American College of Physicians: Internal Medicine — Doctors for Adults ®


In the News for the Week of 10-23-07

News highlights

  • Community- and hospital-associated MRSA on the rise
  • New research unveiled at gastroenterology meeting
  • HPV tests more sensitive than Pap tests
  • Congress fails to override SCHIP veto

Hospital medicine

  • OIG approves medical center's payment plan for ED coverage
  • Rapid treatment of TIA and minor stroke improves outcomes

Clinical news

  • HIV significantly raises African Americans’ renal disease risk
  • CDC issues updated immunization schedule
  • ACP Journal Club: Same-day discharge after elective percutaneous coronary intervention was noninferior for safety to staying overnight in hospital

FDA news

  • Deaths spur black box warnings for echocardiography contrast agents
  • Exenatide may be linked to acute pancreatitis, agency warns
  • First in new class of HIV drugs approved

Education news

College news

  • Reader opinions needed for new political column
  • Cartoon caption contest: And the winner is …
  • NCQA conference on Patient-Centered Medical Home
  • Regent appointed to American Academy of HIV Medicine

News highlights

Community- and hospital-associated MRSA on the rise

Rates of methicillin-resistant Staphylococcus aureus (MRSA) infections are rising rapidly in the community as well as in health care settings, indicating that MRSA has become a major public health problem, according to the authors of a new study.

Researchers from the CDC conducted active surveillance for invasive MRSA at nine sites from July 2004 through December 2005. They found 8,987 cases, most of which were health care-associated. Of the reported infections, 58% were community-onset, 27% were hospital-onset and 14% were community-associated. Most of the cases that occurred outside the hospital affected patients with established risk factors (such as recent hospitalization), and molecular analysis indicated that many of the infections were caused by MRSA strains of health care origin. Incidence rates were highest among people age 65 and older, blacks and males.

Based on the study data, the researchers estimated that 94,360 invasive MRSA infections occurred in the U.S. in 2005, and 18,650 of them led to death. That results in an “astounding” incidence rate of 31.8 per 100,000, noted an accompanying editorial. If the researchers’ calculations are correct, MRSA caused more deaths in the U.S. in 2005 than HIV/AIDS, the editorial writer said. The study and editorial were published in the Oct. 17 Journal of the American Medical Association.

The study authors mentioned several limitations to their work, including the difficulty of determining whether deaths were definitely due to MRSA. Because they found wide geographic variations in MRSA incidence (from 2.8 per 100,000 in Connecticut to 116.7 per 100,000 in Baltimore), it is also difficult to tell how representative their findings are of the entire country.

The study’s findings make clear, however, that public health personnel and health care providers need to work vigorously to both decrease transmission of MRSA and ensure judicious use of antibiotics, the editorial concluded.

The study and editorial are online.


New research unveiled at gastroenterology meeting

PHILADELPHIA--Obesity, colon cancer, NSAIDs and reflux disease were hot topics at the American College of Gastroenterology’s annual scientific meeting held here Oct. 15-17. New research released at the meeting included:

  • A study of 1,252 women who underwent colonoscopy found that obesity was the highest attributable risk factor for colorectal cancer. The researchers classified patients by age, smoking history, family history and BMI. According to the study, BMI accounted for 1 out of 5 significant lesions detected. Of the women who had colorectal neoplasia, 20% were obese and 14% were smokers. The study highlights the importance of identifying and screening these high-risk patients, said study authors.

  • Using a mathematical model, researchers compared the effectiveness of initial screening polypectomies versus surveillance follow-up colonoscopy in reducing colorectal cancer mortality. The model showed a dramatic reduction in expected mortality due to the polypectomy both with and without surveillance. Based on the findings, it may be appropriate to lengthen the interval for follow-up after polyp removal to six or more years, the study authors said. ACG guidelines currently call for surveillance colonoscopy in three to five years.

  • A prospective survey of 100 patients in a private GI practice found that 18% noted use of an NSAID that they hadn’t reported earlier to nursing staff when asked generally about medication use. Of those who didn’t initially report, 14% said they were never asked about the specific medicine, 22% said they didn’t think the medicine was important enough to list, 34% bought the medication with prescriptions and 30% said they didn’t report it because the doctor didn’t prescribe the drugs.

  • A study of 31 patients who came to the emergency department with non-cardiac chest pain found that 57% had gastroesophageal reflux disease, and that more of these patients were women than men. The results suggest the role of acid reflux is overlooked as a potential factor in diagnosing and treating serious chest pain.

--By Jessica Berthold, senior writer, and Stacey Butterfield, staff writer


HPV tests more sensitive than Pap tests

Tests for the DNA of human papillomavirus (HPV) find more pre-cancerous cervical lesions than traditional Pap tests although they may also result in more false positives, according to two studies released last week.

In the first study, 10,154 Canadian women between the ages of 30 and 69 were randomly assigned to HPV or Pap testing. Those with abnormal test results, as well as a random sample of women with negative results, underwent colposcopy and biopsy. According to the study, the HPV test detected cervical neoplasia of grade 2 or 3 with a sensitivity of 94.6%, compared with 55.4% for Pap tests. On specificity, the HPV test was 94.1% accurate compared with 96.8% for the Pap test.

In the second study, 12,527 Swedish women, 32 to 38 years old, received either an HPV test and a Pap test or a Pap test alone. Women with a positive HPV test and a normal Pap test were offered a second HPV test a year later, and those who still had high-risk HPV were offered colposcopy and biopsy. At the initial screening, grade 2 or 3 lesions or cancer were found 51% more often in the women with the double screening compared with controls. At subsequent screenings, the intervention group was 42% less likely to have lesions or cancer compared with controls. Both studies were published in the Oct. 18 New England Journal of Medicine.

The important question raised by these studies is whether clinicians are willing to sacrifice specificity for sensitivity, said an accompanying editorial. Replacing Pap tests with HPV testing could result in more women being referred for colposcopy and greater use of health care resources, the writer noted. The Swedish researchers used a very sensitive HPV test that is not yet widely available, and both studies used conventional cytologic Pap testing, rather than the liquid-based technology that is generally used in the U.S. Further research is needed to determine how the research would apply to current practice and to uncover the optimal approach to reducing incidence of and mortality from invasive cervical cancer, the editorial concluded.

The Canadian and Swedish studies are online, along with the editorial.


Congress fails to override SCHIP veto

In a vote last Thursday, Congress failed to override President Bush’s veto of legislation to expand the government’s children’s health insurance program. The House fell 13 votes short of the two-thirds needed to overturn the veto to the State Children’s Health Insurance Program (SCHIP) bill.

The program was set to expire on Sept. 30 this year. However, at the end of September Congress passed a continuing resolution to keep the program going until Nov. 16.

President Bush has indicated that he is not willing to re-authorize the program’s budget more than the $5 billion over five years that he previously proposed. The unsuccessful legislation would have expanded the program by $35 billion over five years. Democratic Congressional leaders still plan to provide coverage for 10 million children under the revised legislation, according to the Oct. 18 New York Times.

In a statement, ACP President David C. Dale, FACP, noted that ACP was deeply saddened that Congress did not manage to override the presidential veto. “The bill represents good health care policy,” Dr. Dale emphasized. ACP strongly supported the bill’s provisions to increase federal taxes on tobacco products as a principal means of funding the program.

“Until SCHIP is re-authorized, millions of children will be at risk of being denied basic health care needs that give a child a healthy and successful start in life,” said Dr. Dale.

ACP will continue to urge Congress to again pass a bill that provides comparable levels of coverage.

More information about ACP’s reaction is online.

The New York Times is online.


Hospital medicine

OIG approves medical center's payment plan for ED coverage

A medical center that pays physicians for ED coverage will not be subject to sanctions under the federal anti-kickback statute, the Department of Health and Human Services' Office of the Inspector General recently ruled.

The medical center, which was not named in the OIG's advisory opinion, developed its payment program for on-call physicians to address problems in obtaining coverage for the ED and for follow-up inpatient care of admitted patients. Under the program, physicians in certain specialties contract with the medical center for two-year terms to take ED call and provide care to patients they admit through the ED while on call. Physicians are paid per diem rates for each day on call, with the exception of 1.5 days each month that are not reimbursed. The per diem rates vary by specialty and time of call (weekday or weekend).

The OIG examined the payment program at the medical center's request and concluded that it did not violate federal regulations for several reasons. First, participating physicians are paid fair market value for quantifiable services, not for patient referrals. Second, the medical center demonstrated that its program was developed to meet a legitimate need. Third, on-call shifts are divided evenly among participating doctors and "cherry-picking" profitable patients is unlikely because physicians must follow up on all patients they admit from the ED regardless of their financial situation.

The OIG stressed that its opinion applies only to this specific medical center and cannot be cited as support by any other group or institution. However, experts called the opinion good news, the Oct. 22/29 American Medical News reported. "What the OIG is trying to do is signal to the industry that there's nothing inherently wrong with paying for on-call coverage when the service is actually needed and a hospital can demonstrate in good faith that it is trying to get coverage for its community," one health care lawyer said.

The OIG opinion is online.

American Medical News is online.


Rapid treatment of TIA and minor stroke improves outcomes

Rapid treatment of transient ischemic attack (TIA) and minor stroke greatly reduces the risk of recurrent stroke, according to two new studies.

In the first study, French researchers set up a 24-hour hospital clinic to provide more rapid evaluation of patients with suspected TIA. Referred patients with TIA symptoms underwent standard clinical assessment (neurological, arterial and cardiac imaging) within four hours of clinic admission and received treatment and comprehensive stroke prevention therapy as warranted. The researchers compared actual stroke rates within 90 days with the expected rate based on patients' ABCD2 scores. The study was released early online and appears in the November Lancet Neurology.

From January 2003 to December 2005, 1,085 patients with suspected TIA were admitted to the hospital clinic, more than half within 24 hours of symptom onset. Of the 1,085 patients, 701 (65%) were confirmed to have TIA or minor stroke and 144 (13%) were diagnosed with possible TIA. All of the patients with confirmed or possible TIA received comprehensive stroke prevention measures; 43 (5%) underwent urgent carotid revascularization, and 44 (5%) received anticoagulants for atrial fibrillation. Almost 75% of patients seen at the clinic were discharged home on the same day, and their family physicians received discharge summaries stating the goals of stroke prevention therapy (e.g., lowered blood pressure and LDL cholesterol levels and smoking cessation). At 90 days, 1.24% of patients had had a stroke, compared with the predicted rate of 5.96%. The rate of vascular death and myocardial infarction at one year in patients with confirmed TIA or minor stroke was 1.1%.

The authors attributed their results to early neurological assessment and rapid initiation or adjustment of stroke prevention therapy. Although their trial was not randomized and recall bias may have been a factor, the authors concluded that rapid stroke assessment in a 24-hour clinic could reduce hospital length of stay and decrease recurrent stroke risk.

The second study, which was also released early online and appears in the Oct. 20 Lancet, examined rapid assessment of TIA and minor stroke in patients referred to a stroke clinic. In phase 1 of the study, the stroke clinic was appointment-based and recommended treatment to the referring physician rather than providing it, while in phase 2, appointments were not required and treatment was begun immediately once a diagnosis was confirmed. Six hundred thirty-four patients were seen during phase 1 and 644 were seen during phase 2. Treatment was initiated much more quickly during the second phase of the study than in the first (median delay, 1 day vs. 20 days), and the risk for recurrent stroke at 90 days was much lower (2.1% vs. 10.3%). The researchers recommended additional follow-up to ascertain long-term outcome but said their results have immediate public health implications for treatment of patients with suspected TIA and minor stroke.

The Lancet Neurology and The Lancet are online.


Clinical news

HIV significantly raises African-Americans’ renal disease risk

For African-Americans, HIV infection confers about the same elevated risk of developing end-stage renal disease (ESRD) as does diabetes--a much higher risk than for HIV-infected whites, a new study found.

Researchers analyzed data on 2,015,891 veterans who had kidney function tests during 2000-01, and followed them for about 3.7 years to see who would develop ESRD. More than 15,000 of the veterans had HIV, 54% of whom were black. More than 594,000 had diabetes, 16.5% of whom were black. The study will appear in the November issue of the Journal of the American Society of Nephrology.

After adjustment for other factors, like age and sex, the risk of developing ESRD for HIV-infected black patients was about six times the risk of whites with HIV. Black patients with HIV were as likely to develop ESRD as black patients with diabetes, and both had nearly twice the risk of a white patient with diabetes. White patients with HIV, however, had about the same risk of developing ESRD as white patients without HIV or diabetes.

The findings demonstrate the particular importance of managing kidney disease among black patients with HIV, the authors said. In addition, the heightened race-dependence of HIV as a risk factor for ESRD suggests HIV may be a model for understanding racial differences in the progression of kidney disease, they said.

The Journal of the American Society of Nephrology is online.


CDC issues updated immunization schedule

The CDC's Advisory Committee on Immunization Practices (ACIP) last week released its Adult Immunization Schedule for October 2007-September 2008.

Changes in the new schedule include:

  • Varicella vaccine is recommended for all adults without evidence of immunity to varicella;
  • Zoster vaccine is recommended for persons aged 60 years and older;
  • Recommendations for HIV-infected individuals are organized according to CD4 cell count; and
  • Health care workers have the option of either trivalent inactivated flu vaccine or live, attenuated vaccine.

The 2007-08 schedule is online.

ACIP schedules for specific vaccines are online.


ACP Journal Club: Same-day discharge after elective percutaneous coronary intervention was noninferior for safety to staying overnight in hospital

A new study found that same-day discharge is as safe as staying overnight in the hospital for patients who have elective percutaneous coronary intervention.

The randomized, controlled, noninferiority trial involved 800 patients in the Netherlands age 30 to 88 years who were scheduled for elective PCI, and who remained at home without acute coronary syndrome the week before PCI. Patients were either discharged four hours after PCI, unless extended clinical observation was deemed necessary, or stayed overnight and were discharged the next day. In the same-day discharge group, 19% of patients required extended hospital stay, compared to 21% in the overnight-stay group. Seventy-seven percent and 4% of patients, respectively, were discharged four hours after PCI.

Groups didn’t differ at 24 hours or 30 days for incidence of the composite end point, which was major adverse cardiac or cerebral event (MACCE), severe complication of the arterial puncture requiring blood transfusion or repeated compression. Risk for MACCE alone in the first 24 hours was lower in the same-day discharge group than in the overnight-stay group, but was similar at 30 days and one year. In patients suitable for same-day discharge, the only adverse events at 24 hours were false aneurysms in one patient in the same-day discharge group and in two patients in the overnight-stay group. Mean cost savings were 258 euros with same-day discharge. The study is abstracted in the September/October ACP Journal Club.

Though the trial was randomized, it has several major design problems, including that patients were randomized before PCI and the authors “made little effort to identify late PCI complications, especially in the early-discharge group,” said Journal Club reviewers Mark Hlatky, MD, and John Giacomini, MD, of Stanford University School of Medicine. This bias in trial design, along with a low event rate, small sample size and poor follow-up, makes the conclusion of non-inferiority not credible, and more research is necessary, the reviewers said.

Peer ratings for this review: Cardiology: 6/7 stars. Hospitalists: 5/7 stars

ACP Journal Club is online.


FDA news

Deaths spur black box warnings for echocardiography contrast agents

Black box warnings are being added to two echocardiography contrast agents following the deaths of 11 people who used the drugs, the FDA said.

Ten deaths involved Perflutren Lipid Microsphere Injectable Suspension (Definity) and one involved Perflutren Protein-Type A Microspheres for Injection (Optison). Four of the 11 reported deaths were caused by cardiac arrest and occurred during or within 30 minutes of drug infusion, while most occurred 1 to 12 hours after administration and involved patients with severe underlying conditions. Some patients also were being treated with other medications that could have contributed to their deaths, the FDA said.

About 199 serious non-fatal reactions occurred as well, many of them either during or within minutes of administration of the drug. Medical professionals shouldn’t use the drugs in patients with unstable cardiopulmonary status, including patients with unstable angina, acute myocardial infarction, respiratory failure or recent worsening congestive heart failure. The FDA also advises monitoring anyone who receives the drugs for 30 minutes after infusion.

The FDA alert and information sheet are online.


Exenatide may be linked to acute pancreatitis, FDA warns

The FDA has received 30 reports of acute pancreatitis in patients taking exenatide (Byetta) for type 2 diabetes, the FDA said last week.

Twenty-seven of the patients had at least one other risk factor for acute pancreatitis such as gallstones, severe hypertriglyceridemia and alcohol use. In six patients, the pancreatitis symptoms started or got worse soon after their exenatide dose was increased from 5 to 10 micrograms twice daily. Twenty-two of the patients improved after they stopped taking the drug.

Physicians should tell patients taking exenatide to seek immediate care if they have unexplained and persistent severe abdominal pain. The pain may or may not be accompanied by vomiting. Patients should stop using the drug if pancreatitis is suspected, and if the diagnosis is confirmed, the drug shouldn’t be restarted unless another cause is identified.

The FDA alert and information sheet are online.


First in new class of HIV drugs approved

The FDA approved raltegravir (Isentress), the first integrase strand transfer inhibitor, to treat HIV in combination with other antiretroviral drugs.

Raltegravir is designed to interfere with the enzyme that HIV-1 needs to multiply. The drug is meant for treatment-experienced adults with evidence of viral replication and with HIV strains that are resistant to multiple antiretroviral drugs, the FDA said.

The most common side effects in trials were diarrhea, nausea and headache. Some patients also had abnormally high levels of a muscle enzyme in blood tests, so the FDA advises caution when using raltegravir in patients at increased risk for certain types of muscle problems. The long-term effects of the drug are unknown, the FDA said.

The FDA release is online.


Education news

CDC fellowships for med students

The CDC is looking for rising third- and fourth-year medical students who want to explore applied epidemiology. The CDC Experience is a one-year fellowship designed to increase the pool of physicians with a population health perspective. Eight competitively selected fellows spend 10 to 12 months at CDC offices in Atlanta, where they carry out epidemiologic analyses in areas of public health that interest them.

Projects range from investigating outbreaks of tuberculosis among the homeless to investigating an outbreak of leptospirosis among adventure racers in a Florida swamp, or assessing risk factors for reproductive-health visits to emergency departments. CDC’s environment provides multiple opportunities to enhance skills in research and analytic thinking, written and oral scientific presentations, and preventive medicine and public health. All fellowship assignments offer opportunities to complete epidemiologic analyses which may lead to scientific publications.

Experience in public health is not required to apply for this program. CDC staff will help fellows acquire practical tools useful for approaching population-based health problems. The first class of fellows entered in 2004; graduates have followed varying paths--residencies in clinical specialties, even anesthesia and orthopedics. Applications for next year's fellowship class must be postmarked by Dec. 3, 2007.

Information and applications are online.


College news

Reader opinions needed for new political column

For our new “Campaign Trail” column, ACP Observer wants readers’ opinions on the upcoming presidential election. Click here to answer our survey question about which health policy issue is most important to you. The issue that receives the most votes will be the topic of the first Campaign Trail column, slated to run in the January edition.


Cartoon caption contest: And the winner is ...

The winning October cartoon caption comes from Roman Gimpelevich, ACP Associate Member, of Rush Presbyterian-St. Luke's Center in Chicago. He will receive the original Joe Ferris cartoon that inspired his winning quip. A new contest will appear in next week's issue.

Cartoon caption contest

"So we’re in agreement: There is no patient on the table."


NCQA conference on Patient-Centered Medical Home

The National Committee for Quality Assurance (NCQA) will hold its second annual Policy Conference, Building the Patient-Centered Medical Home, in Washington, D.C. on Dec. 6, 2007. The one-day conference features expert panelists who will discuss current and proposed medical home projects and how the concept can address disparities in access and quality of care.

John Tooker, FACP, the College's Executive Vice President and Chief Executive Officer, will be a featured speaker and will discuss ACP’s patient-centered medical home concept and upcoming demonstration project. Other speakers will present up-to-date research, and an international panel will review how the patient-centered medical home concept has been integrated into medical systems in other countries.

More information and registration information are online.


Regent appointed to American Academy of HIV Medicine

Donna E. Sweet, MACP, Chair Emeritus of the Board of Regents and Chair of the ACP Nominations Committee, became Vice Chair of the Board of the American Academy of HIV Medicine (AAHIVM) on Sept. 1. She will assume office as Chair of the AAHIVM Board on Sept. 1, 2008. The American Academy of HIV Medicine is an independent organization of HIV specialists and others dedicated to advancing excellence in HIV/AIDS care.

Dr. Sweet is Chair of the AAHIVM Credentialing Committee. She is a professor of internal medicine at the University of Kansas School of Medicine-Wichita and director of internal medicine education at Via Christi Regional Medical Center-St. Francis in Wichita. Dr. Sweet has been recognized locally and nationally for her work on treatment and research of AIDS and HIV.

The AAHIVM is online.


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