Primecuts – This Week In The Journals

September 13, 2011

By Joshua Strauss, MD

Faculty Peer Reviewed

This past week included the 10th anniversary of the 9/11 terrorist attacks against our city and our nation. We remember the horror of that morning, as well as the unity and selflessness displayed by great Americans in the ensuing days, weeks, months and years. We will never forget the events of that morning, even as we continue to heal.

On to the journals:

This past Thursday the FDA advisory panel recommended approval of Rivaroxaban for the prevention of strokes in patients with atrial fibrillation. [1] This has been a prominent theme in the past year as the parade of Coumadin replacements continues to impress.

However, another potential intervention for the prevention of stroke – cerebral artery stents – was shown to be quite disappointing. The results of the SAMMPRIS trial (Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis) were published online by the New England Journal of Medicine on September 7th. [2] The trial randomized patients with recent TIA’s or strokes attributed to stenosis to either medical management or medical management plus percutaneous transluminal angioplasty and stenting (PTAS). Enrollment was stopped after 451 patients underwent randomization, because the 30-day rate of stroke or death was 14.7% in the PTAS group and 5.8% in the medical-management group (P = 0.002). Surprisingly, up to a third of the strokes in the stented group were hemorrhagic. In an accompanying editorial, the author suggests that the higher rate of hemorrhagic stroke in this group was related to reperfusion injury as well as the technical difficulty in stenting intracranial vessels, as compared to extracranial vessels. The patients in the medical management group did remarkably better than expected, further supporting the need to aggressively manage risk factors in our outpatient clinics.

While medical therapies work well for stroke prevention, surgical intervention is preferred for morbid obesity when lifestyle modification fails. In the Annals of Internal Medicine, two of the most common surgical procedures for obesity, the duodenal switch and the gastric bypass, were compared in a randomized, head-to-head trial. [3] With approximately 30 patients in each group, the duodenal switch group demonstrated more weight loss, but also more adverse events. An editorialist in the same issue questions whether there is any role left for the duodenal switch operation given the severity and frequency of its complications.

Of course, the solution to the obesity epidemic lies deeper than determining the optimal surgery. We already know that the risk of death from any cause among white women increases with an increasing BMI of 25.0 or higher – and this week in the NEJM, we see this pattern is true in black women as well. [4]

In a recent special series in the Lancet [5] dedicated to the obesity epidemic, the journal calls for “government leadership to turn the epidemic around using available cost-effective policies and programs, backed up by adequate monitoring and evaluation.” The four part series discusses obesity: “its drivers, its economic and health burden, the physiology behind weight control and maintenance, and what science tells us about the kind of actions that are needed to change our obesogenic environment and reverse the current tsunami of risk factors for chronic diseases in future generations.”

As was published in a previous Primecuts section (August 8,2011), [6] perhaps the most intriguing article published this past week for those of us still in training was a review in the Annals entitled “’July Effect’: Impact of the Academic Year-End Changeover on Patient Outcomes.” Young and colleagues performed a systematic review of 39 studies looking at how changeovers effect mortality and efficiency in the hospital.  Although the literature does not allow firm statements to be made regarding the degree of risk posed, how changeover affects morbidity and rates of medical errors, or whether particular models are more or less problematic, it is clear and startling that mortality increases and efficiency decreases in hospitals because of year-end changeovers. [7] Efficiency was defined by length of stay, duration of procedure, and hospital charges.

As the academic year is still in its infancy, this serves as a stark reminder for us to ensure that we are providing adequate supervision to those who require it, and that we are seeking help for ourselves when we need it. The consequences of not doing so can be severe, and they are often preventable.

Dr. Joshua Strauss is a third year resident in internal medicine at NYU Langone Medical Center.

Peer Reviewed by Robert J Gianotti, MD, Associate Editor, Clinical Correlations

References:

1) Manesh R. Patel et al and the ROCKET AF Steering Committee for the ROCKET AF Investigators. Rivaroxaban versus Warfarin in Nonvalvular Atrial Fibrillation. New England Journal of Medicine. 2011 September 8. 365:883-891. http://www.nejm.org/doi/full/10.1056/NEJMoa1009638

2) Marc I. Chimowitz et al and the the SAMMPRIS Trial Investigators. Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis. New England Journal of Medicine. 2011 September 7. Published Online. http://www.nejm.org/doi/full/10.1056/NEJMoa1105335

3) Torgeir T. Søvik, Erlend T. Aasheim, Osama Taha, My Engström, Morten W. Fagerland, Sofia Björkman, Jon Kristinsson, Kåre I. Birkeland, Tom Mala, and Torsten Olbers. Weight Loss, Cardiovascular Risk Factors, and Quality of Life After Gastric Bypass and Duodenal Switch: A Randomized Trial. Ann Intern Med September 6, 2011 155:281-291. http://www.annals.org/content/155/5/281.abstract

4) Deborah A. Boggs, Sc.D., Lynn Rosenberg, Sc.D., Yvette C. Cozier, D.Sc., Lauren A. Wise, Sc.D., Patricia F. Coogan, D.Sc., Edward A. Ruiz-Narvaez, Sc.D., and Julie R. Palmer, Sc.D. General and Abdominal Obesity and Risk of Death among Black Women. New England Journal of Medicine. 2011 September 8. 365:901-908 http://www.nejm.org/doi/full/10.1056/NEJMoa1104119

5) http://www.thelancet.com/series/obesity

6) Toklu, Bora. Clinical Correlations: Primecuts. August 8, 2011. http://www.clinicalcorrelations.org/?p=4663

7) Young JQ, Ranji SR, Wachter RM, Lee CM, Niehaus B, Auerbach AD. “July Effect”: Impact of the Academic Year-End Changeover on Patient Outcomes. A Systematic Review. Annals of Internal Medicine. 2011 September  6. http://www.annals.org/content/155/5/309.abstract

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