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Annals of Internal Medicine Tip Sheet
October 17, 2017


Below is information about articles being published in Annals of Internal Medicine. The information is not intended to substitute for the full article as a source of information. Annals of Internal Medicine attribution is required for all coverage.


1. Approximately 1 in 9 U.S. men infected with oral HPV

Abstract: http://annals.org/aim/article/doi/10.7326/M17-1363
Abstract: http://annals.org/aim/article/doi/10.7326/M17-2628

Oral human papillomavirus infection, or HPV, is common among U.S. men, affecting about one in nine, overall. The prevalence is much higher among men who have had many lifetime oral sexual partners, men who reported having sex with men, and men with concurrent genital HPV infection. The findings are published in Annals of Internal Medicine.

HPV infection causes cancer at several sites in the human body, including the throat, anus, penis, and vagina. The most common cancer related to HPV infection is oropharyngeal squamous cell carcinoma (OPSCC), a type of head and neck cancer that is disproportionately prevalent in men. While prophylactic HPV vaccination may protect against infection and has the potential to reverse the rise in this type of cancer among men, uptake is low and many men are over the eligibility age of 26 years. For this reason, epidemiologic studies on oral HPV infection are crucial to guide the design and development of alternative OPSCC prevention strategies. Examining the relationship between HPV infections occurring at different anatomical sites also is also important to understanding HPV transmission dynamics.

A team of researchers led by the Department of Health services Research, Management and Policy at the University of Florida used data from the National Health and Nutrition Examination Survey to determine the prevalence of oral HPV infection and also the concordance of oral and genital HPV infection among U.S. men and women. The data showed that the overall prevalence of oral HPV infection was high among men with almost 11 million men had any HPV infection. Almost 2 million men had oncogenic HPV 16 infection; oral HPV was common among men with genital HPV. The authors conclude that future research needs to be prioritized to improve targeted prevention and advances in screening and early detection procedures to combat head and neck cancer in this high-risk group.

2. Bioresorbable scaffolds increase risk for serious adverse events in the short and long term

Abstract: http://annals.org/aim/article/doi/10.7326/M17-1101
Editorial: http://annals.org/aim/article/doi/10.7326/M17-2522

Compared with everolimus-eluting metallic stents (EESs), bioresorbable vascular scaffolds (BVSs) increased the risks for scaffold thrombosis and other thrombotic events at mid- and long-term follow-up, and risks increased over time. The next generation of BVSs will need to be designed to overcome these issues. Findings from a systematic evidence review and meta-analysis are published in Annals of Internal Medicine.

Drug-eluting stents reduce the rate of in-stent restenosis, myocardial infarction, and target lesion revascularization (TLR) compared with bare-metal stents for adults undergoing percutaneous coronary interventions, but concerns remain about the risk for late and very late stent thrombosis. BVSs were designed to reduce the late thrombotic events associated with metallic stents. However, data from recent trials suggest that BVSs might increase the incidence of late cardiovascular events. Most of the trials were underpowered to detect rare outcomes, such as scaffold or stent thrombosis, and neither the long-term safety and efficacy nor the time courses of improvement or deterioration after BVS implantation are clearly established.

Researchers from Nanjing University School of Medicine (Nanjing, Jiangsu Province, China) performed a meta-analysis of randomized controlled trials and observational studies to estimate the incidence of scaffold thrombosis after BVS implantation and to compare BVSs and EESs in terms of safety and efficacy at mid- and long-term follow-up. The researchers also aimed to investigate the performance differences of BVSs at different time courses. They found that the rate of scaffold thrombosis after BVS implantation was 1.8 percent at median follow-up of 1 year and 0.8 percent beyond 1 year. Compared with EESs implantation, patients who received a BVS had 3.40 times greater odds of scaffold thrombosis at a media follow-up of 25 months. Consistent with this increased risk, patients with BVS were at higher risk for myocardial infarction and target lesion revascularization than those with a drug-eluting stent.

The authors of an accompanying editorial from Yale–New Haven Hospital and Yale University School of Medicine state that these findings demonstrate a role for a robust surveillance program to assess new devices. The FDA's approval of BVS was based largely on 1-year follow-up, and ideally the FDA would have prespecified plans for frequent reassessments of BVS data to incorporate findings from new research and reviews.

3. Nearly half of potentially preventable Medicare spending focused on frail elderly patients

Abstract: http://annals.org/aim/article/doi/10.7326/M17-0767

Nearly half of all potentially preventable Medicare spending is concentrated on frail elderly patients. These findings suggest a need for simple interventions aimed at managing or preventing the illnesses that most often lead to admission in this high-cost population. The observational study is published in Annals of Internal Medicine.

Recently, great efforts have been made to increase the efficiency of the U.S. health care system, but finding areas of care where money can be saved and quality improved has often proved difficult. One approach that has been explored is focusing on high-need, high-cost patients, or the 10 percent of beneficiaries who account for the most Medicare spending. These patients often have several chronic conditions with physical and cognitive limitations and may struggle to care for themselves independently. Characterizing this expensive population into subgroups can help clinical leaders identify where wasteful spending is concentrated and target efforts to improve efficiency.

Researchers from the Harvard T.H. Chan School of Public Health reviewed fee-for-service claims for 6,112,450 high-cost Medicare recipients to determine the proportion of total spending that is potentially preventable across distinct subpopulations. Six subpopulations were identified: nonelderly disabled, frail elderly, major complex chronic, minor complex chronic, simple chronic, and relatively healthy. Potentially preventable spending was calculated by summing costs for avoidable emergency department visits, plus inpatient and associated 30-day post-acute costs for ambulatory care-sensitive conditions.

The researchers found that in 2012, nearly 5 percent of Medicare spending was potentially preventable and about 74 percent of that spending was incurred by high-cost patients. Despite making up only 4 percent of the Medicare population, high-cost frail elderly persons accounted for about 44 percent of total potentially preventable spending. Most of the spending was related to admissions for urinary tract infections, dehydration, heart failure, and bacterial pneumonia. These findings suggest areas were clinical leaders can target interventions for increasing efficiency.

Also in this issue:

Benefits of Direct-Acting Antivirals for Hepatitis C

Anna S. Lok, MD; Raymond T. Chung, MD; Hugo E. Vargas, MD; Arthur Y. Kim, MD; Susanna Naggie, MD, MHS; and William G. Powderly, MD
Ideas and Opinions
Abstract: http://annals.org/aim/article/doi/10.7326/M17-1876

Inpatient Notes: Diagnostic Excellence Starts With an Incessant Watch

Gurpreet Dhaliwal, MD
Annals for Hospitalists
Abstract: http://annals.org/aim/article/doi/10.7326/M17-2447

Lipoprotein Apheresis for Sitosterolemia

Nagahiko Sakuma, MD, PhD; Hayato Tada, MD, PhD; Hiroshi Mabuchi, MD, PhD; Takeshi Hibino, MD, PhD; Hirotake Kasuga, MD
Observation: Case Report
Abstract: http://annals.org/aim/article/doi/10.7326/L17-0502

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