Primecuts – This Week In The Journals

July 8, 2013

By Matthew Light, MD

Faculty Peer Reviewed

As summer continues, the heat presses on, the inevitable slow march towards shorter days progresses and NYU Langone Medical Center marked its first week with a new class of interns. There is much in the news including political unrest in Egypt, verbal escalation in the New York City mayoral race, and the release of new data in the fields of renal transplant and heart failure.

This week as America celebrated its independence, military forces removed democratically elected Egyptian president Mohamed Morsi on July 3rd. After nearly a year of public protest and in the face of a weakening Egyptian economy and supply shortages, Adli Mansour was installed as acting president of the interim government.[1]

With world leaders being ousted from their positions, we learn this week that so too can the failing transplanted kidney be removed, and potentially without the need for biopsy. A new prospective study from investigators at Weill Cornell Medical College and published in the New England Journal of Medicine evaluated urinary cell RNA levels in renal transplant patients in efforts to accurately diagnose rejection.[2] After testing a number of candidate RNAs, researchers found that a three gene model consisting of CD3e mRNA, IP-10 MRNA, and 18s rRNA boasted a 79% sensitivity,78% specificity and an area under the curve (AUC) of 0.85 for detecting acute rejection when compared to the gold standard of biopsy. This data certainly seems promising as levels of these three RNAs remain low in transplant patients with stable kidney function but increase predictably with acute cellular rejection, a treatable condition. The authors are hopeful that this assay may be used to monitor for signs of acute rejection without the need for biopsy. Thus, immunosuppressive therapy can be ramped up earlier, potentially avoiding irreversible graft damage and loss of the transplanted kidney.

In the financial world, European banking leadership supplied their own economic Fourth of July fireworks in the attempts to offset a withdrawal by the U.S. Federal Reserve from its money-printing program. Bank of England and European Central Banking officials simultaneously pledged allegiance to maintain or even lower interest rates for “an extended period of time”, sparking bottle rocket style explosions in major stock indexes worldwide.[3] As Americans celebrate the Fourth with beers, barbeque, and the inevitable elevation in our serum sodium, it’s hard not to wonder how many of those we could help if were able to preemptively halt congetive heart failure as suggested in the STOP-HF Randomized Trial published in JAMA.[4] Outpatients older than forty with either hypertension, hyperlipidemia, diabetes, obesity, vascular disease, arrhythmia or moderate/severe valvular disease were randomized to yearly BNP checks made available to their PMD vs. usual care. Patients in the intervention arm found to have BNP levels greater than 50 pg/mL were given mandatory referral to a specialized cardiovascular center along with an echocardiogram while those receiving conventional care were provided similar lifestyle modification counseling and referral to a cardiovascular specialist at the discretion of the patient’s physician. Patients in the intervention group received more Renin-Angiotensin-Aldosterone system (RAAS) based therapy, and had less LV dysfunction (5.3% intervention vs 8.7% control, p=0.003), and less emergency hospitalizations for cardiac events (22.3 events/1000 patient years intervention vs 40.4 control, p=0.002) compared with the control group. Though the optimal BNP cutoff for this type of risk stratification is debatable and likely varies with the patient population, the number needed to treat for this intervention to prevent a major CV adverse outcome requiring hospitalization was 48 over a one year period. This potentially places BNP screening in the same league as blood pressure control in terms of preventing cardiovascular events.

In local news and in true New Yorker style, mayoral candidate Anthony Weiner told a heckler who had been berating him for his stance on the Iraq War to “take a hike.” [5] Weiner definitively ended the dispute by pointing out that yelling was no way to converse and that he doesn’t “roll like that.” In keeping with this, a recent study in Chest from our very own Dr. Berger describes the phenotype of restrictive lung disease following World Trade Center dust exposure.[6] Study patients had physiology resembling a restrictive pattern which included a reduced vital capacity(VC) and total lung capacity (TLC), with preservation of the FEV1/FVC ratio. However, CT demonstrated no parenchymal abnormality, but instead bronchial wall thickening and air trapping. Furthermore, impulse oscillometry showed increased airway resistance with a small bronchodilator response. Predominant symptoms included cough and dyspnea, both present in 75% of patients. The data suggests a difference between classic restrictive physiology resulting from inspiratory dysfunction, and this new phenotype resulting from distal airway dysfunction.

Finally, since it is July, a piece in Annals “Once Upon a July (Saved)” is worth a look. In this piece an Internist looks back on her intern experience during her time on the Oncology ward.[7] Her first sick patient, a “liquid” referring to the patient’s hematologic malignancy, was crashing overnight. She felt alone, and terrified, until a veteran nurse came to the rescue giving calm and thoughtful advice. The author highlights two important points. First, how out of place she felt as an intern coming into a large academic program; a sentiment shared by many but rarely discussed. Second, in a mantra that should probably be repeated to physicians on a daily basis, “nurses are your friends.” and they are your colleagues and an invaluable resource both during training years, and beyond.

Also in the journals…

1. Margolis et al. Effects of home blood pressure telemonitoring and pharmacist management on blood control, a cluster randomized clinical trial. JAMA. 2013;310(1):46-56. doi:10.1001/jama.2013.6549.

Study participants (450 adults with uncontrolled hypertension treated in 16 clinics in the Minneapolis area) were randomized to home blood pressure monitoring with data transmission to their pharmacists (pharmacist could adjust medications) vs. standard PMD driven care. The intervention resulted in 27.2% more patients reaching their BP target compared with controls during the study period (12 months). Overall home blood pressure monitoring has advantages over physician and nurse practitioner in office BP checks including cost, convenience to the patient, and avoidance of white coat hypertension (to name a few). As long as this strategy does not overburden pharmacists it is a potentially effective means of managing hypertension in the outpatient setting.

2. Goldfine, AB et al. Salicylate in patients with type 2 diabetes: a randomized trial. Ann Intern Med. 2013;159(1):1-12. doi:10.7326/0003-4819-159-1-201307020-00003.

Patients randomized to salsalate 3.5 grams/day had an A1C level 0.37% lower than controls despite more reductions in diabetic medications over 48 weeks. The study was not held for long enough to determine whether the benfit of the intervension was sutainable..

Dr. Matthew Light is a 2nd year resident at NYU Langone Medical Center

Peer reviewed by Brian Greet, MD, Associate Editor, Clinical Correlations

Image courtesy of Wikimedia Commons

References:

[1] Army Ousts Egypt’s President; Morsi Is Taken Into Military Custody. http://www.nytimes.com/2013/07/04/world/middleeast/egypt.html?ref=todayspaper

[2] Suthanthiran, M et al. Urinary-cell mRNA profile and acute cellular rejection in kidney allografts. N Engl J Med. 2013;369:20-31.  http://www.nejm.org/doi/full/10.1056/NEJMoa1215555

[3] ECB, BoE easing signals send shares and bonds higher. http://www.reuters.com/article/2013/07/04/us-markets-global-idUSBRE88901C20130704

[4] Ledwidge, M et al. Natriuretic peptide-based screening and collaborative care for heart failure, the STOP-HF randomized trial. JAMA. 2013;310(1):66-74.

[5] Weiner to Heckler: ‘Take a Hike’. http://www.nytimes.com/2013/07/04/nyregion/weiner-to-heckler-take-a-hike.html?ref=todayspaper&_r=0

[6] Berger, K I. Lessons from the world trade center disaster: airway disease presenting as restrictive dysfunction. Chest. 2013; 144(1):249-257.  http://journal.publications.chestnet.org/article.aspx?articleid=1568885

[7] Nickas, G. Once upon a July (Saved). Ann Intern Med. 2013;159(1):68-69.

Leave a Reply

Your email address will not be published. Required fields are marked *

*