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


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


  • Joint practice guidelines issued for prostate cancer drugs
  • Guidelines focus on managing increasing resistance to Tamiflu
  • Reminders prove effective for colon cancer screening

Test yourself

  • MKSAP quiz: epigastric pain


  • Guidelines based on expert opinion, not evidence

Women's health

Infectious disease

  • Three cases of ciprofloxacin-resistant N. meningitidis found in U.S.

FDA news

  • Zonisamide may cause metabolic acidosis in certain patients

Annals of Internal Medicine

From ACP Internist

  • On the blog: food, drink and Catboy

From ACP Hospitalist

  • February issue launches new Web site

From the College

  • Submit your memorable moment
  • Call for award and Mastership nominations
  • New time-saving In the Clinic slide sets
  • For medical students: Check out internal medicine interest group activities

Cartoon caption contest

  • February's winning entry

Physician editor: Darren Taichman, ACP Member


Joint practice guidelines issued for prostate cancer drugs

Asymptomatic men with a prostate-specific antigen (PSA) < 3.0 ng/mL who are regularly screened or considering screening may benefit from talking with their doctor about the benefits and risks of 5-α-reductase inhibitors (5-ARI). The guidelines apply to a similar population described in the Prostate Cancer Prevention Trial (PCPT): 50 years or older, no prior prostate cancer diagnosis, and PSA and digital rectal exam results that are less than 1 year old.

To develop an evidence-based guideline on prostate cancer chemoprevention, the American Society of Clinical Oncology and the American Urological Association did a systematic literature review of 15 randomized clinical trials to develop evidence-based recommendations. They published the guidelines in The Journal of Urology.

Men taking a 5-ARI can expect a 50% reduction of PSA within 12 months. Because these changes vary and there is no prospectively validated level, the guidelines did not recommend a point at which to biopsy men taking a 5-ARI.

The committee identified some important issues regarding 5-ARIs for physicians to discuss with patients, including:

  • 5-ARIs reduce the incidence of prostate cancer, but not to zero,
  • the elevated rate of high-grade cancer among patients taking 5-ARIs and the potential explanations for it,
  • the lack of information on the long-term effects of 5-ARIs beyond 7 years,
  • possible but reversible sexual adverse effects, and
  • the likely improvement in lower urinary tract symptoms.

Men taking 5-ARIs for lower urinary tract [obstructive] symptoms may benefit from a similar discussion and an explanation that the improvement should be balanced with the potential risks of high-grade prostate cancer. Authors wrote, "Although the majority of the Panel judged that the observed higher incidence of high-grade (Gleason score 8 to 10) cancer in the finasteride group is likely due to confounding factors, the increased incidence of high-grade cancer as a result of induction by the drug cannot be excluded with certainty."

PIER maintains a prostate cancer screening guide.


Guidelines issue options to manage increasing resistance to Tamiflu

Influenza A viruses (H1N1 subtype) resistant to the drug oseltamivir (Tamiflu) circulated widely in the U.S. during the 2007-2008 influenza season, with an even higher prevalence of drug resistance during the current 2008-2009 influenza season.

Preliminary data from early in the current flu season indicates that oseltamivir resistance had been identified among 264 of 268 (98.5%) U.S. influenza A (H1N1) viruses tested, compared with 1,155 viruses, or 12%, during the 2007-08 season . That subtype represented 19% of flu in the U.S. during the previous flu season. The Journal of the American Medical Association released the study early online, citing its public health importance.

In December, the CDC released interim recommendations for using flu medications, based on the early surveillance data from the current flu season. Guidelines recommend that clinicians consider the results of patient testing and local flu surveillance data on circulating types and subtypes when deciding whether oseltamivir alone could be used. The guidelines provide options for resistant viruses, including treatment with zanamivir (Relenza) or a combination of oseltamivir and rimantadine (Flumadine).


Reminders prove effective for colon cancer screening

It's effective to mail fecal test kits to patients if they're overdue for colon cancer screening, researchers learned. Mailed reminder packages to patients and electronic reminders to physicians whose patients are overdue may increase screening among adults who have more frequent primary care visits.

Researchers randomized 21,860 patients and 110 doctors in a controlled trial at 11 ambulatory health care centers. Patients received mailed packages with an educational pamphlet, a fecal occult blood test kit and instructions for scheduling flexible sigmoidoscopy or colonoscopy. Physicians received electronic reminders during office visits with patients overdue for screening. Researchers reported results in the Archives of Internal Medicine.

  • Screening rates were higher (44.0% vs. 38.1%, P<.001) for patients who received mailings. The effect increased 3.7% for those age 50 to 59 years, 7.3% for those age 60 to 69 years 10.1% for those age 70 to 80 years (P=.01).
  • Electronic reminders increased screening rates among patients with three or more primary care visits (59.5% vs. 52.7%, P=.07).
  • Adenoma detection increased with patient mailings (5.7% vs. 5.2%, P=.10) and physician reminders (6.0% vs. 4.9%; P=.09).

ACP Internist offers expert, easy-to-follow guidelines for encouraging colon cancer screening, including video presentations from gastroenterologist Jorge Prieto, MD.


Test yourself

MKSAP quiz: epigastric pain

A 37-year-old woman has a 3-month history of intermittent burning epigastric pain and mild nausea but no vomiting. The discomfort is made worse by fasting and improves with meals. Antacids provide only temporary relief. She has never had similar symptoms; her weight has been stable; and her last menstrual period was 1 week ago. Her only medication is occasional acetaminophen for knee discomfort. She does not smoke cigarettes or drink alcoholic beverages.

Physical examination shows only mild epigastric tenderness to palpation. Vital signs are normal. Serologic testing for Helicobacter pylori is negative.

Which of the following is the most appropriate next step in managing this patient?

A) Begin an antispasmodic agent
B) Begin a proton pump inhibitor
C) Schedule upper endoscopy
D) Schedule upper gastrointestinal barium study

Click here for the answer and critique for this question.



Guidelines based on expert opinion, not evidence

A large proportion of the practice guidelines offered by the American College of Cardiology and the American Heart Association are supported by little or no clinical evidence, according to a new review.

Researchers assessed all ACC/AHA guidelines issued from 1984 to September 2008. They found that about 48% of the guidelines were supported only by level of evidence C, meaning that they are based on expert opinion, case studies or standards of care, rather than clinical evidence. Only 11% were based on level of evidence A, which requires multiple randomized trials or meta-analyses. Even among Class I guidelines (the most strongly recommended), only 19% of the findings were based on level A evidence.

The study authors concluded that the current system of generating research is inadequate to meet the information needs of providers and patients. They suggested that the research community streamline clinical trials, focus on areas of deficient research, and expand research funding. Because of the deficiencies in guideline development, clinicians should exercise caution in reviewing non-evidence-based recommendations, the authors said.

An accompanying editorial went even further, arguing that guideline development should be centralized (under an agency like Agency for Heathcare Research and Quality or the U.S. Preventive Services Task Force), prioritized and made flexible to fit diverse comorbidities, health care settings and patient preferences. If such changes in the guideline development cannot be made, physicians should reject calls for adherence to guidelines and make decisions based on primary data, the editorialist wrote. The study and editorial were published in the Feb. 25 Journal of the American Medical Association.


Women's health

B-vitamin supplements may reduce women's risk of AMD

Daily B vitamins and folic acid may help lower the risk of age-related macular degeneration (AMD) in women at high risk for cardiovascular disease, according to a recent large trial.

The randomized, double-blind trial included 5,442 women age 40 years or older who were diagnosed with, or at high risk for, cardiovascular disease. Participants were randomly assigned to receive daily either placebo or a combination of folic acid (2.5 mg/d), pyridoxine hydrochloride (50 md/d) and cynocobalamin, (1 mg/d).

After an average of about seven years, there were 55 cases of AMD in the treatment group and 82 in the placebo group (relative risk, 0.66; 95% confidence interval, 0.47-0.93 [P = .02]), representing a 35% to 40% risk reduction. The article appears in the Feb. 23 Archives of Internal Medicine.

The benefits of B-vitamin supplementation appeared after two years and continued throughout the trial, the authors reported. They added that the results appear to represent the only identified strategy to date, other than not smoking, for reducing risks of AMD in its early stages.


Infectious disease

Three cases of ciprofloxacin-resistant N. meningitidis found in U.S.

Three cases of meningococcal disease caused by ciprofloxacin-resistant Neisseria meningitidis have been reported in the upper Midwest, according to a report in the February 26 New England Journal of Medicine.

Two cases in Minnesota and one in North Dakota were identified between January 2007 and January 2008, comprising 9% of the confirmed cases of the disease in those states in that period. The first case was a toddler who attended a child-care center where an employee had died of probable meningococcal disease in 2006; the child recovered with ceftriaxone treatment. The second patient was an adult who died of the disease, and the third was a college student who was hospitalized but recovered with ceftriaxone treatment.

Though the cases were caused by the same serogroup B strain, no epidemiologic links were found among the three patients, and none had recently traveled abroad. Frequent use of fluoroquinolones probably helped the fluoroquinolone-resistant strains to emerge, the authors said, which raises concern about current treatment recommendations for meningococcal disease. At the moment, however, widespread resistance to ciprofloxacin doesn’t seem likely because secondary cases are still rare when ciprofloxacin is used routinely. Still, wider surveillance for resistant N. meningitidis is a good idea, they said.


FDA update

Zonisamide may cause metabolic acidosis in certain patients

The anti-seizure drug zonisamide (Zonegran) can cause metabolic acidosis in some patients, the FDA said last week after a review of clinical trials.

Metabolic acidosis can result in hyperventilation, fatigue, anorexia, cardiac arrhythmias or stupor. When chronic, it can adversely affect the kidneys and bones. Patients at greater risk of the condition after using zonisamide include those with renal disease, severe respiratory disorders and diarrhea; those who have had surgery; and those on a ketogenic diet. The risk appears to be more frequent and severe in younger patients.

Providers should measure serum bicarbonate before, and periodically during, treatment of patients with zonisamide, even in the absence of symptoms, the FDA alert said. If patients develop metabolic acidosis, which usually happens at the start of treatment and at higher doses, providers should consider reducing the dose or discontinuing zonisamide via tapering. If a provider decides to continue a patient with metabolic acidosis on zonisamide, he or she should consider alkali treatment, the FDA said.


Annals of Internal Medicine

Patient-physician “connectedness” affects quality of care

Patients who are connected to a specific primary care physician are more likely to receive guideline-consistent care than those who are connected to a practice but not a physician.

Researchers looked at 155,590 adults in a primary care network to determine which patients received most of their care from a specific physician, practice, or neither. They found that patients who were not connected to a particular physician were less likely to receive recommended care. In addition, these patients were less likely to complete recommended testing for preventive and chronic illness care.

Researchers used the term “connectedness” to describe the closeness of the relationship between a patient and an individual physician. The researchers found that patients who were connected to a physician were more likely to have health insurance, speak English, and be non-Hispanic white. However, connectedness was associated with larger disparities in screening rates than was race or ethnicity.

But according to researchers, continuity of care is a shared responsibility between physicians and patients. Even if physicians or practices treated all patients similarly, patients vary in their ability and willingness to adhere to recommendations.

“Pay-for-performance initiatives hinge on the ability to accurately assign performance measures to those practitioners who have some control over the outcome. Our study results suggest that physicians with a relatively low percentage of connected patients are likely to receive lower scores on performance measures when compared to physicians with a higher proportion of connected patients,” said the study author.

Also in Annals of Internal Medicine:

Risk factors, not care, to blame for racial disparities in heart attack outcomes
Researchers looked at 1,849 adults who had a heart attack and were hospitalized at one of 10 U.S. hospitals that participated in a registry of heart attack care. After looking at health and social factors, including information about death, rehospitalization, chest pain and quality of life, they found that black and white patients who had similar severity of heart and other diseases and similar social factors, such as level of education, had similar heart attack outcomes. Strategies to reduce black-white differences in outcomes after heart attack should focus on improving heart risk factors in black patients.

Vitamin K same as placebo for warfarin overdose
Vitamin K can rapidly reverse the effects of a warfarin overdose, but it is not known how it affects outcomes. Researchers studied people taking warfarin whose blood tests showed their blood was too thin. Patients stopped taking warfarin and were randomly assigned either a low dose of vitamin K or placebo over a 90-day period. There were no differences between groups in the number of participants with bleeding events, clots or other complications. Researchers conclude that temporarily stopping warfarin may be all that is needed.

Health care reform papers analyze President Obama's options
Three articles on health care reform will cover a range of topics from universal healthcare to an analysis of the Obama Administration’s options for health care cost control. The authors offer insights and recommendations on how the administration might address important reform issues currently facing health care in the United States. The following articles appeared online on March 3, and will appear in print on April 7.


From ACP Internist

On the blog: food, drink and Catboy

From the link between women's cancer risk and alcohol to the NEJM's big diet comparison, there was a hefty serving of nutrition news this week and ACP Internist's blog is here to digest it for you. We also have an update on the latest international medical news: a boy in China who can read in the dark!


From ACP Hospitalist

February issue launches new Web site

The next issue of ACP Hospitalist is online at our new Web site. The relaunched is the place to find all of our print and online content, including ACP HospitalistWeekly, our upcoming blog, and polls and surveys (including our cartoon caption contest). Go online for the following stories:

New field offers opportunities. The American Board of Medical Specialties last fall began offering board certification in palliative care, opening up an exciting new career path for hospitalists.
Giving hospitalists their space. More hospitals are implementing an assignment tool known as “geographic rounding,” where hospitalists are assigned to cover patients on a by-unit basis.
Recognizing hyponatremic encephalopathy. In our latest Expert Analysis, two clinicians offer tips for diagnosis, prevention and treatment of this life-threatening disorder.


From the College

Submit your memorable moment

As part of a series of books on teaching, ACP Press has extended its deadline to May 1 to submit stories of memorable teaching moments. The first book in the series, to be published in 2010, will include a collection of vignettes about unforgettable moments in medical education, described by teachers or learners. Vignettes should be no more than 1,000 words. Submissions can be anonymous. Samples and submissions are available online.


Call for award and Mastership nominations

ACP’s Awards Committee is accepting nominations for the accomplishments of distinguished individuals and organizations for the 2009-2010 awards cycle. The awards, which are limited in number and very competitive, recognize outstanding contributions in the practice of medicine, teaching, research, public service, leadership, and medical volunteerism.

Only ACP Fellows may be nominated for Mastership, and both Mastership and awards nominations should be handled confidentially. Individuals should not self-nominate. Awards and masterships will be given during the Convocation ceremony at Internal Medicine 2010 in Toronto, Canada. The
Awards and Mastership Booklet contains updated changes for 2009-2010, criteria for the College's awards and Masterships, plus detailed instructions for writing nominating and supporting letters. More information is available online.


New time-saving In the Clinic slide sets

In the Clinic now offers slide sets containing 25 slides summarizing the content and that can be used alone or integrated into another presentation. The feature is now available in a new slide set format to use for personal education or to facilitate clinical instruction to others. Topics that will be available soon include type 2 diabetes, peripheral arterial disease, insomnia, low back pain and smoking cessation. Slide sets are free to ACP members and paid individual subscribers and are also available for purchase online.

"In the Clinic" is a monthly feature in Annals of Internal Medicine offering evidence-based information for physicians on the screening, prevention, diagnosis, therapy, and patient education for common clinical conditions.


For medical students: Check out internal medicine interest group activities

Help increase awareness of Internal Medicine by reaching out to your local medical schools. This month the College profiles The University of Chicago Pritzker School of Medicine's Internal Medicine Interest Group.


Cartoon caption contest

February'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 Morton A. Kapusta, FACP, a rheumatologist in private practice in Montreal, Canada. He will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 236 ballots online to choose the winning entry. Thanks to all who voted!

The winning entry:

Grand rounds are still straight ahead in the same old place, Dr. Smith

"Grand rounds are still straight ahead in the same old place, Dr. Smith."

The winning entry captured 61% of the votes. The runners up were:
"Pediatrics is that way, Mr. Button." (25.8%)
"Go west, old man." (13.1%)

ACP Internist's cartoon caption contest continues next week.


MKSAP Answer and Critique

This topic is available to subscribers in the Gastroenterology and Hepatology section, Item 37.

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.

Answer and Critique

Correct Answer = B, Begin a proton pump inhibitor

Nonulcer dyspepsia is the most common cause of epigastric pain in a young, otherwise healthy patient who does not have signs or symptoms suggesting an ulcer complication. The patient's age also makes a malignancy unlikely. Because this is her first episode of dyspeptic pain and a serologic test for Helicobacter pylori is negative, an empiric trial of acid-suppressive therapy with a proton pump inhibitor is warranted.

Antispasmodic agents could be considered if her symptoms were more consistent with irritable bowel syndrome (cramping lower abdominal pain associated with altered bowel habits and bloating). An ulcer complication, such as bleeding, perforation, or obstruction, is unlikely because of her age, general good health, and lack of alarm symptoms (weight loss, dysphagia, anemia). Therefore, upper endoscopy or an upper gastrointestinal barium study for diagnosing a possible ulcer complication is not indicated at this time.

Key Points

  • Nonulcer dyspepsia is the most common cause of epigastric pain in a young, otherwise healthy patient.
  • A trial of a proton pump inhibitor is warranted in a young patient with a first episode of nonulcer dyspepsia and a negative serologic test for Helicobacter pylori.

Click here to return to the rest of ACP InternistWeekly.


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.

To add your e-mail address to your member record and to begin receiving ACP InternistWeekly, please click here.

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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