Physician's First Watch: Archives

Prone Position for Acute Respiratory Distress Syndrome Doesn't Boost Survival

In patients on mechanical ventilation for acute respiratory distress syndrome (ARDS), prone positioning does not improve survival compared with supine positioning, according to a JAMA study.

Nearly 350 patients with ARDS receiving mechanical ventilation were randomized to be in the prone position for at least 20 hours daily, or to be in the supine position with rescue prone positioning as needed. The primary endpoint — 28-day mortality — did not differ significantly between the groups. In addition, the prone group experienced more complications (e.g., muscle paralysis, hemodynamic instability).

An editorialist says that based on this trial, "prone ventilation should not be used routinely in all patients with ARDS. However, for a patient at imminent risk of death from hypoxemia, it makes sense to try prone ventilation, because multiple studies have demonstrated that it can increase oxygenation."

LINK(S):

JAMA article (Free)

JAMA editorial (Subscription required)

Published in Physician's First Watch November 12, 2009

Low-Fat Diet Associated with Improved Mood After 1 Year

Patients may ask about a small study suggesting that a low-fat diet, compared with a low-carbohydrate one, is associated with improved mood despite similar weight loss.

Reporting in Archives of Internal Medicine, researchers describe randomizing some 100 obese adults to either a low-carb or low-fat diet. After 1 year, participants lost an average of 14 kg, with no significant weight-loss difference between the diets.

Both groups saw initial improvements in mood scores as assessed by questionnaires. But by 1 year, the low-carb group saw its scores return to unfavorable baseline levels, while the low-fat group had sustained improvements in depression, anger, and confusion.

The authors note that average mood scores throughout the study were within the normal range, so their findings "are limited to healthy, obese, young to middle-aged adults with normal mood state and cannot be generalized to clinical populations."

LINK(S):

Archives of Internal Medicine article (Free)

Published in Physician's First Watch November 10, 2009

Primary Care Visit Length Increasing

Contrary to common belief, physicians have been spending more time with their patients, according to an Archives of Internal Medicine study.

In analyzing a sample of over 45,000 adult visits to primary care physicians between 1997 and 2005, researchers noted the following trends:

• During the 9-year period, the length of the average visit increased over 15%, from 18 minutes to about 21.
  
• Visit lengths for the three most common primary diagnoses also increased significantly (diabetes and hypertension, each by about 4 minutes; and visits for arthropathies by about 6 minutes).
  
• Less time was spent with black and Latino patients than with whites, on average.
  

The researchers also note that counseling about medications was generally not associated with longer visits. On this point, they comment that "ensuring that patients are prescribed the appropriate medications need not take more time than allowing their continued use of the wrong medication."

LINK(S):

Archives of Internal Medicine article (Free abstract; full text requires subscription)

Published in Physician's First Watch November 10, 2009

H1N1 Update: CDC Releases 'Quick Facts' for Providers on Antiviral Drug Use

At Friday's CDC press briefing on 2009 H1N1 flu, Dr. Anne Schuchat stressed the importance of antiviral drugs for severe illness and directed clinicians to a fact sheet on "some of the myths and misconceptions about antivirals."

Among the CDC's "Quick Facts for Clinicians on Antiviral Treatments for 2009 H1N1":

• Although initiating treatment within 48 hours of symptom onset is preferable, many patients (including those hospitalized or at high risk for severe illness) may still benefit if treatment is started later.
  
• While antivirals are advised for patients with heightened risk, even those without risk factors might benefit, making clinical judgment "essential."
  
• If flu is suspected and treatment seems warranted, antivirals should be started before laboratory confirmation of illness.
  

LINK(S):

CDC fact sheet (Free)

CDC press briefing transcript (Free)

NEJM/Journal Watch H1N1 Influenza Center (Free)

Published in Physician's First Watch November 9, 2009

CDC Stroke Registry Suggests Ways to Improve Care

In treating stroke, both physicians and the public can improve their roles, according to a 3-year analysis of results published in MMWR.

Data on some 60,000 patients with stroke from Georgia, Illinois, Massachusetts, and North Carolina were entered into the federally sponsored Paul Coverdell National Acute Stroke Registry between 2005 and 2007. Stroke types were as follows: hemorrhagic, 14%; ischemic, 56%; transient ischemic attack, 22%; and "ill-defined," 7%.

Researchers examined 10 treatment performance measures and their use among eligible patients. Among the results:

• Over a third of patients used private transportation rather than emergency medical services to get to the hospital.
  
• Only about 20% arrived at the hospital within 2 hours of symptom onset.
  
• Almost all got antithrombotic therapy at discharge (98%) and within 48 hours of admission (95%).
  
• About two thirds of those eligible received lipid-level testing.
  
• About a third of those eligible received tissue plasminogen activator.
  

LINK(S):

MMWR Surveillance Summaries article (Free)

Published in Physician's First Watch November 6, 2009

'On-Demand' vs. Daily Chest Radiographs for Patients on Mechanical Ventilation

For mechanically ventilated ICU patients, performing chest radiographs as needed rather than daily can lead to more efficient care without compromising patients' safety, according to a Lancet study.

The study included 21 ICUs and nearly 850 patients in France. The ICUs were randomized to perform daily chest radiographs, or to follow an "on-demand" strategy whereby radiographs were performed only if necessary based on patients' morning exams (all ICUs performed additional radiographs as needed throughout the day). The ICUs followed their randomized strategy until all patients were discharged or had been on ventilation for 30 days. Then, they crossed over to the other strategy.

The mean number of radiographs per patient-day was 32% lower with on-demand than with daily radiographs (0.75 vs. 1.09). This reduction was achieved without adverse effects on mortality, number of days on ventilation, or length of ICU stay.

The authors say their findings "strongly support" on-demand radiography over a routine strategy.

LINK(S):

Lancet article (Free abstract; full text requires subscription)

Lancet comment (Subscription required)

Journal Watch General Medicine coverage of previous study questioning daily chest x-rays in the ICU (Your Journal Watch registration required)

Published in Physician's First Watch November 5, 2009

H1N1 Update: Factors Associated with Deaths and Hospitalizations

Although patients hospitalized for 2009 H1N1 influenza infection are younger on average than those hospitalized for seasonal flu, people aged 50 and older have the highest death rates.

Researchers analyzed some 1100 cases who were hospitalized for, or had died from, pandemic influenza in California in the first 4 months of the outbreak. Among their principal findings, presented in the current JAMA:

• The median age of the cases was 27.
  
• Hospitalization rates were highest among infants under age 1 and lowest among the elderly.
  
• Case-fatality rates — at 11% overall — were highest among those 50 and older and lowest in children under 18.
  
• Two thirds had underlying medical conditions associated with severe disease, and over half were obese.
  

LINK(S):

JAMA article (Free abstract; full text requires subscription)

Published in Physician's First Watch November 4, 2009

Aspirin for Primary Prevention 'Should Not Be Routinely Initiated'

Aspirin "should not be routinely initiated" for the primary prevention of cardiovascular disease, and for patients already taking aspirin, its use should be reviewed, advises the BMJ publication Drug and Therapeutics Bulletin.

After considering the recommendations of several meta-analyses, the authors conclude that the available evidence "does not justify the routine use of low-dose aspirin for the primary prevention of [cardiovascular disease] in apparently healthy individuals, including those with elevated blood pressure or diabetes." They say the risk for serious bleeding due to chronic aspirin use sometimes offsets aspirin's benefits.

The authors add that for patients already taking aspirin, "the decision about whether to continue with the treatment should be taken by both the patient and a healthcare professional in light of the available evidence."

LINK(S):

Drug and Therapeutics Bulletin article (Free abstract; full text requires subscription)

USPSTF guidelines on aspirin for prevention of cardiovascular disease (Free)

Previous Physician's First Watch coverage of Lancet meta-analysis on aspirin for primary prevention (Free)

Published in Physician's First Watch November 4, 2009

Sulfonamides and Nitrofurantoins Linked to Birth Defects

Patients may ask about a widely reported, case-control study suggesting that certain antibacterial drugs, including sulfonamides and nitrofurantoins, are associated with increased risk for birth defects. The findings appear in the Archives of Pediatrics and Adolescent Medicine.

Some 13,000 women who had infants with birth defects, and nearly 5000 control mothers whose infants did not have defects, completed interviews on their use of antibacterial drugs from the month before conception through the 3 months afterward.

Among the findings:

• Sulfonamides were associated with the most types of defects, such as anencephaly and left-sided heart defects.
  
• Nitrofurantoins were also linked to several defect types, including hypoplastic left heart syndrome.
  
• Penicillins, erythromycins, cephalosporins, and quinolones were largely unrelated to defects.
  

The authors conclude that their study "lends support to the established safety profiles" for certain antibiotics (e.g., penicillins), but that the increased risks observed with sulfonamides and nitrofurantoins indicate "a need for additional scrutiny."

LINK(S):

Archives of Pediatrics and Adolescent Medicine article (Free abstract; full text requires subscription)

Associated Press story (Free)

Published in Physician's First Watch November 4, 2009

ACCF/AHA Issue Guidelines for Perioperative Use of Beta-Blockers

The American College of Cardiology Foundation and the American Heart Association have updated their 2007 guidelines for perioperative beta-blocker use.

Among the changes, published in the Journal of the American College of Cardiology:

• Routine use of high-dose beta-blockers without dose titration is not helpful and may be harmful to cardiac-surgery patients naive to beta-blockers.
  
• Beta-blockers, titrated to blood pressure and heart rate prior to surgery, are "probably" indicated in patients at high cardiac risk who are undergoing vascular surgery.
  
• Use of the drugs is reasonable in patients undergoing vascular surgery who have coronary artery disease or cardiac ischemia.
  

LINK(S):

Journal of the American College of Cardiology article (Free PDF)

Published in Physician's First Watch November 3, 2009