ShortCuts-This Week in the Journals

May 28, 2008

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Commentary by Josh Olstein MD, NYU Chief Resident 

This week’s edition of shortcuts begins with an article from the NEJM looking at the role of cardiac troponin in patients with acute decompensated heart failure. Many of us have “cycled the trops” countless times to evaluate patients with chest pain. However the utility of troponin measurement in patients with CHF is less clear. In this study the authors examined short-term outcomes of patients admitted with CHF exacerbations that had troponin data available on admission. Patients were excluded if their baseline creatinine was greater than 2mg/dL. The primary outcome was in-hospital mortality and almost 68,000 patients were included. Troponin was positive in 6.2% of patients and in-hospital mortality was significantly higher among this cohort of patients (8% vs. 2.7% (for troponin negative patients), P<0.001). The study had several limitations including its retrospective design and possible patient selection bias but this data suggests that troponin may assist in determining the prognosis for patients with acute decompensated heart failure.

While the data wasn’t available from the previous study, we can assume that some of these decompensated CHF patients required renal replacement therapy (RRT) during their hospitalization. The appropriate amount of RRT in critically ill patients remains a controversial topic. A study released online at NEJM this week attempts to shed some light on this question. The authors studied all cause sixty-day mortality among critcally ill patients with acute kidney injury who were randomized to either an intensive or less intensive RRT strategy. Over 1,100 patients were included in the study and mortality was very high in both groups. The difference however was not significant (mortality 53.6% vs 51.5%, OR 1.09; 95% CI 0.86-1.4) between the two treatment approaches suggesting that more vigorous dialysis prescriptions do not translate into mortality benefit among critically patients with acute kidney injury.

An obvious and unfortunately not infrequent complication of dialysis is catheter related infection. The use of various forms of antibiotics to prophylax against catheter related infections remains a topic of debate and the subject of a recent meta-analysis published in the Annals of Internal Medicine last week. Sixteen trials were included for review, 5 involving topical antibiotics and 11 involving intraluminal antibiotics. While most studies were small and unblinded, there did appear to be a benefit in terms of preventing bacteremia and the need for catheter removal with both antibiotic strategies. The authors did find evidence of publication bias, in particular with small studies on intraluminal antibiotic prophylaxis. Concern over the possibility of antibiotic resistance was also raised but longer-term studies will be needed to address this issue.

If you’re looking to avoid heart failure and dialysis altogether, you may want to start by keeping your newly diagnosed diabetes at bay. A RCT from this week’s edition of The Lancet compared the efficacy of short-term intensive insulin therapy with oral hypoglycemic agents among newly diagnosed diabetics. The primary outcomes included initial glycemic control and remission rates. Quite simply those started on intensive insulin therapy were more likely to achieve glycemic control faster and were more likely to remain in remission at one year, even after insulin therapy had been stopped. The authors speculate that early intensive glycemic control led to pancreatic ß-cell preservation by aborting the effects of glucose toxicity.

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