April 28th 2013
Welcome to the 73rd Critical Care Reviews Newsletter, bringing you the best critical care research published in the past week, plus a wide range of free full text review articles and guidelines from over 300 clinical and scientific journals.
No major critical care studies have been published this week, with the best research publications including large propensity matched cohort studies investigating perioperative beta blockade and coronary revascularization methods, respectively. There are also studies evaluating levosimendan in cardiogenic shock post MI, fish oils and probiotics, pharmacological thromboprophylaxis for traumatic brain injury and a review of current management for traumatic brain injury.
This week's guidelines address the management of hypertension, dialysis at end-of-life and imaging in heart failure. There is an editorial on healthcare-associated infections in the USA and commentaries on etomidate, the medical management of the Boston marathon bombing casualties, and the current coronavirus outbreak.
The clinical review articles include papers on cerebral monitoring, stroke, haemorrhagic shock models, heart transplantation, alcoholic liver disease, NGAL, TB and anti-bacterial drug development. Non-clinical review articles focus on both radiology and EM specialities, ethics, social media, presenting, and having a manuscript rejected for publication.
After a long break, the latest CPD / CME article and quiz, covering delirium, is now availabe. A personalised certificate of CPD activity can be saved and printed after successful completion of the activity.
Journal of American Medical Association: Perioperative Beta Blockade
London et al performed a retrospective cohort analysis evaluating perioperative exposure to β-blockers in major noncardiac surgery among a population-based sample of 136 745 patients who were 1:1 matched on propensity scores (37 805 matched pairs). 55 138 patients (40.3%) were exposed to β-blockers. Exposure was higher in patients undergoing vascular surgery (n=13,863, 66.7%; 95% CI 65.9%-67.5%) than nonvascular surgery (n=122 882, 37.4%; 95% CI 37.1%-37.6%, P < 0.001). Exposure increased as Revised Cardiac Risk Index factors increased, with 25.3% (95% CI 24.9%-25.6%) of those with no risk vs 71.3% (95% CI 69.5%-73.2%) of those with 4 risk factors or more exposed to β-blockers (P < 0.001). Death occurred in 1.1% (95% CI 1.1%-1.2%) and cardiac morbidity in 0.9% (95% CI 0.8%-0.9%). In the propensity matched cohort, β-blockers was associated with lower mortality (RR 0.73; 95% CI 0.65-0.83; P < 0.001; NNT 241, 95% CI 173-397). When stratified by cumulative numbers of Revised Cardiac Risk Index factors, β-blocker exposure was associated with significantly lower mortality among patients with 2 factors (RR 0.63, 95% CI, 0.50-0.80, P < 0.001; NNT 105, 95% CI 69-212), 3 factors (RR 0.54, 95% CI 0.39-0.73, P < 0.001; NNT 41, 95% CI, 28-80), or 4 factors or more (RR 0.40, 95% CI 0.25-0.73, P < 0.001; NNT 18, 95% CI 12-34). This association was limited to patients undergoing nonvascular surgery. β-Blocker exposure was also associated with a lower rate of nonfatal Q-wave infarction or cardiac arrest (RR 0.67, 95% CI 0.57-0.79, P < .001; NNT 339, 95% CI 240-582), again limited to patients undergoing nonvascular surgery. Conclusion: Among propensity-matched patients undergoing noncardiac, nonvascular surgery, perioperative β-blocker exposure was associated with lower rates of 30-day all-cause mortality in patients with 2 or more Revised Cardiac Risk Index factors
Annals of Internal Medicine: Coronary Revascularization
In an observational cohort study comparing CABG versus PCI in an unselected, general patient population, in 105,156 propensity score–matched patients, CABG was associated with lower mortality than PCI (HR 0.92; 95% CI 0.90 to 0.95; P < 0.001). CABG was also associated with lower mortality in diabetics (HR 0.88), smokers or ex-smokers (HR 0.82), and both patients with heart failure (HR 0.84), and peripheral arterial disease (HR 0.85) (p < 0.002 for all). The overall predicted difference in survival between CABG and PCI treatment over 5 years was 0.053 life-year (range, −0.017 to 0.579 life-years).
Abstract: Hlatky. Comparative Effectiveness of Multivessel Coronary Bypass Surgery and Multivessel Percutaneous Coronary Intervention: A Cohort Study. Annals of Internal Med 2013;epublished April 23rd
Journal of Enteral and Parenteral Nutrition: Fish Oils
In a systematic review and meta analysis (6 RCTs, n = 390) the administration of either enteral or parenteral fish oils, containing ω-3 polyunsaturated fatty acids, was associated with a trend toward a reduction in mortality (risk ratio 0.71; 95% CI 0.49 to 1.04; p = 0.08; heterogeneity I2 = 0%), and a reduction in the duration of mechanical ventilation (weighted mean difference in days −1.41; 95% CI −3.43 to 0.61; p = 0.17), but had no effect on infections (RR 0.76; 95% CI 0.42–1.36; p = 0.35) or ICU length of stay (weighted mean difference in days −0.46; 95% CI −4.87 to 3.95; p = 0.84, heterogeneity I2 = 75%).
Journal of Enteral and Parenteral Nutrition: Probiotics for Trauma
In a systematic review and meta-analysis (5 RTCs, n=281) probiotics were associated with a reduced incidence of nosocomial infections (RR 0.65; 95% CI 0.45–0.94, p = 0.02), ventilator-associated pneumonia (3 trials; RR 0.59; 95% CI 0.42–0.81, P = 0.001), and length of ICU stay (2 trials; standardized mean difference −0.71; 95% CI −1.09 to −0.34, p < 0.001) but not a reduction in mortality (4 trials; RR 0.63; 95% CI 0.32–1.26, p = 0.19). There was significant heterogeneity amongst studies limiting these results.
European Journal of Heart Failure: Levosimendan
In a blinded, placebo-controlled, randomized trial in 61 patients with heart failure 48 hours after a primary PCI-treated STEMI (including cardiogenic shock), a 25 hour infusion of levosimendan was associated with (1) a significantly larger improvement in wall motion score index (from baseline to day 5; levosimendan: 1.94 ± 0.20 to 1.66 ± 0.31 vs. placebo: 1.99 ± 0.22 to 1.83 ± 0.26, respectively, P = 0.031) (2) significantly more episodes of hypotension (67% vs. 36%, P = 0.029), but (3) no significant differences in blood pressure at the end of infusion, use of vasopressors, between-group differences in changes in NT-proBNP levels, clinical composite score, frequency of atrial fibrillation or ventricular arrhythmia, infarct size at 6 weeks, or new clinical events up to 6 months. One and four patients died in the levosimendan and placebo group, respectively.
Abstract: Husebye. Levosimendan in acute heart failure following primary percutaneous coronary intervention-treated acute ST-elevation myocardial infarction. Results from the LEAF trial: a randomized, placebo-controlled study. Eur J Heart Fail 2013;15 (5):565-572
Journal of Neurotrauma: Traumatic Brain Injury
Using 44 systematic reviews (21 Cochrane Reviews and 23 from peer-reviewed journals) with satisfactory methodological quality to assess therapeutic interventions for acute traumatic brain injury, 29 high-quality reviews provided no conclusive evidence for the investigated 22 interventions except for an adverse effect of corticosteroids. Less than one-third of the component trials were reported with adequate allocation concealment. Additionally other methodological flaws in design, such as ignoring heterogeneity among the TBI population, also contributed to the failure of past clinical research. Evidence from both systematic reviews and clinical trials does not fully support current management of acute TBI.
Journal of Neurotrauma: Traumatic Brain Injury
In a systematic review and meta analysis, including five retrospective cohort studies (n=1624 patients), early pharmacological thromboprophylaxis (<72 hours, n=713), in comparison with late pharmacological thromboprophylaxis (>72 hours, n=911), was associated with less episodes of venothromboembolism (43 versus 106, risk ratio 0.52, 95% CI 0.37 - 0.73). The relative risk of intracerebral haemorrhage progression in the early compared with the late group was 0.64 ( 95% CI 0.35 - 1.14). Prospective randomized controlled trials are required to adequately address this issue.
Canadian Journal of Cardiology: Hypertension
Journal of the American College of Cardiology: Imaging in Heart Failure
- Patel. 2013 ACCF/ACR/ASE/ASNC/SCCT/SCMR Appropriate Utilization of Cardiovascular Imaging in Heart Failure: A Joint Report of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Foundation Appropriate Use Criteria Task Force. J Am Coll Cardiol 2013;epublished April 23rd
Nephrology: Dialysis at End-Of-Life
Lancet Infectious Diseases: Healthcare Associated Infection
- Anonymous. Health-care associated infection: USA on the right track. Lancet Infectious Diseases 2013;13(5):377
Annals of Emergency Medicine: Etomidate
- Hunter. In Patients With Severe Sepsis, Does a Single Dose of Etomidate to Facilitate Intubation Increase Mortality? Annals of Emergency Medicine 2013;61(5):571-572
New England Journal of Medicine: Boston Marathon Bombing
- Kellermann. Lessons from Boston. N Eng J Med 2013;epublished April 24th
- Jangi. Under the Medical Tent at the Boston Marathon. N Eng J Med 2013;epublished April 23rd
Lancet Infectious Diseases: Novel Coronavirus
- Arnold. 10 years on, the world still learns from SARS. Lancet Infectious Diseases 2013;13(5):394-395
Review - Clinical
ISRN Critical Care: Circulatory Arrest
- Llompart-Pou. Transcranial Sonography and Cerebral Circulatory Arrest in Adults: A Comprehensive Review. ISRN Critical Care 2013;2013:167468
Cerebrovascular Diseases: Stroke Thrombolysis
- Röther. Thrombolytics in Acute Ischaemic Stroke: Historical Perspective and Future Opportunities. Cerebrovasc Dis2013;35:313-319
Cerebrovascular Diseases: Intracerebral Haemorrhage
- Brouwers. Hematoma Expansion following Acute Intracerebral Hemorrhage. Cerebrovasc Dis 2013;35:195-201
Neurology Research International: Subarachnoid Haemorrhage Monitoring
- Arshi. Invasive and Noninvasive Multimodal Bedside Monitoring in Subarachnoid Hemorrhage: A Review of Techniques and Available Data. Neurology Research International 2013;2013:987934
Journal of the American College of Cardiologists: Cardiohepatic Interaction
- Samsky. Cardiohepatic Interactions in Heart Failure: An Overview and Clinical Implications. J Am Coll Cardiol 2013;epublished April 24th
Circulation Journal: Heart Transplantation
European Surgical Research: Haemorrhagic Shock Models
Stem Cells and Cloning: Advances and Applications: Stem Cells for Heart Failure
- Fuentes. Endogenous cardiac stem cells for the treatment of heart failure. Stem Cells and Cloning: Advances and Applications 2013;2013(6):1-12
Vascular Health and Risk Management: Vernakalant for Atrial Fibrillation
- Tsuji. Safety and efficacy of vernakalant for acute cardioversion of atrial fibrillation: an update. Vascular Health and Risk Management 2013;2013(9):165-175
Journal of the American College of Cardiology: High-Sensitivity Troponin Assays
- Korley. Preparing the United States for High-Sensitivity Cardiac Troponin Assays. J Am Coll Cardiol 2013;61(17):1753-1758
Annals of Intensive Care: ARDS
- de Haro. Acute respiratory distress syndrome: prevention and early recognition. Annals of Intensive Care 2013;3:11
Clinical Cardiology: Proton Pump Inhibitors & Clopidogrel
- Chen. Pharmacodynamic Impacts of Proton Pump Inhibitors on the Efficacy of Clopidogrel In Vivo—A Systematic Review. Clin Cardiol 2013;36:184–189
Clinical Liver Disease: Alcoholic Liver Disease
- Drinane. Alcoholic hepatitis: Diagnosis and prognosis. Clinical Liver Disease 2013;2:80–83
- Morgan. Treatment of alcoholic hepatitis. Clinical Liver Disease 2013;2:84–88
- Fernández-Solà. Management of extrahepatic manifestations in alcoholic liver disease. Clinical Liver Disease 2013;2:89–91
- Burra. Liver transplantation for alcoholic liver disease. Clinical Liver Disease 2013;2:92–95
BioMed Research International: NGAL in Acute Kidney Injury
- Noto. “NGAL and Metabolomics: The Single Biomarker to Reveal the Metabolome Alterations in Kidney Injury,” BioMed Research International 2013;2013:612032
Saudi Journal of Kidney Disease Transplantation: ABO-Incompatible Kidney Transplantation
Nephrology: Dialysis at End-Of-Life
- Siva. Inappropriate interventions in the dying patient. Nephrology 2013;epublished April 16th
- Brown. The often difficult decision of which patients will benefit from dialysis. Nephrology 2013;epublished April 16th
- Masterson. Perspective – the issues surrounding ESKD and dialysis in the elderly and those with co-morbidities. Nephrology 2013;epublished April 16th
International Journal of Medical Science: Melatonin
- Lambert. Challenges and promises for the development of donor-independent platelet transfusions. Blood 2013;121 3319-3324
Clinical Infectious Diseases: Anti-Bacterial Development
- Boucher. 10 × '20 Progress—Development of New Drugs Active Against Gram-Negative Bacilli: An Update From the Infectious Diseases Society of America. Clin Infect Dis 2013;epublished April 17th
Indian Journal of Medical Research: Tuberculosis
- Sharma. Tuberculosis: From an incurable scourge to a curable disease - journey over a millennium. Indian J Med Res 2013;137:455-93
Review - Non-Clinical
PLoS Biology: Social Media
Cerebrovascular Diseases: Presenting
Cerebrovascular Diseases: Article Rejection
Canadian Association of Radiologists Journal
- Choy. Past, Present, and Future of Emergency Radiology. Canadian Association of Radiologists Journal 2013;64(2):85-89
Annals of Emergency Medicine: Emergency Medicine in UK & Ireland
- Flynn. Emergency Care Crisis in the United Kingdom and Ireland: Emergency Physician Exodus Looms in Wake of Pay Cuts, Staffing Shortages. Annals of Emergency Medicine 2013;61(5):A15-A19
- Brennan. Ethical principles for patients, families and doctors to consider. Nephrology 2013;epublished April 16th
I hope you find these brief summaries and links useful.
Until next week