Going up in smoke
Smoking cessation treatments seem to have gone out of fashion. I used to light up (with enthusiasm, not pull out a Zippo) when a smoker came to see me and reel off stats about the success rates of our in-house smoking cessation clinic. But when everyone decided it was fine to vape instead (remember the 95% less harmful stat?) the funding was cut, and now we can just direct people to the nearest vape store, petrol station, or sweet shop for their non-smoker nicotine fix.
Maybe a new drug is what we need to reignite our smoking cessation efforts? Could cytisinicline, a plant based alkaloid, be the one? A randomised trial of 810 smokers in the US found five times higher continuous absence rates with a 12 week course of cytisinicline compared with placebo during weeks 9 to 24. However, this still only amounted to around 1 in 5 people (21.1%) successfully quitting smoking.
JAMA doi:10.1001/jama.2023.10042
Cluster luck
The next time you have one of those days when it seems that every other patient on the ward deteriorates take a morsel of comfort in knowing that there’s a proper term for it: “temporal clustering of critical illness events on medical wards,” and there are academics trying to work out why it happens. A retrospective cohort study in five hospitals in Toronto analysed over 100 000 hospital admissions between 2010 and 2017 to see what happens to other ward patients in the hours after a patient is either admitted to the intensive care unit (ICU) or dies. The adjusted odds ratio of another ICU admission from the same ward within six hours was 1.67 (95% confidence interval 1.54 to 1.81). Possible explanations include anchoring bias (see last week’s reviews), resources being diverted to the first patient meaning other ward patients deteriorate, higher ICU bed availability at these times, or rotten luck.
JAMA Intern Med doi:10.1001/jamainternmed.2023.2629
Bundles of joy
Visually estimating blood loss after birth underestimates blood loss, but, according to a Cochrane review, using a calibrated drape to quantify blood loss instead probably makes little or no difference to severe maternal outcomes such as organ failure and intensive care admission. However, a new study has found that a bundle of interventions that include using a blood detection drape as well as “first response treatments” (uterine massage, oxytocic drugs, tranexamic acid, intravenous fluids, examination, and escalation) reduced rates of a composite outcome of severe postpartum haemorrhage, laparotomy for bleeding, or death. This endpoint occurred in 4.3% in the usual care group and 1.6% in the intervention group, in this large multicentre study set across several low and middle income countries. How and where to roll out the whole bundle (and not just the easier or cheaper parts of it—such as the drapes) is a major question, but it may be feasible given the decent adherence to the treatment bundle of 91.2%.
N Engl J Med doi:10.1056/NEJMoa2303966
No shocks in tDCS trial for depression
I’ve not seen many patients who have had electroconvulsive therapy (ECT), transcranial magnetic stimulation, or transcranial direct current stimulation (tDCS) as treatments for depression, but there seems to be plenty of interest in them, as researchers try to refine techniques that seem to belong to a bygone era. In Germany 160 people with major depressive disorder were recruited to a trial of tDCS. They were all taking a selective serotonin reuptake inhibitor (SSRI) and had had no response to at least one SSRI during their current depressive episode. The results don’t seem to support the use of this procedure, with no difference found in depression scores six weeks after tDCS or a sham procedure. More of the people who received tDCS had at least one adverse event (60% versus 43%).
Lancet doi:10.1016/S0140-6736(23)00640-2
HIV treatment for people with barriers to adherence
Long acting injections could be a suitable option for people with HIV infection who struggle with adherence to daily oral medication—for reasons such as their mental health, substance misuse, or housing instability. The only option currently licensed is cabotegravir and rilpivirine administered as two separate injections every two months, but NICE currently recommends this as an option only in people with virological suppression who are on a stable antiretroviral regimen.
An observational cohort study followed 133 people with HIV in San Francisco who were started on long acting antiretroviral therapy—including 56 experiencing homelessness or unstable housing and 45 with substance misuse. All of those with viral suppression at the start of treatment maintained this, and, of the 57 with viraemia, 54 had viral suppression after a median of 33 days.
Ann Intern Med doi:10.7326/M23-0788