Slowing a diabetic's decline (American College of Physicians annual meeting)

ACP works to improve patient understanding of doctor instructions

The American College of Physicians wants to make it more likely that what a doctor says is understood by his or her patient -- no matter what the patient's first language.

ACP is calling for interpreter services to be available and reimbursed. It also urges the establishment of a national clearinghouse for patient education materials in languages other than English, according to a white paper released at Internal Medicine 2007, held in San Diego in April.

"If we are unable to communicate with our patients, it doesn't matter how brilliant the physician is," said Lynne Kirk, MD, ACP's immediate past president.

The American Medical Association has policy calling for interpreters to be paid directly by patients or third-party payers as well as with federal funding.

The ACP's action was taken in response to data from a member survey released at the meeting, in which 65% of the 2,022 respondents had at least a few patients with limited English proficiency. Few practices had mechanisms for documenting the patient's main means of communication, but these patients did take extra time. Reimbursement for translation services was rare, though many physicians provided them.

Experts argue that better funding may save money over the long run by improving compliance, which in turn could reduce complications, emergency department visits and hospitalizations. "The amount of money saved could be enormous," said William E. Golden, MD, immediate past chair of ACP's Board of Regents.

The college also released "Living with Diabetes: An Everyday Guide for You and Your Family," in both English and Spanish. The guide is meant to be used in conjunction with a health care professional to help patients with diabetes make lifestyle changes as well as take oral agents and insulin correctly.

The tool was developed in both languages in order to ensure cultural relevance.

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Debate over stent vs. drug therapy in cardiovascular treatment

Recent studies have complicated decision-making regarding whether to use a stent and what kind it should be, according to a debate at the American College of Physicians' Internal Medicine 2007 meeting in San Diego.

Data presented at medical conferences and Food and Drug Administration advisory committee meetings suggest that drug-eluting stents, in comparison with bare metal ones, may increase the risk of late-stent thrombosis.

In March, results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation -- COURAGE -- trial, which were presented at the American College of Cardiology meeting in New Orleans in March and published simultaneously in the New England Journal of Medicine, questioned whether a stent should be used at all in patients with stable coronary artery disease. This study compared intensive pharmacologic therapy either by itself or in addition to percutaneous coronary intervention. This procedure, which frequently includes stenting, did not provide any additional benefit. Those who received only the intensive drug regimen also had slightly lower rates of death, hospitalization and heart attack.

Armed with this information, physicians said medical therapy was preferable for this population. Although a stent will treat a particular lesion, medical therapy improves overall cardiovascular health.

"Delayed risk of death or MI is really dependent on the behavior of the entire vasculature," said George Vetrovec, MD, chair of cardiology at the Virginia Commonwealth University Medical Center.

Other experts, though, said revascularization should continue to be favored for stable patients because they are more likely to return to normal activity quickly after this procedure and need fewer drugs. This circumstance, in turn, can lead to a reduction in drug-related side effects.

"This is really not a contest between stents and statins. It's more a contest between having your artery opened up and going back to full activity, versus loading up on a bunch of beta-blockers," said Spencer King, MD, director of interventional cardiology at the Fuqua Heart Center in Atlanta and a COURAGE investigator.

Specialists caution, however, that the findings do not say anything about how sicker patients should be treated, although they will most likely end the practice of angioplasty in patients with very mild disease.

"Every patient with a little bump in a coronary artery found on a screening CT scan without evidence of ischemia does not need a stent," said Dr. Vetrovec.

Another session highlighted the impact of data released over the past few years on the care of women with heart disease. Secondary prevention appears to be the same between men and women, but primary prevention seems to be distinct. Aspirin can reduce cardiovascular disease risk, but does not appear to benefit women as much as it does men. And high triglycerides as well as blood glucose and insulin issues appear to have a greater impact on women's hearts.

The question of hormone therapy also has become more complicated with further crunching of data from the Women's Health Initiative. Although it appears that this regimen does not have any cardiovascular benefits and may cause harm for most women, those close to menopause may benefit. Experts caution that this may have more to do with atherosclerotic burden than age. Hormone therapy may still be hazardous for young women with heart disease.

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Research findings: NSAIDs and liver cirrhosis; antibiotics; rheumatoid drugs

Taking low doses of over-the-counter pain medications are unlikely to impact the liver health of a patient with cirrhosis, according to a study presented at Internal Medicine 2007, the American College of Physicians' annual meeting, in April in San Diego.

"These agents should be used with caution, but OTC analgesics can be safely used if the doses are kept within the recommended limits," said Dr. Sakib K. Khalid, lead study author and chief resident at Washington University in St. Louis.

Researchers followed 91 people hospitalized for a worsening of cirrhosis from 2000-02 and compared them with a group of 153 cirrhotic patients who had not required hospital admission and a control group of 89 hospitalized patients with otherwise healthy livers. As expected, alcohol played a significant role in being hospitalized for cirrhosis, but using nonsteroidal anti-inflammatory drugs did not.

Another study examined the value of early switches from IV to oral antibiotics for patients with staphylococcal bone infections. Researchers from Baylor College of Medicine in Houston retrospectively analyzed data on 72 patients, finding that outcomes were similar among those who had six weeks of parenteral antibiotic therapy and those who had as few as two weeks of such treatment followed by oral antibiotics.

Meanwhile, a case study suggested that the trigger for an unusual infection in a patient with rheumatoid arthritis may be the medication the patient is taking. Researchers from Washington University in St. Louis reported on a 41-year-old male who was treated for histoplasmosis after nine months of taking adalimumab. An increased risk of infection is a known complication of the drug, but the authors cautioned that if an infection occurs, the pathogen might sometimes be an uncommon one.

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Treatment tips

Here are some treatment tips from the meeting:

Letting patients talk can save time. Allowing patients to list -- without interruption -- their reasons for an office visit is a potential time-saver.

"There's a place for doctors to talk, but if you're talking, you're not getting much information from the patient," said David Gullen, MD, assistant professor of internal medicine at Mayo Clinic in Scottsdale, Ariz.

This approach can spare physicians from being distracted by the patient's first complaint, which is often not the most important. Priorities can be set, the most urgent concerns can be addressed immediately and less- important issues dealt with later.

"Once you get through that agenda, you're not going to get hit with the doorknob question, which is a real time-waster," said F. Daniel Duffy, MD, executive vice president of the American Board of Internal Medicine.

Other factors may undermine SSRI effectiveness. Depression might not be alleviated by a selective serotonin reuptake inhibitor, for reasons that have nothing to do with the drug.

Patients may be unable to fill their prescriptions because of costs or other reasons. They might not have been prescribed a sufficient dosage or followed the regimen long enough. SSRI effectiveness may also be dampened by the patient's involvement in an abusive relationship or with drugs and alcohol, according to James L. Levenson, MD, professor of medicine, psychiatry and surgery at Virginia Commonwealth University School of Medicine. Also, the patient may actually be bipolar or not have a mental illness at all. "Not every crying patient needs an antidepressant."

Environmental changes and insomnia. Patients who cannot sleep should be advised about home and behavioral changes that can make snoozing easier, such as avoiding stress in the evening and removing clocks from bedrooms.

"Some of my patients have the time projected on their ceiling so they always know what time it is," said David P. White, MD, the Gerald E. McGinnis professor of sleep medicine at Harvard Medical School. "That just creates anxiety."

He also advised being alert to the possibility of sleep apnea in obese patients and using hypnotics when lifestyle changes have not helped.

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