17 Aug 08
Posted in Obstructive sleep apnea at 11:20 by Laci
By A T Mulgrew, N Fox, N T Ayas and C F Ryan
Ann Intern Med 2007;146:157-166
Polysomnography (PSG), despite limited availability and high cost, is currently recommended for diagnosis of obstructive sleep apnea and titration of effective continuous positive airway pressure (CPAP).
Objective
To test the utility of a diagnostic algorithm in conjunction with ambulatory CPAP titration in initial management of obstructive sleep apnea.
Design
A randomized, controlled, open-label trial that compared standard PSG with ambulatory CPAP titration in high-risk patients identified by a diagnostic algorithm.
Setting
A tertiary referral sleep disorders program in Vancouver, British Columbia, Canada.
Patients
68 patients with a high pretest probability of moderate to severe obstructive sleep apnea (apnea–hypopnea index [AHI] >15 episodes/h) identified by sequential application of the Epworth Sleepiness Scale (ESS) score, Sleep Apnea Clinical Score, and overnight oximetry.
Intervention
Patients were randomly assigned to PSG or ambulatory titration by using a combination of auto-CPAP and overnight oximetry. They were observed for 3 months.
Measurements
Apnea–hypopnea index on CPAP, ESS score, quality of life, and CPAP adherence.
Results
The PSG and ambulatory groups had similar median BMI (38 kg/m2), age (55 years), ESS score (14 points), and respiratory disturbance index (31 episodes of respiratory disturbance/h). Each episode is determined by a computer algorithm based on analysis of oxygen saturation measured by pulse oximetry. After 3 months, there were no differences in the primary outcome, AHI on CPAP (median, 3.2 vs. 2.5; difference, 0.8/h [95% CI, –0.9 to 2.3]) (P = 0.31), between the PSG and ambulatory groups, or in the secondary outcomes, ESS score, Sleep Apnea Quality of Life Index, and CPAP. Adherence to CPAP therapy was better in the ambulatory group than in the PSG group (median, 5.4 vs. 6.0; difference, –1.12 h/night [CI, –2.0 to 0.2]) (P = 0.021).
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16 Aug 08
Posted in Coronary artery disease, Heart failure/Cardiogenic shock at 20:57 by Laci
By M Hamon, D Agostini, O Le Page, J Riddell, M Hamon
Crit Care Med 2008;36:2023-2033
The objective of this study was to examine the relationship between right ventricular involvement (RVI) in acute myocardial infarction (AMI) and the increase in mortality and morbidity frequently suggested in the last two decades.
Design
The authors conducted a systematic review and meta-analysis.
Setting
This study was conducted at an academic medical center.
Data Source
The authors reviewed PubMed, BioMedCentral, and the Cochrane database and conducted a manual review of article bibliographies.
Study Selection and Data Extraction
Using a prespecified search strategy, 22 relevant studies involving a total of 7,136 patients with AMI at baseline, of whom 1,963 had RVI (27.5%), were included in a meta-analysis using a random effects model. Pooled relative risks of the impact of RVI on patient mortality and morbidity were calculated.
Main Results
An overall pooled relative risk mortality increase of 2.59 (95% confidence interval, 2.02-3.31) was found (Z = 7.57; p < .00001). RVI in AMI was also associated with a statistically significant increase in all secondary end points assessed, including cardiogenic shock, ventricular arrhythmias, advanced atrioventricular block, and mechanical complications.
Conclusions
Our results support the view that early recognition of RVI, namely by means of right electrocardiographic leads in acute myocardial infarction, may have prognostic value. Whether or not this recognition will permit improvement of outcomes through more aggressive percutaneous coronary intervention would need to be tested in future studies.
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11 Aug 08
Posted in Immunoglobulines, Sepsis at 11:30 by Laci
By M Lambert, D Launay, E Hachulla, S Morell-Dubois, V Soland, V Queyrel, F Fourrier, P-Y Hatron
Crit Care Med 2008;36:2184-2187
The objective of this study was to report the dramatic improvement of patients with systemic capillary leak syndrome obtained with high-dose intravenous immunoglobulins.
Design
Systemic capillary leak syndrome is a rare and life-threatening disorder characterized by hypotension that can lead to shock, weight gain, hypoalbuminemia, and elevated hematocrit secondary to unexplained episodic capillary fluid extravasation into the interstitial space. Because its cause is unknown, systemic capillary leak syndrome treatment has remained largely supportive.
Main Results
Intravenous immunoglobulins administration to a patient with refractory systemic capillary leak syndrome yielded dramatic improvement. The patient is still alive 11 yrs after systemic capillary leak syndrome diagnosis and receives intravenous immunoglobulins monthly. Later, based on that result, intravenous immunoglobulins were successfully given to two other patients during the acute phase of systemic capillary leak syndrome. Both are still alive 8 and 1.5 yrs after receiving intravenous immunoglobulins at the onset of each flare.
Conclusions
Intravenous immunoglobulins were effective against systemic capillary leak syndrome symptoms in three patients, but their exact mechanism remains unknown. Their immunomodulatory effect merits further investigation.
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