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

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In the News
for the Week of 8-18-09

Highlights

  • H1N1 flu update: rapid test news, antiviral recommendations, HHS conference call
  • Aspirin taken after colorectal cancer diagnosis improves survival, study suggests

Test yourself

Breast cancer

  • Weight lifting safe for women with lymphedema
  • Adjuvant chemotherapy increases survival in patients with isolated tumor cells

Rheumatology

  • Herbal remedy may be helpful in treating rheumatoid arthritis

FDA update

  • Glucose monitoring strips may lead to fatal errors

Health care reform

  • Online tools provide up-to-date information on health care reform

From the blogs

  • Swine flu, health reform and video games

Cartoon caption contest

Physician editor: Vincenza Snow, FACP


Highlights

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H1N1 flu update: rapid test news, antiviral recommendations, HHS conference call

Rapid flu tests have low sensitivity for detecting novel swine-origin influenza A (H1N1), warns a new report from the CDC.

Three rapid influenza diagnostic tests were evaluated with 65 specimens (either nasopharyngeal or oropharyngeal swabs) that had been collected in April and May 2009. All samples had previously been tested using real-time reverse transcription-polymerase chain reaction (rRT-PCR) assay. The comparison of results revealed that the rapid tests were capable of detecting novel influenza A when there were high levels of virus present, but the tests had a low overall sensitivity (40% to 69%).

Based on these findings, the CDC advised that positive rapid-test results can be used in making treatment decisions, although the results should be interpreted in the context of currently circulating strains. However, negative results should not be assumed to indicate the absence of infection. Patients who test negative but have suspicious symptoms should be treated empirically based on the level of clinical suspicion, underlying medical conditions, severity of illness, and risk for complications. If a more definitive diagnosis is needed, the rRT-PCR assay or a virus isolation test should be used, according to the CDC. The report was published in the Aug. 7 Morbidity and Mortality Weekly Report.

The World Health Organization also issued a reminder regarding swine-origin flu last week. Per WHO guidelines, antiviral medications are recommended for all patients who have severe cases of the novel influenza virus or who are at risk for complications. The reminder was issued in response to an analysis published last week in BMJ about the use of antivirals in children with seasonal flu.

The Department of Health and Human Services has scheduled a live conference call, “Information Exchange with HHS on H1N1 Healthcare System Preparedness and Response,” from 1:30 to 3:00 p.m. EST on Aug. 20. The call will focus on strategy ideas for reduced emergency department burden, early identification and intervention with high-risk patients and work force protection. Particular emphasis will be given to the value and contribution of primary care networks. During an open question-and-answer period, participants will be encouraged to share their own plans for prevention and intervention, increased patient volume, and more. Participants should call 1-800-837-1935 and enter conference ID H1N1. Questions and thoughts may be submitted ahead of the call at H1N1.listening@hhs.gov.

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Aspirin taken after colorectal cancer diagnosis improves survival, study suggests

Regular aspirin use following diagnosis significantly reduced mortality among colorectal cancer patients in a recent large study.

The prospective cohort study included 1,279 men and women diagnosed with stage I, II or III colorectal cancer who participated in the Nurses' Health Study and Health Professionals Follow-up Study. After almost 12 years, there were 81 cancer-specific deaths among 549 patients who regularly used aspirin following diagnosis compared with 141 cancer-specific deaths among 730 patients who did not use aspirin (15% vs. 19%, respectively). The aspirin group also had improved overall survival compared with no aspirin (35% vs. 39%, respectively). The improvements were noted only in participants with primary tumors that overexpressed COX-2. The results appear in the Aug. 12 Journal of the American Medical Association.

Researchers noted that aspirin use prior to diagnosis did not impact their results, suggesting that aspirin may influence the biology of established tumors. Aspirin conferred similar benefits whether or not patients had received standard adjuvant chemotherapy and regardless of stage of disease at diagnosis.

An accompanying editorial noted that the findings may help tailor treatment to specific patients using COX-2 as a predictive biomarker and may lead to aspirin becoming standard adjuvant therapy in managing colorectal cancer. In addition, the editorial continued, the findings come as close as is possible for an observational study to offering a way for cancer patients to help themselves through lifestyle changes.

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Test yourself

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Correction to last week's quiz

The correct answer to last week's MKSAP quiz should have been C) Oseltamivir plus rimantadine, and the critique should have read as follows:

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.

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MKSAP quiz: managing pregnancy

MKSAP quiz A 27-year-old woman in the 30th week of pregnancy is evaluated during a routine examination. The patient's pregnancy has been uneventful, with no bothersome symptoms or bleeding. The medical history and physical examination are noncontributory.

Laboratory studies include a platelet count of 90,000/μL (90 × 109/L) compared with values of 190,000/μL (190 × 109/L) at week 12 and 177,000/μL (177 × 109/L) at week 23. A recent ultrasound reveals normal fetal development.

Which of the following is the most appropriate next step in management?

A) Corticosteroid therapy
B) Percutaneous umbilical blood sampling
C) Observation and reassurance
D) Low-dose aspirin therapy

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

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Breast cancer

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Weight lifting safe for women with lymphedema

Weight lifting can be safe for breast cancer survivors and appears to decrease the incidence of lymphedema exacerbations, a new study found.

The randomized, controlled trial included 141 women who had been diagnosed with unilateral breast cancer within the past 15 years and who had stable lymphedema of the arm. Half of the women attended twice-weekly exercise sessions in which they did progressive strength training while wearing compression garments. After 13 weeks of training, the women continued the lifting program on their own, with reminders from the trainers. The other study participants received usual care.

After a year, both groups had similar rates of increased limb swelling (11% in weight lifters, 12% in controls). The weight-lifting group reported greater improvements in the severity of symptoms, and had a lower incidence of lymphedema exacerbations as assessed by a certified lymphedema specialist (14% vs. 29%, P=0.04). The weight lifters also had better upper and lower body strength. The study was published in the Aug. 13 New England Journal of Medicine.

The study's findings contradict the common guidance to breast cancer survivors to avoid lifting with affected limbs, the study authors said. Previous trials have had similar results, but were not as large or long in duration. The conclusions should reassure clinicians about the safety of slowly progressive weight lifting programs like this one—which can be offered at YMCAs around the U.S. through the LIVESTRONG program, noted the researchers.

The intervention is also likely to be cost-effective, according to an accompanying editorial. Not only would fewer lymphedema exacerbations reduce health care costs, but it would reduce disability for these patients and possibly increase their ability to return to work.

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Adjuvant chemotherapy increases survival in patients with isolated tumor cells

Isolated tumor cells in the regional lymph nodes of women with breast cancer were associated with reduced survival rates, but disease-free survival was significantly improved in patients who received systemic adjuvant therapy, a study found.

In the study, researchers identified all breast cancer patients in the Netherlands who had favorable early-stage cancer and isolated tumor cells and micrometastases in the regional lymph nodes, and who underwent a sentinel-node biopsy before 2006. Patients were divided into three groups: 856 women with node-negative disease who had not received systemic adjuvant therapy; 856 with isolated tumor cells (node-positive) who had not received adjuvant therapy, and 995 with isolated tumor cells who had received adjuvant treatment.

After five years, researchers found that isolated tumor cells were associated with an almost 10% absolute reduction in disease-free survival. Adjuvant therapy improved the disease-free survival rate by nearly 10%. The study appears in the Aug. 13 New England Journal of Medicine.

Researchers noted that Dutch guidelines for breast cancer management were conservative at the time of the study, recommending systemic adjuvant therapy in patients with node-negative disease only if the estimated 10-year probability of survival was less than 80%. The guidelines have since been revised, resulting in more women receiving systemic therapy. However, that factor might be counterbalanced by the availability of more potent regimens now than was the case during the study period, they added.

The study ruled out axillary lymph-node dissection as a confounder by including it as a variable in a subanalysis comparing the node-negative, no therapy group vs. the node-positive, no therapy cohort. No conclusion was possible as to the effect of axillary lymph-node disease dissection on survival or recurrence, they said. They recommended that future studies address that question by basing analysis on the sentinel node, as opposed to the final node, status.

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Rheumatology

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Herbal remedy may be helpful in treating rheumatoid arthritis

A Chinese herbal remedy may be an effective treatment alternative in patients with active rheumatoid arthritis, according to a new study.

Although anti-inflammatory drugs such as sulfasalazine are effective for initial treatment of rheumatoid arthritis, many patients have no clinically meaningful response or discontinue the drugs because of adverse events. The Chinese herbal remedy Tripterygium wilfordii Hook F (TwHF) (also known as “lei gong teng” or “thunder god vine”) has shown promise in treating autoimmune and inflammatory conditions.

Annals of Internal Medicine Researchers randomly assigned 121 patients with active rheumatoid arthritis and at least six painful joints to take either TwHF root extract, 60 mg three times per day (n=60), or sulfasalazine, 1 g two times per day, for 24 weeks (n=61). Patients were able to continue stable doses of oral prednisone or nonsteroidal anti-inflammatory drugs but had to stop taking disease-modifying antirheumatic drugs at least 28 days before random assignment. The primary outcome was achievement of 20% improvement in American College of Rheumatology criteria (ACR 20) at 24 weeks. The study results appear in the Aug. 18 Annals of Internal Medicine.

Because data were available for only 62 patients at 24 weeks, the researchers used a mixed-model analysis that imputed data for patients who withdrew from the study. In this analysis, 65.0% (95% CI, 51.6% to 76.9%) of those in the TwHF group and 32.8% (95% CI, 21.3% to 46.0%) of those in the sulfasalazine group met the ACR 20 response criteria (P=0.001). Patients in the TwHF group also had less radiographic progression of joint damage, although the difference was not statistically significant. Adverse event rates were similar in both groups.

The study was limited by its high dropout rate and the lack of long-term outcomes data available on those who discontinued treatment. However, researchers concluded that TwHF extract may be safe and effective for treating patients with active rheumatoid arthritis. In addition, the rapid improvement in joint symptoms may make TwHF extract an attractive and affordable alternative to anti-inflammatory drugs, they noted.

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FDA update

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Glucose monitoring strips may lead to fatal errors

Glucose testing with GDH-PQQ strips could lead to fatal errors in patients consuming nonglucose sugars, the FDA reported in a public health notification last week.

Because GDH-PQQ test strips do not distinguish between types of sugars, they may falsely indicate hyperglycemia in patients consuming products containing non-glucose sugars such as maltose, xylose and galactose. This can lead to inappropriate dosing and administration of insulin, potentially resulting in hypoglycemia, coma or death, the FDA said. In addition, actual hypoglycemia could be missed if patients and practitioners rely only on the GDH-PQQ test result. From 1997 to 2009, the FDA has received 13 reports of deaths associated with GDH-PQQ glucose test strips where interference from maltose or other non-glucose sugars was documented.

The FDA noted that this problem does not apply to other glucose test strip methods or laboratory-based blood glucose assays. A list of recommendations to reduce the risk associated with GDH-PQQ test strips is available online.

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Health care reform

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Online tools provide up-to-date information on health care reform

ACP and the AMA have developed online tools to keep physicians informed about the latest developments in health care reform legislation.

ACP has created a continually updated FAQ to help physicians sort through conflicting information and to outline how legislation compares to ACP's policies. ACP also recommends Politifact.com, a Pulitzer Prize-winning Web site produced by nonpartisan journalists, and FactCheck.org, a nonpartisan, nonprofit consumer advocate Web site, as sources of additional information.

The AMA has developed a dedicated Web page including important facts, breaking news and Web links pertaining to health system reform. Physicians can visit the site to sign up for e-updates and download patient information. The AMA has also developed an online FAQ on health care reform.

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From the blogs

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Swine flu, health reform and video games

The ACP Internist blog defies your expectations this week with good news about swine flu and a reason to let kids play violent video games. And the ACP Hospitalist blog is now carrying Medical News of the Obvious.

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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.

E-mail all entries 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) Observation and reassurance. This item is available online to MKSAP subscribers in the Hematology and Oncology section, Item 31.

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 with mild, asymptomatic thrombocytopenia in the 30th week of an uncomplicated pregnancy and previously normal platelet counts has incidental thrombocytopenia of pregnancy. She requires close follow-up monitoring of the platelet count but should be reassured that the cause of her thrombocytopenia appears to be benign. There are many possible causes of thrombocytopenia that occurs in the third trimester of pregnancy, including thrombocytopenia associated with hypertensive disorders or the HELLP syndrome (hemolysis with a microangiopathic blood smear, elevated liver enzymes, and a low platelet count), hemolytic uremic syndrome (HUS), thrombotic thrombocytopenia purpura (TTP), and idiopathic thrombocytopenic purpura (ITP). However, incidental thrombocytopenia of pregnancy, also referred to as gestational thrombocytopenia, is the most common cause of thrombocytopenia in this setting. This disorder is not associated with either poor pregnancy outcomes or fetal morbidity. A decrease in the platelet count to below approximately 70,000/μL (70 × 109/L) would be cause for heightened concern.

Although ITP cannot be excluded in this patient, a platelet count of 90,000/μL (90 × 109/L) would not require treatment; therefore, corticosteroid therapy is not indicated.

Because incidental thrombocytopenia of pregnancy does not affect the fetal platelet count, there is no need for percutaneous umbilical blood sampling in this case. Low-dose aspirin therapy may help to improve fetal outcomes in patients with certain thrombophilic syndromes such as the antiphospholipid antibody syndrome, but there is no evidence of this or any such thrombophilic syndrome in this patient, and aspirin would only increase the propensity toward bleeding should the platelet count decrease further.

Key points

  • Incidental thrombocytopenia of pregnancy requires careful follow-up monitoring of the platelet count.
  • Patients with incidental thrombocytopenia of pregnancy require further diagnostic evaluation when platelet values decrease to lower than 70,000/μL (70× 109/L).

Click here to return to the rest of ACP InternistWeekly.

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About ACP InternistWeekly

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

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Copyright 2009 by the American College of Physicians.

Test yourself

A 38-year-old man is evaluated for a mass in his right neck that he first noticed 2 weeks ago while shaving. The patient also reports experiencing a pressure sensation when swallowing solid foods for the past year and daily diarrhea for the past 2 months. His personal medical history is unremarkable. His younger brother has nephrolithiasis, and his father died of a hypertensive crisis and cardiac arrest at age 62 years while undergoing anesthesia induction to repair a hip fracture. Following a physical exam, lab studies, and a chest radiograph, what is the most likely diagnosis?

Find the answer

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