In the News for the Week of 8-30-05
Clinical news in the headlines
- Diabetes groups raise doubts about "metabolic syndrome"
- Aspirin helps prevent colon cancer but high doses carry risks
- Highlights of ACP Journal Club
- Newly approved blood test helps gauge correct drug dosages
- Obesity rate has sharpest rise in Southeast
Health care coverage
- Employer benefits hold steady but workers pay more
- Latest edition of The Capitol Key highlights legislative gains, pains
Two major diabetes groups last week questioned the legitimacy of metabolic syndrome as a distinct disease and urged doctors not to diagnose it until further studies are done.
The American Diabetes Association (ADA) and the European Association for the Study of Diabetes said in a joint paper that metabolic syndrome is not well-defined, according to an Aug. 25 ADA news release. The “syndrome” is actually a combination of cardiovascular risk factors, the paper argued, not a unique disease. The paper appears in the September Diabetes Care and Diabetologia.
Metabolic syndrome is usually defined as having three or more common risk factors for heart disease, such as high blood pressure, high glucose levels or diabetes, according to the release. However, different groups include different risk factors, the ADA release said, suggesting that there is no clear evidence for how to diagnose the syndrome.
Diagnosing metabolic syndrome in a diabetic, for example, can divert attention away from appropriate care, according to the release. The authors recommended that physicians treat cardiovascular risk factors individually and not attempt to treat metabolic syndrome as a separate condition.
The ADA release is online.
A new study concluded that while regular aspirin use reduces the risk of colorectal cancer, the benefits take years to materialize and higher doses carry the risk of gastrointestinal bleeding.
The study included almost 83,000 nurses enrolled in the Nurses’ Health Study who provided data on their medication use between 1980 and 2000. Women who regularly took more than two standard 325-mg aspirin weekly had a lower risk of colorectal cancer than those who took no aspirin, but only after a decade or more of use. In addition, the benefits of aspirin were most apparent in women who took the highest dose of 14 or more aspirin per week, which led to a higher risk of major gastrointestinal bleeding.
The study, which appears in the Aug. 24 Journal of the American Medical Association (JAMA), found similar results for regular use of non-steroidal anti-inflammatory drugs (NSAIDs). The findings indicate that the protective effects of aspirin and NSAIDs are highly dose-dependent, the authors said. Taking a low aspirin dose of 50 mg a day, they said, is inadequate to prevent colorectal cancer.
The results indicate that use of high-dose aspirin would prevent one to two cases of colorectal cancer per 10,000 person years and result in more than eight episodes of major gastrointestinal bleeding, according to the authors. More research is needed, they said, on whether the risks of long-term high-dose aspirin/NSAID use outweigh the benefits compared with other potential cancer prevention strategies.
The JAMA abstract is online.
Two recent studies of older patients with macular degeneration found that pegatanib slowed or reversed patients’ visual decline with few complications.
The two trials included more than 1,200 men and women over age 50 with subfoveal sites of choroidal neovascularization secondary to age-related macular degeneration. Patients were divided into groups that received 0.3 mg, 1 mg or 3 mg of intravitreous injections or sham injections in one eye every six weeks for 48 weeks. After 54 weeks, patients who received injections had less visual loss than patients who did not get injections.
Over the course of 7,545 injections, only two patients suffered severe visual loss and 22 patients had serious adverse events of endophthalmitis, retinal detachment and traumatic cataract. The study is abstracted in the July-August ACP Journal Club.
The study provides a promising treatment option for the wide range of patients with “wet” macular degeneration, the Journal Club reviewer noted. Currently, physicians must refer these patients to retinal specialists for treatment.
Although there are few therapeutic interventions for macular degeneration, it is the most common cause of binocular visual impairment in older people in the industrialized world, the reviewer said. While longer-term follow up and analyses are needed before physicians should routinely refer patients for treatment, according to the reviewer, the study provides some hope of reversing visual decline in many patients.
ACP Journal Club is online.
The FDA last week approved a new blood test designed to help physicians determine correct drug dosages and minimize adverse reactions.
The Invader UGT1A1 Molecular Assay works by detecting genetic variations that affect how a drug is individually metabolized, according to an Aug. 22 FDA news release. The test can help physicians determine correct dosages of irinotecan, which is used to treat colorectal cancer and is metabolized through the UGT1A1 genetic pathway.
The test is one of several genetic tests that have been approved over the last several years, the release said. Others include the Roche AmpliChip for determining dosages of antidepressants, antipsychotics, beta-blockers and some chemotherapy drugs, and TRUGENE-HIV-1 Genotyping Kit, used to detect virus variations that affect resistance to antiretroviral drugs.
The Invader assay, manufactured by the Madison, Wis.-based Third Wave Technologies, also helps identify patients with a greater risk of side effects for certain drugs, said the release. A study cited by the FDA found that people with a certain genetic variation had five times the risk of experiencing irinotecan toxicity.
While the assay can assist physicians with dosing, other factors should be considered, the FDA said. For example, liver function, kidney function and other drugs may also affect prescribing.
The FDA news release is online.
Pharmacogenomics will play a growing role in preventing drug interactions. See "Tips for heading off harmful drug interactions" in the September ACP Observer.
The number of obese adult Americans rose to almost 25% last year, according to a new report, with Southeastern states leading the list of heaviest states.
Ranking adults in Mississippi as the heaviest and those in Colorado as the least heavy, the report noted that obesity rates have increased in every state except Oregon, according to an Aug. 23 news release from the nonprofit Trust for America’s Health, which conducted the study. Seven out of the 10 states with more than 25% obese adults were in the Southeast.
The report is based on CDC data, which showed that more than 40 states reported an obesity rate of 20% among residents, the Aug. 24 New York Times said. The report noted that the government has set a goal of achieving 15% obesity in adults by 2010.
The report’s authors noted that federal programs are too limited to affect the rise in obesity levels, according to the release. The authors said that more research is needed to develop significant policies to address the problem, such as community design and affordable health food options.
The Trust for Healthy Americans news release is online.
The New York Times is online.
Health care coverage
The percentage of U.S. workers covered by employer-sponsored health plans has stayed about the same over the past five years, according to a new government survey, but more plans now require employees to contribute toward coverage costs.
In the private sector, 70% of workers had access to employer-sponsored medical plans, but only 53% participated in them as of March 2005, according to the Bureau of Labor Statistics’ (BLS) National Compensation Survey released last week. The numbers were about the same in 1999 but the percentage of workers contributing to their plans increased from 67% in 1999 to 76% this year.
Employee contributions to premiums averaged $273.03 monthly for a family and $68.96 for single coverage, according to the BLS report. Employer monthly premiums averaged $575.77 for a family and $252.22 for a single employee.
Employers were less likely to offer employee retirement benefits than health benefits, said the Aug. 25 San Francisco Chronicle. Increasing costs are prompting many employers to cut retiree benefits, the article noted, especially in the West, where industries tend to be smaller, newer and less likely to be unionized than in the East.
The article noted that 88% of unionized workers had access to retiree benefits compared with 56% of nonunion workers. Disparities also exist between blue- and white-collar employees, with 77% of white collar jobs carrying health benefits compared with only 44% of service jobs.
Workers in the West generally fared better than those in the East for health benefits, the San Francisco Chronicle said. About 33% of Western employers paid the entire single-employee premium, and that region also had the lowest average employee contribution at $62.09 a month.
The article noted that the Labor Department’s figures do not reflect a complete picture of health care cost increases because they do not account for employee costs besides premiums, such as copays and limits on coverage. Also, fewer employers are covering employees’ families than in the past.
The BLS National Compensation Survey is online.
The San Francisco Chronicle is online.
The newest edition of The Capitol Key, the College's advocacy newsletter, has been posted online, with legislative updates and news about ACP advocacy efforts.
Highlights of the August issue include information on testimony given this summer by College President C. Anderson Hedberg before a House subcommittee. Dr. Hedberg spoke about the need for positive Medicare fee updates and evidence-based quality improvement measures.
Other newsletter highlights include:
The College has endorsed the Medicare Value-Based Purchasing for Physicians' Services Act (H.3617), sponsored by Rep. Nancy Johnson (R-Conn.). The bill would repeal the sustainable growth rate formula and replace it with the Medicare Economic Index. Dr. Hedberg appeared at a press conference in July with Rep. Johnson.
New patient safety legislation was passed and signed into law this summer, after a five-year struggle. The law calls for voluntary and confidential reporting of medical errors to patient safety organizations. The new legislation does not allow information collected by those organizations to be admitted in court, but lets judges in criminal cases choose to disclose error information if it contains evidence of a criminal act not available from another source.
The House passed a medical liability bill (H. 5) this summer, which establishes basic tort protections and sets limits on attorney fees. A battle is expected in the Senate, where the bill has stalled before.
The Capitol Key is sent by e-mail or fax to ACP Key Contacts, College members who are important links between ACP and each contact's elected officials. When an important advocacy issue comes up before Congress, the College alerts Key Contact members, who then get in touch with their representatives and report back on their exchange to the College.
ACP currently has 4,500 Key Contacts as well as an annual awards program for program members who provide outstanding service. All ACP members are invited to enroll in the Key Contact program.
The latest Capitol Key issue is online.
Information about the Key Contact program—including an enrollment link—is online.
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Copyright 2005 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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