Annals of Internal Medicine Tip Sheet Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information.
1. American College of Physicians updates policy recommendations for reducing gun-related injuries and deaths in the U.S.
Abstract: http://annals.org/aim/article/doi/10.7326/M18-1530URLs go live when the embargo liftsThe American College of Physicians (ACP) has updated its policy recommendations for reducing gun-related injuries and death in the United States. The new policy recommendations build on, strengthen, and expand on current ACP policies based on thorough analysis of newly available evidence. Reducing Firearm-Related Injuries and Deaths in the United States is published in Annals of Internal Medicine.
The United States has the highest firearm-related mortality rate among industrialized nations. ACP believes that a comprehensive, multifaceted approach is necessary to reduce this epidemic of gun violence and that physicians play a vital role. The nine recommendations from ACP cover a range of important issues from supporting background checks to increasing funding for firearm-related research.
Principal among ACP's nine strategic imperatives is the recommendation to approach firearm safety as a public health issue so that policy decisions are based on scientific evidence. As such, ACP strongly suggests that physicians speak to their patients about firearm safety whenever risk factors are present. Physicians can take a public pledge to engage in this type of discussion with their patients at http://annals.org/aim/fullarticle/2658284/what-you-can-do-stop-firearm-violence.
To update its policy position, ACP's Health and Public Policy Committee looked for gaps in policy and existing positions that needed to be strengthened, clarified, or expanded on the basis of emerging research and new initiatives on which ACP did not have clear policy. Many positions from 2014 were still relevant and did not need to be revisited. The authors focused solely on evidence related to the new or modified recommendations and reviewed all available sties, reports, and surveys related to firearm violence.
Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview someone from ACP, please contact Julie Hirschhorn at jhirschhorn@acponline.org.
2. Americans underestimate the relative frequency of firearm-related violent deaths
Abstract: http://annals.org/aim/article/doi/10.7326/M18-1533Editorial: http://annals.org/aim/article/doi/10.7326/M18-2846Editorial: http://annals.org/aim/article/doi/10.7326/M18-2756URLs go live when the embargo liftsMost Americans underestimate the relative frequency of firearm-related violent deaths in their state and may, therefore, underestimate their own risk. Findings from a brief research report are published in Annals of Internal Medicine.
Researchers from the University of Washington and Harvard and Northeastern Universities used data from the National Firearms Survey to describe public misperceptions about the relative frequency of violent death by intent (homicide vs. suicide) and means at the national level. The researchers found that suicide was more common than homicide in all states, and suicide by firearm was more common than homicide by firearm in all states except Illinois, Maryland, and New Jersey. However, most U.S. adults - including health care professionals - did not identify the most frequent intent and means of violent death in their state.
According to the researchers, the public's misperception of the relative frequency of gun deaths may be leading them to underestimate their own risk. Correcting misperceptions may make persons more cognizant of the actual risks to themselves and their family, thus creating more opportunities for prevention. This should include encouraging providers to engage in conversations with their patients about gun safety more often.
Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Erin R. Morgan, MS, please contact Annie Pellicciotti at apell@uw.edu.
3. Gastric bypass most effective for weight loss among common bariatric procedures
Abstract: http://annals.org/aim/article/doi/10.7326/M18-2786Editorial: http://annals.org/aim/article/doi/10.7326/M18-2819URLs go live when the embargo liftsA study from PCORnet, funded by the Patient-Centered Outcomes Research Institute (PCORI), the largest to date of bariatric surgery, found that gastric bypass leads to greater weight loss at 1, 3, and 5 years compared with gastric sleeve and adjustable gastric banding. According to the authors, this data is important because it can help to inform treatment and insurance coverage decisions. Findings from this comparative effectiveness study are published in Annals of Internal Medicine.
Severe obesity affects more than 15 percent of U.S. adults. It is widely believed that bariatric surgery is the most effective way to treat severe obesity, as it induces long-term weight loss. However, less is known about how well the different types of bariatric compare.
Researchers from Kaiser Permanente Washington Health Research Institute, University of Pittsburgh, and other centers studied electronic health record data from 41 geographically-diverse healthcare systems in 11 PCORnet clinical data research networks to compare weight loss and safety among bariatric procedures. They assessed data on more than 46,000 clinically obese patients who were treated with one of the three most common bariatric procedures performed in the U.S.: gastric bypass; sleeve gastrectomy; or adjustable gastric banding. The data showed that patients who had gastric bypass lost the greatest amount of weight, followed by gastric bypass, and then adjustable gastric banding. The researchers noted that sleeve gastrectomy was an effective option. Patients who underwent gastric bypass lost 31 percent of their weight at the first year and maintained 25 percent of their loss at 5 years. Patients who had sleeve gastrectomy lost 25 percent of their pre-surgery body weight at 1 year and maintained 19 percent weight loss at 5 years.
The authors of an accompanying editorial from the University of Texas Southwestern Medical Center suggest that lack of data on comorbidity-specific outcomes makes it difficult to directly assess the clinical importance of the differences in weight-loss observed for the three procedures. The researcher team is continuing to study this. In addition, cohort attrition creates the potential for systematic bias regarding long-term weigh loss. However, the authors note that this important study is just the start of potential actionable information available from PCORnet.
Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, David Arterburn, MD, MPH, please contact Heather Platisha, Heather.Platisha@creation.io.
4. DOACs as safe and effective as warfarin for patients with afib
Abstract: http://annals.org/aim/article/doi/10.7326/M18-1523URLs go live when the embargo liftsDirect-acting oral anticoagulants (DOACs) are at least as effective and safe as warfarin for patients with nonvalvular atrial fibrillation. The medications also had similar benefits across several patient subgroups and seemed safe and efficacious for a wide range of patients with nonvalvular atrial fibrillation. Findings from a comparative effectiveness study were published in Annals of Internal Medicine.
Patients with atrial fibrillation have increased risk for embolic stroke, heart failure, and cognitive impairment. Oral anticoagulation with vitamin K antagonists (VKAs), such as warfarin, have been a standard for stroke prevention but are difficult to monitor and are associated with adverse food and drug interactions. DOACs, such as dabigatran and apixaban, rivaroxaban, and edoxaban, are approved to treat atrial fibrillation, but it is not clear if they are as effective or safe as warfarin for preventing stroke.
Researchers from Duke Clinical Research Institute reviewed 117 published studies to compare DOACs with warfarin in preventing thromboembolic events and bleeding complications. They found that the four available DOACs are at least as effective and safe as warfarin for patients with nonvalvular AF. Dabigatran is superior to warfarin in preventing stroke or systemic embolism. Apixaban is also superior to warfarin in preventing stroke or systemic embolism, and also has less risk for major bleeding. These findings provide evidence for the safety and efficacy of DOACs in treatment of patients.
This systematic review updates previous reviews comparing DOACs with warfarin.
Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Gillian Schmidler, PhD, please contact Susan Landis at susan.landis@duke.edu.
5. On-demand sildenafil may be an effective treatment for Raynaud phenomenon
Abstract: http://annals.org/aim/article/doi/10.7326/M18-0517URLs go live when the embargo liftsOn-demand sildenafil may be an effective treatment for Raynaud phenomenon, a condition that causes restricted blood flow to the extremities in response to cold or emotional stress. Findings from a series of n-of-1 trials are published in Annals of Internal Medicine.
Primary Raynaud's phenomenon effects up to 6 percent of the general population and many patients are not willing to receive daily long-term treatment. Since identifying a trigger for attacks, like exposure to cold, may be difficult for many patients know when their attacks occur, researchers believe that on-demand single doses of vasodilators before or during exposure to cold may be a safe and effective approach to therapy.
Researchers from Universite Grenoble Alpes and Grenoble Alpes University Hospital in Grenoble, France, conducted a series of randomized, double-blind, n-of-1 trials on patients with primary or secondary Raynauld's. This original approach allowed individual evaluation of the efficacy of different doses on the frequency and severity of Raynaud's and frequencies. The findings suggest that sildenafil at 40 mg or 80 mg was about 90 percent likely to be more effective than placebo for all outcomes. However, heterogeniety was important and clinically relevant efficacy was observed in about one third of patients.
Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Matthieu Roustit, PharmD, PhD, please email him directly at MRoustit@chu-grenoble.fr.
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Also in this issue: Clinical Outcomes Associated With Sickle Cell TraitRakhi P. Naik, MD, MHS; Kim Smith-Whitley, MD; Kathryn L. Hassell, MD; Nkeiruka I. Umeh, BA; Mariane de Montalembert, MD, PhD; Puneet Sahota, MD, PhD; Carlton Haywood Jr., PhD; Jean Jenkins, PhD, RN; Michele A. Lloyd-Puryear, MD, PhD; Clinton H. Joiner, MD, PhD; Vence L. Bonham, JD*; Gregory J. Kato, MD*Systematic ReviewAbstract: http://annals.org/aim/article/doi/10.7326/M18-1161
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Annals of Internal Medicine