From Boy to Oncologist

By Dr. Arjun Gupta

You are a zodiac sign, you are a constellation. You are the Northern Tropic, you are but a crab.

You are a summer project in sixth grade. You sound so ubiquitous – are you really a deadly disease?

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Impact of Prognostic Discussions on the Patient-Physician Relationship: Prospective Cohort Study

Reviewed by Dr. Jasmine Singh
Fenton J, et al. J Clin Oncol. 2017 Nov 17:JCO2017756288

In advanced cancer, clinicians often emphasize treatment choices without enough discussion about end of life planning and prognostic awareness, often out of fear this will negatively impact the doctor-patient relationship. In this prospective cohort study, 265 adults with advanced cancer (Stage IV non-hematologic or stage III with prediction of death within 12 months) who visited 38 oncologists from community and hospital-based cancer centers in New York and California were enrolled. The oncologists’ discussion of prognosis was assessed by trained coders from audio-recorded visits using the Prognostic and Treatment Choices scale (PTCC). The coders assessed domains including cancer prognosis, curability, the likelihood of effective treatment and the transition from active to palliative treatment using a point-based scale. Patients rated the strength of the patient-physician relationship using two scales, The Human Connection (THC) and the Perceived Efficacy in Patient-Physician Interactions (PEPPI), at baseline, 2 to 7 days, and 3 months after the discussion.

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Updated Cost-effectiveness Assessments of PCSK9 Inhibitors from the Perspectives of the Health System and Private Payers

Reviewed by Dr. Neil Keshvani
Arrieta A, et al. JAMA Cardiol. 2017 Dec 1;2(12):1369-1374

Innovative new medications such as monoclonal antibodies have the power to profoundly impact patient’s lives. However, due to their skyrocketing price, physicians need a framework to judge if a certain patient will receive a benefit that is worthy of the costs. One such class of medications, proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i), have been shown to significantly reduce LDL levels. The FOURIER trial1 recently compared major adverse cardiovascular events and LDL levels in patients receiving statins with evolocumab versus patients only on statins. This trial showed a significant reduction in LDL levels and lower rates of nonfatal MI, stroke, and revascularization without a significant change in mortality between the two groups. However, despite this benefit, the cost of evolocumab ($14,300 per year) has limited its clinical use.

Continue reading “Updated Cost-effectiveness Assessments of PCSK9 Inhibitors from the Perspectives of the Health System and Private Payers”

Health Literacy Impact on National Healthcare Utilization and Expenditure

Reviewed by Dr. Eddie Hackler III
Rasu RS, et al. Int J Health Policy Manag. 2015 Aug 17;4(11):747-55

Health literacy is associated with healthcare utilization and expenditures and is an essential aspect of patient care. It is defined as “the degree to which an individual has the capacity to obtain, communicate, process and understand basic health information and services to make appropriate health decisions.”1 Health literacy presents a challenge in the delivery of effective healthcare and quality outcomes. The National Assessment of Adult Literacy (NAAL) from 2003 found that only 12% of U.S. adults had a proficient health literacy level (HLL), while 75% had an intermediate or basic HLL and 14% had a below basic HLL. In 2011, U.S. healthcare costs reached 2.7 trillion dollars, which is about $8680 per person, and poor health literacy is thought to play a significant role in healthcare costs.

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Association of Cardiovascular Risk With Inhaled Long-Acting Bronchodilators in Patients With Chronic Obstructive Pulmonary Disease

Reviewed by Dr. Christopher B. Scoma
Wang M, et al. JAMA Intern Med. 2018 Jan 2. doi: 10.1001/jamainternmed.2017.7720

This nested case-control study aimed to evaluate the risk of cardiovascular events occurring after initiation of long-acting β2-agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) in patients with chronic obstructive pulmonary disease (COPD). The study included 284,220 patients obtained from the Taiwan National Health Insurance Research Database from 2007 to 2011. Cohort entry date was marked as date of first COPD clinic visit or date of discharge from a hospital for COPD. Cases were identified at earliest cardiovascular disease (CVD) outcome, defined as an inpatient or ED visit with primary diagnosis of coronary heart disease, cardiac arrhythmia, heart failure or ischemic stroke. Exposure was measured via LABA and LAMA prescription records in the 12 months leading up to the event date for cases and controls. Exclusion criteria included LABA or LAMA use within 12 months prior to cohort entry, patients who initiated any cardiovascular medications within 30 days prior to event date, and patients with a diagnosis of chest pain or dyspnea within 30 days prior to event date. The results of the study show that new LABA use was associated with a 1.50-fold increased risk of CVD events (95% CI, 1.35-1.67; P < .001) and new LAMA use was associated with 1.52-fold increased risk of CVD events (95% CI, 1.28-1.80; P < .001) within 30 days of initiation.

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Romosozumab or Alendronate for Fracture Prevention in Women with Osteoporosis

Reviewed by Dr. Allexa Hammond
Saag KG, et al. N Engl J Med. 2017 Oct 12; 377(15):1417-1427

The ARCH (Active-Controlled Fracture Study in Postmenopausal Women with Osteoporosis at High Risk) trial was a phase 3, double-blinded, randomized trial powered to evaluate the superiority of romosozumab versus alendronate for fracture prevention in postmenopausal women with osteoporosis. 4,093 patients were randomized to receive either a monthly injection of romosozumab or weekly oral alendronate for 12 months. All patients then received another 12 months of weekly alendronate. All patients underwent baseline DEXA studies, which were repeated every 12 months. Measures of bone-turnover (such as ß-CTX, a bone-resorption marker, and P1NP, a bone formation marker) were also obtained from a subgroup of patients at baseline and at the conclusion of the study. The primary endpoints of the study included the cumulative incidence of new vertebral fracture at 24 months and the cumulative incidence of non-vertebral and symptomatic vertebral fractures. Secondary endpoints included bone mineral density at the lumbar spine, hip and femoral neck at 12 and 24 months.

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Opioid Receptor Activation Impairs Hypoglycemic Counterregulation in Humans

Reviewed by Dr. Chad Guenther
Carey M, et al. Diabetes. 2017 Nov; 66(11):2764-73

Hypoglycemia is a major risk factor for morbidity and mortality in patients on insulin therapy. Two risk factors for hypoglycemia include hypoglycemia-associated autonomic failure (HAAF), associated with a recent episode of hypoglycemia, and exercise-associated autonomic failure (EAAF), associated with vigorous exercise. In both of these conditions, counterregulatory responses to hypoglycemia are blunted. Endogenous opioid pathways have been speculated to play a role in these responses. Carey et al. tested this hypothesis using morphine administration.

12 healthy subjects without diabetes, recent hypoglycemia, family history of diabetes, or present medication usage were randomized to saline or morphine infusion in a crossover design with 5-week washout. Each study period took place across two days. On day one, either normal saline or morphine (0.1 µg/kg/min) were infused over 120 minutes, followed by a 120 minute break with snack, followed by the same infusion over 120 minutes. Day two consisted of insulin and glucose infusions titrating to blood glucose levels of 90, 80, 70, and 60 mg/dL with monitoring of laboratory and symptomatic responses.

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