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

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In the News
for the Week of 4-14-09

Highlights

  • Flu season was milder than usual
  • PPIs don't control asthma symptoms
  • ACP, others release consensus standards on transitions of care

Test yourself

  • MKSAP quiz: joint pain, swollen hands and feet, early-morning stiffness

Nephrology

  • Combining GFR, albuminuria predicts end-stage renal disease

Oncology

  • Intensity of early bladder cancer treatment seems unrelated to survival

Rheumatology

  • Provider, consumer guides available on knee osteoarthritis treatment

FDA update

  • Efalizumab to be off U.S. market by June 8 due to PML risk

From ACP Internist

  • Your thoughts exactly: unemployed patients
  • Planning to tweet from Internal Medicine 2009?

From the College

  • Free literature available for young physician members
  • Chapter awardees announced
  • ACP Foundation offers health literacy grants for ACP chapters
  • Two ACP members appointed to government policy committee

Cartoon caption contest

Physician editor: Darren Taichman, ACP Member


Highlights

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Flu season was milder than usual

The 2008-09 flu season was significantly milder than outbreaks in the past several years have been, CDC officials told reporters last week.

Significantly fewer flu-related deaths were reported among both children and adults this year, the Associated Press reported. A record number of doses of flu vaccine, 146 million, were also distributed during the current season. The improvement followed a particularly severe season last year, in which the flu vaccine was only 44% effective against circulating disease strains.

CDC officials did not release effectiveness statistics for the current flu season, but they noted that this year's vaccine was a good match and that the decline in severity may have been due to the predominance of type A H1N1 subtypes (instead of H3N2) in this year's flu. The expansion of vaccination among children might also have contributed to the lighter flu year, a flu expert told Forbes magazine.

Flu season peaked in February and has been on the decline ever since, the officials said. The season is still not over, however, according to the CDC's weekly flu report. In the week ending March 28, the agency reported that 13 states had widespread disease activity and 33 had regional or local flu activity. Only three states, plus Puerto Rico and the District of Columbia, had been downgraded to sporadic activity.

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PPIs don't control asthma symptoms

Although many asthma patients also have acid reflux, a proton pump inhibitor (PPI) has no effect on controlling asthma symptoms, concluded a study of one brand-name drug.

Researchers conducted a parallel-group, double-blind trial that randomly assigned 412 patients with minimal or no symptoms of gastroesophageal reflux and inadequately controlled asthma despite using moderate or high doses of inhaled corticosteroids. Patients received either 40 mg of esomeprazole (Nexium) twice a day or matching placebo. For 24 weeks patients used diaries to record morning peak expiratory flow, asthma symptoms, nighttime awakening from reflux and use of beta-agonists.

The primary outcome measure was episodes of poor asthma control, defined as:

  • a decrease of 30% or more in the morning peak expiratory flow rate on two consecutive days,
  • an unscheduled visit for symptoms, or
  • needing oral prednisone for treatment.

Researchers reported results in the New England Journal of Medicine. Poor asthma control occurred with similar frequency in the placebo and treatment groups (2.3 and 2.5 events per person-year, respectively; P=0.66). Treatment didn't help episodes of poor asthma control, nor did it help secondary outcomes of pulmonary function, airway reactivity, nocturnal awakening or quality of life.

An editorial stated that showing a relationship between reflux and asthma is difficult because there is no way to measure reflux's impact on esophageal or extraesophageal symptoms. It called for a clinical trial to study reflux among patients using medicine or surgery, adding "Until such a trial is undertaken, empirical treatment with proton-pump inhibitors does not make sense."

The American Gastroenterological Association issued a medical position statement on PPIs last year that addressed the use of PPIs for reflux, but also addressed asthma and other extraesophageal syndromes.

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ACP, others release consensus standards on transitions of care

Six professional medical societies, including ACP, have developed a set of consensus standards for improving transitions of care.

ACP, the Society of Hospital Medicine, the Society of General Internal Medicine, the American Geriatric Society, the American College of Emergency Physicians and the Society for Academic Emergency Medicine established 10 principles to address the quality gaps in transitions between inpatient and outpatient care:

  • accountability,
  • communication,
  • timely interchange of information,
  • involvement of the patient and family member,
  • respect for the primary care office as the hub of coordination of care,
  • all patients and their family/caregivers should have a medical home or coordinating clinician,
  • at every point of transition the patient and/or their family/caregivers need to know who is responsible for their care at that point,
  • national standards, and
  • standardized metrics related to these standards in order to lead to quality improvement and accountability.

The group developed standards to help implement these principles, including coordinating clinicians, care plans/transition record, communication infrastructure, standard communication formats, transition responsibility, timeliness, community standards and measurement. The group also identified challenges that will need to be addressed in the future, such as use of electronic health records and the need for patient-centered approaches.

The consensus statement was published online April 3 by the Journal of General Internal Medicine.

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Test yourself

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MKSAP quiz: joint pain, swollen hands and feet, early-morning stiffness

A 40-year-old woman is evaluated for a 1-year history of joint pains and swelling of the hands and feet. She has early-morning stiffness of 3 hours' duration in the small joints of her hands and feet and a flu-like fatigue throughout the day. Ibuprofen has not helped to alleviate her symptoms.

Musculoskeletal examination reveals decreased lateral flexion and rotation of the cervical spine and moderate limitation of internal rotation and abduction of the shoulders. There is marked swelling and limitation in range of motion in both wrists. The second and third metacarpophalangeal joints and all of the proximal interphalangeal joints are swollen and tender. Internal rotation of the hips elicits pain. There are bilateral warm knee effusions, and both ankles are swollen, warm, and tender. All metatarsophalangeal joints are tender bilaterally.

Laboratory Studies

Hemoglobin 11.0 g/dL (110 g/L)
Leukocyte count 8,500/uL (8.5 × 109/L) (normal differential)
Erythrocyte sedimentation rate 88 mm/h
C-reactive protein 10 mg/dL (100 mg/L)
Creatinine Normal
Aspartate aminotransferase Normal
Alanine aminotransferase Normal
Rheumatoid factor 160 U/mL (160 kU/L)
Urinalysis Normal

Radiograph of the right hand reveals marginal erosions in some of the proximal interphalangeal joints and the wrist.

Which of the following is the most appropriate treatment for this patient?

A) Indomethacin
B) Short course of prednisone; methotrexate with folic acid
C) Intra-articular corticosteroids in both knees
D) Hydroxychloroquine

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

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Nephrology

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Combining GFR, albuminuria predicts end-stage renal disease

Estimated glomerular filtration rate (eGFR) and urinary albumin may predict who will develop end-stage renal disease (ESRD), and allow physicians to intervene earlier, according to Norwegian researchers. In the U.S., ESRD is expected to affect 785,000 people by 2020, or more than double the number in 2007. The disease currently costs $32 billion a year to treat.

Norwegian researchers analyzed data from 65,589 adults in a population-based study and found 124 people who developed ESRD after 10 years follow-up. Hazard ratios for eGFR of 45 to 59 ml/min per 1.73 m2, 30 to 44 ml/min per 1.73 m2, and 15 to 29 ml/min per 1.73 m2 were 6.7, 18.8, and 65.7, respectively (P<0.001 for all). Hazard ratios for micro- and macroalbuminuria were 13.0 and 47.2 (P<0.001 for both).

Referrals to ESRD based on progression to chronic kidney disease stage 3 to 4 would include 4.7% of the general population and identify 69.4% of all individuals progressing to ESRD. Referrals to ESRD using eGFR and albuminuria would include 1.4% of the general population without losing predictive power, detecting 65.6% of those expected to progress to ESRD. Combining these measurements might also help reduce the number of patients referred to specialists without eliminating the ability to detect future ESRD cases, as well as improve efficient handling of a large group of patients, authors said in the Journal of the American Society of Nephrology.

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Oncology

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Intensity of early bladder cancer treatment seems unrelated to survival

Patients given more intensive treatment in the first two years after a diagnosis of early stage bladder cancer are just as likely to die, and are more likely to undergo major medical interventions later, as patients given less intensive treatment, a new study found.

Researchers used Medicare data on 20,713 patients diagnosed with early stage bladder cancer, and their 940 physicians, from Jan. 1, 1992 through Dec. 31, 2002. Providers were ranked by the intensity of treatment prescribed, as measured by average expenditures reported to Medicare in the first two years after diagnosis, then grouped into quartiles. Researchers then evaluated associations between treatment intensity and outcomes including mortality through Dec. 31, 2005, and the need for major interventions later. The study is in the April 7 online issue of the Journal of the National Cancer Institute.

Average Medicare expenditures per patient for providers in the top quartile of treatment intensity were $7,131, compared with $2,830 for providers in the bottom quartile. Providers in the former group did endoscopic surveillance and used more intravesical therapy and imaging studies than providers in the latter. There was no difference in mortality between patients seen by low- or high-intensity providers (adjusted hazard ratio 1.03, 95% CI 0.97 to 1.09), and high-intensity patients were more likely to undergo major medical interventions later (11% vs. 6.4%, P=0.2).

The findings suggest there may be opportunities to reduce costs by eliminating unnecessary procedures, and urologists shouldn't assume more aggressive management of early stage bladder cancer will bring better outcomes, the authors said. An accompanying editorial noted, however, that one must interpret association studies with caution. Ultimately, it is still unclear whether the lack of association between expenditures and survival in the study reflects a true lack of impact from procedures, or the authors' inability to fully adjust for differences in prognosis between patients in the low- and high- intensity groups, the editorial said.

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Rheumatology

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Provider, consumer guides available on knee osteoarthritis treatment

Plain-language guides about different treatments for osteoarthritis of the knee are now available to both providers and patients from the Agency for Healthcare Research and Quality.

The guides look at the efficacy, safety and adverse effects of treatments such as glucosamine and chondroitin, arthroscopic surgery, fluid injections and pain medications. The four-page consumer guide defines the condition, and is geared toward helping patients understand the answers to basic questions. The four-page clinician guide is geared toward those with a clinical background, and includes content such as a confidence scale that rates available evidence.

The guides note, for example, that glucosamine and chondroitin have not been shown to improve the condition, and can cause upset stomach, diarrhea, and headache, while fluid injections don't reduce pain and can cause swelling and minor infection. On the other hand, physical activity can help reduce pain and allow for easier joint movement, while weight loss help takes stress off knees. These and other guides on treatments like hypertension and prostate cancer are online via AHRQ.

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FDA update

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Efalizumab to be off U.S. market by June 8 due to PML risk

Psoriasis drug efalizumab (Raptiva) will be phased out of the U.S. market by June 8 because of a potential risk to patients of developing progressive multifocal leukoencephalopathy (PML), the FDA said last week in a statement.

Physicians shouldn't start patients on new treatment with the drug, and should immediately talk with patients currently using efalizumab about transitioning to alternate therapies. PML, for which there is no known treatment, generally occurs in people whose immune systems have been seriously weakened, and often leads to irreversible decline in neurologic function and death.

The FDA issued an advisory in February about the risk of PML after reports that four patients taking efalizumab developed the disease. The drug's label has warned of the risk since October 2008.

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From ACP Internist

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Your thoughts exactly: unemployed patients

Walgreens' in-store clinics are offering free care to established patients who lose their health insurance. How do you handle patients who have lost their jobs or are otherwise uninsured? Take our latest poll online.

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Planning to tweet from Internal Medicine 2009?

Let us know so we can post the best meeting tweets on our blog. For a new ACP Internist article about the pros and cons of twittering in medicine, click here.

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From the College

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Free literature available for young physician members

ACP members are eligible to receive a free copy of the Pocket Guide to Selected Preventive Services for Adults and the Young Physician Practice Management Survival Handbook developed by the 2008-2009 Council of Young Physicians. The Pocket Guide is a proactive way to encourage preventive care in your daily practice, while the Survival Handbook offers helpful tips and resources for starting your own practice.

Electronic copies of the guide and handbook are available on ACP Online. You will need your ACP username and password to access these sites. If you do not know this information, please visit the registration page.

If your chapter is holding an event for Young Physicians and you would like to make copies of the Pocket Guide and Survival Handbook available, please contact Katie Buell, Programs and Services Coordinator, at kbuell@acponline.org or by calling 800-523-1546 ext. 2611. A limited supply is available, so requests will be filled on a first-come, first-serve basis while supplies last.

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Chapter awardees announced

In recognition of their outstanding service, several individuals received chapter awards. The list is online.

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ACP Foundation offers health literacy grants for ACP chapters

The ACP Foundation established the Health Literacy Awards Program to increase awareness of health literacy and the Foundation at the chapter level. The 2008 awards have been given to Delaware, Colorado and Northern Illinois for the following programs: Your Medicine Has Two Names (DE), A Medical Home-Based Low Literacy Tool to Improve Informed Decision-Making in Prostate Cancer Screening (CO), and The Chicago BREATHE Project (IL).

The ACP Foundation begins a second cycle of its Health Literacy Awards Program this month. Chapters submitting proposals to the Health Literacy Awards Subcommittee should consider the focus of the grants on programs that:

  • Develop health literate educational materials for patients
  • Develop patient-centered health literate forms and messages for practices to use with patients
  • Develop community programs to increase awareness of low health literacy.

All projects must be conducted by an ACP Chapter. Five $10,000 grants will be available to ACP Chapters during 2009-2010. A completed grant application and budget are required for the project to be reviewed. The deadline for proposals to be received by the ACP Foundation is September 15, 2009. For more information and to obtain a grant application, please visit the ACP Foundation website.

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Two ACP members appointed to government policy committee

Last week the U.S. Government Accountability Office (GAO) announced that two ACP members would be among the appointees to the Health Information Policy Committee. The new committee was established by the American Recovery and Reinvestment Act, the economic stimulus legislation that was signed in February.

David Bates, MACP, the medical director for clinical and quality analysis and chief of general internal medicine at Brigham and Women’s Hospital, has been appointed to the committee as an expert in health care quality measuring and reporting. Paul Tang, FACP, vice president and chief medical information officer for the Palo Alto Medical Foundation, has been appointed as representative for health care providers. Both physicians are members of ACP’s Medical Informatics Subcommittee.

The new committee consists of 13 members that serve three year terms. They will serve as an advisory board to the federal government on how to create a policy framework to establish a national health information technology infrastructure. More information about the committee and the other 11 members is available on the GAO Web site.

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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.

Put words in our mouth

E-mail all entries by April 17. ACP staff will choose three finalists and post them in the April 21 issue of ACP InternistWeekly for an online vote by readers. The winner will appear in special editions of ACP InternistWeekly that will be generated live from Internal Medicine 2009. 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

The correct answer is B) Short course of prednisone; methotrexate with folic acid. This item is available to MKSAP 14 subscribers in the Rheumatology section, item 56.

This patient has severe, active, seropositive, erosive rheumatoid arthritis. Immediate control of her joint inflammation, systemic disease, and joint damage with a disease-modifying antirheumatic drug (DMARD) (an agent that prevents progressive joint damage) is indicated in this setting. Prednisone will rapidly decrease inflammation and improve function in this patient until methotrexate becomes effective. Concomitant administration of methotrexate may halt progression of joint damage and control this patient's systemic disease. In addition, folic acid therapy administered with methotrexate is indicated to limit some associated side effects, such as oral ulcers, hair loss, and elevation of aminotransferase levels.

Methotrexate remains a vital agent in the treatment of rheumatoid arthritis. When combined with concomitant anti–tumor necrosis factor therapy, methotrexate suppresses joint damage and leads to clinical improvement better than any other medication currently available. However, third-party payers generally will only pay the approximately $15,000 needed for a year's course of anti–tumor necrosis factor therapy after a patient has failed to respond to or developed adverse side effects from full-dose methotrexate therapy.

Single-agent therapy with a nonsteroidal anti-inflammatory drug is not indicated in patients with rheumatoid arthritis because these agents are not disease modifying. Without DMARD therapy, rheumatoid arthritis will progress inexorably. Intra-articular corticosteroid therapy effectively helps to control localized joint inflammation. However, systemic therapy with a DMARD with or without an initial short course of prednisone until the DMARD becomes effective is indicated for patients with a diffuse inflammatory process.

Hydroxychloroquine may improve fatigue and joint inflammation in patients with very mild rheumatoid arthritis and is classified as a DMARD, but this agent has never been convincingly shown to modify disease. Therefore, hydroxychloroquine is not appropriate as single-agent therapy in patients with severe, active disease. However, this agent may be used in combination DMARD regimens, including combination therapy with sulfasalazine and/or methotrexate.

Key Points

  • Methotrexate remains a vital drug in the treatment of rheumatoid arthritis.
  • Combination therapy with methotrexate and anti–tumor necrosis factor-a agents provides the best suppression of joint damage and leads to maximal clinical improvement in rheumatoid arthritis.

Click here to return to the rest of ACP InternistWeekly.

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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.

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

Copyright 2009 by the American College of Physicians.

Test yourself

A 72-year-old woman is evaluated during a routine examination. She has very severe COPD with multiple exacerbations. She has dyspnea at all times with decreased exercise capacity. She does not have cough or any change in baseline sputum production. She is adherent to her medication regimen, and she completed pulmonary rehabilitation 1 year ago. She quit smoking 1 year ago. Her medications are a budesonide/formoterol inhaler, tiotropium, and an albuterol inhaler as needed. Following a physical and pulmonary exam, what is the most appropriate next step in management?

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