Consider The Evidence: Med/Peds Journal Roundup

March 30, 2006

Dont count out G-CSF just yet….

Filed under: CMAJ, stem cells, stroke — medblog @ 5:15 pm

CMAJ 3/28 – Well it didnt work for the heart, but can it work in the brain? G-CSF is a promising treatment for the regeneration of infarcted tissues, due to its trophic and chemotactic effects on stem cells. However, in a JAMA article covered earlier this year, the treatment failed to improve outcomes in MI.

This month, Shyu et al. present a phase I study of such treatment for improving stroke outcomes. Although there appeared to be some benefit, the teeny-tiny (n=10) size of the trial precludes any major conclusions. It seems promising, however, that the group treated early with G-CSF achieved higher stroke-scale scores that the ususal care group. The study did also affirm the safety and feasability of the treatment (as is the point of phase I trials). Larger phase II trials are in the works that will hopefully show conclusively that G-CSF can be neuroprotective as well as stimulate new neuron production.

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March 27, 2006

Depression: if at first you dont succeed

Filed under: Depression, NEJM, SSRI — medblog @ 10:18 pm

NEJM 3/23 – Two articles focusing on the pharmacotherapy of depression appear in the New England Journal this week.

Rush et al present a study of 787 patients with depression that had failed to achieve remission with SSRI therapy. The patients were switched from citalopram to either Buproprion, Sertraline, or Venlafaxine. Although approximately one-quarter of the subjects achieved remission after the switch, the rates were about equal among all three drugs. In other words, it did not seem to matter whether the switch was within class, or to a completely new class of drug.

Trivedi et al. present a study examining the commonly used augmentation strategy for treating resistant depression. The study randomized patients on citalopram therapy that had not achieved remission to recieve either buproprion or buspirone as an additional medication. Although about 30 percent of patients in either group achieved remission, the buproprion group had lower depression scores, and a lower dropout rate.

These studies show that switching or adding a medication to treat depression can improve remission rates. However, the factors that determine whether one particular drug will work for a given patient are still a mystery. Until that issue is answered, treatment remains a trial-and-error process. (more…)

March 25, 2006

Omega-3 fatty acids: Just a fish tale?

Filed under: BMJ, cardiovascular — medblog @ 10:10 pm

BMJ – A meta-analysis published online first on BMJ.com casts doubt on the purported health benefits of omega-3 fatty acid supplementation. The new study contradicts a 2002 meta-analysis by Bucher et al. which found that intake these fatty acids were protective against fatal coronary events. The inclusion of data from a large European study by Burr in 2003 was the main influence for the new conclusion. From the figure of the source data, it appears that the largest RCTs such as GISSI-P actually favored less Omega-3. Some have even suggested that omega-3 FA's can be pro-arrythmogenic. The cohort trials appear to be clustered around the line of no benefit.

Clearly the trials included are highly variable on the type of intake (dietary vs supplemental) as well as the pre-intervention risk (from healthy to post-MI) – so although there may be a specific subgroup who would yield benefit, it appears that this analysis does not support a general reccomendation for increasing omega-3 fatty acid intake. Is something fishy going on? Hopefully futher research will find out…

March 20, 2006

Plaque-busting with statins

Filed under: Cardiology, JAMA, statins — medblog @ 11:14 pm

JAMA 3/13 – Nissen et al. produce the latest, and largest of several trials documenting the effect of statin therapy on atherosclerotic plaques. The earlier studies suggested that intensive therapy with statins led to the decrease in atheroma volume. The authors of this study contend that their measurement parameters (taken via IVUS) were more rigorous than the past studies, allowing them to make a much more definitive conclusion on the issue.

A dramatic result of the study was the reduction median LDL-C levels by over 50% to approx 60mg/dl.“The achieved LDL-C levels were the lowest values ever observed in a statin atherosclerosis progression trial.” The mean change in atheroma volume in the most diseased 10-mm subsegment was –6.1 mm3. Change in total atheroma volume showed a 6.8% median reduction; with a mean reduction of –14.7 mm3. They conclude that, “When viewed in this context, the results of the current study demonstrate that there exists no apparent threshold LDL-C level beyond which the benefits of statin therapy are no longer evident. If regression of disease is the desired outcome, then lower LDL-C is better.”

Put them in the water…..

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March 17, 2006

NEJM quickies

Filed under: Uncategorized — medblog @ 12:55 pm

Lightning round version for match week…

NEJM 3/16 –
Paroxetine therapy for 2 years cuts the risk of depression recurrence in half in patients over 70 with Major Depressive disorder. But psychotherapy does not. [Article]

Papanikolaou shows that culturing embryos longer to the blastocyst stage allows for greater success of single-embryo in vitro fertilization. [Article] Hopefully this will reduce multiple embryo transfers and the high risk of mutiple gestations with IVF. And I just like to say “Papankolaou”.

The upcoming New England should be huge- stay tuned for:
Plavix + Aspirin is no better than Aspirin alone.

Evidence to treat pre-hypertension with ARBs.

and more evidence that Vitamins are bad for you.

March 14, 2006

Flight Risk: Air Travel and DVT

Filed under: lancet, VTE — medblog @ 5:43 pm

Lancet 3/11 – Shreijer et al present an interesting discovery about the increased risk of venous thrombosis during airplane travel. They wondered whether in addition to immobilization as a risk factor, passengers were also prone to hypercoagualibility during flight.

In the crossover controlled study, 71 subjects were tested during 8 hours in flight, 8 hours seated while watching movies, and during 8 hours of daily activities. Several markers of coagulation including Thrombin-Antithrombin complex (TAT), D-dimer, and prothrombin fragment 1 and 2 were measured before and after the the test conditions.

The researchers found that the levels of TAT, D-dimer, and the combination of the three factors were significantly increased after the flight in comparison to the other situations. They conclude that there are other mechanisms beyond immobilization to account for the 2 to 4 fold increased risk of DVT during flight. Whether this is related to pressure, oxygen content, or something else, will requre further research. (more…)

March 12, 2006

Soft drinks and pediatric obesity

Filed under: diet, health, pediatrics — medblog @ 10:47 am

Pediatrics 3/06 – Is the availability of sugary sodas contributing to the epidemic of pediatric obesity?
There is plenty of observational data on the subject, but not very many RCTs. An article in the most recent issue of Pediatrics lends some evidence to the argument. Ebbeling et al. investigated whether offering sugar-free beverages changes the diet patterns of children, and whether this leads to a corresponding weight loss. In the study, adolescents in the intervention group were randomly assigned to receive sugar-free beverages delivered to their home.

Among the children who recieved sugar free beverages, the drop in BMI was only significant in those children with a BMI > 30. Children in the intervention group actually lost some weight, while the control subjects gained weight. The results were not incredibly dramatic as the overall effect was less than 1 kg/m^2. However, it is impressive that such a change was caused by just one simple dietary intervention. (more…)

March 11, 2006

Beverage Guidelines stir controversy; Java in JAMA

Filed under: caffeine, Coffee, diet, health, JAMA — medblog @ 6:41 am

A new set of beverage guidelines published in the American Journal of Clinincal Nutririon are causing quite a stir lately. The reccomendations encourage Americans to drink more water or tea and cut back significantly on sweetened sodas. An interesting detail is that the suggestions allow for more beer than lowfat milk on a daily basis. The prominent nutritionists that published the guidelines claim the study was not influenced by funding from the Lipton corporation.

While the above study cites data supporting the safety and possible benefits of caffeine consumption, an article in JAMA addresses the risk of MI from coffee intake. The study by Cornelis et al. links the risk of MI to those that are "slow" caffeine metabolizers. In the study, carriers of a specific CYP1A2 genotype that resulted in slower caffeine metabolism had an increased odds ratio of having an MI if they drank more than 2 cups of coffee per day.

March 7, 2006

Filed under: Uncategorized — medblog @ 10:10 pm

in case its not obvious – i still havent settled on a theme that I like.

Attack of the clones: Community Aquired MRSA

Filed under: annals of internal medicine, infectious disease, lancet, MRSA — medblog @ 10:00 pm

Community Aquired MRSA and the USA 300 clone are making news in two journals this week… Get used to those stupid yellow gowns 😦
AnnalsIM 3/7 – A study by King et al. in The Annals of Internal Medicine documents the epidemiology of community aquired MRSA in a major hospital system in Atlanta, GA. The study included patients with community aquired skin and soft tissue infections due to Staph aureus. The results show that a majority (63%) of S. aureus isolates were methicillin resistant. 99% of the CA-MRSA samples that were further analyzed were the USA 300 clone.

A second paper, by Graham et al., analyzed the NHANES data on nasal swabs taken in a population sample. They found that, “The prevalence of colonization with S. aureus and with MRSA was 31.6% and 0.84%, respectively, in the noninstitutionalized U.S. population.”

Lancet 3/4 – An article in the Lancet by Diep et al. details the genome of the USA300 clone and the particular elements that lead to its epidemiology and virology. Frankly, much too dense for me to read more than the abstract – but I’m glad somebody else cares… (more…)

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