hyperventilation following severe TBI, this modality is frequently utilized in the prehospital setting. These results suggest that abnormal Pco2 on presentation after severe head trauma is correlated with increased in-hospital mortality and the advocatation of normoventilation in the prehospital setting.
Carotid Atherosclerosis Does Not Predict Coronary, Vertebral, or Aortic Atherosclerosis in Patients With Acute Stroke Symptoms
The purpose of this study was to determine whether significant atherosclerotic disease in the carotid arteries predicts significant atherosclerotic disease in the coronary arteries, vertebral arteries, or aorta in patients with symptoms of acute ischemic stroke. Significant atherosclerotic disease was defined as >50% stenosis in the carotid, coronary, and vertebral arteries, or 4 mm thickness and encroaching in the aorta. Presence of any and significant atherosclerotic disease was compared in the different types of arteries assessed. Overall it was found that significant atherosclerotic disease in the carotid arteries does not predict significant atherosclerotic disease in the coronary arteries, vertebral arteries, or aorta in patients with symptoms of acute ischemic stroke. Significant atherosclerotic disease is most often isolated to 1 type of artery in these patients, whereas nonsignificant atherosclerotic disease tends to be more systemic.
Risk Profiles and Treatment Patterns Among Men Diagnosed as Having Prostate Cancer and a Prostate-Specific Antigen Level Below 4.0 ng/mL
Despite controversy over the benefit of prostate-specific antigen (PSA) screening, little is known about risk profiles and treatment patterns in men diagnosed as having prostate cancer who have a PSA value less than or equal to 4.0 ng/mL. This study found that most men diagnosed as having prostate cancer with a PSA threshold below 4.0 ng/mL had low-risk disease but underwent aggressive local therapy. Lowering the biopsy threshold but retaining our inability to distinguish indolent from aggressive cancers might increase the risk of overdiagnosis and overtreatment.
Comparing the efficacy and safety of two regimens of sequential systemic corticosteroids in the treatment of acute exacerbation of bronchial asthma
Corticosteroids are commonly used in the management of acute asthma. However, studies comparing various steroids in the management of acute asthma are lacking.This article compared the efficacy and safety of two treatment regimens - intravenous (IV) methylprednisolone (MP) followed by oral MP and IV hydrocortisone (HC) followed by oral prednisolone in acute bronchial asthma patients. This study found that in acute asthma patients, IV MP followed by oral MP is a more efficacious and safer treatment regimen than IV HC followed by oral prednisolone.
The value of pre-operative magnetic resonance cholangiopancreatography (MRCP) in management of patients with gall stones
This article analyzed the influence of pre-operative MRCP on the management of patients with gall stones through a prospective randomized study was carried on 250 patients who underwent laparoscopic cholecystectomy within 3 years. It found that MRCP is diagnostically useful in management of patients with gall stones prior to laparoscopic cholecystectomy and its routine use can reduce the incidence of post-operative complications.
Levodopa-carbidopa May Improve Vision loss in Indirect Traumatic Optic Neuropathy
To compare the effect of levodopa-carbidopa on the visual outcome of patients with indirect traumatic optic neuropathy (ITON), this randomized, double-blind, placebo-controlled study was conducted on 32 patients with ITON within 6 days after trauma. In the levodopa group the visual acuity improved significantly after treatment, but not in the placebo group. In those who had visual acuity ≤ figure count, significant improvement in the visual acuity was observed in the levodopa group but not in the placebo group. However, the final visual acuity in these patients was comparable after treatment (p=0.21). Nine patients (56.2 %) in the levodopa group and 1 (10%) in the placebo group experienced improvement in visual acuity (p=0.02). The frequency of unrecordable PVEPs were comparable in both groups (p=0.09). Patients treated with levodopa within 6 days of onset of ITON were more likely to experience improvement in visual acuity than those in the placebo group.
Generic Version of Lovenox Okayed
The FDA has approved the first generic low molecular weight heparin product -- a generic version of Lovenox (enoxaparin sodium injection) for the prevention of deep vein thrombosis.
Approval was given to Sandoz of Broomfield, Colo. -- a unit of Novartis AG -- to make the following strengths of the injectable anticoagulant -- 30 mg/0.3 mL, 40 mg/0.4 mL, 60 mg/0.6 mL, 80 mg/0.8 mL, 100 mg/mL, 120 mg/0.8 mL, and 150 mg/mL.
The FDA's decision came following consideration of a citizen petition filed in 2003 by Aventis Pharmaceuticals (now sanofi-aventis), maker of the branded form of enoxaparin sodium (Lovenox).
Dengue Fever Showing Up In Central Florida
Dengue fever has infected a handful of people in Central Florida, health officials said. “This is not a regular flu virus that you get, you feel a lot worse,” said Dr. Todd Husty. “You get a real great fever, a horrible fever; it's called ‘break bone fever.’ You feel like your bones are breaking, but it's really joint pain,” Husty said. Health officials said more than a dozen people have picked up the virus from Mosquitoes in the Keys.
The Association Between Statin Use and the Diagnosis of Prostate Cancer in a Population Based Cohort
The effect of statin medication use on the risk of prostate cancer is unknown. examined data from a longitudinal, population based cohort of 2,447 men between 40 and 79 years old who were followed from 1990 to 2007. Information on statin use was self-reported and obtained by biennial questionnaires. Of 634 statin users 38 (6%) were diagnosed with prostate cancer vs 186 (10%) of 1,813 nonstatin users. Statin use was associated with a decreased risk of undergoing prostate biopsy (HR 0.31; 95% CI 0.24, 0.40), receiving a prostate cancer diagnosis (HR 0.36; 95% CI 0.25, 0.53) and receiving a high grade (Gleason 7 or greater) prostate cancer diagnosis (HR 0.25; 95% CI 0.11, 0.58). Statin use was also associated with a nonsignificantly decreased risk of exceeding a prostate specific antigen threshold of 4.0 ng/ml (HR 0.63; 95% CI 0.35, 1.13). In addition, a longer duration of statin use was associated with a lower risk of these outcomes (all tests for trend p <0.05).
Obesity in Early Adulthood as a Risk Factor for Psoriatic Arthritis
This article studied whether obesity increases the risk of psoriatic arthritis (PsA), given that obesity is a risk factor for psoriasis and is associated with more severe disease. Overall it was found that BMI at age 18 years was predictive of PsA (odds ratio [OR], 1.06) (P < .01) over and above control variables. Other variables that were predictors of PsA included younger age at psoriasis onset, female sex, higher worst-ever BSA involvement with psoriasis , Koebner phenomenon , and nail involvement. This study suggests that obesity at age 18 years increases the risk of developing PsA. Adiposity is associated with higher levels of inflammatory cytokines known to be associated with psoriasis. This inflammatory milieu could increase the risk of PsA in predisposed subjects. Prevention and early treatment of obesity may decrease the risk of PsA.
Knee ligament tears often need no surgery
Most people who have a common knee ligament injury fare just as well with intense physical therapy as they do with surgery, according to a study comparing the two techniques released on Wednesday. Researchers said that focusing on rehabilitation first could prevent more than half of operations done to repair a tear in the anterior cruciate ligament (ACL), which lies beneath the kneecap and attaches the thigh bone to the shin bone.
No Pap smears for women under 21: guidelines
Pap smears in women under 21 do more harm than good, new guidelines from the American College of Obstetricians and Gynecologists (ACOG) say.In most cases such tests reveal only human papillomavirus (HPV) infections, which rarely lead to cervical cancer in women under 21, said Dr. Mark Einstein of the Albert Einstein College of Medicine (no relation) in the Bronx, New York.
Randomized comparison of Limberg flap versus modified primary closure for the treatment of pilonidal disease
The best surgical technique for sacrococcygeal pilonidal disease is still controversial. The aim of this randomized prospective trial was to compare both the results of Limberg flap procedure and primary closure.
Success of surgery was achieved in 84.62% of Limberg flap patients versus 77.69% of primary closure for which the surgical time for primary closure was shorter, also having a higher wound infection was more frequent in the primary closure group (P = .0254), but experienced less postoperative pain (P < .0001). Recurrence was observed in 3.84% versus 0% in the primary closure versus Limberg flap group. These results do not show a clear benefit for surgical management by Limberg flap or primary closure. Limberg flap showed less convalescence and wound infection; our technique of tension-free primary closure was a day case procedure, less painful, and shorter than Limberg flap.
Peripherally Inserted Central Catheters May Lower the Incidence of Catheter-Related Blood Stream Infections in Patients in Surgical Intensive Care Units
Long-term central venous catheterization is associated with a higher rate of catheter-related blood stream infections (CR-BSI). It is unclear whether there is a difference in the CR-BSI rate associated with central venous catheters (CVCs) and peripherally inserted central catheters (PICCs) in long-stay patients in surgical intensive care units (SICUs). This article hypothesized that PICC use reduces the rate of CR-BSI compared with use of antiseptic CVCs in these patients. In this non-randomized study, PICC was associated with fewer CR-BSIs in long-stay SICU patients, although CVCs were in place longer than PICC lines. The only predictor of CVC infection was the duration the line was in place. These results suggest that minimizing the duration of central venous access and substituting PICC for CVC may reduce the incidence of CR-BSI in long-stay SICU patients.
Angiotensin Receptor Blockers (ARBs): Ongoing Safety Review for Cancer Risk
A recently published study - a meta-analysis combining cancer-related findings from several clinical trials - suggested use of ARBs may be associated with a small increased risk of cancer. The meta-analysis included data from over 60,000 patients in several long-term, randomized, controlled clinical trials evaluating ARBs for which adverse events related to cancer were captured during the study. The mean duration of follow-up ranged from 1.7 to 4.8 years.The study reported the frequencies of new cancer occurrence to be 7.2% for patients receiving ARBs compared to 6.0% for those not receiving ARBs (risk ratio = 1.08, 95% Confidence Interval: 1.01-1.15).FDA has not concluded that ARBs increase the risk of cancer. The Agency is reviewing information related to this safety concern and will update the public when additional information is available. FDA believes the benefits of ARBs continue to outweigh their potential risks.
Colorectal cancer screening test more accurate in winter than summer
Study results show that the immunochemical fecal occult blood test (iFOBT) for detecting colorectal cancer is approximately 13% less accurate in the summer than in the winter. In this study, Grazia Grazzini (Cancer Prevention and Research Institute, Florence, Italy) and colleagues analyzed 199,654 iFOBT results taken as part of the Florence regional colorectal cancer screening program. Overall, the researchers found that there was a 13% lower probability of detecting a cancer or an advanced adenoma with iFOBT in the summer than the winter. Writing in the journal Gut, the investigators warn: "These results will have important implications for the organization of iFOBT-based screening programs, particularly in countries with high ambient temperatures."
Two-step vaccine may offer "universal" flu jab
A two-step flu vaccine using DNA to "prime" the immune system and then a traditional seasonal influenza vaccine may be able to protect against all strains of the virus -- providing a long-sought "universal" flu vaccine, U.S. researchers said on Thursday. The team at the National Institute of Allergy and Infectious Diseases is already testing the new vaccine in people and says the results of tests in mice, ferrets and monkeys suggest the industry may finally be able to dump the cumbersome process of making fresh flu vaccines every year.
First-Void Urine Predicts Renal Events
The albumin:creatinine ratio from a first-void urine sample significantly outperformed other parameters for predicting future renal events in patients with diabetic nephropathy, investigators in a multinational study concluded.
A one-standard-deviation increase in the ratio quadrupled the likelihood of an adverse renal event. The albumin:creatinine ratio based on a first-morning void proved superior to urinary protein excretion, urinary albumin excretion, and urinary albumin concentration for predicting renal events.
The findings have potentially far-reaching implications for following diabetic patients with established nephropathy.
Are 2 smaller intravenous catheters as good as 1 larger intravenous catheter?
Using Poiseuille's law and standardized gauge sizes, an 18-gauge (g) intravenous catheter (IV) should be 2.5 times faster than a 20-g IV, but this is not borne out by observation, in vitro testing, and manufacturer's data. This article sought to determine if the infusion rate of a single 18-g IV was equivalent to the infusion rate of two 20-g IVs.
The mean infusion rate for a single 18-g 500-mL IV administration was 35.6 mL/min (95% confidence interval [CI], 30.3-40.8), with manufacturer's rating being 105 mL/min. The mean infusion rate for two 20-g IVs was 41.3 mL/min (95% CI, 36.1-46.4), with manufacturer's rating being 120 mL/min. The rate of infusion via two 20-g IVs were statistically significantly faster than the single 18-g IV, with a mean difference in flow rate of 5.7 mL/min.
Circadian, day-of-week, and age patterns of the occurrence of acute coronary syndrome
Previous in-hospital studies suggest that there are significant circadian rhythms associated with the incidence of acute coronary syndromes (ACSs). No study to date has examined the presentation of ACS in the prehospital setting. This article sought to examine circadian, day-of-week, and age patterns of occurrence ACS. It was found that the presentation of ACS has significant circadian rhythm characterized by 2 peaks within 24 hours, the morning peak is 0800 to 1000, and the late evening peak is 2200 to 2400 and no significant weekly rhythm observed in the present study.
Psychiatric Emergencies in the Elderly
Psychiatric emergencies are common among the elderly. Diagnosis and treatment can pose a significant challenge because of the high incidence of medical and neurological comorbidities, psychosocial problems, and adverse effects of medications. The most common psychiatric emergencies in this population are delirium, depression with suicidality, substance abuse, and dementia accompanied by aggression. This article identifies key issues that will allow psychiatrists to diagnose, assess, and manage these prevalent psychiatric emergencies in geriatric patients.
Dietary Antioxidants and Long-term Risk of Dementia
The Rotterdam Study previously found that higher dietary intakes of vitamins E and C related to lower risk of dementia and Alzheimer disease (AD) over 6 years of follow-up.This article studied the consumption of major dietary antioxidants relative to long-term risk of dementia. Compared with participants in the lowest tertile of vitamin E intake, those in the highest tertile were 25% less likely to develop dementia (hazard ratio, 0.75; 95% confidence interval, 0.59-0.95 with adjustment for potential confounders). Dietary intake levels of vitamin C, beta carotene, and flavonoids were not associated with dementia risk after multivariate adjustment concluding that higher intake of foods rich in vitamin E may modestly reduce long-term risk of dementia and AD.
Overtime work increases the incident of coronary heart disease
This article examined the association between overtime work and incident coronary heart disease (CHD) among middle-aged employees. It followed Six thousand and fourteen British civil servants (4262 men and 1752 women), aged 39–61 years who were free from CHD and worked full time at baseline (1991–1994), were followed until 2002–2004, an average of 11 years. The outcome measure was incident fatal CHD, clinically verified incident non-fatal myocardial infarction (MI), or definite angina (a total of 369 events). It found that overtime work is related to increased risk of incident CHD independently of conventional risk factors, suggesting that overtime work adversely affects coronary health.
Dronedarone in patients with congestive heart failure
Dronedarone is a new multichannel blocking antiarrhythmic drug for treatment of atrial fibrillation (AF). In patients with recently decompensated congestive heart failure (CHF) and depressed LV function, the drug was associated with excess mortality compared with a placebo group. The present study aimed to analyse in detail the effects of dronedarone on mortality and morbidity in AF patients CHF. It showed that patients with AF and stable CHF, dronedarone did not increase mortality and showed a reduction of CV hospitalization or death similar to the overall population. However, in the light of the ANtiarrhythmic trial with DROnedarone in Moderate to severe CHF Evaluating morbidity DecreAse study, dronedarone should be contraindicated in patients with NYHA class IV or unstable NYHA classes II and III CHF.
Tamoxifen Infrequently Used by Women at Risk for Breast Cancer
The prevalence of tamoxifen use for the primary prevention of breast cancer is "exceptionally low" among women in the United States, according to an analysis of National Health Interview Survey (NHIS) data published recently in Cancer Epidemiology, Biomarkers & Prevention (2010;19:443-446).
According to results of the Breast Cancer Prevention Trial published in 1998, tamoxifen reduced the risk of developing invasive breast cancer by 49%, and the relative risk reduction for estrogen receptor-positive invasive breast cancer was 69% (J Natl Cancer Inst. 1998;90:1371-1988). Despite this substantial risk reduction, subsequent studies have indicated that tamoxifen is used for chemoprevention by only a very small percentage of eligible women.
Non-culprit coronary artery percutaneous coronary intervention during acute ST-segment elevation myocardial infarction
This article examined the incidence of and propensity for non-culprit interventions performed at the time of the primary percutaneous coronary intervention (PCI) and its association with 90-day outcomes. Overall it found that non-culprit coronary interventions were performed at the time of primary PCI in 10% of MVD patients and were significantly associated with increased mortality. This data supports current guideline recommendations discouraging the performance of such procedures in stable primary PCI patients. Prospective randomized study of this issue may be warranted.
Lactulose versus Polyethylene Glycol for Chronic Constipation
Constipation is a common clinical problem. Lactulose and Polyethylene Glycol (PEG) are both commonly used osmotic laxatives that have been shown to be effective and safe treatments for chronic constipation. However, there is no definitive data as to which provides the best treatment. This Cochrane Review reviewed all relevant data in order to determine whether Lactulose or Polyethylene Glycol is more effective at treating chronic constipation and faecal impaction. In the present meta-analysis the findings of our work indicate that Polyethylene glycol is better than lactulose in outcomes of stool frequency per week, form of stool, relief of abdominal pain and the need for additional products.
Detection of Aortic Regurgitation with 64-slice Multidetector Computed Tomography (MDCT)
An article in this months Academic Radiology sought to determine the diagnostic accuracy of 64-row multidetector cardiac computed tomography (MDCT) in detecting aortic regurgitation (AR) on prospectively acquired images with trans-thoracic echocardiography (TTE) as a reference standard. The sensitivity, specificity, positive predictive value, and negative predictive value of MDCT were 100%, 85.7%, 93.5%, and 100%, respectively, showing that MDCT data acquired for the coronary artery evaluation can be used for the detection of aortic regurgitation with high diagnostic accuracy without additional scanning or radiation and can support appropriate referral for TTE.
Combined antiplatelet prophylaxis fails to impact stroke severity
Adding clopidogrel to aspirin treatment in patients at high vascular risk has no effect on the severity of later stroke, say the CHARISMA investigators. The primary finding of the CHARISMA (Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management and Avoidance) trial was that the addition of clopidogrel to aspirin therapy did not reduce the rate of stroke, myocardial infarction, or vascular death in high-risk patients, relative to aspirin alone.
Heart Rate Linked to Progression of Kidney Disease
High resting heart rate and low heart rate variability are both related to the development of renal impairment, researchers found.
Both factors were significantly associated with chronic kidney disease-related hospitalizations and the development of end-stage renal disease, according to Daniel Brotman, MD, of Johns Hopkins Hospital in Baltimore, and colleagues.
The findings have unclear clinical significance, the researchers reported online in the Journal of the American Society of Nephrology.
Depressive Symptoms Increases Risk of Dementia
Depression may be associated with an increased risk for dementia, although results from population-based samples have been inconsistent. This article examined the association between depressive symptoms and incident dementia over a 17-year follow-up period. During the 17-year follow-up period, 164 participants developed dementia; 136 of these cases were AD. A total of 21.6% of participants who were depressed at baseline developed dementia compared with 16.6% of those who were not depressed. Overall depressed participants had more than a 50% increased risk for dementia and AD.
Antibody finding may help in quest for AIDS vaccine
The bodies of some people make these immune system proteins after they are infected with the AIDS virus, when it is too late for them to do much good. But a properly designed vaccine might help the body make them much sooner, the researchers reported in Friday's issue of the journal Science. Two of the antibodies can attach to and neutralize 90 percent of the various mutations of the human immunodeficiency virus that causes AIDS, Nabel said."This is an antibody that evolved after the fact. That is part of the problem we have in dealing with HIV -- once a person becomes infected, the
Routine Ultrasound and Limited Computed Tomography for the Diagnosis of Acute Appendicitis
Acute appendicitis continues to be a challenging diagnosis. Preoperative radiological imaging using ultrasound (US) or computed tomography (CT) has gained popularity as it may offer a more accurate diagnosis than classic clinical evaluation. The optimal implementation of these diagnostic modalities has yet to be established. The aim of the present study was to investigate a diagnostic pathway that uses routine US, limited CT, and clinical re-evaluation for patients with acute appendicitis. Positive and negative predictive values for the clinical diagnosis of appendicitis were 63 and 98%, respectively; for US 94 and 97%, respectively; and for CT 100 and 100%, respectively. The negative appendicitis rate was 3.3%, the perforation rate was 23.5%, and the missed perforated appendicitis rate was 3.4%. This study showed a diagnostic pathway using routine US, limited CT, and clinical re-evaluation for patients with acute abdominal pain can provide excellent results for the diagnosis and treatment of appendicitis.
Computed tomographic colonography in the diagnosis of colorectal cancer
This study aimed to determine the sensitivity of computed tomographic colonography (CTC) in diagnosing colorectal cancer and to explore the reasons why these cancers are missed on CTC. Patients who underwent CTC in the 56-month period from 1 January 2004 to 1 September 2008, and all cases of colorectal cancer recorded in the National Cancer Registry database from 1 January 2004 to 1 December 2008, were identified. Overall the sensitivity of 95 per cent for CTC in the diagnosis of colorectal cancer compares favourably with that of double-contrast barium enema (92 per cent) and colonoscopy (94 per cent).
Femoral-Based Central Venous Oxygen Saturation Is Not a Reliable Substitute for Subclavian/Internal Jugular-Based Central Venous Oxygen Saturation
Central venous oxygen saturation (Scvo2) has been used as a surrogate marker for mixed venous oxygen saturation (Svo2). Femoral venous oxygen saturation (Sfvo2) is sometimes used as a substitute for Scvo2. The purpose of this study is to test the hypothesis that these values can be used interchangeably in a population of patients who are critically ill. This study revealed a significant difference between paired samples of Scvo2 and Sfvo2. More than 50% of Scvo2 and Sfvo2 values diverged by > 5%. Sfvo2 is not always a reliable substitute for Scvo2 and should not routinely be used in protocols to help guide resuscitation.
Routine Fractional Flow Reserve Measuremnet During Angiography for Guiding Percutaneous Coronary Intervention Shows Benefit at 2 Years
In patients with multivessel CAD undergoing PCI, coronary angiography is the standard method for guiding stent placement. The FAME (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) study showed that routine FFR in addition to angiography improves outcomes of PCI at 1 year. It is unknown if these favorable results are maintained at 2 years of follow-up. The purpose of this study was to investigate the 2-year outcome of percutaneous coronary intervention (PCI) guided by fractional flow reserve (FFR) in patients with multivessel coronary artery disease (CAD).The results showed that routine measurement of FFR in patients with multivessel CAD undergoing PCI with drug-eluting stents significantly reduces mortality and myocardial infarction at 2 years when compared with standard angiography-guided PCI.
The potential impact of using glycated haemoglobin as the preferred diagnostic tool for detecting Type 2 diabetes mellitus
There are calls to simplify the diagnosis of Type 2 diabetes mellitus (T2DM) to reduce the burden of undiagnosed disease. Glycated haemoglobin (HbA1c) is therefore being considered as a preferred diagnostic tool to replace the need for an oral glucose tolerance test (OGTT), considered by many as cumbersome and inconvenient. The aim of this study was to examine the potential impact of the preferred use of HbA1c as a diagnostic tool on the prevalence and phenotype of T2DM. Within this multi-ethnic cohort, it was found that introducing HbA1c≥6.5% as the preferred diagnostic test to diagnose T2DM significantly increased numbers detected with T2DM; however, some people were no longer detected as having T2DM.
Outcomes of patients with severe traumatic brain injury who have Glasgow Coma Scale scores of 3 or 4 and are over 65years old
The objective of the study was to investigate the outcomes of patients with traumatic brain injury (TBI) who had Glasgow Coma Scale (GCS) scores of 3 or 4, and were aged 66 years or older. The Factors having significant effect on outcomes were ISS, TRISS and AIS head. Closed or partially closed basal cisterns and/or midline shift > 15mm were associated with unfavorable outcome. SAH was associated with favorable outcome. Patients with GCS 3 or 4 and older than 65 years have a poor, but not hopeless prognosis. Confirmed factors of poor prognosis for this group of patients are closed basal cisterns and midline shift >15 mm on the first CT. Factors possibly related to favorable outcomes were female gender, lower trauma severity, open or partially open basal cisterns and no midline shift on first CT scan.
A meta-analysis of randomized trials for the treatment of nonalcoholic fatty liver disease
Nonalcoholic fatty liver disease (NAFLD) encompasses a histological spectrum ranging from simple steatosis to nonalcoholic steatohepatitis (NASH). NAFLD carries a higher risk of cardio-metabolic and liver-related complications, the latter being confined to NASH and demanding specific treatment. This article assessed the efficacy of proposed treatments for NAFLD/NASH by reviewing reports of randomized controlled trials (RCTs) on online databases and national and international meeting abstracts through January 2010.
Most RCTs were small and did not exceed 1-year duration. Weight loss, thiazolidinediones (especially pioglitazone), and antioxidants were most extensively evaluated. Of them none of them yielded significant results suggesting that well-designed RCTs of adequate size and duration, with histological endpoints, are needed to assess long-term safety and efficacy of proposed treatments on patient-oriented clinical outcomes.
Spread of Pneumocystis jirovecii in the Surrounding Air of Patients with Pneumocystis Pneumonia
Airborne transmission of Pneumocystis has been demonstrated in animal models and is highly probable in humans. However, information concerning burdens of Pneumocystis jirovecii (human‐derived Pneumocystis) in exhaled air from infected patients is lacking. This study sought to evaluate P. jirovecii air diffusion in patients with Pneumocystis pneumonia and provides the first quantitative data on the spread of P. jirovecii in exhaled air from infected patients. It sustains the risk of P. jirovecii direct transmission in close contact with patients with Pneumocystis pneumonia and leads the way for initiating a quantitative risk assessment for airborne transmission of P. jirovecii.
Azithromycin Combination Therapy for the Treatment of Uncomplicated Falciparum Malaria
In recent studies, the combination of azithromycin and artesunate has proven to be a promising alternative for the treatment of uncomplicated falciparum malaria. This study conducted a randomized, controlled clinical trial assessing the efficacy of azithromycin‐artesunate combination therapy. The 42‐day cure rate by Kaplan‐Meier analysis was 94.6% in the azithromycin‐artesunate arm and 97.0% in the control arm. Fever clearance times and parasite clearance times did not show any differences between the 2 arms suggesting that azithromycin‐artesunate is an efficacious and well‐tolerated treatment for patients with uncomplicated falciparum malaria.
Another leaked rosiglitazone manuscript? Controversy spikes as JAMA, Archives publish new papers
The heat facing rosiglitazone (Avandia, GlaxoSmithKline) in the run-up to the drug's July FDA rereview is spiking to new heights on allegations from FDA scientist Dr David Graham that someone else at the agency leaked his rosiglitazone manuscript to a popular blog in the hopes that the Journal of the American Medical Association (JAMA) would opt not to publish it.
Efficacy and Safety of Long-Term Fluoxetine Versus Lithium Monotherapy of Bipolar II Disorder
The authors examined the safety and efficacy of long-term fluoxetine monotherapy, lithium monotherapy, and placebo therapy in preventing relapse and recurrence of bipolar type II major depressive episode. Patients at least 18 years old who recovered from their major depressive episode during initial open-label fluoxetine monotherapy were randomly assigned to receive 50 weeks of double-blind monotherapy with fluoxetine at 10–40 mg/day, lithium at 300–1200 mg/day, or placebo. The mean time to relapse was 249.9 days for the fluoxetine group, 156.4 days for the lithium group, and 186.9 days for the placebo group. The hazard of relapse was significantly lower with fluoxetine compared with lithium, and the estimated hazard of relapse with lithium was 2.5 times greater than with fluoxetine suggesting that long-term fluoxetine monotherapy may provide superior relapse-prevention benefit relative to lithium monotherapy after recovery from bipolar II major depressive episode without an increase in hypomanic mood conversion episodes.
Local Intra-arterial Fibrinolysis in Central Retinal Artery Occlusion versus Conservative Treatment Doesn't Show Benefit
The reported outcomes of central retinal artery occlusion (CRAO) with or without treatment vary considerably. Although local intra-arterial fibrinolysis (LIF) using recombinant tissue plasminogen activator (rtPA) is a promising treatment, outcomes have not been compared in randomized trials. This Prospective randomized multicenter clinical trial (the European Assessment Group for Lysis in the Eye Study) to compare treatment outcome after conservative standard treatment (CST) and LIF for acute nonarteritic CRAO. In light of these 2 therapies' similar outcomes and the higher rate of adverse reactions associated with LIF, we cannot recommend LIF for the management of acute CRAO.
Trimethoprim-Sulfamethoxazole–Induced Hyperkalemia in Patients Receiving Inhibitors of the Renin-Angiotensin System
Trimethoprim therapy can cause hyperkalemia and is often coprescribed with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs). The objective of this study was to characterize the risk of hyperkalemia-associated hospitalization in elderly patients who were being treated with trimethoprim-sulfamethoxazole along with either an ACEI or an ARB. Compared with amoxicillin, the use of trimethoprim-sulfamethoxazole was associated with a nearly 7-fold increased risk of hyperkalemia-associated hospitalization concluding that among older patients treated with ACEIs or ARBs, the use of trimethoprim-sulfamethoxazole is associated with a major increase in the risk of hyperkalemia-associated hospitalization relative to other antibiotics.
Probiotics may help babies with constipation
Some probiotics may help treat chronic constipation in babies, according to a new study. In this study, the researchers used a bacterium called Lactobacillus reuteri, which is found naturally in the intestines of some people. The bug was named after the German microbiologist who discovered it, Gerhard Reuter. Babies taking probiotics had significantly more bowel movements than babies on the placebo after two, four, and eight weeks, suggesting an improvement in their constipation. At the beginning of the study, the probiotic babies had, on average, less than three bowel movements per week. By week eight, they had an average of almost five.
While not going so far as to recommend that parents of infants with constipation run to the pharmacy for probiotics, the authors conclude that "probiotics as a natural, safe, and well-tolerated treatment may provide a simple and attractive way" to treat chronic constipation in babies.
Increased Risks in Elderly Medicare Patients Treated With Rosiglitazone or Pioglitazone
Studies have suggested that the use of rosiglitazone may be associated with an increased risk of serious cardiovascular events compared with other treatments for type 2 diabetes. To determine if the risk of serious cardiovascular harm is increased by rosiglitazone compared with pioglitazone, the other thiazolidinedione marketed in the United States. This was a nationwide, observational, retrospective, inception cohort of 227 571 Medicare beneficiaries aged 65 years or older (mean age, 74.4 years) who initiated treatment with rosiglitazone or pioglitazone through a Medicare Part D prescription drug plan from July 2006-June 2009 and who underwent follow-up for up to 3 years after thiazolidinedione initiation. Compared with prescription of pioglitazone, prescription of rosiglitazone was associated with an increased risk of stroke, heart failure, and all-cause mortality and an increased risk of the composite of AMI, stroke, heart failure, or all-cause mortality in patients 65 years or older.
Cardiovascular Risk in Clopidogrel-Treated Patients According to Cytochrome P450 2C19*2 Loss-of-Function Allele or Proton Pump Inhibitor Coadministration
The aim of this study was to assess the association between the loss-of-function cytochrome P450 2C19 (CYP2C19)*2 variant (10 studies, 11,959 patients) or the use of proton pump inhibitors (PPIs) (13 studies, 48,674 patients) and ischemic outcomes (major adverse cardiovascular events [MACE]) in patients treated with clopidogrel. Of the 11,959 patients, carriers of the loss-of-function CYP2C19*2 allele (28% [n = 3,418]) displayed a 30% increase in the risk for MACE compared with noncarriers, this single gene variant was also associated with an excess of mortality and of stent thrombosis. This increased risk was apparent in both heterozygotes and homozygotes and was independent of the baseline cardiovascular risk. PPI users displayed increased risk for MACE and mortality compared with nonusers. The impact of PPI use was, however, significantly influenced by baseline cardiovascular risk, being significant only in high-risk patients.
CT evaluation of the low severity cervical spine trauma: When is the scout view enough?
The aim of the current study was to compare the diagnostic information obtained from a helical CT examination in low severity cervical spine trauma with that from a lateral CT scout view. Overall sensitivity and specificity of scout view was 70% and 100%, respectively. There were three false negative and one false positive cases. The effective dose value was estimated to be 0.02 mSv which is at least two orders of magnitude lower than that from a CT scan. When clinical examination is not suggestive of a C1–C2 fracture, adequate depiction of an intact cervical spine at the scout view, without proceeding to a full CT scan, is a sufficient dose and time-effective imaging approach.
No pancreatitis risk seen in Byetta, Januvia drugs
Two widely used diabetes medicines, Januvia and Byetta, pose no additional risk for cases of inflamed pancreas compared with other diabetes drugs, according to an analysis of medical claims data released on Sunday. The study also found that diabetics generally are at increased risk of acute pancreatitis, compared with non-diabetics, which the study's author said confirmed previous research, although the risk remains very low.
Role of Prophylactic Antibiotics in Laparoscopic Cholecystectomy and Risk Factors for Surgical Site Infection
The aim of this clinical trial was to determine whether prophylactic antibiotics could prevent surgical site infection (SSI) after laparoscopic cholecystectomy and to identify any risk factors for infection. The study included 100 patients undergoing laparoscopic cholecystectomy. They were randomized to receive either a single dose of ceftriaxone or physiologic saline as placebo. It was shown that a single dose of prophylactic antibiotic failed to decrease the likelihood of SSI after laparoscopic cholecystectomy.
Postoperative Calcium Requirements in 6,000 Patients Undergoing Outpatient Parathyroidectomy: Easily Avoiding Symptomatic Hypocalcemia
This study sought to determine the amount and duration of supplemental oral calcium for patients with varying clinical presentations discharged immediately after surgery for primary hyperparathyroidism. Overall there were seven parameters found to have a substantial impact on the amount of calcium required to prevent symptomatic hypocalcemia: preoperative serum calcium >12 mg/dL, >13 mg/dL, and >13.5 mg/dL, bone density T score less than −3, morbid obesity, removal of >1 parathyroid, and manipulation/biopsy of all remaining glands (all p < 0.05). Each independent variable increased the daily calcium required by 315 mg/day. Using our scaled protocol, <8% of patients showed symptoms of hypocalcemia, nearly all of whom were successfully self-treated with additional oral calcium. Only 6 patients (0.1%) required a visit to the emergency room for IV calcium, all occurring on postoperative day 3 or later.
Clinical course of guttate psoriasis generally good
Study results indicate that guttate psoriasis tends to have a better prognosis than other types of psoriasis, but researchers warn that progression of the guttate form of psoriasis into the chronic plaque form is not uncommon. Moon-Bum Kim, from Pusan National University in Busan, Korea, and colleagues followed the clinical course of guttate psoriasis in 26 patients and found that 22 (61.1%) experienced complete involution of their psoriasis with long remission of at least 1 year, whereas the remaining 14 (38.9%) patients showed incomplete involution and progressed into chronic psoriasis within an average of 6 years.
Rapid Test to Detect Hepatitis C Approved
The OraQuick HCV Rapid Antibody Test to detect antibodies from the hepatitis C virus has been approved by the U.S. Food and Drug Administration. The blood diagnostic is a test strip that does not require an additional device to obtain results in about 20 minutes, the agency said in a news release.
The efficacy of physiotherapy upon shoulder function following axillary dissection in breast cancer
Many patients suffer from severe shoulder complaints after breast cancer surgery and axillary lymph node dissection. Physiotherapy has been clinically observed to improve treatment of these patients. However, it is not a standard treatment regime. The purpose of this study is to investigate the efficacy of physiotherapy treatment of shoulder function, pain and quality of life in patients who have undergone breast cancer surgery and axillary lymph node dissection. Overall quality of life improved significantly, however, handgrip strength and arm volume did not alter significantly showing that physiotherapy reduces pain and improves shoulder function and quality of life following axillary dissection after breast cancer.
Migraine Headache and Ischemic Stroke Risk: An Updated Meta-analysis
Observational studies, including recent large cohort studies that were unavailable for prior meta-analysis, have suggested an association between migraine headache and ischemic stroke. This article performed an updated meta-analysis to quantitatively summarize the strength of association between migraine and ischemic stroke risk and found that migraine is associated with increased ischemic stroke risk. These findings underscore the importance of identifying high-risk migraineurs with other modifiable stroke risk factors. Future studies of the effect of migraine treatment and modifiable risk factor reduction on stroke risk in migraineurs are warranted.
New CDC Guidelines Recommend Use of Blood Tests to Diagnose TB in Certain Populations
The Centers for Disease Control and Prevention (CDC) has issued new guidelines on the detection of Mycobacterium tuberculosis infections.
In these landmark guidelines, the CDC advises that Interferon Gamma Release Assay (IGRA) blood tests are now preferred over the tuberculin skin test (TST) for diagnosing tuberculosis (TB) infection in certain populations, including people who typically do not return for the necessary reading of TST results, and those who have received Bacille Calmette-Guérin (BCG) as a vaccine or for cancer therapy. The CDC report appears in the June 25 issue of the CDC's Morbidity & Mortality Weekly Report (MMWR).
Acute otitis media: To follow-up or treat?
Acute otitis media (AOM) is the most common diagnosis for which antibiotics are prescribed in children. However, due to their widespread use, we are witnesses to increased development of bacterial resistance to antibiotics. The purpose of this study was to evaluate the necessity of antibiotic treatment in patients with AOM. After symptomatic therapy, resolution of the disease, without use of any antibiotics, was established in 61% of patients, compared to the overall sample of children with AOM. None of the children developed complications that would require surgical treatment. In the second group of children, receiving antibiotics, almost the same therapeutic effects (80%) were achieved with the use of amoxicillin, amoxicillin-clavulanate and cefixime, while the worst results were obtained after using azithromycin.
The wait-and-see approach is recommended in forms of AOM without serious signs and symptoms, because it significantly reduces the use of antibiotics and their potential adverse effects.
The Presence of Urinary Nitrites Is a Significant Predictor of Pediatric Urinary Tract Infection Susceptibility to First- and Third-Generation Cephalosporins
Previous studies in adults have refuted the use of nitrites as a predictor of bacterial resistance to both trimethoprim-sulfamethoxazole and cephalosporins. Some centers now consider first-line outpatient therapy with an oral third-generation cephalosporin appropriate for young children. The objective of this study was to determine if nitrite-negative pediatric urinary tract infections (UTIs) were more likely than nitrite-positive UTIs to be resistant to cephalosporins. The absence of urinary nitrites is a significant indicator for potential resistance to cephalosporins in pediatric UTIs. Due to low levels of pediatric UTI resistance, cephalosporins continue to represent useful empiric therapy in the general pediatric population. However, in high-risk patients, physicians may opt to alter their empiric choice of antibiotic based on the presence of urinary nitrites.
Treating Headache Recurrence After Emergency Department Discharge: A Randomized Controlled Trial of Naproxen Versus Sumatriptan
Multiple parenteral medications are used to treat migraine and other acute primary headaches in the emergency department (ED). Regardless of specific headache diagnosis, no medication eliminates the frequent recurrence of primary headache after ED discharge. It is uncertain which medication primary headache patients should be given on discharge from an ED. The aim of this study is to compare the efficacy of oral sumatriptan with naproxen for treatment of post-ED recurrent primary headache. In this trial, nearly three quarters of patients reported headache recurrence within 48 hours of ED discharge. Naproxen 500 mg and sumatriptan 100 mg taken orally relieve post-ED recurrent primary headache and migraine comparably. Clinicians should be guided by medication costs, contraindications, and a patient's previous experience with the medication.
Meta-Analysis Confirms Febuxostat Utility in Gout Patients
A meta-analysis has found that febuxostat (Uloric), a nonpurine xanthine oxidase inhibitor, was able to lower serum uric acid to normal levels (less than 6 mg/dL) in gout patients after barely a month of therapy, researchers reported here. Pooled data from five studies of more than 1,000 patients, found that progressively stronger doses of febuxostat substantially lowered serum uric acid levels within a month compared with placebo, with the strongest dose (120 mg) producing a 68 times greater chance of reaching normal levels within 28 days, said Jean H. Tayar, MD, assistant professor of medicine at the University of Texas M.D. Anderson Cancer Center, Houston.
Left Main Disease Treated With Either Percutaneous Coronary Intervention Using Paclitaxel-Eluting Stents or Coronary Artery Bypass Graft Treatment
Contemporary consensus treatment guidelines continue to recommend coronary artery bypass grafting (CABG) as the "gold standard" for revascularization of unprotected left main (LM) stenosis but note that percutaneous coronary intervention (PCI) is feasible; for example, the American College of Cardiology/American Heart Association PCI guidelines recently upgraded LM PCI from a class III to class IIb (level B) recommendation. In the absence of a large randomized controlled trial, interventional cardiologists have had difficulty developing objective evidence-based criteria for determining the optimal revascularization strategy for a given patient. The Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) trial is the first large trial to randomize patients suitable for revascularization by either CABG or PCI using drug-eluting stents for the treatment of LM and/or 3-vessel disease. This article presents outcomes in the prespecified subgroup of patients (N=705) with LM disease. Patients with LM disease had comparable overall 12-month major adverse cardiovascular and cerebrovascular events in both the PCI and the CABG group (14% CABG versus 16% PCI). When patients were scored for anatomic complexity, those with higher baseline SYNTAX scores had significantly worse outcomes with PCI than those with low or intermediate SYNTAX scores; outcomes for patients with CABG did not correlate with baseline SYNTAX score. Thus, this short-term (1-year) analysis suggests that patients with LM disease who have low or intermediate SYNTAX scores may be safely treated with either PCI or CABG, but longer follow-up is needed.
Emergence of New Virulent Neisseria meningitidis Serogroup C Sequence Type 11 Isolates in France
In France, there have been variations in the incidence of invasive meningococcal infection due to serogroup C isolates. Infection peaks were observed in 1992 and 2003 that involved isolates of phenotypes C:2a:P1.5,2 and/or C:2a:P1.5, which belong to the sequence type 11 (ST‐11) clonal complex. We report an emergence of isolates belonging to the ST‐11 clonal complex since 2003. These isolates displayed a new phenotype, C:2a:P1.7,1, caused infections that occurred as clusters, and were associated with increased infection severity and high virulence in mice. These isolates may be responsible for a peak in the incidence of serogroup C meningococcal infection in France, for which there is no routine vaccination to date.
Standard versus Newer Antibacterial Agents in the Treatment of Severe Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Randomized Trial of Trimethoprim‐Sulfamethoxazole versus Ciprofloxacin
Although the use of antibiotics in the treatment of acute exacerbation of chronic obstructive pulmonary disease (COPD) is largely accepted, controversy remains regarding whether the choice of antibiotic has any impact on outcome. Our aim was to compare the effects of the combination of trimethoprim and sulfamethoxazole and ciprofloxacin in patients treated for severe COPD exacerbation requiring mechanical ventilation and it showed that in patients with acute exacerbation of COPD requiring mechanical ventilation, efficacy of trimethoprim‐sulfamethoxazole was not inferior to ciprofloxacin.
Cardiac Origins of the Postural Orthostatic Tachycardia Syndrome
The purpose of this study was to test the hypothesis that a small heart coupled with reduced blood volume contributes to the postural orthostatic tachycardia syndrome (POTS) and that exercise training improves this syndrome. It is known that patients with POTS have marked increases in heart rate during orthostasis. However, the underlying mechanisms are unknown and the effective therapy is uncertain. This study found that autonomic function was intact in POTS patients. The marked tachycardia during orthostasis was attributable to a small heart coupled with reduced blood volume. Exercise training improved or even cured this syndrome in most patients. It seems reasonable to offer POTS a new name based on its underlying pathophysiology, the "Grinch syndrome," because in this famous children's book by Dr. Seuss, the main character had a heart that was "two sizes too small."
Adult asthma is associated with low socio-economic status
Low socio-economic status is often related to health problems; however, previous studies on asthma, usually cross-sectional, yield inconsistent results. In this study, longitudinal and cross-sectional data on the association between socio-economic status and asthma as well as respiratory symptoms among adults are presented. It was found that Low socio-economic status is significantly associated with an increased risk for prevalent and incident asthma and respiratory symptoms in this longitudinal population-based survey. The increase in risk was most pronounced in manual workers. Several studies have recently shown an association between low socio-economic status and respiratory symptoms and we conclude that asthma can not be considered as a disease that mainly affects the middle and upper socio-economic classes.
Increased mortality and morbidity in mild primary hyperparathyroid patients
This study attempted to describe the mortality and disease-specific morbidities in patients with mild primary hyperparathyroidism (PHPT). In total, there were 1683 (69·1% female) patients identified with mild PHPT. Patients were found to have an increased risk of all-cause mortality and cardiovascular mortality. Patients with mild PHPT had a significantly increased risk of developing cardiovascular and cerebrovascular disease, renal dysfunction and fractures.
Oral and IV Steroids In COPD Exacerbations Shows No Difference
Systemic corticosteroids are beneficial for patients hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD); however, their optimal dose and route of administration are uncertain. This article in this weeks JAMA showed that among patients hospitalized for acute exacerbation of COPD low-dose steroids administered orally are not associated with worse outcomes than high-dose intravenous therapy.
Tranexamic Acid Reduces Mortality in Trauma Patients
Tranexamic acid may be an effective option for reducing bleeding and mortality among trauma patients, without increasing the risk of serious complications such as myocardial infarction, stroke, or pulmonary embolism, according to a study published online June 15 in The Lancet.
Hemoglobin A1C Levels Show Limitations
A previous study of participants with prediabetes found that hemoglobin A1c (HbA1c) levels differed between black and white participants with no differences in glucose concentration. This study evaluated whether black–white differences in HbA1c level are present in other populations and across the full spectrum of glycemia. It found that Black persons have higher HbA1c levels than white persons across the full spectrum of glycemia, and the differences increase as glucose intolerance worsens. These findings could limit the use of HbA1c to screen for glucose intolerance, indicate the risk for complications, measure quality of care, and evaluate disparities in health.
Moderate Alcohol Drinkers After Acute Myocardial Infarction Proves Beneficial
Light-to-moderate alcohol consumption has been previously associated with a lower risk of acute myocardial infarction (AMI) and mortality. The association of changes in drinking behavior after an AMI with health status and long-term outcomes is unknown. Using a prospective cohort of patients with AMI evaluated with the World Health Organization's Alcohol Use Disorders Identification Test, they investigated changes in drinking patterns in 325 patients who reported moderate drinking at the time of their AMI. The data suggested that there are no adverse effects for moderate drinkers to continue consuming alcohol and that they may have better physical functioning compared to those who quit drinking after an AMI.
Infant Overweight Is Associated with Delayed Motor Development
This article in the Journal of Pediatrics examined how infant overweight and high subcutaneous fat relate to infant motor development. It found that motor delay was 1.80 times as likely in overweight infants compared with non-overweight infants and 2.32 times as likely in infants with high subcutaneous fat compared with infants with lower subcutaneous fat . High subcutaneous fat was also associated with delay in subsequent motor development.
Comparison of Natamycin and Voriconazole for the Treatment of Fungal Keratitis
An article out of the Archives of Ophthalmology conducted a therapeutic exploratory clinical trial comparing clinical outcomes of treatment with topical natamycin vs topical voriconazole for fungal keratitis. There were no significant differences in visual acuity, scar size, and perforations between voriconazole- and natamycin-treated patients with a trend toward scraping being associated with worse outcomes.
Testosterone administration improves myocardial ischemia, lipid metabolism and insulin resistance in elderly male diabetic patients with coronary artery disease
The evidence of antiatherogenic and vasodilatatory effects of testosterone (T) suggest a possible role of the lack of this hormone in the development and pathophysiology of coronary artery disease (CAD). The aim of the present study was to evaluate the effects of oral administration of testosterone undecanoate during a period of three months on serum lipid levels and on the occurrence of anginal attacks and daily ischemic episodes in patients with CAD. Overall it found that three months administration of T has beneficial effect on serum cholesterol and triglyceride levels in patients with CAD and reduces the number of anginal attacks, and ischemic episodes. These effect may be related to the metabolic and vasoactive properties of the hormone.
Comparison of local metronidazole and a local antiseptic in the treatment of bacterial vaginosis
Bacterial vaginosis (BV) is characterized by a mixed flora of pathogenic anaerobic bacteria and associated with risks of pathologic conditions. In the present study, therapy with a local antiseptic spray (octenidine hydrochloride/phenoxyethanol, OHP) for 7 or 14 days is compared against the standard local therapy of BV (metronidazole) in a Serbian patient population.Overall it found that Octenidine hydrochloride/phenoxyethanol spray was as effective as the standard therapy with metronidazole. Patients stated that OHP was more comfortable, easier to apply, and side effects were lesser.
FDA Panel Endorses 1st Oral Drug for Multiple Sclerosis
An expert advisory panel of the U.S. Food and Drug Administration on Thursday recommended that the agency approve an oral drug, Gilenia, as a first-line treatment for multiple sclerosis (MS).Gilenia appears to be both safe and effective, the panel confirmed in two separate votes.Approval would mark a major shift in MS therapy since other drugs for the neurodegenerative illness require frequent injections or intravenous infusions.
Valproic Acid Monotherapy in Pregnancy and Major Congenital Malformations
The use of valproic acid in the first trimester of pregnancy is associated with an increased risk of spina bifida, but data on the risks of other congenital malformations are limited. This study out of NEJM combined data from eight published cohort studies (1565 pregnancies in which the women were exposed to valproic acid, among which 118 major malformations were observed) and identified 14 malformations that were significantly more common among the offspring of women who had received valproic acid during the first trimester. We then assessed the associations between use of valproic acid during the first trimester and these 14 malformations by performing a case–control study with the use of the European Surveillance of Congenital Anomalies (EUROCAT) antiepileptic-study database, which is derived from population-based congenital-anomaly registries. As compared with no use of an antiepileptic drug during the first trimester (control group 1), use of valproic acid monotherapy was associated with significantly increased risks for 6 of the 14 malformations under consideration.
Diclofenac: Similar CV risk to rofecoxib in healthy people
The first study to examine the cardiovascular risk associated with nonsteroidal anti-inflammatory drugs (NSAIDs) in healthy individuals has found increased morbidity and mortality with diclofenac, rofecoxib (Vioxx, Merck), and high doses of ibuprofen [1]. Naproxen, in contrast, has a safer cardiovascular risk profile, say Dr Emil Loldrup Fosbøl and colleagues in their paper published online June 8, 2010 in Circulation: Cardiovascular Quality and Outcomes. The increased cardiovascular morbidity and mortality seen with diclofenac, which is similar to that observed with rofecoxib—a drug that was withdrawn from the market in 2004 because of poor cardiovascular safety—is particularly concerning, Fosbøl told heartwire.
The Correlation Between Visual Acuity and Color Vision as an Indicator of the Cause of Visual Loss
This article explored the correlation between visual acuity (VA) and color vision and to establish a guide for the diagnosis of the cause of visual loss based on this correlation. total of 259 patients with visual impairment caused by 1 of 4 possible disease categories were included. Patients were divided into 4 groups according to the etiology of visual loss: 1) optic neuropathies, 2) macular diseases, 3) media opacities, and 4) amblyopia. This study found that diseases of the optic nerve affect color vision earlier and more profoundly than other diseases. When the cause of visual loss is uncertain, the correlation between the severity of color vision and VA loss can imply the possible etiology of the visual loss.
A decrease in maternal plasma concentrations of sVEGFR-2 precedes the clinical diagnosis of preeclampsia
An article in this months American Journal of Obstetrics and Gynecology sought to examine if maternal plasma concentrations of soluble vascular endothelial growth factor receptor (sVEGFR)-2 change prior to the diagnosis of preeclampsia. Through a longitudinal study of normal pregnant women (n = 160) and patients with preeclampsia (n = 40) this study found that mothers destined to develop preeclampsia have lower plasma sVEGFR-2 concentrations than those who will have a normal pregnancy.
Comparison of adnexal torsion between pregnant and nonpregnant women
An article in this months American Journal of Obstetrics and Gynecology sought to compare clinical manifestations, treatment, and pregnancy outcome of adnexal torsion in pregnant and nonpregnant women through a retrospective case-control study in the Departments of Gynecology at 2 tertiary centers between 1999-2008. Forty-one pregnant and 77 nonpregnant women with surgically proved adnexal torsion were assessed. Recurrence rate of torsion was 19.5% in pregnant women and 9.1% in control subjects; 73% of pregnant women conceived through assisted reproductive technologies. Doppler blood flow was falsely normal in 61% of pregnant women and in 45% of nonpregnant women. This study shows that presentation of adnexal torsion is similar in pregnant and nonpregnant women. Past assisted reproductive technology is an important risk factor in pregnancy. Doppler blood flow has a high false-negative rate and should not outweigh clinical suspicion. Although pregnancy outcome is favorable, the high rate of recurrence raises the issue of surgical fixation at the first episode.
Allopurinol proves useful for angina
Researchers from the University of Dundee said that studies on allopurinol, a generic gout drug, showed it helped people suffering from angina to exercise more and delayed the time until their chest pain started. Allan Struthers of the University of Dundee and a team of fellow scientists asked 65 patients with chronic angina to exercise on a treadmill after treating some of them with allopurinol and others with a dummy pill, or placebo.The results of the study were published in The Lancet medical journal on Tuesday.Those who had the real drug were able to walk for 25 percent longer than those on placebo before they complained of chest pain. And electrical recordings of the patients' hearts showed that allopurinol enabled the heart to work for longer before showing signs of oxygen deprivation.
Clinical Findings Distinguishing Hemorrhagic Stroke From Ischemic Stroke
The 2 fundamental subtypes of stroke are hemorrhagic stroke and ischemic stroke. Although neuroimaging is required to distinguish these subtypes, the diagnostic accuracy of bedside findings has not been systematically reviewed. This article out of this weeks JAMA sought to determine the accuracy of clinical examination in distinguishing hemorrhagic stroke from ischemic stroke. Several findings significantly increase the probability of hemorrhagic stroke: coma, neck stiffness, seizures accompanying the neurologic deficit, diastolic blood pressure greater than 110 mm Hg, vomiting, and headache. While other findings decrease the probability of hemorrhage such as cervical bruit and prior transient ischemic attack. In patients with acute stroke, certain findings accurately increase or decrease the probability of intracranial hemorrhage, but no finding or combination of findings is definitively diagnostic in all patients, and diagnostic certainty requires neuroimaging.
The accuracy of pulse oximetry in emergency department patients with severe sepsis and septic shock
Pulse oximetry is routinely used to continuously and noninvasively monitor arterial oxygen saturation (SaO2) in critically ill patients. Although pulse oximeter oxygen saturation (SpO2) has been studied in several patient populations, including the critically ill, its accuracy has never been studied in emergency department (ED) patients with severe sepsis and septic shock. The cohort consisted of 88 subjects, with a mean age of 57 years (19 - 89). The mean difference (SpO2 - SaO2) was 2.75% and the standard deviation of the differences was 3.1%. Subgroup analysis demonstrated that hypoxemia (SaO2 < 90) significantly affected pulse oximeter accuracy. The mean difference was 4.9% in hypoxemic patients and 1.89% in non-hypoxemic patients (p < 0.004). In 50% (11/22) of cases in which SpO2 was in the 90-93% range the SaO2 was <90%. Though pulse oximeter accuracy was not affected by acidoisis, hyperlactatementa, anemia or vasoactive drugs, these factors worsened precision.
Treatment of restless legs syndrome with pregabalin
An article out of Neurology assessed the therapeutic efficacy, required dose, and tolerability of pregabalin in patients with idiopathic restless legs syndrome (RLS). This was a double-blind, placebo-controlled trial with polysomnographic control, providing Class II evidence. Ninety-eight patients underwent a 2-week single-blind period with placebo; 58 were randomized to receive pregabalin or placebo for 12 weeks under a flexible-dose schedule.Patients under treatment with pregabalin had a greater improvement in IRLS score than under placebo (63% vs 38.2%; p < 0.05). The mean effective dose of pregabalin at the end of treatment was 322.50 mg/day (±98.77), although therapeutic effects were already seen at a mean dose of 139 mg/day.
Black Men at Greater Risk of Aggressive Prostate Tumors
Black men are already known to be at higher risk of developing prostate cancer than white men, but now a new study reports that they also appear to be more likely to develop aggressive forms of the disease.Researchers analyzed biopsies from 131 men -- 67 blacks and 64 whites -- whose prostates were removed at the Durham Veterans Affairs Medical Center in North Carolina. The investigators found signs that the black men had more aggressive forms of prostate cancer. The findings are scheduled to be released Wednesday at American Urological Association annual meeting in San Francisco.
Treatment Outcomes among Patients with Extensively Drug‐Resistant Tuberculosis
This meta‐analysis provides evidence that the inclusion of later‐generation fluoroquinolones in the treatment of extensively drug‐resistant tuberculosis significantly improves treatment outcomes, even though drug‐susceptibility testing demonstrates resistance to a representative fluoroquinolone.
No Difference in Mortality in Patients Ventilated With Synchronized Intermittent Mandatory Ventilation With Pressure Support
Few data are available regarding the benefits of one mode over another for ventilatory support. This article compared clinical outcomes of patients receiving synchronized intermittent mandatory ventilation with pressure support (SIMV-PS) compared with assist-control (A/C) ventilation as their primary mode of ventilatory support through a secondary analysis of an observational study conducted in 349 ICUs from 23 countries. SIMV-PS was less likely to be selected if patients were ventilated because of asthma or coma, or if they developed complications such as sepsis or cardiovascular failure during mechanical ventilation. In the stratified analysis according to propensity score, we did not find significant differences in the in-hospital mortality. After adjustment for propensity score, overall effect of SIMV-PS on in-hospital mortality was not significant
Association Between Arterial Hyperoxia Following Resuscitation From Cardiac Arrest and In-Hospital Mortality
Laboratory investigations suggest that exposure to hyperoxia after resuscitation from cardiac arrest may worsen anoxic brain injury; however, clinical data are lacking. This study was a multicenter cohort study using the Project IMPACT critical care database of intensive care units (ICUs) at 120 US hospitals between 2001 and 2005. Patients were divided into 3 groups defined a priori based on PaO2 on the first arterial blood gas values obtained in the ICU. Hyperoxia was defined as PaO2 of 300 mm Hg or greater; hypoxia, PaO2 of less than 60 mm Hg (or ratio of PaO2 to fraction of inspired oxygen <300); and normoxia, not classified as hyperoxia or hypoxia. Of 6326 patients, 1156 had hyperoxia (18%), 3999 had hypoxia (63%), and 1171 had normoxia (19%). The hyperoxia group had significantly higher in-hospital mortality, 63%, compared with the normoxia group, 45%, and the hypoxia group 57%. Among patients admitted to the ICU following resuscitation from cardiac arrest, arterial hyperoxia was independently associated with increased in-hospital mortality compared with either hypoxia or normoxia.
Procainamide Doesn't Help Survival in Ventricular Fibrillation Out-of-hospital Cardiac Arrest
Procainamide is an antiarrhythmic drug of unproven efficacy in cardiac arrest. The association between procainamide and survival from out-of-hospital cardiac arrest was investigated to better determine the drug's potential role in resuscitation. Procainamide is an antiarrhythmic drug of unproven efficacy in cardiac arrest. The association between procainamide and survival from out-of-hospital cardiac arrest was investigated to better determine the drug's potential role in resuscitation. Of the 665 eligible patients, 176 received procainamide, and 489 did not. On average, procainamide recipients received more shocks and pharmacologic interventions and had lengthier resuscitations. Adjusted for their clinical and resuscitation characteristics, procainamide recipients had a lower likelihood of survival to hospital discharge.
Zoledronic Acid Plus Chemo Prior to Breast Cancer Surgery Reduces Number of Tumour Cells
When zoledronic acid is given along with chemotherapy for 3 months before breast cancer surgery, it reduced the number of women who had tumour cells in their bone marrow at the time of surgery, according to a study published in the May issue of The Lancet Oncology.
"Bone marrow seems to be a DTC [disseminated tumour cells] sanctuary, allowing them to adapt and disseminate to different organs, where they're a leading cause of death," said lead author Rebecca Aft, MD, Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri. "We believe that zoledronic acid inhibits the release of growth factors that help support the growth of DTCs."
Ranibizumab for Macular Edema following Central Retinal Vein Occlusion
An article in this month's Journal of Opthalmology assessed the efficacy and safety of intraocular injections of 0.3 mg or 0.5 mg ranibizumab in patients with macular edema after central retinal vein occlusion (CRVO). This prospective, randomized, sham injection-controlled, double-masked, multicenter clinical trial included atotal of 392 patients with macular edema after CRVO. The primary efficacy outcome measure was mean change from baseline best-corrected visual acuity (BCVA) letter score at month 6. Secondary outcomes included other parameters of visual function and central foveal thickness (CFT). Mean change from baseline BCVA letter score at month 6, was better in the ranibizumab groups than in the sham group. The percentage of patients who gained ≥15 letters in BCVA at month 6 was 46.2% (0.3 mg) and 47.7% (0.5 mg) in the ranibizumab groups and 16.9% in the sham group (P<0.0001 for each ranibizumab group vs. sham). At month 6, significantly more ranibizumab-treated patients (0.3 mg = 43.9%; 0.5 mg = 46.9%) had BCVA of ≥ 20/40 compared with sham patients (20.8%; P<0.0001 for each ranibizumab group vs. sham). The median percent reduction in excess foveal thickness at month 6 was 94.0% and 97.3% in the 0.3 mg and 0.5 mg groups, respectively, and 23.9% in the sham group. Intraocular injections of 0.3 mg or 0.5 mg ranibizumab provided rapid improvement in 6-month visual acuity and macular edema following CRVO, with low rates of ocular and nonocular safety events.
No difference between femoral nerve block and fascia iliaca block for analgesia following reconstructive knee surgery in adolescents
An article in the Journal of Clinical Anesthesia compared the femoral nerve block with the fascia iliaca block for postoperative analgesia in adolescents undergoing reconstructive knee surgery. Overall there was no difference between the femoral nerve block and the fascia iliaca nerve block in VAS pain scores or postoperative morphine consumption. Either the femoral nerve block or the fascia iliaca block, followed by patient-controlled analgesia with morphine, provides efficacious analgesia for adolescents undergoing ACL reconstruction.
Prophylactic intravenous magnesium sulfate for treatment of aneurysmal subarachnoid hemorrhage: A randomized, placebo-controlled, clinical study
An article in Critical Care Medicine examined whether the maintenance of elevated magnesium serum concentrations by intravenous administration of magnesium sulfate can reduce the occurrence of cerebral ischemic events after aneurysmal subarachnoid hemorrhage. The incidence of delayed ischemic infarction was significantly lower in magnesium-treated patients (22% vs. 51%; p = .002); 34 of 54 magnesium patients and 27 of 53 control patients reached good outcome. Delayed ischemic neurologic deficit was nonsignificantly reduced (9 of 54 vs. 15 of 53 patients; p = .149) and transcranial Doppler-detected/angiographic vasospasm was significantly reduced in the magnesium group (36 of 54 vs. 45 of 53 patients; p = .028). Fewer patients with signs of vasospasm had delayed cerebral infarction indicating that high-dose intravenous magnesium can reduce cerebral ischemic events after aneurysmal subarachnoid hemorrhage by attenuating vasospasm and increasing the ischemic tolerance during critical hypoperfusion.
Pulmonary Monitor a Winner by All Measures
Among heart failure patients with moderate to severe disease, six months of monitoring with an investigational implantable sensor that measures pulmonary artery pressure was associated with a 30% relative risk reduction in hospitalizations for heart failure, researchers here reported. After six months there were 83 hospitalizations for heart failure among the 270 patients randomized to treatment guided by hemodynamic measurements from the CardioMems Heart Sensor, compared with 120 heart failure hospitalizations in the 280-patient control arm (P<0.001), said William T. Abraham, MD, of Ohio State University.
Doxazosin as a Medical Expulsive Therapy of Distal Ureteric Stones in a Randomized Clinical Trial
This articel assessed the clinical efficacy of doxazosin as the medical-expulsive therapy for distal ureterolithiasis. A total of 65 patients with a symptomatic 4-7 mm distal ureteral stone were included in the study. Patients were randomized to 1 of the 2 treatment groups. Group 1 (n = 32 patients) was the control group and received diclofenac sodium 50 mg for their pain and group 2 (n = 33 patients) received doxazosin (2 mg daily at the night) along with diclofenac sodium 50 mg. Stone expulsion rate was significantly higher in the treatment group (38% for group 1 and 70% for group 2, P = .009) while the expulsion time was significantly lesser in group 2 patients (P = .005).
Inferior Vena Cava Diameter Correlates with Invasive Hemodynamic Measures in Mechanically Ventilated Intensive Care Unit Patients with Sepsis
Early optimization of fluid status is of central importance in the treatment of critically ill patients. This study out of the Journal of Emergency Medicine investigated whether inferior vena cava (IVC) diameters correlate with invasively assessed hemodynamic parameters and whether this approach may thus contribute to an early, non-invasive evaluation of fluid status. The investigators found a statistically significant correlation of both inspiratory and expiratory IVC diameter with central venous pressure, extravascular lung water index , intrathoracic blood volume index, the intrathoracic thermal volume, and the PaO2/FiO2 oxygenation index. In this study, IVC diameters were found to correlate with central venous pressure, extravascular lung water index, intrathoracic blood volume index, the intrathoracic thermal volume, and the PaO2/FiO2 oxygenation index. Therefore, sonographic determination of IVC diameter seems useful in the early assessment of fluid status in mechanically ventilated septic patients.
Shark Cartilage Not Beneficial in Advanced Lung Cancer
A drug derived from shark cartilage failed to improve survival in patients with advanced lung cancer, researchers report. The disappointing results, which came in the final stage of testing, showed that the drug didn't help extend the life spans of patients with inoperable stage III non-small cell lung cancer.Scientists have been testing drugs derived from shark cartilage because it appears to prevent blood vessels from growing around tumors. The hope is that the drugs will prevent cancer cells from being fed by blood, which allows them to grow.
Platelet hyperfunction is decreased by additional aspirin loading in patients presenting with myocardial infarction on daily aspirin therapy
Currently 162-325 mg aspirin is recommended for the treatment of acute coronary syndrome. This article out of the journal Critical Care Medicine tested the effect of an additional loading dose of 250 mg aspirin at the onset of acute coronary syndrome in patients who were already on chronic therapy with 100 mg aspirin. It found that aspirin loading in the emergency room further reduced thromboxane B2 levels and further inhibited platelet function in many patients with acute coronary syndrome already on 100 mg aspirin.
Drug cocktails cut couples' HIV transmission risk
In a study that supports the widespread use of drugs to help control the AIDS pandemic, researchers said on Wednesday that HIV patients who took the drugs were far less likely to infect their partners. Using the drug cocktail reduced the likelihood of transmission by 92 percent, the researchers reported in the journal Lancet. They said the findings mean the drug cocktails known as antiretroviral therapy, or ART, might be a useful prevention tool as well as a treatment. "These results are ... the strongest evidence to date that ART might decrease HIV transmission risk," said Dr. Connie Celum, professor of medicine and global health at the University of Washington, who worked on the study.
An Aspirin A Day Keeps the Schizophrenia Away
Inflammatory processes may play a role in the pathophysiology of schizophrenia. The aim of this study was to determine the efficacy of adjuvant treatment with aspirin (acetylsalicylic acid) in schizophrenia spectrum disorders. It was shown that aspirin given as adjuvant therapy to regular antipsychotic treatment reduces the symptoms of schizophrenia spectrum disorders. The reduction is more pronounced in those with the more altered immune function. Inflammation may constitute a potential new target for antipsychotic drug development.
The risks and benefits of long-term use of hydroxyurea in sickle cell anemia
A randomized, controlled clinical trial established the efficacy and safety of short-term use of hydroxyurea in adult sickle cell anemia. To examine the risks and benefits of long-term hydroxyurea usage, patients in this trial were followed for 17.5 years during which they could start or stop hydroxyurea. The purpose of this follow-up was to search for adverse outcomes and estimate mortality. Although the death rate in the overall study cohort was high (43.1%; 4.4 per 100 person-years), mortality was reduced in individuals with long-term exposure to hydroxyurea. Survival curves demonstrated a significant reduction in deaths with long-term exposure.
Waiting to Clamp the Umbilical Cord May Be Better for Babies
Pregnant women may want to consider asking their doctors to hold off on clamping the umbilical cord for a few minutes after the baby is born, a new study suggests. Clamping the cord in the seconds after birth cuts off the blood flow from mom to baby. While not necessarily harmful, the common practice in delivery rooms potentially robs newborns of those last precious minutes of cord blood, the researchers said, and cord blood contains stem cells that have regenerative properties and can grow into different types of cells. Research suggests there may be some benefits to getting that extra blood from mom right after birth, said senior study author Dr. Paul Sanberg, director of the University of South Florida's Center of Excellence for Aging and Brain Repair.
β-Blockers for Chest Pain Associated With Recent Cocaine Use
Although β-blockers prevent adverse events after myocardial infarction, they are contraindicated when chest pain is associated with recent cocaine use. Recommendations against this use of β-blockers are based on animal studies, small human experiments, and anecdote. This article in the Archives of Internal Medicine tested the hypothesis that β-blockers are safe in this setting and found of 331 patients with chest pain in the setting of recent cocaine use, 151 (46%) received a β-blocker in the emergency department. There were no meaningful differences in electrocardiographic changes, troponin levels, length of stay, use of vasopressor agents, intubation, ventricular tachycardia or ventricular fibrillation, or death between those who did and did not receive a β-blocker. It also found that over a median follow-up of 972 days , after adjusting for potential confounders, patients discharged on a β-blocker regimen exhibited a significant reduction in cardiovascular death.
Very Few Sunscreens Appear To Be Any Good - Hats, Shirts And Shade Still Best
A new report which stated that exaggerated claims made by many sunscreens, as well as possible links between added vitamin A and accelerated growth of skin tumors and lesions, concluded that just 8 out of 500 sunscreen products were any good. The study, carried out by the Sunscreen Guide by Environmental Working Group (EWG) gave low marks to most current sunscreen products.
Industry's uninspiring performance and the federal Food and Drug Administration's (FDA) failure to issue regulations for sunscreens, lead EWG to caution consumers not to rely on any sunscreen for primary protection from the sun's potentially harmful ultraviolet rays. Hats, clothing and shade are still the most reliable sun protectors available.
Aromatase inhibition in male breast cancer patients: biological and clinical implications
The role of aromatase inhibitors (AIs) and their impact on estradiol (E2) levels remain unknown in male breast cancer (MBC) patients. MBC patients with metastatic disease and those treated with AIs were selected from the breast cancer database of the Centre Antoine-Lacassagne (Nice, France). This study found that Aromatase Inhibitors are active in MBC patients. This activity is correlated with a significant reduction in E2 levels. Secondary resistance is in part related to a deleterious feedback loop resulting in a significant increase in substrate for aromatization.
Statins Have Wide Range of Unintended Adverse Effects
Statins appear to have no significant association with a large number of diseases, but they may have a wide range of unintended adverse effects, according to data published in the May 20 online edition of the BMJ. Julia Hippisley-Cox, M.D., and Carol Coupland, Ph.D., of the University of Nottingham in the United Kingdom, conducted a prospective open cohort study of 2,004,692 patients aged 30-84, including 225,922 (10.7 percent) of whom were new users of statins, to quantify the unintended effects of statins according to type, dose and duration of use. The researchers found that statins were not significantly associated with risk of Parkinson's disease; rheumatoid arthritis; venous thromboembolism; dementia; osteoporotic fracture; gastric, colon, lung, renal, breast or prostate cancer; or melanoma. However, statin use was linked to a decreased risk of esophageal cancer, but an increased risk of moderate or serious liver dysfunction, acute renal failure, moderate or serious myopathy and cataract. The adverse effects were similar across all types of statins with the exception of liver dysfunction risk, which was highest for fluvastatin. All increased risks were highest in the first year and persisted during treatment.
Scientists find clues to kidney transplant success
European scientists have found a full range of markers in the blood of kidney transplant patients which could predict whether their new organ will be a success and whether they need large amounts of medication to help it.
Irregular menstrual periods tied to heart disease
Women with a history of irregular menstrual periods may have a higher risk of developing heart disease than do other women, a new study suggests.The study, which followed more than 23,000 Dutch women for a decade, found that those who said they'd typically had irregular periods in the past were 28 percent more likely than women who reported regular monthly periods to develop heart disease.
Increased fructose consumption is associated with fibrosis severity in patients with nonalcoholic fatty liver disease
The rising incidence of obesity and diabetes coincides with a marked increase in fructose consumption. Fructose consumption is higher in individuals with nonalcoholic fatty liver disease (NAFLD) than in age-matched and body mass index (BMI)-matched controls. Because fructose elicits metabolic perturbations that may be hepatotoxic, this article investigated the relationship between fructose consumption and disease severity in NAFLD.
After controlling for age, sex, BMI, and total calorie intake, daily fructose consumption was associated with lower steatosis grade and higher fibrosis stage (P < 0.05 for each). In older adults (age 48 years), daily fructose consumption was associated with increased hepatic inflammation (P < 0.05) and hepatocyte ballooning (P = 0.05). In patients with NAFLD, daily fructose ingestion is associated with reduced hepatic steatosis but increased fibrosis. These results identify a readily modifiable environmental risk factor that may ameliorate disease progression in patients with NAFLD.
Trimethoprim-Sulfamethoxazole for Uncomplicated Skin Abscesses in Patients at Risk for Community-Associated Methicillin-Resistant Staphylococcus aureus Infection Decreases Number of Lesions but Not Treatment Failures
Community-associated methicillin-resistant Staphylococcus aureus is now the leading cause of uncomplicated skin abscesses in the United States, and the role of antibiotics is controversial. We evaluate whether trimethoprim-sulfamethoxazole reduces the rate of treatment failures during the 7 days after incision and drainage and whether it reduces new lesion formation within 30 days. A multicenter, double-blind, randomized, placebo-controlled trial, randomized adults to oral trimethoprim-sulfamethoxazole or placebo after uncomplicated abscess incision and drainage and followed with in 7 days. Overall a statistically similar incidence of treatment failure in patients receiving trimethoprim-sulfamethoxazole (15/88; 17%) versus placebo (27/102; 26%), difference 9%, 95% confidence interval –2% to 21%; P=.12. On 30-day follow-up (successful in 69% of patients), we observed fewer new lesions in the antibiotic (4/46; 9%) versus placebo (14/50; 28%) groups, difference 19%, 95% confidence interval 4% to 34%, P=.02.
Etomidate Decreases Cortisol Levels in Patients After Use in Intubation
An article out the Annals of Emergency Medicine the evidence on the effect of a bolus dose of etomidate on adrenal function, mortality, and health services utilization compared with other induction agents used for rapid sequence intubation. Overall it found that the mean cortisol levels were lower in elective surgical patients induced with etomidate compared with those induced with other agents between 1 and 4 hours postinduction. The differences varied from 6.1 μg/dL (95% confidence interval [CI] 2.4 to 9.9 μg/dL; P=.001) to 16.4 μg/dL (95% CI 9.7 to 23.1 μg/dL; P<.001). Two studies in critically ill patients reported significantly different cortisol levels up to 7 hours postinduction. None of the studies reviewed, nor our pooled estimate (odds ratio 1.14; 95% CI 0.81 to 1.60), showed a statistically significant effect on mortality. Only one study reported longer ventilator, ICU, and hospital lengths of stay in patients intubated with etomidate.
Long Term Diabetes Drug (Metformin) Linked To Gradually Worsening Vitamin B-12 Deficiency
Individuals with diabetes type 2 who are treated for long periods with metformin are at risk of developing gradually worsening vitamin B-12 deficiency - in other words, the vitamin deficiency grows with time, according to new research published today in the British Medical Journal (BMJ). Individuals who had been given metformin were found to have a 19% reduction in their vitamin B-12 levels, compared with those in the placebo group, who had virtually no change in their levels during the study.
Moreover, the drop in levels of vitamin B-12 by metformin was not temporary, but continued, and got worse over time.
Diagnostic Accuracy and Clinical Utility of Noninvasive Testing for Coronary Artery Disease
Computed tomography coronary angiography (CTCA) has become a popular noninvasive test for diagnosing coronary artery disease. A study in the Annals of Internal Medicine compared the accuracy and clinical utility of stress testing and CTCA for identifying patients who require invasive coronary angiography (ICA). The results suggested that computed tomography coronary angiography seems most valuable in patients with intermediate pretest probability of disease and are more accurate than stress imaging, because the test can distinguish which of these patients need invasive angiography. These findings need to be confirmed before CTCA can be routinely recommended for these patients.
Diagnosis of Necrotizing Soft Tissue Infections by Computed Tomography
In contrast to previous beliefs, an article in this weeks Archives of Surgery hypothesized that computed tomography (CT) scanning is sensitive and specific for the diagnosis of necrotizing soft tissue infections (NSTIs). Patients who were clinically suspected of having NSTIs from January 1, 2003, through April 30, 2009, and who underwent imaging with a 16- or 64-section helical CT scanner were studied. Of 67 patients with study inclusion criteria, 58 underwent surgical exploration, and NSTI was confirmed in 25 (43%). The remaining 42 patients had either nonnecrotizing infections during surgical exploration (n = 33) or were treated nonoperatively with successful resolution of the symptoms (n = 9). The sensitivity of CT to identify NSTI was 100%, specificity was 81%, positive predictive value was 76%, and negative predictive value was 100% concluding that a negative CT result reliably excludes the diagnosis of NSTI while a positive CT result correctly identifies the disease with a high likelihood.
Etanercept Injection No Help in the Treatment of Hidradenitis Suppurativa
An article in this months Archives of Dermatology evaluated the effects of etanercept treatment on the cutaneous manifestations of hidradenitis suppurative (HS). Etanercept, 50 mg, or placebo was administered subcutaneously (SC) twice weekly for 12 weeks. After 12 weeks, all patients received open-label etanercept, 50 mg, SC twice weekly for 12 more weeks. After evaluation it was found that Etanercept, 50 mg, SC administered twice weekly did not have significant efficacy in the improvement of HS. In light of our negative results, as well as those of previous studies, we suggest that future studies focus on other agents for the treatment of HS.
Use of Botulinum Toxin Type A for Chronic Cough
An article in the Archives of Otolaryngology reviewed the experience and outcomes of a novel use of botulinum toxin type A (BtxA) in the treatment of chronic cough. In the study all patients had significant relief of cough after BtxA injection, with complete resolution after a median of 7 injections (range, 4-16), using a mean dose of 4.0 U (range, 1.0-10.0 U) per treatment session for a mean duration of 25.7 months. According to this article, this is the first reported series in the literature of the use of BtxA in the treatment of chronic cough in adults. Further research and long-term follow-up are warranted, but BtxA is effective in directly decreasing laryngeal hypertonicity and possibly reducing neurogenic inflammation and neuropeptide-mediated cough. Botulinum toxin type A can be considered for the treatment of chronic cough refractory to other medical therapies.
Improved Glottic Exposure With the Video Macintosh Laryngoscope in Adult Emergency Department Tracheal Intubations
Glottic visualization with video is superior to direct laryngoscopy in controlled operating room studies. However, glottic exposure with video laryngoscopy has not been evaluated in the emergency department (ED) setting, where blood, secretions, poor patient positioning, and physiologic derangement can complicate laryngoscopy. We measure the difference in glottic visualization with video versus direct laryngoscopy.
Home-Measured Blood Pressure Is a Stronger Predictor of Cardiovascular Risk Than Office Blood Pressure
Previous studies with some limitations have provided equivocal results for the prognostic significance of home-measured blood pressure (BP). An article in the Journal Hypertension investigated whether home-measured BP is more strongly associated with cardiovascular events and total mortality than is office BP. The findings suggest that home-measured BP is prognostically superior to office BP. On the basis of the results of this and previous studies, it can be concluded that home BP measurement offers specific advantages more than conventional office measurement.
Association of Body Mass Index With Prostate Cancer Biochemical Failure
The association between obesity and biochemical failure measured by prostate specific antigen after prostate cancer treatment is controversial. An article in the Journal of Urology determined whether there is an association between body mass index and biochemical failure in men treated for low and intermediate risk prostate cancer with various treatment modalities.
There was a significant association with biochemical failure when comparing normal vs overweight and normal vs obese men but not overweight vs obese men. Overall a significant association between body mass index and biochemical failure on univariate analysis that did not hold true on multivariate analysis was found. Black race was associated with biochemical failure on multivariate analysis. The reason for this is unclear. Future studies should further characterize the relationship between race and biochemical failure.
High-resolution ultrasound in the evaluation and prognosis of Bell's palsy
Bell's palsy is a commonly encountered paralysis of the facial nerve occurring worldwide. Prognosis for Bell's palsy is good, but the proportion of patients with poor outcomes may reach 30%. Ultrasound (US) may provide a novel approach for evaluating and prognosticating Bell's palsy, in comparison with known electrophysiological techniques. A study out of the European Journal of Neurology measured the diameter of the distal facial (VII) nerve using US in patients with Bell's palsy treated with prednisolone, in comparison with healthy controls. Overall it was found that the diameter of the distal VII nerve is a good predictor of favorable (positive predictive value: 100%) and bad outcomes (negative predictive value: 77%) in Bell's palsy at 3 months after clinical presentation. US was also found to be superior to VII nerve conduction and blink reflex studies in outcome prediction.
Tachycardia predicts CV events in VALUE
Baseline and in-trial tachycardia are strong, independent predictors of cardiovascular events in patients with high-risk hypertension, a new analysis of the Valsartan Antihypertensive Long-Term Use Evaluation (VALUE) trial has shown [1]. Risk seems to be particularly increased in those with a heart rate (HR) of >80 beats per minute (bpm), Dr Stevo Julius (University of Michigan Cardiovascular Center, Ann Arbor), told a late-breaking clinical-trials session at the American Society of Hypertension (ASH) 2010 Scientific Meeting last week.
Improved Glycemic Control with Insulin Glargine Vs Pioglitazone as ADD-ON Therapy to Sulfonylurea or Metformin in Patients with Uncontrolled Type 2 Diabetes
An article in Endocrine Practice compared glycemic control with add-on insulin glargine vs pioglitazone. Overall insulin glargine significantly reduced A1C compared with pioglitazone, yielded significantly greater Fasting Plasma Glucose reductions and resulted in a lower overall incidence of possibly related treatment emergent Adverse Effectss and fewer discontinuations , but a higher rate of confirmed clinically relevant hypoglycemia. Suggesting that adding insulin glargine early in the diabetes treatment paradigm in patients failing sulfonylurea or metformin monotherapy resulted in significant improvements in glycemic control compared with adding pioglitazone.
Comparison of ketamine and fentanyl with propofol in total intravenous anesthesia: a double blind randomized clinical trial
Propofol has emerged as a gold-standard for total inrtravenous anesthesia (TIVA) for short surgical interventions but lack of analgesia remains it’s main shortcoming therefore it is always combined with an analgesic. Ketamine and fentanyl are the popular analgesic in this context. This study was carried out to compare these drugs with propofol to assess hemodynamic and recovery profile of either combination. Time to spontaneous eye opening was similarly comparable in both the groups (8±3 min and 8±2 min) (p=0.53). Response to postoperative questionnaire at 30 minutes after anesthesia was good in both the groups. Incidence of postoperative nausea and vomiting was also insignificant statistically between both the groups. There were 5 patients in the Propofol-Fentanyl Group that developed hypotension that imporved with fluids. Overall it was shown that both ketamine and fentanyl are equally safe and efficacious with propofol for short surgical procedures.
Morbidity of respiratory illness in children with asthma
Exacerbations of childhood asthma and rhinovirus infections both peak during the spring and fall, suggesting that viral infections are major contributors to seasonal asthma morbidity. Kim and Olenec et al (p 1001) evaluated rhinovirus infections during peak seasons in children with asthma and analyzed relationships between viral infection and illness severity. Although viral infection appeared to be nearly universal, the atopic children experienced more frequent and severe virus-induced illnesses when compared with those children without evidence of allergen-specific IgE; conversely, nonatopic children were twice as likely to have asymptomatic infections (see Figure). The authors conclude that the combination of viral infection and allergy increases the morbidity of respiratory tract illnesses in children with asthma.
Epidemiology of Community-Acquired and Health Care-Associated Staphylococcus aureus Pneumonia
Information is limited on the descriptive epidemiology of community-acquired pneumonia (CAP) and health care-associated pneumonia (HCAP) due to Staphylococcus aureus. An article in Infectious Disease in Clinical Practice retrospectively identified all patients admitted to a large urban US hospital between January 2005 and May 2008 with pneumonia and positive blood or respiratory cultures for S. aureus within 48 hours of admission. The results showed that Methicillin-resistant S. aureus is an important pathogen in both HCAP and CAP, and simple clinical criteria do not permit early identification of patients with MRSA versus MSSA pneumonia. Fewer than one half of patients with MRSA CAP receive appropriate initial antibiotic therapy compared to 75 % of HAP.
Pedal Pump and Thoracic Pump Techniques Safe in Intracranial Pressure in Patients With Traumatic Brain Injuries
Although osteopathic manipulative treatment (OMT) is used to manage myriad conditions, there has been some hesitation regarding the safety of applying OMT to patients with intracranial injuries or elevated intracranial pressure (ICP). An article the JAOA prospectively enrolled consecutive patients admitted to the intensive care unit (ICU) for traumatic brain injury. Patients between the ages of 18 and 75 years and with abnormal CT scans were included in the present study. Patients with baseline ICP values of 20 mm Hg or lower were assigned to group 1, and those with ICP levels greater than 20 mm Hg, group 2. Although not statistically significant group 1 patients had a slight decrease in ICP values and an increase in CPP values and patients in group 2 also had decreased mean ICP values (-1.20 mm Hg) and increased mean CPP values (2.2105 mm Hg) concluding pedal pump and thoracic pump techniques may be used safely in patients with severe brain injuries.
Predicting bacteremic pneumonia in HIV-1–infected patients consulting the ED
HIV-1–infected patients have higher incidence of community-acquired pneumonia (CAP) and risk of complications. Bacteremia has been associated with a higher risk of complications in such patients. An article out of the American Journal of Emergency Medicine investigated factors associated with bacteremia in HIV-1–infected patients with CAP presenting at the emergency department. Overall the study found that bacteremia was present in 24%. Independent predictors of bacteremia were the detection of S pneumoniae antigen in urine and the absence of current antiretroviral treatment. It was also found that the in-hospital mortality was higher in patients with bacteremia (15% vs 0%) showing that bacteremic patients have a poor outcome.
Cardiac Causes More Persistently Tied to Dizziness in Elderly Patients
Although dizzy patients are predominantly seen in primary care, most diagnostic studies on dizziness have been performed among patients in secondary or tertiary care. An article in the Annals of Family Medicine sought to describe subtypes of dizziness in elderly patients in primary care and to assess contributory causes of dizziness. It found that contrary to most previous studies, cardiovascular disease was found to be the most common major cause of dizziness in elderly patients in primary care. In one-quarter of all patients an adverse drug effect was considered to be a contributory cause of dizziness, which is much higher than reported in previous studies.
Estimated equivalency of vitamin D production from natural sun exposure versus oral vitamin D supplementation
A study out of the Journal of the American Academy of Dermatology sought to provide estimates of the equivalency of vitamin D production from natural sun exposure versus oral supplementation.
Using the FastRT simulation tool, they determined sun exposure times needed to achieve serum vitamin D3 concentrations equivalent to 400 or 1000 IU vitamin D for individuals of various Fitzpatrick skin types living in Miami, FL, and Boston, MA, during the months of January, April, July, and October.
Peak ultraviolet B irradiation for vitamin D synthesis occurs around 12 pm Eastern Standard Time (EST). In Boston, MA, from April to October at 12 pm EST an individual with type III skin, with 25.5% of the body surface area exposed, would need to spend 3 to 8 minutes in the sun to synthesize 400 IU of vitamin D. It is difficult to synthesize vitamin D during the winter in Boston, MA. For all study months in Miami, FL, an individual with type III skin would need to spend 3 to 6 minutes at 12 pm EST to synthesize 400 IU. Vitamin D synthesis occurs faster in individuals with lighter Fitzpatrick skin types. The duration to attain 1000 IU of vitamin D is longer in all scenarios.
Splenectomy leads to a persistent hypercoagulable state after trauma
It was hypothesized that splenectomy following trauma results in hypercoagulability. A prospective, nonrandomized, single-center study was performed to evaluate coagulation parameters in trauma patients with splenic injury. Overall it was found that fibrinogen was elevated, tissue plasminogen activator, plasminogen activator inhibitor–1, and activated partial thromboplastin time were higher in splenectomy patients and baseline thromboelastography showed faster fibrin cross-linking and enhanced fibrinolysis following splenectomy. The study also found that deep venous thrombosis developed in 7% of splenectomy patients and no control patients.
Screening for abdominal aortic aneurysms shows cost effectiveness
An article in this months British Journal of Surgery sought to estimate long-term mortality benefits and cost-effectiveness of screening for abdominal aortic aneurysm (AAA) in men aged 64-73 years. 6306 men were invited for abdominal ultrasonography at a regional hospital. Mortality and AAA-related interventions were recorded in national databases. The relative risk reduction of the screening programme in AAA-related mortality was 66 per cent (hazard ratio 0·34, 95 per cent confidence interval (c.i.) 0·20 to 0·57). The corresponding risk reduction in all-cause mortality was 2 per cent showing that there was a mortality benefit of screening for AAA in men aged 64-73 years that it was maintained in the longer term and screening was cost effective.
Time trends in outcome of subarachnoid hemorrhage
Treatment of aneurysmal subarachnoid hemorrhage (SAH) has changed substantially over the last 25 years but there is a lack of reliable population-based data on whether case-fatality or functional outcomes have improved. This article in the Journal of Neurology showed that overall mortality due to subarachnoid hemorrhage fell by about 50% in our study population over the last 2 decades, due mainly to improved outcomes in cases surviving to reach hospital. This improvement is consistent with a significant decrease in case-fatality over the last 25 years in our pooled analysis of other similar population-based studies.
Proton Pump Inhibitors Increase Risk for Recurrent Clostridium difficile Infection
Proton pump inhibitors (PPIs) are widely used gastric acid suppressants, but they are often prescribed without clear indications and may increase risk of Clostridium difficile infection (CDI). An article in the Archives of Internal Medicine sought to determine the association between PPI use and the risk of recurrent CDI. Recurrent CDI was more common in those exposed to PPIs than in those not exposed (25.2% vs 18.5%) and treatment was associated with a 42% increased risk of recurrence.
Plasma homocysteine and cardiovascular risk in heart failure with and without cardiorenal syndrome
Plasma homocysteine (Hcy) has been associated with an increased cardiovascular (CV) risk in patients with chronic heart failure (CHF). An article in the International Journal of Cardiology investigated whether Hcy has a prognostic impact on CV events in CHF-patients with and without cardiorenal syndrome (CRS). 161 patients with CHF were included in the present analysis. 94 patients had systolic (SD) (EF <
40%) and 67 diastolic (DD) dysfunction (EF≥40%). Homocysteine is significantly increased in patients with CHF (20±7 µmol/l). The increase correlates not only with the severity of the disease (NYHA, EF, VO2max), but also with various metabolic (BNP, uric acid) and nephrologic parameters (creatinine, creatinine clearance). During follow-up (23±37 months), patients with the highest homocysteine (≥20 µmol/l) passed away more often (p<0.035) or decompensated more frequently (p<0.004) than those with a low Hcy. In patients with CRS the rate of decompensation was significantly higher than in those without CRS (p<0.0007).
Decreased serum vitamin D levels in children with asthma are associated with increased corticosteroid use
An article in the Journal of Allergy and Clinical Immunology sought to investigate disease variables associated with VitD insufficiency in patients with childhood asthma and interaction of VitD with corticosteroid-mediated anti-inflammatory responses. They analyzed 25-hydroxyvitamin D serum levels in 100 asthmatic children to investigate relationships between 25-hydroxyvitamin D levels and patients' characteristics. They determined VitD's effects on dexamethasone (DEX) induction of mitogen-activated protein kinase phosphatase 1 and IL-10 in PBMCs. Overall it was found that corticosteroid use and worsening airflow limitation are associated with lower VitD serum levels in asthmatic patients. VitD enhances glucocorticoid action in PBMCs from asthmatic patients and enhances the immunosuppressive function of DEX in vitro.
Prognostic Significance of Deep Vein Thrombosis in Patients Presenting with Acute Symptomatic Pulmonary Embolism
Concomitant deep vein thrombosis (DVT) in patients with acute pulmonary embolism (PE) has an uncertain prognostic significance. An article in the American Journal of Respiratory and Critical Care Medicine conducted a prospective cohort study of outpatients diagnosed with a first episode of acute symptomatic PE. Patients underwent bilateral lower extremity venous compression ultrasonography to assess for concomitant DVT.The results showed that In patients with a first episode of acute symptomatic PE, the presence of concomitant DVT is an independent predictor of death in the ensuing 3 months after diagnosis.
Subgroup analysis from ACCORD BP prompts more debate on hypertension targets
Delving deeper into the findings of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) BP study reveals that certain subgroups may benefit more from intensive BP lowering because they are at higher absolute risk of stroke. Among these are the elderly, African Americans, and those with prior cardiovascular disease, said Dr William C Cushman (Veterans Affairs Medical Center, Memphis, TN), who presented the new data at a late-breaking clinical-trials session at the American Society of Hypertension (ASH) 2010 Scientific Meeting.
Initial Bolus Insulin in the Treatment of Diabetic Ketoacidosis
Current guidelines for treatment of diabetic ketoacidosis (DKA) recommend administration of an intravenous bolus dose of insulin followed by a continuous infusion. A study in this months Journal of Emergency Medicine investigated whether the initial bolus dose is of significant benefit to adult patients with DKA and if it is associated with increased complications. Overall there were no statistically significant differences in the incidence of hypoglycemia (6% vs. 1%, respectively, p = 0.12), rate of change of glucose (60 vs. 56 mg/dL/h, respectively, p = 0.54) or AG (1.9 vs. 1.9 mEq/L/h, respectively, p = 0.66), LOS in the Emergency Department (8 vs. 7 h, respectively, p = 0.37) or hospital (5.6 vs. 5.9 days, p = 0.81). Equivalence testing revealed no clinically relevant differences in IVF change, rate of change of glucose, or AG. Administration of an initial bolus dose of insulin was not associated with significant benefit to patients with DKA and demonstrated equivalent changes in clinically relevant endpoints when compared to patients not administered the bolus.
Do Either Corticosteroids or Antiviral Agents Reduce the Risk of Long-Term Facial Paresis in Patients with New-Onset Bell's Palsy?
The cause of Bell's palsy remains uncertain, although accumulating evidence suggests a viral etiology. To date, treatment to minimize long-term deficits from this disorder typically includes anti-inflammatory or antiviral medication. Three multicenter, randomized, controlled trials enrolled over 1500 adult patients with paroxysmal, unilateral paresis of cranial nerve VII and treated them with varying regimens and combinations of prednisolone, antiviral agents, and placebo, and evaluated complete recovery up to 12 months later. Current evidence suggests that prednisolone, an inexpensive and readily available medication, is effective for this common condition, but there was no statistically significant difference observed with acyclovir. Valacyclovir provides minimal added benefit to prednisolone alone.
Nasal Eosinophilia Correlates with Lower Airway Inflammation
It is noteworthy that there is a clear clinical, epidemiological and pathophysiological association between upper and lower airway inflammation in rhinitis and asthma. A study in Clinical and Experimental Allergy compared the eosinophil counts in induced sputum and nasal lavage fluids in asthma, checking their association and the accuracy of nasal eosinophilia as a predictor of sputum eosinophilia by a cross-sectional study. After adjusted for upper airway symptoms sputum eosinophilia was associated with 52 times increase in odds of nasal eosinophilia, whereas each 1% increase in bronchodilator response was associated with 7% increase in odds of nasal eosinophilia, bringing further evidence that upper airway diseases are an important component of the asthma syndrome.
Increased Risk of Myocardial Infarction and Stroke Following Exacerbation of COPD
Patients with COPD are at risk for cardiovascular events. This is attributed to increased systemic inflammation. The course of COPD is punctuated by exacerbations, which further increase systemic inflammation, but the risk of vascular events in the postexacerbation period has never been defined. An article in the journal Chest analyzed data from 25,857 patients with COPD entered in The Health Improvement Network database over a 2-year period. Exacerbations were defined using a health-care use definition of prescription of oral corticosteroids > 20 mg/d and/or selected oral antibiotics. There was a 2.27-fold (95% CI, 1.1-4.7; P = .03) increased risk of MI 1 to 5 days after exacerbation (defined by prescription of both steroids and antibiotics). This relative risk diminished progressively with time and was not significantly different from the baseline MI risk at any other postexacerbation time interval. One in 2,513 exacerbations was associated with MI within 1 to 5 days. There was a 1.26-fold (95% CI, 1.0-1.6; P = .05) increased risk of stroke 1 to 49 days after exacerbation.
Antireflux surgery does not prevent esophageal adenocarcinoma
Antireflux surgery does not prevent development of esophageal or cardia adenocarcinoma in patients with reflux, show study results. To investigate the suggestion that antireflux surgery may have a preventive effect on these cancers in people with reflux, which is a known risk factor, Jesper Lagergren (Karolinska Institutet, Stockholm, Sweden) and colleagues carried out a population based cohort study of 14,102 people with gastroesophageal reflux disease (GERD) who had antireflux surgery from 1965 to 2006. “This large and population-based cohort study with long and complete follow-up evaluation indicates that antireflux surgery does not prevent the development of esophageal or cardia adenocarcinoma among persons with reflux,” conclude the authors in the journal Gastroenterology.
Silver-Coated Endotracheal Tube Reduces Mortality in Patients With Ventilator-Associated Pneumonia
A silver-coated endotracheal tube (ETT) reduced the incidence of ventilator-associated pneumonia (VAP) compared with an uncoated ETT in the North American Silver-Coated Endotracheal Tube (NASCENT) study. An article in the Journal Chest evaluated the effect of an ETT and risk factors on mortality, we performed a retrospective cohort analysis in patients who developed VAP in the NASCENT study. The silver-coated ETT was associated with reduced mortality in patients with VAP, but not in those without VAP. These findings suggest that a silver-coated ETT was associated with reduced mortality in patients who developed VAP.
Risk Factors for Venous Thromboembolism
Studies have suggested a link between risk factors for atherosclerotic disease and venous thromboembolism (VTE), but results are heterogeneous. An article in Circulation sought to identify risk factors for VTE with a focus on risk factors for atherosclerotic disease. Data were taken from the Copenhagen City Heart Study, a prospective cohort study of a random, age-stratified sample of people living in a defined area in Copenhagen, Denmark, started in 1976 with follow-up until 2007. Out of all the different variables such as diabetes, gender, ect, it was shown that obesity and smoking were both found to be important risk factors for VTE whereas total/high-density lipoprotein/low-density lipoprotein cholesterol levels, triglyceride levels, and diabetes mellitus were not.
The Potential for Airborne Dispersal of Clostridium difficile from Symptomatic Patients
The high transmissibility and widespread environmental contamination by Clostridium difficile suggests the possibility of airborne dissemination of spores. We measured airborne and environmental C. difficile adjacent to patients with symptomatic C. difficile infection (CDI). An article in Clinical Infectious Diseases conducted air sampling adjacent to 63 patients with CDI for 180 h in total and for 101 h in control settings. Environmental samples were obtained from surfaces adjacent to the patient and from communal areas of the ward. The results show that aerosolization of C. difficile occurs commonly but sporadically in patients with symptomatic CDI. This may explain the widespread dissemination of epidemic strains. Our results emphasize the importance of single‐room isolation as soon as possible after the onset of diarrhea to limit the dissemination of C. difficile.
Increased incidence of intracranial aneurysms in patients with bicuspid aortic valve
Bicuspid aortic valve (BAV) is a common congenital heart defect affecting half to 2% of the population. A generalized connective tissue disorder also involving the intracranial arteries has been suspected in this patient population. An article published in the Amercian Acadamy of Neurology screened a group of patients with BAV for the presence of intracranial aneurysms. Intracranial aneurysms were detected in 6 of 61 patients with BAV (9.8%; 95% confidence interval [CI] 2.4%–17.3%). This was significantly higher than in the control population (3/291 [1.1%; 95% CI 0%–2.2%]) (p = 0.0012). Female sex (p = 0.02) and advanced age (p = 0.003), risk factors for intracranial aneurysm development, were more common in the control population than among the patients with a BAV. In this case-control study, the frequency of intracranial aneurysms among our bicuspid aortic valve patient population was significantly higher than in the control population.
Radiation Risks Nearly Double for Younger CT Scan Patients
Radiation risks associated with abdominal and pelvic CT scans are twice as high for younger patients as older patients, a new study finds. The study found that the estimated radiation risk for a 31-year-old (0.91 per 1,000) was about double that for a 74-year-old (0.47 per 1,000). The median radiation risk to 25 males was 0.61 per 1,000 and for 26 females was 0.74 per 1,000. The study was to be presented Monday at the American College of Radiology/American Roentgen Ray Society annual meeting in San Diego.
Almost 20% of stroke drug trials never published in full
A systematic review of trials of pharmacological interventions for acute ischemic stroke concludes that 19.6% of completed trials were never published in full [1]. The researchers, led by Lorna M Gibson (University of Edinburgh, Scotland), charge that these unpublished studies constitute "a substantial body of evidence that was of relevance both to clinical practice in acute stroke and future research in the field." However, some stroke experts are not so sure. The findings were published online April 22, 2010 in Trials.
Anabolic steroid users may face heart trouble
While it's nothing new that steroids have bad health effects, the new findings show they may be more harmful than previously thought. In heart failure, a weakened heart can't pump enough blood around the body.The researchers measured the recruits' heart function using ultrasound. Among the 12 steroid users, 10 turned out to have hearts that pumped less blood into the body than they should. In contrast, only one of the seven non-users had this problem. "That is a stunning statistical difference, far greater that could possibly be explained by chance," Pope told Reuters Health. "The heart becomes more flappy and cannot contract with the same force as it usually does, and it also becomes less flexible."
Antimicrobial Resistance to Ampicillin seen in pediatric chronic rhinosinusitis
Few studies in the past decade have focused on antimicrobial resistance of bacteria in pediatric rhinosinusitis. A study in the American Journal of Otolaryngology aimed to characterize organisms cultured from pediatric chronic rhinosinusitis, as well as current resistance patterns of pathogens.
The most common isolates were α-hemolytic Streptococcus (20.8%), Haemophilus influenzae (19.5%), Streptococcus pneumoniae (14.0%), coagulase-negative Staphylococcus (13.0%), and Staphylococcus aureus (9.3%). Anaerobes accounted for 8.0% of all isolates.
Susceptibility rates of H influenzae for ampicillin were 44.7% in the first 3 years of the study and 25% in the next 3 years, suggesting the resistance rate of H influenzae for ampicillin appears to be a growing problem in pediatric rhinosinusitis.
Secondhand Smoke as a Potential Cause of Chronic Rhinosinusitis
An article in this months Archives of Otolaryngology- Head & Neck Surgery assessed the role of secondhand smoke (SHS) in the etiology of chronic rhinosinusitis (CRS). Of controls and case patients, respectively, 28 (9.1%) and 41 (13.4%) had SHS exposure at home, 21 (6.9%) and 57 (18.6%) at work, 258 (84.3%) and 276 (90.2%) in public places, and 85 (27.8%) and 157 (51.3%) at private social functions. Results suggested that approximately 40.0% of CRS appeared to be attributable to SHS.
Gender differences in COPD expression identified
Results from a study conducted in Latin America show significant gender differences in perception of dyspnea and health status among individuals with and without chronic obstructive pulmonary disease (COPD). Writing in the European Respiratory Journal, María Victorina López Varela (Universidad de la República, Montevideo, Uruguay) and team explain: “There is increasing evidence in selected COPD populations supporting gender differences in the clinical expression of COPD.”
Microalbuminuria Harmful for People With High Blood Pressure
Healthy people with hypertension who excrete a slight excess of protein in the urine raise their risk of developing kidney and heart complications, according to a study published early online and appearing in an upcoming issue of the Clinical Journal of the American Society Nephrology.
The results suggest that more attention should focus on the potential health effects of urinary protein excretion in individuals with hypertension.
Which Method of Rotator Cuff Repair Leads to the Highest Rate of Structural Healing?
The purpose of rotator cuff repair is to diminish pain and restore function, and this most predictably occurs when the tendon is demonstrated to heal. Recent improvements in repair methods have led to improved biomechanical performance, but this has not yet been demonstrated to result in higher healing rates. The purpose of our study was to determine whether different repair methods resulted in different rates of recurrent tearing after surgery. An article in this months American Journal of Sports Medicine performed a systematic review of the literature and found double-row repair methods lead to significantly lower retear rates when compared with single-row methods for tears greater than 1 cm. Surgical approach has no significant effect on retear rate.
Repeat Epinephrine Treatments for Food-Related Anaphylaxis in Children
An article in this months Journal of PEDIATRICS sought to establish the frequency of receiving >1 dose of epinephrine in children who present to the emergency department (ED) with food-related anaphylaxis. A medical chart review at Boston hospitals of all children presenting to the ED for food-related acute allergic reactions between January 1, 2001, and December 31, 2006 and focused on causative foods, clinical presentations, and emergency treatments. It found that among children with food-related anaphylaxis who received epinephrine, 12% received a second dose. These results suggest the support of the recommendation that children at risk for food-related anaphylaxis carry 2 doses of epinephrine.
Safety of tPA in stroke mimics and neuroimaging-negative cerebral ischemia
Patients with acute neurologic symptoms may have other causes simulating ischemic stroke, called stroke mimics (SM), but they may also have averted strokes that do not appear as infarcts on neuroimaging, which we call neuroimaging-negative cerebral ischemia (NNCI). A study out of the Journal Neurology determined the safety and outcome of IV thrombolysis within 3 hours of symptom onset in patients with SM and NNCI. The data support the safety of administering IV tissue plasminogen activator to patients with suspected acute cerebral ischemia within 3 hours of symptom onset, even when the diagnosis ultimately is found not to be stroke or imaging does not show an infarct.
B-Vitamin Therapy Increases Progression of Diabetic Nephropathy
Hyperhomocysteinemia is frequently observed in patients with diabetic nephropathy. B-vitamin therapy (folic acid, vitamin B6, and vitamin B12) has been shown to lower the plasma concentration of homocysteine. A study in this weeks JAMA sought to determine whether B-vitamin therapy can slow progression of diabetic nephropathy and prevent vascular complications. This study found that among patients with diabetic nephropathy, high doses of B vitamins compared with placebo resulted in a greater decrease in GFR and an increase in vascular events.
Erythropoietin Suppresses the Formation of Macrophage Foam Cells
In addition to the hematopoietic effect of erythropoietin, increasing evidence suggests that erythropoietin also exerts protective effects for cardiovascular diseases. However, the role of erythropoietin and its underlying mechanism in macrophage foam cell formation are poorly understood. An article in this weeks Circulation Journal found that erythropoietin suppresses foam cell formation via the liver X receptor –dependent upregulation of ABCA1 and ABCG1.
CT Angiography Cuts Costs in Screening for CAD
Noninvasive computed tomography angiography (CTA) can be a cheaper alternative to invasive cardiac catheterization in diagnosing coronary artery disease, researchers performing a decision-tree analysis said.
Using coronary CTA to screen for coronary artery disease reduced the diagnostic cost per patient by an average of $759 for patients who test positive on a stress test, but who otherwise have no symptoms and are at a less than 50% chance of significant coronary artery disease, according to an online report in the American Journal of Roentgenology.
Failure to Perform Cholecystectomy for Acute Cholecystitis in Elderly Patients Is Associated with Increased Morbidity, Mortality, and Cost
Cholecystectomy during initial hospitalization is the current recommended therapy for acute cholecystitis. The rate of cholecystectomy and subsequent health care trajectory in elderly patients with acute cholecystitis has not been evaluated. An article in this months American College of Surgeons used 5% national Medicare sample claims data from 1996 to 2005 to identify a cohort of patients aged 66 years and older, requiring urgent or emergent admission for acute cholecystitis. The results of the study demonstrated that 25% of cholecystectomies on Medicare beneficiaries were not performed on initial hospitalization, leading to readmissions in 38% of surviving patients. For patients requiring readmission, the percentage of open procedures was increased, and the additional Medicare payment was $7,000 per re-admission. Cholecystectomy for acute cholecystitis in elderly patients should be performed during initial hospitalization to prevent recurrent episodes of cholecystitis, multiple readmissions, higher readmission rates, and increased costs.
Low serum 25-hydroxyvitamin D levels are associated with increased all-cause mortality risk in a general population: the Tromsø study
Ecologic and observational studies have suggested an association between serum 25-hydroxyvitamin D (25(OH)D) levels and cardiovascular disease (CVD) risk factors, CVD mortality, and cancer mortality. Based on this, low serum 25(OH)D levels should be associated with higher all-cause mortality in a general population. This hypothesis was tested in the present study. The Tromsø study is a longitudinal population-based multipurpose study initiated in 1974 with focus on lifestyle-related diseases. During a mean 11.7 years of follow-up, 1359 (19.0%) participants died. Overall the study showed that low serum 25(OH)D levels were associated with increased all-cause mortality for non-smokers, but the results did not reach statistical significance for smokers. However, low 25(OH)D levels are known to be associated with impaired general health, and randomized controlled studies are needed to address the question of causality.
Inflammatory Bowel Disease Confers a Lower Risk of Colorectal Cancer to Females Than to Males
Reported differences in cancer risk between male and female animals after chronic inflammation suggest that estrogen has inflammation-modifying properties. Little is known about these effects in human beings. Inflammatory bowel disease (IBD) is associated with an increased risk of colorectal cancer (CRC). An article in this months Journal of Gastroenterology studied differences in inflammation-associated CRC between men and women patients with IBD by using a large population-based cohort (n = 7607) of individuals diagnosed with IBD from 1954 to 1989, we assessed the sex-specific incidence of CRC from 1960 to 2004. During 171,000 person-years of follow-up evaluation, 196 new cases of CRC were observed (123 in males, 73 in females). Males with IBD had a 60% higher risk of CRC than females (cumulative incidence 40 years after IBD diagnosis, 8.3% vs 3.5%). Compared with the rate of CRC among the general population, in males with IBD the RR was 2.6 and the 95% CI was 2.2–3.1, whereas in females the RR was 1.9 and the 95% CI was 1.5–2.4.
Ace Inhibitors Help in Amiodarone Induced Toxicity
Amiodarone (AMD) is a strong antiarrhythmic drug but has severe side effects such as pulmonary toxicity. There are no indicators or drugs that can prevent the development of amiodarone-induced pulmonary toxicity (AIPT). An article out of the International Journal of Cardiology investigated this and the results indicate that Ang II induced by CHF increases the risk of AMD-induced pulmonary toxicity. An angiotensin-converting enzyme inhibitor or ARB should be given at a sufficient dose during AMD treatment.
BNP Improves with Excercising
BNP and the N-terminal portion (NT-pro-BNP) have emerged as powerful tools in the diagnosis and prognosis of heart failure on acute presentation. An article out of the International Journal of Cardiology systematically reviewed the effect of exercise training on BNP and NT-pro-BNP levels in patients with left ventricular dysfunction. Nine randomized controlled studies measuring BNP or NT-pro-BNP met our eligibility criteria. Exercise training had a favourable effect on BNP (mean difference −79 pg/ml 95% C.I. −141 to − 17 pg/ml, P=0.01) and NT-pro-BNP (mean difference −621 pg/ml, 95% C.I. −844 to −398 pg/ml, P=<0.00001). Moreover the trials that showed a significant change in NT-pro-BNP all had a weekly exercise energy expenditure of more than 400 Kcal.
Angiotensin-Converting Enzyme Inhibition Decreases One-Year Mortality and Frequency of Repeat Acute Myocardial Infarction in Patients With Acute Myocardial Infarction
Controversy exists regarding whether all patients with acute myocardial infarction (AMI) benefit from angiotensin-converting enzyme inhibitors (ACEIs). A Journal in the American Journal of Cardiology examined the association between ACEI treatment and mortality in a large, unselected population of patients with AMI. The present study included 105,224 patients with AMI who were not treated with ACEIs on admission. ACEI treatment was associated with a 24% reduction in mortality (relative risk 0.76, 95% confidence interval 0.73 to 0.80). The benefit was largest in patients with a history or present signs of heart failure. In patients without heart failure, a significant benefit of ACEI treatment was seen only in patients with renal dysfunction (relative risk 0.69, 95% confidence interval 0.54 to 0.88). In the whole group, the risk of AMI decreased by 7% (relative risk 0.93, 95% confidence interval 0.90 to 0.96), with a larger effect seen in patients with ST-segment elevation AMI or systolic left ventricular dysfunction.
Migraine Patients to Wait for Triptan Alternative
Scandinavian researchers writing in
The Lancet gave a warm review to an investigational drug for migraine, but patients in the U.S., at least, will have a wait before it reaches them.
The drug, telcagepant, antagonizes the calcitonin gene-related peptide (CGRP) receptor and has
completed phase III studies. Its manufacturer, Merck, was initially expected to seek FDA approval last year.
An online
Lancet review by researchers from Sweden and Norway touted telcagepant as holding out hope for migraine patients with acute attacks that fail to respond to triptan drugs (Zomig, Imitrex).
Comparison of Laparoscopic and Open Repair With Mesh for the Treatment of Ventral Incisional Hernia
Laparoscopic repair of ventral incisional hernias has not been proved to be safer than open mesh repair. An article in this weeks Archives of Surgery published a prospective randomized trial that looked at one hundred sixty-two patients with ventral incisional hernias. Of the 162 randomized patients, 146 underwent surgery (73 open and 73 laparoscopic repairs). Surgical site infection through 8 weeks was less common in the laparoscopic group (5.6% vs 23.3%; AOR, 0.2; 95% CI, 0.1-0.6). The mean worst pain score in the laparoscopic group was 15.2 mm lower on a visual analog scale at 52 weeks (95% CI, 1.0-29.3; P = .04). Time to resume work activities was shorter for the laparoscopic group than for the open repair group (median, 23.0 days vs 28.5 days), with an adjusted hazard ratio of 0.54 (95% CI, 0.28-1.04; P = .06). Overall recurrence at 2 years was 12.5% in the laparoscopic group and 8.2% in the open repair group (AOR, 1.6; 95% CI, 0.5-4.7; adjusted P = .44).
Valsartan decreases the Incidence of Diabetes but not Cardiovascular Events
It is not known whether drugs that block the renin–angiotensin system reduce the risk of diabetes and cardiovascular events in patients with impaired glucose tolerance. An article in this months New England Journal of Medicine published an article which conducted a double-blind, randomized clinical trial with a 2-by-2 factorial design, we assigned 9306 patients with impaired glucose tolerance and established cardiovascular disease or cardiovascular risk factors to receive valsartan (up to 160 mg daily) or placebo (and nateglinide or placebo) in addition to lifestyle modification. The cumulative incidence of diabetes was 33.1% in the valsartan group, as compared with 36.8% in the placebo group and did not significantly reduce the incidence of either the extended cardiovascular outcome or the core cardiovascular outcome.
Early vs Late Tracheotomy Doesn't Show Difference for Prevention of Pneumonia in Mechanically Ventilated Adult ICU Patients
Tracheotomy is used to replace endotracheal intubation in patients requiring prolonged ventilation; however, there is considerable variability in the time considered optimal for performing tracheotomy. This is of clinical importance because timing is a key criterion for performing a tracheotomy and patients who receive one require a large amount of health care resources. An article in this weeks JAMA looked at the effectiveness of early tracheotomy (after 6-8 days of laryngeal intubation) compared with late tracheotomy (after 13-15 days of laryngeal intubation) in reducing the incidence of pneumonia and increasing the number of ventilator-free and intensive care unit (ICU)-free days. It found that among mechanically ventilated adult ICU patients, early tracheotomy compared with late tracheotomy did not result in statistically significant improvement in incidence of ventilator-associated pneumonia.
Effect of Early Cerebral Magnetic Resonance Imaging on Clinical Decisions in Infective Endocarditis
Neurologic complications of endocarditis can influence diagnosis, therapeutic plans, and prognosis. An article in this weeks Annals of Internal Medicine reviewed a single-center prospective study between June 2005 and October 2008 that looked at how early cerebral magnetic resonance imaging (MRI) affects the diagnosis and management of endocarditis in hospitalized adults. Endocarditis was initially classified as definite in 77 patients and possible in 50 and was excluded in 3. Sixteen patients (12%) had acute neurologic symptoms. Cerebral lesions were detected by MRI in 106 patients (82% [95% CI, 75% to 89%]), including ischemic lesions in 68, microhemorrhages in 74, and silent aneurysms in 10. Endocarditis therapeutic plans were modified for 24 (18%) of the 130 patients, including surgical plan modifications for 18 (14%). Overall, early MRI led to modifications of diagnosis or therapeutic plan in 36 patients (28% [CI, 20% to 36%]).
Significance of a prominent Q wave in lead negative aVR (−aVR) in acute anterior myocardial infarction
The aim of this study was to clarify the significance of a Q wave in lead negative aVR (−aVR) in anterior wall acute myocardial infarction (AMI). Eighty-seven patients with a first anterior wall AMI were classified into 2 groups according to the presence (n = 17, group A) or absence (n = 70, group B) of a prominent Q wave (duration ≥20 milliseconds) in lead −aVR at predischarge. Group A had a higher prevalence of a long left anterior descending coronary artery (LAD), a lower left ventricular ejection fraction, and more reduced regional wall motion in the apical and inferior regions than group B concluding that a prominent Q wave in lead −aVR in anterior wall AMI is related to severe regional wall motion abnormality in the apical and inferior regions, with an LAD wrapping around the apex.
Statins Won't Lower Colon Cancer Risk
Statins don't lower the risk of colorectal cancer, and may even increase the chances of developing precancerous polyps, new research suggests. We found patients in this study taking statins for more than three years tended to develop more premalignant colon lesions," said study author Dr. Monica Bertagnolli, chief of the division of surgical oncology at Brigham and Women's Hospital and a professor of surgery at Harvard Medical School. "This is an interesting finding that needs to be followed up, but it should not raise alarm. No one should stop taking their statins."
Long term, tamoxifen stops more cancer than Evista
After nearly seven years of follow-up, researchers found that women who took tamoxifen for five years were less likely to develop breast cancer than those who took Evista, known generically as raloxifene. But they told a meeting of the American Association for Cancer Research that both drugs are useful and that women should be able to choose. Only tamoxifen is approved for women who have not yet gone through menopause, and many may not want to risk its side effects.
Stroke in paroxysmal atrial fibrillation similar to that in permanent atrial fibrillation
Knowledge about stroke risk in paroxysmal atrial fibrillation (PxAF) is limited. Although current guideline recommendations advocate the same treatment as in permanent atrial fibrillation (PermAF), most patients with PxAF do not receive prophylactic anticoagulation. An article in this weeks European Heart Journal investigated whether there are differences in stroke risk between PxAF and PermAF. It was found that Ischaemic stroke is about as common in PxAF as in PermAF, and about twice as common as in the general population. Yet, PxAF patients do not receive protective anticoagulant treatment as often as patients with PermAF do. It is therefore important to increase the use of anticoagulants among PxAF patients in accordance with current guideline recommendations.
Lung recruitment and positive airway pressure before extubation does not improve oxygenation in the post-anaesthesia care unit: a randomized clinical trial
Atelectasis is known to develop during anaesthesia and after operation atelectasis leads to impaired oxygenation. Lung recruitment manoeuvres, positive end-expiratory pressure (PEEP), and continuous positive airway pressure (CPAP) have been proposed for reduction of atelectasis but their benefits have not been shown to persist after operation. An article in this months British Journal of Anaesthesia proposed that a combination of these techniques before extubation would improve oxygenation after operation. It was found that postoperative oxygenation is not improved by a combination of a lung recruitment manoeuvre and maintenance of a positive airway pressure until extubation. Further research is needed to elucidate the mechanism of atelectasis on emergence from anaesthesia and to evaluate more invasive clinical strategies such as post-extubation CPAP.
Effects of exposure to smoking on the microbial flora of children and their parents
The effects of exposure to direct and indirect smoking on the colonization with pathogenic bacteria and organisms that interfere with their growth were examined in an article in this months International Journal of Pediatric Otolaryngology. It found parents that smoked were more often colonized by potential pathogens than parents that did not smoke. The flora of healthy children of Smoking parents contained high number of potential pathogens similar to the one found in their parents and Otitis Media Prone children. Since Smoking parents harbor more potential pathogens and less interfering organisms they may serve as a source of pathogens that can colonize and/or infect their children. These studies illustrate the adverse effects of direct and indirect exposure to smoking on colonization with potential pathogens.
Cranberry Juice and Warfarin: When Bad Publicity Trumps Science
Based on anecdotal reports, the question of whether cranberry juice interacts with warfarin has been raised. An article in this month's American Journal of Medicine discussed and reviewed the potential mechanism, and systematically reviews case reports as well as clinical trials examining the possible interaction. It found that the randomized clinical trials and surrogate markers found no evidence to support the interaction between cranberry juice and warfarin. Because the moderate consumption of cranberry juice does not affect anticoagulation, we encourage the reexamination of initial warnings based on scientific evidence. We conclude that the initial precautionary warnings by administrating bodies are limited to anecdotal case reports and represent misleading conclusions.
Free light chain: a novel predictor of adverse outcome in chronic lymphocytic leukemia
Chronic lymphocytic leukemia (CLL) is characterized by a highly variable clinical course. This retrospective study in this months European Journal of Haematology assessed the prognostic value of serum free light chain (sFLC) levels and FLC ratio (FLCR) in CLL. It found the median time to first treatment was shorter in patients with high sFLC levels and overall survival was shorter in patients with high sFLC levels concluding an adverse prognostic impact of high sFLC levels and abnormal FLCR with regard to survival in CLL, even in early stage patients. Prospective studies are warranted to validate the adverse impact of sFLC and FLCR on clinical outcome.
Comparison by Meta-Analysis of Drug-Eluting Stents and Bare Metal Stents for Saphenous Vein Graft Intervention
This meta-analysis was undertaken to assess the efficacy and safety of drug-eluting stents (DESs) compared to bare metal stents (BMSs) in saphenous vein graft (SVG) interventions. DESs decrease the risk of target vessel revascularization in native coronary arteries compared to BMSs. The ideal treatment strategy in patients with SVG disease is unknown. The ideal treatment strategy in patients with SVG disease is unknown. A search of the published reports was conducted to identify studies that compared DESs and BMSs in SVG intervention with a minimum follow-up of 6 months. Overall the results showed that Using the fixed effect model, target vessel revascularization was less frequently performed in patients who had undergone SVG intervention with a DES than with a BMS, the incidence of myocardial infarction was lower in patients with a DES than in those with a BMS, there was no differences were found in the risk of death or stent thrombosis between the 2 groups concluding the use of Drug Eluting Stents in SVG lesions.
ALS disease onset may occur later in patients with pre-morbid diabetes mellitus
Several metabolic derangements associated with diabetes mellitus type 2 (DM) have been associated with a better outcome in amyotrophic lateral sclerosis (ALS), including hyperlipidemia and obesity. An article in this weeks European Journal of Neurology tested the hypothesis that DM would have a positive effect on the motor and cognitive findings of ALS. The age of onset was later for women, Caucasians and patients with bulbar-onset ALS. However, we also found that after adjusting for gender, ethnicity and site of onset, DM was associated with a 4-year later onset of ALS. Overall it was found that diabetes mellitus type 2 may delay the onset of motor symptoms in ALS. These findings support other studies suggesting a relationship between the pathophysiology of ALS and metabolic derangements. Further investigations are needed to ascertain whether manipulating metabolic parameters would improve outcomes in ALS.
Polyunsaturated Omega-3 Fatty Acids Increase Responsiveness to Dual Antiplatelet Therapy in Patients Undergoing Percutaneous Coronary Intervention
A study out of this weeks Journal of American College of Cardiology investigated whether omega-3 polyunsaturated fatty acids (PUFAs) are able to modify platelet responsiveness to dual antiplatelet therapy in stable coronary artery disease patients undergoing percutaneous coronary intervention (PCI). Patients receiving standard dual antiplatelet therapy (aspirin 75 mg/day and clopidogrel 600 mg loading dose followed by 75 mg/day) were randomly assigned to receive the addition of 1 g of omega-3 ethyl esters (n = 33) or placebo (n = 30) for 1 month. The P2Y12 reactivity index was significantly lower, by 22.2%, after 1 month of treatment with omega-3 polyunsaturated fatty acids compared with placebo when used in addition to dual antiplatelet therapy (p = 0.020). Maximal platelet aggregation induced by 5 and 20 µmol/l adenosine diphosphate was lower by 13.3% (p = 0.026) and 9.8% (p = 0.029), respectively, after 1 month of treatment with omega-3 polyunsaturated fatty acids compared with placebo.
Derivation and Validation of a Simple Perioperative Sleep Apnea Prediction Score
Obstructive sleep apnea (OSA) is a largely underdiagnosed, common condition, which is important to diagnose preoperatively because it has implications for perioperative management. Our purpose in this study was to identify independent clinical predictors of a diagnosis of OSA in a general surgical population, develop a perioperative sleep apnea prediction (P-SAP) score based on these variables, and validate the P-SAP score against standard overnight polysomnography. The P-SAP score was derived from 43,576 adult cases undergoing anesthesia. Of these, 3884 patients (7.17%) had a documented diagnosis of OSA. Three demographic variables: age >43 years, male gender, and obesity; 3 history variables: history of snoring, diabetes mellitus Type 2, and hypertension; and 3 airway measures: thick neck, modified Mallampati class 3 or 4, and reduced thyromental distance were identified as independent predictors of a diagnosis of OSA. A diagnostic threshold P-SAP score ≥2 showed excellent sensitivity (0.939) but poor specificity (0.323), whereas for a P-SAP score ≥6, sensitivity was poor (0.239) with excellent specificity (0.911).
Anticonvulsant Medications and the Risk of Suicide, Attempted Suicide, or Violent Death
In 2008, the US Food and Drug Administration mandated warning labeling for anticonvulsant medications regarding the increased risk of suicidal thoughts and behaviors. The decision was based on a meta-analysis not sufficiently large to investigate individual drugs. In this weeks issue of JAMA a cohort study of the risk of suicidal acts and combined suicidal acts or violent death in patients beginning use of anticonvulsant medications compared with patients initiating a reference anticonvulsant drug was performed and suggests that the use of gabapentin, lamotrigine, oxcarbazepine, and tiagabine, compared with the use of topiramate, may be associated with an increased risk of suicidal acts or violent deaths.
Bacteremia Increases the Risk of Death among Patients
with Soft-Tissue Infections
Soft-tissue infections traditionally have been viewed as carrying a lower risk of death than other
types of infection such as pneumonia, blood stream, and intra-abdominal. The influence of secondary bacteremia on the outcomes of patients with soft-tissue infections is not well described.
This articel sought to describe the risk factors for bacteremia among patients admitted to an urban medical center with
soft-tissue infections and the influence of bacteremia on outcomes through a retrospective cohort study of 717 patients with culture-positive non-necrotizing soft-tissue infections
admitted between April 1, 2005, and December 31, 2007.
The results showed that bBacteremia was present in 52% of the patients. Increasing age, previous hospitalization, decubitus or
lower-extremity ulcers, device-related soft-tissue infection, and polymicrobial infection were independent predictors
of bacteremia. Intensive care unit admission, lower-extremity ulcer , and bacteremia were independent predictors of in-hospital death. When patients with device-related soft-tissue infections
were excluded, the rate of secondary bacteremia was 37.6%, and it remained an independent predictor
of in-hospital death.
Overall this study showed that the occurrence of bacteremia in soft-tissue infections is associated with a greater risk of death. Health
care providers should be aware of the risk factors for bacteremia in patients with soft-tissue infections in order to
provide more appropriate initial antimicrobial therapy and to ascertain its presence as a prognostic indicator.
Endovascular versus Open Repair of Abdominal Aortic Aneurysm
Few data are available on the long-term outcome of endovascular repair of abdominal aortic aneurysm as compared with open repair. An article in this weeks New England Journal of Medicine randomly assigned 1252 patients with large abdominal aortic aneurysms (5.5 cm in diameter) to undergo either endovascular or open repair; 626 patients were assigned to each group. Patients were followed for rates of death, graft-related complications, reinterventions, and resource use until the end of 2009. Logistic regression and Cox regression were used to compare outcomes in the two groups. The 30-day operative mortality was 1.8% in the endovascular-repair group and 4.3% in the open-repair group (adjusted odds ratio for endovascular repair as compared with open repair but by the end of follow-up, there was no significant difference between the two groups in the rate of death from any cause.
Lipid levels in sickle-cell disease associated with haemolytic severity, vascular dysfunction and pulmonary hypertension
Pulmonary hypertension (PH) in sickle cell disease (SCD) is an emerging and important clinical problem. In a single-institution adult cohort of 365 patients, we investigated lipid and lipoprotein levels and their relationship to markers of intravascular haemolysis, vascular dysfunction and PH. In agreement with prior studies, we confirm significantly decreased plasma levels of total cholesterol, high-density lipoprotein-cholesterol (HDL-C) and low-density lipoprotein-cholesterol (LDL-C) in SCD versus ethnically-matched healthy controls. Several cholesterol parameters correlated significantly with markers of anaemia, but not endothelial activation or PH. More importantly, serum triglyceride levels were significantly elevated in SCD compared to controls. Elevated triglyceride levels correlated significantly with markers of haemolysis, endothelial activation, inflammation and PH; prevalence of elevated tricuspid regurgitant velocity.
Is statin use associated with prostate cancer aggressiveness?
To further examine the association between statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) and pathological features in a large group of patients undergoing radical prostatectomy (RP), as epidemiological studies have suggested that statins, in addition to their beneficial cardiovascular effects, might reduce the risk of aggressive prostate cancer.From 2003 to 2009, 1351 men with data on preoperative statin use had RP by one surgeon. The clinical and pathological tumour features were compared between 504 users of statins and 847 who were not users.The preoperative serum prostate-specific antigen levels, tumour volume and percentage of cancer in the RP specimen were significantly lower in patients taking statins. Overall, statin users had a proportionately lower rate of adverse tumour pathology features, including a significantly lower risk of positive (cancerous) surgical margins.
Flu Vaccine With Both B Strains May Offer Better Protection
Children would be better protected by seasonal flu vaccines if the vaccines contained both strains of influenza B instead of just one, the results of a new study suggest. "Adding a second influenza B virus strain to the seasonal influenza vaccine would take some of the guesswork out of strain selection and help improve the vaccine's ability to prevent influenza," lead investigator Dr. Robert Belshe, director of the Center for Vaccine Development at Saint Louis University, said in a news release. "Since in five of the last 10 years, the influenza B component in the vaccine has been the incorrect one, this seems like an obvious advance to me."
Compound Effective In Destroying Antibiotic-Resistant Biofilms
Researchers at North Carolina State University have found a chemical compound that, when used in conjunction with conventional antibiotics, is effective in destroying biofilms produced by antibiotic-resistant strains of bacteria such as the Staphylococcus strain MRSA and Acinetobacter. The compound also re-sentsitizes those bacteria to antibiotics.
12-Lead ECG Findings of Pulmonary Hypertension Occur More Frequently in Emergency Department Patients With Pulmonary Embolism Than in Patients Without Pulmonary Embolism
Acute pulmonary embolism can produce abnormalities on ECG that reflect severity of pulmonary hypertension. Early recognition of these findings may alter the estimated pretest probability of pulmonary embolism and prompt more aggressive treatment before hemodynamic instability ensues, but it is first important to test whether these findings are specific to patients with pulmonary embolism. An article in this months Annals of Emergency Medicine compared hypothesized that ECG findings consistent with pulmonary hypertension would be observed more frequently in patients with pulmonary embolism. Overall the findings of acute pulmonary hypertension were infrequent overall but were observed more frequently in patients with the final diagnosis of pulmonary embolism compared with patients who do not have pulmonary embolism.
Hydroxocobalamin and Sodium Thiosulfate Versus Sodium Nitrite and Sodium Thiosulfate in the Treatment of Acute Cyanide Toxicity
Cyanide can cause severe hypotension with acute toxicity. To our knowledge, no study has directly compared hydroxocobalamin and sodium nitrite with sodium thiosulfate in an acute cyanide toxicity model. A study published in this months Annals of Emergency Medicine compared the return to baseline of mean arterial blood pressure between 2 groups of swine with acute cyanide toxicity and treated with hydroxocobalamin with sodium thiosulfate or sodium nitrite with sodium thiosulfate. Overall it showed that hydroxocobalamin with sodium thiosulfate led to a faster return to baseline mean arterial pressure compared with sodium nitrite with sodium thiosulfate; however, there was no difference between the antidote combinations in mortality, serum acidosis, or serum lactate.
Effect of deferred treatment of supracondylar humeral fractures
Timing of surgery remains a controversial topic in the treatment of the supracondylar humeral fracture. In our institution, patients are not brought to theatre after midnight, except in the ‘life or limb’ situation. We hypothesised that time to surgery has no significant influence on complication rate with supracondylar fracture of the humerus.Overall there was no difference in complication rates when treatment of supracondylar fractures is delayed. Supracondylar fractures which are not grossly displaced, have no neurovascular deficit or risk of skin compromise, can be safely deferred without an increased risk of complication. Operative treatment of supracondylar fractures can be delayed until the next morning, except in the ‘life or limb’ situation.
Long-Term Use of Bisphosphonates in Osteoporosis
Bisphosphonates have been widely used in the treatment of osteoporosis. Uncommon side effects have emerged in postapproval use. Because they accumulate in bone and provide some residual antifracture reduction when treatment is stopped, we recommend a drug holiday after 5–10 yr of bisphosphonate treatment. The duration of treatment and length of the holiday are based on fracture risk and pharmacokinetics of the bisphosphonate used. Patients at mild risk might stop treatment after 5 yr and remain off as long as bone mineral density is stable and no fractures occur. Higher risk patients should be treated for 10 yr, have a holiday of no more than a year or two, and perhaps be on a nonbisphosphonate treatment during that time.
Oral Immunotherapy With Inactivated Nontypeable Haemophilus influenzae Reduces Severity of Acute Exacerbations in Severe COPD
Acute exacerbations of COPD reflect in part an inappropriate host response to abnormal bacterial colonization. Orally administered inactivated nontypeable Haemophilus influenzae (NTHi) can drive a specific T-cell response that by promoting intrabronchial phagocytosis down-regulates bronchus inflammation. An article in the weeks Chest looked at subjects with recurrent exacerbations of COPD were studied in a randomized, multicenter, double-blind, placebo-controlled trial, to test efficacy of an NTHi oral immunotherapeutic (HI-164OV). Exacerbations defined as an increase in volume and purulence of sputum were reduced by 16%, moderate-to-severe exacerbations were reduced by 63%, the proportion with episodes requiring corticosteroid therapy was reduced by 56%, mean duration of episodes was reduced by 37% and prescribed courses of antibiotics were reduced by 56% following therapy. Exacerbations requiring admission into hospital were reduced by 90% (P = .04) in the active group.
Methotrexate Withdrawal at 6 vs 12 Months in Juvenile Idiopathic Arthritis in Remission
Novel therapies have improved the remission rate in chronic inflammatory disorders including juvenile idiopathic arthritis (JIA). Therefore, strategies of tapering therapy and reliable parameters for detecting subclinical inflammation have now become challenging questions. To analyze whether longer methotrexate treatment during remission of JIA prevents flares after withdrawal of medication and whether specific biomarkers identify patients at risk for flares, a prospective, open, multicenter, medication-withdrawal randomized clinical trial including 364 patients (median age, 11.0 years) with JIA recruited in 61 centers from 29 countries between February 2005 and June 2006. Overall, in patients with JIA in remission, a 12-month vs 6-month withdrawal of methotrexate did not reduce the relapse rate and it was shown a higher MRP8/14 concentrations were associated with risk of relapse after discontinuing methotrexate.
Low-Dose Colchicine Effective, Safe in Acute Gout
Low-dose colchicine (Colcrys) was as effective as the commonly prescribed high-dose regimen for pain reduction in acute gout and had a much better side-effect profile, a multicenter randomized trial found.
A total of 37.8% of patients in the low-dose group were responders, compared with 32.7% of those in the high-dose group and 15.5% of those in the placebo group (P=0.005 and P=0.034, respectively, versus placebo), according to Robert A. Terkeltaub, MD, of the University of California, San Diego, and colleagues.
Biomarkers in Osteoarthritis
Osteoarthritis is the most common joint disorder considered as the cumulative result of mechanical and biological events that induce an imbalance between the degradation and synthesis within articular joint tissues. The diagnosis of OA mainly based on physical examination and radiographs which provide semi quantitative assessment of disease state. Biomarkers are sensitive to minor changes so their measurement provides an accurate metabolic status of joint. As osteoarthritis mainly affects bone, cartilage, and synovium, biomarker related to their metabolism act as specific marker for osteoarthritis. Analyses of cartilage markers such as cartilage oligomeric matrix protein, keratan sulfate etc. provide a useful technique to diagnose osteoarthritis at early stages. Osteocalcin measurement provides information about bone while glucosyl- galactosyl pyridinoline reflect synovium turnover. The measurement of inflammatory markers such as YKL-40, matrixmetalloproteinases etc. help to detect target joints. The clinical utility of biomarkers described using BIPED approach. The biomarkers for osteoarthritis used to diagnose disease at an early stage, assess severity of disease and measure efficacy of treatments. Matrix metalloproteinases and pro matrix metalloproteinase are sensitive markers of disease severity and response to treatment.
Early Surgery Versus Conventional Treatment in Asymptomatic Very Severe Aortic Stenosis
The optimal timing of surgical intervention remains controversial in asymptomatic patients with very severe aortic stenosis. An article in this months Circulation Journal therefore compared the long-term results of early surgery and a conventional treatment strategy. Compared with the conventional treatment strategy, early surgery in patients with very severe aortic stenosis is associated with an improved long-term survival by decreasing cardiac mortality. Early surgery is therefore a therapeutic option to further improve clinical outcomes in asymptomatic patients with very severe aortic stenosis and low operative risk.
Bromocriptine in the Treatment of Acute Severe Peripartum Cardiomyopathy
Peripartum cardiomyopathy (PPCM) is a potentially life-threatening heart disease that occurs in previously healthy women. We identified prolactin, mainly its 16-kDa angiostatic and proapoptotic form, as a key factor in PPCM pathophysiology. Previous reports suggest that bromocriptine may have beneficial effects in women with acute onset of PPCM. A prospective, single-center, randomized, open-label, proof-of-concept pilot study of women with newly diagnosed PPCM receiving standard care (PPCM-Std; n=10) versus standard care plus bromocriptine for 8 weeks (PPCM-Br, n=10) was conducted. In this trial, the addition of bromocriptine to standard heart failure therapy appeared to improve left ventricular ejection fraction and a composite clinical outcome in women with acute severe PPCM, although the number of patients studied was small and the results cannot be considered definitive. Larger-scale multicenter and blinded studies are in progress to test this strategy more robustly.
Once-Daily Dosing of Delayed-Release Oral Mesalamine (400-mg Tablet) Is as Effective as Twice-Daily Dosing for Maintenance of Remission of Ulcerative Colitis
The practice of dosing mesalamines in divided doses for the treatment of ulcerative colitis (UC) began with sulfasalazine and was driven by sulfapyridine toxicity. This convention and the assumption that dosing multiple times a day is necessary to treat UC had not been challenged until recently. This study was conducted to determine the efficacy and safety of once-daily dosing of delayed-release mesalamine (Asacol 400-mg tablets) compared with twice-daily dosing for maintaining remission in UC patients. A total of 1023 patients were randomized and dosed. The primary objective of noninferiority was met. At month 6, 90.5% of patients receiving once-daily dosing had maintained clinical remission, compared with 91.8% of patients receiving twice-daily dosing (95% confidence interval for twice daily - once daily, -2.3 to 4.9). At month 12, 85.4% of patients receiving once-daily dosing had maintained clinical remission, compared with 85.4% of patients receiving twice-daily dosing (95% confidence interval for twice daily - once daily, -4.6 to 4.7). Both regimens had low rates of withdrawals as a result of adverse events and serious adverse events.
QRS prolongation in patients with acute coronary syndromes
QRS prolongation with or without bundle branch block (BBB) has been associated with adverse outcome in myocardial infarction;An article in this months American Heart Journal examined the relationship between QRS duration and outcome in a broad spectrum of patients with acute coronary syndrome (ACS). Compared to patients with QRS <120 milliseconds, patients with QRS ≥120 milliseconds without BBB had higher in-hospital (3.5% vs 1.9%, odds ratio [OR] 1.87, 95% CI 0.85-4.09, P = .12) and 1-year mortality (14.9% vs 7.7%, OR 2.10, 95% CI 1.38-3.18, P = .001). In-hospital and 1-year mortality was significantly higher in patients with BBB . In patients presenting with a broad spectrum of suspected ACS, QRS prolongation—particularly in the setting of LBBB—is an independent predictor of in-hospital and 1-year mortality.
Effect of Dutasteride on the Risk of Prostate Cancer
A study published in this weeks New England Journal of Medicine conducted a study to determine whether dutasteride reduces the risk of incident prostate cancer, as detected on biopsy, among men who are at increased risk for the disease. In this 4-year, multicenter, randomized, double-blind, placebo-controlled, parallel-group study, we compared dutasteride, at a dose of 0.5 mg daily, with placebo. Among 6729 men who underwent a biopsy or prostate surgery, cancer was detected in 659 of the 3305 men in the dutasteride group, as compared with 858 of the 3424 men in the placebo group, representing a relative risk reduction with dutasteride of 22.8%. Over the course of the 4-year study period, dutasteride reduced the risk of incident prostate cancer detected on biopsy and improved the outcomes related to benign prostatic hyperplasia.
Elevated resting heart rate is an independent risk factor for cardiovascular disease in healthy men and women
Elevated resting heart rate (RHR) is known to be associated with reduced survival but inconsistencies remain, including lack of significance in most studies of healthy women, lack of independence from systolic blood pressure (SBP) in some, and the suggestion that RHR is merely functioning as a marker of physical inactivity or other comorbidities. A study out of the American Heart Journal aimed to clarify these inconsistencies. Overall a strong, graded, independent relationship between RHR and incident CVD was demonstrated. This was consistent in healthy men and women. We have clarified that the relationship is independent of SBP and that the temporal sequence would be compatible with a causal relationship. New findings include independence from both a validated measure of physical activity and comorbidities and the demonstration of a stronger effect for fatal than nonfatal events, supporting increased arrhythmogenicity of one of the mechanisms.
Long-acting Beta-Agonists with and without Inhaled Corticosteroids and Catastrophic Asthma Events
It is unclear whether long-acting β-agonists with concomitant inhaled corticosteroids increase asthma-related intubations and deaths. A study from this months American Journal of Medicine pooled data on long-acting β-agonists with variable and concomitant inhaled corticosteroids to evaluate the risk for catastrophic asthma events. In pooled trial data that included 36,588 participants, long-acting β-agonists increased catastrophic events 2-fold (Peto odds ratio [OR] 2.10; 95% confidence interval [CI], 1.37-3.22). Statistically significant increases were seen for long-acting β-agonists with variable corticosteroids compared with placebo (OR 1.83; 95% CI, 1.14-2.95) and for concomitant treatment with corticosteroids compared with corticosteroids alone.
What is the complementary role of ultrasound evaluation in the diagnosis of acute appendicitis after CT?
A study in this months European Journal of Radiology estimated the complementary role of ultrasound evaluation in the diagnosis of acute appendicitis after abdominoplevic CT. A total of 104 patients initially underwent abdominopelvic CT before appendix US due to acute abdominal pain. Appendix US images and their radiologic reports were also evaluated retrospectively.In the 41 patients of normal looking appendix on CT, US showed acute appendicitis in five patients (12.2%, 5 of 41). US reevaluation enables us to avoid misdiagnosis of appendicitis on CT and improve diagnostic accuracy of acute appendicitis.
Gene mutation may be key to schizophrenia: study
A genetic mutation linked to schizophrenia appears to rupture communication between the two areas of the brain believed to be responsible for memory and may be an underlying cause of the brain disorder, U.S. researchers suggested in a study published on Wednesday.
Sex infection gonorrhea risks becoming "superbug"
Catherine Ison, a specialist on gonorrhea from Britain's Health Protection Agency said a World Health Organization (WHO) meeting in Manila next week would be vital to efforts to try to stop the bug repeatedly adapting to and overcoming drugs.
"This is a very clever bacteria. If this problem isn't addressed, there is a real possibility that gonorrhea will become a very difficult infection to treat," she said in a telephone interview.
More heat for aspirin in new primary-prevention meta-analysis: "Creativity" needed to determine who will benefit
Two new analyses presented at the American College of Cardiology 2010 Scientific Sessions last week, aimed at updating the groundbreaking Aspirin Treatment Trialists' Collaboration (ATTC) meta-analysis of May 2009, has found that even with the addition of three new trials to the mix, the benefits of aspirin for primary prevention do not appear to "substantially outweigh" the risks. Moreover, in a subgroup analysis looking just at diabetic subjects, investigators found no relationship between aspirin use and 10-year risk of cardiovascular events.
Effectiveness of cardiac resynchronization therapy in mild congestive heart failure: systematic review and meta-analysis of randomized trials
Cardiac resynchronization therapy (CRT) improves echocardiographic parameters, symptoms, hospitalizations, and mortality in patients with New York Heart Association (NYHA) Class III or IV symptoms with left ventricular systolic dysfunction, sinus rhythm, and a prolonged QRS duration. The effectiveness of CRT in patients with mild heart failure symptoms has not been systematically reviewed. An article in this month's European Journal Heart Failure evaluated this and found CRT reduces heart failure events in patients with mild heart failure symptoms, left ventricular dysfunction, sinus rhythm, and prolonged QRS duration.
Twelve-Month, Randomized, Controlled Trial of Bimatoprost 0.01%, 0.0125%, and 0.03% in Patients with Glaucoma or Ocular Hypertension
An article in this month's American Journal of Ophthalmology evaluated the intraocular pressure (IOP)-lowering efficacy and safety of ophthalmic formulations of bimatoprost 0.01% and 0.0125% compared with bimatoprost 0.03%. Overall it showed that Bimatoprost 0.01% was equivalent to bimatoprost 0.03% in lowering IOP throughout 12 months of treatment and demonstrated improved tolerability, including less frequent and severe conjunctival hyperemia. Bimatoprost 0.01% demonstrated a better benefit-to-risk ratio than bimatoprost 0.0125%.
Percent Body Fat and Prediction of Surgical Site Infection
Obesity is a risk factor for surgical site infection (SSI) after elective surgery. Body mass index (BMI) is commonly used to define obesity (BMI ≥30 kg/m2), but percent body fat (%BF) (obesity is >25%BF [men]; >31%BF [women]) might better predict SSI risk because BMI might not reflect body composition and an article in this month's Journal of American College of Surgeons evaluated this. Overall Obesity, defined by %BF, is associated with a 5-fold increased SSI risk. This risk increases as %BF increases. %BF is a more sensitive and precise measurement of SSI risk than BMI. Additional studies are required to better understand this relationship.
Scientists Find New Way To Attack TB
Suspecting that a particular protein in tuberculosis was likely to be vital to the bacteria's survival, Johns Hopkins scientists screened 175,000 small chemical compounds and identified a potent class of compounds that selectively slows down this protein's activity and, in a test tube, blocks TB growth, demonstrating that the protein is indeed a vulnerable target.
Reported Ugandan smallpox is likely chickenpox: WHO
Although declared eradicated in 1979, suspected cases of the previously eradicated disease smallpox in eastern Uganda appear to be chickenpox and not the acute contagious disease, the World Health Organization said on Thursday.
Elevated serum S100B levels in acute spinal fracture without head injury
S100B is a biomarker that reflects injury to the central nervous system. As the spine is an integral part of the spinal cord, a study publised in this months Emergency Medicine Journal was undertaken to investigate whether serum S100B levels are associated with acute spinal fracture without head injury. Serum S100B levels were higher in the spinal fracture group than in the non-spinal fracture group, and 19 of the 20 patients in the spinal fracture group (95%) had an S100B level >0.12 μg/l, whereas all 12 of the non-spinal fracture group had an S100B level ≤0.12 μg/l. Overall the Serum S100B levels are raised in all patients with acute spinal fracture without head injury. Spinal fracture may therefore be one of the extracerebral sources of S100B. Serum S100B levels may be an effective tool for excluding subtle spinal fractures with no clear radiographic findings.
Anti-inflammatory drugs seem to decrease the risk of Parkinson's disease
Anti-inflammatory drugs may prevent Parkinson disease (PD) by inhibiting a putative underlying neuroinflammatory process. An article published in the Journal Neurology tested the hypothesis that anti-inflammatory drugs reduce PD incidence and that there are differential effects by type of anti-inflammatory, duration of use, or intensity of use. Overall, a 15% reduction in PD incidence was observed among users of nonaspirin NSAIDS (relative risk [RR] 0.85, 95% confidence interval [CI] 0.77–0.94), with a similar effect observed for ibuprofen use. The protective effect of nonaspirin NSAIDs was more pronounced among regular users (RR 0.71, 95% CI 0.58–0.89) and long-term users (RR 0.79, 95% CI 0.59–1.07).
Maternal Preeclampsia Predicts the Development of Bronchopulmonary Dysplasia
An article published in this months Journal of Pediatrics tested the hypothesis that exposure to preeclampsia is associated with an increased risk of bronchopulmonary dysplasia (BPD). Of the 107 infants studied, 27 (25%) developed BPD. The bivariate odds ratio (OR) for the relationship between pre-eclampsia and BPD was 2.96 (95% confidence interval [CI] = 1.17 to 7.51; P = .01). BPD is increased for infants exposed to preeclampsia. This has possible implications for the prevention of BPD with proangiogenic agents, such as vascular endothelial growth factor.
How to diurese in acute HF: Dosing strategies get an evidence base
Whether loop diuretics are given in a continuous infusion or intermittently or at conventional or high doses appears to make little difference in their effectiveness at relieving symptoms in patients hospitalized with acute heart failure, according to a study that, its investigators say, also suggests high-dose diuretics in that setting are safe. The trial was billed as the first randomized, controlled exploration of a management strategy that's been a mainstay for decades without much of a supporting evidence base to guide how it's performed.
Acne Drug May Help in the Fight Against AIDS
A cheap acne drug that's been used for decades appears to target infected immune-system cells in which HIV lies dormant before coming back to life and spreading infection, researchers have found. The authors of a new study say the antibiotic drug, minocycline, sold under names such as Minocin, could add to the HIV-fighting powers of existing AIDS drug regimens.
Omega-3 May Safely Treat Precancerous Bowel Polyps
Treatment with a specific type of omega-3 fatty acid can shrink the number and size of precancerous polyps in people at high genetic risk of developing bowel cancer, British researchers say. The study authors reported that the new treatment appears to work as well as a drug called celecoxib (Celebrex), which is prescribed for patients with bowel polyps linked to their genetic risk, but it doesn't cause heart-related side effects.
Comparable patency achieved with radial artery and saphenous vein grafts
Study findings indicate that radial artery vein grafts provide comparable patency to saphenous vein grafts at 1 year after coronary artery bypass (CABG) graft surgery. The study was conducted at 11 centers between 2003 and 2008 and included a total of 733 patients undergoing elective CABG, of whom 366 were randomly assigned to receive radial artery grafts and 367 to undergo saphenous vein grafts. Angiography findings showed that graft patency at 1 week was 99% in patients who received radial artery grafts and 97% in those who had saphenous vein grafts. At 1 year, the patency rate was 89% in both groups.
Extended use of dual antiplatet therapy after stent implantation questioned
Extending the duration of dual antiplatelet therapy for more than 12 months after receipt of drug-eluting stents in patients with no prior bleeding does not appear to be more effective than aspirin monotherapy for reducing the rate of myocardial infarction (MI) or cardiovascular death, researchers report. Presenting the findings at the 59th Annual Scientific Session of the American College of Cardiology in Atlanta, Georgia, USA, Seung-Jung Park also reported the “unexpected finding” of a nonsignificant increase in the secondary composite endpoints of MI, stroke, or death from any cause and MI, stroke, or death from cardiac causes in patients taking dual antiplatelet therapy for more than 12 months.
Newer Blood Thinner Beats Plavix for Bypass Patients
In a trial comparing two anti-clotting drugs, patients given Brilinta before cardiac bypass surgery were less likely to die than those given Plavix, researchers found. "We did see about a 50 percent reduction in mortality in these patients [who took Brilinta], but without any increase in bleeding complications," Dr. Claes Held, an associate professor of cardiology at the Uppsala Clinical Research Center at Uppsala University in Sweden and the study's lead researcher, said during an afternoon press conference Tuesday.
Effect of Cyclosporine on Left Ventricular Remodeling After Reperfused Myocardial Infarction
A study from the Journal of the American College of Cardiology examined the effect of a single dose of cyclosporine administered at the time of reperfusion on left ventricular (LV) remodeling and function by cardiac magnetic resonance 5 days and 6 months after myocardial infarction. Twenty-eight patients of the original cyclosporine study had an acute (at 5 days) and a follow-up (at 6 months) cardiac magnetic resonance study to determine LV volumes, mass, ejection fraction, myocardial wall thickness in infarcted and remote noninfarcted myocardium, and infarct size. The results showed that Cyclosporine used at the moment of acute myocardial infarction reperfusion persistently reduces infarct size and does not have a detrimental effect on LV remodeling.
Chlorhexidine Whole-Body Bathing Decreases Hospital-Acquired Infections Among Trauma Patients
To demonstrate whether daily bathing with cloths impregnated with 2% chlorhexidine gluconate will decrease colonization of resistant bacteria and reduce the rates of health care–associated infections in critically injured patients an article in the Archives of Surgery performed a Retrospective analysis and found Patients receiving chlorhexidine baths were significantly less likely to acquire a catheter-related bloodstream infection than comparators (2.1 vs 8.4 infections per 1000 catheter-days, P = .01). The rate of colonization with MRSA (23.3 vs 69.3 per 1000 patient-days, P < .001) and Acinetobacter (1.0 vs 4.6 per 1000 patient-days, P = .36) was significantly lower in the chlorhexidine group than in the comparison group.
Gender Differences in the Treatment of Non-ST-Segment Elevation Myocardial Infarction
Women are at greater risk for worse outcomes associated with acute coronary syndrome (ACS) than are men. One explanation may be that they tend to be treated less aggressively than men even when more aggressive treatment is warranted. An article out of the Journal of Clinical Cardiology analysed this issue and found men demonstrated significantly higher rates (P < 0.05) of coronary intervention in 7 of the 16 cells and 9 of the 20 medical treatment cells suggesting that men are more likely than women to receive coronary intervention and to be medically treated when presenting with evidence of non-ST-segment myocardial infarction, controlled for age, cardiac catheterization findings, and biochemical evidence of myocardial infarction.
Short Sleep Duration as an Independent Predictor of Cardiovascular Events
It is not known whether short duration of sleep is a predictor of future cardiovascular events in patients with hypertension. To test the hypothesis that short duration of sleep is independently associated with incident cardiovascular diseases (CVD), an article out of the Archives of Internal Medicine performed performed ambulatory blood pressure (BP) monitoring in 1255 subjects with hypertension (mean [SD] age, 70.4 [9.9] years) and followed them for a mean period of 50 (23) months. Overall it was shown that short duration of sleep is associated with incident CVD risk and the combination of the riser pattern and short duration of sleep that is most strongly predictive of future CVD, independent of ambulatory BP levels. Physicians should inquire about sleep duration in the risk assessment of patients with hypertension.
Infections associated with indwelling ventriculostomy catheters in a teaching hospital
Ventriculostomy-associated infections are a serious complication of external ventricular drains. A study out of the International Journal of Infectious Disease analyzed the clinical features of and risk factors for such infections.
A total of 197 drains (2910 catheter-days) placed in 155 patients were studied. Infections developed in 28 of the 197 (14.2%) drains. Re-insertion of the catheter, patients with a longer intensive care unit stay and a longer duration of catheterization placement had a higher risk of infection. It also shoudl that Gram-negative bacilli were the leading pathogens (84%) with Pseudomonas aeruginosa being the most common isolate.
Current Status of Dual Renin Angiotensin Aldosterone System Blockade for the Treatment of Cardiovascular Diseases
Clinical and experimental studies have shown that the initial suppression of angiotensin II after the administration of angiotensin-converting enzyme (ACE) inhibitors is later reversed and returns almost to pretreatment levels. This raised the hypothesis of the “escape phenomenon,” which was strengthened by the discovery that angiotensin II can also be generated through non-ACEs. In conclusion, on the basis of the results of this analysis, dual blockade of the renin-angiotensin-aldosterone system should not be used for the treatment of hypertension, heart failure, and renal disease, with perhaps the exception of diabetic nephropathy with albuminuria, until additional information is provided from ongoing studies.
Bicarbonate therapy in the treatment of septic shock: a second look
The use of supplemental sodium bicarbonate for the treatment of patients with septic shock and elevated blood lactate levels remains a controversial therapy. An article in Internal and Emergency Medicine conducted a retrospective study between March 2004 and February 2009 of 36 consecutive patients diagnosed with septic shock who received continuous infusion of bicarbonate therapy. Although there was no difference in 28-day mortality between the two study groups, infusion of sodium bicarbonate in septic patients with arterial hyperlactatemia the median time to liberation of mechanical ventilation was significantly reduced in the bicarbonate group (10 days [95% CI 5.0–13.0] compared to the control group (14 days [95% CI 9.0–19.0], p = 0.02) and the length of intensive care unit (ICU) stay was also shorter in the surviving patients who received bicarbonate compared to controls
Donating Kidney Doesn't Shorten Lifespan
A study of over 80,000 American live kidney donors found they were likely to live just as long as people who have two healthy kidneys and that the procedure carries very little medical risk.
You can read about the landmark study by lead author and transplant surgeon Dr Dorry L Segev, from the Johns Hopkins University School of Medicine, Baltimore, Maryland, and colleagues, online in the 10 March issue of JAMA, Journal of the American Medical Association.
Endoscopic versus open component separation in complex abdominal wall reconstruction
Open component separation has a high wound complication rate. Newer endoscopic approaches are described with no comparative trials. A study out of the American Journal of Surgery completed retrospective review (2005–2009) of patients undergoing open or endoscopic component separation was performed. It concluded that Open and endoscopic components separation have similar rates of recurrence. The endoscopic group had shorter lengths of stay and less major wound complications. The endoscopic approach may be the ideal technique for complex abdominal wall reconstruction.
Oral Ivermectin versus Malathion Lotion for Difficult-to-Treat Head Lice
A study out of New England Journal of Medicine conducted a multicenter, cluster-randomized, double-blind, double-dummy, controlled trial comparing oral ivermectin (at a dose of 400 µg per kilogram of body weight) with 0.5% malathion lotion, each given on days 1 and 8, for patients with live lice not eradicated by topical insecticide used 2 to 6 weeks before enrollment.
In the intention-to-treat population, 95.2% of patients receiving ivermectin were lice-free on day 15, as compared with 85.0% of those receiving malathion (absolute difference, 10.2 percentage points; 95% confidence interval [CI], 4.6 to 15.7; P<0.001) suggesting for difficult-to-treat head-lice infestation, oral ivermectin, given twice at a 7-day interval, had superior efficacy as compared with topical 0.5% malathion lotion, a finding that suggests that it could be an alternative treatment.
Fixed-dose enoxaparin thromboprophylaxis feasible for morbidly obese
Current practice guidelines recommend utilizing weight-based dosing of LMWH in obese patients, but do not provide specific dosing guidance and US researchers say that enoxaparin administered at a 0.5-mg/kg dose may be effective at preventing thrombosis in morbidly obese patients without increasing the risk for bleeding.
Comparison of Outcomes With Cardiac Surgery and Paclitaxel-Eluting Stents in Diabetic and Non Diabetic Patients
A study out of the Journal of the American College of Cardiology compared contemporary surgical revascularization (coronary artery bypass graft surgery [CABG]) versus TAXUS Express (Boston Scientific, Natick, Massachusetts) paclitaxel-eluting stents (PES) in diabetic and nondiabetic patients with left main and/or 3-vessel disease. The overall 1-year major adverse cardiac and cerebrovascular event rate was higher among diabetic patients treated with PES compared with CABG, but the revascularization method did not impact the death/stroke/myocardial infarction rate for nondiabetic patients (6.8% CABG vs. 6.8% PES, p = 0.97) or for diabetic patients (10.3% CABG vs. 10.1% PES, p = 0.96). These exploratory results may extend the evidence for PES use in selected patients with less complex left main and/or 3-vessel lesions.
Herpes zoster ophthalmicus increases the risk of stroke
An article from this months Neurology investigated the risk of stroke development following a diagnosis of herpes zoster ophthalmicus (HZO). Stroke developed in 8.1% of patients with HZO and 1.7% of patients in the comparison cohort during the 1-year follow-up period. HZO patients had significantly lower 1-year stroke-free survival rates than patients in the comparison cohort. After adjusting for patients' demographic characteristics, selected comorbidities, and medication habits, HZO patients were found to have a 4.52-fold
Detection of elevated right atrial pressure using a simple bedside ultrasound measure
Accurate assessment of right atrial pressure (RAP) often requires invasive measurement. With normal RAP, Valsalva increases right internal jugular vein (RIJV) cross sectional area (CSA) 20% to 30%. With high RAP, when venous compliance is low, an article this months American Heart Journal hypothesized that the increase in CSA would be blunted and could be detected non-invasively with bedside ultrasound. Overal it showed that an increase in RIJV CSA >17% during Valsalva effectively rules out elevated RAP. This simple bedside technique may be useful to assess central venous pressure and reduce the need for invasive pressure measurement.
No Difference in Mortality Seen with Factor VIIa in Emergency Department Patients With Warfarin Use and Traumatic Intracranial Hemorrhage
A study out Academic Emergency Medicine compared outcomes in emergency department (ED) patients with preinjury warfarin use and traumatic intracranial hemorrhage (tICH) who did and did not receive recombinant activated factor VIIa (rFVIIa) for international normalized ratio (INR) reversal. Overall in patients with preinjury warfarin and tICH, use of rFVIIa was associated with a decreased time to normal INR. However, no difference in mortality was identified. Use of rFVIIa in patients on warfarin and tICH requires further study to demonstrate important patient-oriented outcomes.
Insurance Coverage Is Associated with Mortality after Gunshot Trauma
An article in this months American College of Surgeons hypothesized that insurance coverage is also associated with mortality after gunshot trauma and found that Despite similar injury severity, uninsured trauma patients were more likely to die after gunshot injury than insured patients. The in-hospital mortality rate was significantly higher for uninsured patients than for insured patients (9% vs 6%, p = 0.02). After controlling for age, gender, race, and injury severity by logistic regression analysis, the odds ratio for death of uninsured patients was 2.2 (95% CI 1.1 to 4.5).
Proton-Pump Inhibitor Use Is Not Associated With Osteoporosis or Accelerated Bone Mineral Density Loss
Recent studies have shown an association between proton-pump inhibitor use (PPI) and hip fracture. The mechanism by which PPI use promotes the development of hip fracture is uncharacterized. A study out of Gastroenterology sought to determine whether PPI use is associated with osteoporosis or accelerated bone mineral density (BMD) loss. PPI use was not associated with having osteoporosis at either the hip (OR, 0.84; 95% CI, 0.55–1.34) or the lumbar spine (OR, 0.79; 95% CI, 0.59–1.06) for PPI use >1500 doses over the previous 5 years. In the longitudinal study no significant decrease was observed in BMD at either site attributable to PPI use.
Orthostatic Syndromes Differ in Syncope Frequency
There are conflicting opinions on whether postural tachycardia syndrome predisposes to syncope. We investigated this relationship by comparing the frequency of syncope in postural tachycardia syndrome and orthostatic hypotension. Of 810 patients referred for postural tachycardia syndrome, 185 met criteria while another 328 patients had orthostatic hypotension. Of the postural tachycardia syndrome patients, 38% had syncope on head-up tilt, compared with only 22% of those with orthostatic hypotension (P<.0001). In the postural tachycardia group, syncope on head-up tilt was associated with a clinical history of syncope in 90%, whereas absence of syncope on head-up tilt was associated with a clinical history of syncope in 30% (P<.0001). In contrast, syncope on head-up tilt did not bear any relationship to clinical history of syncope in the orthostatic hypotension group (41% vs 36%; P=.49). results demonstrate that syncope (both tilt table and clinical) occurs far more commonly in patients who have postural tachycardia syndrome than in patients with orthostatic hypotension. More Information on Postural Tachycardia Syndrome, also from the National Institute of Health
Bacteriophages Can Treat and Prevent Pseudomonas aeruginosa Lung Infections
Antibiotic‐resistant bacteria threaten life worldwide. Although new antibiotics are scarce, the use of bacteriophages, viruses that infect bacteria, is rarely proposed as a means of offsetting this shortage. Doubt also remains widespread about the efficacy of phage therapy despite recent encouraging results. Using a bioluminescent
Pseudomonas aeruginosa strain, we monitored and quantified the efficacy of a bacteriophage treatment in mice during acute lung infection. Bacteriophage treatment not only was effective in saving animals from lethal infection, but also was able to prevent lung infection when given 24 h before bacterial infection, thereby extending the potential use of bacteriophages as therapeutic agents to combat bacterial lung infection.
Resolution of ST-segment depression: a new prognostic marker in ST-segment elevation myocardial infarction
An article out of the European Heart Journal evaluatee the prognostic impact of ST depression resolution among patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary PCI in the Assessment of Pexelizumab in Acute Myocardial Infarction (APEX-AMI) trial. When compared with patients with both STE-R and STD-R≥50%, patients with both STE-R and STD-R<50% had the worst outcomes [hazard ratios (HR) 90 day death: 2.54; 95% confidence intervals (CI): 1.71–3.77; HR 90 day composite: 2.18; 95% CI: 1.63–2.91]. Overall when ST depression is present in STEMI patients undergoing primary PCI, ST Depression-Resolution <50% provides independent prognostic value that is incremental to ST elevation-Resolution.
Radiation Most Effective Soon After Breast Cancer Surgery
For women who have had breast cancer surgery, the question of whether or not to wait before receiving radiation therapy has been answered by new research that suggests that the longer women wait, the greater the chance of cancer recurrence. The findings, published in the March 3 online edition of BMJ, are based on an analysis of national cancer records for 18,050 American women who were diagnosed with early-stage breast cancer between 1991 and 2002, at age 65 or older.
Radiation After Mastectomy May Be Overused
Many women who undergo mastectomy for early-stage breast cancer may not benefit from radiotherapy, a retrospective study suggested.
Among those who had stage I or II disease with spread to no more than three lymph nodes and who did not undergo radiation therapy, the overall locoregional recurrence rate was just 2.3% at 10 years, according to Ranjna Sharma, MD, of the University of Texas M.D. Anderson Cancer Center in Houston.
Rectally administered misoprostol versus intravenous oxytocin infusion during cesarean delivery to reduce intraoperative and postoperative blood loss
A study out of the International Journal of Gynecology compared the efficacy of rectally administered misoprostol with intravenous oxytocin infusion in preventing uterine atony and blood loss during cesarean delivery. A total of 96 and 94 women were analyzed in the misoprostol and oxytocin groups, respectively. Intraoperative and postoperative blood loss was significantly lower in the misoprostol group than in the oxytocin group. Rectal misoprostol appears to be an effective alternative to intravenous oxytocin in preventing blood loss for routine use during cesarean delivery.
Therapeutic role of water-soluble contrast agent in adhesive small bowel obstruction
A meta-analysis out of the British Journal of Surgery assessed the diagnostic and therapeutic role of water-soluble contrast agent (WSCA) in adhesive small bowel obstruction (SBO). The appearance of contrast in the colon within 4-24 h after administration had a sensitivity of 96 per cent and specificity of 98 per cent in predicting resolution of SBO. It concluded that water-soluble contrast was effective in predicting the need for surgery in patients with adhesive SBO. In addition, it reduced the need for operation and shortened hospital stay.
Chest Tube Size Doesn't Affect Outcome in Pleural Infection
The optimal choice of chest tube size for the treatment of pleural infection is unknown, with only small cohort studies reported describing the efficacy and adverse events of different tube sizes. An article published in Chest evaluated a total of 405 patients with pleural infection and showed smaller, guide-wire-inserted chest tubes cause substantially less pain than blunt-dissection-inserted larger tubes, without any impairment in clinical outcome in the treatment of pleural infection.
No Significant Difference in the Rate of Death Between Patients with Shock Treated with Dopamine or Norepinephrine
Both dopamine and norepinephrine are recommended as first-line vasopressor agents in the treatment of shock. There is a continuing controversy about whether one agent is superior to the other. A multicenter, randomized trial was conducted and assigned 1679 patients with shock to receive either dopamine or norepinephrine as first-line vasopressor therapy to restore and maintain blood pressure. There was no significant between-group difference in the rate of death at 28 days (52.5% in the dopamine group and 48.5% in the norepinephrine group; odds ratio with dopamine, 1.17; 95% confidence interval, 0.97 to 1.42; P=0.10). However, there were more arrhythmic events among the patients treated with dopamine than among those treated with norepinephrine (207 events [24.1%] vs. 102 events [12.4%], P<0.001). A subgroup analysis showed that dopamine, as compared with norepinephrine, was associated with an increased rate of death at 28 days among the 280 patients with cardiogenic shock but not among the 1044 patients with septic shock or the 263 with hypovolemic shock.
Leflunomide: Is a New Oral Agent in Treatment of Acute Pancreatitis?
Nuclear factor-κB (NF-κB) is a potent mediator in several steps of acute pancreatitis. Leflunomide is a novel immunomodulating drug that is also a potent inhibitor of NF-κB activation. The aim of this study was to investigate the effects of leflunomide pretreatment in severe necrotizing pancreatitis. Leflunomide pretreatment significantly ameliorated pancreatic hemorrhage, edema, and neutrophil infiltration and decreased histopathological score compared with the untreated severe necrotizing pancreatitis group. Leflunomide is a beneficial agent in the severe form of acute pancreatitis in rats and should be considered as a potential agent for treatment of acute pancreatitis.
Mortality After Hospitalization for Heart Failure Lower in Blacks Compared to Whites
Heart failure (HF) disproportionately affects black compared to white Americans, and overall mortality from HF is greater among blacks. Paradoxically, mortality rates after a hospitalization for HF are lower in black than in white patients. These racial differences might reflect hospital, physician, and patient factors and could have implications for comparative hospital profiles. A study out of the American Journal of Cardiology identified published studies reporting the posthospitalization mortality for black and white patients with a discharge diagnosis of HF and conducted random-effects meta-analyses with the outcome of all-cause mortality.
Overall it found mortality after hospitalization for HF was 32% lower during short-term follow-up and 16% lower during long-term follow-up for black than for white patients. The mortality differences imply unmeasured differences by race in clinical severity of illness at hospital admission and might lead to biased hospital mortality profiles.
Identifying Children at Low Risk for Bacterial Conjunctivitis
A study out of the Archives of Pediatrics and Adolescent Medicine conducted a prospective observational cohort study to identify a population of children at low risk for bacterial conjunctivitis on the basis of history and physical examination findings. Age 6 years or older, presentation in April through November, no or watery discharge, and no glued eye in the morning were the clinical factors found to be independently associated with a negative conjunctival culture. If 3 factors were present, 76.4% (95% confidence interval, 63.6%-85.6%) of patients had a negative culture. If all 4 factors were present, 92.3% (95% confidence interval, 66.1%-98.2%) of patients had a negative culture.
Decreased Hippocampal Volume in Healthy Girls at Risk of Depression
Researchers have documented that the hippocampus is smaller in individuals with depression than in those without. The temporal or causal association of this reduction in hippocampal volume in depression, however, is not known. A study out the Archives of General Psychiatry used magnetic resonance imaging to examine brain structure volume in individuals at high and low familial risk of depression. Compared with individuals at low familial risk of the development of depression, high-risk individuals have reduced hippocampal volume, indicating that neuroanatomic anomalies associated with depression may precede the onset of a depressive episode and influence the development and course of this disorder.
Association Between Cannabis Use and Psychosis
The early use of marijuana increases the risks for schizophrenia, delusions and hallucinations in young adulthood, according to a study published online March 1 in the Archives of General Psychiatry.
An Algorithm for Tuberculosis Screening and Diagnosis in People with HIV
Tuberculosis screening is recommended for people with human immunodeficiency virus (HIV) infection to facilitate early diagnosis and safe initiation of antiretroviral therapy and isoniazid preventive therapy. No internationally accepted, evidence-based guideline addresses the optimal means of conducting such screening, although screening for chronic cough is common. A study in the New England Journal of Medicine consecutively enrolled people with HIV infection from eight outpatient clinics. The presence of cough of any duration, fever of any duration, or night sweats lasting 3 or more weeks in the preceding 4 weeks was 93% sensitive and 36% specific for tuberculosis.In persons with HIV infection, screening for tuberculosis should include asking questions about a combination of symptoms rather than only about chronic cough. It is likely that antiretroviral therapy and isoniazid preventive therapy can be started safely in people whose screening for all three symptoms is negative, whereas diagnosis in most others will require mycobacterial culture.
Stents, surgery both prevent strokes: study
For many years, surgery has been the preferred way to clear away dangerous fatty deposits in neck arteries that can cause strokes. But newer, less invasive approaches using angioplasty and stents have been approved for use in higher-risk patients, stirring debate over which approach is best.It showed that both approaches were safe and effective overall at preventing stroke, but they did find some differences between the two approaches.They found that patients who had had surgery had lower rates of subsequent strokes, while those who had gotten a stent were less likely to have a heart attack after the procedure.
Myopic Eyes Less Likely to Have Diabetic Retinopathy
Eyes with myopia may be less likely to develop diabetic retinopathy (DR). The relationship between refractive error, ocular biometry, and DR therefore was investigated in the Journal of Ophthalmology that showed Myopic refraction and longer Axial Length are associated with a lower risk of DR, particularly vision-threatening retinopathy, without any evidence of a threshold.
Assessment of the Effects of Desmopressin on Impaired Platelet Function Using Multiple Electrode Whole-Blood Aggregometry in Patients After Cardiac Surgery
Blood loss after cardiac surgery can be caused by acquired platelet dysfunction after cardiopulmonary bypass. Monitoring of platelet function is clinically important for the identification of patients experiencing such platelet dysfunction. 1-Deamino-8-d-arginine vasopressin (desmopressin acetate, DDAVP) has been shown to augment platelet function and to reduce blood loss in patients with platelet dysfunction. In this study, we examined the feasibility of whole blood multiple electrode aggregometry (MEA) for the detection of cardiopulmonary bypass–induced platelet dysfunction and investigated its ability to monitor DDAVP treatment. This study showed that Impaired platelet function after cardiac surgery can be assessed at the bedside using MEA. The effect of DDAVP on impaired platelet function can also be detected as significant improvement in platelet aggregation to all activators. This device might be helpful for the identification of patients who may benefit from DDAVP therapy.
Serum testosterone is associated with aggressive prostate cancer in older men: results from the Baltimore Longitudinal Study of Aging
An Article in the British Journal of Urology evaluated the relationship between testosterone levels and the development of high-risk prostate cancer, by prospectively examining serum androgen concentrations in a well-studied cohort, as the role of testosterone in prostate cancer progression is debated. The study comprised 781 men in the Baltimore Longitudinal Study of Aging who had sex steroid measurements before a diagnosis of prostate cancer, or at their last visit for those without cancer. The likelihood of high-risk prostate cancer doubled per unit (0.1) increase in the free testosterone index (FTI) for patients aged >65 years and concluded that higher levels of serum free testosterone are associated with an increased risk of aggressive prostate cancer among older men. These data highlight the importance of prospective trials to insure the safety of testosterone-replacement therapy.
Lower Dose Alteplase Shows Similar Clinical Outcomes in Middle Cerebral Artery Occlusion than Higher Dose
A study out the Journal Stroke evaluated the efficacy of 0.6 mg/kg intravenous alteplase on vascular and clinical outcomes in patients with middle cerebral artery occlusion in a postmarketing Phase IV trial of prospective cohort study design. Recanalization was noted in 51.7% on 6-hour MR angiography and 69.0% on 24-hour MR angiography. A favorable clinical outcome was achieved in 46.6% concluding the rates of recanalization and favorable outcome are comparable to that previously reported with the 0.9-mg/kg dose.
Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy
A study published in JAMA tested the hypothesis of noninferiority between lactate clearance and central venous oxygen saturation (ScvO2) as goals of early sepsis resuscitation. randomly assigned patients to 1 of 2 resuscitation protocols. The ScvO2 group was resuscitated to normalize central venous pressure, mean arterial pressure, and ScvO2 of at least 70%; and the lactate clearance group was resuscitated to normalize central venous pressure, mean arterial pressure, and lactate clearance of at least 10%. The study protocol was continued until all goals were achieved or for up to 6 hours.Thirty-four patients (23%) in the ScvO2 group died while in the hospital (95% confidence interval [CI], 17%-30%) compared with 25 (17%; 95% CI, 11%-24%) in the lactate clearance group. This observed difference between mortality rates did not reach the predefined –10% threshold concluding additional management to normalize lactate clearance compared with management to normalize ScvO2 did not result in significantly different in-hospital mortality.
Hormone replacement tied to lung cancer risk
Cardiology Groups Stand by Embattled Diabetes Drug
End Tidal CO2 Monitoring Predicts Hypoxia by 60 Seconds During Emergency Department Procedural Sedation and Analgesia With Propofol
An article from the Annals of Emergency Medicine sought to determine whether the use of capnography is associated with a decreased incidence of hypoxic events than standard monitoring alone during emergency department (ED) sedation with propofol. One hundred thirty-two subjects were evaluated and included in the final analysis. We observed hypoxia in 17 of 68 (25%) subjects with capnography and 27 of 64 (42%) with blinded capnography. Capnography identified all cases of hypoxia before onset (sensitivity 100%; specificity 64%), with the median time from capnographic evidence of respiratory depression to hypoxia 60 seconds concluding the addition of capnography to standard monitoring reduced hypoxia and provided advance warning for all hypoxic events.
No Benefit Seen with Early Invasive Versus Selective Invasive Management in Patients With Non–ST-Segment Elevation Acute Coronary Syndrome
A study out of the Journal of the American College of Cardiology present the 5-year clinical outcomes according to treatment strategy with additional risk stratification of the ICTUS (Invasive versus Conservative Treatment in Unstable coronary Syndromes) trial. 1,200 patients were randomly assigned to an early invasive or selective invasive strategy. The outcomes were the composite of death or myocardial infarction (MI) and its individual components. Risk stratification was performed with the FRISC (Fast Revascularization in InStability in Coronary artery disease) risk score. At 5-year follow-up, revascularization rates were 81% in the early invasive and 60% in the selective invasive group. Cumulative death or MI rates were 22.3% and 18.1%, respectively. In patients presenting with NSTE-ACS and elevated troponin T, we could not demonstrate a long-term benefit of an early invasive strategy in reducing death or MI. (Invasive versus Conservative Treatment in Unstable coronary Syndromes [ICTUS].
Risk Factors for Treatment Failure in Patients Receiving Vancomycin for Hospital-Acquired Methicillin-Resistant Staphylococcus aureus Pneumonia
The rate of vancomycin failure in patients with hospital-acquired pneumonia (HAP) caused by methicillin-resistant Staphylococcus aureus (MRSA) has exceeded 40% in several studies. This observation was attributed initially to the lack of weight-based dosing and targeting of lower trough concentrations. However, a subsequent study demonstrated no additional benefit in patients who achieved trough vancomycin concentrations >15mg/L compared with patients with concentrations between 5 and 15mg/L. A study out of Surgical Infections sought to identify contributors to vancomycin failure in patients with MRSA HAP and found data suggest that patients who have recent exposure to vancomycin are at high risk for vancomycin failure and may benefit from an appropriate alternative when a diagnosis of MRSA HAP is made.
The Status of the Fourth Ventricle and Ambient Cisterns Predict Outcome in Moderate and Severe Traumatic Brain Injury
Computed tomography (CT) of the head has become the diagnostic tool of choice, particularly for moderate and severe traumatic brain injury (TBI). Various CT characteristics are associated with outcome, and may therefore be used as outcome predictors. One of the most prominent predictors appears to be the status of the basal cisterns. This study describes the prognostic value of the appearance of individual cisterns and ventricles in relation to that of the basal cisterns. Its results showed that the absence (complete obliteration), but also compression of the ambient cisterns and/or the fourth ventricle were strongly related to unfavorable outcome and death and emerged as the only significant outcome predictors after multivariate analysis.
'Diabetic effect' in dolphins offers new hope for type 2 diabetes cure
Dolphins are the only animals apart from humans to develop a natural form of type 2 diabetes, according to new research. The discovery offers important insights into a disease that is linked to one in 20 deaths. American scientists have discovered that bottlenosed dolphins show a form of insulin resistance very similar to that seen in human diabetes. Unlike patients with the condition, the marine mammals can turn this state on and off when appropriate, so it is not normally harmful.
FDA reports says Avandia can hurt heart: report
Confidential U.S. government reports recommend that GlaxoSmithKline Plc's diabetes drug Avandia be pulled from the market because it can hurt the heart, The New York Times reported on Friday.The newspaper said the findings, which it said it obtained, reported that if all diabetics now taking Avandia were given Takeda's Actos drug instead, about 500 heart attacks and 300 cases of heart failure would be averted each month because Avandia, also known as rosiglitazone, can be harmful to the heart.
Initial Prostate Specific Antigen 1.5 ng/ml or Greater in Men 50 Years Old or Younger Predicts Higher Prostate Cancer Risk
Screening with PSA has been widely used to detect PCa for 2 decades but it continues to be controversial. The results of 2 large randomized, controlled trials were recently released but due to conflicting results the usefulness of PSA screening for decreasing PCa mortality remains hotly debated. A study out of the Journal of Urology showed a median prostate specific antigen in black and white men was 0.7 ng/ml at age 50 years or less. The prostate cancer rate was not significantly different in the groups with prostate specific antigen less than 0.6 and 0.7 to 1.4 ng/ml in black or white men. Black and white men with initial prostate specific antigen in the 1.5 to 2.4 ng/ml range had a 9.3 and 6.7-fold increase in the age adjusted prostate cancer RR, respectively. At up to 9 years of followup initial prostate specific antigen 1.5 ng/ml or greater was associated with gradually increased detection at followup in black and white men.
Sympathetic Nonadrenergic Transmission Contributes to Autonomic Dysreflexia in Spinal Cord–Injured Individuals
Autonomic dysreflexia is a hypertensive episode in spinal cord–injured individuals induced by exaggerated sympathetic activity and thought to be -adrenergic mediated. -Adrenoceptor antagonists have been a rational first choice; nevertheless, calcium channel blockers are primarily used in autonomic dysreflexia management. However, -adrenoceptor blockade may leave a residual vasoconstrictor response to sympathetic nonadrenergic transmission unaffected. The aim was to assess the -adrenergic contribution and, in addition, the role of supraspinal control to leg vasoconstriction during exaggerated sympathetic activity provoked by autonomic dysreflexia in spinal cord–injured individuals and by a cold pressure test in control individuals. These results indicate that the leg vascular resistance increase during autonomic dysreflexia in spinal cord–injured individuals is not entirely -adrenergic mediated and is partly explained by nonadrenergic transmission, which may, in healthy subjects, be suppressed by supraspinal control.
Increased tissue damage and lesion volumes in African Americans with multiple sclerosis
African American (AA) patients with multiple sclerosis (MS) have more rapid disease progression and poorer responses to disease-modifying therapies than white American (WA) patients with MS. A study out of the Journal of Neurology investigated brain MRI characteristics in AA compared to WA in a cohort of consecutive patients with MS. The study showed that African American patients showed increased tissue damage, as measured by magnetization transfer ratio, and presented higher lesion volumes compared to white Americans. The greater tissue damage and faster lesion volume accumulation may explain the rapid clinical progression in African American patients.
