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

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In the News
for the Week of 2-10-09

Physician editor: John A. Mitas II, FACP

Highlights

  • Obama funds, extends SCHIP
  • Breast cancer decline coincided with drop in hormone use

Test yourself

  • MKSAP quiz: facial lesion

Oncology

  • Adding antibody reduces colon cancer regimenís efficacy

Stroke treatment

  • Quick stroke therapy reduces cost and disability

Women's health

  • Primary ovarian insufficiency may cause menopause symptoms in young women

FDA update

  • Prenatal vitamins, iron supplements recalled
  • Manufacturer requests return of five lots of FLUVIRIN vaccine
  • Bleeding events, deaths prompt safety review of drotrecogin alfa

From the College

  • Connect with ACP and your colleagues nationwide through Facebook
  • Deadline for "Internists as Artists" program entries
  • New career guide for residents now online

Cartoon caption contest


Highlights

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Obama funds, extends SCHIP

President Barack Obama signed legislation last week to continue and expand the State Children's Health Insurance Program (SCHIP).

The bill, which is similar to two measures vetoed by former President George W. Bush, will cover the 7 million children already in the program and provide coverage for an additional 4 million, the Feb. 5 Washington Post reported. The legislation passed the House last Wednesday by a 290 to 135 vote.

Key features of the bill include:

  • a 62-cent increase in the federal excise tax on tobacco products, expected to raise $32.8 billion through Sept. 2013,
  • grants (totaling $100 million) to states, local governments and schools to enroll eligible children,
  • a requirement that states offer dental benefits, and
  • permission for states to extend benefits to newly arrived legal immigrants.

The final bill did not include restrictions on physician-owned hospitals as had been proposed by Rep. Pete Stark (D-CA). His version of the SCHIP bill would have prohibited Medicare payments to new physician-owned hospitals and restricted expansion of existing facilities, the Wall Street Journal's blog reported. The Physician Hospitals of America, an interest group representing the doctor-owned hospitals, expressed pleasure at the defeat of the provision but noted that Mr. Stark and other advocates are likely to propose the legislation again.

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Breast cancer decline coincided with drop in hormone use

A recent decline in the incidence of breast cancer in the U.S. appears connected to the drop-off in hormone use following the 2002 report by the Women's Health Initiative warning of heart risks.

The study, published in the Feb. 5 New England Journal of Medicine, analyzes the results of the WHI trial, which was halted in 2002 after it was discovered that combined estrogen-progesterone therapy appeared to increase women's risk of coronary heart disease. Incidence of breast cancer in the hormone therapy group declined by 43% between 2002 and 2003, researchers reported, even though frequency of mammography remained steady. The findings suggest that the carryover effect of hormone therapy on breast cancer risk is time-limited, they added.

Recent statistics show that breast cancer incidence among postmenopausal women in the U.S. continued to decline between 2002 and 2005 among women age 50-69, researchers reported. Those numbers, combined with the lack of evidence that changes in mammography practices accounted for the decline, support the idea that breast cancer decline among postmenopausal women is predominantly related to the decrease in combined hormone use, researchers concluded.

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Test yourself

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MKSAP quiz: facial lesion

A 65-year-old man is evaluated for a facial lesion on his upper cheek bone just below his right eye. The medical history is noncontributory.

On physical examination, a flesh-colored, dome-shaped nodule is noted. It has adjacent telangiectasia and a pearly, translucent surface. The remainder of the examination is normal.

Which of the following is the most likely diagnosis?

A) Basal cell cancer
B) Squamous cell cancer
C) Keratoacanthoma
D) Sebaceous hyperplasia

Click here for the complete answer and critique to this question.

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Oncology

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Adding antibody reduces colon cancer regimenís efficacy

Adding anti-epidermal growth factor receptor antibody cetuximab (Erbitux) to a standard colorectal cancer regimen resulted in significantly shorter progression-free survival and inferior quality of life, researchers reported.

Researchers studied the effect of adding cetuximab to a standard regimen of two chemotherapy drugs, capecitabine and oxaliplatin, and bevacizumab (Avastin) for metastatic colorectal cancer. In an open-label, randomized, phase 3 trial at 79 centers in the Netherlands between June 2005 and December 2006, 755 patients with previously untreated metastatic colorectal cancer were randomized to receive either the standard regimen (378 patients) or the standard regimen plus weekly cetuximab (377 patients). The primary end point was progression-free survival.

Median progression-free survival was 10.7 months in the original regimen group and 9.4 in the cetuximab group (P=0.01). Patients in the cetuximab group had more grade 3 or 4 cetuximab-related adverse cutaneous effects. Patients treated with cetuximab who had tumors with a mutated KRAS gene had significantly decreased progression-free survival. Also, quality-of-life scores were lower in the cetuximab group.

Researchers speculated in the New England Journal of Medicine that their results might be due to a negative interaction between cetuximab and bevacizumab. The studyís lead author told the Washington Post, "This will stand out as a warning," that randomized studies are needed to determine the effects of what otherwise might seem obvious.

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Stroke treatment

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Quick stroke therapy reduces cost and disability

Urgent assessment and treatment of transient ischemic attack (TIA) or minor stroke can reduce hospital admissions, costs and disability, according to new study data.

The EXPRESS study, a prospective population-based sequential comparison conducted in England, had already found that early treatment reduced the 90-day risk of recurrent stroke. The study had two phases, one in which patients with TIA were referred by their primary care physicians to appointment-based outpatient clinics which sent treatment recommendations back to the physicians. In the second phase, patients received immediate assessment and treatment at the clinic. The study was published online by The Lancet Neurology on Feb. 5.

Patients treated in the second phase had fewer hospital admissions for recurrent stroke (5 vs. 25) and fewer inpatient days due to vascular causes (427 vs. 1,365). They also had shorter overall length of stay and were less likely to be disabled six months after the event. Based on the data, researchers concluded that urgent-care clinics offering treatment for TIA and minor stroke could be cost-effective, reducing hospital and disability costs.

However, the trial did not include the cost of setting up such clinics and study authors recommended that follow-up be done to determine the long-term cost-effectiveness. Despite that concern, an accompanying editorial argued that the study provides sufficient evidence to put the research into practice and treat TIA urgently. Hurdles to accomplishing that include setting up clinics, training appropriate personnel and accurately diagnosing TIA and minor stroke, noted MedPage Today on Feb. 4.

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Women's health

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Primary ovarian insufficiency may cause menopause symptoms in young women

Providers should consider primary ovarian insufficiency as a possible cause of menopause symptoms in female patients under age 40, an article in the Feb. 5 New England Journal of Medicine said.

In patients with the condition, previously called "premature menopause," the ovaries stop releasing eggs and producing reproductive hormones, which leads to symptoms like loss of menstrual periods, hot flashes, night sweats, infertility and sleep loss. Primary ovarian insufficiency is diagnosed in women with at least four months of menstrual cycles that are absent, irregular, too few or too frequent; and who show high levels of follicle stimulating hormone in two tests taken more than a month apart.

Treatment comprises estrogen and progestin to relieve the symptoms of menopause. Research indicating these hormones cause heart disease doesn't apply to women with primary ovarian insufficiency who are too young to have undergone normal menopause, the article said. Counseling is also indicated to help women who may experience grief, depression and anxiety associated with the diagnosis, and with infertility in particular.

Women with the condition also are at risk for low bone mineral density, and so should take adequate calcium and vitamin D and get sufficient exercise, it said. The cause of primary ovarian insufficiency is unknown in 90% of cases; in the rest, it can be attributed to a genetic condition or autoimmunity, the article said.

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FDA update

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Prenatal vitamins, iron supplements recalled

Two subsidiaries of KV Pharmaceutical Company are issuing recalls of prenatal vitamins and iron supplements because the products may have been made under conditions that didn't comply with Good Manufacturing Practices, ETHEX Corp. and Ther-Rx Corp. said in releases.

Patients should not stop taking these products suddenly, the companies said, but should call their providers if they feel they have any problems related to the pills. Prescription prenatal vitamin brands affected by the recall include Advanced NatalCare, NatalCare, NataTab, PreCare and PrimaCare, among others. Affected iron supplement brands include Anemagen, Conison, Chromagen, Encora and Niferex, among others.

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Manufacturer requests return of five lots of FLUVIRIN vaccine

Customers should stop using and return any remaining doses of FLUVIRIN Influenza vaccine Luer-Lok pre-filled syringes with lot numbers 878771P, 878772P, 878773P, 878775P and 878776P, FDA said in a notice.

Routine testing of the vaccine found a minor deviation in the potency of the A/Brisbane (H1N1) component, the notice said. The vaccine met all specifications when it was released, and has been monitored monthly during its shelf life. In early January 2009, a minimal decrease in H1N1 antigen content was found.

The FDA and the CDC don't expect a public health impact from the deviation, since all of the vaccine was already shipped when the vaccine met potency requirements, and most was administered when the vaccine still met requirements. Also, the decrease in antigen content is small and would have a negligible effect if any on immune response, the notice said. It's not necessary to revaccinate patients who were vaccinated with the affected lots, it said.

The flu started off slow this year but activity has picked up in recent weeks, according to the CDC. Widespread activity was reported by five states (Colorado, Delaware, New York, Texas, and Virginia) as of Jan. 31, while 21 states reported regional activity.

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Bleeding events, deaths prompt safety review of drotrecogin alfa

The FDA is conducting an ongoing safety review of drotrecogin alfa (Xigris) due to a recent study that found a higher risk of serious bleeding events and death in patients with sepsis and bleeding risk factors who took the drug.

The study, published in the January Critical Care Medicine, retrospectively reviewed the medical records of 73 patients who took drotrecogin alfa. The drug is meant to reduce death in adult patients with severe sepsis. Results showed serious bleeding events in 35% of patients who had a bleeding risk factor compared with 3.8% of patients with no bleeding risk factors. This risk is already indicated on the product's label, which prescribers should read for contraindications, warnings and precautions, the FDA said.

The FDA will work with the drug's maker to further evaluate the incidence of bleeding events and death in patients who take the drug, which may take several months, it said.

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From the College

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Connect with ACP and your colleagues nationwide through Facebook

Facebook users can now keep in touch with news from the College by becoming a Fan of the new ACP Facebook page. Keep updated with news, events, multimedia postings, and more from ACP.

Facebook is one of the top social networking sites with more than 150 million members, and is not just for students anymore. Facebook users age 30 and older grew by 200 percent in 2008, and now the 30-plus segment makes up almost one-third of its users.

If you are already a member of Facebook, join our group now to network with internists across the country and world, interact with colleagues, start and participate in online discussions, and check out who will be attending upcoming ACP events.

If you are not a Facebook member, but would like to learn more about it, step-by-step instructions for how to join are below. Joining Facebook is free and only takes three easy steps:

1. Use your Internet browser to access www.facebook.com.
2. Follow the instructions to sign up and create your personal profile.
3. Once you have a profile, click here and click "Become a Fan."

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Deadline for "Internists as Artists" program entries

Entries for the ACP's national "Internists as Artists" program at Internal Medicine 2009 are now being accepted. All entry application forms must be submitted by March 9. Designed to showcase physicians' talents in the visual arts, the "Internists as Artists" exhibit will be located in the Exhibit Hall of the Pennsylvania Convention Center in Philadelphia during Internal Medicine 2009. Submissions may include painting, sculpture, photography, mixed media, woodworking, jewelry, crafts and ceramics.

Members interested in submitting entries must complete a registration form and send it along with either a photograph or an electronic image of their artwork (a maximum of two entries). Entries will judged by program jury members, and must be completely display-ready. Completed registration forms and electronic or photographic images should be sent to: Helen Canavan, ACP Internists as Artists Program, 190 N. Independence Mall West, Philadelphia, PA 19106-1572, by e-mail hcanavan@acponline.org or by calling 800-523-1546, ext. 2663.

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New Career Guide for residents online

Find articles on career, professional, and personal development as well as career opportunities. View the 2009 guide online.

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Cartoon caption contest

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Put words in our mouth

ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner.

E-mail all entries by to acpinternist@acponline.org by Feb. 19. ACP staff will choose three finalists and post them in the Feb. 24 issue of ACP InternistWeekly for an online vote by readers. The winner will appear in the March 3 issue. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

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MKSAP Answer and Critique

Correct Answer = A) Basal cell cancer. This topic is available to subscribers in the General Internal Medicine section, item 32.

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.

Basal cell carcinoma is the most common malignancy in humans. Early basal cell cancers are small, nodular lesions usually of flesh or pearly color, with areas of translucency and surface telangiectasia. They usually occur on sun-exposed skin and, with time, invade locally both out and down into surrounding tissue. Often, patients describe a nonhealing sore that bleeds easily even with minimal trauma. Early identification with prompt treatment prevents the disfiguring effect of local tissue destruction from expanding tumors.

The characteristics of this patient's lesion do not coincide with those of squamous cell carcinoma (SCC). SCC is characterized by hyperkeratotic, ulcerated, and fast-growing lesions and is associated with a 2% to 6% incidence of metastasis. Higher-risk SCC lesions grow noticeable within 1 to 3 months, show deeper tissue invasion, have ill-defined borders, and are less differentiated on biopsy than lower-risk lesions.

Keratoacanthoma originates in the pilosebaceous glands and typically grows rapidly over a few weeks; it appears on sun-exposed areas. It is generally a solitary reddish-colored, dome-shaped papule with a smooth shiny surface and a central ulceration or keratin plug (horn). Keratoacanthoma spontaneously resolves over 4 to 6 months.

Sebaceous hyperplasia occurs in about 1% of healthy adults. One or more lesions may be present, typically on the nose, cheeks, or forehead. The lesions are soft, discrete, and yellowish, with a smooth or slightly rough surface. Sebaceous hyperplasia is completely benign and does not require treatment.

Key Point

  • Early basal cell cancers are small, nodular lesions usually of flesh or pearly color, with areas of translucency and surface telangiectasia, frequently occurring on sun-exposed skin.

Click here to return to the rest of ACP InternistWeekly.

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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 2008 by the American College of Physicians.

Test yourself

A 66-year-old man comes for a preoperative evaluation before total joint arthroplasty of the left knee. He has a 25-year history of rheumatoid arthritis. He has had progressive pain in his left knee with activity, which limits his ability to hike. The patient has similar pain in the right knee, but it is less severe. He reports no recent morning stiffness. He is able to climb two or three flights of stairs without chest pain or shortness of breath. He has no other medical problems and reports no additional symptoms. Medications are methotrexate and folic acid. Following a physical exam and lab tests, what is the next best step in management?

Find the answer

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