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


In the News
for the Week of 11-10-09


  • H1N1 in California adds to growing knowledge about flu's presentation
  • U.S. lags behind other countries on support for primary care

Test yourself

  • MKSAP Quiz: progressive chest pain on exertion


Smoking cessation

  • Patch plus lozenge works best among five smoking cessation regimens


  • Obesity is biggest risk factor for left atrial enlargement as people age

Regulatory updates

  • CMS releases final 2010 Medicare fee schedule
  • FTC delays “red flags” rule

FDA update

  • Recall of ketorolac tromethamine injection expanded

Cartoon caption contest

Physician editor: Darren Taichman, FACP


H1N1 in California adds to growing knowledge about flu's presentation

A study of H1N1 influenza in California showed that, as reported around the world, the strain presents in younger patients and obese patients and that clinicians should give antiviral treatment regardless of when symptoms begin.

The Journal of the American Medical Association previously presented reports from Canada and Mexico, as well as Australia and New Zealand. The reports were addressed in the Oct. 20 issue of ACP InternistWeekly.

In the California case series, reported in the Nov. 4 JAMA, there were 1,088 hospitalization or deaths due to H1N1 infection from April 23 to August 11, with most cases occurring in June and July.

Among them, 118 patients (11%) died. Of the deaths, eight (7%) were children younger than 18 years. Among fatal cases, the median time from onset of symptoms to death was 12 days (range, 1 to 88 days). Ten patients died at home, in the emergency department, or within 24 hours after hospital admission. Infants had the highest hospitalization rates and those 50 years or older had the highest death rates once hospitalized. The most common causes of death were viral pneumonia and acute respiratory distress syndrome.

Among all 1,088 cases, 340 (31%) were admitted to intensive care units, and of the 297 intensive care cases with available information, 193 (65%) required mechanical ventilation. Of the 884 cases with available information, 701 (79%) received antiviral treatment, including 496 patients (71%) with established risk factors for severe influenza. The mean time from hospital admission to initiation of antiviral treatment was 1.5 days (range, 0 to 34 days).

Among all 1,088 cases, 344 (32%) were children younger than 18 years. The median age was 27 years (range, less than 1 year to 92 years). The median time from onset of symptoms to hospitalization was two days (range, 0 to 31 days). The most common symptoms included fever, cough and shortness of breath. A subset of cases also presented with altered mental status due to respiratory distress and hypoxia. The median length of hospitalization among all cases was 4 days (range, 1 to 74 days)

Forty-six patients (4%) had secondary bacterial infection, defined by isolation of bacteria from either a normally sterile site or a lower respiratory tract specimen in conjunction with new infiltrate on chest radiograph. The most common pathogens identified were Streptococcus pneumoniae, Staphylococcus aureus, gram-negative rods, and group A streptococcus. Of the 833 patients who had chest radiographs, 547 (66%) had infiltrates suggestive of pneumonia or acute respiratory distress syndrome.

Of the 268 adults aged 20 years or older with known body mass index (BMI), 156 (58%) were obese (BMI >30 kg/m2). Of these, 67 (43%) were morbidly obese (BMI >40 kg/m2).

"Clinicians should be wary of excluding a diagnosis of pandemic 2009 influenza A (H1N1) infection based solely on nonmolecular testing," the authors wrote. "One-fifth of hospitalized cases never received antiviral treatment, and about half received treatment more than 48 hours after onset of symptoms. Recent evidence suggests that even if initiated late, antiviral treatment can reduce mortality, and current national guidelines recommend that all hospitalized patients with pandemic 2009 influenza A (H1N1) infection should be treated with a neuraminidase inhibitor at standard dosing (75 mg every 12 hours) as soon as possible, regardless of when symptoms started."


U.S. lags behind other countries on support for primary care

An international survey of primary care physicians found the U.S. lagging behind other countries in use of information technology, adoption of innovative models of care, and national policies that support primary care practices.

The survey, published online Nov. 2 in Health Affairs, found that while the U.S. spends more on health care than the 10 other countries surveyed, it is behind in health information technology (HIT) capacity, incentives or support for primary care, and increasing access through after-hours care. Besides the U.S., the 2009 survey included primary care physicians in Australia, Canada, France, Germany, Italy, the Netherlands, New Zealand, Norway, Sweden and the United Kingdom.

Researchers also found that U.S. physicians have not led implementation of the patient-centered chronic care model, even though the model originated here. The authors point out that U.S. physicians have been stymied by lack of HIT support for small practices and a payment system that does not reward coordinated care for patients with chronic conditions.

U.S. policymakers would do well to examine delivery systems in other countries, they said, where primary care practices are part of integrated systems and operate under coherent payment and coverage policies. HIT, team-based care and continuity during transitions are important elements in new models of care, they said, as primary care physicians increasingly serve as a bridge between hospitals and community care.

Other highlights from the report included:

  • Countries with national payment and HIT policies focused on primary care (including the U.K., Australia, Holland and New Zealand) were more likely to have advanced HIT capacity, and to use quality incentives and care teams.
  • Access to care has been improved in countries that have supported physician-led after-hours cooperatives and 24/7 national call centers.
  • Access to care is hindered in the U.S. by lack of insurance and insurer restrictions on medications and treatments.

In other primary care news, IBM recently announced that it will cover 100% of its U.S. employees' primary care expenses. Beginning in 2010, employees will no longer have to pay deductibles for visits to in-network doctors such as internists and other primary care physicians. IBM's goal is to encourage more frequent physician visits, thereby curbing health care expenses by treating illnesses before they become serious. Previously IBM required health plan participants to pay 20% of the cost of primary care services.


Test yourself

MKSAP Quiz: progressive chest pain on exertion

A 79-year-old man is evaluated for progressive chest pain on exertion. He has had angina pectoris for 4 years. His medical history also includes hypertension and type 2 diabetes mellitus, and his medications include aspirin, a ß-blocker, an angiotensin-converting enzyme inhibitor, a statin, and metformin. When he was diagnosed with angina, coronary angiography showed 75% atherosclerotic narrowing in the left anterior descending artery, 60% in the first obtuse marginal branch of the circumflex, and 75% in the mid portion of the dominant right coronary artery. Left ventricular ejection fraction was 45%. He requested a trial of medical therapy but still has activity limitations due to angina.

On examination at this time, blood pressure is 132/82 mm Hg and pulse rate is 60/min. There is <3 cm jugular vein distention and a faint right carotid artery bruit. The lungs are clear, and cardiac examination reveals a normal S1 and S2, an S4, and a short grade 2/6 early systolic murmur. Examination of the abdomen and extremities is normal. Electrocardiogram shows normal sinus rhythm and an old inferior myocardial infarction.

What is the most appropriate next step in the management of this patient?

A) Electron-beam CT
B) Dobutamine stress echocardiography
C) Myocardial perfusion stress testing
D) Coronary artery bypass graft surgery
E) Coronary stenting

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



Clopidogrel reduces CV risk in both men and women

Men and women each benefit from clopidogrel therapy to reduce cardiovascular risk, according to a new study.

Researchers performed a meta-analysis of trials comparing clopidogrel and placebo to examine the drug's safety and efficacy and to determine if a difference in benefit exists between women and men. Five trials involving 79,613 patients (30% women) were included. One of the included trials looked at patients presenting with acute coronary syndrome without ST-segment elevation, one looked at patients referred for planned percutaneous coronary intervention or coronary angiography, two looked at patients presenting after ST-segment elevation myocardial infarction (MI) or suspected acute MI, and one looked at patients with or at high risk for cardiovascular disease. The results of the meta-analysis were published online this week by the Journal of the American College of Cardiology and will appear in the Nov. 17 issue.

Overall, a 14% proportional reduction in cardiovascular risk was associated with clopidogrel (odds ratio [OR], 0.86 [95% CI, 0.80 to 0.93]). No significant difference in treatment effect was seen between women and men. Clopidogrel seemed to have the largest effect on risk for MI in women (OR, 0.81 [95% CI, 0.70 to 0.93]), while no statistically significant effect was seen for stroke or all-cause mortality (OR, 0.91 [95% CI, 0.84 to 0.97] and 0.99 [95% CI, 0.90 to 1.08], respectively). In men, however, clopidogrel had a statistically significant effect on all three of these outcomes (OR, 0.83 [95% CI, 0.76 to 0.92], 0.93 [95% CI, 0.71 to 0.96], and 0.91 [95% CI, 0.84 to 0.97], respectively). Both men and women had an increased risk for bleeding with clopidogrel compared to placebo (OR, 1.22 [95% CI, 1.05 to 1.42] and 1.43 [95% CI, 1.15 to 1.79], respectively).

The authors acknowledged their study's limitations, including differences in definitions of major bleeding, loading doses of clopidogrel and treatment duration between trials. However, they concluded that clopidogrel reduces cardiovascular risk and that its effects don't differ significantly by sex. An accompanying editorial called the results "reassuring" but pointed out that variations among the included trials may have affected the results. "Overall the differences in the individual cardiovascular events between men and women are provocative and leave the door open for more investigation of this question," the editorialist wrote.


Smoking cessation

Patch plus lozenge works best among five smoking cessation regimens

The nicotine patch plus lozenge produced the greatest benefit relative to placebo for smoking cessation compared to four other regimens, researchers reported.

To assess the relative efficacies of five smoking cessation pharmacotherapy interventions, researchers designed a randomized, double-blind, placebo-controlled clinical trial of 1,504 adults who had smoked at least 10 cigarettes a day during the past six months. Researchers reported results in the November Archives of General Psychiatry.

Participants were randomized to one of six treatments: nicotine lozenge, nicotine patch, sustained-release bupropion, patch plus lozenge, bupropion plus lozenge, or placebo. In addition, all participants received six individual counseling sessions.

The nicotine lozenge was selected because there was limited evidence regarding its efficacy and the patch was selected because it is the most commonly used therapy. Sustained-release bupropion, meanwhile, was selected because modest evidence has shown that it may be more efficacious than the patch and because it's never been directly compared with the nicotine lozenge.

Researchers assessed biochemically confirmed abstinence assessed at one week, eight weeks and six months. All pharmacotherapies differed from placebo (odds ratios [ORs], 1.63 to 2.34) at six months. Only the patch plus lozenge produced significantly higher abstinence rates at six months than did placebo (OR, 2.34; P<0.001).

The study may have been limited because it could have selected participants with greater motivation to quit than smokers in the general population. In addition, it examined only short-term use of smoking cessation therapies and did not include varenicline because it hadn't been approved yet by the FDA.



Obesity is biggest risk factor for left atrial enlargement as people age

Obesity significantly raises people’s risk for left atrial enlargement, which can put them at high risk for atrial fibrillation, stroke and death, a study found.

Researchers prospectively studied 1,212 men and women age 25 to 74 years over a 10-year period. Left atrial enlargement, determined by standardized echocardiography and indexed to body height, was 9.8% at baseline. After follow-up, obese, hypertensive subjects had the highest increase in left atrial volume (+6.0 mL/m) and the highest incidence of enlargement (31.6%). The results appear in the Nov. 17 Journal of the American College of Cardiology.

Besides aging, obesity was the strongest risk factor for left atrial enlargement and its effect was almost twice that of hypertension, the authors noted. Effective primary prevention is essential to avoiding enlargement, they said, but it is not yet clear whether moderate weight loss can result in regression.

The study also suggests that hypertension and obesity may act through different pathophysiologic mechanisms, the authors noted. In hypertensive people, cardiac adaptations may be caused by pressure overload related to impaired left ventricular filling that may ultimately result in left atrial enlargement. In contrast, in obese people, atrial dilation resulting from increased intravascular volume and increased cardiac output appears to lead to left atrial volume overload.

With the increasing prevalence of obesity in developed countries, left atrial enlargement may replace arterial hypertension as the main risk factor for atrial fibrillation, the authors said. Early interventions, especially in young people, are critical in order to prevent premature cardiac remodeling, they concluded.


Regulatory updates

CMS releases final 2010 Medicare fee schedule

CMS released its 2010 Medicare physician fee schedule on Oct. 30. The final rule, which determines Medicare payment rates to physicians for the next year, is largely similar to the proposal that was released in July. While the rule still indicates a 21.2% payment cut due to the use of the flawed sustainable growth rate formula, it is likely that Congress will avert this cut as in years past.

The College has completed an initial evaluation of how the final rule compares to ACP’s policies on physician payment. Look to the Nov. 20 issue of The ACP Advocate for a complete analysis of the impact of the new rule.


FTC delays “red flags” rule

On Oct. 30, the Federal Trade Commission (FTC) announced that it would delay enforcement of the “red flags” rule until June 1, 2010. The rule itself, which was published as part of the Fair and Accurate Credit Transactions Act, went into effect on Nov. 1.

The rule requires “creditors,” including medical practices, to take steps to reduce the risk of identity theft. It requires all creditors to develop and implement written identity theft prevention programs to help identify, detect, and respond to patterns, practices, or specific activities—known as “red flags”—that could indicate identity theft.

More information about the rule and how to comply are available on the Running a Practice section of the Web site. ACP Internist recently published tips on creating a "red flags" program.


FDA update

Recall of ketorolac tromethamine injection expanded

American Regent expanded its voluntary recall of ketorolac tromethamine injection because of a potential for particulate matter in the product, the FDA said last week. The expanded recall now includes all lots of the 15 mg/mL concentration (NDC# 0517-0601-25 [15 mg/mL 1 mL single-dose vial]). The previously recall involved the concentration of 30 mg/mL, including NDC# 0517-0801-25 (30 mg/mL 1 mL single-dose vial) and NDC# 0517-0902-25 (30 mg/mL 2 mL single-dose vial [60 mg/2 mL]).

Use of the product could result in adverse events, including obstruction of blood vessels that can induce pulmonary emboli or thrombosis and activate platelets and/or neutrophils to induce anaphylactic reactions, according to the FDA. Other adverse effects associated with the injection of particulate matter include foreign body granulomas and local irritation. Clinicians and hospitals should immediately quarantine the product for return.


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 to ACP staff will choose three finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.


MKSAP answer and critique

The correct answer is D) Coronary artery bypass graft surgery. This item is available online to MKSAP 14 subscribers in the Cardiovascular Medicine section, Item 108.

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.

This patient has significant (>70% narrowing) disease in two coronary arteries, including the left anterior descending artery, in addition to a reduced left ventricular ejection fraction and persistent anginal symptoms. According to the American College of Cardiology/American Heart Association guidelines for the management of coronary artery disease and stable angina, coronary artery bypass graft surgery is the revascularization technique of choice in patients with left main coronary disease, three-vessel coronary disease (survival benefit greatest when left ventricular ejection fraction <50%), two-vessel disease involving a proximal left anterior descending coronary artery stenosis, or two- or three-vessel coronary artery disease with a left ventricular ejection fraction <50%. Patients with multivessel disease and ischemia on noninvasive testing, as well as survivors of sudden cardiac death or sustained ventricular tachycardia, should also be considered for bypass grafting. The results of the BARI trial indicated that in patients with multivessel disease, especially those with diabetes, surgery had better long-term outcomes than percutaneous coronary intervention.

In contrast, percutaneous coronary intervention is recommended for patients (including those with diabetes) with two-vessel disease and proximal left anterior descending coronary artery stenosis with normal left ventricular function with anatomy amenable to percutaneous coronary intervention.

Revascularization with either percutaneous coronary intervention or coronary artery bypass graft surgery as compared with medical therapy has been shown to reduce angina pectoris, increase longevity, and improve left ventricular performance in patients with one- or two-vessel disease not involving the proximal left anterior descending artery. In similar patients who have involvement of the proximal left anterior descending artery, bypass graft surgery is preferred.

For patients with discrete one- or two-vessel coronary artery disease, a percutaneous intervention avoids the morbidity and mortality of a surgical procedure. The main limitation of percutaneous intervention is restenosis, which has been significantly reduced with drug-eluting stents. Restenosis rates of 30% to 40% after percutaneous transluminal coronary angioplasty and 20% to 25% after uncoated stents have been reduced to 5% to 15% using drug-eluting stents with antiproliferative coatings. Data from the initial studies with 6 months to 1 year of follow-up have shown restenosis rates in the range of zero to 5%. In patients with multi-vessel coronary artery disease, trials are ongoing to identify whether drug-coated stents can compete favorably with long-term outcomes from coronary artery bypass grafting.

Key Point

  • In chronic angina, coronary artery bypass graft surgery is indicated for patients refractory to medical therapy; a large area of ischemic myocardium; high-risk coronary anatomy; and reduced left ventricular systolic function.

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Test yourself

A 38-year-old man is evaluated for a mass in his right neck that he first noticed 2 weeks ago while shaving. The patient also reports experiencing a pressure sensation when swallowing solid foods for the past year and daily diarrhea for the past 2 months. His personal medical history is unremarkable. His younger brother has nephrolithiasis, and his father died of a hypertensive crisis and cardiac arrest at age 62 years while undergoing anesthesia induction to repair a hip fracture. Following a physical exam, lab studies, and a chest radiograph, what is the most likely diagnosis?

Find the answer

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