Hospital practice最新文献

{"title":"Heart Transplantation is Not the Only Option for Patients with Advanced Heart Failure","authors":"J. Barcena, J. Fang","doi":"10.3810/hp.2010.04.288","DOIUrl":"https://doi.org/10.3810/hp.2010.04.288","url":null,"abstract":"The conventional therapy for advanced medically refractory heart failure is heart transplantation, but donors are limited and most patients are not candidates due to signifi cant comorbidities. Until recently, therapeutic options for such patients have been limited and, frankly, palliative. For example, medically refractory advanced heart failure patients considered ineligible for transplantation (most commonly due to age) are often treated with chronic inotropic agents, which temporize their symptoms but are associated with an alarming 10% to 30% 1-year survival rate. Ventricular assist devices (VADs), or heart pumps, have changed the therapeutic landscape for these desperate patients. The pumps are surgically implanted, electrically driven devices that complement the cardiac output of the native but weakened heart (Figure 1). They can be used to support either the left (LVAD), right (RVAD), or both (BiVAD or total artifi cial heart [TAH]) ventricles. There are currently 3 major indications for VADs in advanced heart failure. Most commonly, VADs are used as a bridge to heart transplant when a patient becomes too ill to await transplantation on inotropic agents. Randomized trials have demonstrated the effectiveness of VADs in this capacity. Less commonly, VADs are used to hemodynamically support a patient with acute systolic heart failure and shock until the native heart recovers (ie, as a bridge to recovery). Finally, these devices have been used as a permanent therapy for patients with medically refractory advanced heart failure considered ineligible for transplantation, or so-called destination therapy. It is this last indication that represents a signifi cant change in paradigm for this technology. The principle that LVADs could be used as a “destination” therapy superior to conventional medical therapy was fi rst tested in the landmark Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) study, which used a fi rst-generation pulsatile pump. This study enrolled 129 patients with severe heart failure ineligible for transplantation, with the primary endpoint being death of any cause. There was a striking 48% reduction in mortality with the use of LVADs when compared with optimal medical management as well as marked improvements in functional status. This trial led to US Food and Drug Administration (FDA) approval in 2002 for the HeartMate XVE LVAD (Thoratec Corp., Pleasanton, CA) to be used as a permanent solution for transplant-ineligible patients with refractory heart failure. Recent technologic advances have led to a second generation of devices that provide continuous rather than pulsatile fl ow (eg, HeartMate II [Thoratec Corp., Pleasanton, CA]), which has decreased the size of the device and increased durability. It was this latest generation of LVADs that was used in the recent destination study by Slaughter et al. In this trial, patients with advanced refractory heart failure ineligible ","PeriodicalId":75913,"journal":{"name":"Hospital practice","volume":"38 1","pages":"7 - 8"},"PeriodicalIF":0.0,"publicationDate":"2010-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"70169221","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"2009 Influenza A (H1N1): A Clinical Review","authors":"Jesse W. Delaney, R. Fowler","doi":"10.3810/hp.2010.04.297","DOIUrl":"https://doi.org/10.3810/hp.2010.04.297","url":null,"abstract":"Abstract Since the onset of the 2009 influenza A (H1N1) pandemic, the virus has caused significant morbidity and mortality. Most cases of 2009 H1N1 have presented as mild febrile illnesses with cough, sore throat, and occasional gastrointestinal symptoms. Dyspnea has been more commonly associated with the onset of severe pulmonary disease. Unlike seasonal influenza, the prevalence of 2009 H1N1 is greatest among children and young adults, although older patients and those with comorbidities are more likely to experience worse clinical outcomes. Among the most severely affected, critical illness evolves within 4 to 6 days from symptom onset, and approximately 70% of these patients require mechanical ventilation ranging in duration from days to weeks. Compared with prior influenza seasons, the need for rescue oxygenation therapy with nitric oxide, prone ventilation, high-frequency oscillation, and extracorporeal membrane oxygenation has increased. Specific medical care with neuraminidase inhibitors and antibiotics for secondary bacterial pneumonia are the mainstays of therapy. With optimal care, mortality rates range from 5% to 7% among those hospitalized and reach approximately 20% among those admitted to the intensive care unit.","PeriodicalId":75913,"journal":{"name":"Hospital practice","volume":"38 1","pages":"74 - 81"},"PeriodicalIF":0.0,"publicationDate":"2010-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.3810/hp.2010.04.297","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"70168908","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Practice Implications of Recent Clinical Trials for the Prevention of Acute Kidney Injury in Cardiovascular Surgery","authors":"M. Shimada, B. Dass, Gurjit S. Dhatt, Mourad M. Alsabbagh, A. Asmar, Imtiaz Ather, Rajni Sharma, A. Ejaz","doi":"10.3810/hp.2010.04.296","DOIUrl":"https://doi.org/10.3810/hp.2010.04.296","url":null,"abstract":"Abstract Acute kidney injury in patients undergoing cardiovascular surgery is a complex problem with associated increased risks for dialysis, short- and long-term mortality, and progression to end-stage renal disease. Interventions to prevent and treat renal complications in this cohort have seldom been uniformly satisfactory due to the differences in strategies for intervention, drug doses and duration of treatment, baseline renal functions, and population studied. Nonetheless, significant advances have been made and include recognition of the effect of preexisting organ dysfunction on renal outcomes, reassessment of existing therapeutic interventions, and exploration of the feasibility of newer agents to prevent and treat acute kidney injury in cardiovascular surgery patients. This article briefly reviews several of these issues with an emphasis on recent clinical trials in this cohort.","PeriodicalId":75913,"journal":{"name":"Hospital practice","volume":"38 1","pages":"67 - 73"},"PeriodicalIF":0.0,"publicationDate":"2010-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.3810/hp.2010.04.296","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"70169353","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cardiac Surgery, Carotid Stenosis, and Stroke Prevention","authors":"Yuebing Li, D. Jenny, J. Castaldo","doi":"10.3810/hp.2010.04.292","DOIUrl":"https://doi.org/10.3810/hp.2010.04.292","url":null,"abstract":"Abstract Stroke following cardiac surgery is a major source of morbidity and mortality. In patients undergoing cardiac surgery, the presence of severe carotid stenosis is associated with a higher incidence of postoperative stroke. Carotid revascularization procedures, such as carotid endarterectomy and stenting, are frequently performed under such circumstances in an effort to reduce the incidence of stroke. The available literature suggests that most postoperative strokes are not directly related to carotid stenosis. Synchronous carotid revascularization and cardiac surgery renders a higher risk of cardiovascular complications. In this article, we summarize the incidences of postoperative stroke and carotid stenosis in this population, discuss the pathogenesis of stroke in these patients, and propose strategies for managing patients undergoing cardiac surgery with severe carotid stenosis.","PeriodicalId":75913,"journal":{"name":"Hospital practice","volume":"38 1","pages":"29 - 39"},"PeriodicalIF":0.0,"publicationDate":"2010-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"70169295","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Drug-Induced Thrombocytopenia for the Hospitalist Physician with a Focus on Heparin-Induced Thrombocytopenia","authors":"M. Rondina, A. Walker, R. Pendleton","doi":"10.3810/hp.2010.04.291","DOIUrl":"https://doi.org/10.3810/hp.2010.04.291","url":null,"abstract":"Abstract Acute thrombocytopenia occurs commonly in hospitalized patients. For most, the etiology of an acutely declining platelet count is obvious and includes sepsis with disseminated intravascular coagulation, large-volume crystalloid infusion, or the administration of cytotoxic therapies, such as chemotherapeutic agents. For others, however, the etiology may be less apparent. In these cases, drug-induced thrombocytopenia (DIT), including heparin-induced thrombocytopenia (HIT), must be a diagnostic consideration. The approach to the hospitalized patient with thrombocytopenia, without an obvious cause, includes a careful medication history to identify potential culprits, such as glycoprotein IIb/IIIa inhibitors, vancomycin, linezolid, β-lactam antibiotics, quinine, antiepileptic drugs, or heparin/low-molecular-weight heparin. Usually, discontinuation of the offending medication is all that is necessary for resolution of thrombocytopenia. Heparin-induced thrombocytopenia, however, is an exception to this general rule given its unique pathogenesis and propensity for thrombotic complications and death. Differentiating between HIT and DIT due to nonheparin medications may prove challenging. Through a careful clinical assessment, consideration of the pre-test probability for HIT, and the thoughtful application of laboratory testing, HIT can be accurately diagnosed. Because patients with HIT have a high risk of thrombosis and bleeding is uncommon, the prompt initiation of an alternative anticoagulant (eg, a direct thrombin inhibitor) is warranted in these patients.","PeriodicalId":75913,"journal":{"name":"Hospital practice","volume":"38 1","pages":"19 - 28"},"PeriodicalIF":0.0,"publicationDate":"2010-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"70169258","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Global Health Forum 2009: Connecting Through Innovation & Partnerships","authors":"","doi":"10.1080/21548331.2009.11444164","DOIUrl":"https://doi.org/10.1080/21548331.2009.11444164","url":null,"abstract":"","PeriodicalId":75913,"journal":{"name":"Hospital practice","volume":"42 1","pages":"153 - 158"},"PeriodicalIF":0.0,"publicationDate":"2009-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1080/21548331.2009.11444164","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"60071636","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Controversies in cardiology","authors":"L. Wilkins","doi":"10.1161/circ.112.8.iv","DOIUrl":"https://doi.org/10.1161/circ.112.8.iv","url":null,"abstract":"There are several areas of therapeutics where current practice differs between the United States and Europe. In the case of nesiritide, the use of this drug is undoubtedly controversial. This recombinant human brain natriuretic peptide is given to tens of thousands of patients in the United States every week at a cost of about $500 for each dose, and many physicians there are extremely enthusiastic about this new treatment for acute decompensated heart failure (ADHF).\u0000\u0000Aggressive marketing by the manufacturer, Scios Inc, has been suggested as one reason for its increasing use1 while many cardiologists in Europe are far less enthusiastic and have …","PeriodicalId":75913,"journal":{"name":"Hospital practice","volume":"112 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2005-08-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"64369880","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Harrison's Online Updates","authors":"D. Longo, J. Cohen, T. Barlam","doi":"10.1080/21548331.2001.11444138","DOIUrl":"https://doi.org/10.1080/21548331.2001.11444138","url":null,"abstract":"","PeriodicalId":75913,"journal":{"name":"Hospital practice","volume":"36 1","pages":"4 - 4"},"PeriodicalIF":0.0,"publicationDate":"2001-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1080/21548331.2001.11444138","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"60071219","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Monthly Critical Overview of Current Medicine","authors":"G. Stollerman, A. Bisno","doi":"10.1080/21548331.2001.11444142","DOIUrl":"https://doi.org/10.1080/21548331.2001.11444142","url":null,"abstract":"Placebo Analgesia: When and How It Works A s neurophysiologists have demonstrated experimentally, placebo analgesia is mediated by endogenous opioids. In clinical trials comparing placebo with no treatment, the placebo had no effect on pain management. But the placebo response may depend on psychological factors such as conditioning, expectancy, and the method of analgesic assessment, and these psychological influences may act via endogenous opioids. To explore response expectancies as determinants of placebo analgesia, neuroscientists at Italy's University of Torino assigned 38 thoracotomized patients to three groups. All were treated with the opioid buprenorphine on request, together with a basal infusion of saline solution. Group 1 (natural history) was told nothing about any analgesic effect the basal infusion might provide. Group 2 (classic double-blind administration) was told that the basal infusion would be either a powerful painkiller or a placebo. Group 3 (deceptive administration) was told the basal infusion was a potent painkiller. Analgesia was assessed by the amount of buprenorphine requested during the three-day study period. Compared with the natural-history group, the double-blind group showed a reduction in buprenorphine requests. In the deceptive-administration group, the reduction was even greater. In an earlier report by the same team, the analgesia of the opioids buprenorphine and tramadol and the nonopioids ketorolac and metamizole was greater when the drugs were administered by injection, in full view of the subject instead of in hidden infusions. In a second part of the study, experimental ischemic arm pain induced in healthy volunteers was reduced more effectively by open than hidden administration of ketorolac. Adding naloxone to the injections produced a pharmacologic block of the endogenousopioid-mediated component of placebo analgesia.","PeriodicalId":75913,"journal":{"name":"Hospital practice","volume":"36 1","pages":"23 - 26"},"PeriodicalIF":0.0,"publicationDate":"2001-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1080/21548331.2001.11444142","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"60071571","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Possible AV dissociation after cardioversion.","authors":"Hancock Ew","doi":"10.1080/21548331.2001.11444140","DOIUrl":"https://doi.org/10.1080/21548331.2001.11444140","url":null,"abstract":"Dr. Hancock is Professor of (Cardiovascular) Medicine Emeritus, Stanford University School of Medicine, Stanford, Calif. A 62-year-old man was hospitalized for worsening congestive heart failure. His history included diabetes of four years' duration, episodic atrial arrhythmias, recurrent cellulitis of the lower extremities, and alcoholism. At the time of admission, he had moderate right and left-sided congestive heart failure, atrial flutter with a ventricular rate of 90 to 100/min, and a loud murmur of mitral regurgitation. His medications included warfarin, glyburide, furosemide, arnlodipine, and folic acid. The patient improved slowly, but pleural effusion and hypoxemia continued despite salt restriction and higher doses of furosemide. Cardioversion did not convert atrial flutter to a stable sinus rhythm with a 1:1 conduction; instead, an irregular rhythm developed, as well as what appeared to be AV dissociation. The patient was not taking digoxin at this time. The ECG is shown. What is the rhythm mechanism? What is the underlying physiologic abnormality? What further therapy is indicated?","PeriodicalId":75913,"journal":{"name":"Hospital practice","volume":"36 1","pages":"19-20"},"PeriodicalIF":0.0,"publicationDate":"2001-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1080/21548331.2001.11444140","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"60071267","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}