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Check Your E-mail: Internet Searches: EvidenceMedicine.com / GuidelineMedicine.com Intensive Lipid Lowering with Atorvastatin in Patients with Stable Coronary Disease (nejm 4-05)
“The complicity of US military medical personnel during abuses of detainees in Iraq, Afghanistan, and Guantanamo Bay is of great importance to human rights, medical ethics, and military medicine. Government documents show that the US military medical system failed to protect detainees' human rights, sometimes collaborated with interrogators or abusive guards, and failed to properly report injuries or deaths caused by beatings.” http://www.thelancet.com/journal/vol364/iss9435/full/llan.364.9435.review_and_opinion.30574.1 AHA 2002 Fish Oil Recommendations Still Get Little Attention: Mediterranean Diet Revisited: Lyon Diet Heart Study; from AHA: Study on Diet (low/high carbohydrate) and Breast Cancer gets widespread media coverage (8-6-04) despite being only a “survey” of women in Mexico NEW ACC/AHA JULY 21, 2004 ST-ELEVATION MYOCARDIAL INFARCTION GUIDELINES - SUMMARY http://www.americanheart.org/presenter.jhtml?identifier=3023107 NEW CHOLESTEROL GUIDELINES (UPDATE OF NECEP/ATP 3 2001) RELEASED JULY 12, 2004 IN CIRCULATION: NEW GOAL of LDL<70 in highest risk patients, a consideration Nevirapine plus Zidovudine prevents mother to child transmission of HIV-1 http://content.nejm.org/cgi/content/full/351/3/217 (NEJM 7-04) NEW ACCP (American College of Chest Physicians) July 2004 Guidelines: Diagnosis and Management of Pulmonary Arterial Hypertension released in journal CHEST (supplement) www.chestjournal.org/content/vol126/1_suppl/ ADA releases statement to address myths and misconceptions of “low carb” diets http://www.diabetes.org/diabetesnewsarticle.jsp?storyId=5949638&filename=20040706/washingtonpost20040706engwas hingtonpostwpniengwashingtonpostwpni0005104226827859763411333EDIT.xml (ADA, July 2004) Low carbohydrate vs conventional diet after one year, Cardiosoucre research summary (No difference in small amount of weight loss, but some potential benefits?) Note: other prior studies have shown similar results at one year - NO statistical difference in weight loss but differences in lipids http://www.cardiosource.com/news/cjr_picks/acc/cjrpicks/CJRPick.asp?cjrID=900 Milk, Calcium may reduce the risk of colon cancer; analysis from Journal of the National Cancer Institute July 7, 2004 http://jncicancerspectrum.oupjournals.org/cgi/content/abstract/jnci;96/13/1015 SYNERGY TRIAL results released July 7, 2004 JAMA SYNERGY TRIAL results released July 7, 2004 JAMA Enoxaparin vs Unfractionated Heparin in High-Risk Patients With Non–ST-Segment Elevation Acute Coronary Syndromes Managed With an Intended Early Invasive Strategy Conclusions Enoxaparin was not superior to unfractionated heparin but was noninferior for the treatment of high-risk patients with non–ST-segment elevation ACS. Enoxaparin is a safe and effective alternative to unfractionated heparin and the advantages of convenience should be balanced with the modest excess of major bleeding. http://jama.ama-assn.org/cgi/content/abstract/292/1/45 (abstract) VALUE Trial: Valsartan v Amlodipine in HTN, CARDIOSOURCE summary: http://www.cardiosource.com/library/journals/journal/article/abstract?acronym=LANCET&uid=PIIS0140673604164519&kw highligh= Debate on treatment of Ductal Carcinoma in Situ of breast NYTimes (6-27)http://www.nytimes.com/2004/06/22/health/22brea.html?ex=1089354557&ei=1&en=5bf203b07037efbe NEJM Review (April 04): http://content.nejm.org/cgi/content/extract/350/14/1430 10 million women without cervix get pap smears (contrary to expert advice) JAMA study http://jama.ama-assn.org/cgi/content/short/291/24/2990 NYTimes article http://www.nytimes.com/2004/06/23/health/23PAP.final.html?ex=1089003182&ei=1&en=829132249fa30719 CARD trial: Atorvastatin (lipitor, 10 mg/day) in Diabetes results presented at ADA 2004 scientific meeting - no print citation, highlights reviewed on www.cardiosource.com June 9, 2004 Folate, B6 and B12 may increase risk of coronary restenosis (contrary to previous study) NEJM: http://content.nejm.org/cgi/content/short/350/26/2673 Risk of Recurrent Thromboembolism in Men and Women (NEJM)http://content.nejm.org/cgi/content/short/350/25/2558 Conclusions The risk of recurrent venous thromboembolism is higher among men than women. Med Update 2004.18 June 18, 2004 Risk of Recurrent Thromboembolism in Men and Women (NEJM)http://content.nejm.org/cgi/content/short/350/25/2558 Conclusions The risk of recurrent venous thromboembolism is higher among men than women. *********************************************************************************************** MED UPDATE 2004.17 ASA and other NSAIDS in the prevention of Breast CA? May 26, 2004 Highly publicized research looking at the potential benefits of ASA/NSAIDS in the prevention of Breast Cancer *** NOTE Data collected from surveys/interviews of 2800+ women *** May 25, 2004 ABC, NBC an CBS eve news programs all report on findings only ABC mentions report published in JAMA only NBC reports ibuprofen also evaluated but incorrectly reports findings related to ibuprofen only ABC and CBS discuss side effect of ASA use only ABC and CBS clearly indicate data gathered from a SURVEY of women with and without Br CA all networks correctly report this data alone may be insufficient to recommend ASA use for prevention of Br CA to general public for link to JAMA go to - the article is currently a FREE access article http://www.evidencemedicine.com for literature searches click "PubMed" ******************************************************************************* MED UPDATE 2004.16 Vaccines and Autism - IOM report May 18, 2004 NBC, MSNBC.com and CBS news report findings of the INSTITUTE OF MEDICINE disputing prior popular suspicions and claims limking childhood immunizations with autism. MSNBC.com provides no link to the original report or the IOM. Dan Rather refers to "a team of U.S. medical experts" and the story shows an interview of a CDC expert but there is no mention of the Institute of Medicine. The CBS report focusses mostly on continued fears among parents and one physician-lawmaker (who favors a ban) of mercury containing (thimerosal) vaccines despite the report. The news report states thiomerosal has been virtually eliminated from vaccines with the exception of certain flu vaccine preparations. Institute of Medicine press release: http://www.iom.edu/report.asp?id=20155 "The committee concludes that the body of epidemiological evidence favors rejection of a causal relationship between the MMR vaccine and autism. The committee also concludes that the body of epidemiological evidence favors rejection of a causal relationship between thimerosal-containing vaccines and autism." full report: http://www.nap.edu/books/030909237X/html/ for literature searches click PubMed in left column of http://www.evidencemedicine.com search "vaccination and autism" ******************************************************************************** MED UPDATE 2004.15 High Homocysteine levels as predictors of fractures May 12, 2004 NBC Nightly News reports 2 studies supporting the use of "Folic acid", "B-6" and "B-12" in the treatment of osteoporosis CBS Evening news reports the possible benefits of "folic acid" in osteoporosis *** HOWEVER, neither study from the NEJM evaluated the use of any of these vitamins in the treatment/prevention of osteoporosis or fractures, they evaluate the association between (homocysteine) levels and events (fractures) - prior studies have shown the use of these inexpensive and safe vitamins in lowering homocysteine levels - this is not the same as proof of efficacy in this condition *** study 1: http://content.nejm.org/cgi/content/short/350/20/2033 "Conclusions An increased homocysteine level appears to be a strong and independent risk factor for osteoporotic fractures in older men and women. " study 2: http://content.nejm.org/cgi/content/short/350/20/2042 "Conclusions These findings suggest that the homocysteine concentration, which is easily modifiable by means of dietary intervention, is an important risk factor for hip fracture in older persons." http://www.evidencemedicine.com ******************************************************************************** MED UPDATES 2004.14: New AAP Guidelines on Otitis Media with Effusion (NOTE distinction from Acute Otitis Media - AOM - AOM Guideline link also below) May 11, 2004 New Practice Guidelines from American Academy of Pediatrics, the American Academy of Family Physicians and the American Academy of Otolaryngology-Head and Neck Surgery advocates "WATCHFUL WAITING" in the treatment of Otitis Media (OME) in children "Antihistamines and decongestants are not effective treatments for OME. Antibiotics and corticosteroids are not recommended for routine management of OME" link to 1/2 page press release: http://www.aap.org/advocacy/releases/mayome.htm link to May 2004 Otitis Media with Effusion Guideline in Pediatrics journal: http://pediatrics.aappublications.org/cgi/content/abstract/113/5/1412 link to Acute Otitis Media March 2004 Guideline http://pediatrics.aappublications.org/cgi/content/abstract/113/5/1451 http://www.evidencemedicine.com ******************************************************************************** MED UPDATE 2004.13.: Updated Pneumonia Guideline and Quiz May 1, 2004 Latest IDSA PNEUMONIA Guidelines Nov(web)/Dec(print) 2003 (updates 2000 which replaced 1998) QUIZ A 32 yo M high school teacher is diagnosed with pneumonia in the emergency room, HIV neg history His pneumonia PORT Severity Index score (see p1426) is recorded on the chart as "Class I" by the ED resident. His temperature is 37 C, no fever at home. CXRay shows LLL infiltrate consistent with crackles on exam. He has no recent travel but one of his students just returned from Hong Kong but is not ill. Resident checks CDC website on ED computer - Hong Kong "areas with community transmission of SARS." no other students ill, no recent antibiotic tx, no allergies, no COPD, DM, renal failure, CHF or malignancy (1) choose one A) treat as outpatient; since "Hong Kong" reference documented, document why SARS still not suspected B) outpatient but collect sputum first; any reference to SARS in the U.S. in 2004 could not be an issue C) inpatient IV antibiotics D) admit to ICU with respiratory and contact isolation - fits CDC definition of "suspected SARS" (p 1416) (2) treatment options A) doxycycline, erythromycin, azithromycin or clarithromycin po B) azithromycin, clarithromycin, ciprofloxacin or amoxicillin-clavulanate po C) azithromycin plus cefotaxime or ceftriaxone (or other selected B-lactams) D) azithromycin, clarithromycin or levofloxacin (or other resp fluroquinolone but not Cipro) (3) same scenario but patient has DM (or CHF or RF or COPD or malignancy) A) doxycycline, erythromycin, azithromycin or clarithromycin po B) azithromycin, clarithromycin, ciprofloxacin or amoxicillin-clavulanate po C) azithromycin plus cefotaxime or ceftriaxone (or other selected B-lactams) D) azithromycin, clarithromycin or levofloxacin (or other resp fluroquinolone but not Cipro) (4) a 53 yo F with DM is being admitted to GMB for com acq pneumonia (CAP), no recent antibiotic therapy a) Moxifloxacin, gatifloxacin, levofloxacin or ciprofloxacin alone b) Moxifloxacin, gatifloxacin or levofloxacin alone c) Azithromycin (or clarithromycin) plus cefotaxime (or other select B-lacatam) d) Moxiflox.,gatiflox or levoflox plus B lactam (ie, cefotaxime) e) b or c f) c or d (5) before patient leaves ED or receives antibiotics, admitting physician realizes pt should be admitted to ICU, pseudomonous is not a suspected issue a) Moxifloxacin, gatifloxacin, levofloxacin or ciprofloxacin alone b) Moxifloxacin, gatifloxacin or levofloxacin alone c) Azithromycin (or clarithromycin) plus cefotaxime (or other select B-lacatam) d) Moxiflox.,gatiflox or levoflox pus cefotaxime (or select B-lactam) e) b or c f) c or d (6) Which would be LEAST useful test in the 53 yo patient table 4, p 1412 a) blood culture b) sputum C&S c) Legionella urinary antigen d) Legionella culture of resp secretions e) Chlamidophilia pneumoniae single IgM titer or PCR of secretions f) Influenza a/b antigen g) RSV antigen (7) the 53 yo with DM is being discharged on December 5, the medical student has written DAILY on problem list - no hx of pneumococcal vaccine or flu shot (and no contraindications) a) pt to receive injected influenza vaccine (preferred over FluMist since not age 5-49) upon discharge, repeat every Oct/Nov, the patient is given written documentation (ie, a pre-printed wallet card or added to med list) indicating this, this is dictated on discharge summary b) remind household contacts to receive injected influenza vaccine repeat yearly because patient has DM c) every member of house staff even if no contact with this patient, INJECTED influenza vaccine yearly in Oct/Nov ideally but now ok d) pt to receive Pneumovax and documentation before discharge since she has DM, year of vaccination is placed on patient's med list, dictated on disc summary and written on all future H&Ps e) ask patient's 66 yo husband to discuss Pneumovax with his doctor based on his age f) HIV TESTING with consent for the patient during admission since she is between 15-54 g) a through e h) a through f ANSWERS: 1)a, PORT Class I supports outpatient tx without identification of organism 2)a, outpatient treatment without comorbidities, no recent antbx 3)d, outpatient with comorbidity, no recent antbx 4)e, inpatient medical ward 5)f, inpatient ICU, if pseudomonas not an issue 6)g, RSV testing not recommended in adults - insensitive 7)h, p1422-24 for vaccines; see table 4 p1412 lab test-general assessment for HIV testing see table 1 p1406 for tx for link TO GUIDELINES go to http://wwww.evidencemedicine.com click Infectious Disease Society of America in left column (not idsa.org) then choose GUIDELINES pick 2003 update to cap next CAP guide will be joint IDSA and Amer Thor Soc ******************************************************************************** April 21, 2004 MED UPDATES 2004.12 New Virtual Colonoscopy Study - conclusions challenging those of previous studies (?) from JAMA April 2004 http://jama.ama-assn.org/cgi/content/abstract/291/14/1713 "Conclusions Computed tomographic colonography by these methods is not yet ready for widespread clinical application. Techniques and training need to be improved. " from NEJM Dec 2003 http://content.nejm.org/cgi/content/abstract/349/23/2191 Conclusions "CT virtual colonoscopy with the use of a three-dimensional approach is an accurate screening method for the detection of colorectal neoplasia in asymptomatic average-ris |