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


In the News
for the Week of 1-12-10


  • ADA supports A1C for diabetes diagnosis
  • Expert panel updates adult immunization schedule

Test yourself

  • MKSAP Quiz: 4-day history of swelling and severe pain

Breast cancer

  • Imaging groups issue recommendations on screening for breast cancer

Mental health

End-of-life issues

  • Most doctors delay end-of-life talks with terminal patients who feel well

FDA update

  • High-dose seasonal flu vaccine approved

CMS update

  • CMS to launch provider satisfaction survey

From ACP Internist

  • The next issue of ACP Internist is online

From the College

  • Search committee established for ACP EVP/CEO
  • Web-based tool helps practices improve performance
  • ACP reminds public to get flu shots during National Influenza Week

Cartoon caption contest

Physician editor: Vincenza Snow, FACP

Editorial note: ACP InternistWeekly will not be published next week due to the Martin Luther King Jr. Day holiday.


ADA supports A1C for diabetes diagnosis

The A1C test is now a recommended method of diagnosing diabetes, according to new clinical practice recommendations from the American Diabetes Association.

Under the new recommendations, an A1C of 5.7% to 6.4% should be considered prediabetes and an A1C of 6.5% or higher merits a diagnosis of diabetes. Previously, the ADA had recommended fasting plasma glucose and the oral glucose tolerance test as the preferred diagnostic methods. Those methods are still recommended, but ADA experts hope that the addition of the A1C, which does not require fasting, will increase the use of testing, according to a press release. The recommendations were published in a supplement to the January issue of Diabetes Care.

The ADA also recommended that aspirin therapy should be considered as a primary prevention strategy in patients with diabetes who have a 10-year cardiovascular risk greater than 10%. That group will include most men over 50 and women over 60 who have at least one additional major risk factor. Previously, the ADA had suggested low-dose aspirin for patients who were over 40 or had risk factors. However, the new recommendations found insufficient evidence for primary prevention in lower-risk patients. For younger patients with multiple risk factors, clinical judgment about the use of aspirin is required, the recommendations said.

The document includes many additional recommendations for optimizing diabetes care, both in the general population and specific groups such as children and the elderly, and in inpatient and outpatient settings.


Expert panel updates adult immunization schedule

The Advisory Committee on Immunization Practices (ACIP) recommends several important changes to the adult immunization schedule.

AnnalsHPV. ACIP recommends bivalent HPV vaccine (HPV2), which has been licensed for use in women. Either HPV2 or HPV4 can be used for vaccination of women aged 19 through 26 years to protect against the two strains of HPV associated with 70% of cervical cancer cases. ACIP also includes a permissive recommendation for HPV vaccine in men, as the quadrivalent vaccine has been demonstrated to reduce HPV-associated genital warts.

Influenza. ACIP added the term “seasonal” to differentiate current recommendations from those for pandemic flu such as H1N1.

Measles, mumps, rubella (MMR). Language was revised to clarify that adults born during or after 1957 do not need one or more doses of MMR for the measles and mumps components. Interval dosing information has been added to indicate that a second dose of MMR should be administered four weeks after the first dose. Also, women who do not have documentation of rubella vaccination should receive a dose of MMR. A section has been added to highlight recommendations for vaccinating health care personnel born before 1957 routinely and during outbreaks.

Hepatitis A. Vaccination is now recommended for those providing care for an international adoptee.

Meningococcal. Revisions clarify that the meningococcal conjugate vaccine (MCV4) is preferred for adults aged 55 years or younger and that the meningococcal polysaccharide vaccine (MPSV4) is preferred for adults aged 56 years or older. Revaccination with MCV4 is recommended for adults previously vaccinated with MCV4 or MPSV4 and a new example of who is at increased risk is provided. Information has been added on who does not need to be revaccinated.

Haemophilus influenzae type B (Hib). There is no recommendation for persons older than five years.

ACIP annually reviews the schedule to ensure it reflects the most current scientific knowledge of vaccines and vaccine-preventable disease. Vaccines have been demonstrated to be among the most effective strategies for preventing illness in individuals as well as for protecting the health of the public, and their use cannot be overemphasized.

The schedule was approved by the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists and the American College of Physicians.


Test yourself

MKSAP Quiz: 4-day history of swelling and severe pain

A 69-year-old man is evaluated for a 4-day history of swelling and severe pain of the dorsum of his hand. He has a distant history of gout involving the first toe, midfoot, and ankles. Six days ago, he was bitten by his cat.

MKSAP QuizPhysical examination reveals erythema and warmth of the dorsum of the hand. On musculoskeletal examination, he has decreased flexion and extension of the wrist secondary to swelling and pain.

Aspiration of the wrist joint is performed. The synovial fluid leukocyte count is 23,000/µL (23 × 109/L); polarized light microscopy of synovial fluid reveals extracellular needle-shaped negatively birefringent crystals. Results of synovial fluid Gram stain and cultures are pending.

In addition to updating his tetanus immunization, which of the following is the most appropriate treatment for this patient?

A) Indomethacin
B) Ampicillin–sulbactam
C) Ampicillin–sulbactam; indomethacin
D) Intra-articular corticosteroid injection

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


Breast cancer

Imaging groups issue recommendations on screening for breast cancer

The American College of Radiology and the Society of Breast Imaging have released new recommendations on screening for breast cancer in both average- and high-risk women.

The new recommendations, which appear in the January Journal of the American College of Radiology, include the following:

  • Women at average risk for breast cancer should receive annual mammography beginning at age 40.
  • Women who carry BRCA mutations or who are untested first-degree relatives of a BRCA mutation carrier should have annual mammography and annual MRI starting by age 30 but not before age 25.
  • Women with a 20% or more lifetime risk for breast cancer based on family history should have annual mammography and annual MRI starting by age 30 but not before age 25, or 10 years before the age of their youngest affected relative, whichever is later.
  • Women with dense breasts as their only risk factor may benefit from the addition of ultrasound to mammography for cancer detection.

The ACR/SBI mammography recommendations conflict with the guidelines issued last November by the U.S. Preventive Services Task Force, which recommended that biennial screening start at age 50 for women at average risk and which were strongly criticized by the ACR and others after their release.

The ACR/SBI authors wrote that the new recommendations were based on peer-reviewed published data and expert consensus and were developed to address gaps in existing evidence about use of mammography, MRI, ultrasound and other imaging methods to screen for breast cancer. Unlike the USPSTF, they did not take potential harms of screening into account because they did not consider the effects of such harms to be significant, a study author told Reuters.


Mental health

Antidepressants better than placebo only in severely depressed

Antidepressant medications are more effective than placebo in patients with severe depression, but provide minimal or no benefit to patients with mild or moderate symptoms, according to a new meta-analysis.

The review included six randomized, placebo-controlled trials and 718 patients. The effects of the medications and placebo were compared and patients were stratified according to Hamilton Depression Rating Scale (HDRS) scores. The meta-analysis found that for patients with HDRS scores below 23, the difference in effect between active drugs and placebo was small (less than 0.20 Cohen d effect size). The difference in effect increased as depression severity increased, and became significant at an HDRS score of 25. The study appeared in the Jan. 6 Journal of the American Medical Association.

The researchers were unable to determine whether the difference in effectiveness between severe and less severe cases indicated that medication has greater effect in severely depressed patients or that placebo has less effect in the severely depressed. They concluded, however, that the medications appear to provide substantially more benefit than placebo for severely depressed patients.

For less depressed patients, the analysis reveals little evidence of pharmacological benefit from these medications. Clinicians and patients may be unaware that most proof of the efficacy of these medications has been based on treatment of more severely depressed patients, the researchers noted, and they recommended that efforts be made to clarify general understanding.

The latest issue of the Archives of General Psychiatry also included several studies about depression treatment. A survey of U.S. adults found that about one in five who met the criteria for depression were receiving guideline-recommended treatment and rates of treatment differed by race and ethnicity. A review of claims data revealed that most Medicaid patients who take antipsychotics are not screened appropriately for metabolic risks. Finally, a large study found significant increases in the number of psychotropic drugs prescribed by psychiatrists between 1996 and 2006.


End-of-life issues

Most doctors delay end-of-life talks with terminal patients who feel well

Despite guidelines recommending that physicians discuss end-of-life options with terminally ill patients, most who see cancer patients would not do so as long as their patients are feeling well, according to a nationwide survey. Physicians instead wait for symptoms to develop or until there are no more treatments to offer.

Guidelines from the National Comprehensive Cancer Network and National Consensus Project for Quality Palliative Care recommend discussing end-of-life issues for terminally ill patients with less than one year of life expectancy. Talks should review prognosis; set advanced directives; and review options for "do not resuscitate," palliative care including hospice, and preferred site of death.

Researchers presented a national sample of 4,074 physicians with a scenario of a patient newly diagnosed with metastatic cancer who is currently feeling well but has four to six months to live. They were then asked when they'd discuss prognosis, do-not-resuscitate orders, palliative/hospice care and preferred site of death. Options were "now," "when the patient first has symptoms," "when there are no more nonpalliative treatments," "only if the patient is hospitalized," and "only if the patient or family bring it up." Results appeared in CANCER, a peer-reviewed journal of the American Cancer Society.

While 65% of physicians would discuss prognosis "now," fewer would discuss patients’ preferences for resuscitation (44%), hospice (26%), or where patients would like to die (21%). Instead, most would wait until patients felt worse or until no more treatment options were available.

The survey also found that younger physicians would discuss end-of-life options sooner than older doctors (P=0.008) and that physicians who were not cancer specialists would discuss them sooner than cancer specialists (P<0.001). Female physicians were less likely to discuss prognosis right away (P=0.05). Office-based doctors were more likely to discuss hospice options than their hospital-based peers (P=0.007). Physicians caring for patients in HMO or VA settings were also more likely to start these discussions earlier than physicians who cared for patients in other settings.


FDA update

High-dose seasonal flu vaccine approved

The FDA recently approved a new high-dose vaccine against seasonal influenza subtypes A and B for patients 65 and older.

The vaccine, Fluzone High-Dose (Sanofi Pasteur Inc.), contains a total of 180 micrograms (mcg) of influenza virus hemagglutinin (HA) in each dose, made up of 60 mcg of each of the three influenza virus strains. Other currently licensed vaccines contain a total of 45 mcg of virus hemagglutinin, the FDA announcement said.

In clinical studies, the high-dose vaccine demonstrated an enhanced immune response compared with regular Fluzone in individuals 65 and older, although non-serious adverse events were more frequent. The rate of serious events was comparable. The vaccine was approved under the FDA’s accelerated pathway, which requires the manufacturer to conduct further studies to verify that it will decrease seasonal influenza disease after vaccination.


CMS update

CMS to launch provider satisfaction survey

The annual Medicare Contractor Provider Satisfaction Survey launches this month. Last week the Centers for Medicare and Medicaid Services (CMS) announced that it would begin notifying the 30,000 providers who have been randomly selected for participation. Participation in the survey is confidential and voluntary. While the survey can be completed online, answers can also be submitted by mail, telephone or fax.

CMS will release results later this year. Additional information is available on the CMS Web site.


From ACP Internist

The next issue of ACP Internist is online

The January 2010 issue of ACP Internist is online and coming soon to your mailbox. This issue, ACP Internist features:

Rethinking the value of the annual exam

Rethinking the value of the annual exam. Patients expect it and internists won’t let it go. But does the evidence support the need for the periodic health exam? Data say routine lab tests are of little or no use, but experts weigh in on the value of regularly seeing patients for preventive screening.

Expert explains thyroid diagnosis, treatment and common red flags. The estimate that 25 million people have thyroid problems would double if the normal range for thyroid-stimulating hormone was adjusted, as some medical societies suggest. In this Web-only Q&A, Victor Bernet, FACP, the author of MKSAP 15’s chapter on disorders of the thyroid gland, offers his insights into management.

What to do when lab values, imaging studies conflict. In the latest Mindful Medicine installment, James Hennessey, FACP, reports on a young woman’s elevated testosterone level, and how he made a diagnosis even though the lab results and imaging conflicted. Jerome Groopman, FACP, and Pamela Hartzband, FACP, consider confirmation bias and how this internist sidestepped being misled.

Also, don't miss daily updates on ACP Internist's blog and on Twitter.


From the College

Search committee established for ACP EVP/CEO

The American College of Physicians has established a search committee for the position of Executive Vice President/Chief Executive Officer (EVP/CEO). The committee will be chaired by William B. Applegate, MACP, Immediate Past Chair of the Board of Regents. The committee will begin its work immediately with the goal of filling the EVP/CEO position in July 2010. The position opening has been posted in major medical journals with a deadline of Feb. 19, 2010, for receipt of applicant materials. Interested candidates may find more information online.


Web-based tool helps practices improve performance

ACP has developed a Web-based tool to help primary care practices improve performance. The Medical Home Builder, now available for licensing, was initially designed to assist those interested in participating in a patient-centered medical home demonstration project. The tool guides users through seven modules:

  • Patient-centered care & communication
  • Access & scheduling
  • Organization of practice
  • Care coordination & transition in care
  • Use of technology
  • Population management
  • Quality improvement & performance improvement

Each module contains a background section modeling how a practice might use the resources in the Medical Home Builder. The resources section of each module includes a variety of media from both ACP and non-ACP sources, including sample policies, videos, Web sites and articles/books, and will be expanded as relevant resources are identified. For more information about the Medical Home Builder, see the most recent issue of ACP Advocate.


ACP reminds public to get flu shots during National Influenza Week

ACP is reminding physicians and the public to get their H1NI and seasonal flu shots--if they haven’t already--during National Influenza Week, Jan. 10-16. While vaccination rates typically decline after November, flu viruses can circulate well into the spring and summer. ACP president Joseph W. Stubbs, FACP, says that getting vaccinated is key in preventing a potential third wave of H1N1. Between April and November 2009, the H1N1 virus infected more than 45 million Americans, resulting in more than 200,000 hospitalizations, and complications from seasonal flu place a similar burden on the health care system each year. More information about adult vaccination and resources are available online.

National Influenza Vaccination Week was established to highlight the importance of continuing influenza vaccination, as well as foster greater use of flu vaccine after the holiday season into January and beyond. Every year, certain days are designated to highlight the importance for vaccination of certain groups. The remainder of this year’s schedule is as follows:

  • Tuesday, Jan. 12: People with chronic conditions that put them at high risk for serious influenza-related complications
  • Wednesday, Jan. 13: Children, pregnant women and caregivers of infants less than 6 months old
  • Thursday, Jan. 14: Young adults (19 to 24 years old)
  • Friday, Jan. 15: Seniors
  • Saturday: Wrapup

More information on National Influenza Vaccination Week is available online.


Cartoon caption contest

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 to ACP staff will choose three finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.


MKSAP answer and critique

The correct answer is C) Ampicillin–sulbactam; indomethacin. This item is available online to MKSAP 14 subscribers in the Rheumatology section, Item 27.

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.

Antibiotics, such as ampicillin–sulbactam and others with broad-spectrum coverage, are indicated for animal bites. In this setting, infection with Pasteurella multocida, as well as staphylococcal and streptococcal species and anaerobic bacteria, may be present. Evaluation for prophylactic therapy for tetanus and rabies on an individual basis also is indicated.

The presence of synovial fluid leukocytosis with needle-shaped negatively birefringent crystals consistent with monosodium urate crystals indicates acute gouty arthritis. However, in the setting of a cat bite to the area, coexistent infection must be considered. Initiation of treatment for gout in addition to antibiotic therapy for presumed infection is reasonable because of the severity of this patient's symptoms. Appropriate treatment for an acute attack of gout includes short-course therapy with a nonsteroidal anti-inflammatory drug, such as indomethacin; colchicine; or a corticosteroid. This patient's age warrants close monitoring if a high-dose nonsteroidal anti-inflammatory drug is administered.

Intra-articular corticosteroid therapy is not indicated until culture is shown to be negative, because this patient may have infection. Coexistence of acute gouty arthritis and infection is rare but has been reported, even in the absence of trauma.

Key point

  • Antibiotics, such as ampicillin–sulbactam and others with broad-spectrum coverage, are indicated for animal bites.

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Copyright 2010 by the American College of Physicians.


Test yourself

A 67-year-old man is evaluated for a recent diagnosis of primary hyperparathyroidism after an elevated serum calcium level was incidentally detected on laboratory testing. Medical history is significant only for hypertension, and his only medication is ramipril. Following a physical exam and lab studies, what is the most appropriate management of this patient?

Find the answer

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