Update in Internal Medicine (Adams)

Internal Medicine Update Internal Medicine Update 20082008

Michael Adams, M.D., FACPMichael Adams, M.D., FACP

Associate Professor of Associate Professor of MedicineMedicine

Georgetown University Georgetown University HospitalHospital

CreditsCredits

ACP Annual Session (permission received)ACP Annual Session (permission received)

Robert Cato, M.D., FACPRobert Cato, M.D., FACP Jack Ende, M.D., FACPJack Ende, M.D., FACP

Individual authorsIndividual authors

TopicsTopics

OsteoporosisOsteoporosis Obesity / bariatric Obesity / bariatric

surgerysurgery Hazards of Radiologic Hazards of Radiologic

TestingTesting Cancer risk associated Cancer risk associated

with radiation with radiation exposureexposure

Nephrogenic systemic Nephrogenic systemic fibrosisfibrosis

CardiovascularCardiovascular Gout and CHDGout and CHD PCI for stable CADPCI for stable CAD DM / thiazolidinediones and DM / thiazolidinediones and

CHDCHD AsthmaAsthma

Treatment for mild Treatment for mild persistentpersistent

Symptom-driven therapySymptom-driven therapy Kidney stonesKidney stones HPV vaccinationHPV vaccination Colon cancer screeningColon cancer screening The periodic health examThe periodic health exam

The Health Outcomes and Reduced Incidence withZoledronic Acid Once Yearly (Horizon) trialHorizon) trial

Background / MethodsBackground / Methods

45% of women non compliant with oral 45% of women non compliant with oral bisphosphonates at one yearbisphosphonates at one year

Zoledronic acid is once-yearly, IV infusionZoledronic acid is once-yearly, IV infusion Decreases bone turnover and improves Decreases bone turnover and improves

BMDBMD Fracture trialFracture trial 7000 women with osteoporosis7000 women with osteoporosis Multi center RCT, 3 year follow upMulti center RCT, 3 year follow up Primary endpoints: spine / hip fracturesPrimary endpoints: spine / hip fractures Secondary endpoints: BMDSecondary endpoints: BMD

Horizon - resultsHorizon - results

NNT (hip fx) = 91

NNT (vertebral fx via X-ray) = 13

NNT (clinical vertebral fx) = 48

HorizonHorizon

Fracture outcomes independent of Fracture outcomes independent of bisphosphonate usebisphosphonate use

BMD improved 5-8% (placebo: 1-2% decrease)BMD improved 5-8% (placebo: 1-2% decrease) Temporary side effects noted day of infusionTemporary side effects noted day of infusion ““Serious” atrial fibrillation higher in Zoledronic Serious” atrial fibrillation higher in Zoledronic

acid patients (1.3% vs. 0.5%)acid patients (1.3% vs. 0.5%) Increased creatinine (1.2% vs. 0.4%) - transientIncreased creatinine (1.2% vs. 0.4%) - transient No mortality differencesNo mortality differences Jaw osteonecrosis: 1 per groupJaw osteonecrosis: 1 per group

Horizon – ConclusionsHorizon – Conclusions

Zoledronic acid increases BMD and reduces Zoledronic acid increases BMD and reduces fx at similar rates to oral bisphosphonatesfx at similar rates to oral bisphosphonates

Not a comparison trialNot a comparison trial Hurdles:Hurdles:

InfusionInfusion Concern for a fibConcern for a fib

Bottom line: “Zoledronic acid offers another option to treat postmenopausal osteoporosis after oral therapy has been tried.”

Head-to-head trial is needed; plus investigation into atrial fibrillation side effect.

Bottom line: “Zoledronic acid offers another option to treat postmenopausal osteoporosis after oral therapy has been tried.”

Head-to-head trial is needed; plus investigation into atrial fibrillation side effect.

TopicsTopics







CHDCHD AsthmaAsthma



Obesity surgeryObesity surgery

Bariatric surgeryBariatric surgery

2000 obese (BMI > 34 for men, >38 2000 obese (BMI > 34 for men, >38 for women) who underwent surgery for women) who underwent surgery in Sweden 1987-2001in Sweden 1987-2001

Cohort analysis, non-randomizedCohort analysis, non-randomized No standardization of care, few No standardization of care, few

exclusionsexclusions 99.9% follow up (vital status)99.9% follow up (vital status)

Results – weight lossResults – weight loss

Controls: +1%

Surgical: -18%

Results – mortalityResults – mortality

controlcontrol surgicalsurgical

MortalityMortality6.3%6.3% 5%5%

(P=0.02(P=0.02))

Mortality with Mortality with baseline CVDbaseline CVD

25%25% 19%19%

(p<0.05(p<0.05))

Mortality Mortality without without baseline CVDbaseline CVD

6%6% 5%5%

Results – causes of mortalityResults – causes of mortality

Bariatric surgery trial – ConclusionsBariatric surgery trial – Conclusions Surgery patients had reduced weight, Surgery patients had reduced weight,

mortality from CV causes and cancer mortality from CV causes and cancer (Causal?)(Causal?)

Non-randomizedNon-randomized Most surgery was gastric banding (not Most surgery was gastric banding (not

bypass)bypass) No specific follow up in control group No specific follow up in control group

(selection bias? More participation in health (selection bias? More participation in health care in surgery group?)care in surgery group?)

BMIs used don’t correspond to definition of BMIs used don’t correspond to definition of obesityobesity

Bariatric surgeryBariatric surgery

Bottom line:

Despite some study limitations, this is the first trial to show a mortality benefit from weight loss or obesity surgery. Careful patient selection is crucial.

More study is needed to try to ascertain if this was a simple association or cause & effect.

Bottom line:

Despite some study limitations, this is the first trial to show a mortality benefit from weight loss or obesity surgery. Careful patient selection is crucial.

More study is needed to try to ascertain if this was a simple association or cause & effect.

TopicsTopics







CHDCHD AsthmaAsthma



Cancer risk from CT scans

JAMA 2007; 298(3):317-23.


Computer model to determine Computer model to determine lifetime risk of cancer from a CT lifetime risk of cancer from a CT coronary angiogramcoronary angiogram

Lung / breastLung / breast Calculated age-specific LARs (lifetime Calculated age-specific LARs (lifetime

attributable risk)attributable risk) Delineated by sexDelineated by sex Estimated risk using dose reduction Estimated risk using dose reduction

strategiesstrategies

CTCA - resultsCTCA - results

CTCA results - LARsCTCA results - LARs

MenMen WomenWomen

CTCACTCA + aorta+ aorta modmod CTCACTCA + aorta+ aorta modmod

Age 20Age 20 1/6861/686 1/4351/435 1/10001/1000 1/1431/143 1/1141/114 1/2191/219

Age 40Age 40 1/10071/1007 1/5411/541 1/11501/1150 1/2841/284 1/2201/220 1/3771/377

Age 60Age 60 1/12411/1241 1/5561/556 1/19111/1911 1/4661/466 1/3131/313 1/7151/715

Age 80Age 80 1/32611/3261 1/8331/833 1/25501/2550 1/13381/1338 1/5261/526 1/10001/1000

Highest organ LARs: lung / breast

CTCA - conclusionCTCA - conclusion

CT angiography carries a non-CT angiography carries a non-negligible risk of cancernegligible risk of cancer

Worse in younger womenWorse in younger women May be reduced by modifying May be reduced by modifying

radiation techniquesradiation techniques

Bottom line: CTCA for identifying patients with CAD should not be done indiscriminately.

Bottom line: CTCA for identifying patients with CAD should not be done indiscriminately.

TopicsTopics







CHDCHD AsthmaAsthma



Nephrogenic Systemic Fibrosis(Nephrogenic Fibrosing Dermopathy)


““To determine if NSF is associated To determine if NSF is associated with gadolinium”with gadolinium”

Case-control study conducted by Case-control study conducted by CDC after nephrologist reported a CDC after nephrologist reported a cluster of NSF casescluster of NSF cases

Controlled for other radiologic Controlled for other radiologic contrast agents and erythropoeitincontrast agents and erythropoeitin

4-year data collection4-year data collection

NSF - resultsNSF - results

N = 25

NSF - resultsNSF - results

NSF rate = 4.6 cases per 100 PD patients, 0.61 per 100 HD patients

Gadolinium and NSF - conclusionGadolinium and NSF - conclusion

Patients with stage IV/V chronic Patients with stage IV/V chronic kidney disease are at risk of NSF, kidney disease are at risk of NSF, especially PD patients.especially PD patients.

Time to onset ranges from days to Time to onset ranges from days to years (median = 76 days)years (median = 76 days)

Bottom line: Gadolinium should be avoided if GFR < 30. If absolutely necessary, nongadolinium should be used, or HD should be done ASAP post gadolinium.

Bottom line: Gadolinium should be avoided if GFR < 30. If absolutely necessary, nongadolinium should be used, or HD should be done ASAP post gadolinium.

TopicsTopics







CHDCHD AsthmaAsthma



Circulation. 2007;116:894-900.


Physicians’ Health Study componentPhysicians’ Health Study component 51,000+ men (91% Caucasian)51,000+ men (91% Caucasian) Association between gout, death, Association between gout, death,

CHDCHD Multivariate analysis to adjust for Multivariate analysis to adjust for

other risk factorsother risk factors 12 year follow up12 year follow up

Gout and CHD - resultsGout and CHD - results

Gout and CHD - conclusionGout and CHD - conclusion

Men with gout had an approximately 25% Men with gout had an approximately 25% increase in cardiovascular disease and increase in cardiovascular disease and cardiac mortalitycardiac mortality

Association with uric acid and CVD:Association with uric acid and CVD: Renin-angiotensin system activationRenin-angiotensin system activation Chronic inflammationChronic inflammation Direct effect of uric acid on endotheliumDirect effect of uric acid on endothelium Associated risk factors for goutAssociated risk factors for gout

Bottom line: Gout may be an indicator of coronary heart disease. “The present findings provide support for aggressive management of cardiovascular risk factors in patients with gout.”

Bottom line: Gout may be an indicator of coronary heart disease. “The present findings provide support for aggressive management of cardiovascular risk factors in patients with gout.”

TopicsTopics







CHDCHD AsthmaAsthma



Circulation. 2007;116:894-900.

Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE)


““Optimal medical management” (OMM) Optimal medical management” (OMM) recommended for stable CADrecommended for stable CAD

In 2004, 85% of all PCI procedures were In 2004, 85% of all PCI procedures were elective and in stable CAD patientselective and in stable CAD patients

Aim: to determine if PCI reduces Aim: to determine if PCI reduces mortality and/or events in this mortality and/or events in this populationpopulation

2,000+ patients; PCI (+OMM) versus 2,000+ patients; PCI (+OMM) versus OMM aloneOMM alone

5 years5 years

PCI for stable CAD - resultsPCI for stable CAD - results

Similar use of medications (ASA, beta Similar use of medications (ASA, beta blocker, statin, ACE): 71-95%blocker, statin, ACE): 71-95%

BP similarBP similar LDL 71LDL 71

Short term improvements seen in Short term improvements seen in angina in PCI group (similar to angina in PCI group (similar to previous studies), but this disappeared previous studies), but this disappeared by year 5by year 5

PCI for stable CAD - resultsPCI for stable CAD - results

PCI for stable CAD - conclusionPCI for stable CAD - conclusion

““Elective PCI for patients with stable Elective PCI for patients with stable CAD has not been shown to reduce CAD has not been shown to reduce future coronary events or mortality.”future coronary events or mortality.”

This group had better medical This group had better medical management than usual caremanagement than usual care

Study done prior to DESStudy done prior to DES

Bottom line: Medical management should be initiated first for patients with stable CAD, while PCI should be reserved for patients with progressive, limiting angina despite medical therapy.

Bottom line: Medical management should be initiated first for patients with stable CAD, while PCI should be reserved for patients with progressive, limiting angina despite medical therapy.

TopicsTopics







CHDCHD AsthmaAsthma




Aim: To determine if rosiglitazone Aim: To determine if rosiglitazone has an effect on cardiovascular has an effect on cardiovascular outcomesoutcomes

Meta analysisMeta analysis Excluded studies with zero eventsExcluded studies with zero events 40 studies which lasted 6 months or 40 studies which lasted 6 months or

moremore Outcomes reviewed: MI, Outcomes reviewed: MI,

cardiovascular deathcardiovascular death

Rosiglitazone - resultsRosiglitazone - results

Rosiglitazone - resultsRosiglitazone - results

All cause mortality unchangedAll cause mortality unchanged Risk of MI higher with rosiglitazone use Risk of MI higher with rosiglitazone use

when compared with other diabetic when compared with other diabetic drugs drugs combinedcombined (but not individually) (but not individually) InsulinInsulin MetforminMetformin SulfonylureaSulfonylurea

Overall event rates were very low Overall event rates were very low (0.5%)(0.5%)

Rosiglitazone – questions raisedRosiglitazone – questions raised

Is this a class effect?Is this a class effect? All TZDs are not alike (pioglitzaone better on All TZDs are not alike (pioglitzaone better on

lipid profile, rosiglitazone may increase LDL)lipid profile, rosiglitazone may increase LDL) Was the effect related to LDL levels alone?Was the effect related to LDL levels alone? CHF (TZDs may precipitate heart failure)CHF (TZDs may precipitate heart failure) Is this a function of patients who have Is this a function of patients who have

harder to control diabetes?harder to control diabetes? Typical CHD combined endpoints were not Typical CHD combined endpoints were not

studiedstudied Inherent limitations of meta analysisInherent limitations of meta analysis

Rosiglitazone - conclusionRosiglitazone - conclusion NEJM authors: “Our data suggest a NEJM authors: “Our data suggest a

cardiovascular risk associated with cardiovascular risk associated with the use of rosiglitazone.”the use of rosiglitazone.”

ACP reviewers:ACP reviewers:

Bottom line: Inconclusive. One ongoing study (RECORD) is not showing CV events with rosiglitzaone, and pioglitazone may reduce events (meta analysis). Use caution.

Bottom line: Inconclusive. One ongoing study (RECORD) is not showing CV events with rosiglitzaone, and pioglitazone may reduce events (meta analysis). Use caution.

TopicsTopics







CHDCHD AsthmaAsthma




Aim: To determine if patients with mild Aim: To determine if patients with mild persistent asthma could be controlled with persistent asthma could be controlled with simpler treatment than twice daily inhaled simpler treatment than twice daily inhaled corticosteroidscorticosteroids

3 arms:3 arms: Twice daily ICSTwice daily ICS once daily ICS + LABAonce daily ICS + LABA MontelukastMontelukast

Outcomes: “treatment failure” = more Outcomes: “treatment failure” = more intense management, symptom scores, intense management, symptom scores, physiologic deteriorationphysiologic deterioration


Baseline characteristics were not the Baseline characteristics were not the samesame Fewer smokers in ICS groupFewer smokers in ICS group More patients in montelukast group More patients in montelukast group

used daily ICS at baselineused daily ICS at baseline Higher mini-AQLQ score in ICS group Higher mini-AQLQ score in ICS group

(less severe asthma)(less severe asthma) Less GERD in ICS + LABA groupLess GERD in ICS + LABA group Fewer patients in montelukast group Fewer patients in montelukast group

were triggered by allergenswere triggered by allergens

Mild persistent asthma - resultsMild persistent asthma - results

30% failure

20% failure for both groups

Asthma - resultsAsthma - results

% of symptom-free days similar for all % of symptom-free days similar for all groupsgroups

More patients in ICS group and ICS + LABA More patients in ICS group and ICS + LABA group wanted to continue treatmentgroup wanted to continue treatment

Funding:Funding: GSKGSK

Reviewed protocolReviewed protocol Reviewed final manuscript & offered comments for Reviewed final manuscript & offered comments for

writing committeewriting committee American Lung AssociationAmerican Lung Association

Asthma treatment - conclusionAsthma treatment - conclusion NEJM authors: “Patients whose asthma is NEJM authors: “Patients whose asthma is

well controlled with the use of twice daily well controlled with the use of twice daily fluticasone can be safely switched to once-fluticasone can be safely switched to once-daily fluticasone plus salmeterol. Oral daily fluticasone plus salmeterol. Oral montelukast is not as effective, although it montelukast is not as effective, although it provided good asthma control for most provided good asthma control for most patients.”patients.”

ACP reviewers: similar conclusionsACP reviewers: similar conclusions

Baseline differences in groupsBaseline differences in groups Esp. allergens and ICS use at baselineEsp. allergens and ICS use at baseline

6 month study6 month study

Asthma treatmentAsthma treatment

Bottom line:

Montelukast should be used for patients with a specific indication (allergies, asthma triggered by allergens, exercise-induced asthma), but did not show benefit as “stepdown” therapy for patients with mild persistent asthma who were well controlled with ICS.

Adding a LABA to ICS may be helpful for these patients, but studies of a longer duration are needed.

Bottom line:

Montelukast should be used for patients with a specific indication (allergies, asthma triggered by allergens, exercise-induced asthma), but did not show benefit as “stepdown” therapy for patients with mild persistent asthma who were well controlled with ICS.

Adding a LABA to ICS may be helpful for these patients, but studies of a longer duration are needed.

TopicsTopics







CHDCHD AsthmaAsthma



Beclomethasone plus Salbutamol Treatment (BEST)


Aim: To determine if symptom-driven Aim: To determine if symptom-driven therapy for mild persistent asthma is therapy for mild persistent asthma is effective.effective.

4 arms:4 arms: prn albuterolprn albuterol prn combined ICS + albuterolprn combined ICS + albuterol regular, twice daily ICS (+ prn albuterol)regular, twice daily ICS (+ prn albuterol) regular, twice daily combined ICS + regular, twice daily combined ICS +

albuterolalbuterol Outcomes: PEFs, symptom scores, Outcomes: PEFs, symptom scores,

severity of exacerbationsseverity of exacerbations

BEST – results / conclusionBEST – results / conclusion All three arms better than as needed All three arms better than as needed

albuterolalbuterol Cumulative dose of ICS lower in in as-Cumulative dose of ICS lower in in as-

needed combination group than other needed combination group than other ICS groupsICS groups

Target: mild, persistent asthmatics Target: mild, persistent asthmatics with infrequent exacerbations with infrequent exacerbations (compliance)(compliance)

Bottom line: As needed (symptom-driven) therapy with a combination inhaler for mild persistent asthma is an effective option.

Regular use of short acting beta agonists not recommended.

Bottom line: As needed (symptom-driven) therapy with a combination inhaler for mild persistent asthma is an effective option.

Regular use of short acting beta agonists not recommended.

Asthma – ACP reviewers’ Asthma – ACP reviewers’ commentscomments

Very specified population of asthma patientsVery specified population of asthma patients Mild, persistentMild, persistent Well-controlledWell-controlled Did well in run-in periodDid well in run-in period

Motivation: less expensive / more convenient Motivation: less expensive / more convenient therapytherapy

Concern: “adequate suppression of Concern: “adequate suppression of subclinical airway inflammation (some subclinical airway inflammation (some believe this is little more than theoretical).”believe this is little more than theoretical).”

TopicsTopics







CHDCHD AsthmaAsthma




Aim: To determine if Aim: To determine if alphaalpha–blockers and –blockers and calcium channel blockers hasten stone calcium channel blockers hasten stone passagepassage

Medical therapy may reduce need for Medical therapy may reduce need for surgery / ureteroscopy / lithotripsy and may surgery / ureteroscopy / lithotripsy and may reduce stricture and kidney damagereduce stricture and kidney damage

Meta analysis, 211 studies yielded 22 Meta analysis, 211 studies yielded 22 randomized trialsrandomized trials

2000 patients2000 patients Tamsulosin, nifedipineTamsulosin, nifedipine Outcome = likelihood of stone expulsion at Outcome = likelihood of stone expulsion at

4 weeks4 weeks

Stone therapy - resultsStone therapy - results

Alpha-blocker forest plot

NNT = 3.3


Calcium channel blocker forest plot

NNT = 3.2


Side effects were lowSide effects were low Alpha blocker: 4% had any side effectAlpha blocker: 4% had any side effect

0.2% discontinued use0.2% discontinued use CCB: 15.2% had any side effectCCB: 15.2% had any side effect

2.9% discontinued use2.9% discontinued use Most were mildMost were mild

2 to 6 day average improvement in 2 to 6 day average improvement in stone expulsionstone expulsion

Stone size was 3-18 mm (mean 5 Stone size was 3-18 mm (mean 5 mm)mm)

Stone therapy - conclusionStone therapy - conclusion

Meta analysis; so firm conclusions Meta analysis; so firm conclusions limitedlimited

Consistent with other similar analyses Consistent with other similar analyses reviewing expulsion of stones 5-10 mmreviewing expulsion of stones 5-10 mm

Bottom line: Medical expulsive therapy with tamsulosin (0.4 mg daily) or nifedipine (30 mg daily) for 4 weeks is probably of benefit and may reduce the need for other, more invasive treatment of kidney stones.

Bottom line: Medical expulsive therapy with tamsulosin (0.4 mg daily) or nifedipine (30 mg daily) for 4 weeks is probably of benefit and may reduce the need for other, more invasive treatment of kidney stones.

TopicsTopics







CHDCHD AsthmaAsthma




Aim: To determine if GardasilAim: To determine if Gardasil Reduces HPV infectionReduces HPV infection Reduces infection with HPV 16 and 18Reduces infection with HPV 16 and 18 Reduces CIN 2, CIN3 (and Reduces CIN 2, CIN3 (and

adenocarcinoma)adenocarcinoma) InIn

All women, andAll women, and women without HPV infection or abnormal women without HPV infection or abnormal

PAP smearPAP smear

12000 patients, aged 15-2612000 patients, aged 15-26

Quadrivalent HPV vaccine - resultsQuadrivalent HPV vaccine - results

Vaccine prevented 98% of HPV Vaccine prevented 98% of HPV 16,18-related high-grade cervical 16,18-related high-grade cervical lesions in per-protocol population (no lesions in per-protocol population (no abnormality at baseline)abnormality at baseline)

44% reduction in intention-to-treat 44% reduction in intention-to-treat analysisanalysis

No effect in patients with preexisting No effect in patients with preexisting HPV 16 or 18 infections or abnormal HPV 16 or 18 infections or abnormal PAPsPAPs

Quadrivalent HPV vaccine - resultsQuadrivalent HPV vaccine - results

Gardasil - resultsGardasil - results

Nearly 100% effective in preventing new Nearly 100% effective in preventing new HPV 16 or 18 infectionsHPV 16 or 18 infections

Side effects were lowSide effects were low

This study “was designed, managed, and This study “was designed, managed, and analyzed by Merck in conjunction with analyzed by Merck in conjunction with external academic investigators and external academic investigators and members of the external data and safety members of the external data and safety monitoring board. The academic authors monitoring board. The academic authors had full access to the data and the had full access to the data and the analyses and approved the final analyses and approved the final manuscript.”manuscript.”

HPV vaccine - conclusionHPV vaccine - conclusion

Vaccine very effective in preventing new Vaccine very effective in preventing new infections and cervical abnormalities in infections and cervical abnormalities in susceptible patientssusceptible patients

Studies women aged 15-26 (approved for 11-Studies women aged 15-26 (approved for 11-26)26)

Bottom line: The HPV vaccine seems to be effective as prophylaxis and has limited side effects.

Bottom line: The HPV vaccine seems to be effective as prophylaxis and has limited side effects.

TopicsTopics







CHDCHD AsthmaAsthma




Aim: To compare CT colography to Aim: To compare CT colography to optical colonoscopy for the detection optical colonoscopy for the detection of advanced colon neoplasmsof advanced colon neoplasms

Definition of advanced neoplasm:Definition of advanced neoplasm: > 10mm> 10mm High grade dysplasiaHigh grade dysplasia Prominent villous component (> 75%)Prominent villous component (> 75%)

Retrospective analysis, 3000 patientsRetrospective analysis, 3000 patients

CT colography - resultsCT colography - results

CT colography - resultsCT colography - results

““Fewer invasive procedures”Fewer invasive procedures” Depends upon your idea of invasiveDepends upon your idea of invasive Insufflation necessaryInsufflation necessary

7.7% of CTC patients had 7.7% of CTC patients had extracolonic findingsextracolonic findings Is this good or bad?Is this good or bad?

CTC versus optical colonoscopy - CTC versus optical colonoscopy - conclusionconclusion

““CTC compares favorably to colonoscopy CTC compares favorably to colonoscopy at finding asymptomatic colon polyps”at finding asymptomatic colon polyps”

<50% of eligible patients undergo colon <50% of eligible patients undergo colon cancer screeningcancer screening

Will this increase the # of patients willing Will this increase the # of patients willing to get screened?to get screened?

Bottom line: CTC may be a reasonable alternative to colonoscopy in patients who are otherwise unwilling to undergo optical colonoscopy, BUT…patients need to be informed as to the details of the procedure (insufflation), and the fact that they may need an optical colonoscopy with biopsy if a polyp is found

Bottom line: CTC may be a reasonable alternative to colonoscopy in patients who are otherwise unwilling to undergo optical colonoscopy, BUT…patients need to be informed as to the details of the procedure (insufflation), and the fact that they may need an optical colonoscopy with biopsy if a polyp is found

TopicsTopics







CHDCHD AsthmaAsthma




Some investigators have found little Some investigators have found little evidence to support the periodic evidence to support the periodic health examhealth exam

This review used a model of benefit This review used a model of benefit (improved clinical outcomes) versus (improved clinical outcomes) versus harms (loss time at work, harms (loss time at work, inappropriate tests, cost) of the PHEinappropriate tests, cost) of the PHE

PHE - resultsPHE - results

PHE - resultsPHE - results

Performing a periodic health exam Performing a periodic health exam did show improvement in the did show improvement in the delivery of some routine / delivery of some routine / preventive / screening health preventive / screening health interventionsinterventions

Mixed results on costs, mortalityMixed results on costs, mortality No harms were foundNo harms were found

PHE - conclusionPHE - conclusion

““While more evidence is needed, While more evidence is needed, particularly on long term clinical particularly on long term clinical outcomes, the data assembled in this outcomes, the data assembled in this systematic review support PHEs. We systematic review support PHEs. We hope that third party payers will as hope that third party payers will as well.”well.”

Bottom line: There is evidence to support what we all inherently know - the value of the periodic health exam.

Bottom line: There is evidence to support what we all inherently know - the value of the periodic health exam.

Update in Internal Medicine (Adams)

Health & Medicine

Transcript of Update in Internal Medicine (Adams)