By Louis Kuritzky, MD 

COPD Patients on Triple Therapy: The Safety of Inhaled Steroid Discontinuation

SOURCE: Magnussen H, et al. N Engl J Med 2014;371:1285-1294.

Bronchodilators (long-acting beta-agonists and anticholinergics) form foundation therapy for COPD, and have been found not only to provide symptomatic relief, but also reduce the frequency of acute exacerbations. When chronic obstructive pulmonary disease (COPD) becomes severe, and especially in patients with frequent exacerbations, it is appropriate to also include inhaled corticosteroids. Often, COPD patients are treated with triple therapy: a long-acting beta-agonist (LABA), long-acting anticholinergic agent (LACA), and inhaled corticosteroid (ICS). However, some have questioned whether, once stable, continuation of the ICS exerts meaningful benefit.

To address this issue, Magnussen et al performed a double-blind trial among severe COPD patients (n = 2485). Patients on triple therapy (LABA + LACA + ICS) were randomized to either continue on that regimen or to receive LABA + LACA + placebo ICS. The primary outcome of the study was time to first moderate or severe COPD exacerbation.

ICS withdrawal did not lead to any significant change in time to COPD exacerbation, dyspnea, or other measures of health status at 1 year. Although there were measurable differences between ICS-maintained vs ICS-withdrawn groups in FEV1 at study end (slightly improved FEV1 in the former), the magnitude of difference was of questionable clinical significance. These data would suggest that ICS discontinuation in patients on triple therapy may generally be accomplished without worsening likelihood of exacerbations.

Reason #999 to Endorse Exercise: Mental Health Benefits

SOURCE: Rosenbaum S, et al. J Clin Psych 2014;75:964-974.

With rare exception, advocacy for exercise is warranted. Indeed, several of the most problematic public health issues our nation faces today (diabetes, metabolic syndrome, obesity, hypertension, osteoporosis) could be ameliorated by exercise. Although most often studied for its metabolic effects, this systematic review and meta-analysis by Rosenbaum et al has, instead, evaluated the impact of exercise on persons with mental health issues such as depression and schizophrenia.

Twenty different trials reported the impact of exercise on depression symptoms. None of the studies reported a detrimental effect, and the overall favorable effect size was large (effect size = 0.84, with > 0.8 being large). Similarly, the effect size of exercise upon schizophrenia symptoms was large, even though the effect size on anthropomorphic outcomes (e.g., BMI) was not large.

A variety of different exercise interventions were studied, with a slightly greater effect size among programs that employed aerobic training. Nonetheless, diverse exercise modalities (e.g., tai chi, dance therapy, yoga, aquatic exercise, resistance exercise) all showed at least a favorable trend toward benefit. Clinicians would be wise to more often incorporate an exercise component to the therapeutic regimen for mental health disorders.

Ultrasound vs CT for Diagnosis of Kidney Stones

SOURCE: Smith-Bindman R, et al. N Engl J Med 2014; 371:1100-1110.

There may be greater consequences attendant to our frequent use of CT examinations than readily meet the eye. Whenever I have queried resident physicians about the dose of X-ray produced by an abdominal CT, they consistently underestimate from the literature-documented burden: A single standard abdominal CT is equivalent to the radiation of 500 chest X-rays. Hence, springs forth our enthusiasm for more radiation-friendly tools.

Identification of nephrolithiasis is a commonplace emergency department scenario during which CT may be called upon. Smith-Bindman et al performed a multicenter study to compare the effectiveness of point-of-care ultrasound vs radiologist-performed ultrasound, vs abdominal CT. Patients who presented to emergency departments (n = 2759) were randomized to receive one of these three initial evaluations. The primary outcome of the study was the number of missed or delayed serious diagnoses.

Additional endpoints included cumulative radiation dose over 6 months (to take into account that some initially ultrasounded patients would require follow-up radiographic investigation) and pain.

Ultrasound compared very favorably with CT, demonstrating similar efficacy for not missing high-risk diagnoses, complications, and requirement for return visits to the emergency department. Of course, the radiation exposure incurred in the ultrasound groups was substantially less than the CT group. Clinicians skilled at performing ultrasound, or working at sites with skilled ultrasonographers, may wish to consider ultrasound as an attractive alternative to CT for diagnosis of suspected nephrolithiasis.