Andexanet alfa after 4-factor PCC administration for intracranial hemorrhage: a case series

Journal of Thrombosis and Thrombolysis - The ongoing controversy regarding optimal reversal agent for factor Xa-inhibitors is mainly due to lack of comparative data of andexanet alfa (AA) to...     

Therapies to reduce stress and anxiety

Creativity in meeting patients' needs is required daily by the staff in acute and critical care environments. For critical care patients, many alternative and complementary therapies including aromatherapy, hydrotherapy, humor, imagery, massage, music, and relaxation can be used successfully as adjunct therapies to help decrease stress.     

Cardiovascular magnetic resonance tagging of the right ventricular free wall for the assessment of long axis myocardial function in congenital heart disease

Background

Right ventricular ejection fraction (RV-EF) has traditionally been used to measure and compare RV function serially over time, but may be a relatively insensitive marker of change in RV myocardial contractile function. We developed a cardiovascular magnetic resonance (CMR) tagging-based technique with a view to rapid and reproducible measurement of RV long axis function and applied it in patients with congenital heart disease.

Methods

We studied 84 patients: 56 with repaired Tetralogy of Fallot (rTOF); 28 with atrial septal defect (ASD): 13 with and 15 without pulmonary hypertension (RV pressure > 40 mmHG by echocardiography). For comparison, 20 healthy controls were studied. CMR acquisitions included an anatomically defined four chamber cine followed by a cine gradient echo-planar sequence in the same plane with a labelling pre-pulse giving a tag line across the basal myocardium. RV tag displacement was measured with automated registration and tracking of the tag line together with standard measurement of RV-EF.

Results

Mean RV displacement was higher in the control (26 ± 3 mm) than in rTOF (16 ± 4 mm) and ASD with pulmonary hypertension (18 ± 3 mm) groups, but lower than in the ASD group without (30 ± 4 mm), P < 0.001. The technique was reproducible with inter-study bias ± 95% limits of agreement of 0.7 ± 2.7 mm. While RV-EF was lower in rTOF than in controls (49 ± 9% versus 57 ± 6%, P < 0.001), it did not differ between either ASD group and controls.

Conclusions

Measurements of RV long axis displacement by CMR tagging showed more differences between the groups studied than did RV-EF, and was reproducible, quick and easy to apply. Further work is needed to assess its potential use for the detection of longitudinal changes in RV myocardial function.     

Toward the prevention of acute lung injury: protocol-guided limitation of large tidal volume ventilation and inappropriate transfusion

OBJECTIVE: We evaluated the effect of two quality improvement interventions (low tidal volume ventilation and restrictive transfusion) on the development of acute lung injury in mechanically ventilated patients. DESIGN: Observational cohort study. SETTING: Three intensive care units in a tertiary academic center. PATIENTS: We included patients who were mechanically ventilated for > or =48 hrs excluding those who refused research authorization or had preexisting acute lung injury or pneumonectomy. INTERVENTIONS: Multifaceted interdisciplinary intervention consisting of Web-based teaching, respiratory therapy protocol, and decision support within computerized order entry. MEASUREMENTS AND MAIN RESULTS: Of 375 patients who met the inclusion and exclusion criteria, 212 were ventilated before and 163 after the interventions. Baseline characteristics were similar between the two groups except for a lower frequency of sepsis (27% vs. 17%, p = .030), trend toward lower median glucose level (140 mg/dL, interquartile range 118-168 vs. 132 mg/dL, interquartile range 113-156, p = .096), and lower frequency of pneumonia (27% vs. 20%, p = .130) during the second period. We observed a large decrease in tidal volume (10.6-7.7 mL/kg predicted body weight, p < .001), in peak airway pressure (31-25 cm H2O, p < .001), and in the percentage of transfused patients (63% to 38%, p < .001) after the intervention. The frequency of acute lung injury decreased from 28% to 10% (p < .001). The duration of mechanical ventilation decreased from a median of 5 (interquartile range 4-9) to 4 (interquartile range 4-8) days (p = .030). When adjusted for baseline characteristics in a multivariate logistic regression analysis, protocol intervention was associated with a reduction in the frequency of new acute lung injury (odds ratio 0.21, 95% confidence interval 0.10-0.40). CONCLUSIONS: Interdisciplinary intervention effectively decreased large tidal volumes and unnecessary transfusion in mechanically ventilated patients and was associated with a decreased frequency of new acute lung injury.     

Mortality rate and length of stay of patients admitted to the intensive care unit in July

OBJECTIVE: At the beginning of each academic year in July, inexperienced residents and fellows begin to care for patients. This inexperience can lead to poor patient outcome, especially in patients admitted to the intensive care unit (ICU). The objective of this study was to determine the impact of July ICU admission on patient outcome. DESIGN: Retrospective, cohort study. SETTING: Academic, tertiary medical center. PATIENTS: Patients admitted to the ICU from October 1994 through September 2002. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographics, Acute Physiology and Chronic Health Evaluation (APACHE) III score and predicted mortality, admission source, admission date, intensity of treatment, ICU length of stay (LOS), and hospital mortality of 29,084 patients were obtained. The actual and predicted weighted ICU LOS and their ratio were calculated. Logistic regression analysis was used to compare the hospital mortality rate of patients admitted to the ICU in July with those admitted during the rest of the year, with adjustment for potentially confounding variables. The patients' mean age was 62.3 +/- 17.6 yrs; 57.3% were male and 95.5% white. Both the customized predicted and observed hospital mortality rates of the entire cohort were 8.2%. The majority (76.7%) of the patients were discharged home, and 15.1% were discharged to other facilities. When adjusted for potentially confounding variables, ICU admission in July was not associated with higher hospital mortality rate compared with any other month. There were no significant differences in the discharge location of patients between July and any one of the other months. There were no statistically significant differences in the weighted ICU LOS ratio between July and any of the other months. CONCLUSIONS: ICU admission in July is not associated with increased hospital mortality rate or ICU length of stay.     

RSV604, a novel inhibitor of respiratory syncytial virus replication

Respiratory syncytial virus (RSV) is the most common cause of lower respiratory tract infections worldwide, yet no effective vaccine or antiviral treatment is available. Here we report the discovery and initial development of RSV604, a novel benzodiazepine with submicromolar anti-RSV activity. It proved to be equipotent against all clinical isolates tested of both the A and B subtypes of the virus. The compound has a low rate of in vitro resistance development. Sequencing revealed that the resistant virus had mutations within the nucleocapsid protein. This is a novel mechanism of action for anti-RSV compounds. In a three-dimensional human airway epithelial cell model, RSV604 was able to pass from the basolateral side of the epithelium effectively to inhibit virus replication after mucosal inoculation. RSV604, which is currently in phase II clinical trials, represents the first in a new class of RSV inhibitors and may have significant potential for the effective treatment of RSV disease.