Primecuts – This Week In The Journals

February 13, 2012

By Megha Shah, MD

Faculty Peer Reviewed

Celebrity news often, albeit arguably, is the most read, most gripping, and most discussed of the daily headlines. It then comes as no surprise that the news of the untimely deaths of music icons Michael Jackson, Amy Winehouse, and now Whitney Houston surpass that of the Republican primaries, continued unrest in the Middle East, the battle between Catholic bishops and Obama on the issue of birth control, and even (gasp!), the Doritos baby from the Superbowl. Though the reasons may be many, celebrity news can remind us that no one, not even the rich and famous, are immune to the dangers of unhealthy living. It is our responsibility to do what we can do inspire health in our patients, and, what we often forget, in ourselves. With that, keep on to Primecuts…

Though we all know the importance of measuring blood pressure in both arms when suspicious for an aortic dissection, should we do it routinely for all patients? Current guidelines state to do so, but often this practice is overlooked or ignored. Researchers in England have found evidence to convince us otherwise. As reported in the New York Times, researchers performed a metanalysis of studies looking at differences in blood pressure readings between arms. They found that a difference of 15mmHg in systolic blood pressure could indicate a 2.5 times higher risk of peripheral vascular disease and a 1.6 times higher risk of cerebrovascular disease. It also was associated with a 70 percent higher risk of mortality from heart disease. The study highlights that taking the extra time to measure the additional blood pressure can lead to proper diagnosis and may also affect our treatment choices.

Chemotherapy plus radiation therapy has long been a mainstay in the treatment of limited stage Hodgkin’s lymphoma but often is associated with late, mostly radiation induced, deaths. The New England Journal of Medicine this week published a study looking at ABVD chemotherapy alone versus radiation based therapy for patients with Hodgkin’s lymphoma. The authors hypothesized that chemotherapy alone would improve survival as it would be associated with less radiation related late deaths. In the study, 405 patients with either stage IA or IIA Hodgkin’s lymphoma were randomized to ABVD (doxorubicin, bleomycin, vincristine, and dacarbazine) alone or to subtotal nodal radiation therapy with or without ABVD therapy with a primary endpoint of 12-year overall survival. Overall survival in the ABVD only group with 94% at 12 years versus 87% in those who received radiation therapy (with or without ABVD, p=0.04) though rates of freedom from disease progression were 87% and 92% respectively (p=0.05). Given the late-effects of radiation therapy, the study shows that chemotherapy alone may be an option to consider in patients with Hodgkin’s lymphoma given the higher rates of overall survival.

While the importance of nutrional support in patients with acute lung injury (ALI) may be widely accepted, the volume and type of feeds has been debated. Results of the EDEN (Early Vs. Delayed Enteral Nutrition in ALI) trial were published by the Journal of the American Medical Association in an early online preview. The study was designed to show whether lower-volume trophic enteral feeding would increase ventilator-free days and decrease gastrointestinal intolerances as compared to initial full enteral feeding in patients requiring mechanical ventilation for acute lung injury. Approximately 1000 patients were randomized to either type of feeding for six days with a primary outcome of ventilator-free days over a total of 28 days. Initial trophic feeding compared to full enteral feeding was not associated with a higher number of ventilator-free days (14.9 vs. 15, p=0.89) or reduce 60-day mortality (23.2% vs. 22.2%, p=0.77). Initial trophic feeding did cause less vomiting, constipation, and gastric residual volumes. While the study did not show improved outcomes for initial trophic feeding in ALI, the authors, while noting that this was not an equivalency study, stated that the similarity in outcomes could allow the use of trophic feeding as a more economic, easy to administer option than full enteral feeding.

As the prevalence of Clostridium difficile grows, so does the need to find agents to add to our small arsenal of metronidazole and vancomycin. In another early online publication in the Lancet, researchers reported the results of a non-inferiority study comparing fidaxomicin with vancomycin in the treatment of Clostridium difficile. The study, multinational, multicenter, and double-blind, randomized 535 C.diff positive patients to either fidaxomicin or vancomycin (both oral) for ten days with a primary endpoint of clinical cure, defined by the resolution of diarrhea. Their results showed clinical cure in 91.7% with fidaxomicin compared to 90.6% with vancomycin and no difference in adverse effects (7.6% vs. 6.5%) showing that fidaxomicin, with similar efficacy and safety profile, could be an alternative option for the treatment of C.diff.

The Annals of Internal Medicine this week published an interesting study on end-of-life care, a topic that physicians are often uncomfortable with. According to national recommendations, physicians should discuss end of life (EOL) care planning with patients with cancer whose life expectancy is less than one year. In this prospective cohort study, which included more than 2000 patients with stage IV lung or colorectal cancer, only 27% of patients had their first EOL discussions take place in an office environment versus 55% of patients who had their first EOL discussions take place in the hospital setting during admission. The study highlights that not only do these discussions need to occur more often, but that often they are done in an acute hospital setting which can be very late in the course of illness and under distressing circumstances.

That’s it this week—time to go read TMZ news!

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

Peer reviewed by Robert Gianotti, MD associate editor, Clinical Correlations

Image courtesy of Wikimedia Commons

References:

New York Times. Take Blood Pressure in Both Arms, Study Says. http://well.blogs.nytimes.com/2012/01/29/blood-pressure-should-be-taken-in-both-arms/?ref=research.  Published January 29, 2012. Accessed February 12, 2012.

Meyer RM, Gospodarowicz MK, Connors JM et al. ABVD Alone versus Radiation- Based Therapy in Limited Stage Hodgkin’s Lymphoma. N Engl J Med. 2012; 366: 399-408. http://www.nejm.org/doi/full/10.1056/NEJMoa1111961.

Rice TW, Wheeler AP, Thompson BT et al. Initial Trophic vs. Full Enteral Feeding in Patients With Acute Lung Injury. JAMA. Early online publication. http://jama.ama-assn.org/content/early/2012/02/01/jama.2012.137.abstract.  Published February 5, 2012.  Accessed February 12, 2012.

Cornely OA, Crook DW, Esposito R et al. Fidaxomicin versus vancomycin for infection with Clostridium difficile in Europe, Canada, and the USA: a double-blind, non-inferiority, randomized controlled trial. The Lancet. Early online publication. http://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2811%2970374-7/abstract#aff1.  Published February 8, 2012. Accessed February 12, 2012.

Mack JW, Cronin A, Taback N et al. End of Life Care Discussions Among Patients with Advanced Cancer: A Cohort Study. Ann. of Int. Med. 2012; 156(3): 204-210. http://www.annals.org/content/156/3/204.abstract.

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