Yes to NO for preemies?

NEJM 6/27 – Two articles address the controversial use of inhaled Nitric Oxide in pre-term infants. Prior studies have shown that nitric-oxide may improve gas exchange and lung development in neonates with respiratory failure. Ballard et al. tested this hypothesis on infants weighing less than 1250g, while Kinsella et al. studied all infants less than 34 weeks of age with respiratory failure.

While Ballard et al. found a significant reduction in the incidence of bronchopulmonary dysplasia, the effect size was not large (43.9 vs 36.8) and the P value made it just under the wire at 0.042.

Kinsella et al. found no difference in mortality for the overall group, but did find a significant improvement in outcomes for the group weighing between 1000-1250g, as well as improvement in several secondary outcomes.

Clearly there has to be some futher research into what patients will benefit most from this expensive therapy before it becomes standard of care. 

NEJM Vol. 355(4)

MDCT not quite ready for CAD screening

JAMA 6/26 – Interventional radiologists can breathe a little easier…. for now. A study by Garcia and the CATSCAN investigators in JAMA explored the use of 16 row multidetector CT to assess for coronary artery stenosis. Having a non-invasive method to evaluate the condition would make life much easier for many thousands of CAD sufferers each year, not to mention fattening some radiologist pocketbooks.

But unfotunately, in a study of over 200 patients, the test was only moderately (89%) sensetive and not very specific (65%) in the detection of greater than 50% stenosis. In addition, only 71% of the lesions were evaluable. Clearly not ready for primetime yet, but the technology is probably not that far off.

Skip the Stirrups for More Comfortable Pelvic Exams?

BMJ – In this week’s BMJ, Seehusen et al. present research into making gynecological examinations a little more bearable. The investigators randomized 200 women into recieving pelvic exams in the standard lithotomy position in raised stirrups or with feet placed on the edges of the table. The subjects then rated their feelings of physical discomfort, vunerability, and loss of control using a visual analog scale.

Subjects in the alternative position reported significantly lower levels of physical discomfort and vunerability. The quality of the smears was not significantly affected by the change in position – although there was no information regarding the ease of exam from the examiner’s point of view.

The article suggests that decreasing the discomfort of vaginal exams may increase patient adherence to regular cervical cancer screening.

new drug to help smokers quit

JAMA – With millions of smokers trying to quit, treatment of nicotine addiction has become a hotbed of research. Three articles in last week’s JAMA cover Varenicline, the first new drug made specifically to treat nicotine addiction.

Varenicline is a partial agonist at the nicotine receptor thought to be responsible for the reinforcing effects of the drug. This may result in the blunting of withdrawal symptoms while blocking activation by nicotine from cigarettes.

So how well did it work? Pretty well in fact. The articles indicated that Varenicline was

Dont Re-Invent the Wheel with CRP

ArchivesIM 7/10 – Ever since it was shown that CRP levels are strong predictors of CHD, the controversy has been whether it is really any better than the risk predictors we already have. Several articles have concluded that CRP in some way is a “better” method of stratifying CHD risk.

A paper by Fulstrom et al. addressing this issue presents data from the Atherosclerosis Risk in Communities (ARIC) Study. This was a prospective case cohort study. They looked at the reciever-operator curve using traditional risk factors, and then calculated the improvement of this curve once novel risk markers such as CRP, IL-6, pLA2, etc were added. They found that these fancy-schmancy molecules did not add significantly to the accuracy of the old prediction model.

So maybe CRP levels are a solution without a cause… but there is still a camp that believes that using that measure will include a group of higher-risk individuals that is not identified by the traditional risk factors…

Decaf Drinkers Deftly Dodge Diabetes

ArchivesIM 5/26 – While there has been some recent controversy over the risks and benefits of coffee consumption for diseases such as diabetes and MI, the exact cause for these effects is unknown.

In the current Archives, Pereira et al. present further investigation of this phenomenon using data from an 11-year, 28,000 patient observational trial of post-menopausal women. They found a significant inverse relationship between coffee consumption and incidence of diabetes. In the most comprehensively adjusted model, the results were only significant for decaf drinkers. Unfortunately for the majority, the difference in this model was only significant for drinkers of 4-5, and 6+ cups a day.

Now if they can only explain the purpose of drinking decaf coffee at all, let alone more than six cups of it per day??

N-acetylcysteine for Contrast Nephropathy Re-revisited

NEJM 6/29 – The use of N-Acetylcysteine for contrast nephropathy has been so extensively studied, there are actually meta-analyses of meta-analyses on the subject. And even after all that, the evidence for N-Acetylcysteine for prevention of contrast nephropathy is still pretty much equivocal. For every study that shows a benefit, there is another that shows no benefit at all.

An article in the New England by Marenzi et al. adds weight to the pro-NAc side of the argument. The RCT specifically looked at primary angioplasty and the incidence of contrast nephropathy after the procedure. About 300 subjects were randomized to recieve Low dose NAc, high dose NAc or placebo. According to the study, there was a significant lowering of the incidence of nephropathy with the use of NAc, with the greatest effect in the high-dose group.

Although all patients were hydrated after treatment, I did not find whether the placebo group received a fluid bolus as a control for the NAc solution. Could the effect be related to the extra hydration from the medication solution rather than the NAc itself?