Primecuts – This Week In The Journals

August 3, 2015

Primecuts 8.3.15By David Kudlowitz, MD

Peer Reviewed

In the news this week, 4 people have died from an outbreak of Legionnaires’ disease in the South Bronx (1). A total of 65 people have been affected since mid-July. All deaths have been in older patients with underlying medical problems. NYC health officials have decontaminated several buildings’ water supply, including a hospital and a hotel. The initial outbreak of Legionella was at the American Legion conference in Philadelphia in 1976. There, 221 people were infected and 34 people died.

In medical news:

Does donor hypothermia decrease need for recipient dialysis post kidney transplant?

A significant problem after kidney transplant is delayed graft function, which is defined as the requirement of dialysis within 7 days of renal transplantation. Delayed graft function is an adverse event that can occur in as many as 50% of transplant recipients (2). While therapeutic hypothermia has been shown to improve neurologic outcomes in certain patients who achieve ROSC after cardiac arrest, its renoprotective effects have not been rigorously studied. Hypothermia may prevent ischemia-reperfusion injury and reduce the creation of free radicals.

In a prospective, randomized control trial published in the New England Journal of Medicine last week, Niemann et al. analyzed whether donor induced hypothermia (cooling patients to 34-35°C after neurologic brain death has been declared) would decrease the need for post-transplant dialysis (3). Two hundred eighty patients received kidneys from donors in the hypothermia arm (defined as cooling to 34-35°C), and 286 patients received kidneys from donors in the normothermia arm (defined as maintenance of 36.5-37.5°C). The primary outcome was delayed graft function, which developed in 39% of patients in the normothermia group compared to 28% in the hypothermia group (p=0.008). The study was terminated at a pre-specified interim analysis given hypothermia’s overwhelming efficacy.  No significant adverse events were reported.

This study indicates that induced hypothermia in deceased kidney donors resulted in a significantly reduced incidence of recipient dialysis within 7 days of transplantation. Questions remain as to whether the effects of this intervention will be long lasting and if other donated organs are affected during the cooling process.

Does chemotherapy improve quality of life near death?

A surprising study published in JAMA Oncology evaluates chemotherapy use and its relationship to quality of life at the end of life (4). This trial studied patients with recurrent, metastatic solid tumors in 6 centers from 2002-2008. Three hundred eighty four patients died during the observation period. At death, 158 patients (50.6%) were receiving chemotherapy and 154 (49.4%) were not. Quality of life near death was surveyed postmortem by the most knowledgeable caregiver. Patients receiving chemotherapy with a good ECOG (Eastern Cooperative Oncology Group) score of 1 had a lower quality of life near death (OR, 0.35; 95% CI, 0.17-0.75) when compared to patients not receiving chemotherapy near death. Among patients with a moderate to poor performance status (ECOG 2-3), there was no difference in quality of life near death in the chemotherapy compared to the non-chemotherapy arm.

In this study, chemotherapy did not improve quality of life near death in patients with a moderate to poor performance status. Strikingly, patients with good performance statuses who were receiving chemotherapy had a worse quality of life at death than those not receiving chemotherapy. The goal of palliative chemotherapy should be to either reduce symptoms or to increase length of survival. While this study was not designed to look at survival times, it showed that in this heterogenous population of patients with metastatic cancer, chemotherapy does not improve quality of life. Further studies should be designed in populations that examine specific cancer types and therapies.

Does lung cancer screening decrease patient motivation to quit smoking?

Since the National Lung Cancer Screening Trial, providers have begun to offer high-risk patients lung cancer screening (5). A new study in JAMA Internal Medicine assesses motivation for smoking cessation in patients who have been screened for lung cancer (6). In a 4-month period in 2014, 37 out of 186 patients (in a VA system) agreed to participate in the study. All were questioned in an interview format. Half of the patients stated that lung cancer screening reduced their urge to quit smoking There was also a perception in some of these patients that the CAT scan would provide similar benefits when compared to smoking cessation. There were several weaknesses of this study. Patients were not recorded as to whether they quit smoking or not. Additionally, there was a low study participation rate. However, this study brings to light that a full discussion of the risks and benefits of lung cancer screening must be done with patients (along with an adjunctive discussion about smoking cessation).

Determining who gets gastric cancer

While the total incidence of gastric cancer is decreasing, certain populations, including US whites between the ages of 25-39 years, have increasing incidences (7). A new study in the BMJ examined a national cohort in Sweden to determine the incidence of gastric cancer in patients who had a previous gastric biopsy (8). About 400,000 patients had samples taken between 1979 to 2011 (for non-malignant indications). The incidence of gastric cancer over a 20-year period was as follows: normal mucosa 1/256, gastritis 1/85, atrophic gastritis 1/50, intestinal metaplasia 1/39, and dysplasia 1/19. Researchers disregarded all diagnoses of gastric cancer within a two-year period of the initial endoscopy to reduce selection bias (because cancers that occurred within this time period were likely to have been present on the initial biopsy). Studies such as this one may help physicians decide who and when to screen. However, similar data must be reviewed in higher risk Asian patients.


A case series was published in the Annals of Internal Medicine described the clinical spectrum of Borrelia miyamotoi disease (BMD), a recently discovered tickborne illness in the Northeast United States (9).

A study in the NEJM examined the incidence and pathogenic causes of community acquired pneumonia in adults. A pathogen was only detected 38% of the time and most of were viruses (10).

In a cohort of patients in Italy getting biologic therapy for rheumatologic diseases, none of the 179 patients with prior hepatitis B infection (nor the >1000 patients without history of HBV) had reactivation. This may perhaps minimize the need for prophylactic antiviral therapy (11).

Dr. David Kudlowitz is a 3rd year resident at NYU Langone Medical Center

Peer reviewed by Karin Katz, MD, Chief Resident, Internal Medicine, NYU Langone Medical Center

Image courtesy of


  1. Shortell D. Four dead in Legionnaires’ disease outbreak in New York. August 2, 2015 2:43 PM. Accessed on August 2, 2015.


  1. Yarlagadda SG, Coca SG, Garg AX, et al. Marked variation in the definition and diagnosis of delayed graft function: a systematic review. Nephrol Dial Transplant 2008;23:2995–3003. Accessed August 2, 2015.


  1. Niemann CU, Feiner J, Swain S, et al. Therapeutic Hypothermia in Deceased organ Donors and Kidney-Graft Function. N Engl J Med 2015; 373:405-414. Accessed August 2, 2015.


  1. Prigerson HG, Bao Y, Shah M, et al. Chemotherapy Use, Performance Status, and Quality of Life at the End of Life. JAMA Oncol. Published online July 23, 2015. Accessed on August 2, 2015.


  1. National Lung Screening Trial Research Team, Church TR, Black Wc, et al. Results of initial low-dose computed tomographic screening for lung cancer. N Engl J Med 2013; 368:21:1980-91. Accessed on August 2, 2015.


  1. Zeliadt SB, Heffner JL, Sayre G, et al. Attitudes and Perceptions About Smoking Cessation in the Context of Lung Cancer Screening. JAMA Intern Med. Published online July 27, 2015. Accessed August 2, 2015.


  1. Anderson WF, Camargo MC, Fraumeni JF Jr, et al. Age-specific trends in incidence of noncardia gastric cancer in US adults. JAMA 2010;303:1723-8. Accessed August 2, 2015.


  1. Song H, Ekheden IG, Zheng Z, et al. Incidence of gastric cancer among patients with gastric precancerous lesions: observational cohort study in a low risk Western Population. BMJ 2015;351:h3867. Accessed August 2, 2015.


  1. Molloy PJ, Telford III SR, Chowdri HR, et al. Borrelia miyamotoi Disease in the Northeastern United States: A Case Series. Annals of Internal Medicine 2015;163:2:91-98. Accessed August 2, 2015.


  1. Jain S, Self WH, Wunderink RG, et al. Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults. N Engl J Med 2015;373:415-427. Accessed August 2, 2015.


  1. Barone M, Notarnicola A, Lopalco G, et al. Safety of long-term biologic therapy in rheumatologic patients with previously resolved hepatitis B infection. Hepatology 2015;62:1:40-46. Accessed August 2, 2015.