Right ventricular performance in septic shock: a combined radionuclide and hemodynamic study.

Twenty-five patients with septic shock underwent simultaneous radionuclide ventriculography and right heart catheterization to clarify the role of the right ventricle in this syndrome. A depressed right ventricular ejection fraction (less than 38%) was present in 13 patients and was found in patients with elevated cardiac output (4 of 6 patients) and with normal or low cardiac output (9 of 19 patients). Right ventricular dysfunction was seen with or without acute respiratory failure. In eight patients, a depressed right ventricular ejection fraction was seen in combination with an abnormal left ventricular ejection fraction (less than 48%), but in five patients, right ventricular ejection fraction impairment occurred with normal left ventricular ejection fraction. There was no significant correlation between abnormal right ventricular afterload and depressed right ventricular ejection fraction. No clinical or hemodynamic finding could be used to identify patients with diminished right ventricular ejection fraction. On follow-up study in 17 surviving patients, right ventricular ejection fraction improved in 6 and was unchanged in 11. Improvement in right ventricular ejection fraction occurred more frequently in patients without pulmonary hypertension or respiratory distress. The results suggest that right ventricular dysfunction in septic shock may be more common than previously suspected. It may be caused by abnormalities in right ventricular afterload in some patients and depressed myocardial contractility in others. The findings are of therapeutic importance since interventions that diminish right ventricular afterload and increase right ventricular contractility would be appropriate in patients with septic shock and right ventricular dysfunction.

Clinical applications of slow channel blocking compounds.

The slow-channel blockers constitute a structurally diverse group of drugs with varying mechanisms of action, propensities for site of greatest cardiovascular activity, and clinical efficacy. They share however the property of blocking the slow inward channel in heart muscle and of inhibiting calcium fluxes in smooth muscle. Their in vivo and in vitro actions must be distinguished. The overall actions represent a balance of direct and autonomically-mediated reflex actions interacting with the compounds' varying degrees of intrinsic non-competitive sympathetic antagonism. A knowledge of the pharmacodynamic differences between these drugs allows the physician to select the most appropriate agent for a given clinical situation. The central role of calcium in the cellular processes in the heart and the vascular system forms the basis for the utility of this class of drugs in a wide variety of cardiovascular disorders. Current intensive experimental and clinical investigations are likely to further define the roles of nifedipine, verapamil and diltiazem and their congeners in cardiovascular therapeutics. The prospect of development of newer compounds with greater selectivity of action is real. As pointed out by Braunwald (1982 a,b), with further clarification of the mechanisms of actions of these compounds and elucidation of the role of calcium fluxes throughout the body, more specific and potent agents may be developed. The apparent efficacy of the nifedipine congener nimodipine, in the treatment of cerebral vasospasm associated with subarachnoid hemorrhage (Allen et al., 1983) may simply be the first of a large number of 'specific' or targeted slow channel blockers. The development of such compounds may offer further therapeutic possibilities in the control of a variety of cardiocirculatory diseases.

Low pleural fluid amylase associated with spontaneous rupture of the esophagus.

All previously reported determinations of pleural fluid amylase in Boerhaave's syndrome have demonstrated elevated values. We treated a patient with Sjögen's syndrome who had a low pleural fluid amylase level and the concomitant unusual finding of leakage of esophageal contents into the right pleural space.

Get with the guidelines for cardiovascular secondary prevention: pilot results.

BACKGROUND: The use of Web-based technology and a collaborative model to improve hospital adherence to secondary prevention guidelines has not been previously evaluated. METHODS: Twenty-four hospitals in Massachusetts participated in a collaborative that met quarterly, with didactic and best-practice presentations and interactive multidisciplinary team workshops. A customized tool kit and interactive, Web-based management tool were used for data collection and on-line feedback. Data from 1738 patients admitted with coronary artery disease were collected by hospital staff from July 1, 2000, to June 30, 2001. Outcome measures included differences between baseline and 10- to 12-month follow-up measurements of use of aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, cholesterol measurement and treatment, smoking cessation counseling, blood pressure control, and cardiac rehabilitation referral. RESULTS: Clinically and statistically significant increases from baseline to 10- to 12-month follow-up were demonstrated in smoking cessation counseling (48% [95% confidence interval [CI], 36.6%-58.4%] to 87% [95% CI, 73.1%-100.7%]), lipid treatment (54% [95% CI, 46.6%-70.2%] to 79% [95% CI, 70.2%-88.3%]), lipid measurement (59% [95% CI, 51.5%-66.0%] to 81% [95% CI, 72.0%-89.5%]), and cardiac rehabilitation referral (34% [95% CI, 25.9%-39.7%] to 73% [95% CI, 63.2%-82.9%]). An improving trend was seen in blood pressure control (60% [95% CI, 55.3%-65.6%] to 68% [95% CI, 60.2%-76.1%]). High baseline use was maintained for use of aspirin, beta-blockers, and angiotensin-converting enzyme inhibitors. CONCLUSION: Implementation of a collaborative quality improvement initiative, interactive training of hospital teams with physician champions, and the use of an interactive Web-based Patient Management Tool enhanced adherence to prevention guidelines in hospitalized patients with coronary artery disease.

Multifocal central nervous system lesions in three patients with trichinosis.

Three patients with trichinosis developed central nervous system complications. Cerebral computed tomography showed multifocal hypodense lesions in two patients. The lesions were associated with contrast enhancement and cortical gyral enhancement in the first case, suggesting hypoxia and infarction. In the second patient, magnetic resonance imaging showed multiple high-signal-intensity lesions. Early cerebral computed tomography was normal in the third patient. All patients recovered after treatment with antiparasitic drugs and corticosteroids. We suggest that neurologic complications of trichinosis should be treated by corticosteroids and flubendazole.

Hip replacement and hip hemiarthroplasty surgery: potential opportunities to shorten lengths of hospital stay.

The potential safety and effectiveness of a practice guideline recommending a 5-day postoperative stay in the acute care hospital for hip surgery patients without clinical findings predictive of a complicated hospital course was studied retrospectively in 230 patients hospitalized for total hip replacement, total hip replacement with osteotomy, or hip hemiarthroplasty. Seventy percent of total hip replacement and hip hemiarthroplasty patients were classified as being at "low risk" for complications by the guideline (161 patients, or 73% of patients who remained hospitalized). Use of the guideline could have reduced the hospital length of stay from 8.4 days (standard deviation 3.3) to 5.9 days for these selected low-risk patients. Moreover, physicians' implicit review determined that 0% of patients (95% confidence interval, 0% to 2.3%) had a complication that would have benefited from continued stay in an acute care hospital after the fifth postoperative day. Our practice guideline may have the potential to safely reduce acute care hospital length of stay for patients recovering after total hip replacement and hip hemiarthroplasty. The guideline will require further study in a prospective clinical trial before it can be recommended for widespread use.

Upper gastrointestinal hemorrhage clinical--guideline determining the optimal hospital length of stay.

PURPOSE: Physicians lack objective outcome data to define the medically appropriate length of stay (LOS) for patients hospitalized with acute upper gastrointestinal hemorrhage (UGIH), resulting in wide variations in resource utilization and quality of care. A clinical practice guideline with the ability to assign relative risk for adverse events is proposed. METHODS: A comprehensive scoring system was derived from the literature by using four variables; hemodynamics, time from bleeding, comorbidity, and esophagoduodenoscopy findings. The discriminatory ability, potential safety, and impact on resource utilization of the clinical practice guideline was measured in a retrospective, observational study. RESULTS: Seventy percent of UGIH patients (349 of 500) achieved low-risk status according to the guideline, and, were therefore potentially suitable for early discharge from the hospital. If low-risk patients were discharged based upon the guideline, mean (+/- SD) hospital LOS would have been decreased from 4.8 +/- 2.4 days to 2.7 +/- 1.4 days; mean reduction was 2.1 bed-days per patient (95% CI 1.8 to 2.3, P <0.001). LOS would have increased in 4% of cases. Adopting the guideline's recommendation of early discharge would have resulted in a 0.6% (95% CI 0.07 to 2.1) complication rate, with no worsening of quality of care, as judged by implicit review. CONCLUSIONS: The proposed clinical practice guideline may safely reduce hospital LOS for selected low-risk patients with acute UGIH. Moreover, it also may reduce premature discharge of high-risk patients prone to life-threatening events.

An evidence-based medicine approach to the diagnosis and management of musculoskeletal complaints.

Evidence-based medicine is an approach to clinical practice and teaching that emphasizes decision-making based on rigorous analysis of clinical research tailored to the individual characteristics of a specific patient. As such, it can be considered the scientifically grounded art of medicine. Through evidence-based guidelines, pathways, and algorithms, the care of populations of patients may also be facilitated by informing individual practitioners of optimal decision-making in specific situations or providing the foundation for comprehensive "disease management" programs. These programs coordinate care for patients with chronic conditions, such as rheumatoid arthritis and osteoarthritis, across time and multiple disciplines. We present an approach to the development of decision-making aids, including guidelines and algorithms, which should be helpful in the care of individual patients and populations for whom physicians and other healthcare practitioners are responsible.

Efficacy and safety of sublingual nifedipine in hypertensive emergencies.

Hypertensive emergencies are a diverse group of disorders characterized by a marked elevation of systemic arterial pressure that is associated with acute end-organ dysfunction. The efficacy and safety of sublingual nifedipine were evaluated in 16 men and 14 women (mean age 65 +/- 14 years) who had hypertensive emergencies. Before treatment, mean systolic blood pressure was 224 +/- 23 mm Hg, mean diastolic blood pressure was 125 +/- 18 mm Hg, and the average mean arterial pressure was 158 +/- 16 mm Hg. Administration of 10 or 20 mg of sublingual nifedipine initiated a smooth and predictable decline in blood pressure values within five minutes and produced a peak effect between 30 and 60 minutes. At 30 minutes, the decreases in the systolic blood pressure, diastolic blood pressure, and mean arterial pressure for the group were 49 +/- 24 mm Hg, 31 +/- 17 mm Hg, and 39 +/- 20 mm Hg, respectively, all of which were highly significant (p less than 0.001). By 60 minutes, nifedipine had decreased the diastolic blood pressure to less than 120 mm Hg in 97 percent of patients, less than 110 mm Hg in 93 percent, and less than 100 mm Hg in 67 percent. Fourteen patients required other antihypertensive medications within the first 12 hours for the antihypertensive effect to be maintained. In this group, the systolic, diastolic, and mean arterial pressures were significantly lower than baseline values (p less than 0.001) at the time that the other drugs were started (which occurred at a mean of 4.3 +/- 3.2 hours after entry into the study). The response to nifedipine correlated with the blood pressure value prior to treatment, but did not correlate with age, gender, value prior to treatment, but did not correlate with age, gender, or the type of hypertensive emergency. Twenty mg of nifedipine produced a significantly greater antihypertensive effect than did 10 mg during the first 20 minutes (176 +/- 15 mm Hg versus 201 +/- 18 mm Hg systolic; p = 0.009) and appeared to be more efficacious clinically. In only two of 30 patients (7 percent) was the blood pressure response considered inadequate, and all 10 patients with pulmonary edema or myocardial ischemia showed clinical improvement within 60 minutes of treatment. In one patient, flushing and another symptom suggestive of transient symptomatic hypotension developed after treatment with nifedipine. These results suggest that sublingual nifedipine is a safe, effective, and practical agent for treating patients with hypertensive emergencies.

Selecting the best triage rule for patients hospitalized with chest pain.

PURPOSE: During an observational study, we investigated the potential benefits and risks of the use of admission and early transfer triage rules in 498 patients hospitalized with chest pain. PATIENTS AND METHODS: Appropriateness of triage decisions was measured using explicit and implicit judgments. RESULTS: Application of an admission triage rule (partially based on the Brush electrocardiographic criteria) would have increased coronary care unit (CCU) admissions by 3%, whereas application of a triage rule 24 hours after admission would have reduced bed utilization by 860 intermediate care and 82 CCU bed-days per year when compared with actual patient triage. Although 9.5% of patients who underwent triage according to the early transfer triage rule would have experienced a minor complication after transfer, the medical care of none would have been adversely affected. CONCLUSION: Our results show that application of a triage rule 24 hours after admission may have the potential to shorten length of stay in the CCU and intermediate care unit without significantly compromising patient care. However, use of the admission triage rule would have increased CCU bed utilization. The failure of the admission triage rule to improve bed utilization illustrates the potential hazards of ignoring patient complications, interventions, and co-morbidity when predicting the efficacy of a triage rule.

Can practice guidelines safely reduce hospital length of stay? Results from a multicenter interventional study.

BACKGROUND: Although practice guidelines about appropriate lengths of stay have been widely promulgated, their effects on patient outcomes are not clear. Our objective was to study the effects of length of stay practice guidelines on patient outcomes. PATIENTS AND METHODS: We performed a prospective, nonrandomized, interventional trial in six geographically distributed hospitals, among consecutively hospitalized "low-risk" patients with total hip replacement, hip fracture, or knee replacement. Case managers provided physicians with patient risk information based on guideline recommendations. We measured length of stay, compliance with recommended guideline length of stay, health status, hospital readmission rates, return to emergency department, return to work and recreation, and patient satisfaction. RESULTS: A total of 560 patients were included in the study. For patients with knee replacement, there was a statistically significant increase in practice guideline compliance (27% baseline versus 53% intervention, P <0.0001) and reduction in length of stay (5.2 days versus 4.6 days, P <0.001) when compared with the baseline period. For hip replacement patients, there similarly was an increase in practice guideline compliance (66% baseline versus 82% intervention, P = 0.01) and reduction in length of stay (5.1 days versus 4.8 days, P = 0.03). Significant reductions in length of stay were not observed for patients recovering after hip fracture despite a significant increase in guideline compliance. There were few statistically significant changes in patient outcomes related to reductions in lengths of stay, including health status, hospital readmission rates, return to emergency department, return to work and recreation, and patient satisfaction. For patients undergoing hip replacement, very short lengths of stay (shorter than the guideline recommendation) were associated with an increased rate of discharging patients to nursing homes and rehabilitation facilities (21% versus 7%, P = 0.01), and hip fracture patients with very short lengths of stay required more visits to the doctor after discharge (56% versus 25%, P = 0.04). CONCLUSION: Reductions in lengths of stay were most often associated with no significant change in patient outcomes. However, very short lengths of stay were associated with increased intensity of care following discharge for patients undergoing hip surgery, indicating possible cost shifting (the cost incurred by transferring patients to rehabilitation facilities may have been greater than had the patients remained in the acute care hospital for an additional 1 or 2 days and been sent directly home). These results emphasize the importance of monitoring the effects of cost containment and other systematic efforts to change patient care at the local level.

Triage practice guideline for patients hospitalized with congestive heart failure: improving the effectiveness of the coronary care unit.

BACKGROUND: Decisions regarding the appropriate timing for transfer of patients hospitalized with congestive heart failure from the coronary care unit (CCU) to the medical ward are often not based on well-founded medical data. We investigated the potential safety and effectiveness of a practice guideline recommending early "step-down" transfer of low-risk patients with congestive heart failure. PATIENTS AND METHODS: We studied the use of a practice guideline for 384 patients hospitalized with congestive heart failure in a hypothetic experiment. The guideline stated that patients without any of the following conditions may be suitable for transfer to a nonmonitored bed 24 hours after admission: acute myocardial infarction or ischemia, complications, active or planned cardiac interventions, unstable comorbidity, worsening clinical status, or lack of response to diuretic therapy. Patients with any of the above conditions were classified as higher risk and potentially not suitable for early transfer. RESULTS: Life-threatening complications were 15.2 times more likely (95% confidence interval [CI] 2.2, 70, p = 0.001) and death 14.6 times more likely (95% CI 2.1, 68, p = 0.001) if the patient was classified as "high risk" rather than "low risk" by the guideline. The negative predictive value and sensitivity of the practice guideline for detecting patients who had life-threatening complications were 99.2% and 96.4%, respectively. Thirty-one percent of patients with congestive heart failure hospitalized in either the CCU or intermediate care unit were at low risk and potentially suitable for transfer to a nonmonitored bed 24 hours after admission. Use of the guideline would have reduced intermediate care unit lengths of stay from 2.91 days to 2.22 days and CCU length of stay from 2.06 to 2.04 days had it been used to triage patients with congestive heart failure. This reduction in length of stay would have resulted in 172 more intermediate care unit bed-days available per year to accommodate additional patients. On initial review, at least one cardiologist reviewer judged that use of the guideline may have adversely affected quality of care for 4% (95% CI 1%, 7%) of patients. After a consensus among the cardiologist reviewers, it was judged that the guideline may have adversely affected care for only 0.8% of patients (95% CI, 0%, 2.3%), and that no patient (95% CI 0%, 2.3%) would have had an unexpected life-threatening complication because of the guideline. CONCLUSIONS: Use of a practice guideline has the potential to reduce the intermediate care unit lengths of stay for selected low-risk patients with congestive heart failure.

Reducing lengths of stay for patients hospitalized with chest pain using medical practice guidelines and opinion leaders.

There are few available data on the effectiveness and safety of medical practice guidelines when used for patient care in the coronary and intermediate care units. The aim of this study was to examine the effect of educating physicians about practice guidelines to promote shorter lengths of stay for "low-risk" patients hospitalized with chest pain. Such guidelines were disseminated to physicians working in a health maintenance organization (HMO) by educational conferences, written memoranda, endorsement by opinion leaders, concurrent written feedback, and nursing-to-physician cues. A total of 208 patients were enrolled in the study. Following implementation of the practice guidelines, hospital lengths of stay were reduced from 2.51 +/- 2.1 to 1.96 +/- 1.3 days (22% reduction, p = 0.03) and intermediate care unit lengths of stay from 33.9 +/- 19 to 28.2 +/- 14 hours (17% reduction, p = 0.02) for patients with low-risk chest pain. The reduction in length of stay for patients with low-risk chest pain exceeded reductions in stay for patients hospitalized with cardiac conditions for which no guidelines were introduced. None of the patients treated according to guideline recommendations had unexpected "life-threatening" adverse events in the 2-week period after hospital discharge (95%, confidence interval 0%, 3%). This study supports the effectiveness and possible safety of practice guidelines to reduce lengths of stay for patients with low-risk chest pain.

Variable spectrum and prognostic implications of left and right ventricular ejection fractions in patients with and without clinical heart failure after acute myocardial infarction.

To determine the spectrum and prognostic implications of left and right ventricular (LV and RV) ejection fractions (EFs) in acute myocardial infarction (AMI), radionuclide ventriculography was performed in 114 consecutive patients, admitted without (Killip class I, 78 patients) or with (killip class II, 36 patients) clinical signs of pulmonary congestion within 24 hours of onset of symptoms of a transmural AMI. Mean LVEF was significantly lower in patients in Killip class II than in those in class I (0.32 +/- 0.11 vs 0.46 +/- 0.15, p less than 0.001) and in patients with anterior than inferior AMI (0.34 +/- 0.11 vs 0.52 +/- 0.14, p less than 0.001). Of the 36 patients with a severely depressed (0.30 or less) LVEF, 15 (42%) were in Killip class I. Mean RVEF did not differ significantly between Killip class I and II patients (0.42 +/- 0.11 vs 0.40 +/- 0.12, difference not significant) but was significantly lower in patients with inferior than anterior AMI (0.38 +/- 0.09 vs 0.44 +/- 0.11, p = 0.005). In patients with inferior AMI, a depressed RVEF (0.38 or less) was associated with a normal LVEF in 30% and a depressed LVEF in 20%, whereas in those with anterior AMI, a depressed RVEF, observed in 25% of patients, occurred only in association with a depressed LVEF.(ABSTRACT TRUNCATED AT 250 WORDS)

Felodipine. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic use in hypertension.

Felodipine is a dihydropyridine calcium antagonist which selectively relaxes vascular smooth muscle. By acting at peripheral arterioles, it lowers systemic vascular resistance and thereby produces substantial decreases in blood pressure and increases in cardiac output. Felodipine is indicated for the management of hypertension, and in patients with mild to moderate disease felodipine monotherapy markedly lowers blood pressure. It proved as effective as atenolol, and equivalent to hydrochlorothiazide, either with or without amiloride, in terms of antihypertensive activity. Comparative studies also demonstrated that once daily administration with an extended-release formulation provides equivalent antihypertensive efficacy to the same amount of drug administered twice daily as the standard tablets. As a second- or third-line treatment for patients with moderate to severe hypertension refractory to standard drug combinations, felodipine produced considerable reductions in blood pressure when added to beta-blockers and diuretics, either alone or in combination, in studies lasting up to 48 weeks. In comparative studies of multiple-drug treatments felodipine was found to have superior efficacy to hydralazine and prazosin, and was at least as effective as nifedipine, minoxidil and propranolol, when used with diuretics and/or beta-blockers. As an alternative to hydrochlorothiazide, in combination with beta-blockers, felodipine consistently controlled blood pressure in a greater percentage of patients and usually provided greater decreases in blood pressure. The main side effects with felodipine are ankle oedema, headache and flushing. Although the overall incidence of effects is quite high, they are usually mild in nature. Nevertheless, withdrawal due to side effects has been necessary in about 7% of patients overall. Thus, the efficacy of felodipine has been demonstrated in mild, moderate and severe hypertension. At the present time it seems particularly suitable as a second- or third-line treatment in refractory hypertension, but it also can be used as monotherapy for mild to moderate disease.

Peripherally inserted central catheters in general medicine.

OBJECTIVE: To report the success rate and complications associated with peripherally inserted central venous catheters (PICCs) and to compare costs between PICCs and centrally inserted central catheters. MATERIAL AND METHODS: We undertook a cohort study of the first 1,000 patients referred to the PICC service of a large tertiary-care, university-affiliated, community hospital. The data were analyzed for insertion success rate, insertion mode, complication rate, successful completion, insertion costs, and applicability of PICCs in "high-risk" groups (transplant, human immunodeficiency virus-infected, intensive-care unit, and pediatric populations). RESULTS: Of 1,000 consecutive PICC attempts, 963 (96.3%) were successful. Cutdown procedures were necessary in 141 insertions (14.6%). Complications of PICC placement occurred in 170 cases (17.7%). Among the major complications were a need for multiple attempts at insertion in 92 cases, malpositioning in 56, mechanical phlebitis in 37, clotting in 37, and bleeding in 5. The rate for completion of therapy was 68.9%. Frequent reasons for early termination were dislodgment (in 85 cases) and infection (in 72-37 confirmed and 35 potential cases). The rate of confirmed infection was 11 per 10,000 catheter days. The costs of PICC insertion were less than those associated with centrally inserted central catheters. CONCLUSIONS: PICCs can satisfy long-term vascular needs and are safe in many patient populations. The infection rate did not depend on insertion mode, lumen number, or patient's immune status. Use of total parenteral nutrition was the most important risk factor in all patient subsets. Cost and safety considerations strongly favor PICCs as alternatives to other vascular access devices.

The clinical benefit of in-hospital observation in 'low-risk' pneumonia patients after conversion from parenteral to oral antimicrobial therapy.

OBJECTIVE: To assess the benefit of in-hospital observation in "low-risk" patients with community-acquired pneumonia. DESIGN: Retrospective review of data from a prospective study. SETTING: Teaching community hospital. PATIENTS: We studied 717 consecutive, adult patients admitted to the hospital for pneumonia. MEASUREMENTS AND RESULTS: One hundred forty-five patients were classified at low-risk for complications using previously studied criteria; 144 (99%) charts were available for review. Two patients had "obvious reasons for continued hospitalization" on the day of antibiotic conversion and were excluded. One hundred two patients were observed, and 40 were not observed in-hospital after switch to oral antibiotics. No patient from either group required medical intervention within 24 h after hospital discharge. Five "observed" patients (5%, 95% confidence interval [CI], 2 to 11%) returned to the emergency department, three (3%; 95% CI, 0 to 9%) with respiratory complaints. Two (2%; 95% CI, 0 to 7%) "observed" patients were admitted to the hospital with recurrent pneumonia. One (3%; 95% CI, 0 to 13%) "not observed" patient returned to the emergency department with a nonrespiratory complaint and was not admitted. No patient from either group died within 30-day clinical follow-up. The length of stay for the "observed" and "not observed" groups was 98+/-33 h and 83+/-49 h, respectively. The difference in length of stay was 15 h (95% CI, 3 to 27). CONCLUSIONS: In-hospital observation for low-risk patients admitted with community-acquired pneumonia after switch from parenteral to oral antibiotics is of limited benefit, and elimination of this practice could potentially reduce length of stay by almost 1 day per patient. This could translate into a cost savings of $57,200 for the 22-month study period. These results require prospective validation in a larger study.