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

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In the News
for the Week of 9-22-09

Highlights

  • Online antibiotic sales may be fueling drug-resistance trend, researchers report
  • Changes urged to CDC's guidance on preventing H1N1 transmission

Test yourself

  • MKSAP Quiz: acute eye pain

Diabetes care

  • Insulin and metformin don't reduce CRP, study finds

Cardiology

  • Measures aim to help clinicians prevent heart disease

Women's health

  • Hormone therapy close to menopause may increase breast cancer risk, study finds

Men's health

  • Data show watchful waiting outcomes for prostate cancer improving in post-PSA era

FDA update

  • Approvals for H1N1 vaccines, ovarian cancer test

Educational opportunities

From ACP Hospitalist

  • The next issue of ACP Hospitalist is online

From the College

  • Doctors Company gains financial strength in turbulent times

Cartoon caption contest

Physician editor: Darren Taichman, ACP Member


Highlights

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Online antibiotic sales may be fueling drug-resistance trend, researchers report

Antibiotics are widely available for purchase online without a prescription, making it easy for patients to self-medicate and potentially contributing to antibiotic resistance, a recent study found.

Researchers conducted searches on Google and Yahoo using the keywords “purchase antibiotics without a prescription” and “online” and compared vendors according to classes of drugs, quantity, shipping locations and shipping time. Of the 138 vendors found, almost all shipped to the U.S., 36.2% sold antibiotics without a prescription and 63.8% provided an online prescription. Available antibiotics included penicillins (94.2% of sites), macrolides (96.4%), fluoroquinolones (61.6%) and cephalosporins (56.5%), and drugs were often sold in higher quantities than a single course. The results appear in the September-October Annals of Family Medicine.

The findings suggest that many antibiotics taken in the U.S. are not impacted by physician prescribing practices and may be contributing to antibiotic resistance, the authors said. The Web sites studied promote self-diagnosis and self-medication, they added, and drugs are likely to be used in inappropriate dosages. In addition, because the drugs are available in large quantities and take a week or more to be delivered, it is likely that they are being stored for future use or to sell.

The results indicate that the observed decline in overall antibiotic prescribing for viral illnesses may be misleading because patients are able to go online for medications when they can’t get a prescription from their physician. Physicians can play a role in mitigating the problem, the authors continued, by educating patients who self-medicate about antibiotic resistance and potential drug interactions.

Among other limitations, the study does not analyze how customers in the U.S. are using the Web sites and the quantities being purchased, the authors acknowledged. Nonetheless, the results highlight a need for increased regulation of Internet sites beyond controlled substances, they concluded.

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Changes urged to CDC's guidance on preventing H1N1 transmission

The American Hospital Association last week urged the CDC to update its guidance on infection control for H1N1 influenza in health care facilities.

The CDC's current guidance statement, which dates from May 13, calls for clinicians to use N-95 respirators or higher when providing routine care for patients with confirmed or suspected H1N1 flu. To update this statement, the CDC has gathered input from its own Healthcare Infection Control Practices Committee, labor union stakeholders, and the Institute of Medicine. On July 23, the Healthcare Infection Control Practices Committee issued recommendations supporting standard and droplet precautions (such as use of masks, hand hygiene and face shields) for routine care of patients with suspected or confirmed H1N1 infection and recommended reserving N-95 respirators for "aerosol-generating" procedures. However, on Sept. 3, a committee from the Institute of Medicine concurred with the CDC's initial guidance, recommending N-95 respirators for all health care workers caring for confirmed or suspected H1N1 flu in all settings.

In a Sept. 15 letter to the CDC's National Institute for Occupational Safety and Health, the AHA expressed concern about the conflicting recommendations and noted that the IHI committee's charge "did not permit them to take into account logistical or economic considerations." The association warned that if the IHI's recommendations are finalized, hospitals will not have enough N-95 respirators to go around and "will be forced to limit the number of staff who are available to care for patients at a time when the volume of patients is expected to rise precipitously." Further, the AHA noted, the IHI committee recommended N-95 respirators in all health care settings, not just hospitals, making it less likely that primary care physicians will care for flu patients in their offices.

"We strongly recommend that [the Department of Health and Human Services] adopt a set of recommendations that takes into consideration the supply of N-95 respirators and the most recent epidemiologic data on how H1N1 infections transmit," the letter stated. "We support the use of hierarchy of controls, that surgical or procedure masks should be used for most patient contact and that N-95 respirators be recommended primarily for aerosol-generating procedures."

The CDC plans to issue a revised guidance document by Oct. 1.

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Test yourself

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MKSAP Quiz: acute eye pain

MKSAP QuizA 30-year-old man was evaluated for a 4-day history of acute unilateral eye pain with a foreign-body sensation in the eye. He reported no antecedent trauma, and the pain was worse in the morning on awakening. The medical history was noncontributory.

On physical examination, there was conjunctival erythema of the affected eye, with no evidence of a foreign body. Results of fluorescein staining indicated a corneal ulcer. The patient was prescribed pain medication and was counseled to call the next day if there was no resolution or worsening of symptoms. The patient called the next day, stating that his pain had gotten progressively worse and there was a mucopurulent discharge from his eye.

Which of the following possible patient factors is likely to be helpful in establishing a diagnosis?

A) History of diabetes mellitus
B) Contact lens use
C) Swimming
D) History of chronic allergic conjunctivitis
E) History of systemic lupus erythematosus

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

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Diabetes care

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Insulin and metformin don't reduce CRP, study finds

Treatment with either insulin or metformin did not reduce inflammatory biomarkers in patients with type 2 diabetes, a new study found.

The randomized trial assigned 500 patients to receive one of four treatments: placebo metformin, placebo metformin and insulin glargine, metformin alone, or metformin and insulin glargine. The doses were titrated to target a fasting glucose of less than 110 mg/dL. The study measured the change in patients' levels of high-sensitivity C-reactive protein (CRP) and IL-6 and tumor necrosis factor receptor 2 (sTNFr2) from baseline to 14 weeks.

The active treatment groups had significant reductions in glucose and A1c levels compared to placebo. However, all groups had reductions in CRP and those receiving real metformin did not see any greater decreases than the placebo recipients. The group taking insulin alone saw the least reduction in CRP—a statistically insignificant change in levels. Similar results were found for levels of IL-6 and sTNFr2. The study was published in the Sept. 16 Journal of the American Medical Association.

Researchers suspect that the overall reduction in CRP may be related to weight loss observed in both the metformin and placebo groups, likely resulting from diet and exercise advice. The failure of the medications to affect inflammation levels may explain why recent large studies have failed to find an association between intensive glycemic control and reductions in cardiovascular disease, the study authors speculated.

Because the primary outcomes of this study were short-term surrogate markers, the results cannot be equated to long-term cardiovascular events, the authors cautioned. They did conclude that the findings highlight the necessity of diabetics using other therapies that have been proven to reduce cardiovascular events: exercise, weight management, smoking cessation, blood pressure control and, in patients for whom it is appropriate, antiplatelet and statin therapy.

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Cardiology

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Measures aim to help clinicians prevent heart disease

A joint task force has issued comprehensive performance measures that address 13 key aspects of cardiovascular disease prevention and recommends they be applied to every patient who visits a clinician regardless of the reason for the visit.

The detailed steps are designed to help clinicians reduce patients’ risk for heart problems and translate existing guidelines into practical ways for practitioners and institutions to measure and improve the quality of their cardiovascular care.

The measures, developed by the American College of Cardiology and the American Heart Association, include counseling, testing, recording and/or documenting behavior in these areas:

  • lifestyle/risk factor screening
  • dietary intake counseling
  • physical activity counseling
  • smoking/tobacco use assessment
  • smoking/tobacco cessation
  • weight and body fat assessment
  • weight management
  • blood pressure measurement
  • blood pressure control
  • blood lipid measurement
  • blood lipid therapy and control
  • estimation of a patient’s global risk for developing heart disease
  • aspirin use in at-risk patients

Many of the individual steps should be done every two years, but the authors call for a comprehensive risk assessment for all patients at least every five years, and more frequently for patients with elevated risk factors such as obesity, diabetes or tobacco use. The group that drafted the guidelines, which included a representative of the American College of Physicians, focused on what busy clinicians can accomplish during an office visit.

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Women's health

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Hormone therapy close to menopause may increase breast cancer risk, study finds

Initiating hormone treatment close to menopause can increase a woman’s risk of breast cancer, but including progesterone in combination therapy and limiting the duration of treatment appears to lower the risk significantly, a recent study found.

Researchers identified 1,726 cases of invasive breast cancers among 53,310 postmenopausal women in the French E3N cohort between 1992 and 2005. Overall, the risk of breast cancer was higher for short-term (two years or less) treatments initiated within three years following menopause onset than for short-term treatments initiated later (hazard ratio 1.54 vs. 1.00, respectively). However, the increased risk was not observed in users of estrogen-progestagen therapy containing progesterone (HR 0.87). The study was published online Sept. 14 in the Journal of Clinical Oncology.

The authors noted that hormone treatment lasting longer than two years was associated with a higher breast cancer risk no matter what the interval between menopausal onset and treatment initiation. Even with combinations containing progesterone, significantly increased risks were seen with more than five years of use, although risk was still lower than in patients taking estrogen and a different progestagen, they said.

A major strength of the study compared with the Women’s Health Initiative analysis is its inclusion of a large population of recently postmenopausal women who had recently started hormone therapy, the authors said. The study’s finding that progesterone in hormone therapy combinations mitigates breast cancer risk should be confirmed by future research in other settings, they concluded.

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Men's health

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Data show watchful waiting outcomes for prostate cancer improving in post-PSA era

Outcomes of "watchful waiting" for prostate cancer are improving in men older than 65, according to a study looking at data on prostate-specific antigen (PSA) testing.

Conservative management ("watchful waiting") is used in only about 10% of patients, which researchers attributed to a limited understanding of the approach and its expectations. Most long-term data on conservative management come from a time when PSA testing wasn't done. Further, cancers diagnosed today have been shown to be significantly different from those in earlier eras.

"This lack of reliable contemporary information makes it difficult for patients and their physicians to anticipate outcomes, make informed treatment decisions, and interpret the results of maturing clinical trials (often started in earlier eras) that compare outcomes to conservative management," researchers wrote in the Sept. 16 Journal of the American Medical Association.

Researchers conducted a population-based cohort study of 14,516 men aged 65 years or older (median age of 78) with stage T1 or T2 prostate cancer and whose cases were managed without surgery or radiation for six months after diagnosis. They were followed for a median of 8.3 years.

Ten-year prostate cancer-specific mortality was 8.3% (95% CI, 4.2%-12.8%) for men with well-differentiated tumors; 9.1% (95% CI, 8.3%-10.1%) for those with moderately differentiated tumors; and 25.6% (95% CI, 23.7%-28.3%) for those with poorly differentiated tumors. Mortality for men aged 66 to 74 years diagnosed with moderately differentiated disease was 60% to 74% lower than earlier studies: 6% (95% CI, 4%-8%) in the contemporary PSA era (1992-2002) compared with results of previous studies (15%-23%) conducted in 1949-1992.

Researchers commented that the substantial improvement in survival might be explained by additional lead time, overdiagnosis related to PSA testing, or cancer grade migration, among other factors. Limitations include that results apply only to men over 65 at the age of diagnosis, and that Gleason 5, 6, and 7 tumors were grouped together as moderately differentiated disease so results may overestimate survival for Gleason 7 tumors and underestimate survival for Gleason 5 tumors.

"Physicians and their patients may need to reconsider this management option, particularly in light of randomized trial data from the pre-PSA era suggesting little if any benefit to more aggressive intervention," the authors concluded.

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FDA update

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Approvals for H1N1 vaccines, ovarian cancer test

The FDA recently approved four vaccines for 2009 H1N1 influenza and a test for ovarian cancer.

The vaccines are made by CSL Limited, MedImmune LLC, Novartis and sanofi pasteur Inc. They are expected to become available nationally within the next four weeks, according to an FDA release. In preliminary trials, the vaccines produced a robust immune response in healthy adults and side effects are expected to be similar to those from the seasonal flu vaccine.

The new test, called OVA1, was approved to help detect ovarian cancer in a pelvic mass that is already known to require surgery, an FDA release said. The test uses a blood sample to test for levels of five proteins and combines the five separate results into a single numerical score between 0 and 10 to indicate the likelihood that the pelvic mass is benign or malignant.

The test should be used by primary care physicians or gynecologists as an adjunctive test to complement, not replace, other diagnostic and clinical procedures. It can identify women who will benefit from referral to a gynecological oncologist for their surgery, despite negative results from other clinical and radiographic tests for ovarian cancer, the FDA said.

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Educational opportunities

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Fellowship offered in minority health policy

Applications are now being accepted for The Commonwealth Fund/Harvard University Fellowship in Minority Health Policy (CFHUF).

Supported by The Commonwealth Fund and administered by the Minority Faculty Development Program at Harvard Medical School, this innovative fellowship is designed to prepare physicians, particularly minority physicians, for leadership roles in formulating and implementing public health policy and practice on a national, state, or community level.

Five one-year, degree-granting fellowships will be awarded per year. Fellows will complete academic work leading to a Master of Public Health (MPH) degree at the Harvard School of Public Health, and, through additional program activities, gain experience in and understanding of major health issues facing minority, disadvantaged, and underserved populations. CFHUF also offers a Master of Public Administration degree at the Harvard Kennedy School to physicians possessing an MPH.

For application materials, information, and other training opportunities, contact the CFHUF Program Coordinator by telephone at 617-432-2922; by fax at 617-432-3834; or by e-mail.

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From ACP Hospitalist

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The next issue of ACP Hospitalist is online

The next issue of ACP Hospitalist is online, featuring the following stories and more.

Increasing adherence to spontaneous awakening trials in the ICU. Although research shows spontaneous awakening trials are effective, many hospitals still don't do them.
Lost in transition. Medication discrepancies between hospitals and skilled nursing facilities are common. Learn why and what you can do about it.
Success story: Hospitalist Web site streamlines signouts, helps communication. At St. John’s Mercy Medical Center in St. Louis, Mo., a hospitalist-developed Web site makes it easy to identify and contact each patient’s attending physician.

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From the College

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Doctors Company gains financial strength in turbulent times

ACP-sponsored medical liability carrier The Doctors Company has been named one of Ward’s 50® top performing insurance companies of 2009.

The Ward Group, a Cincinnati-based management consulting firm specializing in the insurance industry, determined the list by analyzing the financial performance of over 3,000 property-casualty insurance companies based in the U.S. The Doctors Company chairman and CEO Richard Anderson, FACP, attributed the award to the firm’s conservative fiscal approach and conscientious investing, which he said allows it to reward physician members for delivery of outstanding patient care. This year’s honor marks the eighth Ward’s 50 award for The Doctors Company.

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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 by Sept. 24. ACP staff will choose three finalists and post them in the Sept. 29 issue of ACP InternistWeekly for an online vote by readers. The winner will appear in the Oct. 6 edition.

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MKSAP answer and critique

The correct answer is B) Contact lens use. This item is available online to MKSAP subscribers in the General Internal Medicine section, Item 128.

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 has fulminant keratitis in the setting of a recent corneal ulcer. Corneal abrasions are often caused by contact lens use, particularly the soft, extended-wear type. Additionally, there is an increased risk for fulminant keratitis caused by pseudomonal infection in contact lens users who develop corneal abrasions. Gram-negative bacteria (particularly Pseudomonas and Serratia species) are relatively common contaminants of contact lens solutions, and when they infect disrupted corneal tissue, can cause rapid corneal destruction, ulceration, and even eye perforation. Soft contact users are more susceptible to these gram-negative infections than are hard contact lens users. Thus, given the association between contact lens use and fulminant progression of this condition, close monitoring, usually consisting of daily follow-up to assure resolution, is required in patients with symptoms of corneal abrasion, and early intervention with antibiotics is indicated in patients with evidence of progression.

Patients with diabetes mellitus and swimmers are at higher risk for developing pseudomonal ear infections than those without these factors, but there is no evidence that they are at higher risk for microbial keratitis in the setting of corneal abrasions. Similarly, chronic conjunctivitis and autoimmune disease, such as systemic lupus erythematosus, have not been associated with progressive keratitis in the setting of corneal abrasions.

Key Points

  • Corneal abrasions are often caused by contact lens use, particularly the soft, extended-wear type.
  • There is an increased risk for fulminant keratitis caused by pseudomonal infection in contact lens users who develop corneal abrasions.

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.

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 66-year-old man comes for a preoperative evaluation before total joint arthroplasty of the left knee. He has a 25-year history of rheumatoid arthritis. He has had progressive pain in his left knee with activity, which limits his ability to hike. The patient has similar pain in the right knee, but it is less severe. He reports no recent morning stiffness. He is able to climb two or three flights of stairs without chest pain or shortness of breath. He has no other medical problems and reports no additional symptoms. Medications are methotrexate and folic acid. Following a physical exam and lab tests, what is the next best step in management?

Find the answer

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