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Thread: What's new in primary care internal medicine

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    Default What's new in primary care internal medicine

    What's new in primary care internal medicine (as of 9/2007)

    GENERAL INTERNAL MEDICINE

    Screening
    At seven year follow-up of a randomized trial of one-time ultrasound screening for abdominal aortic aneurysm (AAA) in men aged 65 to 74 years, screening resulted in a decrease in all-cause mortality, as well as AAA-related mortality
    In a randomized trial of 24,000 women, the rate of detection of invasive breast cancer was greater for screening with full field digital mammography compared to film mammography. The positive predictive value was the same for both technologies.

    Prevention
    A randomized trial of folate supplementation in patients with a recent colonic adenoma found a trend toward an increased risk of advanced colonic lesions, as well as an increased risk of noncolonic cancer. Although the evidence from randomized trials is not conclusive, at this point we recommend not taking folic acid supplementation for the purpose of reducing cancer risk.

    In a study of the effectiveness of hip pads in prevention of hip fractures, nursing home patients wore a panty with a protective hip pad only on one side, thus serving as their own controls. There was no difference in fracture rates between protected and unprotected hips.

    Medical consultation
    A large observational study of veterans age 65 years found an increase in 30-day postoperative mortality for patients with mildly abnormal preoperative hematocrits undergoing major non-cardiac surgery. Mortality increased by 1.6 percent for every one percentage point increase or decrease from a normal hematocrit (39.0 to 53.9 percent). A baseline blood count is suggested for all patients 65 years of age or older who are undergoing major surgery to better assess risk.

    Guidelines from the American College of Physicians and the American Academy of Family Physicians recommend use of compression stockings started within one month of proximal deep venous thrombosis (DVT), and continued for a minimum of one year after diagnosis
    Long-term (four year) results from a randomized trial found that leg ulcer recurrence rates in patients with chronic venous insufficiency were twice as high for patients treated with compression therapy alone, compared to patients who received both compression therapy and surgery for venous reflux in either superficial or mixed superficial and segmental deep venous systems

    Dermatology
    Small randomized trials and a systematic review suggest that oral erythromycin may be effective for treating pityriasis rosea

    An unpublished five-day trial of a newly-approved device that treats acne with a pulse of heat compared treating acne lesions on one side of the face with no treatment to the other side of the face. A blinded analysis of photographs found that more treated lesions had completely cleared. This short-term, nonrandomized, unpublished trial is inadequate to establish the efficacy and safety of heat treatment for acne.

    A small randomized trial that compared low and high glycemic load diets in male patients with acne found a greater reduction in lesion counts with the low glycemic load diet. However, the participants on that diet also lost more weight than those on the high glycemic load diet, so it is possible that the results were due to changes in weight rather than the composition of the diet

    Substance abuse
    A 2002 representative survey of 43,000 US adults found the lifetime prevalence of alcohol dependence to be 12.5 percent; only 24 percent of those reporting alcohol dependence were ever treated

    A meta-analysis found that brief intervention in primary care for problem drinkers, compared to usual care, resulted in a mean reduction of about four glasses of alcohol per week, with greater benefit in men than women

    In a randomized trial, patients with opioid addiction were assigned to initial treatment with buprenorphine/naloxone or methadone; patients were switched to methadone if they remained symptomatic on incremental doses of buprenorphine. Forty-six percent of buprenorphine-treated patients did not require methadone treatment. Buprenorphine is safer than methadone and a reasonable initial treatment choice.

    A systematic review of longitudinal and case-control studies, excluding subjects with known mental illness other than substance-use, found a 40 percent increase in the risk of psychosis for those who had ever used cannabis, as well as a dose-response relationship. However, causality cannot be definitively established from this review of observational studies.

    Other
    A randomized trial comparing early surgery (microdiscectomy) and conservative treatment for patients with lumbar disc herniation and radicular pain of 6 to 12 weeks duration found no difference in disability scores at one year, though patients assigned to surgery reported a faster rate of perceived recovery [14]. More than one-third of the 142 patients assigned to conservative therapy underwent surgery at a mean of 19 weeks.

    A small randomized trial found that the combination of caffeine and promethazine was more effective for motion sickness than a number of other therapies, and produced less sedation

    PRIMARY CARE CARDIOLOGY
    The preferred reperfusion therapy in patients with an acute ST elevation (Q wave) myocardial infarction (STEMI) is primary percutaneous coronary intervention (PCI) within a 90 minute door-to-balloon time window. The optimal strategy beyond this time is uncertain. The GRACIA 2 trial suggests that fibrinolytic therapy followed by adjunctive PCI (within 12 hours) may provide equivalent outcomes to primary PCI

    Beta blockers may improve left ventricular remodeling in patients with asymptomatic left ventricular dysfunction. In a randomized trial,
    an increase in LVEF was observed in patients treated with metoprolol 50 mg or 200 mg, compared to baseline and placebo treatment

    A linear relationship between BNP quartiles and in-hospital mortality was found In patients hospitalized for acute decompensated heart failure

    Cardiac resynchronization therapy resulted in similar improvements for patients with heart failure, regardless of whether atrial fibrillation was present or not

    The survival rates for contemporary transvenous implantable cardioverter defibrillator (ICD) leads at five and eight years were estimated at 85 and 60 percent respectively

    PRIMARY CARE EMERGENCY MEDICINE
    In a small retrospective study of patients with severe frostbite who were treated with intra-arterial tissue plasminogen activator (tPA) within 24 hours of injury, the incidence of digital amputation was 10 percent, compared to 41 percent in patients with comparable injuries not treated with tPA

    PRIMARY CARE ENDOCRINOLOGY
    The response to ACTH is affected by the use of oral contraceptives (OCs). OCs should be discontinued prior to testing to avoid underestimating hypocortisolism

    Although the thiazolidinedione drugs rosiglitazone and pioglitazone cause a similar increase in the incidence of heart failure, meta-analyses suggest that only rosiglitazone is associated with an increased incidence of myocardial ischemic events

    A meta-analysis of 11 studies comparing inhaled to subcutaneous insulin in patients with type 1 or type 2 diabetes found a small difference in hemoglobin A1C decline from baseline, favoring subcutaneous insulin

    A new continuous oral contraceptive (Lybrel 0.2 mg ethinyl estradiol and levonorgestrol 0.09 mg), designed to be taken daily with no placebo phase, has been approved by the US FDA, but is not yet commercially available. Clinical trial data suggest that breakthrough bleeding may be a particular problem with this pill

    Bariatric surgery appears to reduce mortality. In the Swedish Obese Subjects Study, overall mortality was significantly decreased (hazard ratio 0.71)

    PRIMARY CARE GASTROENTEROLOGY
    In a study of patients with diarrhea-predominant IBS and no villous atrophy, the presence of celiac-disease associated serum IgG (but not IgA), combined with the presence of HLA-DQ2, predicted clinical response to a gluten free diet

    The MELD score (Model for End-stage Liver Disease), a statistical prediction model used primarily for patient selection for liver transplantation, may also be useful for predicting nontransplant surgical risk in patients with cirrhosis

    PRIMARY CARE HEMATOLOGY
    A study in community dwelling elderly adults has confirmed the adverse effect of anemia, as defined by WHO criteria, on mortality and mobility disability in white, but not in black, older men and women. Alternative criteria are needed to set parameters for anemia in the older black population.

    Evidence does not support premedication with antihistamines and/or acetaminophen to prevent febrile nonhemolytic transfusion reactions or allergic transfusion reactions

    The combination of warfarin and low-dose aspirin was associated with a greater incidence of gastrointestinal bleeding than with either agent alone

    An algorithm for refining warfarin dosing following joint replacement surgery has been developed, incorporating genotype testing for two enzymes associated with altered sensitivity to treatment with warfarin (ie, hepatic cytochrome P-450 and vitamin K epoxide reductase complex 1), as well as the INR value after three doses of warfarin, estimated blood loss at the time of surgery, and smoking status

    PRIMARY CARE INFECTIOUS DISEASE
    Fatal reactions due to calcium-ceftriaxone precipitates in the lungs and kidneys of neonates have been reported. The FDA has issued an advisory that intravenous ceftriaxone and intravenous calcium-containing solutions should not be co-administered to any patient within 48 hours, even via different infusion lines at different sites

    A decrease in the rate of trimethoprim-sulfamethoxazole resistance (24 to 13 percent) and an increase in the rate of ciprofloxacin resistance (1.7 to 3.4 percent) was reported for patients treated for a first episode of acute pyelonephritis between 1997 and 2001 in Seattle

    A small randomized trial in patients with severe C. difficile associated diarrhea demonstrated a higher cure rate with vancomycin than with metronidazole (97 versus 76 percent)

    A man with chronic HIV infection became superinfected with a multi-drug resistant virus from his sexual partner, as determined by a unique genotypic pattern

    The US FDA issued its first approval for a malaria antigen detection assay, Binax NOW.

    Combination antibiotic therapy (third generation cephalosporin plus a macrolide compared to macrolide monotherapy) may improve survival rates in patients with community-acquired pneumonia and septic shock

    PRIMARY CARE NEPHROLOGY
    ACE inhibitor therapy lowers the rate of progressive kidney disease in children and young adults with IgA nephropathy and moderate proteinuria

    A prospective study of three large cohorts reported that dietary oxalate intake is only a modest risk factor for incident kidney stones

    PRIMARY CARE NEUROLOGY
    A systematic review of surgery for carpal tunnel syndrome found a wide range in success rates reported in individual studies (27 to 100 percent); the pooled success rate of surgery was 75 percent

    Updated guidelines from the American Heart Association/American Stroke Association for the management of intracerebral hemorrhage include new recommendations for managing elevated blood pressure with intravenous medications for acute spontaneous hemorrhage

    Preliminary data suggest that intravenous thrombolytic treatment for acute ischemic stroke can be performed safely and effectively via telemedicine where local stroke expertise is not immediately available. Results from ongoing randomized trials of telemedicine for acute stroke are needed to confirm safety and effectiveness.

    Despite suggestion of efficacy from epidemiologic studies, randomized trials do not confirm that antiinflammatory drugs protect against late life dementia (Alzheimer's disease, AD). One trial was stopped early because of increased risk for myocardial infarction in patients treated with naproxen, but demonstrated an increased risk for AD in active treatment groups when patients with baseline early cognitive decline were excluded from the analysis

    PRIMARY CARE ONCOLOGY
    A preliminary report suggests that the incidence and severity of cardiotoxicity associated with trastuzumab (Herceptin) are not worsening with prolonged follow-up

    Preliminary data presented at the June 2007 ASCO meeting suggest that trastuzumab, indicated for treatment in breast cancer patients who are positive for anti-HER2 antibody, may also provide benefit for some women with HER2-negative breast cancer. However, the data are insufficient to warrant a change in clinical practice

    PRIMARY CARE PSYCHIATRY
    Two large observational studies found that rates of suicide attempts were lower for newly-diagnosed depressed patients who were treated with antidepressants than for those who were not, and were lower in the month following initiation of treatment (either psychotherapy or antidepressant) than for the month preceding treatment

    Updated American Psychiatric Association practice guidelines for obsessive compulsive disorder recommend cognitive behavioral therapy as first line treatment; pharmacologic treatment with a selective serotonin reuptake inhibitor is an acceptable alternative

    In the large randomized STAR*D trial of treatment for depression, patients who did not respond to initial citalopram treatment were given a choice of cognitive behavioral therapy (CBT) or additional medication. Response was more rapid for patients choosing augmentation with a second medication than with CBT, but patients who elected to switch medications experienced more side effects.

    Addition of an antidepressant to a mood stabilizer for treatment of depression in adult patients with bipolar disorder did not improve rates of treatment response (eight weeks of euthymia). For patients with at least two initial concurrent symptoms of mania, antidepressants increased the likelihood of symptoms of mania at three months

    The FDA has issued an alert based on multiple case reports of increased risk for Torsades de Pointes and QT prolongation with intravenous or high doses of haloperidol. EKG monitoring is recommended when haloperidol is given intravenously, and it should not be given to patients with risk factors for QT prolongation

    PRIMARY CARE PULMONOLOGY
    The National Asthma Education and Prevention Program (NAEPP) has issued new guidelines for the diagnosis and management of asthma. The guidelines introduce the concepts of "risk" and "control." The risk of adverse outcomes associated with asthma and its treatment is a factor in determining the severity classification used to choose initial therapy. The level of subsequent asthma "control" determines how therapy is adjusted

    Inhaled corticosteroid (ICS) therapy decreases exacerbations and modestly slows symptom progression in patients with stable chronic obstructive pulmonary disease (COPD), but has minimal or no impact on lung function and mortality, according to a meta-analysis of 47 randomized trials (13,139 patients)

    A meta-analysis found that three antibiotic classes (macrolides, fluoroquinolones, and amoxicillin-clavulanate) were equivalently effective in patients with acute exacerbations of chronic bronchitis

    Inhalation of a hypoxic gas mixture predicts a higher in-flight PaO2 than mathematical equations and, therefore, is less likely to suggest that in-flight supplemental oxygen therapy is necessary, according to a retrospective study of 45 patients with COPD, interstitial lung disease, or cystic fibrosis

    In a large prospective observational study, pathogens that cause ventilator-associated pneumonia (VAP) were similar to those that cause hospital-acquired pneumonia (HAP), except for a greater prevalence of Pseudomonas aeruginosa in patients with VAP

    PRIMARY CARE RHEUMATOLOGY
    Asymptomatic individuals who are persistently positive for antiphospholipid antibodies (aPL) have a low annual incidence of acute thrombosis and do not benefit from low-dose aspirin

    Paroxetine, compared with placebo, resulted in higher response rates in patients with fibromyalgia

  2. #2
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    I'll stick to only what there in park.. Its boring enough .. lolz!

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