Basically just head toward University Hospital. From Martin Luther King, turn right on Burnet or Reading. At the bottom of the hill (about a mile), turn left on Eden and follow that through Eden Park, bearing to the right. About a quarter mile after entering the park, the museum is on the right. Can't miss it. [1]
The VA study mentioned on rounds was a randomized study of nortriptyline versus placebo for smoking cessation. After six months 14% of nortriptyline group was still off cigarettes versus 3% placebo. [1]
A Cochrane Collaborative review of the role of antidepressants in smoking cessation (periodically updated) concludes:
"The antidepressants bupropion and nortriptyline can aid smoking cessation but selective serotonin reuptake inhibitors (e.g. fluoxetine) do not." [2]
Monthly Cost (drugstore.com)
$115.55 Zyban
$69.98 generic bupropion
$19.00 nortriptylline (75 mg hs)
$86.00 Nicoderm CQ patch
Looking at whether intervention during hospitalization was effective, the Cochrane Collaborative has not yet found evidence. They also note:
"There was no strong evidence that clinical diagnosis affected the likelihood of quitting."[3]
How Likely Success?
As far as success rates with bupropion versus placebo at one year, this NEJM study found 12% success in placebo and 23% with bupropion. [4]
No benefit for the patch was found in a 1999 trial [5], but earlier meta-analyses suggested some benefit. [6]
Do serologic tests distinguish between autoimmune hepatitis and non-alcoholic fatty liver disease (NAFLD or NASH)?
This study of 225 patients at the Mayo Clinic suggests that biopsy may be needed to make the distinction. [1]
"Routinely measured autoantibodies are present in one quarter of patients with NAFLD and are associated with more severe histological damage. Liver biopsy is required to rule out AIH in most NAFLD patients with positive autoantibodies."
(Adams LA, Lindor KD, Angulo P. The prevalence of autoantibodies and autoimmune hepatitis in patients with nonalcoholic fatty liver disease. Am J Gastroenterol. 2004 Jul;99(7):1316-20.)
Should we screen relatives of symptomatic patients with Factor V Leiden mutation?
This Danish paper concluded [1]:
"The absolute annual incidence of spontaneous venous thromboembolism in asymptomatic carriers of the factor V Leiden mutation is low and does not justify routine screening of the families of symptomatic patients."
(Middeldorp S, et al. Ann Intern Med 2001;135(5):322-327)
When Factor V Leiden mutation is combined with a prothrombin mutation the risk of venous thrombosis is much higher. [2]
This article suggests that for intevention with an exercise program, the number needed to treat to prevent one fall is 14. [1]
Falls and how to prevent them are reviewed by two excellent papers. One is full-text online free [2], the other is by Mary Tinetti as mentioned on rounds [3].
The National Institutes of Health is sponsoring this prospective study of the effect of statins on cognition and behavior (abstract available online, but full-text is a good review of existing literature.) [1]
This free full-text online article from Archives of Internal Medicine looks at outpatient prescribing of potentially inappropriate medications (PIM). [1]
It includes this table of updated Beers criteria. [2]
Beth mentioned the association of NSAIDs with a higher risk of congestive heart failure (CHF).
Her review points to an Australian case-control study that shows twice the risk of first time CHF admission if NSAIDs had been taken in the past week, and a ten-times greater risk of hospitalization of those with pre-existing CHF diagnosis [1].
A Rotterdam cohort study did not find new CHF to be precipitated by NSAIDs, but did confirm the ten-times risk when NSAIDs are given to individuals with a known history of CHF [2].
More generally the risks of NSAIDs for CHF, renal insufficiency and GI bleeding are reviewed by Bandolier [3].
My sense is that NSAIDs worsen blood pressure control. I am looking for evidence.
As her third point yesterday Megan mentioned surgery for COPD. The National Emphysema Treatment Trial (NETT) [1] reported their results in 2003 [2]. (Their conclusion, as Megan reported, that non-upper lobe involvement and high baseline capacity are poor candidates clarifies misimpressions that I may have left.)
"Overall, lung-volume–reduction surgery increases the chance of improved exercise capacity but does not confer a survival advantage over medical therapy. It does yield a survival advantage for patients with both predominantly upper-lobe emphysema and low base-line exercise capacity. Patients previously reported to be at high risk and those with non–upper-lobe emphysema and high base-line exercise capacity are poor candidates for lung-volume–reduction surgery, because of increased mortality and negligible functional gain."
Sarah Hull's review of uncomplicated urinary tract infection raised the efficacy of cranberry juice--more evidence is clearly reviewed online. [1] A 1994 JAMA paper by Avorn et al did, in fact, use regular old cranberry juice cocktail:
"Subjects were randomly assigned to consume 300 mL per day of a commercially available standard cranberry beverage or a specially prepared synthetic placebo drink that was indistinguishable in taste, appearance, and vitamin C content but lacked cranberry content." [2]
More recent research funded by Ocean Spray also used cranberry juice cocktail and found decreased bacterial adhesion. [3]
Sarah Mallot found that the phenazopyridine (such as AZO-Standard) box does not include a warning for people with diabetes. [1] But complications of urinary tract infections, like pyelonephritis, are more common with diabetes. [2] A 1944 autopsy series "documented a frequency of acute pyelonephritis among patients with diabetes that was four to five times as high as that among patients without diabetes."
More about the Delphi technique, used to put together the Beers list...
"Consensus methods, in particular Delphi, have been described as methods of 'last resort.' Even their advocates have warned against overselling them and suggest that they should be regarded more as methods for structuring group communication on a question, than as a means for providing definitive answers."
Jones J, Hunter D. Qualitative Techniques in Healthcare. BMJ Books 2000.
Full text of this chapter is online. [1]
To download the pneumonia severity index that Karla talked about this morning try this Stanford site.[1] Even if prompted for a login, none is needed to download this and many other handheld medical tools.
A couple of other sites for medical handheld information.[2,3]
To raise our awareness of fall risk, Sarah Malott presented her survey of how we prescribe sedatives. Tom Imhoff mentioned that a consensus panel recently updated the Beers Criteria--an imperfect list to remind us of hazards in prescribing. [1,2,3,4,5]
Our patient's gastric bypass surgery raises a couple of questions:
1. Is medication absorption hindered? (Extended release or large pill size)?
2. What are the risks of post-operative pulmonary embolism?
...I have not yet found data on post-op medication absorption. After surgery our patient could not take her oral medications (including clonidine), perhaps because of gastroenterostomy stenosis. An incidence of 3% for this complication has been reported. [1]
...As for pulmonary embolism, this review of a national database of hospital discharges shows:
'The number of bariatric procedures rapidly increased from 6,868 in 1996 to 45,473 in 2001, with most of the increase attributable to a very large rise in the annual number of Roux-en-Y gastric bypasses performed." The in-hospital complication rate was about 10%. Will get the full-text of this article and another from Virginia Commonwealth University's 2000 patients, to find reported pulmonary embolism incidence. [2,3]]
A Good Review Article (including pictures)
A New England Journal of Medicine review from March of this year estimates that mortality of the procedure ranges from 0.1 to 2%. But good collective data are still pending.
"The National Institutes of Diabetes and Digestive and Kidney Diseases (NIDDK) has established a clinical research consortium, known as the Longitudinal Assessment of Bariatric Surgery, to answer key questions about the risks and benefits of the operations and their physiological effects. The consortium will receive $15 million in funding over a five-year period; the participating medical centers were selected in September 2003." [4]
Since we are doing a rotation in Internal Medicine, here are the US Preventive Services Task Force recommendations on screening for obesity (full-text online). [5]
An update of NHANES US data shows [1]...
...Obesity in half of black population and a third of whites & hispanics. (BMI of 30 or more)
...Morbid obesity in 14% of black and 5% of white populations. (BMI of 40 or more)
This is one article I found that discusses dehydration and hunger in the terminally ill patient with discussion of IVF and tube feed use. [1]
Several candidates for stroke testing have been investigated. [1,2,3]
Following up on this week's Grand Rounds [1], here is a practical review of insulin therapy--full text online. [2]
Tonight Badi El Osta recommended these two excellent review articles from JAMA 2003. [3, 4]
Following up on Karla's talk on hyperkalemia...
The RALES study showed benefit of spironolactone in advanced congestive heart failure.[1] A recent Canadian article reports rising hospital admissions for hyperkalemia since the RALES study. [2]
Accompanying editorials help put hyperkalemia management in perspective.[3,4]
Here are the links as mentioned on today's rounds. The DEFINITE study of 458 patients (70% men) shows reduced arrhythmic death with defibrillators in nonischemic cardiomyopathy (ejection fraction less than 36%). Subgroup analysis suggests that men with Class III heart failure may have improved overall survival with implanted defibrillators. [1]
Devices are put in perspective in editorials. [2, 3,4]