Being an outstanding physician and lifelong learner requires stoking the flames of clinical curiosity. In Chiefs’ Inquiry Corner (CIC) we attempt to succinctly answer actual clinical questions that have been raised on the wards and in the clinics of NYU’s teaching hospitals. Our answers are not meant to be all encompassing or practice changing but rather to serve as springboards for further exploration. For those of us with short attention spans, we hope CIC satisfies that craving for a morsel of knowledge in a digestible format.
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Clinicians frequently recommend symptomatic management for cough, specifically over-the-counter (OTC) medications, but the data doesn’t necessarily back it up. A 2014 Cochrane review of OTC medications for acute cough in adults and children found that among the 29 randomized, placebo-controlled studies, there was poor reporting and little quantitative data. Among the three studies that specifically compared guaifensin and placebo, only one showed a significant difference, with patients taking guaifensin reporting a greater reduction in cough frequency and intensity after 3 days. Overall, only 11 of the 29 studies showed positive results for OTC medications such as guaifensin, dextromethorphan, and pseudophedrine. “Symptomatic management” may be an even more nebulous term than we realize.
References: Cough Review
Assessment of volume status in heart failure patients often relies upon estimation of the central venous pressure by examination of the jugular neck veins. Studies have found that the sensitivity and specificity of physical exam varies from 47-92% and 83-96%, respectively, for detecting CVP greater than 8 cm water. The interobserver reliability also has a wide range, with studies showing kappa-statistics ranging from 0.08 (poor agreement) to 0.71 (substantial agreement).
References: Evidence-Based Physical Diagnosis
Brain natriuretic peptide (BNP) and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) are serum markers that aid clinicians in making the diagnosis of heart failure. Multiple randomized control trials have examined the use of serial BNP or NT-proBNP measurements in the outpatient setting to reduce hospitalizations or mortality, with inconsistent results. However, one large metaanalysis did find that using BNP or NT-pro-BNP to direct dose adjustments in goal directed medical therapy (GDMT) resulted in nearly double the rate of patients achieving target doses of ACE inhibitors and beta blockers. The most recent ACCF/AHA heart failure management guidelines now make a Class IIa recommendation for using BNP or NT-pro-BNP guided heart failure therapy to achieve optimal dosing of GDMT in euvolemic patients.