In the News
for the Week of 2-3-09
Physician editor: John A. Mitas II, FACP
- Sertraline, escitalopram rank best out of 12 newer antidepressants
- PPIs inhibit clopidogrel's effects, study finds
- MKSAP quiz: sudden-onset blindness
- Biomarker-guided therapy no better than standard treatment for heart failure
- Loop diuretics do not increase fracture risk in most women, study finds
- Incontinence reduced with diet, exercise
Annals of Internal Medicine
- Comprehensive hospital discharges can reduce re-hospitalization
- Not all immunochemical fecal occult blood tests equally effective
- Immediate listing for liver transplantation is not a better strategy
- USPSTF: Insufficient evidence for whole-body skin examination
- ETHEX Corp. expands recall of generics to more than 60 drugs
- United extends deadline for reconsideration of physician rating
From the College
- ACP says U.S. health care system needs extensive reforms
From ACP Internist
- ACP Internist is online and coming to your mailbox
- On the blog: Infectious diseases taking over
- Cartoon caption contest: January's winning entry
Sertraline, escitalopram rank best out of 12 newer antidepressants
Escitalopram (Lexapro) and sertraline (Zoloft) are the most effective and well-accepted of the newer generation of antidepressants, a new study found.
Researchers reviewed 117 randomized controlled trials from 1991-2007 that studied the effects of antidepressants in 25,928 patients with major depression. Sixty-four percent of patients were women; the mean duration of studies was 8.1 weeks. The 12 drugs tested were bupropion (Wellbutrin), citalopram (Celexa), duloxetine (Cymbalta), escitalopram, fluoxetine (Prozac), fluvoxamine (Luvox), milnacipran (Ixel), mirtazapine (Remeron), paroxetine (Paxil), reboxetine (Edronax), sertraline, and venlafaxine (Effexor). The main outcomes were the proportion of patients who responded to (effectiveness) or dropped out (acceptability) of the treatment. The study was published in the Jan. 29 online issue of The Lancet.
Escitalopram and sertraline were the most accepted by patients, resulting in fewer treatment discontinuations than duloxetine, fluvoxamine, paroxetine, reboxetine, and venlafaxine. Sertraline was also 30% more effective than duloxetine, 27% more effective than fluvoxamine, 25% more effective than fluoxetine, 22% more effective than paroxetine, and 85% more effective than reboxetine. Escilatopram was 33% more effective than duloxetine, 32% more than fluoxetine, 35% more than fluvoxamine, 30% more than paroxetine, and 95% more than reboxetine. Mirtazapine and venlafaxine scored high on effectiveness, but were less acceptable to patients than escitalopram and sertraline.
Escitalopram and sertraline may be the best options for treating moderate to severe depression because they balance efficacy and acceptability, the study's authors concluded. While sertraline may be preferable because it often costs less, that assertion hasn't been tested by a full economic model, they said. The study, which received no funding from drug manufacturers, is limited in that its findings apply only to treatment for eight weeks and it did not specifically compare side effects of the various drugs..
PPIs inhibit clopidogrel's effect, study finds
In patients who have had an acute myocardial infarction, proton-pump inhibitors (PPIs) can inhibit the beneficial effects of clopidogrel and raise the risk of reinfarction, according to a new study. The results have led study authors as well as the FDA to recommend that clinicians re-evaluate the use of PPIs in patients taking clopidogrel.
The population-based, case-control study included 13,000 patients who were prescribed clopidogrel after an MI, 734 of whom were readmitted with MI within 90 days of discharge. After multivariable adjustment, current use of a PPI increased the risk of reinfarction by 27%. This increased risk was not present for the PPI pantoprazole, which has not been found to inhibit the bioactivation of clopidogrel, as the other drugs do.
Study authors estimated that between 5% and 15% of rapid readmissions in MI patients on clopidogrel may be caused by the drug interaction. They suggested that thousands of recurrent MIs could be prevented each year by using pantoprazole instead of omeprazole, lansoprazole or rabeprazole in patients taking clopidogrel. Ranitidine or another H2-receptor agonist may be another appropriate alternative, the authors said. The study was published online in the Canadian Medical Association Journal on Jan. 28.
The FDA last week announced plans to collaborate with the manufacturer of clopidogrel on research to understand the effects of genetic factors and other drugs, especially PPIs, on the effectiveness of clopidogrel. In the meantime, the agency recommended that healthcare providers and patients maintain clopidogrel therapy, but assess the use of PPIs, including Prilosec OTC, in patients taking clopidogrel.
MKSAP quiz: sudden-onset blindness
A 19-year-old woman is evaluated in the University Health clinic for sudden-onset blindness. School has been in session for 2 weeks, and she admits that this is the first time she has been away from home, and she misses her family. During class before taking a quiz, she began to have vision problems, consisting of a loss of color vision for approximately 5 minutes in which “everything was in black and white,” followed by complete vision loss. She has been having mild headaches for the past 6 weeks, located in the frontal area, and not associated with prodromes or other neurologic symptoms. Her medical history is otherwise noncontributory, and her family history includes a grandmother with multiple sclerosis.
On physical examination, the vital signs are normal. The pupils are equally round and reactive to light, and the optic discs are without evidence of papilledema or retinopathy. The remainder of her physical examination, including neurologic evaluation, is normal.
Which of the following is the most likely diagnosis?
A) Optic neuritis
B) Temporal arteritis
C) Conversion disorder
D) Macular edema
E) Compression of optic chiasm
Click here for the complete answer and critique to this question.
Biomarker-guided therapy no better than standard treatment for heart failure
Intensified heart failure therapy guided by brain natriuretic peptide (BNP) levels showed no advantage over traditional symptom-guided therapy in elderly patients, a recent study reported.
The study, published in the Jan. 28 Journal of the American Medical Association, included almost 500 patients age 60 years or older with systolic heart failure (ejection fraction < 45%) who had been hospitalized within the past year and who had N-terminal BNP levels of two or more times the upper limit of normal. Patients were randomized to receive either intensive symptom-guided or BNP-guided therapy. After 18 months follow up, patients in both groups had similar rates of survival free of hospitalizations and quality of life scores. BNP-guided therapy improved outcomes for patients age 60-75 but not for those aged 75 or older.
The study suggests that it is possible to improve outcomes by intensifying medical therapy in the face of worsening symptoms, said an accompanying editorial. However, increasing therapeutic doses may not be beneficial in older patients who may have a different syndrome of systolic dysfunction mixed with diastolic dysfunction. Future large trials with larger numbers of older patients and women are needed to determine whether this strategy reduces mortality and hospitalization, the editorial said..
Loop diuretics do not increase fracture risk in most women, study finds
Loop diuretics do not appear to reduce bone mineral density (BMD) or increase the risk for fracture in most postmenopausal women, according to an analysis of participants in the Women's Health Initiative (WHI).
The study assessed incidences of falls and fractures over a mean of seven years for 133,855 women (3,411 used loop diuretics) enrolled in the WHI. Researchers found no significant association between the use of loop diuretics and total hip and vertebral fractures and falls. However, prolonged use of loop diuretics (more than three years) was associated with higher fracture risk in postmenopausal women. The study appears in the Jan. 26 Archives of Internal Medicine.
The authors noted that loop diuretics are most commonly used by women in poor health who are already at risk for falls, fractures and loss of BMD. Because of the association between fractures and long-term use of loop diuretics, physicians may want to consider fracture prevention measures in women taking loop diuretics.
Incontinence reduced with diet, exercise
Weight loss can improve urinary incontinence in overweight and obese women, according to a new study.
In the randomized controlled trial, researchers assigned 338 women to either an intensive six-month weight-loss program that included diet, exercise and behavior modification or a structured education program. At the start of the study, the women had BMI of 25 or more and at least 10 urinary-incontinence episodes per week.
In the intervention group, women met weekly with nutrition and exercise experts and were put on a reduced-calorie diet, which included sample meal plans and vouchers for meal-replacement products. After six months, the intervention group had a mean weight loss of 8% compared with 1.6% in the control group. Their weekly number of incontinence episodes (measured by voiding diaries) had decreased by 47% compared with a 28% drop among controls.
When broken down by type of incontinence, the intervention group was found to have a significantly greater decrease in stress incontinence, but not urge incontinence. More women in the intervention group reached the study's standard of clinically relevant improvement, in that they had a 70% or greater reduction in overall incontinence episodes. The study was published in the Jan. 29 New England Journal of Medicine.
The researchers concluded that decreases in urinary incontinence may be another of the many health improvements associated with moderate weight loss. They suggested that clinicians consider weight reduction as a first-line therapy for overweight and obese women with incontinence.
A recent article in ACP Internist discussed incontinence and other pelvic floor disorders.
Annals of Internal Medicine.
Comprehensive hospital discharges can reduce re-hospitalization
Researchers followed 749 hospitalized adults for 30 days to test the effects of an intervention designed to minimize hospital use after discharge. Half of the patients received normal care, while the other half worked with a nurse discharge advocate during their hospital stay to arrange follow-up appointments, confirm medications and receive patient education. A clinical pharmacist called patients soon after discharge to reinforce the discharge plan and review medications. The intervention resulted in a 30% reduction in hospital use, improved patient self-perceived preparation for discharge, and increased primary care physician follow up, even among participants who frequently used hospital services..
Not all immunochemical fecal occult blood tests equally effective
New qualitative immunochemical fecal occult blood tests (FOBT) use specific antibodies against human blood components to detect traces of blood in the stool, and may yield fewer false-positive and false-negative results. To determine if efficacy was similar among the various qualitative immunochemical FOBTs, researchers compared screening results for six different tests against findings at colonoscopy. Sensitivity for detecting advanced adenomas ranged from 25% to 72%, and specificity ranged from 70% and 97%..
Immediate listing for liver transplantation is not a better strategy
Researchers randomly assigned 120 patients with Child-Pugh stage B alcoholic cirrhosis to either immediate listing for liver transplantation or standard medical care. Immediate listing for liver transplantation was not associated with improved patient survival. In addition, patients who received a liver transplant had an unexpectedly high rate of extrahepatic cancer. Patients who continued to consume alcohol had a poor result regardless of treatment. Researchers concluded that immediate listing for transplantation is not a better strategy for patients with Child-Pugh stage B cirrhosis, especially when alcohol withdrawal is associated with recovery of liver function. The best strategy would be to consider liver transplantation on the basis of patient outcome and to actively screen patients for extrahepatic cancer before and after liver transplantation..
USPSTF: Insufficient evidence for whole-body skin examination
U.S. Preventive Services Task Force researchers found that primary care physicians are moderately accurate in diagnosing melanoma when presented with images of skin abnormalities. However, there was not enough evidence to assess the accuracy of real-life total-body skin examinations by doctors or patients themselves. Instead, doctors and patients should consider the individual patient’s risk factors and preferences when deciding whether to make total-body skin exams a regular part of preventive care.
ETHEX Corp. expands recall of generics to more than 60 drugs
ETHEX Corp. has expanded two previous recalls to include more than 60 generic drugs, including two at the retail level, the FDA said in an alert.
The retail drugs under recall are hydromorphone HCl tables in 2 mg, 4 mg and 8 mg doses; and metoprolol succinate ER tablets in 25 mg, 50 mg, 100 mg and 200 mg doses. Wholesale drugs being recalled include benazepril, diltiazem HCl, morphine sulfate, oxycodone and potassium chloride in various doses. The drugs may not comply with good manufacturing practices, ETHEX said. Some of the products already had specific lots recalled in 2008 due to defects such as oversized tablets that delivered higher doses than the label indicated.
FDA advised patients currently taking these medications to continue doing so, as there may be a risk of suddenly stopping, but to contact their providers if they have any problems they think may be linked to the drugs. A full list of drugs being recalled is available online.
United extends deadline for reconsideration of physician rating
UnitedHealthcare announced an extension until Feb. 11 for reconsiderations under the UnitedHealth Premium physician designation program. The new deadline gives physicians two extra weeks to submit their requests.
The physician designation program is a physician performance-rating program that evaluates physicians on the quality and cost of their clinical care. In December, letters were sent to physicians who practice in markets where the program is in use with information about how to access their assessment results. These assessments are available online. Physicians who are still unable to meet the deadline may appeal their rating at any time. However, if you do not meet the deadline your initial assessment may be displayed with the March release. After the release, United will update changes to their physician ratings weekly.
For detailed information about how to submit a reconsideration request please visit the UnitedHealthcare Web site, or call the UnitedHealth Premium program at 866-270-5588.
From the College.
ACP says U.S. health care system needs extensive reforms
ACP called on President Barack Obama and Congress to take steps to improve health care by recognizing that primary care is the best medicine for better health and lower costs, in its annual State of the Nation’s Health Care report.
The College said that immediate, sustained and dramatic steps are needed to expand coverage and access to primary care doctors. Those steps should include an executive order issued by President Obama to assure that all federal agencies are working together to set primary care workforce goals and the policies necessary to achieve those goals.
“The state of America’s health care is poor,” said Jeffrey P. Harris, FACP, president of ACP. “There are too many uninsured and underinsured people. We have too few primary care physicians.”
“The problems are big, so the solutions must also be big,” Dr. Harris declared. “A better health care system must result in everyone having health insurance coverage, and everyone having access to a primary care doctor. Anything less than that will fail to provide Americans with access to affordable, comprehensive and personal care they need and deserve.”
Additional information about the recommendations released at the event can be found on the ACP Web site. Also, detailed coverage of the event will be in Friday’s issue of The ACP Advocate newsletter.
From ACP Internist.
ACP Internist is online and coming to your mailbox
The February issue of ACP Internist is online, featuring stories on how consumers' disposal of their unused meds is possibly polluting our drinking water. And, polycystic ovary syndrome is a stealthy disease whose distressing symptoms can masquerade as other conditions. Experts offer advice on how to manage these patients. And don't miss coverage of the American Heart Association Scientific Sessions..
On the blog: Infectious diseases taking over
The Salmonella outbreak that sickened more than 500 people and killed eight was traced back to the peanut processor, who detected the bacteria at its facility 12 times in the two years leading up to the outbreak. That revelation sickened our blogger, too. And C. diff spores can be found well outside hospital isolation rooms, in work areas and on portable equipment. Finally, substance abuse is fairly common among people with tuberculosis, and makes them harder to treat..
Cartoon caption contest: January's winning entry
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 David P. Perkins, ACP Member, in private practice in Wayne, Pa. He will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 204 ballots online to choose the winning entry. Thanks to all who voted!
The winning entry:
"No, I've just come to start my overnight call. Why do you ask?"
The winning entry captured 53.9% of the votes. The runners up were:
Third-year medical student to his first patient: "Dude, that sounds radical!" (15.7%)
"You threw me out of your bar, and now look how the tables have turned!" (30.4%)
ACP Internist's cartoon caption contest continues in February..
MKSAP Answer and Critique
Correct Answer = C) Conversion disorder. This topic is available to subscribers in the General Internal Medicine section, item 141.
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 conversion disorder, which is manifested by the acute onset of a symptom, usually neurologic, in the face of overwhelming stress. One relatively common setting for conversion disorders is among new recruits at military basic training camps. Blindness is a common form of conversion disorder; others include loss of hearing, sensation, or motor function. The history in patients with conversion disorder often includes components that make no physical sense, such as color vision loss followed by total vision loss, and neurologic findings that conflict with the patient's description of symptoms, such as normally reactive pupils in the case of sudden blindness. This patient's history and physical examination findings are not suggestive of optic neuritis, temporal arteritis, macular edema, compression of optic chiasm, or multiple sclerosis.
Patients with conversion disorder are not consciously “faking” their symptoms; the symptoms are real, and this patient is truly unable to see, despite the proper functioning of her neurologic mechanisms.
- Conversion disorder is manifested by the acute onset of a symptom, usually neurologic, in the face of overwhelming stress.
- Blindness is a common form of conversion disorder; others include loss of hearing, sensation, or motor function.
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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 2008 by the American College of Physicians.
A 67-year-old man is evaluated for a 6-month history of worsening exertional dyspnea. He has severe COPD, previously with minimal exertional symptoms, but now notes activity-limiting shortness of breath when walking short distances. He does not have chest pain, gastrointestinal symptoms, or sleep-related symptoms. Medical history is otherwise unremarkable. Medications are a twice-daily fluticasone/salmeterol inhaler and an as-needed albuterol/ipratropium metered-dose inhaler. He has a 55-pack-year smoking history but quit when COPD was diagnosed. Following a physical exam, chest radiograph, and transthoracic echocardiogram, what is the most appropriate diagnostic test to perform next?
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