Primecuts: This Week in the Journals

April 19, 2010

Chau Che, MD

Faculty Peer Reviewed

In the economic news this week, the Dow Jones Industrial Average closed above 11,000 for the first time since September 2008.  It appears that the economy is rebounding, and despite the news of fraud charges against Goldman Sachs at the end of the week, the Dow Jones still managed to close the week above 11,000.  This provides hope that the United States is heading towards economic recovery. The medical journals also echoed hopes of recovery by addressing recovery from diseases that plague our patients.

This week, in a multicenter trial, randomized, double-blinded trial, the New England Journal of Medicine examined clinical remission in patients with active Crohn’s disease who did not have a response to first-line therapy (1). The study compared the efficacy of infliximab and azathioprine therapy alone or the two drugs combined for inducing and maintaining corticosteroid free clinical remission in patients with moderate to severe Crohn’s disease.  The primary end point was corticosteroid free clinical remission at week 26.  At week 26, 56.8% of patients receiving combination therapy as compared with 44.4% receiving infliximab alone (p =0.02) and 30% receiving azathioprine alone (p < 0.001 when comparing with combination therapy and p = 0.006 when comparing with infliximab) were in corticosteroid free remission.  These results were mirrored similarly in week 50 analysis.  In studying recovery from Crohn’s disease in this article, combination therapy with infliximab plus azathioprine as compared with azathioprine alone or infliximab alone demonstrated the highest rates of corticosteroid free clinical remission in patients with moderate to severe Crohn’s disease.

The Journal of the American Medical Association addressed how the lack of health insurance and financial concerns may affect the time from symptom onset in an acute myocardial infarction to hospital presentation (2). This multicenter prospective trial showed that in analyses adjusted for study site only and then separately adjusted for potential confounders, insured patients with financial concerns and uninsured patients had longer delays to hospital presentation.  The article presents conclusions that are not surprising, since the lack of health insurance cause patients to delay seeking care for their medical issues.  However, it also examines the issue of the underinsured patient and how this may cause delays in seeking adequate care in emergent situations.  Acute myocardial infarction is a disease entity in which time is crucial in order to save viable myocardium. The delay may result in significant morbidity and mortality.  Recovery from a myocardial infarction can be drastically compromised if patients fail to seek healthcare in the appropriate time frame.  The issue of finances proved to be a significant barrier in accessing healthcare and may affect the recovery of a patient.

In some chronic disease states such as diabetes, recovery from a disease is not possible, however clinicians seek to prevent sequelae from the disease.  This is of particular importance in diabetes, and leads to aggressive screening of patients for diabetes.  The Lancet this week examines the cost effectiveness of screening to detect new cases of type 2 diabetes (3). A sample of the US population was used to create a simulated population of 325,000 people over thirty years old without diabetes.  Eight simulated screening strategies for type 2 diabetes were used and once diabetes was diagnosed, treatment was simulated and the effects of each strategy on the incidence of type 2 diabetes and its sequelae in additional to quality of life and costs were calculated.  The findings showed that compared with no screening, all screening strategies reduced the incidence of diabetes complications and increased the number of quality-adjusted life years.  However, in comparing the screening strategies, screening for type 2 diabetes was determined to be the most cost effective when screening began between thirty and forty-five years old, with screening repeated every three to five years.  This article demonstrates that in some disease states, such as diabetes, the most important aspect is detection through screening modalities in order to prevent future complications such as cerebrovascular and cardiac events.

The New England Journal of Medicine also looked at recovery after a myocardial infarction and the proper medications needed for such patients to aid in their recovery.  Park et al. studied the duration of antiplatelet therapy after implantation of drug-eluting stents (4). The trial enrolled patients who had received drug eluting stents and had been free of major adverse cardiac or cerebrovascular events for at least twelve months to receive clopidogrel plus aspirin or aspirin alone.  The primary endpoint examined was myocardial infarction or death from cardiac causes.  At two years, the risk of myocardial infarction was 1.8% with dual antiplatelet therapy and 1.2% with aspirin monotherapy (hazard ratio, 1.65, 95% CI 0.80 to 3.36, p = 0.17).  The study shows that the use of dual antiplatelet therapy for longer than twelve months in patients with drug-eluting stents was not significantly more effective than aspirin monotherapy in reducing the rate of myocardial infarction or death from cardiac causes.  Although this article shows that recovery from a myocardial infarction may not include the need for indefinite dual antiplatelet therapy, the necessity for larger randomized clinical trials with longer term followup is clear before these recommendations for recovery of patients with drug eluting stents will become guidelines.  Until these trials are conducted, this is an area of uncertainty that continues to plague physicians in determining the best manner to guide their patients into recovery.

In examining the medical journals and the economy this week, a central theme seemed to permeate throughout: recovery.  As the country continues to try and recover from the economic recession, the medical journals focus on aiding recovery from disease.

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

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

References

1.  Colombel, J.F., et al. Infliximab, Azathioprine, or Combination Therapy for Crohn’s Disease.  New England Journal of Medicine, 2010; 362: 1383-95.  http://content.nejm.org/cgi/content/full/362/15/1383

2.  Smolderen, K.G., et al. Health Care Insurance, Financial Concerns in Accessing Care, and Delays to Hospital Presentation in Acute Myocardial Infarction. The Journal of the American Medical Association, 2010; 303 (14): 1392-1400.  http://jama.ama-assn.org/cgi/reprint/303/14/1392

3.  Kahn, R., et al. Age at Initiation and Frequency of Screening to Detect Type 2 Diabetes: a Cost-Effectiveness Analysis.  The Lancet, 2010; 375: 1365-74.  http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2962162-0/fulltext#article_upsell

4.  Park, S.J., et al.  Duration of Dual Antiplatelet Therapy after Implantation of Drug-Eluting Stents.  New England Journal of Medicine, 2010; 362: 1383-95.  http://content.nejm.org/cgi/content/full/362/15/1374

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