By Jovan Begovic, MD
Peer Reviewed
On March 26th, a gas explosion on the Lower East Side of Manhattan caused a fire in three adjacent buildings, 25 injuries, and 2 recently confirmed deaths. Bellevue was readied for triage in case of an emergency rush of admissions from the accident, but luckily most victims were not severely injured and many did not require hospitalization. Several days later the 2 missing persons were discovered as search crews cleared out the wreckage from a sushi restaurant on the first floor. Now, most recently, a story has emerged regarding a possible cause of the gas explosion: there may have been an illegal gas siphoning operation underway to provide an adequate supply for the growing population of tenants [1]. This story continues to develop.
Are we overtreating pneumonia?
A study in the NEJM this week looked at the effects of different antibiotic treatment strategies for community-acquired pneumonia for non-ICU patients [2]. The strategies were beta-lactam monotherapy (BL), beta-lactam + macrolide (BLM), and fluoroquinolone monotherapy (FQ). The primary outcome measure was 90-day all-cause mortality, and secondary measures were length of stay and rate of complications. During the course of a year, over 2200 eligible patients in 7 hospitals in the Netherlands were treated using one of the three strategies during consecutive periods of 4 months, and each participating hospital was assigned a random order in which to implement the three separate strategies. The final results did not show a statistically significant difference in 90-day mortality between any of the strategies (9% BL vs. 11.1% BLM vs. 8.8% FQ), and no significant differences in length of hospital stay or rate of complications were observed. This large study attempted to minimize confounding factors by having each participating site rotate through periods of each treatment strategy. The results may have been affected by the characteristics and prevalence of the specific bacteria causing community-acquired pneumonia during different seasons and among different regions. If the results of the study are generalizable to other regions, it is reassuring to know that in case of limited resources we have a wide range of options for treating community-acquired pneumonia.
Should we leave intracranial stenosis be?
A neurointerventional study published in JAMA examined the long-term outcomes of intracranial stenting for patients with >70% intracranial arterial stenosis, a common precursor of ischemic stroke, compared to medical management alone [3]. Patients were randomized to receive balloon-expandable stent plus medical management, or medical management alone. The patients enrolled in this study had symptomatic intracranial stenosis as evidenced by TIA in the past 30 days. This trial was stopped early due to significant adverse events reported from a simultaneous trial (SAMMPRIS) involving intracranial stenting outcomes. The primary safety measure was any stroke, death, hemorrhage, within 30 days of randomization, and any TIA within 2 days to 30 days of randomization. The primary outcome measure was any stroke in the same territory within 12 months of randomization, or a TIA in the same territory day 2 through month 12 post-randomization. The primary outcome measure occurred more than twice as frequently in the intracranial stenting group (36.2%) compared to the medical management group (15.1%) (95% CI 6.7-27.6, p=0.02). Though many of the subgroup results were not statistically significant, this may have been a result of insufficient sample size due to premature termination of enrollment. Although in theory stenting should help alleviate symptomatic intracranial stenosis, the pathophysiology following intervention is in practice more complex and with present techniques leads to unfavorable outcomes when compared to traditional medical management.
Evaluating second-generation drug-eluting stents
A recent prospective cardiology trial published in the NEJM compared complication rates of percutaneous coronary intervention (PCI) using second-generation drug-eluting stents (Everolimus) versus coronary artery bypass grafting (CABG) [4]. The trial was conducted at 27 sites in Southeast Asia and included subjects 18 and older with >70% occlusion in at least 2 major vessels who were deemed acceptable surgical candidates. Over 5 years, 880 patients were enrolled in the study. Major adverse events, including death, myocardial infarction, or target-vessel revascularization), were higher in the PCI group (15.3%) compared to 10.6% of patients in the CABG group (hazard ratio, 1.47; 95% CI, 1.01 to 2.13, p=0.04). The rate of spontaneous MI was significantly higher in the PCI group (4.3% vs. 1.6%, p=0.02). In subgroup analyses, the rate of a major adverse event after PCI was particularly common in patients with diabetes (19.2 vs. 9.1%, p=0.007), suggesting, like several prior studies, that CABG may be more appropriate in the setting of advanced cardiovascular disease attributed to diabetes. While several prior studies have found PCI to be associated with increased risk of subsequent stroke, this trial showed similar risks of stroke in the two groups. Possible explanations proposed are differences in the CABG technique used and the underlying cardiovascular characteristics of the Asian population.
Going forward, larger prospective trials examining PCI versus CABG will aid us in better quantifying the risks and the benefits of the two procedures to our patients and their families, whom we must so often help make urgent, life-changing decisions at stressful times.
Postoperative transfusion goals
There are risks and benefits to consider when deciding on a transfusion strategy in the ICU. While a liberal transfusion strategy may decrease long-term complications by providing more oxygen to sensitive organs in times of bodily stress, the introduction of foreign blood product may also result in immune suppression that could subsequently lead to infection or malignancy. In The Lancet last week, a prospective study looked at the long-term survival of hip surgery patients aged 50 and older with cardiovascular risk factors that were randomized to liberal (Hb >10 mg/dL) versus restrictive (Hb>8mg/dL) blood transfusion strategies postoperatively. There was no significant difference in 3-year mortality between the two groups. In subgroup analyses, risk factors such age and various medical comorbidities did not correlate with a higher risk for either strategy. Likewise, stratified causes of death, including cardiovascular disease, cancer, and infection, contributed similar percentages to total mortality regardless of transfusion strategy. Prior transfusion goal studies have been largely observational and have rarely included follow-up times exceeding 180 days. This prospective trial, the largest of its kind with over 2000 participants enrolled, showed no differences in 3-year mortality even when stratified for causes of death, providing evidence in support of restrictive transfusion strategies that may conserve valuable hospital resources without detrimentally affecting patient outcomes [5].
Other tidbits…
Adverse effects of psychiatric medications
A JAMA paper analyzed the incidence of adverse drug events due to various psychiatric medications in patients admitted to the emergency department. Antipsychotics and lithium were the main players, though the remaining categories combined still made up a significant slice of the pie [6].
Putting Chagas on the radar screen
An impressive and growing number of Latin American immigrants develop heart failure as a sequelae of untreated Chagas disease. An excellent article in JAMA this week outlines the epidemiology as well as treatment strategies that can help control Chagas in the US [7].
Molecular physiology of water balance
Is your spiel on nephron channels getting rusty? Med students starting to give you quizzical looks? Check out this excellent review article in this week’s NEJM [8].
Dr. Jovan Begovic is a Resident at NYU Langone Medical Center
Peer reviewed by Karin Katz, MD, Internal Medicine, Resident, NYU Langone Medical Center
Image courtesy of Youtube
References
[2] Postma DF, Van werkhoven CH, Van elden LJ, et al. Antibiotic treatment strategies for community-acquired pneumonia in adults. N Engl J Med. 2015;372(14):1312-23. http://www.nejm.org/doi/full/10.1056/NEJMoa1406330?query=featured_home
[3] Zaidat OO, Fitzsimmons BF, Woodward BK, et al. Effect of a balloon-expandable intracranial stent vs medical therapy on risk of stroke in patients with symptomatic intracranial stenosis: the VISSIT randomized clinical trial. JAMA. 2015;313(12):1240-8. http://jama.jamanetwork.com/article.aspx?articleid=2208809
[4] Park SJ, Ahn JM, Kim YH, et al. Trial of everolimus-eluting stents or bypass surgery for coronary disease. N Engl J Med. 2015;372(13):1204-12. http://www.nejm.org/doi/full/10.1056/NEJMoa1415447
[5] Carson JL, Sieber F, Cook DR, et al. Liberal versus restrictive blood transfusion strategy: 3-year survival and cause of death results from the FOCUS randomised controlled trial. Lancet. 2014;9984(385):1183-89. http://www.sciencedirect.com/science/article/pii/S0140673614622868
[6] Olfson M. Surveillance of adverse psychiatric medication events. JAMA. 2015;313(12):1256-7. http://jama.jamanetwork.com/article.aspx?articleid=2208788
[7] Kuehn BM. Putting Chagas disease on the US radar screen. JAMA. 2015;313(12):1195-7. http://jama.jamanetwork.com/article.aspx?articleid=2208802
[8] Knepper MA, Kwon TH, Nielsen S. Molecular physiology of water balance. N Engl J Med. 2015;372(14):1349-58. http://www.nejm.org/doi/full/10.1056/NEJMra1404726