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19 October 2010 Annals of Internal Medicine Tip Sheet

Below is information about three articles being published in the September 21 issue of Annals of Internal Medicine. The information is not intended to substitute for articles as sources of information. Annals of Internal Medicine attribution is required for all coverage. For an embargoed copy of a study, contact Angela Collom at acollom@acponline.org or 215-351-2653.

1. Invasive Dental Procedures Raise Short-Term Risk for Negative Cardiovascular Events

People with periodontal disease (inflammation in the gums) are at high risk for cardiovascular disease. However, the relationship between cardiovascular events and invasive dental procedures intended to treat gum disease and other dental problems is uncertain. Researchers studied Medicaid claims for patients that underwent invasive dental treatment and compared the incidence of cardiovascular events (heart attacks and strokes) in periods immediately following invasive dental treatment to the incidence during other times. The rate of events was high during the first four weeks after invasive dental treatment, but returned to normal within six months. The researchers speculate that an acute inflammatory response to the procedure may contribute to the increased cardiovascular risk. An accompanying editorial raises the point that patients undergoing dental surgery often discontinue aspirin use before their procedure. Aspirin cessation could be a trigger for a subsequent coronary event. The editorialists advise against recommending that patients taking aspirin for cardiovascular prevention routinely discontinue it before invasive dental procedures.

2. What’s in Placebos? Does it Matter?

One way to determine whether a new treatment works is to compare it in a randomized controlled trial to a placebo. Placebos are substances with no known activity against the health condition of interest. Currently, no regulations guide placebo composition. However, the composition of placebos could influence study results if the substance thought to be inactive actually had some activity against the disease (using corn oil as a placebo in a study of cholesterol-lowering drug) or if something about the placebo such as a distinctive smell or taste made it easy for study participants to tell which treatment they were getting. Researchers reviewed 176 published randomized controlled trails to evaluate how frequently the studies described placebo composition. In total, the researchers reviewed 86 studies of pills, 65 studies of injections, and 25 studies of other treatment methods. The researchers focused on four influential journals: The New England Journal of Medicine, JAMA, The Lancet, and Annals of Internal Medicine. The trial reports seldom disclosed placebo composition. Disclosure was particularly rare for pill-based placebos. The authors recommend that journals implement a reporting requirement and that the CONSORT (Consolidated Standards of Reporting Trials) group amend their guidelines to include a recommendation to describe placebo composition.

3. Peer Support May Help Patients Get Control of Their Diabetes

Despite being in treatment programs, many diabetic patients still struggle to control their blood sugar and other health factors. While patient education and support can improve outcomes, many practices do not have resources to enable nurses and other trained professionals to provide such education and support. Support programs that use non-professionals such as people who also have the disease to help patients manage their health may be an alternate way to provide this type of education and ongoing support. Researchers randomly assigned 244 men with uncontrolled diabetes to peer support for diabetes management or traditional nurse care management. Peer support paired two patients with diabetes. At start, patients in the peer support group met in a group setting to set disease management goals, learn how to interact with their peer contact, and were advised to talk with their peer once per week. After six months, the researchers found that patients that had peer support achieved HbA1c levels that were lower than those in the nurse care groups. The author of an accompanying editorial points out that the recently enacted Patient Protection and Affordable Care Act endorses community support including peer support programs, especially for medically underserved populations. The editorialist views moving outside medical practices and partnering with the surrounding community as a way to improve health outcomes.

4. In South Africa, Drug-Resistant TB Threatens Availability of Health Care Workers

Health care workers in KwaZulu-Natal, South Africa are front-line care providers for tuberculosis and HIV patients in the province. The epicenter of the HIV/AIDS epidemic, KwaZulu-Natal also has a high incidence of drug-resistant tuberculosis. Multidrug-resistant tuberculosis, or MDR-TB, is TB that is resistant to two antibiotics. Extensively drug resistant tuberculosis, or XDR-TB, is TB that is resistant to four antibiotics. The prevalence of these strains causes concern for health care workers that treat infected patients. Researchers examined hospital admission records between 2003 and 2008 to determine if health care workers were hospitalized with either strain of TB at a higher rate than the general population. Health care workers were found to have a 5- to 6-fold increased rate of hospital admission with either type of TB compared with non health care workers. The authors conclude that policy measures that prioritize health care worker protection and risk may be critical for TB control in resource-constrained countries with high rates of drug resistant disease.