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

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In the News
for the Week of 3-18-08

Highlights

  • One in four teenage girls has STD, CDC says
  • Informing patients of mild dementia won’t overburden them, study finds
  • Physician sues PBM to collect on time spent on prescription inquiries

Oncology

  • Cause of cancer drug allergy pinpointed
  • Estrogen-dependent breast cancer patients may benefit from extended adjuvant therapy

Quality improvement

  • Preliminary results from PQRI released
  • IHI offers quality improvement guide for doctors

Prevention and follow-up

  • Studies on MRSA screening yield conflicting results
  • Reminding patients about beta blockers works
  • Low-dose aspirin may reduce women's risk of asthma

Annals of Internal Medicine

  • Growth hormone does not enhance athletic performance
  • Many older adults have loss of memory and thinking but not dementia
  • Colonoscopy guidelines do not predict subsequent development of advanced polyps
  • Audio summary: Health care reform in Massachusetts

FDA news

  • Anemia drugs’ labels revised with details on breast, cervical cancer risks
  • FDA issues alert on appropriate use of Tussionex cough medicine

Cartoon caption contest

From the College

  • Next LEAD challenge online
  • Call for fall 2008 Board of Governors resolutions
  • Deadline for "Internists as Artists" program extended

Highlights

One in four teenage girls has STD, CDC says
.

New CDC data presented at the 2008 National STD Prevention Conference highlighted the importance of prevention and screening for sexually transmitted diseases, especially among young women and men who have sex with men (MSM).

More than one in four women between the ages of 14 and 19 is infected with at least one STD, according to one study. The study also found that young black women have particularly high rates of the surveyed diseases (which included human papillomavirus (HPV), chlamydia, herpes simplex virus, and trichomoniasis). About 48% of black teenage girls were infected, compared with 20% of whites. The most common diseases were HPV and chlamydia.

U.S. syphilis rates continued to rise for the seventh year in a row, according to another study presented at the conference. Preliminary data from 2007 shows that the rate of primary and secondary syphilis infection increased 12% between 2006 and 2007, from 3.3 to 3.7 cases per 100,000 population. The rate increased slightly among women, but researchers said that substantial increases among MSM likely accounted for the overall trend.

Clinicians are missing opportunities to screen at-risk patients for these diseases, other studies found. A CDC survey of 15 to 24-year-old women found that while 82% receive contraceptive or STD services, only 39% receive both, and among young women who receive services associated with unprotected sex (such as pregnancy testing), only 38% receive STD counseling, testing or treatment. Several studies evaluated STD testing of MSM and one of those--a survey of men in 15 cities--found that the rates of annual testing were below 50% for syphilis, gonorrhea and chlamydia.

Press releases from the conference are online.

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Informing patients of mild dementia won’t overburden them, study finds
.

Contrary to what many physicians believe, telling patients they have dementia doesn’t cause them extra emotional strain, and may relieve anxiety for some, a new study suggests.

Researchers interviewed 90 volunteer subjects--plus one companion for each--at an Alzheimer’s Disease Research Center in St. Louis, Mo. The subject received a comprehensive review of medical history and a physical and neurological examination, while the companion (usually a spouse or adult child) talked separately with researchers about his or her perception of cognitive and behavioral changes. Both parties were then brought together to hear the diagnosis, and were called about 2.5 days later to be evaluated/interviewed separately.

About 31% of subjects received a diagnosis of no dementia, 46% received a diagnosis of very mild dementia and 23% a diagnosis of mild dementia. Depression scores didn’t change significantly before and after diagnosis for subjects or companions. The subjects who were most anxious before the diagnosis, according to the State-Trait Anxiety Inventory (STAI), experienced a decrease in anxiety afterwards (mean decline in STAI score= -12.60, p<.001), as did the companions (mean decline in STAI score = -6.44, p<.001). The article appeared in the March Journal of the American Geriatrics Society.

Past research suggests up to half of doctors don’t tell patients when they suspect the patient has dementia, for fear of worrying them, but the current study indicates these fears are unfounded in the case of patients with early-stage dementia, the authors said. Telling patients can help them plan and prepare for the future, they added. While the study only gauged patient reactions at two points in time, the researchers are continuing to monitor patients’ emotional states over the next year.

The Journal of the American Geriatrics Society is online.

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Doctor sues PBM to collect on time spent on prescription inquiries
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An Ohio physician won a court decision that he can bill a pharmacy benefit management company for the time he spends filling out prescription inquiries.

Gary Gibson, FACP, sued MEDCO Health Solutions of Columbus North, Ltd., in Trumbull County Court to collect on the time he spent filling out two or three prescription inquiries a week, each taking between six and 10 minutes to complete. He told MEDCO in December 2005 that he would bill $150 an hour to fill them out, and when MEDCO said they would not pay, he sued in 2006.

The courts decided March 6 of this year that MEDCO's prescription inquiries were designed to examine whether the prescriptions were the most economical for MEDCO, and since they were solely for MEDCO's benefit, Dr. Gibson could collect payment for his time.

A MEDCO spokeswoman told ACP InternistWeekly, "Medco is simply an administrator working on behalf of the health benefit plans used by Dr. Gibson's patients. … Because the patients belong to plans that require prior authorization for certain medications, filling out these forms should be seen as part of the services the physician provides to his patients."

The court awarded Dr. Gibson $187.50 from his original case. Dr. Gibson said, "It sounds laughable, but the significance is as big as the quantity is small. In two years' time I've had up to 200 more [requests]." He intends to submit an invoice for those as well. MEDCO has a month to appeal or pay, but has not made a decision, according to the spokeswoman.

ACP InternistWeekly has posted the court's decision online[PDF].

Tell ACP InternistWeekly what you think about the case. Take a quick poll online, or write us at acpinternist@acponline.org.

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Oncology

Cause of cancer drug allergy pinpointed
.

Researchers may have found an explanation for why some patients have severe reactions, including anaphylaxis, to the cancer drug cetuximab, according to a report in the March 13 New England Journal of Medicine.

The study was motivated by researchers’ observations of geographic differences in rates of allergies to cetuximab (which is used to treat colorectal and head and neck cancer). In Tennessee and North Carolina, 22% of patients treated with cetuximab had anaphylactic reactions, compared with less than 1% in the northeastern U.S.

In the study, the researchers collected information on 76 patients who had taken the drug, 25 of whom had a hypersensitivity reaction. A particular IgE antibody was found in pre-treatment serum samples of 17 of the 25 reacting patients, and only one of the 51 subjects who had no reaction. Control samples from other cancer patients showed wide regional differences in the prevalence of the antibodies (15 of 72 subjects in Tennessee had the IgE antibody compared with 2 of 341 in Boston).

The findings have potential implications for the use of immunotherapies in treatment of other diseases as well as cancer, study authors said. Based on the research results, they specifically suggested that it may be useful to pre-screen patients for the antibodies to cetuximab. The reasons for the regional differences are currently being investigated, and possible explanations include exposures to ticks, other parasites or infectious organisms, according to a press release from the National Institute of Allergy and Infectious Diseases, which funded the research.

The New England Journal of Medicine is online.

The press release is online.

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Estrogen-dependent breast cancer patients may benefit from extended adjuvant therapy
.

Three studies in the April 20 issue of the Journal of Clinical Oncology suggest that extended adjuvant therapy, even when given years after adjuvant tamoxifen, increases survival for hormone-sensitive breast cancer patients.

Two studies analyzed patients who participated in the National Cancer Institute of Canada Clinical Trial Group MA 17. In one study (Muss et al), researchers looked at the effectiveness of treatment with letrozole on older women. They divided the 5,169 trial participants into three age groups (younger than age 60; age 60-69; and older than age 70) and found that the use of letrozole after five years of tamoxifen therapy increased disease-free survival, regardless of age.

A second study (Goss, et al) examined participants in the same trial (all with postmenopausal hormone receptor-positive early stage breast cancer) who were treated with letrozole within three months after five years of adjuvant tamoxifen therapy. When the trial was unblinded, patients in the placebo group were offered letrozole. Goss et al found that letrozole improved disease-free survival even when patients took letrozole years after stopping tamoxifen (median 2.8 years).

A third study (Mamounas et al), was a randomized, placebo-controlled trial that evaluated exemestane as extended adjuvant therapy, following five years of tamoxifen. Postmenopausal patients were randomly assigned to five years of exemestane (25 mg/day) or placebo. After a median follow up of 30 months, researchers found that the exemestane group had a 32% reduction in disease-free survival (non-statistically significant) and a 56% statistically significant reduction in relapse-free survival.

Authors of the studies noted that aromatase inhibitors and exemestane, a steroidal aromatase inactivator, are options for extended adjuvant treatment of women with hormone-receptor-positive breast cancer. In the case of aromatase inhibitors, this extended therapy can be effective even very late in follow-up, the authors said.

The three JCO studies, Muss et al., Goss et al. and Mamounas et al. are online.

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Quality improvement

Preliminary results from PQRI released
.

Almost 100,000 health care providers--16% of those who were eligible—participated to some degree in the CMS 2007 Physician Quality Reporting Initiative, according to the March 17 issue of AMNews.

The preliminary statistics were released in a letter from a CMS official to Sen. Max Baucus. Of the 99,000 physicians and other providers who reported on at least one of the program’s 47 quality measures, about half will likely get the 1.5% bonus offered by the initiative, the article said. That number could rise, since reporting for the program just ended on Feb. 29.

Based on the measures submitted, emergency physicians, ophthalmologists and anesthesiologists were the specialties with the greatest participation, a CMS spokesperson told AMNews. Because the data was not broken down by specialty, the participation rates of internists are not known. All physicians who treat Medicare patients were eligible for the bonus if they reported on at least three measures of the initiative and applied each one to at least 80% of the patients for whom it was appropriate.

Payments from the 2007 PQRI are expected later this year. The 2008 project, which includes 119 measures, is currently ongoing. The program is expected to continue in 2009 and suggestions for additional quality measures are being accepted now, a CMS official told AMNews.

AM News is online.

PQRI information from ACP is online.

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IHI offers quality improvement guide for doctors
.

The Institute for Healthcare Improvement (IHI) is offering a Road Map for Quality Improvement: A Guide for Doctors, which presents the essentials of quality improvement that every physician needs to know, such as how to engage doctors in quality improvement initiatives. It was developed by Manoj Jain, ACP Member, as part of his work as the medical director of Tennessee's Quality Improvement Organization and his work with the IHI.

Intended as a 15-minute read for busy practitioners, topics include:

  • defining quality improvement,
  • what physicians should learn about quality improvement,
  • measurement,
  • building an improvement team,
  • testing changes and continuous quality improvement, and
  • transforming culture.

The guide, a 14-page pamphlet, can be downloaded for free from the IHI after free registration.

Hard copies can be ordered for a processing fee from Dr. Manoj's Web site.

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Prevention and follow-up

Studies on MRSA screening yield conflicting results
.

Two new studies on screening for methicillin-resistant Staphylococcus aureus (MRSA) reported different results this week, with one study finding that universal screening did not benefit infection rates and one finding that it did.

In the first study, researchers at a Swiss hospital used a crossover design to study the effects of rapid MRSA screening at admission in a cohort of 21,754 surgical patients. Patients underwent rapid screening before or at admission followed by standard infection control measures (10,844 patients) or received standard infection control measures alone (10,910 patients). The results appear in the March 12 Journal of the American Medical Association.

During the intervention periods, 515 patients (5.1%) were identified as being MRSA-positive. Nosocomial MRSA infection developed in 93 patients during the intervention periods versus 76 patients during the control periods (adjusted incidence rate ratio, 1.20 [95% CI, 0.85 to 1.69]; P= 0.29). No significant change was seen in rates of nosocomial MRSA acquisition or MRSA surgical site infection.

The authors offered several explanations for their results, including comparatively low rates of MRSA infection overall at their facility, postoperative transmission, delays in receipt of test results and inadequate use of prophylaxis. They also noted limitations in their study design, such as the inability to randomize wards to a specific intervention. However, the authors concluded that active surveillance may not be enough to reduce rates of surgical site infection and nosocomial MRSA transmission. The authors, and the accompanying editorialists, recommended that hospitals consider local MRSA infection patterns before implementing universal screening. The editorialists also pointed out that MRSA infections account for only 8% of nosocomial infections in the U.S. and stressed the importance of interventions that address all of these types of infections.

In the second study, researchers in Illinois implemented a three-year program to compare three strategies for combating MRSA: no screening, screening those admitted to the emergency departments and screening all people admitted to the hospital (universal surveillance). The study involved three hospitals with a total of 850 beds and approximately 40,000 annual admissions. Universal surveillance was associated with a reduction by more than half of nosocomial bloodstream, respiratory, urinary tract and surgical site MRSA infection occurring during the hospital stay and in the 30 days after discharge. The study was published in the March 18 Annals of Internal Medicine.

An editorial writer noted that the rapid polymerase chain reaction (PCR)-based test used in the universal screening phase of the study was not used in the first two phases and thus could skew results. Further, the PCR-based test costs about $25 to $30 compared to the $5 standard culture lab test, so screening all patients with the fast test may have an economic impact on the hospital. The writer suggested that a strategy of targeting high-risk populations for screening, such as nursing home residents, would be a more cost-effective way to confront MRSA infection. "The one-size-fits-all approach is probably not sensible for MRSA screening," he wrote.

The JAMA abstract is online.

Annals of Internal Medicine is online.

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Reminding patients about beta blockers works
.

A mailed reminder can improve patient adherence to beta blocker therapy after a myocardial infarction, according to a new study.

The randomized controlled trial included 836 post-MI patients who belonged to four health maintenance organizations between June 2004 and March 2005. Patients in the intervention group received two mailings two months apart on the importance of beta blocker use. The main outcomes of the study were the proportion of days covered with beta blocker therapy and percentage of patients with at least 80% of days covered in the nine months after the first mailing. The results were published in the March 10 Archives of Internal Medicine.

Over the follow-up period, patients in the intervention group took their medication on 4.3% more days per month than controls, which translated into 1.3 extra days of medication per month. The patients who received the mailings were also 17% more likely to have 80% of days covered. For every 16 patients who received the mailing, one additional patient adhered to treatment, the researchers concluded.

An accompanying commentary noted one possible concern--that by targeting a single medication, the effort could improve compliance with that medication but lower the use of other medications. However, because the intervention was of low cost and at least moderately effective, both the commentator and the study authors recommended that other HMOs consider adopting the strategy. Further research should investigate both the cost-effectiveness of the strategy and other potential uses of it, they said.

The article and the commentary are online.

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Low-dose aspirin may ward off asthma in women
.

A recent study found that low doses of aspirin may lower a woman's risk of asthma.

In the study, about 37,000 asthma-free women age 45 or older, participants in the Women's Health Study, were randomly assigned to receive either 100 mg of aspirin or placebo every other day. Over 10 years, 5% of the women developed asthma, translating to a 10% risk reduction for those taking aspirin. The protective effect was not lessened by age, smoking status, activity level, hormone use or vitamin E use. However, the decreased risk was not apparent in women with a BMI of 30 or more.

Researchers noted that randomized, controlled trials are needed because this observational study was not designed to assess asthma outcomes. The study was released online March 13 by the journal Thorax.

The study abstract is online.

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Annals of Internal Medicine

Growth hormone does not enhance athletic performance
.

A review of published randomized controlled trials that compared growth hormone (GH) to no-growth-hormone treatment in healthy people between 13 and 45 years of age found that lean body mass increased in people who took growth hormone but strength and exercise capacity did not. People who took GH experienced soft tissue swelling and fatigue more frequently than those who did not take GH.

Authors concluded that claims that GH enhances physical performance are not supported by the scientific literature. GH, they say, may increase lean body mass but may not improve strength and may worsen exercise capacity and increase adverse events. This paper is being released early online at the Web site of Annals of Internal Medicine and will appear in the May 20, 2008, print edition of the journal.

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Many older adults have loss of memory and thinking but not dementia
.

A new study of 856 people age 71 years and older found that 22% had some cognitive impairment that did not reach the threshold for dementia. Each year, about 8% of individuals with cognitive impairment but not dementia at baseline died and about 12% progressed to dementia. Using the 22% figure, researchers calculate that in 2002 in the U.S., 5.4 million people aged 71 and older had cognitive impairment without dementia. Previous estimates of cognitive impairment without dementia ranged from 5% to 29%.

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Colonoscopy guidelines do not predict subsequent development of advanced polyps
.

Current guidelines call for follow-up colonoscopy after polyp removal based on the number, type and size of polyps removed. For example, after removal of a polyp that is about one centimeter in size or three polyps of any size, guidelines recommend that patients have follow-up colonoscopy in three years, while those with smaller and/or fewer polyps are recommended to get a follow-up colonoscopy in five to 10 years.

An analysis of 1,905 people who had colorectal polyps removed found that this risk stratification scheme did not predict development of advanced polyps, which are considered most likely to advance to colorectal cancer. The researchers note that colonoscopy already constitutes about 34% of procedures performed in the U.S., and overuse can affect scarce health resources.

Editorial writers said the issue of follow-up colonoscopy is complicated by that fact that little is known about the natural history of the large polyp to understand which ones grow into cancer, that future guidelines should consider clinical factors such as cigarette smoking, waist circumference and insulin resistance in determining high risk screening categories, and finally, that for some patients, even a small 5% risk for developing advanced polyps is too high not to have early and frequent follow-up colonoscopies.

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Audio summary: Health care reform in Massachusetts
.

In this week's Annals audio summary, Jon Kingsdale, PhD, executive director of the Commonwealth Health Insurance Connector Authority, the Massachusetts state agency implementing health care reform, discusses progress to date and challenges ahead. The podcast, which also includes a summary of all the articles in the current issue, is available at www.annals.org or on iTunes.

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FDA news

Anemia drugs’ labels revised with details on breast, cervical cancer risks
.

New details have been added to the boxed warnings of erythropoiesis-stimulating agents about the higher risk of death and faster tumor growth for cervical and early stage breast cancer patients.

The FDA-approved warning pertains to epoetin alfa (Procrit, Epogen) and darbepoetin alfa (Aranesp), used to treat patients on chemotherapy and anemic patients with kidney failure. In clinical studies, ESAs shortened overall survival and/or time-to-tumor progression in patients with breast, non-small cell lung, head and neck, lymphoid and cervical cancers, when dosed to target a hemoglobin level of 12 g/dL or more.

FDA last updated the labels in November, but since that time the drugs’ maker, Amgen, has given FDA new study results on the drugs' risks in breast and cervical cancer patients, prompting another label revision. Amgen makes all three drugs, but Johnson and Johnson markets Procrit.

It isn’t known if the same risks exist with hemoglobin doses of less than 12 g/dL, Amgen said, so health care providers should use the lowest dose needed to avoid red blood cell transfusions. The drugs should also be used only to treat anemia caused by concomitant myelosuppressive chemotherapy, and should be discontinued after chemotherapy is completed, Amgen said in a release.

Days after the label revision was announced, an FDA panel voted to recommend the drugs be used for anemia caused by cancer treatment, but also said the drugs shouldn’t be taken by patients with head and neck or breast cancer, and shouldn’t be given to patients with cancer that is thought to be curable, the March 14 Los Angeles Times reported. It isn’t known when the FDA will issues a final decision on those recommendations.

The Amgen release is online.

The FDA’s November advisory on ESAs is online.

The Los Angeles Times is online.

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FDA issues alert on appropriate use of Tussionex cough medicine
.

The FDA issued an alert last week on the proper use of Tussionex Pennkinetic Extended-Release Suspension after reports of death and serious side effects from using the cough medicine incorrectly.

The prescription medicine, which contains hydrocodone and chlorpheniramine, should be used only in adults and children over age six, and no more frequently than every 12 hours. Some healthcare providers have prescribed more than the recommended dose, and some patients have taken the medication too frequently, the FDA said. Providers have also prescribed Tussionex for patients less than six years old, and some have died, the FDA said.

Providers should be sure to discuss the correct use of Tussionex with patients, and warn them of the dangers of taking the medication incorrectly. Patients should call a doctor if they take Tussionex and have trouble breathing, slow heartbeat, severe sleepiness or cold, clammy skin. The FDA alert doesn’t apply to short-acting cough products that contain hydrocodone and are given every 4 to 6 hours, though the agency is reviewing these.

The FDA release is online.

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Cartoon caption contest

Put words in our mouth
.

ACP InternistWeekly's cartoon caption contest continues. ACP staff has selected three finalists for the latest contest and is now asking readers to vote for their favorite caption to determine the winner.

Go online to view the cartoon and then pick the winner, who receives a $50 gift certificate good toward any ACP product, program or service.

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From the College

Next LEAD challenge online
.

The next online leadership challenge for LEAD, ACP’s Leadership Enhancement and Development Program, is now available. For the challenge, “A competent physician has a bias against prescribing narcotics,” participants will step into the role of practice director and use their leadership skills to develop a strategy for coaching a competent but narcotics-averse physician. Participants will also explore the way this physician’s attitude might affect patient satisfaction and the perception of clinical competence.

LEAD was created for members looking to develop their leadership skills and offers an online discussion group for members to discuss a variety of challenges with experienced ACP leaders. Ongoing challenges will be announced every two weeks in Internist Weekly. The CME portion of the LEAD program officially debuts at Internal Medicine 2008 with the pre-course, “Essential Competencies for the Emerging Leader,” on May 14. In addition to the pre-course, other courses offered at IM 2008 will count toward the LEAD Certificate of Completion. Registration for the LEAD pre-course is offered with other IM 2008 courses online.

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Call for fall 2008 Board of Governors resolutions
.

The deadline for members to submit new resolutions to their respective Governors for hearing at the September 2008 Board of Governors Meeting is May 19. Initiating a resolution provides ACP members an opportunity to focus attention at the ACP national level on a particular issue or topic that concerns them. A resolution becomes a resolution of the chapter once the chapter council approves it.

In accordance with the ACP Board of Governors Resolutions Process, resolutions should clearly distinguish the action requested within its resolved clause(s) as either a policy resolve (“Resolved that ACP policy…”), or a directive, which requests action/study on an issue (“Resolved that the Board of Regents…”). If more than one action is proposed, each should have its own resolved clause. Please contact your Governor if you have any questions regarding the resolution format. Contact information for Governors is available on their chapter web sites.

The Board of Governors votes on new resolutions which are then presented to the Board of Regents for action. Once the Board of Regents votes on these recommendations, resolutions are adopted as policy, accepted as reaffirmation of current policy, or forwarded to College staff and/or committees for study or implementation.

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Deadline for "Internists as Artists" program extended
.

Entries for the ACP's national "Internists as Artists" program at Internal Medicine 2008 are now being accepted. The deadline for entry application forms has been extended to March 31.

Designed to showcase physicians' talents in the visual arts, the "Internists as Artists" exhibit will be located in the Exhibit Hall of the Walter E. Washington Convention Center in Washington, DC during Internal Medicine 2008. Submissions can include painting, sculpture, photography, mixed media, woodworking, jewelry, crafts and ceramics.

Members interested in submitting entries must complete an application form and send it along with either a photograph or an electronic image of their artwork. (Member artists may submit a maximum of two entries.) Entries will judged by program jury members, and each piece must be completely display-ready when it is submitted for consideration in the exhibit.

"Internists as Artists" is modeled on an Evergreen Award winning event established by ACP's Virginia Chapter. Completed application forms and electronic or photographic images should be sent to: Helen Canavan, ACP Internists as Artists Program, 190 N. Independence Mall West, Philadelphia, PA 19106-1572. Ms. Canavan can also be reached at hcanavan@acponline.org or 800-523-1546, ext. 2663.

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