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Embargoed News from Annals of Internal Medicine
Date:2/15/2010

1. Early Release: Annals Readers Respond to USPSTF Mammography Guidelines

An editorial and a selection of reader responses to the November 17 article, "Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement," will be published early online at www.annals.org on February 15 at 5:00 p.m.


2. Pipe and Cigar Smoking Strongly Associated with Decreased Lung Function, COPD

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Philadelphia, February 16, 2010 Pipe and cigar smoke may be more harmful than once thought. While some believe pipes and cigars are healthier than cigarettes, a major known cause of chronic obstructive pulmonary disease (COPD), a new study directly links pipe and cigar smoking to decreased lung function.

Researchers conducted a population-based study to determine whether pipe and cigar smoking was associated with elevated cotinine levels (the end product of tobacco, which can be detected in the urine), decrements in lung function, and increased odds of airflow obstruction. Among 3,528 participants, those who did not smoke cigarettes but did smoke pipes or cigars were more likely to have airflow obstruction than those who had never smoked.

While cotinine levels among current pipe and cigar smokers were lower than among current cigarette smokers, the relative differences in cotinine levels may reflect differences in nicotine absorption but not necessarily exposure to harmful products of tobacco smoke.

"Our study shows that pipe and cigar smoking is associated with decrements in lung function that are consistent with obstructive lung disease," said R. Graham Barr, MD, Dr.PH, Assistant Professor of Medicine and Assistant Professor of Epidemiology at Columbia Presbyterian and lead author of the study. "These findings, together with increased cotinine levels in current pipe and cigar smokers, suggest that long-term pipe and cigar smoking may damage the lungs and contribute to the development of COPD. Physicians should consider pipe and cigar smoking a risk factor for COPD and counsel their patients to quit."

In a related editorial, Michael B. Steinberg, MD, MPH, of the University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, stresses the importance of educating the public, and expresses concern for the rising rate of tobacco use in the United States.

"We are now witnessing the concerning trend of increased use of other tobacco products," Dr. Steinberg writes. "As changes in public health policy have made cigarette smoking less socially acceptable, a distinct set of characteristics are associated with cigar and pipe use, such as sophistication, affluence, education, and celebration. These images, largely fostered by the tobacco industry, perpetuate the idea that these products play a suitable role in our society."


3. Slight Risk Increase for Heart Attack Persists Six Years After HRT Use

Postmenopausal women who take estrogen plus progestin hormone therapy have a greater risk for coronary heart disease (CHD) during the first few years after starting hormone therapy. To determine how long this risk persists, researchers randomly assigned 16,608 postmenopausal women to either a daily hormone regimen (n = 8,506) or placebo (n = 8,102). The researchers found a possible increased risk for CHD in the first two years in women who started hormone therapy within 10 years after menopause. The increase risk persisted for up to six years after use. Investigators conclude that most women who are considering short-term estrogen plus progestin hormone therapy for the relief of menopausal symptoms should not expect protection against CHD, and may need to worry about a possible slightly increased risk for heart attacks.


4. Superficial Venous Thrombosis Not So Superficial Condition May Indicate More Serious Thromboembolic Risk

Superficial venous thrombosis (SVT) is a blood clot of the superficial vein of the limbs or chest. While the condition is painful and common, it is not considered life threatening. However, new evidence suggests that SVT can occur with deep venous thrombosis (DVT) or pulmonary embolism (venous thromboembolism), two more serious conditions. Researchers studied 844 consecutive patients with symptomatic SVT of the lower limbs that was at least 5 cm on compression ultrasonography. Of the patients studied, approximately 25 percent also had DVT and about 10 percent developed thromboembolic complications over the next three months. Researchers caution that symptomatic SVT of the lower limbs may be more serious than previously thought and may be a marker for more clinically significant thromboembolic risk. For patients presenting with symptomatic SVT, close follow up and evaluation through compression ultrasonography is suggested.


5. "Dead Fish" Odor May Cause Diabetics to Discontinue Treatment with Metformin

Metformin, an oral anti-diabetic drug, is considered the first line of treatment for type 2 diabetes. The drug is associated with few adverse effects, but gastrointestinal upset is common. While the gastrointestinal effects of metformin have been well documented, researchers uncovered one characteristic of the drug that had not been previously reported in medical literature its strong and distinct fishy odor. After examining case files for two patients reporting a "dead fish" or "fishy" odor associated with the immediate release formulation of metformin, researchers searched medical literature for other documented cases. Although reaction to the odor of metformin had not been reported in medical literature, hundreds of postings to message boards on the Internet note the peculiar odor of the drug. In addition, an informal survey of pharmacists found that metformin was easily identified by its smell which was classified as "fishy" or "like old locker-room sweat socks." The researchers believe that the adverse reaction to metformin's odor may not be published because patients may report that the drug makes them nauseous, but they may not distinguish this as a visceral reaction to the smell of the medication. The authors recommend that physicians consider inquiring more closely about revulsion to the odor of the medication when patients stop taking it. Trial of a film-coated, extended release formulation may be a reasonable approach in such cases.


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Contact: Angela Collom
acollom@acponline.org
215-351-2653
American College of Physicians
Source:Eurekalert

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