Internal and emergency medicine
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Randomized Controlled Trial
Two different techniques of ultrasound-guided peripheral venous catheter placement versus the traditional approach in the pre-hospital emergency setting: a randomized study.
We performed a randomized pre-hospital clinical study to compare two different techniques of ultrasound-guided peripheral venous catheter (PVC) insertion and the conventional cannulation technique in the pre-hospital emergency setting, with a specific focus on the procedural success rate and the time required to introduce PVC. This pre-hospital prospective controlled randomized clinical trial allocated patients treated by emergency medical service to undergo PVC insertion fully controlled by ultrasound (ultrasound guidance of the PVC tip until it penetrates the lumen, group A), PVC insertion partially controlled by ultrasound (target vein identification only, group B) or to receive PVC without any ultrasound guidance (group C). The study outcomes were monitored until the patient was admitted to the hospital. ⋯ The number of attempts was significantly lower (A: 1.18 ± 0.54, B: 1.05 ± 0.22, C: 1.22 ± 0.57, p < 0.001) and the time required for the procedure shorter (A: 75.3 ± 60.6, B: 43.5 ± 26.0, C: 82.3 ± 100.9 s, p < 0.001) in group B compared to groups A and C. Both techniques of ultrasound-guided PVC placement were associated with higher success rates than the conventional method. However, PVC insertion partially controlled by ultrasound was superior to full ultrasound guidance in terms of time and number of cannulation attempts required.
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Antagonists of Vascular Endothelial Growth Factor (Anti-VEGF) are widely administered by intravitreal injection for the treatment of ocular pathologies such as Age-related Macular Degeneration, Diabetic Macular Edema, Proliferative Diabetic Retinopathy and occlusion of retinal vessels. Anti-VEGF agents, in particular bevacizumab, were introduced in oncology to inhibit tumor-induced angiogenesis feeding neoplastic tissues. Subsequently, other specific agents were developed for intraocular administration. ⋯ Nevertheless, clinical observations have raised the possibility that, even in these conditions, anti-VEGF agents may increase cardiovascular risk in patients who, being elderly and/or diabetic, are intrinsically prone to such events. This paper aims at reviewing the current knowledge on VEGF and its pharmacologic antagonists from mechanistic and side effect points of view, with specific reference to patients with sight-threatening conditions. Internists should be aware of the need to collaborate with ophthalmologists and pharmacovigilance operators to define as best as possible the risk/benefit balance of intravitreal agents in patients who might lose their sight if left untreated, or increase their risk of suffering a cardiovascular event if treated.
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Observational Study
Hyperchloremia and acute kidney injury: a retrospective observational cohort study on a general mixed medical-surgical not ICU-hospitalized population.
The aim of this observational retrospective cohort study was to analyze the association between hyperchloremia and serum chloride variation with in-hospital acute kidney injury (AKI) and mortality in a general, no-ICU hospitalized population. We performed a retrospective study on inpatient population admitted to Fondazione Policlinico Universitario A. Gemelli IRCCS between January 2010 and December 2014 with inclusion of adult patients with at least two values available for chloride, sodium and creatinine. ⋯ Regression analyses showed that only severe HA-hyperchloremia was associated with increased risk of in-hospital AKI [odds ratio (OR) 2.60, 95% confidence interval (CI) 1.58, 4.30, p value < 0.001] and death (OR 3.89, 95% CI 2.11, 7.18, p value < 0.001). With increasing ΔCl, the OR of in-hospital AKI increased progressively (p value for trend = 0.005). In conclusion, severe hyperchloremia is an independent predictor for in-hospital AKI and mortality; HA-hyperchloremia is more detrimental for patient outcome; higher ΔCl from hospital admission is associated with increased risk of AKI.
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We retrospectively studied the association between changes in exercise capacity at discharge from a home-based exercise program and the risk of all-cause mortality among patients with peripheral artery disease (PAD) and claudication. The records of 1076 consecutive PAD patients were assessed between 2003 and 2013. The exercise program was prescribed during a few visits and executed at home at symptom-free walking speed. ⋯ The completers (71 ± 9 years; 88% exercise sessions completed) showed significant improvements in the lowest ABI (from 0.62 ± 0.18 to 0.67 ± 0.19) and Smax (from 3.3 ± 1.1 to 3.8 ± 1.1 km h-1) at discharge. The completers who reached the clinically important difference of Smax ≥ 0.4 km h-1 at follow-up showed a significantly lower mortality risk (25% vs. 30%; HR 0.72; 95% CI 0.55-0.93) as well a lower rate of hospitalizations (p < 0.001). In conclusion, in PAD patients, active participation in a home-based exercise program was associated with a lower rate of death and better long-term clinical outcomes, particularly for those who attained a moderate increase in exercise capacity.