Journal Club 2012 Flashcards
Result of 2011 NEJM study on maximum barrier precautions and prevention of MRSA/VRE transmission?
No difference in incident MRSA or VRE infection or colonization.
Discuss PROTECT.
NEJM, 2011. 3764 ICU patients randomized to dalteparin 5000 qd or UFH 5000 bid. No difference in DVT’s, bleeding, HIT, mortality. Lower PE risk in dalteparin arm (1% absolute risk difference).
Discuss POET-COPD.
2011 NEJM. 7000 patients with COPD (stage II - IV), randomized to tiotropium qd or salmeterol bid. Tiotropium increased time to first exacerbation and reduced annual exacerbation rates with fewer serious adverse effects. No mortality difference. Benefits in all grades of disease but greatest in severe COPD.
What is the available ultra-long acting beta agonist?
indacaterol; half life 40 - 56 hours; may be better than formoterol, untested against tiotropium
Summarize the 2011 ATS/ERS/JRS/ALAT guidelines on management of IPF.
Sildenafil increased quality of life. IFN and pirfenidone increased side effects. Inadequate data to evaluate steroids, cyclophosphamide, cyclosporine, azathioprine, anticoagulants, NAC, azathioprine. Nothing has positive mortality benefit.
Summarize the data for omalizumab and its mechanism.
8 good trials of children and adults. Fewer exacerbations, more likely to come off steroids. Most common side effects were injection-site reactions. Anti-IgE monoclonal antibody.
Discuss the Papazian NEJM article.
340 patients in 20 French ICU’s with severe ARDS getting LPV. IV cisatracurium for 48 hours. Lower mortality (32% vs 41%) in paralytics arm. Also lower barotrauma. No change in ICU-acquired paresis.
Discuss the Annals review on utility of D-Dimer after cessation of anticoagulation in VTE.
In patients with first unprovoked VTE, positive d-dimer in weeks following cessation of anticoagulation is predictive of future VTE.
Discuss Abernathy’s Lancet article.
239 patients with life-limiting diagnoses but PaO2 > 55 were randomized to nasal cannula oxygen or placebo. No change in breathlessness. Both arms reported benefit (74%).
Discuss the TALC study.
NEJM 2010. 210 asthmatics with uncontrolled asthma on beclomethasone alone, three randomly ordered treatment periods: tiotropium/beclomethasone, double-dose beclomethasone, salmeterol/beclomethasone. Tiotropium/beclomethasone was superior to double-dose beclomethasone, noninferior to salmeterol/beclomethasone.
Discuss Cochrane review on PDE4 inhibitors in stable COPD.
Roflumilast or cilomilast vs placebo. They minimally (but significantly) improved FEV1 and QOL and reduced exacerbations (NNT 25) but had increased risk for diarrhea, nausea, vomiting and headache.
Discuss the ‘disease management’ study from AJRCCM 2010.
743 patients with high risk for COPD hospitalization randomized to usual care or disease management: one class, observation of inhaler techniques, smoking cessation, care plans, refillable scripts for prednisone and antibiotics. Significant decrease in COPD hospitalization or ED visit. No significant mortality difference.
Discuss 2011 Lancet study on steroids in CAP.
300 patients with CAP, randomized to dexamethasone 5 mg IV qday x 4 days vs placebo. Improved median length of stay. No change in mortality, pleural effusions/empyemas, etc.. Increased hyperglycemia.
Result of 2011 Annals analysis comparing various clinical decision rules for PE?
All four (Wells, simplified Wells, Revised Geneva, Simplified Revised Geneva) have about 99.5% sensitivity and 30% specificity when combined with d-dimer.
In the 2010 Thorax reviews, how did various CAP prediction tools fare?
PSI is the most sensitive and least specific for mortality. CURB and CURB-65 have moderate sensitivity and specificity. CRB-65 has lower sensitivity and higher specificity.
Results of 2010 NEJM article on rivaroxaban for DVT?
Rivaroxaban vs enoxaparin ? warfarin. Trend towards decreased recurrent VTE in rivaroxaban arm at 3, 6, 12 months. In continued study, significantly lower VTE in rivaroxaban arm at 6 and 12 months. Rivaroxaban is an oral Xa inhibitor.
Discuss 2011 Chest article on omalizumab. What is the other monoclonal antibody that may help in asthma?
Review of 8 trials looking at omalizumab in children and adults w/ asthma. Outcomes: steroid use, exacerbations. Results: fewer exacerbations, hospitalizations, less steroid use. Omalizumab is an anti-IgE monoclonal antibody. Mepolizumab is anti-IL5.
Discuss 2011 Cochrane review on PPI’s for chronic cough.
4 adequate trials. PPI group did not differ with regard to clinical failure; PPI group had greater reduction in cough scores but no difference in mean cough score.
Summarize the 2010 Chest articles on tiotropium and ipratropium and cardiovascular events.
Celli metaanalysis of tiotropium trials showed lower risk for all-cause death, CV death and major CV events in tiotropium group. In Ogale study of 82,000 veterans with newly diagnosed COPD, exposure to anticholinergics (mostly ipratropium) was associated with 29% increase in CV events. Effect was seen when exposure was within 6 months.
Discuss UPLIFT.
NEJM 2008. 4-year study of tiotropium vs placebo (both plus standard care) in COPD. Tiotropium arm had improvements in lung function, quality of life, and exacerbations during a 4-year period but did not significantly reduce the rate of decline in FEV1.
Discuss the updated BODE index and the ADO index.
Lancet 2009. Updated BODE uses FEV1 on scale of up to 2 instead of 3, and more points are assigned for poor outcomes on 6MW. ADO uses age, dyspnea, FEV1. Both perform better than BODE, which had poor calibration.
Discuss take-aways from 2009 Cochrane Review on therapeutic hypothermia.
5 trials. Improved neurologic outcome and survival at discharge. Nearly at 20 point absolute difference in neurologic outcome (52% vs 34%). NNT 6 for neurologic outcome, 7 for survival to discharge.
Summarize Lancet 2009 study on extubation to NIPPV.
106 patients with chronic respiratory disorders tubed for > 48 hours, still hypercapneic (PcO2 > 45) after otherwise successful T-piece trial. Significant improvement in respiratory failure at 72 hours and mortality at 90 days. NNT = 4 and 6, respectively.
Summarize the 2011 NLST NEJM trial.
53,000 patients at high risk for lung cancer at 33 centers. Randomized to three annual screening with low-dose CT or single-view PA CXR. Positive rate: 24.2% vs 6.9%. About 95% of both were false positives. Relative reduction in lung cancer mortality with CT of 20%, p = 0.004. All-cause mortality decreased by 6.7%, p = 0.004.
Discuss 2008 JAMA review on inhaled steroids in COPD.
11 RCT’s. No change in mortality. Significantly increased pneumonia risk (NNH 29 at 24 months).
Discuss 2008 AJRCCM article on LABA.
Review of 63 RCT’s. LABA’s plus ICS’s did not differ from ICS’s alone in all-cause mortality, asthma-related hospitalizations or asthma-related serious events.
What was the single largest study showing harm from LABA’s?
SMART, Chest 2006. Salmeterol Multicenter Asthma Research Trial, RCT comparing salmeterol plus usual therapy with usual therapy alone in > 26 000 patients with asthma. Stopped early: increased mortality in blacks, 4-fold increase in asthma mortality in salmeterol arm. Less than half were on ICS’s.
