Comparison of diuretic strategies in diuretic-resistant acute heart failure: a systematic review and network meta-analysis.

OBJECTIVE: Up to 50% of patients hospitalized for acute heart failure (AHF) show resistance to diuretics. This condition contributes to a prolonged hospital length of stay and a higher risk of death. This review aimed to investigate whether a diuretic therapeutic approach more effective than furosemide alone exists for patients with diuretic-resistant AHF. MATERIALS AND METHODS: We identified all randomized controlled trials (RCTs) evaluating diuretic therapy in patients with diuretic-resistant AHF. We searched Pubmed, BioMed Central, and Cochrane CENTRAL databases. RESULTS: Six RCTs were identified, involving a total of 845 patients. The P-score ranges from 0.6663 for furosemide to 0.2294 for the tolvaptan-furosemide. We found no significant differences in efficacy for any drug comparison. CONCLUSIONS: None of the diuretics considered in RCTs performed to date (tolvaptan, metolazone, hydrochlorothiazide, indapamide) appear to be more effective than furosemide therapy alone for the treatment of patients with diuretic-resistant AHF.

Which regional anesthesia technique is the best for arthroscopic shoulder surgery in terms of postoperative outcomes? A comprehensive literature review.

OBJECTIVE: The literature offers numerous reviews and meta-analyses assessing the different regional anesthesia techniques employed for arthroscopic shoulder surgery (ATS) in terms of diverse outcome parameters. Most have focused on analgesic efficacy in the limited post-operative period as their primary outcome. Indeed, the most up-to-date guidelines are based on the results of comparisons that focus on analgesic efficacy and analgesic drug consumption. However, a correlation has yet to be demonstrated between post-operative analgesia and functional recovery; indeed, the latter has received relatively less research attention concerning the anesthetic technique despite its clinical importance. Here, we aimed to identify the best loco-regional anesthetic technique for ATS, considering all the evaluation parameters considered to date. MATERIALS AND METHODS: We performed a comprehensive literature review on ATS, searching for all the relative aspects of the regional anesthesia technique employed and the outcome parameters assessed. RESULTS: From the literature, it is not clear which technique is better than the others. No single technique was revealed as being the absolute best, independent of the outcome parameter considered, which included: post-operative analgesic effect, speed of functional recovery, ease, and safety of execution. CONCLUSIONS: The choice of anesthetic technique should be tailored to the patient and type of surgery. When comparing one type of loco-regional anesthesia against another, in addition to analgesic efficacy, a whole plethora of aspects need to be considered (i.e., feasibility, complications, contribution to functional recovery, etc.).

Sepsis outside intensive care unit: the other side of the coin.

INTRODUCTION: A growing body of evidence points out that a large amount of patients with sepsis are admitted and treated in medical ward (MW). With most of the sepsis studies conducted in intensive care unit (ICU), these patients, older and with more comorbidities have received poor attention. Provided the differences between the two groups of patients, results of diagnostic and therapeutic trials from ICU should not be routinely transferred to MW, where sepsis seems to be at least as common as in ICU. METHODS: We analyzed clinical trials on novel tools for an early diagnosis of sepsis published in the last two year adopting strict research criteria. Moreover we conducted a target review of the literature on non-invasive monitoring of severe sepsis and septic shock. RESULTS AND CONCLUSIONS: The combination of innovative and non-invasive tools for sepsis rule in/out, as quick alternatives to blood cultures (gold standard) with bedside integrated ultrasonography could impact triage, diagnosis and prognosis of septic patients managed in MW, preventing ICU admissions, poor outcomes and costly complications, especially in elderly that are usually highly vulnerable to invasive procedures.

Impact of comprehensive pulmonary rehabilitation on anxiety and depression in hospitalized COPD patients.

To prospectively evaluate the effect of inpatient pulmonary rehabilitation (iPR) on anxiety and depression as outcome measures in patients with COPD, we studied 149 consecutive adults COPD referred to our iPR after an exacerbation. Patients were divided according to the GOLD staging into: Group 1 (stage 2a, n = 48, FEV1 63 +/- 9% pred.), Group 2 (stage 2b, n = 53, FEV1 42 +/- 6% pred.) and Group 3 (stage 3, n = 48, FEV1 25 +/- 7% pred.). The iPR consisted of twelve 3-hours daily sessions. Hospital Anxiety Depression (HAD) Scale as well as 6-minute walk (6MWD) with evaluation of dyspnea (D) and leg fatigue (F) at rest and end of effort, and health related quality of life by means of St. George Respiratory Questionnaire (SGRQ) were assessed before (T0) and after (T1) the iPR. 6MWD, D and F at end of effort and SGRQ total score similarly improved (p < 0.001) in all groups after iPR. The mean level of HAD-anxiety (from 9.1 +/- 4.0 to 7.7 +/- 3.5, from 9.0 +/- 4.6 to 7.2 +/- 4.6 and from 8.1 +/- 4.1 to 6.7 +/- 4.3 in group 1,2 and 3 respectively) and HAD-depression (from 9.4 +/- 3.5 to 8.2 +/- 3.5, from 9.1 +/- 4.2 to 8.2 +/- 4.5 and from 9.0 +/- 4.0 to 7.4 +/- 4.5 respectively) similarly changed (p < 0.0001) over time in all groups. The total percentage of patients with abnormal score (> 10) of HAD-anxiety (from 31% to 21%) and HAD-depression (from 30% to 22%) significantly decreased (p < 0.05) after the iPR. Inpatient pulmonary rehabilitation may improve levels of anxiety and depression as well as symptoms, exercise capacity and health related quality of life in moderate to severe COPD patients after an acute exacerbation.

A comprehensive computerized critical laboratory results alerting system for ambulatory and hospitalized patients.

Automatic alerting systems for key events in medical practice have been proven effective in improving the clinician's response to the event. Most of the systems described in current literature are hospital based, some in intensive care units. We designed a clinical alerting system that screens laboratory results of both hospitalized patients and most of Israel's Southern region ambulatory patients for critical results, using an integrative CDR and its interfaces to the hospital's laboratory information systems. New alerts can be defined and activated using a rule editor. Alerts are generated by screening all new laboratory results that are entered in to the CDR, by a decision engine. The alerts are dispatched to clinicians through a customizable preferred alerting device that can be either e-mail, fax or cellular phone SMS, and enables additional alerting devices as they become available. Clinicians may customize both the alerting method and the critical levels for alert generation, according to individual specific needs. We hope that this versatile and customizable alerting system will suite the needs of both the hospital and the community clinical staff. The system will be implemented and tested in the near future.

[Efficacy and safety of clarithromycin in the treatment of community-acquired pneumonia]. / Efficacia e sicurezza della claritromicina nel trattamento della polmonite acquisita in comunità.

Community-acquired pneumonia (CAP) is a serious disease frequently treated empirically, which required the selection of an antibiotic that covers all common pathogens and achieves good pulmonary concentrations. The availability of intravenous (i.v.) formulations may also be helpful, permitting i.v./p.o. sequential therapy. From January 1992 to December 1997 we treated 290 CAP patients with clarithromycin (CL) 500 mg BID, first given i.v. in 250 or 500 ml of saline solution and then switched after 4-5 days to the same dosage given p.o. Of these 290 patients 163 were males (98 smokers) and 127 were females (41 smokers); 87 were over 65 years old and 203 had concomitant diseases (mainly cardiovascular), 172 patients were admitted after unsuccessful therapy (122 cephalosporins and 48 penicillins). Diagnosis was made based on clinical and radiological findings, therapy was initiated prior to microbiological diagnosis. Clinical and radiological improvement was achieved by 261/290 patients (90%) within 10-15 days. Mild adverse events occurred in 11 patients. This results indicate that CL is effective and safe: its antimicrobial spectrum and pharmacokinetic profile, the possibility of i.v./p.o. sequential administration, make it an ideal antibiotic for the treatment of CAP.

[The tolerability and therapeutic efficacy of rifabutin in the treatment of pulmonary tuberculosis]. / Tollerabilità ed efficacia terapeutica della rifabutina nel trattamento della tubercolosi polmonare.

We treated in our unit 25 patients (15M--10F) affected by pulmonary tuberculosis (TB) with rifabutin (RBT). Chronic liver disease, multidrug-resistant TB and HIV infection were featuring the clinical history of our selected patients. The treatment was carried out using a 150 mg/day dose of RBT, or 300 mg/day in case of MDR (multiple-drug-resistance)-TB or chronic TB. Rifabutin, isoniazid, ethambutol, and a fourth anti-mycobacterium drug were used when treating MDR-TB. Chest X-ray, haematological and bacteriological tests were performed on a monthly basis during the patients' follow up. No side effects were observed; only in two cases, both females, leukopenia occurred, but was not such a reason to modify our treatment plan. As a matter of fact, RBT is well tolerated by patients and it is particularly effective in bacterial eradication. In our experience, RBT did not provide the expected results only in one patient, affected by chronic TB.