Established in 1927 by the American College of Physicians


3 December 2013 Annals of Internal Medicine Tip Sheet

Below is information about articles being published in the September 17 issue of Annals of Internal Medicine. The information is not intended to substitute for the full article as a source of information. Annals of Internal Medicine attribution is required for all coverage.

1. Evidence suggests that “healthy and overweight” is a myth

A systematic review and meta-analysis of observational studies published from 1950 until 2013 suggests that there is no such thing as being healthy and overweight, according to an article published in Annals of Internal Medicine ( Persons in the same BMI category can have varied metabolic features, such as lipid profile, glucose tolerance, blood pressure, and waist circumference. Some obese individuals have normal metabolic features, despite their increased body fat. This profile has been described as “benign obesity” or “metabolically healthy obesity.” Similarly, some normal-weight individuals may have adverse metabolic features, despite having a healthy BMI. Researchers reviewed published research to assess the association between metabolic status and all-cause mortality and cardiovascular events in normal-weight (BMI, 18.5 to 25 kg/m2), overweight (BMI, 25 to 30 kg/m2), and obese adults. The research showed that metabolically healthy obese individuals were at increased risk for death and cardiovascular events over the long term compared with metabolically healthy normal-weight persons, suggesting that increased BMI without metabolic abnormalities is not a benign condition. The research also showed that regardless of BMI category, metabolically unhealthy individuals had increased risk for events compared with healthy normal-weight individuals. The researchers conclude that both BMI and metabolic status should be considered when evaluating an individual’s health risks. The authors of an accompanying editorial ( write that recognizing that there is no level of healthy obesity is the first step. Next, physicians need to focus on treating obesity as any other chronic disease that requires long-term attention.

2. American College of Physicians recommends tighter transfusion strategy to treat anemia in patients with heart disease

New ACP guideline presents evidence-based recommendations for treating anemia in patients with heart disease

Red blood cell (RBC) transfusions in patients with heart disease should be restricted to those individuals with severe anemia, the American College of Physicians (ACP) recommends in a new clinical practice guideline ( published in Annals of Internal Medicine, ACP’s flagship journal. ACP also recommends against using erythropoiesis-stimulating agents (ESAs) in patients with mild to moderate anemia and congestive heart failure (CHF) or coronary artery disease (CHD) because the harms, including increased risks of thromboembolic events and stroke rates, outweigh the benefits. Approximately one-third of patients with CHF and 10 to 20 percent of patients with CHD have anemia, which is associated with poor outcomes. It is unclear if treatments such as RBC transfusions, ESAs, and iron replacement improve outcomes. Emerging evidence shows short term benefit of one form of intravenous iron in patients with CHF and low ferritin (less than 100), but ACP found evidence lacking on long-term outcomes. Additionally, the effect of oral iron and how it compares to intravenous iron for treating anemic patients with heart disease is unknown. ACP’s guideline also includes advice to help physicians practice high value care. Annals of Internal Medicine published a summary for patients (

3. Chickenpox vaccination not responsible for increased incidence of shingles

There is no evidence that the childhood varicella (chickenpox) vaccination program is responsible for the increased incidence of herpes zoster (shingles) in older adults in the U.S., according to an article published in Annals of Internal Medicine ( Herpes zoster incidence has been on the rise among U.S. adults. This is a concern because herpes zoster is a serious illness that causes a rash and persistent pain that can last up to 90 days or more. There has been concern that universal varicella vaccination of U.S. children has prevented adults from getting the immunity benefits of external exposure to varicella zoster virus, but this connection has not been proven. Researchers reviewed Medicare claims for more than 2.8 million patients from 1992 through 2010 to determine whether the varicella vaccination program has influenced trends in herpes zoster incidence in the U.S. population older than 65 years. The data showed that the age-specific increase in herpes zoster incidence began before 1996, which is when the childhood varicella vaccination program was introduced. Also, the prevalence of herpes zoster did not vary by state vaccination coverage, nor did the mean age of herpes zoster diagnosis decrease during the study, which could be expected if external boosting helped to maintain protection. The authors cannot explain the increase in herpes zoster incidence in older adults, but suggest that wider use of herpes zoster vaccination should be employed in this population.

Also in Annals of Internal Medicine:

Texting While Doctoring

Texting while driving is associated with a 23-fold increased risk for crashing. Could texting while doctoring – that is, typing into electronic health records while seeing patients – pose similar risks? The authors of an Ideas and Opinions piece in Annals of Internal Medicine argue that physicians multitasking in the exam room is damaging the doctor-patient relationship (

The Mark of a Cane

In this On Being a Doctor personal essay published in Annals of Internal Medicine, the author discusses what happens in clinical practice when the aging patient still regards himself as young and healthy. The challenge for the physician is to help the patient redefine himself and accept help. In this case, the physician gently helps the patient realize that he is someone who needs a cane (