Annals of internal medicine
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Review Meta Analysis
Implantable cardioverter defibrillators in primary and secondary prevention: a systematic review of randomized, controlled trials.
Sudden cardiac death is common in persons with cardiovascular disease. ⋯ Implantable cardioverter defibrillators prevent sudden cardiac death regardless of baseline risk. However, their impact on total mortality is sensitive to baseline risk for arrhythmic death. Decisions about resource allocation for ICDs depend on accurate stratification of patients according to risk.
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Review Meta Analysis
Implantable cardioverter defibrillators in primary and secondary prevention: a systematic review of randomized, controlled trials.
Sudden cardiac death is common in persons with cardiovascular disease. ⋯ Implantable cardioverter defibrillators prevent sudden cardiac death regardless of baseline risk. However, their impact on total mortality is sensitive to baseline risk for arrhythmic death. Decisions about resource allocation for ICDs depend on accurate stratification of patients according to risk.
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Ventilator-associated pneumonia is a common cause of morbidity in critically ill patients. Interventions beneficial to the prevention of ventilator-associated pneumonia would therefore have a significant impact on the care of these patients. ⋯ After evaluation of potential benefits and risks, the authors recommend considering several specific interventions to reduce the incidence of ventilator-associated pneumonia: semi-recumbent positioning in all eligible patients, sucralfate rather than H2-antagonists in patients at low to moderate risk for gastrointestinal tract bleeding, and aspiration of subglottic secretions and oscillating beds in select patient populations. Selective digestive tract decontamination is not recommended because routine use may increase antimicrobial resistance.
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Ventilator-associated pneumonia is a common cause of morbidity in critically ill patients. Interventions beneficial to the prevention of ventilator-associated pneumonia would therefore have a significant impact on the care of these patients. ⋯ After evaluation of potential benefits and risks, the authors recommend considering several specific interventions to reduce the incidence of ventilator-associated pneumonia: semi-recumbent positioning in all eligible patients, sucralfate rather than H2-antagonists in patients at low to moderate risk for gastrointestinal tract bleeding, and aspiration of subglottic secretions and oscillating beds in select patient populations. Selective digestive tract decontamination is not recommended because routine use may increase antimicrobial resistance.
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Despite the advances in supportive care and the availability of potent antimicrobial agents, mortality from sepsis, a leading cause of death in intensive care units, has not improved. Over the last decade, clinical trials with numerous adjunctive therapies, including antiendotoxin antibodies and inhibitors of the inflammatory response, have yielded disappointing results. Recently, treatment with recombinant human activated protein C reduced mortality 6% compared with controls. ⋯ Given the likelihood that sepsis represents an excessive innate immune response to microbial products, vigorous attempts must be made to develop rapid assays that reflect the level of innate immune activation. Such assays could be used to identify patients who would benefit from therapy and to monitor their response so that overtreatment does not completely abrogate host defense mechanisms and render these patients susceptible to fatal infection. It is now time to test a new therapeutic paradigm based on an improved understanding of the pathophysiology of the septic process and the recognition that we may have reached the limits of adjunctive monotherapy.