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21 September 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. Current Stool DNA Tests Not Effective, Cost-Effective for Colorectal Cancer Screening

Questions about test accuracy and cost make the role of a stool DNA test screening for colorectal cancer uncertain. The Centers for Medicare & Medicaid Services (CMS) initiated a National Coverage Determination process to assess under which conditions a stool DNA test would be a cost-effective option for colorectal cancer screening among average-risk Medicare patients. Using a computer model with assumptions based on best available data, researchers concluded that stool DNA testing every three to five years was both more costly and less effective than yearly screening with a sensitive fecal occult blood test, an older test for colorectal bleeding. According to the study authors, even if the test sensitivity were improved, stool DNA testing still would not be cost-effective unless the price was reduced from about $350 to about $50 per test and it was used by a large proportion of the population who might not otherwise be screened.

2. Using Proton Pump Inhibitors and Clopidogrel Together Does Not Increase Risk for Adverse Cardiovascular Outcomes Following First Heart Attack

Due to concerns about risk for adverse cardiovascular reactions such as heart attack, the U.S. Food and Drug Administration and the European Medicines Agency recently discouraged the combined use of proton pump Inhibitors (PPIs) and clopidogrel unless patients had a very strong indication for simultaneous use of these drugs. Using data from hospitals in Denmark, researchers sought to determine the risk for adverse cardiovascular outcomes in patients who simultaneously used the two agents compared with patients who used only PPIs. The researchers found that patients who received clopidogrel and PPIs had similar risks for adverse cardiovascular events as those of patients who received PPIs alone. These results refute concerns about increased risk for ischemic events when using these therapies together.

3. HIV Study Shows More Work Needed to Recruit and Retain Women for Clinical Trials

Women, especially women of color, have been underrepresented in clinical trials of HIV treatment. However, some studies suggest that women with HIV infection are less likely to respond to HICV treatments than their male counterparts. The current study assesses sex-based differences in efficacy of HIV treatments and evaluates the incidence of adverse events among HIV-positive patients taking darunavir-ritonavir-based therapy. The study, which purposefully enrolled a high proportion of treatment-experienced North American women, found no statistically significant differences between women and men in either treatment efficacy or occurrence of clinically relevant adverse events after 48 weeks. However, women were more likely to discontinue study participation for a variety of reasons other than virologic failure. The researchers conclude that any numeric differences in response rates between men and women in the study were probably not driven by differences in true virologic response to therapy, but rather by higher discontinuation rates in women for other reasons.

4. Evidence Review Reaffirms USPSTF Recommendation Against Screening for Testicular Cancer

In 2004, the U.S. Preventive Services Task Force (USPSTF) recommended against screening for testicular cancer due to its relative rarity, the lack of evidence showing the accuracy of clinical or self-examination, and highly favorable outcomes from treatment of cancers identified when patients developed testicular symptoms. Instead, the USPSTF encouraged clinicians to consider testicular cancer when patients present with testicular symptoms. This review searched for new research published since 2004 to inform an updated USPSTF recommendation and found no new evidence on the benefits or harms of screening for testicular cancer that would alter the previous recommendation against screening.

Early Release:

5.Thigh-Length Compression Stockings More Effective than Knee-Length for Preventing DVT After Stroke

Graduated compression stockings are widely used to prevent deep venous thrombosis (DVT) in patients who have limited mobility from conditions such as stroke. However many questions remain about the effectiveness of these stockings including whether below-knee or thigh-length stockings are more effective at preventing DVT. Researchers randomly assigned 3,114 patients admitted to the hospital with acute stroke between 2002 and 2009 to wear either thigh-length stockings or knee-length stockings while in the hospital. Ultrasonography in 1,406 patients in each treatment group between 7 and 10 days after enrollment and a second scan in 643 patients in the thigh-length group and 639 in the below-knee group at 25 to 30 days showed that DVT occurred more often in patients with stroke who wore below-knee stockings than in those who wore thigh-length stockings.