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March 18th, 2016

STAMP IT OUT

THE STORY

Old flames die hard, and some patients want to cling to their cigarettes long after the romance is over. But when it comes to quitting smoking, a clean break beat the slow fade in a head to head trial.

THE BACKGROUND

Smoking remains a critical public health issue, so obviously the USPSTF has a lot to say. Their last recs in October advocated for a mix of medications and behavioral interventions for smoking cessation in non-pregnant adults. They also for the first time considered e-cigarettes, and found a lack of evidence for their use as smoking cessation agents. Since then, the field has seen more action, as a January RCT made waves when it found no significant difference in quit rates following treatment with the fancy anti-smoking drug Chantix (varenicline) vs. standard nicotine replacement therapy.

THE NEWS

Most anti-smoking guidelines call for a firm quit date followed by no more cigarettes, but supporting evidence was lacking. Now, an RCT in primary care clinics found that smokers who quit abruptly rather than gradually were more likely to be abstinent at 4 weeks and 6 months. Both groups received behavioral support and nicotine replacement therapy. The authors found that gradual quitters were less likely to follow through with their plans, possibly because they were less likely to go to pre-quit visits.
Annals

THE TAKEAWAY

Per the USPSTF, offer all interested quitters counseling and their choice of pharmacotherapy. Then tell them to pick a date and stick with it.

SAY IT ON ROUNDS

WHEN DELAYED GRATIFICATION STRIKES A CHORD

Interventions for carotid artery stenosis (CAS) work a lot like intern year: you pay your dues upfront (in 30-day post-procedural safety) and cross your fingers for a smoother ride later (in the form of decreased long-term risk of stroke). Several trials have compared carotid stents to endarterectomies (CEA). The two latest from this week, ACT I and the long-term results from CREST, show that stents are non-inferior to CEA in asymptomatic CAS. Critics point out that the trials don't compare the interventions to medical therapy, which has improved significantly since the whole debate started in the 90's.
NEJM

WHEN YOU FEEL LIKE YOU NEED SOME AIR

Crank up the high-flow. An RCT done in Spanish ICUs found that high-flow nasal cannula reduced the risk of reintubation at 72 hours when compared with sealed masks or nasal prongs. The authors note that high-flow provides a small amount of positive pressure, and may help patients clear secretions better than sealed masks.
JAMA

WHEN THE FIFTH HOUR OF ROUNDS IS PURE AGONY

There are many flavors of pain. For kidney stones, fluids and pain control is an old standby, but what to use as analgesia was never clear. A trial of IM diclofenac, IV morphine, or IV paracetamol (aka Tylenol) to control renal colic found that IM diclofenac and IV paracetamol were more effective than morphine at decreasing pain in the first 30 minutes after administration. The meds had less side effects than IV morphine, too.
Lancet

WHEN YOUR HOSPITAL'S FANCY NEW LAB ISN'T QUITE FIRING ON ALL CYLINDERS

Rely on trained dogs to spot your UTIs. In a double blinded case-control study of urine samples, Rover and friends detected E. Coli, Klebsiella, Staph and others with sensitivities at or near 100% and specificities above 90%. No word yet on how the pooches feel about add-on tests.
Open Forum Infect Dis

BRUSH UP

AFTER THE ARREST

Return of spontaneous circulation is a good first step following cardiac arrest, but there's a lot that comes afterward. ICU care and close monitoring are essential – these patients are delicate. Watch oxygen and ventilation, and know that too much O2 has been shown to be harmful. Circulatory support measures beyond fluids and vasoactive meds include balloon pumps, ventricular assist devices, and a crash landing on planet ECMO. Comatose survivors should be cooled with therapeutic hypothermia. If there's reason to think the problem is from myocardial infarction, take the patient to the cath lab.

WHAT'S THE EVIDENCE

For therapeutic hypothermia following cardiac arrest? 2002's HACA trial found that cooling patients to 33C following witnessed arrest improved neurological outcomes and decreased 6-month mortality in a group of 275 patients. The authors estimated a number needed to treat of 6 to obtain neurological benefit. But 2013's TTM found that cooling patients to 36C was not significantly different than cooling patients to 33C in a larger patient base. Since hypothermia is not without its complications (think: decreased cardiac output, need for sedation), some argue that the focus of cooling should merely be to prevent post-arrest hyperthermia.

NEW CDC GUIDELINES

For prescribing opioids for chronic pain are out and ready to rumble. The CDC, concerned with an epidemic of opioid misuse and overdose, says it wants to fight the idea that opioid prescriptions are harmless and unlikely to lead to addiction. The guidelines (here's a synopsis) recommend against prescribing opioids for chronic pain outside of active cancer or end-of-life care.

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