Shortcuts- This Week in the Journals

September 8, 2008

ravenelbridge.jpgCommentary by Sandeep Mangalmurti MD, JD, Health Care Policy Section Editor

As the summer of 2008 winds down, I hope everyone looks backward with fond memories. Last week was the Republican National Convention, and I suspect that there will be a great deal of discussion of politics in the upcoming weeks. If you’re a politics junkie, you’ll be in ecstasy. If you hate politics, it may be time to subscribe to HBO. Regardless of your preferences, take this opportunity to register to vote!

A fascinating development in detection of breast cancer, molecular breast imaging, was discussed in the New York Times last week. This technique involves the injection of radioactive tracer that is differentially absorbed by abnormal versus healthy cells. Preliminary data indicates that this modality may be more sensitive than mammograms in detecting malignancy, particularly when breast tissue is dense. Another article in the Times, more ominously, mentions problems with a set of rheumatoid arthritis medications. The Food and Drug Administration ordered warnings on Enbrel, Remicade, Humira and Cimzia, suggesting that these medications might increase the risk of fungal infection secondary to immunosuppression.

This week’s New England Journal of Medicine provided compelling new data on the benefits and risks of automatic internal cardiac defibrillators (AICD). Specifically, the authors wished to address the long term prognostic significance of appropriate and inappropriate AICD discharges. First, they found that appropriate AICD discharges were associated with a subsequent increased risk of death from all causes. More troubling, these researchers found increased risk of death in patients who received inappropriately triggered discharges; one possible cause may be the negative inotropic effects of the shock itself.

On the issue of AICDs, the Journal also discussed subsequent quality of life in patients who have placement of these devices. One common concern among physicians is that placement of these devices in those with severe congestive heart failure merely prolongs suffering by preventing a relatively quick death from arrest. Researchers interviewed over two thousand subjects for up to 30 months after the placement of AICD versus medical therapy, and found no significant difference in quality of life between the two groups.

A final Journal article examined the best method for determining survival for those with end stage liver disease. The context of this article is that liver transplants are distributed to those with the highest risk of death; more sophisticated methods for identifying those patients ensures a more efficient and equitable distribution of a very scarce resource. The researchers found that using a combination of Model for End- Stage Liver Disease (MELD) score and serum sodium provided a better predictor of survival than MELD score alone.

A problem virtually every resident has faced is preventing contrast-induced nephropathy from imaging studies and coronary angiography. One possible treatment is alkanizing urine prior to contrast administration, based upon the theory that this will help prevent free radical formation. This week’s issue of the Journal of the American Medical Association addresses this issue squarely, by comparing infusion of sodium bicarbonate to infusion of saline prior, during and after coronary catherization on patients with underlying renal insufficiency. This randomized controlled trial found no significant difference in reno-protective effects between these two infusions, or for any of the other endpoints of death, dialysis, or cerebrovascular events.

See you here next week!