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

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In the News
for the Week of 8-11-09

Highlights

  • Antidepressant use doubles from 1996-2005
  • Study fails to demonstrate benefit from routine screening for intimate partner violence

Test yourself

Cardiology

Evidence-based medicine

FDA update

  • Recall of electronic infusion pumps
  • TNF blockers raise cancer risk for adolescents, kids
  • Diabetes drug, statin approved

CMS update

  • Check or change NPI information online

From the College

Cartoon caption contest


Highlights

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Antidepressant use doubles from 1996-2005

Antidepressant use approximately doubled in the U.S. between 1996 and 2005, from 13.3 million people (5.84%) to 27 million (10.12%).

Data came from the Medical Expenditure Panel Surveys, a telephone survey sponsored by the Agency for Healthcare Research and Quality. Results published in the August Archives of General Psychiatry confirmed previous studies, and also quantified use and offered insight into the changing clinical characteristics of who uses antidepressants, why and how. Among other results:

  • Antidepressant use increased significantly in all socioeconomic demographics except blacks (3.61% in 1996 and 4.51% in 2005) and Hispanics (3.72% in 1996 and 5.21% in 2005), for whom rates remained comparatively low;
  • Among patients treated with antidepressants, use of selective serotonin reuptake inhibitors and other newer antidepressants increased from 54.8% to 66.89%, and use of tricyclic antidepressants waned from 35.32% to 11.09%;
  • Those treated with antidepressants were also more likely to receive antipsychotics in 1996 than in 2005 (5.46% vs. 8.86%), but were less likely to undergo psychotherapy (31.5% vs. 19.87%); and
  • Overall mean number of annual antidepressant prescriptions among antidepressant users rose from 5.6 in 1996 to 6.93 in 2005.

Researchers speculated on reasons for the increase, including:

  • a possible increase in major depression,
  • new drug approvals,
  • clinical guidelines supporting antidepressant use,
  • an increase in direct-to-consumer ad spending, and
  • better public acceptance.

The authors concluded, "These trends vividly illustrate the extent to which antidepressant treatment has gained acceptance in the United States and the growing emphasis on pharmacologic rather than psychologic aspects of care."

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Study fails to demonstrate benefit from routine screening for intimate partner violence

Routine screening for intimate partner violence (IPV) has a negligible effect on recurrence and quality of life, according to a new study.

Although some professional societies recommend routine screening for IPV in clinical practice, the U.S. Preventive Services Task Force and the Canadian Task Force on Preventive Health Care have found insufficient evidence to recommend for or against it. Canadian researchers from the McMaster Violence Against Women Research Group therefore performed a randomized, controlled trial to determine the effect of screening women for IPV and reporting positive results to their clinicians. Eligible women 18 to 64 years of age who presented for care between July 2005 and December 2006 were randomly assigned to the screened group (n=3,271) or the nonscreened group (n=3,472).

Those in the screened group completed the Woman Abuse Screening Tool (WAST), which measures physical, sexual and emotional abuse over the past year, before their health care visit; positive results were reported to their clinician, who provided referrals and follow-up at his or her discretion. Those in the nonscreened group completed the WAST after their health care visit. All women completed the Composite Abuse Scale, which was used to quantify recurrence of IPV, after their health care visit, and all women received a card that provided information on local resources for women experiencing IPV. Women participated in a baseline interview within 14 days of their health care visit and were interviewed again at six, 12 and 18 months. The primary outcome measures were reexposure to IPV and quality of life. The study results appear in the Aug. 5 Journal of the American Medical Association.

Overall, 347 women in the screened group and 360 women in the unscreened group reported IPV in the preceding 12 months at the index visit. Of these, 148 (43%) in the screened group and 148 in the unscreened group (41%) were lost to follow-up. Forty-six percent of screened women and 53% of unscreened women reported recurrence of IPV at 18 months, and screened women had a 0.2-SD greater improvement on quality-of-life scores; however, between-group differences decreased and differences in quality of life were no longer significant when the authors adjusted for sample loss. No harms of screening were reported.

The authors acknowledged their study's limitations, including the high attrition rate and the reliance on self-reported outcomes. They concluded that screening for IPV had some modest benefits and did not cause harm, but that their results "do not provide sufficient evidence to support universal IPV screening in health care settings in the absence of an effective intervention to prevent or reduce IPV." The authors of an accompanying editorial wrote that the study results "should dispel any illusions that universal screening with passive referrals to community services is an adequate response to violence in intimate relationships." The editorialists and the study authors called for the development and testing of effective interventions for IPV.

ACP Internist addressed red flags that should trigger screening and ways to approach it in its March cover article.

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Test yourself

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MKSAP quiz: managing influenza

A 45-year-old man with asthma is evaluated because of malaise, myalgias, coryza, and a cough. Both influenza A and B are occurring in the community, and the patient has not been immunized against influenza. Medications include an angiotensin-converting enzyme inhibitor, an inhaled bronchodilator, and low-dose aspirin. The patient has never traveled outside the United States.

On physical examination, he appears ill. Temperature is 38.3° C (101° F), pulse rate is 95/min, and respiration rate is 24/min. Blood pressure is normal, and the examination is otherwise unremarkable. A chest radiograph is normal.

Which of the following antiviral agents is most appropriate for this patient?

A) Zanamivir
B) Amantadine
C) Oseltamivir
D) Rimantadine

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

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Cardiology

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More severe heart disease gets less preventive care

Patients who had atherosclerosis prior to hospitalization are more likely to die and less likely to receive recommended treatments, according to a new study.

Researchers analyzed treatment and outcomes for 143,999 patients hospitalized for acute coronary syndrome between 2000 and 2008. Overall in-hospital mortality was 5.3%, but the risk increased with the number of prior artery blockages a patient had; for example, those with no prior blockage had a 4.7% risk of death compared to 9.1% for patients who had prior disease in all three vascular territories (P<0.001). The patients with prior disease were also older and had more comorbidities.

The patients with greater prior disease were also less likely to receive coronary revascularization, smoking cessation counseling, lipid-lowering therapy and angiotensin-converting enzyme (ACE) inhibitors. The lower rates of revascularization may be due to a lack of options in patients with diffuse coronary artery disease, the difficulty of vascular access or the higher risk of complications, the study authors suggested.

The reduced use of smoking cessation and evidence-based drug therapies in sicker patients is counterintuitive, the authors said. Higher-risk patients would receive the greatest absolute benefit from compliance with the guideline-recommended treatments. Possible explanations for the disparity include greater comorbidites or interactions in these patients, a sense of futility, or economic issues. Patients with prior disease were more likely to be on Medicaid, the study found.

Patients in all groups were equally and very likely to receive aspirin (92% of the time) and beta-blockers (94%-95% of the time) in accordance with guidelines. The researchers concluded that patients with prior vascular disease would benefit from targeted interventions to improve compliance with the other recommended care. The study was published online by Circulation on Aug. 3.

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Evidence-based medicine

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Vertebroplasty or sham: It’s a toss up, study finds

Two recent studies concluded that vertebroplasty is no more effective than placebo in treating vertebral compression fractures.

In one study, researchers conducted a multicenter trial that randomly assigned 131 patients with one to three painful osteoporotic vertebral compression fractures to undergo either vertebroplasty, in which cement is injected directly into the fracture, or a sham treatment. After one month, there was no significant difference between the two groups in disability or pain scores, although the vertebroplasty group showed a trend toward pain improvement.

In the second study, patients with one or two painful osteoporotic vertebral fractures were randomly assigned to undergo vertebroplasty or sham procedure. There were significant reductions in overall pain in both groups, but no significant difference between groups after one week or after one, three or six months, researchers reported. Both studies appear in the Aug. 6 New England Journal of Medicine.

The number of vertebroplasty procedures has doubled over the past six years to 8.9 per 1,000 persons in the U.S., noted an accompanying editorial, yet the procedure carries some risk (most commonly soft-tissue damage and nerve-root pain and compression related to bone cement leakage) and has now been shown to have limited benefit. The results of these two trials—the first blinded or placebo-controlled trials to test the procedure—may change vertebroplasty from an option that’s “virtually always considered to be successful to one that is considered no better than placebo.”

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FDA update

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Recall of electronic infusion pumps

The FDA issued a class I recall of several modules of Cardinal Health’s Alaris System after the discovery of several functional problems that could cause serious injury or death, the FDA said in a safety alert.

The device, which comprises electronic infusion pumps that deliver controlled amounts of medication or fluids, had problems including failures of the occlusion warning message, syringe volume warning message, electrostatic discharge protection circuitry and fluid ingress tubing. These issues could result in patients experiencing under- or over-infusion, which in turn could lead to injury or death, the FDA said.

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TNF blockers raise cancer risk for adolescents, kids

Tumor necrosis factor (TNF) blockers appear to increase the risk of lymphoma and other cancers in adolescents and children, the FDA said in a safety alert.

Information about the risk will be added to the boxed warnings and medication guides of all TNF blockers, which are marketed as Remicade, Enbrel, Humira, Cimzia and Simponi, the FDA said. The agency has also identified new safety information related to leukemia and new-onset psoriasis in patients who take the medication, which is approved to treat immune system diseases including juvenile idiopathic arthritis, rheumatoid arthritis, psoriatic arthritis, plaque psoriasis, Crohn’s disease and ankylosing spondylitis.

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Diabetes drug, statin approved

The FDA approved the following drugs last week:

  • Saxagliptin (Onglyza), a dipeptidyl peptidase-4 (DPP-4) inhibitor taken once-daily to treat type 2 diabetes in adults. The most commonly observed side effects are upper respiratory tract infection, urinary tract infection, and headache; others include allergic-like reactions such as rash and hives. The FDA is requiring a postmarket study of the cardiovascular safety of the drug in a higher-risk population, though past clinical trials didn’t show an association between the drug and a higher risk of cardiovascular events in low-risk patients.
  • Pitavastatin (Livalo), to help lower blood cholesterol levels when diet and exercise don’t work. The most widely reported adverse reactions were muscle pain, back pain, joint pain and constipation. The statin, which comes in a 4-mg maximum dose, was approved on the basis of five clinical trials comparing its efficacy and safety to that of three currently marketed statins. It is expected to be available in the U.S. in early 2010.

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CMS update

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Check or change NPI information online

CMS has recently started reminding physicians and other health care providers that they should check to ensure that the personal information on record for their National Provider Identifier (NPI) is accurate.

Health plans, health clearinghouses and others use publicly available information on the NPI Registry to obtain information about health care providers, so it is important that your information is up-to-date. If your employer, academic medical center, or university filed to obtain your NPI number for you, and any information has changed since the filing, the information in your file may no longer be accurate. Physicians are responsible for keeping their NPI record updated within 30 days of any change.

You can check your NPI record at the National Plan & Provider Enumeration System (NPPES) Web site. If you find that your information needs to be updated, you can also access your record through the NPPES Web site. Alternately, you can call the NPI Enumerator at 1-800-465-3203 for help in obtaining the correct forms.

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From the College

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2009 Recruit-a-Resident Program underway

The 2009 Recruit-a-Resident program offers educational rewards to those residency programs that recruit at least 90% of their residents to be Associate members in good standing of the College.

Programs that reach the 90% goal will receive the latest 2009 MKSAP Update for Residents, which includes 100 multiple-choice questions from MKSAP 14 Self-Assessment Updates. In addition, each resident will receive handouts from Internal Medicine 2009.

The 90% participation rate must be achieved by Dec. 31 in order for residents to secure these free educational products from the College. For questions, visit online or contact Katie Buell, Programs and Services Coordinator, at 800-523-1546, ext. 2611, or via e-mail at kbuell@acponline.org.

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Free literature available for young physician members

ACP members are eligible to receive a free copy of the Pocket Guide to Selected Preventive Services for Adults and the Young Physician Practice Management Survival Handbook developed by the 2008-2009 Council of Young Physicians. The Pocket Guide is a proactive way to encourage preventive care in your daily practice, while the Survival Handbook offers helpful tips and resources for starting your own practice.

Electronic copies of the Pocket Guide to Selected Preventive Services for Adults and the Young Physician Practice Management Survival Handbook are available on ACP Online. You will need your ACP username and password to access these sites. If you do not know this information, please visit online.

If your chapter is holding an event for Young Physicians and you would like to make copies of the Pocket Guide and Survival Handbook available, please contact Katie Buell, Programs and Services Coordinator, at kbuell@acponline.org, or by calling 800-523-1546, ext. 2611. A limited supply is available, so requests will be filled on a first-come, first-serve basis while supplies last.

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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. 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 to acpinternist@acponline.org by Aug. 20. ACP staff will choose three finalists and post them in the Aug. 25 issue of ACP InternistWeekly for an online vote by readers. The winner will appear in the Sept. 1 edition.

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MKSAP answer and critique

The correct answer is C) Oseltamivir plus rimantadine. This item is available online to MKSAP subscribers in the Infectious Disease section, Item 2.

ACP's Medical Knowledge Self-Assessment Program (MKSAP) allows you to:

  • Update your knowledge in all areas of internal medicine
  • Prepare for ABIM certification or recertification
  • Support your clinical decisions in practice
  • Assess your medical knowledge with 1,200 multiple-choice questions

To order the latest edition of MKSAP, go online.

The presumptive diagnosis of influenza in this patient is based on the history, clinical findings, and influenza activity in the community. Differentiating between influenza A and B is not possible without performing a point-of-care diagnostic study. However, both viruses are circulating in the community, and antiviral agents that are effective against both pathogens are required.

Oseltamivir and zanamivir are licensed for treatment of influenza A and B. However, in the 2008-2009 flu season, there is a high prevalence of influenza A (H1N1) virus strains resistant to oseltamivir. The CDC has recommended that when influenza A exposure is suspected, zanamivir or a combination of oseltamivir and rimantadine is more appropriate than oseltamivir alone. However, zanamivir is not appropriate in this patient because it is associated with bronchospasm in 5% to 10% of patients with asthma. Note that these CDC recommendations are for the 2008-2009 influenza season; physicians should check with the CDC for any advisories for the 2009-2010 season.

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.

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Copyright 2009 by the American College of Physicians.

Test yourself

A 57-year-old woman is evaluated for a 2-week history of decreased exercise tolerance and substernal chest pain on exertion. She also has an 8-month history of macrocytic anemia. Following a physical exam, lab results, and electrocardiogram, what is the most likely diagnosis?

Find the answer

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