Feb 15, 2019

Gray area

The story

Headlines focus on e-cigarette use among teenagers, but can vaping help smokers quit? New research explains. 

The background

E-cigarettes are by all means a public health crisis: rates of use are exploding among teens despite unknown long-term health consequences and high potential for addiction. Stats aside, public health experts believe e-cigs are safer than combustible tobacco, and US smokers are more likely to try e-cigarettes than FDA-approved smoking cessation aides when they try to quit. Some data on efficacy could help.

The study

The UK National Health Service compared traditional nicotine replacement therapy (NRT) to refillable e-cigarettes in 900 smokers who sought help quitting. Both groups received behavioral counseling, and abstinence was confirmed with carbon monoxide testing. One year abstinence rates were 18% in the e-cigarette group compared with 10% in the NRT group, yet 80% of abstinent e-cigarette users continued to vape while only 9% of NRT patients stuck with their product. For comparison, abstinence rates following NRT + buproprion (20% at 1 year) or varenicline (26% at 24 weeks) were similar.

The takeaway

If your patients want to break their nicotine addiction, there are better options out there than e-cigarettes. Vaping looks like a good fit for those who want to replace one habit with another.

Say it on rounds

When you triple-check that the intern is pulling back on the syringe

Ask a 4th time, just to be sure. Efficacy studies for direct-acting antivirals (i.e. Harvoni) in hep C have focused on clearance of infection, but there's less evidence linking treatment to clinical outcomes. A prospective cohort of 10,000 patients with HCV found that those treated with DAAs had half the risk of mortality and one-third the risk of hepatocellular carcinoma compared to untreated patients matched for baseline disease severity. Treatment patients had an unexpectedly lower risk of non-liver-related mortality.

When the cafeteria sushi isn't sitting well

You can't undo lunch, but full trial results from ANNEXA-4 found that the reversal agent andexanet helped patients with acute major bleeding on factor Xa inhibitors (e.g. apixaban, rivaroxaban) achieve hemostasis. The final trial included 350 patients, 64% of whom had intracranial hemorrhage. Andexanet administration helped 80% of patients achieve hemostasis within 12 hours, which compares well with the use of prothrombin complex concentrate (PCC) to control bleeds in coumadin patients. 

When you write the note before you see the patient

Watch out for preconceptions. An analysis of 20,000 Canadian research grant applications found evidence of gender bias in funding. When reviewers were asked to focus on the proposed science while evaluating apps, male and female principal investigators won grants at similar rates. But when programs asked reviewers to base their decision on the perceived caliber of the investigator, women were 4% less likely to win awards. The authors say focus on the science, not the scientist.

Brush up

Peripartum cardiomyopathy (PPCM)

Afraid of mixing medicine and OB? Us too. Watch for PPCM in late pregnancy or the early peripartum period. Risk factors include black ancestry, pre-eclampsia, advanced age, and multiple gestation pregnancy. Rates are on the rise in the US as average maternal age increases. Management recs are similar to those for congestive heart failure, though ACE-inhibitors and ARBs are contraindicated during pregnancy. Over half of patients see LVEF recovery, often within the first 6 months of diagnosis. 

What's the evidence

For bromocriptine in PPCM? Bromocriptine inhibits prolactin, a proposed contributor to myocardial damage in PPCM. A 2017 trial of bromocriptine in 60 patients with severe cardiomyopathy (LVEF < 35%) found that an 8-week treatment course improved left ventricular recovery at 6 months compared to a 1-week course. Consider bromocriptine for severe PPCM, and make sure to also include anticoagulation. The med is associated with thrombosis.

What your psych friends are talking about

You've seen ketamine in the OR and maybe even in the club. Now an FDA advisory panel has recommended that the drug be approved for refractory major depression.

Spread the word

Send your interns something to look forward to


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