In the News
for the Week of 1-13-09
- Cardiology criteria guide therapy over intervention for chest pain
- Salmonella outbreak sickens nearly 400 in 42 states
- MKSAP quiz: sinus congestion and clear nasal drainage
- Elderly can benefit from ICDs as much as the young
- Cardiologists assess risks, benefits of oral contraceptives
- Deep brain stimulation alleviates symptoms of Parkinson's in study
- Proposal to expand coverage for PET scans
- Report reveals physician experiences with quality reporting initiative
- Five contractors to administer Medicare claims payments
Annals of Internal Medicine
- Viral hepatitis outbreaks linked to lapses in infection control practices
- ACP endorses the CDC’s revised adult immunization schedule
- Health care-associated pneumonia requires aggressive treatment
From the College
- College to hold webinar to help physicians prepare for e-Rx
- New titles from ACP Press
- Hybrid forum on patient-centered medical home
- Deadline for "Internists as Artists" program entries
From ACP Internist
- The January issue is online and in your mailbox
- Take our poll: CNN correspondent as surgeon general?
- On the blog: free antibiotics
Cartoon caption contest
- Put words in our mouth
Editorial note: ACP InternistWeekly will not be published on Jan. 20 due to the Martin Luther King, Jr. holiday.
Cardiology criteria guide therapy over intervention for chest pain
Joint criteria offer a practical tool to help physicians choose between therapy and intervention for chest pain, criteria that focus on cardiac treatment rather than on diagnostic testing.
"Appropriate Criteria for Coronary revascularization," a document created jointly by several medical groups, presents information on the type of patients physicians see on a daily basis, as opposed to those included in the clinical trials used to form guidelines. Appropriate use criteria also present easily understood clinical scenarios that characterize patients according to:
- symptom severity and type,
- how much cholesterol plaque has built up and in which arteries,
- ischemia, and
- whether the patient is already taking the right heart medications in the right dosages.
Revascularization was considered appropriate if the expected improvements in survival, symptoms, functional status and/or quality of life outweighed the possible risks, according to a news release from the Society for Cardiovascular Angiography and Interventions (SCAI). In most cases, the panel considered revascularization as either bypass surgery or percutaneous coronary intervention. Because evidence supported either procedure for patients with advanced coronary disease, each revascularization method was independently rated.
The panel determined that revascularization would be inappropriate in a patient who had plaque build-up in one or two arteries, experienced symptoms only during heavy exercise, had a small amount of heart muscle at risk and was not taking medication to help control symptoms. However, revascularization is appropriate if a similar patient had severe symptoms despite already taking medication.
The criteria were published online and will appear in the in the Feb. 10, 2009, issue of the Journal of the American College of Cardiology. They were jointly developed by the American College of Cardiology, SCAI, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, and American Society of Nuclear Cardiology. They have been endorsed by the American Society of Echocardiography, Heart Failure Society of America, and Society of Cardiovascular Computed Tomography..
Salmonella outbreak sickens nearly 400 in 42 states
At least 399 people in 42 states have been sickened by a Salmonella typhimurium outbreak of unknown origin, a CDC spokeswoman said last week.
The outbreak started in September, with most cases occurring after October, spokeswoman Lola Russell said. Eighteen percent of those who have gotten sick have been hospitalized, she said. The most common sources of Salmonella typhimurium are eggs, poultry, produce, small animals, and unpasteurized milk and milk products, she said.
California officials have reported 51 cases, while Ohio officials have reported 50 cases and Michigan officials 20 cases, the Jan. 7 Washington Post reported. Patients with salmonella usually have diarrhea, fever and abdominal cramps that last 4 to 7 days, with the elderly and infants more prone to serious illness, the CDC said. The agency is "vigorously working" to identify the source of the outbreak, the CDC said.
MKSAP quiz: sinus congestion and clear nasal drainage
A 24-year-old man requests antibiotics during an evaluation for symptoms he has attributed to a sinus infection. He reports sinus congestion and clear nasal drainage that has persisted for 1 month after he developed a cold; he has no fever, sinus pain, purulent nasal drainage, sneezing, or nasal itching. Since the onset of his symptoms, he has been using a nasal decongestant spray with only short-term symptomatic relief, but he states that antibiotics have been effective in the past for treating his sinus infections. His history includes allergic rhinitis, but his primary allergens are not in season.
Nasal examination shows congested nasal mucosa with a profuse watery discharge. The nasal septum appears normal, the turbinates are pale, and there are no polyps. The remainder of the physical examination is normal. Which of the following is the most likely reason for this patient's symptoms?
A) Allergic rhinitis
B) Bacterial sinusitis
C) Nonallergic rhinitis
D) Rhinitis medicamentosa
E) Viral upper respiratory infection
Click here or scroll to the bottom of the page for the answer and critique.
Elderly can benefit from ICDs as much as the young
Older people with left ventricular systolic dysfunction can benefit from implantable cardiovascular defibrillators (ICDs) just as much as younger people, a new study found.
In a prospective cohort study of 965 patients, researchers compared mortality in patients who received and didn't receive ICDs. The patients were treated from March 2001 though June 2005 and followed through March 2007. Their median age was 67 years, which is 3-7 years older than previous studies that looked at ICD use in patients with heart conditions. All patients had ischemic or nonischemic cardiomyopathies with an ejection fraction < 35% and no prior ventricular arrhythmias. The study was published in the Jan. 6 online version of Circulation: Cardiovascular Quality and Outcomes.
ICD therapy was associated with a 31% reduction in risk of all-cause mortality compared with not having an ICD (adjusted hazard ratio, 0.69; 95% confidence interval, 0.50 to 0.96; P=0.03). The benefit remained after patients were stratified by age, ejection fraction, ischemic etiology and comorbidities. ICDs were also shown to be about as cost effective in patients age 75 and older compared with younger patients, though cost effectiveness depended on the degree and number of comorbidities.
One limitation of the study is that it included relatively few patients over age 80, the authors said. The decision to use an ICD still needs to be made on a case-by-case basis, but patients shouldn't be ruled out strictly because they are in their 70s or have comorbidities, the authors concluded..
Cardiologists assess risks, benefits of oral contraceptives
A new review article, published in the Jan. 20 Journal of the American College of Cardiology, assesses current research and guidelines on contraceptive hormone use and cardiovascular disease.
An analysis of the safety, efficacy and side effects of hormone therapy was prompted by data from the Women's Health Initiative that demonstrated links between hormone therapy and cardiovascular risk, researchers said. Recent statistics have also shown that mortality from cardiovascular disease has been increasing among women between age 35 and 44 coincident with an increase in oral contraceptive use. The new paper includes basic science, animal and human clinical studies and outlines the physiology and mechanisms of the cardiovascular action of contraceptive hormones, particularly in oral contraceptives.
The study authors concluded that newer generation oral contraceptives do not increase myocardial infarction risk for current users, but that they do carry the increased risk of venous thromoboembolism. Because there is no cardiovascular data available for the newest hormonal contraceptives (including nonoral methods and pills that also lower blood pressure), physicians should consider them similar to, not safer than, other oral contraceptives, the review said.
In general, the risks and benefits of contraceptive hormones should be weighed based on the characteristics of each individual patient, the authors concluded. As stated in current guidelines, women 35 years or older should be assessed for cardiovascular risk factors including hypertension, smoking diabetes, nephropathy and other vascular diseases including migraines before hormonal contraceptives are prescribed.
The authors called for more research to uncover whether oral contraceptives provide protection from atherosclerosis and cardiovascular events. Such a determination will require long-term follow-up of the cardiovascular health of menopausal women compared with their history of oral contraceptive use, they said.
Deep brain stimulation alleviates symptoms of Parkinson's in study
Deep brain stimulation was more effective than medical therapy for advanced Parkinson's disease patients but the procedure was associated with an increased risk of serious adverse events, a recent study concluded.
In the randomized controlled trial, 255 patients (25% age 70 or older) with advanced Parkinson's received either deep brain stimulation or best medical therapy and were assessed after six months. At follow-up, patients who received deep brain stimulation gained a mean of 4.6 hours of day of "on" time (vs. 0 hours for the therapy group), defined as having good motor control with unimpeded motor function, without troubling dyskinesia. Meaningful motor function improvements were experienced by 71% of patients in the deep brain stimulation group vs. 32% in the therapy group. However, at least one serious adverse event occurred in 49 patients in the stimulation group vs. 15 in the therapy group and the cumulative risk for device-related problems was 10% at six months. The study appears in the Jan. 7 issue of the Journal of the American Medical Association.
An editorial said the study is important in being the largest randomized trial to date on deep brain stimulation for advanced Parkinson's (the only other large trial reached similar conclusions) and it is the first randomized study to assess deep brain stimulation of the two known targets (the subthalamic nucleus or the globus pallidus internus). The study confirms the efficacy of deep brain stimulation in the short-term, said the editorial, but more research is needed to determine long-term outcomes, assess adverse events, and answer questions such as the optimal timing for implantation. Some answers may be forthcoming in phase two of the current study.
Proposal to expand coverage for PET scans
Under a proposal announced last week, Medicare would expand coverage of positron emission tomography (PET) for initial diagnostic testing in beneficiaries with cancer. Since 2005, Medicare has covered the PET scans only under its Coverage with Evidence in Development (CED) program, which requires the collection of clinical information about the effect of the test on the beneficiary's cancer care.
Based on the evidence collected under the program, CMS experts determined that coverage should be provided for one PET scan to guide initial cancer treatment strategy. The scans, which use a radioactive tracer to evaluate glucose metabolism in tumors and normal tissue, can help physicians distinguish benign from cancerous lesions and better determine the extent of a tumor's growth or metastasis, a CMS press release noted. This is the first time that Medicare has expanded coverage based on evidence collected in the CED program. CED will still be required for PET scans for subsequent treatment, with some exceptions.
CMS will accept public comments on the proposed decision through Feb. 5 and issue a final national coverage determination in April. Public comments can be submitted online..
CMS issues report on physician experience with quality reporting initiative
In December CMS released a new report, “Physician Quality Reporting Initiative (PQRI): 2007 Reporting Experience.” The report details the experiences of physicians who participated in the 2007 version of the PQRI program, challenges encountered and modifications made to the program for 2008. CMS has also announced that it will apply modifications made to the program analytics for the 2008 version, to the data that was submitted for 2007. This may mean that some eligible professionals who submitted data that previously did not meet the standards for an incentive payment may now qualify for one.
The full report is available online.
The PQRI was introduced by CMS in July of 2007. The program pays physicians a bonus for reporting quality data to CMS on their claims forms. The program has been renewed for 2009, and physicians who are interested in participating can find information and resources on the College’s Web site..
Five contractors selected to administer Medicare claims payments
Last week CMS announced the final five contractors that will process Medicare claims for the Fee-for-Service program. These contractors are part of an effort by Medicare to improve claims processing for providers. Under the current system Part A and Part B providers have separate processors for their claims. The new contractors consolidate that system and allow providers to have a single point-of-contact with Medicare.
The new contractors are:
- For Jurisdiction 6: Noridian Administrative Services, LLC (NAS)
- For Jurisdiction 8: National Government Services (NGS)
- For Jurisdiction 10: Cahaba Government Benefit Administrators, LLC (Cahaba GBA)
- For Jurisdiction 11: Palmetto Government Benefits Administrators, LLC (Palmetto GBA)
- For Jurisdiction 15: Highmark Medicare Services (HMS)
More information about contractors and the states they carry can be found on the CMS Web site.
Annals of Internal Medicine.
Viral hepatitis outbreaks linked to lapses in infection control practices
Recent reports of outbreaks indicate transmission of hepatitis B (HBV) and hepatitis C (HCV) in health care settings is considered a rare but growing problem, notes an article in the Jan. 6 Annals of Internal Medicine. Over the past decade, there have been 33 outbreaks in nonhospital health care settings in the U.S, resulting in 450 people acquiring HBV or HCV infection, and thousands more being placed at risk. In all cases, patient-to-patient transmission resulted from lapses in basic infection control practices among nonhospital health care personnel. According to researchers, health care is increasingly provided in outpatient settings in which infection control training and oversight may be inadequate. A comprehensive preventive approach should include augmented viral hepatitis surveillance, health care provider education, training in appropriate infection control practices and techniques, improved oversight and more uniform regulation..
ACP endorses the CDC’s revised adult immunization schedule
The ACP, along with 16 other medical societies representing various medical practice areas, endorsed the CDC's adult immunization schedule for 2009. Each year, the CDC’s Advisory Committee on Immunization Practices (ACIP) reviews the recommended Adult Immunization Schedule to ensure the schedule reflects current recommendations for the licensed vaccines. The recommendations are intended to guide physicians and other clinicians about the appropriate vaccines for their adult patients. The 2009 schedule contains no new vaccines. However, several indications, footnotes, and clarifications have been made. Several indications were added to the pneumococcal polysaccharide vaccine footnote; clarifications were made to the footnotes for human papillomavirus, varicella, and meningococcal vaccines; and schedule information was added to the hepatitis A and hepatitis B vaccine footnotes..
Health care-associated pneumonia requires aggressive treatment
Researchers sought to determine the epidemiology and outcome for patients with community-acquired, health care-associated or hospital-acquired pneumonia. During two one-week surveillance periods, researchers looked at 362 patients hospitalized with pneumonia. They collected information to identify patients with how their pneumonia was acquired. They then compared information on antibiotics used for treatment, severity of pneumonia, length of hospital stay, and death rates among the three groups. Researchers found that patients with community-acquired pneumonia had the least complicated course, with the shortest hospital stays and the lowest death rates. Conversely, patients with hospital-acquired pneumonia had the most complicated cases, the longest hospital stays and the highest in-hospital death rates. Researchers concluded that health care-associated pneumonia is a more serious illness than community-acquired pneumonia with worse patient outcomes. They suggest that doctors carefully identify how patients contracted pneumonia, and administer the appropriate antibiotics for the type of pneumonia the patient has in accordance with established guidelines.
From the College.
College to hold webinar to help physicians prepare for e-Rx
On Wednesday, Jan. 28, 2009, ACP will be holding the first in a series of interactive webinars for members and nonmembers. The first webinar, to be held at 7 p.m. EST, will focus on the new Medicare e-Prescribing Incentive program.
This kick-off session is free and will be an hour long presentation providing participants with information about the new Medicare program, including why it is being implemented; the reporting requirements; and the financial incentives for successful participation. The presenters will also discuss how to choose an e-prescribing system, and practical considerations in an ambulatory office setting.
Look for announcements about future webinars planned for the next few months. The next webinars will be in February (the Physician Quality Reporting Initiative and the Patient Centered Medical Home) with others to follow. Registration information and details about upcoming webinars can be found online..
New titles from ACP Press
Three upcoming titles from ACP Press offer instruction and support on complementary and alternative medicine, gynecology, and writing and publishing in the health sciences. “The ACP Evidence-Based Guide to Complementary and Alternative Medicine” offers the evidence-based analyses physicians need to effectively counsel patients on CAM medical therapies. The guide focuses on the safety and efficacy of these therapies and contains most-often-asked questions as well as in-depth reviews of research, digested into concise summary tables.
“Practical Gynecology, Second Edition” is useful for physicians with varying levels of gynecologic expertise and focuses on the skills primary care clinicians need to manage a broad range of gynecologic problems. “How to Write, Publish, and Present in the Health Sciences: A Guide for Physicians and Laboratory Researcher,” written by acclaimed medical writer Tom Lang, explains how to create effective scientific articles, research proposals, abstracts, posters, and slide presentations.
The CAM title is available now; the others are due to publish in early 2009. More information including pre-ordering is available online..
Hybrid forum on patient-centered medical home
ACP CEO John Tooker, MBA, FACP, and Bob Doherty, ACP’s senior vice president of government affairs and public policy, will join leading authorities and practitioners to present at the National Medical Home Summit on March 2-3, 2009 in Philadelphia. The hybrid summit, which will be accessible both onsite and online, will explore the patient-centered medical home through discussions, workshops, and training. Key building blocks of the medical home model will be discussed, as well as case studies demonstrating how the model is working for practices currently using it. A pre-conference workshop and training program allow participants opportunity for further examination, and archived access to all summit presentations will be made accessible online. Registration information is available online..
Deadline for "Internists as Artists" program entries
Entries for the ACP's national "Internists as Artists" program at Internal Medicine 2009 are now being accepted. All entry application forms must be submitted by March 9. Designed to showcase physicians' talents in the visual arts, the "Internists as Artists" exhibit will be located in the Exhibit Hall of the Pennsylvania Convention Center in Philadelphia during Internal Medicine 2009. Submissions may include painting, sculpture, photography, mixed media, woodworking, jewelry, crafts and ceramics.
Members interested in submitting entries must complete a registration form and send it along with either a photograph or an electronic image of their artwork (a maximum of two entries). Entries will judged by program jury members, and must be completely display-ready. Completed registration forms and electronic or photographic images should be sent to: Helen Canavan, ACP Internists as Artists Program, 190 N. Independence Mall West, Philadelphia, PA 19106-1572, by e-mail or by calling 800-523-1546, ext. 2663.
From ACP Internist.
The January issue is online and in your mailbox
The latest issue of ACP Internist is online. This month’s issue details:
Cutting short clinical trials. Does speeding a potentially effective drug to market benefit patients, or does it benefit drug companies? Experts offer tips on how to decide.
Overcoming colonoscopy’s image problem. Colon cancer screening saves lives, but internists have to overcome patients' initial unease with the test. They also need to sort through the multiple guidelines released in 2008 and help their patients choose among the many screening regimens.
Mindful Medicine. A physician diagnoses himself, leaving a colleague to undo some of the mistaken thinking and come up with a simple diagnosis.
Find these stories and more online..
Take our poll: CNN correspondent as Surgeon General?
CNN correspondent Sanjay Gupta, MD, is being considered as the next U.S. Surgeon General. Is he the best choice, and what should his priorities be if chosen? Take our survey. Results will be reported in the Feb. 3 edition of ACP InternistWeekly..
On the blog: free antibiotics
Chain groceries are offering antibiotics with free co-pays. But readers question whether that would drive overprescribing and antibiotic resistance. Read more at ACP Internist’s blog.
Cartoon caption contest.
Put words in our mouth
ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner.
E-mail all entries by Jan. 22. ACP staff will choose three finalists and post them in the Jan. 27 issue of ACP InternistWeekly for an online vote by readers. The winner will appear in the Feb. 3 issue. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service..
Test yourself: Answer and Critique
D) Rhinitis medicamentosa
This topic is available to subscribers in the General Internal Medicine section, item 10.
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.
Persistent rhinitis symptoms in the setting of nasal decongestant spray overuse suggests rhinitis medicamentosa. Repeated use of nasal decongestants causes a decreased sensitivity to their vasoconstrictor effect and a rebound phenomenon with increased nasal congestion and discharge. Management involves immediately withdrawing the vasoconstrictor and initiating treatment with a nasal corticosteroid spray. Allergic rhinitis is unlikely in this patient given his lack of allergy symptoms, such as sneezing and nasal itching, and because the symptoms are occurring when the patient's allergens are not in season. The absence of purulent drainage, fever, and sinus pain and the presence of pale turbinates argue against a diagnosis of bacterial sinusitis. Although nonallergic or vasomotor rhinitis can possibly be a complication of allergic rhinitis, environmental changes, such as air pollution, temperature or humidity changes, or nonspecific irritants, such as spicy foods, strong odors, perfume, exhaust fumes, cigarette smoke, and solvents, usually precipitate vasomotor symptoms. Most viral upper respiratory infections resolve within 1 week; long-term symptoms usually indicate a secondary bacterial infection.
Persistent rhinitis symptoms in the setting of nasal decongestant spray overuse suggests rhinitis medicamentosa.
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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.
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Copyright 2008 by the American College of Physicians.
A 67-year-old man is evaluated for a 6-month history of worsening exertional dyspnea. He has severe COPD, previously with minimal exertional symptoms, but now notes activity-limiting shortness of breath when walking short distances. He does not have chest pain, gastrointestinal symptoms, or sleep-related symptoms. Medical history is otherwise unremarkable. Medications are a twice-daily fluticasone/salmeterol inhaler and an as-needed albuterol/ipratropium metered-dose inhaler. He has a 55-pack-year smoking history but quit when COPD was diagnosed. Following a physical exam, chest radiograph, and transthoracic echocardiogram, what is the most appropriate diagnostic test to perform next?
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