PrimeCuts: This Week in the Journals

December 7, 2009

winterJoshua Strauss MD

Faculty peer reviewed

The weather in the Northeast dipped below freezing over the weekend, along with our first snowfall of the season.  Breaking out the heavy coats, scarves and gloves, we have become acutely aware that the winter is fast approaching.  This also means that we are still in the midst of flu season.  Of course, this flu season is not a typical one, with the country worrying about both the seasonal flu as well as the pandemic H1N1 virus. 

On Saturday, the NY Times published an article featuring the CDC’s recent news briefing on the H1N1 vaccine1.  The director of the CDC explained that, having arrived at the two month mark since the vaccine’s introduction, we now have access to preliminary data demonstrating the vaccine’s safety, with a side effect profile similar to that of the seasonal flu vaccine. This new data can have great clinical import if we use it in our clinics to urge at-risk patients to accept the H1N1 vaccine. 

Perhaps partially as a consequence of widespread vaccination, a WHO official stated on Thursday that H1N1 infections continued to decrease in the United States and Canada in the past week2. This was no occasion to celebrate the end of the pandemic, though, as various countries in the northern hemisphere continue to experience spikes in H1N1 incidence.  In a cautious tone, Dr. Keiji Fukuda acknowledged that we may ultimately view this pandemic as mild in comparison to previous pandemics, but he believes it is still too early to tell.  He noted that the H1N1 virus continues to evolve, poses new challenges, and raises new concerns – “we continue to face ongoing uncertainties about the pandemic,” he said.  Readdressing a concern raised at last week’s briefing, Dr. Fukuda reiterated that while there “have been some clusters of oseltamavir resistance occurring in people who are severely immuno-compromised,” the vast majority of viruses remain sensitive to the drug…thankfully.

Given H1N1’s continued susceptibility to Tamiflu at this time, Dr. Tim Uyeki from the CDC writes on the New England Journal of Medicine’s website3 that “empirical antiviral treatment should be started as soon as possible for hospitalized patients with suspected 2009 H1N1.”  He noted several cases where Tamiflu was withheld from patients because of negative diagnostic testing. ” A negative RIDT (rapid influenza diagnostic test) or DFA (direct immunofluorescence assay) result does not exclude 2009 H1N1 virus infection,” he writes.   Additionally, clinicians should not wait for results from viral PCR before initiating antiviral treatment.   This has significant implications for our emergency rooms and outpatient clinics; we must take care to understand the low sensitivity of initial H1N1 diagnostic testing, and we must treat patients for whom we have high clinical suspicion, despite negative tests.

As World AIDS Day was December 1st, the other antivirals that had significant coverage in the journals this past week were antiretrovirals.  In conjunction with observing the day, the WHO updated its HIV guidelines for the first time since 20064. The WHO now advocates antiretroviral treatment for CD4 counts at or below 350 cells/mm3, whether or not they are associated with clinical symptoms; the 2006 guidelines had established the threshold at 200 cells/mm3.  This new recommendation is based on moderate evidence and follows data from pooled studies which demonstrate that doing so will reduce overall mortality in infected, asymptomatic, ART naive patients. WHO also stressed the necessity of routine CD4 and viral load monitoring to determine the appropriate time to initiate therapy.  Finally, WHO expands measures to prevent HIV transmission from mother to child during pregnancy and breastfeeding.

Once the decision has been made to initiate antiretrovirals, what grouping of meds should be used? In this week’s NEJM, Sax et al5 compare two different combinations of nucleoside reverse transcriptase inhibitors.  In a prospective trial, the combination of tenofovir DF-emtricitabine was significantly less likely to lead to initial virologic failure than was abacavir-lamivudine.  These findings may well have important implications for the choice of initial drug therapy in treating HIV infection.

While we are still perfecting treatment regimens, the Holy Grail of infectious disease remains the HIV vaccine.  In the same issue of NEJM, the lead article6 describes a study involving more than 16,000 largely heterosexual subjects in Thailand who were administered a vaccine regimen against HIV.  The results of the trial were largely disappointing, showing only minimal efficacy against HIV acquisition and no effects on subsequent viral load in those who became infected.  As Dr. Raphael Dolin writes in the accompanying editorial7, the important contribution here is in how it will direct further vaccine research.  Unfortunately, the Holy Grail still seems to be several years out of our reach.

While we won’t have an HIV vaccine any time soon, there is certainly ample work to be done globally, as well as in our own hospitals, to prevent HIV transmission.  President Jacob Zuma of South Africa deserves our applause for stepping up to the plate this week and committing his country to fight HIV with all available medications and resources8,9.  This is quite an about-face from a man who once joked that HIV transmission could be prevented by showering after sexual intercourse.

And finally, we must work harder to prevent transmission of infection in our own hospitals.  A troubling study brought to light by the NY Times and published in the December issue of Academic Medicine10,11 surveyed 699 recent medical school graduates, of whom 59 percent claimed they had been stuck by a needle at some point during medical school!  This number is astoundingly high and it follows that thousands of students are being put at risk for contracting HIV and Hepatitis C on a daily basis.  We must work harder to minimize sharps in surgeries and procedures, as well as improve education in handling sharps. Lastly, we must create an environment where students who have had the bad luck of sustaining a stick can be expedited through the treatment process, and be confident that reporting a needle stick will not have a deleterious effect on their grades and careers.

Dr Strauss is a first year resident in internal medicine at NYU Medical Center.

Peer reviewed by Cara Litvin MD, Executive Editor, Clinical Correlations

1.         Grady, Denise. “Review Shows Safety of H1N1 Vaccine, Officials Say” 4 December 2009. The New York Times.

2.         Transcript of virtual press conference with Dr. Keiji Fukuda, Special Adviser to the Director General on Pandemic Influenza, World Health Organization. 3 December 2009.

3.        Uyeki T. Diagnostic Testing for 2009 Pandemic Influenza A (H1N1) Virus Infection in Hospitalized Patients. N Engl J Med 2009.

4.        Rapid advice: antiretroviral therapy for HIV infection in adults and adolescents. 30 November 2009.

5.        Sax PE, Tierney C, Collier AC, et al. Abacavir-Lamivudine versus Tenofovir-Emtricitabine for Initial HIV-1 Therapy. N Engl J Med 2009;361:2230-40.

6.       Rerks-Ngarm S, Pitisuttithum P, Nitayaphan S, et al. Vaccination with ALVAC and AIDSVAX to Prevent HIV-1 Infection in Thailand. N Engl J Med 2009;361:2209-20.

7.       Dolin R. HIV Vaccine Trial Results — An Opening for Further Research. N Engl J Med 2009;361:2279-80.

8.     The Associated Press. “South Africa to Offer Free AIDS Drugs to Babies.” 1 December 2009. The New York Times.

9.     The L. HIV/AIDS: a new South Africa takes responsibility. Lancet 5 December 2009.

10.       Sharma GK, Gilson MM, Nathan H, Makary MA. Needlestick Injuries Among Medical Students: Incidence and Implications. Academic Medicine 2009;84:1815-21

11.      Parker-Pope, Tara. “A Silent Epidemic of Needle Injuries” 3 December 2009. The New York Times.

PrimeCuts: This Week in the Journals

November 30, 2009

pinkskyDavid Ecker MD

Faculty peer reviewed

With Thanksgiving behind us, hopefully we have all had a chance to ruminate on the flurry of changes to cancer screening guidelines and the public reaction they generated. This week the NEJM has published a series of perspectives that not only detail the rationale for those changes but also provide a guide for their interpretation in order to facilitate advice for concerned patient populations.(1,2,3)  They also address some of the missteps in framing discussions for the public. Together they emphasize the role public and private communication has on the perception of medicine and, consequently, how beliefs are shaped.With all the talk of guidelines, we turn to those for the diagnosis of pulmonary embolism (PE). Despite widespread, well-delineated, and validated evidence-based guidelines to direct a noninvasive, diagnostic testing for PE, Roy et. al. in the Annals of Internal Medicine, cites fewer than 25% of patients are managed according to these guidelines.(4) As a result, they conducted a randomized trial in 20 French emergency departments that provided physicians with handheld computers containing a clinical decision-support system (CDSSs). These devices “recommended” the least invasive of the appropriate diagnostic tests after calculating post-test probabilities based on test results at each step of the diagnostic work-up. They were compared to a control grouip that received educational tools (posters and pocket cards). The authors found the proportion of patients who received appropriate diagnostic work-ups was greater during the trial than in the pre-intervention period in both groups, but the increase was greater in the CDSS group. Furthermore, those in the computer-based guidelines group used fewer tests to reach a validated diagnostic decision.

In a related study published in Archives of Internal Medicine, Hall et. al. published a retrospective, cross-sectional study that reviewed 589 pulmonary catscan-angiograms (CTA) that were ordered in the emergency department of a tertiary care hospital.(5) They reported a remarkably low (9%) prevalence of PE possibly due to an inappropriate diagnostic evaluation strategy, in which patients were sent directly to CTA. Interestingly, a third of CTAs revealed an alternative explanation for the patients’ symptoms; half of which were present in the admission chest radiograph,. Moreover, the CTAs ordered were more than twice as likely to show an incidental finding such as a pulmonary nodule or adenopathy rather than a PE. These incidental findings then required further evaluation. The authors argue for higher yield indications for CTA during assessments of acute pulmonary symptoms in the emergency department. Interestingly, the two studies illustrate similar concepts behind the recent changes in recommendations for screening mammography, such as maximizing clinician efficiency, avoiding excessive diagnostic testing, minimizing patients’psychosocial stress, and decreasing the economic implications for the healthcare system.

In another evaluation of guidelines, Olasveengen et. al. published a prospective, randomized control trial to determine whether removing intravenous drug administration from an ACLS protocol would improve survival to hospital discharge after an out-of-hospital cardiac arrest.(6) As a basis for their study, the authors cited a large, retrospective study that found epinephrine administration to be an independent predictor of poor outcome and its near-universal use. Compared to those patients who received out-of-hospital ACLS with IV drug administration to those without, the rate of survival to hospital discharge, survival with favorable neurological outcome, and survival at 1 year were not statistically significant (10.5% v. 9.2%, 9.8% v. 8.1%, and 10% v. 8%, respectively). However, there was a higher rate of short-term survival (i.e., hospital admission with return of spontaneous circulation) after IV drug administration. The authors note the majority of patients that died after initial successful resuscitation in both groups had severe cerebral damage and emphasize the importance of improving brain-directed post-resuscitation treatment for improving long-term survival. Thus, one could argue, these ALCS guidelines with the current state of medicine may have the unintended consequence of causing an additional burden on intensive care units rather than providing an additional opportunity for meaningful recovery.

In the Lancet, Konstam et. al. sought to maximize the clinical benefits stemming from the recommended use of angiotensin receptor blockers (ARB’s)to reduce morbidity or mortality in patients with heart failure and reduced left-ventricular ejection fraction.(7) Their randomized, multinational double-blinded trial contained over 3,800 patients with heart failure of NYHA Class II-IV, left-ventricular ejection fraction 40% or less, and intolerance to ACE. Patients were randomized to either 50 mg. or 150 mg. of losartan daily. After about 4.5 years of follow-up, 150mg of losartan reduced the rate of death or admission for heart failure. Not surprisingly, the rates of hypotension, hyperkalemia, and renal failure were greater with 150mg of losartan than 50mg; however, medication discontinuation occurred with similar frequency to that in previous investigations of ARBs.

These last two studies demonstrate the tools physicians use on a daily basis to reexamine guidelines, maximize efficacy, and discover shortcomings. Usually much of this work remains “behind the scenes” as most patients are not explicitly aware that their doctor is translating medical recommendations to benefit the individual while minimizing harm. Unfortunately, the role of the clinician is often omitted when guidelines are released via mass media. As a result, the public is left alone to draw conclusions perhaps without essential information, or, at worst, misinformation. Is this what leads to polarizing controversies? Could this be mitigated with improved communication of the science behind recommendations?

Our own Dr. Danielle Ofri raises additional concerns in her eloquent account of the emotional epidemiology of H1N1 Influenza vaccination in the NEJM.(8) She describes the evolution of the public psyche after H1N1’s introduction and calls for clinicians to affect both emotional as well as disease epidemiology. Surely this is no easy feat. Fortunately we, as physicians, routinely engage in a dialogue with our patients to address their anxieties and determine treatments best suited for them as individuals. With any luck, these conversations may alleviate our patients concern, confusion, and frustration-perhaps another reason to give thanks.

Dr. Ecker is a 2nd year resident in internal medicine at NYU Medical Center.

Peer reviewed by Neil Shapiro MD, Editor in Chief, Clinical Correlations

1. Partridge AH, Winer EP. On Mammography-More Agreement Than Disagreement. NEJM 2009; Nov 25 [Epub ahead of print].
2. Truog, RD. Screening Mammography and the “R” Word. NEJM 2009; Nov 25 [Epub ahead of print].
3. Sawaya GF. Cervical-Cancer Screening-New Guidelines and the Balance between Benefits and Harms. NEJM 2009; Nov 25 [Epub ahead of print].
4. Roy, PM, et. al. A Computerized Handheld Decision Support System to Improve Pulmonary Embolism Diagnosis. Ann Int Med 2009; 151(10): 677-86.
5. Hall EB, et. al. The Prevalence of Clinically Relevant Incidental Findings on Chest Computed Tomographic Angiograms Ordered to Diagnose Pulmonary Embolism. Arch Intern Med 2009; 169(21): 1961-5.
6. Olasveengen TM, et. al. Intravenous Drug Administration During Out-of-Hospital Cardiac Arrest. JAMA 2009; 302(20): 2222-9.
7. Konstam MA, et. al. Effects of High-Dose versus Low-Dose Losartan on Clinical Outcomes in Patients with Heart Failure (HEAAL Study): A Randomized, Double-Blind Trial. Lancet 2009; 374: 1840-48.
8. Orfi D. The Emotional Epidemiology of H1N1 Influenza Vaccination. NEJM 2009; Nov 25 [Epub ahead of print].

PrimeCuts: This Week in the Journals

November 23, 2009


Rennie Rhee MD

Less is more, some say, and this past week the general direction of screening guidelines seems to affirm this mantra.  After an unprecedented change in the United States Preventive Services Task Force’s (USPSTF) guidelines for breast cancer screening, the American College of Obstetricians and Gynecologists1 (ACOG) announced on Friday, November 20th their new recommendation to delay the onset of cervical cancer screening and to screen less frequently. Of course, following years of aggressive campaigning for preventive medicine and innumerable cancer awareness programs, the natural response of the community is alarm and apprehension.  But, based on recent studies, the continual oath to do no harm has prevailed, although how this will affect practice is yet to be seen.

ACOG recommends beginning baseline cervical screening at age 21 regardless of age of first sexual intercourse.  In addition, women ages 21 to 30 should be screened every two years instead of annually with standard Pap or liquid-based cytology.  After 30 years of age, women with three consecutive negative test results may be screened every three years.  Certain populations at high risk, such as immunosuppressed patients or those already treated for cervical intraepithelial neoplasia (CIN) 2 or 3 or cervical cancer should be screened more frequently.

The more conservative approach attempts to avoid unnecessary treatment of adolescents and young adults who are already at low risk for cervical cancer.  Precancerous lesions are more common in adolescents but tend to resolve without treatment. However, standard protocol for treating these lesions often results in excisional procedures that are thought to have led to a significant increase in premature births and need for Caesarean sections.

Less is indeed more, says a study in The Lancet2 this week that compared routine to on-demand chest radiographs in mechanically ventilated patients in the intensive care unit (ICU).  Twenty-one ICUs in France were randomized to order chest radiographs routinely versus based on clinical examination during morning rounds.  In this cluster-randomized design, the ICU then switched protocol during a second period so that all units received both methods of treatment.  Results showed that the on-demand strategy utilized substantially fewer radiographs without affecting therapeutic or diagnostic interventions, length of stay in the ICU, duration of mechanical ventilation, or mortality.  Although implementation of the on-demand strategy still requires further study and depends on physician level of comfort, our use of diagnostic tools is yet again under scrutiny.

Does the treatment of anemia in patients with type 2 diabetes mellitus and chronic kidney disease reduce mortality, cardiovascular events, and progression to end stage renal disease?  Not so, according to the Trial to Reduce Cardiovascular Events with Aranesp Therapy (TREAT) published this week in the New England Journal of Medicine.3 In this randomized controlled trial, 2012 patients with type 2 diabetes mellitus, chronic kidney disease, and anemia were assigned to darbepoetin alfa to achieve a hemoglobin of 13 g/dL or to placebo, only receiving rescue darbepoetin alfa when hemoglobin dropped below 9 g/dL.  After a median follow-up of 29 months, no difference was seen between the two groups in terms of death or cardiovascular events, but an increased risk of stroke was seen in the darbepoetin group.

On the flip side, more is sometimes better, particularly in the world of cardiology.  The Pacing to Avoid Cardiac Enlargement (PACE) study4 published online in The New England Journal of Medicine compared biventricular pacing to right ventricular apical pacing by randomizing 177 patients with a biventricular device and normal systolic function to receive either biventricular pacing or right ventricular apical pacing.  After 12 months, the primary end point of left ventricular ejection fraction was significantly lower in the right ventricular group (54.8±9.1% vs. 62.2±7.0%, P<0.001).  The left ventricular end-systolic volume was also significantly higher in the right ventricular group (35.7±16.3 ml vs. 27.6±10.4 ml, P<0.001), regardless of the presence of diastolic dysfunction at baseline.  The study is limited by a small sample size as well as the lower success rate of implanting a biventricular pacing system compared to the conventional dual-chamber pacing.

When it comes to prevention, treatment of obstructive sleep apnea (OSA) plays a substantial role in reducing the risk of cardiovascular events, not to mention improving quality of life.  But anyone within five miles of a continuous positive airway pressure machine knows that compliance is an ongoing battle.  The CPAP Promotion and Prognosis – The Army Sleep Apnea Program (CPAP ASAP) was a randomized controlled trial published in the Annals of Internal Medicine5 that studied the use of eszopiclone (Lunesta), a non-benzodiazepine sedative-hypnotic, at the onset of therapy in improving CPAP usage. One hundred sixty patients with newly diagnosed OSA initiating CPAP were randomized to receive eszopiclone or placebo for the first 14 nights.  After a 24-week follow-up, patients in the eszopiclone group used CPAP 64.4% of nights compared with 45.2% in the placebo group (difference 20.8%, p=0.003).  Patients in the eszopiclone group used CPAP 1.3 more hours per night for all nights and 1.1 more hours per night of CPAP use.  No difference in side effects between the groups was observed.  A limitation of the study was the possibility of undertreated insomnia in the placebo group, which may have led to biased results.  Overall, the use of better-fitted masks, humidified air, and close follow-up along with a long-acting non-benzodiazepine sedative-hypnotic like eszopiclone may improve compliance with CPAP use.

As we sum up this week’s Primecuts, the continual balance in medicine between less or more, beneficence and non-maleficence, conservative or invasive, is an ongoing battle.  But when it comes to family, good food, and holidays, more is always better.  We don’t need any evidence to prove that.  Happy Thanksgiving everyone!

Dr. Rhee is a 2nd year resident in internal medicine at NYU Medical Center. 

Faculty peer reviewed by  Michael Tanner MD, Associate Editor, Clinical Correlations


1. American College of Obstetrics and Gynecology. Cervical Cytology Screening. Obstetrics and Gynecology. Forthcoming December 2009. Available from:

2. Siegel MD, Rubinowitz AN. Routine daily vs. on-demand chest radiographs in intensive care. Lancet. 2009;374(9702)1656-1658.

3. Pfeiffer MA, Birdman EA, Chen C. A trial of darbepoetin alfa in type 2 diabetes and chronic kidney disease. N Engl J Med. 2009;361(21):2019-2032. Available from:

4. Yu C, Chan JY, Zhang, QM. Biventricular pacing in patients with bradycardia and normal ejection fraction. N Engl J Med [online]. 2009 Nov 15 [cited 2009 Nov 20]. Available from:

5. Lettieri CJ, Shah AA, Holley AB. Effects of a short course of eszopiclone on continuous positive airway pressure adherence. Ann Intern Med. 2009;141(10):696-702. Available from:

PrimeCuts: This Week in the Journals

November 16, 2009

fallKatie Miro MD

Faculty peer reviewed

Americans took the time last week to honor the men and women who fought for our country as Veteran’s Day was marked with parades and celebration throughout the nation. Clinical Correlations would like to send special thanks not only to the many veterans of this country, but also to the brave men and women serving in the military today. While the war on terrorism continues abroad, President Obama’s battle for health care reform continues at home. Sunday’s front page  of the New York Times highlighted a victory for Obama in his fight for health care reform as the House voted in favor of an extensive plan to revamp the nation’s healthcare system. This plan poses to extend coverage to approximately 36 million Americans currently living without medical insurance. Many Republican representatives continue to fight against the legislation with the concern that the new plan would be too much of a financial drain on the nation’s economy. As Representative Steny H. Hoyer, Democrat, stated, “Much work remains.”

The week came to a close with an article in the New York Times addressing the war on cancer  and taking a look through the research of various cancer treatments. This article suggests that while many Americans are willing to try many vitamin supplements and dietary modifications in an attempt to prevent cancer, evidence has not supported the effectiveness of these treatments. Many pharmacologic treatments, such as finasteride, have shown promise in several research studies in prevention of prostate cancer, although its use has yet to have been initiated for this indication. The new HPV vaccine and smoking cessation have also shown success in cancer prevent. Doctors should continue to utilize those treatments that are proven effective in cancer prevention, and, good nutrition and exercise should always be encouraged.

The New York Times also referred to an article in JAMA,  Prevalence of and factors associated with persistent pain following breast cancer surgery. This nationwide cross-sectional questionnaire study of 3754 women in Denmark who had undergone surgery for breast cancer was conducted to assess the prevalence and severity of continued pain. 1543 patients reported continued pain after surgery, with 86% of these patients experiencing pain in the breast area. A significant association was seen with persistent pain following breast conserving surgery and young age, with a significant increased risk of pain in 18-39 year old as compared to 60-69 years, p<0.001. Pain following mastectomies was most significant in women 40-49, and there was a significant association with this age group and more severe pain as compared to women of other age groups studied. Though each infection was associated with risk of stroke, the results did not prove to be significant, and would need to be further studied. Pain complaints in other areas of the body were associated with increased post-surgical pain. Sensory disturbances, presumably due to nerve damage, following surgical intervention was also significantly (p <0.001) associated with an increase in risk of chronic persistent pain. This study may help guide future therapy including nerve sparing techniques, and special attention shown to those groups shown to have higher incidence of post-operative pain.

On the topic of pain, an article to look out for in a future issue of the Lancet addresses laser therapy as a treatment for neck pain. This article, currently available at Lancet Online, focuses on the efficacy of laser therapy. Neck and back pain is a frequent chief complaint in many primary care offices throughout the country. A systematic review and meta-analysis was conducted to evaluate the efficacy of this treatment of laser therapy for this problem. 16 randomized control trials were evaluated, 2 of which looked at the subject of acute pain while the others looked at chronic pain. Data showed that there was a clinically significant decrease in symptoms in the 2 trials addressing acute neck pain, and clinically significant reduction in pain in the chronic pain group, with 7 of those trials showing an effect lasting up to 22 weeks. Only 50% of the trials reported side-effects of the treatment, although when reported, side-effects were mild, suggesting that this appears to be a promising treatment for both acute and chronic neck pain.

The New England Journal of Medicine published an article this week comparing revascularization versus medical therapy for renal artery stenosis. In a randomized, unblinded trial, 806 patients with atherosclerotic renovascular disease were chosen to undergo revascularization plus medical therapy or medical therapy alone. Patients in the medical therapy group required an increased number of antihypertensive agents when compared to the revascularization group at 1 year follow-up. When assessing renal function, during a 5-year follow-up the mean serum creatinine level was 1.6mmol per liter lower in the group that underwent revascularization as compared to control. Although renal function was shown to significantly improve in the revascularization group, no difference in overall mortality was found, and there was an increase in adverse events associated with the procedure. Based on this article it appears that medical therapy will still be the recommended first treatment for patients with atherosclerotic renovascular disease.

Often times it is a challenge to find the best diabetic regimen to treat our patient. An article in the British Medical Journal tackled this issue. They compared the combination of insulin with metformin vs insulin with an insulin secretagogue in non-obese patients with type 2 diabetes. The researchers randomized 459 patients with type 2 diabetes to either of the above regimens, using the reduction in HbA1C as the primary outcome measure. After 12 months of therapy, there was no significant different in HbA1C levels in patients of either treatment arm, and no difference in the number of patients lowering their A1C to <6.5. There was also no difference seen in the insulin requirements between the two groups. When trying to decide on the adequate regimen for our non-obese diabetic patients, metformin and repaglinide appear to be just as efficacious in achieving superior glycemic control when added to insulin therapy.

Is there an infectious association to the risk of stroke in patients? The New York Times made reference this week to an upcoming article in Archives of Neurology addressing this possible correlation. A prospective cohort study was used to identify, if any, the association between one of the following infections and stroke, H. pylori, Chlamydia pneumonia, CMV, and HSV 1 and 2. The proposed mechanism from this potential association and the reason for studying these infections seems to be that each of these infections are chronic in nature and lead to an increased pro-inflammatory state. Though each infection was associated with risk of stroke, the results did not prove to be significant.

Although this week’s PrimeCuts comes to an end, the battle for health care reform, the war against cancer, and the fight against diabetes continues.

Dr. Miro is a 2nd year internal medicine resident at NYU Medical Center.

Faculty peer reviewed by Michael Poles MD, NYU Division of Gastroenterology

Chow RT, Johnson MI, Lopes-Martins RA, and JM Bjordal. Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomized placebo or active-treatment controlled trials. The Lancet. 2009; Published online November 13, 2009.

Elkind MS, Ramakrishnana P, et al. Infectious burden and risk of stroke. Arch Neurol. Published online November 9 2009.

Gartner R, Jensen M, Nielsen J, et al. Prevalence of and factors associated with persistent pain following breast cancer surgery. JAMA. 2009; 302 (18): 1985-1992.

Hulse C, Pear R. Sweeping health care plan passes house. The New York Times. Published online on November 7 2009.

Kolata G. Medicines to deter some cancers are not taken. The New York Times. Published online on November 12 2009.

Lund SS, Tarnow L, Frandsen M, et al. Combining insulin with metformin or an inslulin secretagogue in non-obese patients with type 2 diabetes: 12 month, randomized, double blind trial. British Medical Journal. Published online November 14, 2009.

The ASTRAL investigators. Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med. 2009; 361: 1953-1962.

PrimeCuts: This Week in the Journals

November 9, 2009

victoriaMegha Shah MD

Faculty peer reviewed

Do we fail to make healthy choices simply because we lack information? If we knew that a tall sized Starbucks Caramel Frappuccino with whip had 300 calories, would we order it anyway? Or would we go for the zero calorie Tazo tea option instead? Well, the jury’s still out…In April 2008, a law was passed that required calorie counts to be posted next to prices in all chains with at least 15 outlets nationwide, affecting close to 2,000 restaurants around New York City. This week, the New York Times reports on two separate studies analzying the effects of this law. The first , performed here at the New York University School of Medicine, and published in the journal Health Affairs is a survey taken of 1,156 adults at four fast-food restaurants in low-income, minority New York communities compared to that of a similar sample population in Newark, New Jersey, where calorie labels have not yet been introduced. Specific survey locations were identified because of high rates of obesity and type II diabetes. The researchers collected about 1,100 receipts two weeks before and four weeks after the law took effect. They found that 27.7 percent stated that calorie labeling had influenced their fast-food choices though overall there was no significant change in the number of calories purchased as seen on the receipts.

A more recent preliminary study released by the city’s health department reports that the calorie labeling law, brought into effect last year and analyzing 10,965 receipts before and 12,153 purchases after the law took effect, showed slightly more promising results, with patrons ordering fewer calories at 4 of the 13 chains surveyed. Though, of note, 8 of the chains had no change at all, and one chain, Subway had an increase in calories ordered, possibly due to the $5 sandwich promotion. Both groups of researchers, though, agree that that the differences in their studies may be from differences in study size and focus. The study by the city health department encompassed most neighborhoods in the city without any particular socioeconomic characteristics with a much larger survey size. Additionally, the first study was conducted shortly after the law took effect and may not have captured more gradual behavioral changes.

Do we overscreen for cervical cancer? A study published in this week’s Annals of Internal Medicine, reports that we just might be. Of the 1,212 physicians surveyed about cervical cancer screening, only about one-fifth were in line with recommendations from groups including the American Cancer Society and United States Preventive Services Task Force. The survey consisted of 4 different situations and asked whether a Pap smear would be appropriate in each. Most responded that they would recommend annual Pap smears for at least three years for an 18 year old, recently sexually active, woman, in line with the current recommendations. Against current recommendations, though, they also advised the same for a 35 year old woman with no history of cancer whose cervix had been removed. This study reminds us of the importance of keeping up-to-date with screening guidelines to ensure that patients do not undergo unnecessary testing and add to already high health costs.

The advent of flu season and particularly that of H1N1 has unsurprisingly put the demand for N95 respirators at an all time high. With fears that these masks may be in short supply during a pandemic, researchers at Ontario area hospitals compared surgical masks with N95 respirators for the prevention of flu in healthcare workers. In a study published in Journal of the American Medical Association, 446 nurses were randomized to either a surgical mask or N95 fitted respirators and monitored for PCR confirmed influenza. The results showed that surgical masks were noninferior to N95 respirators in preventing influenza. The study noted that the results should only be applied to routine care in the health care setting.

Fresh from the lab: In this week’s Science, a group of researchers initiated a gene therapy trial in two X-linked adrenoleukodystrophy (ALD) patients without a matched stem cell donor. ALD, a severe demyelinating disease in boys caused by a deficiency in ABCD1, a gene encoding the ALD protein, can only be managed by allogeneic hematopoietic stem cell transplantation (HCT). In this study, CD34+ cells were removed from the patients and genetically corrected ex vivo with the wild-type ABCD1 gene. These cells were then reinfused into the patients and 24-30 months after the procedure, the normal ALD protein was found to be expressed in a polyclonal cell population. Between 14-16 months after the reinfusion, progressive cerebral demyelination stopped in both patients, showing that gene therapy may be a promising therapy for those unable to go undergo HCT.

And lastly, a new tool for our fight against obesity? Liraglutide, a glucagon-like peptide 1 (GLP-1) analog, marketed under the brand name Victoza by Novo Nordisk for the treatment of type II diabetes, was recently studied for the treatment of obesity. In double blind, randomized trial published in the The Lancet, four different doses of liraglutide were compared to placebo and orlistat, another drug used in obesity management in 564 patients with a controlled diet and exercise regimen. Results showed that most patients lost on average of 5-7kg with liraglutide, approximately 4kg with orlistat, and 3kg on placebo. The drug had minimal side effects including transient nausea and vomiting. Although liraglutide has yet to be approved for use in the United States, with current obesity rates on the rise, this certainly will be a drug to look out for.

Peer reviewed by Sandeep Mangalmurti, MD JD, Chief Resident, NYU Department of Medicine

Dr. Shah is a first year resident in internal medicine at NYU Medical Center.


1. Rabin, Roni Caryn. How Posted Calories Affect Food Orders. The New York Times. Published online November 2, 2009
2. Elbel B, Kersh R, Brescoll VL et al. Calorie Labeling and Food Choices: A First Look at the Effects on Low-Income People in New York City. Health Affairs. Published online October 6, 2009
3. Yabroff KR, Saraiya M, Meissner HI et al. Specialty Differences in Primary Care Physician Reports of Papanicolaou Test Screening Practices: A National Survey, 2006 to 2007. Annals of Internal Medicine. 2009; 151 (9): 602-611
4. Loeb M, Dafoe N, Mahony J et al. Surgical Mask vs. N95 Respirator for Preventing Influenza Among Health Care Workers. JAMA. 2009; 302 (17): 1865-1871
5. Cartier N, Hacein-Bey-Abina S, Bartholomae CC et al. Hematopoietic Stem Cell Gene Therapy with a Lentiviral Vector in X-linked Adrenoleukodystrophy. Science. 2009; 326 (5954): 818-823
6. Astrup A, Rossner S, Van Gaal L et al. Effects of liraglutide in the treatment of obesity: a randomized, double-blind, placebo-controlled study. The Lancet. 2009; 374 (9701): 1006-1616.

PrimeCuts: This Week in the Journals

November 2, 2009

brparkwayTao Xu MD

Faculty peer reviewed

As we approach the end of fall, with large crowds in a variety of costumes gleefully marching in the pouring rain during the 36th Annual Village Halloween Parade, thoughts about flu season warnings seemed far away. But here is a story that will remind us of the global threat of the H1N1 virus. At the end of November, the annual Mecca will take place in Saudi Arabia, where an estimated 2.5 million pilgrims from 160 countries will find themselves shoulder-to-shoulder. As reported in The New York Times,  in preparation for this world-wide pilgrimage, Saudi Arabia has advised the use of preventive measures against the H1N1 flu, including hand-washing, surgical masks, and hand sanitizers. At the same time, the Saudi government has purchased loads of Tamiflu made in India, expanded the nation’s ICUs, and fully-loaded staff into medical centers. On the other hand, The New York Times reports that the Ukraine government’s choice of preventive measure in this flu season is to close schools nationwide for three weeks, ban large crowd gatherings, and restrict traveling.Also this week’s New York Times reported on a recent study showing the prevalence of myocardial infarction decreasing among men and increasing among women. Published in the Archives of Internal Medicine,  Towfighi et al. compared the prevalence of myocardial infarction and the Framingham coronary risk score (FCRS) among US adult females and adult males aged 35 to 54 years who participated in the Nutrition Examination Surveys (NHANES) during two periods, 1988-1994, and 1999-2004. It was found that MI prevalence decreased among men and increased among women, though this result was not statistically significant. The FCRS improved in men and worsened in women in the age group 45 to 54 years, and an FCRS greater than 20% declined in men while remaining stable in women. The only aspect of the FCRS where prevalence increased in both men and women was diabetes mellitus. Several factors may contribute to this trend in sex disparity. Patients may underestimate their cardiovascular risks secondary to their concerns for other health risks. Similarly, physicians may treat female patients differently from male patients given a bias towards less concern for prevention of cardiovascular incidents in women, assuming that premenopausal women are generally at lower risk of cardiovascular diseases compared to men in the same age group. This study urges us not only to be aware of this gender bias in assessing cardiovascular risk, but also to note the increasing prevalence of diabetes mellitus and obesity among both groups.

For over 30 years, a widely held belief has been that patients with chronic kidney disease most commonly die from cardiovascular-related illnesses, and that patients on hemodialysis or peritoneal dialysis have a 10 to 20 times higher risk of dying from cardiovascular diseases than the general population. In this week’s JAMA, de Jager et al. found that patients starting dialysis do have an increased risk of death but not mainly due to cardiovascular disease. The increased risk of cardiovascular mortality in this European cohort of patients starting dialysis is comparable to an equally increased risk of noncardiovascular mortality (most commonly infection and malignancies).

In 2000, 171 million people worldwide were affected by diabetes, and it is estimated that the number of people will increase to 366 million by 2030. The original Diabetes Prevention Program (DPP) a randomized clinical trial conducted by the Diabetes Preventions Program Research Group, found that intensive lifestyle changes reduced diabetes incidence by 58% in high-risk individuals, whereas metformin reduced the incidence by 31%. This week’s advanced online publication in Lancet  released the results of the first phase of the Diabetes Prevention Program Outcomes Study (DPPOS) as a 10-year long-term follow-up of the DPP. It was found that the overall incidence of diabetes was the lowest in the lifestyle group compared to the metformin and placebo groups, and the delay or prevention of diabetes did in fact persist for 10 years with metformin or lifestyle changes.

This week in the New England Journal of Medicine,  Holman et al. published a 3-year open-label multicenter study of complex insulin therapy in Type 2 Diabetes. It was found that adding basal or prandial insulin-based therapy to oral diabetic therapy resulted in better glycemic control compared to adding biphasic insulin-based therapy. Additionally, it was found that the addition of basal insulin therapy to oral regimens in type 2 diabetics resulted in fewer hypoglycemic episodes and less weight gain.

Finally, in an advanced online publication in the Annals of Internal Medicine this week, the American College of Physicians released a clinical practice guideline for hormonal testing and treatment of erectile dysfunction. It is strongly recommended that therapy with a PDE-5 inhibitor be started in men who request treatment for erectile dysfunction and do not have contraindications to using a PDE-5 inhibitor. There is weak recommendation for physicians to base the choice of a PDE-5 inhibitor on ease of use, cost, and adverse effects of the medication. Finally, the guidelines state that there is insufficient evidence for routine use of hormonal blood tests or hormonal treatment in patients with erectile dysfunction.

That concludes this week’s edition of primecuts. Here’s to hoping that we can start off next week’s edition with the mention of another parade – let’s go Yankees!!!!

 Dr. Xu is a first year resident in internal medicine at NYU Medical Center.

Faculty peer reviewed by Danise Schiliro-Chuang MD, Contributing Editor, Clinical Correlations

1. Cabin, Roni Caryn. Patterns: For Heart Attacks, Shifts in Gender Gap. The New York Times. Published online on October 27 2009.

2. De Jager Cardiovascular and noncardiovascular mortality among patients starting dialysis. JAMA. 2009; 302 (16): 1782-1789.

3. Diabetes Prevention Program Research Group. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. The Lancet. Published online October 29, 2009.

4. Holman Three-year efficacy of complex insulin regimens in type 2 diabetes. NEJM. 2009; 361:1736-47.

5. Levy, Clifford J. Ukraine bans big crowds to combat swine flu. The New York Times. Published online on October 31 2009.

6. McNeil Jr, Donald G. Saudis try to head off swine flu fears before Hajj. The New York Times. Published online on October 29 2009.

7. Qaseem, Hormonal testing and pharmacologic treatment of erectile dysfunction: a clinical practice guideline from the American College of Physicians. Ann Intern Med. Published online on October 20, 2009.

8. Towfighi, Amytis Sex-specific trends in midlife coronary heart disease risk and prevalence. Arch Int Med. 2009; 169 (19): 1762-1766.


PrimeCuts: This Week in the Journals

October 26, 2009

mtredoubtTodd Cutler MD

Faculty peer reviewed

It’s a tired cliché, but this week the flies on the wall at the American Cancer Society were undoubtedly privy to some fascinating conversation. The dialogue began, in the popular press at least, with a special communication published in JAMA, in which the authors sounded a clarion call for a nationwide overhaul of the current breast and prostate cancer screening guidelines. In a strongly-worded argument, the authors synthesized the results of multiple studies at the levels of epidemiology, clinical practice, and molecular biology to support their stance that mammograms and PSA testing have the same general failing: they are large screening programs that contribute to minimal, at best, reductions in mortality, but create massive physical and emotional burden to patients.  The likely explanation for this phenomenon, the authors suggested, is that cancers discovered when they are localized rarely progress to life-threatening disease, while aggressive cancers, or interval cancers, metastasize rapidly and therefore are infrequently detected at stages where diagnosis via screening tests and subsequent interventions improve clinical outcomes. Modest decreases in mortality were difficult to attribute to early detection considering the changing landscape of general breast and prostate cancer treatment over the past 20 years.

The authors sketched a broad, if not purposefully nebulous, outline to guide the medical community moving forward. Their recommendations include the development of biomarkers that delineate between aggressive and indolent tumors  as well as systematically reducing treatment for patients with low-risk lesions. The authors, perhaps recognizing the political and social consequences of these implementations, suggest a moratorium on the use of the word “cancer” to describe minimal-risk lesions and instead advise implementing use of the term “indolent lesions of epithelial origin” (IDLE). They also asserted that physicians require more accurate stratification tools to comprehensively educate patients in regards to the risks and benefits of cancer screening.

While deficiencies of mammograms and PSA tests have been widely discussed for many years, their entrenched status in the medical community’s screening armamentarium and their popularity with the general public, make any near-future supplantation seem unlikely. On the same day the article was released, however, the New York Times reported that the American Cancer Society (ACS) was planning to modify its stance on the benefits of breast and prostate cancer screening – partially in response to the JAMA publication. Dr. Otis Brawley, the ACS chief medical officer, was quoted as saying, “We don’t want people to panic…but I’m admitting that American medicine has over-promised when it comes to screening. The advantages to screening have been exaggerated.” Dr. Brawley tepidly continued, “If a woman says, ‘I don’t want [a mammogram],’ I would not think badly of her, but I would like her to get it.”

In order to quash any suggestion of short-term indecision, the next day Dr. Brawley released a statement on the ACS website reaffirming the Society’s stance that women above the age of 40 should receive annual mammograms and that men should discuss the risks and benefits of prostate screening with their physician. He acknowledged, however, that, “Simple messages are not always possible, and over-simplifying them can in fact do a disservice to the very people we serve.” That same day, the New York Times ran a follow-up piece in which Dr. Barnett S. Kramer, associate director for disease prevention at the NIH, charged, “The health professions have played a role in oversimplifying and creating the stage for confusion. It’s important to be clear to the public about what we know and be honest about what we don’t know.” Two days later, the CEO of ACS, Dr. John Seffrin, reiterated the statement of Dr. Brawley, while acknowledging the imperfections of breast and prostate cancer screening.

So, what to make of all of this? The evidence is mounting against the effectiveness of mammograms in preventing metastatic breast cancer. The authors of the JAMA article cleverly strengthened their argument against mammograms by paralleling their inadequacies with PSAs – a test many practicing physicians have already dropped in light of its clinical shortcomings. The paradigm shift called for, however, requires technologic and infrastructural advances that appear to be out of reach considering modern capabilities. While these statements from ACS and other societies will undoubtedly spark a move towards change, for the time being it appears that the status quo will be maintained so as to prevent any conception that physicians are lurching from one recommendation to another a politically dangerous notion when considering the exquisitely sensitive emotions evoked by the topic of breast cancer. This may be the beginning of a reform movement in the medical community that will end up affecting millions of Americans.

In other exciting news, an endothelin type A receptor antagonist was effective in reducing blood pressure in patients who were refractory to at least three anti-hypertensive agents according to a report published this week in the Lancet. Endothelin acts on vascular endothelial cells to induce vasoconstriction. The randomized double-blind placebo-controlled study compares darusentan with placebo and found that blood pressure was equally reduced (p<0.0001) with escalating doses of the drug. The most common side effect in the treatment group was lower extremity edema. The addition of a new class of drug to the battery of anti-hypertensive agents at our disposal is an exciting prospect, especially in patients who are poorly managed on currently available agents. This trial, however, was small (n=329), so future studies will hopefully be powered to assess any impact on clinical outcomes.

Lastly, platelets stored at cool temperatures are rapidly cleared from circulation, which necessitates storage at room temperature, and essentially creating an ideal broth for bacterial growth. For this reason, platelet transfusions are associated with greater risk of sepsis compared to other blood products, limiting their shelf life to five days. A study in Nature Medicine illustrated this process of rapid platelet clearance.  The chilling of platelets results in the upregulation of galactose moieties on their surface that, upon transfusion in mice, are subsequently recognized by the Ashwell-Morell asialoglycoprotein receptor on the surface of hepatocytes. Inhibitors of this receptor improve the survival of refrigerated platelets to a level comparable to those stored at room temperature, a phenomenon that was replicated in Ashwell-Morell knockout mice. Binding by the Ashwell-Morell receptor was also partially dependent on the GPIb-α receptor on platelets. Additionally, this report generates interest because macrophages, and not hepatocytes, are typically considered to be the primary cell type responsible for clearing circulating platelets. While this report did show that macrophages were responsible for the clearance of rapidly chilled platelets in the short term, hepatocytes appear to be more important than previously recognized. In summary, this study raises the tantalizing proposition that modulation of sugar residues or treatment with inhibitors of the Ashwell-Morell receptor may allow for the storage of platelets at refrigerated temperatures, simultaneously decreasing the risk for transfusion-associated infections while alleviating the chronic platelet shortages that plague all hospitals.

Dr. Cutler is a 1st year internal medicine resident at NYU Medical Center.

Faculty peer reviewed by Barbara Porter MD MPH,  Clinical Assistant Professor of Medicine, NYU Medical Center

Esserman L, Shieh Y, Thompson I. Rethinking screening for breast cancer and prostate cancer. JAMA. 2009 Oct 21; 302(15):1685-92.
Kolata G. Cancer Society, in Shift, Has Concerns on Screenings [Internet]. The New York Times; 2009 Oct 20. Available from:
Brawley O. American Cancer Society Stands by Its Screening Guidelines; Women Encouraged to Continue Getting Mammograms [Internet]. The American Cancer Society; 2009 Oct 21. Available from:
Parker-Pope T. Benefits and Risks of Cancer Screening Are Not Always Clear, Experts Say [Internet]. The New York Times; 2009 Oct 21. Available from:
Seffrin J. A Special Message from CEO John Seffrin, Ph.D. on Cancer Screening [Internet]. The American Cancer Society; 2009 Oct 23. Available from:
Weber M, Black H, Bakris G. A selective endothelin-receptor antagonist to reduce blood pressure in patients with treatment-resistant hypertension: a randomised, double-blind, placebo-controlled trial. The Lancet. 2009 Oct 24; 374(9699):1423-1431.
7)Rumjantseva V, Grewal PK, Wandall HH. Dual roles for hepatic lectin receptors in the clearance of chilled platelets. Nat Med. 2009 Sep 27. [Epub ahead of print] Available from:

PrimeCuts: This Week in the Journals

October 19, 2009

glacierxxChau Che MD

This week ended on a high note in the financial world. The Dow bounced back and crossed the 10,000 mark this week, ultimately ending the week slightly below that mark and Goldman Sachs posted a profit of 3.19 billion in the third quarter, signifying a hopeful return to the days before the financial crisis. However, in retrospect, the financial crisis of 2007 was preventable and could have been avoided if the banks gave out loans with a bit more discretion. The hopeful recovery makes the crisis only seem temporary, but steps need to be taken in order to prevent history from repeating itself. This week, the medical journals also addressed many areas of prevention but in a different facet. The journals did not look to protect and safeguard assets, but rather to prevent: prevent mortality, prevent the spread of infection, prevent complications, prevent pain, and prevent disease.

This week, the New England Journal of Medicine examined the clinical course of advanced dementia in a prospective manner (5). Mitchell et al. found that infections and nutritional problems were complications associated with high mortality rates. It also showed that health care proxies who understood the prognosis and clinical course of dementia were not as likely to ask for aggressive end of life care as compared to health care proxies who did not understand the prognosis and expected complications (OR, 0.12; 95% CI, 0.04-0.37). This article reiterates what most health care workers realize; advanced dementia is a terminal disease with complications. However, most importantly, the article emphasizes that in order to prevent unnecessary aggressive care, family members and health care proxies need to be educated to understand the course of the disease. In this scenario, the key to prevention of unnecessary intervention is effective communication.

As influenza season approaches, the prevention of influenza is a topic on everyone’s radar, including the Annals of Internal Medicine (2). Cowling et al. looked at the utility of hand hygiene and facemasks to prevent household transmission of influenza. The use of these techniques within 36 hours of the onset of patient symptoms prevented influenza transmission (adjusted OR, 0.33; 95% CI, 0.13-0.87). This knowledge may enable family members to abstain from other therapeutic interventions, such as use of oseltamivir. The article reiterates a common topic that is familiar to all hospital personnel: hand hygiene. Continuing to practice hand hygiene outside of the hospital setting may limit the dissemination of disease, including influenza.

Doctors try to treat disease, but procedures are not without risks. With that in mind, the advent of minimally invasive surgery has theoretically reduced the risk of complications. Patients and physicians often tout the belief that minimally invasive procedures may prevent complications. The Journal of the American Medical Association explored this notion by comparing the effectiveness of minimally invasive versus open radical prostatectomy (4). Hu et al. showed that men who received minimally invasive prostatectomy had fewer miscellaneous surgical complications and shorter hospital stays. However, it also showed that minimally invasive recipients were more likely to suffer from incontinence (15.9 vs 12.2 per 100 person years; p = .02) and erectile dysfunction (26.8 vs 19.2 per 100 person years; p = .009) eighteen months after the procedure. Although this disputes the belief that minimally invasive surgery may prevent complications, it seems that one may argue that regardless of the modality of the procedure, the most important factor is the surgeon’s experience.

Sometimes, it is too late to prevent disease and instead treatment is needed. This week, The Lancet published an article examining what many of our patients deal with daily: pain. Gilron et al. looked at neuropathic pain and assessed the efficacy of nortriptyline and gabapentin compared with each drug given individually (3). The study showed that pain relief with combination therapy was lower than with gabapentin (-0.9, 95% CI, -1.4 to -0.3, p = 0.001) or nortriptyline (-0.6, 95% CI, -1.1 to -0.1, p=0.02) alone. Although the study gives us evidence of improvement of pain control with the two medications, this is nothing new in the world of treatment. The idea of medications working in synergy is an area that doctors often look to exploit in order to prescribe the most efficacious treatments. It looks like this may be another pair of medications that may improve the treatment of neuropathic pain when used concomitantly.

The idea of prevention is especially important in chronic diseases. Primary prevention may help avoid end organ damage that results from diabetes, hypertension, and coronary artery disease. This study from the New England Journal of Medicine looks at the aftermath when patients have reached end organ failure (6). Tamura et al. examines functional capacity based on the Minimum Data Set-Activities of Daily Living [MDS-ADL] scale once dialysis is instituted in elderly patients with end-stage renal disease. The initiation of dialysis resulted in a decline of functional status. By twelve months after starting dialysis, 58% of the patients died and pre-dialysis functional status was maintained in only 13% of the patients. This is another reason to stress the importance of primary prevention.

Lastly, the modification of risk factors is an important aspect in preventing disease. Cigarette smoking is a modifiable risk factor for many diseases. However, other modifiable risk factors also exist. This week’s Lancet examines the effect of hormone replacement therapy (HRT) on lung cancer (1). Chlebowski, R., et al. showed that HRT did not increase the incidence of lung cancer; however it increased the number of deaths from lung cancer (HR 1.71, 95% CI 1.16-2.52, p= 0.01) especially from non small cell lung cancer. These findings add to the discussion that should occur before physicians start females on hormone replacement therapy following the initial findings of the Women’s Health Initiative.

It is clear from this week’s PrimeCuts that prevention was on everyone’s mind from the medical journals to the economists.

Dr. Che is a second year internal medicine resident at NYU Medical Center.

Faculty peer reviewed by Judith Brenner MD, Associate Program Director and Associate Editor, Clinical Correlations

1. Chlebowski, R., et al. Oestrogen plus progestin and lung cancer in postmenopausal women (Women’s Health Initiative trial): a post-hoc analysis of a randomised controlled trial. The Lancet 2009; 374 (9697): 1243-1251.  2. Cowling, B., et al. Facemasks and Hand Hygiene to Prevent Influenza Transmission in Households. Annals of Internal Medicine 2009; 151 (7): 437-446.

3. Gilron, I, et al. Nortriptyline and gabapentin, alone and in combination for neuropathic pain: a double blind, randomized controlled crossover trial. The Lancet 2009; 374 (9697): 1252-1261.

4. Hu, J., et al. Comparative Effectiveness of Minimally Invasive vs. Open Radical Prostatectomy. JAMA. 2009; 302(14):1557-1564.

5. Mitchell, S., et al. The Clinical Course of Advanced Dementia. N Engl J Med 2009; 361: 1529-38.

6. Tamura, M., et al. Functional Status of Elderly Adults before and after Initiation of Dialysis. N Engl J Med 2009 361: 1539-1547.

PrimeCuts: This Week in the Journals

October 12, 2009

nobelMichael Tees, MD, MPH

While the news was dominated by President Barack Obama winning the Nobel Peace Prize, other American Nobel Laureates should not be forgotten. After all, Elizabeth Blackburn, Carol Greider and Jack Szostak waited over 20 years for theirs. These American scientists shared the Nobel Prize in Physiology or Medicine this week “for the discovery of how chromosomes are protected by telomeres and the enzyme telomerase”[1]. American scientists this year are also sharing the Nobel Prize in the field of Chemistry as well as Physics. While we thank our scientists (and politician) for all their amazing accomplishments, unfortunately, none were recipients of a PrimeCuts Prize this week. These highly selective PrimeCuts Prizes were born on the concept that all recipients must have published newsworthy, scientific information in the preceding week. Further, it must have been interesting. So without further adieu, here are the winners of this week’s PrimeCuts Prizes. Read more »

Primecuts-This Week in the Journals

October 5, 2009

800px-canoe_trail_8173Rachana Jani MD

Faculty Peer Reviewed

As summer officially leaves us and fall sets in, the headlines understandably continue to focus on preventative medicine.  Hopes of an H1N1 vaccine were finally realized last week when Sanofi Pasteur sent out the first batch of this much anticipated vaccine [1]. This week, according to the CDC, 3.4 million doses will be available in the form of a live attenuated nasal spray, which may or may be supplemented with an injectable vaccine.  However, even with the wide availability of the vaccine, authorities are concerned that there will be a surge of cases and a resultant bed shortage. According to the CDC’s FluSurge model, some states are already over capacity. With packed hospitals, this potentially means more rapid transmission of the virus.

Although vaccines and antivirals have been advocated as the anchor of pandemic interventions, the British Medical Journal reminds us of basic infection control precautions [2].  Jefferson et al performed a systematic review and found a significant decrease in transmission of respiratory viruses with proper hand hygiene and use of masks.  The current recommendations for influenza promote the use of N95 respirators, however, these masks are in short supply and cumbersome to use. JAMA compared the effectiveness of the surgical mask vs the N95 respirator in protecting healthcare workers [3]. Loeb et al found the use of the surgical mask was non-inferior to the N95 respirators.  However, this study had many limitations, including inadequate surveillance of compliance and a strong assessment of exposure risk.  All things considered, it is decidedly agreed upon to wash up, gown up and reach for a mask – an N95 if you can find one.

The H1N1 vaccine is not the only vaccine that has gotten the community excited.  The investigators of the RV-144 study gave us a sneak peak on the first HIV vaccine that may have practical efficacy in a Phase 3 trial. [4]  In this trial, approximately 16,400 volunteers in Thailand were randomized to receive placebo or the “prime-boost” vaccine.  The “prime” vaccine consisted of the ALVAC HIV which is a canary pox vector with engineered versions of 3 HIV genes – env, gag, and pro. The “boost” portion is AIDSVAX B/E, a recombinant gp120, with HIV surface fragments found in subtype B and E.  The study found that 51 of 8197 people who received the vaccine became infected as compared to 74 of 8198;  a statistically significant difference, P=0.039.  Cynics argue that the effect is modest at best and that years of research still lie ahead, echoing the fallen dreams of an HIV vaccine originally targeted to be completed by 1986. Nevertheless, most see this as the first step towards progress after a series of failures.

In the meanwhile, Nature took notice of new technologies being developed to improve HIV protection for women [5].  Currently condoms are the most effective against HIV infection during intercourse, with male condoms being used much more frequently than female condoms.  In Seattle, researchers are developing a user-friendly female condom – a small capsule and absorbent foam that will allow the condom to open within the vaginal canal and adhere to the vaginal wall. Other ideas are using pH changes during intercourse to transform vaginal gel into a nanoscopic mesh with pores small enough to block HIV entry and vaginal rings laced with anti-HIV compounds in addition to spermicidal agents that are effective for up to 28 days.  Hopefully these new methods will decrease transmission rates while we wait for a vaccine to developed.

Not all interventions have shown such promising results.  Prostate Specific Antigen screening remains controversial without clear data showing an improvement in morbidity and mortality.  A Swedish case control study in the BMJ reexamined the validity of the PSA test, by looking at 540 cases and 1034 controls and comparing positive likelihood ratios [6]. No likelihood ratio was acceptable to support PSA as a screening test. The +LRs found were 4.5,5.5, and 6.4 for PSA values of 3,4, and 5 ug/l respectively.  One can quietly argue that it may be safe to rule-out low risk men with a PSA test less than 1ug/l.  The Archives also exhumed this issue recently [7].  Howard et al created a model of outcomes of annual PSA screening for men divided by risk and age with the idea to incorporate these results into a decision making aid.   Unfortunately, this study also found it difficult to provide sufficient guidance on delineating the risks versus benefits of PSA screening. Given the flaws of the PSA test, the standard has been to discuss the benefits and the harms associated with PSA testing which implies a strong initiative towards patient education and informed decision-making.  In the same Archives issue, Hoffman et al surveyed 375 men who had undergone PSA testing [8].  93.9% of patients reported having discussed the benefits of PSA testing, while a mere third discussed the harms.  Surprisingly, although 58% of patients felt well-informed about PSA testing, only 47.8% of the patients were able to correctly answer even one of the three knowledge questions.  Hoffman et al found that the only salient characteristic associated with testing was the physician’s recommendation – which means one thing – physicians need to dedicate more time to patient education to assist in decision making.

Physicians should also take the time to educate patients about other factors that contribute to morbidity, including the continuously rising numbers of obese patients and diabetics.  Minamino et. al. found that p53 expression in adipose tissue is closely linked to the development of insulin resistance in mice [9].  They found that excessive caloric intake leads to increases in oxidative stress that ultimately result in cellular senescence, which in turn produces proinflammatory molecules, a process regulated by p53. The upregulation of p53 caused an inflammatory response that ended in insulin resistance and cellular aging, a process bound to the pathogenesis of diabetes.  This kind of data can support economic changes that Brownell et al advocated in NEJM online [10].  Brownell proposed a tax on sugar-sweetened beverages.  He argues that not only is there a clear positive association between intake of sugar-sweetened beverages and body weight, diabetes, and other adverse health effects, but the revenue generated from the tax can also be directed towards more public health education programs.  The obvious goal would be to further decrease the incidence of diabetes and other chronic conditions.

The Annals also looked to see if the increased healthcare spending on Type 2 Diabetes was economically prudent [11].  It was, and thankfully so, as more diabetes treatment options are coming to market after the European Association for the Study of Diabetes Meeting [12].  One drug to look out for is Dapagliflozin, a drug that inhibits the uptake of glucose in the kidneys via SGLT2, which showed a significant reduction in serum glucose and body weight in a phase 3 trial. Though A1c reductions were modest, benefits of this new drug are weight loss and a relatively small side effect profile.   Even with new drugs waiting at the forefront, small steps now may make these drugs unnecessary for younger generations as they age. The NYC Education Department banned traditional bake sales and is refilling the vending machines with healthier items in the city’s schools as part of new wellness programs created because 40% of its students are obese [13].  Though a bold move, this aptly mirrors the emphasis on prevention and protection that has been the theme of medicine clinically and politically over the past few weeks.

Dr. Jani is a 3rd year internal medicine resident at NYU Medical Center.

Peer reviewed by Neil Shapiro, MD, Editor-in Chief, Clinical Correlations


2. Jefferson et al. Physical interventions to interrupt or reduce the spread of respiratory viruses:systematic review. BMJ 2009; 339:b3675 (

3. Loeb et al. Surgical Mask vs N95 respirator for preventing influenza among health care workers. JAMA 2009; 302 (17) 1466-1476. (


5. May M. New technologies promise safer sex for women. Nature Medicine 2009; 15 (9): 979. (

6. Holmstrom et al. Prostate specific antigen for early detection of prostate cancer: a longitudinal study. BMJ. 2009; 339:b3537. (

7. Howard et al. A model of prostate-specific antigen screening outcomes for low- to high-risk men. Arch Intern Med. 2009; 169 (17):1603-1610. (

8. Hoffman et al. Prostate cancer screening decisions:results from the national survery of medical decisions. Arch Intern Med. 2009; 169 (17) 1611-1618. (

9. Minamino et al. A crucial role for adipose tissue p53 in the regulation of insulin resistance.  Nature Medicine. 2009; 15(9) 1082-1087. (

10. Brownell et al. The public health and economic benefits of taxing sugar-sweetened beverages. NEJM.  2009; 1-7. (

11. Eggelston et al. The net value of health care for patients with type 2 diabetes, 1997-2005. Ann Intern Med 2009; 151:386-393. (




PrimeCuts: This Week in the Journals

September 28, 2009

sealions21Daria B. Crittenden MD

Faculty Peer Reviewed

While health care reform is being hotly debated around the country, one aspect of reform on which most people can probably agree is that better preventive care would benefit us as individuals and as a society. The literature this week echoes this theme of preventive care.
The most recent Annals of Internal Medicine features an article investigating how often young adults utilize the primary care outpatient system and if they receive appropriate preventive care. This study looked at cross-sectional data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey to characterize the ambulatory care of non-pregnant young adults, ages 20 to 29. This group has a high prevalence of substance abuse, psychological distress, sexually transmitted diseases, and motor vehicle accidents. According to the article, approximately one third of young adults are uninsured. Perhaps not surprisingly, young men in this age group had fewer visits to the doctor than adolescent boys or older men. They also had fewer visits than young women in the same age range (1.10 versus 2.31 annual visits per capita), with young black and Hispanic men having the fewest visits. The study found that only 30.6% of doctors’ visits by young adults included preventive counseling, with significantly less counseling directed toward mental health, sexually transmitted diseases, and injury prevention [1]. Under-reporting of counseling may be an issue, but the study nonetheless suggests that opportunities for preventive care are being missed.

At the other end of the age spectrum, the September edition of the Archives of Internal Medicine looked at physical activity in the very old to see if this had a survival benefit. This study was an 18-year longitudinal cohort study looking at 1861 subjects in Jerusalem from the ages of 70 to 88 years of age. There was a distinct mortality benefit in subjects who were active versus those who were sedentary. Adjusting for risk factors, the hazard ratios for mortality at ages 70, 78, and 85 were 0.61 (95% confidence interval 0.38-0.96), 0.69 (95% confidence interval 0.48-0.98), and 0.42 (95% confidence interval 0.25-0.68) respectively. Being active was defined as engaging in physical activity for at least 4 hours a week, with some participants participating in vigorous sports at least twice weekly or simply engaging in more regular activity such as our-hour daily walks. The beneficial effect of physical activity was not dose-dependent, so even a modest goal of at least four hours a week of activity may benefit those over 70 [2].

Looking at a population seen more commonly in internal medicine practices, the most recent Circulation featured an article investigating the relationship between the metabolic syndrome, inflammation, and the development of symptomatic peripheral artery disease (PAD). The study used C-reactive protein (C-RP) and intercellular adhesion molecule-1 as markers for inflammation. This was a prospective cohort study looking at 27,111 women over the age of 45 who participated in the Women’s Health Study. The authors found that the metabolic syndrome was associated with a modestly increased risk of symptomatic PAD – adjusted hazard ratio 1.48 (95% confidence interval 1.01 to 2.18). They postulate that this may be mediated by inflammation, given the significantly higher levels of C-RP and intercellular adhesion molecule-1 in subjects with the metabolic syndrome [3]. More data are needed to understand this possible mechanism and help patients successfully modify their risk of disease.

Even closer to home, JAMA featured two articles addressing primary care physician well-being and internal medicine resident fatigue and distress, both of which may affect patient care. We are all aware that there has been a decrease in graduates entering primary care and attrition among current providers. Burnout may be a factor. An article by Michael Krasner et al studies whether a continuing medical education program that teaches primary care physicians about mindfulness, communication, and self-awareness could improve physician well-being, reduce distress and burnout, and improve capacity to relate to patients. Mindfulness can be loosely defined as being “present in the moment.” Seventy primary care physicians in Rochester, New York, enrolled in the study, which consisted of an 8-week intensive phase (2.5 hours per week with a 7-hour retreat) followed by a 10-month maintenance phase (2.5 hours per month). The average number of hours attended was 33.6 out of a possible 52 hours. Sessions included didactic material, meditation, and use of written narrative and group discussions to promote communication and reinforce positive experiences. Mindfulness and other outcomes were measured by surveys throughout the study. Participants showed improvements in mindfulness with decreased burnout, and reported improvements in mood, conscientiousness, and emotional stability. These benefits were sustained over the duration of the study period [4]. The personal significance and long-term sustainability of these changes for the individuals who participated is difficult to characterize. A benefit of such training among a larger physician population, and the feasibility of such training, remains uncertain without further research. Nevertheless, this study does give us reason to pause and recall the old proverb physician, heal thyself.

Directly tying physician well-being to patient care, a study out of the Mayo Clinic investigates the association between fatigue and distress among internal medicine residents with rates of self-perceived major medical errors. This study followed 380 residents between 2003 and 2009, throughout which time the current work-hour regulations were in effect. Subjects completed quarterly surveys regarding self-assessments of medical errors, quality of life, fatigue, depression, and sleepiness. The investigators found higher rates of medical errors among those with greater fatigue (OR 1.14 per unit change in fatigue score, 95% confidence interval 1.03-1.16), and in those with components of distress such as burnout, depersonalization, emotional exhaustion, and depression. For example, residents with a positive depression screen were more likely to report having made a medical error, with OR 2.56 (95% confidence interval 1.76-3.72) [5]. The clinical significance of the self-reported medical errors is not elucidated in the trial, and the generalizability of these results to other residency programs is uncertain. Moreover, there may be overlap between fatigue and distress that makes the individual effects of these two commonplace entities difficult to assess. However, this study supports a hypothesis that many of us would probably believe from personal experience, which is that less stressed and better rested residents are less error-prone.

On an unrelated but important a public health note, the worldwide preparation for the swine flu was addressed in the news and the medical literature this week. This week’s Science documents the major vaccine program against H1N1 influenza already underway in China. As of mid-September, doctors, nurses, border staff, and the military have started to receive the vaccine, with school children coming next. Chinese authorities have 650,000 doses on hand already. They expect 7 million more by the end of the month, 50 million more by mid-October, and 18 million a week after that, with the hope of vaccinating a majority of their 1.3 billion people [6]. In the US, the effort is not far behind. One aspect of the vaccine effort in the US that is still up for debate, as reported in Nature Medicine is whether to allow adjuvants to be added to the vaccine to boost vaccine effectiveness. This could help stretch the vaccine supply, as lower doses may be required to achieve an adequate response. The European Medicines Agency appears poised to approve adjuvanted vaccines soon. The FDA is awaiting results from two trials using adjuvants, which should be available in late September or early October, to help make its decision [7]. Stay tuned. While efforts at mindfulness or decreased fatigue may seem like elusive goals this fall, getting vaccinated against H1N1 should be possible for all of us.

Dr. Crittenden is a 3rd year internal medicine resident at NYU Medical Center.

Peer reviewed by Michael Tanner MD, Section Editor, Clinical Correlations

1. Fortuna RJ, Robbins BW, Halterman JS. Ambulatory care among young adults in the United States. Ann Intern Med. 2009;151:379-385. (

2. Stessman J, Hammerman-Rozenberg R, et al. Physical activity, function, and longevity among the very old. Arch Intern Med. 2009;169(16):1476-1483. (

3. Conen D, Rexrode KM, et al. Metabolic Syndrome, Inflammation, and Risk of Symptomatic Peripheral Artery Disease in Women. Circulation. 2009;120:1041-1047. (

4. Krasner MS, Epstein RM, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA 2009;302(12):1284-1293. (

5. West CP, Tan AD, et al. Association of resident fatigue and distress with perceived medical errors. JAMA 2009;302(12):1294-1300.

6. Stone R. China first to vaccinate against novel H1N1 virus. Science. 2009 Sep 18;325(5947):1482 – 1483. (

7. Schubert C. Swine flu agitates the adjuvant debate. Nature Medicine. 2009;15(9):986-987. (

PrimeCuts: This Week in the Journals

September 21, 2009

healthcareCarolyn Bevan MD

Faculty Peer Reviewed

With health care spending increasing at an unsustainable rate while an estimated 46 million Americans live without insurance [1], the urgent need for healthcare reform in the US is clear. Much less obvious, however, is how to go about it. At the beginning of the month, President Obama addressed Congress in a political call to arms, emphasizing that Americans must come together to address this important issue. This week, many of the major medical journals weighed in on the debate.

For those of us who have been unable to keep up with the healthcare debate this week, it may be helpful to start with a brief overview of a few key developments. The main piece of legislation under debate at the time of the president’s speech was the Affordable Health Choices Act, which would incorporate reform of existing insurance structures while introducing a “public option” for individuals who are unable to obtain private insurance [2]. While the bill represents an important step forward in healthcare reform, according to preliminary estimates by the Congressional Budget Office (CBO), it would increase the federal budget deficit by $1.0 trillion over the ensuing decade and expand coverage to only 16 million previously uninsured Americans [3]. In response to these and other concerns, Senator Max Baucus, chairman of the Senate Finance Committee, introduced “The Baucus Bill.” Made public this week, the bill would, among other things, mandate some form of insurance coverage for most Americans, without a new public option, while incorporating insurance industry reform and implementing strategies to control cost [4]. According to the CBO, the Baucus Bill would actually lower the federal deficit by $16 billion over the next decade, while expanding coverage to 29 million previously uninsured Americans [5]. Still, some Democrats are concerned that mandating insurance will put even more strain on middle income families, while some Republicans call the bill “a back door to the public option.” [6] As Congress continues to fight it out, the editors of the major medical journals have been monitoring the debate, and this week, they focused on the dollars and cents of US healthcare reform.

This week’s New England Journal of Medicine features a perspective article entitled System Wide Cost Control – the Missing Link in Healthcare Reform, in which co-authors Jonathan Oberlander, Ph.D., and Joseph White, Ph.D. question the efficacy of regulating costs by cuts in federal spending alone. Their main concern is that isolated federal cost cuts would limit cost control to Medicare, which would ultimately result in cost shifting to private payers rather than resulting in real cuts in healthcare spending. To address this issue, they advocate for a system of “all payer regulation,” which they define as meetings of insurers with government agents to negotiate regional standardization of payment schedules and fees for medical care reimbursement. Such systems are already used by Germany, Japan, and the Netherlands – all countries featuring multiple insurers rather than single payors. In these countries, all-payer systems have been shown to reduce prices, avoid cost shifting, simplify billing, and allow private and public insurers to, not only coexist, but work together to contain healthcare spending. The authors conclude that any healthcare legislation will have to address cost control while avoiding significant disruptions in care, and they assert that this cannot be achieved by focusing on federal systems alone [7].

The Journal of the American Medical Association also featured a commentary on cost control by Stephen M. Shortell, PhD, MPH, MBA, from the UC Berkley School of Public Health. Dr. Shortell echoes the concern that the cost of expanding insurance coverage will not be adequately offset by the cost control strategies currently under discussion. He suggests a method of “bending the cost curve” to address the underlying causes of skyrocketing healthcare costs. Firstly, he advocates changes at the community level, including focus on disease prevention initiatives. He cites physical activity, nutrition, and smoking cessation as three targets that have shown excellent return on resource investment, both in terms of cost savings and patient welfare. Secondly, he highlights the need for changes at the hospital and physician level, mainly through changes in organizational structure. He suggests the establishment of “Accountable Care Organizations” (ACOs): groups of physicians, hospitals, and other players in the health care industry who would come together to maximize efficiency in controlling healthcare resources. He also recommends that a Center for Comparative Effectiveness Research be founded to collect data and make recommendations about which treatments, interventions, or health promotion strategies are most cost effective and efficient. These concepts seem to echo the “all payer regulation” referred to in the NEJM article, and perhaps highlight a general feeling among public health authorities that providers must increase collaboration and work together to gather evidence to control the costs of healthcare [8].

And what to physicians think about all this? The NEJM reports on a cross-sectional study conducted earlier this year to gauge physicians’ opinions on healthcare reform and cost control strategies. In the study, surveys were sent to 2000 practicing physicians in all specialties. Participants were asked to indicate their level of agreement or disagreement with three statements regarding health care ethics and policy. The statements were as follows (1) “Addressing societal health policy issues, as important as that may be, falls outside the scope of my professional obligations as a physician.” (2) “Every physician is professionally obligated to care for the uninsured and underinsured.” (3)”I would favor limiting reimbursement for expensive drugs and procedures if that would help expand access to basic health care for those currently lacking such care.” They were then asked to indicate whether they had “no” “moderate” or “strong” moral objection to “using cost-effectiveness data to determine which treatments will be offered to patients.” In addition to general demographic information, the physicians were also asked to identify their specialty and classify themselves as conservative, moderate, or liberal on “social issues.” The response rate was 51%, with some variance by region and age category, but not by sex or specialty. Results showed that 78% of respondents felt obligated to address health policy issues, 73% felt obligated to care for the uninsured or underinsured, and 67% would favor limiting reimbursement for expensive interventions in exchange for expanded access. Physicians expressed less comfort with allowing cost-effectiveness studies to determine treatment: a slim majority of 54% did have a moral objection to using cost-effectiveness analysis “to determine which treatments will be offered to patients.” Researchers suggest that physicians may feel unsure of how to incorporate this type of analysis into their practice, while they may also have concerns that an emphasis on cost might disrupt the physician-patient relationship. Based on these data, researchers concluded that while physicians are willing participants in the healthcare debate, they may be slightly more resistant when it comes to implementing many of the currently proposed cost containment strategies. These concerns will need to be addressed if the current health care reform proposals are to be successful [9].

Clearly, the debate on healthcare reform is far from over. In addition to the economic challenges of meaningful reform, as highlighted in the journals this week, there is a deep obligation to secure and uphold high quality patient care. Given the demands of practicing in America, it is difficult for many physicians to participate in the healthcare debate, but it is important for them to lend their unique perspective on the realities of implementing new systems, and to be champions of the ideals of beneficence and nonmaleficence this profession holds so dear. Changes will be difficult, but it is obvious that maintaining the status quo is simply not an option. In the words of President Obama, “we did not come here just to clean up crises. We came here to build a future.”

Dr. Bevan is a 1st year internal medicine resident at NYU Medical Center.

Reviewed by Michael Poles MD, Associate Editor, Clinical Correlations, Assistant Professor of Medicine, NYU Division of Gastroenterology 

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2. Elmendorf, D “Preliminary Analysis of Major Provisions Related to Health Insurance Coverage Under the Affordable Health Choices Act” [Internet]. Washington, DC: Congressional Budget Office; 2009 June 15 [cited 2009 September 21]. 10p. Available from:

3. America’s Affordable Health Choices Act: Quality Affordable Health Care: Summary. [Internet]. Washington, DC: House Committees on Ways and Means, Energy and Commerce, and Education and Labor. 2009 July 1 [cited 2009 September 21]. 4p. Available from:

4. “Half a Loaf, or Half-Baked?” The Economist. 2009 September 17. Available:

5. Elmendorf, D “Preliminary Analysis of Specifications for the Chairman’s Mark of the America’s Healthy Future Act” [Internet]. Washington, DC: Congressional Budget Office; 2009 September 16 [cited 2009 September 21]. 24p. Available from:

6. Hitt G “Baucus Will Tinker with Health Bill to Mollify Critics” The Wall Street Journal. 2009 September 18, Page A4. Available:

7. Oberlander J, White J “Systemwide Cost Control – The Missing Link on Health Care Reform” N Engl J Med. 2009 Sep 17;361(12):1131-3. Epub 2009 Sep 2. (

8. Shortell SM “Bending the Cost Curve: A Critical Component f Health Care Reform” JAMA. 2009 Sep 16;302(11):1223-4. (

9. Antiel RM, Curlin FA, James KM, Tilburt JC “Physicians’ Beliefs and U.S. Health Care Reform – A National Survey” N Engl J Med. 2009 Sep 14. (

10. Obama, Barack. “Remarks by the President to a Joint Session of Congress on Health Care.” U.S. Capitol. Washington, D.C., 9 Sep. 2009. Available: