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

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In the News
for the Week of 3-24-09

Highlights

  • CAD progression slowest for those with very low LDL, normal systolic BP
  • Prostate cancer screening leads to unneeded treatments

Test yourself

  • MKSAP quiz: sleepiness and hypertension

Disease management

  • Simple algorithm improved outcomes for hypertension

Oncology

  • Early detection may double survival chances after second breast cancer

FDA update

  • Two DNA tests approved to detect HPV

Health reform

  • Survey seeks internists' input on priorities for clinical effectiveness research

From ACP Hospitalist

From the College

  • Match Day” results highlight primary care crisis
  • ACP to hold coding webinar
  • College supports new health care coalition’s fight for quality

Cartoon caption contest

  • Vote for your favorite entry

Physician editor: Darren Taichman, ACP Member


Highlights

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CAD progression slowest for those with very low LDL, normal systolic BP

Coronary artery disease (CAD) patients with very low levels of low-density lipoprotein (LDL) cholesterol and normal systolic blood pressure have the slowest disease progression, a new study found.

Researchers analyzed 3,437 patients from seven clinical trials who underwent intravascular ultrasound (IVUS) to monitor changes in atheroma burden at 18-24 months after baseline. Subjects were stratified into four groups based on LDL cholesterol greater or less than 70 mg/dL, and systolic blood pressure greater or less than 120 mm Hg. Researchers measured plaque progression via percent atheroma volume, total atheroma volume, percent of patients with significant plaque progression, and percent of patients with significant plaque regression. The article was published in the March 24 Journal of the American College of Cardiology.

With all four measurements of plaque progression, disease progression was slowest in patients who had a combination of LDL cholesterol less than or equal to 70 mg/dL, and systolic blood pressure less than or equal to 120 mm Hg. Very low LDL seemed to be the more beneficial factor, as patients with systolic blood pressure greater than 120 mm Hg but LDL less than or equal to 70 mg/dL had less progression of atheroma volume than patients with normal blood pressure and LDL greater than 70 mg/dL.

The study is limited in that it is observational, and used IVUS results as outcomes, rather than clinical events or mortality, an editorial said. Still, the results suggest that both LDL and systolic blood pressure contribute to CAD, and patients should be treated aggressively to reach optimal lipid and blood pressure levels, the authors said.

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Prostate cancer screening leads to unneeded treatments

Two large, randomized studies in the U.S. and Europe found little benefit and significant risk of overdiagnosis and overtreatment of cancers that might never result in death. The studies and an accompanying editorial were published in the New England Journal of Medicine.

In the U.S., the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial randomly assigned 76,693 men at 10 U.S. study centers to receive annual screening or usual care from 1993 through 2001.

Men in the screening group received annual PSA tests for six years and digital rectal exams for four years. In the control group, "usual care" sometimes included screening, and screening rates increased during the span of the study. After seven years of follow-up, the incidence of prostate cancer per 10,000 person-years was 116 (2,820 cancers) in the screening group and 95 (2,322 cancers) in the control group (rate ratio [RR], 1.22; 95% confidence interval [CI], 1.16 to 1.29). Deaths per 10,000 person-years were 2.0 (50 deaths) in the screening group and 1.7 (44 deaths) in the control group (RR, 1.13; 95% CI, 0.75 to 1.70).

U.S. researchers concluded that the prostate cancer death rate was very low and did not differ significantly between the screening and control arms.

The European Randomized Study of Screening for Prostate Cancer randomized 182,000 men ages 50 to 74 through registries in seven European countries, using death from prostate cancer as the primary outcome. Men were offered PSA screens every four years or randomized to an unscreened control group.

During a median follow-up of nine years, the cumulative incidence of prostate cancer was 8.2% in the screening group and 4.8% in the control group (RR, 0.80; 95% CI, 0.65 to 0.98; adjusted P=0.04). The absolute risk difference was 0.71 deaths per 1,000 men. Researchers wrote that 1,410 men would need screening and 48 additional cases of prostate cancer would need treatment to prevent one death.

European researchers concluded that PSA-based screening reduced the rate of death from prostate cancer by 20% but was associated with a high risk of overdiagnosis. An editorial said that PSA screening has at best a modest mortality benefit at the risk of substantial overdiagnosis and overtreatment. "Some well-informed clinicians and patients will still see these trade-offs as favorable; others will see them as unfavorable. As a result, a shared decision-making approach to PSA screening, as recommended by most guidelines, seems more appropriate than ever."

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Test yourself

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MKSAP quiz: sleepiness and hypertension

A 55-year-old man is evaluated for excessive daytime sleepiness and hypertension. His wife reports that he snores loudly, causing her to have to sleep in a separate bedroom. He also had a minor car accident when he fell asleep while driving.

On physical examination, the patient is an obese man (BMI 32) with a thick neck; the blood pressure is 145/90 mm Hg. Cardiopulmonary examination is otherwise normal.

What is the most appropriate next step in the management of this patient?

A) An attended laboratory polysomnography
B) Nighttime continuous pulse oximetry
C) Automated positive airway pressure (APAP) therapy
D) Modafinil therapy

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

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Disease management

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Simple algorithm improved outcomes for hypertension

Using a simplified strategy to manage hypertension, consisting of initial low-dose fixed-dose combination therapy, led to better outcomes than adhering to current treatment guidelines, a recent study concluded.

In the cluster randomized controlled trial, researchers compared the simplified algorithm with the Canadian Hypertension Education Program (CHEP) guidelines used at 45 family practices in Ontario. The simplified algorithm consisted of initial therapy with a low-dose angiotensin-converting enzyme inhibitor/diuretic or angiotensin receptor blocker/diuretic combination; up-titration of combination therapy to the highest dose; addition of a calcium-channel blocker and up-titration; and addition of a non-first-line antihypertensive agent. (The most current CHEP guidelines are online).

After six months, the proportion of patients achieving target was significantly higher in the simplified treatment group (64.7% vs. 52.7%), and a multivariate analysis indicated that this group also had a 20% increased chance over patients in the guideline group of reaching target blood pressure. The study appears in the April issue of Hypertension.

The rationale for the algorithm, researchers said, is that low-dose combinations of antihypertensive drugs are more effective, cause fewer side effects and may result in improved patient adherence than low-dose monotherapy. They added that the fixed-dose combination approach used in the algorithm (versus single-agent initiation often recommended by guidelines) reduces the need for physicians to switch drugs and treatment can be escalated easily.

The authors concluded that the complexity of current treatment guidelines may, in part, account for why blood pressure control remains suboptimal despite the availability of medications.

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Oncology

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Early detection may double survival chances after second breast cancer

Early detection of second tumors in breast cancer survivors almost doubled their chances of surviving the second cancer, a recent study reported.

Using data from a center in Florence, Italy, researchers retrospectively reviewed 1,044 cases of breast cancer survivors between 1980-2005 who had a second invasive tumor at least six months after the initial diagnosis. After a median of almost 14 years' follow-up after diagnosis of the primary cancer, 455 women had ipsilateral breast cancer recurrence and 589 developed tumors in the contralateral breast.

Second tumors were more likely than primary cancers to be asymptomatic (67% vs. 33%) at diagnosis and asymptomatic tumors were smaller, were more likely to be early state in situ and were less often node positive. Disease-specific survival from first cancer diagnosis significantly favored asymptomatic cases (hazard ratio 0.53, P<0.0001). The results appear in the March 17 online edition of Annals of Oncology.

Researchers also found that mammography was more sensitive than clinical breast examination overall (86.1% vs. 56.7%), for ipsilateral recurrence (80.5% vs. 59.5%), and for contralateral second cancers (90.5% vs. 54.5%, all P<0.0001). However, 13.8% of cases were only identified clinically.

Researchers concluded that detection of second breast cancers in the asymptomatic phase improves relative survival by between 27% and 47%.

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FDA update

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Two DNA tests approved to detect HPV

The FDA last week approved the first DNA test able to identify the two types of human papillomavirus (HPV) that cause the majority of cervical cancers in the U.S., and a second test for a wider range of HPV types, the agency said in a release.

The first, the Cervista HPV 16/18 test, detects the DNA sequences in cervical cells for HPV type 16 and HPV type 18. Together, the two types cause about 70% of cervical cancers. The second, the Cervista HPV HR test, detects essentially all of the high-risk HPV types in cervical cell samples. Along with a physician's assessment of patient history and other risk factors, the tests can be used in women age 30 and older, and those with borderline cytology, to assess cervical disease risk, the FDA said.

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Health reform

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Survey seeks internists' input on priorities for clinical effectiveness research

The Institute of Medicine (IOM) is asking internists to participate in an online survey to determine the top priorities for clinical effectiveness research funded by the new federal stimulus package.

The stimulus package passed by Congress, called the American Recovery and Reinvestment Act of 2009, allocated $0.4B for clinical effectiveness research (CER) and charged IOM with canvassing the medical community and setting priorities for spending. The College is urging its members to nominate topics of importance to primary care.

The Web-based survey, which closes on March 27, allows organizations and individuals to submit their three top priorities for research. You can also reach the survey through the primary Web site.

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From ACP Hospitalist

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Latest issue of ACP Hospitalist available online

Visit ACP Hospitalist's new Web site for the latest on:

The full March issue of ACP Hospitalist is online.

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From the College

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“Match Day” results highlight primary care crisis

The 2009 National Resident Matching Program results last week continued a recent downward trend in the number of medical school graduates choosing to pursue internal medicine residencies or specialize in primary care.

According to the results, 2,632 U.S. medical school seniors enrolled in internal medicine residency programs, compared with 3,884 in 1985. Of those who do plan to pursue internal medicine residencies, only 20% to 25% choose to specialize in general internal medicine, compared with 54% in 1998.

Steven E. Weinberger, FACP, ACP’s Senior Vice President for medical education and publishing, says the trend is a generational shift and reflects the need for payment reform. “ACP has long been concerned about the rising cost of medical education,” he said, adding how reducing existing payment disparities would encourage students to enter the field in greater numbers. “President Obama himself said at the White House Health Care Summit, ‘We have to produce more primary care physicians.’”

In February, ACP called on President Obama to issue an Executive Order assuring that all federal agencies work together to set primary care workforce goals and the policies necessary to achieve them. In November, ACP released a
white paper documenting the value of primary care by reviewing 20 years of research.

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ACP to hold coding webinar tomorrow

The College will hold the next in a series of educational webinars tomorrow (March 25) at 7 p.m. The session, “Coding: Beyond the Basics” hosted by Doug Leahy, FACP, will cover key Medicare coding issues including "incident-to" billing, modifiers, often-overlooked codes, and the option to bill beneficiaries for services which Medicare considers "non-covered." Registration instructions and recordings of previously held sessions are available online. There is a $25 registration fee to offset costs.

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College supports new health care coalition’s fight for quality

ACP has joined a new health care quality coalition composed of over 150 organizations calling on the Obama administration and Congress to support performance measurement and reporting improvement.

Stand for Quality last week proposed six recommendations for improving the quality and affordability of health care for all patients through public-private partnership. ACP Chief Executive Officer John Tooker, FACP, extended ACP's support of the initiative. “These recommendations are anchored in the reality that quality is about what happens between a clinician and a patient," he said. "We support this effort because it is crucial to giving doctors the tools they want and need to improve care.” The full press release is available on the Stand for Quality Web site.

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Cartoon caption contest

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Vote for your favorite entry

ACP InternistWeekly's cartoon caption contest continues. ACP staff has selected three finalists for the latest contest and is now asking readers to vote for their favorite caption to determine the winner.

Go online to view the cartoon and pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting continues through March 30, with the winner announced in the March 31 issue.

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MKSAP Answer and Critique

The correct answer is A) An attended laboratory polysomnography

This item is available to MKSAP subscribers in the Pulmonary and Critical Care Medicine: Item 18.

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.

Polysomnography is indicated for the evaluation of a patient with clinical features suggestive of obstructive sleep apnea. Neither physical examination findings nor continuous nocturnal pulse oximetry is sensitive or specific enough to make the diagnosis. Several methods have been described to determine the optimal continuous positive airway pressure (CPAP) level to manage obstructive sleep apnea, including attended laboratory polysomnography-guided CPAP titration, unattended home titration, or auto-titrating positive airway pressure (APAP) device–directed titration. The current standard of practice consists of a technician-attended laboratory polysomnography with CPAP pressure titration, during which sleep stages and respiratory variables are monitored. An unattended, portable sleep study may be considered only when full polysomnography is unavailable or when the patient's medical condition necessitates a home study. APAP therapy in the absence of a diagnostic study is not recommended.

Modafinil, a wake-promoting agent, is indicated only for patients with residual sleepiness associated with obstructive sleep apnea being treated with CPAP, and not as an alternative to CPAP therapy.

Key Point

  • The standard of practice to determine the optimal continuous positive airway pressure level to manage obstructive sleep apnea is an attended laboratory polysomnography with CPAP pressure titration.

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 2009 by the American College of Physicians.

Test yourself

A 69-year-old woman is evaluated for a lump under her arm found on self-examination. She is otherwise healthy and has no other symptoms. Medical and family histories are unremarkable, and she takes no medications. A needle aspirate of the right axillary mass reveals adenocarcinoma. Bilateral mammography and breast MRI are normal. CT scan of the chest, abdomen, and pelvis demonstrates the enlarged axillary lymph node and no other abnormalities. What is the most appropriate initial treatment?

Find the answer

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