In the News
for the Week of 11-18-08
- New ACP guideline on drugs used to treat depressive disorders
- New research released at AHA Scientific Sessions
- MKSAP quiz: diabetes mellitus
- ACC reviews best practices for resistant hypertension
- Abdominal fat predicts death risk better than BMI
Annals of Internal Medicine
- Combination of psychological therapies may help patients manage diabetes
- Rifampin safer than standard treatment for preventing recurrent tuberculosis
- Manufacturer expands recall of potentially oversized pills
- Last chance to earn a 2008 Medicare pay-for-reporting bonus
- Sen. Baucus releases plan for health care reform
From the College
From ACP Internist's blog
- More from AHA and the latest medical news of the obvious
Cartoon caption contest
- Vote for your favorite entry
New ACP guideline on drugs used to treat depressive disorders
Second generation treatments for depression are all equally effective according to a new clinical practice guideline released by the College. The guideline is published in Annals of Internal Medicine.
To develop the guideline, ACP reviewed more than 200 published studies about the benefits and harms of second-generation drugsÂ—bupropion, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, nefazodone, paroxetine, sertraline, trazadone, and venlafaxineÂ—used to treat depression.
The guideline contains four recommendations:
- Clinicians should select second-generation antidepressants on the basis of adverse effect profiles, cost and patient preferences. Adverse effects can range from mild, such as constipation or diarrhea, to severe, such as suicidal thoughts.
- Clinicians should assess patient status, therapeutic response and adverse effects of antidepressant therapy on a regular basis within two weeks of starting therapy. The FDA advises that all patients receiving antidepressants should be closely monitored on a regular basis for increases in suicidal thoughts and behaviors. The risk for suicide attempts is greater during the first two months of treatment.
- Clinicians should modify treatment within six to eight weeks if the patient does not have an adequate response.
- Clinicians should continue treatment for four to nine months after a satisfactory response in patients with a first episode of major depressive disorder. For patients who have had two or more episodes of depression, an even longer duration of therapy may be beneficial to prevent relapse or recurrence.
New research released at AHA Scientific Sessions
NEW ORLEANSÂ—While the JUPITER trial took center stage, several other drug and lifestyle modification studies created buzz at the American Heart Association Scientific Sessions conference last week. Among the studies presented were:
- The HF-ACTION study, which found exercise training didnÂ’t reduce death or hospitalization rates for heart failure patients compared to usual care. There was an 11% reduction in death and hospitalization on adjusted analysisÂ—but the main message from the study was that exercise in this population is safe, observers said. A sub-study found that the patients in the exercise group reported significantly better health status (quality of life, symptoms and physical/social limitations) at three months, and the difference lasted for three years. The study involved 2,331 heart failure patients (average age, 59 years) who were followed for about 2.5 years.
- Compared to placebo, irbesartan (Avapro) didnÂ’t significantly lower the death and hospitalization rate of heart failure patients with an ejection fraction of greater than or equal to 45%. The I-PRESERVE study of 4,128 patients over 4.5 years found no difference between the groups, which at least showed the drug is safe for use in these patients to control hypertension, the authors said.
- Two studies reported good news about surgery outcomes in the very elderly. One examined 1,062 patients age 80 years and older who had undergone coronary artery bypass grafts, and found that half lived for six years or more, and about a quarter lived for 10 years. A second study of octogenarians undergoing aortic valve replacement without CABG found that more than half were still alive nearly eleven years later, compared to nine years later for those who had valve replacement with CABG.
- Warfarin patients who did weekly home INR testing had no more strokes, major bleeds or deaths than patients who were monitored monthly at a clinic. Home testing might be a better option for patients who have disabilities or live far from a clinic, the authors noted. The study involved 2,922 VA patients, nearly all of whom were men, and had an average follow-up of three years.
More coverage of the AHA Scientific Sessions meeting is available on the ACP Internist blog.
Â—by Jessica Berthold, senior writer
MKSAP quiz: diabetes mellitus
A 55-year-old woman asks to be tested for diabetes mellitus because she had a fasting blood glucose value of 130 mg/dL (7.22 mmol/L) at a recent local health fair. She has no symptoms of polydipsia or polyuria. She has mild osteoarthritis but no other significant illnesses. Her mother and sister both developed type 2 diabetes mellitus in their 50s. She takes only occasional aspirin or acetaminophen for her joint pains.
On physical examination, the blood pressure is 120/75 mm Hg, pulse rate 72/min, and BMI 25.2.
Which of the following should be done next to establish a diagnosis of diabetes mellitus?
A) Measure the hemoglobin A1C
B) Repeat a fasting plasma glucose measurement
C) Perform a 100-g glucose tolerance test
D) Measure a 2-hour postprandial blood glucose level
E) Measure a fasting plasma insulin level
Click here or scroll to the bottom of the page for the answer.
ACC reviews best practices for resistant hypertension
A new review outlines patient characteristics associated with resistant hypertension, a diagnostic evaluation to assess the problem, and treatment strategies for controlling blood pressure.
Hypertension outcome trials show 20% to 35% of participants could not achieve blood pressure control even though they took three antihypertensive medications, including a diuretic. Resistant hypertension is projected to increase as aging and the rates of obesity, sleep apnea and chronic kidney disease rise, according to the review published in the Journal of the American College of Cardiology.
The review outlines four broad means for reducing resistant hypertension:
- Confirm the diagnosis and exclude pseudo-resistance, such as improper blood pressure measurement, the "white-coat effect" and poor patient adherence to lifestyle and/or antihypertensive medications;
- Educate and reinforce lifestyle issues, such as sodium restriction, reducing alcohol and weight loss for the obese;
- Exclude nonsteroidal anti-inflammatory agents, cold preparations, and certain herbs; and
- Follow an antihypertensive regimen that focuses on the cause of the hypertension. For example, if volume overload is at fault, use diuretics.
Abdominal fat predicts death risk better than BMI
Waist circumference and waist-to-hip ratio are better predictors of death than body-mass index (BMI), according to a large new European study.
The research included 359,000 participants from nine European countries, of whom about 14,000 died during nine years of followup. The study controlled for age, education, smoking status, alcohol consumption, physical activity and height. The lowest death rates were observed at BMIs of 25.3 for men and 24.3 for women. After adjustment for BMI, participants in the highest quintile of waist circumference had more than double the risk of death, and those with high waist-to-hip ratios had a 68% increased risk. The study was published in the Nov. 13 New England Journal of Medicine.
The researchers' assessment of BMI found that patients at both the low and high ends of the spectrum had higher death rates than those in the middle. However, more abdominal fat was consistently associated with mortality risk, and was a particularly strong predictor in patients with lower BMIs. Based on the results, the study authors concluded that waist circumference measurements and/or waist-to-hip ratios may provide a better assessment of mortality risk, especially in patients with lower BMIs.
The findings may explain why past research had not found a constant linear relationship between BMI and the risk of death, researchers said. In accordance with other research, the study did find that the death risk in participants with low BMIs was driven primarily by respiratory and other causes, while the high BMI mortality was more closely related to cardiovascular diseases and cancer. Overall, the results highlight the importance of assessing body fat distribution even in patients of normal weight, the study authors said.
Annals of Internal Medicine.
Combination of psychological therapies may help patients manage diabetes
Psychological issues may interfere with type 1 diabetes management tasks such as insulin injections, diet and exercise. To find out whether psychological therapy could improve diabetes management, researchers assigned 344 patients to either regular care, cognitive behavioral therapy or a combination of nurse-delivered cognitive behavioral therapy and motivational enhancement therapy (brief counseling that focuses on self-motivation). Researchers collected information on change in blood sugar levels, low blood sugar episodes, depression, quality of life, diabetes self-care activities and weight for one year. Patients who received both psychological therapies fared the best, having a greater decrease in blood sugar levels than patients who received usual care. However, the changes were small and this study cannot determine whether they would persist beyond 12 months..
Rifampin safer than standard treatment for preventing recurrent tuberculosis
While patients with latent tuberculosis infection (LTBI) are not contagious and have no symptoms, they are at risk for developing active tuberculosis at a later stage of their life. Typically, LTBI is treated with nine months of daily isoniazid. However, isoniazid is associated with poor patient adherence and dangerous side-effects such as liver damage. Researchers compared adverse events and treatment completion among 847 patients receiving either nine months of isoniazid or four months of rifampin. Researchers found that patients in the rifampin arm had fewer serious adverse events and better adherence. Researchers believe their findings justify a large-scale trial to compare the ability of the two treatments to prevent active TB from developing.
Manufacturer expands recall of potentially oversized pills
Ethex Corporation expanded its previous recall of generic drugs that may contain oversized tablets with too much active ingredient. The recall now affects:
- dextroamphetamine sulfate: 10 mg
- isosorbide mononitrate, extended release: 30 and 60 mg
- morphine sulfate, extended release: 15 mg
- morphine sulfate, immediate release: 15 and 30 mg
- propafenone HCl: 150, 225 and 300 mg
Specific lot information is online. Overdoses can result in arrhythmias and low blood pressure with propafenone HCl; fainting and low blood pressure with isosorbide mononitrate; respiratory depression and low blood pressure with morphine sulfate; and rapid heart rate and high blood pressure with dextroamphetamine sulfate.
Last chance to earn a 2008 Medicare pay-for-reporting bonus
ItÂ’s not too late to earn a Medicare pay-for-reporting bonus under the 2008 Physician Quality Reporting Initiative (PQRI), even for doctors who haven't reported PQRI measures to date. Changes to the reporting options took effect in July 2008 that enable doctors to earn a bonus equal to 1.5% of total allowed Medicare changes for the six-month period July 1 to Dec. 31.
These changes allow physicians to earn a bonus for the second half of the year by successfully reporting on individual quality measures for a condition-specific/clinical area Â“measure group.Â” Even physicians who have yet to report a quality measure this year can still qualify for a bonus by reporting the applicable individual quality measures that make up a group measure set for 15 consecutive Medicare beneficiaries before the end of the year.
More information about this reporting option is available on the CollegeÂ’s Running a Practice Web site. ACP has developed an online tool to help offices appropriately bill with the quality reporting codes. The tool has been designed to facilitate billing for the diabetes measure group, which may be the most accessible group for most internists. To find the reporting tool, click on the Â“ACP PQRI Coding Tool TemplateÂ—Diabetes Measure GroupÂ” under the Â“Participating in PQRIÂ” heading..
Sen. Baucus releases plan for health care reform
Sen. Max Baucus (D-MT), chairman of the Senate Finance Committee, released a plan for comprehensive health care reform. The plan emphasizes the need to provide health insurance coverage to all Americans. It also addressed the need to guarantee access to preventive services, and to strengthen primary care and chronic care management.
From the College.
ACP Press seeks memorable moments
As part of a series of books on teaching, ACP Press is collecting stories of memorable teaching moments. The first book in the series, to be published in 2010, will be a collection of vignettes about unforgettable moments in medical education, described by teachers or learners. Vignettes should be no more than 1,000 words. Submissions can be anonymous. Click here to read a sample and here to submit. Submissions must be received before Feb. 1..
ACP to participate in virtual conference
ACPÂ’s Practice Advocacy and Improvement Vice President, Michael S. Barr, FACP, will deliver an online presentation about how the PCMH model can act as a framework for organizing health care at the practice level, what characteristics practices delivering care as medical homes share, and the role of health information technology within the PCMH model at the Healthcare Information and Management Systems Society (HIMSS) Virtual Conference & Expo on Nov. 19-20. Registration instructions are online.
From ACP Internist's blog.
More from AHA and the latest medical news of the obvious
Why are cardiovascular research studies more likely to favor newer treatments than existing treatments? Find out what researchers at the American Heart Association's Scientific Sessions had to say on the issue. On the lighter side, check out the latest edition of Medical news of the obvious.
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.
Go online to view the cartoon and pick the winner, who receives 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..
B) Repeat a fasting plasma glucose measurement
The complete MKSAP critique on this topic is available to subscribers in the Endocrinology and Metabolism section: Item 44.
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.
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Copyright 2008 by the American College of Physicians.
A 67-year-old man is evaluated for a 6-month history of worsening exertional dyspnea. He has severe COPD, previously with minimal exertional symptoms, but now notes activity-limiting shortness of breath when walking short distances. He does not have chest pain, gastrointestinal symptoms, or sleep-related symptoms. Medical history is otherwise unremarkable. Medications are a twice-daily fluticasone/salmeterol inhaler and an as-needed albuterol/ipratropium metered-dose inhaler. He has a 55-pack-year smoking history but quit when COPD was diagnosed. Following a physical exam, chest radiograph, and transthoracic echocardiogram, what is the most appropriate diagnostic test to perform next?
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