PrimeCuts: This Week in the Journals

October 19, 2009

glacierxxChau Che MD

This week ended on a high note in the financial world. The Dow bounced back and crossed the 10,000 mark this week, ultimately ending the week slightly below that mark and Goldman Sachs posted a profit of 3.19 billion in the third quarter, signifying a hopeful return to the days before the financial crisis. However, in retrospect, the financial crisis of 2007 was preventable and could have been avoided if the banks gave out loans with a bit more discretion. The hopeful recovery makes the crisis only seem temporary, but steps need to be taken in order to prevent history from repeating itself. This week, the medical journals also addressed many areas of prevention but in a different facet. The journals did not look to protect and safeguard assets, but rather to prevent: prevent mortality, prevent the spread of infection, prevent complications, prevent pain, and prevent disease.

This week, the New England Journal of Medicine examined the clinical course of advanced dementia in a prospective manner (5). Mitchell et al. found that infections and nutritional problems were complications associated with high mortality rates. It also showed that health care proxies who understood the prognosis and clinical course of dementia were not as likely to ask for aggressive end of life care as compared to health care proxies who did not understand the prognosis and expected complications (OR, 0.12; 95% CI, 0.04-0.37). This article reiterates what most health care workers realize; advanced dementia is a terminal disease with complications. However, most importantly, the article emphasizes that in order to prevent unnecessary aggressive care, family members and health care proxies need to be educated to understand the course of the disease. In this scenario, the key to prevention of unnecessary intervention is effective communication.

As influenza season approaches, the prevention of influenza is a topic on everyone’s radar, including the Annals of Internal Medicine (2). Cowling et al. looked at the utility of hand hygiene and facemasks to prevent household transmission of influenza. The use of these techniques within 36 hours of the onset of patient symptoms prevented influenza transmission (adjusted OR, 0.33; 95% CI, 0.13-0.87). This knowledge may enable family members to abstain from other therapeutic interventions, such as use of oseltamivir. The article reiterates a common topic that is familiar to all hospital personnel: hand hygiene. Continuing to practice hand hygiene outside of the hospital setting may limit the dissemination of disease, including influenza.

Doctors try to treat disease, but procedures are not without risks. With that in mind, the advent of minimally invasive surgery has theoretically reduced the risk of complications. Patients and physicians often tout the belief that minimally invasive procedures may prevent complications. The Journal of the American Medical Association explored this notion by comparing the effectiveness of minimally invasive versus open radical prostatectomy (4). Hu et al. showed that men who received minimally invasive prostatectomy had fewer miscellaneous surgical complications and shorter hospital stays. However, it also showed that minimally invasive recipients were more likely to suffer from incontinence (15.9 vs 12.2 per 100 person years; p = .02) and erectile dysfunction (26.8 vs 19.2 per 100 person years; p = .009) eighteen months after the procedure. Although this disputes the belief that minimally invasive surgery may prevent complications, it seems that one may argue that regardless of the modality of the procedure, the most important factor is the surgeon’s experience.

Sometimes, it is too late to prevent disease and instead treatment is needed. This week, The Lancet published an article examining what many of our patients deal with daily: pain. Gilron et al. looked at neuropathic pain and assessed the efficacy of nortriptyline and gabapentin compared with each drug given individually (3). The study showed that pain relief with combination therapy was lower than with gabapentin (-0.9, 95% CI, -1.4 to -0.3, p = 0.001) or nortriptyline (-0.6, 95% CI, -1.1 to -0.1, p=0.02) alone. Although the study gives us evidence of improvement of pain control with the two medications, this is nothing new in the world of treatment. The idea of medications working in synergy is an area that doctors often look to exploit in order to prescribe the most efficacious treatments. It looks like this may be another pair of medications that may improve the treatment of neuropathic pain when used concomitantly.

The idea of prevention is especially important in chronic diseases. Primary prevention may help avoid end organ damage that results from diabetes, hypertension, and coronary artery disease. This study from the New England Journal of Medicine looks at the aftermath when patients have reached end organ failure (6). Tamura et al. examines functional capacity based on the Minimum Data Set-Activities of Daily Living [MDS-ADL] scale once dialysis is instituted in elderly patients with end-stage renal disease. The initiation of dialysis resulted in a decline of functional status. By twelve months after starting dialysis, 58% of the patients died and pre-dialysis functional status was maintained in only 13% of the patients. This is another reason to stress the importance of primary prevention.

Lastly, the modification of risk factors is an important aspect in preventing disease. Cigarette smoking is a modifiable risk factor for many diseases. However, other modifiable risk factors also exist. This week’s Lancet examines the effect of hormone replacement therapy (HRT) on lung cancer (1). Chlebowski, R., et al. showed that HRT did not increase the incidence of lung cancer; however it increased the number of deaths from lung cancer (HR 1.71, 95% CI 1.16-2.52, p= 0.01) especially from non small cell lung cancer. These findings add to the discussion that should occur before physicians start females on hormone replacement therapy following the initial findings of the Women’s Health Initiative.

It is clear from this week’s PrimeCuts that prevention was on everyone’s mind from the medical journals to the economists.

Dr. Che is a second year internal medicine resident at NYU Medical Center.

Faculty peer reviewed by Judith Brenner MD, Associate Program Director and Associate Editor, Clinical Correlations

1. Chlebowski, R., et al. Oestrogen plus progestin and lung cancer in postmenopausal women (Women’s Health Initiative trial): a post-hoc analysis of a randomised controlled trial. The Lancet 2009; 374 (9697): 1243-1251.  2. Cowling, B., et al. Facemasks and Hand Hygiene to Prevent Influenza Transmission in Households. Annals of Internal Medicine 2009; 151 (7): 437-446.

3. Gilron, I, et al. Nortriptyline and gabapentin, alone and in combination for neuropathic pain: a double blind, randomized controlled crossover trial. The Lancet 2009; 374 (9697): 1252-1261.

4. Hu, J., et al. Comparative Effectiveness of Minimally Invasive vs. Open Radical Prostatectomy. JAMA. 2009; 302(14):1557-1564.

5. Mitchell, S., et al. The Clinical Course of Advanced Dementia. N Engl J Med 2009; 361: 1529-38.

6. Tamura, M., et al. Functional Status of Elderly Adults before and after Initiation of Dialysis. N Engl J Med 2009 361: 1539-1547.