ShortCuts-This Week in the Journals

July 7, 2008

path.jpgCommentary by Judith Brenner MD, Associate Program Director, NYU Internal Medicine Residency Program

Happy July 4th!  As we celebrate our nation’s 232nd birthday, I sit here wondering what “shortcuts” might have looked like in 1776.  Smallpox inoculation might have made the cut.  Apparently people like Thomas Jefferson inoculated themselves and their families against this dreaded disease via inhalation.  It wasn’t until 20 years later, in 1796, that Dr. Edward Jenner discovered that he could protect people from smallpox by vaccinating them using cowpox.  Hence, the term ‘vaccine’, which comes from ‘vacca’, Latin for cow.

Dysentery would certainly have made the cut as well, which is a perfect segue to 2008, where the salmonella outbreak continues to make headlines.  According to the CDC, since April, 943 people have been confirmed to have acquired Salmonella, particularly the Saintpaul variety, in over 40 states as well as Canada.  There have been 28 confirmed cases in New York.  Features of the disease are bloody diarrhea, crampy abdominal pain and fever 12-72 hours after ingesting infected tomatoes.  As clinicians, we need to remain vigilant to the possibility of our patients presenting with this disease.  For our patients, the CDC and FDA continue to post consumer information daily while this puzzle unravels. 

To stay true to 21st century medicine, the next two ShortCuts focus on diabetes and coronary disease.  The Annals lead article reports on a newly identified association between diabetes and hearing impairment.   We know that hearing loss is common, reported by 30% of US adults >65, and we also know that diabetes is common.  The question is whether there is an association.  Only one previous study addressed a potential association and notably excluded patients younger than 48. The current study, a cross-sectional analysis, used data from NHANES (National Health and Nutrition Examination Survey) from 1999-2004.  In all, 11, 405 people aged 20-69 (which becomes an important point) were studied and about half of them were randomized to audiometric testing.  As pointed out in the accompanying editorial, the degree of hearing loss measured in clinical terms is that which would be difficult to detect without formal testing, but which would likely affect an individual’s ability to communicate. Both low-mid frequency and high frequency losses were looked at and in both subsets, diabetes was associated with a greater likelihood of hearing loss.  The odds ratio in the low-mid frequency loss was 1.82 and the odds ratio in the high frequency category was 2.16.  Age of the population included in this study is important because it may be that diabetes contributes most heavily to younger people.  Once the usual risks for developing hearing loss (male sex, lower education, industrial or military occupation, leisure time noise and smoking) were accounted for, diabetes became less of a risk factor.  Though controversial, the suggested pathophysiologic mecahanism for hearing loss in diabetes is microvascular damage to the cochlea. Since hearing loss is so difficult to avoid or treat, maybe someday soon we will we be adding audiometric screening to our health maintenance recommendations for our diabetics.

JAMA this week featured a meta-analysis adding to the growing literature supporting an underlying difference in coronary disease in men vs. women.  The review included 10,000 patients, 3000 of whom were women, and looked at outcomes for NSTEMI when using an early invasive approach (catheterization) versus a more conservative approach (medical management with catheterization if necessary).  Among women who were specifically identified as “biomarker positive” or “high risk” (positive CPK or troponins), an invasive strategy was associated with a 33% lower risk of combined death, MI or re-hospitalization for ACS (odds ratio 0.67, CI 0.50-0.88).  Among those women who were not biomarker positive, there was no significant decrease found in this end point when comparing an invasive versus conservative management, and, in fact, a non-significant trend toward increase in death or MI was seen.  Among men, the benefit of the invasive approach to NSTEMI was comparable to the “high risk” or “biomarker positive” women.  Though there was also more of a benefit seen among those biomarker positive, (44% lower odds of death, MI or re-hospitalization in the biomarker positive group) unlike women, those in the biomarker negative group were not potentially harmed by early catheterization.  To summarize the findings, for a man with a NSTEMI, an early invasive approach is rational.  For a woman, early catheterization may only be beneficial if they fall into a high risk group. The postulated explanation for these findings is that CAD in men is different from CAD in women, with women less likely than men to demonstrate obstructive epicardial lesions when they present.  An invasive strategy is more beneficial to those with obstructive CAD.  Biomarkers are one of the tools we have to help to identify a subset more likely to have obstructive CAD and thus, more likely to benefit from invasive management. The authors state that these findings provide evidence supporting the ACC guideline that only in high-risk women (biomarker positive) should an early invasive strategy be offered.  

Every once in a while when reviewing articles to be included in this section, I find one that makes me smile.  An article featured in this week’s Clinical Infectious Disease was titled “Medical-Grade Honey Kills Antibiotic-Resistant Bacteria In Vitro and Eradicates Skin Colonization. The investigators studied Revamil, a medical-grade honey, to assess the in vitro bactericidal activity against S. aureus, S. Epidermidis, E. Faecium, E. coli, P. Aeruginosa, Enterobaceter cloacae and Klebsiella oxytoca in forearm colonization.  After 2 days of application of honey, the extent of colonization was reduced 100-fold.  Apparently, honey has other uses too and has been reported to successfully treat chronic wound infections that were unresponsive to antibiotics.  Who would have thought?  Perhaps this could have also made a ShortCuts section in the year 1776…. 

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