In the News
for the Week of 2-26-08
- Stroke conference covers risks and outcomes
- Flu season worse than previous years, CDC reports
- College responds to GAO report on primary care shortage
- CMS announces new demonstration project for EHRs
ACP Journal Club
- Glucose self-monitoring didn’t improve glycemic control in certain type 2 diabetic patients
- As education levels increase, cognitive impairment decreases
- Cancer death rate declines but lack of insurance a barrier to future progress
- More pain-relief patches recalled
- ACP launches e-news for hospital medicine
- Cartoon caption contest: And the winner is ...
- Regent named medical director of Arkansas Medicaid program
Stroke conference covers risks and outcomes.
NEW ORLEANS—Several studies presented at the American Heart Association's International Stroke Conference 2008 here last week illuminated the factors that increase one's risk of stroke and affect stroke outcomes. Study findings included:
- Middle-aged women’s risk of stroke has increased in the last decade due to increasing weight gain. Data from the National Health and Nutrition Surveys show that 0.6% of women aged 35-54 years had strokes in a 1988-1994 survey compared with 1.8% in a 1999-2004 survey. Women in the later study had a higher average waist circumference, higher BMI and higher average glycated hemoglobin than those in the earlier study. There were no differences in blood pressure, total cholesterol, smoking or heart disease between the two time periods, though women in the later study were more likely to report using medication to lower blood pressure or cholesterol.
- Regular daytime dozing—or unintentionally falling asleep—is associated with a higher risk of stroke in elderly patients. In a prospective study of 2,153 patients (average age 73 years), risk of stroke was 2.6 times greater for those who said they did “some dozing” compared with “no dozing.” The risk for those who did “significant dozing” was 4.5 times higher. Researchers recommend screening older patients for sleep problems and considering further evaluation for those who report dozing.
- Nearly a third of the primary care practices that were called by researchers seeking advice on hypothetical stroke symptoms recommended scheduling an appointment later in the day if symptoms persisted, rather than calling 911. When researchers reported hypothetical heart attack symptoms, however, receptionists correctly advised dialing 911. About 40 practices in West Virginia were called. A second Australian study interviewed 198 stroke patients who had recently gone to emergency departments via ambulance, and found calling a doctor’s office first with stroke symptoms greatly lengthened the time before an ambulance was called and a patient reached the hospital. Researchers concluded medical office staff members need more education on the importance of detecting stroke symptoms and advising patients to call 911 immediately, so they can be treated within the critical three hours after onset.
—By Jessica Berthold, InternistWeekly senior writer
Flu season worse than previous years, CDC reports.
Influenza activity appears to be more intense this winter than it has been during the last several flu seasons, according to the CDC.
In the week ending Feb. 9, 49 states reported either widespread or regional flu activity, said an early release from the CDC's Morbidity and Mortality Weekly Report (MMWR). During the past three flu seasons (2004-2007), the number of states reporting such activity had peaked at 41 to 48 states. The percentage of specimens in the CDC’s surveillance areas that tested positive for influenza is also higher than it has been in recent years. The percentage for the week ending Feb. 9, 2008, was 33%, compared with 23% to 25% positive tests during the preceding three seasons. During the same week, 5.7% of outpatient visits to sentinel providers were for influenza-like illness, the CDC said.
The CDC is continuing to assess the degree of match between the circulating viruses and vaccine strains, but the agency still recommends vaccination with the trivalent influenza vaccine to provide at least partial protection and reduce the risk of complications and death. The agency also continues to recommend oseltamivir and zanamivir for treatment and prophylaxis of influenza, although some resistance to oseltamivir (5.9% of specimens tested) has been detected.
However, late last week, an FDA advisory panel recommended three new components to be included in next season's flu vaccine, according to the Feb. 22 Wall Street Journal. While it is hoped that a new vaccine would provide better protection, it may also cause production and shipping delays as manufacturers scramble to incorporate coverage for three new strains at the same time, said the article.
The CDC also announced last week that state health departments have made progress on emergency preparedness, but that some challenges remain. All state health departments can now receive urgent reports 24 hours a day, 7 days a week, while only 12 could in 1999. The states have also developed detailed emergency response plans, and the number of laboratories available to analyze samples has doubled.
Areas where further improvement is needed include the ability to quickly dispense medications or vaccines, the use of electronic health data, and implementation of public health mutual aid agreements that will enable sharing of supplies, equipment, personnel and information during emergencies, the CDC said.
The Morbidity and Mortality Weekly Report is online.
The Wall Street Journal is online (subscription required).
A press release on state preparedness is online.
College responds to GAO report on primary care shortage.
A recent report by the Government Accountability Office (GAO) understates the developing shortage of primary care physicians, the College said last week in a statement submitted to the Senate Committee on Health, Education, Labor and Pensions.
The College agrees with the GAO’s findings that primary care medicine is essential to better quality and lower costs and that the health care system’s current financing mechanisms undervalue primary care services. However, the statement notes that clarification is necessary on two issues:
- Supply of primary care physicians: The GAO study states that the number of primary care physicians has increased from 80 primary care physicians per 100,000 people in 1995 to 90 per 100,000 in 2005. However, the Health Resources and Services Administration's October 2006 report, Physician Supply and Demand: Projections to 2020, projects that the estimated requirements in 2005 were 95 primary care physicians per 100,000 people. In the same report HRSA estimates that the baseline primary care physician requirements per 100,000 people will increase to 100 by 2020.
- Residents training in primary care specialties: The GAO Study states that there were 40,982 residents in primary care graduate medical training programs in 2006, based on data from the National GME Census that appears annually in the Journal of the American Medical Association. This number is misleading as it represents residents in all primary care specialties without regard to where they are in the training process or whether they plan to subspecialize. For example, while 22,099 of the 40,982 primary care residents reported were internal medicine residents, it is important to consider that only a fraction of the 22,099 internal medicine residents will go on to practice primary care. In 2006, 24% of third-year internal medicine residents surveyed stated that they intended to pursue careers in general internal medicine, down from 54% in 1998. The remainder indicated that they planned on pursuing careers in an internal medicine subspecialty or hospital medicine.
Assuming that many of the 7,964 pediatric residents that were included in the 40,982 figure also will likely subspecialize, it is evident that the number of residents who choose to practice office-based primary care upon completion of training is actually far less than what the GAO study indicates, the College statement said.
For more on ACP’s position, read the report, “Creating a New National Workforce for Internal Medicine."
CMS announces new demonstration project for EHRs.
The CMS has launched a new community-based demonstration project of electronic health records (EHRs) designed to show that the adoption of interoperable EHR systems would reduce medical errors and improve the quality of care. Interoperable systems are capable of communicating with each other and sending electronic information back and forth, regardless of the particular physician’s office or hospital in which they are being used.
The demonstration project will be conducted over a five-year period and will focus on small- to medium-sized primary care practices. CMS will offer financial incentives to physician practices in the chosen communities that use certified EHRs to improve quality as measured by their performance on quality measures. Bonus payments will be based on the number of EHR functionalities that the physician practices have incorporated. And, to further demonstrate the effects of financial incentives, CMS will be encouraging public and private payers to offer similar incentives.
CMS is inviting communities to apply to become one of the initial 12 project sites. The application period is open now and continues through mid-May.
- have active involvement of a variety of stakeholders (including providers, consumers, health plans, and employers);
- show private-sector support;
- are geographically large enough to recruit a sufficient number of practices, both for participating practices and control sites; and
- are not already part of any other similar CMS demonstration projects.
ACP Journal Club
Glucose self-monitoring didn’t improve glycemic control in certain type 2 diabetic patients.
A study found that blood glucose self-testing or self-monitoring did not improve glycemic control in patients with type 2 diabetes who were not treated with insulin.
The study involved 453 patients with a mean age of 66 years who were managed with diet or oral hypoglycemic agents alone, had a hemoglobin A1c (HbA1c) level of at least 6.2% and were independent in daily living activities. Interventions included self-testing with a blood glucose meter three times daily for two days a week; self-testing plus training in timing, interpreting and using the test results (i.e. “self-monitoring”); or quarterly blood glucose tests but no use of a blood glucose meter (control group).
After 12 months, the groups did not differ with respect to change in HbA1c level, blood pressure, weight, body mass index, or ratio of total cholesterol to high-density lipoprotein cholesterol. Decrease in total cholesterol level was greater in the self-monitoring group than in the control group, and hypoglycemia risk was highest in the self-monitoring group.
The results suggest that the benefit of self-monitoring blood glucose in patients treated with tablets is minimal at best, wrote Journal Club reviewers Frank Waldron-Lynch, MD, of Galway University Hospitals and Sean Dinneen, MD, of the National University of Ireland, but patients who regularly self-tested were excluded from the study. In addition to this study’s results, physicians should listen to what patients say about self-monitoring, as recent research suggests physicians’ focus on HbA1c levels may lead some patients to think that self-monitoring blood glucose isn’t important, the reviewers added.
Peer ratings for this review: Endocrinology: 6/7 stars. Internal Medicine/Family Practice: 5/7 stars.
ACP Journal Club is online.
As education levels increase, cognitive impairment decreases.
The prevalence of cognitive impairment among older Americans decreased significantly between 1993 and 2002, according to a new study.
Using data from the Health Retirement Study, a population-based longitudinal survey of U.S. adults, the study looked at more than 7,000 adults who were age 70 or older when data were collected in 1993 and 2002. The researchers found that 12.2% of the 70 and over population had cognitive impairment (CI) in 1993, compared with only 8.7% in 2002. However, the risk of death for those with moderate or severe CI increased during the study interval.
Both education and personal wealth were found to have a protective effect against impairment, according to the study. In fact, study authors concluded that increasing levels of education and net worth among older Americans could be responsible for about 40% of the observed decrease in prevalence. Better educated subjects were also more likely to suffer rapid decline and death after CI, indicating that cognitive reserve can protect the brain from minor insults but that a major problem would deplete the reserve rapidly, the study authors said.
The observed decrease in CI could also be due in part to more intensive treatment of cardiovascular risks, the authors said. They noted that improvements in blood pressure control and cholesterol profiles between 1993 and 2004 could have had a spillover effect that reduced the incidence of vascular dementia among older Americans. The study was published online on Feb. 20 in the journal Alzheimer’s & Dementia.
Based on their findings, the authors concluded that societal investment in formal education in childhood and continued cognitive stimulation during adulthood might help limit the burden of dementia among the growing population of older adults worldwide.
Alzheimer’s & Dementia is online.
Cancer death rate declines but lack of insurance a barrier to future progress.
Cancer death rates continued to decline overall in the U.S. in 2005, according to the latest figures from the American Cancer Society, but lack of health insurance is emerging as a major barrier to early detection and treatment in patients without private insurance.
The overall death rate from cancer decreased by 1% from 2004-05 compared with a drop of 2% for both 2002-03 and 2003-04, said the ACS in "Cancer Facts and Figures 2008." The actual number of deaths increased from 553,888 in 2004 to 559,312 in 2005, which researchers attributed in part to a large aging population. Since the early 1990s, said the report, cancer death rates have dropped by 18.4% among men and 10.5% among women.
Researchers identified lack of health insurance as one of the most significant barriers to reducing deaths from cancer in the future. A recent study co-sponsored by ACS and published in the March issue of The Lancet Oncology revealed that uninsured and Medicaid patients had a significantly higher risk of having advanced-stage cancer compared with people who had private insurance. The study, which used data from 1,400 hospitals in the U.S., also reported that these patients were more likely to be diagnosed with late-stage breast and colorectal cancer, both of which can be detected in early stages through screening.
Other findings from the 2008 report include:
- About half of all cancer diagnoses among men are for prostate, lung and colorectal cancers, while breast, lung and colorectal cancer account for about half of diagnoses among women.
- Some cancers showed declines in incidence, including lung cancer in men, breast cancer in women and colorectal cancer in both men and women.
- An estimated 1.4 million new cancers will be diagnosed in 2008 and 565,650 people will die from the disease.
- African-American men have a 19% higher incidence rate and a 37% higher death rate from cancer than white men
- African-American women, while less likely to be diagnosed with cancer than white women, are more likely to die from the disease.
More pain-relief patches recalled.
A second set of pain-relief patches containing fentanyl was recalled last week due to a packaging defect that may bring patients or caregivers in direct contact with the potent opioid gel. The new recall affects patches sold by Actavis South Atlantic LLC and manufactured by Corium International Inc.
The recalled patches are double-branded with the name Actavis on the box and Abrika Pharmaceuticals, the company’s former name, on the pouches. The recall includes 25-microgram-per-hour, 50-microgram-per-hour, 75-microgram-per-hour and 100-microgram-per-hour fentanyl patches with expiration dates between May and August 2009.
The patches may have a fold-over defect, which could cause the gel to leak and expose patients or caregivers to it, potentially causing respiratory depression or overdose. Fentanyl patches sold by a different company, PriCara, were recalled two weeks ago for a similar defect.
Anyone exposed to the gel should wash his or her hands with water and no soap, and any patches affected by the recall should be flushed down the toilet, advised Actavis. The company has not received any reports of injuries related to the defect, the Feb. 18 Washington Post reported.
A press release from Actavis is online.
The Washington Post is online.
ACP launches e-news for hospital medicine.
This week, ACP will launch ACP HospitalistWeekly, a weekly electronic newsletter that supplements its popular print magazine, ACP Hospitalist. Expanding on the hospital news provided by ACP InternistWeekly, the e-newsletter will focus on news specific to hospital medicine.
ACP members already receiving the print edition and who have provided their e-mail address to ACP will automatically receive ACP HospitalistWeekly. If you would like to receive the newsletter in your in-box each Wednesday morning, please e-mail your contact information to email@example.com or call 800-523-1546, ext. 2600 (M-F, 9am - 5pm ET).
Cartoon caption contest: And the winner is ....
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 issue's winning cartoon caption comes from Kostas Marmagkiolis, ACP Associate Member, a Cardiology Fellow at the Montreal Heart Institute - University of Montreal, in Quebec, Canada. He receives 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. ACP InternistWeekly readers cast 231 ballots online to choose the winning entry. Thanks to all who voted!
The winning entry:
"Our anesthesiologists are on strike."
The winning caption received 72.7% of the votes cast. The two runners up were:
- "After they found my wristwatch in another patient, I thought it best to just start carrying this." (15.6%)
- "No wonder you needed a heart transplant. This was your ticker." (11.7%)
Regent named medical director of Arkansas Medicaid program.
William E. Golden, MACP, Immediate Past Chair of the Board of Regents, has been appointed medical director for health policy at the Arkansas Department for Human Services and Medicaid Program. He will assist in developing and representing policy related to quality and health system reform.
Dr. Golden will continue as professor of medicine and public health at the University of Arkansas for Medical Sciences. He had served as vice president of quality improvement at the Arkansas Foundation for Medical Care since 1993.
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.
A 67-year-old man is evaluated for a 6-month history of worsening exertional dyspnea. He has severe COPD, previously with minimal exertional symptoms, but now notes activity-limiting shortness of breath when walking short distances. He does not have chest pain, gastrointestinal symptoms, or sleep-related symptoms. Medical history is otherwise unremarkable. Medications are a twice-daily fluticasone/salmeterol inhaler and an as-needed albuterol/ipratropium metered-dose inhaler. He has a 55-pack-year smoking history but quit when COPD was diagnosed. Following a physical exam, chest radiograph, and transthoracic echocardiogram, what is the most appropriate diagnostic test to perform next?
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