31 Jan 06
Posted in General, Pain medicine at 12:56 by Laci
By S Evers, A Frese
Curr Op Anaest 2005, 18:563-568
Purpose of review
In past years, important advances have been made in the treatment of idiopathic headache disorders. New controlled trials have been published for the acute and the prophylactic drug and non-drug therapies. Furthermore, new headache entities have been described by the International Headache Society for which treatment recommendations can be given.
Recent findings
Triptans and non-steroidal anti-inflammatory drugs are still the drugs of first choice for the treatment of migraine attacks. Recent studies show that early treatment is clearly effective in migraine and that differential therapy with triptans can be helpful. New drugs with new mechanisms are being developed such as a calcitonin gene-related peptide antagonist. For the prophylaxis of migraine, topiramate has been introduced as an effective new drug. Botulinum toxin did not show convincing evidence of efficacy in migraine and tension-type headache. For migraine and cluster headache, surgical procedures such as the closure of the patent foramen ovale (migraine) and neurostimulation of the hypothalamus (cluster headache) are also under evaluation. A group of miscellaneous headaches (group 4 of the International Headache Society classification) is also described, for which treatment recommendations, in particular indomethacin in most cases, can now be given although no placebo-controlled trials have been performed.
Summary
Recent advances in headache treatment comprise growing evidence for an appropriate drug administration and for differential drug therapy rather than the development of new drugs or procedures. Surgical and other non-drug treatment procedures are under discussion and might be an additional tool for headache treatment in future years.
Permalink
Posted in Critical Care, Glucose control at 12:53 by Laci
By JL Vincent
Crit Care 2005, 33:1225-1229
To introduce the Fast Hug mnemonic (Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head-of-bed elevation, stress Ulcer prevention, and Glucose control) as a means of identifying and checking some of the key aspects in the general care of all critically ill patients. Application of this simple strategy encourages teamwork and may help improve the quality of care received by our intensive care unit patients.
Permalink
Posted in Critical Care, Monitoring at 12:51 by Laci
By MR Pinsky, JL Vincent
Crit Care Med 2005, 5:1119-1122
Objective
To clarify the issues related to the use of the pulmonary artery catheter within a rational clinical perspective.
Results
Barriers include a) increased patient risk of pulmonary artery catheter placement; b) ability to measure similar variables via central venous catheterization, echocardiography, or other less invasive techniques; c) increased cost; d) inaccurate measurements; e) incorrect interpretation and application of pulmonary artery catheter-derived variables; and f) lack of proven benefit of pulmonary artery catheter use in the overall management of patients.
Interpretation
a) The risks are mainly due to insertion of a central catheter, not a pulmonary artery catheter; b) continuous monitoring of left ventricular filling pressures, pulmonary vascular pressures, and mixed venous oxygen saturation is a unique feature; c) additional costs are minimal relative to the cost of intensive care; d) measurement errors require ongoing programmatic educational efforts; e) pulmonary artery catheter-derived data need to be used within the context of a defined treatment protocol; and f) no monitoring device, no matter how simple or sophisticated, will improve patient-centered outcomes unless coupled with a treatment that, itself, improves outcome.
Conclusion
A treatment protocol for the use of pulmonary artery catheter-derived variables is proposed that could serve as a basis for a prospective clinical trial.
Permalink
Posted in Critical Care, Sepsis, rhAPC at 12:48 by Laci
By JL Vincent, GR Bernard, R Beale, C Doig, C Putensen, et al.
Crit Care Med 2005 33:2266-2277
Objective
To provide further evidence for the efficacy and safety of drotrecogin alfa (activated) treatment in severe sepsis.
Design
Single-arm, open-label, trial of drotrecogin alfa (activated) treatment in severe sepsis patients. Enrollment began in March 2001 and day-28 follow-up completed in January 2003.
Setting
ENHANCE took place in 25 countries at 361 sites.
Patients: Patients with known or suspected infection, three or four systemic inflammatory response syndrome criteria, and one or more sepsis-induced organ dysfunctions. Of 2,434 adults entered, 2,378 received drotrecogin alfa (activated), and of these, 2,375 completed the protocol.
Interventions
Drotrecogin alfa (activated) was infused at a dose of 24 [mu]g/kg/hr for 96 hrs.
Measurements and Main Results
The 28-day all-cause mortality approximated that observed in PROWESS (25.3% vs. 24.7%). Although patients in ENHANCE had increased serious bleeding rates compared with patients in the drotrecogin alfa (activated) arm of PROWESS (during infusion, 3.6% vs. 2.4%; postinfusion, 3.2% vs. 1.2%; 28-day, 6.5% vs. 3.5%), increased postinfusion bleeding suggested a higher background bleeding rate. Intracranial hemorrhage was more common in ENHANCE than PROWESS (during infusion, 0.6% vs. 0.2%; 28-day, 1.5% vs. 0.2%). The incidence of fatal intracranial hemorrhage was the same during infusion (0.2%) and higher at 28 days (0.5% vs. 0.2%). ENHANCE patients treated within 0-24 hrs from their first sepsis-induced organ dysfunction had lower observed mortality rate than those treated after 24 hrs (22.9% vs. 27.4%, p = .01).
Conclusions
ENHANCE provides supportive evidence for the favorable benefit/risk ratio observed in PROWESS and suggests that more effective use of drotrecogin alfa (activated) might be obtained by initiating therapy earlier.
Permalink
« Previous entries Next Page » Next Page »