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

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In the News
for the Week of 10-21-08

Highlights

  • Vitamin B supplementation does not slow cognitive decline, study finds
  • Aspirin, antioxidants offer no primary benefit in diabetics

Test yourself:

  • MKSAP quiz: exertional dyspnea

Cardiology

  • Episodic amiodarone no better than continuous treatment for atrial fibrillation
  • Stress testing often skipped before elective PCI

Disparities

  • Medicaid patients missing out on cancer screens

Pay for performance

  • P4P increases referrals to smoking quitline

From Annals of Internal Medicine

  • USPSTF recommends primary care providers promote breastfeeding
  • Combining therapies may improve outcomes for pulmonary hypertension patients
  • Nurse-led heart failure management reduces cost, burden
  • Call for papers

FDA review

  • ETHEX recalls potentially oversized Dextroamphetamine tablets
  • New treatment approved for benign prostatic hyperplasia

Education

  • ACP Foundation to sponsor national conference on health literacy
  • Medical students invited to apply for CDC's Applied Epidemiology Fellowship

Medicare update

  • Part D plan details for 2009 now available online

From ACP Hospitalist

  • The October issue is online and in your mailbox

From ACP Internist

  • Mindful Medicine case studies wanted
  • Cartoon caption contest: Vote for your favorite entry

Highlights

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Vitamin B supplementation does not slow cognitive decline, study finds

B vitamin supplements had no effect on cognitive decline in a recent trial involving patients with mild to moderate Alzheimer disease.

In the study, about 400 patients with mild to moderate Alzheimer disease were randomly assigned to receive either high-dose supplements (5 mg/d of folate, 24 mg/d of vitamin B6, 1 mg/d of vitamin B12) or placebo for a mean of 18 months. While supplements were effective in lowering homocysteine levels in the treatment group (mean [SD], ˙2.42 [3.35] vs. ˙0.86 [2.59] in placebo group), they had no effect on cognitive decline and depression was more common among patients in the treatment group. The study appears in the Oct. 15 Journal of the American Medical Association.

An editorial noted that until new data suggests otherwise, vitamin B supplementation is not warranted for Alzheimer's patients with normal vitamin status. The authors recommended further research on the possible connection between B vitamin supplementation and depression, but the editorial pointed out that the adverse event may be a chance finding since there were no differences in the use of antidepressants in the two study groups.

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Aspirin, antioxidants offer no primary benefit in diabetics

A recent trial concluded that aspirin and antioxidants offer no primary benefit in reducing cardiovascular events in diabetics, but researchers noted that diabetic patients should get aspirin anyway for the secondary benefit of preventing heart disease.

Researchers conducted a multicenter, randomized, double blind, 2x2 factorial, placebo-controlled trial to find whether aspirin and antioxidant therapy, combined or alone, reduced the cardiovascular events in type 1 and 2 diabetics with asymptomatic peripheral arterial disease. The study was funded by a government grant.

Researchers randomized 1,276 diabetic adults aged 40 or over with an ankle brachial pressure index of 0.99 or less but no symptomatic cardiovascular disease. Study groups included daily 100 mg of aspirin and antioxidant; aspirin and placebo; placebo and antioxidant; or placebo alone. The antioxidant mix was 200 mg alpha-tocopherol, 100 mg ascorbic acid, 25 mg pyridoxine hydrochloride, 10 mg zinc sulphate, 10 mg nicotinamide, 9.4 mg lecithin and 0.8 mg sodium selenite. Researchers measured primary end points of death from coronary heart disease or stroke, non-fatal myocardial infarction or strokes or amputation above the ankle.

Overall, 116 of 638 primary events (18.2%) occurred in the aspirin groups compared with 117 of 638 in the non-aspirin groups (18.3%), (hazard ratio [HR] 0.98; 95% confidence interval [CI] 0.76 to 1.26). In the aspirin group, 6.7% of deaths occurred from coronary heart disease or stroke compared with 5.5% in the non-aspirin groups (HR 1.23; CI 0.79 to 1.93). Primary event rates also were similar in the antioxidant vs. the non-antioxidant groups.

Researchers noted that they found no evidence to support the use of either aspirin or antioxidants in the primary prevention of cardiovascular events and mortality in diabetics. However, they said that aspirin should still be given to diabetics for secondary prevention of cardiovascular disease.

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Test yourself

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MKSAP quiz: exertional dyspnea

A 64-year-old woman is evaluated for a 9-month history of progressive exertional dyspnea and nonproductive cough. She is an ex-smoker with a 30-pack-year history. She has no constitutional symptoms or environmental exposures. There is no history of cardiovascular disease. She was recently treated with several courses of oral antibiotics for “bronchitis.” On physical examination, no exanthem or joint abnormalities are apparent. Cardiac examination is normal. Bibasilar, coarse mid- to end-inspiratory crackles are noted. Chest radiograph shows increased bibasilar reticular markings in the periphery that were not evident 3 years ago. Pulmonary physiology shows a decreased total lung capacity (TLC), forced vital capacity (FVC), and forced expiratory volume in 1 sec (FEV1), an increased FEV1/FVC ratio, and a decreased diffusing capacity for carbon monoxide (DLCO).

Which of the following tests is most likely to provide specific diagnostic and prognostic information?

A) Measurement of antinuclear antibodies and rheumatoid factor
B) Timed walk test with oximetry (6-minute walk test)
C) High-resolution computed tomographic scan (HRCT)
D) Gallium scan
E) Cardiopulmonary exercise test

Click here or scroll to the bottom of the page for the answer

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Cardiology

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Episodic amiodarone no better than continuous treatment for atrial fibrillation

Episodic amiodarone treatment for patients with atrial fibrillation was not more effective than continuous treatment, and it may contribute to adverse events, a recent study concluded.

In the study, 209 ambulatory patients with recurrent symptomatic persistent atrial fibrillation were randomly assigned to receive either episodic or continuous amiodarone treatment after electrical cardioversion following amiodarone loading. After a mean follow-up of 2.1 years, there was no significant difference between the two groups in the primary endpoint of heart disease-related events related to amiodarone. However, all-cause mortality and cardiovascular hospitalizations were higher in the episodic group compared with the continuous treatment group (53% vs. 34%, respectively) and episodic treatment also was associated with more frequent recurrences of atrial fibrillation. The study was published in the Oct. 15 issue of the Journal of the American Medical Association.

Based on their results, the authors advised against using episodic amiodarone treatment as a first option for most patients with persistent atrial fibrillation. However, in clinical practice, younger patients with less severe underlying disease may choose episodic treatment because of the potential for fewer amiodarone-related adverse events. Decision making should be individualized, said the authors, and include patient preferences.

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Stress testing often skipped before elective PCI

Less than half of Medicare patients with stable coronary artery disease have documentation of ischemia by noninvasive stress testing prior to elective percutaneous coronary intervention (PCI), according to a retrospective, observational study published in the Journal of the American Medical Association.

This finding is in direct opposition to guidelines for PCI published jointly by the American College of Cardiology, the American Heart Association and the Society for Cardiovascular Angiography and Intervention. The guideline states that for patients with stable angina, any vessels to be dilated must have a shown association with a moderate to severe degree of ischemia on noninvasive testing.

Researchers analyzed 23,887 Medicare claims and 1,630 private insurance claims. They found that 45% of the entitlement program patients underwent stress testing in the three months before angioplasty and that 34% of the non-Medicare beneficiaries underwent stress testing within 12 months of their PCI.

Women, patients treated by physicians under age 40, and patients treated by physicians who perform large numbers of angioplasties were less likely to have test-confirmed ischemia. Patients over age 85 and those with concomitant heart conditions such as congestive heart failure or chronic obstructive pulmonary disease were also less likely to undergo a pre-PCI stress test. Conversely, black patients and those with a history of chest pain were more likely to have a stress test before undergoing angioplasty.

The study revealed regional distinctions in pre-PCI stress testing as well, with physicians in the Midwest and Northeast most likely to order stress tests.

The authors point out that elective angioplasty has increased by 300% during the past decade and has accounted for at least 10% of the increase in Medicare spending since the mid-1990s. Current proposals to restructure Medicare payments to reward hospitals and physicians who adhere to guidelines would improve the safety and delivery of health care to Medicare beneficiaries, the authors said.

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Disparities

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Medicaid patients missing out on cancer screens

Routine cancer screenings are less frequently recommended or conducted for older Medicaid recipients, a new study found.

Researchers analyzed medical records and claims data for 1,951 North Carolina Medicaid recipients age 50 or older. Primary care physicians' records documented recommendations for colorectal, breast and cervical cancer screening for only 52.7%, 60.4% and 51.5% of eligible patients, respectively. Only 28.2% of patients had received a colorectal screen, 31.7% of women had a mammogram within two years and 31.6% of women had received a Pap test within three years. The study was published in the Oct. 13 Archives of Internal Medicine.

When the medical records were combined with claims data, approximately half of eligible patients had evidence of screening. Patients were more likely to have been screened if they were black or had a long-term relationship with their primary care physician. The observed rates of screening are substantially lower than those in the general population, despite full Medicaid coverage for the services, the study authors noted.

They suggested that the disparity may be due at least in part to physician assumptions about disabled patients (who make up the majority of older Medicaid beneficiaries), for example, that disabled women are not sexually active, that people with disabilities have shorter life expectancies, or that their disabled patients may be reluctant to undergo screening. Providing coverage for and access to screening services is not sufficient to remedy the socioeconomic disparities commonly seen in screening rates, researchers concluded. The finding that patients who had an established relationship with a physician were more likely to be screened shows that stable medical homes could increase screening, the authors suggested.

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Pay for performance

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P4P increases referrals to smoking quitline

A pay-for-performance program successfully motivated physicians to refer more patients to a state tobacco quitline, a new study found.

In the randomized trial, 24 primary care clinics in Minnesota were each offered $5,000 for 50 quitline referrals. The clinics received monthly updates on their referral numbers and their rates were compared with a control group of clinics not involved in the P4P program. Patients were eligible for referral if they were age 18 or older and intended to quit smoking within the next 30 days. The study was published in the Oct. 13 Archives of Internal Medicine.

Clinics in the P4P program referred 11.4% of their smokers, compared with 4.2% in the other clinics. The program made the least difference among the clinics that had a history of being very engaged with quality improvement; rates in that group were similar between controls and the intervention group. However, clinics that were typically engaged in QI on an average level or less showed substantial changes in their referral rates. Overall, 60% of patients were contacted after their referral to the quitline, and 49% of them enrolled, representing 27% of overall referrals. The marginal cost of the program per additional enrollee was $300, slightly more than typical statewide media campaigns.

The greater effect found in less QI-engaged clinics was particularly interesting, researchers said. It suggests that the effectiveness of P4P programs may be in speeding the spread of innovations from early adopters to other providers. One limitation of the study was that it did not track how many of the smokers successfully quit after enrolling in the quitline, the authors noted. However, based on the findings of the study, Blue Cross and Blue Shield of Minnesota (which funded the research) is now exploring statewide expansion of the P4P quitline program.

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From Annals of Internal Medicine

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USPSTF recommends primary care providers promote breastfeeding

The U.S. Preventive Services Task Force concluded that doctors, nurses, hospitals and health systems encourage and support breastfeeding in an update to its 2003 recommendation. The Task Force evaluated more than 25 randomized trials of breastfeeding interventions conducted in the U.S. and in developed countries around the world. Coordinated interventions throughout pregnancy, birth and infancy can increase breastfeeding initiation, duration and exclusivity and emphasized health care worker assistance with initiating and maintaining breastfeeding and lactation and postnatal breastfeeding support, the Task Force concluded. The guideline and background paper are online. ACP has prepared a video news release.

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Combining therapies may improve outcomes for pulmonary hypertension patients

Adding sildenafil (Viagra) to epoprostenol therapy may improve some outcomes for patients with pulmonary hypertension. Researchers conducted an open-label randomized study of 267 patients to determine whether the combination improves outcomes more than epoprostenol alone. All of the patients in the study had been receiving intravenous epoprostenol for at least three months, and were randomly assigned either oral sildenafil or placebo for 16 weeks. At the end of the study, patients given sildenafil could walk longer distances and had a longer period of time before getting worse than those given placebo.

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Nurse-led heart failure management reduces cost, burden

Nurse-led disease management is a reasonably cost-effective way to reduce the burden of heart failure in an ethnically diverse urban setting, a study concluded. Randomized, controlled trials have shown that nurse-led disease management for patients with heart failure can reduce hospitalizations. However, there is less evidence about the cost-effectiveness of these programs. Researchers looked at cost data from a randomized trial of 203 usual care patients versus 203 nurse-managed patients with heart failure. The study consisted mainly of black and Hispanic patients with lower socioeconomic status. Patients in the nurse-managed group maintained better physical functioning throughout the 12-month intervention than did usual care patients. In addition, nurse-led case management cost $20,000 per additional year of survival in good health.

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Call for papers

Annals of Internal Medicine invites submissions of papers reporting on studies that will be presented at the March 2009 American College of Cardiology meeting. Annals staff will coordinate publication and press releases for all accepted papers to coincide with the presentation. To be eligible for potential publication coincident with the meeting, submit your manuscript online no later than Jan. 5, 2009. Clearly indicate in the cover letter that the manuscript reports findings that will be presented at the meeting.

Annals is particularly interested in 1) trials with clinical end points that test pharmacotherapies, devices, or behavioral interventions and 2) systematic reviews or meta-analyses that address benefits and harms of widely used therapies. The journal reaches a broad audience of clinicians and decision makers through print, electronic, video, and audio-related content. Annals' recent impact factor is 15.5, and its print circulation is over 90,000.

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FDA review

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ETHEX recalls potentially oversized Dextroamphetamine tablets

ETHEX Corporation voluntarily recalled three lots (77946, 81141 and 81142) of Dextroamphetamine Sulfate 5 mg tablets, as a precaution, due to the possible presence of oversized tablets. Oversized tablets may contain as much as about twice the labeled amount of the active ingredient. The recalled lots were distributed under an "ETHEX" label between January 2007 and May 2008. The 5 mg product is an orange round tablet debossed with "ETHEX" and "311" on one side.

A larger dose would increase the risk of adverse effects such as tachycardia, hypertension, tremors, decreased appetite, headache, insomnia, dizziness, blurred vision, stomach upset, and dry mouth. An FDA alert is online.

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New treatment approved for benign prostatic hyperplasia

The FDA approved Rapaflo (silodosin) capsules for symptoms due to benign prostatic hyperplasia (BPH). Rapaflo works by blocking the alpha-1 adrenoreceptors in the prostate, bladder, and urethra, allowing the smooth muscle in these tissues to relax.

Rapaflo will be available in a once-daily capsule. An 8 mg daily dose is recommended for men who do not suffer from kidney or liver impairment. A 4 mg daily dose will be available for men with moderate renal impairment. Rapaflo is not recommended for men with severe kidney or liver impairment and is not approved for pediatric use.

The most common side effect seen with Rapaflo is reduced or no semen during orgasm. This side effect does not pose a safety concern and is reversible with discontinuation of the product. Patients planning cataract surgery must notify their ophthalmologist that they are taking Rapaflo because of the possibility of Intraoperative Floppy Iris Syndrome (IFIS), a complication associated with cataract surgery. Patients on alpha-blockers or those who have severe kidney or liver impairment should not use Rapaflo.

An FDA press release is online.

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Education

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ACP Foundation to sponsor national conference on health literacy

New Directions in Health Literacy, a national conference sponsored by the ACP Foundation and the Institute of Medicine, will be held Nov. 19 in Washington, D.C.

Janet Corrigan, PhD, president and CEO of the National Quality Forum, will deliver a keynote speech on "the importance of health literacy in achieving national goals for health care quality." Another keynote address will be presented by Karen Ignagni, president and CEO of America’s Health Insurance Plans, on "Pathways to Consumer Engagement."

The conference also will include panel presentations on health literacy research focusing on reducing cardiopulmonary re-hospitalizations, functional health literacy and the home safety literacy project. Workshops will focus on clinical skills, system redesign, health care quality and medication label improvement. The conference will be held Nov. 19 at the National Academy of Sciences in Washington, DC. Go online to view the agenda and register.

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Medical students invited to apply for CDC Applied Epidemiology Fellowship

Medical students with a strong interest in public health or in practicing medicine with a broad, analytic perspective are invited to apply for The CDC Experience Applied Epidemiology Fellowship.

Eight competitively selected fellows will spend 10-12 months at the CDC offices in Atlanta, where they will carry out epidemiologic analyses in various areas of public health. Students will have opportunities to investigate outbreaks of disease in different populations, travel to help set up surveillance programs or engage in injury prevention research, to name a few examples.

The opportunity is open to 3rd and 4th year medical students and is designed to increase the pool of physicians with a population health perspective. Application materials for the 2009-2010 fellowship year must be postmarked by Dec. 5, 2008. More information is available online.

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Medicare update

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Part D plan details for 2009 now available online

CMS last week made available the 2009 plan details for Part D and Medicare Advantage on the Medicare beneficiaries Web site.

The Medicare Prescription Drug Plan Finder helps beneficiaries compare the premiums and benefits for Part D plans, as well as for drug coverage under Medicare Advantage plans. Searches can be done based on price, coverage, or pharmacy network. The Plan Finder also has a new feature that allows beneficiaries to compare the costs of substitution drugs that are in the same therapeutic classes as drugs they already take.

The Medicare Options Compare Tool allows beneficiaries to compare Medicare Advantage plans. The tool also includes a comparison with traditional Medicare fee-for-service plans.

Both tools are being offered online in preparation for open enrollment, beginning November 15. More information for beneficiaries about Medicare can be found online. Beneficiaries also can access this information by phone at 1-800-MEDICARE.

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From ACP Hospitalist

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The October issue is online and in your mailbox

The next issue of ACP Hospitalist is online and in your mailbox.

Hospitalist teams embrace age, experience. Physicians who move from the community to the hospital mid-career present a potential solution to the hospitalist field's perennial workforce shortage.
Be your own boss. Hospitalists face issues as they decide whether to start up or join a local hospitalist group, become part of a large group or management company, or be a hospital employee.
Married hospitalists benefit work-life balance. By working as hospitalists in the same practice, some doctors are able to take care of families and spend quality time together.

The latest issue is online. Not a subscriber? Call for a free subscription at 800-523-1546.

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From ACP Internist

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Mindful Medicine case studies wanted

ACP Internist columnists Jerome Groopman, FACP, and Pamela Hartzband, FACP, would like to hear about your stories of difficult or missed diagnoses for possible use in their next Mindful Medicine column.

Dr. Groopman, a hematologist/oncologist and author of the bestselling "How Doctors Think," and Dr. Hartzband, an endocrinologist, are on the Harvard Medical School faculty and serve as staff physicians at Boston's Beth Israel Deaconess Medical Center. Every other issue, they present a case study from an ACP Internist reader describing a difficult or missed diagnosis, and provide commentary on how a mistake was, or might have been, avoided.

Please e-mail your suggestions to Drs. Groopman and Hartzband. The authors will contact you to discuss the case if your submission is selected for the column.

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Cartoon Caption Contest: Vote for your favorite entry

ACP InternistWeekly's cartoon caption contest continues. ACP staff has selected three finalists for the latest contest and is now asking readers to vote for their favorite caption to determine the winner.

Cartoon Caption Contest

Go online to view the cartoon and pick the winner, who receives a $50 gift certificate good for any ACP product, program or service.

EDITOR'S NOTE: For all our readers who submitted their captions through ACP Internist's new Web site at www.acpinternist.org, we did receive your captions despite an error message you saw upon submission. That glitch is fixed.

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MKSAP answer

C) High-resolution computed tomographic scan (HRCT)

The complete MKSAP critique on this topic is available to subscribers in Pulmonary and Critical Care Medicine: Item 12.

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.

Test yourself

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?

Find the answer

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