ShortCuts-This Week in the Journals

July 14, 2008

egret.jpgCommentary by Bani Chander MD, PGY-3 

Childhood obesity, foodborne illness and the evil pharmaceutical industy…sorry to start your day off with some gloomy topics, but the news is full of it these days. Let’s get started.

Childhood obesity, as we know, has been on the rise, and children are starting not only to eat, but to walk, talk, and act like adults. Now should we also start treating them like adults? This week, the American Academy of Pediatrics (AAP) issued a new recommendation statement that children as young as two years of age, who have risk factors for coronary artery disease or an unknown family medical history, should be screened for dyslipidemia, replacing the old 1998 policy statement issued by the AAP. In addition, the new guidelines propose that pediatricians should consider lipid lowering therapy in children 8 years and older whose LDLis >190mg/dL, for a goal LDL < 160mg/dL (although they recommend targets as low as 110 mg/dL in those patients with a strong family history of coronary disease or with risk factors including obesity, diabetes, and the metabolic syndrome). Numerous critics point out the lack of evidence that lipid lowering agents at such a young age will really prevent future coronary disease and events. Pediatricians also point out the potential concerning side effects of statins and other lipid lowering agents over several decades.

Also of interest in the news this week, the New York Times featured an article regarding a new “code” for pharmaceutical reps. The new code bans the use of providing pens, pads, mugs and other gifts to physicians. So does this mean you will never receive another invitation from GlaxoSmithKline for an “educational” dinner talk at Daniel? Not necessarily. The code, written by the Pharmaceutical Research and Manufacturers of America, is actually a voluntary guideline, and provides no definitive limits on the actual money that can be spent on physicians. In addition, the voluntary code does not ban reps from continuing to provide office breakfasts and lunches or arranging educational dinners. So which doctors are going to feel this change the most? Surprisingly enough, physicians in Vermont enjoy the most frequent and lavish gifts and dinners from the pharmaceutical industry. In fact, for the last several years, psychiatrists who live in Vermont have been accepting the most money from the industry; this year, 11 individual psychiatrists received an average of $56,944! The president of the drug industry trade association, Billy Tauzin, said “This updated code fortifies our companies’ commitment to ensure their medicines are marketed in a manner that benefits patients and enhances the practice of medicine.” Although the code takes effect next January, many postulate that despite these new rules, pharmaceutical reps will continue to shower physicians with all of the usual pens, pads, dinners, and even the occasional resort vacation.

Another theme in the news this week is foodborne illnesses. The NY Times gave praise to the rotavirus virus vaccine, which was first introduced last fall, and has already resulted in a significant reduction in the incidence of the illness this season as compared to previous years. In fact, the number of tests positive for the virus fell by 78.5% since the introduction of the vaccine. On the other hand, the number of people struck by the salmonella outbreak continues to climb, with more than 1000 affected. The outbreak, which began on April 10th, does not appear to be slowing down and even more discouraging, food safety experts remain uncertain about the true source of contamination. While raw tomatoes remain one of the chief suspects in this outbreak, the CDC is now urging people to also avoid both raw jalapenos and serrano peppers. There are approximately 25-40 new cases reported per day, although the CDC acknowledges that for each reported case, there may be several others that remain unreported. The salmonella outbreak is now considered to be the largest and worst food borne outbreak in the last decade.

Finally, moving on to some brighter news, this week the NEJM featured an article on the benefits of non-invasive ventilation as compared to standard oxygen therapy in acute cardiogenic pulmonary edema. Earlier studies have suggested that non invasive ventilation seems to improve both symptoms of respiratory distress and physiologic variables, even averting intubation. In fact, some systematic reviews have even suggested that CPAP may also reduce mortality. All prior studies comparing non-invasive ventilation to standard oxygen therapy have been small, single center trials. In a prospective, randomized, multicenter controlled trial composed of 1069 patients (mean age 77.7, 56.9% female), the authors set out to determine whether noninvasive ventilation reduces mortality and if there were differences in outcomes associated with the method of treatment (continuous positive airway pressure [CPAP] or noninvasive intermittent positive-pressure ventilation [NIPPV] ). Patients were assigned to receive standard oxygen therapy, CPAP or NIPPV. The primary end point for the comparison between non invasive ventilation and oxygen therapy was death within 7 days after the initiation of treatment, and the primary end point for the comparison specifically between NIPPV and CPAP was death or intubation within 7 days. As compared to standard therapy, non-invasive ventilation was associated with greater mean improvements at one hour after the beginning of treatment as follows: Patient-reported dyspnea (treatment difference 0.7 on a visual-analogue scale ranging from 1 to 10, 95% CI 0.2 to 1.3, P=0.008), heart rate (treatment difference four beats per minute, 95% CI 1 to 6, P=0.004), acidosis (treatment difference pH 0.03, 95% CI 0.02 to 0.04, P<0.001), and hypercapnia (treatment difference 0.7 kPa [5.2 mm Hg], 95% I 0.4 to 0.9, P<0.001). On the other hand, there were no significant differences in seven-day mortality between patients receiving standard oxygen therapy (9.8%) and those undergoing non-invasive ventilation (9.5%, P=0.87). There were also no significant differences in the combined endpoint of death or intubation between the 2 groups which received non-invasive ventilation (11.7% for CPAP and 11.1% for NIPPV, P=0.81).  In summary, although non-invasive ventilation offered no benefit in regards to short term mortality, non-invasive ventilation did lead to more rapid resolution of dyspnea, respiratory distress, and metabolic abnormalities as compared to the standard oxygen therapy. The authors conclude that non-invasive ventilation should be considered as adjunctive therapy in patients with acute cardiogenic pulmonary edema who have severe respiratory distress or whose condition does not improve with pharmacologic therapy alone.