NEPHROTOXICITY
Certain drugs harsh on kidneys
Clinicians should be aware that some widely used products, including bisphosphonate drugs used to treat osteoporosis and bowel prep solution given before colonoscopy, can cause kidney damage in some. The risks are higher with nitrogen-containing types of bisphosphonate drugs and seem to depend on the individual patient and the total drug dose over time. Fortunately, kidney damage usually reverses after these drugs are stopped. (In 2006, the Food and Drug Administration issued an alert urging clinicians to avoid giving oral sodium phosphate to patients with kidney disease because of the risk of acute or chronic kidney failure.)
Other drugs can cause thrombotic microangiopathy, leading to acute kidney failure. These include immune-suppressing calcineurin inhibitors, which help prevent rejection after organ transplantation; some other immunosuppressants; and certain chemotherapy drugs. Iodine contrast agents used with computed tomography and other imaging studies and gadolinium used with magnetic resonance imaging can also be nephrotoxic in some patients, but gadolinium appears less damaging than iodine-based contrast media.
These problems were discussed at the American Society of Nephrology's 40th Annual Meeting and Scientific Exposition in San Francisco, Calif., last fall.
BLOOD TRANSFUSIONS
RBC pileup risks stroke, MI
Why are blood transfusions associated with a risk of myocardial infarction (MI) or stroke? A lack of nitric oxide in stored blood may be the key. Two recent studies have determined that nitric oxide, a potent vasodilator, begins to break down almost immediately during storage, impairing vasodilation. If blood vessels don't open, oxygen-carrying red blood cells (RBCs) can't reach tissues. Instead, they back up in vessels, increasing the risk of an occlusion.
Researchers discovered that nitric oxide begins breaking down within 3 hours after blood goes into storage. At the end of the first day of storage, nitric oxide levels had decreased significantly, and this decreased level persists for 42 days. Currently, blood can be stored for 42 days before it must be discarded.
When researchers restored nitric oxide to the blood, RBCs were again able to deliver oxygen to tissues, both in the lab and in animal studies. Researchers say that finding ways to maintain nitric oxide in stored blood may help reduce the incidence of MI and stroke associated with transfusions.
Sources: Reynolds JD, et al., S-nitrosohemoglobin deficiency: A mechanism for loss of physiological activity in banked blood, Proceedings of the National Academy of Sciences, October 23, 2007; Bennett-Guerrero E, et al., Evolution of adverse changes in stored RBCs, Proceedings of the National Academy of Sciences, October 23, 2007.
ZAPPINGVAP
Oral washes don't clean up problems
Because most cases of ventilator-associated pneumonia (VAP) are believed to originate with oropharyngeal pathogens, many clinicians use chlorhexidine-based oral washes in hopes of reducing the risk. But a recent small study suggests that these washes have little effect on VAP rates, although they may offer other benefits.
In a study of 82 newly intubated adults on mechanical ventilation, the patients' mouths were swabbed twice a day with either 2 mL of a 0.12% solution of chlorhexidine or a non-antiseptic enzymatic liquid used to prevent dry mouth in ventilated patients. Caregivers knew which treatment patients were receiving, but patients and physician evaluators didn't. All patients received standard procedures to prevent VAP and other ventilator-related complications, including daily sedation vacations, elevating the head of the bed, regular assessment for extubation, and prophylaxis for peptic ulcer disease and deep vein thrombosis.
Eight cases of VAP occurred in each treatment group, suggesting that the antiseptic wash had no effect on this condition. However, patients who received the antiseptic washes spent fewer days on the ventilator (5.1 days versus 9.5 days). Culture studies also showed that oropharyngeal bacterial growth in patients treated with the antiseptic wash was significantly reduced on day three of ventilation.
Researchers speculate that the chlorhexidine solution was too weak for maximum effectiveness in preventing VAP. They say the reduced ventilation days and lower bacteria loads associated with chlorhexidine washes suggest that it could be an effective tool for preventing VAP. Researchers reported their findings at CHEST 2007, the annual meeting of the American College of Chest Physicians.
ENDOCARDITIS
Body art paints a risky picture
Children and adolescents with congenital heart disease should steer clear of tattoos and body piercing (including ear piercing) because of the risk of endocarditis. But British researchers have found a disturbing lack of awareness about this danger among patients and professional caregivers alike.
The researchers surveyed 486 pediatric patients attending cardiology clinics and 69 pediatric cardiologists. Of the 486 patients, 86 had piercings and one had a tattoo. One of the patients developed endocarditis after an ear piercing.
Over 60% of the patients didn't know they should talk with their care provider before getting a tattoo or body piercing. Of 33 patients who got advice from a care provider first, only 9 were advised against it, 14 patients were advised to take precautions, and 10 were told there was no need for precautions.
The disparity in advice given to patients troubled researchers. "Better knowledge and education about the link between body art and endocarditis is required in order to provide guidelines for doctors and patients," they write in their report.
Source: Shebani SO, et al., Awareness of the risk of endocarditis associated with tattooing and body piercing among patients with congenital heart disease and paediatric cardiologists in the United Kingdom, Archives of Disease in Childhood, November 2007.
MENTAL HEALTH
Suicide rates among youths rise sharply
Suicide rates in young Americans rose by 8% from 2003 to 2004-the largest single-year increase in the 1990 to 2004 period, researchers from the Centers for Disease Control and Prevention (CDC) report. Analyzing data from the CDC's National Vital Statistics System, they found increased suicide rates in three groups: females between ages 10 and 14, females between ages 15 and 19, and males between ages 15 and 19.
In 1990, the most common means of suicide for girls and boys was firearms. In 2004, firearm suicide was still the most common method for boys, but hanging/suffocation was the more common method for girls, increasing 119.4% among girls between ages 10 and 14.
In a statement, lead author Keri Lubell, PhD, a behavioral scientist, urged parents, health care professionals, and educators to look for red flags in the behavior of children and adolescents that may indicate suicidal thoughts, such as talking about suicide, feeling hopeless, losing interest in favorite activities, and changes in sleeping or eating habits.
Source: Suicide trends among youths and young adults aged 10-24 years-United States, 1990-2004, Morbidity and Mortality Weekly Report, September 7, 2007.
NEW GUIDELINE
Which seizures call for emergency CT?
To guide treatment decisions, certain patients arriving in the emergency department with seizures should receive an emergency computed tomography (CT) scan, according to a new guideline issued by the American Academy of Neurology. The guideline indicates that an immediate noncontrast CT scan is "possibly useful" for emergency patients presenting with seizure, "especially when there is an abnormal neurologic examination, predisposing history, or focal seizure onset."
Emergency CT scans should also be considered for adults and children presenting with a first seizure.
Evidence indicates that scan results would alter treatment decisions in as many as 17% of adults and 8% of children. Conditions detected by CT scan that could change treatment include tumors, traumatic brain injury with skull fracture, and hemorrhagic stroke.
Source: Harden CL, et al., Reassessment: Neuroimaging in the emergency patient presenting with seizure (an evidence-based review): Report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology, Neurology, October 30, 2007, http://www.neurology.org/cgi/content/full/69/18/1772.
GERIATRICS
Dementia through the ages
One in seven Americans age 71 or older has some form of dementia, according to new findings from the National Institutes of Health (NIH). That adds up to 3.4 million Americans in this age-group with dementia. Alzheimer's disease, the most common form, accounts for 2.4 million cases.
The NIH research is the first to estimate dementia rates using a nationally representative sample of older adults. Participants included 856 adults age 71 and older from 42 states. Researchers conducted in-home evaluations to assess participants' cognitive and functional status and neuropsychiatric symptoms. They also gathered information about their drug and medical history (including prior neuroimaging and lab results) and family history of memory problems.
The prevalence of dementia among age-groups was as follows:
* ages 71 to 79: 5%
* ages 80 to 89: 24%
* age 90 and older: 37%.
Similarly, the prevalence of Alzheimer's disease increases with age, rising to 30% in adults age 90 and older. Investigators say that less education and at least one genetic risk factor for Alzheimer's disease are strong predictors of Alzheimer's disease and other dementias.
Source: Plassman BL, et al., Prevalence of dementia in the United States: The aging, demographics, and memory study, Neuroepidemiology, October 29, 2007 online.
SURVEY RESPONSES
Does your facility have an I.V. team?
Nurses who recently visited our Web site answered this question: Does your facility have a dedicated I.V. team?
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Research has shown that a dedicated infusion therapy team reduces the incidence of catheter-related infections. Visit http://www.nursingcenter.com/poll to answer our monthly survey question and view results from other surveys.
SUBSTANDARD E.D. CARE
Treatment for MI, pneumonia falls short
Emergency departments (EDs) aren't meeting the standard of care for patients with myocardial infarction (MI) and pneumonia, according to findings from a study at Johns Hopkins School of Medicine, Baltimore, Md. Researchers evaluated records of 1,492 patients treated for MI and 3,955 patients treated for pneumonia at 544 EDs between 1998 and 2004. They measured the proportion of patients receiving recommended treatments for MI (aspirin and beta-blockers) and appropriate antibiotics and pulse oximetry for pneumonia. Only 40% of MI patients received aspirin therapy and just 17% received beta-blocker drugs. Among patients with pneumonia, 69% received appropriate antibiotics and 46% were monitored with pulse oximetry as recommended by the American Thoracic Society.
Patients treated in government hospitals were less likely to receive recommended treatment and those with private insurance were more likely to receive appropriate care. White patients were 40% more likely to receive aspirin therapy than other racial groups.
Researchers conclude that the quality of care in EDs for these two common disorders is "below national goals." In a statement, lead investigator Julius Cuong Pham, MD, estimated that as many as 22,000 deaths per year could be prevented if ED caregivers followed standard practices to treat MI and pneumonia.
Source: Pham JC, et al., National study on the quality of emergency department care in the treatment of acute myocardial infarction and pneumonia, Academic Emergency Medicine, October 2007.