In the News
for the Week of 12-23-08
- Heart disease deaths drop but obesity, inactivity still major risks
- Stress leads to unhealthy behaviors that lead to CV disease
- IBS guidelines recommend testing for celiac disease, using antidepressants
- MKSAP quiz: testicular cancer post-discharge
- Suicide risk for antiepileptics, tighter screening for antidiabetics
- Alpha-blockers not effective for prostatitis compared to placebo
- HIVMA soliciting applications for minority fellowship award
From the College
- New issue of ACP Advocate explains how you could earn more in 2009
Cartoon caption contest
- And the year's best is …
Editorial note: ACP InternistWeekly will not be published for the next two weeks due to the Christmas and New Year's holidays.
Heart disease deaths drop but obesity, inactivity still major risks
Deaths from heart disease and stroke fell by about 30% between 1999 and 2006, according to data released in the American Heart Association's 2009 statistical update.
While the reductions are significant, there has not been a similar decline in major risk factors for cardiovascular disease (CVD) and stroke, and some are on the rise, said the AHA's president in a news release.
For example, high blood pressure, high cholesterol and tobacco use are under better control but much work remains to be done to reduce obesity, diabetes and physical inactivity in order to prevent the death rate from rising again, said the release.
The AHA's update also includes data on coronary artery calcification (CAC) scores and carotid intima-media thickness, which can be early warning signs of CVD. A recent National Heart, Lung and Blood Institute study found that 15% of men and 5.1% of women already had CAC and that older adults with CAC are much more likely to suffer a coronary event, especially if their CAC scores exceeded 100.
Other statistics contained in the update include:
- Between 1999-2000 and 2005-06, average total cholesterol levels for men age 40 or older and for women age 60 or older declined from 204 mg/dL to 199 mg/dL.
- 62% of adults who responded to the 2006 National Health Interview Survey reported no vigorous activity lasting at least 10 minutes per session.
- The presence of overweight (BMI-for-age values at or above the 95th percentile) in adolescents aged 12 to 19 increased from 6.1% in the 1970s to 17.6% in 2003-06.
The full update is available online in AHA's journal Circulation..
Stress leads to unhealthy behaviors that lead to CV disease
The association between stress and cardiovascular disease can mostly be explained by behavioral factors, according to a new study.
Using data from the Scottish Health Survey, a prospective study of 6,576 healthy adults, researchers analyzed the psychological distress, behavioral risk factors and pathophysiological risks of participants. The main outcome of the study was all cardiovascular disease (CVD) events. The research found that stress was associated with more cigarette smoking, less physical activity, higher alcohol intake, higher C-reactive protein and hypertension. The study was published in the Dec. 16/23 Journal of the American College of Cardiology.
Participants who were found to have a high level of stress at baseline were at least 50% more likely to have a CVD event than other participants in the seven years of followup. When researchers controlled for the individual potential factors, they found smoking to be the most influential, accounting for 40.7% of the difference in outcomes. Physical activity was next, controlling 22.3%, while alcohol had only a 2% effect. Hypertension explained 13% of the difference and C-reactive protein 5.5%. Overall, behavioral factors explained about 65% of the 223 CVD events recorded in the study.
An accompanying editorial cautioned that the study was small and did not control for sleep issues. However, the author suggested that behavioral interventions be combined with other stress-reducing therapies and then additional research be done to see if such multi-modal programs reduce morbidity and mortality. The lead author recommended a similar course and suggested that cardiologists work together with psychologists, according to the Dec. 15 Washington Post..
IBS guidelines recommend testing for celiac disease, using antidepressants
Updated guidelines for irritable bowel syndrome (IBS) recommmend testing for celiac disease and using anti-depressants in some cases.
The guidelines reflect the increase in IBS causes and management since the previous guidelines were released in 2002. They were published in the American Journal of Gastroenterology.
The guidelines now recommend:
- Most patients with typical IBS symptoms and no bleeding, weight loss or a family history of colon cancer, inflammatory bowel disease or celiac sprue do not need extensive diagnostic testing;
- IBS patients with diarrhea or a mixture of diarrhea and constipation should be screened for celiac disease;
- When patients with IBS and diarrhea undergo colonoscopy, biopsies should be obtained to rule out microscopic colitis;
- Anti-depressants, tricyclic agents and selective serotonin reuptake inhibitors used in low doses before sleep can help some patients because they reduce bloating and discomfort by altering brain-gut signaling about motility and distention. And, tricyclic antidepressants can induce constipation;
- Lubiprostone benefits a subset of women with IBS and constipation;
- The probiotic Bifidobacter infantis benefits some patients with IBS and diarrhea;
- Rifaximin benefits IBS with bloating and diarrhea; and
- Alosetron can be considered for women with more severe IBS and diarrhea who have not responded to standard therapies.
Existing recommendations for lifestyles changes still apply, such as avoiding foods and carbonated beverages that create bloating.
MKSAP quiz: testicular cancer post-discharge
A 40-year-old man is evaluated during a routine examination after being discharged from care by his medical oncologist. His medical history is significant for metastatic testicular germ cell cancer for which he was treated with bleomycin–etoposide–cisplatin therapy 5-and-a-half years ago; he has been disease free ever since. The remainder of his medical history is noncontributory, and his family history is unremarkable. The physical examination is normal.
Which of the following is the most appropriate management strategy for this patient at this time?
A) Biopsy of the remaining testicle
B) Semiannual testicular ultrasonography of the remaining testicle
C) Periodic audiometry
D) Annual serum creatinine and serum blood urea nitrogen measurement
E) Periodic review of symptoms
Click here or scroll to the bottom of the page for the answer and critique.
Suicide risk for antiepileptics, tighter screening for antidiabetics
Antiepileptic drugs must now have a warning in their prescribing information about a higher risk of suicidal thoughts and behaviors, the FDA said last week.
The warning applies to all antiepileptics, including those used to treat migraines and psychiatric conditions. In a review of clinical trials, the FDA found antiepileptic drugs have almost twice the risk of suicidal thoughts or behaviors compared with placebo—or about one additional case for every 500 patients on the drugs, compared with placebo. Patients taking antiepileptics should be monitored for depression or suicidal thoughts and behaviors.
Separately, the FDA gave guidance to new diabetes drug makers that they should provide evidence their drugs won't increase cardiovascular risk, especially in older patients or those with advanced diabetes or renal impairment. Any cardiovascular events that do occur should be analyzed by committees of outside cardiologists who don't know if a patient took a drug or placebo. The FDA is still evaluating how these recommendations will apply to antidiabetic drugs that have already been approved.
Alpha-blockers not effective for prostatitis compared with placebo
Alpha-adrenergic receptor blockers didn't show any significant decrease in pain compared with placebos, for chronic prostatitis–chronic pelvic pain syndrome.
Researchers reported in the New England Journal of Medicine that physician-diagnosed prostatitis affected about 9% of the population in one study, and population-based surveys estimate its prevalence between 6% and 12%. Three-quarters of primary care physicians prescribe antibiotics at least half the time, and more than half regularly recommend anti-inflammatory agents.
To assess the efficacy of alpha-blockers, researchers conducted a multicenter, randomized, double-blind, placebo-controlled trial of alfuzosin. Eligibility required diagnosis in the prior 2 years, pain or discomfort in the pelvis for at least 6 weeks, a score of at least 12 on the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) and no previous treatment with an alpha-blocker.
Researchers randomized 272 eligible participants to 12 weeks of 10 mg of alfuzosin daily or placebo. The primary outcome was a reduction of at least 4 points on the NIH-CPSI. Both study arms saw 49.3% of participants decrease at least 4 points in their total NIH-CPSI score (difference between groups, 0.1%; 95% confidence interval, -11.2 to 11.0). Global response assessment showed similar response rates at 12 weeks: 33.6% in the placebo group and 34.8% in the alfuzosin group (P =0.90).
HIVMA soliciting applications for minority fellowship award
The HIV Medical Association is currently collecting applications from black or Latino candidates for two 2009 Minority Clinical Fellowship Program. Additional information is available on the HIVMA Web site.
From the College.
New issue of ACP Advocate explains how you could earn more in 2009
The latest issue of ACP’s advocacy newsletter looks at two programs under Medicare that can help internists increase their reimbursement for 2009. The Physicians’ Quality Reporting Initiative and the Medicare e-Prescribing incentive program both offer physicians the opportunity to earn a bonus in addition to their standard Medicare reimbursements by reporting additional information to CMS. Also in this issue we examine President-elect Obama’s choice for secretary of Health and Human Services, Senator Tom Daschle, and look at his priorities for health care reform.
Cartoon caption contest.
And the year's best is …
"I don't care which one you use; just get it over with."
53.5% of voters overwhelmingly chose this caption among the three top vote getters from 2008. The winner of the $100 ACP gift certificate, as chosen randomly among all voters, is Malvinder S. Parmar, FACP, medical director of the Medical Program (Internal Medicine), Timmins and District Hospital, Timmins, Ontario, Canada. Congratulations to all those who submitted captions and voted this year. The contest resumes in the Jan. 13 issue of ACP InternistWeekly..
MKSAP Answer and Critique
Correct Answer: E) Periodic review of symptoms
This item is online in MKSAP 14's Hematology and Oncology section, Item 108.
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.
Most testicular cancer relapses occur within 2 years after the completion of definitive therapy; relapse after that point is rare. Many experts advocate follow-up examinations including annual CT scans or laboratory studies focused only on new symptoms rather than an arbitrary schedule of imaging or workups.
Contralateral testicular tumors occur in only a small percentage of men, and neither routine testicular biopsy nor ultrasonography is known to be helpful in establishing an early diagnosis or in changing outcomes. False-positive ultrasound results can be a problem, and performing a blind biopsy of the testicle is invasive and subject to sampling error. Although the heavy metal cisplatin causes decreased high-frequency hearing, it affects sound frequencies in the conversational range infrequently and does not require routine audiometry. Likewise, although cisplatin can cause long-term subclinical deficits in renal function, renal failure after the usual curative bleomycin–etoposide–cisplatin regimen is rare; therefore, routine measurement of serum creatinine and serum blood urea nitrogen is unnecessary.
Follow-up examinations for patients with successfully treated testicular cancer should include studies focused only on new symptoms rather than an arbitrary schedule of imaging or workups.
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Copyright 2008 by the American College of Physicians.
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?
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