Very interesting Dutch study on Two-Year Outcomes after Conventional or Endovascular Repair of Abdominal Aortic Aneurysms in the NEJM. This is the first study to look at prolonged survival (2 years) after placing a tube stent into a dilated abdominal aorta (aneurysm) to prevent rupture. We know that early survival is better with the stent vs. open repair. But what about after the first month? This study shows that after two years, the survival is about the same:
To try to explain this, the authors discuss the following possibilities:
I wonder about a third possibility: did patients having an open repair make lifestyle change that those having the less stressful endovascular repair did not? I ask because one of the frustrations in taking care of patients with vascular disease is the extent to which they do NOT change their eating or smoking habits and so need to come back for yet another procedure at yet another time. The study lists baseline characteristics (55% smoked in the open group and 64% smoked in the endovascular repair group. Half in each group had hyperlipidemia), but no characteristics are given at the two year point. Can the lack of survival advantage after endovascular repair be explained by differences in rates of smoking, hyperlipidemia, and other risk factors at two years?
And thanks to the power of Google, I've sent the lead author an e-mail with just this question!
8: 00 A.M., the lead author writes back:
The New England Journal of Medicine just published The Risk of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late in Labor and it has gotten national attention, including a segment on the Today show on NBC on February 17th. There's nothing here which was not known before. It's a nice study nonetheless, but readers should be aware of several other issues.
There's really nothing here that's new or that we haven't known before. I've been using neuraxial narcotic in women not yet sufficiently dilated for local anesthetic for ten years. I don't like doing it because I find the incidence of prolonged decelerations in the fetal heart rate trace that sometimes occurs makes people very, very nervous. By 'people' I mean patient, family, nurses, obstetricians,......and yours truly. This study in fact confirms that tendency:
To be specific, the incidence of prolonged decels was 3.9% vs. 0.6% (p < 0.003). I'm not saying this is a reason to avoid the technique, only that the obstetrical service needs to be prepared for it when it happens and know how to deal with it.
The Canadian Medical Journal: Clostridium difficile-associated diarrhea in adults (free full-text)
The NEJM will publish two article on the Schiavo case in an upcoming issue. Both are online now and free without a subscription:
Perspective
Terri Schiavo — A Tragedy Compounded
T.E. Quill
Legal Issues in Medicine
"Culture of Life" Politics at the Bedside — The Case of Terri Schiavo
G.J. Annas
Boyer and Shannon's article in the NEJM The Serotonin Syndrome is an excellent review/introduction to a syndrome every anesthesiologist should be familiar with but that had not been defined when I was in training. Excess serotonergic agonism can be triggered not only by certain drug overdoses, but also by many drugs anesthesiologist give frequently (fentanyl!).
NEJM --The Risk of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late in Labor
Bottom Line: Intrathecal fentanyl in women not yet at 4 cm cervical dilation does not increase C-section rate when compared to systemic opioids. Lots of great information to digest over the next several days...
The availability of references and the sponsorship of original research cited in pharmaceutical advertisements (free full text):
[Via UK Medical News Today]
We shouldn't be surprised at these findings. It is just marketing, after all.
JAMA just published Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial and those of us giving anesthesia for open major abdominal surgery should take note. Here's the abstract:
I remember the first time someone suggested using CPAP for the struggling patient in the recovery room after major abdominal surgery. I snorted and mumbled something under my breath about how the patient needed an endotracheal tube and should have taken the offered thoracic epidural. I went back to bed, convinced that I'd be called in an hour or two to intubate the patient who would by then certainly be in extremis. You know what? They never called me that night and this paper helps me understand why.
I think I need to modify my internal algorithm for post-anesthesia management of these often difficult cases to reflect the option of CPAP as a middle ground between mask oxygen and endotracheal intubation.
I was listening to some friends talk about taking a large set of information and making it more useful to the user when I thought about a project I helped with to try to remedy this with regard to the body of published literature in medicine. PubMed is the National Library of Medicine's big online database of medical articles (no, I didn't help with that). Searching for a term on PubMed usually gets lots of results but doesn't necessarily get you any closer to finding that key reference that people consider the classic or definitive paper in the field.
As a teacher in academic anesthesia, I saw residents (note the past tense) had little hope of finding the 'right' paper to read unless I gave it to them. If I said 'read about airway management' they would no doubt find some things about airway management, but probably not the paper on airway management. Unless of course they were able to search a subset of articles in PubMed defined in advance to be especially relevant to their field of study. That's how we conceived of the idea of 'Key References'--make it easy to assemble a list of references for whatever purpose. To make it easy, we used a unique identifier for each article called the PubMed ID Number (PMID). Seth Dillingham then wrote a plugin for Conversant that could take that PMID and go to the PubMed system and (politely) request information about the reference such as title, authors, citation, and even the abstract.
'Citation classics in anesthetic journals' by Baltussen and Kindler is comprised of 'seminal advances in anesthesia' which give 'a historic perspective on the scientific progress of this specialty'. The advantage of having them available online as a compilation lies in the fact that they 1) are searchable and 2) linked to related articles in PubMed (something which even the online version of the original article even does not do).
See for yourself: Citation Classics in Anesthetic Journals
After looking up all 100 PMID's for these articles I wrote to the journal editors and suggested they require authors to include PMID's for references they cite in each article but (apparently) failed to make a convincing enough case. Sort of like in, oh, 1995 when I suggested to the editors of another journal that they could put their articles online using Highwire Press and was told that they had their hands full putting back issues on CD.
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