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

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In the News
for the Week of 11-25-08

Highlights

  • Insurers support universal coverage with individual mandate
  • JAMA study: Ginkgo doesn't work for dementia

Test yourself

  • MKSAP quiz: pain and progressive weakness

Asthma

  • Asthma may be overdiagnosed, study finds

Cardiology

  • Recommendations on ICD as primary prevention for post-MI patients

FDA update

  • Bacteria prompt acne cream recall

Resources and toolkits

  • Checklists, charts encourage Hispanics to get preventive screenings
  • SAMHSA offers free manual on treating opioid addiction

From the College

  • New issue of ACP Advocate examines Sen. Baucus' health reform plan
  • Regents sign joint statement on vaccination

From ACP Internist

  • On the blog: racial profiling, sad docs
  • Cartoon caption contest: November's winning entry

Editorial note: ACP InternistWeekly will not be published next week due to the Thanksgiving holiday.


Highlights

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Insurers support universal coverage with individual mandate

Two major health insurance groups announced last week that they will provide coverage for all Americans, if the government mandates that everyone purchase health insurance.

Under the proposal, the members of America's Health Insurance Plans (AHIP) and the BlueCross BlueShield Association would no longer reject applicants based on their health status or exclude pre-existing conditions from coverage. Their proposal is contingent on Congress enacting an enforceable individual coverage mandate.

Mandatory coverage, a controversial issue in the recent presidential election, was not a component of President-elect Barack Obama's health reform plan. His transition team declined to comment on the insurers' proposal, reported the Nov. 20 New York Times. In support of their proposal, the groups contend that requiring insurers to provide coverage to all applicants without forcing consumers to purchase insurance would provide an incentive for people to wait until they were sick to buy insurance, and thereby raise overall premiums. The AHIP statement also urged expansion of the Medicare and SCHIP programs.

There are several additional components to the AHIP proposal for health care reform, including:

  • Establish an insurance coverage verification system, an automatic enrollment process and effective enforcement of the requirement that all individuals purchase and maintain coverage;
  • Promote affordability by: providing refundable, advanceable tax credits for moderate-income individuals and working families; and promoting tax equity whether coverage is obtained through an employer or the individual market; and
  • Ensure premium stability for those with existing coverage through a broadly funded reimbursement mechanism that spreads costs for the highest-risk individuals.

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JAMA study: Ginkgo doesn't work for dementia

Ginkgo biloba doesn't reduce the incidence of dementia or Alzheimer's in elderly individuals with normal cognition or mild cognitive impairment, a recent study found.

The randomized, double-blind, placebo-controlled trial was conducted in five U.S. academic medical centers between 2000 and 2008 with a median follow-up of 6.1 years. The 3,069 community volunteers age 75 years or older began the study with normal cognition (n=2,587) or mild cognitive impairment (n=482) and were given a dementia assessment every six months, according to the study published in the Nov. 19 Journal of the American Medical Association.

Patients received twice-daily 120-mg ginkgo extract (n=1,545) or placebo (n=1,524). In total, 523 people developed dementia (277 receiving ginkgo; 246 receiving placebo). The overall dementia rate was 3.3 per 100 person-years in the ginkgo group and 2.9 per 100 person-years in the placebo group. The hazard ratio (HR) for ginkgo compared with placebo for all-cause dementia was 1.12 (95% confidence interval [CI], 0.94-1.33; P=.21). For Alzheimer's, it was 1.16 (95% CI, 0.97-1.39; P=.11). Ginkgo didn't affect the rate of progression to dementia in participants with mild cognitive impairment (HR, 1.13; 95% CI, 0.85-1.50; P=.39).

The authors noted that the formulation of Ginkgo biloba used in the study is the one for which most data are available. Based on these results, they concluded that Gingko biloba should not be used for preventing dementia.

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Test yourself

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MKSAP quiz: pain and progressive weakness

Editor's Note: Thanks to all our readers who wrote us and said they wanted to see the critiques posted with the questions. You'll find them included from now on.

A 32-year-old woman is evaluated for a 5-month history of pain and swelling of her hands and progressive weakness. She now has difficulty getting in and out of the bathtub and climbing stairs. She is unable to hold her hairdryer over her head because her arms begin to feel tired. She has moderate dyspnea when walking 1 block.

On physical examination, both hands are diffusely puffy. There are scaly, rough, dry, darkened, cracked horizontal lines on the palmar and lateral aspects of her fingers. Pulmonary examination reveals bibasilar crackles. Musculoskeletal examination shows proximal muscle weakness in the upper and lower extremities, as well as neck flexor weakness.

On laboratory studies, complete blood count is normal and erythrocyte sedimentation rate is 24 mm/h. Creatinine is normal, and creatine kinase is 4250 U/L (70.85 µkat/L). Antinuclear antibody titer is 1:160, and assays for anti–double-stranded DNA, Smith, and ribonucleoprotein antibodies are negative. Urinalysis is normal.

Chest radiograph shows increased interstitial markings. Electromyogram reveals spontaneous fibrillations, repetitive discharges, and positive sharp waves.

Which of the following is the most likely diagnosis?

A) Polymyositis
B) Systemic lupus erythematosus
C) Mixed connective tissue disease
D) Scleroderma

Click here for the answer and critique or scroll to the bottom of the page.

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Asthma

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Asthma may be overdiagnosed, study finds

Almost a third of adults who had been diagnosed with asthma turned out not to have the disease, according to a Canadian study.

Researchers randomly recruited 540 Canadian adults (half of whom were obese) who had been diagnosed with asthma by a physician. The study found that 44 of those patients did not have current asthma, determined by the fact that they had no evidence of acute worsening of symptoms, reversible airflow obstruction or bronchial hyperresponsiveness despite being weaned off asthma medications.

Patients found not to have asthma stopped medications, and 65.5% of them didn't need or asthma-related drugs or health care during the next six months. Only 7.7% required an unscheduled evaluation by a health care provider because of respiratory symptoms. The study was published in the Nov. 18 Canadian Medical Association Journal.

Researchers concluded that in developed countries such as Canada asthma may be overdiagnosed, explaining recent increases in asthma rates. They did not find any difference in overdiagnosis between obese and nonobese patients, however, indicating that asthma actually is more prevalent in the obese population. The study authors suggested that when trying to exclude a diagnosis of asthma, physicians should assess patients after their anti-inflammatory medications have been stopped.

Spirometry is also crucial to a diagnosis of asthma, wrote the researchers and the author of an accompanying editorial. The editorial compared asthma management without spirometry to treating hypertension without measuring blood pressure. The study should not be taken as a reason to lower suspicion of asthma when faced with unexplained respiratory symptoms, the editorial said. Rather, physicians should consider that symptoms assumed to be asthma could signify another serious medical condition, such as chronic obstructive pulmonary disease.

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Cardiology

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Recommendations on ICD as primary prevention for post-MI patients

A review spells out which factors to consider when deciding whether to recommend implantable cardioverter-defibrillators (ICDs) as primary prevention in high-risk patients who have had myocardial infarction.

ICDs are an established device as secondary prevention for patients who have survived a life-threatening ventricular arrhythmia. Major trials also suggest a benefit to ICD use in high-risk patients in whom life-threatening arrhythmias haven't yet occurred, but the studies' limitations make the picture less clear, the reviewer said in the Nov. 20 New England Journal of Medicine.

When selecting primary prevention patients for ICD, physicians should start by assessing ejection fraction (EF), then consider other factors, the reviewer said. Generally, those with an EF of 25% or less after MI are candidates, while those with higher than 35% EF aren't, the reviewer said. For patients with EF between 25% and 35%, studies suggest those at the lower end see more benefit than those near the top; thus additional factors in this 25%-35% EF group can tip the balance. These additional factors include:

  • Heart failure. Those with symptomatic heart failure or a history of heart failure seem more likely to benefit from an ICD, particularly in the 26%-30% group. If a patient's EF is on the borderline, a heart failure history adds support for ICD therapy.
  • QRS duration. Doctors should take into account a prolonged duration of the QRS interval (120 milliseconds or more), which studies have associated with a benefit from ICDs in the 26%-35% EF group.
  • Ventricular tachycardia (VT). Ambient nonsustained VT or VT induced by programmed electrical stimulation increase the indication for ICD in those with 26% to 35% EF.

Patients with none of the above factors can defer ICD implementation, especially if their EF is between 30%-35%. In addition, ICD isn't appropriate for patients with serious comorbidities and expected survival of one year or less. Some research suggests people age 75-plus years are just as likely to benefit as younger patients, but these patients should be in reasonably good shape both physically and mentally to be considered for ICD, the reviewer said.

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FDA update

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Bacteria prompt acne cream recall

Three brands of 10% benzoyl peroxide acne cream are being recalled because samples of the products contained Burkholderia cepacia, an FDA alert and manufacturer's press release said.

The affected one-ounce tubes are "DG Maximum Strength Acne Medicated Gel" (Dollar General), "Kroger Acne Gel 10% Benzoyl Peroxide Acne Medication" (Kroger) and "Equate: Medicated Acne Gel" (Wal-Mart).

The products may carry a heightened risk of infections in people with cuts, scrapes, rashes and other skin conditions, as well as in those with weakened immune systems. No adverse events have been reported.

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Resources and toolkits

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Checklists, charts encourage Hispanics to get preventive screenings

New educational tools for physicians’ offices and patients aimed at helping Spanish-speakers over age 50 keep track of recommended screening tests are now available from the Agency for Healthcare Research and Quality (AHRQ).

Checklists for male and female Spanish speakers list evidence-based recommendations from the U.S. Preventive Services Task Force on screening tests, preventive medicines and healthy lifestyle behaviors. Patients can take the checklists with them to medical appointments to help them keep track of their screening test history and plan follow-up medical appointments. An accompanying wall chart in Spanish is also available.

AHRQ cited statistics showing that Hispanic adults are more likely than whites to be hospitalized for preventable conditions, such as complications of uncontrolled diabetes, congestive heart failure, hypertension and angina. AHRQ also reported that nearly 67% of Hispanics age 50 or older have never had a screening colonoscopy compared with 46% of whites.

English-language versions of the checklists for men and women as well as the wall chart are also available through AHRQ’s Web site. All of the above resources also can be ordered by calling AHRQ’s Publications Clearinghouse at 800-358-9295 or by e-mail.

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SAMHSA offers free manual on treating opioid addiction

A new training manual on medication-assisted treatment for opioid addition is available free from the Substance Abuse and Mental Health Services Administration (SAMHSA).

“Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs Inservice Training,” based on Treatment Improvement Protocol 43, describes opioid use disorders; provides assessment, treatment planning, pharmacology, and dosing information; and presents evidence-based best practices for treatment.

The manual can be downloaded on SAMHSA’s Web site, accessed as a PDF, ordered through SAMHSA’s Health Information Network or by phone at 1-877-SAMHSA-7 (English) / 1-877-726-4727 (Espańol). Ask for publication order number (SMA) 08-4341.

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From the College

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New issue of ACP Advocate

The latest issue of ACP Advocate features a look at Senate Finance Committee Chairman Max Baucus' white paper on health care reform, which proposes increases in Medicare payment rates for primary care physicians and expansion of the Patient Centered Medical Home. The white paper is linked to letter of response from ACP President Jeffery P. Harris, FACP.

Also in this issue:

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Regents sign joint statement on vaccination

The ACP Board of Regents has approved and signed the
Joint Statement of Medical Societies Regarding Vaccination by Physicians.

The joint statement is the collaborative effort of several medical societies, including ACP and the Infectious Diseases Society of America, to emphasize the importance of adult vaccination and the critical roles that primary care and subspecialty physicians play in patients’ vaccination status. The statement stresses the potential role of subspecialists, in particular, to serve as a source of vaccination administration or referral, as they are the primary source of care for many patients with chronic disease.

The statement’s release coincides with a growing emphasis on adult vaccination, which has been bolstered by increased consumer demand for quality care as well as CDC recommendations.

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From ACP Internist

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On the blog: racial profiling, sad docs

On the ACP Internist blog this week genetics expert W. Gregory Feero looks at racial profiling. We also assess new research on the unhappiness of primary care providers and physician substance abuse. As usual, a new Medical News of the Obvious arrives every Monday.

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Cartoon caption contest: November's winning entry

ACP InternistWeekly has compiled the results from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption. This week's contest was a squeaker, with the winning entry tied or leading with less than a handful of votes all week.

This issue's winning cartoon caption was submitted by Leslie Thompson Harris, ACP Associate Member, an internal medicine PGY-1 resident at Gundersen Lutheran Medical Center, La Crosse, Wis. She will receive 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. Readers cast 296 ballots online to choose the winning entry. Thanks to all who voted!

The winning entry:

Next time, try a licensed acupuncturist.
"Next time, try a licensed acupuncturist."

The winning caption received 45.9% of the votes cast. The runners-up were:
"You'll be pleased to know the apple came through unscathed." (42.9%)
"Please tell me you at least won the costume contest." (11.1%)

December's Grand Prize cartoon contest will pit the three top vote getters from 2008 head-to-head, with one lucky voter winning a $100 gift certificate. Voting begins in the Dec. 9 issue of ACP InternistWeekly.

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MKSAP answer and critique

A) Polymyositis

This item is online in MKSAP 14's Rheumatology section: Item 73.

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.

Critique

This patient most likely has polymyositis, which may be associated with elevated antinuclear antibody titers and a normal or elevated erythrocyte sedimentation rate. Her symptom complex, including proximal muscle weakness, elevated creatine kinase levels, abnormal electromyography findings, interstitial lung disease, and “mechanic's hands,” is particularly consistent with the antisynthetase (anti–Jo-1 antibody) syndrome. This syndrome also is characterized by inflammatory arthritis.

This patient's only finding consistent with systemic lupus erythematosus is antinuclear antibody positivity. Patients with mixed connective tissue disease typically present with clinical features associated with rheumatoid arthritis, scleroderma, lupus, and myositis and have very high titers of antiribonucleoprotein antibodies. Scleroderma may be excluded because this patient does not have thickening of the skin, which is a hallmark of this condition. Typically, skin thickening in scleroderma initially affects the hands with sclerodactyly, which may be preceded by puffiness in the fingers. Limited scleroderma includes skin thickening of the hands, feet, and face. Diffuse scleroderma additionally involves the upper arms, thighs, chest, and/or abdomen.

Key Point

Manifestations of inflammatory myositis may include elevated antinuclear antibody titers and creatine kinase levels, abnormal electromyography findings, proximal muscle weakness, interstitial lung disease, arthritis, and skin rashes.

Click here to 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 comes for a preoperative evaluation before total joint arthroplasty of the left knee. He has a 25-year history of rheumatoid arthritis. He has had progressive pain in his left knee with activity, which limits his ability to hike. The patient has similar pain in the right knee, but it is less severe. He reports no recent morning stiffness. He is able to climb two or three flights of stairs without chest pain or shortness of breath. He has no other medical problems and reports no additional symptoms. Medications are methotrexate and folic acid. Following a physical exam and lab tests, what is the next best step in management?

Find the answer

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