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

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In the News
for the Week of 8-25-09

Highlights

  • Study reports drop in Rx for respiratory infections, but use of quinolones on the rise
  • Severe sleep breathing disorders raise risk of death in some men, study finds

Test yourself

  • MKSAP Quiz: microscopic hematuria

Drug comparisons

  • Aromatase inhibitor for early breast cancer as effective as tamoxifen or sequential treatment, study finds
  • Pioglitazone is safer than, as effective as rosiglitazone for diabetes, study finds

Palliative care

  • Palliative care program improves mood but not symptoms

Health care reform

  • White House to hold health reform conference call tonight

From the College

  • ACP EVP recognized on Modern Healthcare “Most Powerful” list
  • Survey asks internists about attitudes concerning psychological disorders

For the record

Cartoon caption contest

  • Vote for your favorite entry

Physician editor: Darren Taichman, ACP Member


Highlights

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Study reports drop in Rx for respiratory infections, but use of quinolones on the rise

Antibiotic prescription rates for acute respiratory tract infection declined between 1995-2006 in the U.S., especially among young children and for non-otitis media infections, but rates for broad-spectrum antibiotics rose sharply during the same period, a study found.

Using data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, researchers examined trends in prescribing by antibiotic indication and class. Annual acute respiratory tract infection (ARTI) visit rates fell by 17% and ARTI-associated prescriptions decreased by 36% among children younger than five years, while among those five years or older, ARTI prescriptions dropped by 18% while ARTI-related visits remained stable.

In addition, researchers reported that antibiotic prescribing for non-otitis media ARTI decreased by 41% among young children and by 24% among those older than five. While prescriptions decreased for penicillin, cephalosporin and sulfonamide/tetracycline, ARTI-related prescriptions of azithromycin increased during the study period (ninefold among those five and under and sixfold among those older than five), and prescriptions for quinolone increased fivefold in those older than five. The results appear in the Aug. 19 Journal of the American Medical Association.

The findings point to improvements in antibiotic prescribing practices since the mid-1990s, when the CDC and other health organizations launched initiatives promoting appropriate use of antibiotics, the authors said. Declines in ARTI visit rates could be due to physicians applying stricter diagnostic criteria for ARTI, they speculated, and parents becoming more educated about how to identify and treat mild ear infections at home.

However, the substantial rise in prescription rates for selected macrolides and quinolones is concerning, the authors said. Increased use of these antibiotics has the potential to fuel emergent antibiotic-resistant microorganisms, especially Streptococcus pneumoniae, they said, suggesting that further efforts are needed to encourage appropriate antibiotic use.

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Severe sleep breathing disorders raise risk of death in some men, study finds

Men between ages 40 and 70 with severe sleep-disordered breathing face a significantly higher risk of death than those without severe disorders, according to results from a recent study.

The prospective cohort study included more than 6,000 men and women age 40 or older who were not being treated for sleep-disordered breathing. Researchers studied participants’ nighttime breathing to calculate each person’s apnea-hypopnea index (AHI). Those with sleep-disordered breathing, defined as having an AHI of 30 or more, were 1.5 times as likely to die from any cause than those without the disorder, even after adjusting for confounding factors. In particular, men age 40 to 70 with severe sleep-disordered breathing had twice the risk of similar-aged men without the disorder of dying from any cause. A small subgroup analysis also suggested an association between sleep disorders in men and death from coronary artery disease. The study was published Aug. 18 in PLoS Medicine.

Previous studies on the potential connection between sleep disorders and mortality have had conflicting results, the authors noted. This study not only illustrates that sleep-disordered breathing is associated with mortality but also that the association depends on the degree of sleep-related intermittent hypoxemia (the association was observed only in those with an AHI above 30). The findings also indicate that sleep-disordered breathing is a predictor of death independent of other risk factors such as age and obesity.

The authors acknowledged that the study had several limitations, including that results were based on data from a single night of sleep studies. They pointed out that while a high AHI increased the risk of death, risk was not increased by arousal frequency or occurrence of central apneas. Future research should include randomized trials to assess whether treatment can reduce premature mortality, they said.

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Test yourself

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MKSAP Quiz: microscopic hematuria

A 49-year-old man comes to the office for evaluation before cystoscopy because of a 20-year history of microscopic hematuria. He feels well and has no intercurrent diseases. Two previous CT scans have excluded renal mass; the most recent CT scan was performed 5 years ago. Findings of a cystoscopy 10 years ago were unremarkable. His mother has a history of microscopic hematuria.

On physical examination, pulse rate is 70/min and regular, and blood pressure is 90/70 mm Hg. The remainder of the examination is unremarkable.

Creatinine is 0.7 mg/dL (61.89 μmol/L). Urinalysis reveals no proteinuria and 7 to 10 dysmorphic erythrocytes/hpf.

Which of the following is the most likely diagnosis?

A) Bladder cancer
B) Polycystic kidney disease
C) Thin basement membrane disease
D) Renal cell carcinoma
E) Recurrent urinary tract infection

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

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Drug comparisons

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Aromatase inhibitor for early breast cancer as effective as tamoxifen or sequential treatment, study finds

Sequential treatment with letrozole and tamoxifen is no better than letrozole alone in improving disease-free survival in postmenopausal women with endocrine-responsive breast cancer, according to the results of a recent trial.

In the randomized, phase three, double-blind trial, postmenopausal women with endocrine-responsive breast cancer were randomly assigned to receive either five years of tamoxifen, five years of an aromatase inhibitor (letrozole) or two years of one agent followed by three years of treatment with the other. After five years, disease-free survival was not better among women who received either sequential treatment versus letrozole alone and there were more early relapses among women taking tamoxifen followed by letrozole than letrozole alone. There was no significant difference in survival rates among women who took tamoxifen alone versus letrozole alone. The results appear in the Aug. 20 New England Journal of Medicine.

The authors acknowledged that the selective crossover to letrozole among women assigned to tamoxifen monotherapy and the inability to assess the influence of a potential carryover effect of letrozole during the follow-up period were limitations of the study. They noted that letrozole followed by tamoxifen had similar outcomes to letrozole alone, perhaps due to a carryover benefit of the initial letrozole therapy. Based on current data, they said, switching to tamoxifen after two years of letrozole would be acceptable if a patient could not tolerate letrozole for any reason.

The updated data confirm earlier studies showing that letrozole monotherapy significantly reduces the risk of recurrence, especially at distant sites, the authors said. Since there were no unexpected life-threatening adverse events in any of the groups involved in the current study, they concluded, adjuvant endocrine therapy with letrozole offers an additional treatment option for postmenopausal women with endocrine-responsive early breast cancer.

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Pioglitazone is safer than, as effective as rosiglitazone for diabetes, study finds

A new large study found that rosiglitazone was associated with a significantly higher risk of heart failure and death than pioglitazone in type 2 diabetics, leading researchers to question its ongoing use.

In the retrospective cohort study, researchers studied records of almost 40,000 outpatients age 66 years or older taking pioglitazone or rosiglitazone and followed them for six years. At follow-up, 5.3% of patients taking pioglitazone suffered death or hospital admission for either acute myocardial infarction (MI) or heart failure, compared with 6.9% of patients taking rosiglitazone. Secondary analyses, after adjustment for demographic and clinical factors and drug doses, revealed a lower risk of death and heart failure with pioglitazone but no significant difference in risk of acute MI. The results appear in the Aug. 18 BMJ.

Rosiglitazone and pioglitazone have been associated with cardiovascular risks in previous studies but it was unclear whether it was a class effect of thiazolidinediones, the authors noted. This study provides evidence that pioglitazone is associated with a lower risk of adverse cardiovascular events and death than rosiglitazone in comparable patients.

While the reasons for the difference are unclear, the authors continued, pioglitazone has more favorable effects on serum lipids than rosiglitazone and may have anti-inflammatory and anti-atherogenic effects. Rosiglitazone can promote excessive salt and water retention, which may underlie the increased risk of death in patients taking it, they added.

The authors acknowledged that their study was limited by the possibility that patients taking rosiglitazone had a higher baseline risk of heart failure and death than those prescribed pioglitazone. However, the two groups were highly similar and baseline risk would not likely explain why rosiglitazone was associated with a higher risk of death and heart failure but not of acute MI. Given the evidence against rosiglitazone and the lack of clinical advantage over pioglitazone, the authors suggested that physicians reevaluate the appropriateness of any patients starting or continuing treatment with rosiglitazone.

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Palliative care

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Palliative care program improves mood but not symptoms

A palliative care intervention improved mood and quality of life for patients with advanced cancer, although it did not affect their symptoms or use of medical services in a recent trial.

Participating patients had been diagnosed with life-limiting cancer 8 to 12 weeks before they entered the study and had been given a prognosis of approximately one year. The 322 patients were randomized to either usual care or an intervention conducted by advanced practice nurses with palliative care training. The intervention included four initial educational and problem-solving sessions followed by telephone follow-up at least monthly. Patients were also invited to shared medical appointments led by a palliative care physician. The study was conducted in rural New Hampshire and Vermont.

All study participants completed questionnaires about their quality of life, symptom intensity and mood every three months until death or study completion. Overall, patients in the intervention group had higher quality of life scores (P=0.02) and less depressed mood (P=0.02) but an insignificant improvement in symptom intensity (P=0.06). Patients who died during the study had similar results to the overall group. There was no difference in the number of hospital days, ICU days or emergency department visits between groups.

Study authors noted that none of the differences met their original target significance level of 0.01. They also could not determine why mood and quality of life improved without any change in symptom intensity. Overall, patients in the study reported relatively low symptom intensity so it may have been difficult for the intervention to have much more effect on symptoms, the authors suggested. The intervention might also have had greater effect if it had been conducted in person rather than by phone, but that was not feasible in the rural study location.

Despite the study's limitations, the researchers did conclude that an early palliative care intervention for patients with advanced cancer can improve quality of life and mood, two high-priority patient-centered goals. The research was published in the Aug. 19 Journal of the American Medical Association.

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Health care reform

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White House to hold health reform conference call tonight

The White House Office of Health Reform will hold a conference call this evening to discuss health insurance reform.

The call is intended as a briefing for physicians to discuss issues related to health reform. Interested physicians are asked to call 800-230-1096 on Tuesday evening, August 25, at 8:30 p.m. EDT. Questions can be submitted in advance of the conference call by e-mail; write “Physician Health Insurance Reform Call” in the subject line.

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From the College

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ACP EVP recognized on Modern Healthcare “Most Powerful” list

ACP Executive Vice President and CEO John Tooker, FACP, MBA, has been named one of Modern Healthcare’s “100 Most Powerful People in Healthcare.”

The list, published in the August 24 issue of Modern Healthcare online, is an annual recognition in which readers nominate influential industry leaders. As the health care debate has gained momentum, Dr. Tooker has increased what is normally an already robust schedule of commitments to national forums, including congressional hearings and legislator panels, to ensure that the views of internists are heard as reform legislation takes shape. Dr. Tooker attributed his nomination to the Modern Healthcare list to the growing recognition of the importance of primary care, as well as the role that ACP has played in health care access, delivery, workforce and payment reform. The list is determined by readers, who submit votes for individuals they consider to be influential industry leaders. For this year’s list, over 52,000 readers cast over 500,000 votes.

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Survey asks internists about attitudes concerning psychological disorders

ACP is making available to its members an online survey that will help guide deliberations about psychiatry's next version of the DSM. The focus of the survey is to learn internists' opinions regarding current diagnostic terminology related to psychiatry. Participation is voluntary and estimated to take five minutes, and responses are anonymous. The survey link can be accessed only once.

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For the record

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Correction to last week's issue

A summary in last week's ACP InternistWeekly on aspirin use after colorectal cancer diagnosis contained an error. The second sentence of the second paragraph should have stated that there were 141 cancer-specific deaths, not 287, among 730 patients who did not use aspirin. The summary has been corrected.

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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.

Vote for your favorite entry

"Sir, I said follow my finger, not swallow my finger."
"This is a new treatment for excessive verbiage about health care reform."
"You'll still need to undress. I told you I wouldn't be able to feel your prostate from this end."

Go online to view the cartoon and pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting continues through Aug. 31, with the winner announced in the Sept. 1 issue.

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MKSAP Answer and Critique

The correct answer is C) Thin basement membrane disease. This item is available online to MKSAP 14 subscribers in the Nephrology section, Item 76.

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 most likely has thin basement membrane disease, also known as benign familial hematuria. This condition presents with glomerular hematuria with dysmorphic erythrocytes on microscopic analysis of the urine without any evidence of proteinuria. Despite a 20-year history of microscopic hematuria, there is no hypertension and his physical examination is unremarkable. Therefore, his presentation is most likely a benign, long-term outcome of a glomerular disease with familial thinning of the basement membrane.

Bladder cancer would be visible on cystoscopy, and this condition is unlikely to cause microscopic hematuria of 20 years' duration. Polycystic kidney disease and renal cell carcinoma also are unlikely in a patient with a decades-long history of microscopic hematuria and two normal CT scans. Urinary tract infection is associated with pyuria, not hematuria, and is equally unlikely.

Key Point

  • Thin basement membrane disease (benign familial hematuria) is characterized by glomerular hematuria with dysmorphic erythrocytes on microscopic analysis of the urine and no evidence of proteinuria.

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 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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