PrimeCuts: This Week in the Journals

December 15, 2008

primerib.jpgCommentary by Christopher Tully MD, PGY-1

Faculty Peer Reviewed 

With the holiday shopping season rapidly rising to its peak and winter weather finally beginning to take hold, take a break from the cold, chaotic world outside and catch up on the news from around the medical world. 

One fall and wintertime tradition that many people would often rather avoid is their yearly flu shot.  While the vaccine itself is here to stay, for those who have complained in the past that the pain of the shot keeps them from getting it, here is one potential solution: half a shot.  Published in the Archives of Internal Medicine, researchers found that antibody responses to an intramuscular half-dose of the trivalent inactivated influenza vaccine (TIV) in healthy, previously immunized adults ages 19-49 were not substantially inferior to the full-dose vaccine.  The authors also observed that across all ages, women had higher antibody averages than their male counterparts.  Given the tenuous nature of our flu vaccine supply – as recently as 2004 the national supply was halved due to production issues – the authors proposed half-dose vaccination as a potential alternative for the immunization of healthy, high priority groups during times of decreased vaccine availability.  Unfortunately, the study did not address whether the half-shot was less painful, so it appears unless future research is initiated, we will all just have to deal with a sore shoulder for a couple of days of the year.

Although the banking and auto industry are making headlines with financial bailouts, before all the recent chaos, the healthcare industry was often viewed as a primary financial problem of our national economy.  As a new presidential administration pledges to reign in the financial albatross of our medical system with the eventual goal of providing medical coverage for all, one area of potential savings is the increased use of generic prescriptions.  Researchers publishing in the Archives of Internal Medicine studied the adoption of electronic prescribing (e-prescribing) and its effect on physician prescribing patterns.  The key to this system is a formulary decision support that prompts physicians to prescribe Tier 1 (typically generic) medications when medically appropriate through a color-coding system.  The researchers found that this active reminder system resulted in a 3.3% increase in the use of Tier 1 medications and a concurrent decrease in Tier 2 and Tier 3 medications.  The estimated savings were $845,000 per 100,000 patients with only 20% e-prescribing in the intervention group. Complete use of e-prescribing would result in an estimated savings of $3.91 million per 100,000 patients.  Clearly there is considerable financial savings associated with generic prescribing and our future will undoubtedly incorporate increased formulary management as we attempt to control spending in our healthcare system.

In the fight against diabetes, it appears we are a long way from gaining full control of this disease. The CDC, publishing in the Archives of Ophthalmology, painted a dismal picture of the number of Americans with diabetes with diabetic retinopathy (DR) and vision-threatening DR (VDR).  Based on projections, the number of Americans 40 years or older with DR will increase from 5.5 million in 2005 to 16 million in 2050 and those with VDR will increase from 1.2 million in 2005 to 3.4 million in 2050.  Also, the number of cataract cases among whites and blacks 40 years or older with diabetes will likely increase 235% by 2050 and the number of glaucoma cases among Hispanics with diabetes 65 years or older will increase 12-fold.  Clearly, considerable effort is required to not only work to prevent the onset of diabetes mellitus, but efforts will be required in the coming decades to adapt our treatment strategies to address the increasing prevalence of these long term complications. 

In a startling analysis of gender-based in-hospital mortality for acute myocardial infarction (AMI) and/or STEMI from the Get With the Guidelines-Coronary Artery Disease database, researchers publishing in Circulation found that while there were no significant gender differences in in-hospital mortality AMI there was a significant increase in in-hospital mortality in females presenting with a STEMI.  In addition, subgroup analysis showed that women presenting with a STEMI were less likely to receive early aspirin treatment, early beta-blocker treatment, reperfusion therapy, or timely reperfusion.  While the authors point out that women presenting with any cardiac event tend to be older with more co-morbidities and may present later to medical care, they ultimately had no answer to the cause of disparity and recommended further investigation.  Given that systems are in place to treat all patients with AMI, increased emphasis needs to be placed to ensure that women receive equal early management to the fullest of an institution’s capabilities.

Finally, while the holiday season is often associated with gift giving, Santa and snow, another equally important part of it all is the annual holiday party and the food that we all eat.  Therefore, what better time then to talk about digestion, and more specifically irritable bowel syndrome.  Irritable bowel syndrome is characterized by abdominal pain or discomfort and accompanied by a change in bowel habit.  Often a frustrating disease for both physicians and patients alike, hope is not lost.  A meta-analysis published in BMJ studied fiber, antispasmodics and peppermint oil vs. placebo in the treatment and attenuation of symptoms in IBS.  The authors found that fiber (psyllium in particular), an antispasmodic (with scopolamine as first line treatment) and peppermint oil are statistically effective treatments with number needed to treat of 11, 5, and 2.5, respectively.  Therefore, while considerable research still is needed in understanding the cause of IBS, there are now at least some options in dealing with this disease. 

That’s all for this week.  Enjoy your holiday season and keep coming back each week for your PrimeCuts update.

References:

1.  Engler et al.  Half- vs Full-Dose Trivalent Inactivated Influenza Vaccine (2004-2005). Archives of Internal Medicine 2008; 168(22):2405-2414.

2.  Fischer et al.  Effect of Electronic Prescribing With Formulary Decision Support on Medication Use and Cost.  Archives of Internal Medicine 2008; 168(22):2433-2439.

3.  Saaddine et al.  Projection of Diabetic Retinopathy and Other Major Eye Diseases Among People with Diabetes Mellitus: United States 2005-2050.  Arch Ophthalmol. 2008; 126(12):1740-1747.

4.  Jneid et al.  Sex Differences in Medical Care and Early Death After Acute Myocardial Infarction.  Circulation 2008; 118.

5.  Ford et al.  Effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome: systematic review and meta-analysis.  BMJ 2008; 337.

Reviewed by Danise Schiliro-Chuang MD, Contributing Editor, Clinical Correlations

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