Therapy for Bronchiolitis?

You could knock me over with a feather. I've watched bronchiolitis attack vulnerable infants over the last four years. There hasn't been much we could do. Supportive care? Nasal saline, intubate or NIPPV for respiratory failure, some people use oxymetazoline drops for the snotty noses thwarting the respiratory efforts of our little obligate nose breathers. Now it seems that there may actually be something helpful to offer. The literature is rife with randomized trials that fail to show that albuterol, racemic epinephrine, or steroids offer any benefits.

The fine folks at Cochrane published an analysis of 4 trials looking at nebulized hypertonic saline for acute bronchiolitis last fall. I have not been able to access the full text at home, because either I am too dim-witted to figure it out, or OSU doesn't subscribe to the most influential EBM resource available. Hopefully the former.

The bear of bronchiolitis is that it attacks the upper respiratory tract via snotty nose and it attacks the lower respiratory tract with more mucous and sloughed epithelium. This is a tough 1-2 punch for infants with little reserve.

Inhaled hypertonic saline has been used to augment airway clearance in CF over the last few years, so it only made sense to try it in infants. The 4 trials reviewed were small, so the total number of patients analyzed was small (254). They looked at both inpatients and outpatients and showed reduction in Length of Stay (LOS) by one day. They also found improvement in clinical score.

Well, according to the cochrane review and the 2007 paper from the journal of pediatrics, it evidently works. In the 2007 paper they gave it every 2 hours for 3 doses and then every 4 hours for 5 doses and then every 6 hours.

There doesn't seem to be a downside.

Anybody used hypertonic saline nebs for acute bronchiolitis?

POISE

I spent a half day a week this month in preop clinic. While there, I took the time to go back and read the POISE trial that much ado was made about last year. POISE was a randomized placebo controlled, I believe double blinded study of extended release metoprolol in patients undergoing non-cardiac surgery. They had >8000 patients. MANY studies have shown the benefit of perioperative beta blockade in reducing perioperative MI, the internist's most feared perioperative complication.

POISE verified this finding, with reduction in nonfatal MI, but they discovered that more people died in the metoprolol group. Oops. What did they die of? Stroke. There was a 0.5% increase in stroke in the metoprolol group (statistically significant).

What the hell happened?

Well, if you look at their methods it is instantly obvious what went wrong. The treatment arm, whow as beta blocker naive, received a whopping 100 mg of extended release metoprolol 2-4 hours before their surgery. They chased it with another dose 6 hours postop, or earlier if they ad a HR > 80 or SBP >100. WOW! That's a lot of metoprolol for somebody who has never seen the drug before. 200 mg total of extended release metoprolol a day was then continued for patients that were able to tolerate it without severe bradycardia or hypotension. Gee, I wonder where the strokes came from? Any IM intern could have seen this coming.

Two take-home points here. Peri-operative betablockade doesn't need and shouldn't have the mega doses used in this trial. Also, if you have time before surgery, why not establish the drug for a week or two beforehand?

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)60601-7/abstract

ACC/AHA 2007 guidelines for perioperative cardiovascular eval for non-cardiac surgery

Cough, Cough

Well, sometimes it seems that nearly every patient you see in an outpatient clinic at this time of the year has a URI. I find myself constantly giving instructions that may or may not be helpful: "Use a cough suppressant with dextromethorphan", "Use a nasal spray with oxymetazoline either during the day so you can breathe and sound normal at work" (the way I do it) or "use a nasal spray with oxymetazoline at night so you can breathe and sleep". My personal favorite: "Drink plenty of water." These conversations are even more common now that cold medicine is essentially off the market for kids. So I embarked on a literature search to figure out if any of this stuff is really helpful. I searched for:

"upper respiratory infection" "supportive care" efficacy

and came up with the article I refer to here. I had heard of this study before, but I had never read it.

The authors at Pennsylvania State randomly assigned 105 patients to receive either buckwheat honey, dextromethorphan thickened and artificially flavored like honey, or nothing. It is not clear if the "nothing" syringe contained a placebo, but I suspect it did. The study population was kids 2-18 with a diagnosis of URI. They asked parents about the patient's coughing frequency, severity, bothersome-ness, affect on patient sleep, and affect on parent sleep. This was surveyed on presentation and diagnosis with the URI and again after treatment. In paired comparisons, honey was superior to "nothing" for cough frequency and combined symptom score. It was also "marginally significant" for child sleep and bothersome nature of cough. It was not significant for cough severity or parents sleep. No difference was detected between dextromethorphan and honey.

Interesting stuff. Maybe I should be comfortable recommending honey for cough. They go on to hypothesize about how this might actually work. There are theories about sweetness leading to reflex salivation, secretion of airway mucous, and a "demulcent effect" in the pharynx and larynx. There is also a theory about these secretions improving mucociliary clearance in the airway via an expectorant mechanism.

LINK

Statins role in CAD

The chiropractor for whom my mom works tried to dissuade my dad from continuing to take statins based off an article: "Dr. Julian Whitaker's Health & Healing-Your Definitive Guide to Wellness Medicine".
Dr. Whitaker's claim is that MI's are caused from inflammation and have nothing to do with cholesterol. Recent research is finding that the role of inflammation is much more involved than originally thought. So Dr. Whitaker has some validity in his claims.
http://content.nejm.org/cgi/content/abstract/336/14/973
http://circ.ahajournals.org/cgi/content/full/105/9/1135

However extensive research still shows that cholesterol plays a role in CAD.

http://jama.ama-assn.org/cgi/content/abstract/285/4/430
http://content.nejm.org/cgi/content/abstract/344/26/1959
http://jama.ama-assn.org/cgi/content/abstract/282/24/2340

The last link is a meta-analysis of Medline articles from 1966 to 1998 on CAD and statins.

Furthermore, Dr. Whitaker's references are a bit concerning: Business Week, 2 science articles-1 from Biofactors and 1 from Circulation (seemingly valid), and a book.

Finally, statins not only help reduce cholesterol, but also help reduce inflammation, which could be another factor in which they are helping to reduce MI's. So be it cholesterol or inflammation, research has shown that statins continue to lower MI's.


"Dr. Julian Whitaker's Health & Healing-Your Definitive Guide to Wellness Medicine". June 2008. Vol. 18; no. 6; pp. 1-3

Soy Beans

So remember studying for Step 1 and having to know that vegetarians are at an increased risk for B12 deficiency? Well, I came across an article talking about the benefits of soy beans. If fortified w/cobalamin as some soy products are, it looks like being a vegetarian isn't so "risky" and actually beneficial.
To make this article peds related...I found it interesting that babies on soy formula can have decreased absorption of iron or thyroid hormone supplementation. Furthermore, soy contains tyramine so could cross react with MAOI's.
Key points from article:

Advantages:
-reduce cholesterol, LDL, and TG levels.
-reduce menopausal hot flashes
-reduce bone turnover-->improve bone mineral density
Disadvantages:
-diarrhea (common)
-Rare:menorrhagia, amenorrhea, HA, dizziness, MSK complaints


Article from American Family Physician, Vol 79, No. 1, Jan. 1, 2009
Michelfelder, Aaron J., MD. "Soy: A complete Source of Protein", pp. 43-47

Burnout and Suicidal Ideation among U.S. Medical Students

I came across this article in the Annals a few months ago. I have been tapped to lead an electronic journal club in January, and this is the article that I will be using. If anyone has any input that they want included in the discussion, lets hear it.
Linky
I know the authors from medical school and have a great deal of respect for them. I exciteded to give it a critical read and will post my thoughts here soon. I will say though, that I know these are huge issues for some medical students.

Cats, Toxoplasmosis, and Pregnancy

The other night, my vet student roommates lectured me that we "human medicine" doctors need to stop scaring people about pregnant women getting toxoplasmosis from changing garfield's litter box. They claimed that kittens are the only ones to shed it in their feces. So I had to find some proof and here are the articles supporting their claim. In the limited time I spent, I didn't find an article specifically talking about kittens vs. cats, but this is just some of the articles that popped up on OMIM.

Sources of toxoplasma infection in pregnant women: European multicentre case-control study

This was a case control study performed in 6 European cities using 252 pregnant women w/either acute infection or w/IgM for anti-Toxoplasma gondii and 858 controls. Risk factors for infection included undercooked lamb, beef, or game, contact with soil, and travel outside Europe and the United States and Canada. Contact with cats was not a risk factor.

Article found on: http://www.bmj.com/cgi/content/full/321/7254/142?view=full%26pmid=10894691

Prevention of toxoplasmosis in pregnancy: knowledge of risk factors.Kravetz JD, Federman DG.

Study was done to compare the knowledge of ocer 100 ob's, internists and fp's when counseling expectant mothers on risk factors for toxoplasmosis. It was found that ob's were more likely to give the appropriate information, but all groups "inappropriately advised avoidance of all cat contact".

Article found on OMIM taken from Infect Dis Obstet Gynecol. 2005 Sep;13(3):161-5.