PrimeCuts – This Week in the Journals

October 16, 2017

By Christian Torres, MD

Peer Reviewed

It’s another week, which means there’s been another attempt by President Trump to undermine Obamacare. On Thursday, Trump signed an executive order that would cut subsidies to insurers providing coverage to low-income individuals [1]. It’s already drawn swift criticism from the American Medical Association, among other health care groups [2]. We’ll see in the coming days if there’s any effort by Congress to keep the subsidies going. Meanwhile, we’ll keep going with a recap of the latest research.

Romosozumab or Alendronate for Fracture Prevention in Women with Osteoporosis

Romosozumab,  a monoclonal antibody that inhibits sclerostin, is a monthly subcutaneous injection that both promotes bone formation and decreases bone resorption. First-line options for the management of osteoporosis may change based on a recent study in the NEJM of Romosozumab[3]. Researchers compared Romosozumab to alendronate in a randomized, controlled trial of more than 4000 postmenopausal women with osteoporosis and a history of vertebral or femoral fractures. Participants received either alendronate or Romosozumab for 1 year, followed by alendronate in the second year. All patients received calcium and vitamin D supplementation.

Primary endpoints for the study were the incidences of new vertebral and clinical fractures (symptomatic, vertebral or otherwise) after 24 months. Patients who received the monoclonal antibody had a 48% and 27% risk reduction, respectively, compared to alendronate alone. Both were statistically significant. Safety profiles were similar, but there was a higher incidence of cardiac ischemia and cerebrovascular events with Romosuzamab.

This comparative-effectiveness trial shows promise for Romosozumab, but as an accompanying editorial [4] notes, the cardiovascular effects of Romosozumab may require further study before alendronate gives way to a new first-line.

Association of Public Health Initiatives With Outcomes for Out-of-Hospital Cardiac Arrest at Home and in Public Locations

When we think of patient education, CPR might not be at the top of the list, but it may be worth at least a second thought. This study of out-of-hospital cardiac arrest in JAMA Cardiology found that a public health initiative in North Carolina was associated with increased rates of bystander CPR and positive outcomes post-arrest[5].

The initiative, called RACE [6], focused on improving cardiac arrest management from its onset on through hospitalization. It included outreach and training in CPR for the general public, along with a review of best practices for EMS and in-hospital providers. From 2010 to 2014, spanning over 8000 cardiac arrests, there were statistically significant increases in bystander CPR at home and in public, along with other positive changes such as an increase in home defibrillation. These interventions correlated with greater odds of survival to discharge.

The authors provide little information on the cost and coordination required to pull off this major initiative. Their work, however, at least shows that the “chain of survival,” as they describe it, can be strengthened by a concerted effort to involve the community in that chain.

Low Rates of Gastrointestinal and non-Gastrointestinal Complications for Screening or Surveillance Colonoscopies in a Population-based Study

Referral for a screening colonoscopy has become such a standard part of the primary care visit, that we might forget how these procedures aren’t necessarily benign. A study of more than 1.5 million screening colonoscopies done in California helps to clarify the risks[7]. Researchers found the post-procedure rate of lower GI bleeding was 5.3 per 10,000, while perforation was 2.9. They also found that among non-GI events, the rate of ischemic stroke (4.7 per 10,000) was higher than in the general population, though myocardial infarction (2.5 per 10,000) was not.

These rates were higher among colonoscopies in which there was an intervention such as a biopsy, and among non-screening colonoscopies. Adverse events were most common within 14 days of colonoscopy, and risk factors for events included Black race, low income, and public insurance.

Cigarette smoking and the risk of systemic lupus erythematosus

Previous research on smoking as a risk factor for SLE has had conflicting findings, but this prospective cohort study makes for yet another strong case against tobacco use[8]. Based on data from the Nurses Cohort Studies, current smokers had 1.86 times the risk of dsDNA-positive SLE compared to never-smokers. Risk was also increased (hazard ratio 1.60) among those who smoked more than 10 pack-years. These were both statistically significant findings, and interestingly, the association was not seen with dsDNA-negative SLE and SLE as a whole.

The researchers note these findings may help delineate the pathogenesis of autoantibodies involved in SLE. For our patients, however, it provides yet another stark example of the risks of smoking, and the importance of cessation. Among this cohort, past smokers appeared to approach the risk of never-smokers after just 5 years without cigarettes.

A few other studies from this week in Minicuts:

An enhanced discharge medication reconciliation process, with both pharmacists and prescribers collaborating, did not reduce 30-day hospital revisit rates in this study of nearly 10,000 patient admissions [9].

Also on the medication front, a Dutch study used a thorough, multidisciplinary approach to medication reconciliation in nursing homes and had more success reducing polypharmacy compared to usual care. It’s a small study, and also showed no difference in outcomes such as  number of falls and quality of life [10].

Lastly, please call, don’t text. A study found that patients were more likely to return their fecal immunochemical test (FITs) after a live phone call reminder than after a text reminder [11].

Dr. Christian Torres is a 2nd-year resident in internal medicine at NYU Langone Health

Peer reviewed by Ian Henderson, MD, contribution editor, Clinical Correlations and Chief Resident,  Internal Medicine, NYU Langone Health

Image referenced at:


  1. Pear R, Haberman M, Abelson R. Trump to Scrap Critical Health Care Subsidies, Hitting Obamacare Again. The New York Times. October 12, 2017.
  1. Schouten F. Trump’s move to end insurance subsidies jolts Washington. USA Today. October 14, 2017.
  1. Saag KG, et al. Romosozumab or Alendronate for Fracture Prevention in Women with Osteoporosis. NEJM. 2017;377:1417-1427.
  1. Rosen, CJ. Romosozumab — Promising or Practice Changing? NEJM. 2017;377:1479-1480.
  1. Fordyce CB, et al. Association of Public Health Initiatives With Outcomes for Out-of-Hospital Cardiac Arrest at Home and in Public Locations. JAMA Cardiol. 2017.
  1. “Optimal Cardiac Arrest System Specification By Point Of Care Operations Manual; Version 3.0”
  1. Louise W, et al. Low Rates of Gastrointestinal and non-Gastrointestinal Complications for Screening or Surveillance Colonoscopies in a Population-based Study. Gastroenterology. 2017.
  1. Barbhaiya M, et al. Cigarette smoking and the risk of systemic lupus erythematosus, overall and by anti-double stranded DNA antibody subtype, in the Nurses’ Health Study cohorts. Ann Rheum Dis. 2017. 
  1. Baker M, et al. Do Combined Pharmacist and Prescriber Efforts on Medication Reconciliation Reduce Postdischarge Patient Emergency Department Visits and Hospital Readmissions? Journal of Hospital Medicine. 2017.
  1. Wouters H, et al. Discontinuing Inappropriate Medication Use in Nursing Home Residents: A Cluster Randomized Controlled Trial. Ann Intern Med. 2017. 
  1. Coronado GD, et al. Effect of Reminding Patients to Complete Fecal Immunochemical Testing: A Comparative Effectiveness Study of Automated and Live Approaches. J Gen Intern Med. 2017.