Established in 1927 by the American College of Physicians


5 April 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. Long Working Hours Can Help Predict Heart Disease Risk

Physicians often use the Framingham risk model to determine a patientís 10-year risk for developing coronary heart disease, or CHD. The Framingham model includes factors such as lipid levels, blood pressure, and smoking habits, but does not take into account psychosocial factors such as stress at work. Researchers studied 7,095 civil service workers between the ages of 39 and 62 who showed no signs of CHD at a baseline medical examination conducted between 1991 and 1993. The patients were then screened for CHD every five years until 2004. Researchers used information from the medical screenings along with hospital data and registry linkage to determine the rate of coronary death and nonfatal myocardial infarction for each patient. They found that adding information about working hours to the Framingham risk model modestly improved prediction of those who would develop CHD. Adults reporting workdays of 11 hours or longer had a 67 percent higher relative risk for CHD than those working 7 or 8 hours a day.

2. Self-Managing Anticoagulant Treatment Can Significantly Lower Death, Bleeding Risks

Many common conditions require long-term treatment with the anticoagulant, warfarin. Warfarin has many unique characteristics that make it difficult for physicians to predict optimal dosing. To maintain an appropriate protime international normalized ratio, or INR (a measure of the time it takes for blood to clot), patients need to make frequent visits to anticoagulation clinics or physiciansí offices to have their dose adjusted. Portable devices are now available to measure INR values. Researchers reviewed 22 randomized controlled trials published between 1966 and 2010 to determine whether patient self-testing alone or in combination with self-adjustment of doses is associated with a reduction thromboembolic complications and mortality without an increase in major bleeding events. The researchers found that self-monitoring or self-adjustment resulted in superior patient outcomes compared with clinical care. Self-care patients had a 26 percent lower risk for death and a 42 percent reduction in major thromboembolism, without any increased risk for a major bleeding event. However, the author of an accompanying editorial cautions that the studies included in the analysis were highly selective in determining eligibility for home-monitoring. The older, weaker, and sicker patients either withdrew from studies or were excluded. In addition, self-care is much more expensive than clinical care. Therefore, self-management of anticoagulant therapy should be reserved for highly-motivated patients.

3. USPSTF Reaffirms Recommendations for Testicular Cancer Screening

Screening Should be Reserved for Men with Symptoms of Testicular Cancer

The USPSTF reviewed research on screening for testicular cancer published since 2004 to update its previous recommendation on the benefits and harms of screening. The researchers found no new studies showing that males who found their testicular cancer during screening had better outcomes than those who developed symptoms or discovered a lump. The USPSTF still recommends that physicians do not screen males who have no symptoms of testicular cancer. The researchers caution that these recommendations apply only to men without symptoms. Men who notice a lump or pain in the testis should visit a doctor to have these symptoms evaluated.

4. Early Release: Annals Publishes Updates on the Yearís Most Important Studies Affecting the Practice of Internal Medicine

Annals of Internal Medicine is publishing several articles summarizing some of the most important studies of 2010 in the fields of cardiology, endocrinology, hematology and oncology, nephrology, pulmonary/critical care medicine, rheumatology, and womenís health. All of the updates can be accessed online at Studies highlighted in the updates were chosen for a variety of factors, including novelty, quality, and potential impact on clinical practice. Updates in each subspecialty include articles on a variety of relevant topic areas. Highlights include the following:

The author summarized 10 cardiology articles published in 2010 that had significant clinical implications. Discoveries were particularly noteworthy in the fields of ionizing radiation procedures, genetic testing, and lifestyle changes that affect cardiovascular risk.

The author summarized 9 articles covering a range of important findings on topics related to endocrinology. Topics areas highlighted include calcium and bone metabolism, diabetes and metabolism, obesity, male hypogonadism, and thyroid hormone levels.

Hematology and Oncology
There were several articles published in 2010 that the authors considered particularly relevant to practicing internists. The authors selected four articles in the field of hematology and nine in the field of oncology. In oncology, the authors highlighted evidence showing that some commonly used medicines may reduce the frequency of some cancers.

According to the authors, 2010 was a landmark year in nephrology. The researchers summarized what they identified as the 10 most clinically important studies addressing seven key areas of nephrology: hypertension, nephrolithiasis, chronic kidney disease, dialysis, transplantation, and acute kidney injury.

Pulmonary/Critical Care Medicine
In pulmonary medicine, researchers cited six trials that provide insight into the management of patients with lung disease. In critical care medicine, the researchers selected six studies that provided new information about caring for critically ill patients.

The author summarized eight articles that are likely to affect practice or lead to larger-scale trials. Articles summarized include two on the potential harms of calcium supplements and fructose-rich beverages.

Womenís Health
The authors summarized 10 articles in the area of womenís health. Topic areas included osteoporosis, calcium and vitamin D supplementation, menopause hormone therapy, heredity and breast and ovarian cancers, cervical cancer, and emergency contraception.