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

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In the News
for the Week of 8-5-08

Highlights

  • Updated RA treatment guidelines include use of DMARDs
  • Study finds big increase in fatal drug errors at home
  • Report: $10 of personal prevention worth $16 billion in health care

Women’s health

  • Diabetes increases birth defect risk
  • Migraine aura plus gene variant ups stroke risk

Cardiology

  • Aging population spurs sharp rise in heart failure hospitalizations

Annals of Internal Medicine

  • No benefit from prostate screening for men over 75, task force says
  • Survey finds chronic illness common among uninsured
  • Rapid HIV test yields lower-than-expected specificity
  • Combination incontinence therapies raise patient satisfaction

Cognitive decline

Regulatory news

  • Access your 2007 PQRI feedback reports
  • HRSA withdraws rule on HPSAs and MUAs

Test yourself

  • MKSAP quiz: Menorrhagia

From the College

  • ACP helps revise CMS rule on costly security paper for tamper-proof Rx

From ACP Internist

  • On the blogs: More exercise needed to maintain weight loss

Cartoon caption contest


Highlights

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Updated RA treatment guidelines include use of DMARDs

The American College of Rheumatology has issued updated evidence-based guidelines on the treatment of rheumatoid arthritis, including its first recommendations on the use of biologic disease-modifying antirheumatic drugs (DMARDs).

Highlights of the recommendations include:

  • Leflunomide or methotrexate monotherapy for all RA patients regardless of disease duration or activity;
  • Hydroxychloroquine or minocycline monotherapy for patients with low disease activity or duration less than 24 months;
  • Sulfasalazine monotherapy for patients without poor prognostic features;
  • Dual-DMARD combination of methotrexate plus hydroxychloroquine for patients with moderate to high disease activity regardless of disease duration or prognostic features;
  • Triple-DMARD therapy of sulfasalazine plus hydroxychloroquine plus methotrexate for all patients with poor prognostic features and moderate to high levels of activity, regardless of disease duration;
  • Anti-tumor necrosis factor agents with methotrexate in early RA for patients who had never received DMARDs and have high disease activity;
  • Anti-tumor necrosis factor agents in intermediate- and longer-duration RA for patients with moderate disease activity and poor prognostic features or patients with high disease activity, who had an inadequate response to prior methotrexate monotherapy;
  • Abatacept for patients with at least moderate disease activity and poor prognostic features who did not respond to methotrexate combined with DMARDs;
  • Rituximab for patients with high disease activity and poor prognostic features who did not respond to methotrexate combined with DMARDs;
  • Biologic therapy combinations are not recommended due to potential adverse events.

The recommendations[PDF] are published in the June 15, 2008 issue of Arthritis & Rheumatism.

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Study finds big increase in fatal drug errors at home

A recent analysis found that fatal medication errors at home account for an increasing number of deaths in the U.S.

In the study, published in the July 28 Archives of Internal Medicine, researchers analyzed almost 50 million U.S. death certificates between January 1983 and December 2004, 224,355 of which involved fatal medication errors. During the study period, the overall fatal medication error death rate increased by 360.5%, far exceeding the increase in death rates from adverse drug effects (33.2%) and alcohol and/or street drugs (40.9%). Marked increases were seen in fatal medication errors occurring at home, whether from combinations of prescription drugs with alcohol and/or street drugs (3,196% increase) or from prescription drug use alone (564% increase).

The observed shift from clinical to domestic locations in which many medications are consumed may be linked to the steep increase in fatal medication errors, said researchers. They noted that the findings reinforce the importance of professional oversight, including screening patients for drug or alcohol use, taking extra precautions when prescribing medicines with known dangerous interactions with alcohol or street drugs, and informing patients of the risks of mixing prescribed medications with alcohol and street drugs.

Even when alcohol abuse or use of street drugs is not suspected, researchers stressed the importance of physicians evaluating patients' capacity to manage their own medications, educating patients about risks associated with their prescriptions, and monitoring patients' progress at home.

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Report: $10 of personal prevention worth $16 billion in health care

Investing $10 per person per year in proven community-based programs that increase physical activity, improve nutrition and prevent tobacco use could save the country nearly $16 billion annually within five years, according to a new analysis.

The Trust for America’s Health (TFAH) issued its report, Prevention for a Healthier America: Investments in Disease Prevention Yield Significant Savings, Stronger Communities, which concluded that within five years Medicare could save more than $5 billion, Medicaid could save more than $1.9 billion, and private payers could save more than $9 billion.

TFAH based its findings on a model developed by researchers at the Urban Institute and a review of evidence-based studies conducted by the New York Academy of Medicine. They focused on programs that do not require medical care and target communities or at-risk segments. Examples include increasing access to affordable and nutritious foods, creating more sidewalks and parks and raising tobacco taxes. Many effective prevention programs cost less than $10 per person, and these programs have delivered results in lowering disease rates, according to the report.

Evidence shows that implementing these programs reduces rates of type 2 diabetes and high blood pressure by 5% within two years; reduces heart disease, kidney disease, and stroke by 5% within five years; and reduces some forms of cancer, arthritis, and chronic obstructive pulmonary disease by 2.5% within 10 to 20 years.

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Women’s health

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Diabetes increases birth defect risk

Women who have been diagnosed with diabetes before pregnancy are more likely to have a child with birth defects, according to a new national study.

The multi-center, case-control study included mothers of 13,000 infants who were born with birth defects and 4,900 who were born without. Data from nine states were gathered for this largest-ever study of birth defects in the U.S. Researchers compared the rates of individual and multiple defects in women with pre-gestational diabetes, gestational diabetes and no diabetes. Women with pre-pregnancy type 1 or type 2 diabetes were three times more likely than nondiabetic women to have infants with one birth defect and eight times more likely to be the mothers of children with multiple defects.

Gestational diabetes also carried some increased risk, but the association was primarily limited to women with a prepregnancy body mass index of at least 25. Researchers observed that birth defects associated with diabetes are most likely to occur during the first trimester, before a diagnosis of gestational diabetes is made, so some of the studied women who were categorized with gestational diabetes may actually have had undiagnosed diabetes before pregnancy. The study was conducted by the CDC and published in the American Journal of Obstetrics and Gynecology[PDF].

The results highlight the importance of increasing the number of women, especially those with diabetes, who receive the best possible preconception and prenatal care, said study authors. Given increasing prevalence of diabetes and the associated risks, researchers concluded that effective detection, control and prevention strategies are urgently needed to deal with impaired glucose tolerance in women of childbearing age.

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Migraine aura plus gene variant ups stroke risk

A certain gene variant appears to increase stroke and cardiovascular disease risk for women who have migraines with auras, according to a new study.

The study used data from 25,000 participants in the Women’s Health Study. About 18% of the women reported history of migraine, and 39.5% of the 3,226 with active migraines had auras. About 11% of the study population had a variant in the methylenetetrahydrofolate reductase gene. During the 12-year follow-up of the study, 625 cardiovascular events occurred.

Using logistic regression, the researchers determined that women who had both the studied gene variant and migraine with aura had more than four times the risk of stroke than women who had neither. Driven by the increased stroke risk, this group also had a three-fold increase in cardiovascular disease (CVD), even though no association was found between the genes, migraines and heart attacks. In women who had migraine with aura but not the variant, CVD risk was doubled. Those who had just the gene and no migraines had no increased risk.

It is too early to start testing young women with migraine with aura for the gene variant, and more research is needed to develop preventive strategies, said a study author. In the meantime, doctors should urge young women who experience migraine with aura not to smoke and to consider alternatives to oral contraception because it can increase the risk of ischemic vascular problems, the author said. The study was published online in the journal Neurology on July 30.

A press release from the American Academy of Neurology is online.

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Cardiology

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Aging population spurs sharp rise in heart failure hospitalizations

Hospitalizations for heart failure more than tripled between 1979 and 2004, with the sharpest increase among older patients covered by Medicare, a recent study found.

Researchers used data from the National Hospital Discharge Survey to assess trends in hospitalizations for heart failure as either a first or additional diagnosis. Hospitalizations with any mention of heart failure rose from 1.27 million in 1979 to 3.86 million in 2004, with more than 80% of the hospitalizations among patients 65 years or older.

Heart failure was listed as the first diagnosis in 30% to 35% of total hospitalizations. However, researchers noted increases in hospitalizations that listed respiratory diseases and noncardiovascular, nonrespiratory diseases as the first diagnosis, as well as an increase in transfers of heart failure patients to long-term care facilities. Meanwhile, in-hospital mortality and length of stay declined. The study appears in the Aug. 5 Journal of the American College of Cardiology.

Better control of other diseases that can exacerbate heart failure, such as pneumonia, diabetes and kidney disease, may help reduce hospitalizations of people with heart failure, a study author told the July 28 Washington Post. However, more research is needed to develop in-hospital treatments for severe heart failure, the author continued, since there is currently no effective treatment for heart failure severe enough to cause hospitalization.

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Annals of Internal Medicine

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No benefit from prostate screening for men over 75, task force says

The U.S. Preventive Services Task Force (USPSTF), updating its 2002 report, now recommends against routine prostate cancer screening for men over the age of 75. More evidence is needed to determine if men under 75 could benefit from screening, according to the updated recommendations in the Aug. 5 issue of Annals of Internal Medicine.

Previously, the Task Force concluded that there was insufficient scientific evidence to recommend screening for all men, and found inconclusive evidence that early detection improves health outcomes. While the prostate-specific antigen tests are effective for detecting disease, the Task Force found that there is insufficient evidence that they improve long-term health outcomes.

“We carefully reviewed the available evidence to measure the benefits and harms of screening for prostate cancer and could not find adequate proof that early detection leads to fewer men dying of the disease,” said Task Force Chair Ned Calonge, MD, MPH, who is also Chief Medical Officer for the Colorado Department of Public Health and Environment, Denver. “At this point, we recommend that men concerned about prostate cancer talk with their health care providers to make a decision based on their individual risk factors and personal preference.”

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Survey finds chronic illness common among uninsured

An analysis of data from the National Health and Nutrition Examination Survey (1999-2004) involving more than 12,000 patients aged 18 to 64 concluded that an estimated 11.4 million Americans with chronic medical conditions, such as cardiovascular disease, hypertension and diabetes, were uninsured.

The survey found that chronically ill patients without insurance were less likely than those with coverage to report a physician visit within the last 12 months and more likely to report using an emergency department as a standard site for care. The authors estimated that nearly one-third of uninsured U.S. adults had at least one chronic condition. However, authors said that given the limited access to care among those without insurance, undiagnosed conditions in this population may be common. The authors called for advocacy focused on expansion of health insurance coverage, as lack of health insurance is strongly associated with poor access to care.

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Rapid HIV test yields lower-than-expected specificity

Information is lacking about how often patients who have a positive rapid test in the emergency department actually have HIV infection confirmed with traditional HIV testing. In 2006, the Centers for Disease Control and Prevention (CDC) recommended that all persons aged 13 to 64 be offered HIV screening in health care settings.

In a study, 849 adults underwent HIV testing with the rapid test when they visited an emergency department for another reason. Of these, 39 tested positive. However, only five of the 39 were shown to actually have HIV infection after traditional testing was done. Twenty-six of 39 were negative and eight refused traditional testing. This study suggests that many patients who test positive with this rapid HIV test are false positives. The authors concluded that quick and more reliable methods of testing are needed.

In related news, the CDC reported this week that the number of new cases of HIV infection in the U.S. is approximately 40% higher than originally thought. The revised numbers are based on new laboratory testing methods that allow more precise measurements of HIV incidence, the CDC said in a press release. Further details are available in the Aug. 6 issue of JAMA.

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Combination incontinence therapies raise patient satisfaction

While urge incontinence, or "overactive bladder," is commonly treated with pharmacotherapy and behavior modification, most patients do not achieve complete continence with either therapy alone.

In a trial, 307 women with urge incontinence were randomly assigned to 10 weeks of drug therapy plus behavioral training or drug therapy alone. Six months later, 41% of women in both groups reported a 70% or greater reduction in the frequency of incontinence episodes without additional treatment. However, more women in the combination therapy group reported that they were completely satisfied with their progress than did women in the drug therapy alone group. According to the authors, the study results suggested that patient satisfaction may be influenced by other features such as volume of urine loss, frequency of voiding, or intensity of the urge sensation.

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Cognitive decline

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More seniors mean more 'moments'

New cases of mild cognitive impairment occur at about 5% per year, higher than the anticipated 1% to 2% incidence rate.

As part of the Mayo Clinic Study of Aging, researchers followed nearly 2,000 healthy people ages 70 to 89 years from Olmsted County, Minn., to detect the earliest point of cognitive impairment. Participants developed mild cognitive impairments at a rate of about 5.3% per year. The rate was 7.2% for 80- to 89-year-olds.

Researchers, who presented the study at the Alzheimer’s Association International Conference on Alzheimer’s Disease in Chicago, added that the finding highlights the urgency for developing new and better Alzheimer’s therapies as the baby boomers age. The primary author discusses his findings online.

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Regulatory news

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Access your 2007 PQRI feedback reports

CMS announced last week that the 2007 Feedback Reports from the Physician Quality Reporting Initiative (PQRI) are now available on the Web.

Physicians who registered and participated in the 2007 PQRI can access their reports on a secure Web site through the Individuals Authorized Access to CMS Computer Services (IACS). Physicians who are part of a group practice need to determine who in the practice will be designated to access the reports. Each organization that registers with IACS to view its reports will be limited to two individuals with access.

Information and instructions for registering with IACS can be found on the CMS Web site. Soon CMS will be posting summary instructions for accessing the 2007 reports on the site.

CMS introduced the PQRI in July of 2007. The program awards a bonus payment of 1.5% of allowed charges for Medicare patients to physicians who submit quality measure codes. More information about PQRI and changes in the program for 2008 are available from ACP.

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HRSA withdraws rule on HPSAs and MUAs

The Health Resources and Services Administration (HRSA) on July 23 withdrew a proposed rule that would have revised the designation process for health professional shortage areas (HPSAs) and medically underserved populations (MUPs).

The rule was an attempt to create a new three-tiered process for designating HPSAs and MUPs. The College and other medical organizations expressed concern about the new designation process, which would have resulted in fewer primary care HPSA designations and would have significantly impacted access to health care and primary care providers in this country.

In May, ACP sent comments jointly with several other physician groups to Michael O. Leavitt, secretary of Health and Human Services, asking that the rule be withdrawn. According to a preliminary analysis by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, approximately 600 HPSAs, containing nearly 32,000 primary care physicians and 32 million people, could lose designation under the rule, jeopardizing access to care for underserved people. It would be unreasonable for HRSA to hurriedly push this revision without more extensive consideration of its effects on patient care in this country, the physician groups said in their submitted comments[PDF].

The controversial proposed rule was withdrawn in response to comments HRSA received after the proposal was first published in the Federal Register on Feb. 29. Because of the substantive nature of the comments, the agency decided to wait and issue a new proposed rule instead of issuing the final rule as the next step.

The notice of withdrawal[PDF] and the proposed rule[PDF] are available on the Federal Register Web site.

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Test yourself

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MKSAP quiz: Menorrhagia

MKSAP case study:
A 32-year-old woman is evaluated during a routine examination. Her medical history is significant for heavy menses, which she has had since her early 20s. Her periods last from seven to 10 days, with a very heavy flow. She also has epistaxis approximately once per month, which has once required packing. She has been examined by her gynecologist on several occasions for her menorrhagia, but no obvious gynecologic cause for her condition was determined. Her mother and one of her three sisters have also had heavy menses.

Physical examination, including vital signs, is normal. Laboratory studies include a prothrombin time of 12 s and an activated partial thromboplastin time of 39 s. The complete blood count indicates a hemoglobin of 10.3 g/dL (103 g/L), leukocyte count of 5400/μL (5.4 × 109/L), mean corpuscular volume of 72 fL, and platelet count of 500,000/μL (500 × 109/L).

Which of the following is the most likely cause of this patient's menorrhagia?

A) Essential thrombocytosis
B) Hemophilia A
C) von Willebrand's disease
D) Factor XII deficiency

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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ACP helps revise CMS rule on costly security paper for tamper-proof Rx

ACP played a key role in revising CMS guidance on tamper-resistant Medicaid prescriptions, allowing physicians who use electronic health records (EHRs) to use plain printer paper instead of special security paper.

The Medicaid Tamper Resistance Prescription Pad law was written to decrease prescription fraud and drug diversion resulting from unauthorized copying or alteration of legitimate prescriptions, and filling of counterfeit prescriptions. All prescription pads used for Medicaid will have to meet an expanded set of tamper-proof requirements by Oct. 1. In the fall of 2007, CMS declared that the law applied not just to written prescription pads, but also to EHR users who print prescriptions for Medicaid.

Peter Basch, FACP, who represented ACP during the CMS' guidance review process, said EHR users must print prescriptions for controlled substances, when the patient hasn't chosen a pharmacy, won't need the prescription for several weeks or just prefers a paper prescription. Dr. Basch, who oversees EHR implementation for a nonprofit health care and hospital chain in the Baltimore-Washington, D.C. area, determined that accommodating tamper-resistant paper would cost his organization between $1 million and $1.5 million, with ongoing costs of hundreds of thousands of dollars per year for special paper.

Dr. Basch and Sarah Corley, FACP, proposed applying security features found on paper checks to prescriptions. The first was micro-printing, very small text that is legible under magnification on originals but illegible when copied. The second was a void pantograph, which appears as small background dots that display the word “VOID” when copied. These could be embedded into an EHR's prescription template and printed on plain paper. CMS has agreed to both measures.

ACP members can read the full details of these revised rules and are also reminded that states may create guidance that is more proscriptive than the CMS rules. For additional information on state requirements, check your state's Medicaid Web site or the National Association of State Medicaid Directors Web site.

ACP will follow up with further details on tamper-proof prescription pad requirements under Medicaid as the Oct. 1 deadline approaches.

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From ACP Internist

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On the blogs: More exercise needed to maintain weight loss

Overweight and obese women need to exercise almost an hour a day, five days a week, just to sustain weight loss. And they must do that in addition to continuing to limit their calories. Find this and Medical News of the Obvious new every Monday on ACP Internist's blog.

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Cartoon caption contest

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July's winning entry

ACP InternistWeekly has compiled the results from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

This issue's winning cartoon caption was submitted by Jerry Antonini, ACP Member, of OSF HealthCare in Bloomington, Ill. He will receive a $50 gift certificate good for any ACP program, product or service. Readers cast 183 ballots online to choose the winning entry. Thanks to all who voted!

The winning entry:

Your insurance plan considers all of your conditions 'pre-existing.'
"Your insurance plan considers all of your conditions 'pre-existing.'"

The winning caption received 54.6% of the votes cast. The runners up were:
"Please stop comparing me to your last doctor." (29.5%)
"In your condition, I consider your gait to be normal." (15.8%)

The cartoon contest continues in August.

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MKSAP answer

Answer: C) von Willebrand's disease

The complete MKSAP critique on this topic is available to subscribers as item 33 in the Hematology/Oncology book.

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 InternistWeekly.

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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 50-year-old man is evaluated in follow-up for a recent diagnosis of cirrhosis secondary to nonalcoholic steatohepatitis. He has a history of asthma, type 2 diabetes mellitus, hyperlipidemia, and obesity. His current medications are inhaled fluticasone, montelukast, insulin glargine, insulin lispro, simvastatin, and lisinopril. Following a physical exam, lab studies, and upper endoscopy, what is the most appropriate treatment?

Find the answer

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