In the News
for the Week of 6-9-09
- Digestive Disease Week: IBS, NASH top research highlights
- Care for hypertension with comorbidities better, P4P study shows
- MKSAP quiz: excoriated oropharynx and mild electrolyte abnormalities
ADA conference coverage
- Death, cardiovascular events don't differ with revascularization vs. medical therapy for diabetics
- Study continues controversy over rosiglitazone's cardiovascular risks
- CBT may help prevent depression in teens of depressed parents
- New recommendations on bleeding disorders in women
- Propylthiouracil associated with liver failure, death
From ACP Internist
- ACP Internist blog to host Grand Rounds
- Have an interesting diagnosis to share? Submit your ideas for 'Mindful Medicine' with Jerome Groopman and Pamela Hartzband
From the College
- Recruit-a-Colleague Program grand prize winner announced
- Provide your perspective on nursing home care
Cartoon caption contest
- Put words in our mouth
Physician editor: Darren Taichman, ACP Member
Digestive Disease Week: IBS, NASH among research highlights
CHICAGO—New data that may affect how physicians help patients deal with the complexities—and chronic nature—of irritable bowel syndrome (IBS) and new studies emphasizing that a minimum 7% weight loss is the key to improving histologic features of nonalcoholic steatohepatitis (NASH) were among the highlights at Digestive Disease Week here last week.
Among the “significant advances in the past year” are studies that look at IBS not just as a diagnosis of exclusion, but as a “thing” unto itself, said Brennan M. Spiegel, MD, during a session on “New and Emerging Approaches to the Management of IBS.” Factors being considered include altered brain-gut interactions, radiographic studies, stool studies looking at serine proteases like trypsin and fecal microbiota, histological studies, genetics, and psychological issues. While not yet ready for “prime time,” some studies are also looking at the old “spastic colon” notion to see if measuring spasm might help make an IBS diagnosis. “It seems like a step back, but it may respond to antispasmodics,” he said.
In reviewing new drug therapy research for IBS, Philip Schoenfeld, MD, said some studies show SSRIs are more likely to improve IBS symptoms, particularly abdominal pain, relative to placebos.
During “Approaches to Weight Loss in NASH: When and How Aggressive,” presenter Kittichai Promrat, MD, said a recent study on lifestyle intervention showed a 9.3% weight reduction in patients who received a portion-control diet limited to 1,200 to 1,500 calories per day, a meal plan, and a pedometer to measure steps and met every other week for seven to 12 months versus 0.2% in those who met with nutritionists four times per year with no specific goals. The major challenge, he said, is finding a self-regulating program that will help patients maintain that weight loss. While a low-carb diet reduced more fat initially, once patients reached a 7% weight loss, the amount of fat reduction was the same. It doesn’t matter which diet the patient chooses as long as it’s one he will stick with.
Although patients with NASH would like a quick fix, bariatric surgery may not always be the answer, said Raphael Merriman, MD. In addition to the many complications of the various types of procedures, he said there just aren't enough data to recommend the procedure for NASH patients. He noted that while the surgery’s main goal is weight loss—not helping NASH—some data show promising results.
Another study found that 98% of 5,000 outpatient adults said their physicians had never talked to them about nonalcoholic fatty liver disease and that 95% did not know that fat in the liver could lead to serious health problems; 80% had never heard of cirrhosis. The solution? Physicians should take more initiative in discussing the disease and encourage their patients to maintain a healthy weight through diet and exercise, said Sury Anand, MD.
More from DDW is on the ACP Internist blog.
—By Paula S. Katz, special to ACP Internist.
Care for hypertension with comorbidities better, P4P study shows
Hypertension patients with comorbidities received better care and gave high ratings to their physicians, dispelling the notion that taking care of medically complex patients may lead to lower performance ratings, researchers concluded.
Previous studies have shown mixed results when trying to assess the impact of pay-for-prerformance (P4P) measures on patients with multiple conditions. Treating multiple diseases may reduce the time allotted to each one, and the burden of treating many diseases may lower the patient's evaluation of the overall care. And, evidence-based guidelines focus on one disease, not treating many at once.
To sort through these potential issues, researchers looked at hypertension outcomes with concordant illnesses and discordant illnesses and looked at how outcomes varied. Researchers at the Houston VA Medical Center and Baylor College of Medicine in Houston divided 141,609 veterans with hypertension into four condition groups:
- only hypertension (16% of patients),
- those with concordant diseases such as diabetes, ischemic heart disease or dyslipidemia (49.5%)
- those with discordant diseases such as arthritis, depression or chronic obstructive pulmonary disease (8.7%), or
- those with both types of concordant diseases (25.9%).
Researchers reported results online in Circulation: Journal of the American Heart Association.
Researchers defined quality care as either meeting the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure blood pressure guidelines and the number of patients who received appropriate care during the 6-month follow-up period. Satisfaction scores were derived from a mailed questionnaire from the VA that applied a Likert scale to the survey question, “Overall, how would you rate the quality of care you received during the past 2 months?”
Compared with hypertensive patients with no comorbidities, hypertensive patients with both concordant and discordant conditions were the most likely to receive overall good quality care (odds ratio [OR] 2.25; 95% confidence interval [CI] 2.13 to 2.38), compared to concordant-only conditions (OR 1.78; 95% CI 1.70 to 1.87) or discordant-only conditions (OR 1.32; 95% CI 1.23 to 1.41). Patient care ratings did not vary with type of comorbidity or the number of primary care and specialty care visits.
Researchers said, "Our findings should be reassuring to those who care for the most medically complex patients and are concerned that they will be penalized by performance measures or patient ratings of their care."
MKSAP quiz: excoriated oropharynx and mild electrolyte abnormalities
A 22-year-old woman is evaluated during a routine evaluation. She has no medical problems except for feeling tired all the time, which she attributes to working part-time while attending classes full-time and her many social activities. She denies depression, anhedonia, or constipation, and, although she has not gained weight, she has not lost any weight despite being on a diet for years. She has occasional heartburn, particularly after alcohol consumption, which she successfully self-treats two to three times per week with calcium carbonate, 500 mg. She admits to occasional binge drinking, once or twice yearly, but her CAGE score is 0/4. She smokes because it helps her to control her weight.
On physical examination, she is slightly overweight, with a BMI of 27. Her heart rate is 68/min and her blood pressure is 188/62 mm Hg. The oropharynx is remarkable for an excoriation at the back of the throat and mild bilateral parotid gland swelling. The remainder of the physical examination is normal. Complete blood count and serum thyroid-stimulating hormone level are unremarkable. Serum electrolytes are notable for mildly decreased serum potassium, slightly elevated serum bicarbonate, and mildly decreased serum chloride levels. The serum creatinine/blood urea nitrogen levels, liver chemistry tests, and urinalysis are unremarkable.
Which of the following is the most likely diagnosis?
A) Bulimia nervosa
B) Anorexia nervosa
C) Primary aldosteronism
D) Surreptitious diuretic ingestion
E) Renal tubular acidosis
Click here or scroll to the bottom of the page for the answer and critique.
ADA conference coverage.
Death, cardiovascular events don't differ with revascularization vs. medical therapy
There is no difference in death or major cardiovascular event rates for diabetic patients who undergo medical therapy compared with prompt revascularization, or between those who undergo insulin sensitization vs. insulin provision, a new study found.
Researchers randomized 2,368 patients with type 2 diabetes and stable ischemic heart disease to have prompt revascularization with intensive medical therapy, or medical therapy alone, and to undergo either insulin-sensitization or insulin-provision therapy (At the 3-year follow-up, the most frequently used drugs in the insulin-provision group were insulin and sulfonylurea; in the insulin-sensitization group, the most frequently used drugs were metformin and a thiazolidinedione). Death and major cardiovascular events (a composite of death, myocardial infarction or stroke) were the primary end points. Randomization was also stratified by choice of percutaneous coronary intervention (PCI) or coronary-artery bypass grafting (CABG), according to which was most appropriate for a given patient. The study was published online June 7 by the New England Journal of Medicine to coincide with a presentation at the American Diabetes Association annual scientific sessions.
The survival rate for the revascularization group was 88.3%, compared with 87.8% for the medical therapy group—a non-significant difference. Cardiovascular event rates also didn't differ, at 22.8% in the revascularization group and 24.1% in the medical therapy group. There was no difference in survival between the insulin sensitization group (88.2%) and the insulin provision group (87.9%), nor did they differ in cardiovascular events (22.3% for insulin sensitization vs. 24.6% for insulin provision). The authors noted that the mean follow-up glycated hemoglobin values in the insulin-sensitization group and the insulin-provision group were close to the target level of 7.0% but differed significantly from each other.
There was also no significant difference in the PCI stratum between revascularization and medical therapy. However, in the CABG stratum, the rate of major cardiovascular events was significantly lower in the revascularization vs. the medical therapy group (22.4% vs. 30.5%, p=0.01), driven mainly by a reduction in nonfatal myocardial infarction. Severe hypoglycemia was also more frequent in the insulin-provision group vs. the insulin-sensitization group (9.2% vs. 5.9%, p=.003).
The study results indicate that, for many patients with heart disease and diabetes—especially those with less severe disease—optimal medical therapy is a good first-line strategy, an editorial accompanying the study said. When revascularization is indicated, however, the study supports previous research suggesting that CABG may be preferred over PCI, the editorial said..
Study continues controversy over rosiglitazone's cardiovascular risks
A new study found that rosiglitazone doubled the risk of heart failure among type 2 diabetes patients but did not raise overall cardiovascular hospitalizations or deaths compared with standard therapy.
The manufacturer-sponsored Rosiglitozone Evaluated for Cardiovascular Outcomes in Oral Agent Combination Therapy for Type 2 Diabetes, or RECORD, trial's results conflict with the findings of a 2007 study showing that rosiglitazone significantly increased the risk of myocardial infarction. The RECORD trial confirmed, however, earlier findings that rosaglitazone doubles the risk of distal fracture in older women. The study results were presented at the American Diabetes Association's annual scientific sessions over the weekend and published online by the Lancet.
In the trial, 4,447 patients with type 2 diabetes on metformin or sulfonylurea monotherapy with mean hemoglobin A1c of 7.9% were randomly assigned to either add rosiglitazone to their existing regimen or take metformin and sulfonylurea alone. After 5.5 years follow up, HbA1c was lower in the rosiglitazone group than the standard therapy group, rosiglitazone did not increase the risk of overall cardiovascular morbidity or mortality, and rosiglitazone patients had a nonsignificant reduction in fatal and nonfatal stroke. However, heart failure causing admission to hospital or death was higher in the intervention group (hazard ratio [HR] 2.10; 95% confidence interval [CI] 1.35-3.27; risk difference per 1,000 person-years HR 2.6; CI 1.1-4.1) and upper and distal lower limb fracture rates were increased mainly in women taking rosiglitazone.
The authors concluded that the data are inconclusive about rosiglitazone's effects on myocardial infarction and that the drug does not increase the risk of overall cardiovascular morbidity or mortality compared with standard glucose lowering drugs. In an interview with Modern Medicine, a study author noted that rosiglitazone should not be used by patients who have heart failure or who are at increased risk of fracture but could be considered in other type 2 diabetics, particularly obese patients.
CBT may help prevent depression in teens of depressed parents
Cognitive behavioral therapy (CBT) was more effective than usual care in preventing the onset of depression in adolescents whose parents had suffered from depression, a recent study found.
The randomized, controlled trial included 316 teens age 13-17 years in four U.S. cities whose parents had current or prior depressive disorders. Participating adolescents, who had either a history of depression, current elevated but subdiagnostic depressive symptoms, or both, were assigned to either eight weeks of 90-minute CBT group sessions followed by six monthly follow-up sessions, or usual care (all participants were allowed to continue or initiate mental health care services during the study). Adolescents were excluded if they had a current DSM-IV mood disorder diagnosis or were taking antidepressant medication. A depressive episode was defined as having a depressive symptom rating score of at least 4 for at least two weeks.
The incidence of depressive episodes was 11% lower in the CBT group than in the usual care group (21.4% vs. 32.7%; hazard ratio, 0.63; 95% confidence interval [CI], 0.40-0.98) and those in the CBT group showed greater improvement in self-reported symptoms. However, CBT was not more effective than usual care for adolescents with a currently depressed parent. The study appears in the June 3 Journal of the American Medical Association.
The authors noted that the number needed to prevent is nine in the current study, compared with 10 for antidepressants, suggesting that CBT can work as well as medication for preventing onset of depression. The finding that CBT was not more effective for teens with a currently depressed parent underscores the potential value of combined parent and adolescent treatment and prevention, they said. The authors also recommended that future research should be conducted in the primary care setting, where families are most likely to receive services.
New recommendations on bleeding disorders in women
A recent consensus conference of obstetricians and gynecologists developed new recommendations for the diagnosis and treatment of bleeding disorders in women.
The panel of international experts focused on Von Willebrand disease and other bleeding disorders. These conditions have historically been underdiagnosed in women because the symptoms can be confused with normal reproductive tract bleeding, the experts said. The consensus was published online in the American Journal of Obstetrics and Gynecology, along with a press release about the new recommendations.
The recommendations listed a number of symptoms that indicate menorrhagia could be related to a bleeding disorder such as Von Willebrand disease. (Experts defined menorrhagia as > 80 mL of blood loss per menstrual cycle plus the following symptoms: soaking through a pad or tampon within 1 hour; soaking through bed clothes; below normal ferritin; anemia; and pictorial blood assessment chart score > 100.) Further evaluation should be undertaken if a woman has menorrhagia since puberty, a family history of a bleeding disorder, or a personal history of one, but usually several, of the following symptoms: nosebleeds (bilateral, more than 10 minutes) more than once in the past year, notable bruising without injury, bleeding from trivial cuts lasting more than five minutes, prolonged or excessive bleeding after surgery or dental extraction.
The consensus report also offered guidance on management of menorrhagia resulting from a bleeding disorder, including a decision-tree algorithm. If obstetrician-gynecologists and hematologists collaborate in using the recommendations, a decrease in diagnosis of idiopathic menorrhagia could be achieved, the experts suggested. More effective management of bleeding would likely in turn lead to improved quality of life and school and work performance for affected patients.
Propylthiouracil associated with liver failure, death
Propylthiouracil carries the risk of serious liver injury, including liver failure and death, in adult and pediatric patients, the FDA said last week in a safety alert.
Thirty-two patient reports of serious liver injury with propylthiouracil have been made to the FDA's Adverse Event Reporting System (AERS), compared with five reports for methimazole. Thirteen of the propylthiouracil cases resulted in death, compared with three with methimazole. Both drugs are indicated to treat hyperthyroidism due to Graves’ disease, but propylthiouracil is generally considered second-line therapy except in patients who are allergic to or intolerant of methimazole.
Patients who are put on propylthiouracil therapy should be closely monitored for symptoms and signs of liver injury, especially during the first six months after the start of therapy. Propylthiouracil shouldn't be used in pediatric patients unless the patient is allergic to or intolerant of methimazole and there are no other treatment options available, the FDA said.
From ACP Internist.
ACP Internist blog to host Grand Rounds
Bloggers among the ACP membership can submit their best entries for Grand Rounds, a weekly summary of the best health blog posts on the Internet. Submitting is easy. E-mail your blog's title, the post's URL and a one-sentence summary of the post by Monday, June 15 at 9 a.m. Then join us on our blog June 16 for our edition of the oldest and most popular medical blog "carnival" on the Internet..
Have an interesting diagnosis to share? Submit your ideas for 'Mindful Medicine' with Jerome Groopman and Pamela Hartzband
Do you have a case where a medical diagnosis required you to dig beyond the obvious? Submit the diagnosis and a two-sentence summary of the case for consideration in future columns of Mindful Medicine, ACP Internist's column by Jerome Groopman, FACP, author of New York Times best-seller "How Doctors Think," and endocrinologist Pamela Hartzband, FACP, both Harvard faculty and staff physicians at Beth Israel Deaconess Medical Center in Boston. Based on reader submissions, they will analyze how doctors arrive at a correct diagnosis, and the missteps that can lead to errors.
Go to our Web site to read past installments of Mindful Medicine.
From the College.
Recruit-a-Colleague Program grand prize winner announced
U.S. Army Chapter member Stephen M. Salerno, FACP, (not shown) was selected as the winner in the 2008-09 Recruit-a-Colleague Program grand prize drawing for a trip to Internal Medicine 2010 in Toronto. Angeline A. Lazarus, FACP, (left) chair of the Membership Committee, and Mitsunori Iwase, FACP, PhD, last year's raffle winner from the Japan Chapter drew Dr. Salerno's name at Internal Medicine 2009 in Philadelphia. For more information about the Recruit-a-Colleague program, visit www.acponline.org/recruitacolleague..
Provide your perspective on nursing home care
The American Medical Directors Association (AMDA), the professional association of medical directors, attending physicians and others practicing in the long-term care continuum, is conducting a survey about physician practice in nursing homes and would like to capture internists' perspectives.
ACP is making this AMDA survey available to its members. Your participation is voluntary. Responses are anonymous and will not be linked to your identity or e-mail address. You can complete the survey whether or not you practice in the nursing home setting.
A major goal of the survey is to generate an updated national prevalence estimate of physicians practicing in nursing homes and identify facilitators and barriers to physician engagement in nursing home practice. AMDA will share the results of its survey, which will also include responses from family physicians, with ACP. In addition to providing ACP with additional insight into nursing home care, the results will help inform College advocacy efforts.
Cartoon caption contest.
Put words in our mouth
ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.
E-mail all entries by June 18. ACP staff will choose three finalists and post them in the June 23 issue of ACP InternistWeekly for an online vote by readers. The winner will appear in the June 30 edition of ACP InternistWeekly..
MKSAP Answer and Critique
The correct answer is A) Bulimia nervosa. This item is available online to MKSAP subscribers in the General Internal Medicine section: Item 134.
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.
Several clues in this patient's history and findings suggest bulimia nervosa. She has excoriations at the back of her throat from self-induced vomiting and hypertrophy of the parotid glands. Chronic purging can lead to mild electrolyte abnormalities, including hypokalemia and slightly elevated serum bicarbonate and slightly decreased serum chloride levels. Other signs suspicious for this disorder include oropharyngeal ulcers, dental erosions, and bite marks or scars on the back of the hand. Anorexia nervosa is another eating disorder but is not as likely as bulimia in this patient because she is slightly overweight and has maintained her normal body weight despite trying to lose weight; patients with anorexia usually have difficulty maintaining weight within 15% of an ideal body weight and often appear emaciated on physical examination. This clinical scenario does not support a diagnosis of surreptitious ingestion of diuretics or renal tubular acidosis.
- Bulimia may be characterized by excoriations at the back of the throat caused by self-induced vomiting, hypertrophy of the parotid glands, and mild electrolyte abnormalities.
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Copyright 2009 by the American College of Physicians.
A 57-year-old man is evaluated in follow-up for a right-sided pleural effusion. He initially presented with increasing dyspnea and a constant dull ache on his right side. He also has lost 9.1 kg (20.0 lb) over the last 6 months. Medical history is otherwise unremarkable. Following chest radiographs and repeat thoracentesis, what is the most appropriate diagnostic test to perform next?
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