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FOR THE PRESS

1 April 2008 Annals of Internal Medicine Tip Sheet

Annals of Internal Medicine is published by the American College of Physicians on the first and third Tuesday of every month. These highlights are not intended to substitute for articles as sources of information. For a copy of an article, call 1-800-523-1546, ext. 2656, or 215-351-2656, or visit www.annals.org. Past highlights are accessible as well.

1. Perils of Testing: What Happens When Tests for Cervical Cancer are Normal but HPV Testing Is Abnormal?

When nearly 10,000 women were screened with Pap tests for cervical cancer and with DNA tests for high-risk human papillomavirus (HPV), 23 percent were found to be infected with high-risk HPV regardless of status on the Pap test (Article, p. 493.) HPV is considered the major cause of cervical cancer.

Prevalence was highest among women age 14 to 19 years. Importantly, 9 percent of women 30 years of age or older with normal Pap tests had high-risk HPV infection.

Authors say that the results of the study imply that many women older than 30 who have the DNA tests for HPV will require follow-up colposcopy, in which the physician directly observes the cervix under magnification.

An editorial writer cautions that we know very little about the risk of cervical cancer in women with a normal Pap test and a positive HPV test. Women over age 30 who agree to have both Pap testing and HPV testing should know that the results could disagree, placing them in a group whose risk of cervical cancer is unknown (Editorial, p. 557).

2. Treat Smoking As Any Chronic Disease and Reimburse for Therapy

Smoking is the leading cause of preventable death in the United States. The authors state that cigarette smoking is an addiction that should be viewed as a chronic disease, as are addictions to other substances. Insurers pay for life-time treatment for chronic diseases such as diabetes. Medications to prevent relapse of serious addictions such as heroin (by methadone) are provided long-term. But insurance companies often do not provide reimbursement for long-term treatment with nicotine replacement therapy, an FDA-approved treatment.

If we adopt the view that tobacco dependence is a chronic condition with severe consequences and death rates higher than those of other chronic conditions, health insurance should pay for long-term behavioral and pharmacotherapy (Perspective, p. 554).

3. Early Kidney Dysfunction Associated with Developing Hypertension

Most people with kidney disease have hypertension, but which comes first? Does kidney disease lead to hypertension, or does hypertension start the process that leads to kidney disease? A study of 2,767 people without kidney disease or hypertension in the Multi-Ethnic Study of Atherosclerosis found that about 20 percent who were initially free of hypertension developed the disease later on (Article, p. 501).

Serum cystatin C levels and urinary albumin excretion -- the most sensitive indicators of kidney dysfunction -- were associated with a statistically significant 15 percent greater incidence of hypertension. Apparently, early kidney damage triggers hypertension, rather than the other way around.


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