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

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In the News
for the Week of 1-26-10

Highlights

  • Frequent self-testing not cost-effective for diabetics not on insulin
  • Atrial fibrillation risk lower with some classes of antihypertensives

Test yourself

  • MKSAP Quiz: fatigue, weight gain and constipation

Opioids

  • Higher doses of prescribed opioids associated with increased overdose risk

Prevention

  • AHA sets new criteria and goals for cardio health

Cardiology

  • ED's strong link to CVD doesn't add predictive value over Framingham

FDA update

  • Tylenol and other products recalled for odor
  • Counterfeit Alli pills found on Internet

From ACP Hospitalist

Internal Medicine 2010

  • ACP Job Placement Center calls for physician profiles

From the College

  • ACP issues position paper on patient-physician-caregiver relationships
  • ACP's Steven Weinberger, FACP, blogs at KevinMD
  • College Fellows honored
  • Chapter awardees noted

Cartoon caption contest

  • Vote for your favorite entry

Physician editor: Darren Taichman, FACP


Highlights

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Frequent self-testing not cost-effective for diabetics not on insulin

Routine self-monitoring of glucose may not be cost-effective for diabetic patients who donít use insulin, according to a new Canadian study.

The study used data from the United Kingdom Prospective Diabetes Study (UKPDS) to calculate the reduction in hemoglobin A1c (HgA1c) associated with frequent self-monitoring (seven or more test strips per week). Then researchers compared the costs of testing with the expected improvements in diabetes-related complications, quality-adjusted life-years and health care costs.

The estimated reduction in HgA1c that resulted from frequent testing was relatively modest at 0.25% (95% CI, 0.15% to 0.36%). The study found that frequent self-monitoring would reduce diabetic complications compared with no self-monitoring, but at a cost of $113,643 per quality-adjusted life-year gained. The authors concluded that at current test strip prices, frequent monitoring does not appear to be an efficient use of health care resources. They noted that less frequent testing (once or twice a week) may be cost-effective.

Another study in the same issue of the Canadian Medical Association Journal analyzed test strip use among diabetic patients 65 and older in Ontario. The study found a 250% increase in test strip use between 1997 and 2008. Almost half of the patients receiving prescriptions for test strips were at low risk of drug-induced hypoglycemia. The authors suggested that modest reductions in the frequency of self-monitoring in these patients could free up resources for other, more evidence-based forms of diabetes care.

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Atrial fibrillation risk lower with some classes of antihypertensives

Certain classes of antihypertensive drugs may be better for reducing incident atrial fibrillation risk, according to a new study.

Researchers examined data from 4,661 patients with atrial fibrillation (AF) and 18,642 matched controls in a population of 682,993 patients treated for hypertension in the United Kingdom. Sixty-two percent of the case-patients were at least 70 years of age when diagnosed with AF, and almost half (47%) were men. Patients who had clinical risk factors for AF were excluded. The study results appeared in the Jan. 19 Annals of Internal Medicine.

The authors compared the risk for AF among hypertensive patients taking angiotensin-converting enzyme (ACE) inhibitors, angiotensin II-receptor blockers (ARBs), or beta-blockers to a reference group taking calcium-channel blockers. Current exclusive long-term therapy with ACE inhibitors (odds ratio [OR], 0.75; 95% CI, 0.65 to 0.87), ARBs (OR, 0.71; CI, 0.57 to 0.89) or beta-blockers (OR, 0.78; CI, 0.67 to 0.92) was associated with lower risk for AF than current exclusive therapy with calcium-channel blockers.

The authors noted that their findings might not apply to patients with severe hypertension requiring multidrug therapy. They also acknowledged several study limitations, including possible misclassification of AF diagnoses and concomitant use of diuretics. Although the authors called for further research to confirm their findings, they concluded that at least 12 months of therapy with ACE inhibitors, ARBs or beta-blockers reduces risk for AF compared with long-term calcium-channel blockers.

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Test yourself

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MKSAP Quiz: fatigue, weight gain and constipation

A 28-year-old woman is evaluated for fatigue, weight gain and occasional constipation. The patient has a history of craniopharyngioma, which was resected; she was subsequently given radiation therapy. She has hypopituitarism and diabetes insipidus after tumor resection and radiation. Her medications include hydrocortisone, levothyroxine, oral contraceptives and desmopressin. She does not have dizziness, nausea, vomiting, polyuria or polydipsia. The physical examination is unremarkable.

Laboratory studies

Complete blood count Normal
Electrolyte panel Normal
TSH 0.1 ĶU/mL (0.1 mU/L)
Free T4 0.5 ng/dL (6.4 pmol/L)

Which of the following changes should be made to the patientís therapy?

A) Hydrocortisone dose should be lowered
B) Oral contraceptives should be discontinued
C) Desmopressin should be discontinued
D) Thyroid hormone dose should be increased

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

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Opioids

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Higher doses of prescribed opioids associated with increased overdose risk

Patients prescribed higher doses of opioids are at increased risk for overdose, according to a new study.

Researchers sought to determine the rate of opioid overdose in relation to an average prescribed daily opioid dose among patients receiving medically prescribed, long-term opioid therapy. The study population included 9,940 adults from a single HMO who had received at least three opioid prescriptions for chronic noncancer pain within 90 days between 1997 and 2005. Patients were followed for a mean of 42 months (range, <1 to 119 months). The primary study outcomes, nonfatal and fatal overdoses, were determined by diagnostic inpatient and outpatient care codes and confirmed by review of medical records. The study results appeared in the Jan. 19 Annals of Internal Medicine.

During follow-up, 51 patients had one or more opioid-related overdoses; six of these overdoses were fatal. The annual overdose rates were 0.2% in patients receiving 1 to 20 mg of opioids per day, 0.7% (a 3.7-fold increased risk) in those taking 50 to 99 mg/d, and 1.8% (an 8.9-fold increased risk) in those taking at least 100 mg/d. The authors found that patients receiving higher opioid doses were more likely to be men and current smokers and were more likely to have a history of depression or substance abuse treatment and higher Charlson comorbidity scores.

The authors acknowledged that their study was observational and could not determine whether difference in overdose risk reflected direct effects of differences in doses or patient characteristics. They concluded that because of uncertainties regarding effectiveness and the risk for overdose, long-term opioid therapy should be prescribed carefully and patients receiving these drugs should be closely monitored.

An accompanying editorial pointed out that prescriber practices could have played a role in the overdoses noted in the study and reiterated the authors' recommendation for monitoring through such measures as an opioid contract between patient and physician. The current study findings "show the need to assess the risk for opioid misuse, provide close oversight, dose judiciously, and continually reevaluate the benefit of these potentially risky drugs," the editorialists wrote.

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Prevention

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AHA sets new criteria and goals for cardio health

A special report from the American Heart Association recently set criteria for ideal cardiovascular health, seven health metrics that can serve as goals for individuals and the U.S. as a whole.

The reportís definition of ideal cardiovascular health includes four health behaviors: nonsmoking for at least a year, body mass index of less than 25, physical activity of at least 150 minutes/week at moderate intensity or 75 minutes/week at vigorous intensity, and four or five components of a healthy diet. (The AHA report offered more detailed guidance on healthy diet, which was similar to the DASH [Dietary Approaches to Stop Hypertension] eating plan.)

There are also three health factors included in the definition: untreated total cholesterol under 200 mg/dL, untreated blood pressure under 120/80 mm Hg and fasting blood glucose under 100 mg/dL. Separate criteria were set for measuring childrenís cardiovascular health. The AHA plans to monitor the metrics to assess change in the U.S. populationís cardiovascular health status. The AHA report also set a goal of improving Americansí cardiovascular health by 20% and reducing deaths from cardiovascular disease and stroke by 20% by the year 2020. The report was published online in the journal Circulation.

Health behavior changes were also recommended by a new study on salt consumption. Using the Coronary Heart Disease Policy Model, researchers calculated the potential health benefits of population-wide reductions in dietary salt. They projected that reducing dietary salt by 3 grams per day per person would reduce the annual number of new cases of coronary heart disease by 60,000 to 120,000, stroke by 32,000 to 66,000 and myocardial infarction by 54,000 to 99,000. They concluded that a regulatory intervention to achieve this reduction would save $10 billion to $24 billion in annual health care costs and would be more cost-effective than using medication to treat all patients with hypertension. The study was published online by the New England Journal of Medicine on January 20.

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Cardiology

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ED's strong link to CVD doesn't add predictive value over Framingham

Although erectile dysfunction is strongly associated with later cardiovascular disease, it's no better a predictor than Framingham risk scores. But its no-cost, low-risk nature makes it an important assessment tool for physicians, researchers concluded.

Both conditions share pathophysiologic mechanisms and are often present together. Men with erectile dysfunction (ED) have a 40% higher risk of developing cardiovascular disease (CVD) than those without. The risk of CVD associated with ED is the same as smoking, hypertension or a family history of myocardial infarction. To determine whether ED predicted CVD beyond such traditional risk factors, researchers conducted a prospective, population-based study of 1,709 men ages 40 to 70. Subjects were followed for CVD for an average follow-up of 11.7 years. Researchers reported results in the Journal of the American College of Cardiology.

Researchers drew reports from the Massachusetts Male Aging Study (MMAS), a prospective, observational cohort study of aging, health, and endocrine and sexual function in a random sample of men. A total of 1,709 respondents completed the baseline protocol from 1987 to 1989 and were seen again twice, from 1995 to 1997 (n=1,156, 77% response rate) and from 2002 to 2004 (n=853, 65% response rate).

ED was assessed by a 23-item questionnaire completed in private and returned in a sealed envelope. Data on CVD were obtained from self reports, comparisons of MMAS data with the National Death Index, and medical records. CVD was based on self-reports of major end points such as myocardial infarction, atherosclerosis, stroke, coronary artery bypass graft surgery or congestive heart failure.

Researchers included 1,057 men with complete risk factor data who were free of CVD and diabetes at baseline. During follow-up, 261 new cases of CVD occurred. ED was associated with CVD incidence controlling for age (hazard ratio [HR], 1.42; 95% CI, 1.05 to 1.90), age and traditional CVD risk factors (HR, 1.41; CI, 1.05 to 1.90) and age and Framingham risk score (HR, 1.40; CI, 1.04 to 1.88).

Despite these significant findings, ED did not significantly improve prediction beyond traditional risk factors. Researchers wrote this was not surprising because of the strength of the association between traditional risk factors and CVD, the magnitude of the hazard ratio associated with ED, and the numerous studies showing that the factors that comprise the Framingham risk score are also associated with ED.

"Nonetheless," researchers wrote, "any reclassification would be useful clinically given that the assessment of ED is associated with little cost and no risks."

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FDA update

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Tylenol and other products recalled for odor

A number of over-the-counter medications are being voluntarily recalled by manufacturer McNeil Consumer Healthcare because of consumers reporting a moldy, musty or mildew-like odor, the FDA announced recently.

The odor was caused by a chemical used to treat wooden pallets that transport and store packaging materials. The health effects of this compound have not been well studied, and to date all of the observed events were non-serious and included nausea, stomach pain, vomiting and diarrhea.

Recalled products include Tylenol (Extra Strength, Regular Strength, PM, 8 Hour, Arthritis Pain, Childrenís), St. Joseph Aspirin, Simply Sleep, Rolaids, Benadryl, Motrin IB and Childrenís Motrin. A full list of products and lot numbers is online.

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Counterfeit Alli pills found on Internet

The FDA recently warned consumers that a counterfeit and potentially harmful version of over-the-counter weight loss drug Alli is being sold on the Internet.

The counterfeit version contains the controlled substance sibutramine instead of orlistat, the active ingredient in the real drug. Sibutramine should not be used in certain patient populations or without physician oversight and can interact in a harmful way with other medications.

The counterfeit Alli product looks similar to the authentic product, with a few notable differences. A full description is available online.

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From ACP Hospitalist

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The next issue of ACP Hospitalist is online

Internists considering or actively planning a switch to hospital medicine can subscribe for free upon request to ACP Hospitalist, the Collegeís monthly magazine reporting on trends in hospital medicine. Featured in the current issue:

Mentoring. These days, many physician mentors act more like coaches, guiding their apprentices to new career heights by helping them publish in prestigious journals or attain positions in hospital administration. Learn tips on how to find a good fit between mentor and mentee, and explore the benefits and challenges of this unique relationship.

Smoking cessation. Hospitalization can offer a prime opportunity for helping patients who smoke to kick the habit. Not only are patients captive in an environment where smoking is prohibited, they may be more motivated than usual to avoid future, tobacco-related health problems. Look at some innovative hospital-based programs that have helped patients stay off tobacco once they're back in the outside world.

Conference coverage. At the Infectious Diseases Society of America, experts were concerned about antibiotic resistance, while at the Medical Group Management Association, an expert outlined practical tips to improve hospitalists' communication with coworkers and patients.

ACP Hospitalist is distributed free of charge to physicians involved in hospital medicine. For a free subscription, contact ACP Customer Service at 800-523-1546 or 215-351-2600 (9 a.m. to 5 p.m. ET) or send an e-mail. custserv@acponline.org To subscribe, request ACP Hospitalist using promo code GAD.

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Internal Medicine 2010

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ACP Job Placement Center calls for physician profiles

Physicians looking for a new job may submit a profile to the ACP Job Placement Center, a service available at Internal Medicine 2010 in Toronto, Canada. The center, located in the Metro Toronto Convention Centreís Exhibit Hall, Booth 222, provides physicians with tools to assist in job searches as well as the opportunity to meet with potential employers.

Physician profiles are distributed to numerous employers participating in Internal Medicine 2010, which will be held April 22-24. After reviewing a profile, a recruiter may contact the physician to schedule a private on-site interview at the Convention Centre. Profiles can be submitted online.

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From the College

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ACP issues position paper on patient-physician-caregiver relationships

More than 30 million people in the U.S. act as caregivers for individuals with acute and chronic illness. A new position paper published in the Journal of General Internal Medicine offers guidance to physicians for developing mutually supportive patient-physician-caregiver relationships.

The authors of the paper noted that while hospice and palliative care address the impact of illness on both patients and families, the focus is primarily on the patientís rights, with less attention paid toward the patientís experience within the context of their family and social relationships. ACP President Joseph Stubbs, FACP, said the ethical guidance in the paper is intended to heighten physician awareness of the importance and complexity of such relationships.

The paper, which was endorsed by 10 other professional medical societies, was developed by the ACP Ethics, Professionalism and Human Rights Committee and approved by the American College of Physicians Board of Regents.

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ACP's Steven Weinberger, FACP, blogs at KevinMD

Steven Weinberger, FACP, ACPís Deputy Executive Vice President and Senior Vice President for Medical Education and Publishing, continues his monthly column at KevinMD.com, one of the Web's most influential medical blogs. This month's column looks at 10 major challenges that confront the continuum of medical education over the next decade.

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College Fellows honored

Two ACP Fellows were recently honored, one for contributions to bioethics and one for volunteerism.

Joseph J. Fins, FACP, was elected president of the American Society for Bioethics and Humanities in recognition of his major contributions to bioethics and broad expertise in the field. He will assume the presidency in 2011 for a two-year term. Dr. Fins is chief of the Division of Medical Ethics in the Departments of Public Health and Medicine and professor of medicine, professor of public health and professor of medicine in psychiatry at Weill Cornell Medical College. He is also director of medical ethics at New York-Presbyterian Hospital/Weill Cornell Medical Center and chairs its ethics committee. Dr. Fins is a governor of the New York Downstate 1 Chapter of the American College of Physicians and a trustee of the American College of Physicians Foundation.

Zaven Ayanian, FACP, was awarded the 2010 Jack B. McConnell Award for Excellence in Volunteerism by the American Medical Association Foundation. The award is part of the Excellence in Medicine Awards program and is presented to senior physicians who increase access to health care for underserved and uninsured patients in the U.S. Dr. Ayanian was recognized for his work at the Parker Family Health Center, a free clinic in Monmouth, N.J., which provides 10,000 patient visits annually with support from 200 volunteers.

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Chapter awardees noted

Chapters honor Members, Fellows, and Masters of ACP who have demonstrated by their example and conduct an abiding commitment to excellence in medical care, education, research, or service to their community, their chapter, and ACP. In recognition of their outstanding service, these exceptional individuals received chapter awards in November and December 2010.

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Cartoon caption contest

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Vote for your favorite entry

ACP InternistWeekly's cartoon caption contest continues. Readers can vote for their favorite caption to determine the winner.

"I know, sir. A lot of our patients feel that way about their health plans."
"Thanks, but I think I'll go with accu-pressure next time."
"Only when I laugh."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting continues through Feb. 1, with the winner announced in the Feb. 2 issue.

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MKSAP answer and critique

The correct answer is D) Thyroid hormone dose should be increased. This item is available online to MKSAP 14 subscribers in the Endocrinology 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.

This patient's thyroid hormone dose should be increased to normalize the free T4 level and alleviate signs and symptoms of hypothyroidism. The TSH cannot be used to monitor thyroid hormone replacement therapy in patients with central hypothyroidism. In these patients, the pituitary thyrotropes do not produce adequate TSH to stimulate thyroid hormone production by the thyroid gland. It is not uncommon for such patients to have their thyroid hormone dose decreased because the suppressed TSH appears to suggest hormone over-replacement. The goal of thyroid hormone replacement in these patients is to titrate the dose to normalize the free T4 (or total T4 and free thyroxine index), not to normalize the TSH.

The hydrocortisone dose does not need to be reduced in the patient because she does not have any signs to suggest over-replacement. Similarly, the desmopressin dose should not be altered because her symptoms are controlled on her current dose and she has normal electrolytes. The desmopressin should not be discontinued as this patient who has had both surgery and radiation will undoubtedly have permanent diabetes insipidus. Finally, the patient is doing well on oral contraceptives and there is no reason to discontinue them. They will help prevent the development of osteopenia/osteoporosis induced by hypogonadism.

Key points

  • The serum TSH cannot be used to monitor thyroid hormone replacement therapy in patients with central hypothyroidism
  • In patients with central hypothyroidism, the goal of thyroid hormone replacement is to titrate the dose to normalize the free T4 (or total T4 and free thyroxine index), not to normalize the TSH.

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 2010 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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