American College of Physicians: Internal Medicine — Doctors for Adults ®

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Weight-loss surgery is a lifesaver

By Linda Gundersen

Bariatric surgery has been remarkably successful in helping obese patients to lose weight. Now, it might help them to live longer. The moderators for the internal medicine update, Jack Ende, FACP, chief of the department of medicine at Penn Presbyterian Medical Center in Philadelphia, and Robert K. Cato, FACP, chief of the division of general internal medicine at Penn Presbyterian Medical Center, will discuss the groundbreaking study on bariatric surgery, as well as the latest news on the rosaglitazone crisis, CT scans and their association with cancer risk, and a new treatment regimen for asthma.

Dr. Ende
Dr. Ende

Bariatric surgery

For the first time, a study showed a connection between weight loss and a reduction in total, cardiovascular and cancer-related mortality. The article in the New England Journal of Medicine (2007;357:741-752) by Sjöström et al looked at 2,000 men and women, with about half randomized to receive bariatric surgery. While it’s long been understood that obesity reduces life expectancy, physicians had no real evidence until now that significant weight loss would prolong life expectancy.

The ideal first recourse in weight loss is lifestyle changes, but as physicians know, the reality is that such interventions are rarely successful, particularly in extremely obese patients.

“Studies have shown for decades that all the counseling, interventions, psychologists, and nutritionists can’t achieve weight loss that lasts,” Dr. Ende said. The new data could result in a change in practice parameters and encourage insurers to reconsider covering the procedure. In addition, public perception could change. “Many people consider such extreme surgery a vanity procedure,” Dr. Ende said, rather than a life-saving technique.

CT scans

A study in the Journal of the American Medical Association by Einstein et al (2007;298:317-323) revealed that CT scans increase the risk of cancer. Generally, younger people and young women in particular are at increased risk of cancer over time. “It is a small, but measurable risk,” Dr. Ende said, cautioning that the study’s results should not provoke a knee-jerk reaction. “This study just raises a note of caution; the tests shouldn’t be used inappropriately,” he said.

In an elderly population, the increased risk is a considerably smaller concern, but more discrimination should be exercised in testing young women.

Rosaglitazone

The best-selling diabetes drug in the country, rosaglitazone, increases the risk of heart attack and mortality, according a meta-analysis by Nissen and Woolski in the New England Journal of Medicine (2007;356:2457-2471). While the drug has been used for several years and has a proven ability to lower blood sugar, no study had shown that it prevented serious complications from diabetes, such as blindness, kidney failure, heart attack, and stroke. Logically, it was thought that lowering blood sugar would improve outcomes.

Dr. Ende called the study “groundbreaking,” resulting in an immediate change in the treatment regimen for diabetes. While the rosaglitazone study has been widely publicized, Drs. Cato and Ende will update internists on the most current information available.

Asthma

Treatment for asthma may be getting a simplified makeover. A study on mild, stable asthma showed that patients do just as well when they use inhalers on an as-needed basis vs. daily. Another study suggested once-daily inhaler use was as effective as twice-daily use. Simplifying the treatment regimen could result in fewer side effects, lower costs, and hopefully, improved compliance in this very large patient population. Dr. Ende cautioned, “The important thing is to be sure that you’re applying this to the right patient population—mild, persistent asthma—not severe asthma.”

Physicals

How valuable are routine physicals? A review article by Bouleware and colleagues in Annals of Internal Medicine (2007;146:289-300) found benefits to the screening. Previous studies showed little usefulness to the annual physical, even recommending against them for healthy patients. This study concluded that periodic health evaluations improve delivery of some recommended preventive services and may alleviate patients’ concerns.

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