December 23rd 2012
Welcome to the 55th 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.
This week's research studies include a French propensity analysis failing to demonstrate any advantage with the use of renal replacement therapy in the critically ill, a randomized controlled trial demonstrating superior outcomes with a BNP guided ventilatory weaning protocol, and a suggestion that critically ill obese people survive better than their leaner counterparts. An interesting Cochrane Review reports more favourable outcomes in industry sponsored studies, while an updated review confirms the lack of efficacy of activated protein C in severe sepsis. A report from the American Heart Association details the epidemiology of coronary and cerebrovascular disease in the USA, describing 68% of adults being overweight or obese, 33% having hypertension and approximately 12% being diabetic. This equates to one in every 6 deaths resulting from coronary disease and one in every 19 deaths from stroke.
There are three American guidelines on the management of ST elevation myocardial infarction, stable ischaemic heart disease and device based therapy for dysrhythmias.
Amongst the numerous clinical review articles are papers on aortic stenosis, respiratory failure in cancer patients, non-alcoholic liver disease, the seemingly obligatory paper on renal biomarkers, and two papers on newer anticoagulants.
Critical Care: Renal Replacement Therapy
In the absence of a renal replacement therapy (RRT) versus no RRT study in the critically ill, Clec'h and colleagues performed a propensity analysis using data from the French longitudinal prospective multicenter Outcomerea database to assess the efficacy of RRT in the critically ill. Two propensity scores for RRT were built to match patients who received RRT to controls who did not despite having a close probability of receiving the procedure. Among the 2846 study patients, 545 (19%) received RRT. Crude mortality rates were higher in patients with than in those without RRT (38% vs 17.5%, p < 0.001). After matching and adjustment, RRT was not associated with a reduced hospital mortality. The two propensity models yielded concordant results.
Amercan Journal of Respiratory and Critical Care Medicine: Fluid Management
Dessap et al performed a randomized controlled multicenter study, in 304 critically ill patients mechanically ventilated with an automatic computer-driven weaning system, to investigate whether fluid management guided by daily BNP plasma levels improved weaning compared with empirical therapy dictated by clinical acumen. In the BNP-driven group, furosemide and acetazolamide were given more often and in higher doses than in the control group, resulting in a more negative median (interquartile range) fluid balance during weaning (–2,320 [–4,735, 738] vs. -180 [–2,556, 2,832] ml; P < 0.0001). Time to successful extubation was significantly shorter with the BNP-driven strategy (58.6 [23.3, 139.8] vs. 42.4 [20.8, 107.5] h; P = 0.034). The BNP-driven strategy increased the number of ventilator-free days but did not change length of stay or mortality. The effect on weaning time was strongest in patients with left ventricular systolic dysfunction. The two strategies did not differ significantly regarding electrolyte imbalance, renal failure, or shock.
Critical Care: Effect of Obesity
In a cohort analysis from a single-centre database of 16,812 critically ill American patients, Abhyankar et al showed that compared to normal weight patients, obese patients had 26% and 43% lower mortality risk at 30 days and one year after ICU admission, respectively (OR 0.74; 95% CI: 0.64-0.86 and 0.57; 95% CI: 0.49-0.67); overweight patients had nearly 20% and 30% lower mortality risk (OR 0.81: 95% CI, 0.70-0.93 and 0.68; 95% CI: 0.59-0.79). Severely obese patients (BMI ≥ 40 kg/m2) did not have a significant survival advantage at 30 days (OR 0.94; 95% CI; 0.74-1.20), but did have 30% lower mortality risk at one year (OR 0.70; 95% CI: 0.54-0.90). There was no significant difference in admission acuity or ICU and hospital length of stay across BMI categories.
Cochrane Review: Activated Protein C
In an update review, including the results of PROWESS-Shock, Martí-Carvajal and colleagues assessed the efficacy of activated protein C in severe sepsis. Six randomized clinical trials involving 6781 subjects were identified, with all studies sponsorsed by the pharmaceutical industry and all having a high risk of bias. APC compared with placebo did not significantly affect all-cause mortality at day 28 compared with placebo (780/3435 (22.7%) versus 767/3346 (22.9%); RR 1.00, 95% CI 0.86 to 1.16; I(2) = 56%). APC did not significantly affect in-hospital mortality (393/1767 (22.2%) versus 379/1710 (22.1%); RR 1.01, 95% CI 0.87 to 1.16; I(2) = 20%). APC was associated with an increased risk of serious bleeding (113/3424 (3.3%) versus 74/3343 (2.2%); RR 1.45, 95% CI 1.08 to 1.94; I(2) = 0%). APC did not significantly affect serious adverse events (463/3334 (13.9%) versus 439/3302 (13.2%); RR 1.04, 95% CI 0.92 to 1.18; I(2) = 0%). Trial sequential analyses showed that more trials do not seem to be needed for reliable conclusions regarding these outcomes.
Cochrane Review: Industry Involvement in Research
Lundh and colleagues performed a systematic review and meta-analysis, including 48 studies, to investigate whether industry sponsored drug and device studies have more favorable outcomes and differ in risk of bias, compared with studies having other sources of sponsorship. Industry sponsored studies more often had favorable efficacy results, risk ratio (RR): 1.24 (95% CI: 1.14 to 1.35), harms results RR: 1.87 (95% CI: 1.54 to 2.27) and conclusions RR: 1.31 (95% CI: 1.20 to 1.44) compared with non-industry sponsored studies. In industry sponsored studies, there was less agreement between the results and the conclusions than in non-industry sponsored studies, RR: 0.84 (95% CI: 0.70 to 1.01).
- Comment: Hynes. Cochrane review questions value of industry-funded clinical trials. CMAJ 2012;10.1503/cmaj.109-4378
Circulation: Coronary and Cerebrovascular Disease Statistics
Study Announcement: Factor Xa Inhibitor Antidote
Following completion of a phase 1 single ascending dose safety and tolerability study of PRT4445, a novel recombinant protein and a potential universal antidote for Factor Xa inhibitor anticoagulants, Portola Pharmaceuticals has announced a Phase 2 study evaluating the safety and effectiveness of this agent in healthy volunteers who have been administered approved and investigational Factor Xa inhibitors, including the oral investigational drug apixaban and Portola’s oral investigational drug betrixaban. The phase 1 study was conducted in 32 healthy volunteers in the United States and showed that PRT4445 was generally safe and well tolerated, and in vitro blood analysis demonstrated that PRT4445 had a rapid (five minute) and sustained (three hour) effect on reversing the activity of that Factor Xa inhibitor.
Journal of the American College of Cardiology: ST-Elevation Myocardial Infarction
- 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2012 epublished December 17th
Journal of the American College of Cardiology: Stable Ischaemic Heart Disease
- 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons
Journal of the American College of Cardiologists: Device-Based Therapy
- 2012 ACCF/AHA/HRS Focused Update Incorporated Into the ACCF/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2012;epublished December 19th
Review - Clinical
Clinical Pharmacology & Therapeutics: Natriuretic Biomarkers
- Motiwala. Motiwala. The Role of Natriuretic Peptides as Biomarkers for Guiding the Management of Chronic Heart Failure. Clinical Pharmacology & Therapeutics 2013;93(1):57–67
JACC Cardiovascular Interventions: Catheterization Drug-Drug Interactions
- Dunn. Drug–Drug Interactions in Cardiovascular Catheterizations and Interventions. J Am Coll Cardiol Intv 2012;5(12):1195-1208
Clinical Cardiology: Aortic Stenosis
- Williamson. Care of Patients With Apparently Asymptomatic Severe Aortic Valve Stenosis. Clin Cardiol 2012;35:E29–E34
Swiss Medical Weekly: Transcatheter Aortic Valve Implementation
Minerva Anesthesiologica: Acute Respiratory Failure in Cancer Patients
- Blot. Diagnostic strategy for oncology patients with acute respiratory failure. Minerva Anestesiologica 2012;78(12):1404-14
Minerva Anesthesiologica: CPAP
- Chiumello. A systematic technical review of the systems for the continuous positive airway pressure. Minerva Anestesiologica 2012;78(12):1385-93
Minerva Anesthesiologica: Liver Transplantation
- Feltracco. Limits and pitfalls of haemodynamic monitoring systems in liver transplantation surgery. Minerva Anestesiologica 2012;78(12):1372-84
Journal of Clinical and Experimental Hepatology: Portal Hypertension
- Sharma. Collateral Pathways in Portal Hypertension. Journal of Clinical & Experimental Hepatology 2012;2(4):338-352
International Journal of Hepatology: Posttransplant Metabolic Syndrome
- Siddiqui. Posttransplant Metabolic Syndrome. International Journal of Hepatology 2012;2012:Article ID 891516
International Journal of Hepatology: Neuroendocrine Tumor Liver Metastases
- Lewis. Treatment of Neuroendocrine Tumor Liver Metastases. International Journal of Hepatology 2012;2012:Article ID 973946
International Journal of Hepatology: Nonalcoholic Fatty Liver Disease
- Durazzo. Focus on Therapeutic Strategies of Nonalcoholic Fatty Liver Disease. International Journal of Hepatology 2012;2012:Article ID 464706
- Nakajima. Multidisciplinary Pharmacotherapeutic Options for Nonalcoholic Fatty Liver Disease. International Journal of Hepatology 2012;2012:Article ID 950693
Journal of Clinical & Experimental Hepatology: Model for End-stage Disease
- Singal. Model for End-stage Disease. Journal of Clinical & Experimental Hepatology 2012; epublished December 3rd
Minerva Anesthesiologica: Acute Kidney Injury Biomarkers
- Gonzalez. Biomarkers for acute kidney injury in critically ill patients. Minerva Anestesiologica 2012;78(12):1394-1403
Methodist Debakey Cardiovascular Journal: Acute Kidney Injury post Cardiac Surgery
- Olivero. Acute kidney injury after cardiovascular surgery: an overview. Methodist Debakey Cardiovasc J 2012;8(3):31-6
Nephrology Dialysis Transplantation: Proximal Renal Tubular Acidosis
- Haque. Proximal renal tubular acidosis: a not so rare disorder of multiple etiologies. Nephrol Dial Transplant 2012;27(12):4237-4287
The Indian Journal of Pediatrics: Nephrotic Syndrome
Clinical Pharmacology & Therapeutics: Anticoagulation
- Mantha. New Avenues for Anticoagulation in Atrial Fibrillation. Clinical Pharmacology & Therapeutics 2013;93(1):68–77
Clinical Cardiology: Anticoagulant-Associated Bleeding
- Peacock. Emergency Management of Bleeding Associated With Old and New Oral Anticoagulants. Clin Cardiol 2012;35:730–737
Interdisciplinary Perspectives on Infectious Diseases: Q Fever
- Honarmand. Q Fever: An Old but Still a Poorly Understood Disease. Interdisciplinary Perspectives on Infectious Diseases 2012;(2012):Article ID 131932
Interdisciplinary Perspectives on Infectious Diseases: Leishmaniasis
- Bhargava. Developments in Diagnosis and Antileishmanial Drugs. Interdisciplinary Perspectives on Infectious Diseases 2012;(2012):Article ID 626838
Journal of Thoracic Imaging: PET Imaging
- Kwee. Overview of Positron Emission Tomography, Hybrid Positron Emission Tomography Instrumentation, and Positron Emission Tomography Quantification. Journal of Thoracic Imaging 2013;28(1):4-10
Insights into Imaging: Interstitial Opacities
- Oikonomou. Mimics in chest disease: interstitial opacities. Insights into Imaging 2012; epublished December 18th
Insights into Imaging: Imaging Aortitis
Anesthesiology: Lüer Locks
- Milamed. Lüer’s Lure: From an International Standards Perspective. Anesthesiology 2012;117(6):1358-1363
Asian Journal of Pharmacology: Transdermal Drug Delivery
Review - Basic Science
Mediators of Inflammation: Macrophage-Mediated Lung Injury
- Gwyer. Macrophage-Mediated Inflammation and Disease: A Focus on the Lung. Mediators of Inflammation 2012;2012:Article ID 140937
Review - Non-Clinical
Annals of Emergency Medicine: Malpractice
I hope you find these brief summaries and links useful.
Until next week