Physician's First Watch: Archives

Arthritis Common in Adults with Diabetes, May Interfere with Physical Activity

Arthritis is nearly twice as common in adults with diabetes as in the general population — and may interfere with physical activity in these patients —reports MMWR.

CDC researchers interviewed U.S. adults in 2005 and 2007. Among the findings:

• 52% of adults with diabetes reported having arthritis, compared with 27% of adults overall.
  
• 30% of adults with both diabetes and arthritis — but only 21% of those with diabetes alone — were physically inactive.
  
• After adjustment for age, sex, and BMI, the odds of inactivity were 30% higher in diabetics with versus without arthritis.
  

An editorial note suggests that "providers interested in improving diabetes management might want to especially consider arthritis-related barriers among persons with diabetes who are physically inactive."

LINK(S):

MMWR article (Free)

Reuters story (Free)

CDC's guide for planning physical activity for older adults (Free PDF)

Published in Physician's First Watch May 9, 2008

Most Americans Unaware of Five Major Stroke Symptoms

Most Americans are unaware of the major warning signs of stroke and the need to call 911, according to a CDC survey in MMWR.

The telephone survey, conducted in 2005 on nearly 72,000 people in 13 states and the District of Columbia, found that just 44% could recognize all five warning symptoms:

• sudden numbness or weakness of the face, arm, or leg;
  
• sudden Item or trouble speaking;
  
• sudden difficulty walking, dizziness, or loss of balance;
  
• sudden trouble seeing;
  
• severe headache.
  

Only 38% recognized all of these plus the need to dial 911 immediately; the Healthy People 2010 goal is to increase this number to 83%.

The authors say clinicians "should continue to stress the importance of learning to recognize stroke symptoms and the need to telephone 911 when someone appears to be having a stroke."

LINK(S):

MMWR article (Free)

Published in Physician's First Watch May 9, 2008

Students Help Peers Quit Smoking, but Outside the Classroom

Using school-based social networks outside the classroom works better than standard classroom-based presentations at reducing the risk that students will start smoking, Lancet reports.

U.K. researchers randomized some 60 schools to either continue their usual antismoking programs or embark on a program in which respected peers tried to influence their classmates not to smoke.

The program was undertaken among 12- and 13-year-olds, some 15% of whom received training as "peer supporters." During a 10-week period, the peer supporters engaged their classmates informally, outside the classroom, about the benefits of not smoking.

At 1- and 2-year follow-up, smoking prevalence in the intervention schools was lower than in standard schools, but by the 2-year mark, the effect had diminished somewhat.

A commentator writes that the program shows "the potential exists to influence adolescents in real time while they make decisions whether to smoke."

LINK(S):

Lancet article (Free abstract; full text requires subscription)

Lancet comment (Subscription required)

Published in Physician's First Watch May 9, 2008

ACIP Updates Rabies Recommendations

The U.S. Advisory Committee on Immunization Practices has presented updated recommendations for human rabies prevention in an MMWR article released early online.

The committee says it has made "no substantial changes to the recommended approach for rabies postexposure or pre-exposure prophylaxis," and that "modifications were made ... to clarify the recommendations and better specify the situations in which ... prophylaxis should be administered."

LINK(S):

MMWR article (Free)

Published in Physician's First Watch May 8, 2008

Hyperglycemia and Adverse Pregnancy Outcomes, Gestational Diabetes Treatment

Pregnant women with hyperglycemia below the threshold for gestational diabetes face increased risks for adverse pregnancy outcomes, according to a report in the New England Journal of Medicine. A study in the same issue finds metformin to be a potential initial treatment option for gestational diabetes.

In the hyperglycemia study, some 23,000 pregnant women without gestational diabetes underwent glucose tolerance testing. Researchers found that increasing levels of glucose intolerance were associated with increasing risk for adverse outcomes — heavier birth weight, cesarean section, and fetal hyperinsulinemia — but found no clear threshold for the effects.

In an open-label study on gestational diabetes, 733 women were randomized to treatment with either metformin or insulin. Neonatal complication rates did not differ between the groups.

Editorialists do not favor changing the threshold for diagnosing gestational diabetes. In Journal Watch General Medicine, Robert Rebar writes that metformin's long-term effects on the fetus are unknown and, agreeing with the editorial, says it should be compared directly with glyburide, a drug whose users in earlier studies required less supplementary insulin than metformin users did.

LINK(S):

NEJM article on hyperglycemia (Free abstract; full text requires subscription)

NEJM article on treatments (Free abstract; full text requires subscription)

NEJM editorial (Subscription required)

Journal Watch General Medicine summary (Subscription required)

Journal Watch Women's Health summary (Free)

Published in Physician's First Watch May 8, 2008

Guideline on Smoking Cessation Updated

The U.S. Public Health Service has revised its clinical practice guideline for treating tobacco addiction.

The update, the first since 2000, encourages doctors to make tobacco cessation using medication and counseling a priority for every patient who smokes. Among the changes in this edition of the guideline:

• Counseling adds significantly to the effectiveness of medications in smoking control, and the two together work better than either alone. Counseling also increases smoking cessation among adolescents.
  
• Telephone quitlines have broad reach and work with diverse populations.
  
• Seven medications are now available that increase the likelihood of long-term smoking abstinence — varenicline (Chantix); bupropion SR (Zyban); and nicotine delivered as gum, inhaler, lozenge, nasal spray, or patch.
  

LINK(S):

Helping Smokers Quit: A Guide for Clinicians (Free)

Updated Treating Tobacco Use and Dependence guideline (Free PDF)

JAMA commentary (Subscription required)

Published in Physician's First Watch May 8, 2008

Corticosteroids May Not Improve Survival in Children with Bacterial Meningitis

Adjuvant corticosteroid therapy does not appear to improve survival or shorten hospital stays in children with bacterial meningitis, according to a retrospective study in JAMA.

Using a database of records from 27 hospitals nationwide, researchers identified roughly 2800 children who had been discharged with bacterial meningitis diagnoses from 2001 through 2006. About 9% had received corticosteroids.

In adjusted analyses, the time to death and time to hospital discharge did not differ significantly with corticosteroid use — regardless of age or infecting organism (Streptococcus pneumoniae or Neisseria meningitides).

In Journal Watch Pediatrics and Adolescent Medicine, Peggy Sue Weintrub calls the study "fraught with methodologic problems." She concludes: "The results should not change the current recommendation for corticosteroid use in children with bacterial meningitis. The risks ... are primarily theoretical and unproven, while the benefit of corticosteroids in reducing hearing loss in children with H. influenzae is evidence-based."

LINK(S):

JAMA article (Free abstract; full text requires subscription)

Journal Watch Pediatrics and Adolescent Medicine summary (Free)

Published in Physician's First Watch May 7, 2008

Sick-Visit Immunization Associated with Fewer Well-Child Visits

Young children given immunizations during sick visits are less likely to return for well-child visits, potentially affecting their overall preventive care, reports a retrospective study in Pediatrics.

Researchers analyzed data from 4800 sick visits and 1700 patients, aged 6 weeks to 24 months, in urban practices. They found that children who received an immunization at a sick visit were 45% less likely to come back for a well-child visit within 60 days, compared with those who were not vaccinated then. After multivariable adjustment, children who did not receive immunizations at sick visits had more well-child visits overall than those with one or more sick visits with immunizations.

The authors write: "Our findings ... suggest that efforts to improve vaccination rates by immunizing at sick visits may reduce children's subsequent and overall preventive care." They suggest physicians counsel parents at sick visits "regarding the non-vaccine-related benefits of well-child care."

LINK(S):

Pediatrics article (Free abstract; full text requires subscription)

Published in Physician's First Watch May 7, 2008

Homocysteine-Lowering Supplements Don't Lessen Cardiovascular Risk in Women

Vitamin B supplements given to reduce homocysteine levels don't improve cardiovascular risk, according to a JAMA report.

Researchers studied some 5400 women with cardiovascular disease or at high risk for it. (Previous studies have underrepresented women in these cohorts.) Women were randomized to receive either vitamin B supplements (folic acid and vitamins B6 and B12) or placebo.

After 7 years of follow-up, the risk for a composite of myocardial infarction, stroke, revascularization, or CVD-related mortality did not differ between the groups.

An editorialist points to some flaws in the study, but concludes that "until further data become available it is essential ... to admit that once again experimental and observational data do not always translate into therapeutic benefits."

LINK(S):

JAMA article (Free)

JAMA editorial (Subscription required)

Journal Watch General Medicine summary (Free)

Published in Physician's First Watch May 7, 2008

Male Osteoporosis Screening Guideline Issued

The American College of Physicians has issued a clinical practice guideline on screening men for osteoporosis. The guideline appears in the current Annals of Internal Medicine.

The College's subcommittee concludes:

• Periodic assessments for osteoporotic fracture risk should start in men before age 65.
  
• Factors that increase risk include age >70, body mass index <25, recent weight loss >10%, physical inactivity, corticosteroid use, androgen-deprivation therapy, and previous fragility fracture.
  
• Men at increased risk should undergo screening with dual-energy x-ray absorptiometry.
  

LINK(S):

Annals of Internal Medicine guideline (Free)

Annals of Internal Medicine evidence review (Free)

Published in Physician's First Watch May 6, 2008