In This Issue of Archives of Internal Medicine

Langer et al evaluated the associations between venous disease ascertained by a standardized visual and Doppler-based examination and symptoms assessed by a standardized interview in a randomly selected free-living population. They found that aching, itching, heaviness, tired legs, cramping, and swelling were related to superficial and deep functional disease, varicose veins, and trophic changes. Swelling and heaviness were also related to telangiectasias. Aching was the most common symptom but was relatively nonspecific. Women were more likely than men to report symptoms. Swelling was the most specific marker for prevalent disease.

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Short-acting insulin analogues have taken over the market based on purported advantages (more physiologic dosing, reduced incidence of hypoglycemic episodes, improved metabolic control, and treatment flexibility), but their superiority over regular insulin has not been convincingly shown. To compare the effect of treatment with short-acting insulin analogues vs regular insulin, Plank et al conducted a meta-analysis of 42 randomized trials. The authors’ results suggests only a minor benefit in terms of hemoglobin A_1c in adult patients with type 1 diabetes but no benefit in the remaining population of patients with type 2 or gestational diabetes mellitus from short-acting insulin analogue treatment.

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Elevated concentrations of homocysteine may lead to a proinflammatory state that could explain its relation with vascular disease risk. In a double-blind, randomized placebo-controlled trial among 530 subjects with slightly elevated homocysteine concentrations, Durga et al show that homocysteine concentrations decreased by 28% after 1 year of daily supplementation with 0.8 mg of folic acid. However, no changes in plasma concentrations of the inflammatory markers were observed. Although homocysteine is associated with vascular disease risk in the general population, marked lowering homocysteine concentrations by 1-year folic acid supplementation does not influence inflammatory responses.

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Optimal first-step antihypertensive drug therapy in type 2 diabetes mellitus or impaired fasting glucose is uncertain. Whelton and colleagues used the experience in 31 512 participants in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) participants to determine whether treatment with a calcium channel blocker (amlodipine besylate) or angiotensin-converting enzyme inhibitor (lisinopril) decreases clinical complications compared with a thiazide-type diuretic (chlorthalidone) in patients with hypertension and diabetes mellitus, impaired fasting glucose, or normoglycemia. Using an intention-to-treat analysis of fatal coronary heart disease or nonfatal myocardial infarction (primary outcome), total mortality, and other clinical complications, the authors found no evidence for superiority of the calcium channel blocker or angiotensin-converting enzyme inhibitor compared with the thiazide-type diuretic during first-step antihypertensive therapy in participants with diabetes mellitus, impaired fasting glucose, or normoglycemia.

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Prochazka et al conducted a postal survey of attitudes and practices regarding the annual physical examination (PE) of primary care providers (PCPs) residing in 3 geographic areas (Boston, Mass; Denver, Colo; and San Diego, Calif). Most PCPs (65%) agreed that an annual PE is necessary, and 88% perform such examinations. Most (94%) agreed that an annual PE provides time to counsel patients about preventive health services, improves patient-physician relationships, and is desired by most patients (78%). Most believe that an annual PE improves detection of subclinical illness (74%) and is of proven value (63%). Many believed that tests should be part of an annual PE, including mammography (44%), lipid panel (48%), urinalysis (44%), blood glucose (46%), and complete blood cell count (39%). Despite contrary evidence, most PCPs believed an annual PE detects subclinical illness and many report performing unproven screening laboratory tests.

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