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3 June 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 Past highlights are accessible as well.

1. Critical Care Management Associated with Higher Mortality in ICU Patients

A database review of 101,832 critically ill patients in 123 hospital intensive care units (ICUs) found that the risk of dying in hospital was higher for patients who were managed by physicians who were critical care specialists than those who were not (Article, p. 801). Patients managed by critical care specialists were generally sicker and received more procedures. However, analyses that adjusted for the tendency for sicker patients to be managed by critical care specialists still showed higher mortality among patients managed by the specialists. Authors say, their "results are surprising and completely contrary to previously published findings." They call for future studies to explore the role of protocol use, procedures, drug-resistant infections and other issues involved in care for patients in hospital ICUs. Two practicing intensivists discuss the study in an accompanying editorial (Editorial, p. 877).

2. Salmeterol Added to Inhaled Corticosteroids Did Not Alter Risk for Asthma-Related Hospitalizations

A review of 66 trials, most conducted by GlaxoSmithKline, involving a total of 20,966 participants with asthma found that the long-acting b-agonist (LABA) salmeterol combined with inhaled corticosteroids decreased the risk for severe exacerbations, but did not seem to alter the risk for asthma-related hospitalizations, deaths or intubations compared with inhaled corticosteroids alone. An accompanying editorial notes that this review "has helped to answer the question of safety of long-acting b-agonists when used with inhaled corticosteroids in an idealized clinical environment" presented by the early studies but does not "resolve the controversy over the safety of LABAs (with or without steroids) in an environment that more closely reflects actually clinical practice." The editorialist says salmeterol with an inhaled corticosteroid is not a first line treatment and should not be prescribed for people mild asthma or those who will not adhere to close monitoring.

(NOTE: This article and editorial are being released early online at They will appear in the July 1, 2008, print edition of the journal.)

3. Study Suggests that Retired Boxers Have High Rate of Pituitary Dysfunction

In this study of 61 male boxers (44 active, 17 retired) comprising the Turkish National Boxing Team, growth hormone and adrenocorticiotropic hormone deficiencies were higher than would be expected in a general population (Article, p. 827). Nearly half of retired boxers, the study participants with the longest boxing histories, had growth hormone deficiency. The authors suggest that chronic head trauma due to sports injury may be associated with pituitary dysfunction and decreased pituitary volume, and they suggest that retired boxers have their pituitary function evaluated.

4. U.S. Group Reaffirms Need for Screening for Diabetes in Adults with High Blood Pressure

The U.S. Preventive Services Task Force, in an updated recommendations statement, says that physicians should screen for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg (Article, p. 846, Review of Evidence, p. 855). The USPSTF concludes that for adults with blood pressure of 135/80 or less, evidence of the value of screening for diabetes is lacking and the balance of benefits and harms cannot be determined.

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