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Marcus Müllner

Publications and source records attributed to Marcus Müllner.

At least 19 recordsLinked to original sources
PubMed2006

Efficacy and safety of endovascular cooling after cardiac arrest: cohort study and Bayesian approach.

BACKGROUND AND PURPOSE: Recently 2 randomized trials in comatose survivors of cardiac arrest documented that therapeutic hypothermia improved neurological recovery. The narrow inclusion criteria resulted in an international recommendation to cool only a restricted group of primary cardiac arrest survivors. In this retrospective cohort study we investigated the efficacy and safety of endovascular cooling in unselected survivors of cardiac arrest. METHODS: Consecutive comatose survivors of cardiac arrest, who were either cooled for 24 hours to 33 degrees C with endovascular cooling or treated with standard postresuscitation therapy, were analyzed. Complication data were obtained by retrospective chart review. RESULTS: Patients in the endovascular cooling group had 2-fold increased odds of survival (67/97 patients versus 466/941 patients; odds ratio 2.28, 95% CI, 1.45 to 3.57; P<0.001). After adjustment for baseline imbalances the odds ratio was 1.96 (95% CI, 1.19 to 3.23; P=0.008). When discounting the observational data in a Bayesian analysis by using a sceptical prior the posterior odds ratio was 1.61 (95% credible interval, 1.06 to 2.44). In the endovascular cooling group, 51/97 patients (53%) survived with favorable neurology as compared with 320/941 (34%) in the control group (odds ratio 2.15, 95% CI, 1.38 to 3.35; P=0.0003; adjusted odds ratio 2.56, 1.57 to 4.17). There was no difference in the rate of complications except for bradycardia. CONCLUSIONS: Endovascular cooling improved survival and short-term neurological recovery compared with standard treatment in comatose adult survivors of cardiac arrest. Temperature control was effective and safe with this device.

Aged↗
PubMed2005

Intra-articular hyaluronic acid for the treatment of osteoarthritis of the knee: systematic review and meta-analysis.

BACKGROUND: Osteoarthritis of the knee affects up to 10% of the elderly population. The condition is frequently treated by intra-articular injection of hyaluronic acid. We performed a systematic review and meta-analysis of randomized controlled trials to assess the effectiveness of this treatment. METHODS: We searched MEDLINE, EMBASE, CINAHL, BIOSIS and the Cochrane Controlled Trial Register from inception until April 2004 using a combination of search terms for knee osteoarthritis and hyaluronic acid and a filter for randomized controlled trials. We extracted data on pain at rest, pain during or immediately after movement, joint function and adverse events. RESULTS: Twenty-two trials that reported usable quantitative information on any of the predefined end points were identified and included in the systematic review. Even though pain at rest may be improved by hyaluronic acid, the data available from these studies did not allow an appropriate assessment of this end point. Patients who received the intervention experienced a reduction in pain during movement: the mean difference on a 100-mm visual analogue scale was -3.8 mm (95% confidence interval [CI] -9.1 to 1.4 mm) after 2-6 weeks, -4.3 mm (95% CI -7.6 to -0.9 mm) after 10-14 weeks and -7.1 mm (95% CI -11.8 to -2.4 mm) after 22-30 weeks. However, this effect was not compatible with a clinically meaningful difference (expected to be about 15 mm on the visual analogue scale). Furthermore, the effect was exaggerated by trials not reporting an intention-to-treat analysis. No improvement in knee function was observed at any time point. Even so, the effect of hyaluronic acid on knee function was more favourable when allocation was not concealed. Adverse events occurred slightly more often among patients who received the intervention (relative risk 1.08, 95% CI 1.01 to 1.15). Only 4 trials explicitly reported allocation concealment, had blinded outcome assessment and presented intention-to-treat data. INTERPRETATION: According to the currently available evidence, intra-articular hyaluronic acid has not been proven clinically effective and may be associated with a greater risk of adverse events. Large trials with clinically relevant and uniform end points are necessary to clarify the benefit-risk ratio.

Humans↗
PubMed2005

How should abridged scientific articles be presented in journals? A survey of readers and authors.

SEVERAL SCIENTIFIC AND GENERAL MEDICAL JOURNALS publish full-length articles on their Web sites and abridged versions in their print journals. We surveyed a stratified random sample of BMJ readers and authors to elicit their preferred format for the abridged print version. Each participant received a research paper abridged in 3 different formats: conventional abridged version, journalistic version and enhanced-abstract version. Overall, 45% (95% confidence interval [CI] 42%-48%) of the respondents said they liked the conventional version most, 31% (95% CI 28%-34%) preferred the journalistic version and 25% (95% CI 22%-27%) preferred the enhanced-abstract version. Twenty-eight percent (95% CI 25%-32%) indicated that use of the journalistic format for abridged articles would very likely stop them from submitting papers to BMJ, and 13% (95% CI 11%-16%) said the use of the enhanced-abstract version would stop them from submitting to BMJ. Publishers of general medical journals who publish shortened articles should consider that authors and readers prefer a more conventional style of abridged papers.

Data Collection↗
PubMed2005

Hypothermia for neuroprotection after cardiac arrest: systematic review and individual patient data meta-analysis.

OBJECTIVE: Only a few patients survive cardiac arrest with favorable neurologic recovery. Our objective was to assess whether induced hypothermia improves neurologic recovery in survivors of primary cardiac arrest. DATA SOURCE: Studies were identified by a computerized search of MEDLINE, EMBASE, CINAHL, PASCAL, the Cochrane Controlled Trial Register, and BIOSIS. STUDY SELECTION: We included randomized and quasi-randomized, controlled trials of adults who were successfully resuscitated, where therapeutic hypothermia was applied within 6 hrs after arrival at the emergency department and where the neurologic outcome was compared. We excluded studies without a control group and studies with historical controls. DATA EXTRACTION: All authors of the identified trials supplied individual patient data with a predefined set of variables. DATA SYNTHESIS: We identified three randomized trials. The analyses were conducted according to the intention-to-treat principle. Summary odds ratios were calculated using a random effects model and translated into risk ratios. More patients in the hypothermia group were discharged with favorable neurologic recovery (risk ratio, 1.68; 95% confidence interval, 1.29-2.07). The 95% confidence interval of the number-needed-to-treat to allow one additional patient to leave the hospital with favorable neurologic recovery was 4-13. One study followed patients to 6 months or death. Being alive at 6 months with favorable functional neurologic recovery was more likely in the hypothermia group (risk ratio, 1.44; 95% confidence interval, 1.11-1.76). CONCLUSIONS: Mild therapeutic hypothermia improves short-term neurologic recovery and survival in patients resuscitated from cardiac arrest of presumed cardiac origin. Its long-term effectiveness and feasibility at an organizational level need further research.

Heart Arrest↗
PubMed2004

Influence of socioeconomic status on mortality after stroke: retrospective cohort study.

BACKGROUND AND PURPOSE: Low socioeconomic status is associated with increased morbidity and mortality from stroke. The purpose of this study was to investigate the association between 4 independent measures of socioeconomic status and mortality of patients with acute ischemic stroke and transient ischemic attack. METHODS: Socioeconomic status was assessed by taking into account levels of education, occupation, occupational status, and income. The end point was overall mortality. We used Cox proportional hazard models to adjust for age, sex, and severity of stroke on admission. RESULTS: A total of 2606 stroke patients were followed up for a median of 2.5 years. Unskilled workers had a hazard ratio of 1.87 for death after stroke (95% CI, 1.37 to 2.55) and skilled workers had a hazard ratio of 1.61 (95% CI, 1.23 to 2.11) compared with white-collar workers. Of 4 income groups, patients with the second lowest level of income had a hazard ratio of 1.60 (95% CI, 1.10 to 2.33) and patients with the third lowest level of income had a hazard ratio of 1.71 (95% CI, 1.25 to 2.32) compared with patients with the highest income. The hazard ratio for death after stroke for early retired patients was 1.75 (95% CI, 1.01 to 3.04) compared with stroke patients in the active workforce at the time of the event. CONCLUSIONS: Socioeconomic status is associated with survival of patients with acute stroke after adjustment for age, sex, and severity of stroke. The influence of socioeconomic status seems to continue to affect the outcome largely independent of stroke severity.

Aged↗
PubMed2004

Heme oxygenase-1 genotype and restenosis after balloon angioplasty: a novel vascular protective factor.

OBJECTIVES: We investigated the association of the heme oxygenase-1 (HO-1) promoter genotype with the inflammatory response and restenosis after balloon angioplasty. BACKGROUND: Heme oxygenase-1, which is induced by balloon angioplasty, can inhibit neointima formation and vascular remodeling. A dinucleotide repeat in the HO-1 gene promoter shows a length polymorphism that modulates HO-1 gene transcription. Short (<25 guanosine thymidine [GT]) repeats are associated with a 10-fold greater up-regulation of HO-1 than are longer repeats. METHODS: We studied 381 consecutive patients who underwent femoropopliteal balloon angioplasty (n = 210) and comparison groups with femoropopliteal stenting (n = 68) and lower limb angiography (n = 103). C-reactive protein (CRP) was measured at baseline, 24, and 48 h. We evaluated patency at six months by duplex sonography and assessed the association of the length of GT repeats in the HO-1 gene promoter with postintervention CRP and restenosis. RESULTS: Restenosis within six months was found in 74 patients (35%) after balloon angioplasty and in 21 patients (31%) after stenting. After balloon angioplasty, carriers of the short length (<25 GT) dinucleotide repeats had a lower postintervention CRP at 24 h (p = 0.009) and 48 h (p < 0.001) and a reduced risk for restenosis (adjusted relative risk 0.43, 95% confidence interval: 0.24 to 0.71, p < 0.001) compared with patients with longer alleles. After stenting or angiography, we found no association between the HO-1 genotype with CRP or restenosis. CONCLUSIONS: The HO-1 promoter genotype that controls the degree of HO-1 up-regulation in response to stress stimuli is associated with the postintervention inflammatory response and the restenosis risk after balloon angioplasty.

Aged↗
PubMed2004

Arterial puncture closing devices compared with standard manual compression after cardiac catheterization: systematic review and meta-analysis.

CONTEXT: Arterial puncture closing devices (APCDs) were developed to replace standard compression at the puncture site and to shorten bed rest following percutaneous coronary intervention. OBJECTIVE: To assess the safety and efficacy of APCDs (Angioseal, Vasoseal, Duett, Perclose, Techstar, Prostar) compared with standard manual compression in patients undergoing coronary angiography or percutaneous vascular interventions. DATA SOURCES: A systematic literature search of MEDLINE (1966-January 2003), EMBASE (1989-January 2003), PASCAL (1996-January 2003), BIOSIS (1990-January 2003), and CINHAL (1982-January 2003) databases and the Cochrane Central Register of Controlled Trials for relevant articles in any language. STUDY SELECTION: Included randomized controlled trials reporting vascular complications at the puncture site (hematoma, bleeding, arteriovenous fistula, pseudoaneurysm) and efficacy (time to hemostasis, time to ambulation, time to discharge from hospital). DATA EXTRACTION: Two reviewers abstracted the data independently and in duplicate. Disagreements were resolved by discussion among at least 3 reviewers. The most important criteria were adequacy of allocation concealment, whether the analysis was according to the intention-to-treat principle, and if person assessing the outcome was blinded to intervention group. Random-effects models were used to pool the data. DATA SYNTHESIS: Thirty trials met the selection criteria and included up to 4000 patients. When comparing any APCD with standard compression, the relative risk (RR) of groin hematoma was 1.14 (95% confidence interval [CI], 0.86-1.51; P =.35); bleeding, 1.48 (95% CI, 0.88-2.48; P =.14); developing an arteriovenous fistula, 0.83 (95% CI, 0.23-2.94; P =.77); and developing a pseudoaneurysm at the puncture site, 1.19 (95% CI, 0.75-1.88; P =.46). Time to hemostasis was shorter in the group with APCD compared with standard compression (mean difference, 17 minutes; range, 14-19 minutes), but there was a high degree of heterogeneity among studies. Only 2 studies explicitly reported allocation concealment, blinded outcome assessment, and intention-to-treat analysis. When limiting analyses to only trials that used explicit intention-to-treat approaches, APCDs were associated with a higher risk of hematoma (RR, 1.89; 95% CI, 1.13-3.15) and a higher risk of pseudoaneurysm (RR, 5.40; 95% CI, 1.21-24.5). CONCLUSIONS: Based on this meta-analysis of 30 randomized trials, many of poor methodological quality, there is only marginal evidence that APCDs are effective and there is reason for concern that these devices may increase the risk of hematoma and pseudoaneurysm.

Aneurysm, False↗
PubMed2004

The effect of mild therapeutic hypothermia on renal function after cardiopulmonary resuscitation in men.

BACKGROUND: Mild therapeutic hypothermia (MTH) improves neurological outcome in patients after cardiac arrest. From animal and human studies it appears that hypothermia impairs renal function. The aim of this study was to examine the effects of MTH on renal function in humans. METHODS: Patients were participants recruited in one of the centres of the hypothermia after cardiac arrest-multicenter trial. We measured serum creatinine and creatinine clearance (C(Cr)) within 24 h of MTH, at 4 hourly intervals. Patients were followed for acute renal failure and need for renal supportive therapy for 28 days. RESULTS: We included 60 patients (32 hypothermic, 28 normothermic). Median serum creatinine on admission was [[119 micromol/l (IQR 108-133)] [1.35 mg/dl (IQR 1.22-1.50)]] in hypothermic and [[114 micromol/l (IQR 99-131)] [1.29 mg/dl (IQR 1.12-1.48)]] in normothermic patients, and decreased to [[69 micromol/l (IQR 62-84)] [0.78 mg/dl (IQR 0.70-0.95)]] in the hypothermic group and to [[88 micromol/l (IQR 71-123)] [1.00 mg/dl (IQR 0.80-1.39)]] in the normothermic group within 24h. C(Cr) was decreased on admission. Within 24 h C(Cr) improved to normal values in normothermic patients [1.53 ml/s (IQR 1.15-2.35) [92 ml/min (IQR 69-141)]] and remained low in hypothermic patients [0.88 ml/s (IQR 0.63-1.38) [53 ml/min (IQR 38-83)]] (P = 0.0006). No difference was found between the groups in the development of acute renal failure or the need for renal supportive therapy. CONCLUSION: Twenty four hours of MTH was associated with a delayed improvement in renal function. This was not reflected in the serum creatinine values, which were low in the hypothermic group. This transient impaired renal function appeared to be completely reversible within 4 weeks.

Acute Kidney Injury↗
PubMed2004

Use of recombinant tissue plasminogen activator in children with meningococcal purpura fulminans: a retrospective study.

OBJECTIVE: Meningococcal disease causes septic shock with associated disseminated intravascular coagulation and hemorrhagic skin necrosis. In severe cases, widespread vascular thrombosis leads to gangrene of limbs and digits and contributes to morbidity and mortality. Uncontrolled case reports have suggested that thrombolytic therapy may prevent some complications, and the use of tissue plasminogen activator (t-PA) has been widespread. Our aim was to summarize the clinical outcome and adverse effects where systemic t-PA has been used to treat children with fulminant meningococcemia. DESIGN: International, multiple-center, retrospective, observational case note study between January 1992 and June 2000. SETTING: Twenty-four different hospitals in seven European countries and Australia. PATIENTS: A total of 62 consecutive infants and children with severe meningococcal sepsis in whom t-PA was used for the treatment of predicted amputations and/or refractory shock (40 to treat severe ischemia, 12 to treat shock, and ten to treat both). INTERVENTIONS: t-PA was administered with a median dose of 0.3 mg.kg(-1).hr(-1) (range, 0.008-1.13) and a median duration of 9 hrs (range, 1.2-83). MAIN RESULTS: Twenty-nine of 62 patients died (47%; 95% confidence interval, 28-65). Seventeen of 33 survivors had amputations (11 below knee/elbow or greater loss; six less severe). In 12 of 50 patients to whom t-PA was given for imminent amputation, no amputations were observed. Five developed intracerebral hemorrhages (five of 62, 8%; 95% confidence interval, 0.5-16). Of these five, three died, one developed a persistent hemiparesis, and one recovered completely. CONCLUSIONS: The high incidence of intracerebral hemorrhage in our study raises concerns about the safety of t-PA in children with fulminant meningococcemia. However, due to the absence of a control group in such a severe subset of patients, whether t-PA is beneficial or harmful cannot be answered from the unrestricted use of the drug that is described in this report. Our experience highlights the need to avoid strategies that use experimental drugs in an uncontrolled fashion and to participate in multiple-center trials, which are inevitably required to study rare diseases.

Amputation, Surgical↗
PubMed2004

Quantification of internal carotid artery stenosis with duplex US: comparative analysis of different flow velocity criteria.

PURPOSE: To compare 13 previously published sets of duplex ultrasonographic (US) criteria with the US criteria used at the authors' institution in terms of agreement with carotid artery angiographic results. MATERIALS AND METHODS: The authors studied 1,006 carotid arteries in 503 patients at duplex US and angiography. The degree of stenosis was determined by using duplex flow US velocities and applying 13 previously published sets of criteria and the criteria used at the authors' institution. Two independent observers evaluated the angiograms according to North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria. kappa statistics, sensitivities, specificities, positive predictive values (PPVs), negative predictive values (NPVs), and generalized linear mixed regression models were used to assess agreement between duplex US and angiographic findings. RESULTS: Stenoses of 0%-29%, 30%-49%, 50%-69%, 70%-99%, and 100% could be differentiated with 73% overall agreement between duplex US and angiographic findings according to flow velocity criteria (kappa = 0.57; 95% confidence interval [CI]: 0.54, 0.60); however, with duplex US, the angiographic degree of stenosis tended to be overestimated. In the differentiation of stenoses of less than 70%, only 45% agreement (kappa = 0.26; 95% CI: 0.23, 0.29) was observed, whereas in the differentiation of high-grade (> or =70%) stenoses, 96% agreement was observed (kappa = 0.85; 95% CI: 0.83, 0.87). The PPV and NPV for the identification of 70%-99% angiographic stenosis were 69% and 98%, respectively, with use of the most sensitive duplex US criteria. CONCLUSION: Duplex US is an excellent examination to screen for high-grade carotid artery stenosis; however, it tends to lead to an overestimation of the degree of stenosis. Exclusion of 70%-99% angiographic stenosis can be achieved with a sensitivity of up to 98%.

Aged↗
PubMed2003

Short versus prolonged bed rest after uncomplicated acute myocardial infarction: a systematic review and meta-analysis.

BACKGROUND: Recently updated guidelines by the American College of Cardiology/American Heart Association and the European Society of Cardiology recommend at least 12 hours bed rest in patients with uncomplicated myocardial infarction. METHODS: We performed a systematic literature review and meta-analysis of randomized and quasi-randomized controlled trials comparing short versus prolonged bed rest in patients with uncomplicated acute myocardial infarction. RESULTS: We found 15 trials with 1332 patients assigned to a short period of bed rest (range 2 to 12 days) and 1326 patients assigned to prolonged bed rest (range 5 to 28 days). Generally, the studies were outdated and seemed to be of poor methodologic reporting quality. There was no evidence that shorter bed rest was more harmful than longer bed rest in terms of death, reinfarction, post-infarction angina, or thromboembolic events. CONCLUSION: We concluded that bed rest ranging from 2 to 12 days seems to be as safe as longer periods of bed rest.

Aged↗
PubMed2003

High-dose parenteral iron sucrose depresses neutrophil intracellular killing capacity.

BACKGROUND: Iron is essential for the formation of hemoglobin. During long-term treatment with human recombinant erythropoietin (rhEPO), the majority of end-stage renal disease (ESRD) patients will not respond adequately to rhEPO unless substituted with intravenous iron. However, concern exists about possible detrimental effects of parenteral iron on cellular host defense and iron-mediated increments of oxidative stress. METHODS: We analyzed phagocytic functions of polymorphonuclear leukocytes (PMN) isolated from 20 ESRD patients on peritoneal dialysis in response to 300 mg of iron sucrose or placebo administered intravenously over two hours in a randomized, double-blind manner. We evaluated Fc gamma R-dependent phagocytosis and killing (primary outcome variable) of opsonized Escherichia coli, Fc gamma R-dependent oxidative burst capacity, and complement receptor 3 (CR3, Mac1, CD11b/CD18)/tumor necrosis factor alpha (TNFalpha)-mediated release of bactericidal lactoferrin before, during, one hour, and two days after administration. RESULTS: The absolute count and the percentage of E. coli killed by PMN of iron sucrose-treated peritoneal dialysis patients decreased significantly over time in comparison to placebo-treated patients (F = 3.48, df = 4, P = 0.008; F = 3.99, df = 4, P = 0.006, respectively). All secondary outcome variables were not different between both groups over time. CONCLUSIONS: Killing capacity of PMN isolated from ESRD patients decreases in response to high-dose parenteral iron sucrose, possibly in part explaining reported higher hospitalization rates and lower survival rates of dialysis patients receiving frequent and high-dose parenteral iron.

Anemia↗
PubMed2003

Acute effect of amino acid peritoneal dialysis solution on vascular function.

BACKGROUND: Oral ingestion of proteins or amino acids is associated with endothelial dysfunction. The effect of commercial amino acid peritoneal dialysis solutions on vascular function is unknown. OBJECTIVE: We compared the acute effect of intraperitoneal amino acid administration with that of intraperitoneal glucose administration on vascular function in peritoneal dialysis patients. DESIGN: In an open-label randomized, controlled, crossover and observer-blinded trial, we examined the acute effect of an intraperitoneal application of 2 L commercial 1.1% amino acid solution compared with that of a 2.27% glucose solution in 13 peritoneal dialysis patients. The primary endpoint was the change in forearm reactive hyperemia 6 h after instillation of either dialysis solution. RESULTS: After 6 h of dwell time, reactive hyperemia was substantially impaired after administration of the amino acid solution compared with the glucose solution (median difference: 202%; 95% CI: 57%, 368%; P = 0.007). In a comparison of differences between values at 6 h and those before treatment, reactive hyperemia significantly decreased during the dwell with the amino acid dialysis solution compared with that with the glucose dialysis solution (median difference: 242%; 95% CI: 53%, -457%; P = 0.013). In an analysis of smoking and nonsmoking patients separately, the difference in forearm blood flow between the 2 treatments was still statistically significant. CONCLUSIONS: One 6-h dwell with a commercial amino acid dialysis solution acutely impairs forearm reactive hyperemia in smoking and nonsmoking peritoneal dialysis patients. Because endothelial dysfunction is associated with increased morbidity and mortality, the long-term use of these solutions may increase the risk of cardiovascular disease.

Adult↗
PubMed2003

Determination of lipid profiles and use of statins in patients with ischemic stroke or transient ischemic attack.

BACKGROUND AND PURPOSE: Statins reduce the risk of myocardial infarction and stroke in patients with vascular disease. Inappropriate serum lipid determination and underuse of statins have been documented in patients with coronary artery disease. Evaluation of hyperlipidemia and treatment with statins in patients with recent ischemic cerebrovascular events have not yet been investigated. METHODS: We determined the frequency of total cholesterol (TC) and low-density lipoprotein cholesterol measurements and the use of statins in a multicenter prospective cohort study of 1743 patients with acute ischemic stroke or transient ischemic attack (TIA). Using multivariate logistic regression analysis, we determined the influence of several clinical variables on lipid measurements and the prescription of statins at hospital discharge. RESULTS: TC was measured in 90% and low-density lipoprotein cholesterol was measured in 48% of the patients. Differences between the centers accounted for most of the observed variability in a multivariate model. Statin prescription also varied widely between the centers. The prescription of a statin at discharge was most strongly associated with statin intake before the event and with increasing TC levels; elderly patients received statins less often. Coronary artery disease, peripheral artery disease, and other manifestations of atherosclerosis were not independently associated with the use of statins; 68% of the patients with manifest atherosclerosis and TC levels >200 mg/dL were discharged without a statin. CONCLUSIONS: The determination of serum lipid profiles varies widely between different centers. Statins are highly underused in patients with recent ischemic stroke or TIA, particularly in those in whom statins are indicated according to existing recommendations (eg, patients with additional coronary artery disease and hypercholesterolemia). Currently, international guidelines concerning the use of statins are not adequately implemented in clinical practice in patients with stroke or TIA.

Aged↗