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

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In the News
for the Week of 12-9-08

Highlights

  • ACE inhibitor plus calcium channel blocker works better than diuretic for hypertension
  • Generic cardiovascular drugs are as effective as brand-name
  • Take a poll and check out the December update of ACP Internist

Test yourself

  • MKSAP quiz: malaise and confusion

Annals of Internal Medicine

Drug news

  • Tinzaparin may heighten death risk for older patients with renal insufficiency
  • National Influenza Vaccination Week is Dec. 8-14

Practice tools and improvements

  • Internists can earn money from Medicare for e-prescribing
  • Patient brochure about warfarin available in Spanish
  • Patient-centered medical home pilot tested in Colorado

From the College

From ACP Hospitalist

  • December's issue is online

From ACP Internist

  • On the blog: flu tracking and doctor rating services
  • Cartoon caption contest: Pick the year's best

Highlights

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ACE inhibitor plus calcium channel blocker works better than diuretic for hypertension

Treating hypertension in patients at high risk for cardiovascular events with a combination of angiotensin-converting enzyme (ACE) inhibitor and a dihydropyridine calcium channel blocker was more effective than using an ACE inhibitor plus a thiazide diuretic, a recent study found.

In the randomized, double-blind trial, 11,506 patients with hypertension at high risk for heart events received the ACE inhibitor benazepril plus either amlodipine or hydrochlorothiazide. After a mean follow-up of 36 months, 9.6% of patients in the amlodipine group suffered primary outcome events (death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, hospitalization for angina, resuscitation after sudden cardiac arrest and coronary revascularization) vs. 11.8% in the hydrochlorothiazide group, representing a relative risk reduction of 19.6% in the amlodipine group. The industry-sponsored trial was stopped early due to better outcomes in patients who received the calcium channel blocker.

The authors noted that many participants in the trial had previous coronary disease and diabetes, so their findings may not apply to all patients with hypertension. However, an editorial said that the findings should trigger a reexamination of current Joint National Committee guidelines, which strongly favor thiazide-type diuretics as initial therapy for hypertension.

The results should not negate the importance of diuretics, the editorial continues, but give physicians greater flexibility in choosing first-line therapy for hypertension.

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Generic cardiovascular drugs are as effective as brand-name

Generic and brand-name cardiovascular drugs are no different in terms of clinical outcomes, a new meta-analysis in the Dec. 3 Journal of the American Medical Association found.

Researchers searched peer-reviewed publications for articles from January 1984 to August 2008, and found 47 articles comparing the safety and efficacy of generic and brand-name drugs. Thirty-eight of the articles were randomized controlled trials (RCT). The generic and brand-name drugs were found to be clinically equal in all seven beta-blockers RCTs; 10 of 11 diuretics RCTs; five of seven calcium channel blockers RCTs; all three antiplatelet agents RCTS; both statins RCTs; one angiotensin-converting enzyme inhibitors RCT; one alpha-blockers RCT; one class 1 anti-arrhythmic agents RCT; and five of five warfarin RCTs.

The clinical outcomes that were measured included vital signs, lab values like international normalized ratio (INR), adverse effects, and use of the health care system. The aggregate effect size was -0.03, showing brand name drugs weren't superior to generics. Despite this, about half of the editorials with the studies revealed negative viewpoints about switching to generics. Still, this article's authors concluded that switching from brand-name to generic drugs is safe, though they advised physicians to monitor the INR of high-risk patients during the transition period.

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Take a poll and check out the December update of ACP Internist

Do you communicate with patients online? Cast your vote and then read about one physician's experience with a patient portal in the December online-first edition of ACP Internist. The update also includes a new article on pelvic floor disorders and a profile of Isabel Hoverman, MACP.

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Test yourself

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MKSAP quiz: malaise and confusion

A 66-year-old woman is evaluated for malaise and confusion. She has smoked one pack of cigarettes a day for the past 40 years. She takes hydrochlorothiazide for hypertension. Physical examination reveals distant breath sounds. Chest radiograph shows a 1.5-cm mass in the proximal upper lobe of the left lung and infiltrates distal to the mass. A bone scan indicates no evidence of focal or metastatic disease.

Laboratory Studies

Calcium 15.8 mg/dL (3.94 mmol/L)
Phosphorus 4.0 mg/dL (1.29 mmol/L)
Chloride 97 meq/L (97 mmol/L)
Intact parathyroid hormone <1.0 pg/mL (1.0 ng/L)

Serum protein electrophoresis shows polyclonal gammopathy.

Which of the following is the most likely cause of the patient's hypercalcemia?

A) Thiazide-induced hypercalcemia
B) Parathyroid adenoma
C) Parathyroid hyperplasia
D) Humoral hypercalcemia of malignancy
E) Multiple myeloma

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

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Annals of Internal Medicine

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New HIV-testing guidelines from ACP

ACP urges physicians to offer routine HIV screening to all patients beginning at age 13, regardless of risk factors, in a new guidance statement published in the Dec. 2 Annals of Internal Medicine. The guidance statement differs slightly from those of the CDC, which recommend routine screening of patients until age 64 unless the prevalence of HIV is known to be less than 0.1% in the patient population. The recommendations also differ from those put forth by the U.S. Preventive Services Task Force, which urge routine screening only of patients at increased risk for infection.

It is very difficult for physicians to determine the HIV prevalence rate for their patient population, said Amir Qaseem, MD, senior medical associate in ACP's department of Clinical Programs and Quality of Care. “It is estimated that 1 million to 1.2 million Americans have HIV, but 24% to 27% of that number are undiagnosed or unaware of their infection,” he explained. “ACP recommends that clinicians adopt routine screening of all their patients.” Each year in the U.S. 20,000 new HIV infections are caused by individuals who are unaware that they are infected. An ACP video news release about the guidance statement is online.

Other articles in the latest issue of Annals assess the impact of hospitalists on emergency room crowding and whether apology laws improve patient-physician relations.

A new free patient education DVD, Living with HIV is now available.

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Drug news

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Tinzaparin may heighten death risk for older patients with renal insufficiency

Tinzaparin (Innohep) may increase the mortality risk of patients age 70 or older with renal insufficiency, the FDA said in an alert.

A clinical study comparing unfractionated heparin to tinzaparin found a 13% all-cause mortality rate for older patients with renal insufficiency who took tinzaparin, compared with a 5% rate for patients who took unfractionated heparin. The study was stopped in February 2008. In July 2008, the maker of tinzaparin revised prescribing information to restrict use of the drug in patients age 90 or older, but recently requested that the restriction apply to patients age 70 and older with renal insufficiency.

Physicians should consider using alternative treatments when treating elderly patients age 70 years and older with renal insufficiency and deep vein thrombosis, pulmonary embolism, or both, FDA said.

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National Influenza Vaccination Week is Dec. 8-14

The CDC is asking physicians to talk to their patients about the importance of flu vaccination during National Influenza Vaccination Week.

Since flu activity typically does not peak until February or later, patients should be encouraged to get their shots this month and next, the CDC said. In particular, seniors should be reminded that flu shots are covered by Medicare Part B, said the CDC, which designated this Thursday as Seniors Vaccination Day.

Health care professionals and their staff can learn more about Medicare’s coverage of the flu vaccine and other Medicare Part B covered vaccines and related provider education resources created by CMS, by reviewing a special edition of MLN Matters.

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Practice tools and improvements

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Internists can earn money from Medicare for e-prescribing

Beginning Jan. 1, physicians who use e-prescribing are eligible to earn a 2% bonus from Medicare for 2009. This bonus payment is part of a new E-Prescribing Incentive Program from CMS. The program is designed to promote the adoption and use of e-prescribing systems, and will be phased in over five years. In order to earn the bonus in 2009, providers must use a qualified e-prescribing system, and report on an e-prescribing quality measure code on at least 50% of their eligible claims over the calendar year.

ACP has developed an e-prescribing Web site to help members with this transition. The Web site has an overview of the new incentive; and helpful material that focuses on how to select an e-prescribing system and how to report once a system is in place.

In addition to the tools from ACP, there are a variety of additional outside resources available to help practices take advantage of the new program:

  • Medicare is also offering a manual to help providers with the new program. Medicare’s Practical Guide to the E-Prescribing Incentive Program is available on their website.
  • Medicare also has available a Web archive of presentations given during their October 2008 E-Prescribing Summit. Free CME credits are available through the Massachusetts Medical Society for physicians who view the presentations online.
  • The eHealth Initiative has developed A Clinician’s Guide to E-prescribing which provides practical information on the implementation of e-prescribing in a physician practice setting.

In a related note, CMS recently decided that they will continue to allow practices to continue to use computer-generated faxes to send Medicare Part D prescriptions to pharmacies. However, these computer-generated faxes do not qualify for the e-prescribing incentive.

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Patient brochure about warfarin available in Spanish

The Agency for Healthcare Research and Quality (AHRQ) has released a new educational brochure about warfarin (Coumadin) for Spanish-speaking patients.

The 13-page brochure, "Su guía para el tratamiento con Coumadin/warfarina" (Your Guide to Coumadin/Warfarin Therapy), tells patients about their medication therapy and potentially dangerous side effects. It also explains how to communicate effectively with health care providers, and emphasizes the importance of telling providers about other drugs and/or supplements the patient is taking. Additionally, the pamphlet instructs how to remember when to take one's medicine, how to stay safe while taking the medicine, and how to keep a consistent diet and make lifestyle modifications.

The Spanish and English versions of the pamphlet are online. Providers may order print copies by calling (800) 358-9295 or by sending an e-mail. This number also can be used to order Spanish and English guides to help patients prevent deep vein thrombosis.

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Patient-centered medical home pilot tested in Colorado

Up to 15 physician practices have been chosen to participate in a new two-year pilot project in Colorado that will test the patient-centered medical home (PCMH). Practices that participate in the pilot, to launch in spring 2009, will receive modified payments for their patients who are enrolled in participating health plans. The project will use a three-tier system of payment that includes standard fee-for-service, a monthly care management fee, and a bonus payment for meeting or exceeding quality indicators.

The project is sponsored by the Colorado Clinical Guidelines Collaborative, a nonprofit, multi-stakeholder health care coalition that aims to improve health care in the state. More information about the Colorado pilot can be found on their Web site.

A PCMH is a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient's lifetime to maximize health outcomes. The PCMH practice is responsible for providing for all of a patient’s health care needs or appropriately arranging care with other qualified professionals. More information about the PCMH can be found on ACP’s Web site.

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From the College

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ACP Press seeks memorable moments

As part of a series of books on teaching, ACP Press is collecting your memorable moments. We're looking for meaningful stories either serious or funny. Taken together, these stories will comprise a tapestry of teaching and learning in internal medicine, to be included in the first book of ACP's teaching medicine series, to publish in 2010. 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.

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From ACP Hospitalist

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December's issue is online

The latest issue of ACP Hospitalist is online and headed for your mailbox. Topics include:

Nocturnists. Disparities between day and night care, as well as new guidelines and public pressure, are pushing hospital administrators and hospitalist practices to offer 24/7 care.
Errors. Hospitals should always work to prevent serious or fatal medical errors, but they also need to have a plan in place for what to do if an error occurs.
Careers. Clinical research at community hospitals in collaboration with academic medical facilities is gaining traction around the U.S.

The latest issue is online.

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From ACP Internist

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On the blog: flu tracking and doctor rating services

This week on ACP Internist's blog, we assess the good and bad of medicine on the web: Sermo is using its members to track the spread of flu, but doctor rating services show little value. There's also talk of an insurer's new plan to charge people for the option to buy insurance. And, we're not counting it as Medical News of the Obvious, but did you know that students and residents are sleepy and sad?

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Cartoon caption contest: 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

D) Humoral hypercalcemia of malignancy

This item is online in MKSAP 14's Endocrinology and Metabolism section: Item 139.

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

Hypercalcemia with a suppressed serum PTH level in a patient who smokes and who has a lung mass is highly likely due to lung cancer. The humoral mediator of hypercalcemia of malignancy in the vast majority of cases, especially in patients with lung cancer, is parathyroid hormone–related peptide (PTHrp), which is secreted by the tumor into the circulation. PTHrp binds to the PTH receptor and to the PTH/PTHrp receptor where it stimulates increased bone resorption with release of calcium into the circulation. Hydrochlorothiazide sometimes causes mild hypercalcemia but seldom raises serum calcium levels to this degree. The suppressed serum PTH rules out hyperparathyroidism, due to either a parathyroid adenoma or hyperplasia. Multiple myeloma, which can cause hypercalcemia by producing high levels of local bone marrow cytokines, is far less likely in this patient who has a polyclonal gammopathy related to the infectious process present in the lungs.

Key Point

The humoral mediator of hypercalcemia of malignancy in most cases, especially in lung cancer, is parathyroid hormone–related peptide (PTHrp), which is secreted by the tumor.

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 42-year-old woman is evaluated for an 8-month history of crampy abdominal pain and three loose bowel movements per day. The pain is relieved by a bowel movement. There are no nocturnal bowel movements, and there is no blood or dark tarry material in the stool. She has not had fever, night sweats, or weight loss. She has a history of Hashimoto disease and is treated with levothyroxine. Following a physical exam, rectal exam, and lab tests, what is the most appropriate next step in management?

Find the answer

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