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News From The Annals Of Internal Medicine: May 7, 2013

1. Ambrisentan Not Appropriate for Patients with Idiopathic Pulmonary Fibrosis

Ambrisentan should not be used to treat patients for idiopathic pulmonary fibrosis (IPF). IPF is a fatal form of chronic, progressive characterized by irreversible scarring around both lungs. IPF causes about 5,000 deaths each year and currently there is no approved treatment. Researchers do not know what causes IPF, but a protein called endothelin-1 that causes the blood vessels to contract and induces lung scarring and proliferation has been associated with the disease. Researchers sought to determine if ambrisentan, a selective endothelin receptor antagonist, could reduce the rate of IPF progression. The authors enrolled patients between 40 and 80 years with IPF and minimal or no honeycombing (a pattern of lung fibrosis associated with advanced disease) on high-resolution computed tomography scans. Patients were prescribed ambrisentan 10mg/d or placebo to assess time to as defined as death, respiratory hospitalization, or decreased lung function. The study was terminated after nearly 35 weeks and enrollment of 492 patients (75 percent intended enrollment) due to the low likelihood of showing efficacy by the end of the study. The researchers found that patients treated with ambrisentan actually had shorter time to and were more likely to require hospitalization.*1

2. Assessing for Acute Changes in Lung Allocation Score Could Inform Organ Wait-list Strategies

An acute increase in Lung Allocation Score (LAS) in the period before transplantation is associated with worse survival rates after transplantation. Assessing for this variable could help inform strategies for allocating organs. The LAS is a lung allocation system that prioritizes patients to receive an organ based on medical urgency and chance for survival after transplantation. The higher the LAS (on a scale from 0 to 100), the higher a patient climbs on the organ waiting list. While the LAS system has succeeded in reducing deaths of patients waiting for organs, it has been shown that patients with higher LASs are more likely to die after transplantation. This is an important consideration when weighing the net benefit of . Past studies have focused on patient LAS at transplantation, but evidence shows that patients may experience changes in LAS between listing and surgery. Researchers reviewed hospital records for 5,749 lung recipients to determine whether an acute increase in the LAS before is associated with reduced posttransplant survival. The researchers concluded that an increase of greater than 5 units within the 30 days before transplantation represented a clinically important deterioration in the patient’s status. They found that patients who experienced an acute change in LAS had a 31 percent increased hazard of death after . The authors suggest that further study of changes in LAS may help refine the most beneficial approaches to . The author of an accompanying editorial writes that the research should prompt a discussion about “whether the current allocation system should be modified to limit access for candidates with unacceptably low predicted posttransplantation survival.” *2

3. Inexpensive Behavioral Interventions Help TB Patients in Poor Countries Quit Smoking

Behavioral support with or without medication is effective for getting smokers with suspected tuberculosis to quit. Tuberculosis is a serious lung disease that kills 1.4 million people every year. Smoking increases the risk for tuberculosis (almost 20 percent of the disease burden from tuberculosis is attributable to tobacco) and patients who smoke deteriorate more rapidly and have higher risk for death than those who do not. Tuberculosis predominantly occurs in low-resource countries, where smoking prevalence is highest. Researchers randomly assigned 1,955 adult smokers with suspected tuberculosis in Pakistan to one of three treatment groups: Two brief behavioral support sessions (BSS); BSS plus seven weeks of bupropion therapy (BSS+); or usual care. Patients in both the BSS and the BSS+ groups achieved continuous abstinence at six months. The researchers conclude that behavioral support with or without medication could form the basis of effective smoking cessation programs in low- and middle-income countries, where 80 percent of smokers live. They recommend scaling up smoking cessation interventions in tuberculosis programs in countries with similar contexts. *3


*1 http://www.annals.org/article.aspx?doi=10.7326/0003-4819-158-9-201305070-00001

*2 http://www.annals.org/article.aspx?doi=10.7326/0003-4819-158-9-201305070-00004

*3 http://www.annals.org/article.aspx?doi=10.7326/0003-4819-158-9-201305070-00006

American College of Physicians