ShortCuts-This Week in the Journals

May 19, 2008

Commentary by Michael Tanner, M.D., Section Editor, Clinical Correlations

PassageIn the May 15th issue of the Morbidity and Mortality Weekly Report,  the CDC recommends vaccinating all people 60 and older against shingles with one dose of zoster vaccine.  Let’s all get straight with the nomenclature here.  Varicella is chickenpox, zoster is shingles, and varicella zoster is the DNA herpesvirus that causes both of them.  Ninety-eight percent of adult Americans have varicella zoster virus latently lurking in their sensory dorsal root ganglia neurons.  The risk of reactivation increases with age, starting at around 50.  Shingles is common, with about a million cases per year in the United States.  Half of us who live to the age of 85 will develop the characteristic dermatomal vesicles at some point.  The often excruciating syndrome of postherpetic neuralgia complicates up to 18 percent of shingles cases and can last for months or years. The zoster vaccine (brand name Zostavax) is basically the same live, attenuated Oka/Merck strain of varicella zoster virus used in the varicella vaccine (brand name Varivax), but with 14 times the potency.  The Shingles Prevention Study  of 38,000 adults aged ≥60 found that the vaccine lowered the risk of zoster by 51%–from 3.3% to 1.6%–at 3.1 years of follow-up (NNT=59).  Not hugely efficacious, but the number needed to treat would progressively decrease with longer follow-up.  At an estimated cost of $150 per dose, the estimated quality-adjusted life years (QALY) gained was on the order of 1 to 3 days. (A QALY, by the way, is considered by the WHO to be a good deal for Society at $95,000 or less.)   Shingles, although easy and exhilarating to diagnose, is bad, common, and preventable.  The zoster vaccine dose is 0.65 mL subcutaneously in the deltoid.  All immunocompetent patients 60 and over are eligible, even if they have already had an episode of shingles. 

“Etiquette-Based Medicine” a Perspective piece by Michael W. Kahn in the New England Journal of Medicine proposes the hypothesis, only half-facetiously, that a doctor’s outward behavior–dress, manners, body language, and eye contact–matter more to patients than the doctor’s inner attributes of curiosity and compassion, which can be invisible even when present.  “Patients may care less about whether their doctors are reflective and empathetic than whether they are respectful and attentive.”  For entering an inpatient’s room, he advocates the use of a checklist like the one used to reduce central-line infections in critical care patients:

  1. Ask permission to enter the room; wait for an answer.

  2. Introduce yourself, showing ID badge.

  3. Shake hands.

  4. Briefly explain your role on the team.

  5. Ask the patient how he or she is feeling about being in the hospital.

We have all been guilty of breaches of etiquette with our patients.  On the Bellevue wards in January, I walked into the room of a woman newly diagnosed with heart failure, meeting her for the first time.  Bristling with energy and getting right into it, I bombarded her with more information about her ejection fraction and its implications than she was prepared to hear from me on such brief acquaintance.  Although we ended up developing an excellent relationship, she later told me, “That first time you came on a little strong.”  Dr. Kahn writes: “Etiquette-based medicine would prioritize behavior over feeling.” It would also seem to place superficiality above substance.  He maintains, however, that behavior is easier to teach to students and residents than curiosity and empathy.   As doctors we must be careful not to take etiquette-based medicine too far.  Or we may find ourselves saying things like: “Carlson, take Mrs. Lovejoy wherever she wants to go this afternoon, and that will be all for today.”1

Ultra Shortcuts:

The trend away from giving peri-operative beta blockers continues with the publication in the Lancet of the POISE trial of extended-release metoprolol in patients undergoing non-cardiac surgery.  The composite endpoint of cardiovascular death, non-fatal MI, and non-fatal cardiac arrest was reduced by metoprolol; however, there was an increase in overall mortality.

The American College of Cardiology/American Heart Association has released new pacemaker/defibrillator guidelines.

In the Annals, the American College of Physicians recommends osteoporosis screening with DXA for men who are 65 and older and at high risk of osteoporosis.

“Don’t worry-it’s only J-point elevation…”   A case-control study by Haїssaguerre et al in the New England Journal of patients resuscitated after cardiac arrest due to idiopathic ventricular fibrillation found a hazard ratio of 2.1 in case subjects with a repolarization abnormality.  Interesting, but no real treatment implications.

1 Post, Emily.  Etiquette.  New York; Funk & Wagnalls, 1950, p. 16.

Image of secret passage in the Bran Castle (aka Dracula’s castle) connecting the first to the third floor.  Courtesy of Wikemedia Commons