2010 Dec 30 - Review Article: General Anesthesia, Sleep, and Coma
In the United States, nearly 60,000 patients per day receive general anesthesia for surgery.1 General anesthesia is a drug-induced, reversible condition that includes specific behavioral and physiological traits — unconsciousness, amnesia, analgesia, and akinesia — with concomitant stability of the autonomic, cardiovascular, respiratory, and thermoregulatory systems.2 General anesthesia produces distinct patterns on the electroencephalogram (EEG), the most common of which is a progressive increase in low-frequency, high-amplitude activity as the level of general anesthesia deepens3,4 (Figure 1). How anesthetic drugs induce and maintain the behavioral states of general anesthesia is an important question in medicine and neuroscience.6 Substantial insights . . .
2010 Dec 23 - NEJM Correspondence: Emergency Treatment of Asthma
N Engl J Med 2010; 363:2567-2569, December 23, 2010
In the article by Lazarus (Aug. 19 issue),1 the author provides a comprehensive and balanced review of the emergency treatment of asthma but does not discuss the controversy around the use of epinephrine for acute severe asthma exacerbations.2
2010 Dec 23 - Clinical Practice: Glycemic Control in the ICU
Stage: A 42-year-old man is admitted to the intensive care unit (ICU) with an acute exacerbation of asthma associated with community-acquired pneumonia. He is treated with cefotaxime and azithromycin, nebulized albuterol, and intravenous hydrocortisone.
2010 Dec 16 - Perspective: NDM-1 — A Cause for Worldwide Concern
The past several years have seen a number of reports of superbugs: methicillin-resistant Staphylococcus aureus, the so-called ESKAPE organisms (an acronym for Enterococcus faecium, S. aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and enterobacter species), and others.1
2010 Nov 4 - Hemodialysis
Fifty years ago, Belding Scribner and his colleagues at the University of Washington developed a blood-access device using Teflon-coated plastic tubes, which facilitated the use of repeated hemodialysis as a life-sustaining treatment for patients with uremia.1,2
2010 Nov 4 - Safety of Recombinant Activated Factor VII in Randomized Clinical Trials
Background
The use of recombinant activated factor VII (rFVIIa) on an off-label basis to treat life-threatening bleeding has been associated with a perceived increased risk of thromboembolic complications. However, data from placebo-controlled trials are needed to properly assess the thromboembolic risk. To address this issue, we evaluated the rate of thromboembolic events in all published randomized, placebo-controlled trials of rFVIIa used on an off-label basis.
2010 Sep 23 - CLINICAL THERAPEUTICS: Targeted Temperature Management for Comatose Survivors of Cardiac Arrest
A 62-year-old man collapses on the street, and emergency medical personnel who are called to the scene find that he is not breathing and that he has no pulse. The first recorded cardiac rhythm is ventricular fibrillation. Advanced cardiac life-support measures, including intubation, a total dose of 2 mg of epinephrine, and six defibrillation attempts, restore spontaneous circulation 22 minutes after the onset of the event.
2010 Sep 16 - NEJM Editorial: Neuromuscular Blocking Agents in ARDS
In this issue of the Journal, Papazian and colleagues1 present intriguing results of their study examining neuromuscular blockade in patients with severe, early acute respiratory distress syndrome (ARDS). The investigators randomly assigned 340 patients to receive the neuromuscular blocking agent cisatracurium or placebo for a period of 48 hours.
2010 Sep 16 - Neuromuscular Blockers in Early Acute Respiratory Distress Syndrome
Background
In patients undergoing mechanical ventilation for the acute respiratory distress syndrome (ARDS), neuromuscular blocking agents may improve oxygenation and decrease ventilator-induced lung injury but may also cause muscle weakness. We evaluated clinical outcomes after 2 days of therapy with neuromuscular blocking agents in patients with early, severe ARDS.
2010 Sep 9 - Rapid Molecular Detection of Tuberculosis and Rifampin Resistance
Background
Global control of tuberculosis is hampered by slow, insensitive diagnostic methods, particularly for the detection of drug-resistant forms and in patients with human immunodeficiency virus infection. Early detection is essential to reduce the death rate and interrupt transmission, but the complexity and infrastructure needs of sensitive methods limit their accessibility and effect.
2010 Sep 2 - NEJM Editorial: Fine-Tuning Therapy for Acute Coronary Syndromes
Aspirin and clopidogrel are mainstays of therapy for patients presenting with an acute coronary syndrome. National guidelines dictate that at the time of the patient's presentation to an emergency department, these therapies should be given expeditiously, whether or not percutaneous coronary intervention is planned.
In this issue of the Journal, Mehta et al. report on the results of the Clopidogrel and Aspirin Optimal Dose Usage to Reduce Recurrent Events–Seventh Organization to Assess Strategies in Ischemic Syndromes (CURRENT–OASIS 7) trial, which evaluated alternative dosing regimens for both of these agents.1
Weblink here
2010 Sep 2 - Dose Comparisons of Clopidogrel and Aspirin in Acute Coronary Syndromes
Background
Clopidogrel and aspirin are widely used for patients with acute coronary syndromes and those undergoing percutaneous coronary intervention (PCI). However, evidence-based guidelines for dosing have not been established for either agent.
2010 Aug 19 - Case Records of the Massachusetts General Hospital:Case 25-2010 — A 24-Year-Old Woman with Abdominal Pain and Shock
Dr. Franklin W. Huang (Medicine): A 24-year-old woman was transferred to this hospital because of abdominal pain, vomiting, ascites, and shock.
2010 Jul 29 - Images in Clinical Medicine: Pneumothorax — An Uncommon Complication of a Common Procedure
A 92-year-old woman was admitted to the hospital with a severe left-sided ischemic stroke causing altered mental status (i.e., a score of 9 on the Glasgow Coma Scale, on which scores range from 3 to 15, with higher scores indicating increased consciousness), weakness on the right side, and dysphagia.
2010 Jul 29 - Compression-Only CPR or Standard CPR in Out-of-Hospital Cardiac Arrest
Background
Emergency medical dispatchers give instructions on how to perform cardiopulmonary resuscitation (CPR) over the telephone to callers requesting help for a patient with suspected cardiac arrest, before the arrival of emergency medical services (EMS) personnel. A previous study indicated that instructions to perform CPR consisting of only chest compression result in a treatment efficacy that is similar or even superior to that associated with instructions given to perform standard CPR, which consists of both compression and ventilation. That study, however, was not powered to assess a possible difference in survival. The aim of this prospective, randomized study was to evaluate the possible superiority of compression-only CPR over standard CPR with respect to survival.
2010 Jul 29 - NEJM Editorial: In CPR, Less May Be Better
Fifty years have passed since Kouwenhoven, Jude, and Knickerbocker1 proposed external chest compression to provide circulation of blood to the brain and heart after cardiac arrest.
2010 Jul 29 - CPR with Chest Compression Alone or with Rescue Breathing
Background
The role of rescue breathing in cardiopulmonary resuscitation (CPR) performed by a layperson is uncertain. We hypothesized that the dispatcher instructions to bystanders to provide chest compression alone would result in improved survival as compared with instructions to provide chest compression plus rescue breathing.
2010 Jul 15 - Rituximab versus Cyclophosphamide for ANCA-Associated Vasculitis
Background Cyclophosphamide and glucocorticoids have been the cornerstone of remission-induction therapy for severe antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis for 40 years. Uncontrolled studies suggest that rituximab is effective and may be safer than a cyclophosphamide-based regimen.
2010 Jul 15 - Rituximab versus Cyclophosphamide in ANCA-Associated Renal Vasculitis
Background Cyclophosphamide induction regimens for antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis are effective in 70 to 90% of patients, but they are associated with high rates of death and adverse events. Treatment with rituximab has led to remission rates of 80 to 90% among patients with refractory ANCA-associated vasculitis and may be safer than cyclophosphamide regimens.
2010 Jul 15 - Review: Acute Pulmonary Embolism
The clinical presentation of acute pulmonary embolism ranges from shock or sustained hypotension to mild dyspnea.