2 Minute Medicine Rewind July 22 – July 28, 2013

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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.

Riociguat for the Treatment of Pulmonary Arterial Hypertension

In this phase III, double-blinded randomized control trial, investigators randomized patients with pulmonary arterial hypertension (n = 443) to riociguat, a guanylate cyclase stimulator, or placebo and measured their exercise tolerance as well as physiologic metrics. At 12 weeks of therapy, patients received riociguat improved 6-minute walk distances by 30m (8.3% of baseline 361m) compared to -6m (-1.6% of baseline 368m) for patients receiving placebo. Patients receiving riociguat had improved pulmonary vascular resistance, NT-proBNP levels, and Borg dyspnea score. Study outcomes were independent of whether they were receiving additional therapy (endothelin-receptor antagonists or prostanoids). Of note, similar results were found for riociguat in patients with chronic thromboembolic pulmonary hypertension (see Riociguat for the Treatment of Chronic Thromboembolic Pulmonary Hypertension, NEJM 2013; 369:319-329) .

Characteristics Associated With Differences in Survival Among Black and White Women With Breast Cancer

Previously studies have identified a racial gap in survival between black and white women with breast cancer. In this retrospective analysis of Surveillance, Epidemiology and End Results (SEER) data, investigators found an absolute difference in 5 year mortality (blacks 55.9% vs. whites 68.8%, absolute difference = 12.9% , p < 0.001), with longer time to time from diagnosis to treatment (29.2 days vs. 22.8 days, p < 0.001), less use of taxols and anthracyclines (3.7% vs. 5.0%, p < 0.001), and more surgery without additional radiation or chemotherapy (8.2 vs. 7.3%, p = 0.04). After matching for presentation characteristics, there was a decrease in absolute difference in 5 year mortality (4.4%, p < 0.001) , suggesting much of the difference in mortality can be attributed to initial presentation characteristics.

Therapies for Active Rheumatoid Arthritis after Methotrexate Failure

In this double-blinded noninferiority trial, investigators randomized patients with rheumatoid arthritis who had active disease despite methotrexate therapy (n = 353) to either etanercept with methotrexate or 3 DMARDs (methotrexate, sulfasalazine, and hydroxychloroquine) with the possibility of cross-over to the other arm at 24 weeks if there was no improvement. Both treatment arms had significant improvement at 24 weeks (improvement from baseline in Disease Activity Score for 28 joint counts or DAS28, p = 0.001), however 27% of patients in each arm underwent cross-over with subsequent improvement (DAS28, p < 0.001) without statistically significant difference between the two arms. There was no significant difference between groups in the secondary outcomes of quality of life, pain, or radiographic progression of disease.

Oronasopharyngeal suction versus wiping of the mouth and nose at birth: a randomised equivalency trial

There is unclear efficacy for oronasophyaryngeal suction in the delivery room compared to gentle wiping of mouth and nose. In this randomized trial of healthy neonates delivered at 35 weeks or more without respiratory distress (n = 506), at 24hrs, neonates who underwent oronasopharyngeal suction had a decreased respiratory rate of 50 breaths per minute vs. 51 breaths per minute in neonates who underwent gentle wiping (difference = 1, p < 0.001). The authors felt there was difference in efficacy for neonates born at 35 weeks or beyond.

In the Wake of the 2003 and 2011 Duty Hours Regulations, How Do Internal Medicine Interns Spend Their Time?

In this descriptive, observational study of medicine interns in the inpatient setting at academic teaching institutions in Baltimore, MD, investigators found that interns spent 12% of their time on direct patient care, 64% on indirect patient care, and 15% on educational activities. Computer use accounted for 40% of intern’s time. Compared to interns in studies prior to 2003 before duty hour regulations, interns in this study spent less time with direct patient care and sleeping and spent more time talking to other providers and documentation.

By David Ouyang

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