American College of Physicians: Internal Medicine — Doctors for Adults ®

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In the News
for the Week of 10-14-08

Highlights

  • End-of-life talks lead to less aggressive care, higher quality of life
  • ACP Internist's new Web site combines best of its features online
  • ACP Honorary Fellow wins Nobel Prize for work on HIV

Test yourself

  • MKSAP quiz: Pleural effusion

Men's health

  • No link between 5-α reductase inhibitors, hip fractures

Adolescent medicine

  • More teens getting HPV, other vaccines

CMS update

  • New program launched to fight Medicare fraud and abuse

Conference highlights

From ACP Governance

  • Call for spring 2009 Board of Governors resolutions
  • Apply for ACP council elections 2009-2010
  • ACP to launch new advocacy newsletter

From ACP Foundation

From ACP Internist

  • On the blog: New government guidelines on physical activity
  • Cartoon caption contest: Put words in our mouth

Highlights

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End-of-life talks lead to less aggressive patient care, higher quality of life

Patients who had end-of-life discussions with physicians received less aggressive medical care and had higher quality-of-life scores in their final weeks of life, a new study found.

The prospective longitudinal cohort study involved 332 patients with advanced cancer, and their informal caregivers, at multiple sites from September 2002 through February 2008. Patients were followed from enrollment until death, with outcomes being aggressive medical care (like resuscitation and ventilation), hospice in the final week of life, and mental health. Caregivers were also assessed about six months after death for mental illness and quality of life. The study was published in the Oct. 8 Journal of the American Medical Association.

About 37% of patients reported having end-of-life discussions, which were associated with lower rates of ventilation (adjusted OR, 0.26; 95% CI 0.08-0.83), resuscitation (OR, 0.16; CI 0.03-0.80), ICU admission (OR, 0.35, CI 0.14-0.90) and earlier hospice enrollment (OR, 1.65, CI 1.04-2.63). Adjusted analyses showed more aggressive medical care was associated with lower patient quality-of-life scores (6.4 vs. 4.6, P= 0.1) and higher risk of major depressive order for caregivers (OR, 3.37, CI 1.12-10.13). Better patient quality of life was associated with better caregiver quality of life at follow-up, as well.

End-of-life discussions between patients and physicians may make patients more realistic about the benefits of aggressive therapies, thus reducing the chances that they will opt for such therapies, the authors said. More than 60% of patients didn't recall having end-of-life conversations—especially if they were at major academic centers--so there is an apparent need to step up these discussions, the authors concluded.

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ACP Internist's new Web site combines best of its features online

ACP Internist has relaunched its Web site as a landing area for all of the exciting content offered in our print and online editions, including ACP InternistWeekly, the blog, and polls and surveys (including our cartoon caption contest). Look over the site and use the quick contact links to tell us your opinions.

In our October issue, online and in your mailbox:

Two-pronged approach to attack prediabetes. Until recently, internists had very little guidance on how to treat prediabetes and reduce the risk of the full-blown disease. The most recent advice: Treat it early, primarily with simple lifestyle changes.
Alaska primary care crisis the tip of the iceberg. When primary care doctors are already stretched, losing even one internist can leave a community in crisis.
Ethical Dilemmas. Harvard ethicist Lachlan Forrow, FACP, reviews how a sexual relationship with a former patient, however brief the doctor’s visit, raises issues after a break-up.

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ACP Honorary Fellow wins Nobel Prize for work on HIV

The Nobel Prize in Medicine was awarded last week to three European researchers, including Luc Montagnier, PhD, an honorary Fellow of the College.

Dr. Montagnier shares half the award with Francoise Barre-Sinoussi, PhD, for their discovery of human immunodeficiency virus (HIV). In the early 1980s, they isolated and cultured lymph node cells from patients that had swollen lymph nodes characteristic of a new immunodeficiency syndrome. They detected activity of retrovirus replication and then began examining the workings of the new retrovirus.

Drs. Montagnier and Barre-Sinoussi's work made rapid cloning of the HIV-1 genome possible and allowed identification of details in its replication cycle and how the virus interacts with its host. Their research also led to the development of methods to diagnose infected patients and to screen blood products, a press release said. Dr. Montagnier has a PhD in virology, a doctorate in medicine from The Sorbonne in Paris, and is currently professor emeritus and director of the World Foundation for AIDS Research and Prevention in Paris.

The other half of the Nobel went to Harald zur Hausen, MD, a German scientist, for his discovery that human papilloma viruses (HPV) cause cervical cancer. During the 1970s, Dr. zur Hausen postulated contrary to prevailing thought that cervical cancer was linked to HPV. He found the DNA of HPV in cervical cancer biopsies and cloned HPV 16 and 18, which cause most cervical cancers, in 1984. His discovery led to characterization of the natural history of HPV infection, an understanding of mechanisms of HPV-induced carcinogenesis, and the development of prophylactic vaccines against the virus.

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Test yourself

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MKSAP Quiz: Pleural effusion

A 75-year-old man with an 80-pack-year smoking history is evaluated for a 3-month history of night sweats, weight loss, and progressive shortness of breath. He has a dull ache in his left chest. He has an occasional cough with mucoid sputum production. He is dyspneic with minimal exertion.

On physical examination, his temperature is 36.8 °C (98.2 °F), pulse rate is 112/min, respiration rate is 26/min, and systolic blood pressure is 96 mm Hg. The trachea is shifted to the right. He has dullness to percussion and decreased breath sounds on examination of the left hemithorax. The abdomen is scaphoid with no organomegaly. There is no peripheral edema.

Laboratory tests show a leukocyte count of 6800/μL (6.8 × 109/L). Metabolic panel and liver and renal chemistry tests are normal. The serum protein is 5.0 g/dL (50 g/L), and the serum lactate dehydrogenase (LDH) is 188 U/L. Chest radiograph shows complete opacification of the left hemithorax with mediastinal shift to the right. Pleural fluid laboratory tests show the following:

Laboratory Studies

Cell count Erythrocyte count 150,000/μL (150 × 109/L); leukocyte count 980/μL (0.98 × 109/L) with 20% neutrophils, 55% lymphocytes, 10% mesothelial cells, and 15% eosinophils
Total protein 4.5 mg/dL (45 g/L)
Lactate dehydrogenase 1200 U/L
Glucose 45 mg/dL (2.5 mmol/L)
pH 7.2

Pleural fluid Gram stain is negative; cytology is pending.

Which of the following is the most likely diagnosis?

A) Transudative pleural effusion
B) Malignant pleural effusion
C) Parapneumonic effusion
D) Rheumatoid pleural effusion
E) Pleural effusion associated with esophageal rupture

Click here or scroll to the bottom for the answer.

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Men's health

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No link between 5-α reductase inhibitors, hip fractures

5-α reductase inhibitors have no short-term impact on hip fractures in men being treated for prostate enlargement, researchers reported.

Short-term studies have shown no effects of 5-α reductase inhibitors on bone metabolism, but researchers wanted to assess the long-term impact. They conducted a population-based, case-control study using data from Kaiser Permanente Southern California's 3.2 million-member database.

Case patients included 7,076 men 45 years and older with incident hip fracture from 1997-2006. The median age at fracture was 77 years. Researchers used the managed care organization's pharmaceutical database to identify use of finasteride (the only 5-α reductase inhibitor dispensed) since 1991, the year the electronic database was established. Results showed 2,547 (36%) case patients and 2,488 (35%) control patients had BPH (P= 0.30). Among this group, 109 (1.5%) of case patients and 141 (2.0%) of control patients had taken finasteride.

Exposure to 5-α reductase inhibitors was not associated with increased risk of hip fracture. The use of α-blockers was slightly greater in men with hip fracture and there was no evidence of a dose response. The risk associated with α-blocker use was increased only among those with the most recent prescriptions (within 30 days vs. none: odds ratio, 2.04; 95% confidence interval, 1.19-3.49). Researchers wrote there appears to be an inverse association between 5-α reductase inhibitors and hip fracture that warrants further study.

The study was published in the Oct. 8 Journal of the American Medical Association. The lead author reported receiving research funding from and serving as an unpaid consultant for Merck. The study was supported through the Kaiser Foundation Community Benefit fund and the Southern California Permanente Medical Group, which had no role in the study's design and conduct.

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Adolescent medicine

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More teens getting HPV, other vaccines

Teen vaccination rates are on the rise, but have not yet met the targets set by Healthy People 2010, according to a new report from the Centers for Disease Control and Prevention (CDC).

The national telephone survey also collected the first data on rates of human papilloma virus (HPV) vaccination. According to the survey, 25% of females between the ages of 13 and 17 had received at least one dose of the HPV vaccine by late 2007.

Rates for older vaccines were higher than those for HPV. More than 80% of teens had received the recommended vaccinations against hepatitis B and measles, mumps and rubella. About 75% had gotten one dose of the varicella vaccine, but only 18.8% had two doses. The 2007 survey saw a significant increase in meningococcal vaccination, with 32.4% of teens having received it, compared to 11.7% in 2006. There was also a bump in Tdap vaccination, from 10.8% to 30.4% of teens.

In a press release, CDC officials called the upward trend good news. They noted, however, that none of the vaccines meet the Healthy People 2010 goal of having 90% vaccine coverage among teens for hepatitis B, measles, mumps, rubella, varicella, tetanus and diphtheria. Because the HPV vaccine was only licensed and recommended in 2006, it is not included in the 2010 set of goals.

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CMS news

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New program launched to fight Medicare fraud and abuse

CMS last week announced the launch of a new, national program that will help to fight fraud and abuse under Medicare. The recovery audit contractor (RAC) program will work to identify improper payments made on Medicare claims.

The RAC program was created by the Tax Relief and Health Care Act of 2006, and is required to be in place by Jan. 1, 2010. The national program follows a successful demonstration program that operated in six states. CMS has awarded contracts to four RACs to identify overpayments and underpayments on Medicare claims.

The newly selected RACs will begin a program of provider outreach in late October and November. This outreach will include town-hall type meetings in each state before the RACs begin operating. Information about when the program will begin in your state is available on the CMS Web site.

The announcement of the RAC program launch came as part of a larger CMS effort to fight fraud and abuse. In addition to the RAC program, CMS is also working to strengthen oversight of medical equipment suppliers and home health agencies. Specifically, it will begin working directly with beneficiaries to ensure they received the medical equipment or home health services for which Medicare was billed. The agency will also be consolidating its fraud detection efforts by combining the work of Medicare’s program safeguard contractors and the Medicare Drug Integrity Contractors into new Zone Program Integrity Contractors.

Go online for more information about CMS’s efforts to fight fraud and abuse as well as further information about the RAC.

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Conference news

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ACP immunization summit

For over five years, ACP has honed it immunization quality improvement (QI) training to better serve its members. The College’s approach combines the entire health care team, physicians, nurses, office managers, and allied health professionals, to assist them in developing new ways of organizing office systems to improve services.

The ACP Immunization Summit, slated for March 18 in Chicago, will offer hands-on learning for beginners and experts. Experienced QI faculty will give instruction on systems change, team-based learning, the chronic care model, and the PDSA cycle. Information on promoting QI through a health care system or network, and tips for maintaining QI momentum during staff turnover and financial stress will be useful for more experienced attendees. Breakout sessions specific to solo, small, hospital-based and residency clinic settings will also be held. More information is available online.

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NIH conference on management of Hepatitis B

Hepatitis B is a major cause of liver disease worldwide, ranking as a substantial cause of cirrhosis and liver cancer. Roughly 1.25 million people are chronically infected with the virus in the U.S., resulting in 3,000 to 5,000 deaths each year.

To help improve the management of Hepatitis B, the National Institutes of Health (NIH) is holding a conference Oct. 20-22 for physicians, researchers, allied health personnel and interested members of the public. Speakers will present on a variety of topics, including the natural history of the disease, the current burden, and the benefits and risks of current therapeutic options. A public discussion and press conference will also be held. The conference is free and can be counted as an AMA PRA Category 1 credit. It will be held at the Natcher Conference Center on the NIH campus in Bethesda, Md.

Registration and more information are available online.

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From ACP Governance

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Call for spring 2009 Board of Governors resolutions

The deadline for submitting new resolutions to be heard at the April 2009 Board of Governors Meeting is Dec. 19. Initiating a resolution provides ACP members an opportunity to focus attention at the ACP national level on a particular issue or topic that concerns them. Members must submit resolutions to their Governor and/or chapter council. A resolution becomes a resolution of the chapter once the chapter council approves it.

In accordance with the ACP Board of Governors Resolutions Process, resolutions should clearly distinguish the action requested within its resolved clause(s) as either a policy resolve (“Resolved that ACP policy …”), or a directive, which requests action/study on an issue (“Resolved that the Board of Regents …”). If more than one action is proposed, each should have its own resolved clause. Please contact your Governor if you have any questions regarding the resolution format.

The Board of Governors votes on new resolutions which are then presented to the Board of Regents for action. Once the Board of Regents votes on these recommendations, resolutions are adopted as policy, accepted as reaffirmation of current policy, or forwarded to College staff and/or committees for study or implementation.

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Apply for ACP council elections 2009-2010

The Council for Young Physicians (CYP), the Council of Associates (COA), and the Council of Student Members (CSM) play a vital role in the College, representing the interests of our younger members and helping to set policies. All are currently seeking candidates to fill all vacant seats for 2009-2010.

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. The CYP supports the professional development and quality for young physicians, fosters young physician involvement in College activities, and ensures that young physicians’ needs are being met. The CSM addresses the needs of medical students and represents the interests of approximately 24,000 Medical Student Members. The COA plays an integral part of the structure, development, and decision making of ACP. COA members sit on committees and subcommittees. It represents the interests of over 18,000 residents, fellows, and junior staff internists.

CYP candidates must be Members or Fellows of the College who are within sixteen years of graduating from medical school as of May 1, 2009; COA candidates must be Associate members of the College; and CSM candidates must be current Medical Student Members. More information is available online or through email.

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ACP to launch new advocacy newsletter

ACP will launch a new biweekly e-newsletter designed to help keep you up-to-date on the College’s advocacy efforts and what ACP is doing in Washington to benefit internists. The first issue of The ACP Advocate will include coverage of the presidential debates, the upcoming election, and the introduction of a new bill designed to support primary care medicine.

ACP members will automatically receive the e-mail newsletters, starting with a pre-election preview, a post-election wrap-up, and continuing through the inauguration, state of the nation's health care and the first 100 days. For more information, contact ACP's Public Affairs department.

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From ACP Foundation

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October is Health Literacy Month

October marks the 10th annual Health Literacy Month, designed to promote the importance of understandable health communication. Health literacy is defined by Healthy People 2010 as “the degree to which people can obtain, process, and understand basic health information and services they need to make appropriate health decisions.” But this definition is only a starting point. Health literacy is about the entire process of exchanging healthcare information.

Organizations across the U.S. are hosting a wide range of Health Literacy Month events. They include communication workshops for health professionals, health literacy displays in libraries and colleges, educational sessions for literacy specialists and discussions with community members about the importance of health understanding. A new podcast series, Health Literacy Out Loud, is available from Helen Osborne, founder of Health Literacy Month and president of Health Literacy Consulting. More information about health literacy and ways to participate in Health Literacy Month are online.

Free health literacy materials are also available from the ACP Foundation.

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From ACP Internist

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On the blog: New government guidelines on physical activity

The government released what is meant to be the definitive word on how much exercise adults and kids need to stay healthy. Read more on the blog, plus check out this week's installment of Medical News of the Obvious.

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Cartoon caption contest: Put words in our mouth

ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner.

Put words in our mouth

E-mail your entry or submit a caption on our Web site by Oct. 17. ACP staff will choose three finalists and post them in the Oct. 21 issue of ACP InternistWeekly for an online vote by readers. The winner will appear in the Oct. 28 issue.

Pen the winning caption and $50 gift certificate good for any ACP program, product or service.

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MKSAP answer

B) Malignant pleural effusion

The complete MKSAP critique on this topic is available to subscribers in Pulmonary and Critical Care Medicine: Item 60.

ACP's Medical Knowledge Self-Assessment Program (MKSAP) allows you to:

  • Update your knowledge in all areas of internal medicine
  • Prepare for ABIM certification or recertification
  • Support your clinical decisions in practice
  • Assess your medical knowledge with 1,200 multiple-choice questions

To order the latest edition of MKSAP, go online.

Return to the rest of ACP InternistWeekly.

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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.

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Test yourself

A 69-year-old woman is evaluated for a lump under her arm found on self-examination. She is otherwise healthy and has no other symptoms. Medical and family histories are unremarkable, and she takes no medications. A needle aspirate of the right axillary mass reveals adenocarcinoma. Bilateral mammography and breast MRI are normal. CT scan of the chest, abdomen, and pelvis demonstrates the enlarged axillary lymph node and no other abnormalities. What is the most appropriate initial treatment?

Find the answer

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