Thursday, November 24, 2005
NEJM: The Origins of Pandemic Influenza--Lessons from the 1918 Virus
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The Origins of Pandemic Influenza--Lessons from the 1918 Virus [free full text]
"...monitoring of the sequences of viruses isolated in instances of bird-to-human transmission for genetic changes in key regions may enable us to track viruses years before they develop the capacity to replicate with high efficiency in humans. Knowledge of the genetic sequences of influenza viruses that predate the 1918 pandemic would be extremely helpful in determining the events that may lead to the adaptation of avian viruses to humans before the occurrence of pandemic influenza. We could then conduct worldwide surveillance for similar events involving contemporary avian viruses. "
Friday, June 17, 2005
Review: Chronic Stable Angina
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The NEJM has a very nice review article titled Chronic Stable Angina.
"It is useful to classify therapeutic drugs into two categories: antianginal (anti-ischemic) agents and vasculoprotective agents. Although medications for angina are widely used, therapy to slow the progression of coronary artery disease, to induce the stabilization of plaque, or to do both is a newer concept and these forms of treatment are underprescribed."
Saturday, June 11, 2005
NEJM -- Two-Years after Endovascular Repair of Abdominal Aortic Aneurysms
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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:
" The cumulative rates of aneurysm-related death were 5.7 percent for open repair and 2.1 percent for endovascular repair. This advantage of endovascular repair over open repair was entirely accounted for by events occurring in the perioperative period, with no significant difference in subsequent aneurysm-related mortality. "
To try to explain this, the authors discuss the following possibilities:
"There may be two possible explanations for the convergence of survival curves in our study. One is that patients who have survived the stress of open repair may be somewhat less likely to die in the first few months after surgery than patients who have undergone endovascular repair, since the latter group has not been subjected to a conventional surgical procedure.
...[snip]...
Another possible explanation for the convergence of survival curves is the failure of endovascular repair to prevent rupture of the aneurysm."
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:
"We haven't studied that in this 2-year analysis but it is part of our long-term study."
Saturday, April 23, 2005
An Anesthesiologists Thoughts on the Early Epidural 'News'
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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:
" There was a higher incidence of prolonged and late decelerations in heart rate in the intrathecal group after the initiation of analgesia. "
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.
Saturday, March 26, 2005
CMJ Review: Clostridium difficile-associated diarrhea in adults
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The Canadian Medical Journal: Clostridium difficile-associated diarrhea in adults (free full-text)
Tuesday, March 22, 2005
NEJM: Two Articles On Schiavo Case
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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
Thursday, March 17, 2005
NEJM: The Serotonin Syndrome
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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!).
Wednesday, February 16, 2005
NEJM -- The Risk of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late in Labor
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NEJM --The Risk of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late in Labor
" Analgesia was initiated in the intrathecal group by a combined spinal–epidural technique. Intrathecal fentanyl (25 µg) was injected, an epidural catheter placed, and an epidural test dose administered. At the second request for analgesia, the cervix was again examined. Epidural analgesia was then initiated as follows: if the cervix was less than 4.0 cm in diameter, a 15-ml epidural bolus of bupivacaine (0.625 mg per milliliter) with fentanyl (2 µg per milliliter) was given, and if the cervix was 4.0 cm or greater in diameter, a 15-ml epidural bolus of bupivacaine (1.25 mg per milliliter) was given (Figure 1). In both instances, patient-controlled epidural analgesia was then begun. "
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...
Monday, February 14, 2005
Truth in Advertising
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The availability of references and the sponsorship of original research cited in pharmaceutical advertisements (free full text):
" Results: In the 438 ads with medical claims, 126 contained no references and 312 contained 721 unique references. Of these ad references, 55% (396/721) cited journal articles and 19% (135/721) cited data on file. In contrast, in the sample of research article references, 88% (351/400) cited journal articles and 8% (33/400) cited books. Overall, 84% of the citations from the ads were available: 98% of journal articles, 86% of books, 71% of meeting abstracts or presentations and 20% of data-on-file references. In all, 99% of the sample of research article references were available. We determined that 58% of the original research cited in the pharmaceutical ads was sponsored by or had an author affiliated with the product's manufacturer, as compared with 8% of the articles cited in the research articles. "
[Via UK Medical News Today]
We shouldn't be surprised at these findings. It is just marketing, after all.
Sunday, February 13, 2005
Think CPAP Mask After Major Abdominal Surgery
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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:
" Results Patients who received oxygen plus continuous positive airway pressure had a lower intubation rate (1% vs 10%; P = .005; relative risk [RR], 0.099; 95% confidence interval [CI], 0.01-0.76) and had a lower occurrence rate of pneumonia (2% vs 10%, RR, 0.19; 95% CI, 0.04-0.88; P = .02), infection (3% vs 10%, RR, 0.27; 95% CI, 0.07-0.94; P = .03), and sepsis (2% vs 9%; RR, 0.22; 95% CI, 0.04-0.99; P = .03) than did patients treated with oxygen alone. Patients who received oxygen plus continuous positive airway pressure also spent fewer mean (SD) days in the intensive care unit (1.4 [1.6] vs 2.6 [4.2], P = .09) than patients treated with oxygen alone. The treatments did not affect the mean (SD) days that patients spent in the hospital (15 [13] vs 17 [15], respectively; P = .10). None of those treated with oxygen plus continuous positive airway pressure died in the hospital while 3 deaths occurred among those treated with oxygen alone (P = .12). "
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.
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Jun Dec
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