In the News for the Week of 3-13-07
- CT scanning doesn’t reduce lung cancer deaths
- Surgical patients at high risk for medication errors
- Aspirin, NSAIDs shouldn’t be used to prevent colorectal cancer
- ACP Journal Club: Discontinuation of medications one month after MI raises death risk in 12 months
- EKG abnormalities indicate heart disease risk in women
- Radiation may increase heart risk for breast cancer survivors
- Kidney disease patients at higher risk for other problems
- ACP and other groups release principles on patient-centered care
- Call for 2008 College Regent and Officer nominations
- Visit ACP's Job Placement Center at Internal Medicine 2007
CT screening increases the rate of diagnosis for lung cancer but does not reduce the number of advanced cases or deaths from the disease, according to a new study. The findings differ from a recent study which found that CT screening dramatically improved survival rates in lung cancer patients.
The new study included 3,246 asymptomatic current or former smokers who were CT screened and followed for a median of 3.9 years. Researchers found that the screened patients had three times the expected rate of new lung cancer diagnoses, and 10 times the number of lung resections, but no significant difference in advanced lung cancer or mortality. The study was published in the March 7 Journal of the American Medical Association.
In contrast, the International Early Action Lung Cancer Program study, published in the Oct. 26 New England Journal of Medicine, reported that CT screening resulted a 10-year survival rate of 88% for stage I patients, and study authors argued that CT screening of high-risk patients could prevent 80% of lung cancer deaths.
The conflicting results can be explained by the studies’ differing outcomes—survival rates vs. deaths, noted an accompanying editorial. Overdiagnosis could result in treatment of early cancers that never would have become clinically significant, while some cancers are still fatal despite early treatment.
Overall, the study found no benefit to CT screening for lung cancer, and the extra surgical treatment prompted by screening can be harmful, study authors told the March 7 New York Times. Policy on screening should be developed after the results are released from two ongoing randomized controlled trials of lung cancer screening, the study and editorial authors concluded.
The New York Times is online.
The lead author of the Early Action Lung Cancer Program study was interviewed in the January-February ACP Observer.
Perioperative patients face the highest risk of harmful medication errors due to a lack of comprehensive oversight of medications, according to a new report from the nonprofit group U. S. Pharmacopeia (USP).
The report examined more than 11,000 medication errors reported by 500 hospitals between 1998 and 2005. Of the perioperative errors, 5% of errors resulted in harm, triple the overall rate of harm for medication errors. Pediatric patients were at the highest risk with 13% of errors resulting in harm. Overall, the most common errors were receiving the wrong drug, the wrong amount of a drug, receiving the drug at the wrong time or not receiving the drug at all, the March 6 Washington Post reported.
The report focused on four parts of the perioperative setting--outpatient surgery, the preoperative holding area, the operating room, and the post-anesthesia care unit. The most errors and the most harmful errors occurred in the operating room, with two of the report’s four deaths taking place there, the Washington Post reported.
USP’s report included 47 recommendations for reducing medication errors, including having surgical staff better coordinate hand-offs to eliminate the loss of patient information and designating a pharmacist to perioperative units.
The USP report is online.
The Washington Post is online.
Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDS) shouldn’t be used to prevent colorectal cancer in people at average risk for the disease, the U.S. Preventive Services Task Force (USPSTF) said in a statement published online March 6 in the Annals of Internal Medicine.
Though there is evidence that NSAIDs and aspirin may reduce risk of colorectal cancer at doses of 300 milligrams and higher by reducing incidence of adenomatous polyps, the benefit is outweighed by potential harm, such as gastrointestinal bleeding, hemorrhagic stroke and renal events, the statement said.
The recommendation applies to asymptomatic adults at average risk for colorectal cancer, including those with a family history of colorectal cancer. It doesn’t apply to individuals with familial adenomatous polyposis, hereditary nonpolyposis colon cancer syndromes (Lynch I or II), or a history of colorectal cancer or adenomas. Clinicians should continue to discuss aspirin use with patients who are at increased risk for coronary heart disease, though the low-dose aspirin used to lower that risk doesn’t seem to reduce incidence of colorectal cancer, the Task Force said.
The USPSTF revised its colorectal cancer recommendation in response to feedback from primary care doctors, and plans to release an updated statement later in 2007. Colorectal cancer is the third most common type of cancer in both men and women and is the second leading cause of cancer-related deaths in the U.S.
The Annals of Internal Medicine is online.
The Washington Post is online.
A new trial found that discontinuation of medications by patients one month after acute myocardial infarction increased their risk for death at 12 months.
In a cohort study, researchers studied 2,498 patients who had biomarker evidence of myocardial necrosis within 24 hours of admission, or who were transferred to the hospital within 24 hours of onset of acute MI. Researchers compared patients who had stayed on aspirin, β-blocker and statins at one month with those who stopped taking one, two or all three of the medications at one month.
Patients who discontinued all three medications were at greater risk for death at 12 months than those who continued use of at least one medication (adjusted hazard ratio [HR] 3.81, 95% CI 1.88 to 7.72), one or two medications (HR 5.00, CI 1.85 to 13.5), or all three medications (HR 3.33, CI 1.52 to 7.14). Patients who discontinued all medications were older; had more comorbid conditions; and were less likely to be married, white, have completed high school or have coronary revascularization during the index hospitalization. The study is abstracted in the March/April ACP Journal Club.
While nonadherence to drug therapy is clearly associated with adverse events, it is unclear whether discontinuation causes death from either the loss of cardioprotective effects or a harmful withdrawal effect from medications, said Journal Club reviewers Chris L. Bryson, ACP Member, and Stephan D. Fihn, FACP, of the Veterans Affairs Puget Sound Health Care System. Strong evidence from past research also supports an alternative hypothesis that the behavior of nonadherence itself may be strongly linked to adverse events and deaths, said Drs. Bryson and Fihn.
Given that low income, impaired health and adverse events may contribute to poor adherence to medications-- as well as to lifestyle interventions to improve diet and exercise—these patients might benefit from interventions designed to increase overall adherence to all of these positive measures, Drs. Bryson and Fihn said.
Peer ratings for this review: Internists and Primary Care Physicians: 6/7 stars. Cardiologists: 5/7 stars.
ACP Journal Club is online.
Abnormalities in electrocardiograms of healthy women can predict an increased risk of cardiovascular events and mortality, according to a new study. The findings are based on data from the Women’s Health Initiative (WHI), a randomized controlled trial of 14,749 women.
Women in the WHI received EKGs at the start of the study, three years later, and six years later, if they were still participating in the study. Of the 9,744 women with normal EKGs, 118 women had a cardiovascular event. Of the 4,095 with minor abnormalities, 91 had an event, compared with 37 of the 910 with major abnormalities. The study was published in the March 7 Journal of the American Medical Association.
Researchers calculated that women with minor abnormalities had a 55% increased risk of an event, and those with major abnormalities had a 300% increase in risk. About 5% of the studied women developed abnormalities during the study and had a 260% higher risk of cardiovascular events. The researchers did not find any association between EKG abnormalities and hormone therapy use, which the WHI was designed to study.
Based on the findings, the EKG appears to be a useful tool for predicting future cardiovascular events in asymptomatic postmenopausal women, study authors concluded. The presence of EKG abnormalities should prompt physicians to consider further risk stratification or intensive therapeutic interventions for the prevention of cardiovascular events, they said.
The Journal of the American Medical Association is online.
Women who were treated with radiation for breast cancer between 1970-1986 may have increased risk of heart disease, a study in the March 7 Journal of the National Cancer Institute found.
Researchers studied treatment-specific incidence of cardiovascular disease in 4,414, 10-year Dutch survivors of breast cancer treated between 1970 and 1986, and compared the risk to general population rates. They also compared patients treated before and after 1980, when a new therapy to conserve breast tissue was introduced.
After a median follow-up of 18 years, researchers found 942 cases of cardiovascular disease, with heart failure the most common (382 out of 942). Radiotherapy to the left or right side of the internal mammary chain was associated with increased cardiovascular risk for those treated between 1970-1979 (myocardial infarction hazard ratio 2.55, 95% CI 1.55 to 4.19; congestive heart failure HR 1.72, 95% CI 1.22 to 2.41). For those treated with radiotherapy after 1979, MI risk declined over time toward unity, while risk of congestive heart failure (HR 2.66, 95% CI 1.27 to 5.61) and valvular dysfunction (HR 3.17, 95% CI 1.90 to 5.29) increased.
Patients who underwent radiotherapy plus adjuvant chemotherapy after 1979 also had higher risk of congestive heart failure than patients treated only with radiotherapy (HR=1.85, 95% CI 1.25 to 2.73). Smoking and radiotherapy together led to a more-than-additive increased risk of MI (HR 3.04, 95% CI 2.03 to 4.55). Breast irradiation only was not associated with increased risk of cardiovascular disease.
The researchers said they were surprised to find that smoking had such a large effect on heart disease risk. "The advice to stop smoking appears to be even more important for irradiated patients and should be given at the time of treatment," the authors wrote. Study limitations include the fact that the study group and referent population may have different baseline risk for CV disease due to socioeconomic status and behavior. The radiation doses to the heart also couldn’t be determined from available data, the authors said.
The Journal of the National Cancer Institute abstract is online.
The FDA last week approved aliskerin (Tekturna), the first available drug to treat hypertension by inhibiting renin.
Aliskerin successfully lowered blood pressure in more than 2,000 patients with mild to moderate hypertension in six placebo-controlled, eight-week clinical trials, the FDA said. The effect was maintained for up to one year, and was heightened when the drug was used in combination with hydrochlorothiazide. Studies also showed aliskerin kept blood pressure down for more than 24 hours per dose, longer than many other blood pressure drugs, the March 7 New York Times reported.
African-American patients tended to have smaller reductions in blood pressure after taking aliskerin than whites and Asians. About 2% of patients on the higher of two doses reported diarrhea--the most common side effect-- compared to about 1% on placebo. Rarely, patients developed an allergic reaction with swelling of the face, lips or tongue and difficulty breathing. Aliskerin shouldn’t be used during pregnancy because it can cause injury or death to the developing fetus, the FDA said.
Aliskerin tablets, which are manufactured as Tekturna by Novartis Pharmaceuticals Corp., should be available in pharmacies by the end of March, the New York Times said.
The FDA release is online.
The New York Times is online.
The FDA last week warned consumers not to drink “Jermuk” brand mineral water because some bottles have been found to contain unhealthy levels of arsenic.
The product, imported from Armenia, has been recalled by several U.S. distributors. FDA testing of the water found 500 – 600 micrograms of arsenic per liter, while FDA standards permit no more than 10 micrograms per liter. No illnesses have been reported.
Symptoms of acute arsenic exposure usually occur within several hours of consumption, with the most likely effects being nausea, vomiting, diarrhea, and stomach pain. Over a few days or weeks, the kidneys, liver, skin, and cardiovascular and nervous systems can be affected, and extended exposure can lead to cancer and death.
In its initial investigation, the FDA sampled 500 mL green glass bottles; it is now investigating whether other sizes or packaging are also tainted. The products were distributed nationwide and were labeled as:
- "Jermuk Original Sparkling Natural Mineral Water Fortified With Natural Gas From The Spring".
- "Jermuk Sodium Calcium Bicarbonate and Sulphate Mineral Water"
- "Jermuk, Natural Mineral Water Sparkling"
The FDA release is online.
People with chronic kidney disease are more likely to have other medical conditions including heart disease and diabetes, according to a report released last week by The National Kidney Foundation in conjunction with observance of the second annual “World Kidney Day."
The survey found that patients with chronic kidney disease (CKD) were more likely to be overweight and have high blood pressure compared to the general population. The report also found that 29% of the high-risk group (which included people with diabetes, high blood pressure and family history of disease) had CKD, while only 2% were aware that they had a kidney problem.
The findings suggest that CKD can multiply the risk of other illnesses and demonstrate the importance of diagnosing and managing the disease in vulnerable patients, NKF officials said. According to the NKF, 20 million Americans—1 in 9 adults—suffer from some degree of CKD and another 20 million are at risk.
If left untreated, CKD can lead to problems including heart attack, stroke, heart failure and kidney failure. In honor of World Kidney Day, the NKF offered free kidney screenings to at-risk patients in 20 cities through the Kidney Early Evaluation Program.
The National Kidney Foundation is online.
The College, in partnership with three other major medical groups, last week released Joint Principles of the Patient-Centered Medical Home (PC-MH). The set of seven principles describes the characteristics of a practice-based care model for providing comprehensive primary care for children, youth and adults in a health care setting.
The PC-MH facilitates partnerships between individual patients and their personal physicians and – when appropriate – the patient’s family. Under a PC-MH each patient has an ongoing relationship with a personal physician, who ensures that their medical practice collectively takes responsibility for their ongoing care.
The personal physician is responsible for taking a whole-person approach that includes care for all stages of life; acute care; chronic care; preventive services; and end of life care. Care is coordinated and integrated across all elements of the complex health care system.
ACP President Lynne M. Kirk, FACP emphasized that it is important to adequately support the time and systems required to assure that all patients can receive the high-quality health care that is delivered in a patient-centered medical home.
Joining with the College in the initiative were the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Osteopathic Association. Together, the four groups represent 333,000 pediatricians, family physicians, internists and osteopathic physicians who provide the vast majority of primary care services to children, adolescents, and adult patients in the U.S.
As part of the ongoing effort by the College to include ACP Members in the nominations process, the 2007-08 Nominations Committee solicits your recommendations to fill new Regent positions on the Board that will become vacant in 2008.
When considering potential candidates for Regent, please keep in mind such qualifications as commitment to the College, dependability, leadership qualities and the ability to represent the College in numerous and diverse arenas. If you choose to nominate an individual, your letter of nomination should highlight these characteristics and should specify the reasons you feel your nominee is qualified for the position. Regent nominees must be Fellows or Masters.
The Nominations Committee is particularity interested in receiving nominations of women, ethnic minorities, international medical graduates, chairs of medicine and practicing physicians. All nominations will be given careful consideration by the Nominations Committee.
The nomination of an individual for first term Regent must be submitted by a standard structured nominating proposal. A letter of nomination is required and should include:
- A brief description of the nominee’s current activities
- Special attributes the candidate would bring to the Board of Regents
- Previous and current service in College-related activities
- Service in organizations other than the College (medical and non-medical)
A seconding letter must be submitted for each nomination. Without the appropriate material the nomination will not be advanced for review.
Potential candidates for Regent are required to have one letter of nomination and two letters of support (the author of which will be identified by the nominator). Officer and Regent candidates must have new letters of nomination and support each year, as the old letters will be discarded. If candidates receive more than two letters (nomination and support) these additional letters will be discarded.
Please send your confidential nominations, no later than Aug. 1, 2007 to:
ATTN: Mrs. Florence Moore
American College of Physicians
190 N. Independence Mall West
Philadelphia, PA 19106-1572
If you have any questions, please contact Florence Moore toll free at (800) 523-1546, ext 2814, or direct at (215) 351-2814.
April's Internal Medicine 2007 conference in San Diego will offer a Job Placement Center where interested candidates can meet with potential employers to discuss employment opportunities.
To participate, members can either prepare a physician profile in advance or prepare at the Job Placement Center. The profiles are provided to hospital and physician group recruiters exhibiting at the meeting. Recruiters may contact members before or during the meeting to set up an interview in the center.
Prospective employer positions will also be placed on job boards in the center for members to view and consider. The ACP Job Placement Center will be located in Booth 130 in the Exhibit Hall.
You can fill out a profile form online.
More information about ACP’s Career Resource Center is online.
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Copyright 2007 by the American College of Physicians.
A 66-year-old man comes for a preoperative evaluation before total joint arthroplasty of the left knee. He has a 25-year history of rheumatoid arthritis. He has had progressive pain in his left knee with activity, which limits his ability to hike. The patient has similar pain in the right knee, but it is less severe. He reports no recent morning stiffness. He is able to climb two or three flights of stairs without chest pain or shortness of breath. He has no other medical problems and reports no additional symptoms. Medications are methotrexate and folic acid. Following a physical exam and lab tests, what is the next best step in management?
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