NEJM Highlights January 2016: a medley of social service, OB, data mining, obesity, and ESRD

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Leveraging community services for health

In poor individuals, a lot of health issues are intimately connected to their socioeconomic circumstances. However, at the system level, there has been a chronic lack of integration between social and health services. Several efforts have tried to remedy this, notably through integration of the Medicare and Medicaid components for duals in the financial alignment demonstration projects sponsored by CMS. But a there are a lot of social services that are not part of Medicaid; and recognizing the need to ensure awareness, and access, CMS is sponsoring experiments (with control arms) to pay providers to educate and sometimes navigate patients to community services and assess whether this improves outcomes and decreases costs.  The intended sample of 44 geographies with a 5 years duration should provide useful information on what works, what does not, and where.  Accountable Health Communities — Addressing Social Needs through Medicare and Medicaid (subscription access)

 

A test for preeclampsia

Preeclampsia is a common (few %) disease of pregnancy with a high potential for danger to both mother and baby.  Initial presentation is typically through new onset / worsening high blood pressure, but many pregnancies with elevated blood pressure do not progress to preeclampsia which drives a lot of uncertainty in how to manage patients. In a study involving more than 1000 pregnancies with suspected preeclampsia, investigators identified a diagnostic biomarker that was able to rule out preeclampsia with a high degree of confidence.   If confirmed at scale, it will lower the burden of monitoring and hospitalization for women who are identified by the test as very low risk. Predictive Value of the sFlt-1:PlGF Ratio in Women with Suspected Preeclampsia; Improving the Prediction of Preeclampsia (subscription access)

 

Mining accidental health experiments: an Ebola case-study

When a patient shows up with symptoms suggestive of Ebola, they are also treated for malaria as the symptoms overlap.  This report shows the result of an accidental experiment whereby for a brief period, the malaria treatment in a Liberia facility was changed from arthemeter-lumefantrine (AL) to artesunate-amodiaquine (AA). Surprisingly, the Ebola death rate of patients treated with AA dropped by about a third. Is this real or chance? Is AA reducing mortality, or AL increasing it- we don’t know for sure, especially given that there is no known mechanistic explanation for the effect. But beyond Ebola, this is a great illustration of the power of natural experiments to drive hypothesis generation in medical care. How many of those take place in the US every year unnoticed and unexploited? We need you Watson!  Effect of Artesunate–Amodiaquine on Mortality Related to Ebola Virus Disease (free access)

 

Bariatric surgery works for morbidly obese teen-agers

A number of long term studies have shown the benefits of bariatric surgery in adults, but data have been lacking in adolescents, and there has been an understandable reluctance in recommending such an invasive approach in minors. This study followed a cohort of 242 extremely morbidly obese teens (mean BMI 53) for 3 years post bariatric surgery.  As for adults, results on metabolic profiles were excellent, with for instance remission of 95% of instances of Type II diabetes at baseline. Most importantly, quality of life was markedly improved (and one wonders why this crucial result is only provided in the supplementary materials rather than the main paper). Interestingly, although there was not much difference in the metabolic outcomes between Roux-en-Y (N=161) and sleeve gastrectomy (N=67) procedures, quality of life was much more improved for subjects with a Roux-en-Y, which continues to strengthen the case seen in adults that this procedure is better even though it is more drastic.   Weight Loss and Health Status 3 Years after Bariatric Surgery in Adolescents; The Obesity Epidemic — Understanding the Disease and the Treatment (free access)

 

Helping patients with end-state renal failure (ESRD) survive by helping their grafted kidney survive

The one thing worse than having kidney failure and needing dialysis, is to have had to go back on dialysis post-transplant because your donor kidney was rejected and failed. At the end of a 7-year study of 666 patients randomized to belatacept (BMS) vs. cyclosporine immunosuppression, the belatacept arm had a 43% reduction in graft loss or death (~10% vs. ~20% loss). Interestingly, BMS (and Medarex) also developed ipilimumab, a cancer drug mainly used for melanoma, which like belatacept interacts with the CTLA-4 immune pathway – but in the opposite direction. As big pharma continues to be tempted to externalize discovery more and more, this highlights a potential advantage of keeping a significant internal core competency around the biology of key pathways of interest. Belatacept and Long-Term Outcomes in Kidney Transplantation; The Clearer BENEFITS of Belatacept (free access)

 

The New England Journal of Medicine is a premier weekly medical journal covering many topics of interest to the health sector. In this monthly series we offer a brief overview of highlights that might be of interest to our clients and others.