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


In the News
for the Week of 8-4-09


  • Evidence extends recommendations for fish oil's cardioprotective effect
  • CDC committee releases vaccination recommendations for novel H1N1 influenza

Test yourself

Diabetes care

  • Intensive control has halved complication risk for type 1 diabetes


  • Postural blood pressure effective, less costly than imaging for diagnosing syncope
  • Look for clinically significant diarrhea before testing for C. diff


  • Large study finds bariatric surgery safe and effective for severely obese

FDA update

From the blogs

  • Putting effectiveness into the health care equation: rational or rationing?

From ACP Internist

From the College

  • National Geographic interviews Post Mortem author
  • Chapter awards given for spring 2009

Cartoon caption contest


Evidence extends recommendations for fish oil's cardioprotective effect

Healthy individuals should consume 500 mg daily of omega-3 fish oil, and people with known heart disease or heart failure should aim for at least 800 to 1,000 mg daily, according to an evidence review. This extends recommendations for fish oil from healthy individuals to patients with existing heart disease, in whom fish oil has also been shown to reduce the incidence of cardiac events and mortality.

Current American Heart Association recommendations for those without coronary heart disease are two oily fish meals per week, equal to about 500 mg daily of combined docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). This level of intake has been associated with the lowest risk for coronary heart disease death in several U.S. prospective cohort studies. Now, recommendations for patients with documented coronary heart disease are 1 g per day of combined EPA and DHA, either from fish or supplements. Options include herring, mackerel, salmon, albacore tuna, sardines and oysters, or fish oil supplements or cod liver oil.

Authors reported in the Journal of the American College of Cardiology that omega-3s appear to convey up to a 30% reduction in cardiovascular-related death in patients who have established cardiovascular disease or who have had a myocardial infarction. Omega-3s may decrease the risk of atherosclerosis, arrhythmias, myocardial infarction, sudden cardiac death and even heart failure. In addition, there is a 9% benefit in reducing heart failure death, which translates to treating 56 patients for four years to prevent one death.

The authors added that more research is now needed to optimize dosing and the ratio of DHA to EPA for heart failure, atrial fibrillation, cardiovascular protection, maximally treated contemporary post-MI patients or others with relatively low-risk coronary heart disease.


CDC committee releases vaccination recommendations for novel H1N1 influenza

The CDC's Advisory Committee on Immunization Practices released recommendations last week on vaccination against novel H1N1 (swine-origin) influenza.

According to a CDC press release, the committee recommended that the following groups be vaccinated first once vaccine becomes available:

  • pregnant women,
  • people who live with or care for children under six months old,
  • health care and emergency services personnel,
  • people six months through 24 years of age, and
  • patients 25 through 64 years of age with chronic health conditions or compromised immune systems who are at higher risk for novel H1N1 infection.

The committee does not expect a shortage of the novel H1N1 vaccine but noted that if supply does become limited, pregnant women, people who live with or care for children younger than six months, health care and emergency services personnel who have direct contact with patients, children from six months through four years of age, and children from five through 18 years of age with chronic medical conditions should be given priority.

ACP has posted a CDC summary for physicians about preparing for vaccination with novel H1N1 vaccine, including information on epidemiology, vaccine manufacturing, purchase and allocation, planning assumptions, and delivery, among other topics. The full summary is available online.

Other influenza news this week includes:

Annals of Internal Medicine. The Aug. 4 issue includes two studies related to flu prevention. A systematic review examined published randomized, controlled trials of neuraminidase inhibitors administered prophylactically for longer than four weeks and found that the drugs prevented symptomatic but not asymptomatic flu. Oseltamivir and zanamivir had no significant difference in efficacy. Another study examined whether improved hand hygiene or surgical face masks could reduce the spread of flu within households. In the cluster-randomized trial of 407 Hong Kong outpatients with flu-like symptoms, hand hygiene and face masks appeared to prevent household transmission of the flu virus when implemented within 36 hours of symptom onset.

Swine-origin flu and pregnancy. CDC researchers reported in The Lancet's July 29 issue that pregnant women infected with swine-origin influenza may be more likely to develop complications than the general population and should receive anti-influenza treatment promptly.

ACP Internist. We've compiled a list of resources to help internists and their patients stay up-to-date about the outbreak of H1N1 influenza.


Test yourself

MKSAP quiz: eye ptosis and mild facial weakness

MKSAP quiz: Managing seasonal allergies A 65-year-old man is evaluated for a 1-month history of intermittent ptosis of the right eye, diplopia, dysarthria, and progressive difficulty swallowing. The symptoms worsen with fatigue and improve with rest. Cranial nerve examination shows right eye ptosis, incomplete abduction of both eyes, and mild tongue and lower facial weakness. Motor examination shows mild weakness of the neck flexors, shoulder abductors, and hip flexors. Sensation and muscle stretch reflexes are normal.

What is the most likely diagnosis?

A) Amyotrophic lateral sclerosis
B) Guillain-Barré syndrome
C) Myasthenia gravis
D) Transient ischemic attack
E) Botulism

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


Diabetes care

Intensive control has halved complication risk for type 1 diabetes

A long-term study further quantified the well-known benefits of intensive glucose control for patients with type 1 diabetes.

The analysis included patients from the Diabetes Control and Complications Trial (DCCT), which from 1983-1993 randomized diabetics to either intensive insulin therapy or what was at the time conventional therapy. The intensive group aimed for near-normal glycemic control with three or more daily injections or a pump. The conventional group received one or two injections and had no specific A1C target. For the new analysis, researchers also included 161 patients from an observational study who matched the DCCT criteria.

Overall, the analysis found that, after 30 years of diabetes, the cumulative incidence rates of proliferative retinopathy, nephropathy and cardiovascular disease were 50%, 25% and 14% in the conventional arm. Patients in the other observational trial had similar rates, 47%, 17% and 14% respectively. DCCT patients who received intensive control had substantially lower rates, 21% developed retinopathy, 9% nephropathy and 9% cardiovascular disease. In that group, fewer than 1% went blind, received a kidney transplant or had an amputation. The study was published in the July 27 Archives of Internal Medicine.

Although intensive control has been the recommended treatment for type 1 diabetes for some time, this analysis provides new information about the likely reduction in complications. Physicians can use these data to explain what their patients with type 1 diabetes can expect in the future, the study authors suggested.



Postural blood pressure effective, less costly than imaging for diagnosing syncope

Measuring postural blood pressure is often more effective than expensive imaging tests in diagnosing and managing syncope in elderly patients, a recent study found, but it is used in fewer than half of patients admitted for syncope.

Researchers reviewed records of 2,106 consecutive patients age 65 or older who were admitted to one hospital following a syncopal episode. The most frequently obtained tests were electrocardiograms (99% of admissions), telemetry (95%), cardiac enzyme tests (95%) and head computed tomographic scans (63%). However, results from these tests affected diagnosis or management in fewer than 5% of cases while postural blood pressure recording (performed in 38% of patients) had a much higher yield in terms of affecting diagnosis (18%-26%) and management (25%-30%) and determining etiology (15%-21%). The results appear in the July 27 Archives of Internal Medicine.

Relatively inexpensive postural blood pressure testing is vastly underused, the researchers commented, potentially leading to missed opportunities to initiate effective treatments, such as medication reduction. They suggested that screening patients with the San Francisco syncope rule, for example, may be helpful in identifying patients most likely to benefit from cardiac testing. The San Francisco syncope rule is defined as a history of one or more of the following, according to the study: congestive heart failure, a hematocrit level of less than 30%, an abnormal result on electrocardiography, shortness of breath, or systolic blood pressure below 90 mm Hg.

An accompanying editorial noted that while the study highlights the importance of postural blood pressure testing, it does not discuss whether the changes made as a result of the more expensive tests were lifesaving or only led to mild improvements. In addition, a statement from the American Heart Association and the American College of Cardiology stresses the risk of mortality and recommends an electrocardiogram for every patient with syncope. More clinical trials are needed to inform guidelines, the editorial added.


Look for clinically significant diarrhea before testing for C. diff

As Clostridium difficile infection becomes more virulent and frequent, it is critical that physicians relearn two basic criteria for diagnosis: clinically significant diarrhea and the presence of toxigenic C. diff in the stool determined by lab testing, according to an expert commentary in the latest Annals of Internal Medicine.

Clinically significant diarrhea, defined as three or more loose stools per day for at least one to two days, is the standard for suspecting C. diff but it is not always followed, the authors said in the Aug. 4 Annals. Studies have shown that asking about the number of loose stools as soon as C. diff is suspected identifies those at high risk, they said. They cited other studies finding that up to 39% of patients would not need testing if simple diagnostic rules were followed.

The authors also noted the following:

  • A real-time polymerase chain reaction test to detect the gene for toxin B is the most sensitive and specific test available for detecting toxigenic C. diff in the stool, and results are often available the same day.

  • Repeat testing is not always useful because the stool may contain something that will continue to cause false-negative test results and the probability of disease decreases with each negative test result. Both issues highlight the value of using a high-sensitivity test.



Large study finds bariatric surgery safe and effective for severely obese

A large, multicenter study of bariatric surgery patients found that the overall short-term risk of death and other adverse outcomes was low despite multiple coexisting conditions in the severely obese patients studied, although the rate of complications varied according to individual patient characteristics and the type of procedure performed.

The prospective, observational study looked at 30-day complication rates in 4,776 patients undergoing primary bariatric surgery at 10 high-volume bariatric centers with experienced surgeons on staff. The overall death rate was 0.3%, while 4.1% of patients had major complications. The study also found that patients who underwent laparoscopic adjustable gastric banding had fewer complications (1.0% 30-day composite end point of death, serious complications, reintervention or prolonged hospitalization) compared with patients who underwent laparoscopic gastric bypass (4.8%) or gastric bypass (7.8%). The results appear in the July 30 New England Journal of Medicine.

The authors noted that short-term safety might not be the only relevant factor when choosing among bariatric procedures. For example, the effects of laparoscopic adjustable gastric banding are dependent on weight loss whereas Roux-en-Y gastric bypass affects glycemic control even before weight loss. More long-term data are needed to assess the impact of these operations on quality of life and other issues, they said.

An accompanying editorial pointed to the daunting financial implications of surgically treating millions of potentially eligible obese adults. However, surgery may prove cost-effective if it reduces medication use, outpatient visits and hospitalizations. For now, the editorialist concluded, the evidence indicates that bariatric surgery is safe, effective and affordable.


FDA update

Coronary dilatation catheters recalled

A Class I recall is in effect for four lots of POWERSAIL Coronary Dilatation Catheters due to complaints that the distal shaft of the catheter showed damage, the FDA said last week.

The damage could cause a leak of contrast material during use, which could lead to catheter functional failures and clinical problems, including air embolism and myocardial infarction (MI), the FDA said. Of four reported complaints of distal shaft damage, one involved a patient with evidence of post-procedural MI. Patients who have already been treated aren’t affected by the recall, the FDA notice said.

The recalled items are:

  • POWERSAIL 3.25×18mm, product number 1005524-18, lot number 7101051
  • POWERSAIL 4.0×8mm (CE), product number 1005726-08, lot number 7112051
  • POWERSAIL 2.75×18mm (U.S.), product number 1005522-18, lot number 8012151
  • POWERSAIL 3.25×8mm (U.S.), product number 1005524-08, lot number 8053061


From the blogs

Putting effectiveness into the health care equation: rational or rationing?

Steven Weinberger, FACP, ACP Deputy Executive Vice President and Senior Vice President for Medical Education and Publishing, tackles striving for effective care that assures physicians are making clinical decisions based on effectiveness, and not misusing or overusing the diagnostic and therapeutic options at their disposal. See his latest column at, one of the Web's most influential medical blogs.


From ACP Internist

Web-first content now online

ACP Internist has updated our site with Web-first content, including:

Conference coverage of acute diarrhea. While most episodes of diarrhea are brief, some do require medical care. As such, internists need to know how to recognize the subtle differences in presentation.

Shared office visits. Shared office visits offer 90-minute blocks of time to groups facing common and chronic conditions. A few distinct models have gained broad acceptance among doctors and their patients.

From peer review to practice. One physician explains how he makes time to teach clinical procedures to staff and follows up on their consistent implementation.



From the College

National Geographic interviews Post Mortem author

Post Mortem author Philip A. Mackowiak, FACP, discusses puzzling medical cases—including those of Mozart, Beethoven, and Columbus—in an interview with National Geographic Weekend. Click on the link and look for the "Play Now" icon.

Post Mortem traces 3,500 years of the history of medicine and endeavors to solve some of history’s most perplexing medical mysteries. In the book, contemporary physicians give their thoughts on the diseases of famous patients and how they might have treated them.

Chapter awards given for spring 2009

In recognition of their outstanding service, these individuals received chapter awards in April, May and June 2009.


Cartoon caption contest

And the winner is …

ACP InternistWeekly has compiled the results from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

This issue's winning cartoon caption was submitted by Jennifer A. Delzell, ACP Member, of Tempe, Ariz.. She will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 100 ballots online to choose the winning entry. Thanks to all who voted!

"So, I guess you won't be breastfeeding?"

The winning entry captured 43% of the votes.

The runners up were:
"I'm afraid we may have to do a C-section."
"And you thought 'OctoMom' got a lot of headlines ... "

ACP Internist's cartoon caption contest continues next week.


MKSAP answer and critique

The correct answer is C) Myasthenia gravis. This item is available online to MKSAP subscribers in the Neurology section, Item 49.

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.

Myasthenia gravis is an autoimmune disease caused by antibodies against the acetylcholine receptor, resulting in impaired neuromuscular transmission. Affected patients present with weakness that characteristically worsens with fatigue. The disease affects the ocular muscles, resulting in diplopia and ptosis, and the bulbar muscles, resulting in dysarthria and dysphagia. Proximal-extremity muscles, neck muscles, and respiratory muscles may also be involved.

Amyotrophic lateral sclerosis may cause dysarthria and dysphagia. However, it does not affect the ocular muscles. In addition, the disorder is characterized by hyperreflexia and distal, asymmetric muscle weakness. Guillain-Barré syndrome and botulism may cause bulbar and ocular muscle weakness, which is, however, neither intermittent nor fatigable. Transient ischemic attack may cause intermittent neurologic deficits, which may include dysarthria and diplopia. However, transient ischemic attacks would not explain the worsening of symptoms with fatigue or this patient's examination findings.

Key points

  • Myasthenia gravis is an autoimmune disease caused by antibodies against the acetylcholine receptor, which result in impaired neuromuscular transmission.
  • Myasthenia gravis is characterized by fatigable weakness with a predilection for ocular, bulbar, proximal-extremity, neck, and respiratory muscles.

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 28-year-old man is evaluated for pain on the radial aspect of the right wrist that occurs with use of the thumb. The pain has been present for 2 weeks. He has never had this pain before and has not had any trauma. He works as a computer programmer and plays video games for 3 to 4 hours each night when he gets home from work. Following a physical exam, what is the most likely diagnosis?

Find the answer

What will you learn from your Annals Virtual Patient?

Annals Virtual Patient

Annals Virtual Patients is a unique patient care simulator that mirrors real patient care decisions and consequences. CME Credit and MOC Points are available. Start off with a FREE sample case. Start your journey now.

Internal Medicine Meeting 2015 Live Simulcast!

Internal Medicine Meeting 2015 Live Simulcast

Unable to attend the meeting this year? On Saturday, May 2, seven sessions will be streamed live from the meeting. Register for the simulcast and earn CME credit after watching each session. Watch it live or download for later viewing.