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


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


  • Nurses tapped for more training, bigger role in health care
  • Updated consensus statement issued for hypertension management in blacks

Test yourself

  • MKSAP Quiz: swollen right elbow for two days


  • Stress tests overused after revascularization

Flu vaccination

  • Maternal flu vaccine protects infants
  • National reimbursement price set for new high-dose flu vaccine

From the College

  • ACP introduces virtual diagnostic challenges
  • Member feedback sought for website redesign

Cartoon caption contest

Physician editor: Darren Taichman, FACP


Nurses tapped for more training, bigger role in health care

The Institute of Medicine says nurses' roles, responsibilities and education should change significantly to meet the increased demand for care expected from health care reform.

Further, nurses should train alongside other health professionals and assume leadership roles in redesigning care, stated the report. Nurses should undergo residencies, increase their ranks of those with bachelor's degrees from 50% to 80% by 2020, ensure that at least 10% of their baccalaureates enter a master's or doctoral program within five years, and double the number of doctoral candidates.

There are more than 3 million nurses in the U.S., and because of their direct patient contact and the proportion of time the profession spends in direct patient care, "Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States," the report said.

Once nurses are trained, scope of practice limits should be lifted, the report stated, as should insurance and regulatory hurdles, so that the health system can reap the full benefit. Scope of practice barriers are particularly problematic for advanced practice registered nurses (APRNs), the report found.

Studies of advanced practice nurses and the experiences of health care organizations, such as the Veterans Health Administration, Geisinger Health System, and Kaiser Permanente, that have increased the roles and responsibilities of nurses in patient care show that these nurses deliver safe, high-quality primary care.

In one example, the VA had been transforming itself since the 1990s in anticipation of an aging veteran population. The results of the VA’s initiatives using both front-line RNs and APRNs showed that patients received significantly better health care based on various quality-of-care indicators such as mammography, flu and pneumococcal vaccination, cancer screening and other conditions than patients enrolled in Medicare’s fee-for-service program. In some cases, the study showed, between 93% and 98% of VA patients received appropriate care in 2000; the highest score for comparable Medicare patients was 84%. Meanwhile, spending per enrollee rose much more slowly than in Medicare, by 30% from 1999 to 2007 compared with 80% for Medicare over the same period.

The report is the product of a study convened by the Robert Wood Johnson Foundation Initiative on the Future of Nursing, which will organize a national conference at the end of November to discuss implementation.

The conclusions aren't without detractors. The American Medical Association responded, "Nurses are critical to the health care team, but there is no substitute for education and training. Physicians have seven or more years of postgraduate education and more than 10,000 hours of clinical experience; most nurse practitioners have just two-to-three years of postgraduate education and less clinical experience than is obtained in the first year of a three year medical residency. These additional years of physician education and training are vital to optimal patient care, especially in the event of a complication or medical emergency, and patients agree."


Updated consensus statement issued for hypertension management in blacks

An updated consensus statement on management of hypertension in blacks was issued last week, focusing on primary and secondary prevention.

The International Society on Hypertension in Blacks released its first consensus statement on this topic in 2003. Available data from subsequent clinical trials prompted the update. The authors reviewed existing guidelines on prevention and treatment of hypertension and cardiovascular disease, hypertension trials that reported clinical end points, and trials that looked at lowering blood pressure in blacks. Studies that included other ethnic groups were also considered. The statement divided blacks with hypertension into two groups according to risk: primary prevention (defined as those with high blood pressure but no target organ damage, preclinical cardiovascular disease, or overt cardiovascular disease) and secondary prevention (defined as high blood pressure with target organ damage, preclinical cardiovascular disease, and/or a history of cardiovascular disease). The consensus statement was published online Oct. 4 by Hypertension.

The statement's recommendations include the following:

  • For primary prevention, a target blood pressure <135/85 mm Hg is recommended.
  • For secondary prevention, a target blood pressure <130/80 mm Hg is recommended.
  • Patients whose blood pressure is >10 mm Hg above target should receive monotherapy with a diuretic or calcium-channel blocker.
  • Patients whose blood pressure is >15/10 mmHg above target should receive two-drug therapy with a calcium-channel blocker and a renin-angiotensin system blocker or, in cases of edema or volume overload, a thiazide diuretic plus a renin-angiotensin system blocker.
  • Lifestyle modifications should be attempted when blood pressure is >115/75 mm Hg.

An accompanying editorial said the statement offered "useful, practical information to guide practitioners in the diagnosis, prevention, and treatment of hypertension in black patients." However, the editorialists questioned the strong recommendation for a calcium-channel blocker and a renin-angiotensin system blocker over other types of two-drug therapy, noting that it is based on data from only one trial. They also questioned the evidence for recommending lower blood pressure targets. "Rather than setting new lower [blood pressure] goals, we suggest a greater focus on increasing the number of patients controlled to the conventional goal of <140/90 mm Hg," they wrote.


Test yourself

MKSAP Quiz: swollen right elbow for two days

A 64-year-old man with intermittent acute gout is evaluated in the office for a swollen right elbow of 2 days’ duration. He recalls no inciting trauma. His last attack of gout occurred 4 months ago and involved his right knee. He takes no medications.

On physical examination, temperature is 38.1 °C (100.5 °F). The right elbow is warm with minimal erythema. Musculoskeletal examination reveals slight fullness and tenderness over the right olecranon process. Passive and active extension of the right elbow is painless, but passive flexion greater than 90 degrees elicits pain. Rotation of the forearm is painless. He is able to extend the arm fully without discomfort.

Which of the following is the most appropriate next step in this patient’s management?

A) Empiric trial of colchicine
B) Measurement of erythrocyte sedimentation rate
C) Radiograph of the right elbow and forearm
D) Right elbow joint aspiration
E) Right olecranon bursa aspiration

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



Stress tests overused after revascularization

More than half of patients who underwent cardiac revascularization received a stress test within the next two years, contrary to American College of Cardiology Foundation recommendations, a new study found.

The retrospective study used a national claims database to identify more than 28,000 revascularization patients (about 21,000 who had percutaneous coronary intervention [PCI] and 7,100 who had coronary artery bypass grafting [CABG]). Between 90 days and two years after the procedure, 59% of the patients had a stress test. A higher percentage of PCI patients were tested (61% vs. 51% of CABG recipients), and nuclear imaging was the predominant method. The rates of testing varied by geographic area, with up to a 50% difference in testing rates by region.

The researchers also identified a spike in testing rates at 6 and 12 months after the procedures, indicating that testing was associated with follow-up office visits. They found that relatively few of the tests led to additional procedures: only 10% of those tested went on to coronary angiography and less than half of those patients received repeat revascularization. The study was published in the Oct. 12 Journal of the American College of Cardiology.

The findings indicate that the diagnostic yield of these tests is very low, the study authors concluded. They noted that appropriate use criteria put out by the American College of Cardiology Foundation recommend against routine stress testing. The study was unable to assess how many of these tests were motivated by patients’ reports of symptoms; however, other research has shown that only 18% of PCI patients report angina symptoms one year after surgery.

The patients included in the study were treated between July 2004 and June 2007, and physicians today are more aware of the criteria for testing, according to an editorial accompanying the study. Still, the results serve as a “wake-up call to cardiovascular specialists,” the editorialist said. Cardiologists should not only adhere to evidence for testing, but also educate patients and referring physicians about this issue, because the likely alternative is that payers will require more pre-authorizations of testing, the editorial concluded.


Flu vaccination

Maternal flu vaccine protects infants

Maternal influenza vaccination was significantly associated with reduced risk of infant flu infection and hospitalization up to 6 months of age and increased influenza antibody titers in infants through 2 to 3 months of age, a study found.

Researchers conducted a nonrandomized, prospective, observational cohort study among 1,169 mother-infant pairs at hospitals located in Navajo and White Mountain Apache Indian reservations during three flu seasons (2002 to 2005). (Navajo and White Mountain Apache children have rates of acute respiratory infection that are significantly higher than in the general U.S. population. Because the flu vaccine is recommended for all pregnant women, a nonrandomized study was not possible.) Results were reported in the Oct. 4 Archives of Pediatrics and Adolescent Medicine.

Of the group, 49% of infants (n=573) were born to mothers who received flu vaccine during their pregnancy. The cohorts were otherwise similar except the vaccinated mothers were more likely to have a wood- or coal-burning stove in the house and to breastfeed.

Researchers measured laboratory-confirmed influenza, flu-like illness and hospitalization, and influenza hemagglutinin inhibition antibody titers. Influenza-like infections were defined as a medical visit with at least one of the following reported: fever of 38.0 °C or higher, diarrhea, or respiratory symptoms. Diarrhea was included because young infants can experience diarrhea with the flu.

Of the 1,160 infants, there were 908 flu-like infections: 193 children (17%) were hospitalized, 412 (36%) were treated as outpatients, and 555 (48%) had no medically attended flu-like infections. The flu-like infection incidence rate was 7.2 per 1,000 person-days and 6.7 per 1,000 person-days for infants born to unvaccinated and vaccinated women, respectively.

Fifty-two percent (n=605) of infants had a flu-like infection, of which 14% (n=83) were laboratory-confirmed influenza. The mean infant age at first flu-like infection was 47 days (median, 41; range, 0 to 175) and did not differ between infants born to vaccinated and unvaccinated mothers.

There was a 41% reduction in the risk of laboratory-confirmed influenza virus infection (relative risk, 0.59; 95% CI, 0.37 to 0.93) and a 39% reduction in the risk of flu-like infection hospitalization (relative risk, 0.61; 95% CI, 0.45 to 0.84) for infants born to influenza-vaccinated women compared with infants born to unvaccinated mothers. Infants born to influenza-vaccinated women had significantly higher hemagglutinin inhibition antibody titers at birth and at 2 to 3 months of age than infants of unvaccinated mothers for all 8 influenza virus strains investigated.

Limitations to the study include uncontrolled residual confounding despite studying variables that could have an influence, and that the study was conducted during three relatively mild flu seasons.

The researchers wrote, "These findings provide support for the added benefit of protecting infants from influenza virus infection up to 6 months, the period when infants are not eligible for influenza vaccination but are at highest risk of severe influenza illness. These findings are particularly relevant with the emergence of 2009 pandemic influenza A (H1N1) virus, which had a substantial effect on pregnant women and high hospitalization rates among young infants."


National reimbursement price set for new high-dose flu vaccine

The Centers for Medicare and Medicaid Services (CMS) decided on a national price for the newly approved high-dose flu vaccine effective Oct. 1. The 0.5-mL dose of the vaccine should be reported with CPT code 90662 (Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use). Medicare’s reimbursement is $29.213. Members who have trouble collecting payment from their contractors for the high-dose vaccine should let ACP know so the organization can investigate.


From the College

ACP introduces virtual diagnostic challenges

ACP is pleased to announce its newest form of self-assessment education, Virtual DxSM—Interpretive Challenges from ACP. Virtual Dx is an online study program that uses images and studies to challenge diagnostic ability.

Physicians can use Virtual Dx to check their interpretive skills through more than 400 high-resolution, scalable images and other diagnostic challenges in 13 major categories. Images are categorized for efficient learning, allowing users to zoom in on important details when necessary. Virtual Dx is competitively priced and ideal for residents and physicians preparing for the ABIM certifying exams or for checking diagnostic acumen. A tour of the new Virtual Dx and more information, including information on ordering, are available online.


Member feedback sought for website redesign

In an effort to better meet the needs of members, ACP is redesigning the Running a Practice landing page of the ACP website. Members who participate in a survey about the section are eligible to win a $50 ACP gift certificate.


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 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 E) Right olecranon bursa aspiration. This item is available to MKSAP 15 subscribers as item 25 in the General Internal Medicine module.

Immediate aspiration of the right olecranon bursa is indicated for this patient. There is a strong clinical suspicion for olecranon bursitis, which may be infectious, crystalline, or traumatic. Synovial fluid analysis will help guide therapy in this setting. Acute crystalline or infectious synovitis usually is associated with extreme pain on passive joint motion. This patient has pain only on full flexion of the joint, most likely because this movement causes tautness of the bursa and surrounding soft tissue.

If gout were evident on the synovial fluid analysis, a trial of colchicine would be reasonable.

Measurement of the erythrocyte sedimentation rate will not help to distinguish between crystal-induced arthritis and infection.

Radiography is useful in evaluating traumatic causes of acute pain near a joint but would not help to differentiate between crystalline and infectious arthritis or to diagnose bursitis. Nuclear scanning and MRI are similarly not particularly useful in establishing a diagnosis among these conditions.

Joint aspiration is not indicated in the absence of convincing evidence that the joint itself is the source of the problem, such as painful elbow joint rotation or extension.

Key Point

  • Olecranon bursitis is typically associated with painful full elbow flexion; acute crystalline or infectious synovitis is usually associated with pain on any passive joint motion.

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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?

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