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Treating Community Acquired Pneumonia: Switching from IV to PO antibiotics. November 13, 2006

Posted by rajkmd in Pulmonary/Critical Care.
6 comments

 These are the official recommendations from New York Presbytarian

Survival of Patients with Stage I Lung Cancer Detected on CT Screening (NEJM, October 26, 2006) November 12, 2006

Posted by rajkmd in Oncology, Primary Care, Pulmonary/Critical Care.
11 comments

 

For the actual article, click here

Background

  • In 1993, the International Early Lung Cancer Action Project (I-ELCAP) studied the use of CT cancer as a screening tool in the early detection of lung cancer .
    • The study found that eighty percent of lung cancers detected by annual screening were stage 1 cancer.
  • But does this actually save lives?
  • Using ELCAP protocal, this study investigates whether early detection leads to a mortality benefit.
  • This study was supported with grants from National Institute of Health

Methods

  • For a flowchart of the actual protocol, click here
  • Pt’s initially underwent baseline screening.  If the patient had a negative CT scan, then they underwent annual screening at 12 month intervals
  • This is a prospective, observational trial with no control group.
  • For baseline screening, a positive result on the initial low-dose CT scan was defined as
    • At least one solid (completely obscuring lung paranchyma) or partly solid (obscuring part of paranchyma) non calcified pulmonary nodule 5 mm or more in diameter
    • At least one non solid, non calcified pulmonary nodule 8mm or more in diameter, or
    • a solid endobronchial nodule
  • For positive results at the baseline screen:
    • Patients with nodules 5 mm to 14 mm were either re-imaged with CT scan or underwent a PET scan.  If the PET scan was positive or after 3 months the CT scan showed nodules that were growing, then a biopsy was performed
    • For lesions greater or equal to 15 mm, biopsy was immediately performed.
    • Lesions that were suspected to be infections underwent a 2wk period of antibiotics
  • For annual screening, a positive results was any newly identified noncalcified nodule, regardless of size.
    • Repeat CT scan performed for nodules less than 5 cm at 3 months or 6 months depending on the size of the nodule.  If there was no growth in the nodules, then the workup was stopped and pt was re-screened at 12 month interval from the previous CT
    • For pts with nodules greater than 5 cm, a 2wk course of antibiotics was prescribed followed by a CT scan one month later.  If the nodules did not resolve, then a biopsy was performed
  • Patients were enrolled from 1993 to 2995
  • Inclusion criteria- 40 yo or older, at risk for lung cancer b/c of cigarette smoking, occupational exposure, or exposure to second hand smoking, pts were “considered fit” to undergo thoracic surgery
  • 31,567 pts underwent baseline screening and of these, 27,456 underwent annual screening
  • The average age 61 yo and median pack year history was 30

Results

  • Among the 31,567 asymptomatic patients that underwent baseline screening, 405 patients were diagnosed with lung cancer.
  • Among the 27,456 patients who underwent annual screening 74 patients were diagnosed with lung cancer.
  • Of the total of 484 patients that developed lung cancer, 411 (85 percent) underwent resection, 57 (12 percent) underwent radiation and/or chemotherapy, and 16 recieved no treatment.
    • Of the 484 patients diagnosed 85% had stage I lung ca 
  • The estimated 10 year survival for all participants was 80% (95%CI, 74 to 85), but in patients with stage I disease the survival rate was 88% (95% CI, 84 to 91).  Moreover, in patients with stage 1 disease who underwent resection within 0ne month of diagnosis the survival rate was 92 % (95% CI, 88 to 95).
  • The operative mortality rate was 0.5%.

Discussion

  • The authors contend that using CT scans to screen for lung cancer could prevent 80% of death from lung cancer.  Currently the death rate of lung cancer in US is 95%.
  • The rate of detection in this study was 1.3% on baseline screen and 0.3% on annual screen, which is comparable to breast cancer screening with mammograms.

THE BOTTOM LINE:  In high risk patients patients, using the I-ELCAP protocol which includes a baseline CT scan and subsequent annual CT scans, 85 percent of the cancers identified in this study were stage I disease.  Moreover, the ten year survival was 80 percent in all patients diagnosed with lung cancer, 88 percent in patients with stage I disease, and 92% in patients with stage I disease and resection within one month of diagnosis.

Intensive Insulin Therapy in the Medical Intensive Care Unit (NEJM, Feb. 2, 2006) October 8, 2006

Posted by rajkmd in Pulmonary/Critical Care.
10 comments

by  Dr. Nicole Malouf

to see the original article click here

Background

  • Hospitalized patients in the ICU with severe illness commonly have hyperglycemia and insulin resisitance

  • Previous studies have shown benefit of tight insulin control in ICU patients.  In 2001, the author of this study demonstrated benefit in 1500 Surgical ICU patients in a prospective, randomized, controlled study of intensive glycemic control versus conventional treatment

    • Showed that intensive insulin therapy had an absolute risk reduction in mortality of 3.4 percent (from 11 percent in the control compared to 7 percent in the experimental group).  This means you have to treat approx 29 patients with intensive insulin therapy in order to save one life

    • Greatest reduction on patients who remained in ICU for 5+days with an absolute risk reduction in mortality of 9 percent (from 26 percent mortality in the control compared to 17 percent in the experimental group).  This means that you need to treat only 11 patients in order to save one life in patients in the ICU greater than five days

Methods

  • Inclusion criteria - Patients admitted to MICU between March 2002 and May 2005 who were expected to stay 3 days or  greater

  • Exclusion criteria

    • Those expected to stay < 3 days

    • Surgical ICU patients

    • Medical patients able to take oral nutrition

    • Postoperative patients

    • Patients participating in another study

    • Those who did not provide consent

  • After exclusion, 1200 patients underwent randomization to either intensive treatment or conventional treatment. Of these, 767 stayed in the ICU for at least 3 days.

  • Intervention – Intensive insulin treatment group: blood glucose titrated to goal of 80-110 mg/dL by insulin infusion.

    • Insulin infusion was started when blood glucose level exceeded 110. 

    • Maximal IV insulin infusion was set at an arbitrary rate of 50 IU per hour

  • Conventional insulin treatment group: blood glucose titrated for  a goal of 180-200 mg/dL by insulin infusion

    • Insulin infusion was started when blood glucose level exceeded 215. 

    • Blood glucose was checked at one to four hour intervals

    • Upon discharge from the ICU, both groups adopted a conventional approach with a goal blood glucose level below 200.

  • Outcome Measures

    • Primary: In-hospital mortality 

    • Secondary: ICU mortality, 90-day mortality, days to mechanical ventilation wean, ICU stay, hospital stay, dialysis, new kidney injury, days of inotropic support, days of vasopressor support, bacteremia, prolonged use of antibiotics, hyperbilirubinemia, hyperinflammation state.

  • Separate analyses were performed for the intention to treat group (every patient that was randomized N 1200)  and the patients who stayed  in the ICU for at least three days (N 767)

Results

  • Hypoglycemia

    • More common in the intensive insulin arm compared to the conventional group (18.7 percent vs 3 percent p<0.001in the intention to treat arm and 25.1 vs 3.9, p <0.001 in the long stayers)

    • Mortality among patients who became hypoglycemic was increased in the conventional arm was increased, but not statistically significant (66.7 vs 46.4 p=0.1)

    • Independent risk factors for developing hypoglycemia regardless of insulin therapy

      • ICU stay longer than 3 days

      • Renal failure requiring dialysis

      • Liver failure defined as an AST>250

  • Morbidity in the intention to treat group (N=1200).  Patients recieving intensive insulin therapy were

    • less likely to receive a new kidney injury (8.9 to 5.9 percent, P=0.04)

    • weaned off of mechanical ventilation earlier (hazard ratio, 1.21; 95 percent confidence interval, 1.02 to 1.44; P=0.03)

    • discharged from the ICU earlier (hazard ratio, 1.15; 95 percent confidence interval, 1.01 to 1.32; P=0.04)

    • discharged from the hospital earlier (hazard ratio, 1.16; 95 percent confidence interval, 1.00 to 1.35; P=0.05)

    • No difference in bacteremia, prolonged use of antibiotics, hyperbilirubinemia, TISS-28 score, rates of readmission to the ICU. 

  • Morbidity in the longer staying group (people who stayed at least 3 days, N=767).  Patients receiving insulin therapy were

    • weaned off of mechanical ventilation earlier (hazard ratio, 1.43; 95 percent confidence interval, 1.16 to 1.75; P<0.001),

    • discharged from the ICU earlier (hazard ratio, 1.34; 95 percent confidence interval, 1.12 to 1.61; P=0.002),

    • discharged from the hospital earlier (hazard ratio, 1.58; 95 percent confidence interval, 1.28 to 1.95; P<0.001).

    • Pt’s also had a lower incidence of acquired kidney failure, acute rises in bilirubin as well as reduced TISS 28 scores.

    • No difference in bacteremia or prolonged use of antibiotics

  • Mortality

    •  No difference seen between the treatment groups and the insulin intensive arm in the intention-to-treat analysis, which includes all 1200 patients regardless if they stayed 3 days or less. 

    • At day 3, there was a slight increase in mortality in patients in the ICU (2.8 percent in conventional  vs. 3.9 percent in insulin-intensive arm , P=0.31) and in-hospital mortality (3.6 percent in conventional vs. 4.0 percent in insulin-intensive arm, P=0.72) for patients receiving intensive insulin therapy.

    • However, there was a significant reduction in mortality in the subgroup analysis (both ICU and in-hospital mortality) in patients who stayed in the ICU for longer than 3 days

    • Patients who stayed beyond five days had a reduction in mortality 54.9 to 45.9 percent (P=0.03)

Discussion

  • In both the intention to treat group as well as the longer staying group there was a decrease in morbidity in the form of decreased acquired renal failure, decreased ICU stay, and decreased hospital stay with no change in rates of bacteremia or in the course of antibiotics

  • The study showed that here was an increase in mortality in patients who stayed in the ICU for less than three days that was statistically insignificant

  • For patients, who stayed in the ICU, there was a clear decrease in mortality, which increased as patients stayed longer

    • It seems that tight glycemic control helps decrease the complications of prolonged ICU stay

  • The mortality benefit extends far after patients are discharged from the hospital suggesting there is a ”carryover” effect and is consistent with other reports which show better rehabilitation in patients that have tight glycemic control in the ICU

THE BOTTOM LINE:  This study shows that maintains tight glycemic control with an insulin gtt (goal blood glucose of 80-110mg/dL) decreased morbidity in patients that meet the study’s criteria regardless of their MICU stay.  A decrease in mortality, on the other hand, is only seen in patients who stay in the MICU for longer than three days and this mortality benefit increases the longer patients stay in the ICU.  It is unclear, though, whether there is increased mortality in patients who stay in the ICU less than three days.