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19 November 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. Experts weigh cancer screening strategy based on life expectancy

Calculating comorbidity-adjusted life expectancy may help physicians determine whether to continue or stop cancer screening in elderly patients, according to a study published in Annals of Internal Medicine (http://www.annals.org/article.aspx?doi=10.7326/0003-4819-159-10-201311190-00005). The benefits of early cancer detection decline sharply with age because older patients are more likely to die of comorbid conditions or other causes. Published guidelines differ on when to stop screening elderly patients for cancer. For example, the U.S. Preventive Services Task Force recommends stopping colorectal cancer screening at age 75, whereas the American College of Physicians recommends taking the patientís comorbidities and life-expectancy into consideration before stopping screening. Researchers used Medicare data on elderly patients without cancer to develop tables estimating life expectancy for those with and those without comorbid conditions. They found that patients with higher levels of comorbidity had shorter life expectancies than healthy patients of the same age. The researchers conclude that using life-expectancy rather than chronological age to individualize cancer screening strategies could maximize benefits of screening and minimize potential harms. However, the researchers note that a complex issue such as cancer screening should also incorporate individual patient preferences into the decision-making process.

2. Available evidence does not support FDA warning linking statin use to cognitive impairment

A systematic review of available evidence (low- to moderate-strength) did not find a link between statin use and adverse cognitive outcomes, according to a study published in Annals of Internal Medicine (http://www.annals.org/article.aspx?doi=10.7326/0003-4819-159-10-201311190-00007). Recently, the FDA issued a warning after case reports suggested that statin use may lead to cognitive impairment. Researchers reviewed 25 published randomized, controlled trials and cohort, case-control, and cross-sectional studies evaluating cognition inpatients taking statins. Among statin users, low-quality evidence suggests no increased incidence of Alzheimer disease and no difference in cognitive performance in procedural memory, attention, or motor speed. Moderate-quality evidence suggests no increased incidence of dementia or mild cognitive impairment, nor any changes in cognitive performance. The researchers note that the strength of the available evidence is limited, especially with regard to high-dose statins. They conclude that larger, better-designed studies are needed to draw definitive conclusions about the effect of statins on cognition.

3. Vascular closure devices reduce complications and bleeding in appropriate cardiac patients

Vascular closure devices (VCDs) significantly reduce complications and bleeding in appropriate patients undergoing percutaneous coronary intervention (PCI), according to an article published in Annals of Internal Medicine (http://www.annals.org/article.aspx?doi=10.7326/0003-4819-159-10-201311190-00004). VCDs permit closure of the access site using sutures, plugs, or metallic clips, especially after PCI by transfemoral route. VCDs are commonly used in clinical practice, yet there is little data on their efficacy for decreasing vascular complications. Researchers studied a large number of patients undergoing transfemoral PCI at 32 Michigan hospitals to assess the association of VCDs with vascular complications. The researchers specifically focused on patient subgroups that may be at particularly high risk for these complications, but in whom data have been lacking. They found that VCDs were associated with a significant reduction in the odds of vascular complications and blood transfusions for all patients except for those with a body mass index of less than 25 kg/m2 and those who received a platelet GP IIb/IIIa inhibitor. In those patients, there was no benefit to using VCDs. These findings should help guide physicians and patients in choosing between manual closure and VCDs in transfemoral PCI.