Postgraduate medicine
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Postgraduate medicine · May 2009
Multicenter Study Comparative StudyAntidiabetic therapy before and 1 year after discharge for patients manifesting in-hospital hyperglycemia.
While studies have evaluated the impact of hyperglycemia during hospitalization, little is known about its management before and after admission. ⋯ Hyperglycemia management was intensified for all DM+ patients, primarily with insulin in the hospital and both insulin and OHAs PD. A better understanding of this natural history and antidiabetic transitional care could facilitate better discharge planning and thus improve diabetes care.
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Postgraduate medicine · May 2009
Multicenter Study Comparative StudyImpact of an intensive care unit telemedicine program on a rural health care system.
We evaluated the impact of a 15-hospital, rural, multi-state intensive care unit (ICU) telemedicine program. Acute Physiology, Age, and Chronic Health Evaluation (APACHE III) scores, raw mortality rates, and actual-to-predicted length of stay (LOS) ratios and mortality ratios were used. Surveys evaluated program impact in smaller facilities and satisfaction of the physicians staffing the remote center. ⋯ In regional hospitals, acuity scores increased (retention of sicker patients) while raw mortality was the same or lower. Length of stay ratios were reduced in these hospitals. In the tertiary hospital, actual-to-predicted ICU and hospital mortality and LOS ratios decreased.
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Postgraduate medicine · May 2009
ReviewThe gravity of JUPITER (Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin).
In the recently published Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER) study, a large, randomized, placebo-controlled trial, rosuvastatin proved to be safe and remarkably effective in the setting of primary prevention. In patients without coronary heart disease or diabetes, with a baseline low-density lipoprotein cholesterol (LDL-C) level < 130 mg/dL and a C-reactive protein (CRP) > or = 2mg/L, a statin-induced LDL-C reduction of 50% reduced serious cardiac events by about 50%, including in women and the elderly, and also lowered all-cause mortality. ⋯ In general, the CRP-lowering efficacy of statin therapy is directly and significantly correlated with its LDL-C-lowering activity. Simvastatin, at the 80-mg daily dose, is more toxic to muscles and liver than other statins at their highest dose, and thus should be used with caution.
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Postgraduate medicine · May 2009
ReviewOriginal research: Intravenous ribavirin--review of the FDA's Emergency Investigational New Drug Database (1997-2008) and literature review.
Intravenous (IV) ribavirin does not have US Food and Drug Administration (FDA) approval, although oral and aerosol formulations have been approved. Intravenous ribavirin can, however, be authorized for use as a result of an Emergency Investigational New Drug (EIND) application as investigational treatment for patients with serious viral infections, including emerging or rare infections for which no alternative treatment is available. This retrospective study evaluated clinical experience with IV ribavirin based on a review of the FDA's EIND database and a literature review. ⋯ However, estimates of frequency, severity, and causality of AEs associated with IV ribavirin could not be determined because of study limitations. Our study findings suggest that the literature is inconclusive on the potential benefit for continued use of IV ribavirin. A review of the literature and the FDA's EIND database suggests that prospective, controlled trials of IV ribavirin in patients with adenovirus, parainfluenza, or serious respiratory syncytial virus infections could be feasible.
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In 2001, Van den Berghe et al published a landmark study of intensive insulin therapy in the setting of a surgical intensive care unit (ICU). Increased attention was also focused on the observational evidence indicating that hyperglycemia is associated with increased morbidity and mortality among diverse patient populations. Because of the dramatic reduction in mortality with normalization of glucose levels in the single center, the Van den Berghe study led to widespread adoption of this practice in ICUs worldwide. ⋯ Subsequent to the initial Van den Berghe study, other multicenter trials have been fraught with an increased frequency of hypoglycemia and have failed to consistently demonstrate improved outcomes with intensive insulin therapy. Hospitals and expert panels are in the process of examining the combined evidence and considering modifying treatment goals. We recommend continued focus on avoiding hyperglycemia with less aggressive glycemic targets in the critically ill and rational subcutaneous insulin in the noncritically ill, avoiding a return to the obsolescence of sliding-scale insulin.