Descriptive analysis of emergency department oxygen use in acute exacerbation of chronic obstructive pulmonary disease

Background: Inconsistencies in oxygen therapy recommendations in acute exacerbation of chronic obstructive pulmonary disease (COPD) may result in variability in emergency department (ED) oxygen management of patients with COPD. The aim of this study was to describe oxygen management in the first 4 h of ED care for patients with exacerbation of COPD. Methods: A retrospective medical record audit was conducted at four public and one private ED in Melbourne, Australia. Participants were 273 adult ED patients with COPD presenting with a primary complaint of shortness of breath from July 2006 to July 2007. Outcome measures were physiological data, including oxygen saturation (SpO₂), oxygen delivery devices and flow rates on ED arrival, 1 and 4 h. Results: Oxygen was used in 82.0% of patients. Patients who required oxygen had higher incidence of ambulance transport (P < 0.001), triage category 2 (P= 0.006), home oxygen use (P < 0.001), and increased work of breathing on ED arrival (P < 0.001), and higher median respiratory rate (P < 0.001) and heart rate (P= 0.001). SpO₂ > 90% occurred in the majority of patients (87.5%; 96.4%; 95.6%); however, a considerable number of patients with SpO₂ < 90% were not given oxygen (61.8%; 30%; 45.5%). Conclusions: A number of patients with documented hypoxaemia were not given oxygen and there may be variables other than oxygen saturation that may influence oxygen use. Future research should focus on increasing the evidence‐based supporting oxygen use and better understanding of clinicians' oxygen decision‐making in patients with COPD.     

Relationships among initial hospital triage,disease progression and mortality in community‐acquired pneumonia

Background and objective: Appropriate triage of patients with community‐acquired pneumonia (CAP) may improve morbidity, mortality and use of hospital resources. Worse outcomes from delayed intensive care unit (ICU) admission have long been suspected but have not been verified. Methods: In a retrospective study of consecutive patients with CAP admitted from 1996–2006 to the ICUs of a tertiary care hospital, we measured serial severity scores, intensive therapies received, ICU‐free days, and 30‐day mortality. Primary outcome was mortality. We developed a regression model of mortality with ward triage (and subsequent ICU transfer within 72 h) as the predictor, controlled by propensity for ward triage and radiographic progression. Results: Of 1059 hospital‐admitted patients, 269 (25%) were admitted to the ICU during hospitalization. Of those, 167 were directly admitted to the ICU without current requirement for life support, while 61 (23%) were initially admitted to the hospital ward, 50 of those undergoing ICU transfer within 72 h. Ward triage was associated with increased mortality (OR 2.6, P = 0.056) after propensity adjustment. The effect was less (OR 2.2, P = 0.12) after controlling for radiographic progression. The effect probably increased (OR 4.1, P = 0.07) among patients with ≥ 3 severity predictors at admission. Conclusions: Initial ward triage among patients transferred to the ICU is associated with twofold higher 30‐day mortality. This effect is most apparent among patients with ≥ 3 severity predictors at admission and is attenuated by controlling for radiographic progression. Intensive monitoring of ward‐admitted patients with CAP seems warranted. Further research is needed to optimize triage in CAP.     

Renal failure in patients with hepatocellular carcinoma and ascites undergoing transarterial chemoembolization

Background: Ascites is often present in patients with hepatocellular carcinoma (HCC) with cirrhosis. Advanced cirrhosis may predispose to renal dysfunction. Acute renal failure (ARF) may occur after transarterial chemoembolization (TACE) for HCC because of radiocontrast agents. This study aimed to investigate the incidence and risk factors of ARF and prognostic predictors in HCC patients with ascites undergoing TACE. Methods: A total of 591 HCC patients receiving TACE were enrolled. Results: In a mean follow‐up duration of 19±17 months, 239 (40.4%) patients undergoing TACE died. Ascites, which was present in 91 (15.4%) patients at entry, independently predicted a poor prognosis in the Cox proportional hazard model [risk ratio (RR): 1.71, P=0.002]. Of these, 11 (12.6%) of 87 patients with complete follow‐up developed ARF after TACE. Serum albumin level <3.3 g/dl (odds ratio: 7.3, P=0.009) was the only independent risk factor associated with ARF in the logistic regression analysis. ARF (RR: 2.17, P=0.036), α‐fetoprotein >400 ng/ml (RR: 1.84, P=0.04), multiple tumours (RR: 2.11, P=0.013), tumour size ≥5 cm (RR: 2.32, P=0.006) and serum sodium level <139 mmol/L (RR: 2.4, P=0.005) were independent poor prognostic predictors for HCC patients with ascites receiving TACE. Conclusions: Pre‐existing ascites is associated with increased mortality in HCC patients receiving TACE. In HCC patients with ascites, hypoalbuminaemia is associated with the occurrence of post‐TACE ARF. Post‐TACE ARF is a poor prognostic predictor in this subset of HCC patients.     

Sole and combined vitamin C supplementation can prevent postoperative atrial fibrillation after cardiac surgery: A systematic review and meta‐analysis of randomized controlled trials

We undertook a systematic review and meta‐analysis to evaluate the effect of vitamin C supplementation (vitamin C solely or as adjunct to other therapy) on prevention of postoperative atrial fibrillation (POAF) in patients after cardiac surgery. PubMed, Embase, Web of Science, and Cochrane Library were systematically searched to identify randomized controlled trials assessing the effect of vitamin C supplementation in adult patients undergoing cardiac surgery, and the meta‐analysis was performed with a random‐effects model. Thirteen trials involving 1956 patients were included. Pooling estimate showed a significantly reduced incidence of POAF (relative risk [RR]: 0.68, 95% confidence interval [CI]: 0.54 to 0.87, P = 0.002) both in vitamin C alone (RR: 0.75, 95% CI: 0.63 to 0.90, P = 0.002) and as an adjunct to other therapy (RR: 0.32, 95% CI: 0.20 to 0.53, P < 0.001). The results remain stable and robust in subgroup and sensitivity analyses, and trial sequential analysis also confirmed that the evidence was sufficient and conclusive. Additionally, vitamin C could significantly decrease intensive care unit length of stay (weighted mean difference: ?0.24 days, 95% CI: –0.45 to ?0.03, P = 0.023), hospital length of stay (weighted mean difference: ?0.95 days, 95% CI: –1.64 to ?0.26, P = 0.007), and risk of adverse events (RR: 0.45, 95% CI: 0.21 to 0.96, P = 0.039). Use of vitamin C alone and as adjunct to other therapy can prevent POAF in patients undergoing cardiac surgery and should be recommended for patients receiving cardiac surgery for prevention of POAF.     

A Comprehensive Hip Fracture Program Reduces Complication Rates and Mortality

OBJECTIVES: To evaluate the rate of postoperative complications, length of stay, and 1‐year mortality before and after introduction of a comprehensive multidisciplinary fast‐track treatment and care program for hip fracture patients (the optimized program). DESIGN: Retrospective chart review with historical control. SETTING: Orthopedic ward (110 beds) at a university hospital (700 beds). PARTICIPANTS: Five hundred thirty‐five consecutive patients aged 40 and older (94%≥60) hospitalized for hip fracture between January 1, 2003, and March 31, 2004. Three hundred and thirty‐six patients (70.3%) were community dwellers before the fracture and 159 (29.7%) were admitted from nursing homes. INTERVENTION: The fast‐track treatment and care program included a switch from systemic opiates to a local femoral nerve catheter block; an earlier assessment by the anesthesiologist; and a more‐systematic approach to nutrition, fluid and oxygen therapy, and urinary retention. RESULTS: In the intervention group, the rate of any in‐hospital postoperative complication was reduced from 33% to 20% (odds ratio=0.61, 95% confidence interval=0.4–0.9; P=.002). Rates of confusion (P=.02), pneumonia (P=.03), and urinary tract infection (P<.001) were lower in the intervention group than in the control group, and length of stay was 15.8 days in the control group, versus 9.7 days in the intervention group (P<.001). For community dwellers, 12‐month mortality was 23% in the control group versus 12% in the intervention group (P=.02). Overall 12‐month mortality was 29% in the control group and 23% in the intervention group (P=.2). CONCLUSION: The optimized hip fracture program reduced the rate of in‐hospital postoperative complications and mortality. Randomized clinical trials are needed to confirm these results and elucidate the elements of the program that have the greatest effect on clinical outcomes and mortality.     

Oxygen Therapy in Patients with Acute Myocardial Infarction: A Systemic Review and Meta-Analysis

Objective

Oxygen therapy is frequently used for patients with acute myocardial infarction. The aim of this study is to perform a systematic review and meta-analysis to compare the outcomes of oxygen therapy versus no oxygen therapy in post–acute myocardial infarction settings.

Sequence of administration and methylation of SOCS3 may govern response to gemtuzumab ozogamicin in combination with conventional chemotherapy in patients with refractory or relapsed acute myelogenous leukemia (AML)

In older patients suffering from acute myelogenous leukemia (AML), aggressive chemotherapy is accompanied with high treatment‐related morbidity and mortality. Gemtuzumab ozogamicin (GO), a humanized monoclonal anti‐CD33 antibody, represents a well tolerated treatment option, but optimal treatment schedules are still unknown. Additionally, Suppressor of cytokine signaling 3 (SOCS3) inhibits the CD33‐induced block on cytokine‐induced proliferation. Consequently, a variable response of AML cells to anti‐CD33‐targeted therapy may be caused by modulation of SOCS3 expression. Twenty‐four patients with refractory or relapsed CD33‐positive AML received GO as a single agent before or after conventional chemotherapy. The methylation status of the SOCS3 CpG island was assessed by methylation‐specific polymerase chain reaction. Response (RR) and overall survival (OS) were significantly higher in 16 patients receiving chemotherapy before GO (RR 81%, OS 14.8 months) compared to three patients who received GO single agent therapy (RR 33%, OS 7.2 months) or 16 with GO before chemotherapy (RR 0% OS 2.2 months, P = 0.01 for RR and P < 0.001 for OS). Methylation of the SOCS3 CpG island was found in 8/24 patients. There was a trend towards a higher RR and longer OS in patients with SOCS3 hypermethylation (RR 86%, OS 25.1 months) compared to unmethylated SOCS3 (RR 56%, OS 10.3 months, P = 0.09). Administration of GO a few days after chemotherapy seems to provide better response and survival compared to administration of GO directly before chemotherapy. The potential role of SOCS3 hypermethylation as a biomarker should be further investigated in patients undergoing GO containing therapies. Am. J. Hematol., 2010. © 2010 Wiley‐Liss, Inc.     

Green banana‐supplemented diet in the home management of acute and prolonged diarrhoea in children: a community‐based trial in rural Bangladesh

Objective To determine the effectiveness of green banana in the home management of acute (<7 days) or prolonged (≥7 days) diarrhoea at the community level. Methods A cluster randomized field trial was conducted among 2968 Bangladeshi rural children 6–36 months old. Wards (villages) were randomly assigned to either a standard care group or a standard care plus green banana group where mothers were instructed to add cooked green banana to the diets of diarrhoeal children. Through a village‐based surveillance system, diarrhoeal morbidity data (severity, duration, compliance) were collected for 14 days. Treatment effects were determined by analysing cumulative probability of cure by testing Cox proportional hazards models and relative risk (RR). Results The cumulative probability of cure was significantly (P < 0.001) different in children receiving GB for both acute [hazard ratio (HR) = 0.63 (95% CI: 0.56–0.67)] and prolonged diarrhoea [HR = 0.38 (95% CI: 0.26–0.59)]. The recovery rates of children with acute diarrhoea receiving GB (vs. control) were significantly more by day 3: 79.9%vs. 53.3% [(RR) = 0.47, 95% CI: 0.41–0.55], (P < 0.001) and day 7: 96.6%vs. 89.1% (RR = 0.32; 0.22–0.46), (P < 0.001). Children with prolonged diarrhoea receiving green banana had significantly higher recovery rates by day 10: 79.8%vs. 51.9% (RR = 0.42; 0.23–0.73), (P < 0.001) and day 14: 93.6%vs. 67.2% (RR = 0.22; 0.08–0.54), (P < 0.001). Conclusion A green banana‐supplemented diet hastened recovery of acute and prolonged childhood diarrhoea managed at home in rural Bangladesh.     

Statins for the prevention and treatment of acute lung injury and acute respiratory distress syndrome: A systematic review and meta‐analysis

The purpose of this meta‐analysis was to assess whether statins could reduce the morbidity of acute lung injury and acute respiratory distress syndrome (ALI/ARDS) in high‐risk patients and improve the clinical outcomes of patients with ALI/ARDS. Studies were obtained from PubMed, Medline, Embase and Cochrane Central Register of Controlled Trials. Randomized controlled trials (RCTs) and cohort studies, which reported morbidity, mortality, ventilator‐free days, length of stay in intensive care unit and hospital or oxygenation index, were included in our meta‐analysis. Risk ratio (RR) and weighted mean difference (WMD) were calculated using fixed or random effect model. A total of 13 studies covering 12 145 patients were included. Both the only RCT (P = 0.10) and cohort studies (RR, 1.02; 95% CI, 0.67 to 1.55; P = 0.94) showed that statin therapy did not lower the morbidity of ALI/ARDS in high‐risk patients. The mortality of ALI/ARDS patients was less likely to be improved by statins (RCT, RR, 1.00; 95% CI, 0.84 to 1.20; P = 0.97; cohort studies, RR, 1.04; 95% CI, 0.85 to 1.27; P = 0.72). Moreover, no significant difference was observed in ventilator‐free days, length of stay in intensive care unit as well as hospital and oxygenation index. This meta‐analysis suggests that statins neither provide benefit for lowering the morbidity of ALI/ARDS in high‐risk patients nor improve the clinical outcomes of ALI/ARDS patients. Hence, it may not be appropriate to advocate statin use for the prevention and treatment of ALI/ARDS.     

Free and fixed‐ratio combinations of basal insulin and GLP‐1 receptor agonists versus basal insulin intensification in type 2 diabetes: A systematic review and meta‐analysis of randomized controlled trials

A meta‐analysis is presented of randomized controlled trials (RCTs) comparing free or fixed combinations of a glucagon‐like peptide‐1 receptor agonist plus basal insulin versus insulin intensification on metabolic control in patients with type 2 diabetes. Electronic databases were searched for RCTs assessing changes in HbA1c, proportion of patients at HbA1c target of <7% (53 mmol/mol), hypoglycaemia and body weight. A random‐effect model was used to calculate the weighted mean difference (WMD) or relative risk (RR) with 95% CI. Eleven RCTs were identified, lasting 24–30 weeks and involving 6176 patients. In the overall analysis, the combination therapy led to a mean HbA1c decrease significantly greater than insulin up‐titration (WMD ?0.53%, 95% CI, ?0.66, ?0.40%, P < 0.001), more patients at HbA1c target (RR 1.69, 95% CI, 1.42, 2.00, P < 0.001), similar hypoglycaemic events (RR 0.97, 95% CI, 0.84, 1.12, P = 0.114), and reduction in body weight (WMD ?1.9, 95% CI ?2.3, ?1.4, P < 0.001), with heterogeneity (I² > 71%, P < 0.001). Results did not differ in either the free or fixed combination subgroups. Combination strategies, either free or fixed, represent a good option for intensifying basal insulin therapy in patients with type 2 diabetes who need amelioration of glycaemic control.     

The Use of Pulse Oximetry to Determine Hypoxemia in Acute Exacerbations of COPD

Background: There is little evidence that the guideline-recommended oxygen saturation of 92% is the best cut-off point for detecting hypoxemia in COPD exacerbations. Objective: To detect and validate pulse oximetry oxygen saturation cut-off values likely to detect hypoxemia in patients with aeCOPD, to explore the correlation between oxygen saturation measured by pulse oximetry and hypoxemia or hypercapnic respiratory failure. Methodology: Cross-sectional study nested in the IRYSS-COPD study with 2,181 episodes of aeCOPD recruited between 2008 and 2010 in 16 hospitals belonging to the Spanish Public Health System. Data collected include determination of oxygen saturation by pulse oximetry upon arrival in the emergency department (ED), first arterial blood gasometry values, sociodemographic information, background medical history and clinical variables upon ED arrival. Logistic regression models were performed using as the dependent variables hypoxemia (PaO2 < 60 mmHg) and hypercapnic respiratory failure (PaO2 < 60 mmHg and PaCO2 > 45). Optimal cut-off points were calculated. Results: The correlation coefficient between oxygen saturation and pO2 measured by arterial blood gasometry was 0.89. The area under the curve (AUC) for the hypoxemia model was 0.97 (0.96–0.98) and the optimal cut-off point for hypoxemia was an oxygen saturation of 90%. The AUC for hypercapnic respiratory failure was 0.90 (0.87–0.92) and the optimal cut-off point was an oxygen saturation of 88%. Conclusions: Our results support current recommendations for ordering blood gasometry based on pulse oximetry oxygen saturation cut-offs for hypoxemia. We also provide easy to use formulae to calculate pO2 from oxygen saturation measured by pulse oximetry.     

A comparison of pulse oximetry and respiratory rate in patient screening

Objective: To examine how well respiratory rate correlates with arterial oxygen saturation status as measured by pulse oximetry, and determine whether respiratory rate measurements detect oxygen desaturation reliably.Methods: Respiratory rate (RR) and oxygen saturation (SaO₂) were measured prospectively on 12 096 consecutive adult emergency department triage patients at a university medical center. Respiratory rate was measured by counting ausculated breath sounds for 1 min. Pulse oximetry was used to measure SaO₂. Measurements were analysed by age (with one group for 18–19 year olds, groups for every 10 yr from age 20 to age 60, and groups for every 5 yr for subsequent ages). Pearson correlation coefficients were calculated for each age group as well as the weighted average coefficient. Cases having oxygen saturation below 90% were examined to determine how frequently they exhibited increased RR (increased RRs were defined as any rate in the upper five percentile by age.Results: Correlation coefficients ranged from 0·379 to −0·465 with a weighted mean of −0·160. Coefficients for ages 18 through 70 years (representing 10 740 patients) all had magnitude <0·252. Overall, only 33% of subjects with oxygen saturation below 90% exhibited increased RR.Conclusions: Respiratory rate measurements correlate poorly with oxygen saturation measurements and do not screen reliably for desaturation. Patients with low SaO₂ do not usually exhibit increased RR. Similarly, increased RR is unlikely to reflect desaturation.     

Selective use of embolic protection devices during saphenous vein grafts interventions: A single‐center experience

Objectives : To report on outcomes with selective use of embolic protection devices (EPD) during percutaneous coronary intervention (PCI) to saphenous vein grafts (SVG). Background : PCI to SVG is associated with increased risk and the use of EPD is recommended in this setting. Methods : Angiographic and clinical outcomes were prospectively obtained from 534 consecutive patients who underwent PCI to SVG with or without EPD at a tertiary cardiac centre. Long‐term outcomes were obtained by linkage to a provincial registry. Results : EPD, deployed in 198 of 373 SVGs (53%) suitable for deployment of a distal EPD, were used more often in ectatic (33% vs. 19%, P = 0.003), ulcerated (17% vs. 9%, P = 0.03), thrombotic (26% vs. 10%, P < 0.0001) vein grafts, with longer degenerated segments (P = 0.002), and in lesions involving the body of the graft (85% vs. 66%, P < 0.0001), and less with lesions involving the graft ostium (29% vs. 44%, P = 0.003). Patients suitable for but not receiving EPD tended to be more likely to have a periprocedural myocardial infarction. During 3 years of follow‐up, 49% of the patients had a cardiovascular event. Cumulative mortality was 8.4%, 18.8% and 14.7% in patients unsuitable for distal EPD, suitable but without EPD, and with EPD (p = 0.11). Nonuse of EPD was an independent predictor of MACE at 3 years. (P = 0.02). Conclusions : Selective use of EPD is associated with low in‐hospital cardiovascular event rates. Long‐term outcomes are manifested by a high rate of events, especially in patients with SVG's suitable for but not receiving EPD. This suggests that routine use of distal EPD may be warranted in unselected patients with suitable SVG anatomy. © 2010 Wiley‐Liss, Inc.     

Management Strategies and Outcomes of ST‐Segment Elevation Myocardial Infarction Patients Transferred After Receiving Fibrinolytic Therapy in the United States

Fibrinolytic therapy is still used in patients with ST‐segment elevation myocardial infarction (STEMI) when the primary percutaneous coronary intervention cannot be provided in a timely fashion. Management strategies and outcomes in transferred fibrinolytic‐treated STEMI patients have not been well assessed in real‐world settings. Using the Nationwide Inpatient Sample from 2008 to 2012, we identified 18 814 patients with STEMI who received fibrinolytic therapy and were transferred to a different facility within 24 hours. The primary outcome was in‐hospital mortality. Secondary outcomes included gastrointestinal bleeding, bleeding requiring transfusion, intracranial hemorrhage (ICH), length of stay, and cost. The patients were divided into 3 groups: those who received medical therapy alone (n = 853; 4.5%), those who underwent coronary artery angiography without revascularization (n = 2573; 13.7%), and those who underwent coronary artery angiography with revascularization (n = 15 388; 81.8%). Rates of in‐hospital mortality among the groups were 20% vs 6.6% vs 2.1%, respectively (P < 0.001); ICH was 8.5% vs 1.1% vs 0.6%, respectively (P < 0.001); and gastrointestinal bleeding was 1.1% vs 0.4% vs 0.4%, respectively (P = 0.011). Multivariate analysis identified increasing age, higher Charlson Comorbidity Index score, cardiogenic shock, cardiac arrest, and ICH as the independent predictors of not performing coronary artery angiography and/or revascularization in patients with STEMI initially treated with fibrinolytic therapy. The majority of STEMI patients transferred after receiving fibrinolytic therapy undergo coronary angiography. However, notable numbers of patients do not receive revascularization, especially patients with cardiogenic shock and following a cardiac arrest.     

Relation between renal function,presentation, use of therapies and in‐hospital complications in acute coronary syndrome: data from the SWEDEHEART register

Abstract. Szummer K, Lundman P, Jacobson SH, Schön S, Lindbäck J, Stenestrand U, Wallentin L, Jernberg T, for SWEDEHEART. (Karolinska Institute, Karolinska University Hospital, Stockholm; Karolinska Institute, Danderyd Hospital, Danderyd; Ryhov County Hospital, Jönköping; University Hospital, Uppsala and University Hospital, Linköping; Sweden) Relation between renal function, presentation, use of therapies and in‐hospital complications in acute coronary syndrome: data from the SWEDEHEART register. J Intern Med 2010; 268 :40–49. Objective. To examine clinical characteristics, presenting symptoms, use of therapy and in‐hospital complications in relation to renal function in patients with myocardial infarction (MI). Design. Observational study. Setting. Nationwide coronary care unit registry between 2003–2006 in Sweden. Subjects. Consecutive MI patients with available creatinine (n = 57 477). Results. Glomerular filtration rate was estimated with the Modification of Diet in Renal Disease Study formula. With declining renal function patients were older, had more co‐morbidities and more often used cardio‐protective medication on admission. Compared to patients with normal renal function, fewer with renal failure presented with chest pain (90% vs. 67%, P < 0.001), Killip I (89% vs. 58%, P < 0.001) and ST‐elevation myocardial infarction (STEMI) (41% vs. 22%, P < 0.001). In a logistic regression model lower renal function was independently associated with a less frequent use of anticoagulant and revascularization in non‐ST‐elevation MI. The likelihood of receiving reperfusion therapy for STEMI was similar in patients with normal‐to‐moderate renal dysfunction, but decreased in severe renal dysfunction or renal failure. Reperfusion therapy shifted from primary percutaneous coronary intervention in 71% of patients with normal renal function to fibrinolysis in 58% of those with renal failure. Renal function was associated with a higher rate of complications and an exponential increase in in‐hospital mortality from 2.5% to 24.2% across the renal function groups. Conclusion. Renal insufficiency influences the presentation and reduces the likelihood of receiving treatment according to current guidelines. Short‐term prognosis remains poor.     

Impact of a high‐dose nitrate strategy on cardiac stress in acute heart failure: a pilot study

Abstract. Breidthardt T, Noveanu M, Potocki M, Reichlin T, Egli P, Hartwiger S, Socrates T, Gayat E, Christ M, Mebazaa A, Mueller C (University Hospital, Basel, Switzerland, University Paris, Paris, France, and Klinikum Nürnberg, Nürnberg, Germany). Impact of a high‐dose nitrate strategy on cardiac stress in acute heart failure: a pilot study. J Intern Med 2010; 267 : 322–330. Background. Intravenous nitrate therapy has been shown to improve short‐term outcome of acute heart failure patients treated in the intensive care unit. The potential of a noninvasive high‐dose nitrate strategy in the Emergency Department and the general ward remains unknown. Methods. A total of 128 consecutive acute heart failure patients were either treated with standard therapy or high‐dose sublingual and transdermal nitrates on top of standard of care treatment. Cardiac recovery, quantified by B‐type natriuretic peptide (BNP) levels during the first 48 h, was the primary endpoint. Secondary endpoints ascertained the safety of the nitrate therapy. Results. The high nitrate group received higher doses of nitrates during the first 48 h compared to the standard therapy group [82.4 mg (46.2–120.6) vs. 20 mg (10–30) respectively, P < 0.001]. The amount of diuretics given in both groups was similar. BNP levels decreased in all patients (P < 0.0001). However, the BNP decrease was larger in the high‐dose nitrate group (P < 0.0001). The larger decrease in BNP in the high‐dose nitrate group was already apparent 12 h after the initiation of treatment. After 48 h BNP values decreased by an average of 29 ± 4.9% in the high‐dose nitrate strategy group compared to 15 ± 5.4% during standard therapy. There was a strong trend towards fewer ICU admissions in the high‐dose nitrate group [high‐dose nitrates: 2 cases (4%) vs. standard therapy: 9 cases (13%); P = 0.06]. During the study period, no intergroup changes were observed in blood pressure, RIFLE classes of acute kidney injury or troponin T. In‐hospital and 90‐day outcome was similar amongst the two groups. Conclusions. A noninvasive high‐dose nitrate strategy on top of standard therapy is safe and notably accelerates cardiac recovery in patients observed on the general ward.     

Effects of Atrioventricular Nodal Ablation on Permanent Atrial Fibrillation Patients With Cardiac Resynchronization Therapy: A Systematic Review and Meta‐analysis

Cardiac resynchronization therapy (CRT) is a well‐established therapy for patients with heart failure (HF) and wide QRS configuration, especially for those in sinus rhythm. However, for those with permanent AF, atrioventricular nodal (AVN) ablation use remains under debate. Our objective was to evaluate clinical outcomes and mortality of AVN ablation in HF patients with permanent AF receiving CRT. Electronic publication database and reference lists through October 1, 2013 were searched. Observational cohort studies comparing CRT patients with AF who received either AVN ablation or medical therapy were selected. Outcomes included mortality, CRT nonresponse, changes in left ventricular remodeling, and functional outcomes, such as New York Heart Association (NYHA) functional class, quality of life, and 6‐minute hall walk distance. Of 1641 reports identified, 13 studies with 1256 patients were included. Among patients with permanent AF and insufficient biventricular pacing (<90%), those who had undergone AVN ablation compared to those who did not had numerically lower all‐cause mortality (risk ratio [RR]: 0.63, 95% confidence interval [CI]: 0.42 to 0.96, P = 0.03) and significantly lower nonresponse to CRT (RR: 0.41, 95% CI: 0.31 to 0.54, P < 0.00001). Furthermore, AVN ablation was not associated with additional improvements on left ventricular ejection fraction, NYHA functional class, 6‐minute hall walking distance, and quality of life. In patients with permanent AF undergoing CRT, AVN ablation tended to reduce mortality potentially and improved clinical response when it was applied to patients with inadequate biventricular pacing (<90%). Randomized controlled trials are needed to further address the efficacy of AVN ablation among this population.     

Systemic combined melatonin–mitochondria treatment improves acute respiratory distress syndrome in the rat

Despite high in‐hospital mortality associated with acute respiratory distress syndrome (ARDS), there is no effective therapeutic strategy. We tested the hypothesis that combined melatonin–mitochondria treatment ameliorates 100% oxygen‐induced ARDS in rats. Adult male Sprague‐Dawley rats (n = 40) were equally categorized into normal controls, ARDS, ARDS‐melatonin, ARDS with intravenous liver‐derived mitochondria (1500 μg per rat 6 hr after ARDS induction), and ARDS receiving combined melatonin–mitochondria. The results showed that 22 hr after ARDS induction, oxygen saturation (saO₂) was lowest in the ARDS group and highest in normal controls, significantly lower in ARDS‐melatonin and ARDS‐mitochondria than in combined melatonin–mitochondria group, and significantly lower in ARDS‐mitochondria than in ARDS‐melatonin group. Conversely, right ventricular systolic blood pressure and lung weight showed an opposite pattern compared with saO₂ among all groups (all P < 0.001). Histological integrity of alveolar sacs showed a pattern identical to saO₂, whereas lung crowding score exhibited an opposite pattern (all P < 0.001). Albumin level and inflammatory cells (MPO+, CD40+, CD11b/c+) from bronchoalveolar lavage fluid showed a pattern opposite to saO₂ (all P < 0.001). Protein expression of indices of inflammation (MMP‐9, TNF‐α, NF‐κB), oxidative stress (oxidized protein, NO‐1, NOX‐2, NOX‐4), apoptosis (mitochondrial Bax, cleaved caspase‐3, and PARP), fibrosis (Smad3, TGF‐β), mitochondrial damage (cytochrome C), and DNA damage (γ‐H2AX+) exhibited an opposite pattern compared to saO₂ in all groups, whereas protein (HO‐1, NQO‐1, GR, GPx) and cellular (HO‐1+) expressions of antioxidants exhibited a progressively increased pattern from normal controls to ARDS combined melatonin–mitochondria group (all P < 0.001). In conclusion, combined melatonin–mitochondrial was superior to either treatment alone in attenuating ARDS in this rat model.     

Is obesity an indicator of complications and mortality in acute pancreatitis? An updated meta‐analysis

OBJECTIVE: To provide a meta‐analyisis on whether obesity could be a prognostic indicator on the severity, development of complications and mortality of acute pancreatitis (AP). METHODS: Eligible articles were retrieved using electronic databases. Clinical studies evaluating the association between obesity and disease course of patients with AP were included. Weighted mean difference (WMD) and 95% confidence interval (CI) were estimated and pooled using RevMan 4.2.8. RESULTS: In all, 12 clinical studies with a total of 1483 patients were included in the analysis. Obese patients had a significantly increased risk of severe acute pancreatitis (SAP; RR = 2.20, 95% CI 1.82–2.66, P < 0.05), local complication (RR = 2.68, 95% CI 2.09–3.43, P < 0.05), systemic complication (RR = 2.14, 95% CI 1.42–3.21, P < 0.05) and in‐hospital mortality (RR = 2.59, 95% CI 1.66–4.03, P < 0.05) compared with non‐obese patients. CONCLUSIONS: Obesity is a definite risk factor of morbidity and in‐hospital mortality for AP and may serve as a prognostic indicator.