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

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In the News
for the Week of 8-12-08

Highlights

  • Aging population drove jump in health care visits, CDC reports
  • Waist-to-height ratio predicts cardiovascular risk most accurately

Geriatrics

  • Light exercise lowers atrial fibrillation in the elderly
  • Physical frailty linked to Alzheimer’s disease

Nephrology

  • Hormone predicts kidney disease mortality

Drug news

  • FDA changes all virus strains for this year’s flu vaccine
  • Dozens of generic drugs recalled from hospitals, pharmacies

Test yourself

  • MKSAP quiz: varicose veins

From the College

  • New Web-based option to verify coverage and bill herpes-zoster vaccine
  • DOD drug formulary now available to all physicians online
  • Participate in physician practice information survey

From ACP Internist

  • Mindful Medicine case studies wanted
  • From the blog: Patients rank bedside manner No. 1, FDA tightens expert panelist guidelines; nurses step up for HIV
  • Cartoon Caption Contest: Put words in our mouth …

Highlights

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Aging population drove jump in health care visits, CDC reports

Visits to physician offices and hospital outpatient (OPD) and emergency departments (ED) jumped by 26% to 1.1 billion between 1996 and 2006, driven by the increasing health care needs of a large aging population, according to statistics released last week by the CDC.

Almost one-half (46.8%) of all ambulatory visits were made to primary care physicians in office-based practices while the remainder were to medical specialists (17.7%) and surgical specialists (15.8%) in office-based practices and to EDs (10.6%) and OPDs (9.1%), according to the National Health Statistics reports[PDF] compiled by the CDC's National Center for Health Statistics.

Other findings from the survey include:

  • At least one medication was provided, prescribed or continued in 7 out of 10 visits in 2006. Analgesics, the most common pain medication used in primary care and EDs, accounted for 13.6% of all prescriptions.
  • Black patients had higher visit rates than whites to OPDs and EDs and lower visit rates to office-based surgical and medical specialists. In addition, the proportion of visits to hospital OPDs and EDs increased as poverty levels increased.
  • Hypertension was the most frequent diagnosis at ambulatory care visits.
  • The rate of knee replacement doubled among people aged 45-64 between 2000 and 2006.
  • A sharp rise in coronary atherosclerosis during the 1990s was followed by a decline starting in 2002, especially among those 65 years and older.
  • The percentage of visits to OPDs by adults with chronic diabetes increased by 43% while visits by adults with chronic hypertension increased by 51% between 1996 and 2006.

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Waist-to-height ratio predicts cardiovascular risk most accurately

Calculating waist-to-height ratio (WtHR) is the most exact way to predict cardiovascular risk, but using body-mass index (BMI) may be the most practical, according to a new study that compared four adiposity measures.

Subjects included 16,332 men in the Physicians’ Health Study and 32,700 women in the Women’s Health study. Researchers used Cox proportional hazards models to determine relative risk for developing cardiovascular disease (CVD) according to self-reported indexes of BMI, waist circumference, waist-to-hip ratio and WtHR. The study will be published in the Aug. 19 Journal of the American College of Cardiology.

CVD risk increased steadily and significantly as all four indexes of adiposity rose, but WtHR show the strongest statistical association. CVD risk for men with the highest WtHR (score > 0.69) was more than four times that of men with the lowest WtHR (score < 0.45 score). For women, the risk was more than three-and-a-half times greater for women with the highest WtHR (score > 0.68) compared to those with the lowest (< 0.42)

Current clinical guidelines that use BMI to define who is overweight or obese may miss people who have normal BMI but higher CVD risk from fat distribution around the middle, the authors noted. Still, the difference between WtHR and BMI in predicting CVD was small, and the ease of using BMI may make it the most practical for clinicians, they said.

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Geriatrics

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Light exercise lowers atrial fibrillation in the elderly

Light to moderate exercises such as leisure-time activities or walking are associated with significantly lower incidence of atrial fibrillation (AF) in older adults.

While vigorous exercise can increase AF incidence, the effect is based on anecdotal reports, case series and retrospective studies of younger and middle-aged athletes. Evidence hasn't determined the impact of light to moderate activity among the elderly.

Researchers prospectively investigated associations between AF and leisure-time activity, and walking from 1989 to 2001 among 5,446 adults 65 years of age or older (average age 73). They reported their results in the Aug. 5 issue of Circulation.

Leisure activities were measured by 15 activities on a questionnaire divided into quintiles graded by degree of exercise intensity. The three light- to moderate-exercise quintiles were associated with 22%, 25% and 36% lower incidence of AF, respectively, but people in the highest intensity quintile had about the same AF risk as those in the lowest, or no exercise, group.

Regular walking decreased the risk of AF, with greater effect seen at longer distances and faster paces. For example, compared with walking less than 4 blocks per week, the incidence of AF was 22% less for those walking 5 to 11 blocks, 24% for those walking 12-23 blocks, 33% lower for those walking 24-59 blocks and 44% for those walking more than 60 blocks a week. Compared with those who walked less than 2 miles per hour, those who walked 2-3 mph had a 32% lower risk of AF and those who walked more than 3 mph had a 41% lower risk. Those in the highest quintile of walking distance and pace had a 50% lower risk than those in the lowest quintile.

The authors noted that 1 in 5 older adults developed AF during the 12-year study, and that one-fourth of AF could be attributed to the absence of any physical activity. "Easily achievable lifestyle habits should be further evaluated as potential preventive measures to reduce the incidence of AF in the particularly high-risk and growing population of older adults," they concluded.

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Physical frailty associated with Alzheimer’s disease

A new study has found an apparent association between Alzheimer’s disease and physical frailty in the elderly.

In a community study of chronic diseases of aging, researchers tested the frailty of 165 people. The yearly tests included grip strength, time to walk eight feet, body composition and tiredness. After death, the study participants’ brains were checked for plaques and tangles that would signify Alzheimer’s disease. Before their deaths, 36% of participants had dementia or memory loss. The study appears in the Aug. 12 issue of Neurology.

Even in patients without dementia, Alzheimer’s disease was associated with physical frailty, the researchers found. People with a high level of Alzheimer’s pathology had about double the level of frailty as those with a low level of Alzheimer’s. This difference remained when the patient’s level of physical activity and history of other diseases were controlled for. Study authors noted that a previous study of the same participants had found that older people with frailty but no cognitive impairment had a heightened risk of developing Alzheimer’s.

Based on the findings, researchers concluded that frailty may be an early indicator of Alzheimer’s disease which could appear before memory loss. It is unclear whether Alzheimer’s disease contributes to frailty or both problems share a common cause, but a study author theorized that the Alzheimer’s plaques and tangles could affect areas of the brain responsible for motor skills and simple movement long before the development of dementia.

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Nephrology

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Hormone predicts kidney disease mortality

Closer monitoring of fibroblast growth factor 23 (FGF-23) might reduce patient mortality, a new study found.

Researchers used data from a prospective cohort of more than 10,000 patients who were beginning hemodialysis. The study analyzed serum phosphate levels for all of the patients and levels of FGF-23 from a case-control sample of 200 people who died and 200 who survived the first year of treatment. The research appears in the Aug. 7 New England Journal of Medicine.

The study found that higher serum phosphate levels were associated with a somewhat high risk of mortality; patients with the highest levels were 20% more likely to die than those with the lowest. However, elevated FGF-23 levels were a strong predictor of mortality. Patients with the highest levels of the hormone had a 600% higher mortality rate. High levels of FGF-23 significantly increased the risk of death even in patients with normal phosphate levels.

The study also uncovered some racial and ethnic differences in hormone levels. Black and Hispanic patients had lower FGF-23 levels overall, and among the patients with the lowest levels, black patients had a lower risk of death than whites. The study authors are now investigating whether such racial differences exist among healthy patients and those with earlier stage kidney disease.

The study’s findings may be most important for early-stage patients who are not yet on dialysis, because these patients typically have normal phosphate but high FGF-23, the study author said in a press release. Routine monitoring of FGF-23 could indicate which patients need to begin phosphate-control therapies and thereby reduce mortality, the author concluded.

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Drug news

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FDA changes all virus strains for this year’s flu vaccine

The FDA changed all three strains of influenza virus in the six vaccines it just approved for the upcoming flu season, the agency said last week.

Changing all three strains is unusual; typically, only one or two are revised. Last year's vaccine didn’t match well with some of the strains in circulation, and it was the roughest flu season in four years.

The six vaccines and their manufacturers are: Afluria, CSL Limited; Fluarix, GlaxoSmithKline Biologicals; FluLaval, ID Biomedical Corporation of Quebec; FluMist, MedImmune Vaccines Inc.; Fluvirin, Novartis Vaccines and Diagnostics Limited; and Fluzone, Sanofi Pasteur Inc.

This virus strains this year are: A/Brisbane/59/2007 (H1N1)-like virus; an A/Brisbane/10/2007 (H3N2)-like virus; and a B/Florida/4/2006-like virus, the FDA said. The latter two are now in use for the Southern Hemisphere's 2008 influenza season, currently underway.

Vaccination of health care workers, the elderly, young children and people with chronic medical conditions is especially important, the FDA said.

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Dozens of generic drugs recalled from hospitals, pharmacies

Generic drug maker Actavis voluntarily recalled more than 60 products after an FDA inspection showed its operations didn’t meet good manufacturing practices.

Recall letters have been issued to wholesalers and retailers, including hospitals and pharmacies. The precautionary recall affects all products made at Actavis’ Little Falls, N.J. facility, including oxycodone, glyburide, guanfacine and mirtazapine. A full list of recalled drugs is online.

Patients should keep taking these medications, however, since stopping suddenly could put them at risk, Actavis said in a release posted on the FDA Web site. More information is available online.

In late April, Actavis issued a Class 1 recall of digoxin tablets (Digitek), saying tablets might contain double the intended amount of active ingredient.

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Test yourself

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MKSAP quiz: varicose veins

Case study: A 69-year-old man is evaluated for chronic leg heaviness and aching. His medical history is notable for hypertension treated with hydrochlorothiazide.

On physical examination, pulse rate is 72/min, and blood pressure is 112/66 mm Hg. The BMI is 30. Examination of the lower extremities is notable for tortuous, large (>4 mm), dilated veins over the thighs and calves. There is no warmth, erythema, ulceration, or hyperpigmentation over his legs, but there is symmetric 1-mm pitting edema of the ankles.

Which of the following is the most appropriate initial management for this patient's symptoms?

A) Compression stockings
B) Furosemide
C) Laser therapy
D) Injection sclerotherapy
E) Vein stripping

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

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From the College

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New Web-based option to verify coverage and bill herpes-zoster vaccine

A private, third-party vendor, eDispense, has implemented a Web-assisted billing system for herpes-zoster vaccine (Zostavax) to address issues such as confirming patient coverage, lack of direct billing options and up-front patient costs that prevent some from getting vaccinated.

Physician offices have reported difficulties providing their Medicare patients with the herpes-zoster vaccine due to billing barriers. Offices cannot verify coverage under the Part D plan or bill the Part D plan directly for the vaccine with any assurance of payment. Part D plans are required to include all preventive vaccines within their formularies except influenza, pneumococcal and hepatitis B vaccines, which are covered under Medicare Part B.

Currently, most practices have their Medicare patients pay an up-front charge for the vaccine and its administration. They then have the patient submit a paper claim to their Part D plan for reimbursement up to the plan’s allowable charge. This approach significantly limits vaccine access because many patients who participate in Part D cannot afford the full payment up-front, which is typically around $200. This approach also places the patient at risk of not recovering their costs from the Part D plan.

Under the new system, physicians would electronically submit claims directly to Part D through a Web-based portal. Practices would also be able to verify patients’ coverage, their required deductible and co-payment, and the Part D plan’s physician vaccine and administration payment. This approach allows the beneficiary to pay the out-of-pocket deductible and co-pay only, and it provides a means for the physician to be reasonably assured of payment by the plan for the vaccine and its administration. eDispense is paid a per-transaction fee by the Part D plan, and physician claims are paid by the vendor to the physician on a monthly basis at no cost to the practice if funds are electronically transferred.

Further information about the new billing system from eDispense is online.

The College does not endorse eDispense or this service, but views it as a service practices may want to explore to address access barriers to the herpes-zoster vaccine. While eDispense is the only vendor currently providing this service, other entities may offer this or a similar service in the future.

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DOD drug formulary now available to all physicians online

Civilian physicians can now access the Department of Defense Uniform Formulary electronically, an important first step in the DOD's e-prescribing initiative.

The DOD e-prescribing initiative is meant to facilitate electronic prescribing from civilian or military treatment facilities to any civilian or military dispensary, including mail order and retail pharmacies. The Uniform Formulary provides prescribers with formulary status, preferred therapeutic and generic alternatives, and coverage information, such as co-payment and relative costs. The formulary has not previously been available in a standard electronic format.

Electronic formulary use is expected to help health insurers and pharmacy benefits managers, including the DOD, save money through better formulary adherence, less therapeutic duplication, and fewer adverse drug effects. In addition, patients may have less waiting time for prescriptions to be filled.

More information about the DOD's Pharmacoeconomic Center is online.

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Participate in physician practice information survey

ACP, the American Medical Association, and more than 70 other organizations are conducting a comprehensive multi-specialty survey of America's physician practices. The section of the study pertaining to your practice expenses is particularly important, and we request that you complete it accurately in its entirety. CMS has indicated it will use the results of this study to help determine physician payment. A survey firm, dmrkynetec, has been retained to contact randomly selected physicians and practice managers to collect responses. All responses will remain confidential.

At this time, internal medicine has only 103 completed surveys, with a goal to collect at least 350 responses. Please alert your staff about this survey and the importance of accepting incoming calls, faxes or e-mails from dmrkynetec. A postcard was mailed to the entire physician sample on June 11. If you have been selected to participate and have questions, please call dmrkynetec at 877-816-8940.

Find out if you have been selected to participate in the survey by visiting the Physician Practice Information Survey Web site and enter your name and zip code. Additional information on the survey and the ACP support for it is available on ACP's Web site.

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From ACP Internist

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Mindful Medicine case studies wanted

What was your most difficult diagnosis?

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

Previous Mindful Medicine columns are online.

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From the blog: Patients rank bedside manner No. 1, FDA updates conflict of interest rules and nurses step up for HIV

A new survey finds patients rank bedside manner as the No. 1 reason for liking their doctor, plus new FDA guidelines for experts who advise during committee meetings, and Africa enlists specially-trained nurses to care for HIV—and gets better patient satisfaction over physician care. Find these stories and Medical News of the Obvious every Monday at ACP Internist's blog.

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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 this week to acpinternist@acponline.org by August 15. ACP staff will choose three finalists and post them in the Aug. 19 issue of ACP InternistWeekly for an online vote by readers. The winner will appear in the Aug. 26 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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MKSAP Answer

A) Compression stockings

The complete MKSAP critique on this topic is available to subscribers in the General Internal Medicine section, item 45.

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 order the latest edition of MKSAP, go online to http://mksap.acponline.org.

Return to the rest of ACP Internist Weekly.

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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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Test yourself

A 48-year-old man is evaluated during a follow-up visit for urinary frequency. He reports no hesitancy, urgency, dysuria, or change in urine color. He has not experienced fevers, chills, sweats, nausea, vomiting, diarrhea, or other gastrointestinal symptoms. He feels thirsty very often; drinking water and using lemon drops seem to help. He has a 33-pack-year history of smoking. He has hypertension, chronic kidney disease, and bipolar disorder. Medications are amlodipine, lisinopril, and lithium. He has tried other agents in place of lithium for his bipolar disorder, but none has controlled his symptoms as well as lithium. What is the most appropriate treatment intervention for this patient?

Find the answer

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