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Embargoed news from Annals of Internal Medicine

Annals of Internal Medicine tip sheet for June 7, 2011

American College of Physicians

1. Smoking, Even for a Short Time, Significantly Increases a Woman's Risk for Peripheral Artery Disease

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A prospective study of initially healthy women aged 45 and over found that smoking is a potent risk factor for symptomatic peripheral artery disease, or PAD. PAD is a serious, often debilitating disorder, caused by narrowing of the arteries in the lower extremities. Symptoms of PAD include pain in the legs with normal activity and a feeling of tiredness in the leg muscles.

Researchers followed 38,825 women for an average of 12.7 years to determine if smoking increased a woman's risk for PAD and if smoking cessation reduced that risk. The women were questioned about their smoking history and if they currently smoked cigarettes. If so, they were asked to disclose how many they smoked per day. During the course of the study, patients periodically filled out questionnaires about their health and smoking habits. Surveys were given twice during the first year and then once per year for the remainder of the study and follow-up period. Participants were asked to report any symptoms of PAD.

The researchers found that smoking increased a woman's risk for PAD 10-fold. Smoking cessation reduced the risk, but even after abstaining from cigarettes for 20 years, the risk did not lower to that of a woman who had never smoked.

"This study showed that--as has been previously shown for heart attacks and for lung cancer--that smoking is actually very harmful for the development PAD," said Eruna Pradhan, Assistant Professor of Medicine at Harvard Medical School and an author of the study. "This is significant because PAD is a disease that not only causes a lot of pain and discomfort with usual, daily activities but it also increases the risk of heart attack."

2. National Institute of Health and Clinical Excellence Outlines Guidelines for Preventing Delirium in the Clinical Setting

Delirium is a common disorder characterized by a recent onset of symptoms related to impaired cognitive function. In addition to causing stress to patients and families, delirium increases health care costs due to longer hospital stays and the need for long-term care. With this issue in mind, the National Institute of Health and Clinical Excellence (NICE) developed guidelines for preventing delirium in patients 18 years or older in a clinical setting. The NICE multidisciplinary guideline development group - which consisted of physicians, psychiatrists, specialist nurses, a care home manager, and patients - posed review questions, discussed evidence, and formulated recommendations which were opened for public and stakeholder comment prior to finalization. The guideline group made 13 specific recommendations that addressed the stability of the care environment and the provision of a multicomponent intervention package tailored for persons at risk for delirium. The intervention package included assessment and modification of factors that may precipitate delirium, including cognitive impairment or disorientation, dehydration or constipation, hyupoxia, infection, immobility or limited mobility, taking several medications, pain, poor nutrition, sensory impairment, and sleep disturbance. A complete list of recommendations can be found at (link goes live on June 6 at 5:00 p.m. ET). In a related editorial, Annals editor, Christine Laine, MD, MPH, summarizes the Institute of Medicine's Proposed Standards for a Trustworthy Guideline to help readers discern which guidelines they should trust. Dr. Laine and her co-authors believe that high-quality practice guidelines promote excellence in care, which is why Annals is eager to publish guidelines that meet the rigorous IOM standards.

3. Cancer Care at VHA Similar or Better Than Care at Fee-for-Service Medicare

Studies have suggested that the Veterans Health Administration (VHA) - the largest integrated health care system in the U.S. - provides better preventive care and treatment for some chronic illnesses than the private sector. To assess quality of cancer care for older patients provided by the VHA versus fee-for-service Medicare, researchers compared treatment of older male patients with colorectal, lung, prostate, or hematologic cancer. Researchers found that care in the VHA population was generally similar to or better than care in the private-sector population. Patients in the VHA system had higher rates of curative resection for colon cancer, recommended chemotherapeutic regimens for hematologic neoplasms, and bisphosphonate use for multiple myeloma. Sensitivity analyses suggests that if veterans are truly sicker than persons in the private sector, the findings might actually underestimate the quality of care provided in VHA. The only process measure on which VHA patients had lower scores than Medicare patients was in the use of 3-dimensional conformal radiation therapy versus intensity-modulated external-beam radiation therapy for prostate cancer, suggesting that the VHA may be slower to adapt newer technologies.

4. Early Release: For Localized Prostate Cancer, Insufficient Evidence to Compare Effectiveness of Radiation Treatments to No Treatment

Radiation therapy is one of many treatment options for patients with prostate cancer. To update findings about the clinical and biochemical outcomes of radiation therapies for localized prostate cancer, researchers reviewed 75 studies (10 randomized controlled trials and 65 nonrandomized comparative studies). Their review found insufficient evidence on patient survival to draw definitive conclusions about the effectiveness of radiation treatments for localized prostate cancer compared to no treatment or no initial treatment. Similarly, there was insufficient evidence to determine whether certain forms of radiation treatment were more effective than others. The studies analyzed inconsistently defined and reported outcomes.


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