Shotrcuts-This Week in the Journals

December 17, 2007

Snow PlowCommentary By: Neil Shapiro, M.D., Editor-In-Chief, Clinical Correlations

It’s hard to believe there was other news this week besides the black cloud that has now been cast over all of baseball.  Barry Bonds must be smiling somewhere knowing that others have now climbed aboard his sinking ship…in fact I had a dream last night that the Yankees were even stripped of their 2000 World Series title just like all those cheating olympic athletes and the title of 2000 World Champions was awarded to the World Series runners up that year, the New York Mets…ahh but I digress…

One of the questions that we have tried to answer here at clinical correlations is how long should you treat someone with coumadin after a thromboembolic event.  To that end the most recent issue of the Annals of Internal Medicine has a prospective cohort study that followed 2052 pts after a deep venous thrombosis or pulmonary embolus (PE) and found that after discontinuation the risk for recurrent fatal PE was 0.19-0.49 events per 100 person years or in other more understandable terms the yearly risk was .19-.49%.  Obviously this number increases yearly and becomes more significant over time.  It’s a difficult number to wrap your mind or your patients around but as most physicians differ on their approach to this issue, the more data we have to help determine how long to treat our patients, the better.

Trying to pile on the anti-thiazolidinediones (TZD’s) bandwagon, JAMA this week published a case control analysis of a retrospective cohort study from Canada that looked emergency room visits or hospitalizations for congestive heart failure and compared patients treated  with TZD’s (rosiglitazone and piogiltaone) or other oral hypoglycemics.   Monotherapy with TZD’s was associated with a significantly increased risk of congestive heart failure (RR 1.60), acute myocardial infarction (RR 1.4) and mortality (RR 1.29).  Although this is retrospective data and subject to multiple biases, it seems to add to the cumulative negative data and it’s more and more starting to sound like the beginning of the end for the TZD’s.

One of the theoretical concerns regarding statin use is the possible risks of causing a hemorrhagic stroke by overly aggressive reduction in cholesterol levels.  This caution was raised by the Stroke Prevention by Aggressive Reduction in Cholesterol Levels SPARCL Trial.  The trial showed that atorvastatin reduced the risk of ischemic stroke in pts with recent stroke or transient ischemic attack (absolute risk reduction at five years 2.2 percent, 95% CI 0.2-4.2 percent) but also showed an increase risk in hemorrhagic stroke (hazard ratio 1.66, 95% CI 1.08-2.55). In this month’s neurology researchers further looked at this risk in the SPARCL trail and using a cox multivariable regression analysis of that data, concluded that the risk was greater in elderly men, those with a hemorrhagic stroke as an entry event and those with stage 2 hypertension or greater.  Surprisingly they did not find a relationship with ldl level at all.  So it seems the absolute risk does exist, but the level of ldl can not guide us.

One of our earliest blog posts discussed the encouraging news from constraint induced therapy for stroke victims.  This months issue of the Lancet-Neurology reports on follow-up data from the EXCITE trial 24 months out from stroke.  Encouraging results for each of the tested functional scores persisted at 2 years after the initial 2 week intervention.  It is likely our rehabilitation department will be looking at this as an immediate intervention soon after our patients suffer a debilitating stroke.

Ultra shortcuts-articles that still make the radar screen

The Acc has updated their 2004 guidelines for st-elevation myocardial infarctions.  Look for a summary here on Clinical Correlations in the coming weeks.

Cardiac resynchronization does not benefit patients with a narrow QRS complex.

There is no difference in 1 month survival between standard out of hospital CPR with compression and mouth to mouth vs. chest compression only.

Something we’ll never see: Over the counter statins-the FDA has rejected over the counter mevacor.

Something we wish we didn’t have to see: the New England Journal of Medicine updates us on what happened to that patient who had the face transplant several months back.  Seems like she’s doing pretty well. Her sensitivity to touch has come back, motor function is a little slower and rejection has been kept to only two episodes both of which were easily reversed with a change in her immunosupression.  In addition, she’s doing well psychologically. In the authors words aesthetic results are “satisfactory.”  Judge for yourself.

Image of a snow plow cleaning the streets in San Diego County courtesy of Wikimedia Commons