In the News for the Week of 7-3-07
- SSRIs present little risk of birth defects, studies find
- Medical homes improve minority care
- CDC identifies who is uninsured
- MRSA may be more widespread than originally thought, survey finds
- Needlestick injuries common among surgeons in training
- CDC expands access to infection tracking system
- Annals of Internal Medicine
- High dose of atorvastatin reduces risk for major cardiovascular events in older as well as younger patients
- Beta-blockers reduce plaque in artery walls
- Annals anniversary: Flagship journal turns 80
- Jump in diabetes cases parallels rise in obesity
- Home monitoring no better than standard care for type 2 diabetics
- Call for 2008 College Regent and officer nominations
- College Master elected to Royal Society of Canada
- Medicare pay-for-reporting program underway
- Chapter dues support local efforts
Pregnant women who use the most common form of antidepressant during their first trimester don’t significantly increase the risk of most kinds of birth defects in their newborns, two new studies found.
The studies in the June 28 New England Journal of Medicine examined the association of birth defects with maternal use of several kinds of selective serotonin reuptake inhibitors (SSRIs), which are commonly used to treat depression and anxiety. SSRIs as a whole didn’t appear to pose a risk, though there were small associations between specific SSRIs and specific birth defects. The numbers of infants with specific defects were small, however.
The first study looked at associations between first-trimester use of SSRIs and birth defects among 9,849 infants with and 5,860 infants without birth defects. It found SSRI use wasn’t associated with significant risk of craniosynostosis (OR, 1.4 [95% CI, 0.2 to 3.5]), omphalocele (OR, 1.4 [95% CI, 0.4 to 4.5]) or heart defects overall (OR, 1.2 [95% CI, 0.9 to 1.6]). There were small associations between sertraline and omphalocele (OR, 5.7 [95% CI, 1.6 to 20.7]) and septal defects (OR, 2.0 [95% CI, 1.2 to 4.0]), as well as between paroxetine and right ventricular outflow tract obstruction defects (OR, 3.3 [95% CI, 1.3 to 8.8]). The study was partially funded by GlaxoSmithKline and Sanofi-Aventis.
The second study examined associations between birth defects and maternal SSRI use in the month before and three months after conception in 9,622 infants with birth defects and 4,092 without. They found no significant associations between SSRI use and congenital heart defects or most other categories of birth defects. However, small associations were found between SSRI use and anencephaly (adjusted odds ratio, 2.4 [95% CI, 1.1 to 5.1]), craniosynostosis (OR, 2.5 [95% CI, 1.5 to 4.0]) and omphalocele (OR, 2.8 [95% CI, 1.3 to 5.7]).
These new studies, combined with others in recent years, “make it clear that neither SSRIs as a group nor individual SSRIs are major teratogens on the order of thalidomide or isotretinoin,” an editorial writer said, adding that any increased risk of specific defects is likely to be small. Study authors noted that untreated maternal depression also poses health risks to both mothers and newborns.
Last November, the American College of Obstetricians and Gynecologists recommended women avoid taking paroxetine if they are pregnant or planning to become pregnant, due to possible risk of birth defects. The FDA has also issued a warning about using paroxetine during pregnancy.
The New York Times is online.
Providing patients with a "medical home" offering timely care, routine access and medical advice would go a long way toward eliminating racial and ethnic health disparities, according to a new report from The Commonwealth Fund.
The report, "Closing the Divide: How Medical Homes Promote Equity in Health Care," is based on the Commonwealth Fund's 2006 Health Care Quality Survey, which included a random, representative sample of 3,535 U.S. adults. Researchers found that linking minorities with a medical home--defined as a regular provider or place of care that offers 24-hour contact by phone--improved care for chronic diseases and increased the use of preventive services.
Highlights from the report include:
- 23% of adults with a medical home report their doctor or doctor's office did not give them a plan to manage their care at home, compared with 65% who have no regular source of care;
- Eight of 10 adults who received a preventive reminder had their cholesterol checked in the past five years compared with half of adults who did not get a reminder;
- More than half of insured adults received a reminder from a doctor's office to schedule preventive visits compared with only 36% of uninsured adults; and
- Three-fourths of adults with a medical home who saw a specialist report that their regular doctor helped them decide which specialist to see and communicated with the specialist about their medical history, compared with 58% of adults without a medical home.
According to the report, in 2006 nearly one-half of Hispanics and more than one in four African Americans were uninsured at some point during the year, compared with 21% of whites and 18% of Asian Americans. In addition to being the groups most likely to go without health insurance, African Americans and Hispanics were the least likely to have a regular doctor or source of care.
Only two-thirds of adults who had a regular provider or source of care reported that it is easy to get care or medical advice after hours. Among all groups surveyed, Hispanics have the hardest time seeking care or advice after hours, and were least likely to have a medical home.
The College has been a leader in advocating for widespread adoption of the medical home model in which patients select a personal physician to manage and coordinate their care. Earlier this year, the College joined with three other major physician groups in support of seven “Joint Principles of the Patient-Centered Medical Home."
The Commonwealth Fund report is online.
An ACP news release on the Joint Principles is online.
The number of uninsured adults in the U.S. continued to rise in 2006, to 43.6 million people or almost 15% of the population, according to new CDC statistics.
Data from the National Center for Health Statistics also showed that 54.5 million people (18.6%) were uninsured for at least part of the year while 30.5 million (11.8%) of those under age 65 had been uninsured for more than a year. Hispanics were more likely than any other ethnic group to be uninsured, with about one-third uninsured for at least part of the year before being interviewed and more than one-quarter without coverage for more than a year. There is no direct comparison with last year because 2006 was the first time that the survey separated out non-Hispanic Asians as a separate ethnic category.
The survey also showed differences by age and gender. Those age 18 to 24 years were most likely to lack insurance than any other age category, while men were more likely than women to be without coverage at the time of the interview. There was a slight decrease from 2005-06 in the percentage of children who lacked insurance for at least part of the year (12.6% to 13.0%) but it was not statistically significant, and followed a gradual decrease from 18.1% to 12.6% between 1997 and 2005.
The report provides health insurance estimates based on data collected in the 2006 National Health Interview Survey, which polled more than 100,000 households throughout the year.
The CDC report is online.
Rates of methicillin-resistant Staphylococcus aureus (MRSA) in the U.S. may be much higher than originally thought, according to a new survey.
Researchers from the Association for Professionals in Infection Control and Epidemiology (APIC) asked infection control staff at 1,237 health care facilities across the U.S. to count the number of patients infected or colonized with MRSA at their facilities on a single day in October or November 2006. The facilities then reported their findings to the APIC.
Of every 1,000 patients in these facilities, 34 had MRSA infection and 12 had colonization, for an overall rate of 46 infections or colonizations per 1,000 patients. This infection rate is much higher than that reported in 2005 by the CDC (3.9 per 1,000 patients), and, when extrapolated to the general U.S. population, could mean that as many as 1.2 million hospital patients develop MRSA infection each year, the Washington Post reported.
"This is a wakeup call that hospital administrators should understand the importance of this problem," the lead study author told the Washington Post.
The survey's unpublished results were presented at APIC's annual meeting last week.
The Association for Professionals in Infection Control and Epidemiology is online.
The Washington Post is online.
For more about MRSA, see the July issue of ACP Hospitalist, available online July 11.
More than three quarters of surgeons in training reported experiencing a needlestick injury while caring for patients, according to a new study in the June 28 New England Journal of Medicine.
Researchers at the Johns Hopkins and Georgetown Schools of Medicine surveyed 741 surgeons in training at 17 hospitals to determine whether they had had a needlestick injury and, if so, the circumstances surrounding it. Responses from 699 surgeons were analyzed (response rate, 95%).
Overall, 83% of respondents reported having a needlestick injury during training, and 99% had had such an injury by the end of their fifth postgraduate year. Fifty-three percent of the injuries occurring during postgraduate years involved a high-risk patient, defined as a patient with HIV, hepatitis B or C, or a history of injection drug use. Fifty-one percent of the most recent injuries, and 16% of these involving high-risk patients, were not reported to employee health services. Forty-two percent of surgeons in training who did not report their injuries cited lack of time as the reason.
Needlestick injuries can be traumatic for surgeons in training and may lead to fears of stigmatization, the study's lead author told the New York Times. In the study, the researchers called for greater attention to reducing these injuries and to developing improved reporting systems.
The New England Journal of Medicine is online.
The New York Times is online.
The CDC has announced that its National Healthcare Safety Network (NHSN), a Web-based system that allows secure tracking of nosocomial infections, will now be available to most hospitals and all outpatient dialysis facilities in the U.S.
Like its predecessor, the National Nosocomial Infection Surveillance (NNIS) system, NHSN allows health care facilities to monitor nosocomial infections internally, but it also allows them to share the information with others, including the general public. NHSN also permits hospitals to create tables and graphs of their data and compare their figures with national performance measures.
Long-term acute care hospitals, surgical hospitals, nursing homes, extended care facilities, ambulatory surgical centers and home care are not currently eligible for NHSN participation, according to the CDC's Web site. Representatives for these facilities are encouraged to check back in October. The CDC press release is online.
More information about the National Healthcare Safety Network is online.
The following articles appear in the July 3, 2007 issue of Annals of Internal Medicine. This issue also includes a study finding that patients who undergo dietary counseling lose about 6% of body weight after one year, but that dieters return to their baseline weight after about five years. To view the report in streaming video format go to www.client.dssimon.com/viewvideo/acp27.wmv. Another study found that levels of cystatin C in the blood can predict the risk of death from all causes, from cardiovascular disease and from kidney failure just as well as standard tests of kidney function can predict those risks. The full text is available to College members and subscribers online.
High dose of atorvastatin reduces risk for major cardiovascular events in older as well as younger patients
In a study of 3,809 people with coronary artery disease, those who took 80 mg of the cholesterol-lowering drug atorvastatin had statistically reduced risk for major cardiovascular events compared with those who took 10 mg of the drug. During 4.9 years of follow-up, 10.3% of the patients who took the high dose had major fatal or nonfatal cardiovascular events compared with 12.6% of those who took the lower dose, a reduction of 2.3%. The same reduction was seen in younger patients
Beta-blockers reduce plaque in artery walls
Beta-blockers appear to prevent recurrent heart events in addition to controlling heart rhythm, but the reasons are unclear. Researchers used data from four randomized trials containing findings of intravascular ultrasonography on 1,515 patients with coronary artery disease. They found that in patients who took beta-blockers, the degree of fatty degeneration or thickening of the large artery walls decreased compared to those who did not take beta-blockers.
ACP’s flagship journal, Annals of Internal Medicine, celebrates its 80th anniversary this month. Annals was established in 1927 to promote excellence in the clinical practice of internal medicine by presenting a wide variety of experimental and clinical subject matter for the benefit of clinicians, researchers, educators, policymakers and the public at large. In addition, the journal offers background and discussion of issues influencing both physicians and patients. As the leading journal for studies in internal medicine, Annals is exclusive in its publishing of original research--for every research article published, 13 are rejected.
Historically, medical journals have been a “go to” source for reliable information about health care. With the rapid expansion of accessible research, the role of the reputable medical journal has grown even more significant. To meet demand, Annals has looked to embrace new technologies and formats to reach its audience in timely and effective ways. For example, a portal has been developed for readers to access in-depth information about clinical trials published in the journal. Likewise, the electronic form of Annals will soon provide linkage between Annals articles and topic-specific material.
For more information about Annals of Internal Medicine and to read today’s editorial from Editor Harold C. Sox, MACP, go to Annals' Web site.
The prevalence of diabetes in the U.S. has risen 5% a year since 1990, according to government research presented at the American Diabetes Association's 67th Annual Scientific Sessions last week in Chicago.
The CDC study, based on data from the 1963-2005 National Health Interview Survey (NHIS), showed that the prevalence of diabetes increased 5.1% per year between 1963-75, did not increase at all between 1975 and 1990 and began to rise again in 1990, according to an ADA news release. A CDC expert speculated that introduction of the first standard diagnostic criteria for diabetes in 1975 may have contributed to the slowdown in incidence between 1975 and 1990 because prior to that there was no consensus on diagnosis.
However, CDC experts did tie the spike in diabetes cases since 1990 to rising obesity, said the ADA release. The NHIS data indicate that obesity among U.S. adults began to increase more rapidly starting in 1986, just a few years before diabetes began to take an upward turn.
An ADA news release is online.
Early results of the 2006 NHIS are online.
In other research presented at the ADA meeting, type 2 diabetes patients who regularly self-monitored their blood glucose levels had no better glycemic control after one year than patients who received only standard office-based hemoglobin A1c tests.
In the study, published online June 25 by the British Medical Journal, 453 adults with type 2 diabetes were assigned to one of three groups. A control group received standard care, visiting their physician for a hemoglobin A1c test once every three months. Two intervention groups measured their blood glucose at home at least six times a week; one group shared results with a research nurse once every three months, while the other received individual training and phone and clinic follow-up to interpret the results and motivate them to set goals and follow medication regimens.
Although the majority of patients in the intervention groups succeeded in self-monitoring at least twice a week, there was no significant difference in hemoglobin A1c levels across all three groups after one year, said an ADA news release. The results should prompt physicians and patients to consider appropriate use of self-monitoring, said study researchers, since the procedure is costly but may not lead to better outcomes.
An ADA news release is online.
A study abstract is online.
The FDA recently approved pregabalin (Lyrica) as the first drug to treat fibromyalgia.
Pregabalin reduced pain and improved daily functions for some patients with fibromyalgia at doses of 300 mg or 450 mg per day, two studies of about 1,800 patients found. The disease affects about three to six million people in the U.S. per year, and typically causes chronic or long-lasting pain, muscle stiffness and tenderness. FDA officials cautioned that some patients didn’t experience a benefit from the drug in clinical trials.
The most common side effects of pregabalin are mild to moderate dizziness and sleepiness. Others include blurred vision, weight gain, dry mouth and swelling of the hands and feet, as well as impaired motor function and problems with concentration and attention. Side effects appear to be dose-related.
Pregabalin is already approved to treat partial seizures, as well as pain associated with diabetic neuropathy and shingles. Lyrica manufacturer Pfizer has agreed to do a study of the drug in breastfeeding women as well as in children with fibromyalgia.
The FDA release is online.
The FDA last week approved for marketing the first rapid test for malaria, called the Binax NOW Malaria Test.
The test is faster and easier to use than standard laboratory tests, with results available within 15 minutes after a few drops of blood are placed on a dipstick. The test can differentiate Plasmodium falciparum, the most dangerous malaria parasite, from less virulent parasites. Results still must be confirmed using standard microscopic evaluation, the FDA said.
The Binax NOW test was 95% accurate compared with standard microscopic analysis in a multicenter study outside the U.S. in areas where malaria is prevalent. The disease affects U.S. residents who travel or work in other countries. The CDC reported 1,528 newly reported malaria cases in 2005, including seven deaths.
The FDA release is online.
Malaria information is online.
As part of the College’s ongoing effort to include ACP Members in the nominations process, the 2007-08 Nominations Committee solicits your recommendations to fill new Board of Regents’ positions 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 ability 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 particularly interested in receiving nominations for 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 via 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; and
- Service in organizations other than the College (medical and non-medical).
A seconding letter must be submitted with 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 authors of which will be identified by the nominator. Officer and Regent candidates must have new letters of nomination and support each year, as old letters are 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
Fax: 215-351-2829 e-mail: firstname.lastname@example.org
If you have any questions, please contact Florence Moore toll free at (800) 523-1546, ext. 2814, or direct at (215) 351-2814.
R. Brian Haynes, MACP, editor of ACP Journal Club and a widely acknowledged leader in the field of evidence-based medicine, has been elected to the Royal Society of Canada (RSC), a body of distinguished Canadian scientists and scholars.
The award citation notes that Dr. Haynes is a "world leader in medical information research and knowledge translation" and led "the scientific development of both evidence-based journals and Internet information services." It also notes that 25 publications authored by Dr. Haynes have been cited over 100 times, with nine of these cited over 300 times.
RSC Fellows are selected by their peers for outstanding contributions to the natural and social sciences and in the humanities. The Society consists of about 1,700 Fellows.
Dr. Haynes is the Michael Gent Professor and chair of the department of clinical epidemiology and biostatistics at McMaster University in Hamilton, Ontario. Besides ACP Journal Club, he also is editor of the journal Evidence-Based Medicine and an associate editor for ACP Medicine.
More information about the Royal Society of Canada is online.
If you have not already started reporting, there is still time to begin participating in Medicare's Physician Quality Reporting Initiative (PQRI). The program, which began on Sunday, enables physicians to receive a bonus payment for successfully reporting on quality measures for services furnished to beneficiaries over the course of a six-month period ending December 31.
Those who successfully report—internists generally have to report on three PQRI quality measures—will earn a bonus that equals 1.5% of the Medicare-allowed charges that they generated during the six-month reporting period.
The legislation that established the PQRI provides an expectation that the program will continue in some form in 2008, although the law fails to specifically fund a 2008 program. While there is uncertainty surrounding whether Congress will continue to fund the program in 2008, ACP encourages internists to participate now because it will help to prepare practices for future reporting.
ACP has developed resources intended to ease members’ participation. Available on the Practice Management Center’s Web site, these resources include information on preparing your practice, a list of measures relevant to internists and a coding tool to identify relevant codes. The College intends that these resources will enable members to collect a 2007 bonus and prepare for future reporting. ACP’s PQRI Web site also allows users to communicate with ACP staff to ask questions about the program or to provide feedback on the resources.
Additional details about the PQRI program and the resources mentioned above are online.
Chapter dues provide the primary support for local initiatives and are vital to the success of your chapter. Activities supported by your chapter dues include educational meetings, mentoring programs for medical students, local Associates’ research competitions, advocacy with state legislators and chapter leaders’ participation in Leadership Day. Chapter dues also help offset the cost of local support staff and provide funding for new and existing chapter initiatives. When you receive your dues notice, remember to include chapter dues in your payment.
If you have any questions regarding your chapter dues or would like additional information, contact Alice Coyle in the Membership Department at email@example.com.
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Copyright 2007 by the American College of Physicians.
A 72-year-old woman is evaluated during a routine examination. She has very severe COPD with multiple exacerbations. She has dyspnea at all times with decreased exercise capacity. She does not have cough or any change in baseline sputum production. She is adherent to her medication regimen, and she completed pulmonary rehabilitation 1 year ago. She quit smoking 1 year ago. Her medications are a budesonide/formoterol inhaler, tiotropium, and an albuterol inhaler as needed. Following a physical and pulmonary exam, what is the most appropriate next step in management?
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