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Internal Medicine News
www.eclinicalpsychia tr ynews.com www.inter nalmedicinenews.com T he Leading Inde p endent Ne wspaper for the Inter nist—Since 1968

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INSIDE

Statins May Lower Risk of Advanced Prostate Cancer
No link was found for localized disease.
BY ROBERT FINN

©K EVIN B ERNE

Shedding Light On Parkinson’s
Radioligand tracers may help identify affected patients.
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San Francisco Bureau

“Knowledge is necessary but not sufficient for change,” said Dr. Vincenza Snow, ACP’s director of clinical programs, with Dr. Alan C. Moses, vice president of medical affairs for Novo Nordisk.

Drugs, Pregnancy, And Lactation
Column debuts with a look at asthma medications.
PAGE 30

ACP Effort Targets U.S. Diabetes Care
BY ROBERT FINN

San Francisco Bureau

S A N F R A N C I S C O — The American College of Physicians and the American College of Physicians Foundation have begun a major 3-year initiative to improve diabetes care in the United States. The initiative, announced at a press briefing during the annual meeting of the ACP, is aimed not only at physicians, but also at the entire diabetes management team, including subspecialists, physician assistants, diabetes educators, nurses, office staff, and the patients themselves. Of the 18.2 million Americans with diabetes, 5.2 million are undiagnosed, according to information distributed at the briefing. Novo Nordisk, the Denmarkbased pharmaceutical company that first commercialized insulin, has funded the initiative with an unrestricted educational grant of $9.27 million. “We believe this intensive 3year project, combining an emphasis on highest standards of care, measurable goals for practice in office settings, and research, can dramatically improve diabetes care,” Charles K. Francis, M.D., president of the ACP said in a prepared statement announcing the initiative.

Some of the educational programs and materials will be available to the medical profession in general, while others will be limited to ACP members. Vincenza Snow, M.D., the ACP’s director of clinical programs, said that the project has three goals: to increase physician awareness of high-quality diabetes care and the gap between current practice and acceptable standards, to provide proven educational interventions for improving care to the entire diabetes team, and to recognize physicians and physiSee Diabetes Care page 6

A N A H E I M , C A L I F . — Cholesterol-lowering drugs, particularly statins, appear to be associated with a greatly reduced risk of advanced prostate cancer, according to a large, prospective, observational study presented at the annual meeting of the American Association for Cancer Research. “Men who used cholesterollowering drugs had about half the risk of advanced prostate cancer,” as those who did not, said Elizabeth A. Platz, Sc.D., the lead author of the study, which was conducted as part of the Health Professionals Follow-Up Study, an ongoing cohort study that be-

gan in 1986 at the Harvard School of Public Health, Boston. “When we limited advanced prostate cancer to just those cases that were metastatic or fatal, men who used cholesterol-lowering drugs had a third of the risk of metastatic and fatal disease,” Dr. Platz of Johns Hopkins University, Baltimore, said at a press briefing. The study followed 34,438 male health professionals (including dentists and veterinarians) who were free of prostate cancer in 1990, when their ages ranged between 44 and 79 years. They completed health questionnaires every 2 years through 2000 to report the use of cholesSee Prostate Cancer page 2

Bent Out of Shape
Be on the lookout for joint hypermobility syndrome.
PAGE 35

Report Conveys Scope of Substance Abuse Problem
BY DOUG BRUNK

San Diego Bureau

V I T A L

S I G N S

Top 10 Diagnoses by Internists in 2004
Hypertension Diabetes mellitus Hyperlipidemia Hypercholesterolemia Routine medical exam Depressive disorder Esophageal disorder Hypothyroidism Asthma Allergic rhinitis
15.6% 6.5% 6.0%
K EVIN F OLEY, R ESEARCH /A NGIE R IES, D ESIGN

2.5% 2.3% 2.1% 2.0% 1.9% 1.6% 1.5%

bout half of children in America—nearly 36 million of them—live in homes where a parent or other adult uses tobacco, drinks heavily, or uses illicit drugs. That’s one of the sobering facts contained in “Family Matters: Substance Abuse and the American Family,” an 81-page white paper produced by the National Center on Addiction and Substance Abuse (CASA) at Columbia University, New York. The report “underscores the

A

magnitude of our national problem with substance abuse, David Fassler, M.D., a child and adolescent psychiatrist who practices in Burlington, Vt., told this newspaper. “It clearly outlines the risk factors and demonstrates the dramatic impact on children of growing up in a family environment where they are exposed to substance abuse.” The CASA report includes these findings: Thirteen percent of children under age 18 live with a parent or other adult who uses illicit drugs. Twenty-four percent of chilSee Substance Abuse page 31

Note: Based on projected nationwide data from a monthly survey of about 360 internists. Source: Verispan

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News

INTERNAL MEDICINE NEWS • May 15, 2005

Initiative Seeks Better Outcomes
Diabetes Care from page 1

cian practices that improve the care of patients with diabetes. “Knowledge is necessary but not sufficient for change,” Dr. Snow said, noting that all internists have extensive training in diabetes care. “It’s not necessarily that our members don’t know what to do. We need to empower them to do that in their real-life practices. What has been shown is that multifaceted and multi-intervention educational programs are what works. You have to hit people over the head many, many times in many different ways to make sure that new things are imple-

mented and that they don’t disappear once the intervention goes away.” The initiative was inaugurated at the ACP annual meeting with a diabetes track consisting of 16 workshops and courses. This track will be a feature of future annual meetings, and clinical skills modules will be offered at local chapter meetings. Other parts of the program will be introduced at a rapid pace, Dr. Snow said. For example, enhanced diabetes information will become part of the ACP’s Webbased point-of-care decision support tool, Physicians’ Information and Education Re-

source (PIER); the medical knowledge selfassessment program (MKSAP); and the college’s Web site (www.acponline.org). Versions of MKSAP will be developed for nonphysician members of the diabetes management team. And ACP will develop a self-management tool kit to help patients become working partners with their health care providers in diabetes care. These materials, available in both English and Spanish, will include versions intended for patients whose literacy is at the third- or fourth-grade level. Additionally, ACP will develop a Web portal collecting all of its diabetes information in one place, offering clinical decision support, CME credit, and the latest research in diabetes care.

“Beating diabetes is our passion, not just our business,” said Alan C. Moses, M.D., vice president of medical affairs for Novo Nordisk. “We try to distinguish ourselves from other companies by acting in accordance with our triple-bottom-line principle, [which] emphasizes a commitment not only to the economic success of the business, but just as importantly, to environmental soundness and social responsibility.” The initiative will include a research component that will assess measurable outcomes as the project progresses. “I hope that 3 years from now we’ll be here again talking about the positive results of the project and the real changes that have occurred in diabetes care,” Dr. Francis said. I

Revamped Federal Food Pyramid Draws Mixed Reviews
“Recommending people eat that much oil I think may exacerbate obesity rather than help reduce it,” Dr. Ornish said. “On the one xperts are applauding the inhand, they’re asking people to exclusion of exercise in the naercise more, but then if they’re tion’s revamped food pyragoing to be eating that many calomid guide, but they also question ries from fat, it’s going to be hard the value of a national dietary icon to control the number of calories that lacks details and requires the as requested.” use of a computer to interpret. Emphasizing a balance between The new “My Pyramid” replaces food and physical activity is a step the familiar horizontal configurain the right direction, but the new tion of the 1992 Food Guide Pyrapyramid may not be able to help mid with six vertical color wedges teach that concept in the clinical that represent the five food groups setting, according to Monica Mykand oils, and adds a staircase to lebust, M.D., director of Integrasymbolize the importance of phystive Medicine clinical services at ical activity. the University of Michigan, Ann Instead of one pyramid, there Arbor. are now 12 different versions. They Even after an electronic session contain 23 general recommendawith their physician, it will be chaltions and 18 specific suggestions lenging for patients to carry the for the elderly, children, and other necessary information in their special populations. heads and apply it in a restaurant, Consumers can obtain personalDr. Myklebust said. ized dietary and exercise recomHer own Healing Foods Pyramid mendations by plugging in their (www.med.umich.edu/umim/ age, gender, and physical activity clinical) includes such images, and levels to either the “My Pyramid The 12 available versions of the new food pyramid represent 23 general recommendations and has water as its foundation, followed Plan” or “My Pyramid Tracker” 18 specific suggestions for the elderly, children, and other special populations. by a variety of fruits and vegetables, features on the U.S. Department of dairy consumption increases blood levels of insulin-like then grains and legumes. There are separate categories for Agriculture’s Web site (www.mypyramid.gov). “It’s as basic ...or as sophisticated as you want it to be,” growth factor-1 (IGF-1), which has been related to a num- herbs, monounsaturated fats, organic dairy, lean meats, and wild fish. Secretary Mike Johanns said at a press briefing sponsored ber of cancers, he said. “All of this reflects the recent data that we need to be A statement by the Center for Science in the Public Inby the USDA. Although printed materials will be available this fall in terest also called the new pyramid a “missed opportu- eating in a plant-based manner,” Dr. Myklebust said. English and Spanish, the Web site is the centerpiece of nity” because one has to go to a Web site for details. It “Such recommendations help to prevent and treat diathe new program. The Web site includes a “For Profes- chided the government for bending “over backward to betes, obesity, heart disease, chronic pain, mood disorsionals” section, which provides information to help pa- avoid upsetting any particular commodity group or food ders—the list goes on and on. [The USDA] uses the term company by not showing any food that Americans plant based, but I don’t feel there was enough emphasis tients apply the new guidelines. on it.” Leading physicians and other parties who spoke with should eat less of.” The food pyramid was never meant to serve as a treatThe inclusion of oils in the pyramid for the first time this newspaper expressed concern regarding the new is a step in the right direction, but the recommendations ment algorithm, observed Scott M. Grundy, M.D., who program. “It’s a lost opportunity to convey information about do not distinguish among them, according to Dean Or- has served on several federal dietary guideline committees. The question about the new pyramid is whether it folhealthy food choices to the American public,” said Wal- nish, M.D., clinical professor of medicine, University of lows the guidelines established by the “Dietary Guidelines ter Willett, M.D., chair of the department of nutrition at California, San Francisco. The pyramid guidelines advise adults who consume for Americans 2005” document, which when released in Harvard University, Boston. “It’s good that it does emphasize physical activity, but the pyramid itself gives no 2,000 calories a day to consume the equivalent of about January were the strongest ever put forth by the governinformation about what people should be using sparing- 6 teaspoons (or 2 tablespoons) of oil daily, with most of ment, Dr. Grundy said. The 70-page scientific document is accessible on the it coming from fish, nuts, and vegetable oils. Solid fats like ly and what they should be emphasizing in their diet.” Not everyone uses the Internet, and even if they have butter, stick margarine, shortening, and lard should be Web site, along with links to a variety of topics such as coronary heart disease, federal nutrition assistance proaccess, it takes quite a bit of motivation to look up the limited. Canola oil and fish oil are high in omega-3 fatty acids, grams, and food labeling. information, he said. “You have to work with it,” said Dr. Grundy, director A new recommendation that adults should consume up but olive oil and corn oil have almost none, Dr. Ornish to the equivalent of three glasses of milk daily represents said. Secondly, each tablespoon of oil is equivalent to of the Center for Human Nutrition, University of Texas a “radical change” in the adult diet, said Dr. Willett, not- about 28-30 g of fat, and fats are the densest form of calo- Southwestern Medical Center at Dallas. “It’s not someing that most men consume only about one-half glass of ries. Only about 3 g of fish oil or flax oil is needed to pro- thing that just strikes you in the face like the old pyramid, but I’m not sure how effective that was either.” milk per day. Moreover, there is definitive proof that high vide the necessary omega-3 fatty acids. I
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