This audio summary is sponsored by Medtronic . The world ex
This summary covers the issue of March 4, 2010. Featured are articles on dopamine vs. norepinephrine for shock; ethosuximide, valproic acid, and lamotrigine in childhood absence epilepsy; glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults; pneumococcal conjugate vaccine in HIV-infected adults; and the collection of data on patients’ race and ethnic group; a review article on the management of varices and variceal hemorrhage in cirrhosis; a Clinical Problem-Solving article on stalking the diagnosis; and Perspective articles on Partners in Health and the Haitian earthquake, on Medicare’s opportunity to encourage innovation in health care delivery, and on the FDA’s review of a new antidiabetic therapy.
Comparison of dopamine and norepinephrine in the treatment of shock by Daniel Debarcar from the Brasma University of Hospital ,Brussel,Belgium.
Both dopamine and norepinephrine are recommended as first line vesopressor agent in the treatment of shock.There is a continuing controversy about whether the one agent is superior to the other. In this trial comparing dopamine and norepinephrine as the initial vesopressor therapy in the treatment of shock.There was no significant between group difference in the rate of death at 28 days. 52.5% in the dopamine group and 48.5% in the norepinephrine group.However there were more arrythmic events among the patients treated with dopamine than among those treated with norepinephrine.24.1% vs 12.4% respectively. A subgroup analysis shows that dopamine as compared with norepinephrine was associated with an increased rate of death at 28 days among the patients with cardiogenic shock but not among the patient with septic shock or hypovolemic shock. Although there was no signifiant difference in rate of death between patient with shock who were treated with dopamine as the first line vasopressor agent and those who were treated with nopepinephrine, the use of dopamine were associated with a greater number of adverse events.Gerald Livi from Amber University School from Atlanta writes in an editorial that historically there is a wide spread clinical perception that the use of noepinephrine in patient with shock may increase the risk of death. As shown in the study shock from any cause carries a high risk of death and vasopressor are temporising agents that are administered until the underlying cause has been treated or the shock has been resolved. The result of the study should been put into end to the outdated view that the use of norepinephrine increases the rate of death.
Ethosuximide valproic acid
and Lamotrigine in childhood absence epilepsy by Tracy Glaucer from the Sinsinati Children Hospital, Ohio. the most efficacious and tolerable initial empirical treatment for childhood absence epilepsy has not defined. This trial compare the efficacy, tolerability and neuropsychological effects of Ethosuximide valproic acid and Lamotrigine in children with newly diagnosed childhood absence epilepsy.After 16 weeks of therapy the freedom from failure rates for Ethosuximide and valproic acid were similar 53% and 58% respectivley and were higher than the rate
for Lamotrigine 29%. There were no significant differences among the three drugs with regard to discontinuation because of adverse effects. Attentional disfunction was more common with valproic acid than with ethosuximide in 49% of children v/s 33%. Ethosuximide and valproic acid are more effective than lamotrigine in the treatment of childhood absonce epilepsy.ethosuccimide is associated with fewer adverse attentional effects.
In an editorial Ilin Vinin from The John Hopkin's University School of Medicine, Baltimore writes this is an age when newest therapy is assumed to be more effective and better tolerated than older therapies.But there is no substantive clinical evidence that this is necessarily true. In addition the new therapy typically come at considerable cost.The study by Glaucer and Colleageus has given us a robost evaluation of 3 anti convulasant agent and the winner was Ethosuximide a drug from 1950s and the oldest of the three.
Glycated hemoglobin ,diabetes and cardiovascular risk in non diabetic adult by Elisabeth Salvin from The John Hopkins bloomberg school of public health baltimore.
This community based study of non diabetic adults compare the prognostic value of glycated hemoglobin and fasting glucose for identifying a person at risk for
clinical outcomes such as diabetes. For glycated hemoglobin values for less than 5% , 5-<5%, 5.%5-<6%, 6-<6.5% and 6.5% or greater.The multivariable adjusted hazard ratio for diagnosed diabetes where 0.5-1.00, 1.86, 4.48 and 16.47 respectively. For coronary heart disease the hazard ratio were 0.96,1.00,1.23,1.78,1.95 respectively. The hazard ratio for stroke were similar. In contrast glycated hemoglobin and death for many casue were found to have J shaped association curve. For coronary heart disease ,measure of risk
discrimination showed significant improvement when glycated hemoglobin was added to models including fasting glucose .in non diabetic adults,glycated hemoglobin was similarly associated with a risk of diabetes and more strongly associated with the risk of cardiovascular disease and death for many cause as compared with fasting glucose.These data add to the evidence supporting the use of
glycated hemoglobin as a diagnostic test for diabetes.
A trial of seven valiant pneumococcal conjugate vaccine in HIV infected adults by Neil French from Liverpool welcome trust clinical research programme
Pneumococcal infection is the important cause of death and complication in adult with HIV infection particularly in Africa. In this trial involving 496 predominatly HIV infected adult who has recently invasive pneumococcal infection. the seven valiant conjugated pneumococcal vaccine was found to have 74 %efficacy in preventing subsequent invasive pneumoccal infection with a vaccine associated serotype.there were 67th episode of pneumococcal disease in 52 patients all in the HIV affected subgroup.In 24 patients there were 19 episodes that were caused by vaccine serotypes
and 5 episodes that were caused by the 6A serotype. Of these episodes ,5 occured in the vaccine group,and 19 in the plosibo group for the vaccine efficacy of 74%. The number of serieous adverse events within 14 days after vaccination were significantly low in the vaccine group than in the plosibo group 3v/s 17 and the number of minor adverse effect were significantly higher in the vaccine group than in the plosibo group 41 v/s 13 . The seven valent pneumoccocal conjugate vaccine protected HIV infected adult from recurrent pneumococcal infection caused by vaccine serotypes or serotype 6A.
the management of varices and variceal hemorrhage in cirrhosis.
A review article by Garcia itself from Yale University School of Medicine New Heaven Canadicap.
Variceal hemorrhage is a lethal complication of cirrhosis particularly in patient in whom clinical decompensation that is ascites, encephaopathy, a previous episode of hemorrhage or jaundice has already developed. Gastroesophageal varices are direct conseqences of portal hypertension that in cirrhosis results from both increased resistance to portal flow and increased portal venous blood inflow. Increased resistance is both structural distorsion of liver vasular architecture by fibrosis and regenerative nazoles and dynamic increased hepatic vascular tone to the endothelial dysfunction and decreased nitric oxide biavailability. When a portal pressure gradient increases above a certain threshold, collateral develop at the sites of communication between portal and systemic circulations. This process is modulated
by angiogenic factors concomitantly with the formation of portal systemic collaterals. Portal venous blood inflow increase as a result of splanchnic vasodilation and increase cardiac output. Increased portal flow maintains and exacerbates portal hypertension. Gastroesophageal varices are the important collaterals because its pressure and flow increase through them. They grow and eventually rupture.this review explain the three main challenges in clinical management. Primary prophylaxis to prevent a first episode of hemorrhage, the treatment of acute bleeding episodes and secondary prophylaxis to prevent the recurrence of variceal hemorrhages.
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