Primecuts-This Week in the Journals

June 28, 2010

File:Lab coat and scrubs.jpgMichael Fingerhood, MD, MPH

Faculty Peer Reviewed

Ah, the long balmy days of summer in New York, replete with dining al fresco, Shakespeare in The Park, bumper-to-bumper traffic to our pristine (for now, at least) local beaches, and of course the armies of fresh-faced, eager young Housestaff  proudly marching through the wards in their new long white coats. July 1st quickly approaches, and with it NYU’s new interns (myself included) excitedly begin their vital role within the nation’s healthcare system. Yet behind this excitement lies trepidation over exactly what the next twelve months hold. This week’s Primecuts is dedicated to the exploration of this angst.

One question most interns ask themselves is, between our patient care and medical education duties, how will we ever have find the time to sleep? While there are no easy answers, we can take heart in knowing the ACGME is looking out for us (more exactly the intern class of 2011). According to the New England Journal of Medicine, the ACGME has proposed changes to the work hour requirements for residency programs to take effect next July [1]. Under the new proposed requirements, continuous work hours for interns will be reduced to a maximum of 16 hours per day, with up to four hours additional “to provide for the transfer of [patient] care”. Junior and senior resident work hour limits will remain at the current 24 hours, as will requirements for time off (24 hours per week) and total work hours (80 hours per week).

Another major cause of anxiety for the incoming intern is the question of how we will ever remember all the medicine we learned as third and fourth year medical students but subsequently forgot in the past 6 months or so since we last had an inpatient rotation. Speaking of memory, The New York Times reported this week that a new radioactive dye may represent a huge leap forward in Alzheimer’s disease research [2]. Brain PET scans of patients who had been injected with the dye, made from Flourine-18, were shown in a clinical trial to provide precise and accurate measurements of the Beta-amyloid plaques diagnostic of Alzheimer’s disease when compared to subsequent post-mortem autopsies. If approved by the FDA, this dye could fundamentally alter the way Alzheimer’s is diagnosed and monitored, both in terms of disease progression and treatment response. The results of the study, funded by the company Avid Pharmaceuticals (which makes the dye), will be presented at the International Conference on Alzheimer’s Disease in Honolulu in July. 

Another issue facing interns is how to maintain a healthy diet. Apparently, one thing we can do is switch from white to brown rice; this week’s edition of Archives of Internal Medicine contains a study by Dr. Qi Sun and colleagues at the Harvard School of Public health which purports to show a relationship between the type of rice consumed and the risk of developing type II Diabetes Mellitus (DM) [3]. Sun et al obtained dietary and health outcomes data from three separate prospective cohort studies (all of which had annual questionnaires on dietary intake and health) and performed a survival analysis, using cox proportional hazards ratios to obtain relative risk (RR) for DM based on various levels of white rice and brown rice consumption separately. They then performed a pooled analysis to estimate the effect on RR of substituting brown rice intake for white rice intake. To adjust for potential confounding variables, established risk factors for DM (including age, ethnicity, BMI and family history of DM) were included in the model. Results showed that between the three studies there was an average reduction in risk of developing DM of 16% by switching rice consumption from 50 grams of white rice to 50 grams of brown rice daily. Although the study suffers from several methodological issues (most notably missing data on dietary variables which the author’s filled in using prior years’ responses), based on these results I would still suggest we get our burritos with brown rice… just don’t use that as an excuse to get extra cheese as well. 

Of all the things I am worried about most as an intern, tops on the list  is caring for the patient suffering from acute variceal bleeding. This week in The New England Journal of Medicine, a new study by Dr. Garcia-Pagan and colleagues from the hepatic hemodynamic laboratory at the University of Barcelona shows a change in the current standard of care may yield major improvements in long-term outcomes [4]. Garcia-Pagan et al randomly assigned 63 cirrhotic patients with acute variceal bleeding confirmed on endoscopy who were at high risk for re-bleeding (Child-Pugh class C or class B with persistent bleeding at endoscopy) to standard therapy of propanalol and endoscopic band ligation, with later insertion of transjugular intrahepatic portosystemic shunt (TIPS) as rescue therapy if needed (31 patients total) or TIPS therapy within the first three days of treatment (32 patients total). Over the ensuing 16 months of follow-up on average, compared to the standard treatment group those in the early-TIPS group had lower incidences of re-bleeding (14 versus 1 respectively, p=0.001) and lower mortality rates (12 versus 4 respectively, p=.01) without any significant differences in adverse events. Although the primary composite endpoint of this study was re-bleeding and not mortality (so the study may not be have been adequately powered for determining differences in mortality between the two groups) the size of the treatment effect seen in this study makes it clear that in this patient population, use of TIPS as a first-line therapy is clearly the preferable choice.

While all of us as incoming interns know the road ahead is long and arduous, we also know it is rewarding and exciting; plus we take heart in the knowledge that we have such wonderful residents, attendings, nurses and ancillary staff to educate us and support us. Good luck to this year’s intern class and look out each week for a new edition of Primecuts!

Michael Fingerhood is a very soon to be first year internal medicine resident at NYU Langone Medical Center

Peer reviewed by Danise Schiliro, MD Contributing Editor, Clinical Correlations

References:

  1. Nasca, TJ, Day, SH et al. The New Recommendations  on Duty Hours from the ACGME Task Force. [Internet] New England Journal of Medicine; 2010, June 23rd. http://content.nejm.org/cgi/content/full/NEJMsb1005800
  2. Kolata, G. The Vanishing Mind – Promise Seen for The Detection of Alzhemier’s. [Internet] The New York Times; 2010 June 23rdhttp://www.nytimes.com/2010/06/24/health/research/24scans.html
  3. Sun, Q, Spiegelman, D et al. White Rice, Brown Rice, and Rick of Type 2 Diabetes in US Men and Women. Archives of Internal Medicine; 2010 June 24; 170(11): 961-969. http://archinte.ama-assn.org/cgi/content/abstract/170/11/961
  4. Garcia-Pagan, JC, Caca, K et al. Early Use of TIPS in Patients with Cirrhosis and Variceal Bleeding. New England Journal of Medicine; 2010 June 24; 362: 2370-9.  http://content.nejm.org/cgi/content/short/362/25/2370

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