Consider The Evidence: Med/Peds Journal Roundup

March 25, 2009

Nail in the coffin for intensive glucose control?

Filed under: Uncategorized — medblog @ 7:17 pm

NEJM 3/26/09 – The NICE-SUGAR investigators published the latest of several trials that show no benefit to intensive glucose control (see meta-analysis). In fact, this study shows increased mortality from tight gylcemic control in the ICU.

This appears to be a well done study – over 6,000 subjects, multicenter, both medical and surgical patients, 90-day follow up. Withdrawals were slightly higher in the treatment arm (10 vs 7 percent) but intent-to-treat analysis was used. Insulin use was non-blinded.

So should the intensive glucose control protocol be shelved next to blood-letting and COX-2 inhibitors?

December 12, 2007

Antibiotics no good for acute sinusitis?

Filed under: Uncategorized — medblog @ 8:12 pm

JAMA 12/5/07 – House of God Law #13: “The delivery of good medical care is to do as much nothing as possible.” The last time we saw this rule at work was with otitis media.

A study in JAMA by Williamson et al. sought to see just what good comes from the common practice of prescribing antibiotics and nasal steroids for acute bacterial sinusitis. The study included 240 patients seen by family practitioners in the UK. To be included, the patients had to have 2 or more of the classic clinical diagnostic criteria. No radiology or lab studies were used in diagnosis.

Treatment groups were randomized to receive either antibiotics and nasal steroids, a placebo of one plus the other, or a placebo of both. Patients kept symptom diaries to track outcome.

The findings showed that symptom severity scores were similar for all groups on each of the 10 days following initiation of treatment. In short – symptoms improved by day 10, and at the same rate, regardless of whether the patient received antibiotics and/or steroids vs placebo. The hard part is now to convince patients that they dont need either.

Interestingly – the study does mention the Cochrane review on this subject which DID find a treatment effect for both antibiotics and steroids. However, they point out that the studies included in the review used radiographic evidence as diagnostic criteria – which does not commonly happen in the community. (And the utility of which is whole other bag of worms that will have to be covered another day)

July 6, 2007

Do SSRIs reduce bone density?

Filed under: Uncategorized — medblog @ 10:53 am

ArchivesIM 6/25 – The current issue contains a pair of articles that make a connection between SSRI use and bone mineral density (BMD). The pair of observational studies by Diem et al. and Haney et al. seperately studied a cohort of men and women respectively. The study involving women showed a greater yearly decrease in BMD when compared to nonusers as well as trazodone and TCA users. The study of men simply showed overall lower mean BMD associated with SSRIs as well with no effect seen from TCAs.  Obviously both studies suffer from the typical observational methodology pitfalls – but definitely merit further investigation. The main question to be answered is whether this effect translates into a greater clinical risk of fracture or other negative outcomes.  Given the large burden of both depression and osteopenia in the elderly, clearly the interaction needs further study.

May 19, 2007

Changing the asthma treatment paradigm?

Filed under: Uncategorized — medblog @ 6:18 pm

NEJM 5/17/07- I can’t help but wonder if this is a “welcome mat for new drug cocktail” study. Papi et al in the BEST study group publish a paper showing that using a steroid inhaler on an as-needed basis might be just as good as twice daily use.

The double-blind, double dummy design seems pretty robust, although makes the data a little complicated. In short – all subjects took a regular inhaler twice daily, plus an as-needed inhaler – the design just varied what was in the inhalers among groups. The most relevant comparison was – twice daily beclamethasone plus rescue albuterol (old skool method) versus twice daily placebo and rescue beclamethasone and albuterol combo.

It looks as if using a PRN steroid was just as good as the old twice daily method. The money graph seems to show that time to first exacerbation was the same in both groups and clearly better than albuterol rescue alone. Frankly the comparisons of PFTs and symptom scores got a little too crazy for me to handle but a cursory look seems to confirm the equivalence in most comparisons.

Any guesses as to what new combo inhaler we might be seeing soon? Check out the laundry list of financial disclosures at the end – Im sure one of those companies is planning to cash in on this one.

October 13, 2006

DREAMing of diabetes prevention. Part I

Filed under: Uncategorized — medblog @ 8:03 pm

NEJM 10/12 – ACE-Inhibitors are pretty much standard of care in diabetics for prevention of nephropathy. But some evidence suggests that angiotensin blockade may have direct beneficial effects on glucose tolerance. An editorial in the latest New England by Ingelfinger and Solomon explains the evidence that led to a trial of ramipril for the prevention of diabetes mellitus. Take note of their mention of potential confounding by the often overlooked fact that thiazide diuretics and B-blockers may promote diabetes – and the ACEIs were often compared to these drugs.
The study by the DREAM trial investigators involved subjects with impaired fasting glucose or impaired glucose tolerance. Subjects were given ramipril or placebo and followed for three years. Unfortunately, it didnt appear to work too well. The incidence of diabetes was similar in both ACEI treatment and placebo groups. However, treatment group patients did show a significantly better response in an oral glucose tolerance test. The trial seems to show that there may well be an effect of RAS blockade on glucose homeostasis, but not enough for primary prevention of diabetes.

September 28, 2006

zzzzzz….all about sleep

Filed under: archives of internal medicine, Uncategorized — medblog @ 8:43 pm

So I’m an issue behind, but I had to blog on the sleep-themed Sept 18th issue of Archives of Int Med. (one of my favorite subjects). Just how important is it?

Steptoe et al. found that young adult subjects that slept less than 6 hours per night were almost twice as likely to report their health as being poor – even after adjustment for socioeconomic factors, physical activity, BMI and Beck Depression Inventory scores. However, I cant help be a little cautioned by the fact that both sleep time and health status were based on self-report.

From the basic science side, Irwin et al. found that monocyte production of the proinflammatory cytokines IL-6 and TNF-alpha was significantly higher on the morning after sleep deprivation. (sounds like a bad thing)

Arzt et al warn of a condition that may obscure the diagnosis of obstructive sleep apnea. Their research found that comorbid heart failure resulted in less daytime sleepiness in sufferers of OSA. Unfortumately, the detrimental effects of poor sleep remained present. Because excessive daytime sleepyness is often the presenting symptom leading to the diagnosis of OSA, the researchers caution that physicians may miss the presence of OSA in HF patients.

And in the midst of the obesity epidemic, Kothatsu et al. show that a significant inverse relationship between sleep duration and BMI also exists in a rural population. Other researchers have already shown the same to be true in the urban and suburban populations. But watch out for that giant 70% confidence interval.

July 23, 2006

Skip the Stirrups for More Comfortable Pelvic Exams?

Filed under: Uncategorized — medblog @ 9:02 pm

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.

June 30, 2006

statins sort of might possibly be antioxidants

Filed under: Uncategorized — medblog @ 6:34 am

JAMA – According to an article by Klein et al., age-related cataract formation has been thought to be associated with oxidative stress. In addition, statins have been shown to have antioxidant properties.

So, in the age-old tradition of testing two unproven hypotheses against each other, the researchers looked at data from the observational Beaver Dam Eye study. The data showed that use of statins was associated with a significant reduction in risk of nuclear cataract – the most common type of age-related cataract.

Possibly the reason behind the possible anti-cancer effects of statins (if such an effect actually exsists)? Interesting idea, especially since most anti-oxidant trials have failed to show any clinical effect in RCTs.

May 30, 2006

Hiatus

Filed under: Uncategorized — medblog @ 3:16 pm

sorry for the short hiatus – Graduation throws a wrench in the schedule. Maybe having those two new letters after my name will give my blog a much needed credibility boost.

May 7, 2006

actually practical research

Filed under: Uncategorized — medblog @ 10:24 pm

BMJ – Common advice to the post-surgical patient is to avoid getting the suture site wet for 24-48 hours. But is there any evidence to support it?

Heal et al. present a study in the BMJ investigating whether such advice is warranted. The study was done in Queensland, Australia – the last place you would really want a thick roll of gauze to cover anything in the summer heat. They find that there was no significant increase in surgical site infection if the suture line is exposed to water within 48 hours.

Responding physicians bring up the fact that this may contribute to the spread of disease in developing countries in which HBV infection is endemic.

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