This week’s Clinical Correlations begins with email revelations implicating the administration of New Jersey Governor Chris Christie in the closure of traffic lanes across the George Washington Bridge, thus making one of the country’s busiest thoroughfares log-jammed with traffic for days this previous summer.
Earlier this week emails were released from high-level public servants in the Christie administration which suggest the secretive, planned closure of traffic lanes in the borough of Fort Lee, whose mayor had previously refused to endorse the Governor during the recent gubernatorial elections. For the larger-than-life second term Governor, viewed as a serious Republican candidate for the 2016 Presidential election, these revelations are seen to have the potential to cause considerable harm to his future political aspirations. Fighting against accusations of vindictiveness, pettiness and the appearance of being a ‘bully’, Gov. Christie held a two-hour news conference expressing his own disappointment at his staff, asking the people of New Jersey for his forgiveness, and summarily firing the implicated members of his administration. With the US Attorney in New Jersey looking into the matter on behalf of the Federal Government, how this affects the short list of Republican candidates for the 2016 Presidential election remains to be seen.
In other (less controversial) news, this week the Journal of the American Medical Association (JAMA) celebrated the anniversary of the publication of the 1964 landmark surgeon general report entitled Smoking and Health with smoking cessation-related research. One study sought to empirically assess the effect of combination pharmacotherapies in tobacco-dependent patients seeking to quit smoking . Testing the hypothesis that combination varenicline/bupropion –sustained release would serve better than varenicline alone in tobacco cessation at 12 weeks (determined by biochemical confirmation and self report), researchers randomized 506 participants into two arms in a blinded, placebo-controlled multicenter trial.
Participants were required to be motivated to want to quit smoking, be at least 18 years of age, and to smoke more than 10 cigarettes per day for at least 6 months. Exclusion criteria included pregnant or lactating women, those with unstable medical conditions including angina, renal failure and seizures, allergies to either varenicline or bupropion, or evidence of suicidality or depression.
Analysed according to intention-to-treat protocols, it was reported at 12 weeks that 53% of the intervention group (combination varenicline/bupropion SR) had achieved prolonged smoking cessation (defined as no smoking from 2 weeks after a set quit date) and 56.2% had achieved 7 day point-prevalence smoking abstinence (defined as no smoking within the past 7 days of testing). This was compared to 43.2% in the varenicline monotherapy group for prolonged smoking cessation, and 48.6% in the 7 day point-prevalence smoking abstinence (OR, 1.49; 95% CI 1.05-2.12, p=0.03, and OR 1.36; 95% CI 0.95-1.93, p=0.09). At 26 weeks, prolonged smoking cessation remained statistically significant in the combination group, but this was lost at 52 weeks. Of note, patients receiving combination pharmacotherapy reported more symptoms of anxiety, depression and flatulence.
Based on these results, it seems like the holy grail of smoking cessation is still beyond the reach of the medical profession. While the combination of varenicline/bupropion is encouraging in the short term, it seems longstanding measures, including nicotine replacement and smoking counseling remain important factors in the sustainment of cessation.
This week in the Green Journal, further evidence for the use of digoxin in heart failure to reduce readmissions was published . As part of a series of studies published out of the University of Alabama and the Alabama Heart Failure Project, a retrospective cohort study involving data from 921 patients discharged on digoxin after being hospitalized with heart failure (mean age 75 years, 55% female, 25% African-American, 58% with an ejection fraction of less than 45% , 69% of an ACEI or ARB, 32% on a beta-blocker, 18% on potassium-sparing diuretics) were matched to cohort of 921 not taking digoxin (with similar baseline characteristics and pharmacology profiles).
Using the primary outcome of all cause 30-day hospital readmission, 17% of the digoxin cohort were readmitted as compared to 22% of the matched non-digoxin group (HR 0.77, 95% CI 0.63-0.95). Furthermore, this benefit was particularly noted in those patients with ejection fractions less than 45%, persisted over the following 12 months, and did not change all-cause mortality between the two groups. Like the studies preceding it , this well-designed study points to the usefulness of digoxin in heart failure patients, particularly amongst a population of patients known to be susceptible to exacerbations and readmissions.
In separate news, the New England Journal of Medicine published data suggesting the beneficial use of a surgically implanted upper airway stimulation device as a novel therapy in the treatment of obstructive sleep apnea for those patients unable to tolerate continuous positive airway pressure (CPAP). In a multicenter, prospective uncontrolled cohort study with 126 participants (83% men, average age 54.5, average body mass index 28.4), there was both statistically significant reduction in the median 12 month apnoea-hypopnoea index (AHI) of 68% ( p< 0.001), as well as subjective improvement in sleep as determined by the Epworth Sleepiness Scale score (11 to 6, p < 0.001)) and Functional Outcomes of Sleep Questionnaire (FOSQ) (14.6 to 18.2, p< 0.001). This suggests that for appropriate patients suffering from OSA who do not tolerate CPAP, upper airway stimulation may be an alternative means of therapy.
Of interest to physicians and residents themselves, Mayo Clinic Proceedings published this week a study examining the effects of an incentivized exercise program on rates of burnout, quality of life and physical activity on fellows and residents . Using survey tools to assess the amount of physical activity, quality of life and burnout, all residents and fellows at the Mayo Clinic were invited to participate in a 12 week voluntary, self directed exercise program. Fifty-nine percent of residents and fellows participated in the study, of which only 23% enrolled in the exercise program. Compared to non-enrollees, those enrolled in the study met the standard US Department of Health recommendation for exercise (48% vs 23%, p < 0.001), their quality of life was better (P < 0.001), although burnout rates were not statistically significantly reduced (24% vs 29%, p=0.17).
In other news:
1. Rates of influenza have increased across 25 states in the Union . The strain H1N1 2009 seems to be predominating in the cases being seen.
2. For the fourth consecutive year, it seems that growth in healthcare spending nationally has decreased (3.7% in 2012), in line with a decrease in Gross Domestic Product allocated to healthcare (from 17.3 to 17.2%), while the nominal GDP increased 4%.
Dr. Arnab Ghosh is a 3rd year resident at NYU Langone Medical Center
Peer reviewed by Brian Greet, MD, Associate Editor, Clinical Correlations
Image of the cover of the 1964 landmark surgeon general report entitled Smoking and Health
1. Ebbert J, Hatsukami D, Croghan I et al Combination Varenicline and Bupropion SR for Tobacco-Dependence Treatment in Cigarette Smokers: A Randomized Trial JAMA. 2014;311(2):155-163 http://jama.jamanetwork.com/article.aspx?articleid=1812959
2. Ahmed A, Bourge R, Fonarow G et al. Digoxin Use and Lower 30-day All-cause Readmission for Medicare Beneficiaries Hospitalized for Heart Failure. Am J Medicine (2014) 127,61-70 http://www.amjmed.com/article/S0002-9343(13)00786-9/abstract
3. Bourge R, Fleg J, Fonarow G et al. Digoxin Reduces 30-day ALL-cause Hospital Admission in Older Patients with Chronic Systolic Heart Failure. Am J Med. 2013;126(8): 701-708 http://www.amjmed.com/article/S0002-9343(13)00137-X/abstract
4. Strollo P, Soose R, Maurer J et al. Upper-Airway Stimulation for Obstructive Sleep Apnea. NEJM. 370;2 139-149 http://www.nejm.org/doi/full/10.1056/NEJMoa1308659
5. Weight C, Sellon J, Lessard-Anderson C et al. Physical Activity, Quality of Life, and Burnout Among Physician Trainees: The Effect of a Team-Based, Incentivized Exercise Program. Mayo Clin Proc. 2013 Dec; 88(12):1435-1443 http://www.researchgate.net/publication/259107687_Physical_activity_quality_of_life_and_burnout_among_physician_trainees_the_effect_of_a_team-based_incentivized_exercise_program
6. http://www.cdc.gov/flu/weekly/summary.htm Accessed 1/11/2014 @0700
7. Martin A, Hartman M, Whittle L at al. National Health Spending in 2012: Rate of Health Spending Growth Remained Low for the Fourth Consecutive Year. Health Aff (Milwood) Jan 06 2014; 33: 67-77 http://www.ncbi.nlm.nih.gov/pubmed/24395937