In this section, we highlight the key high-impact studies, updates, and analyses published in medicine during the past week.
Multiple mutations are often required to initiate the unregulated cell division in cancer, however individual mutations are often subclinical and without phenotype. In this proof of concept study, investigators compared the whole-exome DNA sequencing of 12,380 individuals and compared cancer risk in the subsequent 2 to 7 years through the Swedish national patient registry. Clonal somatic hematopoiesis mutations were identified in 10% of the cohort above age 65, while present in only 1% of individuals less than 50 years old. Clonal hematopoiesis was a significant risk factor for later developing hematologic cancer (HR 12.9, 95% CI 5.8-28.7). 42% of individuals who subsequently developed hematologic cancer had a clonal expansion from whole exome sequencing more than 6 months prior to cancer diagnosis. Common somatic mutations found were in DNMT3A, ASXL1, and TET2 genes. This study suggests that earlier diagnosis of hematologic cancer is possible with whole-exome DNA sequencing.
Multiple studies have shown cyclic variation of hospital morbidity and mortality around the beginning of July, when there are new trainees and many individuals have new responsibilities. National scientific and medical association meetings can also impact hospital staffing as a result of attendance by faculty members and house staff. In this retrospective analysis of national Medicare claims data, the investigators examined the 30-day mortality of Medicare beneficiaries with acute myocardial infarction, heart failure, and cardiac arrest during and around national cardiology meetings between 2002 and 2011. They identified 8570 relevant hospitalizations during 82 meeting days and 57471 hospitalizations during 492 meeting days and found significantly reduced 30-day mortality in high risk heart failure admissions (17.5% vs. 24.8%, p < 0.001) and high risk cardiac arrest admissions (59.1% vs. 69.4%, p = 0.01), but no difference in high risk acute myocardial infarction hospitalizations (39.2% vs. 38.5%, p = 0.86). High risk was defined as being in the top quartile of predicted mortality. The rate of percutaneous coronary intervention at teaching hospitals was also decreased during national society meetings (20.8% vs. 28.2%, p = 0.02). There was no difference in mortality rates for low-risk patients and for patients at non-teaching hospitals. There appears to be cyclical variation in the 30-day mortality of patients admitted for cardiac disease around the time of national cardiology meetings.
While medical homes have described to be the cornerstone of accountable care organizations and hoped to decrease healthcare costs, current literature has not been prove cost-savings in such a healthcare delivery model. In this single center randomized trial, 201 children with frequent healthcare contacts and a high estimated risk of rehospitalization were randomized to either a clinic providing comprehensive care ( a medical home model including a physician, two nurse practitioners, nutritionist, and social worker) or routine care (previously organized resident and general pediatric faculty clinic visits). In this analysis, comprehensive care decreased total costs ($16,523 vs. $26,781, cost ratio 0.58, 95% CI 0.38 – 0.88), had fewer episodes of serious illness (10 per 100 child-years vs. 22 per 100 child years, RR 0.45, 95% CI 0.28 – 0.73). The effect was consistent in describing a decrease in emergency room visits, hospitalizations, pediatric ICU admissions, and length of stay in hospitals. This single center study suggests that medical homes can decrease healthcare costs in children with chronic illness at high risk for hospitalization.
While there has been significant advances in biologic therapies in inflammatory bowel disease, many patients with Crohn’s disease still undergo intestinal resection. In this multicenter randomized controlled study of 17 centers in Australia and New Zealand, 174 patients who underwent intestinal resection were randomized to colonoscopy at 6 months or routine care to guide further medical management (including thiopurine and adalimumab. At 18 months, there was less endoscopic recurrence in patients who underwent active surveillance (49% vs. 67%, p = 0.03). Of active surveillance patients (n = 122), 47 (39%) underwent increased treatment as result of surveillance and 18 (15%) of those patients had remission at 18 month follow-up. This study suggests that medical treatment after surgical resection tailored to patient’s colonoscopy results is superior to standard drug therapy to prevent Crohn’s disease recurrence.
The optimal management of pelvic floor dysfunction is unknown as it is unclear whether pelvic floor muscle training is superior to waitful waiting in preventing the progression of symptomatic pelvic organ prolapse. In this multicenter randomized control trial, 247 Dutch women over the age of 55 with mild pelvic organ prolapse were randomized to pelvic floor muscle training with pelvic physiotherapists or watchful waiting and assessed on the Pelvic Floor Distress Inventory-20 (PFDI-20, scored out of 300) in three months. Patients who underwent pelvic floor muscle training experienced greater improvement on the PFDI-20 (average improvement compared to control arm of 9.1 points, 95% CI 2.8 – 15.4) however it is unclear whether that is a clinically significant change (the investigators used a difference of 15 points in sample size calculations). At three months, 57% of patients undergoing pelvic floor muscle training reported improvement of symptoms, compared to 13% of patients who were in the watchful waiting group (p < 0.001). This study shows that for patients with mild pelvic prolapse, pelvic floor muscle training can improve subjective assessment of symptoms and satisfaction of management.
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