Established in 1927 by the American College of Physicians


16 August 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

1. Chinese Herb Works as Well as Oseltamivir for Shortening Flu Duration

The antiviral, oseltamivir has been used to reduce severity of and mortality from H1N1 influenza. In rural China, where there is limited access to medications such as oseltamivir, traditional Chinese medicine has been used to treat seasonal flu. To compare the efficacy and safety of oseltamivir and maxingshigan-yinqiaosan (a Chinese herbal remedy) for treating uncomplicated H1N1 influenza, researchers assigned 410 young adult patients in 11 Chinese hospitals to receive either oseltamivir alone, oseltamivir plus maxinghigan-yingiaosan, maxinghigan-yingiaosan alone, or no treatment for five days. Fever resolved sooner in all three therapeutic groups compared with the group that received no treatment. Among patients with mild H1N1 infection, the Chinese herb maxingshigan-yinqiaosan can be used as an alternative treatment to oseltamivir.

2. Underlying Medical Conditions, Not Delayed Surgery, to Blame for Poor Outcomes in Hip Fracture

Generally accepted clinical practice guidelines recommend surgery within 24 hours after hip fracture. However, for some vulnerable or otherwise compromised patients, a delay in surgery is necessary. The literature is not clear on whether delayed surgery leads to poor outcomes. To assess the effect of surgical delay on outcomes according to the cause of delay, researchers studied health records for 2,250 consecutive elderly patients with hip fracture. The researchers measured the time to surgery, reasons for surgical delay, adjusted in-hospital death, and risk for complications. Although there were some associations between very delayed surgery (>120 hours) and poor outcomes, shorter operative delays were not associated with in-hospital mortality or medical complications after adjustment for acute medical conditions. The authors conclude that medical conditions that lead to the delay rather than the delay itself may account for poor outcomes in patients with hip fracture. According to the author of an accompanying editorial, because of the multiple care settings involved, hip fracture can serve as a model for patient-centered medical care. The author describes five critical elements that should be addressed before or around surgery to improve outcomes: 1) surgery should take place as soon as possible to reduce patient pain and hospital costs; 2) any clinical abnormalities should be addressed prior to surgery; 3) care plans should be made for anticoagulation therapy, early catheter removal, early mobilization, and physical therapy; 4) pain management should be considered; and 5) steps should be taken to create seamless transitions across care settings.

3. USPSTF Updates Bladder Cancer Screening Recommendations

No Evidence to Support Screening in Asymptomatic Adults

Bladder cancer is the seventh-leading cause of cancer deaths. In an update to its 2004 recommendation statement on screening for bladder cancer, the U.S. Preventive Services Task Force (USPSTF) changed its recommendation from a D (lack of evidence) to an I statement (insufficient evidence). Researchers reviewed new evidence on the benefits and harms of screening, the accuracy of tests that can be performed in primary care, and the benefits and harms of treatment. They found inadequate evidence that screening for bladder cancer in asymptomatic adults results in improved disease-specific morbidity or mortality. In addition, screening may result in false-positives that lead to anxiety, pain, and additional complications. The researchers conclude that there is insufficient evidence to weigh the benefits of screening for bladder cancer in primary care against potential harms.

4. Updated NICE Guidelines Not so Fast to Recommend Echcardiography in All Patients

The United Kingdom’s National Institute for Health and Clinical Excellence (NICE) summarizes its updated guideline on diagnosis, treatment, and monitoring of heart failure. According to the updated guidelines, patients should be categorized by a symptom assessment and health history. Patients with no history of myocardial infarction should undergo measurement of serum natriuretic peptide followed by echocardiography only if natriuretic peptide levels are elevated, as symptoms of heart failure have little bearing on diagnosis. Patients with a history of heart attack should proceed directly to echocardiography. Patients who are diagnosed with heart failure with left ventricular systolic dysfunction should be treated with beta blockers and ACE inhibitors. A second option for treatment would be aldosterone antagonists, ARBs, or combination therapy with nitrate and hydralazine. The guideline recommends group exercise-based rehabilitation programs regardless of contraindications. The authors of an accompanying editorial stress that clinical guidelines can improve patient care. According to the authors, clinicians in the U.S. could prevent nearly 68,000 deaths a year if they followed six heart failure guideline recommendations. The authors write that it is also important to involve patients in the care process, “Clinical decisions should be based on guideline recommendations, but individualized according to a patient’s risk-benefit ratio, and incorporate patient preferences through shared decision-making.” The editorialists commend NICE for engaging patients in the guideline development process.