Established in 1927 by the American College of Physicians


4 October 2011 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 215-351-2653 or e-mail Angela Collom at

1. Key to Thwarting Bioterrorism Threat Lies in Clinicians’ Ability Recognize Signs

Ten Years Later, Doctor Who Identified Anthrax Case Reflects on Lessons Learned

October 2011 marks the 10th anniversary of the anthrax attacks that led to one of the largest epidemiologic and criminal investigations in U.S. history. Following the September 11th attacks, was a bioterrorism attack that used the U.S. postal service to disseminate anthrax spores to homes, businesses, government headquarters, and major newsrooms, resulting in five deaths and 21 additional confirmed or suspected cases – six of which caused serious illness. Larry M. Bush, MD, FACP, Clinical Professor of Infectious Diseases at the Charles E. Schmidt College of Medicine, Florida Atlantic University in Boca Raton, Florida was the clinician who diagnosed the first case of inhaled anthrax that resulted from this attack. A patient appeared confused and febrile in his emergency room. After examining a sample of the patient’s cerebrospinal fluid, Dr. Bush suspected anthrax and passed the sample on to additional experts for confirmation. Within 48 hours, the anthrax diagnosis was confirmed and Dr. Bush and his team notified the local health department. While initially thought to be an isolated incident, further evidence led investigators to conclude that terrorists were using the U.S. mail to disseminate anthrax in a deliberate act of bioterrorism. Since then, experts have learned that their knowledge of anthrax was outdated. They also learned many lessons about timely administration of vaccines and antibiotics in the face of a national emergency. According to the article authors, the most important lesson learned is that real-time disease recognition and swift communication to appropriate authority is crucial. Dr. Bush writes that he is often asked the question, “What made you think of anthrax?” After 10 years, the answer has remained the same, “What would have transpired if I had not?”

2. USPSTF: Behavioral-Based Treatments Are Safe and Effective for Weight Loss

Higher Intensity Equals Greater Weight Loss, Drugs Can Increase Results

Nearly one-third of Americans are clinically obese, which is associated with increased mortality, coronary heart disease, type 2 diabetes, some cancers, and many other health problems. As part of its 2003 recommendation statement, the U.S. Preventive Services Task Force (USPSTF) recommended that clinicians screen all adults for obesity and offer intensive counseling and behavioral interventions for their obese patients. In preparation for an update to the 2003 recommendations, researchers reviewed trials of obese and overweight adults undergoing behavioral interventions (38 trials), behavioral interventions plus orlistat (18 trials), or behavioral interventions plus metformin (3 trials) for weight loss. Patients prescribed behavioral interventions with at least 12 to 26 sessions during the first year lost the most weight at 9 to 15 lbs, whereas control groups lost little or no weight. Overweight patients who received orlistat plus intensive behavioral interventions lost 11 to 22 lbs compared to 7 to 13 lbs with placebo. Patients given metformin plus intensive behavioral interventions lost 4 to 9 lbs. The researchers conclude that behavioral weight-loss interventions with or without orlistat or metformin yielded clinically meaningful weight loss, especially at a higher number of counseling sessions. The researchers found minimal evidence of harms associated with behavioral counseling, but more research is needed to determine potential harms of medications for weight loss.

3. With Proper Selection and Programming, MRI Safe, Beneficial for Cardiac Device Patients

An estimated 75 percent of patients with implanted cardiac devices (pacemakers and cardioverter defibrillators) develop comorbid conditions for which magnetic resonance imaging (MRI) would aid in diagnosis. However, because of safety concerns, MRI is avoided in most patients with these devices. In this study, researchers conducted a total of 555 MRI scans on 438 patients with pacemakers (237) or defibrillators (201) while monitoring patients before, during, and after the scans. Overall, only 3 patients experienced problems with the devices and none resulted in a serious problem. The authors emphasize that patients were selected and treated based on previous safety studies. Therefore, only patients with pacemakers manufactured after 1998 and defibrillators manufactured after 2000 were enrolled, and the researchers carefully followed programming and monitoring protocol. The authors of an accompanying editorial write that the clinical benefits of MRI should be accessible to appropriate patients with ICDs. As with any important medical decision, the risks and benefits of MRI should be assessed on an individual basis.