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Physician's First Watch:
Medical News from Journal Watch
A free daily alert on current news that affects your practice — from medical journals, government agencies, scientific conferences, and major media reports.
May 22, 2013
Adenotonsillectomy Associated with Symptom Improvement in Kids with Sleep Apnea
By Kelly Young
Adenotonsillectomy is associated with improved symptoms and quality-of-life in children with obstructive sleep apnea, according to a New England Journal of Medicine study, although it does not improve attention and executive function.
Roughly 450 children (aged 5 to 9 years) with obstructive sleep apnea were randomized to adenotonsillectomy or to watchful waiting. At 7 months, the change in patients' attention and executive function score (primary outcome) did not differ significantly between the groups. However, the adenotonsillectomy group did improve significantly in scores measuring apnea symptoms, polysomnography, behavior, and quality-of-life, compared with the watchful-waiting group.
Adenotonsillectomy showed benefits in both obese and nonobese children, but polysomnographic findings were less likely to normalize in obese children, regardless of treatment group. Accordingly, the authors conclude that their results "support a strategy of early adenotonsillectomy in both obese and nonobese children ... but they underscore the need to carefully follow obese children after surgery."
LINK(S):
NEJM article (Free)
NEJM editorial (Free)
Background: Journal Watch Pediatrics and Adolescent Medicine coverage of guidelines on obstructive sleep apnea in children (Your Journal Watch registration required)
Published in Physician's First Watch May 22, 2013
Glucocorticoids for COPD Exacerbations: 5 Days' Treatment Is Enough
By Amy Orciari Herman
A 5-day course of glucocorticoids is sufficient to treat acute exacerbations of COPD, according to a placebo-controlled noninferiority trial published in JAMA. Currently, most guidelines recommend 10 to 14 days' treatment.
Some 300 patients presenting to Swiss emergency departments with COPD exacerbations were randomized to receive systemic glucocorticoids for 5 or 14 days. Patients also received antibiotics and other standard COPD medications (additional glucocorticoids were given as needed throughout the study).
During 6 months' follow-up, re-exacerbation rates did not differ significantly between the groups. Similarly, secondary outcomes such as death and need for mechanical ventilation did not differ. Patients in the 5-day group had less cumulative glucocorticoid exposure.
Editorialists write: "The clinical implications of this study are clear. Most patients with acute COPD exacerbations can be treated with a 5-day course of prednisone or equivalent. ... This is welcome news for patients ... who experience multiple exacerbations annually and are exposed to repeated courses of systemic corticosteroids."
LINK(S):
JAMA article (Free)
JAMA editorial (Free)
International COPD management guidelines (Free PDF)
Published in Physician's First Watch May 22, 2013
Cancer Risk from CT in Young People Is Small, But Measurable
By Joe Elia
Children and adolescents who undergo computed tomography increase their relative risk for cancer by roughly 25%, according to a cohort study in BMJ.
Using national health records, researchers studied nearly 11 million Australian children aged 0 to 19 years. Some 700,000 had received a CT scan, and they were followed for roughly 10 years after exposure.
Compared with non-scanned controls, those exposed to CT had an overall cancer-incidence rate ratio of 1.24, with higher risks associated with exposure at younger ages. An editorialist says the effect "would equate to roughly one excess cancer per 4000 head CTs at the more typical doses in use with current day technology."
Separately, the Wall Street Journal reports that some hospitals now track radiation exposure automatically and share those data with patients.
LINK(S):
BMJ article (Free)
BMJ editorial (Subscription required)
Wall Street Journal story on tracking radiation exposure (Free)
Background: Journal Watch Pediatrics and Adolescent Medicine summary of 2012 study on CT and cancer (Free)
Published in Physician's First Watch May 22, 2013
Interview: Marathon Bombings' Lessons — Part 3
By Joe Elia
The Clinical Conversations series of brief interviews regarding the Boston Marathon bombings continues with Andrew Ulrich, executive vice chair of emergency medicine at Boston Medical Center.
LINK(S):
Clinical Conversations podcast (Free)
Last week's conversation with Alasdair Conn from Massachusetts General Hospital (Free)
Published in Physician's First Watch May 22, 2013
Japanese Encephalitis Vaccine Approved for Children
By The Editors
The Japanese encephalitis vaccine Ixiaro, previously approved for use in those aged 17 and older, is now approved for children as young as 2 months old.
In a news release, the manufacturer noted that it is the first time in nearly 2 years that traveling children and children of military personnel deployed to Asia will be able to receive a licensed vaccine against Japanese encephalitis.
LINK(S):
Manufacturer's news release (Free)
Background: Journal Watch Infectious Diseases coverage of CDC recommendations on JE vaccination (Your Journal Watch registration required)
Published in Physician's First Watch May 22, 2013
Featured in Journal Watch: Another Step Toward Eliminating HIV Infection?
By The Journal Watch Editors
In two patients, reported in the Journal of Infectious Diseases, allogeneic stem-cell transplantation under the cover of antiretroviral therapy produced sustained reduction of HIV reservoirs in peripheral blood mononuclear cells.
LINK(S):
Journal Watch HIV/AIDS Clinical Care summary (Free)
Published in Physician's First Watch May 22, 2013
May 21, 2013
Vigorous Sports OK for Some Patients with ICDs
By Amy Orciari Herman
Many patients with implantable cardioverter-defibrillators (ICDs) can safely participate in vigorous sports, despite recommendations against such activity, a Circulation study finds.
Researchers followed nearly 400 athletes (aged 10 to 60) with ICDs for about 2.5 years; participants were involved in either organized or high-risk sports (most commonly, running, basketball, soccer, and skiing). Overall, no one experienced the primary endpoint, defined as tachyarrhythmic death, resuscitated tachyarrhythmia, or severe injury resulting from arrhythmia-related syncope or shock. Participants were not significantly more likely to receive shocks during sporting activities (10%) than during other recreational activities (8%). The ICD terminated all arrhythmia episodes.
The researchers conclude: "Many athletes with ICDs can engage in vigorous and competitive sports without physical injury or failure to terminate the arrhythmia. ... These data provide a basis for more informed physician and patient decision making in terms of sports participation for athletes with ICDs."
LINK(S):
Circulation article (Free)
Published in Physician's First Watch May 21, 2013
Use of Prone Positioning During Ventilatory Support Found Superior in ARDS
By Joe Elia
In patients with acute respiratory distress syndrome (ARDS), use of the prone position during ventilatory support roughly doubled survival at the 1- and 3-month marks, according to a New England Journal of Medicine study.
Researchers followed outcomes in nearly 500 patients with severe ARDS who were randomized either to prone positioning for at least 16 consecutive hours a day, or to being left supine. By 28 days, mortality was 16% in the prone group, versus 33% in the supine group; at 90 days, the prone-positioning advantage held: 24% versus 41%.
An editorialist calls the results "compelling," and the treatment effect "virtually unprecedented in modern medicine." He cautions, however, that the logistics of turning patients to the prone position from supine requires teamwork to avoid kinking and extubation. The article includes a video showing how this can be accomplished with three people.
LINK(S):
NEJM article (Free)
NEJM editorial (Free)
Published in Physician's First Watch May 21, 2013
Bronchodilators Associated with Increased CV Risk in Older Patients with COPD
By Kelly Young
Long-acting anticholinergics (LAAs) and long-acting β-agonists (LABAs) are associated with similarly increased risks for cardiovascular events in older patients with chronic obstructive pulmonary disease (COPD), according to a JAMA Internal Medicine study.
Using Canadian registry data, researchers identified patients with COPD aged 66 years and older; nearly 27,000 who'd had a cardiovascular event were matched to controls. New use of LABAs and LAAs was associated with greater risk for cardiovascular events relative to nonuse (odds ratios: 1.31 and 1.14, respectively), with no significant difference between LABAs and LAAs. Risk appeared to be highest 2 to 3 weeks after starting treatment.
The authors note that LABAs are thought to stimulate sympathetic control, while LAAs may suppress parasympathetic control. Both actions are tied to increased risks for arrhythmias, myocardial ischemia, and stroke.
A commentator concludes: "Although the authors recommend that 'subjects should be monitored closely,' a firm recommendation on what that monitoring should be cannot be made."
LINK(S):
JAMA Internal Medicine article (Free abstract)
JAMA Internal Medicine invited commentary (Subscription required)
Background: Journal Watch General Medicine summary on the long-acting anticholinergic tiotropium (Your Journal Watch registration required)
Published in Physician's First Watch May 21, 2013
Treatment of New Prostate Cancers Unlikely to Benefit Older, Sicker Men
By Joe Elia
Men with comorbid conditions who are newly diagnosed with prostate cancer should consider their risk for other-cause mortality before choosing aggressive therapy for their cancer, according to an Annals of Internal Medicine study.
Some 3200 men newly diagnosed with nonmetastatic prostate cancer were followed for 14 years. At entry, the men self-reported whether they had any of 12 comorbidities, including diabetes, chronic lung disease, heart failure, and stroke.
By the 14-year mark, other-cause mortality was 24% for those with no comorbidities, 33% with one comorbidity, 46% with two, and 57% with three or more. The authors point out that for those aged 60 or older with three or more comorbidities, mortality is nearly 50% at 10 years after diagnosis. These men, they say, should "strongly weigh the risk for death from other causes before realizing any potential survival benefit from aggressive therapy."
LINK(S):
Annals of Internal Medicine article (Free abstract)
Annals of Internal Medicine editorial (Subscription required)
Background: Journal Watch General Medicine summary on overly aggressive screening and treatment of prostate cancer (Your Journal Watch registration required)
Published in Physician's First Watch May 21, 2013
Featured in Journal Watch: Higher-Dose Citalopram and the FDA Warnings — Not Much to Worry About?
By The Journal Watch Editors
In a large study, published in the American Journal of Psychiatry, no increased cardiac risks were associated with citalopram doses higher than 40 mg/day.
LINK(S):
Journal Watch Psychiatry summary (Free)
Published in Physician's First Watch May 21, 2013
