Established in 1927 by the American College of Physicians


1 March 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. Initial Treatment with Oral Steroids May Improve Symptoms of Chronic Rhinosinusitis with Polyposis

Chronic rhinosinusitis (CRS), or inflammation of the lining of the nose and sinuses, affects 32 million Americans. About five percent of patients with CRS also develop nasal polyps that can exacerbate symptoms of blocked nasal passages, facial pain, and reduced ability to smell. While topical steroids have proven effective at reducing symptoms, relapses are common, and patients are often referred to an otolaryngologist where oral steroids are then administered. Researchers sought to determine if an initial course of oral steroids followed by sequential use of topical steroid treatments could improve patient outcomes. The researchers studied 60 adults with CRS and at least moderate-sized nasal polyps that had been referred to an otolaryngologist by their primary care physician. Patients were randomly assigned to receive either two weeks of oral steroids or placebo, followed in both groups by steroid nasal drops and then steroid nasal spray over the next 26 weeks. Over 28 weeks of therapy, the oral steroids group experienced a greater reduction in the size of polyps and greater improvement in their sense of smell than those in the placebo group. The authors of an accompanying editorial caution that oral steroids should be used reserved for patients that did not respond to topical steroids, as side effects can be serious.

2. Making Surrogate Treatment Decisions Has Negative Health Consequences for the Decision-maker

At the end of life, many patients cannot make treatment decisions for themselves and require a surrogate to interact with physicians and make medical decisions on their behalf. While some studies have evaluated how surrogates make or help make treatment decisions, none have looked at the psychological effect of decision-making on surrogates. Researchers reviewed 40 published articles that provided data on 2,832 surrogates, more than half of whom were family members of the patient, to determine the effects on surrogates of making treatment decisions for adults that cannot make decisions for themselves. The researchers found that making treatment decisions has a negative emotional effect on at least one third of surrogates, which is often substantial and typically lasts for months or years. Negative effects include stress when making decisions, guilt over the decisions made, and doubt regarding whether they had made the right decisions. Surrogates that knew the patientsí wishes (if the patient had a living will, for example), suffered less stress than surrogates acting without an advance directive.

3. Vaccination Programs Leading to a Decline in Hep B Infections Among Children, More Targeted Efforts Needed for Adults

Between 1988 and 1994, approximately 5.1 percent of the U.S. population had been exposed to Hepatitis B virus, or HBV. Since then, education about safe practices and more widespread vaccination in children should have resulted in a decrease in HBV infection. However, during the same timeframe, the population of racial groups at highest risk for HBV increased, leaving a question as to current HBV levels in the U.S.. Researchers conducted a national population-based survey to determine the prevalence and associations of HBV, past exposure, and immunity in the U.S. from 1999 to 2008. The researchers found that exposure to HBV is very low among persons 18 years or younger, suggesting that vaccination programs are working. While young people are likely to have significant protection against future infection, high-risk adults continue to have low rates of immunity for HBV. The researchers conclude future vaccination efforts should target at-risk adults.

4. USPSTF to Update its Screening Recommendations for Hearing Loss in Older Adults

In an ongoing effort to clarify its work and methods, the United States Preventive Services Task Force (USPSTF) is making all draft recommendation statements available for public comment prior to final publication. Recently, the USPSTF reviewed available published research on screening for hearing loss to update its 1996 evidence review. While one large (n=2,305) randomized trial that found screening for hearing loss was associated with increased hearing aid use at one year, additional research is needed to understand the effects of screening compared with no screening on health outcomes and to confirm benefits of treatment in primary care settings. Data presented in a review in this issue of Annals will be used to draft an updated recommendation statement to be posted for public comment at (date of posting to be determined).