Established in 1927 by the American College of Physicians


19 July 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. Testing for the Lynch Syndrome in All Colorectal Cancer Patients Cost-effective

Relatives of Those Who Test Positive Are at Increased Risk and Should Also be Tested

The Lynch syndrome is the most common genetic cause of colorectal cancer and is also associated with endometrial and other types of cancer. While only three percent of colorectal cancer patients carry the gene, it has been suggested that testing for the Lynch syndrome in all patients newly diagnosed with colorectal cancer could help identify families at risk. Researchers used a computer model to estimate the effectiveness and cost-effectiveness of screening for the Lynch syndrome in all colorectal cancer patients. The model took into account risk for gynecologic cancer, sex differences, and various age limits for screening. This analysis suggests that it is cost-effective to test everyone with colorectal cancer for mutations associated with the Lynch syndrome, and then screen healthy first-degree relatives of persons with cancer who screen positive for Lynch syndrome.

2. Early Release: In Africa, Combined Antiretroviral Therapy Dramatically Increases Life Expectancy to Almost Normal Levels

Combination antiretroviral therapy (cART) has dramatically increased life expectancy for HIV patients in developed countries but little is known about cART and patient outcomes in resource-constrained nations. Researchers studied a cohort of 22,315 HIV-positive patients aged 14 years or older who initiated cART at The AIDS Support Organization (TASO) clinics in Uganda between 2000 and 2009. They found that treatment with cART increased life expectancy to nearly normal levels. In Uganda, life expectancy at birth is approximately 55 years and increases as individuals survive key milestones. For patients in the study, life expectancy at age 20 was an additional 26.7 years and at age 35 was an additional 27.9 years. Males showed consistently lower life expectancy than females. For males, life expectancy at age 20 years was 19.1 years. For females, it was 30.6 years. At age 35, life expectancy increased to 22 years for males and 32.5 years for females. According to the researchers, men typically access care at a later stage, with more advanced disease, resulting in poorer outcomes. The study also found a strong association between baseline CD4 cell status and mortality when controlling for factors such as age, year of cART initiation and gender. Those who started cART earlier, at a higher CD4 cell status, lived longer. The authors conclude that cART for HIV infection can dramatically increase life expectancy in Africa, where the burden of the disease is greatest.

3. Low Health Literacy Leads to Poor Health Outcomes

Navigating the health care system requires people to understand labels, interpret numbers and measurements, and talk to their doctors effectively. Those skills are known as “health literacy.” Approximately 80 million Americans have limited health literacy, which puts them at greater risk for poorer access to care and poorer health outcomes. In an update to a 2004 review article, researchers identified 96 new articles that compared patient outcomes by differences in directly measured health literacy and numeracy (ability to interpret labels and adhere to medication regimens) levels. The researchers found that people with low health literacy have less ability to take medicine correctly and receive fewer mammograms and flu vaccines. They also use the emergency room more and are hospitalized more often, yet have poorer outcomes, and among the elderly, a demonstrated higher mortality rate. The authors of an accompanying editorial suggest that health literacy needs to be considered in improving medication labeling and pretesting materials with the target audience. According to the authors, these actions will help improve heath literacy and outcomes along with them.

4. Rural Patients in Geographically Isolated Areas More Likely to Die from COPD

Chronic obstructive pulmonary disease (COPD) is projected to be the third leading cause of death nationwide, making it imperative to identify patient and organizational factors that contribute to mortality. Evidence suggests that patients living in rural areas have worse health outcomes. Researchers studied health records for 129 veterans hospitalized for COPD to determine whether mortality is higher for those living in rural areas and if hospital characteristics had any influence on mortality. The researchers found that patients with COPD who live in isolated rural areas seem to be a greater risk for COPD exacerbation-related mortality, independent of hospital characteristics. Outcomes for patients in rural areas that were not isolated did not differ from those living in urban settings. Researchers suggest that patients in rural settings may have a higher prevalence of COPD due to increased indoor air exposures from burning of biomass fuels, underrecognition of disease, deficits in the delivery of pulmonary rehabilitation, limited use of spirometery to document disease progression, and problems with access and/or distance to medical care. In addition, it has been reported that lower-volume hospitals have the highest COPD mortality rates, possibly due to fewer full-time specialty board staff and fewer noninvasive ventilator support resources. According to the authors, these findings could be used to investigate whether providing an appropriate workforce and other support resources to isolated rural areas would reduce the difference in mortality.