Primecuts – This Week In The Journals

January 17, 2017

PrimeCuts Uncategorized 5 min read

Trump 1.16.17By Scott Butler, MD 

Peer Reviewed

A presidential goodbye. A contentious press conference.  A salacious dossier from a British spy.  It’s been quite a week.

As Republican legislators transition from symbolically voting to repeal Obamacare (over 50 times since its inception) to making its dissolution a reality, it becomes increasingly clear that “replace” is the much more challenging half of the promise to “repeal and replace” the law. Theodore Roosevelt backed a plan for universal coverage when he sought an elusive third term in 1912.  His fifth-cousin Franklin was reportedly mulling over a similar idea when he died during his fourth term in 1945.  Richard Nixon proposed comprehensive coverage in 1974 before getting distracted by a hotel scandal1. If President Trump struggles to come up with a US healthcare silver bullet, he’ll be in good company.

As we ramp up to President-Elect Trump’s inauguration, news is coming in fast, so let us summarize some of the more interesting and useful studies from the medical literature over the last week.

Tranexamic Acid in Patients Undergoing Coronary Artery Surgery2 

One of the greatest contributors to morbidity and mortality in the setting of cardiac surgery is bleeding, and antifibrinolytic agents have been hypothesized to mitigate these risks. One such medication is tranexamic acid, a lysine analog with known prothrombotic effects.  In this week’s New England Journal of Medicine, Myles et al published a randomized control trial where 4662 patients were assigned to either tranexamic acid (100 mg/kg, subsequently lowered to 50 mg/kg) or placebo (normal saline) during coronary-artery surgery, with end points of death and thrombotic complications within 20 days2. Thrombotic events included stroke, pulmonary embolism, renal failure, myocardial infarction or bowel infarction.  Included patients were selected to be at high risk due to comorbidities or age, and were scheduled to undergo coronary artery surgery.  Primary outcomes occurred in 16.7% of the tranexamic acid cohort compared to 18.1% of the placebo group (p=0.22), however the therapeutic arm required fewer transfusions than the placebo group (32.8% vs.  46.8%, p<0.001), with reduced severe bleeding complications (1.4% vs. 2.8%, p=0.001).  The authors conclude that tranexamic acid reduces hemorrhagic complication of coronary artery surgery without being significantly thrombogenic, but acknowledge an increased risk of seizure (0.7% vs 0.1%, p=0.002).

Breast Cancer Screening in Denmark: A Cohort Study of Tumor Size and Overdiagnosis3 

Appropriate screening guidelines for breast cancer, specifically mammography, must balance the goal of intervening early in the course of disease with the desire to avoid morbidity associated with false-positives. Jorgensen et al performed a retrospective cohort study to assess the effect of twice-yearly mammography on the incidence of advanced breast cancer (>20 mm)3 and published the results in Annals of Internal Medicine.  Data were drawn from two databases that include all Danish women diagnosed with breast cancer between 35 and 85 years of age.  The screening cohort was comprised of three cities that began regimented breast cancer screening in the early 1990’s, and the non-screening cohort was defined as the remainder of Denmark.  There was a measured increase in the diagnosis of nonadvanced cancers (<20 mm) in the screening group, with an incidence rate ratio of 1.49, but with no statistically significant decrease in advanced cancers.  Overdiagnosis was estimated by comparing the number of cancers found in screening areas versus non-screening areas, with an estimated overdiagnosis rate of as high as 48.3% for invasive tumors and DCIS.  The authors suggested that mammogram screening in Denmark has not reduced the incidence of advanced breast cancers, and that a significant proportion of the cancers diagnosed likely represent overdiagnosis.

Coronary Artery Calcium to Guide a Personalized Risk-Based Approach to Initiation and Intensification of Antihypertensive Therapy4 

Counseling patients regarding blood pressure control can be challenging in light of varying guidelines and contradictory trial data, with recommended SBP goals ranging from <120 to <150 in some patient populations5,6. McEvoy et al sought to determine whether coronary artery calcium (CAC) seen on CT could assist in identifying an appropriate SBP goal for patients4 in a study published in Circulation. The authors estimated patients’ 10-year risk of cardiovascular disease or heart failure using previously validated equations (ASCVD risk score) after stratifying for CAC (1-100 vs. >100).  Patients with ASCVD risk below 15% with SBP 120-139 had hazard ratios for the development of the primary endpoint of 1.7 and 3.0 with CAC of 1-100 and >100, respectively, relative to coronary artery calcium of 0.  This pattern held for the SBP 140-159 group as well (hazard ratio 2.0 vs. 5.7), but there was no statistical relationship of CAC with outcomes for SBP>160.  The 10-year number needed to treat with SBP goal <120 to prevent primary endpoints was 24 for CAC >100 compared to 99 for CAC=0 in the ASCVD<15% and SBP<160 cohort.  These differences were less pronounced in the ASCVD>15% groups.  The authors concluded CAC was a useful adjunct to determine ideal SBP goal, particularly for patients with ASCVD<15% and SBP<160.

Effectiveness of Screening Colonoscopy to Prevent Colorectal Cancer Among Medicare Beneficiaries Aged 70 to 79 Years7 

Colonoscopy is widely accepted by medical professionals and the public as an important screening modality for the early detection of colorectal cancer (CRC), despite no randomized control trial data evaluating the procedure for this function7. Given the presence of alternatives (FOBT and sigmoidoscopy) proven to reduce mortality, and the heavy resource burden of colonoscopy, Garcia-Albeniz et al undertook a prospective cohort study in Annals of Internal Medicine to evaluate the effectiveness of colonoscopy in preventing CRC. Medicare patients 70-79 years old without history of CRC, and with no CRC screening for the past 5 years, were eligible for inclusion.  Risk of CRC over 8 years was lower in the screening group compared to the non-screening group (2.19% vs. 2.62%) in patients aged 70-74, compared to 2.84% vs 2.97% in patients aged 75-80.  The authors interpreted this as supporting the current USPSTF guideline of performing colonoscopy until age 75 given the reduction in 8-year risk of CRC, with patient preference guiding screening plan after age 75 considering the diminishing benefit.

MINI CUTS 

Survey data from Columbia University suggests that past-month marijuana consumption among pregnant women has increased from 2.37% to 3.85% between 2002 and 2014. This compares to a current prevalence of 9.27% in 2014 among non-pregnant women.

Researchers at University of Texas MD Anderson suggest that laboratory tests drawn within 2 days of hospital admission, specifically lactate dehydrogenase, white blood cell count, platelet count and albumin, along with demographic data can help predict 14-day mortality in patients with advanced cancer in a logistic regression model.

Surveillance from the CDC’s US Zika Pregnancy Registry indicates that 11% of fetuses and newborns born to women with laboratory evidence of Zika infection during pregnancy have manifested Zika-derived birth defects. The primary defects are microcephaly and CNS malformations.

Dr. Scott Butler is a 1st year internal medicine resident at NYU Langone Medical Center

Peer reviewed by Amar Parikh, MD, 3rd year internal medicine resident at NYU Langone Medical Center and Contributing Editor  

Image courtesy of NBCnews.com 

References 

  1. Jacobson L. Julian Castro says seven presidents before Barack Obama sought universal health care. Available at: http://www.politifact.com/truth-o-meter/statements/2012/sep/05/julian-castro/julian-castro-says-seven-presidents-barack-obama-s/.
  2. Myles PS, Smith JA, Forbes A, et al. Tranexamic Acid in Patients Undergoing Coronary-Artery Surgery. N Engl J Med. 2016:NEJMoa1606424. doi:10.1056/NEJMoa1606424. http://www.nejm.org/doi/full/10.1056/NEJMoa1606424
  3. Jørgensen KJ, Gøtzsche PC, Kalager M. ORIGINAL R ESEARCH Breast Cancer Screening in Denmark A Cohort Study of Tumor Size and Overdiagnosis. 2017:6–7. doi:10.7326/M16-0270.
  4. Mcevoy JW, Martin SS, Dardari ZA, et al. Coronary Artery Calcium to Guide a Personalized Risk-Based Approach to Initiation and Intensification of Antihypertensive Therapy. Circulation. 2016:153–165. doi:10.1161/CIRCULATIONAHA.116.025471.
  5. SPRINT Research Group, Wright JT, Williamson JD, et al. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med. 2015;373(22):2103–16. doi:10.1056/NEJMoa1511939.
  6. James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. Jama. 2013;311(5):507. doi:10.1001/jama.2013.284427.
  7. García-Albéniz X, Hsu J, Bretthauer M, Hernán MA. Effectiveness of Screening Colonoscopy to Prevent Colorectal Cancer Among Medicare Beneficiaries Aged 70 to 79 YearsA Prospective Observational StudyEffectiveness of Screening Colonoscopy in the Elderly. Ann Intern Med. 2016;N/A(N/A):N/A–N/A. doi:10.7326/M16-0758.
  8. Brown QL, Sarvet AL, Shmulewitz D, et al. Trends in Marijuana Use Among Pregnant and Nonpregnant Reproductive-Aged Women, 2002-2014. JAMA. 2016;72(12):1235–1242. doi:10.1001/jama.2016.17383.
  9. Cheng L, DeJesus AY, Rodriguez MA. Using Laboratory Test Results at Hospital Admission to Predict Short-Term Survival in Critically Ill Patients with Metastatic or Advanced Cancer. J Pain Symptom Manage. 2017. doi:10.1016/j.jpainsymman.2016.11.008.
  10. Honein MA, Dawson AL, Petersen EE, et al. Birth Defects Among Fetuses and Infants of US Women With Evidence of Possible Zika Virus Infection During Pregnancy. JAMA. 2016;30333(1):59–68. doi:10.1001/jama.2016.19006.