Effect of Non-Invasive Ventilation through Helmet Mask Vs Endotracheal Intubation

A recent randomized trial published in JAMA showed statistical significant decrease of endotracheal intubation in I.C.U patients with ARDS.

Total study population was 83 patients, with 45% being female and median APACHE II score 26. Among its results the study showed:

• 43.3% difference in endotracheal intubation between mask group and helmet group, P<0.001)
• increased ventilator-free days between the 2 groups (28 vs 12.5, P<0.001)
• decreased mortality between the 2 groups (22.3% difference, P: 0.02)

The helmet's adverse events were confined to 6.8% neck ulcers.

Source: JAMA , clinicaltrials.gov

New Evidence-based Guideline from the 8th Joing National Committee (JNC 8) for Hypertension Management (2014)

Recommendations for Management of Hypertension

Recommendation 1

In the general population aged ≥60 years, initiate pharmacologic treatment to lower blood pressure (BP) at systolic blood pressure (SBP) ≥150 mm Hg or diastolic blood pressure (DBP) ≥90 mm Hg and treat to a goal SBP <150 mm Hg and goal DBP <90 mm Hg. (Strong Recommendation – Grade A)

Corollary Recommendation

In the general population aged ≥60 years, if pharmacologic treatment for high BP results in lower achieved SBP (eg, <140 mm Hg) and treatment is well tolerated and without adverse effects on health or quality of life, treatment does not need to be adjusted. (Expert Opinion – Grade E)

Recommendation 2

In the general population <60 years, initiate pharmacologic treatment to lower BP at DBP ≥90 mm Hg and treat to a goal DBP <90 mm Hg. (For ages 30-59 years, Strong Recommendation – Grade A; For ages 18-29 years, Expert Opinion – Grade E)

Recommendation 3

In the general population <60 years, initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg and treat to a goal SBP <140 mm Hg. (Expert Opinion – Grade E)

Recommendation 4

In the population aged ≥18 years with chronic kidney disease (CKD), initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to goal SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert Opinion – Grade E)

Recommendation 5

In the population aged ≥18 years with diabetes, initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to a goal SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert Opinion – Grade E)

Recommendation 6

In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). (Moderate Recommendation – Grade B)

Recommendation 7

In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. (For general black population: Moderate Recommendation – Grade B; for black patients with diabetes: Weak Recommendation – Grade C)

Recommendation 8

In the population aged ≥18 years with CKD, initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes. This applies to all CKD patients with hypertension regardless of race or diabetes status. (Moderate Recommendation – Grade B)

Recommendation 9

The main objective of hypertension treatment is to attain and maintain goal BP. If goal BP is not reached within a month of treatment, increase the dose of the initial drug or add a second drug from one of the classes in recommendation 6 (thiazide-type diuretic, CCB, ACEI, or ARB). The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached. If goal BP cannot be reached with 2 drugs, add and titrate a third drug from the list provided. Do not use an ACEI and an ARB together in the same patient. If goal BP cannot be reached using only the drugs in recommendation 6 because of a contraindication or the need to use more than 3 drugs to reach goal BP, antihypertensive drugs from other classes can be used. Referral to a hypertension specialist may be indicated for patients in whom goal BP cannot be attained using the above strategy or for the management of complicated patients for whom additional clinical consultation is needed. (Expert Opinion – Grade E)

Source:  JAMA Network (http://jama.jamanetwork.com/article.aspx?articleid=1791497&utm_source=fbpage&utm_medium=social_jn&utm_term=480080132&utm_content=content_engagement%7carticle_engagement&utm_campaign=article_alert)

Novel anti-diabetic drug SLGT2 inhibitor Empagliflozin reduces cardiovascular mortality

The EMPA-REG OUTCOME study published in NEJM  showed multipe interesting effects of EMPAGLIFLOZIN, a sodium-glucose cotransporter 2 inhibitor, regarding redaction of cardiovascular morbidity in patients with type-2 diabetes.

The study randomized 7020 patients in 2 different doses of Empagliflozin (10 or 25mg) or placebo with primary composite outcome death from cardiovascular causes, not fatal myocardial infarction, or non fatal stroke.

Results showed statistically significant between group differences in death from cardiovascular causes, hospitalization for heart failure and death from any cause.

The mechanisms are still under investigation, however these effects are possibly attributed to pleiotropic effects of the drug, such as its anti-hypertensive action and weight reduction and  of SGLT-2 inhibitor.

For the full study click the link: http://www.nejm.org/doi/pdf/10.1056/NEJMoa1504720

Source: PUBMED, NEJM 

Low-dose versus High-dose Alteplase for Acute Ischemic Stroke

Primary and Secondary outcomes at 3 months

Thrombolytic therapy for Acute Ischemic stroke in lower doses may improve recovery, with simultaneous less haemorrhagic complications. 

The findings of a clinical trial of 3310 patients were randomized in 2 groups: a low-dose intravenous alteplase (0.6 mg per kilogram of body weight) or the standard dose (0.9 mg per kilogram).

The primary objective was to determine whether the low dose would be noninferior to the standard dose with respect to the primary outcome of death or disability at 90 days, which was defined by scores of 2 to 6 on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]). Secondary objectives were to determine whether the low dose would be superior to the standard dose with respect to centrally adjudicated symptomatic intracerebral hemorrhage and whether the low dose would be noninferior in an ordinal analysis of modified Rankin scale scores (testing for an improvement in the distribution of scores).

RESULTS

The primary outcome occurred in 855 of 1607 participants (53.2%) in the low-dose group and in 817 of 1599 participants (51.1%) in the standard-dose group (odds ratio, 1.09; 95% confidence interval [CI], 0.95 to 1.25; the upper boundary exceeded the noninferiority margin of 1.14; P=0.51 for noninferiority). Low-dose alteplase was noninferior in the ordinal analysis of modified Rankin scale scores (unadjusted common odds ratio, 1.00; 95% CI, 0.89 to 1.13; P=0.04 for noninferiority). Major symptomatic intracerebral hemorrhage occurred in 1.0% of the participants in the low-dose group and in 2.1% of the participants in the standard-dose group (P=0.01); fatal events occurred within 7 days in 0.5% and 1.5%, respectively (P=0.01). Mortality at 90 days did not differ significantly between the two groups (8.5% and 10.3%, respectively; P=0.07).

CONCLUSION

This trial involving predominantly Asian patients with acute ischemic stroke did not show the noninferiority of low-dose alteplase to standard-dose alteplase with respect to death and disability at 90 days. There were significantly fewer symptomatic intracerebral hemorrhages with low-dose alteplase.

SOURCE: Pubmed, NEJM, ENCHANTED ClinicalTrials.gov number, NCT01422616.)

The 3rd International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) of Feb 2016

Algorithm for Sepsis and Septic Shock identification

SOFA Score

New consensus definitions regarding sepsis and septic shock are proposed from Sepsis-3 consenus in February 2016.

Basic concepts of the new definitions are SOFA Score and Bedside quick SOFA Score (qSOFA). The latter is easily used since it is calculated using Clinical Criteria (decrease in mental status of more than 2 points in Glasgow Coma Scale, systolic blood pressure ≤100 mm Hg, or respiratory rate ≥22/min.).

SOFA Score of more than 2 is associated with in hospital mortality of more than 10%. In cases of septic shock mortality rate exceeds 40%.

SOURCE: JAMA network (http://jama.jamanetwork.com/mobile/article.aspx?articleid=2492881#jsc160002b3)

New Toronto Consensus Guidelines regarding Helicobacter pylori eradication therapy

The new guidelines regarding Helicobacter pylori eradication therapy propose 14-day regimens.

Because of increasing failure of therapy, the consensus group strongly recommended that all H. pylori eradication regimens now be given for 14 days. Recommended first-line strategies include concomitant non-bismuth quadruple therapy (proton pump inhibitor, PPI + amoxicillin + metronidazole + clarithromycin, PAMC), and traditional bismuth quadruple therapy (PPI + bismuth + metronidazole + tetracycline, PBMT). PPI triple therapy (PPI + clarithromycin and either amoxicillin or metronidazole) was restricted to areas with known low clarithromycin resistance or high eradication success with these regimens. Recommended rescue therapies include PBMT and levofloxacin-containing therapy (PPI + amoxicillin + levofloxacin, PAL). Rifabutin regimens should be restricted to patients who fail at least 3 prior options.

SOURCE: American Gastroenterology Association (http://www.gastrojournal.org/article/S0016-5085(16)30108-1/abstract)

ARDS New Definition and Classification

As from 2012 there is a new classification of Acute Respiratory Distress Syndrome (ARDS). I attach the Berlin Consensus of 2012 and a review article regarding the new classification and definition of ARDS.

ARDS New Definition - Berlin Consensus by Andreas Ioannou

ARDS New Definition - Journal of Thoracic Diseases 2013 by Andreas Ioannou