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

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In the News
for the Week of 6-3-08

Highlights

  • Short-term antipsychotic use carries risks for elderly with dementia
  • Treat post-stroke depression before it happens, study suggests
  • Neurologists offer guidance on treatment of vertigo

Gastroenterology

  • Study finds positive long-term results from GERD surgery

Cardiology

  • Measuring arterial plaque distribution and amount predicts heart risk best

Annals of Internal Medicine

  • Critical care management associated with higher mortality
  • Adding salmeterol to corticosteroids doesn’t reduce asthma-related hospitalizations
  • Retired boxers have high rate of pituitary dysfunction
  • Task force recommends diabetes screening in adults with high blood pressure
  • Annals audio summary: subclinical thyroid disease

Tools and resources

  • ACP launches personalized literature updating service
  • AHRQ announces patient guide for warfarin therapy
  • NIH launches undiagnosed diseases program
  • New free patient education DVDs target bipolar disorder and chronic pain

ACP news and advocacy

  • College Fellow selected for CMS council
  • ACP releases framework of policies for universal coverage
  • Legislation to ban genetic discrimination enacted

From ACP Hospitalist

  • Recommend your colleague as a Hospitalist of the Year

From ACP Internist

  • Check out our new blog
  • Your next issue is online and in your mailbox

Cartoon caption contest


Highlights

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Short-term antipsychotic use carries risks for elderly with dementia

Older adults with dementia who use antipsychotics in the short term are more likely to have a serious event leading to hospitalization or death, a new study found.

The retrospective cohort study compared 20,682 adults with dementia living in the community with 20,559 adults with dementia living in a nursing home between 1997 and 2004. All were older than 65 years. Each cohort was divided into adults who took atypical drugs (olanzapine, quetiapine, risperidone), conventional drugs (haloperidol, loxapine) or no antipsychotics (control group). The study was published in the May 26 Archives of Internal Medicine.

At 30 days' follow-up, community-dwelling adults taking conventional antipsychotics were 3.8 times more likely to have experienced an adverse event, and those taking atypical antipsychotics were 3.2 times more likely, compared with the control group. Among nursing home residents, those taking conventional antipsychotics were 2.4 times more likely to have an adverse event, and those taking atypical antipsychotics were 1.9 times more likely, compared with the control group.

The study probably underestimates the risk of adverse events from antipsychotics because it focused only on events that led to acute care hospitalization or death, and because the follow-up time was short, the authors noted. It’s especially important to understand the short-term effects of antipsychotics in nursing homes because research shows the drugs are widely used in this setting to treat agitation, they said. “Antipsychotic drugs should be prescribed with caution, even for short-term therapy,” the authors concluded.

The Archives of Internal Medicine abstract is online.

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Treat post-stroke depression before it happens, study suggests

A recent study found that preemptively treating patients with an anti-depressant following stroke may prevent post-stroke depression.

In the yearlong randomized controlled trial, 176 stroke patients at three U.S. centers were randomly assigned to receive escitalopram, placebo or problem-solving group therapy. Patients taking escitalopram were significantly less likely than those on placebo or those in the therapy group to develop depression (23.1% vs. 34.5% and 30.5%, respectively).

The authors calculated that 7.2 patients would need to be treated with escitalopram or 9.1 patients with problem-solving therapy to prevent one case of depression. The study is published in the May 28 Journal of the American Medical Association.

While acknowledging the study's limitations, including a relatively small sample size, the authors said the results suggest that it may be possible to prevent post-stroke depression in a significant number of patients. They noted that previous studies have shown an association between post-stroke depression and increased mortality.

Noting that depression is often missed by physicians during standard stroke care, the authors recommended further study on whether preventive intervention is more effective than early detection and treatment.

The JAMA article is online.

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Neurologists offer guidance on treatment of vertigo

The most common cause of recurrent vertigo should be treated with a series of simple head positioning maneuvers, according to a new guideline from the American Academy of Neurology.

Benign paroxysmal positional vertigo (BPPV) causes a feeling of spinning or whirling when the head is moved in certain ways, and is characterized by recurrent brief episodes which can be severe. The disorder is believed to be caused by loose calcium carbonate crystals moving into the sensing tubes of the inner ear and is resolved by moving the crystals into a chamber of the ear where they can be absorbed.

According to the new guideline, canalith repositioning or the Epley maneuver, which involves a series of head and body movements performed by a doctor or therapist on the patient, is an effective and safe treatment for all ages. The guidelines rated an alternative procedure, the Semont maneuver, as only “possibly effective.”

The guideline writers reviewed a number of other treatments for the condition. They found no reason to place restrictions on patients’ activities after the procedures and determined that mastoid oscillation is probably of no added benefit. There is little risk in patients performing exercises at home, but insufficient evidence that their efforts would be as effective as maneuvers performed by a doctor or therapist.

The guideline authors also reviewed studies of surgical fixes for the problem, and found them insufficiently supported by the evidence. They recommended additional research on all potential treatments for BPPV.

The guideline and a press release are online.

PIER describes the head positioning maneuvers in its module on BPPV.

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Gastroenterology

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Study finds positive long-term results from GERD surgery

Laparoscopic antireflux surgery may be more successful than previously thought, according to the authors of a new study.

The researchers used a survey, the Gastroesophageal Reflux Disease-Health-Related Quality of Life Scale (GERD-HRQL), to evaluate long-term results and quality of life among patients who had undergone laparoscopic fundoplications between 1997 and 2006. The surveys were sent to 405 consecutive patients of a tertiary care referral center, and a 54% response rate was obtained with a median follow-up of 60 months.

Of the patients who answered the survey, 71% were satisfied with their long-term results, although 43% took antireflux medications at some point following surgery. Patients who were having a redo of their surgery were less satisfied, were more likely to require medication, and had higher GERD-HRQL scores. That finding highlights the importance of careful patient selection and surgical technique during primary surgeries, the study authors concluded.

They also found a relation between body mass index and GERD-HQRL scores, with thin patients and the morbidly obese having worse outcomes from the surgery. Overall, however, the vast majority of patients said they would have the surgery again (88% in the primary group, 76% of the redo patients). The research was published in the May issue of the Archives of Surgery.

The study differs from much of the medical literature in finding that most patients who have the laparoscopic operation have very good results, the study authors said. They also noted that even among the patients who took acid suppression medication after the surgery there was frequently no physiologic evidence of recurrent reflux.

The Archives of Surgery is online.

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Cardiology

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Measuring arterial plaque distribution and amount predicts heart risk best

Measuring the distribution as well as the amount of calcified plaque in a person’s arteries is a better predictor of his or her heart disease risk than measuring amount alone, a new study found.

The study examined CT images of 3,252 people with calcific plaque and 3,416 people without plaque, and developed calcium coverage scores (CCS) for each. The scores took distribution and amount of plaque into account. Participants were then followed for incident cardiovascular events for a median of 41 months. Quasi-Poisson models were used to estimate associations between CCS and risk factors. The study is in the June Radiology.

After adjustment for age, race, ethnicity and sex, CCS was associated with hypertension, dyslipidemia and diabetes. Diabetes showed the strongest association, with about 44% more of the length of the coronary arteries of a diabetic patient being affected by plaque compared to the arteries of a non-diabetic. A twofold increase in CCS was associated with a 52% higher risk for any coronary heart disease (CHD) event, and a 34% higher risk of a serious cardiac event like myocardial infarction.

When Agatston or mass scores were included with CCS in a prediction model for CHD events, neither the Agatston nor mass score was a significant predictor, while CCS was still significantly associated with CHD events. No differences in prediction of “hard cardiac events,” such as death or myocardial infarction, were found between the three, however.

A drawback to using CCS is that it requires tracing the entire length of the arteries, and thus the reading time may take longer. While more testing of CCS still needs to be done, the authors said they expect it to be useful in clinical settings “by helping physicians to classify patients according to risk more accurately than through use of the Agatston or mass scores, and thereby devise improved individual treatment strategies.”

The Radiology article is online.

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Annals of Internal Medicine

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Critical care management associated with higher mortality

A database review of 101,832 critically ill patients in 123 hospital intensive care units (ICUs) found that the risk of dying in the hospital was higher for patients who were managed by physicians who were critical care specialists than those who were not. Patients managed by critical care specialists were generally sicker and received more procedures. However, analyses that adjusted for the tendency for sicker patients to be managed by critical care specialists still showed higher mortality among patients managed by the specialists. Authors say their "results are surprising and completely contrary to previously published findings." They call for future studies to explore the role of protocol use, procedures, drug-resistant infections and other issues involved in care for patients in hospital ICUs. Two practicing intensivists discuss the study in an accompanying editorial.

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Adding salmeterol to corticosteroids doesn’t reduce asthma-related hospitalizations

A review of 66 trials, most conducted by GlaxoSmithKline, involving a total of 20,966 participants with asthma found that the long-acting beta-agonist (LABA) salmeterol combined with inhaled corticosteroids decreased the risk for severe exacerbations, but did not seem to alter the risk for asthma-related hospitalizations, deaths or intubations compared with inhaled corticosteroids alone. An accompanying editorial notes that this review "has helped to answer the question of safety of long-acting beta-agonists when used with inhaled corticosteroids in an idealized clinical environment" presented by the early studies but does not "resolve the controversy over the safety of LABAs (with or without steroids) in an environment that more closely reflects actual clinical practice." The editorialist says salmeterol with an inhaled corticosteroid is not a first-line treatment and should not be prescribed for people with mild asthma or those who will not adhere to close monitoring. This article and editorial are being released early online and will appear in the July 1 print edition of the journal.

Top

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Retired boxers have high rate of pituitary dysfunction

In this study of 61 male boxers (44 active, 17 retired) comprising the Turkish National Boxing Team, growth hormone and adrenocorticotropic hormone deficiencies were higher than would be expected in a general population. Nearly half of retired boxers, the study participants with the longest boxing histories, had growth hormone deficiency. The authors suggest that chronic head trauma due to sports injury may be associated with pituitary dysfunction and decreased pituitary volume, and they suggest that retired boxers have their pituitary function evaluated.

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Task force recommends diabetes screening in adults with high blood pressure

The U.S. Preventive Services Task Force, in an updated recommendations statement, says that physicians should screen for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. The USPSTF concludes that for adults with blood pressure of 135/80 or less, evidence of the value of screening for diabetes is lacking and the balance of benefits and harms cannot be determined.

The Annals of Internal Medicine is online.

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Annals audio summary: subclinical thyroid disease

In this week's Annals audio summary, Paul Ladenson, MD, of Johns Hopkins University discusses findings linking subclinical thyroid dysfunction to coronary heart disease. The podcast, which also includes a summary of all the articles in the current issue, is available online or on iTunes.

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Tools and resources

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ACP launches personalized literature updating service

ACP members now have access to the most useful article summaries from more than 120 peer-reviewed medical journals more frequently with the launch of ACP Journal Club PLUS. The new online service allows internists to customize literature updates and receive e-mail alerts based on preferred areas of specialty and on clinical impact.

"ACP Journal Club Plus is an ideal resource for evidence-based clinical decision making," said John Tooker, FACP, Executive Vice President and CEO of ACP. "Single-sentence study summaries that allow readers to zero in quickly on the article focus and a searchable database of the best studies and reviews since 2002 are just two of the many value-added benefits."

Additional benefits of ACP Journal Club PLUS include:

  • Each article is pre-rated by a panel of specialists based on areas of interest.
  • Each article passes ACP Journal Club's quality filter so readers get only what's newsworthy and pertinent. The research staff assesses scientific quality before the physician panel assesses relevance to clinical practice.
  • Users can set preferences to automatically receive customized e-mail alerts based on personal choices.
  • Alerts are stored in a searchable database.
  • The database is updated daily as articles are reviewed and rated, giving readers access to the latest information.

In a related move, ACP Journal Club is now mailed with Annals of Internal Medicine, on the third Tuesday of the month, rather than as a separate bimonthly publication. Brian Haynes, MACP, will continue as editor of ACP Journal Club content.

You can sign up for ACP Journal Club PLUS online.

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AHRQ announces patient guide for warfarin therapy

AHRQ released a consumer publication, Your Guide to Coumadin®/Warfarin Therapy, about what patients should expect while undergoing therapy.

The 20-page, easy-to-read patient brochure, available in English and Spanish, educates patients about their medication therapy and potentially dangerous side effects, explains how to communicate effectively with their health care providers and provides tips for lifestyle modifications. It also provides information on remembering when to take the medicine, learning how to stay safe while taking the medicine, maintaining a consistent diet and alerting health care providers to concurrent drugs and/or supplements patients are taking to avoid any potential adverse interactions.

The new booklet can be found online. Free single copies are available by calling the AHRQ Publications Clearinghouse at 800-358-9295 or by sending an e-mail.

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NIH launches undiagnosed diseases program

The National Institutes of Health (NIH) Office of Rare Diseases established a new "Undiagnosed Diseases Program," a clinical research initiative to provide answers to patients with mysterious conditions that have long eluded diagnosis.

Dozens of participating senior attending physicians will represent the fields of endocrinology, immunology, oncology, dermatology, dentistry, cardiology and genetics. The program will begin accepting patients in July. Patients will then approach their caregiver, who will submit clinical information to the NIH. Acceptance will be limited.

Details about the program are online.

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New free patient education DVDs target bipolar disorder and chronic pain

ACP has released two new DVDs and guidebooks on managing chronic pain and bipolar disorder. Managing Chronic Pain encourages patients to educate themselves about their pain, to be responsible about use of prescription medications, and to have confidence that relief from chronic pain is within their reach. A Guide to Bipolar Disorder will help patients learn more about bipolar disorder and understand how it can be treated, as well as teach patients how to cope with this disorder. These two new DVDs, along with a comprehensive series of videos and guidebooks on other conditions, including Alzheimer's disease, insomnia, GERD, and migraines, are available free online. (A small shipping charge applies).

You can also call ACP Customer Service to order at 800-523-1546, extension 2600 or 215-351-2600 (M-F, 9 a.m.-5 p.m. ET).

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ACP news and advocacy

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College Fellow selected for CMS council

Frederica Smith, FACP, was recently selected for a position on CMS' Practicing Physicians Advisory Council (PPAC). ACP nominated Dr. Smith for the position last year.

Dr. Smith is a rheumatologist who has been practicing in Los Alamos, N.M. for 32 years. She has served as the president of the New Mexico Society of Internal Medicine and has served numerous committee appointments with both the ACP and the American College of Rheumatology. In 2003, Dr. Smith received the laureate award from ACP's New Mexico Chapter. This annual award is given to the physician who has demonstrated an abiding commitment to excellence in medical care, education, research, and service to the community.

PPAC is a congressionally mandated council that advises the secretary of the Department of Health and Human Services and the administrator of CMS on proposed changes to federal regulations. The council regularly hears testimony and provides advice to senior officials at CMS on issues important to internists and other physicians. The council is composed of 15 members, 11 of whom must be physicians. They meet quarterly in Washington.

Information about the Practicing Physicians Advisory Council is online.

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ACP releases framework of policies for universal coverage

ACP released a new position paper that included a framework for policies that would enable all Americans to have access to affordable health insurance coverage. The updated position paper, Achieving Affordable Health Insurance Coverage for All within Seven Years: A Proposal From America’s Internists, Updated 2008, is based on a 2002 College position paper.

ACP reviewed the key reforms recommended in the 2002 paper and said they remain, with some revisions, a viable approach to making health insurance coverage available to all Americans. The paper emphasized ACP’s belief that reforms to expand coverage should be done in concert with changes in health care financing and delivery to improve outcomes and efficiency of care.

“Expanding health insurance coverage to all Americans is a moral imperative,” said ACP President Jeffrey Harris, FACP. “ACP’s framework would assure that all lower-income working persons—who constitute the vast majority of the uninsured—will have access to affordable coverage either from improved public safety net programs or by having the means to buy into the same insurance program available to members of Congress and their families.”

Many of the key elements of ACP’s framework already have been incorporated into a bipartisan bill, called the Health Coverage, Access, Responsibility and Affordability Act (HealthCARE Act – H.R. 2351), introduced by Reps. Marcy Kaptur (D-OH) and Steve LaTourette (R-OH).

The paper is available online[PDF].

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Legislation to ban genetic discrimination enacted

President Bush signed into law the Genetic Information Nondiscrimination Act of 2008 (H.R. 493), prohibiting genetic discrimination in the workplace. Under the bill, employers would not be permitted to use genetic information as a basis for discharge, refuse to hire, or otherwise discriminate against employees. In addition to employers, the law also applies to employment agencies and labor unions.

Earlier this year ACP released a new policy paper, Establishing Federal Guidelines Protecting against Genetic Discrimination, that highlighted the need for protection against discrimination both in the workplace and in insurance decisions.

ACP’s policy positions result from a March 2007 survey conducted by the John Hopkins Genetics and Public Policy Center. It found that 86% of patients trust their physicians and 66% of patients trust genetic researchers with access to their genetic information. However, most people do not trust health insurers and employers not to misuse their genetic information through disclosure or discriminatory practices.

A press release about the new legislation is online.

ACP’s policy paper is online[PDF].

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From ACP Hospitalist

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Recommend a colleague as a Hospitalist of the Year

ACP Hospitalist is seeking candidates for its first annual Hospitalists of the Year issue. To recommend a colleague who made notable contributions to the field in 2008, whether through cost savings, improved work flow, patient safety, leadership, mentorship or quality improvement, readers can fill out the online form. All recommendations must be received by July 14. Hospitalists of the Year will be profiled in our November 2008 issue.

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From ACP Internist

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ACP Internist launches its blog

ACP Internist launched its first blog during Internal Medicine 2008. Regular features include “Medical News of the Obvious,” and irregular features include anything, absolutely anything, that crosses our desks but can’t wait to find its way into print. In upcoming months we'll add new expert columnists and opinion leaders in internal medicine. Post your comments today.

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Your next issue is online and in your mailbox

The latest issue of ACP Internist is online and in your mailbox. Check out this month's issue for stories on:

  • Osteoporosis no longer just a woman’s disease. New ACP guidelines urge internists to assess their older male patients for osteoporosis risk factors, especially those over the age of 65.
  • Improving access tops list of small-office tips. The final part of a series on small practice issues advises tackling practice improvements one at a time and putting one person in charge of the process.
  • Medicine and the environment. A new department in ACP Internist will analyze the planet’s impact on medical practice and, conversely, medicine’s impact on the environment. The series launches this month with an investigation of the health impacts of climate change.

The entire June issue of ACP Internist is online.

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Cartoon caption contest

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Put words in our mouth

ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner.

Put words in our mouth

E-mail acpinternist@acponline.org all entries by June 13. ACP staff will choose three finalists and post them in the June 17 issue of ACP InternistWeekly for an online vote by readers. The winner will appear in the June 24 issue.

Pen the winning caption and win 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.

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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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A 63-year-old man is evaluated for pleuritic left-sided anterior chest pain, which has persisted intermittently for 1 week. The pain lasts for hours at a time and is not provoked by exertion or relieved by rest but is worse when supine. He reports transient relief with acetaminophen and codeine and occasionally when leaning forward. He has had a low-grade fever for 3 days, without cough or chills. Medical history is significant for acute pericarditis 7 months ago. Following a physical exam and electrocardiogram, what is the most appropriate management

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