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


In the News
for the Week of 10-5-10


  • Highest-risk childhood cancer survivors don't follow recommended screenings
  • ACGME approves final duty hour and supervision standards

Test yourself

  • MKSAP Quiz: progressive, dull, epigastric pain


  • Statins may be cost-effective for lower-risk populations, model finds

Breast cancer

  • Study shows benefit of mammography screening in women age 40-49

Dialysis options

  • Peritoneal dialysis offers same outcomes as hemodialysis, but is rarely used

Medicare update

  • CMS releases new Medicare Contractor Provider Satisfaction Survey
  • CMS distributing 2009 eRx Program incentive payments

Educational opportunities

  • Medical students invited to apply for CDC Applied Epidemiology Fellowship
  • ACP’s Washington office now accepting internship applications

From ACP Internist

  • The October issue is online and coming to your mailbox

From the College

  • New iPhone app available for Annals of Internal Medicine
  • ACP launches campaign on adult immunization awareness
  • Chapter awardees noted

Cartoon caption contest

Physician editor: Darren Taichman, FACP


Highest-risk childhood cancer survivors don't follow recommended screenings

Most survivors of childhood cancers at highest risk for a second neoplasm in adulthood didn't follow recommended screening intervals, a study found.

To examine adherence to population cancer screening guidelines, researchers conducted a retrospective cohort study among 26 centers to find long-term survivors of childhood cancer diagnosed between 1970 and 1986.

Researchers identified 4,329 male and 4,018 female survivors of childhood cancer and surveyed them about mammography, Pap smears, colonoscopy or skin examinations. They compared screening rates to U.S. Preventive Services Task Force guidelines for survivors at average risk for breast or cervical cancer or the Children's Oncology Group guidelines, which recommend more aggressive surveillance and screening for survivors at high risk for breast, colorectal or skin cancer. The study results appear in the Oct. 5 Annals of Internal Medicine.

Researchers found that while average-risk female survivors were somewhat compliant with cervical and breast cancer guidelines for screening, surveillance was alarmingly low in survivors at the highest risk for colon, breast or skin cancer.

In average-risk female survivors, 2,743 of 3,392 (80.9%) reported having a Pap smear within the recommended period, and 140 of 209 (67.0%) reported mammography within the recommended period. In high-risk survivors, rates of recommended mammography among women were only 241 of 522 (46.2%) and the rates of colonoscopy and complete skin examinations among both sexes were 91 of 794 (11.5%) and 1,290 of 4,850 (26.6%), respectively. Reported screening rates were worst for colorectal cancer (11.5%), followed by skin cancer (26.6%) and breast cancer (46.2%).

Survivors of childhood cancer and their physicians must be better educated about the potential benefits of enhanced cancer screening, the authors wrote: "Interventions to improve adherence to cancer surveillance should be directed at the primary care physicians who care for most long-term survivors of childhood cancer, as well as to the survivors themselves."

Physician recommendation promotes compliance, the authors wrote, but many primary care physicians are probably unaware of the surveillance guidelines for these high-risk patients. ACP Internist addressed how primary care physicians can treat adult survivors of cancer, as well as a host of other childhood diseases, in the recent article "History is key after childhood disease."


ACGME approves final duty hour and supervision standards

New duty hour rules received final approval, keeping work levels of 80 hours per week but also detailing supervision for first-year residents and capping their work to 16 hours a day.

The Accreditation Council for Graduate Medical Education (ACGME) approved last week the new rules, which take effect July 2011.

Other changes include:

  • establishing graduated requirements for minimum time off between scheduled duty periods;
  • expanding program and institutional requirements regarding handovers of patient care; and
  • setting more specific requirements for alertness management and fatigue mitigation strategies designed to ensure both continuity of patient care and resident safety.

The standards are based on recommendations made by the Institute of Medicine in 2008, which were based on a scientific review of sleep issues, patient safety and resident training, as well as testimony from more than 100 experts on those topics and statements from 100 medical organizations.

A cost impact analysis will be posted on the ACGME website next week. A compliance review is under development. Under this program, ACGME will review every residency program for its ability to integrate residency education, supervision and fatigue management into its existing patient safety and quality improvement initiatives.

In related news, the Association of American Medical Colleges advocated that ACGME keep the sole oversight role of resident duty hours. In a letter to the Occupational Safety and Health Administration, the organization urged OSHA to reject a petition by public watchdog groups to the contrary.


Test yourself

MKSAP Quiz: progressive, dull, epigastric pain

A 73-year-old man is evaluated for a 3-month history of progressive, dull, epigastric pain. The pain is constant and does not radiate. The patient has had early satiety during this time and has lost 13.5 kg (30 lb); he has had mild nausea but no vomiting. The patient has a history of peptic ulcer disease and occasional heartburn; his only medication is an over-the-counter antacid as needed.

On physical examination, the patient appears cachectic; BMI is 19. There is tenderness and fullness in the epigastric region with hepatomegaly. Laboratory studies reveal a hemoglobin of 10.4 g/dL (104 g/L) with a mean corpuscular volume of 74 fL. Bilirubin, aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase concentrations are normal. Esophagogastroduodenoscopy shows a large ulcerated mass in the gastric body with heaped-up edges; biopsy specimens show adenocarcinoma.

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

A) CT scan of the abdomen
B) Endoscopic ultrasonography
C) Helicobacter pylori stool antigen test
D) Positron emission tomography

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



Statins may be cost-effective for lower-risk populations, model finds

Statin therapy may be a cost-effective way to prevent cardiovascular events in moderate- to low-risk populations without testing for high-sensitivity C-reactive protein (hs-CRP), a new study has found.

Researchers used a decision analytic Markov model to test three treatment strategies in hypothetical patients who had normal lipid levels and no coronary artery disease, peripheral arterial disease or diabetes mellitus. The treatment strategies tested were statin therapy according to existing Adult Treatment Panel (ATP) III guidelines (10-year predicted risk for coronary events >20%, or diabetes mellitus), statin therapy in patients with elevated hs-CRP levels but no other risk factors, and statin therapy in patients at predicted risk thresholds without hs-CRP testing. All three hypothetical cohorts were assumed to have lipid levels that matched the median levels in the JUPITER study: total cholesterol, 186 mg/dL; low-density lipoprotein cholesterol, 108 mg/dL; and high-density lipoprotein cholesterol, 49 mg/dL. Statin cost was assumed to be equal to that of simvastatin, 80 mg/d ($1.10 daily). The study results were published early online Sept. 27 by Circulation.

The authors found that treating with statins based on predicted risk thresholds but not hs-CRP testing was the most cost-effective strategy when statins were assumed to work equally well, regardless of hs-CRP level. Statin therapy based on hs-CRP testing was most cost-effective when normal hs-CRP levels were assumed to identify patients whose relative risk reduction on statins was less than 20%. ATP III guidelines were the optimal strategy if statin use was assumed to be associated with significant harms. An interactive presentation of the models' results is available online.

The authors concluded that prescribing statins according to predicted cardiovascular risk without hs-CRP testing in patients whose low-density lipoprotein levels are not elevated is the most effective of the three strategies, assuming that statins are safe and effective in this population. An accompanying editorial agreed with the authors that their results were "particularly sensitive" to variations in statins' presumed relative risk reduction and presumed long-term safety, and noted that determining the optimal strategy for primary prevention of cardiovascular events in the U.S. will be difficult.

"Further evaluations using well-informed decision analytic models such as that presented [here] will help inform health policy decision making relating to the primary prevention of cardiovascular disease in a manner that is consistent with the society goal of rational and judicious use of limited healthcare resources," the editorialist wrote.


Breast cancer

Study shows benefit of mammography screening in women age 40-49

Mammography screening in women age 40 to 49 reduces breast cancer mortality rates, according to a new study.

Between 1986 and 1997, based on national recommendations, counties in Sweden began inviting women age 40 to 74 to mammography screening for breast cancer. Women age 40 to 54 were invited to screening every 18 months, while women age 55 to 74 were invited to screening every other year. The recommendations were modified in 1987 and 1988, allowing counties with fewer resources to focus screening on women age 50 to 74. As a consequence, about half of the counties screened women beginning at age 40 and half screened women beginning at age 50.

Researchers performed a study to compare death from breast cancer in women age 40 to 49 in areas that did and did not invite this age group to screening from 1986 to 2005. The authors also defined a prescreening reference period from 1970 to 1985, before organized screening began.

The study's main outcome measure was "refined mortality," defined as women age 40 to 49 who received a diagnosis of breast cancer and died of the disease during follow-up. The results were presented last week at the 2010 Breast Cancer Symposium and were published online by Cancer.

The study's average follow-up was 16 years. No difference was seen in breast cancer mortality during the prescreening period: 607 women died of breast cancer during 4.8 million person-years and 846 women died of breast cancer during 6.3 million person-years, respectively, in areas that did and did not adopt screening in the 40- to 49-year age group after 1986. From 1986 to 2005, 803 women during 7.3 million person-years and 1,238 women during 8.8 million person-years died of breast cancer in the intervention and control groups, respectively (estimated crude relative risk [RR], 0.79 [95% CI, 0.72 to 0.86]).

Women who were invited to screening had an RR of 0.74 (95% CI, 0.66 to 0.83), while those actually attending screening had an RR of 0.71 (95% CI, 0.62 to 0.80). Among women age 40 to 44, the RR was 0.83 (95% CI, 0.70 to 1.00) in those who were invited to screening and 0.82 (95% CI, 0.67 to 1.00) in those who attended; in women age 45 to 49, the corresponding RRs were 0.68 (95% CI, 0.59 to 0.78) and 0.63 (95% CI, 0.54 to 0.75), respectively. The authors estimated that 1,252 women (95% CI, 958 to 1,915) needed to be invited to screening over 10 years to save one life.

Undetected differences between the intervention and control groups might have affected the results, among other limitations, the authors noted. However, they concluded that screening mammography reduced death from breast cancer by 26% to 29% in women age 40 to 49 years. The benefit was greater in women age 45 to 49 than in those age 40 to 44, they said.


Dialysis options

Peritoneal dialysis offers same outcomes as hemodialysis, but is rarely used

Although hemodialysis and peritoneal dialysis result in similar outcomes for most patients, few patients are choosing peritoneal dialysis, according to two new studies published by Archives of Internal Medicine.

The first study used data from the U.S. Renal Data System (USRDS) to uncover and compare trends in survival among patients on the two modes of dialysis. More than 600,000 hemodialysis patients and almost 65,000 peritoneal dialysis patients were included, and they were followed for up to five years. Three date ranges were included: 1996-1998, 1999-2001 and 2002-2004.

Although in the earlier date ranges there was a higher risk of death for patients on peritoneal dialysis, that risk progressively attenuated so that there was no significant difference by 2002-2004. Analyses of 8 subgroups (patients of different ages and comorbidities) showed that only older patients with diabetes and at least one other comorbidity were more likely to die on peritoneal dialysis in the most recent time range. But even that risk had become progressively lower over time.

The findings, and the lower cost, support broader use of peritoneal dialysis, especially in younger and nondiabetic patients, the authors concluded. They did caution, however, that the improvements in outcomes could be the result of more selective assignment of patients to peritoneal dialysis in recent years.

Peritoneal dialysis patients are a relatively small group, confirmed the second study. The cohort study surveyed patients in the USRDS from 2005 to 2007 about whether peritoneal dialysis had been discussed with them. Sixty-one percent of the patients said they had discussed it, which was a higher proportion than previous studies have found. However, only 10.9% of those patients initiated peritoneal dialysis. The rates of peritoneal dialysis differed by region of the country and the dialysis organization caring for the patient.

The results indicate that nephrologists are discussing peritoneal dialysis with patients, but the quality and quantity of the information presented may be lacking, according to an editorial accompanying the studies. A problematic cycle may be under way in which fewer patients undergo peritoneal dialysis and so fewer physicians receive extensive training on their care, the editorialist speculated. That dynamic may be changed by the recently added Medicare benefit covering education for patients with stage 4 chronic kidney disease. If these initiatives successfully reverse the trend of decreasing peritoneal dialysis use, patient satisfaction may be increased while not compromising cost-effectiveness or survival, the editorialist concluded.


Medicare update

CMS releases new Medicare Contractor Provider Satisfaction Survey

The Centers for Medicare and Medicaid Services last week released the results from its 2010 survey of clinician satisfaction with the performance of their Medicare fee-for-service contractors.

Among this year’s survey findings: 69% of clinicians responded that they were satisfied or very satisfied with their contractor overall, while 13% said they were dissatisfied or very dissatisfied. The complete survey is available on the CMS website.


CMS distributing 2009 eRx Program incentive payments

The Centers for Medicare and Medicaid Services recently began distributing incentive payments to clinicians who successfully reported under the 2009 Electronic Prescribing Incentive Program.

Under the program, physicians who use e-prescribing can qualify for a bonus payment by submitting an additional e-prescribing code on claims for eligible patient visits. The payment distribution is scheduled to be completed by Oct. 22, and the complete feedback reports for the 2009 program will be available on the Internet the second week of November.

Additional information about the Medicare incentive program is available on the College website.


Educational opportunities

Medical students invited to apply for CDC Applied Epidemiology Fellowship

Medical students with a strong interest in public health or in practicing medicine with a broad, analytic perspective are invited to apply for the CDC Experience Applied Epidemiology Fellowship.

Eight competitively selected fellows will spend 10 to 12 months at the CDC offices in Atlanta, where they will carry out epidemiologic analyses in various areas of public health. Students will have opportunities to investigate outbreaks of disease in different populations, travel to help set up surveillance programs or engage in injury prevention research, to name a few examples.

The opportunity is open to third- and fourth-year medical students and is designed to increase the pool of physicians with a population health perspective. Application materials for the next fellowship class must be submitted by Dec. 3, 2010. More information is available online.


ACP’s Washington office now accepting internship applications

The College’s Washington office is now accepting applications for a newly created Health Policy Internship Program.

The interns will work with ACP staff to plan ACP’s annual Leadership Day and will be responsible for researching and presenting students and residents at Leadership Day with information on health policy issues relevant to those groups. Applicants must be enrolled in an accredited medical school or internal medicine training program and must be members of ACP. One associate member and one medical student member will be chosen for the month-long spring internship.

Additional details are available on the College website.


From ACP Internist

The October issue is online and coming to your mailbox

Monitoring glucose minute by minute The October issue of ACP Internist highlights continuous glucose monitoring, house calls and managing irritable bowel syndrome.

Monitoring glucose minute by minute. Continuous glucose monitoring presents challenges not only to patients, but to internists learning how best to teach their patients how to use monitors. With a lack of enough endocrinologists to care for the 1 million patients with type 1 diabetes, internists have to pick up the slack.

House calls becoming a viable practice model. Think of it as the patient-centered medical home’s ultimate evolution—care inside the patient’s own home. More doctors are making house calls, either to patients who don’t travel easily, or to improve the quality of care they can deliver in an office.

Expressive writing could help erase irritable bowel syndrome. Expressive writing, used for other illnesses with a known psychological component, is now being studied to control the symptoms of irritable bowel syndrome.

Also included are the latest installments of Mindful Medicine, how your photocopier is really your office's biggest security risk, and the latest MKSAP Quiz.


From the College

New iPhone app available for Annals of Internal Medicine

ACP has released a new iPhone application for its flagship journal, Annals of Internal Medicine. Available for free at the iPhone App Store, the Annals of IM application allows iPhone, iPod Touch, and iPad users to:

  • view abstracts from the current issue,
  • access published clinical guidelines,
  • see listings of In the Clinic and ACP Journal Club articles,
  • listen to podcasts and view videos and
  • access the “Popular” feed to see which recent Annals articles are creating the most media buzz.

The new Annals of IM iPhone application is available online.


ACP launches campaign on adult immunization awareness

In support of ACP’s ongoing commitment to educating patients about the importance of adult immunization, the College has launched a public awareness campaign, “Give Your Health A Shot.” The campaign emphasizes the need for adults to collaborate with their clinicians to ensure that vaccinations are part of their overall health and wellness goals. ACP worked with GlaxoSmithKline to develop patient education materials on vaccinations for adults.

More information about ACP’s Adult Immunization Initiative is online.


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 September and October 2010.


Cartoon caption contest

And the winner is …

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

"Welcome to New Age Podiatry Associates, where we treat the foot as if it were the whole person."

This issue's winning cartoon caption was submitted by Benjamin Galen, ACP Associate Member, an intern in the Yale Traditional Internal Medicine Residency Training Program in New Haven, Conn. Readers cast 104 ballots online to choose the winning entry. Thanks to all who voted!

The winning entry captured 37.5% of the votes.

The runners-up were:
"Sorry, we don't admit de feet."
"Worst case of pedal edema I've ever seen."


MKSAP Answer and Critique

The correct answer is A) CT scan of the abdomen. This item is available to MKSAP 15 subscribers as item 48 in the Gastroenterology and Hepatology module.

In a patient with a newly diagnosed gastric adenocarcinoma, the most important next step in staging would be to evaluate for metastatic disease. CT scan of the abdomen would assess for distant metastases, which would be concerning in this patient with profound weight loss and hepatomegaly. If no distant metastases are detected on initial staging, then endoscopic ultrasonography would be a helpful next test, because it can assess depth of invasion, whereas CT cannot accurately assess depth of early lesions. However, ultrasonography is less sensitive at determining metastatic disease, which is why it is not considered the initial test of choice for staging, especially considering most symptomatic patients such as this one have advanced disease at presentation.

Testing for Helicobacter pylori and eradication of the organism if present are recommended in patients with early-stage gastric cancer but would not be of benefit in someone with advanced disease. Positron emission tomography (PET) scanning should be considered preoperatively to follow up suspicious but indeterminate lesions on CT imaging, but it is not recommended as the initial step in staging.

Key Point

  • CT imaging is the next step after esophagogastroduodenoscopy in the staging of newly diagnosed gastric adenocarcinoma to evaluate for metastatic disease.

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 2010 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

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