Latest Articles
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Meta Analysis Comparative Study
Efficacy of hypertonic 7.5% saline and 6% dextran-70 in treating trauma: a meta-analysis of controlled clinical studies.
Individual trials of small-volume resuscitation of 7.5% NaCl (HS) with and without 6% dextran 70 (HSD) for the treatment of trauma have failed to provide convincing evidence of efficacy. We performed a meta-analysis to evaluate the effects of HS and HSD on survival until discharge or for 30 days. We identified eight double-blinded, randomized controlled trials of HSD and six trials of HS. In all cases, administration of 250 ml of HSD or HS was compared with a control group administration of 250 ml of isotonic crystalloid for the treatment of hypotension either in the field or at admission to the emergency department. ⋯ The meta-analysis of the available data shows that HS is not different from the standard of care and that HSD may be superior.
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To review the literature addressing the use of the pulmonary artery catheter (PAC) in patients with cardiovascular disease. ⋯ Pulmonary artery catheterization is often used to optimize patient management, although this may not be demonstrable in terms of prospective trials using mortality or other "hard" outcome measures. Nonetheless, more rapid diagnosis and achievement of therapeutic endpoints guided by PAC use can decrease morbidity and intensive care days.
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To review the literature addressing the new pulmonary artery catheters: continuous venous oximetry, right ventricular ejection fraction, and continuous cardiac output. ⋯ Clinician misinterpretation and misapplication of the data appear to be the greatest impediment to using pulmonary artery catheterization to alter pathophysiologic processes and improve outcome in critically ill patients. Future research should first document effectiveness or lack of effectiveness of the "standard" pulmonary artery catheter (PAC). Pending these results, outcome and cost/benefit studies should be performed comparing "standard" with new PACs.
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The main therapy for primary breast cancer is not surgery, but a systemic therapy involving administration of cytotoxic chemotherapy or the use of ablative or additive endocrine therapy to control disseminated micrometastasis. The results of randomized trials and meta-analysis show that CMF, the standard adjuvant chemotherapy, is effective regardless of axillar lymph node involvement or menopausal status. Effectiveness of adjuvant chemotherapy with an anthracyclin-based regimen remains controversial. The trial by CUBC and NSAS-BC comparing UFT, widely used in the management of patients with breast cancer in Japan, with CMF is on-going.
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The prognostic significance of major organ and tissue infection was examined in 909 episodes of bacteremia that were selected from 10 consecutive, randomized clinical trials of antibiotic therapy for infection in patients with cancer and neutropenia. Extensive tissue infection significantly compromised response to initial therapy (38% vs. 74%; P < .0001), ultimate outcome of infection (73% vs. 94%; P < .0001), median time to normalization of temperature (5.3 days vs. 2.5 days; P < .0001), and survival (P < .0001). Other poor prognostic factors revealed by logistic regression included shock (P < .0001) and bacteremia caused by Pseudomonas species (P = .03), Clostridium species (P = .006), or a pathogen resistant to antibiotics used for initial therapy (P < .0001). ⋯ Patients with bacteremia due to alpha-hemolytic streptococcus died more often when vancomycin was not included in the initial empirical regimen (P = .004). Because of the prognostic significance of extensive tissue or major organ infection, this factor should be considered in decisions concerning modification of therapy and use of colony-stimulating factors. The cost-effectiveness of initial monotherapy and delayed vancomycin therapy remains to be demonstrated.