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15 February 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 acollom@acponline.org.

1. Obesity and Knee Osteoarthritis Significantly Cut Quality and Duration of Life

With obesity and life expectancy on the rise in the United States, knee osteoarthritis has become an increasingly prevalent problem. Researchers used a comprehensive computer model to assess the effect of obesity and knee osteoarthritis on remaining duration and quality of life among persons aged 50 to 84 years. Additionally, the researchers sought to determine the health benefits of reducing obesity prevalence in the United States to the level it was 10 years ago. According to the researchersí model, 40 percent of the 86 million Americans in the 50 to 84 age range have osteoarthritis, are obese, or both. Obesity reduces duration and quality of life by 12 percent and osteoarthritis by about 12 percent, suggesting that measures need to be taken to prevent and treat these conditions. The researchers found that black and Hispanic women had disproportionately high losses due to obesity and knee osteoarthritis, thus underscoring the need for prevention and treatment strategies specifically tailored to patient gender and race. The model suggested that reversing obesity prevalence to levels seen 10 years ago would avert hundreds of thousands of cases of knee replacements in addition to other diseases such as heart disease and diabetes and would increase life expectancy.

2. Patient Race, Other Personal Characteristics Determine Intensity of Care at End of Life

There is great variability in the intensity and cost of care near the end-of-life, but the characteristics that explain this variability are not well understood. Researchers studied Medicare records for 2,394 patients aged 65 and older to determine how regional and patient-level characteristics influence medical expenditures at end of life. The researchers found that while regional differences (number of hospital beds per capita, local or institutional patterns of care, physician practice patterns, etc.) in care intensity exist, a larger proportion of overall care variation is driven by differences in patient characteristics. Decline in functional status, minority race and ethnicity, certain chronic conditions, and the lack of nearby family support were associated with higher expenditures, accounting for approximately 10 percent of the variability in end-of-life care. According to the author of a corresponding editorial, ineffective communication may lead to some patients receiving more intensive care than they would choose if adequately informed about the benefits and harms associated with intense end-of-life care.

3. New Guideline from American College of Physicians: Use of Intensive Insulin Therapy for the Management of Glycemic Control in Hospitalized Patients

Recommendations are departure from current practice

Poorly controlled hyperglycemia is associated with increased illness, death, and worsening health outcomes in hospitalized patients. While most doctors make efforts to prevent and control hyperglycemia in hospital settings, the use of intensive insulin therapy and optimal blood glucose range to target in hospitalized patients has been uncertain. The Clinical Guidelines Committee of the American College of Physicians (ACP) analyzed published evidence to determine the appropriate use of intensive insulin therapy for the management glucose levels in hospitalized patients. Based on their review, ACP recommends that physicians not use intensive insulin therapy to strictly control blood glucose in non-surgical intensive care unit (SICU) or non-medical intensive care unit (MICU) patients with or without diabetes. ACP also recommends not using intensive insulin therapy to normalize blood glucose in SICU or MICU patients with or without diabetes. If insulin therapy is used in SICU or MICU patients, physicians should target a blood glucose level of 140 to 200 mg to avoid hypoglycemia.

Early Releases:

4. Cardiac Resynchronization Therapy Safe and Effective for Patients with Less Symptomatic Heart Failure

Cardiac resynchronization therapy (CRT) has been shown to reduce morbidity and mortality in patients with advanced heart failure (HF) symptoms. In an update to their previous review, researchers studied data from 25 published randomized controlled trials with a total of 9,082 patients to determine if CRT also benefits less symptomatic heart patients. All-cause mortality was the primary end point for the study, but the researchers also looked at HF hospitalizations, quality of life, and functional outcomes. They found that CRT is beneficial for patients with reduced left ventricular ejection fraction (the percentage of blood pumped during each contraction) symptoms and prolonged QRS (time between heart beats), regardless of NYHA class (measurement of severity of HF symptoms). They concluded that CRT improves left ventricular ejection fraction and reduces all-cause mortality and HF hospitalizations in patients with less severe disease, supporting the expansion of indications for CRT.

5. Atazanavir/Ritonavir Combo has Similar Virologic Efficacy to Efavirenz When Used as Part of a Three-Drug Regimen for Initial Treatment of HIV-1

Current treatment guidelines for initial treatment of HIV-1 recommend two nucleoside reverse transcriptase inhibitors (NRTIs) with either a non-NRTI (NNRTI), ritonavir-boosted protease inhibitor (PI) or integrase inhibitor. Limited data compare atazanavir/ritonavir and efavirenz, which are once-daily options for inclusion in initial therapy of human immunodeficiency virus type 1 (HIV-1). Researchers randomly assigned 1,857 patients over the age of 16 to take either atazanavir/ritonavir or efavirenze with either of the following combinations abacavir/lamivudine or tenofovir DF/emtricitabine HR. The researchers' analysis showed that atazanavir/ritonavir and efavirenz-based regimens had -similar virologic efficacy. The safety and tolerability endpoints were lower among those assigned to atazanavir/ritonavir than efavirenz when combined with abacavir/lamivudine, but were the same when combined with tenofovir DF/emtricitabine. The study authors suggest that these results be taken into consideration when clinicians select initial treatment regimens for patients with HIV-1 infection.