Top Medical Journal Articles of 2013 What is old is new… and what is new is old once more

1. Top Medical Journal Articles of 2013
What is old is new… and what is new is old once more
Ethan Cumbler MD, FHM, FACP
Associate Professor of Medicine
University of Colorado School of Medicine
Director UCH Acute Care for the Elderly Unit
Associate Chief of Hospital Medicine

2. Criteria For Selection
Peer Reviewed Publication from 2013-2014
Sound Methodology
Subject Area Relevant to Internal Medicine
Potential to Change Clinical Practice

3. What is Old?
On December 13, 1799, George
Washington developed a sore throat. What
was his therapy that day?
A. Willow bark tea
B. Fresh air and exercise
C. Removal of 5-7 pints of blood
2000 years ago 200 years ago

4. What’s New?
A 42 year old man presents with 3 days of melena
followed by bright red hematemesis. What Hb
level should trigger transfusion?
A. 11 g/dl
B. 9 g/dl
C. 7 g/dl
D. 5 g/dl
E. Let me get my lancet…

5. Liberal Transfusion not beneficial for GIB.
Clincial Question
What is the best transfusion threshold in a GIB?
Villaneuva C, et al. Transfusion Strategies for Acute Upper Gastrointestinal Bleeding. NEJM 2013;368:11-21

6. Design
Unblinded RCT
921 pts with severe UGI bleed
– Excluded if massive exsangination, recent CVA or ACS
Transfusion for Hb <7 g/dl
Transfusion for Hb <9 g/dl
Primary outcome
45 day mortality

7. Findings
Only 14% got blood with restrictive strategy
compared to half in liberal group
– 1.5 units vs 3.7 units
Less re-bleeding with restrictive strategy
– 10% vs 16% (p=0.01)
Survival higher with restrictive strategy
– 95% vs 91% (p=0.02)
– HR for death 0.55 (0.33-0.92, p=0.02)
TAKE HOME POINT
Let GIB patients bleed down to Hb <7 before transfusion

8. Meta-analysis on liberal vs restrictive strategy for
pts with MI
Conclusion- Blood transfusions and liberal thresholds
associated with more re-infarctions and higher mortality
– HR for death 2.25 (1.68-3.02)
TAKE HOME POINT
What is old is new once more
Maybe less blood IS better
JAMA Intern Med 2013;173;132-9

9. What was old
“Take scabwort and grind and squeeze its juice through a cloth, collect in
an eggshell and temper with honeycomb; give the patient daily a full shell
of the juice, do this for eleven days when the moon is waning because also
man wanes in his abdomen.”
Was the recommended treatment for what disease?
A. Dropsy
B. Quincy
C. Scrivener’s palsy
D. Catarrh
E. Siriasis

10. What’s New?
A 64 year old man is admitted with acute systolic
dysfunction. What is the best salt and fluid order?
A. 800mg sodium, 800 ml fluid restriction
B. 2000 mg sodium, 2000 ml fluid restriction
C. 3000-5000mg sodium, 2500ml fluid restriction
D. Loco Moco burger and fries with a big gulp q6 hours

11. Clincial Question
What diet order should you write for in CHF admits?
JAMA Intern Med 2013;173:1058-1064.

12. DESIGN
RCT
Fairly small- only 75 patients
– Acute systolic HF exacerbations
Restricted (0.8g Na, 0.8L fluid)
vs.
Liberal (3-5g Na, 2.5L fluid)
Primary Outcome- Weight loss and
clinical stability 3 days after admit

13. Findings
Both groups lost the same amount of weight by day 3
– 4.4kg vs 4.7kg
Clinical stability was the same
Restricted group was very thirsty
On follow-up restricted group was more congested
TAKE HOME POINT
Intensive salt and fluid restriction not beneficial for CHF exacerbations

14. A 70 year old woman presents with acute COPD
exacerbation. How would you prescribe steroids?
A. Methylprednisolone 125mg IV q6 hours x 3
days then 60mg po to complete 14 days
B. Prednisone 60mg po then taper over 14 days
C. Methylprednisolone 40mg IV x1 day
Then prednisone 40mg for 4 more days x 5 days
A. Anabolic-ly

15. Clinical Question
How much steroid is “enough” in COPD exacerbations
JAMA 2013;309:717-718.

16. Design
RCT
314 pts in ED with
COPD flare
All pts received 40mg IV
methylpred X 1 day
Then
Pred 40 total 5 D
vs.
Pred 40 total 14 D
Primary
Outcome
– COPD
exacerbation in
next 180 days
Also:
Abx, inhaled
steroids,
tiotropium
and, b-agonist
inhalers

17. Findings
No difference in COPD re-exacerbations
– 35.9% in short course vs 36.8% in long course
No difference in need for intubation or mortality
– 11% vs 14% for intubation
– 7.7% vs 8.4% for death
Shorter hospital LOS
– 8 days vs 9 days hospital stay (p=0.04)
Less total steroid exposure- no difference in adverse events
TAKE HOME POINT
5 days prednisone just as good as longer
course for COPD exacerbation

20. What’s New?
A 57 year old diabetic patient on the vent
due to sepsis with ARDS was started NG
tube feeds 24 hours after intubation. You
are called by nursing with a gastric residual
of 450 ml. What is your response?
A. Stop feeds for one hour then resume at prior rate
B. Stop feeds for 2 hours then resume at 80% of prior rate
C. Stop feeds for 4 hours then resume at 50% of prior rate
D. Continue current rate. Stop measuring residuals

21. Clincial Question
How should you respond to calls about gastric residuals?
JAMA. 2013;309(3):249-256

22. Design
9 French ICUs with 449 vented pts
– Unblinded RCT
Gastric residuals q 6 h
vs
Symptom monitoring only
– Emesis, regurgitation
Primary Outcome-Vent Acquired PNA

23. Findings
Higher proportion of patients
without residual monitoring
received goal nutrition
– OR 1.77 (p=0.08)
No difference in VAP
– 15.8% control vs 16.7%
intervention
Context
2010 REGANE study
– Threshold of 500ml for
residuals compared to
200ml
Also found no difference
in aspiration pneumonia
TAKE HOME POINT
Monitoring Gastric Residuals may not be necessary

24. 3315 patients- 72% had inpatient stress test
Stress test reduced subsequent ED visits for chest pain
Once in ED the chance of admission did not change
As a strategy- inpatient stress testing increased overall cost
Journal of Hospital Medicine 2013;8:564–568

25. Quick Hitter
14 trials with 3828 pts were included
No effect on non-specific anxiety
No effect on symptom persistence
No effect on illness-specific worry
– OR 0.87 (0.55-1.39)
TAKE HOME POINT
Testing to rule out unlikely
Small reduction in subsequent visits
– OR 0.77 (0.62-0.96)
disease offers little
reassurance
JAMA Intern Med 2013;173(6):407-416

26. More than half of both groups report burnout
More than 40% in both groups report emotional exhaustion and depression
TAKE HOME POINT
Good Gracious Take Care of
Yourselves

27. • Cross-sectional study from VA
• Examined patients at increased risk for hypoglycemia
• Age >75 with dementia or renal insufficiency
• On insulin, sulfonylurea or both
How many are being “over-treated”?
Depends on how you define “over-treatment”
JAMA Intern Med. 2014;174(2):259-268.

28. A1c less than 6.0
Overtreatment
11.30%

29. A1c less than 6.5
28.60%
Overtreatment

30. A1c less than 7.0
Overtreatment
50.00%

31. Context
• American Diabetes Association
– “Glycemic goals for some older adults might reasonably be
relaxed, using individual criteria, but hyperglycemia leading to
symptoms or risk of acute hyperglycemic complications
should be avoided in all patients”
• American Geriatrics Society
– “Avoid using medications to achieve hemoglobin A1c <7.5%
in most adults age 65 and older”
• International Diabetes Federation
– 7.0% to 7.5% for functionally independent older adults
– 7.5% to 8.0% for functionally dependent older adults
– 8.0% to 8.5% for those with frailty or dementia
American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care. 2013 Jan;36 Suppl 1:S11-66.
https://www.idf.org/sites/default/files/IDF%20Guideline%20for%20Older%20People.pdf

32. What is Old?
Children treated with the first Sulfa
drugs had which of the following
adverse reactions?
Serum sickness
Hypersensitivitiy reaction
Skin permanently turned lobster red
Smelled like rotten eggs
Temporarily thought they were chickens

33. What’s New
A 57 year old man with afib and bi-leaflet aortic
mechanical valve is admitted with a TIA with
complete symptom resolution. He is has been on
dabigatran for 3 years. What would you do?
A. Continue dabigatran
B. Add aspirin to the dabigatran
C. Add clopidogrel to the dabigatran
D. Stop dabigatran and transition to warfarin plus
aspirin
E. Call your stockbroker.

35. Clincial Question
If novel oral anticoagulants work for afib…how about
mechanical heart valves?
N Engl J Med 2013;369:1206-14.

36. Design
Double blind RCT
252 pts with mechanical valves
– 39 centers in 10 countries
Dabigatran vs warfarin
Primay outcome
– Death, CVA/TIA, embolism, valve thrombus, MI, major bleeding

37. Kaplan–Meier Analysis of Event-free Survival.
Study Stopped Early
Stroke in 5% of dabigatran group
None in warfarin group
Bleeding in 4% with dabigatran
2% in warfarin group (pericardial)
NNH 7
TAKE HOME POINT
Drug effects are complicated…
Take mechanical valve patients off
dabigatran
http://www.fda.gov/drugs/drugsafety/ucm332912.htm

38. Take Home Points
• Liberal Salt and Fluid management during CHF hospitalizations is fine
• Even in acute UGIB do not transfuse unless Hb < 7
• Avoid overtreatment of diabetes in the elderly
• Monitor symptoms not gastric residuals when tube feeding
• Do not use novel oral anticoagulants in patients with mechanical heart valves

39. FIN
Ethan.Cumbler@ucdenver.edu