ShortCuts-This Week in the Journals

April 7, 2008

TurtlesCommentary by Neil Shapiro, MD, Editor in Chief, Clinical Correlations

The hot news stories this week were the early release articles highlighted at the American College of Cardiology (ACC) meetings. We will save most of those stories for our upcoming summary of the meeting. Let it be said however that there is serious zetia fatigue around these parts, as the same controversial article made the rounds on the news cycles for the second time now that it was officially released. Unfortunately most of us have had our fill of negative studies being paraded out one after another all concluding that one of our new “blockbuster” drugs is not quite as effective as we thought. The fact that any drug can become a blockbuster before the full story and evidence is clear is as much our fault as it is the pharmaceutical industry’s. Maybe one day we as physicians will learn to fight back against direct to consumer/direct to doctor advertising before we over-prescribe the latest and greatest…yes the jury is still out about zetia, avandia, olanzapine and the like, but on the other hand the jury is not in either…ok I’ll get off my soapbox now, let’s move on to this week in internal medicine:

There is one article from the ACC I thought I’d highlight for it’s clinical applicability. I’m not sure about you but extrapolating the current JNC VII targets to our very aged, (elderly, geriatric, really old, what’s the politically correct term here?) is difficult. Frequently my hypertensive patients complain of dizziness, malaise and fatigue, symptoms that all usually get better when I back off their antihypertensives. The NEJM this week reminds us however that patients over the age of 80 need treatment for their hypertension. Specifically they showed that treating these patients, with indapamide showed a statistically significant benefit in all cause moratlity albeit at a target of150/80, a reasonable number in my view. Quality of life, so often overlooked while everyone shouts about target goals and performance measures, certainly should be factored in when treating our patients.

Not only has Gardasil, the HPV vaccine, been a controversial addition to our immunization inventory, but there is now controversy as to who should be tested for high risk HPV in addition to a pap smear. The Annals of Internal Medicine this week reports a study of 10,000 women who underwent pap and HPV dna testing. 15% of women with normal pap results tested positive for high risk HPV. What to do with this information is confusing. Likely, it will lead to discussions about weighing the chance that even with a negative pap they can still have HPV. If the patient is found to be positive this might lead to an unnecessary colposcopy. There are no guidelines available yet telling us who to test for high risk HPV. My guess is soon we’ll be seeing the recommendation that we should let the patient guide us. Sounds eerily similar to the discussion we have with our patients about an elevated psa. If we’re confused, imagine how our patients will feel.

And now for a bit of good news on the subject of death…Circulation this week updates their resuscitation guidelines and recommends that bystanders to a cardiac arrest should no longer perform mouth to mouth resuscitation. If you find a person pulseless, simply compress hard and fast ~100 compressions/minutes ~2 inches deep. Multiple studies have shown this strategy to be equivalent to conventional cardio-pulmonary resusitation. Hopefully this will embolden many more witnesses who may have been previously reluctant to take the lead when they witness someone collapse.

Also making headlines this week in the lay press is a survey released by the US Department of Health and Human Services that showed patients are frequently dissatisfied with their communication with hospital staff. This survey covered all facets of an admission including discharge information, medications, follow-up information, call buttons and pain. Patients faulted everyone in the system including nurses and doctors. We’ll definitely be hearing more about this as we did about medical errors a few years ago. JCAHO already is focusing on communication and handoffs.

Ultra Shortcuts:

The USPTF took a stand this week giving a grade D recommendation (against) routine screening with pulmonary function tests.

Some good news about thiazolidinediones, the PERISCOPE trial in JAMA shows that pioglitzone treatment in Type 2 DM showed a lower rate of progression of coronary atherosclerosis compared with glimepride by coronary ultrasound.

3 studies were released in Nature and Nature Genetics showing a genetic link for not only the development of lung cancer but also for nicotine addiction.

And from the maybe it was obvious to you but we thought we’d do a study anyway department, scientists at Kaiser Permanente have confirmed that a potbelly (central obesity) is a risk factor for dementia. For our readers at this point, whatever you do, don’t look down…

Have a great week…