NEJM Audio Summary - Sep 29, 2011

TIME TABLE

00:54 | Genomewide Association between GLCCI1 and Response to Glucocorticoid Therapy in Asthma
02:40 | A Step toward Personalized Asthma Treatment
03:27 | Changes in Forced Expiratory Volume in 1 Second over Time in COPD
05:15 | Variable Loss of Lung Function in COPD
05:42 | Placebo-Controlled Trial of Cytisine for Smoking Cessation
06:49 | Treatment of Neonatal Sepsis with Intravenous Immune Globulin
07:53 | End-of-Life Transitions among Nursing Home Residents with Cognitive Issues
09:27 | Treating Smokers in the Health Care Setting
11:12 | Case 30-2011 — A 62-Year-Old Woman with Renal Failure
12:57 | Restrictions on the Use of Prescribing Data for Drug Promotion
14:38 | Reducing Unnecessary Hospitalizations of Nursing Home Residents
16:26 | Who Owns Federally Funded Research? The Supreme Court and the Bayh–Dole Act
17:53 | Providing for Those Who Have Too Little
19:40 | Ectopic Tooth in the Maxillary Sinus
20:19 | Orbital and Cerebral Arteriovenous Malformations

NEJM BLOGGERS' REMARKS

• 内科開業医のお勉強日記「喘息：吸入ステロイド治療不応性関連遺伝子」
• 内科開業医のお勉強日記「COPDにおける1秒量時間推移：個体差が大きく、現行喫煙、気管支拡張剤効果、肺気腫の存在が要素」
• 呼吸器内科医「COPDのFEV1変化率は、喫煙者や気管支拡張薬の可逆性がその影響を強くする」
• 内科開業医のお勉強日記「Cytisine:禁煙治療プラセボランダム化トライアル」
• 呼吸器内科医「シチシンは禁煙補助薬として有用」
• 呼吸器内科医「新生児敗血症への免疫グロブリンはプラセボと比較して効果なし」
• 内科開業医のお勉強日記「NEJM: 医療施設での禁煙治療」

EXCERPTED SCRIPT

05:42 | "Placebo-Controlled Trial of Cytisine for Smoking Cessation" by Robert West from University College London in United Kingdom.

Cytisine is a low-cost medication that is potentially beneficial in smoking cessation. In this trial participants were randomly assigned to receive cytisine or matching placebo for 25 days. The rate of sustained 12-month abstinence was 8.4% (31 participants) in the cytisine group as compared with 2.4% (9 participants) in the placebo group. The 7-day point prevalence for abstinence at the 12-month follow-up was 13.2% in the cytisine group versus 7.3% in the placebo group. Gastrointestinal adverse events were reported more frequently in the cytisine group. Cytisine was more effective than placebo for smoking cessation. The lower price of cytisine as compared with that of other pharmacotherapies for smoking cessation may make it an affordable treatment to advance smoking cessation globally.  

07:53 | "End-of-Life Transitions among Nursing Home Residents with Cognitive Issues" by Pedro Gozalo from Brown University, Providence, Rhode Island.Health care transitions in the last months of life can be burdensome and potentially of limited clinical benefit for patients with advanced cognitive and functional impairment.
In this study, we attempted to define patterns of transition among persons with advanced cognitive impairment who were in a nursing home 120 days before death. Among 474,829 nursing home decedents, 19.0% had at least one burdensome transition (range, 2.1% in Alaska to 37.5% in Louisiana). In adjusted analyses, blacks, Hispanics, and those without an advance directive were at increased risk. Nursing home residents in regions in the highest quintile of burdensome transitions (as compared with those in the lowest quintile) were significantly more likely to have a feeding tube (adjusted risk ratio, 3.38), have spent time in an ICU in the last month of life (adjusted risk ratio, 2.10), have a stage IV decubitus ulcer (adjusted risk ratio, 2.28), or have had a late enrollment in hospice (adjusted risk ratio, 1.17). Burdensome transitions are common, vary according to state, and are associated with markers of poor quality in end-of-life care. 

09:27 | "Treating Smokers in the Health Care Setting", a CLINICAL PRACTICE article by Michael Fiore from University of Wisconsin School of Medicine and Public Health, Madison.Tobacco use is directly responsible for about one fifth of all deaths in the United States. Approximately 70% of smokers in the United States see a primary care physician each year; thus, there is a good opportunity to deliver effective interventions for smoking cessation. Many smokers lack the motivation to attempt to quit, but various interventions can increase the number of smokers who make an attempt and the likelihood of success. One such intervention is motivational interviewing, in which the clinician uses nonconfrontational counseling to resolve the patient's ambivalence about quitting by encouraging choices that are consistent with the patient's long-term goals. Another approach is to encourage and instruct unwilling smokers to substantially and persistently reduce their daily smoking, while they are receiving nicotine-replacement therapy. Extensive research provides support for the effectiveness of counseling and pharmacologic interventions, alone or in combination, in increasing smoking-cessation rates among patients who are willing to attempt to quit. However, many smokers will not engage in counseling. Therefore, a smoker's willingness to try to quit should guide the management plan. In this article strategies to facilitate smoking cessation are reviewed, including documentation of smoking status for all patients, regular assessment of readiness to quit, counseling, and medications. An audio version of this article is available at NEJM.org.

14:38 | "Reducing Unnecessary Hospitalizations of Nursing Home Residents", a PERSPECTIVE article by Joseph Ouslander from Florida Atlantic University, Boca Raton.More than 1.6 million Americans live in nursing homes. Hospitalizations are common in this population; in 2006, 23.5% of the people admitted to a post-acute-care skilled-nursing facility were rehospitalized within 30 days. Studies suggest that many hospitalizations of US nursing home residents are inappropriate, avoidable, or related to conditions that could be treated outside the hospitals — and they cost over $4 billion per year. But the causes of preventable hospitalizations in this population are complex. One fundamental problem is not clinical but financial, stemming from a misalignment of Medicare and Medicaid: state Medicaid programs do not benefit from savings that Medicare accrues from prevented hospitalizations of nursing home residents, even though the nursing home incurs expenses when managing changes in condition without hospital transfer. In addition, nursing homes have a financial incentive to hospitalize residents who have Medicaid coverage, because after a 3-day inpatient stay, the resident may qualify for Medicare Part A payment for post-acute care in the nursing home at three to four times the daily rate paid by Medicaid. Multifaceted strategies will be needed to address the current incentives for hospitalization if we are to improve nursing home care and prevent unnecessary hospitalizations, with their related complications and costs.