Physician's First Watch: Archives

Automated Calls for Colorectal Cancer Screening Reminders Don't Work

Automated telephone calls to patients do not improve screening rates for colorectal cancer, according to an Archives of Internal Medicine study.

Roughly 20,000 people ages 50 to 64 were randomized either to usual care or to a single 3-minute automated telephone call using speech recognition that encouraged people to call their healthcare providers for screening. In the year after the call, the rate of any colorectal cancer screening — the primary outcome — did not differ between the two groups.

These results, the authors suggest, show yet another instance in which "potentially ineffective policies and programs achieve widespread acceptance before evidence is available from controlled trials."

LINK(S):

Archives of Internal Medicine article (Free abstract; full text requires subscription)

Published in Physician's First Watch February 9, 2010

Outpatients with Inflammatory Bowel Disease at Increased Risk for VTE

Nonhospitalized patients with inflammatory bowel disease have a nearly 16-fold increased risk for venous thromboembolism during acute flare-ups, according to a Lancet study released online.

Using a U.K. general practice database, researchers identified some 14,000 bowel disease patients with a recent prescription for corticosteroids and some 72,000 controls without inflammatory bowel disease matched for age, sex, and provider. In the 4 months after patients received the prescription (corresponding to a likely disease flare-up), the relative risk for VTE outside the hospital setting was roughly 16 (absolute risk, 6.4 per 1000 person-years).

Risks were increased at all stages of disease, including remission.

Commentators caution against a drug-based approach to prophylaxis in these patients until further studies are done. They recommend, instead, educating patients on the symptoms of VTE and the use of support stockings.

LINK(S):

Lancet article (Free abstract; full text requires subscription)

Lancet comment (Subscription required)

Published in Physician's First Watch February 9, 2010

FDA Approves Expanded Use of Crestor

Rosuvastatin (Crestor) has been approved for use as primary prevention in patients without elevated LDL cholesterol but with a combination of other risk factors that put them at increased risk for heart disease, the FDA announced on Monday.

The statin is now indicated for men aged 50 or older and women 60 or older who have elevated C-reactive protein levels (2 mg/L or higher) and at least one additional cardiovascular risk factor such as low HDL cholesterol or high blood pressure.

LINK(S):

FDA Q & A for healthcare professionals (Free)

Reuters story (Free)

Physician's First Watch coverage of advisory panel's recommendation to expand Crestor use (Free)

Published in Physician's First Watch February 9, 2010

Usual Care for Low Back Pain Doesn't Align with Guideline Recommendations

General practitioners rarely follow guidelines when managing new episodes of low back pain, reports the Archives of Internal Medicine. (The analysis was conducted in Australia, but the guidelines assessed match those in the U.S.)

Researchers examined data on some 1700 visits to GPs for new low back pain from 2005 to 2008, after national guidelines for treating musculoskeletal pain were released. Among the findings:

• Although guidelines recommend acetaminophen as a first-line analgesic, it was prescribed for only 18% of patients. NSAIDs and opioids were prescribed for 37% and 20%, respectively.
  
• One fourth of patients were referred for imaging, despite guidelines advising against routine referral.
  
• Only one fifth of patients received advice and education as recommended.
  

These findings were similar to those from the period before guideline publication.

The authors conclude: "The results indicate that in most cases, usual care is not evidence-based care and so is not likely to provide the best outcomes."

LINK(S):

Archives of Internal Medicine article (Free)

Archives of Internal Medicine commentary (Subscription required)

American College of Physicians/American Pain Society guideline on managing low back pain (Free)

Published in Physician's First Watch February 9, 2010

H1N1 Update: Flu Activity Levels Off, but CDC Official Warns Against 'Complacency'

"H1N1 flu activity seems to have leveled off," according to the CDC, but vaccination "remains a good idea."

In an online briefing, Dr. Anne Schuchat, the agency's director for immunization, added that most current flu activity is from the 2009 H1N1 virus and that "we're not seeing seasonal flu strains yet in any substantial numbers." She said that although some people believe the H1N1 outbreak is over, "it's too soon for us to have that type of complacency."

Dr. Schuchat reported that vaccine safety monitoring has been "extremely reassuring."

LINK(S):

CDC news briefing (Free)

Published in Physician's First Watch February 8, 2010

Certain H1N1 Vaccines Should Be Given by Feb. 15

All lots of Sanofi Pasteur H1N1 vaccine in prefilled syringes should be administered by February 15 because of concerns over reduced potency, the CDC reported on Wednesday.

The expiration includes Sanofi Pasteur's 12 million doses of H1N1 vaccine in prefilled syringes. The announcement does not affect multidose vials.

LINK(S):

CDC Q&A on shortened expiration period (Free)

Physician's First Watch coverage of earlier vaccine recall (Free)

Published in Physician's First Watch February 4, 2010

Lancet Retracts 1998 Paper Linking Autism to MMR Vaccination

The Lancet has "fully" retracted a paper it published in 1998 that suggested a link between measles-mumps-rubella vaccination and the subsequent development of autism.

The journal's editors point to a recent judgment by a panel of the U.K.'s General Medical Council, saying that "it has become clear that several elements of the 1998 paper by Wakefield et al. are incorrect, contrary to the findings of an earlier investigation."

The editors say that two claims in the paper "have been proven to be false." Contrary to the authors' claims, the patients studied were not consecutively referred, and the local ethics committee had not approved the investigations. The editors conclude: "Therefore we fully retract this paper from the published record."

Asked to comment on the journal's action, Dr. Andrew Wakefield sent the following statement: "The allegations against me and against my colleagues are both unfounded and unjust and I invite anyone to examine the contents of these proceedings and come to their own conclusion."

LINK(S):

Lancet retraction (Subscription required)

Guardian coverage of GMC judgment (Free)

Lancet paper (PubMed abstract) from 1998 (Free abstract)

Journal Watch General Medicine coverage of 1998 Lancet study (Your Journal Watch registration required)

Published in Physician's First Watch February 3, 2010

Proteinuria Associated with Adverse Outcomes, Regardless of GFR

Proteinuria independently predicts mortality and other adverse outcomes, regardless of estimated glomerular filtration rate (eGFR), JAMA reports.

Researchers in Canada studied more than 900,000 adults without end-stage kidney disease who had both serum creatinine and proteinuria measured as part of routine care. During a median follow-up of roughly 3 years, 3% of patients died and less than 1% experienced an MI, began renal-replacement therapy, or had a doubling of serum creatinine.

Risks for these adverse outcomes were higher among patients with lower eGFRs and heavier proteinuria. However, at all levels of eGFR — even those not "overtly abnormal" — heavier proteinuria remained an independent predictor of risk.

The authors note that current guidelines for classifying chronic kidney disease are based on eGFR "without explicit consideration of the severity of concomitant proteinuria." They conclude that revisions of such guidelines should take proteinuria into account.

LINK(S):

JAMA article (Free)

National Kidney Foundation's 2002 guidelines for classifying chronic kidney disease (Free)

Published in Physician's First Watch February 3, 2010

Metformin Aids Weight Loss in Obese, Nondiabetic Teens

Metformin can help obese adolescents lose weight, according to a small, industry-supported study in the Archives of Pediatrics and Adolescent Medicine.

Roughly 80 obese, nondiabetic teenagers were randomized to a lifestyle intervention emphasizing diet and exercise, plus either metformin or placebo daily for 48 weeks. At the end of treatment, the mean BMI in the metformin group had dropped 0.9 units, while that in the placebo group had increased 0.2 units — a significant difference. However, 12 to 24 weeks after treatment ended, there was no longer a difference between the groups.

Adverse events did not vary significantly between groups.

The authors call for additional studies but conclude that the drug "may have an important role in the treatment of adolescent obesity."

LINK(S):

Archives of Pediatrics and Adolescents Medicine article (Free)

Published in Physician's First Watch February 2, 2010

Androgen Deprivation May Increase CVD Risk, Circulation Statement Warns

It's "reasonable" to conclude that a link may exist between androgen-deprivation therapy (ADT) for prostate cancer and heightened cardiovascular risk, according to a group comprising members of major heart, cancer, and urological societies.

The group's statement, issued online in Circulation, points to published evidence that ADT increases body weight, reduces insulin sensitivity, and adversely affects lipid profiles.

The group makes the following recommendations:

• Patients starting ADT should have periodic follow-up with their primary-care physician beginning within 3 to 6 months.
  
• Such evaluations should include assessment of blood pressure, lipid profile, and glucose level.
  
• Glucose and lipids should be checked at least yearly.
  

LINK(S):

Circulation statement (Free PDF)

Published in Physician's First Watch February 2, 2010