ShortCuts-This Week in the Journals

October 22, 2007

Commentary by Neil Shapiro MD, Editor-In-Chief, Clinical Correlations

Death ValleyAs fall begins in earnest and the leaves start to change we find a diverse group of articles that make the cut and a few that didn’t quite make it but should remain on your radar screen…

Suburban parents were panicked this week by the media portraying the end of the world coming in the form of community acquired MRSA. The explosion of media interest stems from a CDC report released this week outlining the scope of the problem. The report suggested that such infections might be twice as common as previously thought. Adding fuel to this fire, JAMA published an article assessing the incidence of the disease. There were 94,360 infections occurring in 2005, 18,650 of which were fatal. 58% occurred outside of the hospital, caused by strains commonly attributed to both community and health care sources. It’s no wonder that after these reports were released many schools across the nation were closed to allow for disinfecting, and parents everywhere started bringing their kids to the pediatrician after every scrape, cut and bruise…

The Lancet this week highlights the need for early intervention and management of transient ischemic attacks (TIA). The authors compared a strategy of 24 hour referral to a neurovascular clinic compared to referral to the same clinic with recommendations then sent to the pcp. Delays of assessment decreased from 3 days to <24 hours, and delay to treatment from 20 days to 1 day were associated with a very significant decrease in the incidence of stroke within 90 days from 10% to 2 %. Despite this and other supporting articles, you still get the sense the neurologists are a few steps behind the cardiologists in getting the word out there that new neurologic symptoms need to be treated as aggressively as chest pain.

This week’s New England Journal confirms what has been in practice for many years-namely that early steroids are effective for Bell’s palsy. A double blind RCT of patients with a new Bell’s palsy showed that at 9 months 94% recovered with prednisone compared to 82% without (P<0.001, NNT 8 ). Surprisingly, treatment with acyclovir resulted in no significant improvement over placebo (85% with acyclovir vs. 91% without (adjusted P=0.10)). Acyclovir also did not seem to make a difference when steroids were given, perhaps lessening the possibility that HSV is a major player in the etiology of this difficult syndrome. Whether the same results would hold for other antivirals-famvir, valtrex etc. remains to be seen.

A disturbing article that did not seem to get much media play was in the JNCI discussing the risks of hormonal treatment for prostate cancer. A retrospective review found an increased risk for cardiovascular death for patients who received androgen deprivation therapy after prostatectomy (hazard ratio 2.6) and a nonsignificant increase in those treated without surgery. These results further confuse the already difficult issue of screening for prostate cancer. Confusing as it is for us as practitioners, patients still are more likely to ask me for a psa than they are for a screening colonoscopy.

Realizing that many articles did not seem to have the impact of those above, the following “ultrashortcuts” should nevertheless be on your radar screen:

  • Post-exposure prophylaxis with Hepatitis A vaccine equal to immune globulin
  • Annals meta-analysis shows that extending triple therapy for helicobacter pylori beyond 1 week is not useful.
  • Death rates from cancer are dropping 2.1% annually, a dramatic decrease over the last 5 years.
  • 2 articles in the NEJM support HPV DNA testing instead of or in addition to pap smears.
  • And finally Pfizer has pulled the plug on inhaled insulin…ending an era before it had even started-diabetic asthmatics are now breathing easier…
  • Image of Death Valley, Zabriskie Point Tourist Parking Courtesy of Wikimedia Commons