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

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In the News
for the Week of 11-3-09

Highlights

  • Benefits of lifestyle changes to prevent diabetes persist over a decade
  • Very early DMARDs improve rheumatoid arthritis outcomes

Test yourself

  • MKSAP Quiz: persistent hyperglycemia and diabetes

Women's health

  • Primary care physicians overusing Pap tests
  • Migraine with aura linked to stroke risk

Nephrology

  • Dialysis patients' mortality risk tied to noncardio causes

FDA update

  • Insulin syringe recall expanded
  • IV antiviral authorized under H1N1 emergency

Educational opportunities

  • Congress on health system readiness next month
  • Medical students invited to apply for CDC Applied Epidemiology Fellowship

Free toolkits

  • AHRQ offers free tools for assessing health literacy

From ACP Internist

  • The November/December issue is online

From the College

  • ACP’s Steven Weinberger, FACP, blogs at KevinMD

Cartoon caption contest

Physician editor: Darren Taichman, FACP


Highlights

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Benefits of lifestyle changes to prevent diabetes persist over a decade

Lifestyle changes or metformin can prevent or delay diabetes for up to 10 years, according to the first phase of a follow-up study to a large diabetes prevention trial.

Researchers followed more than 3,000 participants in the original Diabetes Prevention Program (DPP) trial, which compared the impact of intensive lifestyle intervention, metformin and placebo on diabetes incidence in high-risk adults, concluding that diabetes incidence was significantly reduced through lifestyle intervention (58%) and metformin (31%). The follow-up study enrolled 88% of the original participants, who were told about their treatment assignments and were offered the lifestyle intervention. After three years, the metformin and lifestyle groups saw similar reductions in diabetes incidence, but lifestyle intervention led to the largest reduction in diabetes over the 10 years since the DPP trial. The results were published online Oct. 29 in The Lancet.

Diabetes was delayed by four years in the lifestyle group and two years in the metformin group compared with placebo, the authors said. There was no significant difference in diabetes incidence during follow-up, which might be because all participants were offered lifestyle sessions, they noted.

The study fails to answer the question of whether metformin masks or delays diabetes, said an accompanying editorial. It is also unclear whether it is cost-effective to take metformin for a decade to put off diabetes by two years and whether prevention of diabetes would improve cardiovascular or mortality risks, the editorial said. More research is needed to find more effective drugs for those who may not be able to follow intensive lifestyle therapy, the editorial added.

A second follow-up phase to DPP will conclude in 2014, the authors said. The goal of the next phase is to assess interventions on diabetic retinopathy, nephropathy or reduced light touch sensation in the feet, as well as secondary outcomes of cardiovascular disease and worsening of diabetes.

In related news, ACP Foundation is offering free patient and clinical materials to members in recognition of American Diabetes Month. The materials were developed and launched in 2007 for the ACP and ACP Foundation Diabetes Initiative, funded by Novo Nordisk. “Living with Diabetes: An Everyday Guide for You and Your Family” is available free through Nov. 30 by calling 800-523-1546. Other resources, including a six-minute instructional DVD on patient action plans for diabetes, as well as a similar guide for COPD, are available on the ACP Foundation Web site.

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Very early DMARDs improve rheumatoid arthritis outcomes

Early treatment of rheumatoid arthritis (RA) with antirheumatic drugs for newly diagnosed patients is cost-effective and increases quality-adjusted life-years, researchers reported.

AnnalsVery early initiation of disease-modifying antirheumatic drugs (DMARDs) or biologic therapy may permanently result in milder RA or possibly achieve remission and eliminate the need for more therapy. But the optimal strategy has not been determined, researchers wrote in the Nov. 3 Annals of Internal Medicine.

Researchers compared three management strategies to assess the cost-effectiveness of therapies for RA diagnosed less than three months earlier. The first involved a “pyramid” strategy with nonsteroidal anti-inflammatory drugs, patient education, pain management, and low-dose glucocorticoids, followed by DMARDs at one year for nonresponders. The second involved early DMARD therapy with methotrexate, and the third involved early therapy with biologics (three sequential tumor necrosis factor inhibitors) and methotrexate.

Researchers modeled the course of the disease by using functional disability and radiographic evidence of structural joint damage. They categorized each patient’s response to treatment as excellent (low residual disease activity), good, moderate or none. Both early intervention strategies reduced the progression of joint erosions and subsequent functional disability, as well as increased quality-adjusted life-years (QALYs) more than the pyramid strategy.

Over a lifetime, the benefits of the early DMARD strategy are approximately 0.3 QALY higher than those of the pyramid strategy (15.0 [95% CI, 13.1 to 16.5] vs. 14.7 [95% CI, 12.8 to 16.3]). The cost-effectiveness ratio of the early DMARD strategy is $4,849 per QALY (95% CI, $0 to $16,354 per QALY) compared with the pyramid strategy. Additional expenses are nearly offset by the costs saved through reduced hospitalizations (total lifetime costs, $133,340 [CI, $106,976 to $146,401] for the early DMARD strategy vs. $131,890 [CI, $103,569 to $145,432] for the pyramid strategy). Also, early DMARDs maximize their effectiveness and reserve the use of biologics for patients with treatment-resistant RA.

Benefits of the early biologic strategy come at a substantial incremental cost, researchers wrote. The early biologic strategy becomes more cost-effective if drug prices are reduced, risk for death is lowered, patients experience drug-free remission, responders can be selected before therapy initiation, or effective alternative antirheumatic agents are available for patients for whom several biologics have failed. The early biologic strategy offers the most benefit during the first 10 years (7.3 vs. 7.0 QALYs for the pyramid strategy).

In related news, the journal Arthritis & Rheumatism reported in its November issue that anti-tumor necrosis factor α therapies (TNF) don’t increase cancer risk when given for RA.

Swedish researchers culled data from national disease registries to analyze a national cohort of 6,366 RA patients who first started anti-TNF therapy between January 1999 and July 2006. They compared them to a biologics-naďve cohort of 61,160 patients, a methotrexate cohort of 5,989 patients, a DMARD combination therapy cohort of 1,838 patients and then to the general population of Sweden.

During 25,693 person-years of follow-up in the anti-TNF group, 240 first cancers occurred (relative risk, 1.00 [95% CI, 0.86 to 1.15]) compared to the other cohorts. Relative risk did not increase with duration of therapy.

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Test yourself

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MKSAP Quiz: persistent hyperglycemia and diabetes

A 62-year-old man is evaluated for persistent hyperglycemia. He has had type 2 diabetes mellitus for 6 years and also has hypertension, hyperlipidemia, coronary artery disease, and class II-III congestive heart failure. His only current diabetes medication is glyburide, 10 mg twice a day.

On physical examination, the blood pressure is 125/80 mm Hg, pulse rate is 84/min, and BMI is 33.1. He has mild basilar crackles and 2+ pitting edema but no evidence of infection.

Laboratory studies  
Fasting glucose 298 mg/dL (16.54 mmol/L)
Hemoglobin A1C 10.2%
Creatinine 1.8 mg/dL (159.16 µmol/L)
Aspartate aminotransferase 55 U/L
Alanine aminotransferase 62 U/L

In addition to diet, exercise, and weight loss, what would be the most appropriate therapeutic intervention at this time to control his blood glucose?

A) Insulin
B) Repaglinide
C) Metformin
D) A thiazolidinedione
E) Metformin plus a thiazolidinedione

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

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Women's health

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Primary care physicians overusing Pap tests

A recent survey of primary care physicians found that the majority of them are using Pap tests more than guidelines recommend, reported the Nov. 3 Annals of Internal Medicine.

AnnalsThe cross-sectional national survey presented a series of clinical vignettes to 1,212 primary care physicians. For example, physicians were asked about screening for a non-sexually experienced 18-year-old woman. Although 49% recommending no Pap test screening, 32% recommended annual testing. The survey also found significant variations in the frequency of screening that physicians recommended, and reluctance to stop screening—only 52% of respondents would not screen a woman who had already had her cervix removed for benign reasons.

Overall, 22.3% of surveyed physicians had guideline-consistent recommendations across multiple vignettes. Internists were more likely to be compliant than OB/GYNs or family and general practitioners (27.5% vs. 16.4% and 21.1%, respectively). The study authors offered a number of possible explanations, including local guidelines with different recommendations, confusion about changes in guidelines, financial incentives for screening and concern about malpractice. Given that the majority of physicians said that guidelines were influential in their practice, the researchers recommended development and dissemination of interventions to bring screening practices in line with evidence.

A majority of the surveyed physicians also reported greater use of and belief in the effectiveness of liquid cytology, as opposed to conventional Pap testing. However, a study in the Oct. 18 Journal of the American Medical Association found that liquid-based cytology was no better than a conventional Pap test in terms of relative sensitivity and positive predictive value for cervical cancer precursors. The randomized, controlled trial involved almost 90,000 Dutch women.

An accompanying editorial in JAMA noted that the Dutch study is unlikely to change practice in the U.S. Although liquid cytology is more expensive, laboratories prefer it. The results may be most relevant in countries with centrally managed screening programs such as the Netherlands.

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Migraine with aura linked to stroke risk

People who have migraine with aura, especially younger women, may be at increased risk for ischemic stroke, according to a new study.

Researchers performed a meta-analysis to examine the relationship between migraines and cardiovascular disease, including stroke, myocardial infarction, and cardiovascular disease-related death. Twenty-five cohort and case-control studies were analyzed. The results were published early online by BMJ on Oct. 27.

Nine of the 25 studies looked at the association between any migraine and ischemic stroke and found a pooled relative risk (RR) of 1.73 (95% CI, 1.31 to 2.29). People who had migraine with aura were at significantly higher risk than those who had migraine without aura (pooled RR, 2.16 [95% CI, 1.53 to 3.03] vs. 1.23 [95% CI, 0.90 to 1.69]), and women were at higher risk than men (pooled RR, 2.08 [95% CI, 1.13 to 3.84] vs. 1.37 [95% CI, 0.89 to 2.11]). Other factors that increased risk included age younger than 45 years, oral contraceptive use, and smoking. The authors found no overall association between migraine and myocardial infarction or death from cardiovascular disease.

The study had several limitations, including potential misclassification of migraines and migraines with aura and possible publication bias. However, the authors concluded that risk for ischemic stroke is significantly higher in people who have migraines with aura and in women compared with men, and that age younger than 45 years, smoking and use of oral contraceptives further increased risk. "In particular, young women who have migraine with aura should be strongly advised to stop smoking, and methods of birth control other than oral contraceptives may be considered," they wrote.

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Nephrology

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Dialysis patients' mortality risk tied to noncardiovascular causes

Patients starting dialysis have an increased risk of death due to noncardiovascular causes as well as cardiovascular causes, a recent study found.

The cohort study tracked mortality and causes of death in more than 100,000 European adults starting dialysis in 1994 to 2006 and compared those findings to the general European population. Standardized death rates were much higher in the dialysis patients (of whom 35% died) than the general population. Age-standardized cardiovascular mortality was 8.8 times increased in the dialysis patients, and noncardiovascular mortality was 8.1 times normal. Infections and malignancies were the most common causes of noncardiovascular mortality.

After comparing absolute mortality rates, the researchers determined that, for dialysis patients, the increased risk of dying from noncardiovascular disease was higher than that for dying from cardiovascular disease. These findings conflict with historic assumptions about the risks of dialysis, the researchers noted. Contributing factors could include the association between uremia and immune dysfunction, which could lead to both infections and cancers. Patients with end-stage renal disease are also more likely to be frail, which carries an additional mortality risk.

The study authors concluded that dialysis patients' risk of noncardiovascular mortality has been underestimated and future research should focus more on this risk. The study appeared in the Oct. 28 Journal of the American Medical Association.

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FDA update

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Insulin syringe recall expanded

A nationwide recall has been issued for all Accusure insulin syringes, according to an FDA alert.

Certain lots of the syringes were recalled in August, but the recall has expanded to all syringes distributed between January 2002 and October 2009, regardless of lot number. The syringes may have needles that detach from the syringe. If the needle becomes detached during use, it can become stuck in the insulin vial, push back into the syringe, or remain in the skin after injection.

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IV antiviral authorized under H1N1 emergency

The FDA has issued emergency use authorization (EUA) for the investigational antiviral drug peramivir intravenous in certain adult and pediatric patients hospitalized with confirmed or suspected 2009 H1N1 influenza.

Patients should be given the drug only if they meet one or more of the following criteria: 1) They do not respond to either oral or inhaled antiviral therapy, 2) drug delivery by a route other than an IV route is not expected to be dependable or feasible, or 3) for adults only, the clinician judges IV therapy is appropriate due to other circumstances, according to an FDA release.

There are no FDA-approved intravenously administered antivirals for the treatment of influenza. EUA authority allows the FDA, based on the evaluation of available data, to authorize the use of unapproved or uncleared medical products in an emergency. Peramivir is the only intravenously administered influenza treatment currently authorized for use under EUA for 2009 H1N1 infections. As part of the conditions of the EUA, health care providers must report adverse events and all medication errors associated with peramivir to FDA's MedWatch program within seven days.

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Educational opportunities

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Congress on health system readiness next month

The Third National Congress on Health System Readiness: Medicine and Public Health Preparedness in the 21st Century is scheduled for Dec. 1-3, 2009, at the Washington Marriott Wardman Park in Washington, D.C.

At this three-day conference, stakeholders representing the fields of medicine, nursing, public health, allied health, emergency medical services, emergency management, academia, and health care industry will join together to:

  • integrate lessons from recent public health emergencies—such as H1N1 influenza, terrorist attacks and natural disasters—into clinical and public health practice.
  • advance health systems to appropriately prepare for, respond to and recover from disasters and other public health emergencies.
  • develop a distinct educational framework for all health professionals to ascribe to in catastrophic events.

Additional information pertaining to the congress may be found online.

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Medical students invited to apply for CDC Applied Epidemiology Fellowship

Medical students with a strong interest in public health or in practicing medicine with a broad, analytic perspective are invited to apply for the CDC Experience Applied Epidemiology Fellowship.

Nine competitively selected fellows will spend 10 to 12 months at the CDC offices in Atlanta, where they will carry out epidemiologic analyses in various areas of public health. Students will have opportunities to investigate outbreaks of disease in different populations, travel to help set up surveillance programs or engage in injury prevention research, to name a few examples.

The opportunity is open to third- and fourth-year medical students and is designed to increase the pool of physicians with a population health perspective. Application materials for the next fellowship class must be postmarked by Dec. 4, 2009. More information is available online.

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Free toolkits

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AHRQ offers free tools for assessing health literacy

The Agency for Healthcare Research and Quality has released a new free toolkit to help physicians assess their patients' health literacy.

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) Item Set for Addressing Health Literacy measures how well health information is communicated by health care professionals. The item set, which is available in English and Spanish, allows physicians to:

  • identify specific topic areas for quality improvement (communication about test results, medications, and forms),
  • measure their health literacy practices,
  • recognize behaviors that inhibit effective communication (e.g., talking too fast), and
  • design an environment where patients feel comfortable discussing their health concerns.

The item set and other materials are available on the AHRQ Web site.

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From ACP Internist

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The November/December issue is online

The next issue of ACP Internist is online and coming to your mailbox. Check out the latest stories:

Experts debate pros, cons of vitamin DExperts debate pros, cons of vitamin D. A once-obscure nutrient is now being hailed as a link to prevention of diseases as disparate as diabetes, schizophrenia, cancer, strokes and heart attacks. Experts square off on how vitamin D relates to these illnesses, the proper amount that people should get, and how they can get it.

Work up the whole patient when treating IBS. With so many confounding factors to consider with irritable bowel syndrome, physicians can benefit their patients most with an important diagnostic tool—listening. Learn how to work up these patients from first steps to cognitive therapy options.

Uncertain diagnosis for pain leads doctor to dig further. A 66-year-old woman presents with abdominal pain radiating to her back, and CT scans show multiple lesions worrisome for metastatic disease. But when the pain resolves and the lesions don’t change, one internist reconsiders the diagnosis.

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From the College

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ACP’s Steven Weinberger, FACP, blogs at KevinMD

Steven Weinberger, FACP, ACP’s Deputy Executive Vice President and Senior Vice President for Medical Education and Publishing, continues his monthly column at KevinMD.com, one of the Web's most influential medical blogs. At issue are three overarching strategies for fixing the primary care shortage and its associated access to care: 1) increasing the overall number of physicians trained; 2) increasing the percentage of physicians who enter primary care; and 3) increasing the number of alternative providers besides traditional primary care physicians.

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Cartoon caption contest

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And the winner is …

ACP InternistWeekly has compiled the results from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

This issue's winning cartoon caption was submitted by Howard C. Crisp, ACP Associate Member. He will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 168 ballots online to choose the winning entry. Thanks to all who voted!

"Livin' the dream—how about you?"
The winning entry captured 42.3% of the votes.

The runners up were:
"What forms do I need to fill out to get preauthorization on a second inbox?" (36.9%)
"That’s why I’m called an in-ternist." (20.8%)

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MKSAP answer and critique

The correct answer is A) Insulin. This item is available online to MKSAP 14 subscribers in the Endocrinology and Metabolism section, Item 54.

  • 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.

Insulin is the only therapy listed that will control his blood glucose levels adequately. Repaglinide, an insulin secretagogue, would add no benefit in a patient already on the maximal dose of a sulfonylurea. Metformin should not be used in men with creatinine levels greater than 1.5 mg/dL (132.63 µmol/L) or in women with creatinine levels greater than 1.4 mg/dL (123.79 µmol/L). A thiazolidinedione should not be used in patients with class III congestive heart failure and will often cause worsening edema even in patients with less severe congestive heart failure. A combination of metformin and a thiazolidinedione might lower the hemoglobin A1C adequately but should not be used for the reasons stated above for the individual agents.

Key Points

  • Metformin should not be used in men with creatinine levels greater than 1.5 mg/dL (>132.63 µmol/L) or in women with creatinine levels greater than 1.4 mg/dL (>123.79 µmol/L).
  • A thiazolidinedione should not be used in patients with class III congestive heart failure and will often cause worsening edema even in patients with less severe congestive heart failure.

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 2009 by the American College of Physicians.

Test yourself

A 76-year-old woman is evaluated for a 3-month history of left knee pain of moderate intensity that worsens with ambulation. She reports minimal pain at rest and no nocturnal pain. There are no clicking or locking symptoms. She has tried naproxen and ibuprofen but developed dyspepsia; acetaminophen provides mild to moderate relief. The patient has hypertension, hypercholesterolemia, and chronic stable angina. Medications are lisinopril, metoprolol, simvastatin, low-dose aspirin, and nitroglycerin as needed. Following a physical exam, lab results and radiograph, what is the next best step in management?

Find the answer

Have questions about the new ABIM MOC Program?

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