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

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ACP InternistWeekly

For the Week of 5-19-09


HIGHLIGHTS

  • SGIM Research Targets Health Disparities, Drug Errors
  • Pain Management Guidelines Updated for Geriatric Use

TEST YOURSELF

  • MKSAP Quiz: Elevated Blood Levels, Lytic Lesion, Osteoporosis Circumscripta

CARDIOLOGY

  • Clopidogrel Plus Aspirin Lowered Stroke Risk for Some Afib Patients
  • Aspirin No Better Than Placebo for Preventing Cardiovascular Events in PAD Patients

RISK ASSESSMENT TOOLS

  • Risk Index Assesses Dementia Within Six Years
  • NIH Launches 'Rethinking Drinking' Resources For Doctors, Patients

ANNALS OF INTERNAL MEDICINE

  • Kyphosis, Fractures May Predict Increased Mortality in Older Women

FDA UPDATE

  • Testosterone Gel Recalled for Possible Pediatric Exposure
  • Caraco Recalled for Active Ingredient

FROM ACP INTERNIST

  • ACP Members Discuss Medical Reports in The Mainstream Media

FROM THE COLLEGE

  • ACP Launches New, Improved Web Site
  • ACP and ATS Team Up for Discounted Dues
  • Announcing the 2009 ACP National Abstract winners

CARTOON CAPTION CONTEST

  • Vote for Your Favorite Entry

Physician Editor: Darren Taichman, ACP Member

Editorial Note: ACP InternistWeekly will not be published next week due to the Memorial Day holiday.

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HIGHLIGHTS

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SGIM Research Targets Health Disparities, Drug Errors

MIAMI—Health care disparities were a theme among research abstracts selected for presentation at the Society of General Internal Medicine's annual meeting last week.

In one study, researchers used data from the Women's Health Initiative to evaluate the association between a woman's risk of coronary heart disease (CHD) and the socioeconomic status (SES) of her residential neighborhood. After adjusting for a number of factors (including hypertension, hyperlipidemia and obesity), they found that a 1-point drop in SES equated to 1% increase in heart disease risk. For example, a woman living in a poor neighborhood in southeast Washington D.C. would have a 50% higher risk of CHD than a woman living in the wealthier northwest end of the city.

Another study looked at the impact of different patient populations on physician quality measures. Researchers in the Massachusetts General Hospital system rated 159 physicians' performance on several cancer screening and chronic care quality measures. They then looked at differences in the characteristics of the physicians and in 87,000 of their patients. The study found that physicians who rated in the bottom quartile for performance treated significantly more non-English speakers, minorities and nonpaying patients, leading them to conclude that physician quality measures may represent the composition of a doctor's patient population, rather than just the quality of his or her care. The study also found that female physicians met more measures in the treatment of female patients, while male physicians scored better treating men.

During the same session, researchers from Brigham and Women's Hospital showed how implementation of bedside barcode scanning affected medication errors at their hospital. The study had clinical nurses record administration of medications given to patients on the medical, surgical and intensive care wards and then compare the drugs actually administered to the orders given to check for errors. Before the barcodes to match patients to medications were implemented, 11.6% of administrations resulted in errors. With barcodes, the error rate declined to 7%. Pre-barcode, potential adverse drug events occurred in 3.2% of cases, compared to 1.6% after implementation. The study authors noted that although their results are not necessarily generalizable to other hospitals, the study does indicate that barcode systems have the potential to dramatically reduce adverse drug events.

—By Stacey Butterfield, staff writer

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Pain Management Guidelines Updated for Geriatric Use

The American Geriatrics Society updated guidelines nearly eliminating non-steroidal anti-inflammatory drugs (NSAIDs) in drug management of persistent pain in elderly patients.

The society focused on drug therapy and those age 75 or older in this latest revision because of new drugs and treatment approaches available, and because drugs are the most common strategy for managing persistent pain among the elderly.

The major change is the near elimination of NSAIDs. Newer information suggests increased cardiovascular risk and gastrointestinal toxicity usually outweigh the benefits. Based on newer clinical trials as well as clinical observation, the panel recommends that NSAIDs and COX-2s be considered rarely, and with extreme caution, in highly selected individuals (high quality of evidence, strong recommendation).

The guidelines also recommend that all patients with moderate-severe pain or diminished quality of life due to pain should be considered for opioid therapy, which may be safer than long-term NSAIDs. The authors provide some discussions and recommendations about the use of adjuvant and other drugs for older persons with recalcitrant pain problems.

The guidelines and a patient tip sheet are online, and the guidelines will be published in the August issue of the Journal of the American Geriatrics Society.

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TEST YOURSELF

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MKSAP Quiz: Elevated Blood Levels, Lytic Lesion, Osteoporosis Circumscripta

A 60-year-old man presents for an annual physical examination. His only symptom is intermittent headaches. Physical examination is unremarkable including a normal digital rectal examination. However, laboratory evaluation reveals an isolated elevation of the serum alkaline phosphatase to 600 U/L. The calcium is 9.0 mg/dL (2.25 mmol/L), albumin 4.0 g/dL (40 g/L), alanine aminotransferase 20 U/L, aspartate aminotransferase 25 U/L, prostate-specific antigen 1.5 ng/mL. Radiographs reveal a lytic lesion in the left femoral shaft and osteoporosis circumscripta of the skull.

Which of the following is the most likely diagnosis?

A) Metastatic carcinoma
B) Osteomalacia
C) Paget's disease of bone
D) Osteoporosis
E) Primary hyperparathyroidism

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

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CARDIOLOGY

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Clopidogrel Plus Aspirin Lowered Stroke Risk For Some Afib Patients

Clopidogrel plus aspirin reduced the rate of stroke in patients with atrial fibrillation who were deemed unsuitable for vitamin K antagonists, but the risk of hemorrhage increased, a recent study found.

In the study, 7,554 patients with atrial fibrillation with an increased risk of stroke (defined as having at least one of the following risk factors: age 75 years or more; 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 age 55 to 74 years and diabetes mellitus or coronary artery disease) and who were deemed unsuitable for vitamin K-antagonists were randomly assigned to receive daily aspirin plus either 75 mg of clopidogrel or placebo. After 3.6 years, fewer patients in the clopidogrel than the placebo group suffered major vascular events (6.8% per year vs. 7.6% per year, respectively). The difference was mainly due to fewer strokes in the clopidogrel group, researchers found. However, those taking clopidogrel were more likely to have major bleeding than those taking placebo (2% per year vs. 1.3% per year, respectively). The study appears in the May 14 New England Journal of Medicine.

An accompanying editorial noted that it is still unclear which patients would most benefit from the study's results. Less than one-quarter of enrolled patients had a documented contraindication to vitamin K antagonist therapy, whereas the remaining patients were enrolled based on a physician's judgment or patient preferences. The editorial also pointed out that vitamin K-antagonist therapy has been proven to be more effective than clopidogrel plus aspirin or aspirin alone in preventing ischemic stroke.

For now, the editorial continued, vitamin K-antagonist therapy is the best option for patients with atrial fibrillation who are at moderate-to-high risk for stroke to prevent thromoboembolism, with an acceptable risk of bleeding. Aspirin plus clopidogrel should be considered for those patients who cannot tolerate a vitamin K antagonist, have resisted high-quality anticoagulation or are at lower risk for stroke.

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Aspirin No Better Than Placebo for Preventing Cardiovascular Events in PAD Patients

A large meta-analysis concluded that aspirin appeared to be no better than placebo in preventing cardiovascular events in patients with peripheral arterial disease (PAD).

Researchers analyzed 18 trials involving more than 5,000 patients that focused on aspirin therapy with or without dipyridamole and reported cardiovascular event rates. Aspirin therapy was associated with a significant reduction in nonfatal stroke but not with all-cause or cardiovascular mortality, myocardial infarction or major bleeding. Researchers concluded that treatment with aspirin alone or with dipyridamole resulted in a non-significant decrease in cardiovascular events.

The researchers noted that their analysis was limited by the small size and short duration of many of the included trials, which underpowered the meta-analysis' ability to detect risk reductions of less than 25%. An accompanying editorial added that more than one-quarter of the participants were from two studies that included only PAD patients with diabetes, who may derive less benefit from aspirin than non-diabetics. In addition, the editorial continued, many of the trials were more than a decade old and therefore may have limited applicability to clinical practice today.

Due to the limited data, said the editorial, these findings should not alter current recommendations for aspirin for secondary prevention in patients with PAD. More high-quality clinical trials are needed to determine the benefits and risks of aspirin in PAD, noted the study authors and editorialist.

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RISK ASSESSMENT TOOLS

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Risk Index Assesses Dementia Within Six Years

A 15-point risk index can identify older adults at low, intermediate and high risk for dementia in the next six years.

Researchers studied 3,375 participants ages 65 and older (mean age 76) in the Cardiovascular Health Cognition Study without evidence of dementia at baseline. In six years, 480 (14%) developed dementia. The researchers then identified independent predictors, including older age, poor cognitive test scores, history of coronary bypass, slow physical performance and lack of drinking alcohol.

The risk index included older age (1-2 points), poor cognitive test performance (2-4 points), body mass index <18.5 (2 points), >1 apolipoprotein E e4 alleles (1 point), cerebral MRI findings of white matter disease (1 point) or ventricular enlargement (1 point), internal carotid artery thickening on ultrasound (1 point), history of bypass surgery (1 point), slow physical performance (1 point), and lack of alcohol consumption (1 point).

Four percent with low scores (< 3 total points) developed dementia over six years, compared with 23% of subjects with moderate scores (4-7 points) and 56% of subjects with high scores (> 8 points) (c statistic 0.81; 95% confidence interval 0.79-0.83).

The authors said, "A late-life dementia risk index could have several important uses: it could be used to identify high-risk individuals for clinical trials and to target preventions toward those at greatest risk; to identify older adults who should be monitored for new dementia symptoms, so that treatments could be initiated at the earliest possible stage of disease; and to provide information to concerned patients or their family members."

The study abstract is online at Neurology.

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NIH Launches 'Rethinking Drinking' Resources for Doctors, Patients

The National Institutes of Health launched a "Rethinking Drinking" Web site and guides for doctors and patients to reduce risk for alcohol-related problems

The updated materials defines a “standard drink,” and present evidence-based information about risky drinking patterns, the alcohol content of drinks and the signs of an alcohol problem, as well as information about medications and other resources to help people who choose to cut back or quit drinking. The Web site also features interactive tools, such as calculators for measuring alcohol calories and drink sizes.

Based on results of a NIAAA survey of 43,000 U.S. adults, Rethinking Drinking presents single-day and weekly low-risk limits for men and women. For men, these limits are no more than four drinks on any single day and 14 drinks per week, and for women, no more than three drinks on any day and seven per week. Among people who exceed these limits, about one in four already has alcoholism or alcohol abuse, and the rest are at increased risk for these and other problems. Also presented are behaviors and symptoms that signal an alcohol-related problem regardless of the amount of alcohol consumed (e.g., attempts at cutting down, or alcohol-related problems with family, friends, or the law).

Copies of the Rethinking Drinking booklet can be downloaded from the Rethinking Drinking Web site or ordered by phone at 301-443-3860. The clinicians guide and patient booklet are available for download.

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ANNALS OF INTERNAL MEDICINE

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Kyphosis, Fractures May Link To Increased Mortality in Older Women

Studies have long linked vertebral fractures to an increased risk for death in older persons. Some studies have suggested that kyphosis may also be associated with poor health and death. To assess whether increased kyphosis or undetected vertebral fractures were the underlying reason for earlier death, researchers conducted a prospective cohort study of 610 white women between the ages of 67 and 93. The authors measured the degree of kyphosis, bone mineral density, and vertebral fractures. The researchers then assessed the women’s mortality rates over an average follow-up of 13.5 years. Women with vertebral fractures and hyperkyphosis had greater risk for mortality than women with only one of these conditions. Among women without vertebral fracture, kyphosis and death were not associated.

Also featured in the current issue of Annals:

  • Quality more important than volume in predicting coronary bypass outcomes
    When choosing a surgeon or surgery center, quality of care is the most important factor. Patients and payers often associate high procedure volume with better outcomes. Researchers collected data on 81,289 patients cared for by 1,451 surgeons at 164 hospitals and found that hospital and surgeon procedure volume had few consistent associations with outcomes. However, overall adherence to quality measures was strongly associated with differences in mortality rates, regardless of volume. According to researchers, this finding is important because improving quality of care at hospitals is potentially more feasible and desirable than increasing case volume. They suggest that efforts to increase quality of care so patients can “shop for the best” is a wise approach that hospitals should undertake wherever coronary artery bypass surgery is done.
  • Splinting reduces pain, disability in base-of-thumb OA
    Researchers studied 112 patients with base-of-thumb osteoarthritis (BTOA) to determine whether wearing a hand splint could improve pain and hand function. Fifty-seven patients were randomly assigned to wear a custom-made nighttime splint, and 55 patients were randomly assigned to usual care. Nighttime splinting had no effect after one month, but it significantly reduced patients’ pain and disability after 12 months. The study authors conclude that splinting could be an inexpensive and effective alternative to drug treatment for patients with BTOA.
  • USPSTF recommends syphilis screening for pregnant women
    The U.S. Preventive Services Task Force recommends that all pregnant women be screened for syphilis at their first prenatal visit, because it can cause severe problems or death and it’s not always symptomatic. If the blood and follow up tests are positive, the woman should be treated with antibiotics. Antibiotic treatment protects the woman and her baby from the affects of syphilis. Researchers conclude that the benefits of screening for syphilis outweigh the potential harms that include unnecessary worry and unnecessary antibiotic treatment.

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FDA UPDATE

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Testosterone Gel Recalled for Possible Pediatric Exposure

The FDA will require two prescription topical testosterone gel products, AndroGel 1% and Testim 1%, to include a boxed warning on the products’ labels after receiving reports of eight cases of secondary exposure to testosterone in children ages nine months to five years.

Adverse events reported in these children included inappropriate enlargement of the genitalia, premature development of pubic hair, advanced bone age, increased libido and aggressive behavior. Recommendations and precautions to minimize the potential for secondary exposure are online.

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Caraco Recalled for Active Ingredient

All tablets of Caraco brand Digoxin, USP, 0.25 mg, distributed prior to March 31, 2009, which are not expired and are within the expiration date of August 2011, are being voluntarily recalled to the consumer level. The tablets are being recalled because they may differ in size and therefore could have more or less of the active ingredient, digoxin.

The existence of higher than labeled dose may pose a risk of digoxin toxicity in patients with renal failure. Digoxin toxicity can cause nausea, vomiting, dizziness, low blood pressure, cardiac instability, and slow heart rate. Death can also result from excessive digoxin intake. A lower than labeled dose may pose a risk of heart failure and abnormal heart rhythms.

Consumers with the products that are within expiration date and labeled Caraco Digoxin A-S Medication Solutions, Digoxin 0.25 mg is a scored round biconvex white tablet imprinted with “441,” NDC Numbers: Digoxin Tablets, USP, 0.25 mg 54569-5758-0 (30-count) should return these products to the place of purchase.

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FROM ACP INTERNIST

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ACP Members Discuss Medical Reports in the Mainstream Media

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 THE COLLEGE

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ACP Launches New, Improved Web Site

This week, the College launched a new, redesigned Web site that makes it easier for users to find and access information and resources. The new homepage was developed after months of research, feedback from Web users and usability testing, and provides a more organized and comprehensive starting point for the ACP Online experience.

This new page provides easy access to the most sought-after ACP content, a more visual representation of products and services, and a rotating preview of the most current content on the site. Additional components include a scrolling calendar of ACP’s courses and meetings, a live feed of blog postings, an ACP e-commerce tool to browse products, and a collection of online resources organized by topic and task that link to our diverse clinical, practice management and advocacy resources. This redesign project only affects the ACP Online homepage. All other pages and areas of the site will stay the same.

We welcome your feedback. Please visit our new page today and use the survey on the bottom to tell us what you think.

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ACP and ATS Team Up for Discounted Dues

ACP and the American Thoracic Society (ATS) are offering a joint dues reduction for members paying dues to both organizations. Members with one or more subspecialties in pulmonary, critical care or sleep medicine are eligible to receive the dues reduction. Current members who are paying both full due payments for ACP and ATS will receive a 10% discount off dues in both organizations. The discount is effective for the July 1, 2009-June 30, 2010 membership year. To verify your membership and discounts with ACP or ATS, contact ACP or ATS.

More information about ATS is available online.

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Announcing the 2009 ACP National Abstract Winners

More than 2,200 abstracts were submitted to the 2009 National Associates and Medical Students Abstract Competitions. This year's competition concluded at the Internal Medicine meeting with an impressive poster showcase from Associate and Medical Student Members. Over 300 Associates and 80 medical students presented their displays to a team of judges for review. Also featured at the meeting were oral presentations of the highest scoring abstracts from the national competition. A complete list of poster winners and oral presenters is posted online.

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CARTOON CAPTION CONTEST

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Vote for Your Favorite Entry

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

View the cartoon and pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting will be extended through the Memorial Day weekend until June 1, with the winner announced in the June 2 issue.

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MKSAP ANSWER AND CRITIQUE

The correct answer is C) Paget's disease of bone. This item is available online to MKSAP subscribers in the Endocrinology and Metabolism section, Item 75.


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.


Paget's disease is a focal disorder of bone remodeling that leads to greatly accelerated rates of bone turnover, disruption of the normal architecture of bone, and sometimes to gross deformities of bone (enlargement of the skull, bowing of the femur or tibia).

Most patients with Paget's disease are asymptomatic. The diagnosis is often suspected from radiographs obtained for other reasons or from an isolated elevation of the serum alkaline phosphatase level. The most common symptom is a dull, aching bone or joint pain. Headache, bone deformity, fracture, warmth of skin over involved bone, high-output cardiac failure or entrapment neuropathies causing loss of hearing are less common.

In the osteolytic phase an advancing wedge-shaped resorption front at either end of the long bones or circumscribed osteolytic lesions in the skull (osteoporosis circumscripta) may be seen. The osteolytic phase evolves into the mixed phase of both osteoclastic and osteoblastic overactivity. The mixed phase is followed by a less active period of bone remodeling and marked sclerosis. The affected bone may enlarge, show bowing deformities, and undergo incomplete or complete fractures. A “cotton-wool” appearance of the skull with a patchy increase in bone density may be seen in the osteoblastic phase. Osteoblastic lesions avidly take up the technetium-labeled bisphosphonate used in bone scans. The bone scan is useful in identifying the full extent of disease. It may be negative in relatively inactive “burned-out” Paget's disease. Active Paget's disease of bone is associated with an increase in biochemical indices of bone turnover. The total serum alkaline phosphatase is usually sufficient to monitor disease activity.

Osteomalacia usually presents with an elevation of alkaline phosphatase in association with hypocalcemia and hypophosphatemia. Osteoporosis is a silent metabolic bone disease which only gives rise to pain once fractures occur. Metastatic cancer is unlikely since the patient does not have any evidence of a primary carcinoma which spreads to bone such as lung cancer or prostate cancer. Primary hyperparathyroidism presents with hypercalcemia.

Key Points

  • Paget's disease is a focal disorder of bone remodeling that leads to greatly accelerated rates of bone turnover, disruption of the normal architecture of bone, and sometimes to gross deformities of bone (enlargement of the skull, bowing of the femur or tibia).
  • Osteomalacia usually presents with an elevation of alkaline phosphatase in association with hypocalcemia and hypophosphatemia.

Click here to return to the rest of ACP InternistWeekly.

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Copyright 2009 by American College of Physicians.

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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?

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