Hospital practice (1995)
-
Hospital practice (1995) · Oct 2011
Perioperative management of patients receiving anticoagulant or antiplatelet therapy: a clinician-oriented and practical approach.
The management of patients who are receiving warfarin, aspirin, clopidogrel, or combinations of these drugs and require their interruption because of an elective surgical or other invasive procedure is a common and sometimes challenging clinical problem. For the practicing clinician, there are 2 key issues for perioperative anticoagulant management: 1) having an approach to stratify patients according to their risk for thromboembolism when warfarin or antiplatelet drug therapy is interrupted, and also having an approach to stratify patients according to the risk of bleeding associated with the surgery or procedure; and 2) determining which patients may require bridging anticoagulation and, if required, how to administer bridging, typically with a low-molecular-weight heparin, before and after surgery in a manner that minimizes the risk for bleeding. The overall goal is to minimize patients' risk for thromboembolism and bleeding throughout the perioperative period. The objective of this article is to provide an evidence-based but practical approach relating to these 2 key issues in a manner than can be applied to everyday clinical practice.
-
Hospital practice (1995) · Oct 2011
ReviewLung cancer screening: a review of available data and current guidelines.
Lung cancer is the leading cause of cancer mortality worldwide. A lack of clinical symptoms in early-stage disease frequently leads to diagnosis at a late stage, and a 15% 5-year survival rate in all patients so diagnosed. This has led to significant interest in effective screening methods to detect early-stage cancers, particularly for high-risk groups, such as current or former smokers. ⋯ The most recent trials have focused on LDCT scans, including the National Lung Screening Trial. Data released from the National Lung Screening Trial demonstrated a statistically significant reduction in lung cancer deaths in patients screened with LDCT scans. When data from the study, including cost-effectiveness, are completely analyzed, they may lead to revision of current lung cancer screening recommendations to include LDCT scans in specific populations at high risk of developing lung cancer.
-
Hospital practice (1995) · Oct 2011
ReviewApixaban for stroke prevention in atrial fibrillation: a review of the clinical trial evidence.
The objective of this review is to summarize data from the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) and Apixaban Versus Acetylsalicylic Acid to Prevent Stroke in Atrial Fibrillation Patients Who Have Failed or Are Unsuitable for Vitamin K Antagonist Treatment (AVERROES) trials of apixaban for stroke prevention in patients with atrial fibrillation (AF). The ARISTOTLE trial compared apixaban with warfarin in 18 201 patients with AF and ≥ 1 additional risk factor for stroke. The AVERROES trial compared apixaban with aspirin in 5599 patients with AF who were at increased risk of stroke and for whom vitamin K antagonists were unsuitable. ⋯ Discontinuation of study medication was significantly lower with apixaban than with either warfarin in ARISTOTLE or aspirin in AVERROES. Apixaban is the first new oral anticoagulant that has been shown to be superior to warfarin in reducing stroke or systemic embolism, all-cause mortality, and major bleeding in patients with AF. Moreover, in patients with AF who are considered unsuitable for warfarin therapy, apixaban was more effective than aspirin for stroke prevention and had a similar rate of major bleeding.
-
Hospital practice (1995) · Oct 2011
ReviewA review of recent clinical trials and guidelines on the prevention and management of delirium in hospitalized older patients.
Treatment of acute illness in older adults is frequently complicated by the presence of delirium. Delirium is characterized by the development of an altered mental status over the course of hours to days, and can have a fluctuating course. Patients with delirium have difficulty paying attention to their environment, have disorganized thinking, and usually have an altered level of consciousness. ⋯ Perioperative use of antipsychotics may further reduce the incidence of delirium, although hospital length of stay has not been routinely reduced. Appropriate management of analgesia, sedation, and delirium in the intensive care unit is also associated with reduced duration of mechanical ventilation, as well as intensive care unit and hospital length of stay. The use of dexmedetomidine, an α-adrenergic receptor agonist, for sedation may reduce intensive care unit length of stay when compared with use of benzodiazepines.
-
Hospital practice (1995) · Aug 2011
ReviewSepsis: the inflammatory foundation of pathophysiology and therapy.
Sepsis, defined as an infection accompanied by inflammation, is a complex disease process wherein the body's response to a pathogen is amplified far beyond the initial site of infection. The process begins when pathogen-associated molecular patterns on the bacteria or other pathogens induce an inflammatory cascade in the host. In the United States, it is estimated that every minute a patient with severe sepsis or septic shock presents to an emergency department and that > 751 000 cases of severe sepsis occur annually, resulting in an estimated 215 000 deaths. ⋯ The clinical management of severe sepsis and septic shock has evolved dramatically over the past decade and these new therapeutic approaches have been built on a deeper understanding of the natural evolution of sepsis. This article examines the underlying pathophysiological mechanisms of sepsis to help explain the clinical signs and symptoms manifested by severe sepsis patients. It also examines the significance of current proposed treatment strategies, including early goal-directed therapy, from a pathophysiological and inflammatory perspective.