Primecuts – This Week In The Journals

January 18, 2011

By Keri Herzog, MD

Faculty Peer Reviewed

This past week we watched the nation come together following the shootings in Tucson, Arizona. President Obama eulogized those killed in the tragedy and urged us to ensure that we are “talking with each other in a way that heals.” As a grieving nation struggled to find meaning in the actions of a troubled young assassin, the President also reminded us that “terrible things happen for reasons that defy human understanding.” While we cannot always find simple explanations for unfortunate events such as this, physicians and scientists from around the world showed us how we can improve our health and quality of life, as topics in disease prevention and health promotion made headlines this week.

 In recent news, the US Food and Drug Administration approved the human papillomavirus vaccine Gardasil for use in the prevention of anal cancer [1]. This vaccine had already been approved to protect young women against vaginal, cervical and vulvar cancer. Recent studies have shown the vaccine to also be effective in preventing precancerous anal lesions.

 Additionally, the efficacy of the herpes zoster vaccine was evaluated this week in a new study published in JAMA [2]. While evidence has shown that the herpes zoster vaccine works in selected study groups, this retrospective cohort study focused on a very general population: immunocompetent community-dwelling adults over the age of 60. More than seventy-five thousand individuals in the vaccinated cohort were age matched (1:3) to 227, 283 unvaccinated members.  The number of herpes zoster cases among vaccinated individuals was 828 or 6.4 per 1000 person-years, compared to 4,606 or 13 per 1000 person-years in the unvaccinated group. Using an adjusted analysis, vaccination was associated with a reduced risk of herpes zoster (hazard ratio, 0.45; 95% confidence interval, 0.42-0.48). Unlike earlier research, this very large cohort study supported the use of the zoster vaccine in the general population and it showed a decreased risk of zoster across all age strata and in those with chronic diseases. 

 Protection from colorectal cancer was also discussed this week in the Annals of Internal Medicine [3]. While colonoscopy has been studied and proven to reduce colorectal cancer incidence by early detection and removal of adenomas, the degree of risk reduction in patients with prior colonoscopies has not been previously quantified. In this population-based case-control study, 1,688 case patients with colorectal cancer and 1,932 control patients, all older than 50 years, were identified to assess the association between previous colonoscopy and colorectal cancer risk. The results demonstrated that a colonoscopy done in the preceding 10 years was associated with a 77% lower risk for developing colorectal cancer and a significantly decreased risk at any colonic site (except for right-sided cancers in individuals aged 50-59). The big limitation of this study is its observational nature which makes it more prone to confounding and other biases. Overall, this study and its risk reduction data remind us of the importance of colonoscopy for screening and the prevention of colon cancer. 

 Smoking cessation was also highlighted in the Archives of Internal Medicine this week [4]. Reducing the prevalence of smoking continues to be a worldwide challenge. Acknowledging the importance of this problem, Graham et al. encouraged us to take a proactive approach toward addressing this issue. They used a three-arm, randomized controlled study to determine the effect of internet and internet-plus-telephone treatment strategies on smoking cessation. The three treatment groups consisted of a basic internet group, enhanced internet group, and a combined enhanced internet and telephone treatment group. The three-year trial included adults if they smoked 5 or more cigarettes per day. The outcome measure was the 30-day point prevalence of abstinence measured at 3, 6, 12, and 18 months. At 18 months the abstinence prevalence was the highest in the combined internet and telephone group (7.7%) compared to 3.5% and 4.5% in the basic and enhanced internet groups respectively. This study highlights that smoking cessation, while difficult, is more successful via a multifaceted approach.

 In a comparative effectiveness trial published in JAMA this week, two ARBs, candesartan and losartan, were compared to study their effects on mortality in patients with heart failure [5]. These drugs are commonly used and are known to reduce mortality and hospitalization rates. A total of 5139 patients from the Swedish Heart Failure Registry were treated with candesartan (2639) or losartan (2500) and the main outcome was all-cause mortality at 1 and 5 years. The researchers found that 1- and 5-year survival for patients receiving candesartan was 90% and 61%, and those for losartan were 83% and 44%, respectively. The reported hazard ratio was 1.43 (95% confidence interval, 1.23 -1.65, p<.001) for losartan compared to candesartan (HR, 0.7 for candesartan compared to losartan), showing that candesartan was associated with a lower 1- and 5-year mortality. Many experts believe that a CER trial such as the trial discussed above have the potential to improve the quality of health care and reduce health care spending by “optimizing health while minimizing waste.” States such as Oregon have developed an approach for evidence-based coverage policies in an attempt to provide quality health care to more people [6].

 In other health care improvement news, the Infectious Diseases Society of America published its first clinical practice guidelines for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) this week [7]. These guidelines provide recommendations on management of common syndromes due to MRSA infections, allowing us to better care for our patients.

 In the aftermath of the events in Arizona this past week, it is comforting to know that while some things cannot be explained, the medical journals showed us that certain preventative measures taken today can have lasting positive impacts on our lives. 

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

Peer reviewed by Ishmeal Bradley, MD, Section editor, Clinical Correlations

Image courtesy of Wikimedia Commons

References:

1. US Food and Drug Administration. Gardasil approved to prevent anal cancer. Press Release. December 22, 2010. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm237941.htm. Accessed January 5, 2011

2. Tseng HU, Smith N, Harpaz R, et al. Herpes zoster vaccine in older adults and the risk of subsequent herpes zoster disease. JAMA 2011; 305 (2): 160-166. http://jama.ama-assn.org/content/305/2/160.full

 3. Brenner H, Chang-Claude J, Seiler CM, Rickert A, Hoffmeister M. Protection from colorectal cancer after colonoscopy: a population-based, case-control study. Ann Intern Med January 4, 2011; 154: 22-30. http://www.annals.org/content/154/1/22.full.pdf+html

 4. Graham AL, Cobb NK, Papandonatos GD, et al. A randomized trial of internet and telephone treatment for smoking cessation. Arch Intern Med 2011; 171: 46-53. http://archinte.ama-assn.org/cgi/content/full/171/1/46

 5. Eklind-Cervenka M, Benson L, Dahlstrom U, et al. Association of candesartan vs. losartan with all-cause mortality in patients with heart failure. JAMA 2011; 305 (2): 175-182. http://jama.ama-assn.org/content/305/2/175.full.pdf+html

 6. Saha S, Coffman DD, Smits AK. Giving teeth to comparative-effectiveness research-the Oregon experience. N England Journal of Medicine 2010; e18(1)-e18(3). http://www.nejm.org/doi/pdf/10.1056/NEJMp0912938

 7. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011; 52: 1-38. http://cid.oxfordjournals.org/content/early/2011/01/04/cid.ciq146.full.pdf+html

 

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