PrimeCuts: This Week in the Journals

November 16, 2009

fallKatie Miro MD

Faculty peer reviewed

Americans took the time last week to honor the men and women who fought for our country as Veteran’s Day was marked with parades and celebration throughout the nation. Clinical Correlations would like to send special thanks not only to the many veterans of this country, but also to the brave men and women serving in the military today. While the war on terrorism continues abroad, President Obama’s battle for health care reform continues at home. Sunday’s front page  of the New York Times highlighted a victory for Obama in his fight for health care reform as the House voted in favor of an extensive plan to revamp the nation’s healthcare system. This plan poses to extend coverage to approximately 36 million Americans currently living without medical insurance. Many Republican representatives continue to fight against the legislation with the concern that the new plan would be too much of a financial drain on the nation’s economy. As Representative Steny H. Hoyer, Democrat, stated, “Much work remains.”

The week came to a close with an article in the New York Times addressing the war on cancer  and taking a look through the research of various cancer treatments. This article suggests that while many Americans are willing to try many vitamin supplements and dietary modifications in an attempt to prevent cancer, evidence has not supported the effectiveness of these treatments. Many pharmacologic treatments, such as finasteride, have shown promise in several research studies in prevention of prostate cancer, although its use has yet to have been initiated for this indication. The new HPV vaccine and smoking cessation have also shown success in cancer prevent. Doctors should continue to utilize those treatments that are proven effective in cancer prevention, and, good nutrition and exercise should always be encouraged.

The New York Times also referred to an article in JAMA,  Prevalence of and factors associated with persistent pain following breast cancer surgery. This nationwide cross-sectional questionnaire study of 3754 women in Denmark who had undergone surgery for breast cancer was conducted to assess the prevalence and severity of continued pain. 1543 patients reported continued pain after surgery, with 86% of these patients experiencing pain in the breast area. A significant association was seen with persistent pain following breast conserving surgery and young age, with a significant increased risk of pain in 18-39 year old as compared to 60-69 years, p<0.001. Pain following mastectomies was most significant in women 40-49, and there was a significant association with this age group and more severe pain as compared to women of other age groups studied. Though each infection was associated with risk of stroke, the results did not prove to be significant, and would need to be further studied. Pain complaints in other areas of the body were associated with increased post-surgical pain. Sensory disturbances, presumably due to nerve damage, following surgical intervention was also significantly (p <0.001) associated with an increase in risk of chronic persistent pain. This study may help guide future therapy including nerve sparing techniques, and special attention shown to those groups shown to have higher incidence of post-operative pain.

On the topic of pain, an article to look out for in a future issue of the Lancet addresses laser therapy as a treatment for neck pain. This article, currently available at Lancet Online, focuses on the efficacy of laser therapy. Neck and back pain is a frequent chief complaint in many primary care offices throughout the country. A systematic review and meta-analysis was conducted to evaluate the efficacy of this treatment of laser therapy for this problem. 16 randomized control trials were evaluated, 2 of which looked at the subject of acute pain while the others looked at chronic pain. Data showed that there was a clinically significant decrease in symptoms in the 2 trials addressing acute neck pain, and clinically significant reduction in pain in the chronic pain group, with 7 of those trials showing an effect lasting up to 22 weeks. Only 50% of the trials reported side-effects of the treatment, although when reported, side-effects were mild, suggesting that this appears to be a promising treatment for both acute and chronic neck pain.

The New England Journal of Medicine published an article this week comparing revascularization versus medical therapy for renal artery stenosis. In a randomized, unblinded trial, 806 patients with atherosclerotic renovascular disease were chosen to undergo revascularization plus medical therapy or medical therapy alone. Patients in the medical therapy group required an increased number of antihypertensive agents when compared to the revascularization group at 1 year follow-up. When assessing renal function, during a 5-year follow-up the mean serum creatinine level was 1.6mmol per liter lower in the group that underwent revascularization as compared to control. Although renal function was shown to significantly improve in the revascularization group, no difference in overall mortality was found, and there was an increase in adverse events associated with the procedure. Based on this article it appears that medical therapy will still be the recommended first treatment for patients with atherosclerotic renovascular disease.

Often times it is a challenge to find the best diabetic regimen to treat our patient. An article in the British Medical Journal tackled this issue. They compared the combination of insulin with metformin vs insulin with an insulin secretagogue in non-obese patients with type 2 diabetes. The researchers randomized 459 patients with type 2 diabetes to either of the above regimens, using the reduction in HbA1C as the primary outcome measure. After 12 months of therapy, there was no significant different in HbA1C levels in patients of either treatment arm, and no difference in the number of patients lowering their A1C to <6.5. There was also no difference seen in the insulin requirements between the two groups. When trying to decide on the adequate regimen for our non-obese diabetic patients, metformin and repaglinide appear to be just as efficacious in achieving superior glycemic control when added to insulin therapy.

Is there an infectious association to the risk of stroke in patients? The New York Times made reference this week to an upcoming article in Archives of Neurology addressing this possible correlation. A prospective cohort study was used to identify, if any, the association between one of the following infections and stroke, H. pylori, Chlamydia pneumonia, CMV, and HSV 1 and 2. The proposed mechanism from this potential association and the reason for studying these infections seems to be that each of these infections are chronic in nature and lead to an increased pro-inflammatory state. Though each infection was associated with risk of stroke, the results did not prove to be significant.

Although this week’s PrimeCuts comes to an end, the battle for health care reform, the war against cancer, and the fight against diabetes continues.

Dr. Miro is a 2nd year internal medicine resident at NYU Medical Center.

Faculty peer reviewed by Michael Poles MD, NYU Division of Gastroenterology

Chow RT, Johnson MI, Lopes-Martins RA, and JM Bjordal. Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomized placebo or active-treatment controlled trials. The Lancet. 2009; Published online November 13, 2009.

Elkind MS, Ramakrishnana P, et al. Infectious burden and risk of stroke. Arch Neurol. Published online November 9 2009.

Gartner R, Jensen M, Nielsen J, et al. Prevalence of and factors associated with persistent pain following breast cancer surgery. JAMA. 2009; 302 (18): 1985-1992.

Hulse C, Pear R. Sweeping health care plan passes house. The New York Times. Published online on November 7 2009.

Kolata G. Medicines to deter some cancers are not taken. The New York Times. Published online on November 12 2009.

Lund SS, Tarnow L, Frandsen M, et al. Combining insulin with metformin or an inslulin secretagogue in non-obese patients with type 2 diabetes: 12 month, randomized, double blind trial. British Medical Journal. Published online November 14, 2009.

The ASTRAL investigators. Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med. 2009; 361: 1953-1962.