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

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In the News
for the Week of 4-7-09

Highlights

  • Same-day scheduling doesn't help diabetics
  • Clopidogrel plus aspirin lowers stroke risk for patients with atrial fibrillation
  • High rate of readmissions tied to poor transitions at discharge

Test yourself

  • MKSAP quiz: genital lesions

Drug and supplement research

  • Early antiretroviral therapy seen to aid HIV treatment
  • High-dose vitamin D reduces fractures
  • Glitazones linked to diabetic macular edema
Radiology
  • Cumulative CT radiation may increase cancer risk

Annals of Internal Medicine

  • Treat smoking as a chronic disease and with intensive intervention

FDA update

  • Digoxin recalled due to errors in pill size

From ACP Internist

  • Planning to tweet from Internal Medicine 2009?

From the College

  • Internal Medicine 2009 virtual exhibit hall is already open
  • Call for fall 2009 Board of Governors resolutions

Physician resources

  • ABIM Foundation announces grants for medical professionalism
  • Local Medicare contractor news available electronically

Cartoon caption contest

Physician editor: Darren Taichman, ACP Member


Highlights

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Same-day scheduling doesn't help diabetics

Diabetic patients treated at open access clinics fared worse than those who were seen under traditional scheduling models, according to a retrospective study.

The cohort study compared diabetes processes and outcomes for 4,000 mostly low-income patients treated at 12 clinics. Half of the clinics used open access scheduling, in which all patients schedule immediate appointments, ideally for the same day they call. The two groups showed no difference in two of the study's three measures of health-care use, emergency visits and hospitalization. However, the open-access group had substantially higher systolic blood pressure (mean difference, 6.4 mm Hg). The implementation of open access also appeared to decrease the number of outpatient visits patients made, the study's third measure.

Authors cautioned that the study, which included only one health plan in one city, had significant limitations and may not be generalizable. However, the findings may reinforce some existing concerns about open access scheduling, including the possibility that timely care for everyone comes at the expense of patients with chronic diseases. Patients may not remember to schedule their follow-up appointments at the appropriate intervals, and the management of acute problems may distract from chronic care management during appointments. Open access schedules also often fail to result in same day appointments, the authors noted.

The researchers suggested that more research be conducted into the outcomes of open access scheduling. Future studies should be conducted in multiple health care settings and incorporate measures of patient satisfaction, continuity of care and access to care, the authors said. The study was published in the March issue of the Journal of General Internal Medicine.

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Clopidogrel plus aspirin lowers stroke risk for patients with atrial fibrillation

Patients with atrial fibrillation who took clopidogrel (Plavix) with aspirin had a lower risk of vascular events, especially stroke, than patients who took aspirin alone, a new study found.

Researchers randomly assigned 7,554 patients with atrial fibrillation and high stroke risk, and for whom vitamin K-antagonist therapy was unsuitable, to receive 75 mg of clopidogrel or placebo daily with aspirin. To be considered at high stroke risk, patients needed to have at least one of the following risk factors:

  • at least 75 years old; systemic hypertension during treatment; previous stroke, transient ischemic attack, or non–central nervous system systemic embolism;
  • a left ventricular ejection fraction of less than 45%;
  • peripheral vascular disease; or
  • an age of 55-74 years and diabetes mellitus or coronary artery disease.

The primary endpoint was a composite of stroke, myocardial infarction, non-central nervous system systemic embolism or death from vascular causes. Follow-up was for a median of 3.6 years. The industry-sponsored study was published online March 31 in the New England Journal of Medicine.

Patients taking clopidogrel had 11% fewer vascular events (6.8% per year vs. 7.6% per year with placebo patients). The bulk of the difference was due to a 28% lower stroke rate in clopidogrel patients (2.4% of patients per year vs. 3.3% per year with placebo). Myocardial infarction occurred in 0.7% of patients per year on clopidogrel vs. 0.9% on placebo. Adding clopidogrel did, however, increase the risk of major bleeding by 58%, taking it from 1.3% per year in placebo patients to 2% per year in clopidogrel patients.

By comparison, warfarin (Coumadin) reduces stroke risk by 38%, but increases major extracranial hemorrhage risk by 70% when compared to aspirin, the NEJM authors said.

Thus, it appears therapy with a vitamin K antagonist is more effective than clopidogrel plus aspirin, but is also associated with a greater hemorrhage risk, they said. Physicians and patients will need to weigh the risks and benefits accordingly, though warfarin is still the first-line treatment of choice, said study author Stuart Connolly, MD, at the American College of Cardiology's annual meeting last week.

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High rate of readmissions tied to poor transitions at discharge

Poor transitions between hospital and ambulatory care led to high rates of rehospitalization among Medicare patients, a recent analysis found.

Researchers analyzed Medicare claims data for almost 12 million beneficiaries who were hospitalized in 2003-04. They found that almost 20% of those patients were readmitted within 30 days and 34% were rehospitalized within 90 days. In addition, more than half of patients discharged with medical conditions or after surgery were rehospitalized or died within the first year following discharge. The results appear in the April 2 New England Journal of Medicine.

According to billing records, half of the patients who were rehospitalized within 30 days following a medical discharge had not followed up with a physician between hospitalizations, the study found. Researchers estimated that only 10% of rehospitalizations were planned, and that the cost to Medicare of unplanned rehospitalizations in 2004 was $17.4 billion.

The study's findings on readmission rates, lack of follow-up and poor communication between doctors at discharge suggests that there is a "lack of shared incentives for hospitals and physicians to use hospital care efficiently," said an accompanying editorial. The Medicare Payment Advisory Commission has recommended that Medicare reduce payments to hospitals with relatively high readmission rates for certain conditions, such as heart failure. However, noted the editorial, readmission rates are a "crude outcome" and hospitals are likely to argue that many factors that affect readmission, such as the quality of ambulatory care, are out of their control.

Addressing the problem will require greater integration of the delivery system, the editorialist said. For example, hospitals could receive financial incentives for managing the initial transition and follow-up care. The study's authors added that "from a system perspective, a safe transition from a hospital to the community or a nursing home requires care that centers on the patient and transcends organizational boundaries."

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Test yourself

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MKSAP quiz: genital lesions

A 35-year-old man has a 2-day history of painful sores on his penis without fever, headache, dysuria, or photophobia. He has never had similar lesions. The patient reports a new sexual partner for the past 6 months but does not know if his partner has a history of any sexually transmitted diseases.

On physical examination, vital signs are normal. There is no rash or evidence of meningismus. Nontender right inguinal lymphadenopathy is noted. Examination of the genitals reveals three vesiculoulcerative lesions clustered on the right side of the penile shaft. The lesions have an erythematous base and a serpiginous border.

Which of the following is the most likely diagnosis?

A) Herpes zoster
B) Herpes simplex virus infection
C) Syphilis
D) Group B streptococcal infection

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

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Drug and supplement research

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Early antiretroviral therapy seen to aid HIV treatment

Early antiretroviral therapy significantly improved survival compared with deferred therapy, found a study addressing a central controversy in HIV treatment.

Researchers conducted two parallel observational analyses of asymptomatic HIV patients in the U.S. and Canada from 1996 through 2005. None had undergone previous antiretroviral therapy (a regimen of at least three antiretroviral drugs, including a protease inhibitor, a nonnucleoside reverse-transcriptase inhibitor, or three nucleoside reverse-transcriptase inhibitors, including abacavir [Ziagen] or tenofovir [Viread]). Patients were stratified by early therapy or deferred therapy for CD4+ of 351 to 500 cells/mm3 or >500 cells/mm3. They reported results in the New England Journal of Medicine.

In the first analysis of 8,362 patients with CD4+ of 351 to 500 cells/mm3, 2,084 (25%) started therapy and 6,278 (75%) deferred therapy. There were 137 deaths in the early-therapy group and 238 deaths in the deferred-therapy group. The deferred-therapy group had a 69% increase in risk of death (relative risk [RR], 1.69; 95% confidence interval [CI], 1.26 to 2.26; P<0.001).

In the second analysis of 9,155 patients with CD4+ counts of >500 cells/mm3, 2,220 (24%) initiated early therapy and 6,935 (76%) deferred therapy. There were 113 deaths in the early-therapy group and 198 deaths in the deferred-therapy group. There was an increase in the risk of death of 94% (RR, 1.94; 95% CI, 1.37 to 2.79; P<0.001).

The majority of deaths in both arms of both groups were from non-AIDS-defining conditions, including hepatic, renal and cardiovascular diseases and cancers.

An editorial cautioned about applying the results of observational studies to all patients, and noted that three randomized, prospective clinical trials are planned or underway. Still, it continued, five years ago, most experienced clinicians would have deferred treatment in asymptomatic patients with CD4+ >500 cells/mm3. "Today, if a similar patient were eager to start, we should be ready and willing to prescribe therapy—with ongoing careful monitoring of toxic effects that could arise during decades of treatment."

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High-dose vitamin D reduces fractures

When taken in higher doses, vitamin D supplements can reduce fractures among older patients, according to a new meta-analysis in the Archives of Internal Medicine.

The study included 12 double-blind randomized controlled trials of nonvertebral fractures and eight randomized controlled trials of hip fractures among people age 65 and older. The included patients took various doses of oral vitamin D, with or without calcium, or placebo. The authors of the analysis also used statistics on adherence to estimate the actual received doses for each trial.

The analysis found no reduction in fractures when patients took vitamin D at doses of 400 IU/day or less. However, among the subgroup of patients who received 482 to 770 IU/day, there was a 20% reduction in nonvertebral fractures and an 18% difference in hip fractures. The study also compared the effects of cholecalciferol and ergocalciferol. Ergocalciferol was not found to cause a significant improvement, perhaps because it is less potent in maintaining 25-hydroxyvitamin D levels, said the researchers, who recommended that future research focus on cholecalciferol.

Additional calcium did not have an effect on fractures in any subgroup. The effect of high-dose vitamin D on nonvertebral fractures was significant in all subgroups, including the younger, community-dwelling patients. Based on the results, study authors recommended that future research include higher doses of vitamin D, as well as earlier initiation and longer duration of supplementation. The evidence does not support using low-dose vitamin D with or without calcium to prevent fractures, the authors concluded.

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Glitazones linked to diabetic macular edema

Patients taking glitazones were 2.6 times more likely to develop diabetic macular edema and, even after adjusting for confounding factors, people taking them were 60% more likely to develop the condition, according to a prospective cohort study.

About 170,000 diabetics taking glitazones were identified using diabetes and pharmacy databases of Kaiser Permanente Southern California. Most of the glitazone users in the study were taking pioglitazone (Actos), although both drugs in the class (rosiglitazone [Avandia] is the other) have been linked to fluid retention and edema, said a press release.

There were 996 new cases of macular edema in the study. Glitazone users were more likely to develop macular edema (odds ratio [OR], 2.6; 95% confidence interval [CI], 2.4 to 3.0). Glitazones were modestly associated with diabetic macular edema after adjusting for age, glycemic control and insulin use.

This study, published in the April American Journal of Ophthalmology, is not the first to show a link, authors said, but rather, confirms that glitazones are modestly associated with diabetic macular edema.

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Radiology

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Cumulative CT radiation may increase cancer risk

Recurrent exposure to radiation from computed tomographic (CT) scans may increase cancer risk, a new study found.

Researchers reviewed data on 31,462 patients who had undergone 190,712 CT exams over a 22-year period. They estimated each patient's cumulative CT radiation exposure by adding up typical CT-effective doses, and used ICD-9 codes and electronic order entries to stratify patients with a lifetime attributable risk of radiation-induced cancer greater than 1%. Thirty-three percent of patients had had more than five CT exams in their lifetime, 5% had more than 22 exams, and 1% had more than 38. The study is in the April issue of Radiology.

The baseline rate of cancer incidence in the U.S. is 42%. About 7% of patients in the study had a cancer risk that was more than 1% higher than this baseline risk rate. ICD-9 codes showed that 85% of this group of patients had at least one code indicating malignancy history, and 40% had a code indicating metastasis. The 315 patients who had received the most cumulative radiation saw their risk increase from 2.7% to 12% above the baseline rate. The study's model predicted that about 0.7% of the subjects' lifetime cancers may have been caused by CT examination.

Limitations of the study include the fact that it reflects only past CT exposures at a single institution, and thus may not be generalizable to other institutions, the authors noted. As well, cumulative exam counts may have been underestimated, as the records only went back 22 years and didn't capture exams done at other facilities. Still, the results suggest that when deciding whether to order a CT exam, a provider should carefully consider the context of a patient's past, and expected future, exposure to CT scans, the authors said.

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Annals of Internal Medicine

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Treat smoking as a chronic disease and with intensive intervention

Physicians should treat smoking as a chronic disease if they want to help their patients quit successfully. Patients may require repeated or intensive interventions that include pharmacotherapy and counseling, as well as continued dialogue.

Two new studies in the April 7 issue of Annals of Internal Medicine coincide with the largest federal tobacco tax increase ever. On April 1, the per-pack tax will climb from 39 cents to $1.01.

In the first study, researchers studied 750 primary care patients who smoked at least 10 cigarettes a day to determine which interventions worked best. Participants were randomly assigned to pharmacotherapy (nicotine patch or bupropion), pharmacotherapy supplemented with up to two calls from trained counselors, or pharmacotherapy supplemented with up to six counseling calls. During the two-year study, patients in the high-intensity counseling group were the most successful.

In the second study, researchers studied 127 smokers with chronic conditions such as cardiovascular disease or COPD. The smokers were randomly assigned to receive a nicotine patch for 10 weeks or a combination of a nicotine patch, a nicotine oral inhaler, and bupropion for as long as required. At about six months, the patients in the combination therapy group had a success rate of approximately 35%. The nicotine patch group achieved a 19% success rate.

Video about these studies is available here by clicking on "View and search videos."

For a recent National Trends feature analyzing anti-smoking efforts state-by-state, click here.

Also in Annals of Internal Medicine:

Colorectal cancer screening should target healthier older patients
In practice, doctors do not consistently consider life expectancy and comorbid conditions when they recommend screening. Researchers reviewed records for 27,068 VA patients age 70 or older. Screening did not target healthier patients, and severely ill patients were screened almost as frequently. Cancer screening guidelines should be more explicit about which combinations of age and comorbidity identify older patients who have substantial life expectancies and those who are likely to die within five years.

LDL particle concentration may independently predict heart attack risk
Researchers reviewed 24 published studies that reported relationships between LDL subfractions and cardiovascular outcomes. Higher LDL particle concentration is consistently associated with increased risk for cardiovascular disease, independent of other lipid measurements. However, LDL subfraction measurement methods were inconsistent across laboratories. The researchers found insufficient evidence that adding the test for particle number to traditional cardiovascular risk factor measurements was worthwhile, at least not until laboratories adopt a standardized way to measure particle number.

Eighty-two years of Annals back issues now online
The first 65 years of Annals of Internal Medicine (1927 to 1992) are available to institutional subscribers online. Content includes fully-searchable and printable high-resolution PDFs, HTML abstracts and “landing pages” that display the article citation, abstract, and all references.

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FDA update

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Digoxin recalled due to errors in pill size

The FDA last week issued a recall of Caraco brand digoxin, USP 0.125 mg and USP 0.25 mg, because the pills may differ in size and contain more or less digoxin than indicated, the agency said in an alert.

Digoxin (Lanoxin) is used to treat heart failure and abnormal heart rhythms and has a narrow therapeutic index. Patients with renal failure are at particular risk of digoxin toxicity from higher-than-labeled doses; such toxicity can cause nausea, vomiting, dizziness, low blood pressure, cardiac instability, bradycardia and death. Lower-than-labeled doses can result in cardiac instability.

The drugs affected by the recall were distributed before March 31, 2009 and are within the expiration date of September 2011. Caraco digoxin 0.125 mg is a scored round biconvex yellow tablet imprinted with “437”, while Caraco digoxin 0.25 mg is a scored round biconvex white tablet imprinted with “441”.

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From ACP Internist

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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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Internal Medicine 2009 virtual exhibit hall is already open

Participants attending Internal Medicine 2009 in Philadelphia this April can plan their visit ahead of time with a new Virtual Exhibit Hall.

Users can search by exhibitor, product or trade name; a “My Show” feature allows you to tailor your visit specifically to exhibitors of your choice, and a “featured” section offers additional information about exhibiting companies. It’s a simple, effective way to organize your time and educate yourself before stepping foot on the trade show floor.

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Call for fall 2009 Board of Governors resolutions

The deadline for members to submit new resolutions to their Governors for hearing at the October 2009 Board of Governors Meeting is May 29. Initiating a resolution provides ACP members an opportunity to focus attention at the ACP national level on a particular issue or topic that concerns them.

A resolution becomes a resolution of the chapter once the chapter council approves it. Resolutions should clearly distinguish the action requested within its resolved clause(s) as either a policy resolve or a directive, which requests action or study on an issue. If more than one action is proposed, each should have its own resolved clause. All resolutions should support the College’s strategic themes.

Please contact your Governor if you have any questions regarding the resolution format. The Board of Governors votes on new resolutions which are then presented to the Board of Regents for action. Once the Board of Regents votes on these recommendations, resolutions are adopted as policy, accepted as reaffirmation of current policy, or forwarded to College staff and/or committees for study or implementation.

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Physician resources

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ABIM Foundation announces grants for medical professionalism

The ABIM Foundation will award grants for Putting the Charter into Practice, a program that will provide financial support to health systems/hospitals, academic medical centers and medical groups to advance professionalism.

Applicants from health systems/hospitals, academic medical centers are encouraged to apply, and proposed initiatives must target practicing physicians. The Foundation will award four grants of up to $20,000 each. The deadline is June 1. More information is online.

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Local Medicare contractor news available electronically

Physicians are now able to receive news and information regarding Medicare business in your practice area by signing up for your Medicare Administrative Contractor’s (MAC) electronic mailing list.

Information relevant to your geographic area, such as local coverage determinations (LCD), local provider education activities, and notifications of claims issues, are provided with this free service. Most contractors have links on their home page to take you to their registration page to subscribe to their listserv. If you have issues locating the link on your MAC homepage, search their site for "listserv" or "e-mail list" to find the registration page. The web address of your contractor's homepage is available online.

In addition to the electronic mailing lists, other ways to stay informed on time sensitive issues and topics important to you include:

  • visiting your MAC website on a regular basis,
  • reviewing the FAQs on your MAC website,
  • participating in MAC-sponsored conference calls and face-to-face meetings, and
  • reviewing your MAC’s LCDs.

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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.

Cartoon caption contest

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) Herpes simplex virus infection

This item is available to MKSAP subscribers in Infectious Disease section: Item 53.

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.

The presentation is most compatible with recurrent genital herpes simplex virus infection. The limited number of lesions and absence of systemic findings support this diagnosis. Herpes zoster lesions would be more extensive and would involve other areas in a dermatomal distribution. Lesions in patients with syphilis are not painful and do not have a serpiginous border. Group B streptococcal infection would involve the scrotum rather than the penis and only rarely causes lesions.

Key Point

Genital herpes simplex virus in a male patient is generally characterized by a limited number of genital vesiculoulcerative lesions without systemic symptoms.

Click here to return to the rest of ACP InternistWeekly

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Copyright 2009 by the American College of Physicians.

Test yourself

A 76-year-old woman is evaluated for a 3-month history of left knee pain of moderate intensity that worsens with ambulation. She reports minimal pain at rest and no nocturnal pain. There are no clicking or locking symptoms. She has tried naproxen and ibuprofen but developed dyspepsia; acetaminophen provides mild to moderate relief. The patient has hypertension, hypercholesterolemia, and chronic stable angina. Medications are lisinopril, metoprolol, simvastatin, low-dose aspirin, and nitroglycerin as needed. Following a physical exam, lab results and radiograph, what is the next best step in management?

Find the answer

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