Effects on hemodynamics and gas exchange of omega-3 fatty acid-enriched lipid emulsion in acute respiratory distress syndrome (ARDS): a prospective, randomized, double-blind, parallel group study

<p>Abstract</p> <p>Introduction</p> <p>We investigated the effects on hemodynamics and gas exchange of a lipid emulsion enriched with omega-3 fatty acids in patients with ARDS.</p> <p>Methods</p> <p>The design was a prospective, randomized, double-blind, parallel group study in our Intensive Medicine Department of Vall d'Hebron University Hospital (Barcelona-Spain). We studied 16 consecutive patients with ARDS and intolerance to enteral nutrition (14 men and 2 women; mean age: 58 ± 13 years; APACHE II score: 17.8 ± 2.3; Lung Injury Score: 3.1 ± 0.5; baseline PaO₂/FiO₂ratio: 149 ± 40). Patients were randomized into 2 groups: Group A (n = 8) received the study emulsion Lipoplus^®20%, B.Braun Medical (50% MCT, 40% LCT, 10% ω-3); Group B (n = 8) received the control emulsion Intralipid^®Fresenius Kabi (100% LCT). Lipid emulsions were administered during 12 h at a dose of 0.12 g/kg/h. Measurements of the main hemodynamic and gas exchange parameters were made at baseline (immediately before administration of the lipid emulsions), every hour during the lipid infusion, at the end of administration, and six hours after the end of administration lipid infusion.</p> <p>Results</p> <p>No statistically significant changes were observed in the different hemodynamic values analyzed. Likewise, the gas exchange parameters did not show statistically significant differences during the study. No adverse effect attributable to the lipid emulsions was seen in the patients analyzed.</p> <p>Conclusion</p> <p>The lipid emulsion enriched with omega-3 fatty acids was safe and well tolerated in short-term administration to patients with ARDS. It did not cause any significant changes in hemodynamic and gas exchange parameters.</p> <p>Trial registration</p> <p>ISRCTN63673813</p

B vitamins in patients with recent transient ischaemic attack or stroke in the VITAmins TO Prevent Stroke (VITATOPS) trial:a randomised, double-blind, parallel, placebo-controlled trial

SummaryBackgroundEpidemiological studies suggest that raised plasma concentrations of total homocysteine might be a risk factor for major vascular events. Whether lowering total homocysteine with B vitamins prevents major vascular events in patients with previous stroke or transient ischaemic attack is unknown. We aimed to assess whether the addition of once-daily supplements of B vitamins to usual medical care would lower total homocysteine and reduce the combined incidence of non-fatal stroke, non-fatal myocardial infarction, and death attributable to vascular causes in patients with recent stroke or transient ischaemic attack of the brain or eye.MethodsIn this randomised, double-blind, parallel, placebo-controlled trial, we assigned patients with recent stroke or transient ischaemic attack (within the past 7 months) from 123 medical centres in 20 countries to receive one tablet daily of placebo or B vitamins (2 mg folic acid, 25 mg vitamin B6, and 0·5 mg vitamin B12). Patients were randomly allocated by means of a central 24-h telephone service or an interactive website, and allocation was by use of random permuted blocks stratified by hospital. Participants, clinicians, carers, and investigators who assessed outcomes were masked to the assigned intervention. The primary endpoint was the composite of stroke, myocardial infarction, or vascular death. All patients randomly allocated to a group were included in the analysis of the primary endpoint. This trial is registered with ClinicalTrials.gov, NCT00097669, and Current Controlled Trials, ISRCTN74743444.FindingsBetween Nov 19, 1998, and Dec 31, 2008, 8164 patients were randomly assigned to receive B vitamins (n=4089) or placebo (n=4075). Patients were followed up for a median duration of 3·4 years (IQR 2·0–5·5). 616 (15%) patients assigned to B vitamins and 678 (17%) assigned to placebo reached the primary endpoint (risk ratio [RR] 0·91, 95% CI 0·82 to 1·00, p=0·05; absolute risk reduction 1·56%, −0·01 to 3·16). There were no unexpected serious adverse reactions and no significant differences in common adverse effects between the treatment groups.InterpretationDaily administration of folic acid, vitamin B6, and vitamin B12 to patients with recent stroke or transient ischaemic attack was safe but did not seem to be more effective than placebo in reducing the incidence of major vascular events. These results do not support the use of B vitamins to prevent recurrent stroke. The results of ongoing trials and an individual patient data meta-analysis will add statistical power and precision to present estimates of the effect of B vitamins.FundingAustralia National Health and Medical Research Council, UK Medical Research Council, Singapore Biomedical Research Council, Singapore National Medical Research Council, Australia National Heart Foundation, Royal Perth Hospital Medical Research Foundation, and Health Department of Western Australia

Effects of an omega-3 fatty acid-enriched lipid emulsion on eicosanoid synthesis in acute respiratory distress syndrome (ARDS): A prospective, randomized, double-blind, parallel group study

<p>Abstract</p> <p>Background</p> <p>The use of lipid emulsions has been associated with changes in lung function and gas exchange which may be mediated by biologically active metabolites derived from arachidonic acid. The type and quantity of the lipid emulsions used could modulate this response, which is mediated by the eicosanoids. This study investigates the use of omega-3 fatty acid-enriched lipid emulsions in ARDS patients and their effects on eicosanoid values.</p> <p>Methods</p> <p>Prospective, randomized, double-blind, parallel group study carried out at the Intensive Medicine Department of Vall d'Hebron University Hospital (Barcelona-Spain). We studied 16 consecutive patients with ARDS and intolerance to enteral nutrition (14 men; age: 58 ± 13 years; APACHE II score 17.8 ± 2.3; Lung Injury Score: 3.1 ± 0.5; baseline PaO₂/FiO₂ratio: 149 ± 40). Patients were randomized into two groups: Group A (n = 8) received the study emulsion Lipoplus^®20%, B. Braun Medical (50% MCT, 40% LCT, 10% fish oil (FO)); Group B (n = 8) received the control emulsion Intralipid^®Fresenius Kabi (100% LCT). Lipid emulsions were administered for 12 h at a dose of 0.12 g/kg/h. We measured LTB₄, TXB₂, and 6-keto prostaglandin F_1αvalues at baseline [immediately before the administration of the lipid emulsions (T-0)], at the end of the administration (T-12) and 24 hours after the beginning of the infusion (T 24) in arterial and mixed venous blood samples.</p> <p>Results</p> <p>In group A (FO) LTB₄, TXB₂, 6-keto prostaglandin F_1αlevels fell during omega-3 administration (T12). After discontinuation (T24), levels of inflammatory markers (both systemic and pulmonary) behaved erratically. In group B (LCT) all systemic and pulmonary mediators increased during lipid administration and returned to baseline levels after discontinuation, but the differences did not reach statistical significance. There was a clear interaction between the treatment in group A (fish oil) and changes in LTB₄over time.</p> <p>Conclusions</p> <p>Infusion of lipids enriched with omega-3 fatty acids produces significant short- term changes in eicosanoid values, which may be accompanied by an immunomodulatory effect.</p> <p>Trial registration</p> <p><a href="http://www.controlled-trials.com/ISRCTN63673813">ISRCTN63673813</a>.</p

Krótszy czas wyprowadzania z cukrzycowej kwasicy ketonowej podczas leczenia w ośrodku referencyjnym u osób z cukrzycą typu 1 i innymi specyficznymi typami cukrzycy

Introduction and objective. Diabetic ketoacidosis (DKA) is one of the most serious and potentially life-threatening, acute metabolic complications of diabetes, resulting from absolute deficiency of insulin. This condition requires hospitalization and intensive treatment. Despite the recommendations of Polish Diabetes Association (PTD) for treatment of DKA, the derogation from the protocol are observed in clinical practice. The Department of Internal Medicine and Diabetology, Poznan University of Medical Sciences, is a referral medical center for Wielkopolska, where patients with DKA are admitted directly or transferred from other hospitals. The duration of ketosis treatment is of prognostic importance. The aim of the study was to compare the time of treatment of patiens hospitalised in the referral medical center from the beginning with patients transferred from other hospitals. Material and methods. We analyzed the duration of DKA treatment in 124 patients with type 1 diabetes (n = 119) and class 3 (n = 5), hospitalized in the Department of Internal Medicine and Diabetology, Poznan University of Medical Sciences in years 2008–2011. We compared the duration of treatment of patients hospitalized in the Department from the beginning (n = 70) and transferred from other medical centers (n = 54). The achievement of acid-base balance was regarded as the end of treatment of diabetic ketoacidosis. Results. The mean duration of treatment of the whole group of patients with DKA was 35 ± 18 h. Patients transferred to a referral center and immediately treated at the Department did not differ significantly in severity of diabetic ketoacidosis. Duration of recovering from DKA in the group of patients hospitalized in the referral center from the beginning was 32 ± 19 h. The duration of treatment of patients transferred from other hospitals was 38 ± 18 h (p = 0.03). There was a significant difference in the frequency of administration of bicarbonate in the group of patients transferred from other medical centers [7 (12.9%) vs. 2 (2.8%), p = 0.03]. Conclusions. Immediate hospitalization of patients with diabetic ketoacidosis in the referral center, which is experienced in treatment of patients with acute hyperglycaemic complications, is associated with shorter duration of treatment.Wstęp i cel. Cukrzycowa kwasica ketonowa (DKA) jest jednym z najpoważniejszych i potencjalnie śmiertelnych ostrych powikłań metabolicznych cukrzycy, wynikających z niedoboru insuliny. Stan ten wymaga hospitalizacji i intensywnego leczenia. Pomimo zaleceń Polskiego Towarzystwa Diabetologicznego (PTD) dotyczących prowadzenia DKA w praktyce klinicznej obserwuje się odstępstwa od protokołu. Do Katedry i Kliniki Chorób Wewnętrznych i Diabetologii w Poznaniu będącej ośrodkiem referencyjnym dla Wielkopolski trafiają pacjenci z DKA bezpośrednio lub przekazywani są z innych ośrodków medycznych. Czas wyprowadzania ze stanu kwasicy ketonowej ma znaczenie prognostyczne. Celem pracy było porównanie czasu leczenia DKA u pacjentów z cukrzycą hospitalizowanych od początku w ośrodku referencyjnym oraz przekazanych z innych ośrodków medycznych. Materiał i metody. Analizie poddano czas leczenia DKA u 124 pacjentów z cukrzycą typu 1 (n = 119) i innymi specyficznymi typami cukrzycy (n = 5), hospitalizowa­nych w Katedrze i Klinice Chorób Wewnętrznych i Diabetologii UM w Poznaniu w latach 2008–2011. Porównano czas leczenia pacjentów hospitalizowanych od początku w Klinice (n = 70) i przekazanych z innych ośrodków medycznych (n = 54). Za czas zakończenia leczenia DKA uznano osiągnięcie równowagi kwasowo-zasadowej. Wyniki. Średni czas leczenia całej grupy pacjentów z DKA wynosił 35 ± 18 h. Pacjenci przekazani do ośrodka referencyjnego i od razu leczeni w Klinice nie różnili się istotnie stopniem ciężkości DKA. Czas wyprowadzania z DKA pacjentów od początku hospitalizowanych w ośrodku referencyjnym wynosił 32 ± 19 h. U pacjentów przekazanych z innych ośrodków medycznych leczenie trwało 38 ± 18 h (p = 0,03). Obserwowano istotną różnicę w zakresie częstości podawania wodorowęglanów w innych ośrodkach medycznych [7 (12,9%) vs. 2 (2,8%), p = 0,03]. Wnioski. Hospitalizacja pacjenta z DKA w ośrodku referencyjnym, doświadczonym w prowadzeniu ostrych stanów hiperglikemicznych, związana jest z krótszym czasem leczenia

The Code Stroke: medical evaluation by a pre-hospital attention service

In 1996, the NINDS (National Institute of Neurological Disorders and Treatment of Acute Stroke) published targets for the management of patients with acute cerebrovascular events, setting a time of 3 h or less for administration of thrombolytics, creating the Code Stroke. Objective: Evaluate the time between onset of symptoms and arrival at the emergency department of a hospital as prognostic factors in patients with cerebrovascular events attended by the prehospital emergency medical service in the metropolitan area of Monterrey, Nuevo Leon. Materials and methods: Calls received in the ED (EMME) between January and December 2012 were included in a retrospective cross-sectional study, with symptoms showing within the first 8 h or with an unknown onset. The Mann---Whitney test and Fisher’s exact test were used. Results: Thirty-six patients were included in the study. In 21, the final diagnosis was cerebral infarction, 5 patients were treated with thrombolysis (23.8%). They were divided into two groups: group 1 died or were left with severe neurological sequelae (n = 9) and Group 2 survived without sequelae or mild neurological sequelae (n = 12). The door hospital arrival time was 67 (29---116) min (Group 1) versus 54 (24---86) min (Group 2) (p = 0.110). The neurological status at the start of the event affected prognosis and mortality (p = 0.018). Conclusions: There are few studies analyzing the time between the inception of the symptomatology and the arrival to the emergency room. In our study 23.8% of this series were thrombolyzed, which puts us in the range of international statistics, compared to the series published by Geffner-Sclarsky et al. The population of this study is small so it is not able to show statistical differences, but the few studies that evaluate the Code Stroke in Mexico open the doors to future work with a larger population in Latin American society

A New Age in Dementia Care: Turning Evidence into Practice

A New Age in Dementia Care: Turning Evidence into Practice Come celebrate the opening of the new Living Laboratory for Elder Care. September 17, 2008 7:30 am - 4:30 pm Thomas Jefferson University, Dorrance H. Hamilton Building 1001 Locust St., Philadelphia, PA 19107 Speakers Include: Christine Arenson, MD Associate Professor Director, Division of Geriatric Medicine Department of Family and Community Medicine Jefferson Medical College Director, Eastern-Pennsylvania Delaware Geriatric Education Center Co-Director Jefferson InterProfessional Education Center Thomas Jefferson University Louis D. Burgio, PhD Harold R. Johnson Endowed Chair in Gerontology, Professor of Social Work Research Professor, Institute of Gerontology School of Medicine Adjunct Professor School of Nursing and Department of Psychology University of Michigan Ann Arbor, MI Janice P. Burke, PhD, OTR/L, FAOTA Dean, Jefferson School of Health Professions Chair and Professor Department of Occupational Therapy Co-Executive Director Living Laboratory for Elder Care Jefferson College of Health Professions Thomas Jefferson University Christopher M. Callahan, MD Cornelius and Yvonne Pettinga Professor of Aging Research Director, Indiana University Center for Aging Research Investigator, Regenstrief Institute, Inc. Robert Egge Project Director Center for Health Transformation Washington, DC Lynn Friss Feinberg, MSW Deputy Director, National Center on Caregiving Family Caregiver Alliance San Francisco, CA Laura N. Gitlin, PhD Director, Jefferson Center for Applied Research on Aging and Health Professor, Department of Occupational Therapy Co-Executive Director Living Laboratory for Elder Care Jefferson College of Health Professions Thomas Jefferson University Barry J. Jacobs, PsyD Licensed Psychologist Director of Behavioral Sciences Crozer-Keystone Family Medicine Residency Program Springfield, PA Katie Maslow, MSW Associate Director, Quality Care Advocacy Alzheimer’s Association Public Policy Division Washington, DC Nancy B. O’Connor Regional Administrator Centers for Medicare and Medicaid Services Philadelphia Regional Office United States Department of Health and Human Services Philadelphia, PA Catherine Verrier Piersol, MS, OTR/L Clinical Director, Living Laboratory for Elder Care Jefferson Center for Applied Research on Aging and Health Jefferson College of Health Professions Thomas Jefferson University Susan C. Reinhard, PhD, RN, FAAN Senior Vice President, Public Policy Institute AARP Washington, DC Barry W. Rovner, MD Professor Departments of Psychiatry and Neurology Jefferson Hospital for Neuroscience Director of Clinical Alzheimer’s Disease Research Farber Institute for Neurosciences Thomas Jefferson University Richard Schulz, PhD Professor of Psychiatry, Epidemiology, Sociology, Psychology, Community Health, and Health and Rehabilitation Sciences Director University Center for Social and Urban Research Associate Director University of Pittsburgh Institute on Aging Pittsburgh, PA Leslie M. Swann, PhD Aging Program Management Specialist United States Department of Health and Human Services United States Administration on Aging Washington, DC A tour of the new multidisciplinary Hamilton Building and reception to follo

Alcohol Use during Pregnancy: Considerations for Australian Policy

Although there is an extensive recorded history of concerns related to alcohol exposed pregnancies and possible outcomes of fetal alcohol spectrum disorder in recent scientific literature, Australia has only recently begun to accurately or systematically diagnose and record these conditions, or to provide comprehensive, coordinated, policy-guided funding, prevention, and treatment. This article discusses some considerations that can guide policy development within the Australian context including the social context and determinates of alcohol consumption during pregnancy and the need to consider the issue as one that goes beyond the decision making of individual women. The article also identifies the contribution of research to guide evidence-based policy development, including emerging evidence of epigenetics, and systematic reviews for prevention. Other policy considerations include costs, and the possibility of the prevention paradox applying to this field, with its associated impact on costs and focus of prevention

Irinotecan Hydrochloride (CPT-11) in Dialysis Patients with Gastrointestinal Cancer

We investigated changes in drug disposition and toxicities with CPT-11 in 15 dialysis patients with gastrointestinal cancers to clarify whether CPT-11 could be administered safely in such patients. For comparison, the same parameters were also investigated in 10 cancer patients not undergoing dialysis. Items investigated included (1) plasma concentrations of SN-38, SN-38G and CPT-11 at 0, 1, 12, 24, 36, 48 and 72h after administration, together with a comparison of mean AUC values for 3 dose levels of CPT-11 (50, 60 and 70mg/m2) in dialysis patients and controls;and (2) occurrence of adverse events. Several findings emerged from this study:(1) No significant difference was observed in the AUC for SN-38 or CPT-11 between the dialysis and control groups;(2) The AUC for SN-38G at each dose was significantly higher in dialysis patients;and (3) Grade 1-4 leucopenia was observed in 11 of the dialysis patients. One patient developed grade 4 leucopenia and died due to sepsis. Anorexia, diarrhea, nausea, alopecia and interstitial pneumonia occurred in 6 dialysis patients. We found changes in drug dispositions of CPT-11, SN-38 and SN-38G in dialysis patients, suggesting that hepatic excretion, especially that of SN-38G, was increased. No significant difference in occurrence of adverse events was observed between the 2 groups. This indicates that CPT-11 can be administered safely in patients on dialysis.</p

Advancing Patient Safety in the U.S. Department of Veterans Affairs

As part of a systemwide transformation, the VA formed its National Center for Patient Safety to foster an organizational culture of safety within its nationwide network of hospitals and outpatient clinics. A recent medical team training program designed to improve communication among operating room staff was associated with a reduction in surgical mortality and improvements in quality of care, on-time surgery starts, and staff morale. The program is now being expanded to other clinical units, along with a patient engagement program that prevents errors by facilitating communication relating to patients' daily care plans. A recognition program stimulated facilities to conduct timelier and higher-quality root-cause analyses of reported safety events to identify stronger actions for preventing their recurrence. Other initiatives have reduced rates of health care -- associated infections, patient mortality, and post-operative complications. Success factors include leadership accountability for performance and organizational support for testing, expanding, and adopting improvements

BUMC Annual Report

Annual report of the Boston University Medical Center