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Update in General Internal Medicine

Christopher L. Knight, MD; and Stephan D. Fihn, MD, MPH
[+] Article and Author Information

From University of Washington Medical Center and Veterans Affairs Puget Sound Health Care System, Seattle, Washington.


Acknowledgments: The authors thank John Sheffield, MD, and Eric Larson, MD, MPH, for their advice and guidance. They also thank the many colleagues who suggested articles for inclusion in this review.

Potential Financial Conflicts of Interest: None disclosed.

Corresponding Author: Christopher L. Knight, MD, University of Washington Medical Center, 4245 Roosevelt Way NE, Campus Box 354760, Seattle, WA 98105; e-mail, clknight@u.washington.edu.

Current Author Addresses: Dr. Knight: University of Washington Medical Center, 4245 Roosevelt Way NE, Campus Box 354760, Seattle, WA 98105.

Dr. Fihn: Veterans Affairs Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101.


Ann Intern Med. 2006;145(1):52-61. doi:10.7326/0003-4819-145-1-200607040-00010
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In 2005, several important studies challenged the general internist's definition of routine care for many conditions (Table). New data were published on the benefits of high-dosage statin therapy in patients with coronary disease and on the benefits and risks of β-blockers in the perioperative setting. New findings forced a reassessment of the effectiveness of vitamin E supplementation, cholinesterase inhibitor regimens in dementia, low-dosage aspirin therapy in women, sigmoidoscopy for colon cancer screening in women, alendronate therapy for osteopenia, and β-blockers as first-line therapy for uncomplicated hypertension. Other studies supported broader use of HIV screening and recommended ultrasonography to detect abdominal aortic aneurysms. Combination therapy with aspirin and a proton-pump inhibitor was also found to be the antiplatelet strategy of choice in patients who have a history of nonsteroidal anti-inflammatory drug–induced ulcers and who do not specifically require clopidogrel. Methicillin-resistant Staphylococcus aureus is becoming endemic in the community, but other news from the infectious disease arena was more encouraging: A vaccine to prevent shingles and postherpetic neuralgia will probably be available soon.

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Correction
Posted on August 25, 2006
Robert D. Lafsky
No Affiliation
Conflict of Interest: None Declared

Serious error in "Update in General Internal Medicine" July 4 issue. The IDEAL study studies patients up to 80 years of age, not "at least 80 years of age" as the summary reads.

Conflict of Interest:

None declared

Clarification of USPSTF recommendation on Abdominal Aortic Aneurysm
Posted on September 26, 2006
Ned Calonge
Chair, US Preventive Services Task Force
Conflict of Interest: None Declared

To the Editor:

In their "Update in General Medicine,"(1) Christopher Knight and Stephan Fihn comment on the 2005 U. S. Preventive Services Task Force (USPSTF) recommendation, Screening for Abdominal Aortic Aneurysm.(2) We write to clarify several points, but first, we restate the recommendations:

The USPSTF recommends that men aged 65-75 who have ever smoked receive ultrasound screening for abdominal aortic aneurysm once (grade B recommendation). For men aged 65-75 who have never smoked the USPSTF gave a grade C recommendation (made no recommendation either for or against screening for abdominal aortic aneurysm.) For women, the USPSTF recommends against routine screening (D recommendation).

It is well demonstrated in the literature that smoking is a major risk factor for the development of abdominal aortic aneurysm"“about 90% of AAA deaths occur in older men who have ever smoked"“and a sizable body of evidence supports screening this population. The USPSTF review also found good evidence that screening men aged 65 to 75 who have never smoked leads to decreased abdominal aortic aneurysm-specific mortality. However, because of the lower prevalence of aneurysms in this population and the potential for significant harms from open abdominal aortic aneurysm repair, the USPSTF concluded that the balance between the benefits and harms of screening was too close to recommend that all men be screened.

It is true that the article by Lindholt et al, "Screening for abdominal aortic aneurysms: a single centre randomized controlled trial"(3), published in the British Medical Journal in February 2005, was not referenced in the systematic review on which the USPSTF based its recommendations; the USPSTF review, published in the Annals in February 2005, included literature published between January 1994 and July 2004. (4) However, Knight and Fihn are incorrect in supposing that the data by Lindholt et al were not considered by the USPSTF--the 2005 article published in the British Medical Journal merely provided follow-up data on a trial that had reported essentially the same findings in 2002 (5); these findings were included in the USPSTF's review.

Lindholt first described the Viborg County cohort and provided data on smoking prevalence in 1996. (6) Sixty-one percent of those who screened positive for abdominal aortic aneurysm had smoked during their lifetime; 41% of those who screened negative had smoked; however, information on smoking as a risk factor was not reported in any of the investigator's subsequent publications. (3, 5, 7) While the Viborg County trial findings present evidence that all men, without regard to smoking history, benefit from screening, the USPSTF review of screening found a greater yield of screening among those who have ever smoked. (4, 8) This was persuasive to the USPSTF in making its recommendation.

Finally, Lindholt et al's study was conducted with 12,639 men but included no women. (7) The comment that the USPSTF did not include this study when considering the question of screening women for AAA is, therefore, difficult to understand.

The USPSTF provides evidence-based recommendations about preventive health services for use in primary health care delivery settings based on the available evidence and the comparison of benefits and harms. The USPSTF recommends clinicians use available data and their best judgment in the care of individual patients. At the population level, the USPSTF summarizes the available data and makes its best judgments based on that data.

Sincerely,

Ned Calonge, M.D., M.P.H. Chair, USPSTF

Diana Petitti, M.D., M.P.H. Co-Chair, USPSTF

1. Knight CL and Fihn SD. Update in General Internal Medicine: Abdominal Aortic Aneurysm. Ann Intern Med. 2006; 145(1):52-61.

2. US Preventive Services Task Force. Screening for Abdominal Aortic Aneurysm: Recommendation Statement. Ann Intern Med. 2005; 142(3):198-202.

3. Lindholt JS, Juul S, Fasting H, Henneberg EW. Screening for abdominal aortic aneurysms: single centre randomised controlled trial. BMJ. 2005;330(7494):750.

4. Fleming C, Whitlock EP, Beil TL, Lederle FA. Screening for abdominal aortic aneurysm: a best-evidence systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2005;142(3):203-11.

5. Lindholt JS, Juul S, Fasting H, Henneberg EW. Hospital costs and benefits of screening for abdominal aortic aneurysms. Results from a randomised population screening trial. Eur J Vasc Endovasc Surg. 2002;23(1):55-60.

6. Lindholt JS, Henneberg EW, Fasting H, Juul S. Hospital based screening of 65-73 year old men for abdominal aortic aneurysms in the county of Viborg, Denmark. J Med Screen. 1996; 3(1):43-6.

7. Lindholt JS, Henneberg EW, Fasting H, Juul S. Mass or high-risk screening for abdominal aortic aneurysm. Br J Surg. 1997;84(1):40-2.

8. Fleming C, Whitlock EP, Beil TL, Lederle FA. Screening for Abdominal Aortic Aneurysm: A Best-evidence Systematic Review for the U.S. Preventive Services Task Force. [Web site] 2005 [cited 22 August 2006]; Available from: http://www.ahrq.gov/clinic/uspstf/uspsaneu.htm

Conflict of Interest:

None declared

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