In the News for the Week of 1-8-08
- Many in-hospital defibrillations are delayed, study finds
- FDA approves first rapid blood test to detect MRSA
- ACP Journal Club: Low-fat diet did not reduce breast cancer recurrence
- COPD therapies have similar effects on exacerbations
- Testosterone supplements offer little benefit for older men
Health care disparities
- Poor, uninsured least likely to receive free drug samples
- ED prescriptions for pain vary by ethnicity
- Congress provides reprieve on Medicare cuts to physicians
ACP publishing news
- ACP Internist now available online and in your mailbox
- Cartoon caption contest: And the winner is ...
- You could become our next caption contest winner!
- Nominate candidates for upcoming ACP council elections
- ACP offers analysis of candidates’ health care platforms
Almost a third of patients who have in-hospital cardiac arrests are not defibrillated within the recommended two minutes, according to a new study.
The observational research included 6,789 patients who had cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia at 369 hospitals. Although the overall median time to defibrillation among the patients was one minute, 30% of the studied patients received delayed defibrillation. The researchers found several factors that increased the likelihood of delay: patients who were black, had a noncardiac admitting diagnosis, were at a hospital with fewer than 250 beds, or were on an unmonitored hospital unit. Delays were also more likely after hours (between 5 p.m. and 8 a.m. and on weekends).
The study also found that patients whose defibrillation was delayed were 48% less likely to survive to hospital discharge (22% in the group who were defibrillated within two minutes died vs. 39% of the delayed). A graded association was found between increasing time to defibrillation and poorer survival, both before and after two minutes. The patients who received delayed defibrillation also were more likely to have major disabilities in neurologic or functional status, according to the study.
The study authors noted that although several of the delaying factors were clearly hospital-related and resulted from limited availability of personnel and failure to quickly recognize ventricular arrhythmia, other associated factors, such as black race, raise concerns of disparity and merit further study. The study was published in the Jan. 3 New England Journal of Medicine.
An accompanying editorial suggested that automatic detection algorithms could help remedy the problems highlighted by the study. Electrodes on the patient’s skin could wirelessly transmit electrocardiogram data to a centralized alarm and computer station, which would alert nurses if the algorithm indicated ventricular tachycardia or ventricular fibrillation. Such a system could alleviate staffing-related factors as well as any disparities due to bias, the editorialist said.
The FDA approved for marketing a test that can identify in two hours whether blood is infected with MRSA (methicillin-resistant Staphylococcus aureus) or a different staph bacterium.
The BD GeneOhm StaphSR Assay identified 100% of MRSA-positive specimens and more than 98% of more common staph infections in a clinical trial at five locations. Other tests take more than two days to yield results, the FDA said.
The new test shouldn’t be used to monitor treatment for staph infections because it can’t quantify a patient’s response to treatment, the FDA said. The test also may reflect the bacteria’s presence in patients who have been successfully treated for staph infections, so it shouldn’t be used as the sole basis for diagnosis. It also can’t rule out other complicating conditions or infections, the FDA said.
The FDA release is online.
A diet low in fat and high in vegetables, fruit and fiber did not reduce risk for recurrent or new primary breast cancer and all-cause mortality in women previously treated for early-stage breast cancer, a new trial found.
The randomized, controlled trial included 3,088 women at seven U.S. sites who were diagnosed with primary operable invasive breast cancer within four years and had axillary dissection and mastectomy or lumpectomy following primary breast radiation. Half of the women received dietary interventions consisting of telephone counseling, 12 cooking classes and monthly newsletters. Controls were given printed dietary guidelines, were offered cooking classes and received the newsletter.
After a mean follow-up of 7.3 years, the researchers found no significant difference between the two groups for the composite endpoint of recurrent (local, regional or distant metastasis but not carcinoma in situ) or new primary breast cancer. The groups also had no significant difference in all-cause mortality, which was 10% for each group. The study is abstracted in the January/February ACP Journal Club.
This study’s results differed from those of the Women’s Intervention Nutrition Study (WINS), noted Journal Club reviewer Vered Stearns, MD, of the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins. He suggested that a dietary intervention might be more effective at decreasing risk for breast cancer in women who have not yet developed cancer than in those who have already been treated. A balanced diet and exercise should be encouraged for all women, with or without breast cancer, Dr. Stearns concluded.
Peer ratings for this review: Primary Care, Internal Medicine, Oncology-Breast: 5/7 stars.
ACP Journal Club is online.
Treating COPD patients with the combination of salmeterol and fluticasone instead of tiotropium does not reduce exacerbations but may have a positive effect on other outcomes, according to the first large-scale trial to compare the treatments.
In the double-blind, double-dummy study, 1,323 patients with severe COPD were randomized to receive either salmeterol/fluticasone (SFC) or tiotropium for two years. The primary endpoint was health care utilization exacerbation rate. Other endpoints included mortality, adverse events, study withdrawal, and health status measured by St. George’s Respiratory Questionnaire (SGRQ). The study was published in the early January print edition of the American Journal of Respiratory and Critical Care Medicine.
The study found no difference in exacerbation rates between the two groups, but the patients in the SFC group did show a statistically, but not clinically, significant improvement in SGRQ scores. That group also had a lower rate of withdrawal from the study and a 50% lower rate of mortality during the study. Researchers noted that the study was not powered to detect a difference in mortality, which was 3% in the SFC group, compared with 6% in the tiotropium group.
Study authors also noted that patients in the tiotropium group required oral corticosteroids more often, while patients on SFC took more antibiotics. That difference warrants further study, concluded the lead author, who also suggested that future research should investigate the difference in mortality that his group found.
The American Journal of Respiratory and Critical Care Medicine is online.
Testosterone supplements have no effect on strength, mobility or cognitive ability for older men with low testosterone levels, but they do decrease body fat and increase lean body mass, a new study found.
The double-blind, randomized trial assigned 237 Dutch men between age 60 and 80 years, and with a testosterone level lower than 13.7 nmol/L, to receive 80 mg of testosterone undecenoate or a matching placebo twice daily for six months. Functional mobility measures included a timed “get up and go” test and isometric handgrip strength. Eight cognitive assessment instruments were used. Bone mineral density, body composition, plasma lipids, quality of life and safety parameters were also measured. The study appears in the Jan. 3 Journal of the American Medical Association.
Thirty men didn’t complete the study. Of the rest, there was no significant change in functional mobility, muscle strength, cognitive function or bone mineral density for men who took testosterone vs. placebo. Total body fat mass and fat percentage dropped significantly in the testosterone group, and total body lean mass increased, while the placebo group saw no change on those measures. Men who took testosterone also had lower total and HDL cholesterol levels, lower glucose levels and increased insulin sensitivity after six months.
For healthy men with circulating testosterone levels in the lower range, the results “do not support a net benefit on several indicators of health and functional and cognitive performance with six months of modest testosterone supplementation,” the authors concluded.
The Journal of the American Medical Association is online.
Health care disparities
Poor and uninsured patients are less likely than wealthy or insured patients to receive free drug samples from doctors, likely because they lack access to office-based care, according to the results of a new study.
In the study, researchers analyzed the 2003 Medical Expenditure Panel Survey that included data on 32,681 U.S. residents. They found that of the 12% of Americans who received a free sample, 82.1% were insured all year while only 17.9% were uninsured for all or part of the year. In addition, 71.9% of those who received samples had incomes 200% or more above the federal poverty line vs. 28.1% whose incomes fell below that level.
Respondents who usually received their care in a doctor's office were more likely to receive samples (14.3%) compared with those who used hospital clinics or emergency departments (10%) or those without a usual provider (6.3%). The study appears in the February issue of the American Journal of Public Health.
The authors noted that the disparities were most likely due to differences in access to care rather than provider discrimination. While many physicians direct samples to their neediest patients, they explained, many uninsured and other disadvantaged patients never see an office-based physician due to access barriers.
The authors concluded that free drug samples are being used more as a marketing tool for drug makers than a safety net for disadvantaged patients.
An abstract of the study is online.
Nonwhites presenting to the emergency department are less likely than whites to be prescribed opioids for pain, according to a new study.
Over the past decade, The Joint Commission and the Veterans Health Administration have conducted campaigns to increase the awareness of appropriate analgesia and improve treatment for pain. Researchers used data from the National Hospital Ambulatory Medical Care Survey to examine whether these national initiatives affected prescription of opioids for pain in U.S. emergency departments. The results appear in the Jan. 2 Journal of the American Medical Association.
From 1993 to 2005, 42% of ED visits (156,729 of 374,891) were pain-related. Opioids were prescribed for 23% of pain-related ED visits in 1993 and 37% in 2005, with a more pronounced trend toward an increase in such prescribing from 2001 to 2005 (P = 0.02).
However, although opioid prescribing increased overall, racial disparities in opioid prescribing did not change. For all years examined, white patients were more likely than black, Hispanic or Asian/other patients to receive opioids for pain in the ED (31% vs. 23%, 24% and 28%, respectively). In 2005, opioid prescribing rates were 40% for white patients and 32% for patients of all other ethnicities. Racial disparities were observed for all types of pain-related visits and persisted after adjustment for pain severity and other factors.
The authors concluded that national initiatives to improve appropriate analgesia resulted in increased opioid prescribing for pain-related ED visits overall but had no effect on racial disparities in such prescribing. While these results may be attributed to overprescribing of opioids for pain among whites, the authors believe they are more likely to indicate undertreatment of pain among racial and ethnic minorities. The authors noted that such disparities are complex and that ethnic and racial bias alone is unlikely to completely explain their findings. System-level changes and future initiatives involving patients and nurses as well as physicians could help decrease these disparities, the authors wrote.
The Journal of the American Medical Association is online.
Longstanding anxiety markedly increases the risk of heart attack, even when other common risk factors are taken into account, according to results from the Normative Aging Study.
Researchers examined four different measures of anxiety:
- psychasthenia, or excessive doubts, obsessive thoughts and irrational compulsions;
- social introversion, or anxiety, insecurity, and discomfort in interpersonal and social situations;
- phobias, or excessive anxieties or fears about animals, situations or objects; and
- manifest anxiety, tension and physical arousal in stressful situations.
Men who tested at the highest 15th percentile on any of the four scales or a scale combining them all faced an approximate 30%-40% increased risk of heart attack, reported researchers in the Journal of the American College of Cardiology.
Those with higher levels of anxiety faced an even higher risk of heart attack. This finding held true even after researchers adjusted for standard cardiovascular risk factors, health habits, and negative psychological and personality traits.
Each of the 735 men participating in the analysis completed psychological testing in 1986 and was in good cardiovascular health at the time. Separate sections of the psychological test measured other behavioral and lifestyle issues, and patients had had a medical exam every three years over a follow-up period that averaged more than 12 years.
The Journal of the American College of Cardiology is online.
Upbeat people have less of the hormones and proteins linked to health problems, but the potential mechanism of action differs between men and women.
A recently published phase of the Whitehall II study measured associations between positive affect, cortisol and C-reactive protein and interleukin-6. Researchers examined healthy London-based civil service workers from 2002–04. Researchers had two goals: to discover whether associations between positive affect and cortisol were independent of depressed mood and to investigate the relationship between positive affect and two measures of chronic inflammation. They reported their findings in the January issue of the American Journal of Epidemiology.
A physical exam measured body size and a questionnaire assessed socioeconomic data. Doctors drew blood samples to measure C-reactive protein and interleukin-6, which are linked to chronic inflammation. To measure cortisol levels, patients drew their own saliva upon waking, four times throughout the day and at bedtime, self-assessing their mood each time.
Salivary cortisol was inversely associated with positive affect after controlling for age, gender, income, ethnicity, body mass index, waist/hip ratio, smoking, paid employment, time of waking in the morning and depression. Results of this study confirmed earlier results from a smaller sample that suggested that a positive affect is associated with lower cortisol only in men.
Higher positive well-being was associated with lower C-reactive protein and interleukin-6 in women. The adjusted odds of C-reactive protein ÿ3 mg/L was 1.89 (95% CI: 1.08, 3.31) in low-positive-affect women compared with high-positive-affect women. Interleukin-6 was an average 17% higher in the low-affect group than in the positive-affect group in women. Neither inflammatory marker was related to positive affect in men.
The study abstract is online.
News coverage is online.
Congress passed legislation in December that will provide physicians with a six-month reprieve from a 10.1% payment cut that was scheduled to go into effect on Jan. 1. President Bush signed the bill into law on Dec. 29.
Under the “Medicare, Medicaid, and SCHIP Extension Act of 2007” doctors will receive a 0.5% increase in Medicare payments for the first six months of 2008. However, without additional legislation the 10% cut will go into effect on July 1.
Because of the late-passing legislation, physicians who wish to change their Medicare participation status are still able to do so. The CMS has extended the deadline until Feb. 15. ACP has additional guidance about physician participation status options to help you make that decision.
The legislation also provides an extension for the State Children’s Health Insurance Program (SCHIP) through March 31, 2009. The extension provides sufficient funding so that no child who is currently covered will be dropped from the program; however, it does not provide the long-term reauthorization and expanded funding that congressional Democrats attempted to pass earlier in 2007.
ACP’s guidance on the Medicare cuts is online.
ACP publishing news
Readers will notice many changes to ACP’s weekly e-mail and print edition this month. Both titles have a new name and new look in addition to the same award-winning reporting that readers have come to expect.
Following are some of the new features to look for in the January issue that arrives in Members' mailboxes this week:
Mindful Medicine: Husband-and-wife team Jerome Groopman, FACP, author of the bestselling “How Doctors Think,” and endocrinologist Pamela Hartzband, FACP, both faculty members at Harvard, write about the importance of creative thinking in medicine, using actual cases submitted by readers.
Clinical Ethics: Lachlan Forrow, FACP, director of the Ethics Program at Harvard/Beth Israel Deaconess Medical Center, moderates a column featuring case studies on ethical dilemmas. Readers are encouraged go online to voice their opinions.
Regulatory Review: Senior Writer Jessica Berthold provides an overview of FDA actions, recommendations and upcoming decisions.
The Campaign Trail: Staff Writer Stacey Butterfield reports on the health care agendas of the major presidential candidates as the campaign progresses.
Web Watch: Senior Writer Jessica Berthold highlights useful low-cost or free medical Web sites and medical blogs.
We look forward to hearing your feedback on the new content and format. E-mail your comments to firstname.lastname@example.org.
The latest edition of ACP Internist is online.
ACP InternistWeekly has compiled the results 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 Kurt Kelley, ACP Associate Member, a resident in the Department of Medicine at Fletcher Allen Health Care in Burlington, Vt. He receives a $50 gift certificate good for any ACP product, program or service. ACP InternistWeekly readers cast their ballots online to choose the winning entry. Thanks to all who voted!
The winning entry:
"Maybe we should rethink our new 'low overhead' strategy."
The winning caption received 64.2% of the 215 votes cast. The two runners up were:
"Let's see … one pill makes you larger, and one pill makes you small. Which one was which?” (26.5%)
Being Doctor Malkovich (9.3%)
Pick a caption for this cartoon and e-mail all entries to email@example.com by Jan. 17. ACP staff will choose three finalists and post them online the following week for a vote by readers. The winner will appear 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.
The Council for Young Physicians (CYP), the Council of Associates (COA) and the Council of Student Members (CSM) are currently seeking candidates to fill all vacant seats for 2008-09. Each council meets twice a year in Philadelphia and is responsible for developing College policy, creating Internal Medicine workshops and advocating for their respective constituencies on Capitol Hill.
CYP candidates must be Members or Fellows of the College who are within 16 years of graduating from medical school as of May 1, 2008; COA candidates must be Associate Members of the College; and CSM candidates must be current Medical Student Members. The deadline for submitting nomination materials is Jan. 31, 2008.
CYP: Available positions include one at-large seat and seats for representatives from the Western and Southern Zones. More information on CYP and how to apply is available online.
COA: Available positions include representatives from the North Eastern, Southern, Midwestern and Western Zones, as well as for the Latin American Chapters. Interested candidates can find out more online.
CSM: Available positions include representatives from the Midwest, New England, North Atlantic, Southeastern and Southwestern Regions, as well as the Military Representative (Army, Navy, Air Force active duty or scholarship students) and the Osteopathic Representative (Osteopathic schools). More details regarding the upcoming elections are available online.
As the primary season kicks into gear ACP is offering a new guide to help internists sort through presidential candidates’ health care platforms.
The non-partisan Web tool analyzes the health care reform proposals of the presidential candidates, drawing on recommendations ACP made in its position paper "Achieving a High Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries." In the evidence-based paper, the ACP analyzes health care in the U.S. and 12 other industrialized countries. It identifies lessons that could be applied to the particular political and social culture of the U.S. to achieve a high-performing health care system for all Americans.
ACP has examined the health care recommendations of the major candidates and compared them to six benchmarks for health care reform. It is designed to help internists conduct a personal analysis of the candidates. The tool will be updated continually throughout the 2008 election cycle. Watch for updates as candidates release additional information and the field narrows.
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 76-year-old woman is evaluated for a 3-month history of left knee pain of moderate intensity that worsens with ambulation. She reports minimal pain at rest and no nocturnal pain. There are no clicking or locking symptoms. She has tried naproxen and ibuprofen but developed dyspepsia; acetaminophen provides mild to moderate relief. The patient has hypertension, hypercholesterolemia, and chronic stable angina. Medications are lisinopril, metoprolol, simvastatin, low-dose aspirin, and nitroglycerin as needed. Following a physical exam, lab results and radiograph, what is the next best step in management?
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