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Oncology

Peritumoral lidocaine injection before incision for breast cancer surgery (September 2023)

In a multicenter, randomized trial of over 1000 patients with early breast cancer undergoing mastectomy or breast-conserving surgery, peritumoral injection of 0.5% lidocaine prior to incision improved five-year disease-free survival (87 versus 83 percent) and five-year overall survival (90 versus 86 percent).3 The mechanism is unknown but thought to involve blocking voltage-gated sodium channels and thereby preventing activation of prometastatic pathways. The trial protocol for surgical management of breast cancer deviated from what may be considered standard treatment in many clinical practices, so further validation is necessary; however, peritumoral injection of lidocaine may be a reasonable intervention given its simplicity and minimal cost.

Infectious Diseases

Nutritional supplementation for prevention of tuberculosis (September 2023)

Malnutrition is an important risk factor for tuberculosis (TB) disease; the optimal approach to nutritional supplementation for TB prevention is uncertain. In a cluster-randomized trial in Jharkhand, India, over 10,000 household contacts of patients with pulmonary TB were randomly assigned to receive nutritional intervention (a food basket comprising 750 kcal per day [including 23 g of protein] plus micronutrients) or not.4 During two-year follow-up, fewer cases of TB, most diagnosed via sputum smear, were observed in the intervention group (1.7 versus 2.1 percent); there were no adverse effects. Those who referred participants for TB evaluation were unblinded to randomization assignment. These findings are important for policy decisions regarding nutritional supplementation as a tool for TB prevention.

Family Medicine

Over-the-counter opioid antagonist for opioid overdose (September 2023)

Drug overdose is a major public health problem; opioids were reported to be involved in nearly 80 percent of the 600,000 overdose deaths worldwide in 2019. The increasing rate of fatal overdose is driven by the presence of the synthetic opioid fentanyl. Naloxone 4 mg nasal spray rapidly reverses the effects of opioid overdose and is now the first opioid antagonist agent available for over-the-counter purchase in the United States.5 The increased availability is part of an ongoing effort by the US Food and Drug Administration Overdose Prevention Framework to encourage harm reduction through developing and expanding access to novel overdose reversal products.

Cardiovascular Medicine

Intravenous iron supplementation in heart failure with reduced ejection fraction (September 2023)

Iron deficiency is common in patients with heart failure (HF), but it remains unclear whether iron supplementation reduces mortality or hospitalization in this population. Recently published research on the effects of intravenous (IV) iron supplementation included the following observations:

* In a trial in nearly 3100 patients with HF and reduced ejection fraction (HFrEF), IV iron supplementation improved iron stores but did not clearly reduce the risk of cardiovascular mortality or HF hospitalization.1

* In a meta-analysis of randomized trials of IV iron in patients with HFrEF, IV iron reduced the risk of HF hospitalization but had an unclear effect on cardiovascular mortality.2

These data support the use of IV iron to reduce hospitalization in patients with HFrEF who have iron deficiency.

1. Mentz RJ, Garg J, Rockhold FW, Butler J, et al. Ferric Carboxymaltose in Heart Failure with Iron Deficiency. N Engl J Med. 2023. [Context Link]

2. Salah HM, Savarese G, Rosano GMC, Ambrosy AP, Mentz RJ, Fudim M. Intravenous iron infusion in patients with heart failure: a systematic review and study-level meta-analysis. ESC Heart Fail. 2023;10(2):1473. [Context Link]

3. Badwe RA, Parmar V, Nair N, et al Effect of Peritumoral Infiltration of Local Anesthetic Before Surgery on Survival in Early Breast Cancer. J Clin Oncol. 2023;41(18):3318. [Context Link]

4. Bhargava A, Bhargava M, Meher A, et al Nutritional supplementation to prevent tuberculosis incidence in household contacts of patients with pulmonary tuberculosis in India (RATIONS): a field-based, open-label, cluster-randomised, controlled trial. Lancet. 2023;402(10402):627. [Context Link]

5. Naloxone Nasal Spray prescribing information. US Food and Drug Administration. 2015. https://www.accessdata.fda.gov/drugsatfda_docs/label/2015/208411lbl.pdf. [Context Link]

Disclaimer: This content is provided for reference purposes only and represents a portion of the UpToDate topic. Readers should not rely on the content or any information cited here as being applicable to specific patient circumstances. All topics are updated as new evidence becomes available and our peer review process is complete.