Current issues of ACP Journal Club are published in Annals of Internal Medicine


Editorials

Update in general internal medicine, 1995

ACP J Club. 1995 Sept-Oct;123:A12. doi:10.7326/ACPJC-1995-123-2-A12



Keeping physicians up to date is a basic function of medical journals, continuing medical education, and many voluntary professional societies. This universal aspect of a physician's commitment to lifelong learning explains the enduring popularity of updates, advances, and state-of-the-art columns and lectures.

How would you choose the content of an update in general internal medicine (GIM)? Given that GIM prides itself on both depth and breadth, we found that selecting material for such an update for the 1995 Annual Meeting of the American College of Physicians (ACP) was a formidable task.

The job was to choose approximately 8 to 12 articles published in the preceding year that represented the most clinically important advances for practicing general internists. We did not feel confident that we could choose the articles by ourselves. We were also challenged by the need to organize our update into selected topics and not to cover the entire breadth of GIM.

We began by inviting 18 of our GIM colleagues to list the 3 to 5 articles or advances most important to the practice of GIM, urging them to focus on common or important problems; 12 responded. We supplemented this list by reviewing ACP Journal Club and our personal reading.

This process identified a wide range of topics covered in approximately 60 articles. Ultimately, we created 8 general topics (coronary heart disease [CHD], hypertension, human immunodeficiency virus [HIV] disease, treatment of acid-peptic diseases, asthma, breast cancer surveillance, anticoagulation, and prevention) on the basis of 20 articles. We circulated these topics and the list of articles to the ACP Journal Club editors for review. They generally concurred with our selections. We subsequently added 2 articles on prevention on the basis of an editor's suggestions and 2 more articles that were published just before the meeting.

For CHD, we identified 5 key points. First, percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) are both effective treatments for multivessel coronary disease. The tradeoffs with PTCA are faster recovery and lower costs in exchange for less effective control of angina. Patients who had CABG also had fewer subsequent diagnostic and interventional procedures (1, 2). Second, lowering cholesterol with simvastatin monotherapy reduces mortality in symptomatic CHD (3). Third, angiotensin converting enzyme inhibitors reduce mortality in persons who have or are at risk for left ventricular dysfunction (4). Fourth, the combination of estrogen and progestin appears to be a cardioprotective hormone replacement therapy, as does estrogen alone (5). Fifth, the routine use of thallium exercise tolerance testing for persons with normal electrocardiograms is not recommended—selective use is more efficient (6).

One of the key points for hypertension is that thiazides are best used in low doses (12.5 to 25 mg). High doses, which are associated with sudden cardiac death, may explain the confusing effects on CHD mortality seen in previous trials (7). Increased support also exists for treating systolic hypertension in elderly persons, and no evidence shows that lowering blood pressure by 11 to 14 mm Hg impairs cognition (8, 9).

For HIV disease, we found that the evidence supporting the treatment of asymptomatic persons with zidovudine has become less convincing (10, 11). Currently available antiretroviral therapies frequently have side effects (11, 12) and are generally similar in efficacy (13).

In the treatment of acid-peptic diseases, omeprazole is superior to H2-receptor antagonists for patients with esophagitis who have relapse and stricture (14-16). Helicobacter pylori causes duodenal ulcer, and eradicating it can cure duodenal ulcer (17). Also, eradication with "double" therapy is an alternative to traditional triple therapy (18, 19).

In the management of asthma, inhaled corticosteroid is efficacious for early and ongoing care, and maintenance therapy can be given at reduced doses for patients with mild to moderate asthma (20). A long-acting β2-agonist (salmeterol) is a useful adjunct for persons not responding adequately to inhaled steroids (21) and may be more effective than albuterol for the maintenance of symptom control (22), but short-acting β2-agonists must be used for acute exacerbations.

2 large randomized trials addressed diagnostic surveillance in breast cancer after surgery (23, 24). Both concluded that periodic intensive follow-up does not improve quality of life or survival and thus cannot be recommended as routine procedure. Rather, periodic history, physical examination, and mammography should be the cornerstones of care for asymptomatic women.

For anticoagulation, warfarin may not provide enough benefit for patients at low risk for stroke to justify the risk for complications (25). Age increases the risk for warfarin complications, but the level of anticoagulation is the most important risk factor for these complications (26). We cited several articles from the past 7 years (27-30) that raised the seminal question: What is the lowest effective dose of warfarin?

We compiled a prevention troika, beginning with a follow-up paper by Sir Richard Doll, based on 40 years of follow-up in more than 34 000 British physicians, that concluded that half of all regular smokers will eventually be killed by their habit (31). Persons who stopped smoking before age 35 had life expectancies similar to those of nonsmokers. The second part of the troika was Doll's study showing the "J"-shaped relation of alcohol consumption to mortality. Ischemic heart disease and all-cause mortality were lowest in persons consuming 8 to 21 units/wk (32) (1 unit = 1 ounce of liquor) and were higher in nondrinkers. For persons consuming more than 21 units/wk, there was a dose-response curve for increased alcohol consumption and total mortality. Finally, a randomized trial showed that influenza vaccines achieved a 50% reduction in serologic and clinical influenza but had little effect on self-reported influenza (33).

A late addition to our review was a Finnish study showing that continued ordinary activity, within limits permitted by pain, led to more rapid recovery than enforced bed rest for acute low-back pain (34).

We considerably exceeded our assigned limit of articles, but ended up with 8 topics that dealt with common and important problems in GIM. In so doing, we found that clinically useful information tended to be support-ed by several papers, many of which appeared almost simultaneously or were supported by publications in previous years. Many important topics and articles could not be included because of time and space limitations (e.g., the effectiveness of once-daily dosing of aminoglycosides for infection and selective serotonin reuptake inhibitors for depression).

We were gratified to discover that the results of our independent judgments and the choices of our colleagues and the ACP Journal Club editors converged on a manageable number of topics. At the ACP meeting itself, the lively discussion and insightful questions seemed to validate our choice of clinically important topics. It will be interesting to revisit the conclusions of these clinically "most important articles" in 5 or 10 years to see how durable they are.


References

1. Hamm CW, Reimers J, Ischinger T, et al. A randomized study of coronary angioplasty compared with bypass surgery in patients with symptomatic multivessel coronary disease. N Engl J Med. 1994; 331:1037-43.

2. RITA Trial Participants. Coronary angioplasty versus coronary artery bypass surgery: the randomized intervention treatment of angina trial. Lancet. 1993; 341:573-86.

3. Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet. 1994;344:1383-9.

4. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico. GISSI-3: effects of lisinopril and transdermal glyceryl trinitrate singly and together on 6-week mortality and ventricular function after acute myocardial infarction. Lancet. 1994;343:1115-22.

5. Psaty BM, Heckbert SR, Atkins D, et al. The risk of myocardial infarction associated with the combined use of estrogens and progestins in postmenopausal women. Arch Intern Med. 1994;154:1333-9.

6. Christian TF, Miller TD, Bailey KR, Gibbons J. Exercise tomographic thallium-201 imaging in patients with severe coronary artery disease and normal electrocardiograms. Ann Intern Med. 1994; 121:825-33.

7. Siscovick DS, Raghunathan TE, Psaty BM, et al. Diuretic therapy for hypertension and the risk of primary cardiac arrest. N Engl J Med. 1994;330:1852-7.

8. Applegate WB, Pressel S, Wittes J, et al. Impact of the treatment of isolated systolic hypertension on behavioral variables. Arch Intern Med. 1994;154:2154-60.

9. Insua JT, Sacks HS, Lau T-S, et al. Drug treatment of hypertension in the elderly: a meta-analysis. Ann Intern Med. 1994; 121:355-62.

10. Concorde Coordinating Committee. Concorde: MRC/ANRS randomised double-blind controlled trial of immediate and deferred zidovudine in symptom-free HIV infection. Lancet. 1994; 343:871-81.

11. Lenderking WR, Gelber RD, Cotton DJ, et al. Evaluation of the quality of life associated with zidovudine treatment in asymptomatic human immunodeficiency virus infection. N Engl J Med. 1994; 330:738-43.

12. Abrams DI, Goldman AI, Launer C, et al. A comparative trial of didanosine or zalcitabine after treatment with zidovudine in patients with human immunodeficiency virus infection. N Engl J Med. 1994;330:657-62.

13. Fischl MA, Stanley K, Collier AC, et al. Combination and monotherapy with zidovudine and zalcitabine in patients with advanced HIV disease. Ann Intern Med. 1995;122:24-32

14. Dent J, Yeomans ND, Mackinnon M, et al. Omeprazole v. ranitidine for prevention of relapse in reflux oesophagitis. A controlled double blind trial of their efficacy and safety. Gut. 1994;35:590-8.

15. Marks RD, Richter JE, Rizzo J, et al. Omeprazole versus H2-receptor antagonists in treating patients with peptic stricture and esophagitis. Gastroenterology. 1994;106:907-15.

16. James OF, Parry-Billings KS. Comparison of omeprazole and histamine H2-receptor antagonists in the treatment of elderly and young patients with reflux oesophagitis. Age and Ageing. 1994; 23:121-6.

17. Forbes GM, Glaser ME, Cullen DJ, et al. Duodenal ulcer treated with Helicobacter pylori eradication: seven-year follow-up. Lancet. 1994 ;343:258-60.

18. Logan RP, Gummett PA, Schaufelberger HD, et al. Eradication of Helicobacter pylori with clarithromycin and omeprazole. Gut. 1994;35:323-6.

19. Labenz J, Gyenes E, Rühl GH, Börsch G. Amoxicillin plus omeprazole versus triple therapy for eradication of Helicobacter pylori in duodenal ulcer disease: a prospective, randomized, and controlled study. Gut. 1993;34:1167-70.

20. Haahtela T, Järvinen M, Kava T, et al. Effects of reducing or discontinuing inhaled budesonide in patients with mild asthma. N Engl J Med. 1994;331:70-5.

21. Greening AP, Ind PW, Northfield M, Shaw G. Added salmeterol versus higher-dose corticosteroid in asthma patients with symptoms on existing inhaled corticosteroid. Lancet. 1994;334:219-24.

22. D'Alonzo GE, Nathan RA, Henochowicz S, et al. Salmeterol xinafoate as maintenance therapy compared with albuterol in patients with asthma. JAMA. 1994;271:1412-6.

23. The GIVIO Investigators. Impact of follow-up testing on survival and health-related quality of life in breast cancer patients. JAMA. 1994;271:1587-92.

24. Del Turco MR, Palli D, Cariddi A, et al. Intensive diagnostic follow-up treatment of primary breast cancer. JAMA. 1994;271:1593-9.

25. Stroke Prevention in Atrial Fibrillation Investigators (SPAF). Warfarin versus aspirin for prevention of thromboembolism in atrial fibrillation: Stroke Prevention in Atrial Fibrillation II study. Lancet 1994;343:687-91.

26. Hylek EM, Singer DE. Risk factors for intracranial hemorrhage in outpatients taking warfarin. Ann Intern Med. 1994;120:897-902.

27. Levine M, Hirsh J, Gent M, et al. Double-blind randomised trial of very-low-dose warfarin for prevention of thromboembolism in stage IV breast cancer. Lancet. 1994;343:886-9.

28. Bern MM, Lokich JJ, Wallach SR, et al. Very low doses of warfarin can prevent thrombosis in central venous catheters: a randomized prospective trial. Ann Intern Med. 1990;112:423-8.

29. Poller L, McKernan A, Thomson JM, et al. Fixed minidose warfarin: a new approach to prophylaxis against venous thrombosis after major surgery. BMJ. 1987;295:1309-12.

30. Meade TW, Roderick PJ, Brennan PJ, et al. Extra-cranial bleeding and other symptoms due to low dose aspirin and low intensity oral anticoagulation. Thromb Haemostat. 1992;68:1-6.

31. Doll R, Peto R, Wheatley K, et al. Mortality in relation to smoking: 40 years' observations on male British doctors. BMJ.1994;309:901-11.

32. Doll R, Peto R, Hall E, et al. Mortality in relation to consumption of alcohol: 13 years' observations on male British doctors. BMJ. 1994;309:911-8.

33. Govaert TM, Thijs CT, Masurel N. The efficacy of influenza vaccination in elderly individuals. JAMA. 1994;272:1661-5.

34. Malmivaara A, Häkkinen U, Aro T, et al. The treatment of acute low back pain—bed rest, exercises, or ordinary activity? N Engl J Med. 1995;332:351-5.

Our thanks to Eric Larson and Steve McGee for rounding up the highlights of the past year in general internal medicine. Although the process was informal and not independent of ACP Journal Club, it is perhaps noteworthy that more than 70% of the current articles chosen for review by Larson and McGee have been featured in Journal Club. The closest traditional journal was The Lancet, which published 26% of the chosen articles.—The Editor