Journal Club Archive - Discussed Articles

Risk of Community-Acquired Pneumonia and Use of PPIs
JAMA 10/04
PPIs double the Pneumonia risk? Check the editorial.
F/U: Dr. Manolache presented the article.

Combination of Isosorbide Dinitrate and Hydralazine in Blacks with CHF
NEJM 351:2049-2057 2004
The addition of isosorbide dinitrate plus hydralazine to standard therapy for heart failure increases survival among black patients with advanced heart failure. There was an impressive reduction in the rate of death from any cause of approximately 45 percent, leading to an early termination of the study. Click for the editorial 1, 2.
F/U: Dr. Ojukwu presented the study.

Prognostic implications of elevated troponin in patients with suspected ACS but no critical CAD
J Am Coll Cardiol. 2005 Jan 4 ;45(1):19-24
It looks like an elevated troponin is never an innocent finding.
Dr. Tamhane discussed the study in detail.

Preventing Microalbuminuria in Type 2 DM
NEJM Volume 351:1941-1951 November 4, 2004
Mavik plus Verapamil and Mavik alone decreased the microalbuminuria. Verapamil alone did not differ from placebo.
Dr. Anand presented the article.

Risk Stratification for In-Hospital Mortality in Decompensated CHF
JAMA - 02/05
Just three measurements (BUN, Cr and SBP) stratisfy CHF patients in low to high risk groups for in-hospital mortality. It is that simple.
Dr. Randhawa presented the study.

Clopidogrel vs. Aspirin and Esomeprazole to Prevent Recurrent Ulcer Bleeding
NEJM 352:238-244 1/20/05
ASA plus Nexium was superior to Plavix in the prevention of recurrent GI bleeding. This is against current recommendation that patients with GI intolerance of ASA be given Plavix. Check the editorial, even NYTimes mentioned this study (also, Kevin MD)
Dr. Bahandari discussed the article

C-Reactive Protein Levels and Outcomes after Statin Therapy
NEJM Jan 6, 2005
This is an article that will change our practice. "This is the first time that a study has shown lowering CRP (via statins) improves cardiac outcomes independent of cholesterol level. Earlier this year, the goal LDL ("bad" cholesterol) for those at very high risk was lowered to 70. Now it seems that targeting and monitoring CRP as well (i.e. to less than a level of 2) would be the next step in cardiac risk stratification." - via Kevin, MD blog. Check the NEJM ediorial. CRP test is not covered by most insurances but it costs just $15. Some of the NEJM investigators are consultants for CRP test making companies.
Dr. Khasawhen presented this study.

Safety and efficacy of daptomycin for the treatment of complicated skin infections
Clin Infect Dis. 2004 Jun 15
Dr. Al Nemr took a look at this new (or old forgotten) antibiotic.

Efficacy and Safety of Inhaled Insulin (Exubera) Compared With Subcutaneous Insulin Therapy in Patients With Type 2 Diabetes
Diabetes Care 27:2356-2362, 10/2004
Inhaled insulin appears to be effective, well tolerated, and well accepted in patients with type 2 diabetes and provides glycemic control comparable to a conventional subcutaneous regimen.
What about sensitization and asthma as a side effect? Exantha was promising as an oral anticoagulant to replace Coumadin but it does not look like it will ever be on the market (Dr. Altaqi presented the article in 2003).
F/U: Dr. Gamerman presented this study. Inhaled insulin (Exubera) caused cough in 20% of patients but the PFTs were not affected. Exubera also caused an increase in the insulin-binding antibodies but this increase reached a plateu after 1 year and did not affect the management.

Fecal DNA versus Fecal Occult Blood for Colorectal-Cancer Screening
NEJM Volume 351:2704-2714 December 23, 2004
Fecal DNA detected a greater proportion of colorectal CA than did Hemoccult but failed miserably when compared to colonoscopy. Is it really a smarter strategy - check the NEJM editorial.
F/U: Dr. Schwartzman presented the article. Clearly, stool DNA testing is not readly for prime time. Patients had to collect stools over 34 hours and to keep them in the fridge was sounded gross. Interesting enough, two of the authors were on the board of the DNA testing company and it looks like they left when the dissapointing results were announced. Fecal DNA is more sensitive than the plain FOBT (which according to the recent studies is almost useless), but cannot compare to the colonoscopy for colon CA diagnosis.

Screening for Chlamydia trachomatis in Women 15 to 29 Years of Age: A Cost-Effectiveness Analysis
Ann of Int Med 5 October 2004 Volume 141 Issue 7 Pages 501-513
Dr. Bhatnagar presented the study. Check the accompanying editorial (you will need your Ann of Int Med password).
F/U: It turned out that the study is only a statistical simulation (computer model) without real patients involved in analysis of the intervention. It was interesting to see this quality improvement project. Unfortunately, as often happens recently, the study authors had affiliations with the manufacturers of the Chlamydia testing kits.

Catheter Ablation for AFib in CHF
NEJM Volume 351:2373-2383 December 2, 2004
Restoration of NSR by catheter ablation in patients with CHF and AFib improves cardiac function and quality of life. Check the editorial.
F/U: Dr. Edula took a look at the new treatment options for Afib especially new techniques like the radiofrequency ablation. The results were promising: in patients with CHF, the EF increased by 25% after the catheter ablation of AFib, and restoration of NSR. The study included only 58 patients though, and was not powered to show any mortality benefit. The CCF is one of the 9 centers in the USA where the procedure is done. We all are aware of the results of the AFFIRM trial showing no advantages of the rhythm control over rate control but a subanalysis of the AFFIRM data showed that patients with CHF actually benefited from the rhythm control. The jury is still out on the question whether we should try to restore NSR in patients with CHF and AFib. A bigger trial which is designed as a RCT is needed.
Dr. Merugu started his contribution as a Journal Club mentor and supervisor (1/3/05).

Risk of cardiovascular events and rofecoxib: cumulative meta-analysis
Lancet 2004, Dec 4
Researchers reached a conclusion that Vioxx should have been withdrawn from the market several years earlier
F/U: Dr. Mood presented this meta-analysis focused on the Coxibs and the cardiovascular risk.

Prevalence and Correlates of Accelerated Atherosclerosis in SLE
NEJM Volume 349:2399-2406 December 18, 2003
Atherosclerosis occurs prematurely in patients with SLE and is independent of traditional risk factors for CAD.
F/U: Dr. Zouwayhed presented the study. He discussed that the markers of inflammation like CRP have less predictive value for atheroslerosis in SLE patients.

Spinal Manipulative Therapy for Low Back Pain - A Meta-Analysis of Effectiveness Relative to Other Therapies
Annals of IM - 6/03
While some patients with LBP may prefer spinal manipulation to traditional therapies, there is no evidence that it achieves better outcomes than standard treatments.
Dr. Chen presented the study.

ACE inhibitors in Stable CAD (PEACE trial)
NEJM - 11/04
ACEi use in patients with vascular disease without left ventricular dysfunction. There was no evidence that the addition of an ACE inhibitor provided further benefit in terms of death from cardiovascular causes. May ACEi Rest in PEACE? (editorial)
F/U: Dr. Erfan presented this article.

Erectile dysfunction has a strong association with cardiac ischaemia in people with DM
Circulation 2004;110: 22-6

Firstly, ED might become a useful marker to identify DM patients at risk of silent ischaemia. Secondly, it might be sensible to perform a stress test before starting treatment for ED, especially in people with other cardiovascular risk factors. BMJ 7/04

F/U: Dr. Salman's presentation brought up a debate over the guidelines for working-up and treating ED.

Association of HA1c with Cardiovascular Disease and Mortality
Annals of IM - 21 September 2004

Researches found a 21 percent increase in cardiovascular events such as heart attack, for every 1 percentage point increase in HA1c above 5 percent.
A meta-analysis focused on 13 studies involving nearly 10,000 people from North America and Europe confirmed these findings. One percentage point increase in HA1c predicted an 18 percent increase in risk for CAD and a 28 percent risk for PVD.
This was true regardless of BP or cholesterol levels.

F/U: Dr. Unnithan presented this study.

Erythromycin and the Risk of Sudden Death
NEJM Volume 351:1089-1096 September 9, 2004

Next time when you think about prescribing Erythromycin, think twice. According to a new study published in NEJM in 9/04 prescribing erythromycin to patients taking such common medications like CCB (verapamil, diltiazem) can increase their risk of sudden cardiac death by two fold. What about Zithromax and Biaxin, aren't they in the same group?...

F/U: Dr.Al-Shahed presented this study. The methods used in the protocol were criticized. A RCT is needed in order to assess the risk properly.

Hyperkalemia seen more often after Publication of the RALES Study (Spironolactone in CHF)
The publication of RALES in NEJM was associated with abrupt increases in the rate of prescriptions for spironolactone and in hyperkalemia-associated morbidity and mortality.
Do you remember the first principle of medicine? Primum Non Nocere = First Do Not Harm.
Check the editorial.
F/U: Dr.Akhtar presented this article in the middle of September.

Breast Cancer Screening with MRI
NEJM Volume 351:427-437 July 29, 2004
This is Dr.Sharma's choice for the journal club which completes the month of August.
Click for the editorial.
F/U: Good presentation. MRI is twice as sensitive as mammogram which is good but results in more unnecessary biopsies and is much more expensive. Mammogram is $50 and MRI is $ 15000.

Early Goal-Directed Therapy in the Treatment of Septic Shock.
NEJM Volume 345:1368-1377 November 8, 2001

Central venous oxygen saturation monitoring by SVC catheter brought better results than standard care guided by Swan-Ganz catheter. Should we start using it instead of the Swan?
Dr.Kalepu was on assignment investigating the issue.
You can check the editorial as well.
F/U: Presentation was good, we're planning to use the PreSep catheter in ICU. The protocol is being devoloped.

BNPep and the Risk of Cardiovascular Events and Death
NEJM Volume 350:655-663 February 12, 2004

Should we really check BNpep for every patient admitted to the hospital?
You will know after Dr.Damodaran presents the article. The NEJM editorial is helpful.
F/U: Good presentation, BNPep (20< but <100) shows that something is wrong but we don't know what yet. Just like Anand says if there is a smoke there must be fire. Right now we're looking for the fire.

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