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15 October 2013 Annals of Internal Medicine Tip Sheet

Below is information about articles being published in the September 17 issue of Annals of Internal Medicine. The information is not intended to substitute for the full article as a source of information. Annals of Internal Medicine attribution is required for all coverage.

1. President Taftís letters to his physician show emerging modern approach to treating obesity

Correspondence between President William H. Taft, one of the first public figures in U.S. history to be defined popularly in terms of his obesity, and his physician, Nathaniel E. Yorke-Davies, provide a rare glimpse into the history of the obesity experience in the United States. At 314 pounds, Taft wrote to English diet expert Yorke-Davies because he thought weight loss could alleviate uncomfortable symptoms (heartburn, indigestion, fatigue, and restless sleep) and help him become a better civil servant. Yorke-Davies replied with a detailed diet plan that included permitted and forbidden foods, the time of day at which to eat them, and instructions on how to document and report his progress to his physician. Over the course of 10 years, Taft wrote to Yorke-Davies at least weekly, providing candid, intimate details of his food intake, physical activity, and bowel habits. Yorke-Daviesí letters reveal an approach to obesity management focusing on continued patient-physician contact, long-term adherence to physician recommendations, and patient accountability. Taft was able to lose 60 pounds while following York-Daviesí plan, but his weight struggles influenced public opinion. Taftís letters began at the time in history when weight emerged as a measure of a personís ability to lead and succeed in the modern United States of America.

2. Lifestyle changes can prevent diabetes in high-risk patients

A review of published evidence found that comprehensive lifestyle changes can reduce the incidence of type 2 diabetes in high-risk patients. Evidence was not strong enough to determine if patients already diagnosed with type 2 diabetes could benefit from such interventions. Researchers reviewed available research to assess the effects of comprehensive lifestyle interventions in the prevention of diabetes in adults who have been identified as high-risk (having metabolic syndrome or prediabetes) and the prevention of diabetic complications in adults diagnosed with type 2 diabetes. All lifestyle interventions studied for both groups included a diet and exercise component and were supported by individual, group, and/or telephone counseling. Other lifestyle interventions included a smoking cessation course, regular blood glucose and blood pressure monitoring, and stress management. The research suggests that lifestyle changes can decrease the incidence of type 2 diabetes in high-risk patients. There was no evidence that lifestyle interventions could reduce all-cause mortality in patients already diagnosed with diabetes and insufficient evidence to suggest a reduction in disease-related complications in these patients.

3. Unruptured brain aneurysms are common, but few cause harm

Undetected, unruptured cerebral aneurysms (UCA) are prevalent, but may not be clinically significant. A brain aneurysm is a weak spot on a blood vessel in the brain that fills with blood and bulges. Only a small percentage of aneurysms cause complications or rupture. Since ruptures can be catastrophic and have high mortality and morbidity rates, doctors have an interest in finding ways to detect aneurysms and figure out which ones present a potential risk to the patient. Researchers used three-dimensional time-of-flight magnetic resonance angiography (3D-TOF MRA) to screen 4,813 Chinese adults aged 35 to 70 for brain aneurysm. Three radiologists who were blinded to patient information identified the location and size of UCAs and estimated the overall and age-and sex-specific prevalence. UCAs were present in approximately 7 percent of the adults studied, but only about 8.7 percent of the aneurysms were thought to be at risk for rupture based on their size, shape, and location. UCAs were more common in women, and prevalence in both sexes increased with age.

4. Administrative data too subjective to provide a reliable basis for hospital comparisons

Administrative-reported rates of hospital-acquired pressure ulcers (HAPUs) may not be a reliable measure of hospital performance. The Centers for Medicare & Medicaid Services require hospitals to make rates of hospital-acquired conditions (HACs) publicly available. A hospitalís total HAC score includes a HAPU measure generated from administrative data. Accurate measurement is important because under the Patient Protection and Affordable Care Act, hospitals with the highest HAC rates will be financially penalized. To assess the validity of the measurement, researchers compared HAPU rates generated by administrative data to those generated from direct surveillance. Direct surveillance revealed that administrative data frequently misclassified hospitals as having high or low HAPU rates relative to others. The authors of an accompanying editorial write that the problem with the care and documentation of pressure ulcers is that physicians have limited knowledge of this particular clinical issue. The authors suggest that all providers learn pressure ulcer assessment and terminology. Until then, administrative data alone may not be an appropriate method for comparing hospitals by HAPU rates for public reporting or financial penalty.