2009 Sep 16 - Lancet Comment: Will CESAR answer the adult ECMO debate?

Joseph B Zwischenberger a, James E Lynch b. The Lancet, Early Online Publication, 16 September 2009
Over the past 30 years, extracorporeal membrane oxygenation (ECMO), in both venoarterial and venovenous configuration, has become the standard of care for neonates with severe respiratory failure and for postoperative support after congenital heart repair. However, the use of ECMO in adults is not so straightforward. The ECMO experience in adults has been confined to a few highly specialised centres due to the associated expense and training necessary as well as the disappointing results reported in the only two randomised trials.

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2009 Sep 16 - Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial

Giles J Peek MD a b , Prof Miranda Mugford DPhil c, Ravindranath Tiruvoipati FRCSEd b, Prof Andrew Wilson MD d, Elizabeth Allen PhD e, Mariamma M Thalanany MSc c, Clare L Hibbert PhD f, Ann Truesdale BSc e, Felicity Clemens MSc e, Nicola Cooper PhD d, Richard K Firmin MBBS a b, Prof Diana Elbourne PhD e, for the CESAR trial collaboration. The Lancet, Early Online Publication, 16 September 2009
NEW on 19.9.2009: Critical Appraisal here

Figure. ECMO in operation (Photo courtesy of ICU, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China)
Severe acute respiratory failure in adults causes high mortality despite improvements in ventilation techniques and other treatments (eg, steroids, prone positioning, bronchoscopy, and inhaled nitric oxide). We aimed to delineate the safety, clinical efficacy, and cost-effectiveness of extracorporeal membrane oxygenation (ECMO) compared with conventional ventilation support.

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2009 Sep - Otamixaban for the treatment of patients with non-ST-elevation acute coronary syndromes (SEPIA-ACS1 TIMI 42): a randomised, double-blind, active-controlled, phase 2 trial

Dr Marc S Sabatine MD a , Prof Elliott M Antman MD a, Prof Petr Widimsky MD b, Iftikhar O Ebrahim MBBCh c, Robert G Kiss MD d, André Saaiman MD e, Rostislav Polasek MD f, Charles F Contant PhD a, Carolyn H McCabe BS a, Prof Eugene Braunwald MD a. The Lancet, Volume 374, Issue 9692, Pages 787 - 795, 5 September 2009
Otamixaban is an intravenous direct factor Xa inhibitor. We aimed to assess its efficacy and safety in non-ST-elevation acute coronary syndromes and to identify the optimum dose range for further assessment in a phase 3 study.

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2009 Sep - Rapid screening tests for meticillin-resistant Staphylococcus aureus at hospital admission: systematic review and meta-analysis [Review]

Tacconelli E, De Angelis G, de Waure C, Cataldo MA, La Torre G, Cauda R.; Lancet Infect Dis, 2009 Sep;9(9):546-54.
Detection and eradication of meticillin-resistant Staphylococcus aureus (MRSA) represents a public health priority worldwide. Our aim was to do a systematic review and meta-analysis of randomised, non-randomised, and observational studies to summarise the available evidence on the effect of MRSA detection by rapid screening tests on hospital-acquired MRSA infections and acquisition rate.

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2009 Sep - Case Report: H1N1 pneumonitis treated with intravenous zanamivir

Dr I Michael Kidd FRCPath a , Jim Down FRCA b, Eleni Nastouli FRCPath a, Rob Shulman DHCPharm b, Paul R Grant PhD a, David CJ Howell MRCP b, Mervyn Singer FRCP bThe Lancet, Early Online Publication, 4 September 2009

Figure (click image to enlarge): IV preparation of Zanamivir. Previous studies have also used this preparation for trial for nebulization. This preparation is not yet registered in Hong Kong.
On July 8, 2009, a 22-year-old woman, neutropenic after chemotherapy for Hodgkin's disease, was referred to ICU with 3 days’ (d) increasing dyspnoea, bilateral chest infiltrates, and laboratory-confirmed pandemic H1N1 2009 influenza virus infection not responding to oseltamivir 75 mg twice daily and broad-spectrum antimicrobials (meropenem, teicoplanin, and caspofungin). No other organisms were detected from blood or respiratory tract. Deterioration necessitated invasive ventilation from ICU d 3 (figure).

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2009 Aug - Review: New drugs for exacerbations of chronic obstructive pulmonary disease

Dr Trevor T Hansel FRCPath a , Prof Peter J Barnes FRS aThe Lancet, Volume 374, Issue 9691, Pages 744 - 755, 29 August 2009
Tobacco smoking is the dominant risk factor for chronic obstructive pulmonary disease (COPD), but viral and bacterial infections are the major causes of exacerbations in later stages of disease. Reactive oxygen species (ROS), pathogen-associated molecular patterns (PAMPs), and damage-associated molecular patterns (DAMPs) activate families of pattern recognition receptors (PRRs) that include the toll-like receptors (TLRs).

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2009 Comment: Leaving invasive ventilation behind

PMA Calverley a. The Lancet, Early Online Publication, 13 August 2009doi:10.1016/S0140-6736(09)61462-8
The ability to assist ventilation, usually by addition of inspiratory pressure support with increased expiratory pressure, is the essence of non-invasive ventilation. This technique reduces the work of breathing, decreases ventilatory drive and respiratory rate, boosts tidal volume and alveolar ventilation, and can be applied with a nasal or full facemask without compromising the defences of the upper airway.1

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2009 Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial

Miquel Ferrer MD a d , Jacobo Sellarés MD a d, Mauricio Valencia MD a, Andres Carrillo MD c, Gumersindo Gonzalez MD c, Joan Ramon Badia MD a d, Josep Maria Nicolas MD b, Antoni Torres MD a d. The Lancet, (Early Online Publication, 13 August 2009) The Lancet, Volume 374, Issue 9695, Pages 1082 - 1088, 26 September
Non-invasive ventilation can prevent respiratory failure after extubation in individuals at increased risk of this complication, and enhanced survival in patients with hypercapnia has been recorded. We aimed to assess prospectively the effectiveness of non-invasive ventilation after extubation in patients with hypercapnia and as rescue therapy when respiratory failure develops.

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2009 Case Report - Steroids for acute spinal cord injury: revealing silent pathology

Yu-Tzu Tsao, Wei-Liang Chen, Wei-Chi Tsai. The Lancet, Volume 374, Issue 9688, Page 500, 8 August 2009
A F/37 developed corticosteroid-induced acute tumour lysis syndrome after being given high dose methylprednisolone for acute spinal cord injury.

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2009 Clinical Picture - Chest radiography of life-supporting medical interventions

Dr Eduardo Barge-Caballero MD a , Francisco Estevez-Cid MD b, Alberto Bouzas-Mosquera MD a, Alberto Juffe-Stein MD b, Alfonso Castro-Beiras MD a; The Lancet, Volume 374, Issue 9688, Page 476, 8 August 2009
The chest radiography of a 71-year-old man shows the following devices: (A) ECG monitoring. (B) Sternal suture. (C) Surgical staples. (D) Central line in left internal jugular vein. (E) Endotracheal tube. (F) Mediastinal drainage tube. (G) Chest tube. (H) Intra-aortic balloon. (I) Haemostatic packing in pericardial bag. Cannulas in (J) left atrium and (K) ascending aorta, belonging to a centrifugal left-ventricular assistance device.

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2009 (July - Early online publication) H1N1 2009 influenza virus infection during pregnancy in the USA

Denise J Jamieson MD a , Margaret A Honein PhD b, Sonja A Rasmussen MD b, et al, , the Novel Influenza A (H1N1) Pregnancy Working Group‡.The Lancet, Early Online Publication, 29 July 2009
Pandemic H1N1 2009 influenza virus has been identified as the cause of a widespread outbreak of febrile respiratory infection in the USA and worldwide. We summarised cases of infection with pandemic H1N1 virus in pregnant women identified in the USA during the first month of the present outbreak, and deaths associated with this virus during the first 2 months of the outbreak.

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2009 Clinical Picture: The many faces of tension pneumothoraces

Dr Tora Leong MB, William Bourke MD. The Lancet, Volume 374, Issue 9687, Page 404, 1 August 2009 

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2009 Nosocomial infections in patients with cancer [Review]

Kamboj M, Sepkowitz KA.; Lancet Oncol. 2009 Jun;10(6):589-97.
Nosocomial infections are those that become evident 48 h or more after a patient is admitted for treatment in a hospital or in another health-care setting. These infections cause substantial morbidity and mortality in patients who are immunosuppressed. Over the past few decades, understanding of host vulnerability has improved and more rigorous management and infection-control practices have been adopted for treating susceptible populations. Despite efforts, outbreaks continue to occur. In this Review, we outline current knowledge of the incidence and microbiology of various nosocomial infections in patients with cancer-a large, immunosuppressed population.

2009 Influenza in immunosuppressed populations: a review of infection frequency, morbidity, mortality, and vaccine responses

Kunisaki KM, Janoff EN.; Lancet Infect Dis. 2009 Aug;9(8):493-504.

Patients that are immunosuppressed might be at risk of serious influenza-associated complications. As a result, multiple guidelines recommend influenza vaccination for patients infected with HIV, who have received solid-organ transplants, who have received haemopoietic stem-cell transplants, and patients on haemodialysis. However, immunosuppression might also limit vaccine responses. To better inform policy, we reviewed the published work relevant to incidence, outcomes, and prevention of influenza infection in these patients, and in patients being treated chemotherapy and with systemic corticosteroids.

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2009 Non-invasive ventilation in acute respiratory failure [Review]

Stefano Nava, Nicholas Hill; The Lancet, Volume 374, Issue 9685, Pages 250 - 259, 18 July 2009
Non-invasive mechanical ventilation has been increasingly used to avoid or serve as an alternative to intubation. Compared with medical therapy, and in some instances with invasive mechanical ventilation, it improves survival and reduces complications in selected patients with acute respiratory failure. The main indications are exacerbation of chronic obstructive pulmonary disease, cardiogenic pulmonary oedema, pulmonary infiltrates in immunocompromised patients, and weaning of previously intubated stable patients with chronic obstructive pulmonary disease.

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2009 Seminar: Blast injuries

Stephen J Wolf MD, Maj Vikhyat S Bebarta MD, USAF, Carl J Bonnett MD, Prof Peter T Pons MD, Stephen V Cantrill MD. The Lancet, Early Online Publication, 23 July 2009
Health-care providers are increasingly faced with the possibility of needing to care for people injured in explosions, but can often, however, feel undertrained for the unique aspects of the patient's presentation and management.

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2009 Best pharmacological practice in prehospital intubation

Volker Wenzel, Karl H Lindner. The Lancet, Early Online Publication, 1 July 2009 
Emergency intubation outside hospital can increase morbidity and mortality 1 because of a lack of careful pre-oxygenation, 2 inadvertent oesophageal intubation, 3 or hypoxic episodes after endotracheal intubation. 4 A Cochrane review last year of 452 studies of a range of cases, providers, and techniques assessing emergency intubation reported that “the efficacy of emergency intubation as currently practised has not been rigorously studied”, and that “the skill level of the operator may be key in determ ...

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2009 Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial

Patricia Jabre MD a b c, Xavier Combes MD b, Frederic Lapostolle MD a, Mohamed Dhaouadi MD d, Agnes Ricard-Hibon MD e, Benoit Vivien MD f, Lionel Bertrand MD g, Alexandra Beltramini MD h, Pascale Gamand MD i, Stephane Albizzati MD j, Deborah Perdrizet MD k, Gaelle Lebail MD l, Charlotte Chollet-Xemard MD b, Virginie Maxime MD m, Prof Christian Brun-Buisson MD n, Prof Jean-Yves Lefrant MD o, Prof Pierre-Edouard Bollaert MD j, Prof Bruno Megarbane MD p, Prof Jean-Damien Ricard MD q, Nadia Anguel MD r, Prof Eric Vicaut MD s, Prof Frederic Adnet MD a , on behalf of the KETASED Collaborative Study Group‡
The Lancet, Volume 374, Issue 9686, Pages 293 - 300, 25 July 2009

Critically ill patients often require emergency intubation. The use of etomidate as the sedative agent in this context has been challenged because it might cause a reversible adrenal insufficiency, potentially associated with increased in-hospital morbidity. We compared early and 28-day morbidity after a single dose of etomidate or ketamine used for emergency endotracheal intubation of critically ill patients.

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2009 Review: Bite-related and septic syndromes caused by cats and dogs

Richard L Oehler MD, Ana P Velez MD, Michelle Mizrachi MD, Jorge Lamarche MD, Sandra Gompf MD
The Lancet Infectious Diseases, Volume 9, Issue 7, Pages 439 - 447, July 2009

Bite infections can contain a mix of anaerobes and aerobes from the patient's skin and the animal's oral cavity, including species of Pasteurella, Streptococcus, Fusobacterium, and Capnocytophaga. Domestic cat and dog bite wounds can produce substantial morbidity and often require specialised care techniques and specific antibiotic therapy. Bite wounds can be complicated by sepsis. Disseminated infections, particularly those caused by Capnocytophaga canimorsus and Pasteurella multocida, can lead to septic shock, meningitis, endocarditis, and other severe sequelae.

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2009 Changes in case fatality of aneurysmal subarachnoid haemorrhage over time, according to age, sex, and region: a meta-analysis

The Lancet Neurology, Early Online Publication, 4 June 2009doi:10.1016/S1474-4422(09)70126-7

In a systematic review, published in 1997, we found that the case fatality of aneurysmal subarachnoid haemorrhage (SAH) decreased during the period 1960—95. Because diagnostic and treatment strategies have improved and new studies from previously non-studied regions have been published since 1995, we did an updated meta-analysis to assess changes in case fatality and morbidity and differences according to age, sex, and region.
Methods: A new search of PubMed with predefined inclusion criteria for case finding and diagnosis identified reports on prospective population-based studies published between January, 1995, and July, 2007. The studies included in the previous systematic review were reassessed with the new inclusion criteria. Changes in case fatality over time and the effect of age and sex were quantified with weighted linear regression. Regional differences were analysed with linear regression analysis, and the regions of interest were subsequently defined as reference regions and compared with the other regions.

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