Explore the vast range of titles available.

In this trial, patients with acute MI and cardiogenic shock who were expected to undergo coronary revascularization were randomly assigned to receive or not to receive intraaortic balloon support. Balloon support had no effect on 30-day mortality. The rate of death among patients with cardiogenic shock complicating acute myocardial infarction is high even when the patients undergo early revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). 1 – 4 Intraaortic balloon counterpulsation is the most widely used form of mechanical hemodynamic support in this clinical setting. 5 In U.S. and European guidelines, the use of an intraaortic balloon in the treatment of cardiogenic shock is given a class IB and class IC recommendation, respectively. 6 – 8 However, evidence is based mainly on registry data, and there is a lack of adequately powered randomized trials. A meta-analysis that . . .

In current international guidelines the recommendation for intra-aortic balloon pump (IABP) use has been downgraded in cardiogenic shock complicating acute myocardial infarction on the basis of registry data. In the largest randomised trial (IABP-SHOCK II), IABP support did not reduce 30 day mortality compared with control. However, previous trials in cardiogenic shock showed a mortality benefit only at extended follow-up. The present analysis therefore reports 6 and 12 month results. The IABP-SHOCK II trial was a randomised, open-label, multicentre trial. Patients with cardiogenic shock complicating acute myocardial infarction who were undergoing early revascularisation and optimum medical therapy were randomly assigned (1:1) to IABP versus control via a central web-based system. The primary efficacy endpoint was 30 day all-cause mortality, but 6 and 12 month follow-up was done in addition to quality-of-life assessment for all survivors with the Euroqol-5D questionnaire. A masked central committee adjudicated clinical outcomes. Patients and investigators were not masked to treatment allocation. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov, NCT00491036. Between June 16, 2009, and March 3, 2012, 600 patients were assigned to IABP (n=301) or control (n=299). Of 595 patients completing 12 month follow-up, 155 (52%) of 299 patients in the IABP group and 152 (51%) of 296 patients in the control group had died (relative risk [RR] 1·01, 95% CI 0·86–1·18, p=0·91). There were no significant differences in reinfarction (RR 2·60, 95% CI 0·95–7·10, p=0·05), recurrent revascularisation (0·91, 0·58–1·41, p=0·77), or stroke (1·50, 0·25–8·84, p=1·00). For survivors, quality-of-life measures including mobility, self-care, usual activities, pain or discomfort, and anxiety or depression did not differ significantly between study groups. In patients undergoing early revascularisation for myocardial infarction complicated by cardiogenic shock, IABP did not reduce 12 month all-cause mortality. German Research Foundation; German Heart Research Foundation; German Cardiac Society; Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte; University of Leipzig—Heart Centre; Maquet Cardiopulmonary; Teleflex Medical.

Circulatory shock is present when physical signs and changes in laboratory values suggest tissue hypoperfusion. This article in the Critical Care Medicine series reviews the diagnosis and treatment of various forms of shock. Shock is the clinical expression of circulatory failure that results in inadequate cellular oxygen utilization. Shock is a common condition in critical care, affecting about one third of patients in the intensive care unit (ICU). 1 A diagnosis of shock is based on clinical, hemodynamic, and biochemical signs, which can broadly be summarized into three components. First, systemic arterial hypotension is usually present, but the magnitude of the hypotension may be only moderate, especially in patients with chronic hypertension. Typically, in adults, the systolic arterial pressure is less than 90 mm Hg or the mean arterial pressure is less than 70 . . .

The HeartMate II left ventricular assist device is widely used to support failing myocardium. In early 2011, one large center noticed an increasing frequency of thrombosis with this LVAD. It was confirmed at three other centers, but the cause has not been identified. The HeartMate II (Thoratec), a small, axial-flow left ventricular assist device (LVAD), rapidly became integral to the treatment of patients with advanced heart failure. 1 Pivotal trials and postmarketing approval studies of the HeartMate II provide a reference occurrence of thrombosis of 2 to 4% 2 – 4 ; however, an unexpected abrupt increase in the incidence of pump thrombosis was observed in a single-center quality review. To confirm that this finding was not an isolated phenomenon, two additional experienced centers pooled data to investigate the incidence of pump thrombosis and of elevated lactate dehydrogenase (LDH) levels as its clinical biomarker (indicating hemolysis), . . .

Abstract Background Measurement of fractional nitric oxide (NO) concentration in exhaled breath (FeNO) is a quantitative, noninvasive, simple, and safe method of measuring airway inflammation that provides a complementary tool to other ways of assessing airways disease, including asthma. While FeNO measurement has been standardized, there is currently no reference guideline for practicing health care providers to guide them in the appropriate use and interpretation of FeNO in clinical practice. Purpose To develop evidence-based guidelines for the interpretation of FeNO measurements that incorporate evidence that has accumulated over the past decade. Methods We created a multidisciplinary committee with expertise in the clinical care, clinical science, or basic science of airway disease and/or NO. The committee identified important clinical questions, synthesized the evidence, and formulated recommendations. Recommendations were developed using pragmatic systematic reviews of the literature and the GRADE approach. Results The evidence related to the use of FeNO measurements is reviewed and clinical practice recommendations are provided. Conclusions In the setting of chronic inflammatory airway disease including asthma, conventional tests such as FEV1 reversibility or provocation tests are only indirectly associated with airway inflammation. FeNO offers added advantages for patient care including, but not limited to (1) detecting of eosinophilic airway inflammation, (2) determining the likelihood of corticosteroid responsiveness, (3) monitoring of airway inflammation to determine the potential need for corticosteroid, and (4) unmasking of otherwise unsuspected nonadherence to corticosteroid therapy.

Abstract Rationale The mechanistic basis for cardiac and renal dysfunction in sepsis is unknown. In particular, the degree and type of cell death is undefined. Objectives To evaluate the degree of sepsis-induced cardiomyocyte and renal tubular cell injury and death. Methods Light and electron microscopy and immunohistochemical staining for markers of cellular injury and stress, including connexin-43 and kidney-injury-molecule-1 (Kim-1), were used in this study. Measurements and Main Results Rapid postmortem cardiac and renal harvest was performed in 44 septic patients. Control hearts were obtained from 12 transplant and 13 brain-dead patients. Control kidneys were obtained from 20 trauma patients and eight patients with cancer. Immunohistochemistry demonstrated low levels of apoptotic cardiomyocytes (<1–2 cells per thousand) in septic and control subjects and revealed redistribution of connexin-43 to lateral membranes in sepsis (P < 0.020). Electron microscopy showed hydropic mitochondria only in septic specimens, whereas mitochondrial membrane injury and autophagolysosomes were present equally in control and septic specimens. Control kidneys appeared relatively normal by light microscopy; 3 of 20 specimens showed focal injury in approximately 1% of renal cortical tubules. Conversely, focal acute tubular injury was present in 78% of septic kidneys, occurring in 10.3 ± 9.5% and 32.3 ± 17.8% of corticomedullary-junction tubules by conventional light microscopy and Kim-1 immunostains, respectively (P < 0.01). Electron microscopy revealed increased tubular injury in sepsis, including hydropic mitochondria and increased autophagosomes. Conclusions Cell death is rare in sepsis-induced cardiac dysfunction, but cardiomyocyte injury occurs. Renal tubular injury is common in sepsis but presents focally; most renal tubular cells appear normal. The degree of cell injury and death does not account for severity of sepsis-induced organ dysfunction.

In a single-group trial, 48 children with severe heart failure received a ventricular assist device designed for children. Survival rates were significantly higher in this group than among propensity-score–matched children receiving support with extracorporeal membrane oxygenation. Systolic heart failure causes 280,000 deaths in adults annually in the United States. 1 Heart failure is much less common among children than among adults, but it is highly lethal, with 46% of children with heart failure dying or undergoing transplantation within 5 years after diagnosis, according to one estimate. 2 The survival rate among children after heart transplantation is estimated at 83% at 3 years, 3 , 4 but the limited availability of donor hearts for children prolongs the waiting period, 5 resulting in a high rate of death among children on waiting lists. 6 – 8 Options for mechanical circulatory support as a bridge to . . .

Background. Incidence and impact on adult patients' outcomes of nosocomial infections (NIs) occurring during venoarterial extracorporeal membrane oxygenation (VA-ECMO) support for refractory cardiogenic shock have rarely been described. Methods. We retrospectively reviewed the charts of a large series of patients who received VA-ECMO in our intensive care unit (ICU) from January 2003 through December 2009. Incidence, types, risk factors, and impact on outcomes of NIs occurring during ECMO support were analyzed. Results. Among 220 patients (49 ± 16 years old, simplified acute physiology score (SAPS) II 61 ± 20) who underwent ECMO support for >48 hours for a total of 2942 ECMO days, 142 (64%) developed NIs. Ventilatorassociated pneumonia (VAP), bloodstream infections, cannula infections, and mediastinitis infections occurred in 55%, 18%, 10% and 11% of the patients, respectively. More critical condition at ICU admission, but not antibiotics at the time of ECMO cannulation, was associated with subsequently developing NIs (hazard ratio, 0.73; 95% confidence interval [CI], .50-1.05; P = .09). Infected patients had longer durations of mechanical ventilation, ECMO support, and hospital stays. Independent predictors of death were infection with severe sepsis or septic shock (odds ratio, 1.93; 95% CI, 1.26-2.94; P =. 002) and SAPS II, whereas immunosuppression and myocarditis as the reason for ECMO support were associated with better outcomes. Conclusions. Cardiogenic shock patients who received the latest generation VA-ECMO still had a high risk of developing NIs, particularly VAP. Strategies aimed at preventing these infections may improve the outcomes of these critically ill patients.

This comparative-effectiveness trial assessed clinical outcomes in patients with advanced heart failure who were not candidates for cardiac transplantation and who had a continuous-flow left ventricular assist device as compared with a pulsatile-flow device. The continuous-flow device resulted in better clinical outcomes, but it has not yet been approved by the Food and Drug Administration. This comparative-effectiveness trial assessed clinical outcomes in patients with advanced heart failure who had a continuous-flow left ventricular assist device as compared with a pulsatile-flow device. The continuous-flow device resulted in better clinical outcomes. Medical and electrical therapies for systolic heart failure have improved outcomes and altered the natural history of the disease. 1 – 9 However, heart failure commonly progresses and becomes refractory to current treatments. Continuous intravenous inotropic support may improve clinical status in the short term but results in a survival rate at 1 year of only 10 to 30%. 10 , 11 Cardiac transplantation is available for only a minority of patients, because of a lack of suitable donor hearts. The paucity of effective therapies for advanced heart failure led to the evaluation of mechanical circulatory-support devices as permanent therapy. To date, only two . . .

Purpose To determine whether nutritional support guided by repeated measurements of resting energy requirements improves the outcome of critically ill patients. Methods This was a prospective, randomized, single-center, pilot clinical trial conducted in an adult general intensive care (ICU) unit. The study population comprised mechanically ventilated patients ( n  = 130) expected to stay in ICU more than 3 days. Patients were randomized to receive enteral nutrition (EN) with an energy target determined either (1) by repeated indirect calorimetry measurements (study group, n  = 56), or (2) according to 25 kcal/kg/day (control group, n  = 56). EN was supplemented with parenteral nutrition when required. Results The primary outcome was hospital mortality. Measured pre-study resting energy expenditure (REE) was similar in both groups (1,976 ± 468 vs. 1,838 ± 468 kcal, p  = 0.6). Patients in the study group had a higher mean energy (2,086 ± 460 vs. 1,480 ± 356 kcal/day, p  = 0.01) and protein intake (76 ± 16 vs. 53 ± 16 g/day, p  = 0.01). There was a trend towards an improved hospital mortality in the intention to treat group (21/65 patients, 32.3% vs. 31/65 patients, 47.7%, p  = 0.058) whereas length of ventilation (16.1 ± 14.7 vs. 10.5 ± 8.3 days, p  = 0.03) and ICU stay (17.2 ± 14.6 vs. 11.7 ± 8.4, p  = 0.04) were increased. Conclusions In this single-center pilot study a bundle comprising actively supervised nutritional intervention and providing near target energy requirements based on repeated energy measurements was achievable in a general ICU and may be associated with lower hospital mortality.