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Despite therapy with inhaled corticosteroids (ICS) and long-acting β2-agonists (LABAs), severe asthma remains inadequately controlled in some patients. This randomized trial evaluated the efficacy and safety of adding omalizumab in 850 patients with inadequate asthma control while receiving high-dose ICS and LABAs. Over 48 weeks, patients receiving omalizumab had fewer asthma exacerbations, better mean Asthma Quality of Life Questionnaire scores, reduced mean daily use of albuterol, and better mean asthma symptom scores than patients receiving placebo. The incidences of adverse events and serious adverse events were similar in both groups.
Inhaled LABAs and anticholinergics are recommended to treat moderate to severe chronic obstructive pulmonary disease, but little is known about their comparative effectiveness. Among 46 403 older patients with chronic obstructive pulmonary disease as defined by administrative data, rates of mortality, hospitalization, and emergency department visits were higher in those initially prescribed an anticholinergic agent than in those initially prescribed a LABA. These findings should be confirmed in younger patients and in a randomized, controlled trial.
Mathematical models of epidemics can aid understanding of epidemic processes and help define control strategies. Tuite and colleagues used such a model to examine the sequence and timing of regional cholera epidemics in Haiti and explore the potential effects of disease-control strategies. The order and timing of regional cholera outbreaks predicted by the model were closely correlated with empirical observations. Analysis of changes in disease dynamics over time suggests that public health interventions have substantially affected this epidemic.
This systematic review compared the effectiveness of the vast array of treatment regimens for type 2 diabetes and found little evidence on the relative effects of various antihyperglycemic therapies on long-term clinical outcomes. Most monotherapies reduced hemoglobin A1c levels by similar amounts. Metformin therapy reduced body weight compared with thiazolidinediones and sulfonylureas; decreased low-density lipoprotein cholesterol levels compared with pioglitazone, sulfonylureas, and dipeptidyl peptidase-4 inhibitors; caused less hypoglycemia than sulfonylureas; and caused more diarrhea than thiazolidinediones. The authors conclude that available evidence suggests that metformin should be the initial drug therapy for type 2 diabetes.
This Update summarizes studies published in 2010 that the authors consider highly relevant to the practice of pulmonary and critical care medicine. Topics include anticholinergic therapy in asthma, identification of patients with chronic obstructive pulmonary disease who are at risk for exacerbations, pulmonary vasodilator therapy in idiopathic pulmonary fibrosis, tuberculosis testing, tyrosine kinase inhibitors in non–small cell lung cancer, early palliative care and cancer survival, outcomes of critical illness, sedatives and neuromuscular blockade in critically ill patients, interventions and monitoring in patients with shock, and management of acute hypoxemic respiratory failure.
Centers for Medicare & Medicaid Services policy states that deep sedation can be administered only by an anesthesiologist, a certified registered nurse anesthetist, or a trained medical doctor or doctor of osteopathy not involved in the performance of the procedure requiring sedation. However, available evidence shows that nonanesthesiologists can safely administer propofol for procedural sedation. The lack of evidence supporting a need for monitored anesthesia care to deliver propofol, combined with the high cost of monitored anesthesia care, suggest that alternatives for delivering propofol merit fair and balanced evaluation.
This computer model compared use of conventional guidelines for blood pressure management with use of guidelines that were individualized according to readily available information on each patient's characteristics. The researchers estimate that individualized guidelines could prevent the same number of myocardial infarctions and strokes as the Joint National Committee 7 (JNC 7) guidelines at 67% cost savings, or they could prevent 43% more myocardial infarctions and strokes for the same cost as the JNC 7 guidelines. Individualized guidelines may increase the quality and reduce the cost of care.
In this issue, Tuite and colleagues use a mathematical model that considers both waterborne and person-to-person cholera transmission to predict the spread of disease in Haiti. The editorialists discuss the contributions and limitations of this analysis and explore the need for a comprehensive strategy to limit the spread of cholera. They advocate a strategy that ranges from rehydration and antibiotic therapy to strengthening Haiti's public water and sanitation systems.
In this issue, Eddy and colleagues' mathematical model shows that initiating treatment for hypertension on the basis of individual patient characteristics results in better outcomes than does use of the simpler JNC 7 guidelines. The editorialist notes the tradeoffs that guideline developers face in terms of usability versus tailoring: The relative simplicity of generic recommendations makes them easier for clinicians to remember and implement, but the simplicity could come at a loss of potential benefit, increased cost, or both. For individualized guidelines to improve outcomes, they must be easy for clinicians to apply.
Not every physician gets patted down daily in his own hospital. As I walked the long tunnel connecting the outside world to the prison hospital, I couldn't prevent mixed feelings, but there was no time to explore them.