Physician's First Watch: Archives

Many U.S. Physicians Overuse Pap Testing

Only about one fifth of U.S. clinicians consistently follow guidelines for Pap testing, with many overusing such screening, according to a federally funded survey in Annals of Internal Medicine.

Some 1100 clinicians (internists, family practitioners, or obstetrician-gynecologists) were given a series of clinical vignettes that described women by age, sexual experience, and Pap testing history. Participants provided their screening recommendations for each scenario.

While over 80% said that at least one set of screening guidelines (e.g., U.S. Preventive Services Task Force) was "very influential" in their practices, only 22% recommended guideline-consistent care for every vignette. Obstetrician-gynecologists were less guideline-concordant than the other specialties.

Of note, one third of participants recommended annual Pap testing for an 18-year-old who hadn't had sexual intercourse, while almost half continued to recommend Pap testing for a women whose cervix had been removed for benign reasons.

LINK(S):

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

American Cancer Society guidelines on cervical cancer screening (Free)

American College of Obstetricians and Gynecologists guidelines (Free)

USPSTF guidelines (Free)

Published in Physician's First Watch November 3, 2009

Exenatide Label Updated to Highlight Kidney Risks

The type 2 diabetes drug exenatide (Byetta) will have a revision to its label warning of altered kidney function, according to the FDA.

The agency says it has received reports of over 60 cases of acute renal failure among patients on the drug. Some of the problems occurred in patients with existing renal disease.

The new label will advise against using exenatide in patients with severe renal impairment (creatinine clearance rates under 30 mL/min) or end-stage renal disease. In addition, it will urge caution when beginning or increasing doses of the drug in those with moderate impairment (creatinine clearance rates between 30 and 50 mL/min).

LINK(S):

FDA news release (Free)

FDA information for clinicians (Free)

Physician's First Watch coverage of exenatide and pancreatitis (Free)

Published in Physician's First Watch November 3, 2009

H1N1 Update: Interim Results Show Two Vaccine Doses Required in Young Children

Children under 10 will require two shots of 2009 H1N1 vaccine, according to interim results of clinical trials announced Monday by the National Institute of Allergy and Infectious Diseases.

Researchers found that the second dose prompted a "robust" immune response that was a "significant improvement" over the response following the first dose. The agency says the results support the current Advisory Committee on Immunization Practices recommendation for two shots in children under 10 to "achieve an immune response likely to protect them from illness."

LINK(S):

National Institute of Allergy and Infectious Diseases update on children's vaccine (Free)

Previous Physician's First Watch coverage of 2009 H1N1 vaccine dosing in children (Free)

Published in Physician's First Watch November 3, 2009

H1N1 Update: Questions About Vaccine Dosing in Younger Children

Patients might ask about reports that younger children may receive only one dose of the H1N1 vaccine, not two.

On Friday, the World Health Organization's immunization advisory group recommended that in countries where children are given early vaccination priority, one dose of the vaccine should be administered to as many children as possible.

The U.S. Advisory Committee on Immunization Practices currently recommends two vaccine doses for children aged 6 months to 9 years. CDC Director Thomas Frieden said on Friday that the National Institutes of Health may release additional pediatric data from clinical trials as early as this week. "If the data show the difference, we will reconsider our recommendations," he said. "For the time being ... we're sticking with what the ACIP has recommended."

The CDC also reported that 19 children in the U.S. died of H1N1 influenza in the previous week.

LINK(S):

WHO update (Free)

CDC news briefing transcript (Free)

ACIP recommendations (Free)

Associated Press story (Free)

Previous Physician's First Watch coverage of pediatric dosing of H1N1 vaccine (Free)

Published in Physician's First Watch November 2, 2009

Darbepoetin Alfa Associated with Heightened Stroke Risk

Darbepoetin alfa (Aranesp) is associated with increased risk for stroke in patients with diabetes and chronic kidney disease, according to an industry-sponsored study published online in the New England Journal of Medicine.

Researchers randomized some 4000 patients with type 2 diabetes, chronic kidney disease, and moderate anemia to darbepoetin alfa (hemoglobin goal of 13 g/dL) or placebo (rescue therapy initiated if hemoglobin fell below 9 g/dL). After a median follow-up of roughly 2.5 years, the groups did not differ in rates of the two primary composite outcomes (death or end-stage renal disease; death or a cardiovascular event). However, darbepoetin alfa recipients were more likely to experience a stroke (5.0%, vs. 2.6% with placebo).

The treatment group saw "a humble improvement at best" in fatigue scores, notes an editorialist.

The authors conclude that for many patients, the heightened risk for stroke "will outweigh any potential benefit" of an erythropoiesis-stimulating agent.

LINK(S):

NEJM article (Free)

NEJM editorial (Free)

Published in Physician's First Watch November 2, 2009

(Some of) You Are Feeling Very Sleepy...

Just over 10% of U.S. adults report getting insufficient sleep in each of the preceding 30 days, reports MMWR.

A telephone survey taken as part of the CDC's Behavioral Risk Factor Surveillance System interviewed over 400,000 people in all 50 states and several territories. One question was, "During the past 30 days, for about how many days have you felt you did not get enough rest or sleep?"

Among the findings:

• Sleep insufficiency was most prevalent among those aged 25 to 34; least among those 65 and older.
  
• People unemployed or unable to work were at increased risk.
  
• The areas most likely to report sleep insufficiency were Puerto Rico, Oklahoma, Kentucky, and Tennessee (all between 14% and 15%), and West Virginia (19%).
  
• Areas at least risk were North Dakota (7%), and California, the District of Columbia, Wisconsin, and Oregon (all between 8% and 9%).
  

The authors recommend that clinicians consider adding an assessment of sleep habits to routine office visits.

LINK(S):

MMWR report (Free)

Physician's First Watch coverage of sleep and BP (Free)

Published in Physician's First Watch October 30, 2009

Antibiotic Prophylaxis Lowers Risk for UTIs in Predisposed Kids

In children at risk for urinary tract infection, the use of antibiotic prophylaxis lowers infection risks, if only modestly, reports a New England Journal of Medicine study.

In a double-blind study, researchers randomized nearly 600 children who'd completed treatment for a proven UTI to either prophylaxis with daily low-dose trimethoprim–sulfamethoxazole or placebo. About 40% had known vesicoureteral reflux. After 12 months' treatment, UTIs (the primary outcome) occurred in 13% of the treatment group versus 19% of controls. The authors calculate a number-needed-to-treat of 14 to prevent one infection.

Editorialists, addressing whether the results should influence clinical decisions, stress that the effect size is modest overall. They write: "The need to detect vesicoureteral reflux is probably the most important issue facing parents and clinicians" in children with UTIs. Writing in Journal Watch Pediatrics and Adolescent Medicine, Dr. Howard Bauchner says: "Whether antibiotic prophylaxis after UTI in children with significant reflux preserves long-term renal function remains an unanswered question."

LINK(S):

NEJM article (Free abstract; full text requires subscription)

NEJM editorial (Subscription required)

Journal Watch Pediatrics and Adolescent Medicine summary (Free)

Published in Physician's First Watch October 29, 2009

Diabetes Prevention Interventions Have Long-Lasting Effects

The benefits of lifestyle intervention or metformin for preventing the development of diabetes in high-risk adults can persist for 10 years, according to a follow-up report from the Diabetes Prevention Program (DPP) trial published online in Lancet.

Researchers examined longer-term follow-up data on some 2800 high-risk adults who had been randomized to intensive lifestyle intervention, metformin, or placebo in the DPP trial. At the end of that period (roughly 3 years), both lifestyle intervention and metformin had significantly lowered diabetes incidence relative to placebo (by 58% and 31%, respectively). Then, all participants were offered lifestyle counseling; those originally assigned to lifestyle intervention received additional lifestyle support, while the metformin group continued their treatment.

Over a median of 10 years' total follow-up, benefits of the interventions persisted — overall diabetes incidence was reduced by 34% in the lifestyle group and by 18% in the metformin group, relative to placebo.

LINK(S):

Lancet article (Free abstract; full text requires subscription)

Lancet comment (Subscription required)

Journal Watch General Medicine coverage of initial Diabetes Prevention Program results (Free)

Published in Physician's First Watch October 29, 2009

Insulin Syringes Recalled

Qualitest Pharmaceuticals has recalled all of its Accusure insulin syringes because the needles may detach from the syringes.

Clinicians may report adverse reactions associated with these syringes to the FDA's MedWatch program.

LINK(S):

Manufacturer news release (Free)

MedWatch site (Free)

Published in Physician's First Watch October 28, 2009

Migraine with Aura Linked to Increased Stroke Risk

Patients who suffer migraine with aura face twice the risk for ischemic stroke as those with migraine without aura, according to an industry-funded meta-analysis in BMJ.

Researchers analyzed 25 studies examining associations between migraine and cardiovascular risk. Among the findings:

• Overall migraine was associated with increased risk for stroke; however, the association appeared limited to migraine with aura.
  
• Female migraineurs had greater overall stroke risk than males.
  
• Stroke risk was further increased in migraineurs younger than 45, those who smoked, and those who used oral contraceptives.
  
• Migraine was not associated with risk for MI or cardiovascular death.
  

An editorialist notes: "The absolute risk of stroke for most patients with migraine is low, so a doubling of risk is not cause for panic." She adds that while some experts recommend against using oral contraceptives in women with migraine with aura, the benefits of treatment should be weighed against the harms in women without additional stroke risk factors.

LINK(S):

BMJ article (Free)

BMJ editorial (Subscription required)

Journal Watch Women's Health summary of previous study linking migraine with aura to stroke (Free)

Published in Physician's First Watch October 28, 2009