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Physician's First Watch: Archives
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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
Featured in Journal Watch: ID Learning Unit — Antibiotics with Excellent Absorption
By The Journal Watch Editors
Paul Sax shares a list that "all ID doctors have encoded deep in their genome": antibiotics that can be given orally in place of their IV counterparts, or even more importantly, substituted for something IV on discharge.
LINK(S):
HIV and ID Observations blog (Free)
Published in Physician's First Watch May 20, 2013
Fries with That? Immigrants' Health Found to Deteriorate After Life in U.S.
By Joe Elia
For immigrants, the effects of life in the U.S. include greater income along with higher cardiovascular risks, researchers are concluding.
In a survey of the problem in the New York Times, it's reported that American-born children of immigrants tend to have shorter lifespans than their parents. American-style behaviors, such as eating high-calorie diets and not getting enough exercise, seem to be to blame.
One researcher has found that Hispanic immigrants live almost 3 years longer than American-born Hispanics.
LINK(S):
New York Times story (Free)
Published in Physician's First Watch May 20, 2013
WHO: Yellow Fever Booster No Longer Necessary
By The Editors
The yellow fever booster shot, given 10 years after the initial vaccination, is no longer needed, the World Health Organization announced on Friday. Upon reviewing the recent evidence, the WHO's Strategic Advisory Group of Experts on immunization concluded that just one dose is enough to provide lifelong immunity against the disease.
LINK(S):
WHO news release (Free)
Published in Physician's First Watch May 20, 2013
Would You Like a Shot with That Shot? A New Venue for Vaccinating MSM Against Invasive Meningococcal Disease
By Amy Orciari Herman
The rise of invasive serogroup C Neisseria meningitidis disease among men who have sex with men (MSM) in New York City has at least one doctor taking a creative approach to vaccination: offer the meningococcal shot to as many men as possible in gay bars and clubs in the city.
The New York Times details the mission of Dr. Demetre Daskalakis to confer herd immunity by setting up his own vaccination "clinics" in several after-hours hotspots. Dr. Daskalakis's efforts highlight concern over this deadly strain of meningitis, which has infected 22 MSM in New York City since 2010, killing seven of them. Twelve of those infected were also HIV-positive.
Asked to comment, Paul Sax of Journal Watch HIV/AIDS Clinical Care noted: "The practice of bringing preventive health interventions directly to those at greatest risk is highly desirable, and frequently must take healthcare providers outside of clinics, offices, and hospitals."
LINK(S):
New York Times story (Free)
Background: Journal Watch Infectious Diseases coverage of meningitis in MSM in New York City (Your Journal Watch subscription required)
Published in Physician's First Watch May 20, 2013
DSM-5 Debuts to a Scornful Review in Annals, Skepticism from NIMH
By Joe Elia
The new, fifth edition of the Diagnostic and Statistical Manual of Mental Disorders has been panned in an Annals of Internal Medicine commentary. The author, chair of the DSM-4 task force, advises that clinicians use it "cautiously, if at all."
Separately, the director of the National Institute of Mental Health says that "patients with mental disorders deserve better." Late last month he wrote that the institute will be "re-orienting its research away from DSM categories" to focus on biomarkers of mental disease rather than clusters of symptoms.
The Annals commentator seems especially disappointed with the proliferation of diagnoses "at the fuzzy boundary with normality." He says the result "will probably lead to substantial false-positive rates and unnecessary treatment." Perhaps most damning is his charge that the American Psychiatric Association has a financial conflict of interest driven by DSM revenues (the new edition costs about $200), which led to "premature publication of an incompletely tested and poorly edited product."
LINK(S):
DSM-5 website (Free)
Annals of Internal Medicine comment (Free)
National Institute of Mental Health director's blog (Free)
Published in Physician's First Watch May 20, 2013
