Rapid response teams. Jones DA et al. NEJM 2011;365:139-146. FULL FREE TEXT
Casaer et al randomized 4,640 critically-ill patients who could not get enough calories by enteral feeding to receive TPN either on ICU day 3, or to wait until ICU day 8. While waiting for their TPN in the late group, patients got calories in sugar water along with liquid vitamins and minerals. There were no differences [... read more]
New York’s city council banned smoking in almost all public spaces on May 23. Colgrove et al raise the interesting point that because the risk from secondhand smoke outdoors is nil, the political move oversteps the mandate of public health, and is instead heavyhanded social engineering that will further stigmatize smokers, a sad and addicted [... read more]
Menthol doesn’t kill people — cigarettes that are tastier and easier to smoke because of menthol do. The FDA’s Tobacco Products Scientific Advisory Committee blandly concluded that removing menthol from cigarettes would improve public health, but in the current pro-economic recovery environment, there is no political will to take on Big Tobacco, Siegel, Benowitz and [... read more]
Most clinical trials for asthma drugs exclude ~95% of potential subjects and test under highly controlled conditions, limiting their results’ generalizability. Price et al publish results of 2 “pragmatic” open-label trials set in the real world. In #1, they randomized 300 symptomatic asthmatics in 53 U.K. primary care clinics to get either a leukotriene receptor [... read more]
Using expression of the c-kit antigen as an identifier, Brigham researchers Kajstura et al identified stem cells in adult human lungs (from unused donor lungs and a Brigham tissue bank), established a clonal cell line from the isolated stem cells, and infected those cells with a fluorescing lentivirus. With a cryoprobe, they destroyed some mice’s [... read more]
De Smet et al reheat the data from their 2009 NEJM study, in which they cluster-randomized and crossed-over 5,939 patients staying >48hrs in 13 Dutch ICUs to receive either 1) standard care; 2) selective oropharyngeal decontamination (topical amphotericin B, colistin, and tobramycin in the oropharynx), or 3) selective digestive tract decontamination (the same drugs in the mouth, stomach, [... read more]
After implementing an “MRSA bundle” in 2007 including nasal surveillance, contact precautions for positive patients, hand hygiene, and culture-indoctrination of employees, MRSA infections among all VA hospital ICUs fell from 1.64 to 0.62 per 1000 patient-days (a 62% reduction, p<0.001). MRSA infections on the wards fell from 0.47 to 0.26 per 1000 patient-days (45% reduction, [... read more]
Huskins et al cluster-randomized 18 ICUs to an intervention of surveillance cultures with contact precautions for positive patients, or a control of no cultures and universal precautions (gloves). The intervention ICUs used contact precautions more frequently (51% vs. 38%), but had the same MRSA/VRE colonization/infection rates, the primary endpoint (40 vs 35%, p=0.35). Clinician compliance [... read more]
Latent tuberculosis infection in the U.S.: Horsburgh CR, NEJM 2011;364:1441-1448
Remember when you were a third year medical student? Me neither. But that’s when you first started to build that tough & isolating carapace to protect you from all the overwhelming emotions flying through the hospital, & you, this essay suggests. A seasoned clinical educator and a third-year med student have a conversation about our [... read more]
Establishing mediastinal spread of non-small cell lung cancer (N2-3 disease) precludes surgery and worsens prognosis; whether PET-CT imaging can improve overall accuracy or safely prevent mediastinoscopies is still unknown. Fischer et al re-heat the data from their 2009 NEJM randomized trial in Denmark, with EUS-FNA and mediastinoscopy on 189 NSCLC patients, in which they concluded that the [... read more]
Busse et al randomized 419 inner-city kids (age 6-20) with uncontrolled, skin-test-positive, mostly severe allergic asthma and IgE < 1,300 IU/mL to 60 weeks of omalizumab or placebo. The treated group had modest improvements: ~1 fewer day of symptoms per month and a 5% absolute reduction in hospitalizations (1.5% vs 6.3%); 18% fewer of them [... read more]
DVT of the upper extremity: Kucher N, NEJM 2011;364:861-869.
Warfarin is the best drug for stroke prevention in atrial fibrillation. In people with a-fib for whom warfarin was unsuitable (unstable INR, unlikely adherence, etc, but excluding those with prior bleeding on warfarin), twice daily oral direct Xa inhibitor apixaban had a hazard ratio of 0.45 over aspirin for the primary outcome of stroke (absolute [... read more]
How “hard” should we “hit” our patients with Lasix? And does that hurt? Felker et al asked that (sort of) in a NHLBI-funded trial. They gave furosemide to 308 patients hospitalized for ADHF in an IV dose either equivalent to their home dose, or at 2.5 times their home dose, and either at q12-hour intervals [... read more]
Treating NSCLC with tyrosine kinase / EGFR inhibitors erlotinib & gefitinib: Cataldo VD, NEJM 2011;364:947-955. Non small cell lung cancer chemotherapy treatment review.
Point-of-care ultrasonography: Moore CL, NEJM 2011;364:749-757.
MedPAC wants the next generation of MDs to be cost-conscious, evidence-minded, and amenable to standardization of care. To prod GME programs to train young MDs thusly, the influential government advisory body recommends allocating $3.5B of the $9.5B annual GME outlay as at-risk incentive payments. A proposed committee would have 3 years to design metrics for [... read more]
Moses & Martin see an impending crisis of public trust in the entire enterprise. They call for an epic shift in national priorities, policy, and funding of research, envisioning a more collaborative, value-based system– while acknowledging that such a sea change would take decades. NEJM 2011;364:567-571. FREE FULL TEXT