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18 March 2008 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. New Study: Growth Hormone Does Not Enhance Athletic Performance

A review of published randomized controlled trials that compared growth hormone (GH) to no-growth-hormone treatment in healthy people between 13 and 45 years of age found that lean body mass increased in people who took growth hormone but strength and exercise capacity did not. People who took GH experienced soft tissue swelling and fatigue more frequently than those who did not take GH. Authors conclude that claims that GH enhances physical performance are not supported by the scientific literature. GH, they say, may increase lean body mass but may not improve strength and may worsen exercise capacity and increase adverse events.

Note: This paper is being released early online at the Web site of Annals of Internal Medicine It will appear in the May 20, 2008, print edition of the journal.

2. Testing Everyone Admitted to 3 Hospitals for MRSA Infection Greatly Reduced Disease in Hospital and After Discharge

A three-year program compared three strategies for tackling MRSA (methicillin-resistant Staphlococcus aureus) infection (Article, p. 409). Researchers compared no screening for MRSA with screening those admitted to the emergency departments and with screening all people admitted to the hospitals (universal surveillance). Universal surveillance was associated with a reduction by more than half of healthcare-associated MRSA bloodstream, respiratory, urinary tract, and surgical site disease occurring during hospital stay and in the 30 days after discharge.

An editorial writer notes that the rapid polymerase chain reaction (PCR)-based test used in the universal screening phase of the study was not used in the first two phases and thus could skew results (Editorial, p. 474). Further, the PCR-based test costs about $25 to $30 compared to the $5 standard culture lab test, so screening all patients with the fast test may have an economic impact on the hospital. The writer suggests that a strategy of targeting high-risk populations for screening, such as nursing home residents, would be a more cost-effective way to confront MRSA infection. “The one-size-fits-all approach is probably not sensible for MRSA screening.”

3. New Study: Large Number of Older Adults Have Some Loss of Memory and Thinking but Not Dementia

A new study of 856 people age 71 years and older found that 22 percent had some cognitive impairment that did not reach the threshold for dementia (Article, p. 427). Each year, about 8 percent of individuals with cognitive impairment but not dementia at baseline died and about 12 percent progressed to dementia. Using the 22 percent figure, researchers calculate that in 2002 in the United States, 5.4 million people aged 71 and older had cognitive impairment without dementia. Previous estimates of cognitive impairment without dementia ranged from 5 percent to 29 percent.

4. Current Guidelines for Colonoscopy after Removal of Polyps Do not Predict Subsequent Development of Large, Advanced Polyps

Current guidelines call for follow-up colonoscopy after polyp removal based on the number, type, and size of polyps removed (Article, p. 419). For example, after removal of a polyp that is about one centimeter in size or three polyps of any size, guidelines recommend that patients have follow-up colonoscopy in three years, while those with smaller and/or fewer polyps are recommended to get a follow-up colonoscopy in five to 10 years. An analysis of 1,905 people who had colorectal polyps removed found that this risk stratification scheme did not predict development of advanced polyps, which are considered most likely to advance to colorectal cancer. The researchers note that colonoscopy already constitutes about 34 percent of procedures performed in the United States, and overuse can affect scarce health resources.

Editorial writers say the issue of follow-up colonoscopy is complicated by that fact that little is known about the natural history of the large polyp to understand which ones grow into cancer, that future guidelines should consider clinical factors such as cigarette smoking, waist circumference and insulin resistance in determining high risk screening categories, and finally, that for some patients, even a small 5 percent risk for developing advanced polyps is too high not to have early and frequent follow-up colonoscopies (Editorial. 477).

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