PrimeCuts: This Week in the Journals

February 9, 2009

trees.JPGCommentary by Michael Poles MD, Associate Editor, Clinical Correlations 

Welcome to this week’s primecuts. Let’s slice right in and take a big bite out of last week’s medical news, starting with a little political news. On Wednesday February 4th, the Obama administration expanded SCHIP. SCHIP is a children’s health insurance program, and its passage will allow about 7 million children to continue to receive healthcare coverage and will allow an additional 4 million children to sign up. This appears to be an important step toward providing universal health insurance coverage to all Americans. Similar bills had been vetoed twice by then-President Bush.

Let’s turn to a more local item on the medical/political front. Last year, New York City mandated that restaurants with more than 15 units (typically fast-food establishments) provide calorie counts for their food. While strongly opposed by the foodservice industry, a new survey that was conducted by foodservice consultant Technomic, Inc. has shown that this approach may be working. I guess New Yorkers are starting to realize that fast food may be calorie-rich and healthful, because the survey found that 90 percent of customers claimed that the calorie count of the offerings was higher than they had expected. Further, 82 percent claimed that the information influenced what they ordered and many claimed that the information would alter their decisions on which establishments to visit.

Let’s move onto some more medical, medical news. Medical research has brought an increasing array of biological treatments of inflammatory diseases and cancers. In a number of cases, especially in terms of anti-neoplastic antibodies, use of biologics has decreased mortality, though often at significantly increased expense. Can you take this approach too far? If one anti-neoplastic biologic increases longevity, how about adding a second biologic? An article in this week’s New England Journal of Medicine provides a cautionary tale. While one may be good, two may not be better. In this article, Dr. Jolien Tol and colleagues randomly assigned 755 patients with previously untreated metastatic colorectal cancer to capecitabine, oxaliplatin, and bevacizumab or the same regimen plus weekly cetuximab. Bevacizumab is an anti–vascular endothelial growth factor (VEGF) antibody that has become a first-line treatment for metastatic colorectal cancer, while cetuximab is an anti–epidermal growth factor receptor (EGFR) antibody that has also been shown to be beneficial in the treatment of metastatic colorectal cancer. The authors found that while the median progression-free survival was 10.7 months in the group receiving the bevacizumab, capecitabine and oxaliplatin, it was significantly decreased when cetuximab was added to the regimen (9.4 months, P = 0.01). In addition to the decreased longevity, quality-of-life scores were also lower in the group receiving both biologics, seemingly due to the greater incidence of grade 3 or 4 adverse events. Based on this study, we should not assume that more is always better. In this case, it is just less effective and more expensive.

This week’s Annals of Internal Medicine brings us an interesting article that examines an intervention designed to decrease repeat emergency room visits. Twenty percent of hospitalizations are complicated by postdischarge adverse events which may result in the patient returning to the hospital. This has a significant negative impact on health care costs. In this study, Dr. Jack and colleagues randomized 749 English-speaking hospitalized adults to an intervention in which a nurse discharge advocate worked with patients during their hospital stay to arrange follow-up appointments, confirm medication reconciliation, and conduct patient education with an individualized instruction booklet or to no intervention. Furthermore, the intervention group also received a phone call from a clinical pharmacist 2 to 4 days after discharge to reinforce the discharge plan and review medications. The authors showed that the intervention resulted in a lower rate of hospital utilization than those receiving usual care (0.314 vs. 0.451 visit per person per month P = 0.009). Though there is obviously an increased cost associated with hiring nurses to perform this role, overall, the intrevention was associated with a 33.9% lower observed cost, due to decreased patient return visits to the hosptial. This approach will not work for every patient, but I can scarcely imagine the decrease in healthcare costs and morbidity across the country if we were able to decrease the rate of re-hospitalizations.

Finally, let’s turn to an article in this week’s Lancet.  All medical residents know how difficult it is to deal with transient insomnia associated night float, or with jet lag. Many have proposed use of melatonin to combat this problem. Dr Rajaratnam, and colleagues performed a phase II and a phase III study to examine the efficacy of a melatonin agonist, tasimelteon, for the treatment of transient insomnia associated with shifted sleep and wake time. In the phase II study, 39 subjects were randomly assigned to tasimelteon or placebo. In the phase III study, 411 healthy subjects, who had transient insomnia induced in a sleep clinic by a 5-h advance of the sleep-wake schedule and a first-night effect in a sleep clinic, were given tasimelteon 30 min before bedtime. In the phase II study, the authors found that tasimelteon reduced sleep latency and increased sleep efficiency compared with placebo. In the phase III study, tasimelteon improved sleep latency, sleep efficiency, and wake after sleep onset (ie, sleep maintenance). The melatonin agonist did not result in any adverse effects. So, as we close down this primecuts, somewhat more satiated than before, I offer a good-bye and good night.