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3 June 2014 Annals of Internal Medicine Tip Sheet

Below is information about articles being published in 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. Task Force finds insufficient evidence to recommend for or against screening for suicide risk

The U.S. Preventive Services Task Force (USPSTF) finds insufficient evidence to recommend for or against screening adolescents, adults, and the elderly for suicide risk, according to a final recommendation statement being published in Annals of Internal Medicine (http://www.annals.org/article.aspx?doi=10.7326/M14-0589). Suicide is the 10th leading overall cause of death in the United States. Past studies estimated that 38 percent of adults (up to 70 percent of older adults) visited their primary care physician within one month of dying by suicide and nearly 90 percent of suicidal youths were seen in primary care during the previous year. As such, researchers for the USPSTF considered whether screening all adolescents, adults, and older adults in the primary care setting for risk factors for suicide would be effective. A systematic review of published research showed that current evidence is insufficient to make a recommendation for or against screening. However, health care professionals should consider identifying patients with risk factors or those who seem to have high levels of emotional distress and referring them for further evaluation. Some risk factors for suicide include having a mental health disorder, such as depression, schizophrenia, or post-traumatic stress disorder, having a substance abuse issue, or being socially isolated. American Indians or Alaskan natives also have higher rates of suicide. The Task Force continues to recommend that adults and adolescents be screened for depression, as evidence has shown that screening for depression coupled with available treatments is effective. This statement applies to adolescents, adults, and older adults without signs or symptoms of a current mental health disorder or history of mental illness.

2. Vaccination during ‘optimal window’ is the key to saving lives and money in next flu pandemic

Early vaccination could reduce morbidity, mortality, and health care costs associated with pandemic flu, according to an article being published in Annals of Internal Medicine (http://www.annals.org/article.aspx?doi=10.7326/M13-2071). Response to a 2009 H1N1 pandemic was not optimal, with large-scale vaccination not occurring until nine months after outbreak. Using lessons learned from the 2009 pandemic, researchers sought to determine how quickly vaccination should be completed to reduce infections, deaths, and health care costs in a pandemic with characteristics similar to influenza A (H7N9) and A (H5N1), which are associated with high mortality rates. Researchers used a computer model to estimate the health and economic consequences of a severe outbreak in a large metropolitan U.S. city with demographic characteristics similar to those of New York City. The population was assumed to have no preexisting immunity. The researchers considered various timing options for pharmaceutical interventions (vaccination) coupled with nonpharmaceutical interventions (facemasks, hand washing, social distancing). They found that vaccinating at six months after the start of the outbreak instead of nine would prevent more than 230,000 infections and almost 6,000 additional deaths in a city of 8.3 million people. The city would also save $51 million in medical costs. Additional measures, such as wearing face masks, washing hands or closing schools, can limit the virus’s spread while a vaccine is in production. The researchers conclude that vaccination timing is crucial, and there is an optimal window for large-scale pandemic vaccination. A delay of just four weeks leads to substantial increases in infection, deaths, and costs.

3. Two separate studies suggest that longer echocardiographic screening intervals for childhood cancer survivors effective, cost-effective for detecting heart issues

Less frequent echocardiographic screening of childhood cancer survivors is effective for detecting asymptomatic left ventricular dysfunction (ALVD) and is more cost-effective than following the widely accepted Children’s Oncology Group (COG) screening guidelines, according to two separate articles being published in Annals of Internal Medicine. More than half of all childhood cancers are treated with anthracyclines, a highly effective chemotherapeutic agent that increases risk for ALVD, subsequent heart failure, and death. As such, the COG developed Long-Term Follow Up Guidelines for Survivors for Childhood, Adolescent, and Young Adult Cancers in 2003, recommending periodic lifetime echocardiography screening to detect ALVD. In two separate analyses, researchers reviewed the guidelines and also looked at alternative screening schedules to determine effectiveness and cost-effectiveness of the different approaches.

In the first study, researchers used a computer model to simulate the life histories of 10 million childhood cancer survivors from five years after cancer diagnosis until death for each of the 12 risk profiles outlined in the COG guidelines (e.g. lifetime anthracycline dose, age at cancer diagnosis, and history of chest irradiation). Lifetime costs, quality-adjusted life-years, and total risks for heart failure for different screening intervals based on risk profile were compared to no screening. The researchers found that increasing the screening interval could provide similar health benefits at about half the cost of the COG guidelines.

In the second study, researchers used a computer model and a similar hypothetical patient population to compare risks for congestive heart failure (CHF), quality-adjusted life-years, and total costs for different screening intervals. Screening intervals were based on risk for CHF. Persons were categorized as low- or high-risk based on cumulative anthracycline dose. The researchers conclude that less frequent screening may be a more reasonable approach for preventing CHF and is more cost-effective. They suggest that a revision of the current COG guidelines may be warranted.