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 firstname.lastname@example.org
Following a negative colonoscopy result at initial screening, regular follow-up with less-invasive screening tools may provide the same life-saving benefit with fewer risks for complication and at a lower cost than rescreening with colonoscopy every 10 years. Researchers used a microsimulation model to assess the effectiveness and costs of colonoscopy versus other rescreening strategies after an initial negative colonoscopy result. The model compared several rescreening interventions for persons aged 50 years who had no adenomas or cancer detected on an initial screening colonoscopy. Interventions included no further screening or rescreening with colonoscopy every 10 years, annual screening with fecal occult blood testing or fecal immunochemical testing, or computed tomographic colonography (CTC) every five years. The data showed that compared with no further screening, all rescreening strategies provided approximately the same benefit in life-years as colonoscopy every 10 years, but with fewer complications and at a lower cost. While life-years saved were similar in all intervention groups, the authors of an accompanying editorial caution that screening reduces colorectal cancer mortality because earlier-stage cancer is less likely to result in death. But highly-sensitive endoscopic screening methods like colonoscopy may be more effective in reducing cancer incidence than FOBT. The editorialists argue that if the study authors had measured for quality-adjusted life-years, they might have reached a different conclusion. They suggest that most people would likely pay more to never have colorectal cancer at all than to suffer with cancer and survive.
Patients who initiated treatment for diabetes with sulfonylureas had a higher rate of cardiovascular events and death compared to patients initiating treatment with metformin. Researchers reviewed data on 253,690 veterans initiating treatment for diabetes to compare the effects of sulfonylureas (n= 98,665 patients) and metformin (n = 155,025 patients) on cardiovascular disease (CVD) outcomes or death. They found that sulfonylurea use was associated with a 21 percent increased risk of acute myocardial infarction, stroke, or death. The researchers could not conclude whether sulfonylureas themselves are harmful, or if metformin is protective. They also could not determine if differences in patient characteristics could account for rates of cardiovascular events and death among patients taking sulfonylureas. According to the researchers, these observations support the use of metformin for first-line diabetes therapy. The author of an accompanying editorial has studied the cardiovascular outcomes associated with diabetes therapies. While observational data is useful and credible, it does not provide a definitive answer as to why sulfonylureas increase adverse cardiovascular outcomes. The author suggests that public health authorities sponsor a randomized controlled trial to provide high-quality evidence on the issue.
Low-strength evidence suggests that aerobic and aquatic exercise can reduce pain and improve function and disability for community-dwelling adults with osteoarthritis-associated knee pain. Researchers conducted a literature review of 193 published randomized, controlled trials on physical therapy interventions for community-dwelling adults with knee osteoarthritis. Interventions were analyzed for their effect on pain reduction, physical function, and disability. Physical therapy interventions reviewed included education programs, proprioception exercise, aerobic exercise, aquatic exercise, strength training, tai chi, massage, orthotics, taping, electrical stimulation, pulsed electromagnetic fields, ultrasonography, and diathermy. Few physical therapy interventions were effective at reducing knee pain or improving function and disability. The researchers found low-strength evidence that aerobic and aquatic exercise improved disability and that aerobic exercise, strength training, and ultrasonography reduced pain and improved function. Patients with high adherence to their exercise program had better outcomes, leading the researchers to conclude that therapeutic exercise programs should focus on achieving higher adherence rather than increasing the amount or intensity of exercise.