In the News for the Week of 2-20-07
- Surgeon performs first whole ovary transplants
- Peanut butter recalled due to salmonella
- First state-by-state heart disease survey finds wide variations
- Annals of Internal Medicine:
- Periodic Health Evaluation beneficial as part of regular health care
- Immunochemical FOBT has success in identifying cancer
- New algorithm predicts women’s heart risk
- Antithrombotic therapy after AF often veers from guidelines
- Seniors, physicians fail to communicate about medication
- Telithromycin should only be used to treat pneumonia, FDA says
- EHR criteria available for public comment
- ACP approves principles on retail health clinics
- MKSAP 14 now available online and on CD
- Business of Medicine course at Internal Medicine 2007
A surgeon in St. Louis recently performed two separate transplant operations of whole ovaries, the first to occur in the U.S. On Feb. 5, an ovary was transplanted from a woman to her sister, following a successful transplant between twins in January.
Sherman Silber, MD, of the Infertility Center of St. Louis at St. Luke’s Hospital in Chesterfield, Mo., has been successfully transplanting strips of ovarian tissue between twins since 2004, said the Feb. 13 Washington Post. Recipients of the tissue transplants have conceived and given birth, but ovarian function may last only a few years. A whole ovary with its own blood supply could last decades, said Dr. Silber in the article.
The transplant procedure requires a form of microsurgery, sewing the tiny ovarian artery of the donor to the ovarian artery of the recipient. One 30-year-old transplant recipient had undergone early menopause as a result of treatment for non-Hodgkins lymphoma. The transplant may allow her to conceive children as well as alleviate her menopause symptoms, said the Washington Post.
Surgeons in China reported a successful whole-ovary transplant a few years ago, but there is no published medical literature on the case, the Washington Post reported. Dr. Silber’s work also holds potential for researchers who are looking at freezing and retransplanting ovaries to preserve cancer patients’ fertility.
The Washington Post is online.
A salmonella scare led the FDA to warn consumers to discard Peter Pan peanut butter and certain batches of Great Value peanut butter last week.
Any peanut butter jar with a product code on the lid starting with “2111,” and which has been purchased since May 2006, should be discarded, said a Feb. 14 FDA news release. The CDC has tied an outbreak of at least 288 cases of food-borne illness in 39 states with consumption of Peter Pan peanut butter, which is produced in the same Georgia facility as some batches of the Great Value brand.
The known onset dates for the outbreak of Salmonella Tennessee infections are from Aug. 1, 2006 to Jan. 21, 2007, a Feb. 15 CDC update said. There have been no deaths, but about 20% of the ill were hospitalized.
The greatest number of cases were reported in New York, Pennsylvania, Virginia, Tennessee and Missouri, the Feb. 16 New York Times said. It’s not yet clear how salmonella got into the peanut butter.
Salmonella sickens about 40,000 people, and kills about 600, in the U.S. each year, the CDC said.
The FDA release is online.
The CDC is online.
The New York Times is online.
The CDC's first-ever survey on the variation of heart disease prevalence among U.S. states and territories found that some states had double the prevalence of heart disease as others. Prevalence of disease also varied by gender, ethnic background and education.
The telephone survey of more than 350,000 people found that the prevalence of heart attack, angina or coronary heart disease ranged from 3.5% in the U.S. Virgin Islands to 10.4% in West Virginia, according "Prevalence of Heart Disease – United States, 2005," published in the Feb. 16 Morbidity and Mortality Weekly Report.
States with the highest prevalence scores for all three conditions were clustered in the lower Mississippi and Ohio River valleys, areas known to have high proportions of residents with heart disease risk factors and mortality, said an accompanying editorial. Other states with low prevalence scores included Colorado (4.8%), Hawaii, (4.9%) and Utah (5.0%).
Overall, 6.5% of respondents said they had been told by a doctor that they had one of the three conditions, with 4% reporting that they had experienced a heart attack and 4.4% reporting angina or coronary heart disease. Other findings included:
- Men had a significantly higher prevalence than women (8.2 % vs. 5 %) for coronary heart disease or non-fatal heart attack, and angina.
- American Indians/Alaska Natives had the highest heart disease prevalence (11.2%) while Asians had the lowest prevalence (4.7%).
- People with fewer than 12 years of education had a higher prevalence (9.8%) of heart disease than college graduates (5%).
The editorial accompanying the MMWR report also noted that the findings indicate that public health programs should target disproportionately affected populations in order to lower the incidence of heart disease and eliminate health disparities.
The CDC news release is online.
The MMWR report is online.
The following articles appear in the Feb. 20 issue of Annals of Internal Medicine. This issue also includes an article on the widening income gap between primary care physicians and specialists and a study finding that a bronchodilator plus another inhaler improves outcomes for people with COPD. The full text is available to College members and subscribers online.
Periodic Health Evaluation beneficial and should be part of regular health care. A review of 21 published studies that evaluated the benefits and harms of periodic health evaluations (PHEs) on patient health and health care costs found that the benefits justify PHE implementation in clinical practice. The study found that people who had PHEs had more gynecologic examinations and Pap tests, cholesterol screenings and fecal occult blood tests and had less worry than those who had usual care. The available evidence did not reveal harms associated with the PHE, e.g., ordering or receiving inappropriate tests. The definitions of what constitutes an adequate PHE varied among studies reviewed. The authors say that more research is needed to clarify the long-term benefits, harms, and costs of receiving a PHE.
Immunochemical FOBT has success in identifying cancer. A three-sample clinical immunochemical test that measures the hemoglobin content of a stool sample (I-FOBT) had 88% sensitivity and 90% specificity for detecting colorectal cancer and 62% sensitivity and 93% specificity for detecting abnormal growths. One thousand patients considered at above-average risk for colorectal cancer received an I-FOBT, followed by a colonoscopy. The I-FOBT does not require dietary restrictions as does the guaiac-based FOBT. An editorial writer said that I-FOBT is a potentially important test for colorectal cancer screening because it is better than guaiac-based FOBT for detecting occult bleeding and should be preferred to guaiac-based FOBT wherever FOBT is a component of a recommended screening strategy.
Researchers have developed a new assessment tool that may better predict women’s risk of cardiovascular diseases. The new risk model, called the Reynolds Risk Score, adds family history and levels of C-reactive protein to the measures currently recommended in the National Cholesterol Education Program Adult Treatment Panel III guidelines (ATP-III).
The Reynolds model was developed by researchers at Brigham and Women’s Hospital using the Women’s Health Study, in which researchers followed 25,000 initially healthy women for an average of 10 years. Information from two-thirds of the study participants was used to design the new risk model, and data from the other third were used to assess the validity of the algorithm. The model includes age, blood pressure, total and HDL cholesterol, smoking, C-reactive protein (CRP) and family history (whether a parent had a heart attack before age 60). The study was published in the Feb. 14 Journal of the American Medical Association.
Based on the new model, researchers reclassified 40%-50% of women identified as intermediate risk by ATP-III into higher- or lower-risk categories. The results could have a significant impact on disease prevention, study authors told the Feb. 13 Washington Post, because the new model will allow physicians to give aspirin and statins to women who need them (without exposing those who don’t) in a cost-effective manner.
A JAMA editorial writer agreed that the model is an important finding but questioned whether routinely incorporating family history and CRP into treatment decisions would result in lowered cardiovascular morbidity in a cost-effective manner. He noted that based on the model about 20% of women would have different lipid treatment goals. Further studies are needed to determine the model’s application to men’s health and to develop predictors of women’s long-term risk, the editorial said.
The Journal of the American Medical Association is online.
The Washington Post is online.
Forty-one percent of atrial fibrillation patients at high risk of stroke didn’t receive warfarin as recommended by treatment guidelines, a Feb. 12 study in Archives of Internal Medicine found.
Researchers analyzed the medical records of 597 patients at Seattle’s Group Health Cooperative, aged 30 to 84, with newly diagnosed AF. Patients were stratified by embolic risk according to American College of Chest Physicians’ Criteria. Study authors analyzed how many received warfarin or aspirin during the six months following AF.
Overall, 73% of patients had antithrombotic use after AF onset. Of the 76% of patients with high stroke risk, 59% used warfarin, 28% used aspirin and 24% used neither (11% used both warfarin and aspirin). AF classification, not stroke risk factors, was the strongest predictor of warfarin use. Aspirin use, on the other hand, was similar across strata.
The lack of influence of stroke risk factors on warfarin use is cause for concern, given that several studies show warfarin reduces the risk of stroke in AF patients, the authors said.
Study limitations include the fact that the Group Health population tend to have higher income and education and fewer African-Americans compared to the rest of the U.S., thus the study results may not be generalizable to all populations. Also, it wasn’t determined whether noncompliance with guidelines was due to physician noncompliance or patient refusal of treatment, the authors said.
The Archives of Internal Medicine abstract is online.
A new study found a significant communication gap between U.S. seniors and their physicians regarding prescription medication. Approximately 40% of surveyed seniors reported not adhering to their prescribed regimens, according to the study.
In the national survey of 17,000 low-income Medicare beneficiaries, noncompliance was particularly prevalent among seniors with three or more chronic conditions. Of those seniors, 52% were not taking medicine as directed, 35% of them citing cost as a reason. Within that group, 39% did not discuss their cost concerns with their doctor. Among the patients who did tell their doctors about cost issues, 41% were switched to a lower-cost medication.
The survey also found that 27% of patients who skipped doses, stopped taking a drug because of side effects or felt they did not need the drug failed to inform their doctors. The study was published in the January issue of the Journal of General Internal Medicine.
The findings show the need for improved physician-patient communication about prescriptions, especially in light of the challenges posed by new Medicare prescription plans, study authors said. They suggested that more attention be devoted to medication management during all clinical encounters.
The Journal of General Internal Medicine is online.
Telithromycin (Ketek) should be used only to treat mild to moderate community-acquired pneumonia, not bronchitis and sinusitis, the FDA said last week. The agency also added a black-box warning against using the drug in patients with myasthenia gravis.
Telithromycin was previously indicated for acute bacterial sinusitis and acute bacterial exacerbations of chronic bronchitis, but reports of liver disease led the FDA to remove it for those conditions. The agency has determined that the balance of benefits and risks no longer support approval of the drug for these indications, the FDA said in a Feb. 12 release.
Label warnings were added for loss of consciousness (following post-marketing adverse event reports, some associated with vagal syndrome) and visual disturbances (including blurred vision, difficulty focusing and diplopia). The label had already warned of hepatotoxicity. An FDA review in December cited 13 reports of liver failure in patients treated with the drug, and the FDA has since learned of one additional such case, said the Feb. 12 Washington Post.
The FDA and manufacturer Sanofi Aventis developed a Patient Medication Guide, to be provided with each prescription, which informs patients about the risk of the drug and how to use it safely. As of late last year, doctors had prescribed telithromycin more than 5.6 million times in the U.S. since it got FDA approval in 2004, the Washington Post said.
The FDA release is online.
The telithromycin medication guide for patients is online.
The Washington Post is online.
The Certification Commission for Healthcare Information Technology (CCHIT) last week released new proposed certification criteria for both inpatient and ambulatory electronic health records. The proposals are currently open for public comment through CCHIT’s Web site.
The inpatient certification criteria are in the second draft stage and are open to comment from Feb. 16 to March 16. CCHIT is also seeking comment on proposed test strategies for inpatient EHR products.
The final criteria for ambulatory EHR certification were presented for two weeks of public comment on Feb. 14. The new criteria will take effect May 1, and changes from last year’s certification requirements include new interoperability requirements for sending electronic prescriptions and receiving laboratory test results. These would be the first CCHIT criteria to require common standards for sending and receiving patient care information, making EHRs compatible with emerging health information networks.
A pilot test of the 2007 ambulatory EHR test scripts was successfully completed, according to CCHIT officials.
The CCHIT is online.
At its January meeting, ACP’s Board of Regents approved a set of principles to guide ACP Chapters in dealing with any individual, company or other entity that seeks to establish and/or operate a retail health clinic in their region.
Retail health clinics located in grocery and drug stores offer patients convenient settings and competitive pricing. However, the clinics, which are primarily staffed by nurse practitioners and physicians’ assistants, do not allow for the providers to know the patient’s complete background and do not encourage continuity of care.
ACP’s guidelines state that retail health clinics should have a well-defined and limited scope of clinical services given the limited clinical services that can be provided in such settings. They also say that these clinics should have a system in place so that information about the care provided is communicated to the patient’s primary care physician.
The complete guidelines are online.
The most recent edition of ACP’s premier education resource, Medical Knowledge Self-Assessment Program® (MKSAP), is now available in an online version and on CD-ROM.
These electronic versions of MKSAP 14 offer new features, including immediate feedback, critique, a peer-comparison response, and a cross-link between multiple choice questions and related syllabus material. Users can also perform instant access searches for a single word or topic, and access additional tutorials on pathology, diagnosis and more.
The CD-ROM can be used by both PC and MAC users. MKSAP 14 online is available on any computer with internet access 24 hours a day. The online edition also offers the lowest-priced access to MKSAP; however, it does not provide CME credits or tutorials.
A sample chapter and ordering information for both versions are online.
The College is offering a new one-day course at Internal Medicine 2007 to provide physicians with necessary training in the non-clinical aspects of practice.
The Business of Medicine 101, developed by ACP’s Council of Young Physicians and the Practice Management Center, focuses on the ‘gap’ between a physician’s medical knowledge and business acumen. A mixed faculty of internists and management specialists will present core elements of functional business training that specifically apply to the needs of practicing physicians, from solo practitioners to those in larger groups.
Participants will learn critical skills in:
- Coding and compliance
- Personnel management
- Managing office finances
- Payer contract negotiations
- Practice information technology
- Malpractice avoidance
- Negotiating an employment contract
- Increasing productivity and revenue
The Business of Medicine 101 (course code PRE710) will be offered on April 17 and 18 at Internal Medicine 2007.
Registration is online.
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Copyright 2007 by the American College of Physicians.
A 30-year-old woman is evaluated for difficult-to-treat migraine. She has had severe headaches, usually on the first day of menses, since menarche. The pain is hemicranial, pulsatile, and associated with severe nausea and vomiting but no aura. She frequently awakens with the attack already in progress. A series of drug regimens have become ineffective in controlling pain. Following physical and neurological exams, what is the most appropriate next step in treatment?
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