Clinical news in the headlines
- Physicians urged to "prescribe" healthier lifestyles
- Highlights from the Feb. 17 Annals of Internal Medicine
- Elevated iron stores in women associated with greater diabetes risk
- Physicians establish group to push for malpractice reform
- ImClone's Cetuximab approved for treating advanced colon cancer
- FDA asks drug companies to update HRT labels with dementia risk
Resident lawsuit update
- Judge OKs proceeding with resident class-action suit against the Match
- Pre-Session course will show physicians how to use technology to fine-tune their practice
Clinical news in the headlines
Authors of a report released last week issued a "call to action" for primary care physicians to put a higher priority on advising patients about lifestyle issues. The report includes a checklist of recommendations physicians should make to help patients lose weight and increase physical activity.
The article, which was published in the Feb. 9 Archives of Internal Medicine (AIM), found that only 34% of patients who had seen a physician in the previous year had been counseled at their last visit about developing a more active lifestyle.
The checklist for physicians include:
Measuring the patient's body mass index, height and weight, and assessing his or her diet and physical activity at every visit. Office staff can do this assessment, while referring patients who need further advice to nutritionists can also save office time.
Writing a prescription for increased exercise and a healthier diet, including strength training, setting regular times for meals and increasing intake of high-fiber foods.
Recommending that patients take stairs whenever possible and wear a pedometer to gauge the number of steps they walk daily. (They should aim for 10,000.)
Putting seriously overweight patients on medications (including orlistat, sibutramine or phentermine) in six months if they don't respond to smaller food portions and increased activity.
The Feb. 10 Washington Post noted that two-thirds of American adults are overweight, which leads to 300,000 early deaths and at least $90 billion in costs for health care in the United States every year.
An AIM abstract is online at http://archinte.ama-assn.org/cgi/content/abstract/164/3/249. (Full text is available only to subscribers.)
The Washington Post article is online at http://www.washingtonpost.com/ac2/wp-dyn/A28133-2004Feb10.
Highlights from the Feb. 17 Annals of Internal Medicine
The following articles appear in today's Annals of Internal Medicine. The full text of the issue is available to College members and subscribers online at http://www.annals.org?wkly/.
USPSTF does not recommend EKG, treadmill tests or CT scans to screen patients at low risk for heart disease. The U.S. Preventive Services Task Force has issued new recommendations for screening asymptomatic people for heart disease, saying that evidence is insufficient to recommend either for or against these three screening tests for heart disease in asymptomatic patients. http://www.acponline.org/journals/annals/series/uspstf/screening-for- coronary-heart-disease.pdf
Hospice care doesn't lower overall Medicare costs. While hospice care reduced Medicare expenditures for cancer patients under age 85, it increased costs for patients without cancer and for all patients over age 85. Savings were highest (between 7% and 17%) among hospice patients with lung cancer and other very aggressive types of cancer. http://www.annals.org/cgi/content/abstract/140/4/269
Cognitive decline associated with left carotid artery disease even in patients with no symptoms of artery disease. Researchers studying more than 4,000 right-handed patients age 65 or older with no symptoms of heart disease and no history of transient ischemic attack or stroke found that narrowing of the left carotid artery was associated with cognitive impairment and decline in cognitive function over time. http://www.annals.org/cgi/content/abstract/140/4/237
Elevated iron stores in women associated with greater diabetes risk
A study released last week found that women who have "moderately elevated" blood levels of iron may be three times more likely to develop type 2 diabetes than women with normal iron levels.
Data were drawn from the Nurses' Health Study, which for 10 years followed more than 32,000 women who were free of diabetes, cardiovascular disease and cancer. Results indicated that otherwise healthy, middle-aged women with higher iron levels were at significantly greater risk for developing type 2 diabetes, independent of other risk factors such as obesity. The study was published in the Feb. 11 Journal of the American Medical Association (JAMA).
The women found to be at higher risk had baseline ferritin concentration of 109 ng/mL versus 71.5 ng/mL for women at lower risk.
Authors noted that ferritin concentration may indicate other mechanisms, such as inflammation associated with insulin resistance. However, they found that elevated ferritin levels could be used to identify women at risk for developing diabetes, who could benefit from lifestyle or therapeutic interventions and follow-up.
An abstract of the JAMA study is online at http://jama.ama-assn.org/cgi/content/abstract/291/6/711. (Full text is avaiable only to subscribers.)
Physicians establish group to push for malpractice reform
A new physicians' group dedicated to medical malpractice reform has begun a print and television campaign to further national reform efforts. The group, called Doctors for Medical Liability Reform (DMLR), wants to see noneconomic damages in malpractice cases capped at $250,000, according to the Feb. 10 Modern Physician.
The Washington, D.C.-based coalition represents 230,000 physicians from nine different medical societies, including the American College of Cardiology and the American College of Emergency Physicians.
The group plans to run print ads calling for liability insurance reform in several national newspapers including the Wall Street Journal and USA Today. The group is also sponsoring 30-minute television "newsmagazines" in North Carolina and Washington state, where it sees a liability insurance crisis developing, according to a Feb. 10 press release from the group.
The DMLR plans to extend its campaign to several other "crisis" states, including South Carolina, Georgia, Florida, Illinois, Nevada and Pennsylvania.
Nineteen states are experiencing medical liability crises, while only six -- California, Colorado, Indiana, Louisiana, New Mexico and Wisconsin - are stable, the group reported. All six of those states have caps on noneconomic damage awards.
According to the group's 30-minute television newsmagazine, physicians are being driven out of business by skyrocketing insurance rates, hindering patients' access to care, according to the group's press release. Both the television and print campaigns predict the crisis will have a long-term negative impact on state economies.
The DMLR press release is online at: http://www.protectpatientsnow.org/866.html.
Modern Physician is online at http://www.modernphysician.com/news.cms?newsId=1788.
The CMLR's Web site is online at http://www.protectpatientsnow.org.
ImClone's cetuximab approved for treating advanced colon cancer
The FDA last week approved the sale of cetuximab (Erbitux) to treat patients with metastatic colon cancer, according to the Feb. 13 Washington Post.
The drug was cleared for use alone or in combination with another approved chemotherapy drug. In clinical trials of combination therapy, cetuximab shrank tumors in 23% of advanced colon cancer patients.
Trials are underway to see if the drug can prolong the lives of colon cancer patients. The drug, part of the "targeted therapy" class of cancer treatments, works by targeting those molecules that cause cancer cells to grow.
However, the newly-approved cetuximab may soon get stiff competition from bevacizumab (Avastin), which the FDA is also expected to shortly approve. Bevacizumab, also for treating metastatic colon cancer, will probably be approved to be used as an initial therapy, while cetuximab was approved only to be used after traditional chemotherapy had failed.
Also according to the Feb. 11 New York Times, avastin has been shown in clinical trials to prolong patients' lives by five months.
Cetuximab, which is manufactured by ImClone Systems Inc., has a controversial history. The FDA failed to initially approve the drug for treating colon cancer in December 2001, a decision that led to alleged insider-trading activity. That activity landed the company's co-founder in prison and led to charges against Martha Stewart.
The Washington Post is online at http://www.washingtonpost.com/wp-dyn/articles/A37886-2004Feb12.html.
The New York Times report is online at http://www.nytimes.com/2004/02/11/business/11biotech.html.
For more on targeted therapies, see "In cancer treatment, targeted therapies are giving physicians and patients hope" in the December 2003 ACP Observer at http://www.acponline.org/journals/news/dec03/cancer.htm.
FDA asks drug companies to update HRT labels on dementia risk
The FDA last week asked pharmaceutical companies to revise their labeling of hormone replacement therapy (HRT) products to include information on increased risk of dementia among women 65 and older who use those products.
Need for the updated warning grew out of data from the Women's Health Initiative Memory Study that showed a link between older women developing dementia and taking estrogen alone or in combination with progestin (Prempro). Manufacturers previously were required to warn women that the hormone combination increases the risk of breast cancer, heart attacks and strokes.
According to a Feb. 10 FDA press release, it is not known whether the increased dementia risk also applies to younger postmenopausal women who take estrogen alone. While the higher dementia risk is "statistically significant," the FDA said that the increased risk for dementia remains small for individual women taking HRT products.
Although estrogen and combined estrogen products are still an effective treatment for menopausal symptoms, the FDA says that those products should be used in "the lowest effective dose" for the shortest possible time.
The FDA press release is online at http://www.fda.gov/bbs/topics/NEWS/2004/NEW01022.html.
Resident lawsuit update
Judge OKs proceeding with resident class-action suit against the Match
A federal judge last week approved proceeding with a class-action antitrust lawsuit filed by medical residents in May 2002 that claims the National Resident Matching Program (NRMP) unfairly restricts residents' ability to negotiate wages and work hours.
At the same time, the judge also dropped several defendants named in the original suit, including the AMA, the American Hospital Association, the Council of Medical Specialty Societies and the American Board of Medical Specialties, according to the Feb. 11 Modern Physician.
The judge ruled that the suit can proceed, however, against other defendants that include the Association for American Medical Colleges (AAMC), the Accreditation Council for Graduate Medical Education, the NRMP and 27 teaching hospitals.
The ruling came in response to a motion brought by the AAMC to dismiss the suit. In a Feb. 12 press release, the AAMC expressed disappointment that the case will proceed, although it applauded the dismissal of claims against several defendants.
Modern Physician is online at http://www.modernphysician.com/news.cms?newsId=1796.
The AAMC press release is online at http://www.aamc.org/newsroom/pressrel/2004/040212.htm.
Pre-Session course will show physicians how to use technology to fine-tune their practice
A special two-day pre-Session course, "How to Use Technology to Reduce Overhead and Increase Time with Patients," will help small-group practitioners learn how to use information technology to improve their practice.
Participants will learn about cost-effective computer solutions and how to use inexpensive, off-the-shelf software to make their office more efficient. The course will also identify which practice problems can be solved by information technology and which cannot, and how to get the office staff to embrace technological changes.
The course is being offered April 21-22, 2004, in New Orleans. Physicians may attend the course without attending Annual Session.
Full details of the pre-Session course are online at http://www.acponline.org/cme/as/2004/advance/pre_session.htm.
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Copyright 2004 by the American College of Physicians.
A 67-year-old man is evaluated for a 6-month history of worsening exertional dyspnea. He has severe COPD, previously with minimal exertional symptoms, but now notes activity-limiting shortness of breath when walking short distances. He does not have chest pain, gastrointestinal symptoms, or sleep-related symptoms. Medical history is otherwise unremarkable. Medications are a twice-daily fluticasone/salmeterol inhaler and an as-needed albuterol/ipratropium metered-dose inhaler. He has a 55-pack-year smoking history but quit when COPD was diagnosed. Following a physical exam, chest radiograph, and transthoracic echocardiogram, what is the most appropriate diagnostic test to perform next?
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