Monthly Archives: September 2013

Gentle Wiping of Face, Nose and Mouth Appears as Effective as Suction for Clearance of Secretions at Birth of Term Neonates

Reference: Lancet 2013 Jul 27;382(9889):326, (level 3 [lacking direct] evidence)

Oronasopharyngeal suction is frequently used immediately following routine delivery to clear the airway secretions of neonates both to prevent aspiration and to provide stimulation to start spontaneous respiration. However, due to an increase in the risk of bradycardia and apnea, guidelines from the American Heart Association recommend suction for babies born through clear amniotic fluid only in cases of obvious obstruction or need for mechanical ventilation (Circulation 2010 Nov 2;122(18 Suppl 3):S909). A recent randomized trial assessed the efficacy of simply wiping the mouth and nose at birth in 506 term neonates.

Infants born at ≥ 35 weeks gestational age (median 39 weeks) at a single hospital were randomized to gentle wiping of the face, mouth, and nose with a towel vs. suction of mouth and nostrils with a bulb syringe immediately after cutting of umbilical cord and were followed for 24 hours. After randomization, 15 nonvigorous neonates with meconium-stained amniotic fluid were intubated and excluded from analysis. The primary outcome to assess successful clearance of secretions was mean 24-hour respiratory rate.

The rates of crossover to the alternate treatment were high in both groups: 26% in the wiping group received suction, and 14% in the suction group received wiping. The mean 24-hour respiratory rates were 51 breaths/minute with wiping vs. 50 breaths/minute with suction in the intention-to-treat analysis (not significant). Respiratory rates also showed no significant differences in per-treatment and per-protocol analyses. There were also no significant differences in incidence of tachypnea (respiratory rate > 60 breaths/minute) (46% vs. 46%), need for advanced resuscitation at birth (10% vs. 7%), or 5-minute Apgar scores (9 vs. 9). Wiping was associated with a nonsignificant increase in need for admission to neonatal intensive care (18% vs. 12%, p = 0.07).

For more information, see the Overview of labor and delivery topic in DynaMed.

How often do different cardiovascular risk calculators agree with one another?

Different CV risk calculators are inconsistent in classifying risk for the same patients

Bottom Line

The use of risk calculators is increasingly common, but many calculators still use data gathered in older, homogeneous populations that predate the modern era of statins, aspirin, and antihypertensives. This article serves as a warning that we need to carefully choose which calculator to use with which population, and we need to make sure that the calculators are regularly updated and appropriately calibrated. (LOE = 2c)

Reference

Allan GM, Nouri F, Korownyk C, Kolber MR, Vandermeer B, McCormack J. Agreement among cardiovascular disease risk calculators. Circulation 2013;127(19):1948-1956.

Study Design: Cross-sectional Funding: Government
Setting: Population-based Allocation: Unknown

Synopsis

Practice guidelines are increasingly based on cardiovascular risk factors, because overall risk is critical for determining how much a patient will benefit from a preventive medication such as aspirin or a statin. These authors identified 25 such calculators, and created 128 imaginary patients, each with a different combination of 7 cardiovascular risk factors (diabetes mellitus, age, sex, tobacco use, blood pressure, and HDL and total cholesterol levels). They determined whether each risk calculator placed each patient in a low-, moderate- or high-risk category. They then compared each calculator with each other calculator and determined the percentage of times that the calculators’ results agreed with one another. For example, if the calculators both placed 20 patients in the low-risk group, 22 patients in the moderate-risk group, and 22 patients in the high-risk group, but disagreed about the other 64 patients, they would have 50% agreement. Agreement varied, with the average agreement generally in the 60% to 70% range (mean = 67%). The Progetto Cuore score (average agreement = 46%) and 2 scores based on the United States National Cholesterol Education Program guidelines (55.4% and 56.2% agreement) were noticeably worse. For 41% of the 128 imaginary patients, at least one calculator put them in the low-, moderate-, and high-risk groups. Only 28% of patients were assigned to the same risk group by all 25 calculators.

Mark H. Ebell, MD, MS
Associate Professor
University of Georgia
Athens, GA

Does universal decolonization for MRSA in patients in the ICU decrease the rate of MRSA-positive clinical cultures?

Bottom Line

As compared with no decolonization or targeted decolonization, a universal decolonization strategy for MRSA using intranasal mupirocin and chlorhexidine bathing cloths for all patients admitted to the intensive care unit (ICU) is most effective at decreasing MRSA-positive clinical cultures and ICU-acquired bloodstream infections. Overall, you would need to treat 54 patients with universal decolonization to prevent one bloodstream infection. The cost effectiveness of this strategy as well as the concern of emerging resistance was not addressed in this study. (LOE = 1b-)

Reference

Huang SS, Septimus E, Kleinman K, et al, for the CDC Prevention Epicenters Program; AHRQ DECIDE Network and Healthcare-Associated Infections Program. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med 2013;368(24):2255-2265.

Study Design: Randomized controlled trial (nonblinded) Funding: Government
Setting: Inpatient (ICU only) Allocation: Uncertain

Synopsis

Prior research has shown that daily bathing with chlorhexidine lowers the rate of MRSA acquisition and decreases the overall number of hospital-acquired bloodstream infections in the ICU (Daily POEM 4/26/13). The current study’s goal was to identify whether targeted or universal MRSA decolonization is the most effective at reducing MRSA infections in the ICU. Investigators randomized 43 hospitals to use 1 of 3 strategies within all their adult ICUs: (1) MRSA screening and contact isolation only; (2) screening, isolation, and decolonization of MRSA carriers; (3) decolonization of all patients without any screening procedures. Screening for MRSA was performed via swabs of bilateral nares upon ICU admission in the first 2 groups. Contact precautions were implemented for those with a positive MRSA screening result in groups 1 and 2 and for those with history of MRSA colonization or infection in all groups. Decolonization in groups 2 and 3 consisted of 5 days of twice-daily intranasal mupirocin, as well as daily bathing with chlorhexidine cloths during the entire ICU stay. Baseline characteristics of the patient populations in each group were similar. Patients in all adult ICUs of a participating hospital were assigned to the same study group. Although both universal and targeted decolonization resulted in a significant reduction in the primary outcome of MRSA-positive clinical cultures, the universal strategy was found to be most effective (hazard ratio [HR] = 0.63 for the universal strategy; HR = 0.75 for the targeted strategy; and HR = 0.92 for screening and isolation; P = .01). Additionally, universal decolonization led to the greatest reduction of overall bloodstream infections (HR = 0.56 for universal; HR = 0.78 for targeted; HR = 0.99 for screening and isolation; P < .001). Of note, the universal decolonization group contained 3 of the 4 hospitals that performed bone marrow and solid-organ transplants, resulting in a higher baseline risk of infection than the other groups, but this difference was not statistically significant. Overall, only severe adverse events were noted in this study and all were classified as mild pruritus or rash due to chlorhexidine bathing. Investigators did not evaluate the cost-effectiveness of the different strategies nor did they examine the emergence of resistance with widespread use of chlorhexidine and mupirocin.

Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL

Is dextrose prolotherapy effective in treatment of osteoarthritis of the knee?

Bottom Line

Dextrose prolotherapy appears to be more effective in decreasing pain and stiffness and improving function in patients with knee degenerative joint disease (DJD) than saline injections and home exercise. (LOE = 1b)

Reference

Rabago D, Patterson JJ, Mundt M, et al. Dextrose prolotherapy for knee osteoarthritis: a randomized controlled trial. Ann Fam Med 2013;11(3):229-237.

Study Design: Randomized controlled trial (double-blinded) Funding: Government
Setting: Outpatient (any) Allocation: Concealed

Synopsis

Prolotherapy basically involves injecting nonmedical irritants into musculoskeletal tissues to promote healing. Some report that it has been around for a few millennia but was “rediscovered” in the 1930s. These researchers compared dextrose prolotherapy (n = 30) with saline (n = 29) and home exercise (n = 31) in adults with moderate to severe pain and radiographically confirmed DJD of the knee. The researchers’ pharmacy prepared syringes of saline or dextrose, covering them with opaque paper sleeves to conceal the contents from the physician and the patient. The paper has lengthy details on the dextrose concentrations and volume of solution used (largely based on intra-articular and extra-articular injection). The injections were administered at 1, 5, and 9 weeks with optional sessions at 13 and 17 weeks. These latter injections were based on physician recommendation and NOT based on patients’ preferences. The researchers offered a dose of opiates prior to each injection, as well as opiates for 1 week afterward. Additionally, the patients were told to rest the knee for 2 days after the injection. Researchers, who were masked to treatment group assignment, evaluated the patients at baseline, before any interventions, and at 5, 9 and 12 weeks. Masked researchers also conducted telephone follow-up at 26 and 52 weeks. At the end of the study, patients in all 3 treatment groups improved, but the degree of improvement on an arthritis-specific scale (overall, pain, stiffness, and function) was greater in the prolotherapy-treated patients. Although the magnitude of improvement appears to be clinically important, 91% of prolotherapy-treated patients, 82% of saline-treated patients and 89% of home exercise-treated patients would recommend their treatment to others!

Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI

What is the best way to diagnose and treat exercise-induced bronchoconstriction?


Bottom Line

The American Thoracic Society recommends formal post exercise spirometric testing in patients with suspected exercise-induced bronchoconstriction (EIB). In those patients with confirmed EIB, pre-exercise use of an inhaled short-acting beta-agonist (SABA) is still the mainstay. The panel also recommends using mast cell stabilizers or anticholinergic medications in patients who don’t respond well to SABA’s. For patients using SABA’s every day, the panel recommends adding a daily controller medication (inhaled corticosteroids [ICS] or leukotriene receptor antagonists), but recommends against the use of long-acting beta-agonists (LABA’s). (LOE = 5)

Reference

Parsons JP, Hallstrand TS, Mastronarde JG, et al, for the American Thoracic Society Subcommittee on Exercise-induced Bronchoconstriction. An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction. Am J Respir Crit Care Med 2013;187(9):1016-1027.

Study design: practice guideline

Funding: Unknown

Setting: Outpatient

Allocation: Unknown

Synopsis

The American Thoracic Society assembled a panel of content and methodologic experts (many with ties to industry) — but nobody representing patients or societal perspectives — to develop guidelines for managing patients with EIB. Librarians systematically searched multiple databases for relevant research. Panel members reviewed the search results, evaluated the quality of the research, and generated recommendations. The panel recommends (expert opinion) that the diagnosis of EIB should NOT be based on symptoms, but on spirometric changes after exercise. Pharmacologic treatment: A systematic review of 8 clinical trials that demonstrated patients using pre-exercise SABAs showed significantly less spirometric decline after exercise than patients using placebo. Additionally, 2 clinical trials evaluating LABAs found a higher rate of treatment failure with LABAs. Several other trials and meta-analyses exist, but these included patients also using inhaled corticosteroids. A systematic review of 6 clinical trials of daily ICS reported that patients using steroids had modestly less spirometric decline after exercise than those using placebo. However, another systematic review of 4 trials found pre-exercise ICS was no better than placebo. The panel also summarized systematic reviews of randomized trials of several other classes of medications (daily leukotriene receptor antagonists, mast cell stabilizers, antihistamines, and short-acting inhaled anticholinergic medication). For all except antihistamines, the active medication was modestly better than placebo. Although pre-exercise antihistamines were no better than placebo, the panel felt they might be helpful in allergic patients. Nonpharmacologic treatment: A systematic review of several randomized trials of warm-up periods (interval, low-intensity continuous, high-intensity, or combination) before exercise reported that patients doing interval and combination warm-up periods had modestly less postexercise spirometric decline than patients not doing a formal warm up. One randomized trial of limited quality and 2 nonrandomized trials provided weak evidence of modest benefit to warming or humidifying the air (with a face mask or scarf) during exercise. Although the panel identified limited quality research on sodium restriction, fish oil supplementation, and ascorbic acid for patients interested in dietary modification to control symptoms, the panel basically said “it couldn’t hurt.”

Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI