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

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In the News
for the Week of 5-12-09

Highlights

  • Urine protein predicts clot risk
  • Cardiologists urge alternatives to PPIs for stent patients taking clopidogrel

Test yourself

  • MKSAP quiz: buzzing sounds in both ears

Cardiology

  • Drug-eluting stents safe, more effective than bare metal, two studies conclude
  • Naproxen safer than other NSAIDs in patients with serious coronary heart disease

Lyme disease

  • Free CME module offered for Lyme disease

FDA update

  • New suicidality warning for antiepileptic drugs
  • Hydroxycut products may carry risk of liver injuries
  • Some ACCU-CHEK Spirit insulin pumps being recalled
  • FDA approves new facility for producing flu vaccine

From ACP Internist

  • ACP members discuss how they handle patients who can't afford to pay

From ACP Hospitalist

From the College

  • Follow ACP on Facebook and Twitter

Cartoon caption contest

Physician editor: Darren Taichman, ACP Member


Highlights

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Urine protein predicts clot risk

Patients with microalbuminuria are at higher than average risk for venous thromboembolism (VTE), a new community-based prospective study found.

The study population included all inhabitants of Groningin, the Netherlands, between the ages of 28 and 75. Researchers mailed everyone in the town a questionnaire and a vial to collect a first morning urine sample. Slightly less than half of the sample (40,856 people) responded and a cohort of 8,592 participants completed screening at an outpatient clinic. The main outcome was symptomatic and objectively verified VTE between 1997 and 2007.

Of the 8,547 participants who completed the study, 129 experienced VTE. When the data were adjusted for age, cancer, use of oral contraceptives and atherosclerosis risk factors, people with a urinary albumin excretion (UAE) of 30 to 300 mg per 24 hour urine collection has a 120% higher risk than those with < 15 mg/24 h. A level over 300 mg/24 h meant a 182% higher risk. Overall, the study participants with microalbuminuria (> 30 mg/24 h) had double the VTE risk of those with normoalbuminuria.

The study's findings indicate that microalbuminuria is as good a predictor of VTE as it is of myocardial infarction or stroke, the researchers concluded. Because microalbuminuria has a high prevalence in the general population, it may be a useful risk factor for predicting VTE. Unlike many other risk factors, microalbuminuria can be treated with nonanticoagulant medications, although it is not known whether the use of such treatments would alter the risk of VTE, the study authors said. The study appeared in the May 6 Journal of the American Medical Association.

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Cardiologists urge alternatives to PPIs for stent patients taking clopidogrel

Cardiology experts last week advised physicians to consider alternatives to proton-pump inhibitors (PPIs) for stent patients taking clopidogrel, due to a high risk for adverse events found in a recent study.

The advice from the Society for Cardiovascular Angiography and Intervention (SCAI) is based on results of the Clopidogrel Medco Outcomes Study, presented during the society's annual scientific sessions. In the study, patients taking both clopidogrel (Plavix) and a PPI had a 70% increased risk of heart attack or unstable angina, a 48% increased risk of stroke or stroke-like symptoms, and a 35% increase in the need for repeat revascularization, said an SCAI statement. The study included 16,690 patients who took clopidogrel for a year following coronary stenting.

PPIs taken by patients in the study included pantoprazole (Protonix), esomeprazole (Nexium), omeprazole (Prilosec) and lansoprazole (Prevacid). Newer PPIs, such as rabeprazole (Aciphex) or dexlansoprazole (Kapidex), were not included.

While noting that more research is needed, SCAI advised physicians treating post-stenting patients on dual-antiplatelet therapy to consider prescribing histaminergic (H2) blockers or antacids as alternatives to PPIs.

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Test yourself

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MKSAP quiz: buzzing sounds in both ears

An 81-year-old man is evaluated for a 6-month history of a constant buzzing sound in both ears. The noise interferes with reading, watching television, and sleep. He denies headache, vertigo, or sinus pain. His medical history includes diabetes mellitus, hypertension, coronary artery disease, and emphysema for which he takes glyburide/metformin, metoprolol, clopidogrel, and an albuterol inhaler. Depression screening results are negative.

On physical examination, the pulse rate is 62/min, and blood pressure is 137/84 mm Hg. Cardiopulmonary examination is normal. No sounds are audible over his carotid arteries or periaural region, and there are no pulsatile neck masses. On cranial nerve examination, the patient only faintly hears finger rubbing next to both ear canals. Which of the following is the most appropriate initial management step in this patient?

A) Audiometric testing
B) MRI of the head
C) Magnetic resonance angiography
D) Institution of sertraline
E) Cessation of clopidogrel

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

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Cardiology

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Drug-eluting stents safe, more effective than bare metal, two studies conclude

Drug-eluting stents are safe, according to a large, registry-based study, and they reduce restenosis and the need for repeat revascularizations for ischemia, according to a second trial.

The studies reported no difference in long-term survival or in the risk of myocardial infarction between those who received drug-eluting stents and those who received bare-metal stents, said two studies published in the New England Journal of Medicine.

Drug-eluting stents provided a clinically important decrease in the rate of restenosis among high-risk patients, said researchers in a study that compared outcomes of patients who received one drug-eluting coronary stent (10,294 patients) with those who received one bare-metal stent (18,659), taken from a larger consecutive cohort of more than 48,000 stent recipients in Sweden between 2003 and 2006 with between 1 to 5 years of follow-up.

There was no overall difference between drug-eluting and bare-metal stent groups in the combined end point of death or myocardial infarction (relative risk [RR] with drug-eluting stents, 0.96; 95% confidence interval [CI], 0.89 to 1.03) or the individual end points of death (RR, 0.94; 95% CI, 0.85 to 1.05) and myocardial infarction (RR, 0.97; 95% CI, 0.88 to 1.06).

The average rate of restenosis during the first year was 3.0 events per 100 patient-years with drug-eluting stents, compared to 4.7 with bare-metal stents (adjusted RR, 0.43; 95% CI, 0.36 to 0.52). The number needed to treat (NNT) was 39 patients treated with drug-eluting stents to prevent one case of restenosis. Among high-risk patients, the adjusted risk of restenosis was 74% lower with drug-eluting stents than with bare-metal stents, and the NNT was 10 lesions treated to prevent one case of restenosis.

In a second study in patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI), researchers randomly assigned 2,257 patients to receive paclitaxel-eluting stents and gave otherwise identical bare-metal stents to 749 patients.

Patients who'd received paclitaxel-eluting stents had significantly lower 12-month rates of ischemia-driven target-lesion revascularization (4.5% vs. 7.5%; hazard ratio [HR], 0.59; 95% confidence interval [CI], 0.43 to 0.83; P=0.002) and target-vessel revascularization (5.8% vs. 8.7%; HR, 0.65; 95% CI, 0.48 to 0.89; P=0.006) than patients who'd received bare-metal stents. Patients with paclitaxel-eluting stents and bare-metal stents had similar 12-month death rates and stent thrombosis. The 13-month rate of binary restenosis was significantly lower with paclitaxel-eluting stents than with bare-metal stents (10.0% vs. 22.9%; HR, 0.44; 95% CI, 0.33 to 0.57; P<0.001).

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Naproxen safer than other NSAIDs in patients with serious coronary heart disease

Patients hospitalized for serious coronary heart disease who were taking naproxen had better cardiac safety than those taking other nonsteroidal anti-inflammatory drugs (NSAIDs), a recent study reported.

In a multi-site retrospective study, researchers looked at 48,566 patients recently hospitalized for myocardial infarction, revascularization or unstable angina pectoris and found that naproxen users had lower adjusted rates of serious coronary heart disease/cardiovascular disease than users of other NSAIDs. Risk did not increase with doses of 1,000 mg or higher.

Compared with patients who did not receive NSAIDs, serious coronary heart disease risk increased with short-term use (<90 days) of ibuprofen (1.67 [95% CI, 1.09 to 2.57]), diclofenac (1.86 [95% CI, 1.18 to 2.92]), celecoxib (95% CI, 1.37 [0.96 to 1.94]), and rofecoxib (1.46 [95% CI, 1.03 to 2.07]), but not naproxen (0.88 [95% CI, 0.50 to 1.55]). The study was published online May 5 in Circulation: Cardiovascular Quality and Outcomes.

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Lyme disease

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Free CME module offered for Lyme disease

As the season for Lyme disease approaches, the Infectious Diseases Society of America has released online a free CME course made up of case studies and based on the organization's published guidelines. The case studies are designed to educate clinicians regarding the proper diagnosis and treatment of Lyme disease and also provide an opportunity to better understand the guidelines. Using submitted cases that have been vetted by IDSA's education and guidelines committees, this project was fully funded by the Centers for Disease Control and Prevention with no commercial support.

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FDA update

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New suicidality warning for antiepileptic drugs

The FDA has approved updated labeling and a patient medication guide for all antiepileptic drugs to warn about the risk of suicidal thoughts and actions, a safety alert said.

The drugs are used to treat epilepsy, psychiatric disorders, and other conditions like migraines. The action reflects a pooled analysis of placebo-controlled clinical studies involving 11 antiepileptic drugs. Because the increased risk of suicidal thoughts or behavior was consistent among all 11, the FDA expects the risk of suicidality is shared by all drugs in the class given for any indication.

Providers should monitor patients taking or starting these antiepileptics for changes that could suggest suicidal thoughts or behavior, or depression, the FDA said.

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Hydroxycut products may carry risk of liver injuries

Consumers should immediately stop using Hydroxycut dietary supplements due to a risk of serious liver injuries, the FDA said in a release.

The FDA has gotten 23 reports of serious health problems associated with the products that range from jaundice and elevated liver enzymes to liver damage requiring transplant and death from liver failure. Other reported health problems include seizures, cardiovascular disorders, and rhabdomyolysis. Product maker Iovate Health Sciences Inc has agreed to recall Hydroxycut products from the market.

Liver injury, although rare, may have symptoms including jaundice, brown urine, nausea, vomiting, light-colored stools, excessive fatigue, weakness, stomach or abdominal pain, itching, and loss of appetite.

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Some ACCU-CHEK Spirit insulin pumps being recalled

Disetronic Medical Systems Inc. is recalling ACCU-CHEK Spirit insulin pumps with "up" and/or "down" buttons that don't work, the FDA said in a release.

The buttons are used for changing the program in the menu or administering additional insulin. If they don't work, users may not be able to change any programmed setting on the pump. The recall applies to pumps with serial numbers from SN02119552 through SN10006093. Pumps with serial numbers including and above SN10006094 aren't affected and aren't being recalled.

Insulin pump users who experience button failure should call the ACCU-CHEK Spirit hotline at 1-800-778-5095.

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FDA approves new facility for producing flu vaccine

The FDA last week approved a new manufacturing facility for producing seasonal influenza virus vaccines, and could be used for production of vaccine against the new 2009 H1N1 influenza strain.

The facility is owned and operated by Sanofi Pasteur, which manufactures Fluzone Influenza Virus Vaccine. Located in Swiftwater, Pa., the new facility will greatly increase the company's production capability, the FDA said in a release.

The FDA Web site has information on the agency's response to the 2009 H1N1 influenza virus, its Pandemic Influenza Preparedness Strategic Plan, and seasonal influenza vaccines in general.

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From ACP Internist

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ACP members discuss how they handle patients who can't afford to pay

Members reported in a recent ACP Internist survey that they're helping patients without insurance get by, often by offering free care or reduced payments, free samples for prescriptions or referrals to community clinics. Despite these and other measures, nearly every physician reported that they suspect patients are skipping needed health care. Find out specifics and read colleagues' comments on ACP Internist's blog.

Also, ACP Internist's current poll relates to an Annals of Internal Medicine study which concluded that press releases from academic medical centers often exaggerate the importance of new medical research. How is this finding reflected in mainstream media coverage of medical news? Tell us in our current poll, "Your Thoughts Exactly: Media reporting of medical research."

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From ACP Hospitalist

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Suggest a colleague as a Top Hospitalist

ACP Hospitalist is seeking candidates for our second annual Top Hospitalists issue. We're looking for the hospitalists who made notable contributions to the field in 2009, whether through cost savings, improved work flow, patient safety, leadership, mentorship or quality improvement.

Do you know a colleague who might qualify? Fill out our form and tell us who and why. All recommendations must be received by July 13, 2009, when our editorial advisory board will pick the winners. Top Hospitalists will be profiled in our November 2009 issue.

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From the College

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Follow ACP on Facebook and Twitter

Get the latest news and information from the American College of Physicians on our Facebook and Twitter pages. Connect with ACP and your colleagues, post comments on our posts and updated videos, or start a discussion. Take a look and let us know what you think—we'd love to hear from you.

If you are not a Facebook or Twitter member yet, joining is easy and free. Just go to www.facebook.com and https://twitter.com and follow the sign-up instructions.

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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.

E-mail all entries by May 21. ACP staff will choose three finalists and post them in the May 26 issue of ACP InternistWeekly for an online vote by readers. The winner will appear in the June 2 edition of ACP InternistWeekly. 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 A) Audiometric testing. This item is available to MKSAP subscribers in General Internal Medicine: Item 85.

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.

A comprehensive audiometric evaluation is essential in this patient with subjective tinnitus to assess for hearing loss. Hearing aids may reduce symptom bother in patients with documented conductive hearing loss by increasing ambient noise. Asymmetric high-frequency hearing loss combined with poor speech discrimination may indicate an acoustic neuroma or meningioma. MRI of the head is appropriate for evaluating asymmetric audiologic abnormalities, but neuroimaging is not recommended as an initial diagnostic test. Objective tinnitus may arise from carotid vascular anomalies, with patients reporting pulsatile sounds that may also be heard on auscultation. However, this patient's symptoms and examination are consistent with subjective tinnitus; therefore, vascular imaging with magnetic resonance angiography is not indicated. Studies have shown that tricyclic antidepressants, benzodiazepines, and cognitive behavioral therapy can improve disability and loudness of tinnitus in patients with chronic tinnitus. There is no similar evidence, however, supporting the use of selective serotonin reuptake inhibitors or newer antidepressants in this setting. Additionally, screening results for depression were negative in this patient. Tinnitus is a side effect of many medications, including NSAIDs, aminoglycosides, loop diuretics, and chemotherapeutic agents. However, aspirin—not clopidogrel—is the antiplatelet drug associated with tinnitus.

Key Point

  • A comprehensive audiometric evaluation is appropriate in patients with subjective tinnitus to assess for hearing loss.

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 50-year-old man is evaluated in follow-up for a recent diagnosis of cirrhosis secondary to nonalcoholic steatohepatitis. He has a history of asthma, type 2 diabetes mellitus, hyperlipidemia, and obesity. His current medications are inhaled fluticasone, montelukast, insulin glargine, insulin lispro, simvastatin, and lisinopril. Following a physical exam, lab studies, and upper endoscopy, what is the most appropriate treatment?

Find the answer

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