Primecuts-This Week in the Journals

December 23, 2014

By: Kristina Cieslak

This Wednesday, President Obama announced plans to “end an outdated approach, that for decades, has failed to advance our interests,” ordering restoration of full diplomatic relations between the United States and Cuba.1 This step marks a momentous reversal of an embargo first initiated by former president Dwight D. Eisenhower in 1960, with full break of diplomatic relations in January, 1961.  Citing the previous embargo as “a rigid policy rooted in events that took place before most of us were born,” Obama spoke of hope that the renewed relationship will advance shared interests in “health, migration, counter-terrorism, drug trafficking, and disaster response.”  Many in the scientific community applaud this loosening of restrictions, hopeful that increased joint research will be possible, particularly in the areas of emerging pathogens such as the chikungunya virus, and atmospheric hurricane patterns.  The United States may now be able to sponsor scientific workshops and meetings in Cuba, in addition to exporting state-of-the-art instruments.2

Additional hopeful news for the scientific and medical community this week includes appointment of the new United States Surgeon General.

Senate, Ending Long Battle, Confirms Nominee for Surgeon General3

Dr. Vivek H. Murthy, an internal medicine physician at Brigham and Women’s Hospital, was appointed as the 19th Surgeon General of the United States this Monday, a position vacant since July of 2013.  Dr. Murthy’s appointment was not without controversy, as his public stance on gun restriction and former involvement in groups supporting Obama’s 2008 campaign and passage of the Affordable Care Act raised concern of a heavy political bias.  Citing a pressing need for a more concerted emphasis on medicine and public safety, particularly in light of the recent Ebola threat, Obama responded, “Vivek’s confirmation makes us better positioned to save lives around the world and protect the American people here at home.”

There has long been a call within the scientific community not only to expedite this appointment, but also for the surgeon general to effect change with an increased public presence.  Particularly, several groups advocate for Dr. Murthy to increase public education surrounding insurance and the Affordable Care Act, streamline anti-obesity efforts, stifle falsified science surrounding anti-vaccination, and report regularly on the ‘State of American Health.’4 Dr. Murphy seems eager to heed this call, as he has spoken of hopes to “marshal partnerships across the country to address the epidemics of obesity and tobacco related disease, to reduce the crippling stigma of mental illness, to rollback the resurgence of vaccine preventable disease, and to make prevention and health promotion the backbone of our communities.”

Televised medical talk shows—what they recommend and the evidence to support their recommendations: a prospective observational study5

The British Medical Journal published an article this week examining the validity of claims made by physicians on the popular television programs The Dr. Oz Show and The Doctors, together drawing over five million viewers per day.  Though public health education remains an extremely important venture, and television has proven one of the most important and effective means to do so, little evidence had existed until now as to the quality, completeness, and accuracy that the public is receiving.  Forty episodes of each show from 2013 were randomly selected for review, with primary outcome as the percentage of recommendations and claims supported by scientific evidence, and secondary outcomes as topics discussed, number of recommendations made, types and details of recommendations, and general episode characteristics.

Perhaps not surprising to the medical community, evidence (considered as case study or better) was found to support only 46% of claims on The Dr. Oz Show and 63% of claims on The Doctors.  Furthermore, evidence was found that directly contradicted 15% and 14% of recommendations on The Dr. Oz Show and The Doctors, respectively.  The most common recommendations on The Dr. Oz Show centered on dietary advice (39%), while most common advice on The Doctors involved consultation of a healthcare provider (19%).  These results show that the medical advice on these wildly popular television shows is often no more accurate than flipping a coin. The article draws warning to the public that recommendations from these popular sources should be heeded with caution, as they are often not supported by scientific evidence, and patients are encouraged to discuss risks/harms of recommendations with other medical professionals.

Heart Disease and Stroke Statistics—2015 Update: A Report From the American Heart Association6

This annual joint report from the American Heart Association (AHA), Centers for Disease Control and Prevention, and the National Institutes of Health compiles the latest data available on cardiovascular health behaviors, risk factors, and outcomes for major clinical disease conditions including stroke, rhythm disorders, and valvular disease, among others.  The report details that tobacco use, though declining, with 17.9% of adults reporting current use, remains responsible for one-third of coronary heart disease deaths, and smoking-attributable economic costs in the US exceed $289 billion.  The leading risk factor for death and disability in the US continues to be suboptimal diet, namely insufficient intake of fruits, nuts/seeds, whole grains, vegetables, and seafood, and excess intake of sodium.  Although obesity has decreased among those of higher socioeconomic status (SES), it continues to increase among those of lower SES.

Partly in response to the increase in prevalence, the total number of inpatient cardiovascular operations and procedures has increased 28% in the past decade.  Cardiovascular disease costs more than any other diagnostic group, with estimated annual costs of $320.1 billion in 2011.  Some encouraging data has demonstrated a decline in stroke mortality over the past decades, concurrent with cardiovascular risk factor control interventions targeting diabetes and smoking cessation.  The AHA cites a continued effort and strategies to improve promotion of positive cardiovascular health and prioritization of good health behaviors (diet, energy intake, physical activity, nonsmoking) and factors (lipid levels, blood pressure, glucose control) in support of these improved outcomes.

Cytisine versus Nicotine for Smoking Cessation7

Continuing the focus on a smoking, a major culprit of cardiovascular disease, an article in the New England Journal of Medicine this week turns its attention to cytisine, a partial agonist of nicotinic acetylcholine receptors (nAChRs) that has long been used for smoking cessation, primarily in Eastern Europe.  Despite its proven benefits and low cost (~$20-30 for 25 day treatment compared to $112-685 for 8-10 weeks of nicotine-replacement therapy), cytisine remains relatively unknown and underutilized in the United States.  This non-inferiority trial investigated cytisine compared to nicotine-replacement therapy for a group of current smokers recruited through the New Zealand national quitline.  All participants received low-intensity telephone behavioral support, and were randomized either to receive eight weeks of nicotine-replacement therapy in the form of patches, lozenges, or gum and lozenges or a 25-day course of oral cytisine.

The primary outcome assessed was self-reported continuous abstinence from smoking. Cytisine was superior to nicotine in this regard, with 40% of participants reporting abstinence at 1-month, vs. 31% of participants in the nicotine-replacement group.  Self-reported adverse events occurred more frequently in the cytisine group (incidence rate ratio of 1.7), the most frequent of which were nausea, vomiting, and sleep disorders.  Median time to relapse was significantly longer in the cytisine group (53 days vs. 11 days in the nicotine-replacement group).  This trial demonstrates that cytisine is an effective smoking-cessation aid and paves the way for a future head-to-head trial of varenicline (a more expensive nAChR) vs. cytisine to evaluate cost-effectiveness.

In Other News…

The Journal of the American Medical Association  (JAMA) published a study comparing several diets with varying glycemic indices to determine the impact on risk factors for cardiovascular disease and diabetes.  Interestingly, the study found that diets with low glycemic indices did not result in improvements in insulin sensitivity, lipid levels, or systolic blood pressure.8

JAMA also published a paper focusing on Hepatitis B (HBV) in patients with lymphoma currently receiving chemotherapy, finding that prophylactic entecavir is superior to lamivudine in preventing HBV-related hepatitis and HBV reactivation.9

In an advanced online publication, Nature Reviews Endocrinology published a study showing that an oral bisphosphonate can prevent bone loss in postmenopausal women at high risk for breast cancer and on aromatase inhibitor therapy.10 This data may ease conversations weighing the benefit of aromatase inhibitors in preventing breast cancer against patients’ increased risk of bone loss and future fractures.

For patients suffering from an acute ischemic stroke secondary to a proximal intracranial occlusion, the NEJM published a study showing both efficacy and safety of intraarterial treatment with retrievable stents within six hours of stroke onset11

Kristina Cieslak is a fourth year medical student at NYU School of Medicine

Peer Reviewed by Jessica Taff, MD Associate Editor, Clinical Correlations

Photo of Cuban Flag courtesy of Jorge Royan, Wikimedia Commons

1. Baker P. U.S. to Restore Full Relations With Cuba, Erasing a Last Trace of Cold War Hostility. New York Times online Dec. 17, 2014;

2. Stone R, Wilkinson A. Researchers applaud U.S.-Cuba accord. Science Insider online 2014;

3. Peters J. Senate, Ending Long Battle, Confirms Nominee for Surgeon General. New York Times online Dec. 15, 2014;

4. Morris NP. A to-do list for the next US surgeon general. JAMA internal medicine. Feb 1 2014;174(2):177-178.

5. Korownyk C, Kolber MR, McCormack J, et al. Televised medical talk shows—what they recommend and the evidence to support their recommendations: a prospective observational study. British Medical Journal 2014;3049:g7346

6. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart Disease and Stroke Statistics—2015 Update: A Report From the American Heart Association. Circulation. December 17, 2014 2014.

7. Walker N, Howe C, Glover M, et al. Cytisine versus Nicotine for Smoking Cessation. New England Journal of Medicine. 2014;371(25):2353-2362.

8. Sacks FM, Carey VJ, Anderson CA, et al. Effects of high vs low glycemic index of dietary carbohydrate on cardiovascular disease risk factors and insulin sensitivity: the OmniCarb randomized clinical trial. JAMA. Dec 17 2014;312(23):2531-2541.

9. Huang H, Li X, Zhu J, et al. Entecavir vs lamivudine for prevention of hepatitis B virus reactivation among patients with untreated diffuse large B-cell lymphoma receiving R-CHOP chemotherapy: a randomized clinical trial. JAMA. 2014;312(23):2521-2530.

10. Suva LJ, Makhoul I. Bone: Will breast cancer chemoprevention stand on ‘solid bone’? Nat Rev Endocrinol. 12/16/online 2014;advance online publication.

11. Berkhemer OA, Fransen PS, Beumer D, et al. A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. The New England Journal of Medicine. Dec 17 2014.