Annals
Established in 1927 by the American College of Physicians

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17 May 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. No Significant Difference in Antihyperglycemics as Part of a Three-drug Regimen for Type 2 Diabetes

All add-on drugs control blood sugar about equally when added to metformin/sulfonylurea, but more weight gain and hypoglycemia episodes with insulin
Metformin is recommended first line treatment for type 2 diabetes, and sulfonylureas are often added as a second treatment when metformin alone does not control blood sugar. Several classes of diabetes drugs including insulin can be added when metformin and sulfonylurea fail to achieve control, but it is not clear whether one class of diabetes drug is better than another in this situation. Researchers conducted a meta-analysis of 18 published trials to compare the efficacy of add-on diabetes drugs for patients whose diabetes is uncontrolled on a combination of metformin and a sulfonylurea. Trials of insulin, α-glucosidase inhibitors, receptor agonists, and dipeptidyl peptidase-4 were reviewed to ascertain effect on blood glucose level, weight, and frequency of severe hypoglycemia. The data showed that all drugs decreased blood glucose levels about equally when added to the metformin/sulfonylurea regimen, without any clear between-drug differences. However, insulin was associated with more weight gain and hypoglycemia. Based on the evidence, physicians can base their choice of third line diabetes drugs on patient preferences and clinical characteristics.

2. High-Selenium Yeast Supplements Slightly Reduce Cholesterol, but Could be Harmful

People with low selenium concentrations in their blood have a two- to three-fold increased risk for death from heart disease. Conversely, people with higher selenium concentrations have been shown to have high blood cholesterol and triglycerides. Investigators studied 501 volunteers aged 60 to 74 to determine the effect of selenium supplementation on cholesterol levels. Volunteers were assigned to receive either a yeast-based placebo or a low-, medium-, or high-dose selenium yeast pill. After six months, researchers measured changes in selenium levels and in total, good, and bad cholesterol levels in all participants. On all selenium doses, participants’ selenium levels went up, and total and bad cholesterol levels decreased by a small amount. Good cholesterol levels increased very slightly in only the group that received the highest dose of selenium. The researchers caution that the findings do not justify selenium supplementation, as the results are not statistically significant and because the safety of selenium supplements is not well-defined.

3. Obesity Linked to Functional Decline in Older Adults

Previous studies have linked obesity to premature death in the general population. As these patients age, the effect of obesity on mortality seems to decline, but other effects may remain or worsen. Researchers analyzed data from 1994 – 2000 Medicare surveys of 20,975 community-dwelling adults aged 65 years or older to examine and compare the relationship between obesity and mortality and also obesity and functional decline associated with daily living. Among older adults, obesity only caused higher mortality when a patient’s BMI was significantly above normal range. However, the more elevated the BMI, the more likely the patient was to experience functional decline within a two-year period. According to researchers, these results suggest that older obese adults may be an appropriate target group for interventions to prevent or decrease disability.

4. Despite Government Incentives, Few Hospitals Able to Adopt Electronic Health Records

Congress has allocated $30 billion to stimulate adoption and meaningful use of electronic health records. Meaningful use is defined by three central components: 1) electronic prescribing with decision support; 2) automated quality measurement; and 3) health information exchange (HIE). To be considered meaningful, providers must purchase technology and comply with metrics related to implementation. Regional health information organizations (RHIOs) are entities that facilitate clinical data exchange in a local area. With grant support from the federal government, RHIOs give local providers an efficient way to exchange data with other participating providers and stakeholders (laboratories, physician practices, public health departments, etc.) so they may comply with expert-derived criteria for meaningful use of electronic records. In 2009, investigators surveyed 179-U.S.-based RHIOs to assess the state of HIE. Of the 179 RHIOs surveyed, only 13 could support meaningful use of health information technology and none met expert-derived criteria for the comprehensive HIE needed to substantially improve care quality and efficiency. The author of an opinion piece in the same issue says that “meaningful use” policies are unrealistic from a provider’s perspective. The author recommends that policy makers take a new approach that focuses on improving usability and functionality before emphasizing widespread adoption. The author of an accompanying editorial says that no matter what the obstacles, it is time to leave paper records behind and move closer to full adoption of electronic records. He writes: "Our patients increasingly demand that we operate with at least the same level of service as their banks, car rental companies, and online retailers." According to the author, these demands are perfectly reasonable in 2011.

5. Early Release: AHRQ Presents “State of the Evidence” for Managing Pain Following Hip Fracture

Following hip fracture, it is imperative to get patients mobilized as quickly as possible. Patients who experience greater pain, are slower to mobilize, and have much poorer health outcomes and greater pain three to six months after injury. For this reason, pain management is an important factor in recovery. Researchers reviewed 83 published studies to determine the benefits and harms of drug and non-drug pain management interventions following hip fracture. These interventions included: nerve blockade; spinal anesthesia; systemic analgesia; traction; multimodal pain management; neurostimulation; rehabilitation; and complementary and alternative medicine. The evidence showed that most pain management interventions result in improvements in short-term pain, but few studies of long-term clinical importance were documented. Based on published research, nerve blockade seemed to offer the most effective pain relief and lowered the risk of delirium compared with usual care.