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


In the News
for the Week of 3-17-09


  • Medications not helpful for some elderly heart failure patients
  • Blood pressure treatment reduces Afib dangers in diabetics

Test yourself

  • MKSAP quiz: diarrhea with colon inflammation

Cancer Screening

  • Density plus risk factors best predicts breast cancer
  • Screening tests hold promise for early detection of ovarian cancer

FDA update

  • Class I recalls for infusion pumps, tracheostomy tubes
  • More affordable female condom approved

Medicare News

  • CMS developing new EHR demonstration project


  • PAD screening tool refines risk of functional decline, disability

Annals of Internal Medicine

  • USPSTF recommends aspirin for heart attack, stroke prevention

From ACP Internist

  • Grand Rounds with ACP Internist
  • Your thoughts exactly: direct-to-consumer genetic tests

From the College

  • Hal Sox, MACP, to chair diagnostic and treatment services panel
  • New national education program available for internists
  • ACP to cosponsor physician symposium on IT, coding webinar

Cartoon caption contest

Physician editor: Darren Taichman, ACP Member


Medications not helpful for some elderly heart failure patients

Common cardiac medications don't appear to improve the long-term survival of elderly patients with heart failure and preserved ejection fraction, a new study found.

Researchers reviewed admission records of 142 patients age 80 years and older with heart failure and ejection fraction of 50% or greater. The mean age was 87 years, and 31% of patients were men. Medication status was determined from lists included in discharge records from a patient's first admission for heart failure. Researchers obtained mortality data from the Social Security death registry, and re-hospitalization data via chart review. The study is in the March 15 issue of the American Journal of Cardiology.

At five-year follow-up, 69% of patients had died; there was no significant difference in medication use between patients who died and survived. Medications used included beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, calcium-channel blockers, diuretics, digoxin and statins. There were also no differences in gender, creatinine and co-morbidities (hypertension, diabetes, coronary artery disease, anemia) between survivors and those who died. There were trends toward a survival benefit with statins, and toward decreased survival with digoxin or diuretics, but these weren't significant. Medication use also didn't affect re-hospitalization, although patients using calcium-channel blockers had a significant increase in annual cardiac hospitalizations compared with those not taking them (2.7 ± 3.6 vs. 1.5 ± 2.5; P=0.045).

The study was retrospective and limited in its subject size, the authors noted. Researchers also couldn't verify whether patients were compliant with medication regimens, or whether those regimens changed during follow-up. Still, given the study findings of lack of benefit, cardiac drugs should be used cautiously in this population of octogenarians, particularly digoxin and diuretics, the authors said.


Blood pressure treatment reduces Afib dangers in diabetics

Atrial fibrillation (AF) dramatically increases diabetic patients' risk of death, but that increase can be mitigated with blood-pressure medication, new data from the ADVANCE trial revealed.

The ADVANCE study included 11,140 patients with type 2 diabetes who were randomized to receive either a fixed combination of perindopril and indapamide or placebo. Measured outcomes included total mortality and cardiovascular disease outcomes over a four-year follow-up. Overall, patients with AF had a 61% increased risk of dying from any cause, 77% higher risk of death from cardiovascular causes, and a 68% higher risk of heart failure or other cerebrovascular problems.

Treatment with the blood-pressure medications reduced the risk of cardiovascular death by 18% and the all-cause risk of death by 14%. The reductions were similar in patients both with and without AF, but because the patients with AF had a higher baseline risk, a greater number were helped by the drugs, a press release explained. The researchers estimated that five years of active treatment would prevent one death for every 42 diabetic patients with AF and one for every 120 diabetics without.

The study authors noted that while rate and rhythm control is the usual therapeutic focus in patients with AF, this study indicates the importance of treating overall cardiovascular risk factors, such as blood pressure. Diabetic patients should be actively evaluated for the presence of AF, an author said. The study was published by the European Heart Journal on March 11.



Test yourself

MKSAP quiz: diarrhea with colon inflammation

A 26-year-old man has a 4-week history of increasingly severe bloody diarrhea, urgency, tenesmus, and abdominal pain without fever, chills, or excessive sweating. The patient has an 8-pack-year smoking history.

On physical examination, he appears well. The abdomen is mildly tender without guarding or rebound. Rectal examination is normal. Hemoglobin is 12 g/dL (120 g/L), the leukocyte count is 11,300/µL (11.3 × 109/L), and the erythrocyte sedimentation rate is 38 mm/h. Colonoscopy shows areas of inflammation throughout the colon associated with friability, granularity, and deep ulcerations. The inflamed areas are separated by relatively normal-appearing mucosa, including normal rectal mucosa. The ileum appears normal. Biopsy samples from the inflamed areas of the colon show moderately active chronic colitis without granulomas. Biopsy samples from the ileum are normal.

Which of the following is the most likely diagnosis?

A) Crohn's disease
B) Ulcerative colitis
C) Microscopic colitis
D) Yersinia enterocolitis
E) Ischemic colitis

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



Cancer screening

Density plus risk factors best predicts breast cancer

Breast density, combined with an assessment of demographic and medical history risk factors, is the best way to predict a postmenopausal woman's risk of breast cancer, according to a new review.

Researchers reviewed prospective studies of risk-prediction models, sex hormone levels and the effects of exercise, weight management, healthy diet, alcohol consumption and fruit and vegetable consumption to assess the factors' predictive accuracy. They found that the models which used just demographic characteristics and medical history were moderately predictive of cancer risk. Breast density was a strong predictor (women who scored in category IV on the Breast Imaging Reporting and Data System scale had more than quadruple the risk of those in category I), and improved the accuracy of the models when combined with them.

The researchers also analyzed the use of tamoxifen and raloxifene for primary prevention of breast cancer and concluded that the drugs reduced risk and should be considered for women at high risk. However, cost-benefit analysis is needed to determine which women should be offered chemoprevention, the study authors said in an accompanying press release.

The review found that exercise, weight reduction, a low-fat diet and reduced alcohol intake also modestly reduced risk. Because of their safety and low cost, the healthy lifestyle changes should be recommended to all women, regardless of risk. The study was published online by the Journal of the National Cancer Institute on March 10.


Screening tests hold promise for early detection of ovarian cancer

Postmenopausal women who received routine screening for ovarian cancer with transvaginal ultrasound or ultrasound plus CA125 blood test were more likely to have tumors detected at an early, more treatable stage, according to preliminary results from a large, ongoing trial.

Between 2001-2005, researchers in the United Kingdom randomly assigned about 200,000 post-menopausal women to receive annually either CA 125 screening with transvaginal ultrasound, transvaginal ultrasound alone, or no screening. Almost half of the invasive cancers detected were stage I or II. Sensitivity was similar in both groups but specificity was higher in the ultrasound plus CA 125 group than the ultrasound alone group (99.8% vs. 98.2%) and fewer women in the combination group had to undergo repeat testing and surgery. The study was published online March 11 by the Lancet Oncology.

While the results are encouraging, researchers cautioned that the trial is ongoing and there are still no data on the effects of screening on mortality. In addition, it is still unclear whether the benefits of widespread screening would outweigh the risks (e.g., unnecessary surgery), the lead researcher told the New York Times.



FDA update

Class I recalls for infusion pumps, tracheostomy tubes

The FDA issued Class I recalls last week of specific model numbers and lots of infusion pumps and tracheostomy tubes, according to two safety alerts.

Several models of Colleague Single and Triple Channel Volumetric Infusion Pumps, manufactured by Baxter, are being recalled due to software and battery usage failures which can delay or interrupt infusion and cause serious injury or death. The model numbers are: Mono 2M8151 and 2M8153, CX 2M8161 and 2M8163, and CXE 2M9161and 2M9163. The products were manufactured and distributed from February 1997 through December 2008, the alert said.

Twenty-one lots of the Shiley 3.0PED Cuffless Pediatric Tracheostomy Tube, made by Covidien Inc, are being recalled due to reports about difficulty inserting the obturator and catheter. The problem may require the tracheostomy tube to be removed and replaced, the FDA said. Affected lots were distributed from July 24, 2008 through Dec. 23, 2008; the numbers can be viewed online.

Both companies have sent letters to customers with more details on the product recalls.


More affordable female condom approved

The FDA approved the FC2 Female Condom, a second generation female condom that is less expensive than the original and is made from a nitrile polymer instead of polyurethane, a company press release said.

The new condom will cost about 30% less than the current, first-generation version, which ranges from $1.15 to $2.75 per condom, the Chicago Tribune reported. A randomized, double-blind trial of more than 200 women compared the new and original versions, and found the new version equally safe and effective, the release said. The original version was approved in 1993.


Medicare news

CMS developing new EHR demonstration project

CMS is developing a new demonstration project about the use of electronic health records (EHRs) in small- and medium-sized practices. The Physician Resource Use Feedback Program is designed to show how EHRs can be used to reduce medical errors and improve the quality of care.

CMS has selected 12 practices to participate in the project. Phase one, including the first four sites, is scheduled to begin the demonstration on June 1, 2009. On March 2, letters were sent to eligible practices who applied for this phase to let them know whether they had been accepted and whether they are in the treatment or control group.

Further information, including the complete list of demonstration sites, can be found on the CMS Web site.




PAD screening tool refines risk of functional decline, disability

People with borderline or low normal ankle brachial index (ABI) have a two- to three-fold higher risk for mobility loss, according to data published in the Journal of the American College of Cardiology. The loss of function in patients with peripheral artery disease (PAD) suggests changing the clinical threshold for normal ABI to 1.10 or higher, researchers said.

PAD patients with ABI below 0.90 experience significant and progressive loss of function and mobility, and those with borderline or low normal ABI values appear to be at significantly greater risk of functional decline, including losing the ability to walk up a flight of stairs or walk a quarter of a mile without assistance, compared to people who have no evidence of PAD based on ABI values between 1.10 and 1.30.

A prospective, observational study of 666 patients (62% with PAD) in the Walking and Leg Circulation Study examined functional outcomes related to ABI measures after five years of follow-up. Participants underwent baseline assessments and an annual ABI measurement, functional assessment, a six-minute walk test, and questionnaire on mobility loss. Patients were categorized according to normal ABI (1.10 to 1.30), PAD (ABI <0.90), borderline PAD (ABI 0.90 to 0.99) and low normal ABI (ABI 1.00 to 1.09).

Patients with ABI values between 0.90 and 1.09 had higher rates of mobility loss compared to people with ABI of 1.10 to 1.30. They were also more likely to progress to an ABI of less than 0.90 during the 5-year follow-up than are people with an ABI of 1.10 and above.

Lower ABI values were associated with significantly higher rates of mobility loss (defined as becoming unable to walk up and down one flight of stairs or walk one-quarter mile without assistance) even after adjusting for age, sex, race, comorbidities, smoking, body mass index and physical activity.

ACP Internist offers a PAD supplement and PIER offers a PAD module.



Annals of Internal Medicine

USPSTF recommends aspirin for heart attack, stroke prevention

The U.S. Preventive Services Task Force (USPSTF) found good evidence that aspirin decreases first heart attacks in men, but not stroke. In women, aspirin reduces first strokes, but not heart attacks. Men age 45 to 79 should take aspirin if the chances of preventing heart attack outweigh the chances of bleeding in the digestive tract. Women age 55 to 79 years should take aspirin if the chances of reducing ischemic stroke outweigh the bleeding risks. The recommendation statement and background paper are online.

Also in this issue of Annals:

  • Older patients may not regain mobility after non-surgical hospitalization. Researchers looked at 687 community-dwelling Medicare beneficiaries to assess the effects of surgical and non-surgical hospitalization on life space, a measure of where a person goes, how often and how independently. While patients with surgical hospitalizations improved in life space mobility over time, those with non-surgical hospitalizations did not return to pre-hospitalization levels after two years of follow up.

  • Nursing home physician specialty proposed. Authors propose creating a nursing home medical specialty to fix significant care issues. Challenges include mainstream medicine's recognition of the nursing home as a legitimate practice site, policymakers linking physician practice to quality of care, and financial viability to warrant doctors considering it as a career path.



From ACP Internist

Grand Rounds with ACP Internist

Join us for Grand Rounds, the best of the medical blogosphere, when ACP Internist hosts this week. Find out what doctors are saying about:

  • how the cost of health care turns patients and doctors into enemies,
  • how lifting the embargo on federal funding for embryonic stem cells touched off a firestorm of debate among diabetes patients, and
  • how regulation has forced mammography screening centers to close in the U.S
  • .

Learn more on ACP Internist's Grand Rounds.


Your thoughts exactly: direct-to-consumer genetic tests

ACP Internist is assessing how often internists are asked by patients about direct-to-consumer genetic tests. Tell us about your experiences.

Learn more about the impact of direct-to-consumer genetic tests here and here.



From the College

Hal Sox, MACP, to chair diagnostic and treatment services panel

Past president of the ACP and current editor of Annals of Internal Medicine, Harold C. Sox, MACP, will chair the Institute of Medicine’s (IOM) Committee on Comparative Effectiveness Research Priorities. Dr. Sox will lead a panel of nationally renowned medical experts to make recommendations to the U.S. government about which preventive, diagnostic and treatment services should have the highest priority for research funding from the stimulus package.

The panel will spend the next three months developing recommendations to the Secretary of the Department of Health and Human Services and Congress. This initiative will further extend past and future studies by the IOM in the field of comparative effectiveness. Studies include a past study on the national capacity to identify what works in health care and future federally funded studies on standards for systematic reviews of evidence, and standards for developing trustworthy clinical practice guidelines.

Once the report is completed, the IOM will focus its efforts on disseminating information to the public, with the goal of raising awareness and interest in the project’s results.


New national education program available for internists

ACP together with Pri-Med Institute (PMI) introduces this month a continuing education program for internists.

"Pri-Med Access with ACP" gives physicians greater access to leading educators through a nationwide series of local, two-day programs with curriculum covering diabetes, cardiovascular disease, dependency, and immunizations, all with a focus on disease risk prevention and risk management. The format includes a combination of case-based lectures, interactive workshops, and “work the expert” sessions, taught by renowned course directors and over 55 faculty members from academic medical centers and health care institutions across the country.

ACP and PMI designed the CME curriculum after a review of clinical care needs and practice gaps of primary care physicians, leveraging extensive Pri-Med physician member surveys, and supplementing with other studies on practicing primary care physicians. The program will be available to internists in 26 U.S. cities with a total of 48 programs in 2009. Pri-Med Institute specializes in clinically relevant educational activities for clinicians to advance health care practice and the outcomes of care for patients. The complete "Pri-Med Access with ACP" schedule is available online.


ACP to cosponsor physician symposium on IT and coding webinar

The College will cosponsor the Physician IT Symposium in conjunction with the Healthcare Information and Management Systems Society (HIMSS) annual conference in Chicago next month. The one-day symposium, slated for April 4, will focus on the impact that implementation of health information technology has on physicians in both hospital and office settings.

Peter Basch, FACP, a member of the College’s Medical Services Committee and Medical Informatics Subcommittee, will give the keynote address on The Future of Healthcare IT: An Opportunity for Clinicians to Provide Leadership. Physicians who attend are eligible for up to five credits of CME.

Additional information and registration instructions can be found on the HIMSS Annual Conference Web site.

ACP also continues its series of webinars on March 25th at 7 pm with Doug Leahy, FACP, and "Coding: Beyond the Basics." This one-hour webinar will review key Medicare coding issues including "incident-to" billing, modifiers, often overlooked codes, and the option to bill beneficiaries for Medicare-defined "non-covered" services.

Go online to register. There is a nominal $25 fee to help offset the cost of providing these presentations. Previously recorded sessions are also available under the "Recorded Sessions" link.


Cartoon caption contest

Put words in our mouth

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

Cartoon caption contest - Put words in our mouth

E-mail all entries by to by March 19. ACP staff will choose three finalists and post them in the March 24 issue of ACP InternistWeekly for an online vote by readers. The winner will appear in the March 31 issue. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.


MKSAP Answer and Critique

The correct answer is A) Crohn's disease.

This item is available to MKSAP subscribers in the Gastroenterology and Hepatology section, Item 1.

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 colitis with biopsy samples consistent with idiopathic inflammatory bowel disease. Because his colonoscopic examination shows areas of deep ulceration separated by areas of normal mucosa (skip lesions) and rectal sparing, his findings are more consistent with Crohn's disease than with ulcerative colitis. The absence of ileal inflammation and granulomas on biopsy does not rule out a diagnosis of Crohn's disease. In addition, the patient is a smoker, which increases the risk for Crohn's disease.

Patients with ulcerative colitis have continuous inflammation, typically including the rectum, and usually do not have deep ulcers or skip lesions. Ulcerative colitis is also more common in former smokers or nonsmokers. Microscopic colitis would not be associated with the significant changes found on this patient's colonoscopic examination. Finally, the patient's history and biopsy findings are not consistent with infectious colitis or ischemic colitis.

Key Points
  • Crohn's disease is more common in current smokers, whereas ulcerative colitis occurs more often in former smokers and nonsmokers.
  • Colonoscopic findings in Crohn's disease include deep ulcerations separated by areas of normal mucosa (skip lesions) and rectal sparing.
  • Colonoscopic findings in ulcerative colitis include continuous inflammation, typically including the rectum, but without deep ulcerations or skip lesions.

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Copyright 2008 by the American College of Physicians.


Test yourself

A 67-year-old man is evaluated for a recent diagnosis of primary hyperparathyroidism after an elevated serum calcium level was incidentally detected on laboratory testing. Medical history is significant only for hypertension, and his only medication is ramipril. Following a physical exam and lab studies, what is the most appropriate management of this patient?

Find the answer

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