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7 April 2009 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. Two New Studies Suggest an Intensive Disease Management Approach to Smoking Cessation

According to two new studies being published in the April 7 issue of Annals of Internal Medicine, physicians should treat smoking as a chronic disease if they want to help their patients quit successfully. Patients may require repeated or intensive interventions that include pharmacotherapy and counseling, as well as continued dialogue with their physicians.

In the first study, researchers studied 750 primary care patients who smoked at least 10 cigarettes a day to determine which interventions worked best to help them quit. Participants were randomly assigned to pharmacotherapy (nicotine patch or bupropion), pharmacotherapy supplemented with up to two calls from trained counselors, or pharmacotherapy supplemented with up to six counseling calls. During the two-year study, patients in the high-intensity counseling group were the most successful.

“These studies show the importance of taking a disease management approach to smoking cessation,” said Edward Ellerbeck, M.D., Associate Professor and Chair of the Department of Preventive Medicine and Public Health at the University of Kansas, and lead author of the study. “We found that smokers are willing to make repeated medically-assisted attempts at quitting smoking, resulting in progressively greater smoking abstinence. Physicians should talk to their patients continually about quitting, and should facilitate access to a smoking cessation medication.”

In the second study, researchers studied 127 smokers with chronic conditions such as cardiovascular disease or COPD. The smokers were randomly assigned to receive a nicotine patch for 10 weeks (standard treatment) or a combination of a nicotine patch, a nicotine oral inhaler, and bupropion (combination treatment) for as long as required. At about six months, the patients in the combination therapy group had a success rate of approximately 35 percent. The nicotine patch group achieved a 19 percent success rate.

“Medically ill smokers are often highly addicted and at great risk for complications from continued smoking,” said Michael B. Steinberg, M.D., M.P.H., Division of General Internal Medicine, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, and lead study author. “Our trial demonstrates that intensive treatment with a triple combination of medications could work well for them.”

Both studies suggest that continued, intensive interventions could be the key to helping patients quit successfully, even if they’ve tried to stop unsuccessfully in the past.

2. Colorectal Cancer Screening Should Target Healthier Older Patients

Current colorectal cancer screening guidelines recommend that screening efforts focus on older adults who can expect to live at least four years. However, researchers found that in practice, doctors do not consistently consider life expectancy and comorbid conditions when they recommend screening. Researchers reviewed records for 27,068 patients in Veterans Affairs (VA) medical centers in four U.S. cities. Each patient was 70 years or older and had an outpatient screening visit at one of the four VA medical centers in 2001 or 2002. In this population of elderly men, screening did not target healthier patients. In fact, severely ill patients were screened almost as frequently as healthy ones. The authors suggest cancer screening guidelines should be more explicit about which combinations of age and comorbidity identify older patients who have substantial life expectancies and those who are likely to die within five years. Clinicians and older patients could then make informed decisions about the risks and benefits of screening.

3. LDL Particle Concentration May Help Predict Heart Attack Risk, Independent of Other Lipid Measurements

A critical component of lowering the cardiovascular disease burden across the population is identification and aggressive treatment of high-risk individuals. Traditional risk factors for heart attack include elevated low-density lipoprotein (LDL) cholesterol concentrations, reduced high-density lipoprotein (HDL) cholesterol concentrations, cigarette smoking, hypertension, family history, and older age. Medical research has focused on finding additional diagnostic criteria that could improve cardiovascular disease prediction. Researchers reviewed 24 published studies that reported relationships between LDL subfractions and cardiovascular outcomes. Higher LDL particle concentration is consistently associated with increased risk for cardiovascular disease, independent of other lipid measurements. However, LDL subfraction measurement methods were inconsistent across laboratories. The researchers found insufficient evidence that adding the test for particle number to traditional cardiovascular risk factor measurements was worthwhile, at least not until laboratories adopt a standardized way to measure particle number.

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