Embargoed news from Annals of Internal Medicine

Health care professionals recognize sexuality as an important component of overall well being. However, attitudes persist that elderly people are not capable of, or interested in sex. Researchers in Australia sought to determine how often men continue to be sexually active into their 70s, 80s, and 90s, and what social and medical factors contribute to their level of sexual activity. Researchers surveyed 3,274 community-dwelling men three times over 13 years. At the time of the second and third round of questionnaires, hormone levels were taken along with information about sexual activity. Of the 3,274 men surveyed, 2,783 provided information about sexual activity. About one-third of the respondents reported having at least one sexual encounter in the last year. About half (56.5 percent) of those who reported being sexually active said they were satisfied with the frequency of the sex. Of those, 43 percent had sex less often than they would like. The researchers found that as patients aged, sexual activity decreased, with respondents in the 70 – 75 age range having more sex than those in the 90 – 95 age range. Factors such as increasing age, lower testosterone levels, partner's disinterest or physical limitations, osteoporosis, prostate cancer, diabetes, depression drugs, and some blood pressure medications were associated with absence of sexual activity.

Atrial fibrillation (AF) is a common concern after heart surgery. Current guidelines recommend β-blockers as the first-line treatment for prevention of AF following heart surgery, but some physicians report using amiodarone instead. Few studies directly compare the two treatments. Researchers randomly assigned 316 consecutive heart patients to receive a 48-hour infusion of metroprolol (n=159) or amiodarone (n=157) within 24 hours after heart surgery to directly compare the efficacy of metroprolol vs amiodarone. Both treatment groups had similar occurrence of AF, but because of the wide range of confidence intervals, the authors could not conclude that the treatments were equally effective. The authors recommend more head-to-head research comparing the two treatments.

The Accreditation Council for Graduate Medical Education (ACGME) is responsible for the accreditation of post-MD medical programs, including internal medicine. Accreditation is accomplished through a peer review process and is based upon established standards. The current process provides goals and objectives, but lacks a clear path on how to achieve them. Within the last decade, the ACGME has focused on refining medical education to be more competency-based, which could address this issue. The Alliance for Academic Internal Medicine Education Redesign Task Force II was tasked with drafting the framework for competency-based educational training (CBET) for internal medicine residents. They sought to refine six core competencies (medical knowledge, patient care, professionalism, interpersonal and communications skills, practice-based learning and improvement, systems-based practice) by defining detailed milestones and providing examples of training program initiatives. According to the Task Force report, "physicians-in-training should be able to demonstrate that they have acquired the knowledge, skills, attitudes, and behaviors encompassing a well-defined set of competencies necessary for safe and effective practice." While CBET is not time-based, the Task Force does not favor reducing internal medicine training to less than three years. Rather, the three-year timefame should allow ample opportunity for remediation and refinement, as needed.

Note: The following is a USPSTF Recommendation Statement update.

Update Recommendations on Behavioral Counseling to Promote Healthy Habits for Disease Prevention Up Next

In an ongoing effort to clarify its work and methods, the United States Preventive Services Task Force (USPSTF) is making all draft recommendation statements available for public comment prior to final publication. Recently, the Task Force reviewed new data to update its previous recommendations on behavioral counseling to promote physical activity and a healthful diet to prevent cardiovascular disease. Data from 73 studies published from 2001 to January 2010 and presented in a review in this issue of Annals will be used to draft an updated recommendation statement to be posted for public comment at http://www.uspreventiveservicestaskforce.org/tfcomment.htm (date of posting to be determined). According to the review, counseling to improve diet or increase physical activity changed health behaviors and was associated with small improvements in body fat, blood pressure, and lipid levels. Study analysis and conclusions are published in Annals of Internal Medicine and will be used to draft the updated recommendation.

Early Releases:

For patients who have had type 2 diabetes for a long time, glycemic control can present a challenge. Typically, these patients are treated with sequential addition of oral antihyperglycemic drugs with the goal of reaching a specific glycemic target. Many patients take insulin glargine alone or in combination with metformin or pioglitazone, or both. As time passes, patients on this regimen may have difficulty reaching glycemic targets and could require additional intervention. Researchers conducted a parallel, randomized, placebo-controlled trial to test whether twice-daily exenatide injections could reduce HbA1c levels more so than placebo in patients treated with insulin glargine. More than 200 patients were randomly assigned to receive exenatide, 10 µg twice daily (n=112), or placebo (n=101). After 30 weeks, patients in the exenatide group had improved glycemic control without increased hypoglycemia or weight gain. Adverse reactions were mild. Researchers conclude that twice daily injections of exenatide may be safe and effective for controlling diabetes in basal insulin-treated patients.

2. Heathcare Reform Perspective: Impact of Elections on Health Care Reform

Affordable health care insurance for all Americans is a goal long supported by the American College of Physicians (ACP). Robert Doherty, ACP's senior vice president for governmental affairs and public policy, contends that the U.S. Congress will not repeal the Affordable Care Act (ACA), but underfunding and state resistance could make it less effective at a time when the nation is experiencing an unprecedented crisis in access to affordable coverage. The Census Bureau reported that 50.7 million residents from nearly every demographic and geographic group had no health insurance in 2009. While the ACA's requirements for the individual mandate can only be changed by repealing or amending the ACA itself, provisions to expand the primary care workforce, improve clinical outcomes, reduce health care disparities, and promote wellness and prevention could be rolled back. Physicians, because they directly see the health consequences on patients of lack of health insurance, could play a crucial role in re-focusing the health reform debate on the uninsured.