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

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In the News
for the Week of 7-14-09

Highlights

  • More patients surviving AAA repairs
  • Some cancer survival tied to race, not socioeconomics

Test yourself

  • MKSAP quiz: breast cancer risk

Diabetes care

  • Trial tests electronic tracking for diabetics and doctors

Annals of Internal Medicine

  • Missed test results: Overlooking CT findings
  • Poor working conditions may reduce primary care workforce
  • Travel associated with threefold increase in VTE risk
  • Stepped dosing may relieve efavirenz's severe side effects

FDA news

  • Drugs with propoxyphene must carry stronger warnings
  • Boxed warning for varenicline, bupropion
  • Arthroscopic shavers under safety review
  • FDA approves arrhythmia, lung cancer maintenance drugs

Regulatory updates

  • CMS releases Medicare Fee Schedule for 2010
  • Joint Commission annual conference coming up in September

From the College

  • Discounted accommodations for Summer Session
  • ACP Press offers evidence-based title about alternative medicine
  • Take a survey on online clinical resources
  • Executive Vice President report now available

Cartoon caption contest


Highlights

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More patients surviving AAA repairs

Over the past few decades, survival rates have improved for repair of intact abdominal aortic aneurysms (AAAs), a new Swedish study found.

Researchers used data from the Swedish Vascular Registry to assess the outcomes of 8,663 intact AAA repairs and 4,171 ruptured repairs conducted between 1987 and 2005. Specifically, they looked at patients who received repairs from 1987 to 1999 compared to those who got them between 2000 and 2005. Although patients in the later group were older, had more comorbidities and were more likely to have endovascular repair, they were also more likely to survive for at least 5 years. The study was published online by Circulation on July 6.

Overall, survival was better for men than women, and for patients older than age 80 years than the group as a whole. The octogenarians made up a small percentage of the whole and were probably required to be healthier to have the surgery, researchers noted. There was no difference in long-term survival depending on whether patients had open or endovascular repair. Patients who had a ruptured aneurysm did not experience any gain in long-term survival over the study period, and survived an average of 5.4 years compared to almost 9 years for intact repairs.

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Some cancer survival tied to race, not socioeconomics

A recent study attributed higher mortality among blacks for breast, ovarian and prostate cancer to race and not socioeconomic factors.

Specifically, black race was associated with increased mortality from early-stage premenopausal and postmenopausal breast cancer, advanced-stage ovarian cancer and advanced-stage prostate cancer, but not from lung cancer, colon cancer, lymphoma, leukemia or multiple myeloma. Results were published online July 7 by the Journal of the National Cancer Institute.

Researchers at the Southwest Oncology Group, a National Cancer Institute-sponsored cooperative group, identified 19,457 adult cancer patients (2,308 black) treated in 35 consecutive, randomized, phase III clinical trials from 1974 through 2001. Types of cancer included breast (n=6,676), lung (n=2,699), colon (n=1,244), ovarian (n=1,429), prostate (n=1,843), lymphoma (n=1,291), leukemia (n=2,067) and multiple myeloma (n=2,208). Patients were grouped by similar histology and stage, and the authors controlled for prognostic factors. Education and income were used as surrogates for socioeconomic status.

After adjustment for prognostic factors, blacks had increased mortality for early-stage premenopausal breast cancer (hazard ratio [HR] for death, 1.41 [95% CI, 1.10-1.82]; P= 0.007), early-stage postmenopausal breast cancer (HR, 1.49 [95% CI, 1.28-1.73]; P < 0.001), advanced-stage ovarian cancer (HR, 1.61 [95% CI, 1.18-2.18]; P=0.002), and advanced-stage prostate cancer (HR, 1.21 [95% CI, 1.08-1.37]; P=0.001).

Researchers said in a release that their findings point to "biological or host genetic factors" as a reason for the observed difference in survival. The consecutive, randomized, phase III clinical trial setting ensured similarities in disease stage, eligibility and treatment and allowed adjustment for potential prognostic factors, researchers wrote. But an editor's note acknowledged that cancer in non-black patients may have been more likely to be detected through screening, that some racial disparities in overall survival may be related to comorbidities, and that racial disparities may exist for adherence to hormone therapy in the trials.

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Test yourself

MKSAP quiz: Breast cancer risk

A 35-year-old Jewish woman of Ashkenazi descent is evaluated during a routine examination. Her medical history is noncontributory. The family history includes a paternal grandmother who had bilateral breast cancer at ages 42 and 50 years and died of metastatic breast cancer at age 53 years, and a paternal great aunt who had had ovarian cancer at age 45 years and breast cancer at age 51 years. Her two sisters, mother, and mother's relatives have not had breast or ovarian cancer, and her father is healthy without any cancer.

MKSAP quiz: breast cancer risk Physical examination, including breast and pelvic examination, is normal. She is concerned about her family history and wants to know whether there is anything she can do to reduce her risk for cancer.

Which of the following is the most appropriate next step in management?
A) Prophylactic bilateral mastectomy
B) Prophylactic oophorectomy
C) Low-fat diet
D) Genetic counseling
E) Tamoxifen

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

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Diabetes care

Trial tests electronic tracking for diabetics and doctors
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An electronic tracking system improved processes of care and some clinical markers for patients with type 2 diabetes, a Canadian study found.

The trial included 46 primary care providers and 511 of their patients who were randomized to either usual care or the electronic intervention. The intervention gave patients and physicians access to a Web-based diabetes tracker that provided monitoring values and targets for 13 diabetes risk factors and brief advice messages. Patients were also sent a color-coded tracker page by mail, and they received automated telephone reminders.

After six months, patients in the intervention group showed some (although statistically insignificant) improvement in processes of care. The patients who participated in the electronic tracking also had statistically significant declines in blood pressure and glycated hemoglobin. Physicians and patients noted difficulty accessing the Web portal as the major shortcoming of the system. The study was published in the July 7 Canadian Medical Association Journal.

The study was unusual in that it tested an electronic monitoring system outside of a large institution, so technology support was less available and the system had to work across different, non-interoperable electronic medical records. It was limited by patients' lack of access to the Web. At baseline, about half of patients used a computer. Therefore, it's difficult to isolate the effects of the computer system from those of the telephone and mail reminders, which encouraged patients to see their physicians.

Although researchers favored the creation of patient-centered electronic systems to facilitate clinical management, it's not known yet what innovations will result in durable improvements in diabetes care, concluded the accompanying editorial.

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Annals of Internal Medicine

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Missed test results: Overlooking CT findings

Researchers studied the electronic health records of 4,112 patients and found 91 who had newly diagnosed abdominal aortic dilation observed on computed tomography (CT). Using the electronic medical record (EMR) as evidence, the authors found that the clinical care team had not noted the dilation in the EMR in 58% of cases within three months of CT. In 18% of cases, the dilations were never documented during an average follow-up of more than three years. The researchers found no evidence of patient harm associated with the failed documentation but concluded innovative solutions are needed to ensure that physician awareness of abnormal test results is consistently noted in the medical record.

The June 30 issue of ACP InternistWeekly summarized a study showing that 7% of patients were not told about abnormal lab results.

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Poor working conditions may reduce primary care workforce
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Researchers performing a cross-sectional analysis of 422 family practitioners and general internists at 119 U.S. ambulatory clinics found that chaotic work pace, lack of control over work and poor organizational culture were strongly associated with poor physician satisfaction, high stress levels, burnout, and intent to leave. However, adverse physician reactions were not found to be associated with worse patient care or with errors. The study authors suggest that current practice-redesign projects, such as those focusing on the patient-centered medical home, could create healthier work environments for primary care physicians. Hospitals and clinics that focus on quality-of-work conditions may better recruit and retain primary care physicians.

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Travel associated with threefold increase in VTE risk
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Long-distance travel confers an increased risk for venous thromboembolism (VTE), but the extent of this risk has not been previously quantified. Researchers performed a meta-analysis of 14 studies involving 4,055 cases of VTE to investigate the association between travel and VTE for patients using any mode of transportation. Nontraveling patients were used as controls. The authors found that travel was associated with a nearly threefold higher risk of VTE, with a dose-response relationship of 18% higher risk for each two-hour increase in travel duration. Physicians should investigate the use of low-cost, low-risk interventions such as increased hydration and ambulation for all long-distance travelers, the authors concluded. Additional interventions and therapies should be evaluated for higher-risk subgroups, they wrote.

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Stepped dosing may relieve efavirenz's severe side effects
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More than half of HIV patients who start efavirenz treatment develop neuropsychiatric adverse events. In a randomized, double-blind, controlled trial, researchers studied 114 HIV-infected patients to determine that stepped-dose administration of efavirenz over two weeks significantly decreases the incidence and severity of side effects while appearing to maintain the same efficacy over the short term as the standard schedule.

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FDA news

Drugs with propoxyphene must carry stronger warnings
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The FDA is requiring the manufacturers of drugs with propoxyphene (Darvon, Darvocet) to strengthen their boxed warnings about potential overdose, and provide patient medication guides about proper use of the drugs, the agency said in a news release.

Physicians need to carefully review patients' histories before prescribing these drugs, and be aware of the risk of overdose at doses higher than recommended, the FDA said. The agency is requiring safety studies to examine the effects of propoxyphene on the heart at higher-than-recommended doses, triggered in part by reports from Europe that the drug may be deadlier in overdose than other pain medications, the FDA said. An expert panel advised the FDA in January to pull the drugs from the market.

The FDA will also work with several groups, such as CMS and the Veterans Health Administration, to study how often the elderly are prescribed propoxyphene instead of other pain relievers, and the difference in the safety profiles of propoxyphene compared to other drugs, the agency said.

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Boxed warning for varenicline, bupropion
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Smoking cessation drugs varenicline (Chantix) and bupropion (Zyban) must now have boxed warnings on their labels about the risk of serious mental health events, the FDA said in a release.

The events at issue include changes in behavior, depressed mood, hostility and suicidal thoughts. Similar information on mental health events will be required for bupropion marketed as the antidepressant Wellbutrin and for generic versions of bupropion—drugs that already carry a boxed warning for suicidal behavior in treating psychiatric disorders.

Providers who prescribe these drugs should monitor patients for any unusual changes in mood or behavior, the FDA said. In many reported cases, the problems began shortly after starting the medication and ended when the medication was stopped, though some people continued to have symptoms after stopping the medication.

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Arthroscopic shavers under safety review
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The FDA is conducting a safety review of arthroscopic shavers in light of reports that pieces of tissue sometimes remain within the shaver, even after cleaning according to the manufacturer's instructions, the agency said in an alert.

Retained tissue in the shavers can compromise sterilization, and the FDA is working with manufacturers to gather more data, it said. The agency encourages facilities that use these devices to evaluate their cleaning procedures, and, if retained tissue is discovered, to file a voluntary report with MedWatch, the FDA Safety Information and Adverse Reporting program online.

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FDA approves arrhythmia, lung cancer maintenance drugs
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The FDA last week approved dronedarone (Multaq) to help maintain normal heart rhythms in patients with a history of atrial fibrillation or atrial flutter, according to a release.

Dronedarone is approved for patients whose hearts have returned to normal rhythm or who will undergo drug or electric-shock treatment to restore a normal heartbeat. Because the drug can cause critical adverse reactions, including death, in patients with recent severe heart failure, its label will contain a boxed warning against use in severe heart failure patients. The most common adverse reactions to dronedarone are diarrhea, nausea, vomiting, fatigue and loss of strength.

Separately, the agency also approved pemetrexed (Alimta), the first available drug for maintenance therapy of advanced or metastatic lung cancer, a release said.

Pemetrexed represents a new approach to treating advanced non-small-cell lung cancer, an FDA expert said. While patients whose tumors respond to chemotherapy do not usually receive further treatment after four to six chemotherapy cycles, research has shown a survival benefit in certain patients who received pemetrexed for maintenance therapy, he said. Reported adverse events included damage to blood cells, fatigue, nausea, loss of appetite, tingling or numbness in the hands and feet and skin rash.

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Regulatory updates

CMS releases new Medicare Fee Schedule for 2010
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On July 1, CMS released the proposed rule for the 2010 Medicare Physician Fee Schedule.

The new proposal contains a number of changes that would principally benefit primary care physicians. General internists are projected to gain 6% in total Medicare payments, and geriatricians are projected to gain 8%. The proposal also increases the payment for the Welcome to Medicare Exam. However, the new rule also includes cuts to payments for imaging and eliminates separate, higher payments for outpatient consultations. These changes are likely to be very controversial for some internal medicine subspecialists.

The new rule is still only a proposal, and CMS will be accepting comments on the proposed rule until August 31. ACP will work through its committees to develop its comments. It will also consult organizations representing the internal medicine subspecialties. The final rule should be issued by November 1. Look for a more detailed analysis of what the new fee schedule might mean in the July 17 edition of The ACP Advocate. Additional information can be found on the CMS Web site.

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Joint Commission annual conference coming up in September
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The Joint Commission’s annual conference will be held September 14-16 in Rosemont, Ill. The conference will focus on how health care executives can improve quality and reduce errors while still containing costs and increasing productivity. The conference will feature four tracks of concentration: leadership; patient/family-centered care; quality/patient safety; and process improvement management.

Participants who register by August 14 will save $200 off the registration fee. Physicians attending the conference are also eligible to receive up to 14 hours of CME credits. For more information visit The Joint Commission’s Web site.

From the College

Discounted accommodations for Summer Session
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Luxury accommodations are available at a significantly discounted rate for ACP Summer Session, in Orlando, Fla. Aug. 7-8 and San Francisco Aug. 14-15. Summer Session offers the latest evidence-based findings in an interactive format, instructed by nationally recognized faculty. The cost of the meeting is $50 for ACP members and $75 for nonmembers. More information about discounted accommodations is available online.

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ACP Press offers evidence-based title about alternative medicine
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More than one-third of Americans use complementary or alternative medicine (CAM). The vast majority of patients use CAM in addition to, rather than instead of, a conventional medical regimen. With more and more conversations about CAM taking place at the point of care, ACP Press released "The ACP Evidence-Based Guide to Complementary & Alternative Medicine," a comprehensive analysis of CAM treatments that busy clinicians can use to incorporate evidence-based information into point-of-care discussions with patients.

Organized by medical condition, the book focuses on the safety and efficacy of a full range of CAM therapies, providing at-a-glance answers to the questions patients often ask physicians.

Every chapter includes concise and easy-to-read tables that offer quick access to bottom-line recommendations after in-depth reviews of the research. Chapters address which patients are using CAM, unfamiliar terminology, ways to evaluate evidence, practical implications of CAM in the office, and common conditions that characterize most patient-clinician interactions, such as osteoarthritis.

Evidence is evaluated based on the Grading of Recommendations Assessment, Development and Evaluation working group, a system endorsed by the American College of Physicians, the U.S. Department of Health and Human Services Agency for Healthcare and Research and Quality and the World Health Organization.

"The ACP Evidence-Based Guide to Complementary & Alternative Medicine" can be ordered online. The book is also available at all major booksellers, both in stores and online, and an e-version is available. To order by phone, call 800-523-1546, ext. 2600 (M-F, 9:00 a.m.-5 p.m. ET).

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Take a survey on online clinical resources
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ACP is conducting a short online survey to determine how members use various online clinical information resources in order to improve their usefulness and functionality. Survey results will show how members use each resource for specific purposes, for example, as a point-of-care resource while treating patients, for general research, to help implement quality improvement in a practice, or to earn CME. A drawing will be held at the end of the month of all survey respondents. The winner will receive a gift certificate for 50% off products from ACP's online store.

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Executive Vice President report now available
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The 2009-2010 EVP Report from the Executive Vice President is now available online. The report outlines the year's events at the College, including new programs, services and clinical resources, as well as news in quality improvement, research and advocacy. The report is formatted as a calendar. However, members are encouraged to refer to the Meetings & Courses calendar on the ACP home page for the most recent and up-to-date information.

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Cartoon caption contest

Put words in our mouth
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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.

Put words in our mouth

E-mail all entries by to acpinternist@acponline.org by July 23. ACP staff will choose three finalists and post them in the July 28 issue of ACP InternistWeekly for an online vote by readers. The winner will appear in the Aug. 4 edition of ACP InternistWeekly.

 

 

 

MKSAP answer and critique
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The correct answer is D) Genetic counseling. This item is available online to MKSAP subscribers in the Hemotology/Oncology section, Item 60.

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.

This patient's family history of breast and ovarian cancer and the constellation of disease in the affected relatives—combined with the patient's Ashkenazi Jewish descent—may increase her risk for these types of cancer. Compared with the general population, women who are of Ashkenazi Jewish descent are five times more likely to harbor BRCA1 or BRCA2 mutations, which confer a significantly higher risk for breast and ovarian cancer compared with persons without these mutations. Therefore, referral to a genetic counselor is appropriate for this patient and will enable her to become informed about her options for reducing cancer risk. Although women with BRCA1/BRCA2-postive breast or ovarian cancer do not necessarily have a worse prognosis than those without these genetic mutations, they do have a substantially higher risk for mortality simply because of the enormously increased frequency with which breast and ovarian cancer occur in these higher-risk populations.

Retrospective and prospective studies have suggested that prophylactic mastectomy decreases the risks for breast cancer incidence and mortality by 90% or more. Likewise, prophylactic oophorectomy should be considered in women who have tested positive for a BRCA1/2 mutation and who have completed childbearing. However, these are drastic approaches and not a consideration for this patient until she learns more about her degree of cancer risk through genetic counseling.

Breast cancer risk was not reduced in an unplanned, retrospective subset analysis of women who appeared likely to harbor BRCA1 and/or BRCA2 abnormalities and who participated in a prospective randomized clinical trial of tamoxifen versus placebo for chemoprevention. However, other studies have suggested that tamoxifen is equally effective in preventing breast cancer regardless of BRCA1 and/or BRCA2 status. Nonetheless, tamoxifen therapy would be premature in this patient before she is determined to be at high risk for breast and/or ovarian cancer.

Key Points

  • Patients with BRCA1/2 mutations have a higher risk for breast and ovarian cancer compared with the general population.
  • Patients with a family history suggestive of germline-susceptibility cancer should be referred for genetic counseling.

Click here to return to the rest of ACP InternistWeekly.


About ACP InternistWeekly

ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.

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

Copyright 2009 by the American College of Physicians.

Test yourself

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

Find the answer

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