In the News for the Week of 6-1-04
Clinical news in the headlines
- Aspirin may help prevent estrogen-related breast cancers
- Highlights of the June 1 Annals of Internal Medicine
- Depressed patients need to stop medication gradually
- Racial disparities found in survival rates after colon cancer surgery
Access to care
- One-third of country's ERs providing disproportionate care
- Physician neckties may spread bacteria
- Consortium issues consensus statement on palliative care
- Speakers' kit available on lung cancer diagnosis and management
- College newsgroup: incorporating part-time physicians into your practice
- ACP comments on CMS' chronic care pilot programs
- College endorses recommendations to expand physician workforce
Clinical news in the headlines
Researchers have found an association between taking regular doses of aspirin or other NSAIDs and a lower risk of developing breast tumors sensitive to estrogen.
The study, published in the May 26 Journal of the American Medical Association (JAMA), found that women taking aspirin or other NSAIDS seven or more times a week had a 20.9% of developing hormone-sensitive tumors, compared to 24.3% of women not taking the medications.
According to the May 26 New York Times, study authors claimed that results were too preliminary to recommend that women take aspirin as a preventive measure. They did suggest that women at high risk for breast cancer should discuss taking aspirin or other NSAIDs with their physician.
Hormone-sensitive tumors account for as many as 70% of all breast cancers.
The JAMA study is online.
The New York Times is online.
The following articles appear in today's Annals of Internal Medicine. The full text of the issue is available to College members and subscribers online.
Early use of statins among hospitalized patients may benefit some. An observational study of 19,537 patients admitted to 94 hospitals in 14 countries found that people who used statins before admission had better outcomes than patients who never took the drugs. The benefit occurred only if patients continued taking statins during their hospital stay. Researchers also found that patients who had not been taking statins but who started taking them in the hospital had fewer deaths than those who never took statins.
Study: Little evidence of usefulness of bioterrorism surveillance systems. While surveillance systems to detect illnesses and syndromes related to bioterrorism have proliferated, researchers have found little evidence of how reliably those systems can detect bioterrorist acts and emerging infections. Researchers identified 115 systems that collect various surveillance reports and found that only three of the systems had been evaluated for accuracy.
Supplement on diabetes. Six different papers in this issue explore diabetes control and prevention, evolving disease burden, environmental issues in diabetes self-management education, application of economic analysis to diabetes and diabetes care, and moving diabetes care from science to practice. The ideas were first presented at the CDC's Diabetes and Public Health 25th Anniversary Symposium.
As many as 20% of patients who abruptly stop taking SSRIs can experience troublesome withdrawal symptoms.
Stopping SSRIs without first ramping down the dosage can cause dizziness, nausea, headache and fatigue as well as feelings of anxiety, irritability and sadness, according to the May 25 New York Times. Patients who want to quit should stay under a physician's supervision rather than quit on their own.
Experts quoted in the article said that SSRIs with the shortest half-life-exiting the body quickly when medication is discontinued-cause the most severe withdrawal symptoms. Of the SSRIs commonly prescribed for depression, venlafaxine (Effexor) and paroxetine (Paxil) have the shortest half-lives. Fluoxetine (Prozac) lingers longer in the system and results in milder or no side effects, while bupropion (Wellbutrin), which does not work directly on serotonin, typically does not cause withdrawal symptoms.
Physicians interviewed recommended tapering off fluoxetine for seven to 10 days before stopping, and allowing several weeks or months when weaning patients off paroxetine and venlafaxine. One doctor suggested bringing down the dosage in five-milligram increments, with each stage lasting five to seven days.
The article noted that more Americans may be considering stopping the medications in wake of warnings earlier this year about potentially harmful side effects.
The New York Times is online.
A new study has found that black patients are more likely than whites to die from colon cancer following surgery.
The study, published in the online edition of the journal Cancer, looked at black and white patients who underwent surgery between 1981 and 1993 for colorectal adenocarcinoma. Researchers found that black patients were 50% more likely to die within five to 10 years, than whites. The study, based at the University of Alabama-Birmingham, suggested that the disparity is greatest among patients with early stage colonic adenocarcinoma.
The findings indicate that genetic or environmental factors may make the cancer more aggressive in blacks, according to the lead researcher quoted in the May 25 New York Times. Other studies have suggested that diets high in fat might influence outcomes.
The New York Times noted that the study should prompt black Americans to be aggressive about follow-up care, even when tumors are removed early.
The Cancer abstract is online.
The New York Times is online.
Access to care
One-third of the country's emergency departments serve as "high safety-net" facilities, providing care for significant populations of low-income and uninsured patients.
According to a report released last week by the CDC, more than 36% of the nation's emergency departments serve patient populations with at least 30% Medicaid beneficiaries, 30% uninsured patients or 40% falling into either category. Study findings were based on 2000 data.
The study found that "high safety-net" facilities tended to be located in areas with fewer primary care physicians and that patients access emergency departments for non-urgent care. The study also found that only 41% of "high safety-net" emergency departments received federal assistance for caring for a disproportionate share of Medicaid and uninsured patients.
A CDC press release with a link to the full study is online.
In related news, ACP last week called on Congress' Republican Uninsured Task Force to work with their Democratic colleagues to reduce the number of uninsured Americans and strengthen Medicaid and other safety-net programs.
In a letter dated May 17 and sent to several Republican senators, College President Charles K. Francis, FACP, commended the task force for developing proposals aimed at expanding health care coverage. Those proposals include the use of tax credits and new insurance options.
Dr. Francis also applauded the task force's recommendations to limit noneconomic damages in malpractice suits and encourage more Americans to sign up for safety net programs such as Medicaid and SCHIP.
The letter is online.
Physicians' neckties may harbor pathogens that can contribute to the spread of nosocomial infections.
A study found that almost half of physician neckties tested in a hospital contained pathogens, including Staphylocococcus aureaus and Klebsiella pneumoniae, compared to only 10% of the ties worn by hospital security personnel.
The study's lead author, a medical student who presented the findings at a conference of the American Society of Microbiology, noticed that physicians' ties often touch patient bedding when physicians are examining patients. According to the May 24 Reuters, the author recommended that physicians in hospitals should consider wearing bow-ties or tie-tacks and regularly wash ties in strong detergent.
Reuters is online.
To reduce variation in end-of-life care programs, a consortium of palliative care organizations has issued broad guidelines for designing and implementing palliative care programs.
Those guidelines, issued by the National Consensus Project for Quality Palliative Care, identified and discussed eight different domains of quality palliative care. Those domains include the psychological and psychiatric aspects of care; cultural aspects; spiritual and religious aspects; and ethical and legal aspects.
Those domains are meant to help clinicians with family communication and decision-making, as well as with delivering quality palliative care.
The guidelines as well as information about the project are online.
The American College of Chest Physicians (ACCP) is making free PowerPoint slides addressing the diagnosis and management of lung cancer available to physicians.
The slide sets--designed as speakers' kits for presentations to health care professionals--cover more than 20 different topics related to lung cancer, including screening, staging and treating, as well as follow-up, palliative and end-of-life care. The slides summarize the ACCP's 2003 evidence-based guideline on the diagnosis and management of lung cancer.
The slide sets can be downloaded online.
Are you thinking of hiring a part-time physician--or is one of the physicians in your practice considering working only part time?
Hiring part-time physicians is this month's topic on the ACP's Small Practice Management Discussion Group. The group will discuss those factors that go into deciding whether to use part-time physicians, from how the practice works together as a team to balancing the needs of the practice with the needs of individual physicians.
The group will also consider different approaches to setting up part-time work arrangements, whether by job-sharing or hiring a single physician. And the group will address ways to maximize part-time physicians' job satisfaction, efficiency and profitability.
Sarah K. Warren, ACP Member, who is a member of the College's Young Physicians Subcommittee, will lead the online discussion. As a physician who works part-time, Dr. Warren will talk about the hurdles encountered in part-time work arrangements and how those can be successfully overcome.
Targeted to members in practices with between one and five physicians, the Small Practice Newsgroup features a new topic each month, allowing participants to exchange information about what works in a small-practice setting.
The newsgroup is free to ACP members and can be found online.
Saying that internists are best suited to oversee the care of chronically ill patients, the College has issued recommendations to the CMS on its launch of pilot chronic care improvement programs.
In written testimony last week, the College urged the CMS to designate internists as the leaders of pilot care management teams and to give team leaders increased payments for coordinating patient care. In addition, the College said that physician leaders should receive incentives to produce better outcomes and reduced costs in chronic care.
The College also noted that the chronic care pilot program requires each participant to oversee as many as 150,000 Medicare beneficiaries, making it impossible for small physician practices to participate in any of the 10 pilot sites. The CMS needs to make sure that practicing physicians "are fully vested in all the care models," the testimony stated, to ensure the program outcomes and reduced costs.
The College applauded the CMS for attempting to improve the cost-effectiveness and quality of chronic care. The testimony, which was submitted to the Subcommittee on Health of the House Ways and Means Committee, noted that Medicare patients with five or more chronic conditions represent 20% of the Medicare population, but account for 66% of all Medicare spending.
You can link to the College's testimony online.
The College has voiced its support for several recommendations that would expand the physician workforce over the next 15 years.
The recommendations were included in a report issued last year by the Council on Graduate Medical Education (COGME). In a letter sent to COGME last week, College President Charles K. Francis, FACP, said the College endorsed several of the report's recommendations, including:
expanding the number of physicians entering residency training from approximately 24,000 in 2002 to 27,000 in 2015;
increasing by 15% the number of students enrolled in U.S. medical schools by 2015;
expanding the J-1 visa waiver and Conrad 30 programs to alleviate the workforce shortage in critically underserved areas;
increasing the scope of the National Health Service Corps and other programs under Title VII of the Public Health Service Act designed to improve health care access in medically underserved areas; and
offering low-interest loans with service obligations to encourage medical graduates to pursue careers in primary care and to serve in shortage areas.
ACP's letter is online.
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A 67-year-old man is evaluated for a 6-month history of worsening exertional dyspnea. He has severe COPD, previously with minimal exertional symptoms, but now notes activity-limiting shortness of breath when walking short distances. He does not have chest pain, gastrointestinal symptoms, or sleep-related symptoms. Medical history is otherwise unremarkable. Medications are a twice-daily fluticasone/salmeterol inhaler and an as-needed albuterol/ipratropium metered-dose inhaler. He has a 55-pack-year smoking history but quit when COPD was diagnosed. Following a physical exam, chest radiograph, and transthoracic echocardiogram, what is the most appropriate diagnostic test to perform next?
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