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

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In the News
for the Week of 1-27-09

Highlights

  • Average heart attack has gotten less severe
  • Study: LDL levels don't measure risk of heart disease hospitalizations
  • Escitalopram may help older adults with generalized anxiety disorder

Test yourself

Geriatric medicine

  • Personality predicts dementia risk for isolated seniors
  • Chronic kidney disease increases risk for heart disease and death in elderly, study finds

Annals of Internal Medicine

  • Adjust diabetic regimens immediately following bariatric surgery
  • Researchers question value of genetic testing for heart disease
  • Vigilance may reduce sudden cardiac death among methadone patients
  • Debate continues about critical care during health emergencies

FDA news

  • Nearly 500 people sickened by Salmonella from peanut butter
  • Improper use of topical anesthetics can have dangerous side effects

Advocacy update

  • New York settlement will reform insurance industry rate database
  • CMS suspends enrollment for WellPoint

From ACP Internist

  • Your thoughts exactly: Sanjay Gupta doesn’t poll well as potential Surgeon General

From the College

  • New, free patient education DVD on respiratory infections
  • ACP seeks proposals for clinical skills workshops for Internal Medicine 2010

Cartoon caption contest

  • Vote for your favorite entry

Physician editor: John A. Mitas II, FACP


Highlights

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Average heart attack has gotten less severe

The severity of myocardial infarctions has declined since the 1980s, according to a new community surveillance study.

The Artherosclerosis Risk in Communities Study tracked residents of four diverse communities in North Carolina, Maryland, Minnesota and Mississippi between 1987 and 2002. Data was collected on more than 10,000 heart attacks in patients age 35 to 74 and several markers of severity were selected. The research was published online Jan. 19 by the journal Circulation.

The study found that between 1987 and 2002, the percent of myocardial infarctions with major ECG abnormalities decreased. Specifically, there was a 1.9% decrease in initial ST-segment elevation, a 3.9% decrease in the proportion of patients with subsequent Q-waves and 4.5% fewer had any major Q wave. The maximum creatine kinase and creatine kinase-MD values also declined, as did the percent with shock. The study was motivated by researchers' speculation that recent declines in deaths from coronary heart disease were due to a decline in severity of myocardial infarctions (MI). Based on the study's findings, the authors concluded that MI severity may be one contributing factor.

However, the study was not able to determine the cause of the decline in severity. It could be better preventive measures and treatment of risk factors or better in-hospital care, the study's lead author told the Jan. 20 Washington Post. The change cannot be explained by improved public awareness of the need to seek care quickly, because there was no change in the percentage of patients who arrived at the hospital within two hours of symptom onset, she said.

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Study: LDL levels don't measure risk of heart disease hospitalizations

Many hospitalized coronary artery disease patients had low-density lipoprotein (LDL) levels that are not considered high-risk by current guidelines, a new
study found.

Using the Get with the Guidelines database, researchers analyzed 136,905 hospitalizations from 2000-2006 which had documented lipid levels within the first 24 hours of admission. Patients were divided into LDL, high-density lipoprotein (HDL) and triglyceride categories. About 54% had hypertension, 26% had diabetes and 30% were smokers, while 16.5% had prior myocardial infarction. Prior to admission, 21% of patients were on lipid-lowering medication. Admission diagnosis was most commonly related to acute coronary events.

Mean LDL was 104.9 milligrams per deciliter ± 39.8; while mean HDL was 39.7 mg/dL ± 13.2 and mean triglycerides was 161 ± 128 mg/dL. Nearly half the hospitalized patients had an LDL of less than 100 mg/dL—a level the National Cholesterol Education Program (NCEP) considers "optimal."

About 18% had LDL levels less than 70 mg/dL, which the NCEP considers an optional goal for high-risk patients. By contrast, fewer than 10% of patients had an optimal HDL level of 60 mg/dL or more. The article is in the January issue of American Heart Journal.

The results indicate that, although high LDL is considered a major risk factor for heart disease, a substantial portion of patients come to the hospital with coronary artery disease events with levels that are within guidelines, the study's authors said. The results support guideline revisions with lower LDL goals, and may also suggest a need to develop treatments to raise HDL, the authors said.

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Escitalopram may help older adults with generalized anxiety disorder

Escitalopram (Lexapro) may help relieve symptoms of generalized anxiety disorder in older adults, a new study found.

Researchers randomized 177 people aged 60 years and older with generalized anxiety disorder to either 10-20 mg/day of escitalopram or placebo for 12 weeks. Patients were recruited from primary care practices or specialty clinics in Pittsburgh, Pa. Outcomes included cumulative response on several scales including the Clinical Global Impressions-Improvement scale and the Hamilton Anxiety Rating Scale. The study was published in the Jan. 21 issue of the Journal of the American Medical Association.

Sixty-nine percent of people taking escitalopram saw their anxiety levels drop compared to 51% of patients taking placebo. A conservative intention-to-treat (ITT) analysis didn't show a difference in cumulative response rate between groups, however. As a secondary finding, hypertensive patients taking escitalopram saw blood pressure decrease significantly more than patients on placebo. This was the first large-scale study to examine the effect of a selective serotonin reuptake inhibitor (SSRI) on anxiety in older adults.

The lack of difference in outcomes in ITT analysis suggests escitalopram's efficacy is lowered by nonadherence, the authors said. As such, clinicians need to ensure their patients are aware of common side effects of escitalopram that may lead to nonadherence, such as fatigue or somnolence, sleep disturbance and urinary symptoms. Side effects were more likely to appear in the study when the dose was bumped from 10 mg to 20 mg. One major study limitation was its brief duration; more research is needed to examine the drug's effect over a longer time period, the authors said.

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Test Yourself

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MKSAP quiz: Jaw pain

A 74-year-old man is evaluated for a 1-month history of severe paroxysmal left lower jaw pain. There is no evidence of infection on examination or radiograph. His pain can often be elicited by a cold breeze over his face, brushing his teeth, or chewing. The pain is sharp, stabbing, and typically lasts for 1 to 2 seconds.

Physical examination and vital signs are normal. Neurologic examination is significant for the ability to elicit the pain with a cotton swab over the left lower portion of his jaw, gums, or cheek. There is no change in sensation otherwise in the region compared with the right side. Contrast MRI of the head is normal. Erythrocyte sedimentation rate is normal.

What is the most appropriate management for this patient?

A) Carbamazepine
B) Prednisone
C) A triptan
D) Acyclovir
E) Amitriptyline

Click here for the answer and critique to this question

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Geriatric medicine

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Personality predicts dementia risk for isolated seniors

Older adults who were less neurotic and more extroverted had a reduced risk of developing dementia, a recent Swedish study found.

The 506 study participants were given a personality inventory and then followed for an average of six years. No single trait was associated with a change in risk of dementia, but people who scored low on neuroticism and high on extraversion had half the dementia risk of those who were neurotic and extraverted. The researchers then stratified the results by lifestyle, and found that the association was primarily true for people who were socially isolated. Also, for the isolated participants, lack of neuroticism alone was apparently protective against dementia.

The researchers concluded that their findings followed from existing theories about a relationship between stress and dementia because being less neurotic and more extraverted can help a person handle stressful situations without anxiety. For people lacking those traits, a more active and socially integrated lifestyle could potentially provide some protection against dementia and should be considered as a public health and clinical implication, the authors concluded.

The authors noted several limitations to the study, including the possibility that personality changes may have significantly preceded diagnosis of dementia. Subjects were examined for cognitive performance during follow-up, however, making it less likely that personality traits were caused by neuropathologic changes. The research was published in the Jan. 20 issue of Neurology.

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Chronic kidney disease increases risk for heart disease and death in elderly, study finds

Impaired kidney function in elderly patients is associated with significantly increased risk for fatal and non-fatal heart failure and for death from all causes, a recent study reported.

Using data from the Prospective Study of Pravastatin in the Elderly at Risk (funded by a grant from Bristol Myers-Squibb), researchers at the University of Glasgow in Scotland looked at the effect of pravastatin on the development of cardiovascular disease in patients age 70 to 82 with pre-existing vascular disease or an increased risk of cardiovascular disease (CVD). The study was published in the Jan. 20 issue of PLoS medicine.

Researchers found significant independent associations between reduced estimated glomerular filtration rate (eGFR) (below 50 ml/min/1.73 m2) and all-cause mortality, vascular deaths, coronary heart disease events and heart failure death or hospitalization. Risks were greatest in patients with an eGFR in the range of (20-40) ml/min/1.73 m2.

The results also indicated that statins may reduce CVD risk in people with severe kidney damage, but the findings were borderline statistically significant and more research is needed, the authors said. Physicians should encourage elderly patients with reduced eGFR and other vascular risk factors to make lifestyle changes to reduce their overall CVD risk, they added.

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Annals of Internal Medicine

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Adjust diabetic regimens immediately following bariatric surgery

Physicians must anticipate the rapid improvements in insulin action after bariatric surgery and adjust diabetic regimens accordingly to avoid severe post-operative hypoglycemia. Study authors suggest that future research should focus on making postoperative medical management safer for patients on diabetes therapy.

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Researchers question value of genetic testing for heart disease

Genetic variation at chromosome 9p21.3 is associated with cardiovascular disease. To determine if incorporating information on this genetic variation into risk prediction would improve predictions based on non-genetic risk factors alone, researchers looked at more than 22,000 initially healthy white women enrolled in the Women’s Genome Health Study for a median of 10.2 years for incident cardiovascular disease. This genetic variation did not improve prediction over the traditional risk factors alone.

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Vigilance may reduce sudden cardiac death among methadone patients

Recent reports suggest that methadone can cause QTc interval prolongation and a rare but life-threatening heart rhythm problem known as torsade de pointes. A panel of experts reviewed all available evidence and found that both oral and intravenous methadone can cause dose-dependent arrhythmia. However, how often patients treated with methadone develop arrhythmia is not clear. Authors recommend that doctors:

  • inform patients of arrhythmia risk when they prescribe methadone,
  • ask about any history of heart disease, arrhythmia or fainting spells,
  • perform a baseline electrocardiogram before starting methadone, and
  • repeat the test at 30 days, and annually thereafter.

They caution physicians to be aware of any other medications a patient is taking, especially those that may prolong QTc intervals or slow the elimination of methadone.

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Debate continues about critical care during health emergencies

There has been little agreement in the medical community about how to ethically allocate ventilators and other life-saving treatments during a public health emergency, such as an influenza pandemic. To stimulate debate, researchers propose rethinking the previously proposed “save the most lives” allocation strategy in favor of a multi-principle approach that reflects the moral complexity of the issue and applies the same criteria to all patients. The researchers also suggest that the public be meaningfully engaged in the policy-making process to ensure procedural justice.

Last spring, the New York State Workgroup on Ventilator Allocation in an Influenza Pandemic published its recommendations for ventilator allocation during a public health disaster.

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FDA news

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Nearly 500 people sickened by Salmonella from peanut butter

At least 486 people in 43 states have been sickened by Salmonella Typhimurium linked to a plant that manufactures peanut butter and peanut butter paste used in many commercial products, federal officials said last week. Six people have died.

More than 100 products containing the peanut butter and peanut paste have been recalled, including crackers, cookies, cereal and dog biscuits. The supplier, Peanut Corporation of America, also distributes peanut butter to institutional settings like long-term care facilities and cafeterias. Major brands of peanut butter in jars aren't affected by the recall.

FDA and the CDC are advising consumers to avoid eating products with peanut butter until more information become available on which brands are affected. A continually updated list of recalled products is available online. People infected with Salmonella develop diarrhea, fever, and abdominal cramps 12–72 hours after infection, which is commonly diagnosed by stool sample. The illness usually lasts 4 to 7 days, the CDC said.

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Improper use of topical anesthetics can have dangerous side effects

Improper use of topical anesthetics can lead to life-threatening side effects like irregular heartbeat, breathing problems, coma, seizures and deaths, FDA said in an advisory last week.

Two women died from using topical anesthetics before laser hair removal, and others have experienced adverse events, FDA said. Improper use includes applying too much, applying to a large area of skin, applying to irritated skin, or covering the skin with a wrap or heating pad after applying. Providers who recommend topical anesthetic to patients should discuss correct use and potential side effects, including what to do if side effects occur. They should also ensure patients use the lowest possible dose.

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Advocacy update

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New York settlement will reform insurance industry rate database

New York State Attorney General Andrew Cuomo announced a settlement with UnitedHealth that will overhaul the insurance industry database of billing information. The settlement marks the end of an investigation by the Attorney General’s office that determined the existing database undervalued the true market rates of medical care by up to 28%.

The database, operated by Ingenix, Inc. (a subsidiary of UnitedHealth), is used to determine the reimbursement rate paid to patients when they use an out-of-network provider. Because the database undervalued the market pricing for care, patients would typically be reimbursed at a much lower rate than warranted for their out-of-network provider care. A hypothetical example would go something like this:

  • A patient's health plan agrees to pay 80% of the amount that is "usual and customary" for physician services in the geographic area;
  • The patient receives a service from an out-of-network physician;
  • The patient pays that physician his or her full established charge out of the patient's own pocket;
  • The health plan use of the Ingenix database determines an artificially low "usual and customary";
  • The plan pays the patient less than the true 80% of "usual and customary" amount; and
  • The patient—having already paid the physician his full charge—incurs a greater total out-of-pocket cost because the health plan failed to live up to its true payment amount obligation.

Under the settlement, the existing database will no longer be used. UnitedHealth will instead pay $50 million to establish an independent database run by a nonprofit organization. More information is on the Attorney General's Web site.

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CMS suspends enrollment for WellPoint

CMS has suspended marketing and enrollment for WellPoint Medicare Advantage and Prescription Drug plans, as of Jan. 12. Beneficiaries who are currently enrolled in WellPoint plans will continue to receive coverage.

CMS suspended enrollment and marketing due to failures by WellPoint to administer their contracts in accordance with CMS requirements. The problems included failures in enrollments and disenrollments, benefits administration, grievances and appeals, marketing, claims processing, coordination of benefits, billing, and meeting call center and customer service requirements.

Beneficiaries who have had difficulty getting services from WellPoint may have the opportunity to enroll in a different Medicare plan, and should call 1-800-MEDICARE with questions. More information is in the Kaiser Daily Health Policy Report.

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From ACP Internist

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Your thoughts exactly: Sanjay Gupta doesn’t poll well as potential Surgeon General

Most readers who took ACP Internist's most recent Web poll voted against Sanjay Gupta, MD, as a potential choice for Surgeon General.

Vote # (n=173) %
Yes 61 35.3
No 97 56.1
He's no C. Everett Koop 15 8.7

(The results aren't scientific and only reflect the opinions of poll respondents.)

Asked what they thought should be the Surgeon General's next priorities, respondents said they want more attention paid to obesity and all its negative health impacts, smoking cessation and universal access to health care. Respondents mainly objected to Dr. Gupta's lack of experience in public health and health policy.

One respondent wrote: "At least everybody knows his name. Who was the last Surgeon General?? Exactly!!!!" [Editor's Note: It's currently Steven K. Galson, MD, an internal-medicine trained epidemiologist who'd worked at the FDA, CDC, EPA, Department of Energy, and Department of Health and Human Services.]

Other responses include:

"The Surgeon General should have and be an advocate for the diversity in medicine in order to be able to discuss the many facets of disease states, such as diabetes, hypertension, obesity that is the "bread and butter" of the medical issues compelling our society today. Being able to "speak" of the disease is not as convincing as someone who has had clinical experience." [Editor's note: In recent history, surgeons general have been mostly trained in public health, with some internal medicine and family practice physicians thrown in. C. Everett Koop, M.D., was a pediatric surgeon and the outspoken Jocelyn Elders, M.D., was a pediatrician. Dr. Gupta is a practicing neurosurgeon.]

"First, Dr. Gupta is best known to me because he is featured on so many pharmaceutical house sponsored 'educational' programs shown on proprietary equipment in waiting rooms of hospital clinics. This makes me think he is very much connected to the pharmaceutical industry. Also, he is rather young and seems to have spent a lot of time being a TV and advertising star rather than a doctor. I would prefer a seasoned clinician for this post."

"He has no public health experience. It is also unlikely he is going to address the primary care shortage, because he tends to lean toward helping specialists."

"His bias toward private insurers shows a lack of understanding of unacceptably high administrative costs and gaps in coverage and why. He needs an unbiased look at government vs. private insurers, and the pros and cons of each. If [President Barack] Obama picks Sanjay Gupta, I fear it would demonstrate that Obama also lacks an understanding of these problems as well."

Check out ACP Internist's latest poll, Your thoughts exactly: using placebos.

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From the College

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New, free patient education DVD on respiratory infections

A new patient education DVD/guidebook explains the different types of respiratory infections and how to treat them. “Breathe Easy: Guide to Respiratory Infections” discusses the differences between viral and bacterial infections, and how to recognize and treat them. The product is free and can be ordered online, but quantities are limited. A small shipping fee applies.

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ACP seeks proposals for clinical skills workshops for Internal Medicine 2010

The Clinical Skills Subcommittee (CSSC) is now accepting proposals for Internal Medicine 2010, to be held in Toronto from April 22–24, 2010. The CSSC welcomes all proposals but places a priority on interactive workshops that focus on the acquisition or improvement of physical examination skills, communication skills and procedural skills. The CSSC is most interested in workshops that have a high likelihood of changing physician behavior using proven teaching techniques or innovative teaching strategies that have yet to be tested. The deadline for submissions is May 1. More information is online.

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Cartoon caption contest

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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.

Go online to view the cartoon and pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting continues through Feb. 2, with the winner announced in the Feb. 4 issue.

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Test Yourself

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Answer and Critique

Correct Answer = A) Carbamazepine. This topic is available to subscribers in the Neurology section, item 63.

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.

Carbamazepine is the appropriate treatment for this patient, whose symptoms are most consistent with trigeminal neuralgia. Although temporal arteritis should be considered in any elderly patient with new-onset head pain, this patient's symptoms and normal erythrocyte sedimentation rate do not suggest this condition; therefore, prednisone is not indicated. The features of the patient's pain are not consistent with migraine, making triptan therapy inappropriate. Herpetic neuralgia is a possibility, but there usually is a history of vesicular rash in the affected area that is not present in this patient. The use of amitriptyline may have some benefit for pain control, but anticonvulsants are typically considered to be of greater benefit for trigeminal neuralgia. In addition, the use of tricyclic antidepressants may be associated with hallucinations in individuals over age 65 years and thus may not be the first choice in this patient.

Key Point
Carbamazepine is the appropriate treatment for trigeminal neuralgia.

Click here to 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.

Test yourself

A 19-year-old man is evaluated for a sore throat, daily fever, frontal headache, myalgia, and arthralgia of 5 days' duration. He also has severe discomfort in the lower spine and a rash on his trunk and extremities. He returned from a 7-day trip to the Caribbean 8 days ago. The remainder of the history is noncontributory. Following a physical exam and lab studies, what is the most likely diagnosis?

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