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


In the News
for the Week of 9-16-08


  • New ACP guideline for drug treatment of osteoporosis and low bone density
  • Patient medical homes slow going, but one group finds benefits
  • Arthroscopic surgery for knee osteoarthritis yields no benefit over drugs, physical therapy

Test yourself

  • MKSAP quiz: fever, cough and wheezing


  • Benefits of glucose control persist after therapy stopped
  • Tight BP control does not produce long-term effects

Career trends

  • Put off by challenges of primary care, younger docs opt for subspecialties

FDA news

  • Recalls of LifePak external defibrillators, Thymoglobulin
  • New Rituxan prescribing information reflects fatal PML case

Quality reporting

  • AMA seeking physician input on quality reporting initiative

Annals of Internal Medicine

  • Massage therapy provides relief for advanced cancer patients
  • Respiratory drugs linked to increased death risk in veterans with COPD
  • Early release: review of comparative effectiveness of premixed insulin for type 2 diabetes

College news

  • Master named president of informatics group
  • Turn to ACP's Web tools for election news
  • ACP partners on conference on EHRs
  • Closing the Gap: Diabetes Care open for enrollment

Cartoon caption contest

  • Put words in our mouth …


New ACP guideline for drug treatment of osteoporosis and low bone density

A new clinical practice guideline issued today in Annals of Internal Medicine recommends physicians offer drug treatment to men and women who have been diagnosed with osteoporosis or a previous fracture not caused by substantial trauma.

While authors did not find evidence to prove one drug’s definitive advantage over other medications in the treatment of the disease, they pointed to good information that bisphosphonates are reasonable options for beginning drug treatment as they decrease the risk of vertebral, non-vertebral, and hip fractures.

“Because treatment options may affect various parts of the skeletal system differently, we analyzed the available evidence on numerous drugs to prevent fractures in men and women,” said Vincenza Snow, FACP, a co-author of the guideline and Director of Clinical Programs and Quality of Care at ACP. “Bisphosphonates can be considered a first-line therapy, particularly for patients at risk for hip fracture. However, there is no clear evidence showing the appropriate duration of treatment with these drugs.”

In the guideline, the authors encourage doctors and their patients to consider drug treatment to prevent fracture for men and women who are at risk of developing osteoporosis, and also urge physicians to make individual treatment decisions based on the risks, benefits, and side effects profile of available drug options.

The “Pharmacologic Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women” guideline is based on a systematic evidence review of previously published studies is available online:

A clinical practice guideline on screening for osteoporosis in men was released in May.


Patient medical homes slow going, but one group finds benefits

Large practices adopted the patient-centered medical home (PCMH) model sooner than small ones, but it is slow going regardless of practice size, said one study. However the model cut one health chain's hospital admissions by 20% and costs by 7%, according to another study.

The first study, from Health Affairs (subscription required), assessed how much infrastructure that large practices have in place to support the PCMH concept. Acknowledging that infrastructure isn't necessarily implementation, researchers used data from the 2006-07 National Study of Physician Organizations and the Management of Chronic Illness, a 30-minute phone survey of managers of large practices. Researchers identified 291 medical groups who responded to the survey and that treat four chronic ailments: asthma, diabetes, congestive heart failure and depression.

Results showed:

  • One-third use primary care teams at a majority of their practice sites;
  • 41% have a majority of physicians use a basic electronic medical record;
  • 65% participate in quality improvement collaboratives;
  • Except for distributing guidelines, less than half of the groups use patient educators and other health promotions); and
  • 30% use group visits for chronic illnesses.

A second paper highlighted success from Geisinger Health System, a series of hospitals, employed physicians, clinics, programs and a health plan in central and northeastern Pennsylvania. Administrators outlined their application of PCMH-like concepts in a second paper in Health Affairs.

As just one example of its efforts, Geisinger offers its physicians monthly payments of $1,800 per doctor to recognize an expanded scope of practice, and monthly stipends of $5,000 per thousand Medicare patients to pay for extra staff and extended hours. Monthly performance reports are reviewed and the payouts are then prorated to quality measures.

First-year results at two pilot sites showed a 20% reduction in all-cause hospital admissions and 7% total medical cost savings. Geisinger will roll out 10 more in-system sites and one non-system site.

The report outlines three implications when applying its experience to national health change:

Aligned incentives. Geisinger subsidizes "important but nonprofitable functions (such as primary care, autism treatment, and so forth.)" Commercial insurers would need to adopt similar methods to reap benefits.
Electronic infrastructure. EHRs offered benefits only years after installing them.
Collaboration and integration. Geisinger can offer incentives otherwise not allowed by regulations that prohibit hospital-physician collaborations, the report said.


Arthroscopic surgery for knee osteoarthritis yields no benefit over drugs, physical therapy

Arthroscopic surgery for knee osteoarthritis adds no additional, long-term benefit beyond what is achieved with physical and medical therapy, a new study found.

The study involved 178 men and women with moderate-to-severe knee osteoarthritis and an average age of 60, all of whom received standardized physical therapy, as well as medical treatment with acetaminophen, NSAIDS, hyaluronic acid and/or glucosamine according to an evidence-based algorithm. Nearly half of the patients also received surgical lavage and arthroscopic debridement along with these therapies. All patients were seen in the clinic at 3, 6, 12, 18 and 24 months after the start of treatment. The study was published in the Sept. 11 New England Journal of Medicine.

At the end of two years, patients who underwent surgery saw no greater improvement in scores measuring physical function, pain or health-related quality of life than those who underwent physical/medical therapy alone. Surgery patients did see a greater improvement in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores in the first three months, but this vanished on further follow-up. The authors chalked up the result to a short-term placebo effect.

The study's results are in line with a 2002 study conducted by a single surgeon that found a sham operation was just as effective as knee surgery, the authors noted, and should call into question the widespread use of arthroscopic surgery to treat knee osteoarthritis. An editorialist wrote, however, that arthroscopic surgery may still be appropriate for some patients with arthritis if the osteoarthritis isn't the primary cause of pain.


Test yourself

MKSAP quiz: fever, cough and wheezing

A 35-year-old woman has a 3-day history of fever, productive cough, and wheezing. Her 2-year-old son recently had a cough and fever to 38.9° C (102° F) that subsequently resolved. The patient has mild asthma that has not required treatment. She has a 10-pack-year smoking history but stopped smoking 3 years ago.

On physical examination, she coughs frequently and has mildly audible wheezing. Temperature is 38.2° C (100.8° F), pulse rate is 100/min, respiration rate is 16/min, and blood pressure is 115/75 mm Hg. Examination of the chest reveals bronchial breath sounds and a few crackles in the lateral right lower chest near the mid-axillary line. Arterial oxygen saturation is 94% by pulse oximetry with the patient breathing room air.

The leukocyte count is 11,900/ μL (11.9 × 109/L) with 80% neutrophils, 2% band forms, 14% lymphocytes, and 4% monocytes. A chest radiograph shows right middle lobe consolidation.

In addition to starting inhaled bronchodilators, which of the following is most appropriate at this time?

A) Await results of sputum culture before beginning therapy
B) Begin trimethoprim–sulfamethoxazole
C) Begin ciprofloxacin
D) Begin azithromycin
E) Begin gentamicin

Click here or scroll to the bottom for the answer.



Benefits of glucose control persist after therapy stopped

Tight glucose control improves the cardiovascular risk of patients with type 2 diabetes years after intensive therapy is discontinued, a new study found.

Researchers looked at follow-up data from the United Kingdom Prospective Diabetes Study, in which 4,209 newly diagnosed patients were randomly assigned either conventional diabetes therapy (dietary restriction) or intensive therapy (either sulfonylurea or insulin or, in overweight patients, metformin). After the trial was concluded, 3,277 of the patients were followed over the next 10 years. The results were published in the Sept. 10 online New England Journal of Medicine.

One year after the study, differences between the groups in glycated hemoglobin levels had disappeared. However, after 10 years, the sulfonylurea-insulin group still had a 9% risk reduction in all diabetes-related end points, 24% lower rates of microvascular disease, and 15% and 13% reductions in myocardial infarction and death from any cause, respectively. The metformin group had even more dramatic differences, with 21% lower diabetes-related end points, 33% lower MI, and 27% less death from any cause.

The results of this study, which included more than 66,000 person-years of follow-up, indicate that the "legacy effect" of intensive glucose lowering is longer than has been previously reported, the authors concluded. The findings highlight the importance of glucose lowering (in addition to lipid-lowering and antihypertensive therapy) in reducing the risk of coronary events and death for patients with type 2 diabetes, they said.


Tight BP control does not produce long-term effects

In patients with type 2 diabetes, tight blood-pressure control reduces complications in the short-term but the benefits disappear after the intensive treatment stops, according to a new study.

In the United Kingdom Prospective Diabetes Study, 1,148 newly diagnosed patients (who also had hypertension) were randomly assigned to four years of tight or less-tight control of blood pressure. After the study, 884 of the patients were followed, through questionnaires and/or clinic visits, for 10 more years. The results were published in the Sept. 10 online New England Journal of Medicine.

During the trial, the two groups had significant differences in blood pressure, several diabetes-related endpoints (including diabetes-related death), and stroke. However, the differences in blood pressure disappeared within two years of the trial's termination. There was a continuing risk reduction in peripheral vascular disease in the tight-control group, but otherwise, the researchers found no sustained benefit for patients who had tight control of blood pressure. The two groups had no significant differences in myocardial infarction, death, or any of the additional endpoints.

The authors concluded that optimal blood-pressure control is important to reducing diabetic patients' risk of micro- and macrovascular disease, but that the treatment must be maintained in order for patients to sustain the benefits over the long term.


Career trends

Put off by challenges of primary care, younger docs opt for subspecialties

A survey of graduating medical students found that only 2% planned to specialize in general internal medicine, and that lifestyle was more important than financial compensation in their decisions to choose subspeciality careers over primary care.

The survey of more 1,174 fourth-year medical students at 11 U.S. medical schools found that while 23.2% of respondents planned careers in internal medicine (IM) and were satisfied with the quality of their educational experience, many had reservations about the lifestyle and financial rewards associated with practicing primary care compared with subspecialty careers. Concern about the challenges of caring for elderly patients with complex chronic diseases in the current practice environment also contributed to students' low interest in general IM. The results appear in the Sept. 10 Journal of the American Medical Association.

Even though many procedure-based subspecialties come with substantially higher incomes than IM, researchers found that interest in IM was low regardless of debt level. Overall, lifestyle was the most important factor in selecting a career path, the survey found. Many respondents said that they were influenced not to choose general IM by hearing disgruntled practicing internists talk about pressure to keep visits short despite the complexity of patients' conditions and increasing administrative expectations.

In related news, a survey of final-year medical residents by Merritt Hawkins & Associates similarly found that younger doctors tend to value lifestyle over financial rewards when choosing careers. In assessing job opportunities, 57% of respondents to the national survey rated "geographic location/lifestyle" as the most important factor in their decision, while 46% listed financial package and 42% named loan forgiveness. Having adequate call and personal time was rated highly by 82% of respondents.

The resident survey also found that only 1% of respondents found solo practice attractive, while 70% hoped to work in a large group or hospital. Only 3%-4% of respondents said they would prefer to practice in a rural setting, while upward of 80% said they hoped to practice in communities of 50,000 or more.


FDA news

Recalls of LifePak external defibrillators, Thymoglobulin

The FDA issued a Class I recall of LifePak CR Plus Automated External Defibrillators (AED) because a flaw in the product's design makes it difficult to operate, according to an alert last week.

Specifically, the AED's voice prompt says to press a shock button which is not visible because it is covered. The device should be removed from service, or the manufacturer-provided diagram should be consulted to remove and discard the shock button cover, the FDA said.

Separately, the FDA issued a recall of 25 mg/vial Thymoglobulin (anti-thymocyte globulin [Rabbit]) with lot number C7010C01, because it failed a periodic stability test based upon the appearance of the product. Providers and hospitals should return the product to its manufacturer, Genzyme Corporation, an FDA notice said. A similar recall of three other lots of Thymoglobulin was issued last April.


New Rituxan prescribing information reflects fatal PML case

Prescribing information for rituximab (Rituxan) has been revised to reflect a fatal case of progressive multifocal leukoencephalopathy (PML) that developed in a patient with rheumatoid arthritis, the FDA said in an alert.

This is the first reported case of PML in a Rituxan-treated patient with rheumatoid arthritis, the company said in a letter[PDF] to healthcare providers. The patient, who received the drug in a long-term safety extension clinical study, died 18 months after taking the last dose of Rituxan. S/he first developed a JC virus infection, then PML. The drug's prescribing information already includes reports of PML in patients with hematologic malignancies and autoimmune diseases.

Providers who treat patients with rituximab should consider PML in any patient who presents with new onset neurologic symptoms. Brain MRI, lumbar puncture and consultation with a neurologist should also be considered, if indicated.


Quality reporting

AMA seeking physician input on quality reporting initiative

The AMA has put together a survey about physician experience with the Medicare Physician Quality Initiative (PQRI) in 2007 and is seeking information from physicians about their experience with the program, which involved a six-month reporting period.

The PQRI, introduced by CMS in July 2007, pays physicians a bonus for reporting quality data to CMS on their claims forms. It awards a bonus payment of 1.5% of allowed charges for Medicare patients to physicians who submit quality measure codes. The 2007 feedback reports and payments were distributed, starting in mid-July. The program was renewed for 2008 with some changes, and the reporting period for 2008 runs through the end of the year.

ACP has heard from some members about their experience and concerns with PQRI 2007. These include: failure to qualify for a bonus they thought they had earned; receiving a lower bonus amount than expected; and difficulty in accessing reporting and performance scores through CMS’s secure Web site. The College is encouraging all members who participated in PQRI to take the survey so that AMA, ACP, and other physician organizations can have the best possible information to use in advocating program improvements to CMS.

The online survey from AMA takes 10 to 15 minutes to complete. The responses are anonymous and can not be linked to your identity unless you choose to provide your email address at the end of the survey. Go online to take the survey.


Annals of Internal Medicine

Massage therapy provides relief for advanced cancer patients

A new study from the National Institutes of Health finds that massage therapy may have immediate benefits on pain and mood among patients with advanced cancer. In a randomized trial of 380 advanced cancer patients at 15 U.S. hospices, improvement in pain and mood immediately following treatment was greater with massage than with simple touch.

Researchers speculated that massage may interrupt the cycle of distress, offering brief physical and psychological benefits. Physically, massage may decrease inflammation and edema, increase blood and lymphatic circulation, and relax muscle spasms. Psychologically, massage may promote relaxation, release endorphins, and create a positive experience that distracts temporarily from pain and depression. Researchers cautioned that while massage may offer some immediate relief for patients with advanced cancer, the effects do not last over time, demonstrating the need for more effective strategies to manage pain at the end of life. A report in streaming video format is online.


Respiratory drugs linked to increased death risk in veterans with COPD

In a large-scale, case-control study examining associations between commonly prescribed respiratory medications and risk for death in veterans with newly diagnosed COPD, researchers followed a cohort of patients enrolled in the U.S. Veterans Health Administration health care system to assess mortality rates at one year. Inhaled corticosteroids were associated with decreased risk for death, while theophyline and ipratropium were associated with increased risk for respiratory and cardiovascular death, respectively. Ipratropium was associated with an 11% increase in the risk for death, raising researchers’ concerns about the potential harm associated with the drug rather than simply a lack of effectiveness. Researchers urge more research to weigh the benefits of these medications against the risk for death.


Early release: review of comparative effectiveness of premixed insulin for type 2 diabetes

According to a National Health Interview Survey, 28% of patients with type 2 diabetes use insulin alone or in combination with oral antidiabetic agents to control their glucose levels. Because of the increasing prevalence of type 2 diabetes, the number of patients who use insulin for glycemic control, and the importance of glycemic control in decreasing mortality and morbidity, researchers wanted to establish the weight of evidence for the safety and effectiveness of premixed insulin compared with other antidiabetic agents. Researchers at the Agency for Healthcare Research and Quality found that premixed insulin provides tighter glycemic control than long-acting insulin and non-insulin antidiabetic agents. However, researchers cautioned that studies with longer follow-up are needed to determine long-term outcomes. The article will be published in the October 21 print issue of Annals of Internal Medicine.


College news

Master named president of informatics group

The American Medical Informatics Association (AMIA), a professional organization for biomedical and health informatics, last week announced the appointment of Edward H. Shortliffe, MACP, as its incoming president and chief executive officer. He will assume the role full-time in July 2009. Dr. Shortliffe comes to AMIA from the University of Arizona, where he is a professor of basic medical sciences, medicine, and (at Arizona State University) biomedical informatics. He was also founding dean of the Phoenix campus of the University of Arizona's College of Medicine. Dr. Shortliffe is a founding member of AMIA.


Turn to ACP's Web tools for election news

The presidential election campaigns are in full swing, and the candidates continue to release details about their proposed health care reforms. However, these proposals can often be difficult to sort through. ACP has developed several tools to help internists cast a critical eye over these plans and find ways to get involved.


ACP partners on conference on EHRs

Join national, state and local leaders and policy-makers as they take the pulse of medicine’s adoption of electronic health records. The eHealth Initiative’s Fifth Annual Conference and Awards Dinner, of which ACP is a strategic partner, will be held Dec. 3-5 in Washington, D.C.

Key focus areas of the conference include:

  • improvements in quality and efficiency,
  • engaging consumers and patients,
  • care coordination and chronic care management,
  • increasing access and addressing disparities,
  • getting to better evidence on outcomes and effectiveness,
  • financing and sustainability,
  • standards for interoperability, and
  • privacy and confidentiality.

Registration is online.


Closing the Gap: Diabetes Care open for enrollment

ACP’s first entirely web-based quality improvement program, Closing the Gap: Diabetes Care, is now available to members. The team-oriented, practice-based, online educational intervention program is designed to help physicians and their staffs develop strategies for creating practice-wide systems change to improve the care of patients with diabetes. It incorporates the Chronic Care Model for systems change, the Plan-Do-Study-Act (PDSA) cycle for quality improvement, and individualized coaching by expert faculty.

Participants in previous ACP Closing the Gap programs have shown statistically significant improvement in both process and outcomes measures for diabetes, and the current program offers many new benefits. They include online access to educational modules on the chronic care and Plan-Do-Study-Act (PDSA) models, the latest standards of care for diabetes, and entry forms for baseline and follow-up data. Additionally, regular conference calls with experienced faculty allow participants to share successes and challenges with colleagues, and participants can earn over 50 hours of both traditional and practice-based CME credit; those who complete baseline and follow-up assessments are eligible for the ABIM's Part 4 MOC.

For more information, please visit the Web site or contact Lia Bennett at 215-351-2602.


Cartoon caption contest

Put words in our mouth …

ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner. Craft your caption “Mad Libs” style by filling in the blanks to the caption we’ve started.

Cartoon caption contest
“It’s _______ [noun]. They’re ____ [adjective] about their _____ [noun].”

E-mail all entries by Sept. 19. ACP staff will choose three finalists and post them in the Sept. 23 issue of ACP InternistWeekly for an online vote by readers. The winner will appear in the Sept. 30 issue.

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



MKSAP Answer

D) Begin azithromycin

The complete MKSAP critique on this topic is available to subscribers in Infectious Disease, Item 114.

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.

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 28-year-old man is evaluated for pain on the radial aspect of the right wrist that occurs with use of the thumb. The pain has been present for 2 weeks. He has never had this pain before and has not had any trauma. He works as a computer programmer and plays video games for 3 to 4 hours each night when he gets home from work. Following a physical exam, what is the most likely diagnosis?

Find the answer

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Internal Medicine Meeting 2015 Live Simulcast!

Internal Medicine Meeting 2015 Live Simulcast

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