In the News for the Week of 1-25-05
Flu vaccine shortage
- Many states lift vaccination restrictions
Clinical news in the headlines
- Clopidogrel linked to increased risk of ulcers
- Drugs now preferred treatment as number of psychiatric cases rise
- Highlights of ACP Journal Club
- CMS expanding defibrillator coverage
- Blacks less likely than whites to get esophageal cancer surgery
- College members surveying patients about Information Rx
- New guide promotes national cessation event
- Register early for Annual Session and save up to $70
Flu vaccine shortage
Several states recently announced they are lifting restrictions on who can receive flu vaccine in an effort to vaccinate patients who couldn't receive vaccine earlier this season.
Patients in those states who are 50 or older or in close contact with high-risk patients can now get vaccinated. Restrictions were imposed last fall when it became clear that a major portion of the injectable vaccine ordered for the United States could not be delivered because of contamination.
In a news release earlier this month, the National Influenza Vaccine Summit—which is co-sponsored by the CDC and the AMA—encouraged patients to continue to be vaccinated through February and March. Patients should contact their physician or local health department to see if local vaccine supplies are available.
States lifting restrictions include Alaska, California, Colorado, Kansas, Massachusetts, New Jersey and North Carolina. Vaccine will continue to be shipped to providers through the end of this month.
The CDC's Advisory Committee on Immunization Practices recommends that the following groups get injectable vaccine:
- All children age 6-23 months;
- Adults age 65 and older;
- People age 2-64 who have underlying chronic medical conditions;
- All women who are pregnant during the flu season;
- Those living in nursing homes and longterm care facilities;
- Children age 2-18 on chronic aspirin therapy;
- Health care workers directly taking care of patients; and
- Out-of-home caregivers and those coming into contact with children under six months of age.
While supplies last, two other groups should be immunized: out-of home caregivers and household contacts of persons in high-risk groups; and all adults age 50-64.
A list of states that have lifted vaccination restrictions is online.
The Vaccine Summit's press release is online.
Clinical news in the headlines
Research results released last week found that patients taking clopidogrel to prevent stroke were more than 12 times as likely to suffer recurrent ulcer bleeding than patients who took a combination of aspirin and esomeprazole.
The 12-month study randomly assigned 320 patients who were negative for helicobacter pylori to receive either 75 mg of clopidogrel daily or 80 mg of aspirin daily plus 20 mg of esomeprazole twice daily. Recurrent ulcer bleeding occurred in 13 patients taking clopidogrel but in only one patient taking aspirin plus esomeprazole. The results were published in the Jan. 20 New England Journal of Medicine (NEJM).
The findings were surprising given that many doctors prescribing clopidogrel assume the drug is easier on the gastrointestinal tract than aspirin, the Jan. 20 New York Times reported. Current guidelines from both the American Heart Association and the American College of Cardiology recommend clopidogrel for patients with major gastrointestinal aspirin intolerance.
Experts said the results suggest that those guidelines should be changed and that patients at risk for ulcer should substitute aspirin plus a heartburn pill, according to the New York Times. Switching would result in significant savings for patients: Clopidogrel, which is marketed as Plavix, sells for $3-$4 a pill, compared to less than 10 cents a pill for aspirin.
An NEJM abstract is online.
The New York Times is online.
Psychiatric disorders such as substance abuse and major depression are increasingly being treated with prescription drugs alone with no psychotherapy.
More than 30 million people were treated for psychiatric disorders in 2001, up from 25 million in 1996, according to a recently published report from the Agency for Healthcare Research and Quality. The study appeared in the January/February issue of Health Affairs. Of those treated, 34% received drug treatment alone, up from 26% in 1996, while the number receiving psychotherapy did not change, according to the Jan. 13 WebMD Medical News.
The report found that the average annual cost of taking antidepressants and other mental health drugs rose from $374 to $639 per user from 1996-2001. Most of that growth in spending was due to the increased use of antidepressants and expensive atypical antipsychotics used to treat schizophrenia, WebMD reported.
About half of those who seek treatment for mental health problems do so through a primary care physician, according to an expert interviewed by WebMD. This may be effective for depression, he said, but psychotherapy combined with drugs is usually more effective in treating conditions like schizophrenia.
The Health Affairs abstract is online.
WebMD Medical News is online.
Also see "Special Focus: Depression" in the January/February ACP Observer.
A trial was designed to investigate the gastrointestinal safety of lumiracoxib, a new COX-2 inhibitor, in a substantially larger patient population than was used in previous studies on celecoxib and rofecoxib. The study of patients with osteoarthritis found that those treated with lumiracoxib had fewer ulcer complications than those treated with ibuprofen and naproxen.
The study followed 18,325 patients age 50 or older with osteoarthritis of the hip, knee or hand, or of the cervical or lumbar spine. Patients received either 400 mg of lumiracoxib daily, 800 mg of ibuprofen three times a day or 500 mg of naproxen twice a day for 52 weeks. Patients were stratified by low-dose aspirin use or nonuse. The study was abstracted in the January-February ACP Journal Club.
The size and duration of the study, the Journal Club reviewer noted, ensured that researchers could evaluate even rare adverse events with reasonable confidence. Lumiracoxib showed a three- to four-fold reduction in ulcer complications compared with naproxen and ibuprofen, and patients taking the COX-2 inhibitor did not experience serious cardiovascular events.
While the data did not show any difference in the number of myocardial infarctions between lumiracoxib and ibuprofen or naproxen users, an accompanying editorial noted that there was a nonsignificant excess of mostly nonfatal heart attacks in those taking lumiracoxib vs. those taking naproxen, especially in patients not taking aspirin.
The editors also noted that the study excluded patients with preexisting coronary artery disease. While the data seem encouraging, said the Journal Club reviewer, valid criticisms of the study will leave physicians hesitant to use even the newer COX-2 inhibitors in day-to-day practice.
The ACP Journal Club article is online.
Medicare officials announced last week that the CMS will expand coverage for implantable cardioverter-defibrillator devices to include patients who have congestive heart failure but have never suffered a potentially fatal arrhythmia.
Nearly 500,000 beneficiaries could be eligible for the implants and accompanying surgery, according to the Jan. 20 Washington Post. Medicare officials said the plan, which is estimated to cost about $3 billion a year, will become effective within a month.
The new coverage is also an attempt by the CMS to more aggressively collect health data from beneficiaries, said the Washington Post. To qualify for the implantable device, congestive heart failure patients must agree to provide the CMS with ongoing health information to help the agency determine the effectiveness of the devices.
Collecting long-term data from beneficiaries may provide more reliable information about treatment effectiveness and safety, the Washington Post reported. However, analysts pointed out that collecting data may also raise concerns about separating medical care from research.
A major government study of the implantable devices, which was published in the Jan. 20 New England Journal of Medicine (NEJM), found a 23% reduction in the number of deaths in patients with a device compared to those who received standard therapy—which included ACE inhibitors and other medications—for mild to moderate congestive heart failure. The study involved more than 2,500 patients. Researchers also found that most of the devices never fired, and that infections and other problems occurred in 14% of patients who received them.
The NEJM abstract is online.
The Washington Post is online.
Research findings published last week found that African Americans were only half as likely as whites to see a surgeon and undergo potentially life-prolonging surgery for esophageal cancer.
The eight-year study involved 2,946 white and 367 black patients with esophageal cancer age 65 or older. Only 25% of black patients received surgery compared to 46% of white patients, and the two-year survival rate for blacks was lower than whites (18% vs. 25%). Results were published in the Jan. 20 Journal of Clinical Oncology (JCO).
The study revealed that blacks were generally undertreated for esophageal cancer, which is three times more common in blacks than in whites, according to a Jan. 18 press release from the American Society of Clinical Oncology (ASCO), which publishes JCO. Twenty percent of black patients received radiotherapy as their only treatment, compared to 13% of white patients, even though surgery is the most common form of esophageal cancer treatment.
Researchers also found that fewer blacks than whites were assessed by a surgeon (70% vs. 78%) and of those, 35% went on to have surgery, compared to 59% of assessed white patients, the ASCO release reported. While black patients had poorer survival rates overall, those who had surgery experienced similar survival rates to white patients who had surgery.
The JCO abstract is online.
The ASCO press release is online.
The College has long advocated for ending racial and ethnic health disparities. ACP's position paper on disparities is online.
This winter, 32 College members in 19 states will conduct a survey to assess the impact of the Information Rx project, in which physicians refer patients to the MedlinePlus Web site for authoritative, commercial-free health care information. The 32 physicians will issue "prescriptions" for the information Web site and then survey their patients to judge the effect of the information on patient compliance, doctor-patient communication and patient outcomes.
The survey will encompass 1,100 patients, with results to be reported at a National Library of Medicine conference on the project that will be held in 2006. The Information Rx project, which is co-sponsored by the ACP Foundation and the National Library of Medicine, was made available to all College members at Annual Session 2004.
Physicians participating in the survey practice in geographically diverse locations. Patients surveyed will also vary in terms of incidence of chronic disease and in Internet use.
More information about Information Rx is online.
Physicians are encouraged to participate in "Kick Butts Day," a national event to highlight youth advocacy and activism in quitting smoking. This year's event will be held April 13.
A free activity guide is available to physicians and educators who want to host a "Kick Butts Day" event in their community. Kit resources include a CD-ROM, information about purchasing merchandise and tips for organizing a wide range of local events.
"Kick Butts Day" is a nationwide event designed to teach young people about the dangers of smoking. Activities included rallies, local carnivals, marches and pledge events. This year marks the event's 10th anniversary.
More information is online.
Register for Annual Session 2005 in San Francisco by Feb. 11, and you'll save up to $70 on registration fees. You'll also get the best choice of hotels and reserved scientific sessions.
Annual Session, internal medicine's premier educational and networking event, helps you keep abreast of the latest clinical information and find answers to common patient management problems. It's also a great way to network with colleagues from around the world.
This year's meeting features over 260 CME offerings in general internal medicine and its subspecialties. Learning Center activities and hands-on clinical skills workshops allow you to learn valuable skills in physical examination, office-based procedures and more.
Annual Session 2005 will be held in San Francisco from April 14-16, and you must register by Feb. 11 to get the discounted rate. More information and a registration form are online.
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Copyright 2005 by the American College of Physicians.
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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