In the News
for the Week of 5-13-08
- Stay up-to-date with live coverage from Internal Medicine 2008
- B vitamin supplements fail to lower women's cardiovascular risk, study finds
- New study projects shortage of primary care physicians
- USPHS issues revised tobacco dependence guideline
- Neurologists offer guidelines on Botox
- Pain society's low-back guideline covers interventions
- Obesity, inflammation and heart failure may be linked
- Obesity may increase risk of dementia, Alzheimer’s
- Episodes of fainting after vaccination increase
Tools and surveys
- Survey assesses confusion over drug-name suffixes
- Site offers prescription assistance to patients, providers
- Have you been selected to participate in the Physician Practice Information survey?
- ACP Foundation releases new HEALTH TiPS
- Medicare cuts will hurt small practices, ACP President tells Congress
Cartoon caption contest
- Put words in our mouth: vote for your favorite entry
Stay up-to-date with live coverage from Internal Medicine 2008
ACP Internist is providing live online coverage of Internal Medicine 2008. Those attending the meeting can read about upcoming sessions and get recaps of previous sessions they may have missed through our onsite daily newspaper, Internal Medicine 2008 News. For those not attending, our Web site will be updated throughout the day with a synopsis of news and events from the meeting. Also, visit our blog where you can read our staff postings and add your own comments..
B vitamin supplements fail to lower women's cardiovascular risk, study finds
Folic acid and B vitamin supplements have no impact on lowering risk in women at high risk for cardiovascular disease (CVD), according to a recent large study.
In the study, 5,442 female health professionals age 42 and older with CVD or at high risk for the disease were randomized to receive either a combination pill containing 2.5 mg folic acid, 50 mg vitamin B6 and 1 mg vitamin B12, or placebo, for 7.3 years. Despite an overall 18.5% decrease in homocysteine levels, at the end of the follow-up period the vitamin group had no significant difference in myocardial infarction, stroke, coronary revascularization, or CVD mortality than the placebo group. The study appears in the May 8 Journal of the American Medical Association.
While past studies have shown an association between lowering homocysteine levels and cardiovascular risk, this trial has several unique strengths, said an accompanying editorial. It is the largest study to date, the first to focus on women and the first to include women without prior vascular events.
In this trial, the B vitamin supplements may have lowered homocysteine levels less than expected because the U.S. already mandates the addition of folic acid to certain foods, said the editorial. Ongoing research may provide more evidence about whether B vitamin supplements should play a role in CVD prevention.
Based on the current evidence, however, B vitamin supplements should not be recommended for CVD prevention and there is no basis for routinely screening for elevated homocysteine levels, the editorial concluded..
New study projects shortage of primary care physicians
A new study published in Health Affairs predicts an impending shortage of primary care physicians.
The study, by researchers from the University of Missouri-Columbia and the U.S. Department of Health and Human Services, says that by 2025 the U.S. will be short 35,000 to 44,000 adult care physicians practicing general internal medicine and family medicine.
The authors used data from the National Ambulatory Medical Care Survey to project the demand for care by generalist physicians. They determined that the number of ambulatory care visits for adults would increase by 29% between 2005 and 2025. At the same time the number of physicians graduating from generalist residency programs has been declining.
“The demand for primary care is increasing because of a growing and aging population. At the same time, fewer physicians are becoming generalists, and more are opting for more lucrative and less demanding careers as specialists. If we don’t take steps to rectify this imbalance, the result will be an increasingly stressed and poorly coordinated medical system,” said lead author Jack Colwill, MD, a professor emeritus of family and community medicine at University of Missouri-Columbia.
The study notes that a medical home model of care may make generalist practice more attractive to physicians frustrated by the strains placed on primary care medicine. However, it also notes that “reimbursement reform is essential to realign incentives for primary care teams to provide more comprehensive care.”
USPHS issues revised tobacco dependence guideline
The U.S. Public Health Service released an updated clinical practice guideline for treating tobacco use and dependence—the first update since 2000.
Eight federal agencies and nonprofit groups crafted the guidelines after a review and analysis of research on 11 topics, including quit lines, medications and interventions for different demographic populations. The overarching message is that providers should strongly encourage patients who smoke to use counseling or medication, and that health insurers and purchasers should help providers make treatments available.
Key points include:
- Individual, group and phone counseling are effective. The more intense the treatment, the more effective it is. Problem solving, skills training and social support are especially effective aspects of counseling.
- Unless contraindicated, providers should encourage patients to use medications that have been proven to help smokers quit. These include nicotine patches, gum, inhalers, lozenges and nasal spray; varenicline (Chantix); and bupropion SR (Zyban). Certain combinations of medications also can work.
- Providers should encourage patients to use both counseling and medication, as the combination is more effective than either treatment alone.
- Providers should promote and help patients gain access to telephone quit lines, which are effective for all populations.
Also available is a guide for physicians on tactics to use when encouraging patients to quit smoking. Recommendations include:
- Implementing a system so every patient is asked about tobacco use, and the answer is recorded;
- Advising all patients who smoke to quit and assessing their readiness to do so;
- For those willing, helping to devise a quit plan that includes picking a quit date, anticipating challenges, identifying reasons to quit, and providing Web/hotline resources;
- Scheduling follow-up visits to check progress, and encouraging another quit attempt if relapse occurs.
The clinical practice guideline, the guide for clinicians, and patient support materials are online.
The Journal of the American Medical Association commentary on the guidelines is online.
PIER’s module on smoking cessation is online..
Neurologists offer guidelines on Botox
Botulinum toxin is a safe and effective treatment for a number of neurological disorders, but not for headaches, according to new guidelines from the American Academy of Neurology.
In developing the guidelines, the authors systematically reviewed all available research on the use of the toxin for spasticity, movement disorders, autonomic disorders and pain. They found it to be effective for excessive sweating of armpits and hands, cervical dystonia, spasticity and other forms of muscle overactivity related to upper motor neuron syndrome. The drug can also be used for hemifacial spasm, blepharospasm, some voice disorders, focal limb dystonias, essential tremor and some forms of spastic bladder disorders, according to the guidelines.
However, the review of the data indicated that botulinum toxin injections should not be used to treat episodic migraine or chronic tension-type headaches, the guidelines recommended. It works no better than a placebo for those types of headaches, said a guideline author.
The authors found one small study in which botulinum toxin appeared to be effective in relieving low-back pain. Based on that research, they said that the drug may be considered as a treatment option, but that further comparison of the toxin to alternate treatments is needed. The guidelines also were endorsed by the American Academy of Physical Medicine and Rehabilitation and were published in the May 6 issue of Neurology.
A press release on the guidelines is online..
Pain society's new low-back guideline covers interventions
The American Pain Society expanded its diagnosis and treatment guidelines for chronic low-back pain to include recommendations on surgery and other interventional treatments.
The second part of the APS guideline is based on a multidisciplinary panel's review and analysis of diagnosis and treatment of low-back pain with a number of interventional procedures and surgeries.
Low-back pain is the fifth most common reason for doctor's office visits. One in four adults report having it last a least a day. Annually, low-back pain is estimated to account for more than $26 billion in direct health care costs in the U.S.
Researchers reported at the society’s symposium last week that the evidence from randomized, controlled trials for many interventional procedures is mixed, sparse, not available or showed no benefits. The new APS guideline reports that:
- Invasive diagnostics, such as provocative discography, facet joint block and sacroliliac joint block tests have not been proven to accurately diagnose various spinal conditions. Their ability to effectively guide therapeutic choices and improve ultimate patient outcomes is uncertain.
- Epidural stenosis injections are an option for short-term pain relief for persistent radiculopathy. Other interventional therapies, such as local injections, prolotherapy, botulinum toxin injection, facet joint injection, sacroliliac joint injection, radiofrequency denervation and intradiscal electrothermal therapy, are not supported by convincing, consistent evidence of benefits from randomized trials.
- Surgery to treat radiculopathy and spinal stenosis is effective, though the benefits diminish over time.
- Effectiveness of surgery for non-radicular low back pain is less certain, with some studies showing no benefits compared with intensive interdisciplinary rehabilitation. And, a significant proportion of patients experience suboptimal outcomes, including persistent pain or functional deficits following surgery.
Researchers reaffirmed at the symposium their previous recommendation that all low-back pain patients stay active, talk honestly with their physicians about self-care and other interventions, and try non-invasive therapies supported by evidence before considering interventional therapies or surgery.
The second part of the guidelines is scheduled for a fall release in the journal Spine. The original diagnosis guidelines were released in the Oct. 2, 2007 Annals of Internal Medicine.
The American Pain Society is online.
PIER’s module on low-back pain is online.
Obesity, inflammation and heart failure may be linked
Obesity may increase the risk of congestive heart failure through the effects of inflammatory proteins, according to a new study.
The community-based cohort study included more than 6,000 men and women between 45 and 84 years old who were of white, black, Hispanic or Chinese descent. The Multi-Ethnic Study of Atherosclerosis followed the participants, all of whom had no history of symptomatic cardiovascular disease, for a median of four years. A total of 79 participants developed congestive heart failure (CHF) during follow-up and 44% of those patients were obese.
Using multivariable analysis, the researchers determined that higher levels of serum interleukin-6, C-reactive protein and macroalbuminuria were all predictors of CHF, independent of obesity and other established risk factors. In fact, the researchers found that although obesity was significantly associated with CHF, the association was no longer significant when inflammatory markers were added to the model. The study was published in the May 6 issue of the Journal of the American College of Cardiology.
The researchers concluded that inflammation may be the chemical route by which obesity affects the heart and that the association of obesity and CHF may be related to pathophysiologic pathways associated with inflammation. The authors noted that this finding would be particularly significant for obese patients with metabolic syndrome.
The study is the first wide-scale evidence linking obesity to prolonged inflammation of heart tissue, according to a press release about the study. To apply the study’s findings to practice, the authors recommended that physicians monitor their obese patients for early signs of inflammation in the heart and use the information in determining how aggressively to treat.
The study is online.
The press release is online..
Obesity may increase risk of dementia, Alzheimer’s
Obesity moderately increases one’s risk of developing dementia, a new study suggests.
Researchers conducted a review and meta-analysis of 10 cohort studies of adults aged 40-80 years at baseline, with end points of dementia and its subtypes, and body fat measures including body mass index (BMI) and waist circumference.
There was a significant U-shaped association between BMI and dementia (P= 0.03) with dementia risk increased for the obese and underweight. Compared with normal weight patients, the risk of incident dementia for patients who were underweight, overweight and obese was 36%, 9% and 42%, respectively. Obese patients had an 80% higher risk of incident Alzheimer’s disease, and a 73% higher risk of vascular dementia; the risk was stronger in studies with a follow-up of more than 10 years, and with a baseline age of patients under 60 years.
Weight gain and high waist circumference or skin-fold thickness increased the risks of dementia in all included studies. Preventing or treating obesity at a young age could play a large role in reducing the number of dementia and Alzheimer’s patients in the future, one study author said in a news release. Future studies are needed to determine the optimal weight and biological mechanisms associated with obesity and dementia, another author added.
The Obesity Reviews study is online.
The Johns Hopkins Bloomberg School of Public Health news release is online.
Episodes of fainting after vaccination increase
The number of adolescents who faint after receiving vaccines has increased during the past few years, according to the CDC's latest Morbidity and Mortality Weekly Report.
Physicians should strongly consider the preventive recommendations published by the Advisory Committee on Immunization Practice and the American Academy Pediatrics, the MMWR said. The recommendations suggest that vaccine providers observe patients for 15 minutes after vaccination and be aware of presyncopal manifestations. The relative rapid onset of syncope after vaccination suggests that having vaccine recipients sit or lie down for 15 minutes after vaccination could prevent many syncopal episodes and secondary injuries, the recommendations say.
The Vaccine Adverse Event Reporting System, a passive surveillance system operated jointly by the FDA and CDC, received 463 reports of postvaccination syncope in people 5 years and older between Jan. 1, 2005 and July 31, 2007. During 2002-04, the system received only 203 reports.
However, the number of vaccinations provided also increased during that time, due to new approvals of the HPV vaccine, the quadrivalent meningococcal conjugate vaccine and the Tdap vaccine. The rate of reported syncope per vaccine doses distributed were: 0.30 reports per million doses in 2002, 0.35 in 2003, 0.28 in 2004, 0.31 in 2005, and 0.54 in 2006.
More than 63% of the reports in 2005-07 involved one of the new adolescent vaccines. The biggest increase in fainting was seen among females age 11-18 years, and almost 70% of the incidents occurred within 15 minutes of vaccination. Although only 7% of the reports were classified as serious, one fatality was reported.
The MMWR is online.
Tools and surveys.
Survey assesses confusion over drug-name suffixes
The National Coordinating Council for Medication Error Reporting and Prevention is asking for ACP members’ input on using suffixes in drug names. The anonymous, 10-minute survey will assess their current use, problems that may arise from their use and how those situations are handled.
The current practice of naming drug products within the same product line, such as those with different strengths or formulations, is to add a suffix to the existing name rather than an entirely different one. Suffixes may be a letter, number, word, or combination of letters and/or numbers attached to the end of a proprietary drug name. They can range from one to four character strings of numbers or letters than don't spell anything, or can be a word or a word part that describes the package, a package characteristic or a product characteristic.
The survey is online..
Site offers prescription assistance to patients, providers
A new Web site offers prescription assistance programs for more than 1,000 drugs to patients and their caregivers, doctors or hospitals. Published by Johnson & Johnson Health Care Systems, the site combines information about the company’s own patient assistance program, as well as the Partnership for Prescription Assistance, Together Rx Access, Medicare Part D, and state and local programs. A simple two-step tool will help determine eligibility for any of the assistance programs described on access2wellness.com.
The site is online..
Have you been selected to participate in the Physician Practice Information survey?
The American Medical Association and more than 70 other organizations are conducting the 2008 Physician Practice Information Survey, a comprehensive, multi-specialty survey of America’s physician practices. The Centers for Medicare and Medicaid Services will use the results of this study to help determine physician payment. Results will also be used to positively influence national decision-makers to ensure accurate and fair representation for all physicians and patients, and to articulate the challenges of running a practice that provides expert patient care, while operating a sustainable business.
Of particular importance is the section of the study pertaining to practice expenses and the amounts that are attributable to physicians. The survey firm, dmrkynetec, will contact randomly selected physicians and practice managers to collect responses. All responses will remain confidential.
Please alert your staff regarding your willingness to participate in this survey and the importance of accepting incoming calls, faxes or emails from dmrkynetec.
If you have been selected to participate in this important effort and have any questions about this survey, please call toll-free at 1-877-816-8940 and ask to speak with one of dmrkynetec’s executive interviewers about the 2008 Physician Practice Information Survey..
ACP Foundation releases new HEALTH TiPS
According to the Royal Society of Medicine, most patients are likely to forget 80% of what they were told by their health care provider upon leaving the office. To help physicians reinforce this important information, ACP Foundation offers HEALTH TiPS, takeaway sheets for patients containing easy-to-understand information on common conditions and diseases.
Several new HEALTH TiPS topics will be introduced this spring at Internal Medicine 2008, including depression, high cholesterol, osteoporosis, prostate cancer screening and rheumatoid arthritis, for which they partnered with the National Arthritis Foundation.
Other available HEALTH TiPS topics include diabetes, hypertension, smoking, chronic obstructive pulmonary disease (COPD) and more. All are written at a fifth-grade reading level and are available in English and Spanish. A complete list of all HEALTH TiPS topics and ordering information is available online.
The ACP Foundation is committed to providing resources to serve patients who may have difficulty accessing and understanding important health information. More information is available online.
Medicare cuts will hurt small practices, ACP President tells Congress
In testimony before the House of Representatives Small Business Committee, ACP President David C. Dale, FACP, said that physicians across the country who lead small practices are at a breaking point.
“I’ve become extremely concerned about the doctor in the small town, where a single departure—that is, a doctor who moves to the city, retires or dies and has no replacement—creates a major workforce shortage,” said Dr. Dale. “There is simply no elasticity in the system, other than for small town folk to drive farther to the doctor.”
On July 1, physicians face a 10.6% cut in Medicare reimbursements. Another 5% cut is anticipated on Jan. 1, 2009. The Sustainable Growth Rate (SGR) formula that is used to calculate Medicare payments to physicians was created in 1997 and ties physician payments to growth in the overall economy. When growth in physician expenditures exceeds growth in the economy, the difference is subtracted from physician payments. The SGR formula has led to scheduled annual cuts for six consecutive years.
Dr. Dale emphasized that small practices are medicine’s small businesses, and that much of their revenue is tied directly to Medicare’s flawed reimbursement rates and formulas.
ACP is asking Congress to avert the immediate SGR cut, but also to go a step beyond. The College is asking Congress to set a timeline for completely eliminating the use of the SGR formula. ACP also wants Congress to direct Medicare, as part of replacing the SGR formula, to change payment policies to support primary care and patient-centered medical home model of care.
At the same hearing, Herb Kuhn, deputy administrator for CMS, testified that the agency is considering ways, through future rule-making, to address concerns that “the current distribution of Medicare physician payments may still undervalue primary care.”
Dr. Dale’s complete testimony is online.
Cartoon caption contest.
Put words in our mouth: vote for your favorite entry
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 pick the winner, who receives a $50 gift certificate good for any ACP product, program or service.
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Copyright 2008 by the American College of Physicians.
A 66-year-old man comes for a preoperative evaluation before total joint arthroplasty of the left knee. He has a 25-year history of rheumatoid arthritis. He has had progressive pain in his left knee with activity, which limits his ability to hike. The patient has similar pain in the right knee, but it is less severe. He reports no recent morning stiffness. He is able to climb two or three flights of stairs without chest pain or shortness of breath. He has no other medical problems and reports no additional symptoms. Medications are methotrexate and folic acid. Following a physical exam and lab tests, what is the next best step in management?
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