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

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In the News
for the Week of 12-16-08

Highlights

  • Colonoscopy significantly reduces left-sided colon cancer mortality
  • Studies support wider selection of beta-blockers for heart failure

Test yourself

  • MKSAP quiz: retroperitoneal mass

Preventive medicine

  • Patients lose weight when money's on the line, study finds
  • Supplements ineffective to prevent prostate cancer

Substance abuse

  • Overdose statistics point to drug diversion as primary cause

Annals of Internal Medicine

  • Interruptions in Medicaid coverage increase unnecessary hospitalizations
  • Family members want straight talk about poor patient prognosis
  • Home rehab safe, viable for COPD

FDA update

  • Boxed warning ordered for bowel prep used before colonoscopy

Advocacy update

  • Help for Medicare enrollment problems available
  • NCOIL encourages regulation of “silent PPO” arrangements
  • Medicare announces Web-based enrollment

From ACP Internist

  • On the blog: wrap-up of the week's strange and fascinating events

From the College

  • ACP Foundation releases new patient education materials for physicians
  • New patient-education DVD: Living with HIV

Cartoon caption contest

  • Pick the year's best

Highlights

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Colonoscopy significantly reduces left-sided colon cancer mortality

Colonoscopy is strongly associated with fewer deaths from left-sided colorectal cancer but offers almost no mortality prevention benefit for right-sided cancers.

Annals of Internal Medicine released online a study that reviewed health records for persons aged 52 to 90 who received a colorectal cancer diagnosis between 1996 and 2001 and died of colorectal cancer by 2003. These patients were compared to a control group that had not died of colorectal cancer.

According to the researchers, complete colonoscopy was strongly associated with fewer deaths from left-sided colorectal cancer. Conversely, colonoscopy had almost no mortality prevention benefit for right-sided colorectal cancer. The study will appear in the Jan. 6 print issue of Annals.

An accompanying editorial cautioned physicians not to tell patients that colonoscopy will reduce the risk of dying from colorectal cancer by 90%. A 60% to 70% risk-reduction rate seems more reasonable, the author said.

Researchers suggested several potential explanations. First, some colonoscopies considered complete may not evaluate the entire right colon. Second, bowel preparation may be worse in the right colon. Third, right-sided polyps may grow more rapidly or may be less likely to have a fleshy stalk and are occasionally flat, making them harder to find and remove.

A patient summary and editorial were also released. To help internists stay up to date, a new article from ACP Internist reviews two colon screening guidelines released in 2008, the Annals colon cancer studies released between October and now, and expert advice on overcoming patient resistance to undergoing screening and easing the experience for patients.

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Studies support wider selection of beta-blockers for heart failure

Two large epidemiologic studies published in Archives of Internal Medicine suggest that non-evidence-based beta-blockers may be as effective as and less costly than evidence-based beta blockers in treating elderly patients with heart failure.

In one study, researchers compared mortality rates associated with the use of different beta-blockers in almost 8,000 adults age 65 and older who had survived hospitalization for heart failure. Compared with atenolol, a non-evidenced based drug, the rate of death a year after discharge was higher for patients who received the metoprolol tartrate and similar for patients who were given carvedilol.

In a second study, researchers looked at whether beta-blockers other than those considered evidence-based (carvedilol, metoprolol succinate and bisoprolol fumerate) would improve survival in almost 12,000 patients age 65 and older with heart failure. After one year, mortality rates were similar for patients receiving evidence-based drugs vs. non-evidence-based (24.2% vs. 22.8%, respectively), and the rehospitalization rate was higher in the evidence-based group.

Two accompanying editorials differed on whether the results of the studies should be applied in clinical practice. Noting that both studies replicated each other's findings, one editorial recommended that physicians should be comfortable using non-evidence-based beta-blockers in patients with heart failure. However, a second editorial said only evidence-based beta-blockers should be used in patients with heart failure caused by left ventricular systolic dysfunction, since the dosing strategy of the non-evidence-based drugs is not known.

The authors said their results should be considered cautiously and that large-scale randomized trials are needed. However, an editorial noted that such trials are unlikely to occur given the high cost and small incentive for industry to study low-cost generic agents.

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Test yourself

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MKSAP quiz: retroperitoneal mass

A 27-year-old man is evaluated for increasing abdominal girth with intermittent midabdominal pain radiating to the back and a 4.5-kg (10-lb) weight loss over the past 3 months. He has no symptoms of reflux disease or heartburn. The medical history is otherwise noncontributory, and the family history is unremarkable.

Physical examination, including vital signs and cardiopulmonary evaluation, is normal. The abdomen is not tender to palpation, but there is a sense of fullness in the midabdomen. The testes are both descended with no palpable abnormalities. A CT scan of the abdomen indicates a 10-cm retroperitoneal mass. Laboratory studies indicate a serum ß-human chorionic gonadotropin level of 212 mU/mL (normal <5 mU/mL) and serum a-fetoprotein concentration of 478 ng/mL (478 µg/L). Testicular ultrasound is normal. A needle biopsy of the mass reveals a poorly differentiated carcinoma, with molecular genetic analysis detecting the presence of isochromosome 12p.

Which of the following is the most appropriate next step in management?

A) Testicular biopsy
B) Cisplatin-based chemotherapy
C) Upper endoscopy
D) Radiation therapy

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

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Preventive medicine

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Patients lose weight when money's on the line, study finds

Financial incentives can successfully motivate obese patients to lose weight, a new study of behavioral economic techniques found.

In the trial, 57 obese veterans were randomized to one of two incentive weight-loss plans or a control group that underwent monthly weigh-ins. One incentive group operated under a lottery system, in which patients who met their weight-loss goal (one pound per week for everyone in the study) were eligible to win money in a lottery. The other incentive group had a deposit contract system, in which they had the option to deposit money and receive matched (or more) funds back if they met their goals. The study was conducted for 16 weeks and published in the Dec. 10 Journal of the American Medical Association.

During the study, the incentive groups lost significantly more weight than the control group (3.9 lbs. in controls, 13.1 lbs. in the lottery group, and 14.0 lbs. in the deposit group). About half of patients in the incentive groups met their 16-lb. target weight loss, but only 10.5% of those in the control group did. However, when researchers followed up with the participants after seven months, all of the groups had regained weight (total weight loss of 9.2 lbs. in lottery group, 6.2 lbs. in deposit contract group and 4.4 lbs. in controls) and the differences in weight loss between groups were not statistically significant.

The study shows that incentive approaches can be highly effective in inducing initial weight loss, the researchers concluded. They noted that the study was limited by its inclusion of veterans at a single facility, who were mostly male and volunteered to participate, indicating higher than average motivation. Further research is needed to assess the cost-effectiveness of such programs and to determine if the results can be sustained over the longer term, the study authors said.

An article in the May 2008 ACP Internist assessed the possibility of using behavioral economics to help patients lose weight and includes an interview with the author of the new study.

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Supplements ineffective to prevent prostate cancer

Physicians should not recommend selenium, vitamin E or any other antioxidant supplements to prevent prostate cancer, according to two studies and an editorial published online by the Journal of the American Medical Association.

The first trial was the Physicians' Health Study II, a 10-year randomized, double-blind, placebo-controlled factorial trial of vitamins E and C. It enrolled 14,641 male U.S. physicians aged 50 years or older, including 1,307 men with a history of prior cancer at randomization, and gave 400 IU of vitamin E every other day and 500 mg of vitamin C daily.

In eight years mean follow-up, 1,008 confirmed incident cases of prostate cancer occurred. Vitamin E had no effect vs. placebo on the incidence of prostate cancer (active and placebo vitamin E groups, 9.1 and 9.5 events per 1,000 person-years; hazard ratio [HR], 0.97; 95% confidence interval [CI], 0.85-1.09; P =.58). Vitamin C had no significant effect on prostate cancer (active and placebo vitamin C groups, 9.4 and 9.2 cases per 1,000 person-years; HR, 1.02; 95% CI, 0.90-1.15; P =.80).

According to a second analysis, selenium or vitamin E, alone or in combination, did not prevent prostate cancer. The trial of 35,533 men from North American and Puerto Rico were double-blinded and randomly assigned to four groups (selenium, vitamin E, both, and placebo) for three years from Aug. 2001 to June 2004. The men were aged 50 years or older, had a serum prostate-specific antigen level of 4 ng/mL or less, and a digital rectal examination not suspicious for prostate cancer.

Hazard ratios for prostate cancer were 1.13 (99% CI, 0.95-1.35) for vitamin E, 1.04 (99% CI, 0.87-1.24) for selenium, 1.05 (99% CI, 0.88-1.25) for selenium and vitamin E and 1.00 for placebo.

According to an editorial, "Given its statistical power, it is unlikely that the study missed detecting a benefit of even a very modest size."

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Substance abuse

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Overdose statistics point to drug diversion as primary cause

The majority of people who died from unintentional overdoses of pharmaceuticals did not have a prescription for the medication they were taking, according to a new study of West Virginian medical examiner records.

The observational study included all 295 state residents who died of unintentional overdoses during 2006. More than two-thirds of the decedents were men and 92% were between the ages of 18 and 54. About 63% of the deaths resulted from a person taking a drug without a prescription, known as pharmaceutical diversion. The characteristics of the drug diversion group matched the profile of street drug abusers, most were young, male and unmarried.

By contrast, the 21.4% of deaths that were associated with doctor shopping (obtaining controlled substances from 5 or more clinicians in the past year) had very different characteristics. This group was almost half female, older and higher income. Opioid analgesics were involved in 93% of the reported deaths. Methadone was involved in more deaths than any other drug. The study was published in the Dec. 10 Journal of the American Medical Association.

The statistics for West Virginia (which has one of the highest overdose rates in the U.S.) may not apply to other states, but clinicians play an important role in preventing the diversion of the drugs that are likely to be abused, the study authors said. They recommended that physicians and pharmacists counsel patients who take opioids not only about their own risk of overdosing but also about the risk to anyone with whom they share medication. An accompanying editorial suggested that physicians use opioid treatment agreements, conduct frequent urine toxicology screens, and screen for substance abuse or mental health problems when prescribing opioids.

ACP Internist's supplement on proper opioid management is available online.

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Annals of Internal Medicine

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Interruptions in Medicaid coverage increase unnecessary hospitalizations

A study of more than 4.7 million California adults on Medicaid found an association between interruptions in coverage and a higher rate of hospitalization for ambulatory care-sensitive conditions such as diabetes and chronic obstructive pulmonary disease. Hospital admissions for these types of conditions indicate a decline in the quality of health care that lower-income people receive outside the hospital. Authors suggest that policies that reduce the frequency of interruptions in Medicaid coverage might prevent some of these hospitalizations and reduce health care costs.

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Family members want straight talk about poor patient prognosis

Researchers conducted face-to-face interviews with 179 family members of seriously ill patients to determine their opinions about balancing hope and telling the truth about a poor prognosis. Nearly all of the surrogates said that withholding bad news was not acceptable. They felt that knowing the truth was important because it gave them an opportunity to prepare emotionally and practically for a loved one's death.

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Home rehab safe, viable for COPD

Exercise training can reduce shortness of breath, even in severe chronic obstructive pulmonary disease (COPD). While hospitals have programs that provide closely supervised exercise training, access to these programs is limited. Researchers conducted a study of 252 COPD patients to find out if a home-based, largely unsupervised exercise program could be as effective as a hospital-based program. All patients had four weeks of education about living with COPD before being randomly assigned to either hospital or home rehabilitation. In both programs, patients were instructed to perform three exercise sessions per week for eight weeks. During the eight weeks, trainers called home exercisers weekly to provide encouragement. After eight weeks, trainers called once every two months. At one year, patients in both groups reaped equal benefits, with both reporting less shortness of breath than before. Researchers conclude that tailoring pulmonary rehabilitation to meet individual needs could improve accessibility to this effective intervention.

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FDA update

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Boxed warning ordered for bowel prep used before colonoscopy

The FDA will add a boxed warning to prescription oral sodium phosphate (OSP) products Visicol and OsmoPrep, often used for bowel prep before colonoscopy, due to risk of acute phosphate nephropathy.

The warning applies to both prescription and over-the-counter OSP products, such as Fleet Phospho-soda, the FDA said. There is no apparent risk of kidney injury when the OTC products are used as laxatives at lower doses, but the risk increases when they are used at higher doses for bowel cleansing.

The agency recommended caution in using OSP prescription products for:

  • people over age 55,
  • those who suffer from dehydration, kidney disease, acute colitis, or delayed bowel emptying, and
  • people taking certain medicines that affect kidney function, such as diuretics, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and possibly nonsteroidal anti-inflammatory drugs.

The FDA safety alert is online.

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Advocacy update

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Help for Medicare enrollment problems available

Palmetto GBA recently announced that advance payments for Part B providers will be available in limited circumstances. The offer of these advance payments are due to serious enrollment processing problems at Palmetto that physicians have been reporting, both to the Centers for Medicare and Medicaid Services (CMS) and ACP. The enrollment delays have, in turn, led to significant delays in claim payments for a large number of physicians.

Palmetto’s Web site includes information about how providers who are experiencing financial hardship due to the delays in claim payments can request an advance payment. In order to qualify, the claims must fall outside the established time limit for reimbursement, and CMS must provide written approval for the advance payment. Palmetto is the Medicare Administrative Contractor (MAC) for three states: California, Hawaii, and Nevada.

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NCOIL encourages regulation of “silent PPO” arrangements

The Nation Conference of Insurance Legislators (NCOIL) adopted the Rental Network Contract Arrangements Model Act, model legislation that would prohibit any “silent PPO” activity.

The Act would regulate the rental network PPO market and require that any entity that accessed a physician contract comply with the terms of the underlying contract, and not claim any associated discounts. NCOIL is an organization of state legislators who mainly handle insurance legislation and regulation. The model legislation has been adopted in time so that it may be considered during the 2009 sessions of state legislatures. Further information is online.

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Medicare announces Web-based enrollment

CMS announced that Internet-based Medicare enrollment is now available to providers in 15 states and the District of Columbia. The Internet-based Provider Enrollment, Chain and Ownership System (PECOS) allows physicians and other providers to enroll in Medicare, change their enrollment, view enrollment information on file and check the status of an enrollment application.

CMS will expand the system to all states within two months. For now, in addition to the District of Columbia, PECOS is available in: Delaware, Idaho, Illinois, Iowa, Minnesota, Missouri, Nebraska, Maryland, Michigan, New Jersey, North Carolina, Pennsylvania, Tennessee and Wisconsin.

CMS recommends that before accessing PECOS for the first time, providers visit the CMS Web site to learn more about the new system. Once you’ve done that, you can access PECOS online.

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From ACP Internist

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On the blog: wrap-up of the week's strange and fascinating events

There are kids taking CAM, surgeons on Ritalin, Kool-Aid as bowel prep, and a new gun for the disabled. ACP Internist's blog reports and analyzes the strange and fascinating events in medicine this week. As always, Medical news of the obvious is new on Monday.

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From the College

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ACP Foundation releases new patient education materials for physicians

Ninety-two percent of physicians surveyed by the ACP Foundation say that HEALTH TiPS, two-sided sheets containing health information on common diseases and conditions, saves them time in explaining health issues with patients. HEALTH TiPS are evidence-based and developed specifically at or below a fifth-grade reading level to facilitate comprehension among the 90 million people who have trouble understanding and acting on health information. The tips cover a range of topics, including diabetes, hypertension, dementia, osteoporosis and more, as well as related health issues such as smoking. New topics are now available, including osteoarthritis, fibromyalgia, and opioid-induced constipation. HEALTH TiPS are available online in English and Spanish.

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New patient-education DVD: Living with HIV

ACP DVDs and guidebooks are designed to help educate patients on a variety of conditions, including Alzheimer's disease, insomnia, GERD, and migraines. A new DVD, "Living with HIV," explains in detail what HIV and AIDS are and the differences between them, what to do if HIV-positive, as well as how to find the best care and medicines available. Patient-education DVDs are free, and available for order online, but quantities are limited. A small shipping fee applies.

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Cartoon caption contest

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Pick the year's best


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 continues through Dec. 22, with the winner announced in the Dec. 23 issue of ACP InternistWeekly.

Voting is online.

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MKSAP answer and critique

Answer B) Cisplatin-based chemotherapy

This item is online in MKSAP 14's Hematology and Oncology section, Item 98.

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 has a poorly differentiated tumor that is primarily in the midline, expresses germ cell cancer markers, and contains isochromosome 12p; this type of tumor is likely to respond to cisplatin-based chemotherapy and may occasionally be cured. Although isochromosome 12p is not diagnostic of a germ cell malignancy, this clinical pattern is highly suggestive of an extragonadal germ cell cancer.

Performing a biopsy is unlikely to be helpful in this case because the testicular ultrasound is normal. This patient's abdominal pain is likely due to his large midline mass; he is unlikely to derive any additional benefit from an upper endoscopy. The systemic illness present in this patient is potentially curable with cisplatin-based chemotherapy, which is the typical treatment approach for patients with germ cell cancer. Although radiation therapy has the potential to diminish the size of the patient's abnormal abdominal mass, it is not curative and therefore not warranted.

Key Point
Young, male patients with poorly differentiated midline carcinoma containing germ cell cancer markers and isochromosome 12p are likely to have extragonadal germ cell cancer and may respond to cisplatin-based chemotherapy.

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 63-year-old man is evaluated for pleuritic left-sided anterior chest pain, which has persisted intermittently for 1 week. The pain lasts for hours at a time and is not provoked by exertion or relieved by rest but is worse when supine. He reports transient relief with acetaminophen and codeine and occasionally when leaning forward. He has had a low-grade fever for 3 days, without cough or chills. Medical history is significant for acute pericarditis 7 months ago. Following a physical exam and electrocardiogram, what is the most appropriate management?

Find the answer

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