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

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In the News
for the Week of 3-25-08

Highlights

  • Match Day 2008 breaks records but doesn’t help IM
  • Heparin contaminant found to be modified chondroitin
  • Quality of life after prostate cancer treatment varies by type of treatment

Oncology

  • Alternate radiation regime works as well in breast cancer
  • New generic, customizable chemotherapy plan available

Cardiology

  • FDA encourages on-label use for stent for AAA
  • Cardiovascular drug use improves mortality after MI
  • Angina more common among women than men, study finds

ACP Journal Club

  • Low and conventional intensity oral coagulation did not differ for patients with mechanical heart valve replacements

FDA actions

  • Data analysis suggests potential stroke risk with tiotropium

Cartoon caption contest

News for hospitalists

  • Latest issue of ACP Hospitalist is online and in your mailbox

From the College

  • ACP supports legislation to provide assistance to Medicaid programs
  • ACP policy paper calls for protection against genetic discrimination
  • UHF and Pfizer join list of ACP collaborators for patient-centered medical home

Highlights

Match Day 2008 breaks records but doesn’t help IM
.

A record-high number of medical students matched with a residency of their choice last week, but internal medicine saw a decline in the number of U.S. students filling residency programs, according to results released by the National Resident Matching Program.

While the overall number of students matching in internal medicine increased from 4,720 in 2007 to 4,751 this year, the number of slots filled by U.S. medical graduates decreased from 2,680 to 2,660. Overall, internal medicine saw a slight decline in the percentage of slots filled, from 98.4% last year to 97.8%.

"If this trend continues, a shortage of general internists and other primary care physicians will likely develop more rapidly than many now anticipate. Since the education and training of new physicians takes a number of years, this problem must be addressed now to assure access to care and to prevent a crisis in the future," said Steven E. Weinberger, FACP, ACP Senior Vice President for Medical Education and Publishing.

The match as a whole was the largest ever, with 28,737 applicants, including 15,242 U.S. grads, vying for 22,240 first-year residency positions. Of the U.S. applicants, 94.2% successfully matched and 84.6% got one of their top three program choices. Notable increases this year were seen in the number of international and osteopathic applicants.

Family medicine residencies saw increases in both the number of slots and the percentage filled for the first time in several years. This year, 1,156 (7.6%) of U.S. medical seniors matched in family medicine compared with 7.2% last year. Continuing recent trends, plastic surgery, orthopedic surgery, dermatology, otolaryngology, diagnostic radiology, radiation oncology and general surgery proved to be popular specialties among U.S. medical graduates.

A press release and data from the National Resident Matching Program is online.

An ACP statement on the Match is online.

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Heparin contaminant found to be modified chondroitin
.

The FDA has found that the contaminant in recalled heparin from China was an altered form of chondroitin sulfate, according to several news reports.

The agency is still investigating whether the chemically modified compound was mixed with heparin by mistake, or was used deliberately to cut costs, the March 20 Washington Post reported. The compound comprised as much as 20% of the active ingredient in the recalled heparin. The FDA has gotten reports of at least 785 serious injuries and 19 deaths that appear connected with the product, but hasn’t conclusively proven the contaminant is the cause.

The FDA has ordered all imported heparin and its active ingredients be tested at the border, the March 14 Washington Post said. It also got approval last week to establish eight permanent positions at U.S. diplomatic posts in China, pending authorization from China’s government, and five Chinese staff to help with inspections. Most of the world’s heparin supply originates in China, as do many other pharmaceutical ingredients distributed worldwide, and there is growing concern that the FDA doesn’t have the resources to adequately inspect products, devices and facilities from foreign countries.

Baxter Corp., which typically supplies half of the nation’s heparin, began recalling lots of heparin products in November on reports of serious allergic reactions in patients. The company has now recalled all products and stopped production.

The March 20 and March 14 Washington Post is online.

The FDA release is online.

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Quality of life after prostate cancer treatment varies by type of treatment
.

A recent study that examined patients' quality of life following treatment for prostate cancer found that outcomes vary according to patients' treatment choices.

In the study, researchers followed 1,201 patients and 625 spouses or partners for a median of 30 months after undergoing radical prostatectomy, brachytherapy, or external-beam radiotherapy. Quality outcomes were measured based on urinary, sexual, bowel and hormonal function. The study appears in the March 20 New England Journal of Medicine.

Among other findings, researchers reported that patients who underwent brachytherapy and radiotherapy followed by adjuvant hormone therapy experienced worse outcomes across multiple quality-of-life areas. The study is limited because patients selected their own treatments instead of being randomized, said the authors, so the findings can only be used to examine outcomes within groups, not to compare the different treatments.

Other findings included:

  • Brachytherapy was associated with long-lasting urinary irritation, bowel and sexual symptoms
  • Brachytherapy patients reported problems with vitality or hormonal function
  • Nerve-sparing surgical procedures mitigated the effects of prostatectomy on sexual function
  • Urinary incontinence was observed after prostatectomy, but urinary irritation and obstruction improved, especially in patients with large prostates
  • Adverse effects of treatment were exacerbated by obesity, large prostate size, high prostate-specific antigen score, and older age
  • Black patients were less satisfied with overall treatment outcomes, despite receiving care at similar quality institutions as other patients.

The study abstract is online.

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Oncology

Alternate radiation regime works as well in breast cancer
.

Fewer, larger doses of radiation prevent breast cancer relapse as well as the dosages that are the international standard, found a new British study of more than 4,000 women.

The randomized, controlled Standardization of Breast Radiotherapy Trial included two components—START A and START B. In both trials, women with early stage breast cancer were assigned to receive either conventional doses of radiotherapy or fewer fractions of radiation with a higher dose per fraction.

In the START B trial, the intervention group also received their doses over a shorter period of time (three weeks vs. five weeks), while both START A groups were treated for five weeks. The results of both studies were very similar outcomes for patients whether they received the standard dose or the different fractionation regimes. In START A, relapse rates were almost identical after five years of followup and in START B, the intervention group had a 3.3% relapse rate compared with 2.2% in controls after six years.

The results confirm previous research conducted in the U.S., an expert told the March 19 Washington Post. He noted that the new regime with fewer doses can be more convenient for some patients, especially those who live far from cancer centers.

A comment that accompanied the START B trial in the April issue of The Lancet expressed some concerns about the long-term effects of the larger doses. Previous studies have found that increasing the dose per fraction in radiotherapy increases tissue damage, he noted. He suggested that longer followup is needed to determine whether the hypofractionation would lead to more severe late side effects, including congestive heart failure.

Both the commentator and the study authors agreed that longer follow up is needed to determine which patients might benefit from special fractionation plans in the future. The START A trial was published early online and will appear in an upcoming issue of The Lancet Oncology.

The START B trial is online.

The START A trial is online.

The comment is online.

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New generic, customizable chemotherapy plan available
.

The American Society of Clinical Oncology (ASCO) last week released a new chemotherapy treatment plan and summary template that can be customized for almost any cancer diagnosis.

The new tools should help improve documentation and coordination of treatment, particularly in the transition from active treatment to post-treatment care, ASCO officials said. The generic template should be useful to community oncology practices that see patients with a variety of diagnoses.

The new generic cancer treatment plan and summary template joins breast and colorectal cancer treatment templates, which have been available from ASCO since 2007. The organization is continuing to develop and test treatment plans and summaries for additional cancer diagnoses, including several lung cancer templates that will be available this summer, a press release said.

Some of the core elements of all of the treatment plans and summaries include:

  • the patient's diagnosis, including the cancer site, histology and stage
  • a summary of the chemotherapy and other treatment that is planned and actually delivered
  • the reason treatment was stopped or modified, if relevant
  • information on appropriate follow-up care and relevant providers
  • information on evidence-based survivorship and surveillance guidelines from ASCO

The oncologist should complete the chemotherapy treatment plan before the patient begins receiving chemotherapy, to map out the patient's planned treatment. After treatment is complete, the treatment summary will describe what care the patient actually received. The patient can keep these documents and share them with the doctors and other medical professionals who provide their follow-up care.

The treatment plans and summaries are online.

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Cardiology

FDA encourages on-label use of stent for AAA
.

The FDA strongly encouraged following product labels and conducting patient follow-up for Medtronic's AneuRx stent, citing factors that could increase late mortality rates for abdominal aortic aneurysm (AAA).

In a public health notification, the FDA released data suggesting that aneurysm-related mortality continues to increase three years after implantation, reaching 1.3% by year 4 and 1.5% by year 5. Those rates are substantially higher than the mortality rate for open surgical repair, which averages 0.18% per year with a range of 0% to 0.3% per year, the FDA said.

Mortality factors include:

  • long-term AAA-related mortality, especially due to AAA rupture,
  • physician or institutional experience,
  • surgical risk factors for the individual patient, and
  • the patient’s willingness to comply with the follow-up schedule.

In a letter to physicians, Medtronic said that the FDA's late aneurysm-related mortality data was based on a total of 13 deaths in years 4 and 5 out of 931 total patients. Eight of the late deaths were in patients 80 years or older when they were initially treated and several of the late deaths were in patients who either missed follow-up or refused secondary treatment.

The letter continued that the FDA's public health notice focused on late mortality, while results from the UK EVAR-I trial results published in 2005 showed better short-term benefits of endovascular repair compared to open surgical repair, which were sustained out to four years.

The FDA notice is online.

Associated Press coverage is available online.

Top

Cardiovascular drug use improves mortality after MI
.

Improvement in long-term mortality among elderly patients with myocardial infarction (MI) may be due to increased cardiovascular drug use, according to a study.

Using data from Medicare and pharmacy programs in Pennsylvania and New Jersey, researchers compared mortality trends and cardiovascular drug use after MI in multivariate models. They identified patients with MI who survived 30 days after discharge and recorded filled prescriptions for statins, beta blockers, angiotensin-converting enzyme inhibitors/angiotensin-II receptor blockers, or antiplatelet agents within 30 days after discharge.

Among 21,484 MI patients who survived 30 days after discharge, mortality decreased significantly, with a 3% reduction in each year (1995 to 2004) (HR for annual trend 0.97; 95% CI 0.97 to 0.98). Adjusting for the use of drugs after discharge completely eliminated the association between time trend and mortality (HR 1.00; 95% CI 0.99 to 1.01). The results appear in the April 1 Journal of the American College of Cardiology.

Significant challenges remain in translating evidence-based medicine into clinical practice, a paradox that particularly affects the elderly, according to an accompanying editorial. "This should motivate clinicians to avoid the 'treatment-risk paradox' and to apply evidence-based preventive interventions as readily and intensively in high-risk elderly CHD [coronary heart disease] patients as in younger CHD patients at lower risk."

The Journal of the American College of Cardiology is online.

Top

Angina more common among women than men, study finds
.

A recent meta-analysis found that stable angina is 20% more common among women than men, challenging the long-held assumption that being male is a risk factor for developing angina.

In the review, published in the March 25 Circulation: Journal of the American Heart Association (AHA), researchers analyzed 74 studies from 31 countries that included a total of more than 400,000 patients; of those, 13,331 women and 11,511 men had stable angina. Researchers found that angina prevalence was slightly higher among women compared with men across all countries and over four decades. Overall, angina prevalence ranged from 0.73% to 14.4% (population weighted mean 6.7%) among women in the studies compared with a range of 0.76% to 15.1% (weighted mean 5.7%) in men.

The gender difference persisted despite varying heart disease risk factors, such as smoking, across countries. In addition, pre- and postmenopausal women had statistically similar higher rates of stable angina, said a March 17 AHA news release.

A study author noted that physicians should not assume that narrowing of the large arteries is the only underlying cause of angina. Compared with men, women develop angina more often in the small vessels of the heart, he said, so a woman with typical angina symptoms may still have myocardial ischemia despite no narrowing of the large arteries.

More large epidemiologic studies involving thousands of stable angina patients are needed to investigate the causes and consequences of angina and how they differ between the sexes, said the AHA release.

The Circulation abstract is online.

The AHA news release is online.

Top

ACP Journal Club

Low and conventional intensity oral coagulation did not differ for patients with mechanical heart valve replacements
.

A new study of patients with mechanical heart valve protheses found that oral anticoagulation, comparing targets of low- or conventional-intensity international normalized ratio (INR), did not differ for thromboembolic events or adverse effects.

The randomized controlled trial included 2,673 German adults with mechanical aortic, mitral, tricuspid or double heart-valve replacements. Patients were assigned to either low intensity INR targets (1.8 to 2.8 for aortic valves and 2.5 to 3.5 for mitral or double valves) or conventional target INRs of 2.5 to 4.5. All of the patients were trained in INR self-management and checked INR values weekly during the first year and biweekly during the second year of the two-year study. The patients were assessed at six-month intervals, and researchers found that the groups did not differ for thromboembolic events, bleeding, or mortality over the course of the study.

Clinicians should exercise caution in drawing conclusions on the efficacy and safety of low-intensity versus conventional-intensity anticoagulation based on this study, said Journal Club reviewer Sebastian M. Schellong, MD, of the University Hospital Carl Gustav Carus in Germany. No null-hypothesis or sample size calculations were provided comparing the intervention group with the control group.

Overall, the study supports the growing body of evidence that INR self-management (including training, self-adjustment of INR, and close clinical follow-up) is an appropriate approach among those patients who are willing and able to perform it, Dr. Schellong concluded. The trial is abstracted in the March/April ACP Journal Club.

Peer ratings for this review: Internal medicine: 7/7 stars. Primary care, Hematology, Cardiology: 6/7 stars.

ACP Journal Club is online.

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FDA actions

Data analysis suggests potential stroke risk with tiotropium
.

Tiotropium (brand name Spiriva) may increase the risk of stroke, the FDA said last week.

An analysis of safety data from 29 placebo-controlled trials showed an estimated excess risk of stroke with tiotropium in 2 out of every 1,000 patients, compared to placebo, manufacturer Boehringer Ingelheim Pharmaceutical reported to the FDA. The drug is used to treat bronchospasm associated with chronic obstructive pulmonary disease.

The FDA urged caution in interpreting the results, noting they were preliminary and hadn’t been confirmed by the agency. Data from a large four-year study on tiotropium—conducted by Boehringer Ingelheim-- is expected to be available in June, the agency said.

The FDA safety alert is online.

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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 was submitted by three people, so each will share in the prize.

Paul D. Wentland, ACP Member, a consultant for Unum, an employee benefits provider, in Chattanooga, Tenn.

Scott Lauter, ACP Member, the managing director of Medical Associates of Lancaster in Lancaster, Pa.

Bharat Khandheria, FACP, an associate professor of internal medicine of the Texas Tech University Health Sciences Center in Amarillo.

They'll each receive a gift certificate good for any ACP product, program or service.

ACP InternistWeekly readers cast 239 ballots online to choose the winning entry. Thanks to all who voted!

The winning entry:

Do we take Aflac?
"Do we take Aflac?"

The winning caption received 49.8% of the votes cast. The two runners up were:

"He wants to know if you'll see him pro bono; he already has a large bill." (35.6%)
"The next patient appears to be suffering from avian flu." (14.6%)

Top

News for hospitalists

Latest issue of ACP Hospitalist now available online and in your mailbox
.

The March issue of ACP Hospitalist addresses the latest trend in patient-centered care, developments in the field of bariatric surgery and launches a new department, Success Stories. Go online to www.acphospitalist.org for the latest stories on:

Cultural competency. The Joint Commission and other groups encourage physician's knowledge of their increasingly diverse patient populations, and training has become the norm at many institutions.

Bariatric surgery. The number of gastric bypass operations increased nearly tenfold between 1998 and 2004.With obesity rates also rising, hospitalists can expect more perioperative care for these patients.

Success Story. Crouse Hospital in Syracuse, N.Y. created a dedicated unit for methicillin-resistant Staphylococcus aureus, reducing the average stay from 30 days to 12 while saving more than $1 million.

For a free subscription to ACP Hospitalist or ACP HospitalistWeekly, contact ACP Customer Service at 800-523-1546 or 215-351-2600 (9 a.m. to 5 p.m. ET) or send an e-mail to custserv@acponline.org.

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From the College

ACP supports legislation to provide assistance to Medicaid programs
.

ACP recently commended congressional legislators on legislation introduced that would provide temporary assistance from the federal government to state Medicaid programs. The bill, HR 5268, would temporary increase the Federal Medical Assistance Percentage (FMAP) to states by 2.95%.

“During this time of economic downturn, ACP believes it is imperative to help preserve the safety net function of state and federally funded health care programs,” said David C. Dale, FACP, president of ACP. “Without this temporary increase, many states might be forced to limit enrollment or cut physician reimbursement rates; thereby reducing access to health care for many vulnerable citizens.”

The FMAP is the portion of each state’s Medicaid budget that is paid by the federal government. It is designed to account for differences in state economies, and uses a formula to pay a higher rate to states with lower per capita incomes. The newly introduced legislation from Representatives Frank Pallone, Jr. (D-NJ) and Peter King (R-NY) would increase that rate from April 1, 2008 through June 30, 2009.

“The College believes the Medicaid program is integral to shrinking the numbers of uninsured,” concluded Dr. Dale. “In fact, we support expansion of Medicaid to allow more eligible individuals to enroll.”

ACP’s letter in support of the legislation is available online[PDF].

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ACP policy paper calls for protection against genetic discrimination
.

ACP has released a new policy paper that highlighted the need for federal government protections against genetic discrimination in employment and insurance practices.

The U.S. is moving into an era of genetics and genomics—as evidenced by the ever-increasing number of clinically available genetic tests and advances in pharmacogenetics. As the availability of genetic tests increases, so does fear in the general public that employers and health insurers may use an individual’s genetic test results to limit or deny access to employment or health insurance.

“While they’re not quite there, Congress does continue to move closer to passing federal legislation that protects the use of genetic information in employment and insurance coverage decisions,” noted David C. Dale, FACP president ACP. “This monograph is important for the ongoing discussion.”

The ACP paper lays out six positions that the College feels need to be included in any federal protections that are adopted. The positions include:

  • Insurance providers should be prohibited from using genetic information to deny or limit health coverage or establish eligibility, enrollment, or premium contribution requirements.
  • Insurance providers should be prohibited from establishing differential premiums based on genetic information.
  • Employers should be prohibited from using genetic information in employment decisions.
  • Insurers and employers should be prohibited from requiring individuals and families to undergo genetic testing.
  • Insurers and employers should be prohibited from collecting and/or disclosing an individual or family’s genetic information.
  • Congress should establish comprehensive and uniform federal protection against genetic discrimination that closes the gaps in protection due to varying state laws.

The paper is available online[PDF].

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UHF and Pfizer join list of ACP collaborators for patient-centered medical home
.

The United Health Foundation (UHF) and Pfizer have awarded grants to ACP for the development of tools to support internal medicine practice changes around the patient-centered medical home model of care.

UHF and Pfizer join a growing number of employers, organizations and consumers who have collaborated with ACP to fund and test the model, including The Commonwealth Fund, United Health Group, the American Academy of Family Physicians, the American Academy of Pediatrics, IBM, General Motors, Exelon, ERISA Industry Committee, the National Business Group on Health and AARP. The model of care also continues to gain momentum on a national level—Congress has committed to testing a pilot and a number of states including Washington, North Carolina, West Virginia, Louisiana and Missouri actively reference it in their health care efforts.

The patient-centered medical home is a conceptual model of care in which a personal physician leads a team of health care professionals at the practice level who collectively take responsibility for the treatment and management of care for the whole patient. It incorporates health information technology, the coordination of specialty and inpatient care, preventive services, behavioral health services and patient education.

The UHF and Pfizer grants, in addition to a grant awarded to ACP by the Commonwealth Fund in late 2007, will help ACP continue the design and implementation of practice-based resources for internists and their office teams. ACP Executive Vice President and Chief Executive Officer John Tooker, FACP, said the grants are an indication of how the model of care could be here to stay. “The patient-centered medical home, in coordination with the other components of the health care delivery system, is the future of health care,” he said.

More information on the patient-centered medical home is online.

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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.

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