Primecuts – This Week In The Journals

April 18, 2011

By Melissa Mroz, MD

Faculty Peer Reviewed

Protection was the theme in journals for the second week of April.  The New York Times and NEJM both published the results from the VA initiative to prevent MRSA infections [1].  This initiative was implemented in 2007 throughout the VA hospitals.  The “MRSA bundle” included nasal surveillance of all patients on admission, transfer and discharge, contact precautions for colonized and infected patients, hand hygiene, and strict infection control.  The rate of MRSA infection was calculated in events per 1000 patient-days both before and after implementing the bundle.  The investigators found a 62% decrease, 1.64 to 0.62 infections per 1000 patient-days in the ICU setting, and 45% decrease, 0.47 to 0.26 infections per 1000 patient-days in the non-ICU setting.  Though a cost benefit analysis was not provided with the data, this suggests that those ugly yellow gowns do protect patients from MRSA infection – even if just by reminding us to wash our hands.

 Across the pond, a group in the UK looked at the protective effects of statins in patients [2] with pneumonia in the British Medical Journal.  We know that there are benefits beyond using statins for LDL reduction, including likely reduction in inflammation.  The group examined retrospective cohorts looking for mortality benefit in patients on statins who subsequently developed pneumonia compared to age-matched control patients who were not on a statin.  The investigators found that 109/847 statin users died and 578/2927 statin non-users died within six months which gave a hazard ratio of 0.67 (0.49 to 0.91).  This suggests that statins may be protective in pneumonia, though it remains to be seen if starting a statin at time of diagnosis will decrease mortality or if statin use with other infections will have a mortality benefit.

 On the international front, a group published in JAMA looked at the benefit of fixed dose combination drugs to treat pulmonary tuberculosis[3].  In a non-inferiority trial of fixed dose combination (FDC) treatment versus standard 4-drug therapy, patients from 11 sites in 9 countries with pulmonary tuberculosis were randomized to receive 4 drug FDC vs the 4 drugs separately in the intensive phase of treatment.  Both groups received 2 drug FDC for the remainder of treatment.  The primary outcome was adverse events, a composite of relapse, adverse event, and drug resistance.  Though the modified intention to treat analysis did not show non-inferiority in adverse events, as the confidence intervals crossed the predetermined 4% non-inferiority margin, the group maintains that FDCs in real practice will likely decrease resistance. 

 An article in Science gives us a preview of what is in the works for patient protection. Investigators are hopeful that Losartan will protect patients with Marfan’s from aortic aneurysm[4].  The drug, which is thought to work by blocking transforming growth factor-B, was tested in mice models of marfan syndrome in 2006 and shown to prevent aneurysm.  There is a clinical trial in Marfan patients that just finished enrollment of 608 patients.  Though a rare disease, this may change standard of care for these patients who often require surgery. 

 Finally, do we need to protect ourselves from our work hours?  In the study of risk factors for cardiac disease, the Annals published a study using additional information on working hours to predict coronary heart disease (CHD)[5].  The Whitehall II study took a cohort of 7095 adults without prior CHD and predicted their risk of CHD according to the Framingham risk and the Framingham risk score plus working hours.  The authors found that participants working 11 or more hours per day had 1.67 more risk than people working 7 to 8 hours per day when adjusted for Framingham risk score.  When working hours were added to Framingham risk, there were a few more patients put into higher risk categories and this seemed to improve sensitivity, but the c-statistic did not change. Limitations of this study include lower than estimated events of nonfatal MI and coronary death which did not allow separating the cohort into derivation and validation sets.  Further studies are needed both to determine if working hours improve prediction of risk and if decreasing working hours also decrease risk of CHD.  But for now, we can use it as an excuse to get outside and enjoy the spring weather. 

Dr. Mroz is a 3rd year resident at NYU Langone Medical Center

Peer reviewed by Cara Litvin, Executive Editor, Clinical Correlations

Image courtesy of Wikimedia Commons

References:

1. Jain R, Kralovic SM, Evans ME, Ambrose M, Simbartl LA, Obrosky SD, Render ML, Freyberg RW, Jernigan JA, Muder RR, Miller LJ, Roselle GA. Veterans Affairs Initiative to Prevent Methicillin-Resistant Staphylococcus aureus Infections.  N Engl N Med. 2011;364(15):1419-1430. http://www.nejm.org/doi/full/10.1056/NEJMoa1007474

2.  Douglas I, Evans S, Smeeth L.  Effect of statin treatment on short term mortality after pneumonia episode: cohort study.  BMJ. 2011;342:d1642. http://www.bmj.com/content/342/bmj.d1642.full

3.  Lienhardt C, Cook SV, Burgos M, Yorke-Edwards V, Rigouts L, Anyo G, Kim S-J, Jindani A, Enarson DA, Nunn AJ.  Efficacy and Safety of a 4-Drug Fixed-Dose Combination Regimen Compared With Separate Drugs for Treatment of Pulmonary Tuberculosis.  JAMA. 2011;305(14):1415-1423.  http://jama.ama-assn.org/content/305/14/1415.short?rss=1

4.  Couzin-Frankel, J. Frightening Risk of Marfan Syndrome, And Potential Treatment, Elucidated.  Science. 2011;332(15): 297. http://www.sciencemag.org/content/332/6027/297

5.  Kivimaki M, Batty GD, Hamer M, Ferrie JE, Vahtera J, Virtanen M, Marmot MG, Singh-Manoux A, Shipley MJ.  Using Additional Information on Working Hours to Predict Coronary Heart Disease. Ann Intern Med. 2011;154(7):457-463. http://www.ncbi.nlm.nih.gov/pubmed/21464347

 

One Response to Primecuts – This Week In The Journals

  1. A Los Angeles Cardiologist on April 19, 2011 at 5:05 pm

    The Whitehall study population is British civil servants. They had previously found a correlation with lack of control at work and the risk of heart disease. I wonder how many of the subjects in the longer working hours wanted to work overtime. If the overtime was mandated, then it may have contributed to the workers’ feelings of loss of autonomy and control.

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