2 Minute Medicine Rewind April 21 – April 27, 2014

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In this section, we will highlight the key high-impact studies, updates, and analyses published in medicine during the past week.

High versus Low Blood-Pressure Target in Patients with Septic Shock

While there are numerous recommendations for goal mean arterial pressure (MAP) during resuscitation of patients with septic shock, there is limited knowledge or evidence for an optimal target mean arterial pressure. In this multicenter, open-label, randomized trial, 776 patients with septic shock were resuscitated with a target MAP of 80-85mmHg or 65-70mmHg. There was no significant difference in 28-day or 90-day mortality. There was no difference in the incidence of serious adverse events. There does not appear to be any significant advantages to a high target mean arterial pressure in the resuscitation of patients with septic shock compared to a goal MAP of 65-70mmHg.

Effect of the Use of Ambulance-Based Thrombolysis on Time to Thrombolysis in Acute Ischemic Stroke

In acute ischemic stroke management, the “time to needle” or time to thrombolysis is considered crucial to decrease mortality and morbidity. In this trial of 6182 patients in Berlin, Germany, participants were randomized to either an ambulance equipped with CT scanner, point-of-care laboratory, and a prehospital stroke or  standard of care. When indicated by a stroke identification algorithm and ischemic stroke confirmed, thrombolysis was started before transport to hospital. There was a reducation of 15 minutes (95% CI 11 – 19 mins, 76.3min vs 61.4 min, p < 0.001) in alarm-to-treatment times than during control weeks. The early intervention did not result in an increased risk for intracerebral hemorrhage (7/200 vs. 22/323, OR (0.42, p = 0.06), however neither was there a difference in 7-day mortality (9/199 vs. 15/323, OR 0.76, = 0.53). Compared to usual care, early ambulance-based intervention in acute ischemic stroke improved time to thrombolysis, however further study is required to assess its effect on clinical outcomes of morbidity and mortality. 

Outcome After Conservative Management or Intervention for Unruptured Brain Arteriovenous Malformations

The optimal management of unruptured intracerebral arteriovenous malformations (bAVMs) is unknown as, in addition to conservative watchful managment, endovascular embolization, neurosurgical excision, or stereotactic radiosurgery are all options. There is no long term comparative data for the management of these bAVMs. In this retrospective cohort study of 204 Scottish residents greater than 16 years of age with unruptured bAVMs, investigators compared the long term morbidity of conservative management (no intervention) vs. any intervention. Of 204 patients, 103 (50.5%) underwent intervention. Patients were more likely undergo intervention if they were younger, presented with seizure, or had smaller bAVMs. During the first 4 years, there was a lower rate of primary outcome (death or sustained morbidity) in patients who underwent the conservative management (9.5 vs 9.8 events per 100 person years, HR 0.59, 95% CI 0.35-0.99). The rate of secondary outcome (nonfatake stroke or death, arterial aneurysm, or intervention) was also lower during 12 years of follow up with conservative management (1.6 vs. 3.3 events per 100 person-years, HR 0.37, 95% CI 0.19 – 0.72). IN early follow-up, conservative management was associated with better clinical outcomes than with intervention.

Treatment of HCV with ABT-450/r–Ombitasvir and Dasabuvir with Ribavirin

Current therapy for viral hepatitis C includes interferon, which has significant side-effects and complications that limit treatment tolerability and durability. Novel interferon-free therapies are being developed including the combination of protease inhibitor ABT-450, ritonavir, dasabuvir, ombitasvir, and ribavirin. In this multicenter randomized trial, 631 patients with HCV genotype 1 infection and no cirrhosis were randomized 3:1 to 12 weeks of the combination therapy or matching placebos. Patients with active therapy achieved a sustained virologic response in 96.2% of patients, which is superior to historical response of 78% with telaprevir, peginterferon, and ribavirin. Adverse events including nausea, pruritis, insomnia, diarrhea, and asthenia occured more commonly with the active therapy than with placebo, however the rate of discontinuation was only 0.6% in each study group. This suggests novel therapies for HCV without interferon are highly effective and with a low rate of treatment discontinuation.

Incidence and Causes of Sudden Death in U.S. College Athletes

Cardiovascular-related sudden deaths occur in competitive athletes and raises the question whether pre-participation screening strategies can decrease the incidence of sudden cardiac death. In this retrospective database study, 182 sudden deaths in the U.S. National Registry of Sudden Death in Athletes were investigated. Over the 10-year study period, 64 deaths had a probably or likely attribution ot cardiovascular causes. Of these athletes, 21 were diagnosed post-mortem with hypertrophic cardiomyopathy and 8 were diagnosed with congenital coronary anomalies. Cardiovascular deaths were 5 times more common in African-American athletes than white athletes (3.8 vs. 0.7deaths/100,000 athlete participation-years; p < 0.01) but did not differ from rates of the general population of the same age and race. In college athletes, the rate of sudden death due to cardiovascular disease is low, with rates similar to suicide and drug abuse. Given the post-mortem diagnoses, a substantial minority would not have been detected by standard pre-participation screening with 12-lead ECGs.

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