Faculty peer reviewed
Although the frequent rounds of snow hitting New York City and First Avenue (hopefully) seem to be coming to an end and the outside world is drawing New Yorkers out of their winter bubbles, Primecuts is still here inside for your indoor reading.
In an open-label, randomized controlled trial based in South Africa and published in the NEJM, patients diagnosed with both HIV infection and tuberculosis were assigned to start anti-retroviral therapy either during tuberculosis therapy or after completion of the tuberculosis regimen (1). With a primary outcome of death from any cause, the trial showed that patients receiving concurrent antiretroviral and tuberculosis therapy had improved survival outcomes when compared to those who received sequential treatment with a 56% reduced mortality. The death rate in the concurrent treatment group had a death rate of 5.4 per 100 person years versus 12.1 per 100 person years in the sequential treatment group. Although the incidence of immune-reconstitution events was higher in the concurrent group and therefore these patients must receive closer monitoring while on treatment, the survival benefit for this dually at risk population is obvious. Given the higher rates of HIV and tuberculosis in New York City, co-infection must always be a consideration especially when known untreated HIV patients present with symptoms of typically pulmonary tuberculosis (fever, night sweats, hemoptysis). This trial has appropriately demonstrated the need to treat both infections simultaneously and should serve as an important guideline for physician management.
Also in the NEJM researchers from the Sepsis Occurrence in Acutely Ill Patients (SOAP) group attempted to create an evidence-based answer to the question of the appropriate vasopressor use in shock (2). With a primary outcome of death at 28 days, the investigators compared dopamine and norepinephrine for patients presenting with septic, cardiogenic or hypovolemic shock. The multicenter, randomized trial of 1679 patients found no significant difference between the dopamine and norepinephrine in the death rates at 28 days (52.5% and 48.5%, respectively). Secondary analysis did note, however, a significant increase in the incidence of arrhythmic events with dopamine versus norephinephrine (24.1% vs. 12.4%, respectively). While the accompanying editorial (3) illustrated many of the questionable aspects in the study including the minimal amounts of pre-vasopressor fluid resuscitation, the applied definition of shock and the questionable equivalent dosages of the agents, the study still represents an effort to delineate what is often left to provider preference. These results clearly guide practitioners toward norephinephrine as the agent of choice.
From the primary care front in the NEJM, given the new clinical practice guidelines from the American Diabetes Association advocating the use of glycated hemoglobin for the diagnosis of diabetes, researchers analyzed A1C blood samples drawn from a community-based prospective cohort of 11,092 non-diabetic patients in Atherosclerosis Risk in Communities group and stratified their hazard ratio risk of developing diabetes (4). The analysis revealed that increasing glycated hemoglobin levels was associated with an increasing risk of developing diabetes. For glycated hemoglobin values less than 5.0%, 5.0 to less than 5.5%, 5.5 to less than 6.0%, 6.0 to less than 6.5% and 6.5% and greater, the multivariate-adjusted hazard ratio for diagnosed diabetes were 0.52, 1.00, 1.86, 4.48, 16.47, respectively. A similar pattern was observed for cardiovascular disease and death. Although not groundbreaking in terms of the outpatient management of disease, it does provide primary care providers for another tool in accessing the risk for the development of diabetes and guide sugar controlling practices before the disease occurs.
Finally, although by no means current publication, a colleague of mine recently showed me this study and I feel it needs to be shared with an even wider population. Published in The Lancet 133 consecutive homeless adults visiting one-inner city emergency room who were not psychotic, intoxicated, unable to speak English or medically unstable were randomized to receive compassionate care from a trained volunteer versus standard care (5). The study found that the average number of visits per month after intervention was significantly lower for patients who received compassionate care (0.43 vs. 0.65, p=0.018) and adjusting for previous use rate confirmed an average 30% reduction in the number of return visits. So although compassion may often be lost in the setting of chronic ER visitors in many New York City emergency rooms, it is definitely food for thought. Being nice now may save you some work later.
Dr. Tully is a second year internal medicine resident at NYU Medical Center.
Faculty peer reviewed by Judith Brenner MD, Associate Editor, Clinical Correlations.
That’s all from Primecuts. Have a great week.
1) Karim, Salim S. Abdool et al. Timing of Initiation of Antiretroviral Drugs during Tuberculosis Therapy. NEJM 2010;362(8):697-706.
2) De Backer, Daniel et al. Comparison of Dopamine and Norepinephrine in the Treatment of Shock. NEJM 2010;362(9):779-789.
3) Levy, Jerrold H. Treating Shock – Old Drugs, New Ideas. NEJM 2010;362 (9):841-843.
4) Selvin, Elizabth et al. Glycated Hemoglobin, Diabetes, and Cardiovascular Risk in Nondiabetic Adults. NEJM 2010;362(9):800-811.
5) Redelmeier, Donald A. et al. A randomised trial of compassionate care for the homeless in an emergency department. The Lancet 1995;345(8958): 1131-34.