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

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In the News
for the Week of 9-23-08

Highlights

  • Study supports longer intervals between colorectal cancer screenings
  • Health officials try to raise awareness of DVT

Test yourself

  • MKSAP quiz: Patient management

Disease prevention

  • Pelvic floor disorders very common, especially in seniors
  • Time to talk to patients about immunization

Cardiology

  • Using beta blockers to prevent heart failure carries stroke risk for elderly

Drug news

  • FDA bans dozens of generics from entering U.S. over quality concerns

College news

  • College releases policy paper calling for support of IMGs
  • Turn to ACP's Web tools for election news

From ACP Internist

  • On the blog: new diabetes device on the horizon
  • Cartoon caption contest: vote for your favorite entry

Highlights

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Study supports longer intervals between colorectal cancer screenings

Two studies published last week bolster the evidence for recommending screening colonoscopy every five to 10 years for people who have had normal exam results, and recommending computed tomographic colonography as a noninvasive alternative to colonoscopy.

In the first study, researchers analyzed 2,531 CT colonographic images from asymptomatic adults age 50 or older at 15 study centers and found that CT colonographic screening identified 90% of subjects with adenomas measuring 10 mm or more in diameter, with 86% specificity. The second study identified 2,436 adults (mean age 56.7 years) with no adenomas on baseline screening who returned for a five-year follow-up colonoscopy. No cancers were found on rescreening, although advanced adenomas developed in 1.3% of patients and men were more likely than women to have an advanced adenoma. The studies appear in the Sept. 18 New England Journal of Medicine.

The results of the first study suggest that CT colonography is accurate enough to substitute for screening colonoscopy, said an editorial, but physicians should consider the consequences of a positive finding. In the study, 17% of patients had a positive finding for one or more polyps 1 cm or larger, but only 1 in 4 of those actually had polyps and extracolonic findings were common. While some extracolonic findings are life-threatening, few can be effectively treated, the editorial said, and positive colonographies require follow-up testing with diagnostic colonoscopy.

The low rates of cancer and advanced adenomas found in the second study support a five-year interval between screenings, said the authors. However, it is not clear whether that can be extended to 10 years, as some guidelines recommend. Many endoscopists say they perform follow-up tests at substantially shorter intervals than what is recommended by expert groups, but that carries a cost, noted the editorial, considering that colonoscopy is somewhat risky as well as inconvenient and costly compared with other screening tests.

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Health officials try to raise awareness of DVT

Deep vein thrombosis (DVT) is the target of a new awareness campaign announced last week by the AHRQ and the Surgeon General's office.

Acting Surgeon General Steven K. Galson, MD, issued a call to action urging clinicians and patients to reduce the incidence of deep vein thrombosis and pulmonary embolism (PE). Annually, the conditions affect an estimated 350,000 to 600,000 Americans and contribute to at least 100,000 deaths, a press release said. Risk factors, in addition to hereditary clotting disorders, include being hospitalized or confined to bed rest, having major surgery, suffering a trauma, or traveling for several hours, Dr. Galson noted.

The call to action resulted from a 2006 Surgeon General's Workshop on the disorders and its goals include:

  • increasing awareness about DVT and PE;
  • encouraging evidence-based practices for DVT; and
  • obtaining more research on the causes, prevention and treatment of DVT.

The AHRQ has released two new resources to help physicians and consumers prevent the blood clots from developing. The clinician guide, "Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement," is a 60-page guide which details how to start, implement, evaluate and sustain a quality improvement strategy. It includes case studies, as well as example forms.

The AHRQ's consumer booklet is a 12-page easy-to-read resource that helps patients and their families identify the causes and symptoms of blood clots, learn tips on how to prevent them and know what to expect during treatment. Both guides and a press release are on the AHRQ Web site.

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Test yourself

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MKSAP quiz: Patient management

A 43-year-old woman is evaluated during an initial visit. She has brought with her a written list of health problems, including headaches, muscle pain and weakness, abdominal pain, diarrhea, sinusitis, and frequent urinary tract infection. She also reports problems with sexual intimacy. For the past 4 years, her health problems have interfered with her ability to work. Previous treatments for headache have included venlafaxine, verapamil, propranolol, and gabapentin. For each of these, she reports no relief or an intolerance to the medication. Previous evaluation by a neurologist, gastroenterologist, and rheumatologist yielded no diagnosis of her medical problems. Previous laboratory studies, including complete blood count; erythrocyte sedimentation rate; serum B-12/folate, electrolyte, creatinine, blood urea nitrogen, and thyroid-stimulating hormone levels; liver chemistry tests; serum lipid panel; serum rheumatoid factor and antinuclear antibody assays; heterophile antibody testing; and urinalysis, were normal. Results of MRI of the head, colonoscopy, and CT of the abdomen were negative. She has not had any tick exposures or bites nor any memory of experiencing an expanding red rash. The patient describes health problems in response to each portion of the general review of systems. When she is asked if she feels depressed, she becomes visibly angry.

The physical examination, including vital signs, is normal.

Which of the following is the most appropriate management option for this patient?

A) Repeated MRI of the head
B) Cognitive behavioral therapy
C) Enzyme-linked immunosorbent assay for Borrelia burgdorferi
D) Lumbar puncture and cerebral fluid analysis
E) Switch from nortriptyline to venlafaxine

Scroll to the bottom or click here to review the answer.

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Disease prevention

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Pelvic floor disorders very common, especially in seniors

Almost a quarter of U.S. adult women has one or more pelvic floor disorders, according to the first nationwide, population-based study of the conditions.

In the 2005-2006 National Health and Nutrition Examination Survey, 1,961 women over age 20 were examined and interviewed about their experience with urinary incontinence, fecal incontinence and pelvic organ prolapse. Among the study subjects, 15.7% experienced urinary incontinence, 9% had fecal incontinence and 2.9% had experienced symptoms of pelvic organ prolapse.

Risk for the condition increased with age, weight and parity. About 10% of women under 40 had at least one disorder, compared with almost 50% of those 80 and over. Among obese study participants, 30.4% had at least one of the problems, as did 26% of overweight women and 15% of women of normal weight. Unlike past research on the conditions, no differences in prevalence were found by ethnic or racial group. The study was published in the Sept. 17 Journal of the American Medical Association.

The study's prevalence statistics are probably underestimates, study authors said, because they defined the conditions conservatively, and their symptom-based diagnostic criteria would exclude women who had undergone successful treatment and those who had not noticed pelvic organ prolapse. The researchers concluded that pelvic floor disorders affect a substantial proportion of women, especially older ones.

They suggested that further research is needed to understand the pathophysiology, prevention and treatment of the conditions. In a press release, a representative of the National Institute of Child Health and Human Development, which helped fund the study, said that the NIH Pelvic Floor Disorder Network is currently conducting studies toward that goal.

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Time to talk to patients about immunization

During National Adult Immunization Week this week, CMS is reminding physicians that Medicare Part B reimburses for influenza, pneumococcal, and hepatitis B vaccines and their administration.

All adults age 65 and older should get influenza and pneumococcal shots, and Medicare beneficiaries who are under age 65 but have chronic illness, including heart disease, lung disease, diabetes or end-stage renal disease should get a flu shot. People at medium to high risk for hepatitis B should get hepatitis B shots.

For more information about Medicare’s coverage of adult immunizations and a list of related educational resources, visit CMS’ Medicare Learning Network Preventive Services Educational Products Web page. Medicare's Web site also has information about coverage of the influenza virus vaccine[PDF] as well details on how to order a free quick reference chart on Medicare Part B Immunization Billing[PDF].

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Cardiology

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Using beta blockers to prevent heart failure carries stroke risk for elderly

Beta blockers prevent heart failure about as well as other drugs, but they shouldn't be used as first-line agents due to a heightened risk of stroke in the elderly, authors of a new study concluded.

Researchers analyzed the results of 12 randomized controlled trials which evaluated 112,177 patients with hypertension. All studies evaluated beta blockers as first-line therapy, had a follow-up of at least one year, and included data on new-onset heart failure—the primary outcome. The study was published in the Sept 16 Journal of the American College of Cardiology.

Beta blockers lowered blood pressure by 12.6/6.1 mm Hg compared with placebo, or a 23% trend reduction in heart failure risk (p=0.055). This is comparable to other antihypertensive drugs, as were the results for myocardial infarction, all-cause mortality and cardiovascular mortality. However, beta blockers conferred a 19% higher stroke risk for people age 60 years and older.

Study limitations include that researchers didn't adjust their analyses for dose of medication used, or for compliance to treatment. Heart failure was also a secondary end point in the trials studied, so it's possibly they weren't sufficiently powered to evaluate the current analysis' end point. Also, 66% of the patients on beta blockers were taking atenolol, so the results may not be generalizable to other beta blockers.

The authors concluded that beta blockers appear to be as effective as other antihypertensives in preventing heart failure, but their associated risk of stroke for elderly patients suggests they shouldn't be used as primary prevention, except in certain circumstances like prior myocardial infarction.

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Drug news

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FDA bans dozens of generics from entering U.S. over quality concerns

The FDA banned more than 30 Indian-made generic drugs from entering the U.S. last week over "deficiencies … in the manufacturing process," a press release said.

The drugs, made by Ranbaxy Laboratories, come from two specific facilities in India, and include simvastatin, metformin, pravastatin, amoxicillin, clarithromycin. A complete list of affected drugs is available on the FDA site.

The action is a proactive measure; as of press time, there was no evidence that people had been harmed from the drugs, and the drugs which are already in the U.S. don't appear to pose a risk, an FDA official said in a Sept. 16 Washington Post article. The agency has determined that its action won't lead to a drug shortage, except in the case of the antiviral ganciclovir, because Ranbaxy is its sole U.S. supplier. As such, the FDA won't detain shipments of this drug, but plans to enhance oversight of it.

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From the College

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College releases policy paper calling for support of IMGs

ACP has released a new position paper[PDF] calling on the U.S. to enact measures that would support the important role that international medical graduates (IMGs) “have and will continue to have” in the internal medicine workforce.

"The College has long recognized the value of IMGs in the U.S. health care system," said Jeffery P. Harris, FACP, president of ACP. "They are crucial to our continuing to be able to provide adequate care to the populations they serve."

As part of the paper, the College listed seven recommendations to improve conditions for physicians seeking to train and practice in the U.S. ACP:

  • opposes measures that would prevent qualified IMGs from emigrating to the U.S.;
  • supports streamlining the process for IMGs to obtain J-1 and H-1B visas;
  • supports a permanent expansion of J-1 visa waiver programs to help alleviate physician shortages in underserved areas;
  • supports exempting physicians trained in specialties facing a shortage from the annual H-1B visa cap;
  • supports classifying physicians trained in internal medicine and other specialties facing a shortage as Schedule A under the Department of Labor, indicating there is an insufficient number of U.S. workers for that occupation;
  • encourages collaborations between the U.S. and less-developed countries to improve medical education and training in those countries; and,
  • supports the development of a Global Health Corps to provide opportunities for U.S. physicians and providers to serve in less-developed countries.

The paper also noted that while ACP strongly advocates for policies to support the role of IMGs in meeting the U.S. health care needs, the College also advocates for policies that would increase the number of U.S.-trained physicians in primary care. The College cautions that IMGs should not be viewed as the solution to physician workforce shortages.

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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.

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From ACP Internist

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On the blog: new diabetes device on the horizon

On the ACP Internist blog this week, we look at trials of a gastrointestinal liner for type 2 diabetes , the effectiveness of TV shows in providing health information, and as always, Medical News of the Obvious.

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Cartoon caption contest: vote for your favorite entry

ACP InternistWeekly's cartoon caption contest continues. ACP staff has selected three finalists for the latest contest and is now asking readers to vote for their favorite caption to determine the winner. In this contest, readers were asked to fill in the blanks "Mad Lib" style in this caption: It's ________. They're ________ about their __________.

Cartoon caption contest: vote for your favorite entry

Go online to view the cartoon and pick the winner, who receives 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

B) Cognitive behavioral therapy

The complete MKSAP critique on this topic is available to subscribers in General Internal Medicine, Item 130.

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.

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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 42-year-old woman is evaluated for an 8-month history of crampy abdominal pain and three loose bowel movements per day. The pain is relieved by a bowel movement. There are no nocturnal bowel movements, and there is no blood or dark tarry material in the stool. She has not had fever, night sweats, or weight loss. She has a history of Hashimoto disease and is treated with levothyroxine. Following a physical exam, rectal exam, and lab tests, what is the most appropriate next step in management?

Find the answer

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