ShortCuts- This Week in the Journals

November 24, 2008

101px-male_north_american_turkey_supersaturated.jpgCommentary by Frederick Gandolfo, MD PGY-3 and Michael Tanner, MD Section Editor, Clinical Correlations

Need an escape? With the weather turning frigid, the economy collapsing, and unemployment rates rising just in time for the holiday season, most people would probably feel better staying home, shutting the blinds, and vegetating in front of the TV-watching anything but a news channel.  But not so fast, says the New York Times, citing a study by Dr. John Robinson and colleagues showing an inverse relationship between the amount of time spent watching television and a person’s happiness.  While the exact relationship is yet to be defined, it is probably wise to tune out whenever possible and smile. 

Well if TV is bad for adults, what could it do to children you might ask? The New York Times is on it again, citing a study by Dr. Michael Grossman showing by statistical modeling that the more time spent watching fast food advertising on TV, the more likely a child is to become obese.  The author states that since obese children generally watch the same amount of television than normal weight children do, there is a causal effect of these fast food advertisements on obesity.  Rumor is, there is a new study on the way proving the causal effect of watching too much Top Chef: Season 5 and type 2 diabetes in a New York City medical resident population-Clinical Correlations will keep you updated!

If inflammation is a key pathway in the pathogenesis of many diseases, perhaps we should just screen all low-risk people for nonspecific inflammatory markers and treat all the people that test positive with a statin-a drug shown to decrease inflammatory markers.  This was the premise of the Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) when it was pre-released on November 9th to much fanfare… The trial randomized 17,802 apparently healthy patients with good LDL levels (<130 mg/dL) but with elevated high-sensitivity C-reactive protein levels (greater than or equal to 2 mg/L) to rosuvastatin 20 mg daily or placebo.  The primary endpoint was a composite of MI, stroke, revascularization, hospitalization for unstable angina, or cardiovascular death.  The trial was stopped two years early after 1.9 years because of compelling evidence that rosuvastatin was superior to placebo in preventing not only the composite endpoint but all of the individual components.  There was significantly more new-onset diabetes in the rosuvastatin group.  As Mark Hlatky notes in an accompanying editorial, JUPITER raises but does not answer the questions of whether the indications for statins should be broadened and whether high-sensitivity C-reactive protein should become a routine part of cardiovascular risk assessment. Despite this caution look for sales of rosuvastatin to skyrocket.

Moving on to the prevention of other diseases, DeKosky et al. in The Journal of the American Medical Association reported a randomized controlled trial of Ginko biloba vs. placebo in over 3,000 volunteers aged 75 or older ;16% with mild cognitive impairment, the remainder with all of their wits about them. The good news is that there was no statistically significant difference in the rates of adverse effects between treatment and placebo, including bleeding outcomes.  The bad news is that there was no effect of Ginko on reducing the incidence of dementia over an approximate 6 year follow-up period. .  The overall dementia rate was 3.3 per 100 person-years in the G. biloba group versus 2.9 per 100 person-years in the placebo group.  The GEM trial is the largest and longest Ginkgo biloba trial to date and adds to the evidence against this popular but inefficacious herb.

 In further prevention news, Baron et al. in The Lancet reported an additional analysis of the APPROVe trial of rofecoxib on recurrence of neoplastic polyps of the colon, further examining the adverse cardiovascular endpoints that originally halted the trial.  They examined the occurrence of these adverse cardiovascular endpoints (combined incidence of nonfatal myocardial infarction, nonfatal stroke, and death from cardiovascular, hemorrhagic, or unknown causes) after stopping treatment with the cyclo-oxygenase-2 (COX-2) inhibitor rofecoxib, and found that a non-significant increase in these endpoints persisted for a follow-up period of at least 1 year.  So for the moment at least, Ginko and COX-2 inhibitors are out of the new top-secret panacea pill that is under development, while statins remain one of the main ingredients.

The Annals of Internal Medicine published a randomized, open-label trial comparing four months of rifampin with nine months of isoniazid  for the treatment of latent tuberculosis, from the point of view of safety, not efficacy.  Only 1.7% of the rifampin group developed grade-3-to-4 adverse events, compared to 4.0% of the isoniazid group (hepatotoxicity most commonly).  Also in favor of the shorter treatment with rifampin was the significant absolute increase in on-time treatment completion of 18% between the groups.  The authors write that these findings justify a large-scale efficacy trial of the two treatments. 

The American Journal of Respiratory and Critical Care Medicine published a placebo-controlled trial of twelve months  of erythromycin 250 mg bid in 109 outpatients  with COPD and an average FEV1 50% of predicted in order to determine if macrolide therapy reduces the frequency of COPD exacerbations.  The erythromycin group had significantly fewer moderate or severe COPD exacerbations, defined as requiring systemic steroids, antibiotics, or hospitalization.  Also, the duration of exacerbations was shorter in the erythromycin group.

Patients tend to do better when they like, trust, and respect their doctors.  In an Annals article called “Healing Skills for Medical Practice,” Larry Churchill and David Schenk interviewed fifty highly respected “healers” and boiled outstanding bedside manner down to eight elements: Do the little things.  Take time and listen. Be open. Find something to like, to love.  Remove barriers.  Let the patient explain.  Share authority.  Be committed and trustworthy.

So in general, this week in the journals had a conservative message: watch less TV, eat less junk, do not take Ginko, do not take COX-2 inhibitors, and maybe take less latent tuberculosis treatment.  Are statins and erythromycin the exception? We will see over time at least what JUPITER has in store for us.  Most importantly though it always pays to be reminded that we should all occasionally stop and take a moment to really hear what our patients are saying, even if all we hear is “give me my rosuvastatin…”  Happy thanksgiving.