In the News
for the Week of 1-29-08
- College expresses concerns about new proposal for internist certification
- Vaccine awareness, coverage low among American adults
CDC reports ineffective antiviral agents still prescribed last flu season
- New data shed light on use of drug-eluting stents
- ACP Journal Club: High nonfasting triglycerides associated with increased risk
- Trial finds little difference between cardio drugs
- Gastric banding can put diabetes into remission, study finds
- Heparin and saline pre-filled flushes recalled on contamination fears
- Label change for birth control patch reflects study on VTE risk
- Real-time test for respiratory viruses cleared for marketing
- Chantix label warns doctors to monitor patients for neuropsychiatric symptoms
- Delayed-release prednisone better at reducing morning joint stiffness
ACP publishing news
- ACP and AMA conducting Physician Practice Information survey
- Submit your 2008 ACP Job Placement Center physician profile
- ACP seeks participants for alcohol use disorder quality improvement project
- Free literature available for young physician members
- Officers and Regents election results
The ACP has expressed significant concerns about the American Board of Internal Medicine's recent proposal to offer a credential in "comprehensive care internal medicine (CCIM)" to office-based general internists, saying it would create a burden for physicians and may hurt efforts to attract students to primary care.
While agreeing with the ABIM that action is needed to prevent a severe shortage of primary care physicians, the College's statement notes that requiring physicians to obtain another credential may make the problem worse. "CCIM may pose another burdensome hoop that adds time, expense and limited value, leading to fewer students choosing careers in and fewer physicians practicing office-based internal medicine," the statement says.
Under the ABIM proposal, "comprehensive care internists" would hold a separate credential reflecting that they provide ongoing, coordinated care for a panel of patients, distinguishing them from internists who work in urgent care, academic, administrative or research settings.
While the College statement advocates a health care system based on the patient-centered medical home with the internist as coordinator of care, it lists several additional concerns about requiring separate certification, including:
- General internists who do not obtain the CCIM certificate may be devalued, which may result in further fragmentation within internal medicine at a time when cohesion and unity are critical.
- Unless CCIM is preceded by supporting reforms in reimbursement, it may contribute to the worsening financial state of traditional general internal medicine.
- CCIM will not be an effective differentiator as it describes competencies that apply broadly across specialties and settings.
- The lack of valid and reliable assessment tools for CCIM competencies is a substantial limitation.
The ACP instead continues to support acknowledgment of a physician's scope of practice through customization of Maintenance of Certification, which does not establish a hierarchy of internists. A new CCIM designation may "contribute to the splintering of internal medicine into site-specific subgroups," says the ACP statement, "with further adverse effects on traditional internal medicine." The ACP's response was developed by the Strategic Planning Committee, based on input from the Board of Regents, the Board of Governors, the Health and Public Policy Committee, the Medical Services Committee, the Education Committee, the Council of Associates, and the Council of Young Physicians.
ABIM is accepting open comments on the proposal until Feb. 15. Individuals can read the report and provide comments directly to ABIM via its CCIM Web page.
The full text of ACP's response is online.
American adults have little awareness of the vaccines available to protect them from a variety of infectious diseases, according to data released last week by the CDC.
According to a telephone survey of 7,000 adults conducted last summer by the CDC, only 2.1% of Americans between ages 18 and 64 have received the Tdap (tetanus, diphtheria and pertussis) vaccine, while only 1.9% of people 60 and over have received the new shingles vaccine. About 10% of women in the recommended age range (18 to 26) have been given the human papillomavirus vaccine, said CDC officials.
Vaccination rates among the elderly were also well below the CDC's goals of 90%. Rates for both influenza and pneumococcal disease were below 70%. Of all the vaccines, American adults seemed most familiar with influenza. CDC officials also commented on a new survey conducted by the National Foundation for Infectious Diseases, which found that while almost half of adults could identify influenza as a vaccine-preventable disease, only 3% to 18% of adults could name additional vaccines.
There are now 17 vaccine-preventable diseases, including three new adult-specific vaccines licensed since 2005, CDC officials said. Immunization is now recommended for chickenpox, diphtheria, hepatitis A, hepatitis B, human papillomavirus, influenza, measles, meningococcal disease, mumps, pertussis, pneumococcal disease, rubella, shingles and tetanus.
The low vaccine coverage has a significant public health impact, noted the officials. For example, if the shingles vaccine were used as recommended, the U.S. could eliminate 280,000 cases of shingles and 47,000 cases of postherpetic neuralgia every year, according to the Jan. 23 MedPage Today.
A press release on the survey is online.
MedPage Today is online.
In related news, the CDC released a survey showing that during the 2006-07 flu season some physicians continued to prescribe antiviral agents no longer recommended due to viral resistance.
Of the 730 primary care physicians included in the survey, 69% had administered influenza tests to patients with influenza-like illness and 54% prescribed antiviral agents, said the CDC's Jan. 25 Morbidity and Mortality Weekly Report. While most physicians (87%) prescribed oseltamivir, a significant number prescribed amantadine (17.8%) and rimantadine (8.7%), which are no longer recommended by the CDC due to a high rate of viral resistance (the remaining 5.3% prescribed zanamivir).
The survey also found that the majority of PCPs ordered influenza testing and, of those, almost 90% ordered rapid antigen testing. An editorial noted that while these tests are convenient because they can be performed in the office, they have been found to produce false-negative results in 25% to 30% of patients. Results of such tests should be combined with clinical judgment, the editorial said.
The MMWR report is online.
Two observational studies published last week in the New England Journal of Medicine shed new light on the use of drug-eluting stents to treat coronary disease.
In the first study, researchers in New York used data from statewide databases to identify patients who had undergone coronary artery bypass grafting (CABG) or had received a drug-eluting stent from Oct. 1, 2003, and Dec. 31, 2004, then compared adverse outcomes through Dec. 31, 2005. The study appears in the Jan. 24 New England Journal of Medicine.
Patients with two- or three-vessel disease who received CABG had lower mortality rates and lower rates of death or myocardial infarction (MI) at 18 months compared with patients who received drug-eluting stents. Patients with two- and three-vessel disease who had CABG had an adjusted hazard ratio for death of 0.71 (95% CI, 0.57 to 0.89) and 0.80 (CI, 0.65 to 0.97), respectively, and an adjusted hazard ratio for death or MI of 0.71 (CI, 0.57 to 0.89) and 0.75 (CI, 0.63 to 0.89), respectively. Adjusted survival rates and adjusted survival rates without MI were statistically significantly higher in patients with two- and three-vessel disease who received CABG than in those who received drug-eluting stents. Repeated revascularization rates were also lower in patients who had CABG.
The authors acknowledged that their study had limitations, including its observational nature and possible unmeasured confounding of the data. However, they concluded that CABG is associated with lower rates of mortality, death or MI, and repeated revascularization than drug-eluting stents in patients with multivessel coronary disease.
In the second study, researchers analyzed data on 6,551 patients from the National Heart, Lung and Blood Institute Dynamic Registry to compare the safety and effectiveness of off-label use of bare-metal and drug-eluting stents. Overall, off-label use of bare-metal stents was more common (54.7% of patients with bare-metal stents vs. 48.7% of patients with drug-eluting stents). Patients who received drug-eluting stents were more likely to have diabetes, hypertension, renal disease, multivessel coronary artery disease, and previous percutaneous coronary intervention and coronary artery bypass grafting. After one year, no significant differences were found between the groups in adjusted risk of death or MI. Patients who received drug-eluting stents had a significantly lower risk of repeated revascularization.
Although this study was also observational and could have been affected by residual confounding, the authors concluded that drug-eluting stents do not increase the risk for death or MI when used off-label and may improve rates of revascularization at one year. These findings, they wrote, support off-label use of these devices.
A study found that elevated nonfasting triglycerides were associated with increased risk for death, myocardial infarction, and ischemic heart disease.
The cohort study included 6,394 men and 7,587 women from Denmark, between the ages of 20 and 93, who were followed for a mean of 26 years. At the end of the study period, 64% of men and 49% of the women had died, 17% of men and 9% of women had had an MI, and 30% of men and 21% of women had ischemic heart disease. The study results were controlled for age, total cholesterol, body mass index, hypertension, diabetes, smoking, alcohol consumption, physical inactivity, lipid-lowering therapy, and postmenopausal status and hormone therapy in women.
The researchers found that a 1-mmol/L (88.5-mg/dL) increase in the level of nonfasting triglycerides was associated with an increased risk of death, MI and ischemic heart disease in women and death and MI in men. For example, men with triglycerides between 265.5 and 353.1 mg/dL had a 50% increased relative risk of death and more than double the risk of MI compared to those with levels under 88.5 mg/dL. The study is abstracted in the January/February ACP Journal Club.
Although the study's results are intriguing and suggest directions for future research, one limitation of the study is that it did not compare the predictive value of fasting triglycerides with that of nonfasting levels, wrote Journal Club reviewer Edward P. Havranek, FACP, of the Denver Health Medical Center. The study's results are not ready to be applied clinically, he added, and established measures of cardiovascular risk should continue to be applied.
Peer ratings for this review: Internal Medicine/Family Practice, Cardiology, Endocrinology: 6/7 stars.
ACP Journal Club is online.
The American College of Cardiology is advising physicians not to make clinical decisions based solely on the results of a recent trial showing that the combination of ezetimibe and simvastatin is no more effective than simvastatin alone in preventing atherosclerosis progression.
The trial included 720 patients with heterozygous familial hypercholesterolemia who took either combined ezetimibe/simvastatin (brand name Vytorin) or simvastatin alone for two years. The primary end point was mean change in the intima-media thickness at three sites in the carotid arteries. The study found that the combination group had a mean change of 0.0111 mm compared with 0.0058 for the simvastatin group.
In response to media coverage of the results, ACC issued a statement noting that the overall incidence of cardiac events was nearly identical in the treatment groups and both medications were generally well-tolerated. According to the ACC, the findings merit serious thought, but conclusions should not be drawn about the value of the medications until results are available from the three large outcomes trials of ezetimibe/simvastatin that are currently under way and involve more 20,000 patients.
In the meantime, ezetimibe remains a reasonable option for patients who are currently on a high-dose statin but have not reached their goal or cannot tolerate statins or can tolerate only a low-dose statin, the ACC said. The group recommended that physicians speak to concerned patients who are using the drug. The results of the trial have been submitted as an abstract for presentation at the ACC annual meeting to be held in March.
A press release from Merck/Schering-Plough Pharmaceuticals is online.
The statement from the American College of Cardiology is online.
Gastric band surgery results in significantly more remission of type 2 diabetes than conventional therapy, according to the first randomized trial to compare the two treatments. It was also the first study to document the results of surgery in diabetics with BMIs of less than 35, the usual threshold for recommending bariatric surgery.
The Australian study included 60 patients who had BMIs between 30 and 40 and had been diagnosed with diabetes in the past two years. The patients were randomized to receive either laparoscopic adjustable gastric banding or conventional medical/behavioral therapy only. (The banding patients also received the conventional therapy, which consisted of medication and lifestyle counseling, including consultation with a health care provider once every six weeks.)
After two years, 73% of patients in the surgery group had achieved complete remission of their diabetes, compared with 13% in the conventional therapy group (remission was defined as fasting glucose level <126 mg/dL [7.0 mmol/L] and glycated hemoglobin [HbA1c] value <6.2% while taking no glycemic therapy). The surgery group lost a mean of 20.7% of their weight compared with 1.7% in the other group. The study was published in the Jan. 23 Journal of the American Medical Association.
The remission appeared to be a result of weight loss, the study authors found, and patients generally had to lose 10% of their weight in order to experience remission. The authors noted that while the number of participants with a BMI between 30 and 35 was small (22%), this group experienced the same benefits from weight loss as the group with BMIs in the 35-40 range.
According to an accompanying editorial, it is difficult to determine the widespread applicability of the study's findings because the authors are some of the most experienced surgeons in the world at gastric banding. However, the editorial noted, other research has shown that the operation more common in the U.S.—the Roux-en-Y gastric bypass—results in even faster resolution of diabetes. Therefore, the editorial concluded, professional societies and clinicians should reconsider the role of surgery in diabetes treatment and consider offering surgical options to all obese patients with diabetes.
The authors of the study were more guarded in their recommendations, and although they concluded that the study provided strong evidence for surgically induced weight loss for treatment of obese patients with diabetes, they also cautioned that the results need to be confirmed in a larger, more diverse population over a longer term.
The FDA last week issued notice of a recall of heparin and saline pre-filled flushes due to possible contamination.
All lots of both heparin and saline pre-filled flushes manufactured by AM2 PAT are being recalled nationwide. The products are distributed under the brand names Sierra Pre-Filled Inc. and B. Braun, and are sold in 3ml and 5ml sizes for heparin, and 3ml, 5ml and 10ml sizes for normal saline. Both products are sold as pre-filled syringes.
Consumers and facilities with any of the recalled pre-filled syringes should stop using the product, quarantine it and return it to the distributor immediately, the FDA said.
One lot of the 100-unit, 5 ml Heparin Lock Flush product was found to be contaminated with Serratia marcescens, which has resulted in patient infections. The CDC has confirmed growth of S. marcescens from several unopened syringes of the product. S. marcescens can present a serious adverse health consequence that could lead to life-threatening injuries and/or death, the FDA said.
FDA information on the syringe recall is online.
The FDA last week revised the label for Ortho Evra Contraceptive Transdermal (Skin) Patch to reflect a new study that found patch users aged 15-44 were at higher risk of developing venous thromboembolism (VTE) than women who used birth control pills.
The new study was undertaken on behalf of the patch's maker. The FDA had already revised the Ortho Evra label in September 2006 to reflect findings that women who used the patch were at a two-fold higher risk of developing VTE. Another study didn't find a higher risk for women compared with those who used birth control pills containing 30-35 micrograms of estrogen and the progestin norgestimate, however.
Ortho Evra is a weekly prescription patch that releases ethinyl estradiol and norelgestromin through the skin into the bloodstream. Women who use the product are exposed to about 60% more estrogen than if they were using typical birth control pills containing 35 micrograms of estrogen. Higher levels of estrogen may increase the risk of side effects, including VTE, and this risk should be discussed with patients, the FDA said.
The FDA release is online.
The FDA cleared for marketing last week a test that simultaneously detects four common respiratory viruses in a short period of time.
The ProFlu+ test isolates and amplifies viral genetic material in secretions taken from the back of a patient's throat, delivering results in as few as three hours. The test detects influenza A virus, influenza B virus, and respiratory syncytial virus A and B (RSV). Other respiratory tests are either fast but not as accurate or accurate but not as fast.
Since antiviral drugs are most effective when initiated within the first two days of symptoms, the new test will help health professionals treat patients more effectively, an FDA official said. The test is specific to the four viruses named, and is more accurate when used with other diagnostics, like culture and X-rays, when diagnosing a patient, the FDA warned.
The FDA release is online.
Pfizer, the maker of Chantix (generic: varenicline), last week changed the label of its anti-smoking pill to include a warning that doctors monitor patients for neuropsychiatric symptoms.
Specifically, patients should be observed for changes in behavior, agitation, depressed mood, suicidal ideation and suicidal behavior, the company said in a release.
While a causal relationship between the drugs and the reported symptoms hasn't been established, "an association could not be excluded" in some reports, Pfizer said. Some reports of symptoms might have been complicated by nicotine withdrawal symptoms, but other patients experienced symptoms without having stopped smoking. Some patients with pre-existing psychiatric illness experienced a worsening of their conditions, as well.
A company-sponsored clinical trial of more than 5,000 patients found that neuropsychiatric changes occurred at a rate comparable to placebo-treated patients, Pfizer said. Patients with serious psychiatric illness didn't participate in the trial.
The drug, approved in 2006, already had an advisory about the symptoms in the "post-marketing experience'' section of the drug's prescribing information. In late November, the FDA announced it was evaluating adverse event reports for Chantix, including reports of drowsiness, and suicidal and erratic behavior.
The Pfizer release is online.
The November FDA announcement on Chantix is online.
A new modified-release prednisone tablet is better than immediate-release prednisone at reducing morning joint stiffness for rheumatoid arthritis patients, a new study found.
The 12-week, multi-center, double-blind trial randomly assigned patients with active rheumatoid arthritis to either the modified-release tablet, which was taken at bedtime and released the drug four hours later, or the immediate-release tablet, which was taken in the morning. All patients took pills both in the morning and at bedtime, one of which was a placebo. The study was published in the Jan. 19 Lancet.
The mean relative change in duration of morning stiffness of joints was significantly higher in the modified-release prednisone group compared with the immediate-release group (-22.7% vs. -0.4%, P = .045). Patients in the modified-release group had a mean reduction of 44 minutes of stiffness compared to baseline; the absolute difference between groups was 29.2 minutes. The safety profile between the drugs didn't differ.
The study results are "clearly relevant for daily clinical practice," and the relevance "could go far beyond rheumatic disease," study commentators concluded. Future studies should examine whether the advantage of modified-release prednisone persists for a longer period of time than 12 weeks, and what, if any, the long-term effects of that formulation are, they said.
ACP publishing news
The College has launched a new Web site to provide general internists and subspecialists with easy access to information on clinical topics, practice management tools, and continuing medical education and other useful information. ACP's new Web site also has resources for medical students, residents, fellows, and patients and their families.
Visitors to the Web site can now browse and search ACP's comprehensive collection of clinical resources such as evidence-based clinical practice guidelines, Annals of Internal Medicine and the Physicians' Information and Education Resource (PIER) in one easy-to-find location, easily access tools to help run a practice, stay up-to-date with continuing medical education from ACP, prepare for certification, search for a fellowship, and access information and resources developed specifically for patients on topics related to internal medicine.
We've worked hard to make this a valuable resource for all site visitors. Share your thoughts and impressions about the new ACP Web site.
ACP InternistWeekly has compiled the entries from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption. This issue's winning cartoon caption comes from Theresa Sheridan, a third-year medical student at the Touro University Nevada College of Osteopathic Medicine. She receives MKSAP's Board Basics, which highlights MKSAP 14, as well as additional new material that you need to know before taking your boards.
"I found my symptoms of anxiety decreased even faster if I gave the prescription to my husband."
Look for our next contest in the Feb. 5 edition of ACP InternistWeekly.
For the first time in nearly a decade, the ACP, the American Medical Association (AMA), and more than 70 other medical specialty societies have worked together to coordinate a comprehensive multi-specialty survey of America's physician practices. The purpose of the survey is to collect up-to-date information on physician practice characteristics in order to positively influence national decision makers. Thousands of practices will be surveyed in 2007 and 2008 from virtually all physician specialties to ensure accurate and fair representation for all physicians and their patients.
This project is unique because it explores both the clinical and business side of medical practice. This information is important for the nation's policy-makers to learn what is truly involved in running a practice that provides expert patient care, while operating a business that is sustainable. A complete understanding of the landscape and the requirements for today's care is critical. These data will allow medicine to articulate practice concerns to national policy-makers that will lead to policy initiatives that not only help in the short-term but will allow future generations of doctors to continue providing superior care to their patients.
There is a small section in this study pertaining to practice expenses and the amounts that are attributable to you. Please encourage your staff to make these numbers available. The CMS recently announced that the results of this study are considered critical to update physician payment. This is a vital part of the research and we need to have accurate and complete data. This information remains confidential. The survey firm will not identify any individuals or entities participating in this research to any of the participating organizations.
Dmrkynetec has been retained to conduct the Physician Practice Information survey among a representative random sample of practices in each of the participating specialties. The survey is an important and necessary vehicle for positive change. Please watch for this survey and do your part in completing it in a thorough and accurate manner if selected to represent our specialty.
Get your career on the right track by submitting your profile for the 2008 ACP Job Placement Center.
The ACP Job Placement Center is a service available at Internal Medicine 2008 that provides you with the tools to assist you in your job search and the opportunity to meet with potential employers.
By submitting a physician profile, you increase the odds of finding your dream position. Prior to the meeting, your profile will be sent to hospital and physician group recruiters only. After reviewing the profiles, a recruiter may contact you to set up an interview in one of the private interview booths in the Center. Only hospital and physician recruiters may use the Job Placement Center for interviews.
ACP's Quality Improvement Practice-based Research Network (ACPNet) is currently recruiting for "Raising Achievement: What We Do vs. What We Know for Alcohol Use Disorders," a project examining the inadequate screening, detecting, and counseling of patients with alcohol use disorders.
The prevention of morbidity and mortality related to alcohol use disorders is an important strategy for a primary care physician, yet many of these patients are not identified by their physician as problem drinkers. "Raising Achievement" aims to close this quality gap through educational intervention; the goal is to produce a Web-based module covering Quality Improvement (QI) techniques and methods for practice improvement related to alcohol use disorders, especially in patients with associated chronic diseases such as hypertension, sleep disorders, and depression.
All ACP members are eligible for this project. A total of 50 physicians will be recruited for the project. If you are interested in participating in this project and would like more information, please contact Meghan Gannon at firstname.lastname@example.org or by phone at 215-351-2847. You may also visit our Web site for more information about PRISM.
ACP Members are eligible to receive a free copy of the Pocket Guide to Selected Preventive Services for Adults and the Young Physician Practice Management Survival Handbook developed by the 2006-07 Council of Young Physicians. The Pocket Guide is a proactive way to encourage preventive care in your daily practice, while the Survival Handbook offers helpful tips and resources for starting your own practice.
Electronic copies of the Pocket Guide to Selected Preventive Services for Adults and the Young Physician Practice Management Survival Handbook are available on ACP Online. You will need your ACP username and password to access these sites. If you do not know this information, please visit www.acponline.org/help/register/.
If your chapter is holding an event for Young Physicians and you would like to make copies of the Pocket Guide and Survival Handbook available, please contact Jodi Todd, Programs and Services Coordinator, at email@example.com or by calling 800-523-1546 ext. 2611. A limited supply is available, so requests will be filled on a first-come, first-serve basis while supplies last.
The election of ACP Officers and Regents is complete, and terms become effective at the conclusion of the Annual Business Meeting at Internal Medicine 2008 on May 17. (E-mail addresses are provided for those who wish to send congratulations.)
Joseph W. Stubbs, FACP, Albany, Ga.
The following Regents were elected for a second three year term to expire in 2011:
Virginia L. Hood, FACP, Burlington, Vt.
Richard L. Neubauer, FACP, Anchorage
Dennis R. Schaberg, MACP, Los Angeles
Yul D. Ejnes, FACP, Scituate, R.I.
Robert M. Centor, FACP, Birmingham, Ala.
If you have any questions regarding the election, please contact Florence Moore.
About ACP InternistWeekly
ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.
To add your e-mail address to your member record and to begin receiving ACP InternistWeekly, please click here.
Copyright 2008 by the American College of Physicians.
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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