2009 Sep 16 - Chronic Dialysis and Death Among Survivors of Acute Kidney Injury Requiring Dialysis

Ron Wald, MDCM, MPH, FRCPC; Robert R. Quinn, MD, FRCPC; Jin Luo, MD; Ping Li, PhD; Damon C. Scales, MD, PhD, FRCPC; Muhammad M. Mamdani, PharmD, MPH; Joel G. Ray, MD, MSc, FRCPC; for the University of Toronto Acute Kidney Injury Research Group. JAMA. 2009;302(11):1179-1185.
Context Severe acute kidney injury among hospitalized patients often necessitates initiation of short-term dialysis. Little is known about the long-term outcome of those who survive to hospital discharge.

Objective To assess the risk of chronic dialysis and all-cause mortality in individuals who experience an episode of acute kidney injury requiring dialysis.

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2009 Sept - Effect of Procalcitonin-Based Guidelines vs Standard Guidelines on Antibiotic Use in Lower Respiratory Tract Infections: The ProHOSP Randomized Controlled Trial

Philipp Schuetz, MD; Mirjam Christ-Crain, MD; Robert Thomann, MD; Claudine Falconnier, MD; Marcel Wolbers, PhD; Isabelle Widmer, MD; Stefanie Neidert, MD; Thomas Fricker, MD; Claudine Blum, MD; Ursula Schild, RN; Katharina Regez, RN; Ronald Schoenenberger, MD; Christoph Henzen, MD; Thomas Bregenzer, MD; Claus Hoess, MD; Martin Krause, MD; Heiner C. Bucher, MD; Werner Zimmerli, MD; Beat Mueller, MD; for the ProHOSP Study Group. JAMA. 2009;302(10):1059-1066.

Video for reference only. The assays for the diagnosis of invasive bacterial infection/sepsis and the diagnosis of LRTI and invasive bacterial infections/sepsis could be different. Come here for more information. Disclaimer: The HKSCCM has no direct commercial relationship with the company producing the procalcitonin assays mentioned in the video or the link.

Context In previous smaller trials, a procalcitonin (PCT) algorithm reduced antibiotic use in patients with lower respiratory tract infections (LRTIs).

Objective To examine whether a PCT algorithm can reduce antibiotic exposure without increasing the risk for serious adverse outcomes.

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2009 Sep - Immediate vs Delayed Intervention for Acute Coronary Syndromes: A Randomized Clinical Trial

Gilles Montalescot, MD, PhD; Guillaume Cayla, MD; Jean-Philippe Collet, MD, PhD; Simon Elhadad, MD; Farzin Beygui, MD, PhD; Hervé Le Breton, MD; Rémi Choussat, MD; Florence Leclercq, MD; Johanne Silvain, MD; François Duclos, MD; Mounir Aout, PhD; Jean-Luc Dubois-Randé, MD; Olivier Barthélémy, MD; Grégory Ducrocq, MD; Anne Bellemain-Appaix, MD; Laurent Payot, MD; Philippe-Gabriel Steg, MD; Patrick Henry, MD; Christian Spaulding, MD; Eric Vicaut, MD, PhD; for the ABOARD Investigators; JAMA. 2009;302(9):947-954.
Context International guidelines recommend an early invasive strategy for patients with high-risk acute coronary syndromes without ST-segment elevation, but the optimal timing of intervention is uncertain.

Objective To determine whether immediate intervention on admission can result in a reduction of myocardial infarction compared with a delayed intervention.

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2009 Aug - Sex Differences in Mortality Following Acute Coronary Syndromes

Jeffrey S. Berger, MD, MS; Laine Elliott, MS; Dianne Gallup, MS; Matthew Roe, MD; Christopher B. Granger, MD; Paul W. Armstrong, MD; R. John Simes, MD; Harvey D. White, DSc; Frans Van de Werf, MD, PhD; Eric J. Topol, MD; Judith S. Hochman, MD, MA; L. Kristin Newby, MD, MS; Robert A. Harrington, MD; Robert M. Califf, MD; Richard C. Becker, MD; Pamela S. Douglas, MD. JAMA. 2009;302(8):874-882.
Context Conflicting information exists about whether sex differences modulate short-term mortality following acute coronary syndromes (ACS).

Objectives To investigate the relationship between sex and 30-day mortality in ACS, and to determine whether this relationship was modified by clinical syndrome or coronary anatomy using a large database across the spectrum of ACS and adjusting for potentially confounding clinical covariates.

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2009 Aug - Association of Cytochrome P450 2C19 Genotype With the Antiplatelet Effect and Clinical Efficacy of Clopidogrel Therapy

Alan R. Shuldiner, MD; Jeffrey R. O’Connell, DPhil; Kevin P. Bliden, BS; Amish Gandhi, MD; Kathleen Ryan, MPH; Richard B. Horenstein, MD; Coleen M. Damcott, PhD; Ruth Pakyz, BS; Udaya S. Tantry, PhD; Quince Gibson, MBA; Toni I. Pollin, PhD; Wendy Post, MD, MS; Afshin Parsa, MD; Braxton D. Mitchell, PhD; Nauder Faraday, MD; William Herzog, MD; Paul A. Gurbel, MD. JAMA. 2009;302(8):849-857.
Context Clopidogrel therapy improves cardiovascular outcomes in patients with acute coronary syndromes and following percutaneous coronary intervention by inhibiting adenosine diphosphate (ADP)–dependent platelet activation. However, nonresponsiveness is widely recognized and is related to recurrent ischemic events.

Objective To identify gene variants that influence clopidogrel response.

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2009 JAMA Editorial: International Differences in the Treatment of Sepsis: Are They Justified?

John A. Kellum, MD; Shigehiko Uchino, MD. JAMA. 2009;301(23):2496-2497. 

Statute of Liberty, New York, USA Tokyo Tower, Tokyo, Japan

Imagine a patient with acute coronary syndrome on a flight from New York to Tokyo. Given how small the world of medicine has become, it is reasonable to assume that the treatment he/she would receive would be very similar no matter if the plane returned to New York or continued to Tokyo. Now imagine that the patient had septic shock instead of heart disease—landing in New York or Tokyo would result in drastically different treatment. In New York, early goal-directed therapy (EGDT) and drotrecogin alfa are widely used while the former is less common and the latter is unavailable in Tokyo. Conversely, for more than 10 years, a patient with sepsis would likely receive therapy with an endotoxin adsorber (polymyxin B hemoperfusion) in Tokyo, a treatment unavailable in New York.

Why such radical differences? Aren't physicians treating sepsis in Japan and the United . . . [Full Text of this Article]

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2009 Early Use of Polymyxin B Hemoperfusion in Abdominal Septic Shock: The EUPHAS Randomized Controlled Trial

Dinna N. Cruz, MD, MPH; Massimo Antonelli, MD; Roberto Fumagalli, MD; Francesca Foltran, MD; Nicola Brienza, MD, PhD; Abele Donati, MD; Vincenzo Malcangi, MD; Flavia Petrini, MD; Giada Volta, MD; Franco M. Bobbio Pallavicini, MD; Federica Rottoli, MD; Francesco Giunta, MD; Claudio Ronco, MD. JAMA. 2009;301(23):2445-2452. 

Figure.  The adsorbent column containing polymyxin B in polystyrene fiber (Toraymyxin, Toray Industries, Tokyo, Japan) used in the study. Source: トレミキシン (TM), Toray Industries (Disclaimer: The HKSCCM has no direct commercial relationship with Toray Industries)

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2009 CLINICIAN'S CORNER: Corticosteroids in the Treatment of Severe Sepsis and Septic Shock in Adults - A Systematic Review

Djillali Annane, MD; Eric Bellissant, MD; Pierre-Edouard Bollaert, MD; Josef Briegel, MD; Marco Confalonieri, MD; Raffaele De Gaudio, MD; Didier Keh, MD; Yizhak Kupfer, MD; Michael Oppert, MD; G. Umberto Meduri, MD; JAMA. 2009;301(22):2362-2375.

Context The benefit of corticosteroids in severe sepsis and septic shock remains controversial.

Objective We examined the benefits and risks of corticosteroid treatment in severe sepsis and septic shock and the influence of dose and duration.

Data Sources We searched the CENTRAL, MEDLINE, EMBASE, and LILACS (through March 2009) databases as well as reference lists of articles and proceedings of major meetings, and we contacted trial authors.

Study Selection Randomized and quasi-randomized trials of corticosteroids vs placebo or supportive treatment in adult patients with severe sepsis/septic shock per the American College of Chest Physicians/Society of Critical Care Medicine consensus definition were included.

Data Extraction All reviewers agreed on trial eligibility. One reviewer extracted data, which were checked by the other reviewers and by the trials' authors whenever possible. Some unpublished data were obtained from the trials' authors. The primary outcome for this review was 28-day mortality.

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2009 Acid-Suppressive Medication Use and the Risk for Hospital-Acquired Pneumonia

Shoshana J. Herzig, MD; Michael D. Howell, MD, MPH; Long H. Ngo, PhD; Edward R. Marcantonio, MD, SM; JAMA. 2009;301(20):2120-2128.

Context The use of acid-suppressive medication has been steadily increasing, particularly in the inpatient setting, despite lack of an accepted indication in the majority of these patients.

Objective To examine the association between acid-suppressive medication and hospital-acquired pneumonia.

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2009 Relationship Between Spontaneous and Iatrogenic Hypoglycemia and Mortality in Patients Hospitalized With Acute Myocardial Infarction

Mikhail Kosiborod, MD; Silvio E. Inzucchi, MD; Abhinav Goyal, MD, MHS; Harlan M. Krumholz, MD, SM; Frederick A. Masoudi, MD, MSPH; Lan Xiao, PhD; John A. Spertus, MD, MPH

JAMA. 2009;301(15):1556-1564.


Context While glucose control is recommended by professional societies for patients with hyperglycemia hospitalized with acute myocardial infarction (AMI), enthusiasm for glucose lowering is tempered, in part, by concerns of inducing hypoglycemia. Yet, whether episodic hypoglycemia that occurs as a result of glucose-lowering therapy is harmful in patients with AMI is unknown.

Objective To determine whether the mortality risk associated with hypoglycemic events is similar in patients who develop hypoglycemia spontaneously and those who develop it as a result of insulin therapy.

Design, Setting, and Patients Retrospective cohort study using data from Health Facts, a contemporary database of patients hospitalized across the United States in 40 hospitals between January 1, 2000, and December 31, 2005. Of all the patients in the database, 7820 patients were hospitalized with AMI and were hyperglycemic on admission (glucose level 140 mg/dL). Patients were stratified based on whether they developed a hypoglycemic event (random glucose level <60 mg/dL) during subsequent hospitalization. Logistic regression models were used to evaluate the association between hypoglycemia and in-hospital mortality within subgroups of patients who were and were not treated with insulin therapy.

Main Outcome Measure All-cause in-hospital mortality.

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2009 Communicating With Seriously Ill Patients - Better Words to Say

Steven Z. Pantilat, MD
JAMA. 2009;301(12):1279-1281.

HKSCCM Editor notes: Important to read! The more tactful use of words as suggested makes a whole lot of difference in our daily communications. Good communications in turn facilitate our work.   

Since this article does not have an abstract, we have provided the first 150 words of the full text and any section headings.

Words matter. What clinicians say and how they say it hugely affect patients.1-3 Communicating about emotionally and medically complex topics such as advance care planning, preferences for care, prognosis, and death and dying is challenging. Doing so requires clinicians to attend to their own and the patient's cognitive reactions, tone, affect, and nonverbal cues.4-6 Communicating goals of care is so important that in California it is now the law.7 Although poor communication may harm patients by leading to unwanted invasive procedures, generating unnecessary anxiety, or creating feelings of abandonment, good communication can improve outcomes for patients and their families by promoting shared decision making and addressing patient concerns.1-2,8

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2009 Chlorhexidine-Impregnated Sponges and Less Frequent Dressing Changes for Prevention of Catheter-Related Infections in Critically Ill Adults - A Randomized Controlled Trial

Jean-François Timsit, MD, PhD; Carole Schwebel, MD, PhD; Lila Bouadma, MD; et al; for the Dressing Study Group

JAMA. 2009;301(12):1231-1241.

Also see accompanying Editorial by Eli N. Perencevich; Didier Pittet. Preventing Catheter-Related Bloodstream Infections: Thinking Outside the Checklist. JAMA. 2009;301(12):1285-1287.


The chlorhexidine gluconate-impregnated sponge (CHGIS) (BioPatch; Ethicon Inc, Somerville, NJ) used in the study. Download information from the www hereDisclaimer: The HKSCCM has no commercial relationship with the producer of BioPatch.

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2009 Consciousness, Coma, and Brain Death-2009

JAMA Classics. Commentary by Roger N. Rosenberg, MD JAMA. 2009;301(11):1172-1174.

A Definition of Irreversible Coma: Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death

Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death

JAMA. 1968;205(6):337-340.

This landmark classic article was the first to quantitatively define the clinical and laboratory criteria used to measure the presence of brain death. The study included "only those comatose individuals who have no discernible central nervous system activity." Criteria to establish the presence of irreversible coma included (1) unreceptivity and unresponsitivity; (2) no movements or breathing; (3) no reflexes (brain stem); and (4) flat electroencephalogram. These criteria are still considered to be reliable and acceptable by the medical community and have become established into law, which states that brain death is equivalent to death and that all artificial support systems sustaining heart, respiratory, and metabolic functions can be legally stopped.

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2009 Methicillin-Resistant Staphylococcus aureus Central Line–Associated Bloodstream Infections in US Intensive Care Units, 1997-2007

Deron C. Burton, MD, JD, MPH; Jonathan R. Edwards, MStat; Teresa C. Horan, MPH; John A. Jernigan, MD; Scott K. Fridkin, MD

JAMA. 2009;301(7):727-736.

Context  Concerns about rates of methicillin-resistant Staphylococcus aureus (MRSA) health care–associated infections have prompted calls for mandatory screening or reporting in efforts to reduce MRSA infections.

Objective  To examine trends in the incidence of MRSA central line–associated bloodstream infections (BSIs) in US intensive care units (ICUs).

Design, Setting, and Participants  Data reported by hospitals to the Centers for Disease Control and Prevention (CDC) from 1997-2007 were used to calculate pooled mean annual central line–associated BSI incidence rates for 7 types of adult and non-neonatal pediatric ICUs. Percent MRSA was defined as the proportion of S aureus central line–associated BSIs that were MRSA. We used regression modeling to estimate percent changes in central line–associated BSI metrics over the analysis period.

Main Outcome Measures  Incidence rate of central line–associated BSIs per 1000 central line days; percent MRSA among S aureus central line–associated BSIs.

Results  Overall, 33 587 central line–associated BSIs were reported from 1684 ICUs representing 16 225 498 patient-days of surveillance; 2498 reported central line–associated BSIs (7.4%) were MRSA and 1590 (4.7%) were methicillin-susceptible S aureus (MSSA). Of evaluated ICU types, surgical, nonteaching-affiliated medical-surgical, cardiothoracic, and coronary units experienced increases in MRSA central line–associated BSI incidence in the 1997-2001 period; however, medical, teaching-affiliated medical-surgical, and pediatric units experienced no significant changes. From 2001 through 2007, MRSA central line–associated BSI incidence declined significantly in all ICU types except in pediatric units, for which incidence rates remained static. Declines in MRSA central line–associated BSI incidence ranged from –51.5% (95% CI, –33.7% to –64.6%; P < .001) in nonteaching-affiliated medical-surgical ICUs (0.31 vs 0.15 per 1000 central line days) to –69.2% (95% CI, –57.9% to –77.7%; P < .001) in surgical ICUs (0.58 vs 0.18 per 1000 central line days). In all ICU types, MSSA central line–associated BSI incidence declined from 1997 through 2007, with changes in incidence ranging from –60.1% (95% CI, –41.2% to –73.1%; P < .001) in surgical ICUs (0.24 vs 0.10 per 1000 central line days) to –77.7% (95% CI, –68.2% to –84.4%; P < .001) in medical ICUs (0.40 vs 0.09 per 1000 central line days). Although the overall proportion of S aureus central line–associated BSIs due to MRSA increased 25.8% (P = .02) in the 1997-2007 period, overall MRSA central line–associated BSI incidence decreased 49.6% (P < .001) over this period.

Conclusions  The incidence of MRSA central line–associated BSI has been decreasing in recent years in most ICU types reporting to the CDC. These trends are not apparent when only percent MRSA is monitored.


Author Affiliations: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.

2009 Dexmedetomidine vs Midazolam for Sedation of Critically Ill Patients: A Randomized Trial

Richard R. Riker, MD; Yahya Shehabi, MD; Paula M. Bokesch, MD; Daniel Ceraso, MD; Wayne Wisemandle, MA; Firas Koura, MD; Patrick Whitten, MD; Benjamin D. Margolis, MD; Daniel W. Byrne, MS; E. Wesley Ely, MD, MPH; Marcelo G. Rocha, MD; for the SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group
JAMA. 2009;301(5):489-499. Published online February 2, 2009 (doi:10.1001/jama.2009.56).


Context -Aminobutyric acid receptor agonist medications are the most commonly used sedatives for intensive care unit (ICU) patients, yet preliminary evidence indicates that the 2 agonist dexmedetomidine may have distinct advantages.

Objective To compare the efficacy and safety of prolonged sedation with dexmedetomidine vs midazolam for mechanically ventilated patients.

Design, Setting, and Patients Prospective, double-blind, randomized trial conducted in 68 centers in 5 countries between March 2005 and August 2007 among 375 medical/surgical ICU patients with expected mechanical ventilation for more than 24 hours. Sedation level and delirium were assessed using the Richmond Agitation-Sedation Scale (RASS) and the Confusion Assessment Method for the ICU.

Interventions Dexmedetomidine (0.2-1.4 µg/kg per hour [n = 244]) or midazolam (0.02-0.1 mg/kg per hour [n = 122]) titrated to achieve light sedation (RASS scores between -2 and +1) from enrollment until extubation or 30 days.

Main Outcome Measures Percentage of time within target RASS range. Secondary end points included prevalence and duration of delirium, use of fentanyl and open-label midazolam, and nursing assessments. Additional outcomes included duration of mechanical ventilation, ICU length of stay, and adverse events.

Results There was no difference in percentage of time within the target RASS range (77.3% for dexmedetomidine group vs 75.1% for midazolam group; difference, 2.2% [95% confidence interval {CI}, -3.2% to 7.5%]; P = .18). The prevalence of delirium during treatment was 54% (n = 132/244) in dexmedetomidine-treated patients vs 76.6% (n = 93/122) in midazolam-treated patients (difference, 22.6% [95% CI, 14% to 33%]; P < .001). Median time to extubation was 1.9 days shorter in dexmedetomidine-treated patients (3.7 days [95% CI, 3.1 to 4.0] vs 5.6 days [95% CI, 4.6 to 5.9]; P = .01), and ICU length of stay was similar (5.9 days [95% CI, 5.7 to 7.0] vs 7.6 days [95% CI, 6.7 to 8.6]; P = .24). Dexmedetomidine-treated patients were more likely to develop bradycardia (42.2% [103/244] vs 18.9% [23/122]; P < .001), with a nonsignificant increase in the proportion requiring treatment (4.9% [12/244] vs 0.8% [1/122]; P = .07), but had a lower likelihood of tachycardia (25.4% [62/244] vs 44.3% [54/122]; P < .001) or hypertension requiring treatment (18.9% [46/244] vs 29.5% [36/122]; P = .02).

Conclusions There was no difference between dexmedetomidine and midazolam in time at targeted sedation level in mechanically ventilated ICU patients. At comparable sedation levels, dexmedetomidine-treated patients spent less time on the ventilator, experienced less delirium, and developed less tachycardia and hypertension. The most notable adverse effect of dexmedetomidine was bradycardia.

Trial Registration clinicaltrials.gov Identifier: NCT00216190

Editorial comment: A New Era for Sedation in ICU Patients
Hannah Wunsch, MD, MSc; John P. Kress, MD
JAMA. 2009;301(5):542-544. Published online February 2, 2009 (doi:10.1001/jama.2009.24).

2008 Testing Protocols in the Intensive Care Unit - Complex Trials of Complex Interventions for Complex Patients (Editorial)

Jean-Daniel Chiche, MD; Derek C. Angus, MD, MPH
JAMA. 2008;299(6):693-695.

In this issue of JAMA, Meade and colleagues1 and Mercat and colleagues2 report the results of 2 large international trials of alternative strategies for setting positive end-expiratory pressure (PEEP) in ventilated patients with acute lung injury or acute respiratory distress syndrome. Both trials ... 

Read more at JAMA's website here.

2008 Renal Replacement Therapy in Patients With Acute Renal Failure - A Systematic Review

Neesh Pannu, MD, SM; Scott Klarenbach, MD, MSc; Natasha Wiebe, MMath, PStat; Braden Manns, MD, MSc; Marcello Tonelli, MD, SM; for the Alberta Kidney Disease Network
JAMA. 2008;299(7):793-805.


Context Acute renal failure requiring dialytic support is associated with a high risk of mortality and substantial morbidity.

Objectives To summarize current evidence guiding provision of dialysis for patients with acute renal failure, to make recommendations for management, and to identify areas in which additional research is needed.

Data Sources Systematic searches of peer-reviewed publications in MEDLINE, EMBASE, and All EBM Reviews through October 2007.

Study Selection Randomized controlled trials (RCTs) and prospective cohort studies studying dialytic support in adults with acute renal failure that reported the incidence of clinical outcomes such as mortality, length of stay, need for chronic dialysis, or development of hypotension.

Data Extraction Quality was independently assessed by 2 reviewers using the Jadad score (RCTs) and the Downs and Black checklist (cohort studies). A single reviewer extracted data, which were independently verified by a second reviewer. Results of RCTs were pooled using a random-effects model.

Data Synthesis From 173 retrieved articles, 30 RCTs and 8 prospective cohort studies were eligible. No conclusions could be drawn about optimal indications for or timing of renal replacement. Available data comparing continuous renal replacement therapy (CRRT) with intermittent hemodialysis demonstrated no clinically relevant difference between modalities, including for all-cause mortality (relative risk [RR], 1.10; 95% confidence interval [CI], 0.99-1.23; I2 = 0%) or for the requirement for chronic dialysis treatment in survivors (RR, 0.91; 95% CI, 0.56-1.49; I2 = 0%). For patients treated with CRRT, limited data suggest that bicarbonate may be preferable to other forms of dialysate alkali and that citrate infusion may be an alternative to systemic anticoagulation in patients at high risk of bleeding. Among patients treated with continuous venovenous hemofiltration (CVVHF), the risk of death was lower at doses of 35 mL/kg per hour (RR of death compared with doses of 20 mL/kg per hour, 0.74; 95% CI, 0.63-0.88). The use of unsubstituted cellulosic membranes should be avoided in intermittent hemodialysis (RR of death compared with biocompatible membranes, 1.23; 95% CI, 1.01-1.50).

Conclusions Based on current data, intermittent hemodialysis and CRRT appear to lead to similar clinical outcomes for patients with ARF. If CVVHF is used, a dose of 35 mL/kg per hour should be provided. Given the paucity of good-quality evidence in this important area, additional large randomized trials are needed to evaluate clinically important outcomes.

2008 Femoral vs Jugular Venous Catheterization and Risk of Nosocomial Events in Adults Requiring Acute Renal Replacement Therapy - A Randomized Controlled Trial

Jean-Jacques Parienti, MD, DTM&H; Marina Thirion, MD; Bruno Mégarbane, MD, PhD; Bertrand Souweine, MD, PhD; Abdelali Ouchikhe, MD; Andrea Polito, MD; Jean-Marie Forel, MD; Sophie Marqué, MD; Benoît Misset, MD; Norair Airapetian, MD; Claire Daurel, MD; Jean-Paul Mira, MD, PhD; Michel Ramakers, MD; Damien du Cheyron, MD, PhD; Xavier Le Coutour, MD; Cédric Daubin, MD; Pierre Charbonneau, MD; for Members of the Cathedia Study Group
JAMA. 2008;299(20):2413-2422.


Context Based on concerns about the risk of infection, the jugular site is often preferred over the femoral site for short-term dialysis vascular access.

Objective To determine whether jugular catheterization decreases the risk of nosocomial complications compared with femoral catheterization.

Design, Setting, and Patients A concealed, randomized, multicenter, evaluator-blinded, parallel-group trial (the Cathedia Study) of 750 patients from a network of 9 tertiary care university medical centers and 3 general hospitals in France conducted between May 2004 and May 2007. The severely ill, bed-bound adults had a body mass index (BMI) of less than 45 and required a first catheter insertion for renal replacement therapy.

Intervention Patients were randomized to receive jugular or femoral vein catheterization by operators experienced in placement at both sites.

Main Outcome Measures Rates of infectious complications, defined as catheter colonization on removal (primary end point), and catheter-related bloodstream infection.

Results Patient and catheter characteristics, including duration of catheterization, were similar in both groups. More hematomas occurred in the jugular group than in the femoral group (13/366 patients [3.6%] vs 4/370 patients [1.1%], respectively; P = .03). The risk of catheter colonization at removal did not differ significantly between the femoral and jugular groups (incidence of 40.8 vs 35.7 per 1000 catheter-days; hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.62-1.16; P = .31). A prespecified subgroup analysis demonstrated significant qualitative heterogeneity by BMI (P for the interaction term < .001). Jugular catheterization significantly increased incidence of catheter colonization vs femoral catheterization (45.4 vs 23.7 per 1000 catheter-days; HR, 2.10; 95% CI, 1.13-3.91; P = .017) in the lowest tercile (BMI <24.2), whereas jugular catheterization significantly decreased this incidence (24.5 vs 50.9 per 1000 catheter-days; HR, 0.40; 95% CI, 0.23-0.69; P < .001) in the highest tercile (BMI >28.4). The rate of catheter-related bloodstream infection was similar in both groups (2.3 vs 1.5 per 1000 catheter-days, respectively; P = .42).

Conclusion Jugular venous catheterization access does not appear to reduce the risk of infection compared with femoral access, except among adults with a high BMI, and may have a higher risk of hematoma.

Trial Registration clinicaltrials.gov Identifier: NCT00277888

2008 Electromagnetic Interference From Radio Frequency Identification Inducing Potentially Hazardous Incidents in Critical Care Medical Equipment

Remko van der Togt, MSc; Erik Jan van Lieshout, MD; Reinout Hensbroek, MSc; E. Beinat, PhD; J. M. Binnekade, PhD; P. J. M. Bakker, MD, PhD
JAMA. 2008;299(24):2884-2890.


Context Health care applications of autoidentification technologies, such as radio frequency identification (RFID), have been proposed to improve patient safety and also the tracking and tracing of medical equipment. However, electromagnetic interference (EMI) by RFID on medical devices has never been reported.

Objective To assess and classify incidents of EMI by RFID on critical care equipment.

Design and Setting Without a patient being connected, EMI by 2 RFID systems (active 125 kHz and passive 868 MHz) was assessed under controlled conditions during May 2006, in the proximity of 41 medical devices (in 17 categories, 22 different manufacturers) at the Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands. Assessment took place according to an international test protocol. Incidents of EMI were classified according to a critical care adverse events scale as hazardous, significant, or light.

Results In 123 EMI tests (3 per medical device), RFID induced 34 EMI incidents: 22 were classified as hazardous, 2 as significant, and 10 as light. The passive 868-MHz RFID signal induced a higher number of incidents (26 incidents in 41 EMI tests; 63%) compared with the active 125-kHz RFID signal (8 incidents in 41 EMI tests; 20%); difference 44% (95% confidence interval, 27%-53%; P < .001). The passive 868-MHz RFID signal induced EMI in 26 medical devices, including 8 that were also affected by the active 125-kHz RFID signal (26 in 41 devices; 63%). The median distance between the RFID reader and the medical device in all EMI incidents was 30 cm (range, 0.1-600 cm).

Conclusions In a controlled nonclinical setting, RFID induced potentially hazardous incidents in medical devices. Implementation of RFID in the critical care environment should require on-site EMI tests and updates of international standards.

2008 Sodium Bicarbonate vs Sodium Chloride for the Prevention of Contrast Medium-Induced Nephropathy in Patients Undergoing Coronary Angiography - A Randomized Trial

Somjot S. Brar, MD; Albert Yuh-Jer Shen, MD; Michael B. Jorgensen, MD; Adam Kotlewski, MD; Vicken J. Aharonian, MD; Natasha Desai, BS; Michael Ree, BS; Ahmed Ijaz Shah, MD; Raoul J. Burchette, MS
JAMA. 2008;300(9):1038-1046.


Context Sodium bicarbonate has been suggested as a possible strategy for prevention of contrast medium-induced nephropathy, a common cause of renal failure associated with prolonged hospitalization, increased health care costs, and substantial morbidity and mortality.

Objective To determine if sodium bicarbonate is superior to sodium chloride for preventing contrast medium-induced nephropathy in patients with moderate to severe chronic kidney dysfunction who are undergoing coronary angiography.

Design, Setting, and Patients Randomized, controlled, single-blind study conducted between January 2, 2006, and January 31, 2007, and enrolling 353 patients with stable renal disease who were undergoing coronary angiography at a single US center. Included patients were 18 years or older and had an estimated glomerular filtration rate of 60 mL/min per 1.73 m2 or less and 1 or more of diabetes mellitus, history of congestive heart failure, hypertension, or age older than 75 years.

Interventions Patients were randomized to receive either sodium chloride (n = 178) or sodium bicarbonate (n = 175) administered at the same rate (3 mL/kg for 1 hour before coronary angiography, decreased to 1.5 mL/kg per hour during the procedure and for 4 hours after the completion of the procedure).

Main Outcome Measure The primary end point was a 25% or greater decrease in the estimated glomerular filtration rate on days 1 through 4 after contrast exposure.

Results Median patient age was 71 (interquartile range, 65-76) years, and 45% had diabetes mellitus. The groups were well matched for baseline characteristics. The primary end point was met in 13.3% of the sodium bicarbonate group and 14.6% of the sodium chloride group (relative risk, 0.94; 95% confidence interval, 0.55-1.60; P = .82). In patients randomized to receive sodium bicarbonate vs sodium chloride, the rates of death, dialysis, myocardial infarction, and cerebrovascular events did not differ significantly at 30 days (1.7% vs 1.7%, 0.6% vs 1.1%, 0.6% vs 0%, and 0% vs 2.2%, respectively) or at 30 days to 6 months (0.6% vs 2.3%, 0.6% vs 1.1%, 0.6% vs 2.3%, and 0.6% vs 1.7%, respectively) (P > .10 for all).

Conclusion The results of this study do not suggest that hydration with sodium bicarbonate is superior to hydration with sodium chloride for the prevention of contrast medium-induced nephropathy in patients with moderate to severe chronic kidney disease who are undergoing coronary angiography.

Trial Registration clinicaltrials.gov Identifier: NCT00312117