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


In the News
for the Week of 10-13-09


  • Influenza update: Vaccine arrives, hard-hit cities see fewer cases, how to code
  • Cocaine vaccine may help treat addiction

Test yourself

  • MKSAP Quiz: changes to menstrual cycle

Low back pain

  • Time heals one-third of chronic low back pain cases


  • ICD soon after heart attack doesn't help survival

Mental health and primary care

  • ACPM reiterates screening all adults for depression
  • SSRIs during pregnancy linked with pre-term birth, ICU admission

Medicare changes

Cartoon caption contest

Physician editor: Darren Taichman, FACP


Influenza update: Vaccine arrives, hard-hit cities see fewer cases, how to code

Health departments in three states began administering the first of the 7 million currently available H1N1 flu vaccines. Next, 40 million doses will be available by mid-October and 10 million to 20 million will become available each week after that.

Meanwhile, health officials from the federal government and cities hit hard by H1N1 in the spring—New York, Boston and Philadelphia—are contemplating whether the outbreaks conveyed some amount of herd immunity leading to fewer than expected cases so far this fall.

More patient and physician resources on influenza are available at, including one-pagers for people who are pregnant or have children and patients who have asthma, diabetes or are immunocompromised, and advice specific to doctors and other clinicians. Another patient resource includes Emory University's interactive Web site to screen potential H1N1 cases using the same triage calculations their doctors and the CDC use. Questions about fever, symptoms and underlying health then determine whether patients have H1N1 flu, and what to do next—rest, call a doctor or seek immediate treatment.

ACP addressed how to code for administering the H1N1 vaccine. In preparation for an H1N1 influenza outbreak, the CDC will be providing the vaccine and ancillary supplies for free to CDC Public Health Emergency Preparedness grantees, otherwise known as project area designated sites.

Because the federal government will be paying for the vaccine itself, health insurers are only planning to reimburse for administration of the vaccine. Most of the country’s large insurers, including Medicare, will be covering the administration, but with varying degrees of comprehensiveness.

One of several CPT procedure codes will apply to the immunization administration:

  • CPT codes 90465-90468, Immunization administration for patients younger than 8 years
  • CPT code 90470, H1N1 immunization administration (intramuscular, intranasal), including counseling when performed
  • CPT codes 90471-90474, Immunization administration
  • HCPCS code G9141, Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family)

When billing Medicare or Medicaid, the new HCPCS code, G9141, should be used. If you do not use this code, the portion of the claim for the vaccine will be denied. Medicare and Medicaid reimbursement will be similar to the seasonal influenza vaccine administration in that the beneficiaries’ deductibles and copayments do not apply to the vaccine administration. CMS offers additional information on its Web site.

While most private payers will be covering the vaccine administration, most are still in the process of developing their guidelines. CIGNA has already issued guidance and it will be covering the vaccine administration for insured-plan customers at 100% with no copayment, prior authorization, or co-insurance. CIGNA is also working with its self-insured employers in its role as third-party administrator to encourage them to cover the full cost of the vaccine administration. Further information about CIGNA's guidance is
available online.

The College will provide additional information as more plans begin to announce their guidelines. Also, the Practice Rx coding column in the November issue of ACP Internist will have additional details.


Cocaine vaccine may help treat addiction

More than one-third of cocaine addicts in a recent study were able to reduce their drug use after taking a vaccine developed to treat cocaine dependence.

Over 24 weeks, researchers looked at 115 patients who were addicted to cocaine and opioids and were being treated with methadone. Patients were randomly assigned to receive five vaccinations of succinylnorcocaine linked to recombinant cholera toxin B-subunit protein, or placebo, over 12 weeks. Vaccinated patients who attained serum IgG anticocaine antibody levels of 43 µg/mL or higher (38%) were significantly more likely than those with lower IgG levels to have a 50% reduction in cocaine use (53% vs. 23%, respectively). The results appear in the October Archives of General Psychiatry.

The authors noted that only 38% of vaccinated patients attained target antibody levels at eight weeks and that antibody levels substantially dropped between weeks 16 and 24. Enrolling patients who were being treated with methadone helped with retention during the initial series of injections as antibody levels gradually increased, they added. Because antibody levels started to drop after 16 weeks, optimal treatment likely will require repeated booster vaccinations.

While the vaccine did not result in abstinence, the reduction in cocaine use by a significant number of patients is therapeutically meaningful because such reductions have been shown to improve social functioning, the authors said. More than half of patients with high antibody levels had no new episodes of cocaine use at least 50% of the time and doubled their cocaine-free urine samples.

Future vaccine development should focus on increasing the proportion of patients who can attain target antibody levels and long-term maintenance strategies that will lead to longer periods of abstinence, the authors concluded.


Test yourself

MKSAP Quiz: changes to menstrual cycle

MKSAP QuizA 23-year-old woman is evaluated for worsening discomfort and severe pelvic pain just prior to and during menses for the past 3 to 4 months. Her cycle has been 2 to 3 days longer than usual. Previously, her cycles were normal, with no pain. She has a 4-year history of dyspareunia, which is now worsening. She recently married and is monogamous. History includes eight previous sexual partners, with whom she used barrier contraception. She takes no medications and has never been pregnant. She has no known history of abnormal Pap smears, sexually transmitted disease, or pelvic inflammatory disease. Her last Pap smear was 7 months ago. She has no fever, chills, or vaginal discharge. Her weight has been stable.

On examination, she is in no acute distress. The temperature is normal, pulse rate is 88/min, and blood pressure is 104/72 mm Hg. There is no costovertebral tenderness to palpation. The abdomen is tender to palpation in lower quadrants, with no rebound or guarding. External genitalia are normal, and the cervix appears healthy. There is no cervical motion tenderness, but there is tenderness with deep palpation of the uterus.

Polymerase chain reaction assay for Neisseria gonorrhoeae and Chlamydia trachomatis is negative.

Which of the following is the most appropriate next step in diagnosis?

A) Laparotomy
B) Colonoscopy
C) Transvaginal ultrasonography
D) Cystoscopy
E) Hysterosalpingography

Click here or scroll to the bottom of the page for the answer and critique.


Low back pain

Time heals one-third of chronic low back pain cases

More than one-third of patients with chronic low back pain recover in less than one year, a recent study reported.

Researchers studied 406 patients in primary care who complained of non-radicular low back pain persisting for three months. The probability of complete recovery was 35% at nine months and 41% at 12 months. Risk factors for delayed recovery included previous sick leave due to low back pain, high disability or pain intensity at onset, low education level, and greater perceived risk of persistent pain (rated on scales from 0-10, with higher scores indicating more tension and anxiety, more feelings of depression or higher risk of persistent pain.) The results appear in the Oct. 6 BMJ.

The authors noted that while much research has been done on prognosis for acute low back pain, few data are available on chronic pain. Strengths of this study include that researchers followed patients with newly developed conditions as opposed to longstanding disease, the authors added. The study followed 99% of the acute pain cohort to three months and then recruited all patients who developed chronic conditions, thus ensuring a representative inception cohort.

The findings suggest that patients with recent onset, non-radicular chronic low back pain have a moderately optimistic prognosis with a good chance of recovery, the authors concluded.



ICD soon after heart attack doesn't help survival

Patients who received an implantable cardioverter-defibrillator (ICD) within 40 days after a myocardial infarction had no better survival than those who were treated with medical therapy alone, a new study found.

The randomized, prospective trial included 898 patients who had recently had a myocardial infarction (MI) and had either a heart rate of 90 or more beats per minute on the first available electrocardiogram or nonsustained ventricular tachycardia during Holter monitoring, or both. Of those patients, 445 were randomly assigned to receive an ICD and 453 were assigned to medical therapy only. After a mean follow-up of 37 months, the groups had no significant difference in overall mortality: 116 patients in the ICD group died compared to 117 in the other group. The ICD patients had a reduced risk of sudden cardiac death (hazard ratio [HR], 0.55; P=0.049), but an increased risk of non-sudden cardiac death (HR, 1.92; P=0.001).

The study's results confirmed the findings of the Defibrillator in Acute Myocardial Infarction Trial (DINAMIT) and offered no evidence that implantation of an ICD improved survival in this high-risk group of patients who were receiving optimal medical therapy, the authors concluded. They speculated that the increase in non-sudden cardiac deaths could be due to untoward effects of the ICD shocks, the substrate of MI studied (such as rapid ventricular tachycardia and fibrillation due to pump failure), other effects of the ICD, or differences in the use of other therapies, but said that further research would be required to determine which factor is responsible.

The study shows the value of confirmatory trials in comparative effectiveness research, an accompanying editorial noted. Such trials can direct research and clinical efforts away from ineffective procedures toward new or established alternatives, the editorialist said. The study was published in the Oct. 8 New England Journal of Medicine.


Mental health and primary care

ACPM reiterates screening all adults for depression

The American College of Preventive Medicine (ACPM) reiterated support for U.S. Preventive Services Task Force recommendations that primary care clinicians should have systems to screen all adults for depression, ensure accurate diagnosis and either treat or refer.

Primary care clinicians are the principal contacts for more than 50% of patients with mental illnesses, ACPM said in the position paper, which appeared in the October 2009 issue of the Journal of Family Practice. About 35% of patients seen have some form of depression and 10% suffer from major depression. Further, because depressed individuals use health care more frequently, the prevalence of major depression is two to three times higher in primary care settings than in the general population.

ACPM issued its new position statement because of controversy over how to apply the USPSTF recommendations. ACPM recommended paper-and-pencil assessments that can be quickly completed by patients in the waiting room. They take approximately 5 to 10 minutes for patients to complete and do not interfere with clinical practice. An even briefer screen asks two questions:

  • Over the past month, have you felt down, depressed, or hopeless?
  • Over the past month, have you felt little interest or pleasure in doing things?

Elevated scores on the self-completed questionnaire or the answer of yes to both questions must be confirmed with diagnostic interviewing. A differential diagnosis should exclude depressive symptoms that often overlap with medical conditions, such as hypothyroidism, and with other psychiatric illnesses, such as generalized anxiety disorder.

Patients meeting criteria for a depressive disorder should also be screened for bipolar disorder. And while DSM-IV-TR criteria are well established and avoid over- or underdiagnosis or billing and legal problems, clinical judgment sometimes must supersede strict adherence.


SSRIs during pregnancy linked with pre-term birth, NICU admission

Taking antidepressants during pregnancy was associated with increased risk of premature delivery, lower Apgar scores and neonatal ICU admission, according to a new study.

Researchers studied more than 55,000 pregnant women receiving prenatal care in a Denmark hospital between 1989 and 2006. Among this group, 329 pregnant women reported treatment with SSRIs, 4,902 were not treated with SSRIs but had a history of psychiatric illness, and 51,770 reported no history of psychiatric illness. The 329 women treated with selective serotonin reuptake inhibitors (SSRIs) had twice the risk for preterm birth as women who did not take SSRIs. In addition, SSRI-exposed newborns had an increased risk of being admitted to neonatal intensive care units (NICUs) and of having five-minute Apgar scores of less than eight. The results appear in the October Archives of Pediatrics and Adolescent Medicine.

The findings are consistent with past studies that have described withdrawal symptoms among infants after in utero exposure to SSRIs, they continued. Infants in the study admitted to the NICU had symptoms that could be due to adverse effects of withdrawal symptoms, such as jitteriness, seizures, respiratory problems or infections.

The authors acknowledged that treatment for depression might be warranted in some women during pregnancy. They called for more research comparing the safety of individual SSRIs.


Medicare changes

Premiums rising for many Part D plans

Premiums for many of Medicare's prescription drug plans will be rising in 2010, according to a Kaiser Family Foundation analysis of details recently released by CMS.

"Medicare Part D Spotlight: Part D Plan Availability in 2010 and Key Changes Since 2006" finds that Part D stand-alone prescription drug plans will rise 11% on average next year if beneficiaries stay in their current plan. If beneficiaries choose to stay with their current plan, as many as 1.2 million people on Medicare will have monthly premium increases of at least $10. Alternative drug plans in their geographic region may provide better value. The complete report is available online.

Physicians may wish to encourage patients who are concerned about their rising premiums to examine the other Part D plans being offered by Medicare. Open enrollment will run from Nov. 15 to Dec. 31, but information about the 2010 Medicare program will be sent to beneficiaries (and available at starting in mid-October.

Beneficiaries can also use the updated Medicare Prescription Drug Plan Finder at


Cartoon caption contest

Put words in our mouth

ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

Put words in our mouth

E-mail all entries by October 22. ACP staff will choose three finalists and post them in the Oct. 27 issue of ACP InternistWeekly for an online vote by readers. The winner will appear in the Nov. 3 edition.


MKSAP answer and critique

The correct answer is C) Transvaginal ultrasonography. This item is available online to MKSAP subscribers in the General Internal Medicine section, Item 31.

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.

Endometriosis is a common cause of pelvic pain that cycles with menses. Diagnostic clues include a change in menstrual discomfort after a history of pain-free menses, lower back pain, and tenderness in cul-de-sac or uterosacral ligaments. Transvaginal ultrasonography is 100% sensitive and specific for endometriosis in the ovary; it is much less useful in identifying disease in other sites. MRI can be helpful for identifying retroperitoneal disease, and new cytokine assays are being studied as diagnostic tools. Laparoscopy with biopsy of endometrial tissue on serosal surfaces used to be the gold standard for definitive diagnosis, but it has considerable limitations: Its utility depends on the experience of the surgeon, the disease may not be grossly apparent, and it is inconvenient, expensive, and invasive, with some risk of complications.

Laparotomy is not indicated unless the cause of abdominal pain is less certain than in the scenario described.

Colonoscopy is indicated for symptoms involving the lower gastrointestinal tract, such as diarrhea, tenesmus, or blood in the stool. Cystoscopy is sometimes used to evaluate endometriosis and help determine whether the disease involves the bladder or ureter. However, patients usually report dysuria or hematuria when the genitourinary tract is involved.

Hysterosalpingography is indicated in the evaluation of infertility and recurrent miscarriage to rule out mechanical obstruction within the fallopian tube. Any obstruction seen on this study would not be diagnostic and would require further testing to confirm the leading diagnosis of endometriosis in this patient.

Key Points

  • Diagnostic clues for endometriosis include a change in menstrual discomfort after a history of pain-free menses, lower back pain, and tenderness in cul-de-sac or uterosacral ligaments.
  • Transvaginal ultrasonography is 100% sensitive and specific for endometriosis in the ovary; it is much less useful in identifying disease in other sites.

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Copyright 2009 by the American College of Physicians.


Test yourself

A 67-year-old man is evaluated for a recent diagnosis of primary hyperparathyroidism after an elevated serum calcium level was incidentally detected on laboratory testing. Medical history is significant only for hypertension, and his only medication is ramipril. Following a physical exam and lab studies, what is the most appropriate management of this patient?

Find the answer

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