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


In the News
for the Week of 11-11-08


  • Groups release updated clinical guidelines
  • Rosuvastatin lowers heart risk in healthy adults with high C-reactive protein

Test Yourself

  • MKSAP case study: ulcerative colitis surveillance


  • Cervical cancers highest among HPV-associated cancers, CDC reports


  • Heart failure but not ischemia ups risk of death after MI
  • Many have prediabetes, but few know it

FDA News

  • Insulin syringes recalled; may deliver more than double intended dose
  • U.S. seizes 11 lots of contaminated heparin


  • ACP Advocate: How the Obama administration could begin health care reform

From The College

From ACP Internist

  • On our blog: Onsite coverage of AHA's Scientific Sessions
  • Cartoon caption contest: Put words in our mouth


Groups release updated clinical guidelines

Several medical organizations issued updated clinical guidelines in recent weeks focusing on congenital heart disease, chronic kidney disease and prevention of cardiovascular disease and type 2 diabetes.

  • Management of adults with congenital heart disease: Recognizing that more patients are surviving CHD into adulthood, the American College of Cardiology and the American Heart Association jointly released guidelines aimed at managing adult care. Most children who undergo surgical procedures for CHD need lifelong follow-up, the authors noted. Some will need additional surgery to correct complications (such as a leaky heart valve) while many others need physician guidance on how their heart condition impacts their daily activities. The guidelines appear in the Dec. 2 issues of the Journal of the American College of Cardiology and Circulation.

  • Chronic kidney disease: The Royal College of Physicians in London issued clinical guidelines for the early identification and management of adult CKD. The guidelines present clear criteria for testing for CKD, suspecting progressive CKD and referring for specialist assessment. Guidance is also provided on starting treatment once proteinuria has been assessed, as well as self-management, blood pressure control, reducing cardiovascular disease, asymptomatic hyperuricaemia, managing isolated microscopic haematuria, and specific complications of CKD (renal bone disease and anemia).

  • Prevention of cardiovascular disease and type 2 diabetes: The Endocrine Society guideline focuses on the primary prevention of cardiovascular disease and type 2 diabetes in patients at metabolic risk. The presence of three or more risk factors, such as enlarged waist circumference, hypertension, and elevated plasma glucose levels, should alert a clinician to a patient at metabolic risk, the authors state. Among other recommendations, the guideline advises primary care physicians to incorporate regular screening procedures for metabolic risk factors into their practice and to have all patients at risk undergo a 10-year global risk assessment (i.e., calculate based on such factors as smoking, blood pressure, total cholesterol, diabetes) for cardiovascular disease to determine the targets for lipoprotein-lowering therapy. The guidelines appear in the November Journal of Clinical Endocrinology and Metabolism .


Rosuvastatin lowers heart risk in healthy adults with high C-reactive protein

Rosuvastatin lowers the risk of first major cardiovascular events for healthy-seeming people with high C-reactive protein levels, according to a new study in the Nov. 20 New England Journal of Medicine.

Researchers studied 17,802 men and women who had no history of cardiovascular (CV) disease, had LDL cholesterol levels of less than 130 mg/dL, and had high-sensitivity C-reactive protein levels of 2.0 mg/L or higher. Subjects were randomized to 20 mg/day of rosuvastatin or placebo. The combined primary endpoint was myocardial infarction (MI), stroke, arterial revascularization, hospitalization for unstable angina, or death from CV causes. The trial was stopped after 1.9 years of its proposed four years of follow-up, and was financially supported by AstraZeneca, which collected data but wasn’t involved in analysis.

Rosuvastatin lowered LDL cholesterol levels by 50% and high-sensitivity C-reactive protein levels by 37%. For the rosuvastatin group, the primary end point rate was 0.77 per 100 person-years of follow-up, compared with 1.36 for the placebo group (hazard ration [HR] for rosuvastatin, 0.56; 95% confidence interval [CI], 0.46 to 0.69; P<0.00001). Other rates were 0.17 vs. 0.37 for MI (HR, 0.46); 0.18 vs. 0.34 for stroke (HR, 0.52); 0.41 vs. 0.77 for revascularization or unstable angina (HR, 0.53); 0.45 vs 0.85 for the combined end point of MI, stroke or death from CV causes; and 1.00 vs. 1.25 for any-cause death. The rosuvastatin group had a higher incidence of physician-reported diabetes and higher glycated hemoglobin levels.

Given that half of MIs and strokes are in healthy-seeming patients with acceptable LDL levels, the results beg the question of whether statin use for CV prevention should be expanded, an editorialist noted. One must weigh the positive study results against safety issues, including the unknown effect of lowering LDL to 55 mg/dL (as happened in the trial), and the high cost of rosuvastatin relative to generics. As well, adverse events might increase with rosuvastatin therapy longer than 1.9 years, the authors noted.



Test yourself

MKSAP case study: ulcerative colitis 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 of the page for the answer.




Cervical cancers highest among HPV-associated cancers, CDC reports

A CDC analysis estimates that 25,000 cases of human papillomavirus (HPV)-associated cancers occurred in the U.S. from 1998-2003—before the development of the HPV vaccine—with the cervix topping the list of HPV-associated cancer sites.

Cervical cancer accounted for 10,800 HPV-associated cancers annually during the study period, with black and Hispanic women having higher rates than white and non-Hispanic women, the CDC reported. Annual rates of other types of HPV-associated cancers were oral cavity and oropharynx (7,400); anal (3,000); vulvar (2,300); penile (800); and vaginal (600).

The analysis provides baseline data to measure the impact of HPV vaccine and cervical cancer screening programs, noted a CDC news release. The analysis, based on cancer registry data from the CDC's National Program of Cancer Registries and the National Cancer Institute's Surveillance, Epidemiology and End Results Program, is the largest assessment of HPV-associated cancer data to date, the CDC said.

The report, “Assessing the Burden of Human Papillomavirus (HPV)-Associated Cancers in the United States (ABHACUS),” was published online and appears in the Nov. 15, 2008, supplement edition of Cancer.




Heart failure but not ischemia ups risk of death after MI

During the first month after a myocardial infarction, patients have a higher than average risk of sudden cardiac death, and after 30 days, their death risk is increased by heart failure but not by recurrent ischemia, a new study found.

The population-based surveillance study included 2,997 residents of Olmsted County, Minn., who experienced a myocardial infarction (MI) between 1979 and 2005. Patients were followed for a median of 4.7 years. Of the patients who survived to hospital discharge, 1.2% had sudden cardiac death during the next 30 days, four times higher than the rate in the general population. After 30 days, however, the survivors' risk declined significantly, to 1.2% per year, which is lower than the risk in the general population. The study was published in the Nov. 5 Journal of the American Medical Association.

If the patients experienced heart failure during followup, the risk of sudden cardiac death more than quadrupled. The researchers also tracked patients with recurrent ischemia and they did not find it to be a factor in the risk of death. The findings highlight the importance of continued surveillance of patients after MI and remind clinicians to be particularly concerned about the development of heart failure in these patients, the study authors said.

The study also found that the risk of sudden cardiac death after MI declined more than 40% over the study period. Because the decrease in risk predated the widespread use of defibrillators, the study authors attributed it to changes in medical therapy, including reperfusion and secondary prevention. In contemporary times, the risk of sudden cardiac death after MI is quite low, except in cases of intercurrent heart failure, the authors concluded.


Many have prediabetes, but few know it

About one in four of all U.S. adults have prediabetes, but fewer than one in 20 has been told they have it.

The CDC compared questions about prediabetes asked for the first time in the 2006 National Health Interview Survey to laboratory test results in the 2003-06 National Health and Nutrition Examination Survey (NHANES). They defined prediabetes as impaired fasting glucose (plasma glucose level of 100 to <126 mg/dL after an overnight fast), impaired glucose tolerance (plasma glucose level of 140 to <200 mg/dL after a 2-hour oral glucose tolerance test), or both.

Among those few who had been told they have prediabetes, 68% tried to lose or control weight, 55% increased physical activity or exercise, 60% reduced dietary fat or calories, and 42% did all three.

The CDC published criteria for testing for prediabetes and diabetes in asymptomatic adults.

The American College of Endocrinology published a consensus statement on managing prediabetes.

A recent issue of ACP Internist features interviews with experts on simple lifestyle changes to control prediabetes.


FDA news

Insulin syringes recalled; may deliver more than double intended dose

Manufacturer Covidien is recalling one lot of ReliOn hypodermic insulin syringes because of possible mislabeling that may cause patients to get up to 2.5 times the intended dose, the FDA said in a news release.

The extra dose of the single-use, disposable syringes could lead to hypoglycemia and/or death. The recall applies to lot number 813900 of the product labeled “ReliOn 1cc, 31-gauge, 100 units for use with U-100 insulin.” Some syringes labeled for use with U-40 insulin were mixed with these, packaged together, and sold at Wal-Mart and Sam’s Club stores from Aug. 1 to Oct. 8.

Thus far, one adverse event has been reported to Covidien, which distributed 471,000 individual syringes of the recalled lot. Providers and patients can call 866-780-5436 or go online for more information.


U.S. seizes 11 lots of contaminated heparin

U.S. Marshals seized 11 lots of contaminated heparin from Cincinnati's Celsus Laboratories last week at the FDA’s request, the agency said in a release.

Five lots of Heparin Sodium Active Pharmaceutical Ingredient (API) and six lots of Heparin Lithium, which were made from Chinese materials, were contaminated with over-sulfated chondroitin sulfate (OSCS), the FDA said.

OSCS has been linked to multiple adverse events and deaths in the last year. FDA has a heparin inspection and import control program in place, but the Celsus product entered the U.S. before import controls were in place. To date, there have been 13 FDA recalls of products containing contaminated heparin, the agency said.




Look for these stories in the latest edition of ACP Advocate, produced by ACP's Washington, D.C., office.


From the College

Chapter awardees announced

Chapters honor awardees from July through October 2008 in recognition of their outstanding service are online.


From ACP Internist

On our blog: Onsite coverage of AHA's Scientific Sessions

Conference coverage continues with a look at the American Heart Association's Scientific Sessions. Also, look for the latest installment of Medical News of the Obvious, new every Monday.


Cartoon caption contest: Put words in our mouth

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


E-mail all entries by Nov. 14. ACP staff will choose three finalists and post them in the Nov. 18 issue of ACP InternistWeekly for an online vote by readers. The winner will appear in the Nov. 25 issue.

Pen the winning caption and win a copy of "Medicine in Quotations," ACP's comprehensive collection of famous sayings relating to sickness and health, disease and treatment and a portrait of medicine throughout recorded history.



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 the Gastroenterology and Hepatology section, 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.


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 28-year-old man is evaluated for pain on the radial aspect of the right wrist that occurs with use of the thumb. The pain has been present for 2 weeks. He has never had this pain before and has not had any trauma. He works as a computer programmer and plays video games for 3 to 4 hours each night when he gets home from work. Following a physical exam, what is the most likely diagnosis?

Find the answer

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