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

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In the News
for the Week of 10-7-08

Highlights

  • Guidelines for sexually transmitted infections, colorectal cancer screening
  • Three medical groups issue guidelines on reducing GI risks of antiplatelets and NSAIDs
  • Therapy, rather than supplements, helps arthritis

Test yourself

  • MKSAP quiz: colon surveillance

Oncology

  • Hepatitis B may be risk factor for pancreatic cancer, study suggests
  • Circulating tumor cells refine prostate cancer prognosis

Cardiology

  • AHA: Routinely screen patients with CHD for depression
  • Younger women at risk from hormone therapy

Annals of Internal Medicine

  • Newest stool DNA test shows promise for detecting colon polyps and cancer
  • High levels of growth hormone linked to increased prostate cancer risk
  • Call for papers

Health information technology

  • CMS announces new tool to help access quality reports
  • New resources to help with EHR selection available

FDA news

  • New genetic test can identify flu strains in four hours
  • New test can detect MRSA, SA within one hour
  • Preliminary study suggests epoetin alfa heightens stroke risk
  • No apparent risk of ALS with statins

From ACP Internist

  • On the blog: Study dovetails with passage of mental health parity bill

Cartoon caption contest


Highlights

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Guidelines for sexually transmitted infections, colorectal cancer screening

In the current issue of Annals of Internal Medicine, the U.S. Preventive Services Task Force (USPSTF) recommends that high-intensity behavioral counseling be provided to all individuals at increased risk for sexually transmitted infections (STI). People at high risk include all sexually active adolescents, adults with a history of STIs within the past year, and adults with multiple sexual partners.

The CDC estimates that 19 million new STIs occur each year, almost half of which occur among persons 15 to 24 years of age. Good-quality evidence suggests that multiple behavioral counseling sessions conducted in STI clinics and primary care settings effectively reduce STI incidence at both six months and one year after counseling. Additional trial evidence is needed to determine the effectiveness of both lower-intensity behavioral counseling interventions and counseling in lower-risk patient populations.

Also in Annals, the USPSTF updated its 2002 recommendations on colorectal cancer screening, taking into consideration the positive impact of screening on life expectancy.

The updates recommend annual screening for colorectal cancer with a sensitive fecal occult blood test (FOBT); every 10 years with a colonoscopy; or every five years with a flexible sigmoidoscopy and a mid-interval sensitive FOBT. Screening should begin at age 50 and continue until age 75. More evidence is needed to assess the benefits and harms of newer tests such as computed tomographic colonography and fecal DNA testing.

The USPSTF recommends against routine screening for colorectal cancer in adults 76-85 years old. However, physicians should make screening decisions based on an assessment of the individual patient’s risk factors and personal history. After 85 years of age, risks of screening may outweigh the benefits and, therefore, is not recommended.

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Three medical groups issue guidelines on reducing GI risks of antiplatelets and NSAIDs

Three medical groups released consensus guidelines outlining a stepwise approach for reducing the risk of ulcers and gastrointestinal (GI) bleeding among patients using nonsteroidal anti-inflammatory drugs (NSAIDs) along with antiplatelet agents.

Patients taking low-dose aspirin plus NSAIDs have a two- to four-fold increased risk of gastrointestinal bleeding compared with those not taking these medications, according to a statement by the American College of Cardiology, the American College of Gastroenterology and the American Heart Association.

To reduce problems, providers must assess patient risk factors for possible GI complications, including age, previous history of ulcers or bleeding, presence of H. pylori, dyspepsia or acid reflux symptoms, as well as the simultaneous use of NSAIDs, anticoagulants or corticosteroids. The presence of several risk factors further increases the possibility of bleeding.

The specific recommendations include:

  • Use a gastroprotective therapy for at-risk patients using any NSAID, including COX-2–selective agents and over-the-counter agents;
  • Enteric-coated or buffered preparations do not reduce bleeding risk. Gastroprotection should be prescribed. For the chronic phase of therapy, do not routinely prescribe doses greater than 81 mg;
  • The combination of aspirin and anticoagulant therapy (including unfractionated heparin, low molecular-weight heparin, and warfarin) is associated with a significantly increased risk of major extracranial bleeding events, a large proportion from the upper GI tract. This combination should be used with established vascular, arrhythmic or valvular indication. Patients should receive proton pump inhibitors. When warfarin is added to aspirin plus clopidogrel, an international normalized ratio (INR) of 2.0 to 2.5 is recommended;
  • Substituting clopidogrel for aspirin is not recommended to reduce the risk of recurrent ulcer bleeding in high-risk patients and is inferior to the combination of aspirin plus proton pump inhibitors.
  • The combination of clopidogrel and warfarin therapy is associated with an increased incidence of major bleeding when compared with monotherapy alone. It should be considered only in cases in which the benefits are likely to outweigh the risks. When warfarin is added to aspirin plus clopidogrel, an INR of 2.0 to 2.5 is recommended;
  • Proton pump inhibitors are the preferred agents for the therapy and prophylaxis of NSAID- and aspirin-associated GI injury;
  • Testing for and eradicating H. pylori in patients with a history of ulcer disease is recommended before starting chronic antiplatelet therapy;
  • Stopping aspirin when there is acute ulcer bleeding is based upon cardiac risk and GI risk assessments to discern potential thrombotic and hemorrhagic complications; and
  • Endoscopic therapy may be performed in high-risk cardiovascular patients on dual antiplatelet therapy, and collaboration between the cardiologist and endoscopist should balance the risks of bleeding with thrombosis when deciding to end antiplatelet therapy.

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Therapy, rather than supplements, helps arthritis

Glucosamine and chondroitin show no benefit for patients with osteoarthritis, but occupational therapy does, two new studies found.

In the first trial, 572 patients with knee osteoarthritis were randomized to 500 mg of glucosamine three times daily, 400 mg of chondroitin sulfate three times daily, both supplements, 200 mg of celecoxib daily, or placebo. This research was a continuation of the Glucosamine/chondroitin Arthritis Intervention Trial (GAIT); participating patients had opted to continue their trial treatments an extra 18 months, for a total of two years.

The study found no statistically significant differences in arthritis progression among the groups. The patients who took only glucosamine did have a very slightly reduced rate of joint loss—0.013 mm compared with an average of 0.166 in the placebo group. That difference could hint at an effect that would be more apparent in a longer study, a study author told the Sept. 30 Washington Post.

In the other study, 54 older adults with knee or hip osteoarthritis were enrolled in exercise programs. They were randomized to exercise plus health education or exercise plus occupational therapy (specifically, activity strategy training). Researchers found that the occupational therapy group had increased levels of physical activity during exercise by the end of the program. There was also a statistically insignificant improvement in pain and physical function. Both studies were published in the October issue of Arthritis and Rheumatism.

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Test yourself

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MKSAP quiz: colon surveillance

A 35-year-old man with a 10-year history of ulcerative colitis involving the entire colon comes for a follow-up office visit. A small bowel follow-through radiographic series obtained at the time of diagnosis was normal.

The patient is doing well on mesalamine maintenance therapy. He has only occasional diarrhea and bleeding and has rarely required corticosteroids. A colonoscopic examination with biopsies 1 year ago showed changes of chronic ulcerative colitis but no signs of dysplasia.

Which of the following surveillance options is most appropriate for this patient?

A) Repeat colonoscopy with biopsies starting at age 50; then repeat examination every 5 years
B) Repeat colonoscopy with biopsies now; then repeat examination every 5 years
C) Repeat colonoscopy with biopsies now; then repeat examination every 1 to 2 years
D) Colonoscopy with biopsies only if the patient has symptoms refractory to medical therapy
E) Barium enema examination or virtual colonoscopy (CT colonography) now; repeat studies every 1 to 2 years

Click here or scroll to the bottom for the answer.

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Oncology

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Hepatitis B may be risk factor for pancreatic cancer, study suggests

A recent study suggests that people who have been infected with the hepatitis B virus may be more likely to develop pancreatic cancer.

In the study, 476 patients with pathologically confirmed adenocarcinoma of the pancreas were compared with 876 healthy controls matched by age, sex and race. Researchers at the University of Texas M.D. Anderson Cancer Center tested blood samples for evidence of infection with the viruses that cause hepatitis B and C, and found that 7.6 % of people in the cancer group had been infected with hepatitis B, compared with 3.2% in the control group. There was no connection to hepatitis C. The study appears in the Oct. 1 Journal of Clinical Oncology.

Hepatitis B has already been linked to liver cancer, and researchers speculated that the proximity of the liver to the pancreas and that fact that the two organs share blood vessels and ducts makes the pancreas another potential target for the hepatitis virus, according to a M.D. Anderson Cancer Center news release.

The study also suggests that chemotherapy may trigger reactivation of HBV in pancreatic cancer patients, said the release. Chemotherapy may suppress the immune system, researchers said, leading to reactivation of a latent HBV infection and possible liver damage or eventual failure. Pending the results of further research, physicians may want to test pancreatic cancer patients for HBV before they get chemotherapy, researchers said.

If further research confirms HBV as a risk factor, researchers said, the HBV vaccine might one day be recommended as a preventive measure for people at risk for pancreatic cancer.

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Circulating tumor cells refine prostate cancer prognosis

Circulating tumor cells (CTC)—cancer cells that have broken away from an existing tumor and have entered into the bloodstream—refine the prognosis of prostate cancer and are an independent indicator for overall survival of the disease, a study found.

CTC can help tailor treatments and possibly extend the survival of men with aggressive forms of metastatic prostate cancer, according to an industry-funded study led by researchers at The Institute of Cancer Research.

The FDA approved a test to determine the prognosis of patients with metastatic breast, colorectal or prostate cancer. So the prospective study looked at the relationship between post-treatment CTC count and overall survival in castration-resistant prostate cancer (CRPC). Secondary objectives included determining the prognostic ability of CTC measurement before beginning therapy, and the relationship of CTC to prostate-specific antigen (PSA) changes and overall survival.

The study involved 231 patients undergoing chemotherapy treatment at 65 clinical centers in Europe and the U.S. The patients underwent monthly CTC monitoring. A count of more than 5 CTC per 7.5 ml of blood deemed unfavorable prognosis and a count of less than 5 CTC per 7.5 ml was deemed favorable. This was compared with the progression of the metastatic prostate cancer tumors.

Patients with unfavorable pretreatment CTC (57%) had shorter overall survival (median overall survival, 11.5 versus 21.7 months; Cox hazard ratio, 3.3; P < 0.0001). Unfavorable post-treatment CTC counts also predicted shorter overall survival at weeks 2 to 5, 6 to 8, 9 to 12, and 13 to 20 (median overall survival, 6.7-9.5 versus 19.6-20.7 months; Cox hazard ratio, 3.6-6.5; P < 0.0001). Also, CTC counts predicted overall survival better than PSA at all time points, researchers concluded.

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Cardiology

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AHA: Routinely screen patients with CHD for depression

Physicians should routinely screen their coronary heart disease (CHD) patients for depression in various settings, including the office, clinic, hospital and cardiac rehabilitation center, the American Heart Association said in a scientific advisory last week.

Given a recent study that found cardiac disease patients had nearly twice the prevalence of depression (9.3%) in a 12-month period compared with those with no comorbid illness, providers should screen CHD patients with the two-item Patient Health Questionnaire (PHQ-2), at a minimum, according to the advisory published in the Sept. 29 online version of Circulation. If the patient answers yes to either question, the PHQ-9 should then be used.

Depression is associated with worse outcomes in CHD patients, and increases the chances that patients won't adhere to medications or comply with treatment, the advisory said. Patients whose screenings indicate they have major, or mild-to-moderate, depression should be referred to a specialist for further evaluation and treatment. Those with minimal symptoms should receive education and support, and follow-up after one month, it said.

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Younger women at risk from hormone therapy

A huge observational trial of Danish women has confirmed the findings of the Women's Health Initiative with regard to the cardiovascular risks of hormone replacement therapy (HRT).

Researchers analyzed data from all healthy Danish women between the ages of 51 and 69 during 1995-2001 (n=698,098). They looked at hormone use, method of delivery and age at use and correlated those factors with the 4,947 myocardial infarctions (MI) that were reported. The research was published online in the European Heart Journal.

Overall, the study found no increased risk of MI among women who were currently using hormones compared with those who never had. However, younger hormone users (who were between ages 51 and 54) had a 24% increased risk, and the longer the duration of use at a young age, the greater the risk became, the study found.

The study also found that continuous combined therapy of estrogen and progesterone resulted in a higher risk of heart attack than was seen in women on cyclic therapy or estrogen or tibolone alone. Dermal application of hormones was also found to be lower risk than oral use, with a 38% reduction seen for patch users and 44% lower risk for vaginal gel.

Based on the results, cyclic combined therapy should be preferred for women with an intact uterus, the study author told the Oct. 1 Washington Post. However, she cautioned that further research is needed on the surprising finding that vaginal estrogen resulted in significantly lower risk before clinical recommendations can be made.

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Annals of Internal Medicine

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Newest stool DNA test shows promise for detecting colon polyps and cancer

The newest stool DNA test is twice as effective at detecting colon cancer and polyps than either the fecal occult blood test or an older version of the DNA test. In a multicenter study of 3,764 healthy adults with an average risk for colon cancer, patients collected samples of stool at home and sent them to a laboratory that tested for hidden blood. Another laboratory tested the stool using two different types of DNA tests to see whether it contained DNA abnormalities associated with polyps or cancer. Researchers concluded that the best test for blood in the stool detected 21% of the cancer cases and the most worrisome types of polyps. The older of the two stool DNA tests (SDT-1) detected 20% of them. The newer stool DNA test (SDT-2) detected 40% of the cases of cancer and the most worrisome types of polyps. Researchers theorize that more user-friendly and widely distributable screening tools could improve screening effectiveness, acceptability, and access.

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High levels of growth hormone linked to increased prostate cancer risk

A person’s blood normally contains a certain amount of insulin-like growth factor, or IGF-I, a peptide that influences growth and other biological functions. However, at elevated levels, IGF-I is associated with a moderate increase in prostate cancer risk, a study found. Researchers reanalyzed data from 12 studies to determine the link between IGF-I and its associated binding proteins (IGFBPs) with risk of prostate cancer. Looking at 3,700 men with prostate cancer and 5,200 control participants, researchers noted that the greater the IGF-I concentration in the blood, the greater the risk for prostate cancer. Researchers conclude that this is an important study because IGF-I levels can by modified through diet and lifestyle changes. However, whether modifying levels would reduce prostate cancer risk is not known.

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Call for papers

The 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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Health information technology

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CMS announces new tool to help access quality reports

In an effort to respond to provider concerns about accessing their reports for the Physician Quality Reporting Initiative (PQRI) 2007, the Centers for Medicare and Medicaid Services (CMS) announced a new Web-based tool. A new self-service look-up tool is now available on the PQRI Portal that allows providers to see whether or not their 2007 PQRI Feedback Reports are available.

On the Web site, look to the bottom, left of the screen for the section labeled “Verify TIN Report Portlet.” In that section, enter the tax identification number of the provider who participated in PQRI, and a message will appear that tells you whether the 2007 report is available. This new portal does not give access directly to the 2007 PQRI Feedback Reports. However, the portal is useful for providers who need to know if their reports are available before they register for an account to access the reports.

In order to access the actual reports, providers need to register for access through a CMS security system known as the Individuals Authorized Access to CMS Computer Services (IACS). Further information about that registration process, and how to access the 2007 PQRI Feedback Reports, for both individual[PDF] practitioners and group[PDF] practices can be found online.

The PQRI was introduced by CMS in July of 2007. The program pays physicians a bonus for reporting quality data to CMS on their claims forms. The program has been renewed, and is underway for 2008.

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New resources to help with EHR selection available

The Certification Commission for Healthcare Information Technology (CCHIT) recently launched several new tools for physicians and others who are choosing electronic health records. Resources on the EHR Decisions Web site include:

  • A podcast, featuring CCHIT Chair Mark Leavitt, Commissioner Jim Morrow, MD, and Bridges to Excellence CEO Francois de Brantes, introducing the availability of newly CCHIT-certified 2008 ambulatory EHRs, information on EHR incentive programs, and some tips on how to approach selection of EHR products.
  • A new 2008 version of the Physician’s Guide to CCHIT Certification[PDF], including questions physicians should be asking before they purchase an EHR.
  • The CCHIT Incentive Index™, a new catalog of incentives that helps physicians find programs that could benefit them before or after they buy.

For more help with selecting and installing EHRs, go to ACP's online EHR road map.

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FDA update

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New genetic test can identify flu strains in four hours

The FDA last week approved a genetic test that can diagnose influenza strains within four hours, instead of the four days that previous tests took, the CDC said in a release.

The Human Influenza Virus Real-Time RT-PCR Detection and Characterization Panel (rRT-PCR Flu Panel) can detect and identify common human influenza viruses as well as influenza A (H5N1) viruses. Its quick turnaround time could help health officials stave off a pandemic from a mutant H5N1 strain, said the CDC, which helped develop the test. In the case of common flu, the test can help doctors decide which medication to prescribe for patients, the Oct. 1 Washington Post reported.

The test will be available to CDC-qualified laboratories this fall. In order to run the test, the CDC is requiring labs to buy equipment from Applied Biosystems, Inc—which also helped make the test—while the CDC will provide the necessary chemicals, the Post reported.

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New test can detect MRSA, SA within one hour

The FDA last week approved a test that can detect methicillin-resistant staphylococcus aureus (MRSA) and staphylococcus aureus (SA) within one hour.

Cepheid's Xpert MRSA/SA Blood Culture (BC) test may help doctors figure out which antibiotic would work best in treating the infections—which would not only improve patient outcomes but reduce resistance, the company said in a release.

Results from existing MRSA and SA tests typically take 2-3 days, the release said.

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Preliminary study suggests epoetin alfa heightens stroke risk

Epoetin alfa (Aranesp, Epogen and Procrit) may increase the risk of death for acute ischemic stroke patients, according to preliminary results from a German study.

Researchers investigated the use of epoetin alfa to treat acute ischemic stroke, and used doses that were "considerably higher" than those recommended to treat anemia, the FDA said in a safety alert. In a 90-day period, about 16% of patients on the drug died compared to 9% of those on placebo.

About half of all deaths in both groups occurred within the first seven days after starting the drug or placebo. About 4% of epoetin alfa patients died of intracranial hemorrhage compared to 1% of placebo patients. More data should be available within the next several weeks, the FDA said.

Last July, the FDA asked the manufacturers of Aranesp and Procrit to add a warning to their labels about use of the product in cancer patients, in light of trials that showed the drugs might raise the risk of bleeding and cause tumors to spread. In June, an FDA committee said the drugs shouldn't be used in patients with breast or head and neck cancer.

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No apparent risk of ALS with statins

Statins don't appear to increase the incidence of amyotrophic lateral sclerosis (ALS), a new FDA analysis found.

The FDA began to review a possible link in 2007, after receiving a number of reports of ALS in patients on statins. It analyzed 41 long-term, placebo-controlled clinical trials, and found no higher incidence of ALS in patients treated with a statin versus placebo, the agency said in a release.

Results from a separate case-control or epidemiological study of ALS and statins should be available within nine months, and the FDA is examining whether additional epidemiologic studies are feasible, the agency said. Health care providers shouldn't change their prescribing practices for statins, based on current information.

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From ACP Internist

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On the blog: Study dovetails with passage of mental health parity bill

Long-term therapy is best for those with complex mental illness-- and the treatment may actually be covered by insurance now that Congress has passed a parity law. This and Medical news of the Obvious every Monday at ACP Internist's blog.

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Cartoon caption contest

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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 all entries by to acpinternist@acponline.org 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

C) Repeat colonoscopy with biopsies now; then repeat examination every 1 to 2 years

The complete MKSAP critique on this topic is available to subscribers in Gastroenterology and Hepatology: Item 11.

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.

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Copyright 2008 by the American College of Physicians.

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Test yourself

A 72-year-old woman is evaluated during a routine examination. She has very severe COPD with multiple exacerbations. She has dyspnea at all times with decreased exercise capacity. She does not have cough or any change in baseline sputum production. She is adherent to her medication regimen, and she completed pulmonary rehabilitation 1 year ago. She quit smoking 1 year ago. Her medications are a budesonide/formoterol inhaler, tiotropium, and an albuterol inhaler as needed. Following a physical and pulmonary exam, what is the most appropriate next step in management?

Find the answer

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