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

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In the News
for the Week of 12-22-09

Highlights

  • New estimates on cancer risk of CT scans
  • Age, CRP level can signal higher cardiovascular risk regardless of LDL, study reports

Test yourself

  • MKSAP Quiz: prophylaxis prior to overseas travel

Stroke

  • Web-based tool may help predict short-term risk for stroke recurrence
  • Most stroke survivors take antithrombotics but ethnic, gender disparities remain, study finds

Regulatory update

Education

From ACP Hospitalist

  • The next issue of ACP Hospitalist is online

From the College

  • Are you ready for Medicare changes for 2010?
  • John Tooker co-authors article on payment reform in New England Journal of Medicine

Cartoon caption contest

Physician editor: Darren Taichman, FACP

Editorial note: ACP InternistWeekly will not be published for the next two weeks due to the Christmas and New Year’s holidays. See you next year!


Highlights

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New estimates on cancer risk of CT scans

Two new studies warn of the cancer risk posed by CT scans and suggest some risk-reduction strategies.

A retrospective cross-sectional study calculated the radiation doses delivered by computed tomography (CT) scans performed at four different California hospitals. Doses ranged from 2 millisieverts (mSv) for a routine head CT to 31 mSv for a multiphase abdomen and pelvis scan. Many of the scans provided more radiation than is usually assumed to be the case; the median dose for a routine abdomen and pelvis scan was 66% higher than the expected 8 to 10 mSv. Even within each type of study, the effective dose varied significantly within and among the hospitals. There was a mean 13-fold variation between the highest and lowest doses for each procedure.

Extrapolating from these data, researchers calculated cancer risks, such that 1 in 270 women who underwent CT coronary angiography at age 40 would develop cancer from the scan. Risks were lower for men than women, and higher for younger than older patients (20-year-olds faced double the risk, 60-year-olds only half). The study was published in the Dec. 14/28 Archives of Internal Medicine.

Another study in the same issue used risk models to calculate how many cancers could eventually be attributed to CTs based on current scanning rates. Overall, they estimated that 29,000 future cancers could be caused by CT scans performed in the U.S. in 2007. Scans of the abdomen and pelvis contributed the most to the tally, and one-third of the cancers would be due to scans performed on patients between the ages of 35 and 54.

The authors of the studies and an accompanying editorial offered a number of solutions to this problem, including standardized protocols (such as have been applied to mammography), fewer multiple series examinations, dose reduction and registration, and greater use of American College of Radiology accreditation and criteria. The experts also called for a reduction in the number of inappropriate and unnecessary CT scans.

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Age, CRP level can signal higher cardiovascular risk regardless of LDL, study reports

Age and elevated C-reactive protein level regardless of LDL cholesterol level can identify patients at higher risk for cardiovascular events, a recent study reported.

Researchers analyzed almost 9,000 “JUPITER-eligible” (Justification for the Use of statins in Prevention: an Intervention Trial Evaluating Rosuvastatin) individuals and compared the trial’s observed cardiovascular event rates in four groups based on low-density lipoprotein (LDL) cholesterol and high-sensitivity C-reactive protein (CRP) levels (cutoffs at 130 mg/dL and 2.0 mg/L, respectively).

JUPITER-eligible participants (18.2% of total) had an absolute cardiovascular disease (CVD) risk of almost 11% over a seven-year follow-up period, or a CVD event rate of 1.57% per year. The number needed to treat was calculated at 38 over five years and 26 over 6.9 years. Elevated CRP was associated with increased CVD risk and mortality regardless of LDL cholesterol, providing a simple way of identifying those at higher risk for events. The results appear in the Dec. 15/22 Journal of the American College of Cardiology.

The group with elevated CRP and high LDL cholesterol had the highest rate of major adverse events of the four groups, the authors noted. The results suggest that physicians should consider treating all patients with elevated CRP with statins for primary prevention of CVD, they said. However, they noted that their study had limitations, including limited generalizability to patients other than whites and blacks and inclusion of patients who used hormone replacement therapy and had peripheral vascular disease.

The authors also observed that groups with elevated CRP had a higher proportion of women and that, overall, women with elevated CRP had higher event rates than women with CRP levels below 2.0 mg/L. Women made up the majority in groups with elevated CRP that had the highest event rates.

The risk of CVD was higher in groups with elevated CRP regardless of the presence of other risk factors, the authors noted. As a result, using age (men 50 or older; women 60 or older) and elevated CRP alone can identify patients at higher CVD and mortality risk who would benefit from statin therapy, they concluded.

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Test yourself

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MKSAP Quiz: prophylaxis prior to overseas travel

MKSAP QuizA 63-year-old woman is evaluated because of increasing nausea, malaise and decreased appetite. The patient has just returned from her second trip to rural areas of southern India, and her symptoms developed two days before returning to the United States. She developed Plasmodium falciparum malaria following her first trip to India, when she had not taken antimalarial prophylaxis. She took mefloquine for this current trip. None of her traveling companions have become ill.

On physical examination, she is awake and oriented but is in moderate distress because of nausea and malaise. Temperature is 38 °C (100.4 °F), pulse rate is 116/min and regular, respiration rate is 28/min, and blood pressure is 98/60 mm Hg. Crackles are heard at the pulmonary bases bilaterally, and a grade 2/6 systolic murmur is auscultated. The abdomen is obese with decreased bowel sounds and moderate right upper quadrant tenderness. The liver is palpated 4 cm below the right costal margin and is very tender. There are no other masses or organomegaly. The extremities and neurologic examination are normal.

Laboratory studies  
Hemoglobin 10.9 g/dL (109 g/L)
Hematocrit 31%
Leukocyte count 6100/µL (6.1 × 109/L)
Platelet count 98,000/µL (98 × 109/L)
Blood urea nitrogen 24 mg/dL (8.57 mmol/L)
Serum creatinine 1.9 mg/dL (168 µmol/L)
Serum electrolytes Normal
Serum aspartate aminotransferase 6200 U/L
Serum alanine aminotransferase 8500 U/L
Serum alkaline phosphatase 720 U/L
Serum total bilirubin 6.9 mg/dL (117.99 µmol/L)

Plain radiographs of the abdomen are normal. The patient is hospitalized for rehydration. She becomes increasingly icteric, her condition deteriorates rapidly, and she develops multi-organ system failure.

Which of the following prophylactic measures may have prevented this patient's illness if given before her current trip?

A) Malarial prophylaxis with a drug other than mefloquine
B) Hepatitis A immunization
C) Hepatitis B immunization
D) Typhoid immunization

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

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Stroke

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Web-based tool may help predict short-term risk for stroke recurrence

A new Web-based prediction tool combining clinical and imaging information may be effective in predicting short-term risk of recurrent stroke, according to a recent study.

Researchers analyzed data on more than 1,400 consecutive ischemic stroke patients and calculated the 90-day risk of recurrent stroke. Predictors of recurrence included etiologic stroke subtype at admission, history of transient ischemic attack or stroke, and topography, age and distribution of brain infarcts. The recurrence risk estimator at 90 days (RRE-90) demonstrated good discrimination (area under the curve=0.80) in predicting 14- and 90-day risk of recurrence. The results were published online Dec. 16 and will appear in the Jan. 12 Neurology.

The findings suggest that combining clinical variables with imaging information has better predictive value than clinical information alone or scores based on long-term risks, such as hypertension, diabetes and smoking, the authors said. The potential effectiveness of the RRE-90 is particularly significant considering that about half of 90-day recurrent strokes occur in the first two weeks, they added.

Several issues must be considered before incorporating the tool into clinical practice, said an accompanying editorial. For example, no follow-up information was available for almost half of the patients and the actual number of recurrent strokes was relatively small. In addition, the effect of early preventive treatment is unclear. For example, atrial fibrillation had no impact on recurrence using the RRE-90, suggesting that these patients may have been treated with early anticoagulation.

Independent, prospective validation is needed before the tool can be recommended for broader use, the editorial added. However, once validated, the Web-based tool can be easily and quickly expanded to many clinical settings.

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Most stroke survivors take antithrombotics but ethnic, gender disparities remain, study finds

Most survivors of stroke take recommended antithrombotic medications but preventive care is lower among patients who are young, female or Hispanic, a study found.

Researchers studied more than 4,000 people with cerebrovascular disease who participated in the Medical Expenditure Panel Survey from 2000-2006. After exclusion of those who said they could not take aspirin safely because of existing health problems, 81% of participants were using an antithrombotic agent (57% aspirin, 66% any antiplatelet agent, 75% antithrombotic agent). Being young, female or Hispanic was associated with not taking an antithrombotic agent. The study will appear in the January 2010 American Journal of Preventive Medicine.

The results show that aspirin remains the predominant antithrombotic agent in secondary stroke prevention and its use appears to be increasing, the authors said. However, there was no improvement in use of any antithrombotic agent, which may be because usage is already high, the authors noted.

While there were no differences in antithrombotic use by socioeconomic or insurance status, disparities existed by gender and ethnicity, the authors said. Future studies should examine why 20% of stroke survivors are not taking recommended medications and why use is especially low among women and Hispanic patients.

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Regulatory update

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Pediatric H1N1 vaccine recalled

Certain lots of the pediatric H1N1 influenza vaccine were recalled last week after declines in potency were found by the manufacturer.

The recall affects approximately 800,000 doses of 0.25 mL prefilled syringes for children 6 to 35 months of age. During recent potency testing of the lots, manufacturer Sanofi-Pasteur found that the vaccine had dropped below specified minimums for the level of antigen.

The recalled vaccines do not pose a safety risk and children who have already been vaccinated with these lots do not need to be vaccinated again (unless they have not yet received the recommended second dose of vaccine). Providers who received the affected vaccines are being notified by the manufacturer and asked to return the unused shots, according to a CDC information sheet.

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Education

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NIH announces conference on lactose intolerance

The National Institutes of Health has announced an upcoming conference on lactose intolerance and health.

The conference, to be held Feb. 22-24 in Bethesda, Md., will examine the following questions:

  • What is the prevalence of lactose intolerance, and how does this prevalence differ by race, ethnicity and age?
  • What are the health outcomes of dairy exclusion diets?
  • What amount of daily lactose intake is tolerable in subjects with diagnosed lactose intolerance?
  • What strategies are effective in managing individuals with diagnosed lactose intolerance?
  • What are the future research needs for understanding and managing lactose intolerance?

The conference is part of the NIH Consensus Development Program, which organizes major conferences focused on emerging controversies in health and medicine. Additional information about the conference is available online.

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From ACP Hospitalist

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The next issue of ACP Hospitalist is online

The next issue of ACP Hospitalist is online, featuring stories on the following topics and more.

A bundle of joy or trouble? Bundled payments could prove the value of hospitalists or destroy their income, dramatically improve patient care or hurt outcomes, or be a return to capitation or a new way forward.

So you want to be an academic hospitalist. For those contemplating an academic career, it may not always be easy to arrive at the right mix of clinical practice, teaching and research. Learn what to look for.

Results pending at discharge often stay in limbo. How can hospitalists separate the wheat from the chaff?

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From the College

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Are you ready for Medicare changes for 2010?

With the new year fast approaching, now is the time to begin preparing for changes to the Medicare program in 2010. To help you, the College has prepared resources to highlight what you need to know.

In the ACP Web site’s Running a Practice section, you’ll find information about:

  • how to prepare for the upcoming elimination of consultation codes for payment purposes;
  • changes to the Medicare E-Prescribing Incentive program in 2010;
  • changes to the Physician Quality Reporting Initiative for 2010; and
  • additional information about changes to Medicare payments in 2010.

Also, this past weekend Congress passed a short-term fix for the 21% sustainable growth rate (SGR) cut that was scheduled for Jan. 1. The fix will prevent the SGR cut from going into effect through the end of February, with the expectation that Congress will pass a longer-term fix as part of comprehensive health care reform legislation in the next two months. The SGR situation is also discussed on the Running a Practice site.

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John Tooker co-authors article on payment reform in New England Journal of Medicine

ACP Executive Vice President and CEO John Tooker, FACP, discusses health care reform in "Payment Reform: The Need to Harmonize Approaches in Medicare and the Private Sector," published in the Dec. 9 New England Journal of Medicine. The article highlights provisions currently being considered by Congress on payment reforms that offer simple yet important actions to harmonize payment approaches among public and private purchasers.

The article represents the personal views of Dr. Tooker and his co-authors, and does not constitute an official statement of ACP policy. The article is co-authored by Peter V. Lee, JD, executive director for national health policy of the Pacific Business Group on Health, and Robert Berenson, FACP, an institute fellow at the Urban Institute and former senior staff member of the Health Care Financing Administration, now CMS.

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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 Brian Clay, ACP Member, associate professor of medicine, division of hospital medicine, UC San Diego Medical Center, who will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 119 ballots online to choose the winning entry. Thanks to all who voted!

"I have one of those 'Cadillac' health care plans."

The winning entry captured 42% of the votes.

The runners-up were:
"Let's celebrate. I have been converted from observation to inpatient status."
"Way to go on the champagne tap! This round's on me."

ACP Internist continues a new year of cartoon caption contests in January.

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MKSAP answer and critique

The correct answer is B) Hepatitis A immunization. This item is available online to MKSAP 14 subscribers in the Infectious Disease section, Item 47.

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's presentation is most typical of fulminant hepatitis A or hepatitis E and could be either infection. A highly effective vaccine is available for hepatitis A, which must be administered at least 2 weeks before a potential exposure. If this is not possible, standard pooled gamma globulin provides effective prophylaxis. There is no vaccine for hepatitis E, and gamma globulin is not protective against this virus.

The patient's findings are not consistent with malaria. In addition, mefloquine is very unlikely to cause significant hepatotoxicity, so giving a different antimalarial agent would not have prevented her illness. Although an effective vaccine is available for hepatitis B, patients with this infection tend to be asymptomatic and have a more chronic course. Typhoid fever is typically associated with mild hepatic findings and would also not have a fulminant course.

Key point

  • A highly effective vaccine is available for hepatitis A, which must be administered at least 2 weeks before a potential exposure.

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.

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Copyright 2009 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?

Find the answer

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