PrimeCuts: This Week in the Journals

November 2, 2009

brparkwayTao Xu MD

Faculty peer reviewed

As we approach the end of fall, with large crowds in a variety of costumes gleefully marching in the pouring rain during the 36th Annual Village Halloween Parade, thoughts about flu season warnings seemed far away. But here is a story that will remind us of the global threat of the H1N1 virus. At the end of November, the annual Mecca will take place in Saudi Arabia, where an estimated 2.5 million pilgrims from 160 countries will find themselves shoulder-to-shoulder. As reported in The New York Times,  in preparation for this world-wide pilgrimage, Saudi Arabia has advised the use of preventive measures against the H1N1 flu, including hand-washing, surgical masks, and hand sanitizers. At the same time, the Saudi government has purchased loads of Tamiflu made in India, expanded the nation’s ICUs, and fully-loaded staff into medical centers. On the other hand, The New York Times reports that the Ukraine government’s choice of preventive measure in this flu season is to close schools nationwide for three weeks, ban large crowd gatherings, and restrict traveling.Also this week’s New York Times reported on a recent study showing the prevalence of myocardial infarction decreasing among men and increasing among women. Published in the Archives of Internal Medicine,  Towfighi et al. compared the prevalence of myocardial infarction and the Framingham coronary risk score (FCRS) among US adult females and adult males aged 35 to 54 years who participated in the Nutrition Examination Surveys (NHANES) during two periods, 1988-1994, and 1999-2004. It was found that MI prevalence decreased among men and increased among women, though this result was not statistically significant. The FCRS improved in men and worsened in women in the age group 45 to 54 years, and an FCRS greater than 20% declined in men while remaining stable in women. The only aspect of the FCRS where prevalence increased in both men and women was diabetes mellitus. Several factors may contribute to this trend in sex disparity. Patients may underestimate their cardiovascular risks secondary to their concerns for other health risks. Similarly, physicians may treat female patients differently from male patients given a bias towards less concern for prevention of cardiovascular incidents in women, assuming that premenopausal women are generally at lower risk of cardiovascular diseases compared to men in the same age group. This study urges us not only to be aware of this gender bias in assessing cardiovascular risk, but also to note the increasing prevalence of diabetes mellitus and obesity among both groups.

For over 30 years, a widely held belief has been that patients with chronic kidney disease most commonly die from cardiovascular-related illnesses, and that patients on hemodialysis or peritoneal dialysis have a 10 to 20 times higher risk of dying from cardiovascular diseases than the general population. In this week’s JAMA, de Jager et al. found that patients starting dialysis do have an increased risk of death but not mainly due to cardiovascular disease. The increased risk of cardiovascular mortality in this European cohort of patients starting dialysis is comparable to an equally increased risk of noncardiovascular mortality (most commonly infection and malignancies).

In 2000, 171 million people worldwide were affected by diabetes, and it is estimated that the number of people will increase to 366 million by 2030. The original Diabetes Prevention Program (DPP) a randomized clinical trial conducted by the Diabetes Preventions Program Research Group, found that intensive lifestyle changes reduced diabetes incidence by 58% in high-risk individuals, whereas metformin reduced the incidence by 31%. This week’s advanced online publication in Lancet  released the results of the first phase of the Diabetes Prevention Program Outcomes Study (DPPOS) as a 10-year long-term follow-up of the DPP. It was found that the overall incidence of diabetes was the lowest in the lifestyle group compared to the metformin and placebo groups, and the delay or prevention of diabetes did in fact persist for 10 years with metformin or lifestyle changes.

This week in the New England Journal of Medicine,  Holman et al. published a 3-year open-label multicenter study of complex insulin therapy in Type 2 Diabetes. It was found that adding basal or prandial insulin-based therapy to oral diabetic therapy resulted in better glycemic control compared to adding biphasic insulin-based therapy. Additionally, it was found that the addition of basal insulin therapy to oral regimens in type 2 diabetics resulted in fewer hypoglycemic episodes and less weight gain.

Finally, in an advanced online publication in the Annals of Internal Medicine this week, the American College of Physicians released a clinical practice guideline for hormonal testing and treatment of erectile dysfunction. It is strongly recommended that therapy with a PDE-5 inhibitor be started in men who request treatment for erectile dysfunction and do not have contraindications to using a PDE-5 inhibitor. There is weak recommendation for physicians to base the choice of a PDE-5 inhibitor on ease of use, cost, and adverse effects of the medication. Finally, the guidelines state that there is insufficient evidence for routine use of hormonal blood tests or hormonal treatment in patients with erectile dysfunction.

That concludes this week’s edition of primecuts. Here’s to hoping that we can start off next week’s edition with the mention of another parade – let’s go Yankees!!!!

 Dr. Xu is a first year resident in internal medicine at NYU Medical Center.

Faculty peer reviewed by Danise Schiliro-Chuang MD, Contributing Editor, Clinical Correlations

1. Cabin, Roni Caryn. Patterns: For Heart Attacks, Shifts in Gender Gap. The New York Times. Published online on October 27 2009.

2. De Jager Cardiovascular and noncardiovascular mortality among patients starting dialysis. JAMA. 2009; 302 (16): 1782-1789.

3. Diabetes Prevention Program Research Group. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. The Lancet. Published online October 29, 2009.

4. Holman Three-year efficacy of complex insulin regimens in type 2 diabetes. NEJM. 2009; 361:1736-47.

5. Levy, Clifford J. Ukraine bans big crowds to combat swine flu. The New York Times. Published online on October 31 2009.

6. McNeil Jr, Donald G. Saudis try to head off swine flu fears before Hajj. The New York Times. Published online on October 29 2009.

7. Qaseem, Hormonal testing and pharmacologic treatment of erectile dysfunction: a clinical practice guideline from the American College of Physicians. Ann Intern Med. Published online on October 20, 2009.

8. Towfighi, Amytis Sex-specific trends in midlife coronary heart disease risk and prevalence. Arch Int Med. 2009; 169 (19): 1762-1766.