PrimeCuts: This Week in the Journals

February 23, 2009

flowers.JPGCommentary by Ryan Farley MD, PGY-3

Faculty Peer Reviewed

Hot off the press from the New England Journal of Medicine (NEJM) this week is an original article comparing percutaneous coronary intervention (PCI) with coronary artery bypass graft surgery (CABG) for severe coronary artery disease. This study, also known as the Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial, was a prospective clinical trial conducted at 85 sites in 17 countries in Europe and the United States that randomly assigned 1800 patients with three-vessel or left main coronary artery disease to undergo PCI with a drug-eluting stent or CABG. The primary end point was a composite of major adverse cardiac and cerebrovascular events (i.e. death from any cause, myocardial infarction, stroke, or repeat revascularization) in the 12 months following the intervention. A noninferiority comparison of the two groups revealed a significantly higher number of adverse outcomes in the PCI group (17.8%, versus 12.4% for CABG, P=0.002), largely secondary to the increased rate of revascularization (13.5% versus 5.9%, P<0.001). While the rates of death and myocardial infarction were similar between the two groups, the incidence of stroke was higher in the CABG group (2.2%, versus 0.9% for PCI, P=0.003). In summary, the criteria for noninferiority were not met because the rate of the combined end points was lower for CABG, hence, it remains the standard of care for the treatment of three-vessel or left main coronary artery disease. However, for those patients with significant contraindications to surgery, PCI remains a viable option without the increased risk of death or MI in the subsequent year to follow.

In this week’s Journal of the American Medical Association (JAMA), the Centers for Disease Control and Prevention (CDC) evaluated the incidence of methicillin-resistant S. Aureus (MRSA) central line-associated blood stream infections (BSI) in U.S. intensive care units. From an extensive national database, the CDC identified 33,587 central line-associated BSIs from 1684 ICUs. 7.4% of all infections were identified as MRSA while 4.4% were MSSA. In further analysis, which included distinction between different types of ICUs (i.e. medical, surgical, nonteach versus teach, etc.) the incidence of MRSA line infections increased between 1997-2001. However, from 2001-2007, the data show statistically significant declines in the incidence of MRSA central line-associated BSI across all ICUs (except pediatric ICUs, which showed no change). Although the overall proportion of S. aureus infections due to MRSA increased 25%, the overall incidence of MRSA decreased 49%, suggesting that public health efforts have been successful in recent years to curb the seemingly rising spread of this pathogen.

The New York Times reported this weekend that counties surrounding New York City have followed suit in the ban on partially hydrogenated oils used in licensed restaurants. Suffolk county executive Steve Levy signed the law, which prohibits use of artificial trans fat, into effect on February 6. This move follows the actions of New York, Nassau, Westchester and Albany counties in the fight against obesity and obesity related illness. NYU’s own Jennifer Crum, a nutritionist at the Langone Medical Center, provided some nutritional recommendation to the authors (i.e. that no more than 10 percent of daily calories should come from saturated fats as found in red meat, butter and daily products). County health inspectors will be monitoring adherence to the new law and have the authority to cite and fine restaurants for non-compliance.

Had a flu shot this year? There’s some exciting research being done examining the efficacy of human antibodies to the influenza virus as reported in Nature and CNN online. Seasonal flu kills more than 250,000 people worldwide and the more virulent strains like the bird flu has resulted in the death of millions of birds and more than 400 people since 1997. Scientists from the Dana-Farber Cancer Institute in Boston, Massachusetts, the Burnham Institute for Medical Research in La Jolla, California, and the CDC collaborated on the isolation and characterization of a novel family of human antibodies capable of binding to an obscure region of the flu virus and prohibiting it from changing shape to cause infection. When tested on mice, the antibodies were shown to be protective, even when they were administered three days after being infected with strains of the flu. The next step will be testing the antibodies in ferrets, then developing an appropriate version to be used in human clinical trials potentially as soon as 2011 or 2012. Robert Liddington, director of the Burnham Institute, said the antivirals can be very effective in the event of a pandemic outbreak, but need to be used judiciously and approved by the U.S. Food and Drug Administration.

2009 is a special year for Charles Darwin fans. This year is the 150th anniversary of the publication of On the Origin of Species (November 24, 1859), and the 200th anniversary of the birth of Darwin (February 12, 1809). It was such a milestone that during June of 1909, over 400 scientists and dignitaries from 167 different countries gathered at Cambridge to celebrate the centenary of Darwin’s birth and the fiftieth anniversary of the publication of On the Origin of Species. The event was an unprecedented success. Darwin Day is held annually on February 12 in celebration of the evolutionary biologist’s birthday, and is widely considered a day of global celebration of science and reason.

Reviewed by Barbara Porter MD, Associate Residency Program Director