Shortcuts-This Week in the Journals

February 11, 2008

arctic_ice_melt.jpgCommentary by Aaron Lord MD, Copy Editor, Clinical Correlations

The medical news event of the week was of course the early termination of the glucose control arm of the ACCORD trial, which showed increased mortality with intensive glucose control. You can check it out via our post on the trial by Endocrinology Section Editor Melissa Freeman.  Also, make sure to eyeball Goede’s et al. study in this week’s NEJM which showed decreased mortality with intensive glucose control.  Stay tuned as this interesting story unfolds.

We all love evidence-based medicine, but how well do we practice it? The results of the ENDORSE study, an international trial investigating rates of venous thromboembolism (VTE) prophylaxis in medical and surgical patients, were published last week in the Lancet with the answer- not consistently enough. Over 68,000 patients were enrolled, and while 41.5% of patients 40 and over admitted to the medical ward met American College of Chest Physicians (AACP) criteria indicating prophylaxis, only 39.5% of those meeting criteria received appropriate therapy. Our surgical colleagues vastly outperformed us, but still only 58.5% of those needing prophylaxis received it. Although country-by-country data is affected by the specific hospitals enrolled in the study, the US performed above average, but with only 48% of eligible medical patients receiving therapy, we have a long ways in making evidence-based medicine a reality.

Putting patients on clopidogrel (Plavix) after or during ACS is easy enough, but when, if at all, should patients stop therapy? Ho et al. have cast some light on the topic with their recent study in JAMA that assessed rates of death and recurrent MI after stopping clopidogrel treatment which had been initiated during treatment for ACS. The investigators showed that these VA patients, both those treated medically or with PCI for their ACS, had a clustering of adverse events in the first 90 days after stopping clopidogrel treatment (hazard ratios of 1.98 and 1.82 for the 1st 90 days compared to the 2nd 90 days for the medically and PCI-treated groups respectively) . Importantly, this effect was independent of how long patients had been on the medication. Is this evidence of a clopidogrel rebound effect? With clopidogrel being such an expensive drug, this has potentially huge fiscal as well as medical ramifications.

On a more humanistic front, check out the New York Times “Well” blog this week. Dr. Robert Klitzman, a psychiatrist at Columbia University, is interviewed about his new book, “When Doctors Become Patients.” The interview emphasizes the struggles of medicine from the patient’s point of view, and how simplistic problems, such as broken televisions in a hospital room, often cause the greatest distress. Check it out.