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Internal Medicine News
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Statins May Lower Risk of Advanced Prostate Cancer
No link was found for localized disease.


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

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.

ACP Effort Targets U.S. Diabetes Care

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.

Report Conveys Scope of Substance Abuse Problem

San Diego Bureau



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%

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


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




American Association for Cancer Research American Academy of Neurology Society of Gynecologic Oncologists American College of Cardiology

A Beneficial Statin Side Effect?
Prostate Cancer from page 1







Pro & Con: Is coiling better than

clipping when an aneurysm can be treated by either method? Guest Editorials: Dr. David Dahl sees a lesson in the Schiavo case, 7; Dr. Alan B. Fleischer Jr. has doubts about black box warnings for tacrolimus and pimecrolimus, 8
Letters, 10

11 Clinical Rounds
Neurology, 11 Early Parkinson’s may be detected by a simple olfactory test. Mindful Practice: Dr. Jon O. Ebbert and Dr. Eric G. Tangalos examine evidence on combination therapy for neuropathic pain, 15 Psychiatry, 16 States face obstacles in dealing with methamphetamine addiction. Women’s Health, 22 A new guideline covers vulvodynia diagnosis and treatment. Adolescent Health, 31 Early intervention may be needed to prevent child molestation by teens, 32 Rheumatology, 35 Bone mineral density in early menopause is a strong predictor of bone health 10 years later, 37 Exercise Rx: Dr. Willibald Nagler offers exercises to relieve acute lumbago, 42

terol-lowering drugs and whether they had been diagnosed with prostate cancer. The study investigators reviewed the medical records of all men with a prostate cancer diagnosis. The reduction in risk held only for advanced prostate cancers, defined as cases in which the cancer was regionally invasive, metastatic, or fatal. The investigators found no association between the use of cholesterol-lowering drugs, and disease that was confined to the prostate. Through January 2000, during 313,728 person-years of follow-up, the investigators confirmed 2,074 cases of prostate cancer, of which 283 were advanced. Among those cases, 206 were metastatic or fatal. The hazard ratio for advanced prostate cancer was 0.54 for men using cholesterol-lowering drugs, compared with nonusers of such drugs. Similarly, the hazard ratio for metastatic or fatal prostate cancer was 0.34. The results were adjusted for “purported prostate cancer risk factors” using Cox proportional hazards regression. The study also yielded statistically significant evidence that the risk of advanced prostate cancer declined with increasing duration of the use of cholesterol-lowering drugs. Only the final questionnaire, covering the years 1998 to 2000, asked the

documented changes in testosterone levels, ... but there is that possibility,” she added. To investigate these possibilities, the men specifically about whether they investigators have measured serum were taking statins, which were intro- cholesterol in a subset of these same duced in 1986, or other cholesterol- men, in nested case-control studies. Dr. lowering drugs. But the investigators Platz said she was not yet ready to rebelieve that most of the protective ef- veal the results of that analysis. She also said that although the relafect comes from statins because by 2000, more than 90% of the men on tionship between cholesterol-lowering drugs and adcholesterol-lowervanced prostate ing medication reAlthough the finding is cancer is intriguported using intriguing, randomized ing, randomized statins in particucontrolled trials lar. The investigacontrolled trials are needed would be needed tors did not gather to confirm the results before to confirm the redata about which sults before one specific statins the making recommendations to could make recmen were taking. patients. ommendations to The possibility patients. remains that the Andrew J. Danneberg, M.D., of Correduction in risk was due, not to the drugs themselves, but to their effects on nell University, New York, concurred. “I lowering total cholesterol or the ratio think the result is extremely exciting. of LDL to HDL. “By reducing choles- The suggestion has been made that terol there are a number of factors the statins do not have an impact on the that are altered,” said Dr. Platz, who incidence of prostate cancer, [but], collaborated on the study with associ- rather, the natural history of the disates at the National Cancer Institute ease, thereby leading to a better prognosis,” said Dr. Danneberg, who was and Harvard University. “Cholesterol is overrepresented in not involved in Dr. Platz’s study. The study, he added, “also underprostate cell membranes. If you remove high levels of cholesterol you scores a growing theme in human dismight have some effect on the survival ease: the commonality of mechanism of those cells. Cholesterol, of course, related to heart disease and cancer. Inis also the precursor of sex steroid hor- flammation, for example, [is] shared by mones. I’m not aware of work that has both.” I

Internal Medicine News
President, IMNG Alan J. Imhoff
Editor-in-Chief Mary Jo M. Dales Publication Editor Calvin Pierce Publication Associate Editor Christina Chase Senior Editors Kathryn DeMott, Denise Fulton, Catherine Hackett, Gina L. Henderson, Sally Koch Kubetin, Teresa Lassman, Catherine Cooper Nellist, Kathy Scarbeck, Terry Rudd, Elizabeth Wood Associate Editors Jay C. Cherniak, Richard Franki, Deeanna Franklin, Joyce Frieden, Gwendolyn Hall, Mark S. Lesney, Jennifer Silverman, Robin L. Turner Bureaus Betsy Bates (Los Angeles), Sherry Boschert (San Francisco), Doug Brunk (San Diego), Robert Finn (San Francisco), Bruce Jancin (Denver), Kate Johnson (Montreal), Timothy F. Kirn (Sacramento), Jane Salodof MacNeil (Southwest), Diana Mahoney (New England), Damian McNamara (Miami), Michele G. Sullivan (Mid-Atlantic), Nancy Walsh (New York), Patrice Wendling (Chicago), Sharon Worcester (Tallahassee), Mitchel L. Zoler (Philadelphia) Senior Writers Jeff Evans, Kevin Foley, Elizabeth Mechcatie, Mary Ellen Schneider, Heidi Splete, Miriam E. Tucker, Kerri Wachter Copy Chief Felicia R. Black Copy Editors John R. Bell, Therese Borden, Virginia Ingram-Wells, Rachel Keith, Jane Locastro, Carol Nicotera-Ward Executive Director, Operations Jim Chicca Director, Production/Manufacturing Yvonne Evans Production Manager Judi Sheffer Production Specialists Anthony Draper, Rebecca Slebodnik, Mary D. Templin Senior Systems Administrator Lee J. Unger Application Systems Specialist Doug Sullivan Operations Assistant Melissa Kasimatis Art Director Louise A. Koenig Assistant Design Supervisor Elizabeth B. Lobdell Design Staff Sarah L. Gallant, Forhad S. Hossain, Julie Keller, Angie Ries Photo Editors Lolita Jones, Vivian E. Lee, James E. Reinaker Project Manager Susan D. Hite Assignments Coordinator Megan Evans Departmental Coordinator Vicki Long H.R. Manager Philip Cooksey Regional Manager of Facilities Chris Horne Receptionist YoLanda L. Mitchell V.P., Med. Ed./Bus. Development Sylvia H. Reitman Senior Director, Marketing/Research Janice Theobald Program Managers, Med. Ed. Sara M. Hagan, Margo Ullmann Sales Director Jeffrey R. Davis Sales Manager, Primary Care Mark E. Altier National Account Manager Barbara Napoli Classified Sales Manager Robin Cryan Director, Bus. Operations/Recruit. Adv. Bari Edwards Bus. Manager Brian O’Connor Adv. Services Manager Joan Friedman Credit Supervisor Patricia H. Ramsey Manager, Administration/Conventions Lynne Kalish Sales Assistant Evelyn Ploch Secretary Gloria DeMaio Editorial Offices 12230 Wilkins Ave., Rockville, MD 20852, 877-524-9332, imnews@elsevier.com Advertising Offices 60 Columbia Rd., Building B, Morristown, NJ 07960, 973-290-8200, fax 973-290-8250 Address Changes Fax change of address (with old mailing label) to 301-816-8736 or e-mail change to subs@elsevier.com Reprints Call 301-816-8726

44 Rx
Belimumab and rituximab appear promising for rheumatoid arthritis. New & Approved: Experts comment on Boniva for osteoporosis and Hyzaar for lowering stroke risk, 45

48 Cardiovascular Medicine
Statins may improve survival markedly in advanced heart failure.

63 Infectious Diseases
Micafungin, a new echinocandin, is available to treat fungal infections.

67 Gastroenterology
Medical management is first step in treating constipation.

70 Practice Trends
Some subspecialists are recertifying only in their subspecialty.
Policy & Practice The Rest of Your Life: Doctors talk

about raising a child with special needs, 72



Reader Services
Index of Advertisers, 72 Classifieds, 73

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