Dabigatran: will it change clinical practice?

Dabigatran (Pradaxa) is a new oral anticoagulant approved in the United States for the primary prevention of stroke and systemic embolization in patients with nonvalvular atrial fibrillation. It offers clinicians an alternative to warfarin (Coumadin), and it has received considerable interest because of its convenience of use, clinical efficacy, and safety profile. However, it is more expensive, and this may limit its widespread use.     

Renovascular hypertension: can we identify a population at high risk?

Renovascular hypertension is a common cause of secondary hypertension. However, diagnostic tests are limited by lack of sensitivity and specificity, cost, or invasiveness. Selecting patients with hypertension for evaluation of renal artery stenosis can be challenging. This review focuses on the sensitivity and specificity of commonly used screening tests for renal artery stenosis and on the clinical variables that are most likely to distinguish patients with renal artery stenosis from patients with other causes of their hypertension. This approach allows for the rational screening of patients at high and moderate risk for renal artery disease.     

Sedation practice: is it time to wake up and embrace change?

Recommendations for sedation regimes in the intensive care unit (ICU) have evolved over the last decade based on findings that relate the clinical approach to improved patient outcomes. Martin and co-workers conducted two surveys into German sedation practice covering the time period during which these changes occurred and as such provide an insight into how these recommendations are being incorporated into everyday clinical practice.     

Aromatherapy: does it work?

Results from Itai et al.'s (2000) study support a group utilization project to educate nurses regarding aromatherapy, so that nurses can implement it in their practice to reduce their patient's anxiety levels. A major feasibility issue would be the price tag; one must consider both the cost of paying for the training that the nurses would need and the materials needed to implement the practice or aromatherapy. Future research would be very valuable, especially if it replicated this study using a larger, more diverse sample of patients.     

Assessing alcohol use in college: is it time for a new approach to identify risky drinking behavior?

Abstract

Objectives: The purpose of this study is to demonstrate how traditional risky drinking indicators, such as binge drinking, are inefficient when identifying college students who are in need of alcohol-related services. Methods: Using data collected from the 2010 National College Health Assessment II (NCHA-II), the sensitivity, specificity, positive predictive value and negative predictive value of binge drinking was analyzed relative to experiencing negative alcohol-related consequences in the previous 12 months. Results: Despite a considerable mathematical advantage, binge drinking demonstrated a sensitivity of 0.80 and a specificity of 0.69. Additionally, more than 56% of the sample who were identified as binge drinkers did not experience a major negative consequence in the previous 12 months. Conclusions: Risky drinking indicators constructed solely of frequency, quantity and duration items have a limited capacity to discriminate at-risk college drinkers from the general student body. New indicators comprised of novel drinking behaviors are necessary to properly identify students at high risk.     

Chimney grafts: is there a need and will they work?

Endovascular repair has become the primary treatment option for abdominal aortic aneurysms over the past decade. The favorable results as well as technical evolution have led endovascular repair to include fenestrated and branched technology for complex juxtarenal, suprarenal, and thoracoabdominal aneurysms. These grafts are, however, extensively customized and patient tailored at present precluding their use in emergency situations. Certain aspect of aneurysm anatomy also limits them. The chimney technique uses standard, off-the-shelf endovascular devices that extend the use of standard aortic stent grafts for aneurysms without suitable proximal landing zones particularly in acute situations. Early results are promising and warrant a continued development of the technique until such time that dedicated devices are available for the treatment of these complex aneurysms.     

Emerging infection and sepsis biomarkers: will they change current therapies?

Introduction: Sepsis is a heterogeneous syndrome characterized by both immune hyperactivity and relative immune suppression. Biomarkers have the potential to improve recognition and management of sepsis through three main applications: diagnosis, monitoring response to treatment, and stratifying patients based on prognosis or underlying biological response.

Areas covered: This review focuses on specific examples of well-studied, evidence-supported biomarkers, and discusses their role in clinical practice with special attention to antibiotic stewardship and cost-effectiveness. Biomarkers were selected based on availability of robust prospective trials and meta-analyses which supported their role as emerging tools to improve the clinical management of sepsis.

Expert commentary: Great strides have been made in candidate sepsis biomarker discovery and testing, with the biomarkers in this review showing promise. Yet sepsis remains a dynamic illness with a great degree of biological heterogeneity – heterogeneity which may be further resolved by recently discovered gene expression-based endotypes in septic shock.     

Novel serum biomarkers in carotid artery stenosis: useful to identify the vulnerable plaque?

Objectives

Serum biomarkers representing inflammatory activity in vulnerable carotid plaques may be used to identify high-risk patients for cerebral ischemic events. We aimed to analyze the relationship between concentrations of four novel biomarkers and neurological symptoms: Neopterin, PTX3, sCD163, and sTREM-1. In addition, we analyzed the relationship between these markers and the presence of coronary (CAD) and peripheral (PAD) artery disease.

Design and methods

Serum biomarker levels were determined in 100 patients undergoing carotid endarterectomy; 33 for stroke, 32 for transient ischemic attack, and 23 for amaurosis fugax. 12 Patients were asymptomatic. Risk factors for atherosclerotic disease and history of CAD and PAD were also assessed.

Results

Symptomatic patients did not show significantly elevated biomarker levels compared to asymptomatic patients and levels did not differ among symptomatic subgroups. Neopterin levels were elevated in patients with concomitant coronary and peripheral artery disease (CAD (32%) 10.2 ± 6.6 vs no CAD (68%) 7.6 ± 2.9 nmol/L, PAD (20%) 12.3 ± 7.4 vs no PAD (80%) 7.5 ± 3.0 nmol/L, p < 0.05). sTREM-1 was elevated in patients with CAD (50.8 ± 53.2 vs 28.0 ± 31.6 ng/L, p < 0.05). PTX3 and sCD163 were not significantly elevated in CAD nor PAD.

Conclusion

Our findings suggest that serum neopterin and sTREM-1 levels may be related to the presence of atherosclerotic disease, but not to carotid plaque vulnerability.     

How to identify patients with no risk for postextubation stridor?

The aim of this study was first, to evaluate the value of cough following tracheal tube cuff deflation, and second, to reassess the value of the cuff-leak test to predict postextubation stridor (PES). In spontaneously breathing patients, immediately before extubation, the tracheal tube was deflated and the absence of cough was monitored. The tube was then obstructed with a finger, and the absence of leak was monitored. Extubation was then performed. Four PESs were observed after 115 extubations (incidence: 3.5%). The absence of cough was more frequently observed when PES occurred than when it did not (75% v 21%, P =.04). The absence of leak was observed in 100% of PES and in 20% of PES free extubations (P =.01). The absence of both leak and cough was more frequently observed in PES (75% v 7%, P <.0001). In the absence of leak, the likelihood ratio of developing PES was 5.04 and rose to 10.4 when cough was also absent. The likelihood ratio of not developing PES in the absence of leak alone was 0. We conclude that in a population of medical intensive care unit spontaneously breathing patients, just before extubation, the presence of leaking around the endotracheal tube rules out PES, whereas the absence of cough and of leak are good predictors of PES.