In the News for the Week of 1-15-08
- Dengue fever could become widespread in the U.S., experts say
- Government report: doctor-owned hospitals fall short on emergency care
- Breast cancer risk may be lower than thought for BRCA carriers
- New research sheds light on sepsis treatment
- U.S. hospitals inconsistent in UTI prevention efforts, survey finds
- Annals: College issues guidelines on end-of-life care
Health care disparities
- First test to differentiate 12 respiratory viruses from one sample is cleared
- Severe bone, joint and muscle pain may accompany bisphosphonate use
- FDA approves tadalafil for daily use
- CMS releases fee schedule of 2008 Medicare payment rates
ACP publishing news
- You could become our next caption contest winner
Editorial Notice: ACP InternistWeekly will not be published on Jan. 22 due to technical issues related to the redesign of our Web site.
Dengue fever may become prevalent in the U.S. if the disease continues to increase in severity and expand into temperate climates, according to a commentary in the Jan. 9/16 Journal of the American Medical Association.
Formerly found in tropical and subtropical climates, dengue is becoming a more serious problem along the U.S.-Mexico border and in the commonwealth of Puerto Rico, according to the article by Anthony S. Fauci, MACP, director of the National Institute of Allergy and Infectious Diseases (NIAID) and his senior scientific advisor, David M. Morens, MD.
While there is minimal dengue-related illness in the U.S. currently, the disease tends to take hold in dramatic epidemics, and efforts to control mosquitoes that transmit dengue have fallen short of goals, said Drs. Fauci and Morens. Considering that the mosquitoes have been found in 36 states since 1985, the authors wrote, "widespread appearance of dengue in the continental United States is a real possibility."
The doctors called for more research into the illness, for which there are no specific vaccines or treatments. People infected with dengue often have no symptoms, or a mild fever. Some who get sick have minor bleeding, as from the nose or gums, and develop a high fever, severe headache, pain behind the eyes and in the joints and muscles, and a rash. Early diagnosis and treatment is critical to preventing shock and death, the NIAID said in a release.
The Journal of the American Medical Association is online.
The NIAID press release is online.
Many physician-owned specialty hospitals are doing a less-than-adequate job of providing emergency care, according to a report released last week by the Office of the Inspector General in the Department of Health and Human Services.
The review of 109 physician-owned specialty hospitals was ordered by the U.S. Senate Finance Committee in response to concerns over two deaths at specialty hospitals where no doctor was on duty and 911 was called. Findings include:
- 28% of hospitals had a physician on-site at all times;
- 34% of hospitals rely on 911 for medical assistance to stabilize a patient;
- 55% of hospitals had emergency departments; of those, 58% had just one emergency bed;
- 7% didn’t meet Medicare requirements to have a nurse on duty and have at least one physician on call if there are none in the hospital;
- 24% don’t have policies on the use of emergency medical equipment;
- 6% don’t have policies saying who should respond in a medical emergency.
The office reported to the CMS the names of those hospitals that failed to meet existing CMS guidelines on issues like inappropriate reliance on 911. It also recommended CMS set up a system to track physician-owned hospitals on emergency measures; CMS responded that it would do so. A Finance Committee spokeswoman said the panel will push for stronger laws on physician-owned hospitals when Medicare legislation comes before Congress this year, the Jan. 10 Washington Post reported.
The inspector general’s report is online.
The Washington Post is online.
Women who carry the BRCA1 or BRCA2 gene mutations may be at lower risk for breast cancer than previously thought, according to the results of a new study.
The study, published in the Jan. 10 Journal of the American Medical Association, tested and interviewed 1,394 women with unilateral and 704 women with contralateral breast cancer who were diagnosed before age 55 between 1985 and 2000. Researchers observed a trend of increasing risk for breast cancer among relatives of BRCA1 or BRCA2 carriers who were diagnosed at a younger age or affected in both breasts.
They speculated that other unknown risk factors or genetic variations in these families--apart from the two genetic mutations--may explain why cases tend to cluster in families. In fact, they noted, the preponderance of familial clustering occurs in families in which the first affected family member is not a BRCA1 or BRCA2 carrier.
The authors concluded that the risk of carriers developing breast cancer before age 70 should be lowered to 40%, contrary to previous estimates of between 45% and 65%, and that the risk may be even lower in carriers with no known family members affected by breast cancer. Given the future potential for widespread genetic screening and tailored treatments, they added, accurate calculation of the risks has significant clinical implications for BRCA1 and BRCA2 carriers.
The JAMA abstract is online.
Hydrocortisone does not reverse shock or improve survival in patients with septic shock, and intensive insulin therapy may lead to greater risk of hypoglycemic events in sepsis, two new studies in the Jan. 10 New England Journal of Medicine report.
In the first study, the CORTICUS Study Group randomly assigned patients to receive 50 mg of hydrocortisone or placebo every six hours for five days. The primary outcome was death at 28 days in patients without a response to a corticotropin test.
Approximately 47% of all patients, 125 of 251 in the hydrocortisone group and 108 of 248 in the placebo group, had no response to corticotropin. Mortality rates at 28 days did not differ significantly between the hydrocortisone and placebo groups among those who did not respond to corticotropin (39.2% vs. 36.1%, respectively; P = 0.69) or among those who did (28.8% vs. 28.7%; P = 1.00). Overall, 86 of 251 (34.3%) of patients in the hydrocortisone group and 78 of 248 patients in the placebo group (31.5%) had died at 28 days. Although septic shock reversed more quickly in the hydrocortisone group, these patients were also at higher risk for superinfection.
The authors concluded that low-dose hydrocortisone had no effect on 28-day mortality rates in patients with septic shock. Although their study had limitations, including a lack of adequate power, the authors wrote that their findings do not support the use of hydrocortisone as general adjuvant therapy for vasopressor-responsive septic shock or corticotropin testing to determine the appropriateness of hydrocortisone therapy. However, the authors noted that hydrocortisone may be useful in early treatment of patients with septic shock who do not respond to high-dose vasopressors.
In the second study, researchers for the German Competence Network Sepsis studied the efficacy and safety of intensive insulin therapy in patients with severe sepsis. They also assessed whether low-molecular-weight hydroxyethyl starch (HES) or modified Ringer's lactate was more effective for fluid resuscitation. The primary end points were 28-day mortality rate and mean organ failure score.
Intensive insulin therapy was stopped at the first safety analysis. Patients in the intensive therapy group had higher rates of hypoglycemia (30 of 247 patients, or 12.1%, vs. 5 of 241 patients, or 2.1%; P < 0.001), higher rates of severe hypoglycemia (17.0% vs. 4.1%; P < 0.001) and higher rates of serious adverse events (10.9% vs. 5.2%; P = 0.01). The intensive insulin therapy group was switched to conventional therapy, and fluid resuscitation methods continued to be compared until the planned interim analysis. At that time, researchers found that patients receiving HES had a greater incidence of renal failure and a trend toward higher 90-day mortality rates compared with those receiving Ringer's lactate. The data safety and monitoring board suspended the study.
The authors concluded that intensive insulin therapy is not advisable in critically ill patients with sepsis, and that using 10% HES 200/0.5 for fluid resuscitation in this population leads to renal impairment and, at higher doses, decreases long-term survival rates.
U.S. hospitals may not be doing enough to prevent urinary tract infections (UTIs), according to a new survey.
Researchers in Michigan surveyed 2,790 randomly sampled hospitals (119 of which were part of the Veterans Administration system) to determine what methods they used to prevent UTIs. Hospitals were mailed a study questionnaire asking how often they used specific prevention methods for catheter-related UTIs and how UTIs and urinary catheters were monitored. The study appears in the Jan. 15 Clinical Infectious Diseases.
The survey response rate was 72% (80% for VA hospitals and 70% for non-VA hospitals). More than half of the hospitals (56%) had no system for monitoring which patients had catheters, and almost two-thirds (74%) didn't monitor the duration of catheter placement. Portable bladder scanners and antimicrobial urinary catheters were used by 30% of hospitals, while 14% reported using condom catheters and 9% reported using catheter reminders.
The study yielded several significant findings, the authors wrote:
- Few hospitals reported monitoring urinary catheter use;
- No single strategy was widely used to prevent UTI;
- VA hospitals were more likely to use portable bladder scanners, condom catheters and suprapubic catheters than were non-VA hospitals but were less likely to use antimicrobial catheters; and
- Fewer than 10% of hospitals used urinary catheter reminders despite evidence of their effectiveness.
The authors noted several study limitations, including reliance on self-reported data and possible lack of generalizability. However, they concluded that their results provide a "snapshot" of UTI prevention methods in U.S. hospitals and could have important policy implications, given Medicare's new policies on reimbursement for hospital-acquired infections.
Clinical Infectious Diseases is online.
The Jan. 15 issue of the Annals of Internal Medicine includes ACP’s new guidelines on palliative care, as well as studies of community-acquired MRSA among men and pain associated with sickle cell disease. The full text is available to College members and subscribers online.
New ACP guideline to improve palliative care of at end of life. The new guidelines, “Evidence-based Interventions to Improve the Palliative Care of Pain, Dyspnea, and Depression at the End of Life,” offer strategies for clinicians to use in improving palliative care for patients nearing the end of life. The guidelines, which were developed by the College’s Clinical Efficacy Assessment Subcommittee, recommend that clinicians regularly assess such patients for symptoms of pain, shortness of breath and depression. Clinicians should use proven therapies to treat these conditions and ensure that advance care planning occurs for all patients with serious illness. “End-of-life care has been identified by the Institute of Medicine as one of the priority areas to improve quality of health care,” noted Amir Qaseem, MD, PhD, ACP’s Senior Medical Associate in the Clinical Programs and Quality of Care Department.
Other items on palliative care in this issue of Annals of Internal Medicine include an update that reviews literature to answer questions such as, “Does opioid use hasten death in patients with advanced disease?” Also, a systematic review looks at evidence of improving palliative care.
Antibiotic-resistant staphylococcal infections in men who have sex with men. A multidrug-resistant strain of the S. aureus bacteria isolated in two cities was more common in areas where male same-sex couples lived and appeared to be more commonly transmitted sexually among men who have sex with men than those who do not, a new population-based, retrospective study found. This paper is being released early online at the Web site of Annals of Internal Medicine and will appear in the Feb. 19, 2008, print edition.
In adults with sickle cell disease, daily pain more prevalent and severe than previously indicated. Authors of this prospective study gave diaries to 232 sickle cell disease patients to record daily pain and indicate whether they used hospital emergency or unscheduled ambulatory care for their pain. Most patients (65.9%) had homozygous sickle cell disease. Over half of the patients completing up to six months of diaries reported having pain on a majority of days. Almost one-third had pain nearly every day. The major finding of the study was that pain in sickle cell disease is a daily phenomenon and that patients are at home struggling with their pain rather than coming into the hospital, said a study author. A streaming video report on this study is online.
Releasing health care performance data may not improve care. Peer-reviewed evidence on public reporting as a mechanism to improve quality of health care found that public reporting stimulates hospital quality improvement activity but doesn’t consistently influence consumers when they choose a health plan, according to this article. Few studies have looked at improving patient safety and patient-centeredness or at the new public reporting systems. An accompanying editorial writer says that the content and format of the public reports on quality of care have been difficult to understand and use and should be improved before re-evaluating the effect of public reporting on quality.
Health care disparities
Recent efforts to reduce racial disparities in cancer treatment have been unsuccessful, according to the authors of a new analysis of Medicare beneficiaries.
The researchers used the Surveillance, Epidemiology and End Results Medicare database to evaluate the care received by white and black patients between 66 and 85 years of age who were diagnosed with breast, colorectal, lung or prostate cancer from 1992 through 2002. In total, they reviewed more than 140,000 cancer cases. The study was published online in the journal Cancer on Jan. 7 and will appear in the Feb. 15 print edition.
Throughout the 10-year period, the study found that black patients were significantly less likely than white patients to receive therapy for cancers of the lung (surgical resection of early stage, 64% for blacks vs. 79% for whites), breast (radiation after lumpectomy, 78% vs. 86%), colon (adjuvant therapy for stage III, 52% vs. 64%), and prostate (definitive therapy for early stage, 72% vs. 77%). The racial disparities persisted even when researchers controlled for whether patients had access to a physician prior to diagnosis.
For white as well as black patients, the researchers found that there was little improvement in the proportion of patients receiving therapy over the 10 years. They concluded that efforts made during the 1990s to mitigate racial disparities in cancer care were unsuccessful and they suggested that future projects should be incorporated into more general quality improvement frameworks.
The findings are most likely the result of continuing educational and socioeconomic inequities, a representative of the American Cancer Society told Reuters on Jan. 7. He also suggested that other factors contributing to the disparity could include black Americans having less access to quality care, being more likely to have chronic medical conditions such as diabetes, and being less trusting of the medical establishment.
Reuters is online.
Americans who live in rural areas are less likely to receive organ transplants, or even to be put on waiting lists for hearts, livers and kidneys, according to a new study.
The findings came from a cohort study of more than 174,000 patients who were wait-listed and underwent heart, liver or kidney transplantation between 1999 and 2004. Compared with urban residents, patients who lived in small towns and isolated rural areas were 9% less likely to be placed on the list for a heart, 14% less likely to make the liver list and 8% less likely to be on the list for kidney transplants. The differences in actually getting a transplant were even larger—rural residents were 12% less likely to get a heart, 20% less likely to get a liver, and 10% less likely to receive a kidney transplant than urbanites.
The researchers found that the disparities were consistent across the country, and that rural patients on the waiting list for a heart also had to wait longer than urban patients, although the same was not true of liver and kidney transplant candidates. After receiving a transplant, the rural and urban patients did not have any significant difference in outcomes. The study was published in the Jan. 9/16 Journal of the American Medical Association.
The study adds rural residents to the list of demographic groups--including racial minorities, women and patients with lower socioeconomic status--that research has shown face disparities in access to transplantation, the study authors noted. Based on the study’s results, the researchers could not definitively determine whether the observed disparities were due to underlying disease burden or specific barriers faced by rural residents.
However, the authors did suggest the urban/rural disparity may reflect the difficulties faced by rural patients in completing the complex referral and evaluation process required for transplantation. Delayed referrals to specialists and greater distances to transplant centers could also contribute to the problem. With the increasing concentration of transplant centers in urban areas, it is possible that this disparity will only grow, and further assessment of the burdens facing rural residents requiring transplants is needed, the authors concluded.
The Journal of the American Medical Association is online.
The FDA cleared for marketing a rapid test that detects and identifies 12 different respiratory viruses from a single sample.
The xTAG Respiratory Viral Panel is the first test to detect and differentiate influenza A subtypes H1 and H3; influenza A is the most severe form of human influenza and the cause of major epidemics. The panel is also the first test for human metapneumovirus (hMPV), and identifies influenza A, influenza B, respiratory syncytial virus subtype A and B, parainfluenza 1, 2 and 3, rhinovirus and adenovirus, as well.
The test uses small amounts of genetic material found in secretions taken from the back of the throat, then replicates it many times. The process speeds up the usual method of detecting respiratory viruses, which can take up to a week, and uses less of a specimen than previous testing, the FDA said. Results occur within a few hours, manufacturer Luminex Corp. said.
The test is specific to the viruses listed and should be used with other diagnostics like patient data, bacterial or viral cultures and X-rays. Positive results don’t rule out other infection or co-infection, and the virus detected may not be the specific cause of the disease or patient symptoms, the FDA cautioned.
The FDA release is online.
The Luminex Corporation release is online.
Bisphosphonates may bring “severe and sometimes incapacitating” bone, joint and musculoskeletal pain, the FDA said in an alert.
The pain may occur within days, months or years after starting a bisphosphonate. Some patients have reported complete relief of symptoms after discontinuing the bisphosphonate, while others have reported slow or incomplete resolution. The risk factors for, and incidence of, this pain are unknown.
Further, the severe pain is different from the fever, chills, bone pain, myalgias and arthralgias that sometimes accompany initial administration of intravenous bisphosphonates or once-weekly or once-monthly oral doses. Those initial symptoms usually resolve within several days, the FDA said.
Severe musculoskeletal pain is already included in the prescribing information for all bisphosphonates, but the association may be overlooked by health care professionals, who should consider temporary or permanent discontinuation of bisphosphonates in patients who present with severe musculoskeletal pain, the FDA said.
The FDA alert is online.
The FDA last week approved erectile dysfunction drug tadalafil (Cialis) for daily use in 2.5-mg or 5-mg tablets.
While the former dosage of tadalafil worked for about 36 hours, the new dosing regimen will allow men to attempt sexual activity at any time. It will be marketed for those who expect to have sex two or more times a week.
Men who are taking organic nitrates shouldn’t use tadalafil, the FDA said. The drug recently received a label change to highlight potential risk of sudden hearing loss.
The updated Medicare 2008 Physician Fee Schedule is now available on the CMS' Web site.
The updated fee schedule is the result of the “Medicare, Medicaid and SCHIP Extension Act of 2007” that was passed in late December. The new legislation replaced a 10.1% cut in physician payments under the 2008 Physician Fee Schedule with a 0.5% increase for the first half of 2008. Physicians will be paid based on the new fee schedule starting with the first claims for 2008.
CMS has posted the carrier specific public use files with the updated 2008 fees to the Medicare Web site. The “Medicare Physician Fee Schedule Look-Up” customizable search engine will be updated with the new 2008 fees during the week of Jan. 21. The new fees also should have been posted to your local contractor’s website by Jan. 11.
Because of the change to the 2008 fee schedule, providers still have until Feb. 15 to change their participation status. All changes to participation status became effective retroactive to Jan. 1, 2008. Further guidance about switching your participation status and other changes to Medicare in 2008 is available from ACP online.
ACP publishing news
Pick a caption for this cartoon and e-mail all entries to firstname.lastname@example.org by Jan. 17. ACP staff will announce a winner in the Jan. 29 issue of ACP InternistWeekly.
Pen the winning caption and win MKSAP’s Board Basics, which highlights MKSAP 14, as well as additional new material that you need to know before taking your Boards.
Entries for ACP's national "Internists as Artists" program at Internal Medicine 2008 are now being accepted. All entry application forms must be submitted by March 14.
Designed to showcase physicians' talents in the visual arts, the "Internists as Artists" exhibit will be located in the Exhibit Hall of the Walter E. Washington Convention Center in Washington, D.C., during Internal Medicine 2008. Submissions can include painting, sculpture, photography, mixed media, woodworking, jewelry, crafts and ceramics.
Members interested in submitting entries must complete an application form and send it along with either a photograph or an electronic image of their artwork. (Member artists may submit a maximum of two entries.) Entries will be judged by program jury members, and each piece must be completely display-ready when it is submitted for consideration in the exhibit.
"Internists as Artists" is modeled on an Evergreen Award-winning event established by ACP's Virginia Chapter.
Completed application forms and electronic or photographic images should be sent to: Helen Canavan, ACP Internists as Artists Program, 190 N. Independence Mall West, Philadelphia, PA 19106-1572. Ms. Canavan can also be reached via e-mail at email@example.com or by calling 800-523-1546, ext. 2663.
ACP chapters honor Members, Fellows, and Masters of the College who have demonstrated by their example and conduct an abiding commitment to excellence in medical care, education, research, or service to their community, their region, their chapter, and ACP.
Awardees are physicians with a long history of excellence and peer approval in the specialty of internal medicine. In recognition of their outstanding service, these exceptional individuals received chapter awards in November and December 2007:
Col. Jeffrey L Jackson, FACP, MC USA, Bethesda, Md. - COL William Crosby Superiority in Research Award
Col. John E Atwood, MD, Washington D.C.: Master Teacher Award
Col. (ret) Christina M Yuan, FACP, MC USA, Laureal, Md.: Laureate Award
Col. (ret) Daniel F Battafarano, FACP, Fort Sam, Houston: Laureate Award
Col. (ret) Gregg T Anders, FACP, MC USA, San Antonio, Texas: Laureate Award
Ltc. Roger A. Gallup, MD, MC USA, San Antonio, Texas: Excellence in Operational Medicine Award
Maj. Donald R Lazarus, ACP Member, MC USA, Temple, Texas: Moser Award – Outstanding Army Internist
California Northern Region
Dominic T Dizon, ACP Member, Clovis: Volunteerism and Community Service Award
Washington, D.C. Region
Geraldine P Schechter, MACP, Bethesda, Md.: Laureate Award
A Kaldun Nossuli, FACP, Potomac, Md.: Leadership Award
Richard B Perry, MACP, Potomac, Md.: Volunteerism and Community Service Award
Carmella A Cole, FACP, Falls Church, Va.: Sol Katz Teaching Award
Virginia L. Kan, FACP, Kensington, Md.: Sol Katz Teaching Award
James F Graumlich, FACP, Peoria: Laureate Award
Janet A Jokela, FACP, Urbana: Laureate Award
John E Tulley, FACP, Oak Park: Laureate Award
Carlos Lijtszain Sclar, FACP: Education Award
Rafael A Harari, Ancona, ACP Member: Associate Promotion Award
David N Williams, MBChB FACP, Minneapolis: Laureate Award
Richard H Rubin, FACP, Albuquerque: Laureate Award
Stephen R. Jones, FACP, Portland: Laureate Award
James R Patterson, MD, Portland: HP Lewis Distinguished Service Award (Volunteerism)
Mark R Rosenberg, ACP Member, Portland: HP Lewis Distinguished Teaching Award
Edward R Bollard, FACP, Lebanon: Laureate Award
Stephen H. Cooksey, ACP Member, Pittsburgh: Clinical Practice Award
Eric C. Newman, FACP, Danville: Clinical Practice Award
Paul A. Bialas, FACP, Warren: Waxman Award
John P. Fitzgibbons, FACP, Allentown: Special Recognition Award
Elliot B. Goldberg, FACP, Pittsburgh: Laureate Award
Delbert L Chumley, FACP, San Antonio: Laureate Award
Joseph Viroslav, FACP, Dallas: Laureate Award
Douglas S. Paauw, FACP, Seattle: Laureate Award
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A 66-year-old man is evaluated for vague abdominal pain of several months' duration and a 10-kg (22-lb) weight loss. He drinks alcohol socially but does not smoke. The patient is otherwise well, has good performance status, and takes no medications. Following a physical exam, lab studies, and a CT scan, what is the most appropriate initial management of this patient?
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