ShortCuts-This Week in the Journals

March 25, 2008

spring.jpgCommentary by Henry Tran MD

The seasons of the year, like governors of New York, change quickly. And with that, we welcome the new spring, a time of rebirth and renewal!

Well sticking with the spring theme, it seems “newer blood” might be safer than “older blood.” There has been evidence to suggest that during storage, red blood cells undergo functional and structural changes which impair RBC function (termed “storage lesion”). A retrospective study from Cleveland Clinic published in the NEJM examined outcomes of patients given red-cell transfusions during CABG surgery. Blood stored for more than 14 days prior to transfusion was considered “older blood” and blood stored less than 14 days was considered “newer blood.” Patients who received older blood had increased perioperative complications (25.9% vs. 22.4%), higher in-hospital mortality (2.8% vs. 1.7%), and decreased survival at one year. In recent years, there have been several studies that found improvement and benefit with conservative strategies of blood transfusions. An incremental increase of adverse outcomes has been observed with each additional unit of PRBC transfused. This new study suggests that it may not only be quantity, but the quality of blood we should be concerned with as well.

The truth is “newer” isn’t always better. The FDA announced this week that they would evaluate a potential association between tiotropium bromide (Spiriva) and the risk of stroke. A meta-analysis of 29 placebo controlled clinical trials estimates that there might be an increased incidence of stroke with spiriva usage for one year compared to placebo: 8 pts per 1000 vs. 6 pts per 1000. (NNH = 500). If you have recently been switching your patients with COPD from ipratropium to tiotropium due to its more convenient daily dosing, you should consider informing your patients of this ongoing safety review and discuss switching back to ipratropium (Atrovent).

Recently, there has been a lot of coverage in press about the “recent” epidemic of methicillin-resistant Staph Aureus (MRSA) infections. In reality, we know that the MRSA epidemic really isn’t new, but it is a huge problem that isn’t improving on its own. So what is the most effective way to reduce MRSA infections? A study from Northwestern published in the Annals of Internal Medicine examined the outcomes of instituting a comprehensive MRSA screening in a large academic medical system. Starting in Arpil 2004, all patients admitted to an ICU had nasal swabs to test for MRSA colonization (74% adherence). Patients that were positive based on PCR testing were placed on contact isolation. After 12 months of this protocol, the surveillance program was expanded to the entire hospital system. During this phase of the study, patients that tested positive underwent decolonization with muciporin and a chlorhexidine wash/shower (how clean!). The study found a decrease in the incidence of MRSA disease by 70%. Most notably, while there was decreased MRSA surgical site and UTI, there was no statistically significant decrease in MRSA bacteremia with universal surveillance. Also since MRSA is associated with higher mortality, it’s odd that this study did not try to observe for decreased mortality. These results contradict the findings of a recent study published in JAMA (see last week’s ShortCuts) that did not find any significant reduction in surgical site infections with universal screening. While this study does not absolutely prove universal MRSA surveillance is ready for primetime, it is a significant step in creating a robust and sensible system to improve our detection and containment of MRSA transmission.