Primecuts – This Week In The Journals

June 17, 2013

By Brian Greet, MD

Faculty Peer Reviewed

Making headlines in the news this week 94 year old Nelson Mandela appears to be recovering after again being hospitalized for pneumonia. Thought possibly to be a complication of the tuberculosis he contracted while in prison, this is the second time the previous South African president has been hospitalized for pneumonia this year. The most destructive wildfire in Colorado history continues to wreak havoc, incinerating at least 450 homes. Controversy continues after Edward Snowden, a 29 year old a contractor for the National Security Agency, released information pertaining to the methods of surveillance of US citizens. Latest comments from Dick Cheney have posited the man as a “traitor” and “deeply suspicious obviously because he went to China.” Controversy has also surrounded the very public debate over angiotensin receptor blockers between two FDA officials. The debate between Thomas Marciniak and his boss Ellis Unger, has come from the link between ARBs and cancer risk. Marciniak contests that the safety of ARBs have been reliant on summary data from drug companies and despite early studies linking a potential increase in risk, not enough evaluation has not been performed to further evaluate the risk.

On the topic of ARBS, ACEs and RAAS inhibition, the ACC/AHA have released their 2013 guidelines for the management of heart failure this week [1]. Additions to this year’s guidelines include recommendations regarding the greater role of biomarkers and their guidance in clinically euvolemic outpatients, an approach to diagnosis of dilated cardiomyopathies with the use of genetics and family screening, an expanded indication for aldosterone blockade to now include NYHA class II, more clearly defined indications for cardiac resynchronization therapy, broader recommendations for the use of mechanical circulatory support in end stage heart failure, and much more.

Diabetes, a major contributor to systolic heart failure, is notoriously difficult to treat and can be frustrating for both provider and patient alike. Surgical options for potential cure have become an interesting area of intense research as of late. Evidence has shown bariatric surgery to be beneficial in improving glycemic control in those with a BMI of greater than 35, but it has remained unclear whether or not those with a lower BMI would benefit. In a systematic review in JAMA, Maggard-Gibbons et al looked at three randomized controlled trials looking at a total of 290 patients with BMIs between 30 and 35 undergoing bariatric surgery [2]. Surgery was associated with greater weight loss and improved glycemic control over the one to two years of follow up. While interesting in its findings, long term follow up still does not exist for this patient population and the morbidities of surgery may have been underestimated due to the selectivity in participating centers. Overall, it would be premature to recommend this treatment to those with a BMI between 30 and 35 but further research is certainly warranted.

With the summer months upon us, your friendly dermatologist is likely to recommend that you lather up with sunscreen. While previously based on expert recommendation from animal models, a new study from the Annals of Internal Medicine affirms such recommendations with its findings [3]. In this randomized controlled trial, 903 Australian patients younger than 55 years old were followed for an average of 4.5 years. In a two by two study design, half of patients were randomized to daily use of broad-spectrum “sun-protection factor 15+” sunscreen while the other half continued standard sun avoidance techniques. In addition, half of those assigned to the sun screen arm and half of those assigned to the control group were given 30mg of daily ?-carotene. Patients were followed with microtopography which was graded by assessors blinded to treatment allocation. While ?-carotene showed no overall effect on skin aging, those in the sunscreen group had 24% less skin aging. Although not a direct measurement of neoplasm, skin aging has been correlated to both actinic keratoses as well as skin cancer. These findings lend further credence to current common beliefs that sunscreen is beneficial and help to bolster common practice.

Continuing in the world of oncology, the results of a recent phase III trial entitled the DECISION trial were presented at the annual American Society of Clinical Oncology meeting in Chicago this week [4]. The trial investigated the use of sorafenib in locally advanced or metastatic patients with radioactive iodine-refractory differentiated thyroid cancer. Sorafenib, an oral inhibitor of VEGFR1-3 and Raf kinases, was randomly given to 207 of 417 patients included in the study. Patients all had locally advanced or metastatic RAI-refractory disease. The primary endpoint of investigation was progression-free survival. Median progression-free survival was found to be 10.8 months in the sorafenib arm versus 5.8 months in the placebo arm. Costs are estimated to be around $96,000 per year of treatment. This news is exciting given the lack of current therapeutic treatments for advanced thyroid cancer, though it still remains unclear whether or not this treatment will impact mortality.

Additional interesting reads this week…

Barefoot or Not?

Don’t lose the shoes just yet! The hallmark of barefoot running is that it promotes forefoot landing, whereas those wearing shoes are generally heel strikers. In this physiologic study, 37 experienced runners of whom 19 were habitual heel-strikers and 18 were fore-strikers were monitored for physiologic outcomes [5]. The participants were monitored using their natural method of running and then made to cross over into the opposite running style group where physiologic data was again recorded. Ultimately in this study heel-strikers won out in terms of running efficiency by a considerable margin requiring less oxygen consumption and burning fewer carbohydrates as a percentage of their energy exposure.

Dr. Brian Greet is Chief Medical Resident at NYU Langone Medical Center

Peer reviewed by Deborah Shapiro, MD, wife of Editor-In-Chief Neil Shapiro, Clinical Correlations

Image courtesy of Wikimedia Commons

References

[1] Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2013.  http://www.cardiosource.org/Science-And-Quality/Journal-Scan/2013/06/2013-ACCF-AHA-Guideline-for-the-Management-of-Heart-Failure.aspx

[2] Maggard-Gibbons M, Maglione M, Livhits M, et al. Bariatric Surgery for Weight Loss and Glycemic Control in Nonmorbidly Obese Adults With Diabetes: A Systematic Review. JAMA. 2013;309(21):2250-2261.  http://www.ncbi.nlm.nih.gov/m/pubmed/23736734/

[3] Maria Celia B. Hughes, Gail M. Williams, Peter Baker, Adèle C. Green. Sunscreen and Prevention of Skin Aging, A Randomized Trial. Annals of Internal Medicine. 2013 Jun;158(11):781-790.  https://annals.org/article.aspx?articleid=1691733

[4] Marcia S. Brose et al. (2013, May). Sorafenib in locally advanced or metastatic patients with radioactive iodine-refractory differentiated thyroid cancer: The phase III DECISION trial. 2013 ASCO Annual Meeting, Chicago, IL.

[5] Gruber AH, Umberger BR, Braun B, Hamill J. Economy and rate of carbohydrate oxidation during running with rearfoot and forefoot strike patterns. J Appl Physiol. 2013 May 16.  http://www.ncbi.nlm.nih.gov/pubmed/23681915

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