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6 August 2013 Annals of Internal Medicine Tip Sheet

Below is information about articles being published in the August 6 issue of Annals of Internal Medicine. The information is not intended to substitute for the full articled as a source of information. Annals of Internal Medicine attribution is required for all coverage.

1. Poorly Controlled Celiac Disease Linked to Higher Risk for Lymphoma

Patients with Celiac disease and persistent intestinal damage have a higher risk for lymphoproliferative malignancy (LPM) than patients whose intestines have healed. Celiac is an autoimmune disease in which a reaction to gluten (a protein found in wheat, barley, and rye) causes symptoms such as diarrhea, weight loss, and iron-deficiency anemia. Several studies have found an increased risk for LMP in patients with Celiac disease. The risk for LMP decreases over time after diagnosis, presumably from the beneficial effects of following a gluten-free diet. Some patients with Celiac disease – especially those with poor adherence to a gluten-free diet -- have persistent villous atrophy, which is the erosion of the microscopic, finger-like projections that line the wall of the small intestine. Follow-up intestinal biopsies are often performed on patients with Celiac disease to evaluate whether mucosal damage or healing has occurred but current guidelines are not clear as to whether follow-up biopsies should be done routinely. Researchers studied 7,625 patients with biopsy-proven celiac disease to determine whether the presence of villous atrophy on follow-up biopsy is associated with the risk for LMP compared with the presence of mucosal healing on follow-up biopsy. The researchers found that patients with Celiac disease and persistent villous atrophy had an increased risk for LPM compared to patients with Celiac disease and mucosal healing. Patients with mucosal healing were not at increased risk compared to the general population, suggesting that mucosal healing should be a goal of Celiac disease treatment.

2. Prioritizing USPSTF Recommendations Based on Patient Characteristics May Improve Life-Expectancy

A mathematical model shows that United States Preventive Services Task Force (USPSTF) recommendations can be prioritized on the patient level to improve life-expectancy. Currently, the USPSTF makes recommendations for 60 distinct clinical services. However, only about half of these recommended services are provided to patients and utilization for some services remains very low. How to prioritize what to do in the limited time of a clinical encounter is a pervasive problem in primary care. Researchers used a mathematical model to prioritize preventive care services by examining each USPSTF recommendation in the context of a person’s risk-benefit profile and how life-expectancy could be influenced by the intervention. The model showed that the rank order of benefits varied considerably based on demographic characteristics, medical conditions, and lifestyle choices. Based on the model, a 62-year-old obese man who smoked and had high cholesterol, hypertension, and a family history of colorectal cancer would benefit most from USPSTF recommendations on tobacco cessation, weight loss, and blood pressure control. Changing or adding other characteristics influences which recommendations become a priority and their rank order. The authors of an accompanying editorial write that the model helps physicians to understand the relative importance of different interventions for a specific patient. They suggest that extending the analysis to measure for a broader set of outcomes, such as quality-adjusted life years and cost effectiveness, may be valuable. In addition, issues such as public health should also be considered.

3. Self-Monitoring Leads to Better Blood Pressure Control at 12 Months

Researchers reviewed 52 published studies to evaluate the effectiveness of self-measured blood pressure monitoring (SMBP) with or without support in adults with hypertension. SMBP is the measurement of BP at home or outside the clinical setting. The reviewers assessed three comparisons: SMBP monitoring alone versus usual care; SMBP monitoring with additional support (e.g. educational materials, web resources, nurse or pharmacist visits, and telecounseling) versus usual care; and SMBP monitoring with additional support versus SMBP monitoring with no additional support or less intense additional support. Moderate-strength evidence shows that compared to usual care, SMBP monitoring alone improves BP control at 6 months, but not at 12 months. Strong evidence suggests that SMBP monitoring with support leads to better BP control at 6 and 12 months compared to usual care. The studies included in the analysis did not show a difference between SMBP monitoring plus support versus SMBP monitoring alone or with little support. The analysis suggests that SMBP monitoring lowers BP in the short term, but its sustainability and long-term clinical effectiveness remain uncertain. The researchers conclude that more research is needed to determine the long-term benefits of SMBP monitoring.