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The New England Journal of Medicine
Resident e-Bulletin
TEACHING TOPICS from the New England Journal of Medicine
Teaching Topics | August 25, 2011
Azithromycin to Prevent COPD Exacerbations: What was the effect of
daily azithromycin treatment on the frequency of exacerbations in
this study?
Primary Immune Thrombocytopenia: What is the initial approach to
managing patients with primary immune thrombocytopenia?
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TEACHING TOPIC
Azithromycin to Prevent COPD Exacerbations
ORIGINAL ARTICLE,
Azithromycin for Prevention of Exacerbations of COPD,
(
http://www.nejm.org/doi/full/10.1056/NEJMoa1104623?query=BUL)
R.K. Albert and Others
CME Exam | Comments
Acute exacerbations of chronic obstructive pulmonary disease (COPD)
result in frequent visits to physicians' offices and emergency rooms
and numerous hospitalizations and days lost from work.
Clinical Pearls
- How do acute exacerbations of COPD affect patient outcomes?
Patients who have acute exacerbations of COPD, as compared with
patients with COPD who do not have acute exacerbations, have an
increased risk of death, a more rapid decline in lung function, and
reduced quality of life.
- What was the effect of daily azithromycin treatment on the frequency
of exacerbations in this study?
The frequency of exacerbations was 1.48 exacerbations per
patient-year in the azithromycin group, as compared with 1.83 per
patient-year in the placebo group (P=0.01), and the hazard ratio for
having an acute exacerbation of COPD per patient-year in the
azithromycin group was 0.73 (95% CI, 0.63 to 0.84) (P<0.001).
Table 2. Effect of Treatment for Chronic Obstructive Pulmonary
Disease (COPD) on Hospitalization Rates, Emergency Department or
Urgent Care Visits, and Unscheduled Office Visits.
(
http://www.nejm.org/action/showImage?doi=10.1056/NEJMoa1104623&iid=t02&query=BUL)
Morning Report Questions
Q: How did daily treatment with azithromycin affect antibiotic
resistance patterns among treated patients?
A: Cultures from 68% of the participants in the azithromycin group and
70% in the placebo group who were not colonized with selected
respiratory pathogens at the time of enrollment but who became
colonized during the course of the study were available for
susceptibility testing (P=0.76), and the incidence of resistance to
macrolides was 81% and 41% in the two groups, respectively (P<0.001).
Q: What adverse event was significantly more frequent among patients
treated with azithromycin as compared to placebo in this study?
A: No significant differences were observed in the frequency of serious
adverse events or of adverse events leading to discontinuation of the
study drug, but an audiogram-confirmed hearing decrement occurred in
142 of the participants receiving azithromycin (25%), as compared
with 110 of those receiving placebo (20%) (P=0.04).
TEACHING TOPIC
Primary Immune Thrombocytopenia
CLINICAL THERAPEUTICS,
Thrombopoietin-Receptor Agonists for Primary Immune Thrombocytopenia,
(
http://www.nejm.org/doi/full/10.1056/NEJMct1014202?query=BUL)
P. Imbach and M. Crowther
CME Exam
Immune thrombocytopenia is a disorder that is characterized by
immune-mediated platelet destruction and impaired platelet production
resulting in a platelet count of less than 100,000 per cubic
millimeter and varying degrees of bleeding risk.
Clinical Pearls
- Does platelet count correlate with bleeding risk in patients with
primary immune thrombocytopenia?
Bleeding in immune thrombocytopenia is rare in patients who have a
platelet count of more than 50,000 per cubic millimeter. The bleeding
risk at lower platelet counts varies greatly from none to very
severe, although spontaneous, life-threatening or fatal bleeding is
generally confined to patients with a platelet count of less than
10,000 to 20,000 per cubic millimeter.
- What is the initial approach to managing patients with primary immune
thrombocytopenia?
Initial treatment for immune thrombocytopenia is generally a course
of glucocorticoids, intravenous immune globulin, or both. The only
second-line treatment that has been shown to produce sustained
increases in the platelet count is splenectomy. Rituximab is widely
used as a second-line agent, although the median duration of response
with this agent is only 10.5 months.
Figure 1. Structure of Romiplostim and Eltrombopag and the Cellular
Mechanisms of Action.
(
http://www.nejm.org/action/showImage?doi=10.1056/NEJMct1014202&iid=f01&query=BUL)
Morning Report Questions
Q: What is the efficacy of the thrombopoietin-receptor agonists,
romiplostim?
A: Romiplostim is administered subcutaneously once weekly. In an ongoing
open-label extension study involving 292 patients treated with
romiplostim, 94.5% achieved a platelet count of at least 50,000 per
cubic millimeter during the study.
Q: What is the efficacy of the thrombopoietin-receptor agonist,
eltrombopag?
A: Eltrombopag is given orally daily. In an ongoing open-label extension
study involving 299 patients who completed a previous eltrombopag
study, 87% of patients achieved a platelet count of at least 50,000
per cubic millimeter during treatment.
QUOTE OF THE WEEK
"Among selected subjects with COPD, azithromycin taken daily for 1
year, when added to usual treatment, decreased the frequency of
exacerbations and improved quality of life but caused hearing
decrements in a small percentage of subjects."
R.K. Albert and Others, Original Article, "Azithromycin for
Prevention of Exacerbations of COPD"
(
http://www.nejm.org/doi/full/10.1056/NEJMoa1104623?query=BUL)
IMAGE CHALLENGE
Question: What is the diagnosis?
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