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

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In the News
for the Week of 11-4-08

Highlights

  • First universal flu shot program results in fewer deaths, hospitalizations
  • New studies analyze cost, effectiveness of diabetes meds
  • Rheumatology research looks at cardiovascular health

Test yourself

  • MKSAP quiz: wrist swelling and pain

Cardiology

  • Calcium channel blockers may interfere with clopidogrel
  • C-reactive protein reflects, but doesn't cause, cardiac disease

Diabetes

  • Diabetes incidence nearly doubles this decade

Men's health

  • Statin use linked to PSA level drops

From Annals of Internal Medicine

  • Stimulating growth hormone increases muscle mass in elderly
  • Patient management decreased incidence, deaths from cardiogenic shock

Medicare news

  • CMS releases 2009 physician fee schedule

From the College

  • Abstract competition for students opens

From ACP Hospitalist

From ACP Internist

  • Election poll finds voters pulling for Obama's health care plan
  • On the blog: MGMA, CHEST 2008
  • Cartoon caption contest: Put words in our mouth

Highlights

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First universal flu shot program results in fewer deaths, hospitalizations

A free, universal immunization initiative in Canada—the world's first such program—led to reductions in influenza-associated mortality, hospitalizations and doctor visits compared with areas with targeted immunization programs, a recent study found.

In the study, researchers compared outcomes (rates of influenza-related mortality, hospitalizations, emergency department use and visits to physicians' offices) of the universal immunization program in Ontario, Canada (free influenza vaccines for the entire population aged six months or older) with outcomes of targeted programs in Canada's nine other provinces. After the universal program was introduced in 2000, influenza-associated motality decreased more in Ontario (relative rate [RR]=0.26) than in other provinces (RR=0.43; ratio of RRs=0.61, P= 0.002). Similar differences were observed for influenza-associated hospitalizations, ED use and doctors' office visits.

On average, vaccination rates rose from 18% to 38% in Ontario since the universal program began, compared with from 13% to 24% in the other provinces, researchers reported Oct. 28 in PLoS Medicine. During the same time period, influenza-associated deaths decreased by 74% in Ontario but by only 57% in the other provinces combined.

The authors noted that the results of this large-scale study suggest that universal vaccination may be an effective strategy for reducing influenza-related illness and mortality—especially among those age 65 and younger—as well as the burden on health care resources.

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New studies analyze cost, effectiveness of diabetes meds

Use of newer, more expensive medications is increasing the average cost of treating diabetes, but metformin appears to be the most effective means of reducing cardiovascular complications, according to two new studies.

In the first study, researchers analyzed medications prescribed during all U.S. office visits for type 2 diabetes patients age 35 or older. In 1994, there were 25 million visits and the mean number of diabetes medications per treated patient was 1.14. In 2007, the number of visits had increased to 36 million and the meds to 1.63 per patient.

Over the same time period, insulin use declined from 38% of visits to 28%, and sulfonylurea use declined from 67% to 34%. In 2007, biguanides and glitazones were the leading therapeutic classes. Newer drugs were largely responsible for the increase in mean cost per prescription ($56 in 2001 to $76 in 2007) and aggregate drug expenditures ($6.7 billion in 2001 to $12.5 billion in 2007), researchers concluded. The study was published in the Oct. 27 Archives of Internal Medicine.

In a meta-analysis published in the same issue, data from 40 controlled trials tracked cardiovascular events in adults with type 2 diabetes. Metformin decreased the risk of cardiovascular mortality more than any other oral diabetes agent or placebo (odds ratio=0.74), and similar but not statistically significant trends were seen for cardiovascular morbidity and overall mortality. No other drug had a significant positive effect.

Metformin appeared to be moderately protective, the authors said, but larger, long-term studies with hard end points and short-term studies with better reporting of cardiovascular events are needed to draw firm conclusions about the medications.

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Rheumatology research looks at cardiovascular health

San Francisco—The cardiovascular risks of rheumatoid arthritis (RA) were a focus of research presented at the American College of Rheumatology's annual meeting here last week. Among the studies presented were:

  • An analysis of about 8,000 Swedish patients with RA which found that patients' relative risk for heart attack increased dramatically after they were diagnosed with RA and continued to increase over time. Overall, arthritis patients had nearly double the rate of heart attacks and deaths as the control group during the decade after diagnosis.

  • A British study assessed the relationship between heart attacks and drugs used to treat RA in 966 patients. Hydroxycholoroquine, methotrexate and sulphasalazine appear to be protective against heart attack, while prednisolone modestly increased risk. A second study by the same group found that lipid drugs were effective at reducing RA patients' cardiovascular risk.

  • A small study conducted at the Mayo Clinic found that RA patients may also fare worse after they have a heart attack. The analysis of 38 patients hospitalized for a first heart attack found that they had a higher risk of dying after the heart attack or developing heart failure.

—by Stacey Butterfield, staff writer

More coverage of the ACR meeting is available on the ACP Internist blog.

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Test yourself

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MKSAP quiz: wrist swelling and pain

A 39-year-old female corporate secretary is evaluated for a two-month history of proximal interphalangeal and wrist joint swelling and pain. There is some stiffness of these joints in the morning. Her pain is interfering with her work, particularly her use of a computer. Her maternal grandmother had arthritis that made her hands “bony.”

Physical examination reveals mild symmetrical synovitis of the metacarpophalangeal, wrist, and knee joints.

Laboratory Studies
Hemoglobin 10.9 g/dL (109 g/L)
Rheumatoid factor Negative
Antinuclear antibodies Negative
ELISA for anti–cyclic citrullinated peptide antibodies Positive

Which of the following is the most likely diagnosis?

A) Osteoarthritis
B) Psoriatic arthritis
C) Rheumatoid arthritis
D) Calcium pyrophosphate deposition disease

Click here or scroll to the bottom for the answer.

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Cardiology

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Calcium channel blockers may interfere with clopidogrel

Calcium channel blockers may decrease the effectiveness of clopidogrel when the drugs are taken together, a new study found.

Austrian researchers studied 200 coronary artery disease patients undergoing percutaneous coronary intervention. All patients took clopidogrel, and about 23% also took calcium channel blockers (CCB). Patients were followed for six months, and were tested for levels of platelet reactivity. The study's composite end point was death from cardiovascular causes, non-fatal myocardial infarction, stent thrombosis, and revascularization. It was published in the Nov. 4 Journal of the American College of Cardiology.

The platelet reactivity index was higher in patients taking both drugs (61%) than patients taking clopidogrel alone (48%), implying that CCBs decreased the effect of clopidogrel on platelets. The absolute difference was 13% and the relative difference was close to 21%; differences persisted after adjustment for cardiovascular risk factors. Patients taking both drugs were more likely to have high blood pressure (91% vs. 78% of those on clopidogrel alone) and diabetes mellitus (49% vs. 29%). The composite end point was more frequent with those taking CCBs (25%) than those who didn't take them (8%), driven by a higher rate of revascularization procedures.

The clinical implications of the study are unclear, an editorial said, in part because confounding factors may have increased platelet activation in those taking CCBs. It's also likely that patients who were prescribed CCBs were more likely to have severe disease, which may have swayed outcomes. Still, the results should lead clinicians to carefully weigh the pros and cons when prescribing multiple medications that may interact, the editorial said.

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C-reactive protein reflects, but doesn't cause, cardiac disease

High levels of C-reactive protein (CRP) appear to reflect cardiovascular disease or risk, not cause them, a new genetic study suggests.

Researchers studied four independent cohorts of white Danish people, with subjects totalling more than 50,000. In two of the studies, they used subjects from the general population, some who developed ischemic heart disease and some who developed ischemic cerebrovascular disease. The third study compared subjects with each of these two diseases to two separate sets of control subjects. They measured levels of high-sensitivity CRP and did genotyping for four CRP polymorphisms and two apolipoprotein E polymorphisms.

People who had CRP levels above 3 mg/L had 1.6 times the risk of ischemic heart disease, and 1.3 times the risk of ischemic cerebrovascular disease, compared with those with CRP levels below 1 mg/L. While genotype combinations of the four CRP polymorphisms were associated with a rise in CRP levels of up to 64%, they were not associated with a higher risk of ischemic heart or cerebrovascular disease. The study was published in the Oct. 30 New England Journal of Medicine.

The finding on CRP polymorphisms suggests that the higher risk of ischemic vascular disease associated with higher plasma CRP levels, which has been observed in other studies, may be just a marker for atherosclerosis and ischemic vascular disease, not a cause of these conditions, the authors said.

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Diabetes

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Diabetes incidence nearly doubles this decade

Diagnosed diabetes in the U.S. rose by about 90% in the past decade, according to a CDC analysis.

The CDC analyzed data from Behavioral Risk Factor Surveillance System (BRFSS) surveys from 1995-97 and 2005-07 by a phone survey that covered adults by state or territory. They published their results in the Oct. 31 Morbidity and Mortality Weekly Report.

Age-adjusted incidence of diabetes increased nearly 90% from 4.8 per 1,000 in 1995-97 to 9.1 (range among states, 5.0 to 12.8) in 2005-07. Age-adjusted incidence rates were significantly higher for 2005-07 than for the earlier period in 27 of the 33 states (P <0.05). (View table.)

By U.S. Census region, the average age-adjusted incidence was greatest in the South (10.5 per 1,000; CI= 9.9-11.1) (View map). This was followed by the Northeast (8.6, CI= 7.8-9.4), West (8.5, CI= 7.7-9.3), and Midwest (7.4, CI= 6.6-8.2).

States with the greatest number of annual new cases in California (208,000), Texas (156,000) and Florida (139,000).

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Men's health

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Statin use linked to PSA level drops

Statin use was associated with a small, statistically significant and dose-dependent decline in prostate specific antigen (PSA) levels, and that decline was most pronounced in men with the largest decreases in low-density lipoprotein (LDL) and those with the highest initial PSA levels, a study found.

Statins may complicate cancer detection by lowering PSA levels, although further studies are needed to confirm that, researchers reported in the Journal of the National Cancer Institute.

To assess the influence of statins on PSA levels, researchers did a longitudinal study of 1,214 men prescribed a statin between 1990 and 2006 at the Durham Veterans Affairs Medical Center. Subjects did not have prostate cancer, had not had prostate surgery and did not take medications known to alter androgen levels. Subjects had at least one PSA value within the past two years and at least one PSA value within one year of starting a statin.

After starting a statin, median LDL decline was 27.5% (P <0.001), and the median PSA decline was 4.1% (P <0.001). Every 10% decrease in LDL after starting a statin was associated with PSA levels declining by 1.64% (95 % confidence interval [CI], 0.64%-2.65%; P =0.001). Among men with pre-statin PSA levels greater than 2.5 ng/mL, those with more than 41% declines in LDL after starting a statin had a 17.4% decline in serum PSA (95% CI, 10.0%-24.9%).

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From Annals of Internal Medicine

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Stimulating growth hormone increases muscle mass in elderly

Researchers sought to determine if stimulating growth hormone release in healthy older adults could alter body composition via a randomized trial of 65 healthy older adults ranging in age from 60-81 years. Participants received either a placebo or an oral ghrelin mimetic, MK-677, an experimental drug that stimulates normal release of growth hormone. Over one year, patients receiving the new drug increased their growth hormone levels to those of healthy young adults, resulting in an increase in lean, fat-free mass. Also, the body’s sensitivity to insulin decreased, and blood sugar increased in people taking the new drug. The importance of the increase in fat-free mass is unknown because neither the drug nor placebo had an effect on thigh muscle area, muscle strength or function.

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Patient management decreased incidence, deaths from cardiogenic shock

Angioplasty is reducing the incidence of cardiogenic shock by improving blood flow to the damaged heart muscle. Researchers reviewed data from a Swiss hospital registry of more than 23,000 patients to assess associations of therapeutic management with death and shock development during hospitalization. Rates of cardiogenic shock in patients with acute coronary syndromes (a term that encompasses myocardial infarction and other conditions) declined from 1997 to 2006.

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Medicare news

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CMS releases 2009 physician fee schedule

CMS last week released the final 2009 Medicare Physician Fee Schedule, which includes a 1.1% increase in physician payments effective Jan. 1, 2009. This increase replaces a planned 10.6% cut in payment rates that would have gone into effect in July as a result of the sustainable growth rate (SGR) formula used to calculate physician payments under Medicare. ACP played a key role in successfully lobbying Congress to pass legislation that averted the cuts scheduled for the second half of 2008 and for 2009.

ACP will develop a detailed analysis of the new fee schedule, which will include information on how to qualify for a bonus payment for prescribing electronically and reporting on quality measures that will be included in an upcoming issue of the bi-weekly e-mail newsletter ACP Advocate. In the meantime, go to the CMS Web site for a summary of the changes to payment policies.

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From the College

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Abstract competition for students opens

ACP is accepting submissions from Student Members and Associates for its annual Abstract Competition series, to be held during Internal Medicine 2009 in Philadelphia, April 23-25. Four categories are offered, including Clinical Vignette, Basic Research, Clinical Research and Quality Improvement-Patient Safety.

Complete Rules, Guidelines, and FAQs can be found in the electronic abstract system. ACP's Guide to Preparing for the Abstract Competition offers more details. The deadline for the National Medical Students Abstract Competitions is Dec. 8.

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From ACP Hospitalist

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The November issue is now online

The November issue of ACP Hospitalist is now online, featuring its first annual Top Hospitalists feature highlighting doctors reinventing and expanding the role of the hospitalist at their facilities. Meet the teachers, quality improvement gurus, researchers and bloggers who've focused on improving geriatric care, growing hospital admissions, facilitating transitions of care and raising staff satisfaction. Also in this issue:

Calling for backup before it’s needed. Failure to rescue, the failure to identify patients with critical abnormalities and provide the resources necessary to prevent harm, was one of the top three preventable errors found in hospitals in 2004-06, accounting for 17% of total errors. Experts offer their solutions.
The hospitalized hospitalist. Medical editor James S. Newman, FACP, recalls (somewhat fuzzily) his hip transplant.

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From ACP Internist

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Election poll finds voters pulling for Obama's health care plan

Voters in ACP Internist's poll found most of its voters pulling for the health care plan offered by Sen. Barack Obama over that of Sen. John McCain, and that the proposed health care plans formed at least part of the reason why they voted.

In the poll, 73.9% chose Mr. Obama's plan while Mr. McCain's plan drew 21.6% of voters and 4.6% were undecided. Almost 70% of voters said that the proposed health care reforms were partly why they voted (as opposed to the primary reason or not an influence). Just over 150 readers voted through ACP InternistWeekly, the ACP Internist blog or our Web site.

With today being Election Day, readers will quickly find out if ACP InternistWeekly readers are tracking with election outcomes and how much influence the candidates' health care proposals played.

This survey is not scientific and is not an endorsement of either candidate or their respective health care plans.

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On the blog: MGMA, CHEST 2008

ACP Internist's writers have crossed the country in recent weeks, reporting from conferences at the Medical Group Management Association, the American College of Chest Physicians and American College of Rheumatology. They've covered the breaking news as it happens and some hilarious minutiae when it doesn't. Read their coverage plus check out the latest Medical News of the Obvious, new every Monday.

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Cartoon caption contest: Put words in our mouth

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

Cartoon caption contest: Put words in our mouth

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.

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MKSAP Answer

C) Rheumatoid arthritis

The complete MKSAP critique on this topic is available to subscribers in the Rheumatology section, item 15.

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 19-year-old man is evaluated for a sore throat, daily fever, frontal headache, myalgia, and arthralgia of 5 days' duration. He also has severe discomfort in the lower spine and a rash on his trunk and extremities. He returned from a 7-day trip to the Caribbean 8 days ago. The remainder of the history is noncontributory. Following a physical exam and lab studies, what is the most likely diagnosis?

Find the answer

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