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


In the News
for the Week of 7-15-08


  • Senate passes legislation to avert Medicare physician payment cut; presidential veto expected
  • PADT does not improve survival in elderly men with localized prostate cancer, study finds

Disease management

  • Combination drug relieves migraines when taken early
  • Treating hypertension in elderly may reduce dementia risk

Annals of Internal Medicine

  • Prehypertension common among youths, leads to later diseases
  • Low-molecular-weight heparin may prevent clots after knee arthroscopy
  • Disconnect found between patient-reported hospital errors, medical record review

FDA updates

  • Boxed warning on fluoroquinolones for tendon ruptures, tendinitis
  • Contaminated antiseptic cloths recalled
  • Mycophenolate mofetil poses risk of progressive multifocal leukoencephalopathy
  • Wireless insulin pump, genetic test for cancer treatment approved

Tools and resources

  • Recruitment opens for ACP’s free, online QI programs
  • ABI may improve accuracy of cardiovascular risk prediction

Test yourself

  • Take the latest MKSAP quiz

From ACP Internist

  • The latest issue of ACP Internist is online
  • Mindful Medicine case studies wanted
  • What they’re saying on the blog

From ACP Hospitalist

  • Last chance to suggest a colleague as a Hospitalist of the Year

From the College

  • Earn a Medicare bonus for reporting quality information in 2008

Carton caption contest


Senate passes legislation to avert the Medicare physician payment cut; Presidential veto could still result in cut going into effect on July 15

The Senate passed legislation that would reverse a 10.6% physician payment cut that went into effect July 1 by passing the Medicare Improvements for Patients and Providers Act of 2008 (H.R. 6331). The Act also allows for a 1.1% increase in payment rates for 2009 instead of the rate cut that had been expected.

The legislation contains several other important provisions related to primary care. These measures, which were championed by ACP, include:

  • increased payments for internists' office visits,
  • increased funding for the Medicare medical home demonstration project,
  • expanded coverage of preventive services, and
  • phasing out higher co-payments for mental health benefits.

"The Senate today gave overwhelming, bipartisan approval to legislation to avert cuts in Medicare physician payment updates-the best outcome possible given the difficult circumstances facing us," said ACP President Jeffery P. Harris, FACP.

The bill now moves on to the President for his signature before becoming law. Although the Senate and the House of Representatives passed the legislation with margins large enough to overcome a presidential veto, ACP cautioned that a veto override cannot be taken for granted and will not necessarily occur in time to stop the cut from going into effect later this week. "H.R 6331 is an excellent bill that will halt a catastrophic collapse in patient access to physicians. It deserves the president's immediate signature," said Dr. Harris. "If necessary, though, we will ask both the House and Senate to override a presidential veto."

ACP is concerned that if the President does not sign the bill into law by July 15, CMS's announced "hold" on processing claims will expire and Medicare contractors will have no choice but to begin paying them with the 10.6% cut required under current law. On Monday, ACP released a statement asking every U.S. senator and member of the House of Representatives, even those who initially voted against H.R 6331, to tell the President that signing the bill into law today is the only way to stop the devastating cuts from going into effect. ACP also asked them to go on record and tell him that they have made an unequivocal commitment to patients and doctors to vote for an override."

ACP will keep you updated as the situation progresses, including the latest on how your claims may be affected, on the ACP Advocacy Web site.

For information about what you can do encourage your legislators to overcome a possible veto, visit ACP's Legislative Action Center.


PADT does not improve survival in elderly men with localized prostate cancer, study finds

Compared with conservative management, primary androgen deprivation therapy (PADT) does not improve survival of elderly men with localized prostate cancer, according to a study published in the July 9 Journal of the American Medical Association.

Researchers looked at outcomes among 19,271 Medicare patients age 66 or older who did not initially receive surgery or radiation for clinical stage T1-T2 prostate cancer. Among patients with localized prostate cancer, 41% received PADT vs. conservative management only. After a median follow-up of seven years, PADT was associated with a lower 10-year prostate cancer-specific survival (80.1% vs 82.6%; hazard ratio [HR], 1.17; 95% confidence interval [CI], 1.03-1.33) and no increase in 10-year overall survival (30.2% vs 30.3%; HR, 1.00; 95% CI, 0.96-1.05) compared with conservative management.

While the popularity of PADT has increased in recent years, there is little evidence to support its use in men with early stage, localized prostate cancer, the authors noted. Considering PADT's high cost and significant potential adverse side effects (such as increased risks of fracture, diabetes, coronary heart disease, myocardial infarction, and sudden cardiac death as well as gynecomastia nd hot flashes), they urged physicians to carefully consider the rationale for initiating PADT in this population.

The JAMA study is online.


Disease management

Combination drug relieves migraines when taken early

A combination drug effectively relieves migraine symptoms when taken within an hour of headache onset, two studies found.

Researchers tested the drug in two randomized, double-blind trials involving 1,111 people age 18-65 years who had experienced two to six migraines per month in the three months before the studies began. Half the patients took a single tablet containing 85 mg sumatriptan and 500 mg naproxen sodium within an hour of migraine onset; the other half took a placebo within the hour. The studies were published in the July 8 Neurology.

Two hours after the doses were given, more than 50% of the sumatriptan/naproxen patients reported no pain, compared with about 16% of placebo patients. Those who took the drug were also 2-3 times less likely than placebo patients to progress to moderate or severe pain over four hours, and had significantly lower rates of migraine-associated symptoms like nausea and light/sound sensitivity, and nontraditional symptoms like neck and sinus pain.

The studies provide evidence that treating a migraine at the first sign of pain increases the chances of getting some relief, the study’s lead author said. He noted, however, that the studies involved only those whose migraines start out mildly, so it’s not known if the results apply to those who have migraines with moderate or severe pain right away. The studies were sponsored by migraine drug developer POZEN, Inc. and supported by GlaxoSmithKline.

The Neurology article is online. (subscription required)

The American Academy of Neurology press release is online.


Treating hypertension in elderly may reduce dementia risk

Treating hypertension in the elderly reduces the risk for dementia slightly, a new analysis found.

Researchers studied 3,336 patients aged 80 or older with systolic blood pressure of 160-200 mm Hg and diastolic blood pressure below 100 mm Hg, and no apparent dementia. Patients were randomly assigned to receive 1.5 mg sustained release iadapamide (with the option of 2-4 mg perindopril), or placebo. The target systolic blood pressure was 150 mm Hg, and target diastolic blood pressure was 80 mm Hg. The study, which was stopped for ethical reasons when it became clear the drug lowered stroke and mortality risk, was published in the July 8 Lancet Neurology.

There was no significant difference in incident dementia between groups in the trial, but when the data were combined in a meta-analysis with other placebo-controlled trials of antihypertensive treatments, the treatment reduced the rate of dementia by 13%. (HR: 0.87, p=.045).

The negative finding from the single study may have resulted from the short follow-up due to terminating the trial, or from the modest effect of treatment. Given the results of the meta-analysis, however, hypertensive treatment may be an additional benefit to the elderly beyond its cardiovascular advantages, a study author said.

The Lancet Neurology article is online. (subscription required)


Annals of Internal Medicine

Prehypertension common among youths, leads to later diseases

Prehypertension during young adulthood is common and is associated with subsequent coronary atherosclerosis. Researchers from the University of California, San Francisco, analyzed blood pressure measurements of 3,560 adults aged 18 to 30 from seven examinations over the course of 20 years. Nearly 20% (635) of the study participants developed prehypertension (systolic blood pressure 120 to 139 mm Hg or diastolic blood pressure 80 to 89 mm Hg) before the age of 35.

Systolic prehypertension appeared to be more important than diastolic prehypertension, and the association was graded: the higher and the longer exposure to prehypertension during young adulthood, the higher the likelihood of having coronary calcium later in life.

Although these blood pressure levels are below the cutoff for hypertension, the young adults with prehypertension were more likely than those with lower blood pressure to have calcium in their coronary arteries later in life. Prehypertension before the age of 35 also was associated with having diabetes, low HDL cholesterol levels, and higher exposure to blood pressure elevation later in life.

Prehypertension was most common in young adults who were black, male, overweight, and of low socioeconomic status. Participants with low annual income (less than $25,000) and no college education were about twice as likely to have had early prehypertension as were participants with postgraduate education and an annual income greater than $100,000.

The authors said that their findings support existing recommendations to optimize blood pressure early in adulthood with lifestyle modifications, such as regular physical activity, healthy eating and weight control, with the goal of lowering blood pressure to less than 120/80 mm Hg and preventing progression to hypertension.

A streaming video report is online.


Low-molecular-weight heparin may prevent clots after knee arthroscopy

Researchers studied 1,761 patients undergoing knee arthroscopy, randomly assigning them to three groups. One wore a graduated compression stocking for seven days, the second group received injections of low-molecular-weight heparin (LMWH) for seven days, and the third group received LMWH injections for 14 days. Although blood clots were uncommon in all groups, fewer patients receiving LMWH developed blood clots compared with those wearing compression stockings (0.9% vs. 3.2%). Patients receiving LMWH for 14 days did not have fewer clots than those receiving LMWH for seven days. Blood thinners made the biggest difference in people having meniscectomy.


Disconnect found between patient-reported hospital errors, medical record review

Among 998 patients who completed a questionnaire about their hospitalization experience, poor agreement about the occurrence of adverse hospital events exists between patient interviews and medical records. A study suggests that patients report serious and preventable events that are not documented in medical records. It also suggests that hospitals should consider monitoring patient safety by adding questions about adverse events to post-discharge interviews.

The Annals of Internal medicine is online.


FDA updates

Boxed warning on fluoroquinolones for tendon ruptures, tendinitis

Fluoroquinolone antimicrobial drugs need boxed warnings and patient medication guides about their higher risk for tendinitis and tendon rupture, the FDA told drug manufacturers last week.

Patients at highest risk include those over age 60; kidney, heart or lung transplant recipients; and people taking corticosteroids. Patients should stop using fluoroquinolones at the first sign of tendon pain, swelling or inflammation; avoid using or exercising the area; and call their doctors about switching drugs.

The warning applies to fluoroquinolones for systemic use, like pills, capsules and injections, and not those for topical ophthalmic or otic use. Affected medications include ciprofloxacin (Cipro), gemifloxacin (Factive), levofloxacin (Levaquin), moxifloxacin (Avelox), norfloxacin (Noroxin), and ofloxacin.

The FDA alert and news release are online.


Contaminated antiseptic cloths recalled

Limited lots of 2% chlorhexidine gluconate cloth patient preoperative skin preparation product are being recalled because some lots tested positive for Burkholderia cepacia, the FDA said.

Patients with weakened immune systems or chronic lung diseases like cystic fibrosis may be especially susceptible to B. cepacia respiratory infections. The cloths were shipped to hospitals and medical centers nationwide between April 28 and June 19.

The lots being recalled are numbers 10722, 10729, 10718, 10357, 10365, 10641, 10672, 10753, 10755, 10944.

The FDA recall notice is online.


Mycophenolate mofetil poses risk of progressive multifocal leukoencephalopathy

Mycophenolate mofetil (CellCept) may carry a heightened risk of progressive multifocal leukoencephalopathy (PML) for transplant recipients, the FDA said last week.

Postmarketing reports indicate 17 patients treated with CellCept developed PML; six of them died from the disease. The patients usually had risk factors for PML, including immune function impairment and treatment with immunosuppressant therapies.

The most common clinical features of PML were hemiparesis, apathy, confusion, cognitive deficiencies and ataxia. Doctors should consider PML as a cause if patients develop neurologic symptoms and possibly consult a neurologist, manufacturer Roche said in a letter to healthcare professionals.

Novartis, manufacturer of Myfortic, sent a similar letter to health professionals, because mycophenolate mofetil is metabolized to make the active ingredient of Myfortic (mycophenolic acid). Both companies are changing their prescribing information to reflect the risks, they said.

The FDA alert is online.

Copies of the letters sent to healthcare professionals by the manufacturers are online here[PDF] and here[PDF].


Wireless insulin pump, genetic test for cancer treatment approved

The FDA last week approved the first insulin pump that wirelessly communicates with a remote blood glucose meter, and a genetic test to determine if patients with breast cancer are good candidates for treatment with trastuzumab (Herceptin).

The SPOT-Light HER2 CISH genetic test counts the number of HER2 genes in a tumor sample. If there are more than two copies of the HER2 gene, they may overproduce HER2 protein and the breast cells will grow and divide too quickly. Trastuzumab helps retard growth by targeting HER2 protein production.

Separately, the newly approved OneTouch Ping Glucose Management System allows patients to calculate and deliver insulin doses without touching their pumps.

The press releases for the gene test and insulin pump are online.


Tools and resources

Recruitment opens for ACP’s free, online QI programs

ACP’s Quality Improvement Program, ACPNet, has launched two new Web-based Quality Improvement Programs for COPD and pain management. Both projects will offer CME; the COPD Initiative also will offer credit towards ABIM Part 4 MOC. Both projects will offer a Web-based education module that will consist of a coordinated set of tools to help implement the intervention and organize the practice to facilitate patient care related to COPD or pain.

  • The COPD Initiative is designed to evaluate how you manage patients with COPD and help you make improvements in your clinical management of patients with COPD. The educational toolkit will include: diagnosis and management of COPD, pharmacologic management of stable COPD, pharmacologic management of acute COPD exacerbation, non-pharmacologic management of COPD, management of non-pulmonary COPD complications, management of patient end-stage COPD and patient education resources.
  • The Pain Management Project is designed to evaluate how you manage patients with non-malignant pain. The educational module will cover quality improvement techniques/methods for practice improvement related to pain, including diagnosis and assessment of pain, general approaches to pain management, how to treat specific types of pain (neuropathic, low back pain, and pain in the elderly), evidence based guidelines and patient education resources.

For more information, contact Meghan Gannon by phone at 215-351-2847, by e-mail at, or online.


ABI may improve accuracy of cardiovascular risk prediction

The ankle brachial index (ABI) may improve the accuracy of cardiovascular risk prediction, according to a meta-analysis published in the July 9 Journal of the American Medical Association.

The Framingham risk score (FRS) has limited accuracy, tending to overestimate risk in low-risk populations and underestimate risk in high-risk populations, according to study authors. To improve risk prediction, researchers conducted a meta-analysis of data from 16 studies to determine if the ABI provides information on the risk of cardiovascular events and death independently of the FRS. The studies included a total of 24,955 men and 23,339 women who had ABI measured at baseline and were followed up to detect total and cardiovascular mortality.

The 10-year cardiovascular mortality in men with ABI 0.90 or less was 18.7% and with ABI of 1.11 to 1.40 was 4.4%, about a four-fold higher risk of cardiovascular death for men with low ABI. Corresponding mortalities in women were 12.6% and 4.1%. The risks remained elevated after adjusting for FRS (2.9 for men vs. 3.0 for women). A low ABI (0.90 or less) was associated with about twice the 10-year total mortality, cardiovascular mortality, and major coronary event rate compared with the overall rate in each FRS category. Including ABI in cardiovascular risk stratification using the FRS resulted in reclassifying the risk category and modification of treatment recommendations in about 19% of men and 36% of women.

Authors concluded that in men, changes from higher to lower categories of risk would likely have an effect on decisions to begin preventive treatment, such as lipid-lowering therapy. The main effect in women of including ABI scores would be that many at low risk with the FRS (less than 10%) would move into a higher risk level. They also wrote that because ABI is easy to use in a primary care setting, inexpensive and can be done by a trained nonphysician provider, it has advantages over coronary artery calcium and carotid intima media thickness.

The JAMA article is online.


Test yourself

Take the MKSAP quiz

ACP Internist has brought back its MKSAP quiz. This popular feature was so heavily requested by our readers that we’re restoring it weekly in our e-mail updates.

Case Study: Excessive fatigue

A 65-year-old man is evaluated for a gradual loss of strength, libido and sexual function over the past four years. He says that he has been having difficulty concentrating, especially at work, and that his overall performance at work has deteriorated in recent weeks; in addition, he reports being excessively fatigued at work, despite having had eight hours of sleep each night. He has hypertension, for which he takes hydrochlorothiazide, and obesity and smokes one pack of cigarettes daily.

On physical examination, his pulse rate is 88/min and blood pressure is 146/85 mm Hg. BMI is 33. Visual fields are intact. He has no gynecomastia, and secondary sex characteristics are normal. Testicular size is 18 mL. Results of a digital rectal examination are normal.

Initial laboratory studies show a total serum testosterone level of 160 ng/dL (5.6 nmol/L). Blood is redrawn at 8:30 a.m. 2 days later for repeat studies.

Repeat laboratory studies* Value
Hematocrit 43%
Prostate-specific antigen 1.0 ng/mL (1.0 µg/L)
Follicle-stimulating hormone 6.6 mU/mL (6.6 U/L)
Luteinizing hormone 6.0 mU/mL (6.0 U/L)
Prolactin level 11 ng/mL (11 mg/L)
Sex hormone–binding globulin 12 nmol/L (normal, 13-17 nmol/L)
Total testosterone 180 ng/dL (6.2 nmol/L)

* For reference, a full list of normal laboratory values is online[PDF].

Which of the following is the most appropriate next step in management?

A. Measurement of free testosterone level
B. MRI of the pituitary gland
C. Sleep study
D. Initiation of testosterone replacement therapy

Click here or scroll to the bottom of the page for the correct answer.


From ACP Internist

The latest issue of ACP Internist 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:

  • Internal Medicine 2008. A complete wrap-up of clinical and Leadership Day coverage from the College's annual meeting in Washington, D.C.
  • Practice management. It’s not too late to recoup bonus payments from Medicare for reporting quality measures. Practice Rx lays out simple steps to garner more reimbursement. Also, ways to recoup money for filling out patient’s forms.
  • Mindful Medicine. The case of a young woman mistakenly diagnosed with asthma illustrates the danger of confusing correlation and causation. Commentary by Jerome Groopman, FACP, and Pamela Hartzband, FACP.

The July/August issue of ACP Internist is online.


Mindful Medicine case studies wanted

ACP Internist columnists Jerome Groopman, FACP, and Pamela Hartzband, FACP, would like to hear about your stories of difficult or missed diagnoses for possible use in their next 'Mindful Medicine' column.

Dr. Groopman, a hematologist/oncologist and author of the bestselling "How Doctors Think," and Dr. Hartzband, an endocrinologist, are on the Harvard Medical School faculty and serve as staff physicians at Boston's Beth Israel Deaconess Medical Center. Every other issue, they present a case study from an ACP Internist reader describing a difficult or missed diagnosis, and provide commentary on how a mistake was, or might have been, avoided.

Please email your suggestions to Drs. Groopman and Hartzband. The authors will contact you to discuss the case if your submission is selected for the column.


What they're saying on the blogs

Join ACP Internist's community on its blogs, featuring daily updates on news that just can't wait. Find popular features such as entries on the effectiveness of food diaries, expert commentary on direct-to-consumer genetic tests, and the latest Medical News of the Obvious. Post your comments today.


From ACP Hospitalist

Last chance to suggest 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.

Recommendations received by July 18 are eligible to be included. Hospitalists of the Year will be profiled in our November 2008 issue.


From the College

Earn a Medicare bonus for reporting quality information in 2008

ACP is co-hosting a forum via conference call with CMS to discuss internist participation in the Physician Quality Reporting Initiative (PQRI), a program that pays physicians a bonus for reporting quality data to CMS on their claims forms. You are still able to participate and earn a bonus even if you have yet to report quality data for 2008.

The program awards a bonus payment of 1.5% of allowable charges for Medicare patients to physicians who successfully submit quality data. PQRI was first introduced in July 2007 and was renewed for 2008. The reporting period for 2008 started in January and runs through the end of the year.

The toll-free call will take place on Tuesday, July 15 from 3:30 to 5:00 p.m. EST. Internists and/or a designated staff member, such as an office manager, are invited to dial in to hear about PQRI participation options, including new mechanisms available beginning July 1. The focus of the call will be on the steps that internists need to take to collect and report the necessary quality data for participation in the program. Callers will have an opportunity to ask questions and receive answers from both ACP and CMS experts.

Members who wish to participate should call-in at (800) 837-1935 and enter the conference ID number: 53531371. A Power Point presentation that will be used during the call is available ahead of time at ACP’s Running a Practice Web site.


Cartoon Caption Contest

Put words in our mouth …

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

cartoon caption contest

E-mail all entries to by July 25. ACP staff will choose three finalists and post them in the July 29 issue of ACP InternistWeekly for an online vote by readers. The winner will appear in the Aug. 5 issue.

Pen the winning caption and win a $50 gift certificate good for any ACP product, program or service.


MKSAP answer

C. Sleep study, to diagnose hypogonadism secondary to obstructive sleep apnea.

ACP's Medical Knowledge Self-Assessment Program (MKSAP) allows you to:

  • Update your knowledge in all areas of internal medicine
  • Prepare for ABIM certification or recertification
  • Support your clinical decisions in practice
  • Assess your medical knowledge with 1,200 multiple-choice questions

To view the complete MKSAP syllabus and critique on this topic (subscribers only) or to order the latest edition of MKSAP, go online.

Return to the rest of ACP InternistWeekly.


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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Test yourself

A 67-year-old man is evaluated for a recent diagnosis of primary hyperparathyroidism after an elevated serum calcium level was incidentally detected on laboratory testing. Medical history is significant only for hypertension, and his only medication is ramipril. Following a physical exam and lab studies, what is the most appropriate management of this patient?

Find the answer

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