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

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In the News
for the Week of 12-7-10

Highlights

  • PAD performance measures set to improve diagnosis, treatment
  • WHO issues guidelines on TB prevention in people with HIV in resource-constrained settings

Test yourself

  • MKSAP Quiz: follow-up visit for dermatomyositis

Hypertension

  • Home BP monitoring significantly lowers pressure

Prostate cancer

  • Simulation model suggests active surveillance offers greatest quality-adjusted life expectancy

Stroke

  • Recommended therapies after ischemic stroke less likely to be received by the elderly

Regulatory news

  • GAO to conduct survey on vaccinations under Medicare
  • 2009 PQRI and eRx feedback reports available

From the College

  • ACP's John Tooker, MACP, blogs at KevinMD
  • ACP Online medical students' page relaunched
  • Depression quality improvement program seeks participants

Cartoon caption contest

Physician editor: Darren Taichman, FACP

Editor's note: The WHO guidelines article has been updated to clarify that the guidelines apply to resource-constrained settings.


Highlights

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PAD performance measures set to improve diagnosis, treatment

The ankle brachial index (ABI), statins and antiplatelets, smoking cessation and supervised exercise programs form the core of new peripheral artery disease (PAD) performance measures intended to systematically improve diagnosis and treatment and thereby prevent cardiac events and premature death.

The American College of Cardiology/American Heart Association issued the performance measures for PAD. The measures are online and will be co-published in several cardiovascular journals.

Patients with peripheral artery disease have the highest rate of heart attacks, stroke and cardiovascular death, noted the report. They are up to six times more likely to die of heart disease compared to age-matched controls, and pooled results of eight randomized, prospective trials show patients with PAD and coronary disease are more than twice as likely to die one year after undergoing percutaneous coronary intervention than patients with coronary disease alone. Yet, PAD patients receive antiplatelet or statins much less frequently than patients with coronary artery disease.

The performance measures call for screening for PAD using the ankle brachial index in patients deemed at risk, defined as

  • all patients with exertional leg symptoms,
  • all patients ages 50 to 69 with cardiovascular risk factors, particularly diabetes or smoking,
  • all patients age 70 or older regardless of risk factors, or
  • all patients with a Framingham Risk Score 10% to 20%.

The measures also recommend treatments for PAD patients, including:

  • statin therapy to lower the low-density lipoprotein cholesterol to less than 100 mg/dL,
  • smoking cessation interventions ("the most potent modifiable risk factor for development of PAD," noted the report; continued tobacco use affects disease progression and graft patency),
  • antiplatelet therapy with aspirin or clopidogrel to reduce risk of heart attack, stroke or death in people with history of symptomatic PAD, defined as claudication, critical limb ischemia (ischemic rest pain, nonhealing ischemic ulcers, gangrene), a history of vascular reconstruction, bypass surgery, percutaneous intervention to the extremities, or amputation for critical limb ischemia.
  • supervised exercise programs (a minimum of 30 to 45 minutes, in sessions performed at least three times per week, for a minimum of 12 weeks. Randomized trials show that a supervised exercise program for claudication is able to increase patient walking distance by up to 200% as well as walking speed),
  • lower-extremity vein bypass graft surveillance via periodic ABI and ultrasound, and
  • monitoring of abdominal aortic aneurysms that are between 4.0 and 5.4 cm.

The goal of the performance measures is to increase the use of ABI and exercise programs, and thus improve patientsí overall well-being, quality of life and pain-free walking distance and speed, as well as reduce their risk of heart attack, stroke and death.

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WHO issues guidelines on TB prevention in people with HIV in resource-constrained settings

The World Health Organization issued new guidelines last week on preventing tuberculosis (TB) in people with HIV infection in resource-constrained settings.

Although HIV-infected people are more likely to develop active TB, isoniazid preventive therapy (IPT), a cost-effective way to protect against TB, is often underused in this population, the WHO said in a press release.

The guidelines' key recommendations, which update the WHO's 1998 policy on this topic, are as follows:

  • All HIV-infected children and adults, including pregnant women and those on antiretroviral treatment, should receive IPT.
  • IPT should be taken for six to 36 months, or for life in settings where HIV and TB are highly prevalent.
  • HIV-infected people with TB symptoms, such as cough, fever, weight loss or night sweats, should be further screened for active TB or other conditions so they can be treated appropriately.

Chest radiography is no longer required before starting IPT in HIV-infected patients, nor is a positive tuberculin skin test needed, although the latter "may be done as a part of eligibility screening in some settings," according to the guidelines. "The provision of IPT should not be viewed as an isolated intervention for people living with HIV. Rather, it should be part of a TB prevention package along with infection control for TB, [intensified case-finding] and provision of [antiretroviral therapy]," the guidelines stated.

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Test yourself

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MKSAP Quiz: follow-up visit for dermatomyositis

A 73-year-old man is evaluated during a follow-up visit for dermatomyositis. His condition was diagnosed 6 months ago. His serum creatine kinase level at that time was 3,000 U/L. His disease responded well to prednisone, 60 mg/d, which was gradually tapered to 20 mg/d. He also takes azathioprine, 150 mg/d; alendronate; and calcium and vitamin D supplements. He mentions that his muscle weakness has increased over the past month but denies myalgia, tenderness, or side effects related to azathioprine.

On physical examination, there are cushingoid facial changes. There is no rash. Muscle strength in the hip flexors and upper arms is 4/5. The muscles of the neck, back, upper arms, and legs are not tender to palpation.

Laboratory studies reveal a leukocyte count of 9,800/ĶL (9.8 ◊ 109/L) and a serum creatine kinase level of 170 U/L.

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

A) Decrease prednisone dosage
B) Increase azathioprine dosage
C) Substitute cyclosporine for azathioprine
D) Substitute methotrexate for azathioprine

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

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Hypertension

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Home BP monitoring significantly lowers pressure

Home monitoring lowers blood pressure significantly more than clinic care alone, according to a new meta-analysis of home monitoring trials.

More than 300 randomized controlled trials with over 9,000 participants were included in the analysis. All studies randomized patients to home-based or office-based blood pressure measurements and reported on either changes in blood pressure or percentage of patients achieving a pre-established goal of therapy. Overall, home-based monitoring lowered blood pressure by 2.63 mm Hg systolic and 1.68 mm Hg diastolic compared to clinic-based monitoring. Home monitoring also resulted in 11% more patients meeting their goal blood pressures, but the difference was not statistically significant. The analysis was published online by Hypertension on Nov. 29.

Some of the included trials used telemonitoring as part of the home measurement intervention, and even greater reductions in blood pressure were seen in those trials. Hemodialysis patients also appeared to benefit even more from the intervention than those not on dialysis. Another result of the home monitoring was that it overcame some therapeutic inertiaóthe home treatment arms showed more frequent antihypertensive medication reductions and fewer cases in which medication went unchanged despite elevated blood pressure.

Study authors concluded that home blood pressure monitoring is associated with a small but significant improvement in blood pressure control. However, they noted that the monitoring is of little value unless patients and their physicians act on the results, by titration of antihypertensive drugs, for example. The authors called for larger studies of home monitoring for hemodialysis patients, since the intervention appeared to be particularly beneficial to them. Future studies should also research the impact of factors such as patient motivation, physician commitment, frequency of visits and the need for quick treatment adjustment on the effectiveness of home monitoring, an accompanying editorial suggested.

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Prostate cancer

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Simulation model suggests active surveillance offers greatest quality-adjusted life expectancy

Active surveillance was associated with the greatest quality-adjusted life expectancy (QALE) in men over the age of 65, a simulation model comparing treatments for prostate cancer predicted.

To examine the value of active surveillance compared with initial treatment, researchers used a simulation model of hypothetical cohorts of 65-year-old men newly diagnosed with clinically localized, low-risk prostate cancer, defined as prostate-specific antigen level <10 ng/mL, stage ≤T2a disease, and Gleason score ≤6. Results appeared in the Dec. 1 issue of the Journal of the American Medical Society.

The model projected outcomes of treating the hypothetical men in various ways. The first involved active surveillance, defined as closely monitoring newly diagnosed patients with serial prostate-specific antigen measurements, digital rectal examinations and biopsies, with treatment at disease progression or patient choice. The second involved treatment at diagnosis with brachytherapy, intensity-modulated radiation therapy or radical prostatectomy. Probabilities and utilities were derived from previous studies and literature review. The relative risk of prostate cancer-specific death for initial treatment vs. active surveillance was assumed to be 0.83. Men incurred short- and long-term adverse effects of treatment.

Active surveillance was associated with the greatest QALE (11.07 quality-adjusted life-years [QALYs]), followed by brachytherapy (10.57 QALYs), radiation (10.51 QALYs), and prostatectomy (10.23 QALYs). When compared, surveillance was associated with 6.0 more months of QALE than brachytherapy, which itself provided 4.1 more months of QALE than prostatectomy.

Researchers also conducted a threshold analysis to identify how much greater the risk of death from prostate cancer would have to be for the surveillance and treatment to be associated with equal QALE. They found that 15% of men undergoing surveillance would have to die of prostate cancer compared to 9% who underwent treatment, a lifetime relative risk of death of 0.6 for treatment compared to surveillance.

"Even if choosing active surveillance places men at a substantially higher risk of dying of prostate cancer or the risk of progressive disease on active surveillance is doubled, active surveillance is associated with higher QALE," the authors wrote.

Limitations include that the model applies only to men age 65 or more, and doesnít consider comorbidities common in older men. This study also includes the limitations of the research upon which model inputs were based. Also, decisions must still be tailored to individuals, and models should be developed to account for such variables, the authors concluded.

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Stroke

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Recommended therapies after ischemic stroke less likely to be received by the elderly

Older patients, especially those who are very elderly, those admitted from skilled nursing facilities, and those with functional dependence, are less likely to receive recommended antithrombotic medications after an ischemic stroke, according to a new study.

Researchers analyzed data from 31,554 Medicare fee-for-service beneficiaries who were discharged after an ischemic stroke and were randomly chosen for the Medicare Health Quality Improvement Program's National Stroke Project in 1998-1999 and 2000-2001. The purpose of the study was to examine age-specific differences in receipt of deep venous thrombosis (DVT) prophylaxis and antithrombotics, as well as whether certain patient characteristics were associated with appropriate treatment or lack thereof. Patients were divided into age groups of 65 to 74 years, 75 to 84 years, and 85 years or older. The study was published online Nov. 23 by Circulation: Cardiovascular Quality and Outcomes.

The authors found that 14.9% of those eligible to receive in-hospital pharmacologic DVT prophylaxis actually received it. Rates were higher among those eligible for in-hospital treatment with antiplatelet drugs (83.9%) and anticoagulants for atrial fibrillation (82.8%), and for those eligible to be dismissed on an antithrombotic medication (74.2%). In general, treatment became less likely with increasing age, and patients older than 85 years were least likely to receive recommended treatment (11.4% received DVT prophylaxis, 78.3% received antiplatelet medications, 76.3% received anticoagulants for atrial fibrillation, and 70.3% received antithrombotics at discharge). Patients admitted from a skilled nursing facility and those with functional dependence were also less likely to receive these therapies.

The authors noted that their study may have underestimated the proportion of patients prescribed antithrombotics because of missing documentation, especially for aspirin, and that they had no data on physicians' decision-making regarding prescription of these therapies. However, they concluded that antithrombotic therapies were likely to be underused in elderly patients, particularly in those of increasing age, those transferred from a skilled nursing facility, and those with functional dependence. They called for further studies to determine the reasons behind the apparent discrepancies between recommended and actual treatment in these groups, since their data suggest an opportunity to improve care.

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Regulatory news

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GAO to conduct survey on vaccinations under Medicare

The Governmental Accountability Office will be sending a survey this week to selected internal medicine and family physicians about Medicare beneficiariesí access to recommended vaccines.

The survey is being conducted to provide Congress with information about potential barriers that Medicare beneficiaries may face in obtaining routinely recommended vaccines. Physicians were randomly selected from those who see a minimum number of Medicare beneficiaries. ACP encourages physicians who receive the survey to complete and return it. The survey will be conducted until the middle of February. For additional information, e-mail nkirschner@acponline.org.

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2009 PQRI and eRx feedback reports available

Feedback reports for the 2009 Physician Quality Reporting Initiative (PQRI) and the Electronic Prescribing (eRx) Incentive Program became available at the end of November.

CMS had begun the release of these reports earlier this fall. However, production was halted after problems were found with the information in some of the reports. The problem has been resolved and the reports are available on the PQRI portal.

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From the College

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ACP's John Tooker, MACP, blogs at KevinMD

John Tooker, MACP, ACP's Associate Executive Vice President, continues his monthly column at KevinMD.com, one of the Web's most influential medical blogs. This month's column looks at two recent reports that remind us of the urgent need to improve safety and quality.

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ACP Online medical students' page relaunched

ACP's newly reorganized medical student landing page offers unique and useful resources to students in an interactive, easy-to-navigate setting.

Features include career guidance, competitions and quiz questions, peer groups, a social networking group, blogs, mentoring programs, and a newsletter including advocacy updates. Check out the new series of IMpact "My Kind of Medicine" multimedia physician profiles, highlighting interesting people and career paths in internal medicine. The entire archive of the "My Kind of Medicine" series, and many other valuable resources, is available with just one click.

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Depression quality improvement program seeks participants

Physicians are invited to participate in ACPís new quality improvement program on depression.

This free Web-based program offers physicians the chance to earn up to 30 performance improvement CME credits and credit towards American Board of Internal Medicine Part 4 Maintenance of Certification. This program will help physicians to analyze their own practice patterns, evaluate actual practice data in identifying gaps, and learn how to implement clinical quality improvement tools and techniques.

Participants will also communicate with national experts via conference call to interact and receive guidance on practice improvement. The program is done for free without leaving the office. Physicians will be asked to complete both a survey and set of chart abstractions twice during the program and will be given access to a Web-based educational module on depression. The first 50 physicians to enroll in the program will be entered into a raffle to win either MKSAP 15 or Internal Medicine 2011 registration. If you are interested in participating in this program, please contact Meghan Gannon at mgannon@acponline.org.

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Cartoon caption contest

And the winners are Ö

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. The vote was tied this week, with two winners who will share in the prize.

"Most men your age would be more than pleased to be able to touch their toes."
Submitted by William Arkinstall, FACP, Kelowna, British Columbia, Canada

"If this impresses you, just wait until the genital exam."
Submitted by Erin Coleman, FACP, Birmingham, Ala.

Readers cast 133 ballots online to choose the winning entry. Thanks to all who voted! The winning entries each captured 27.8% of the votes.

The runners-up were:

"I should have listened when you told me Ehlers-Danos and monkey bars don't mix."
"I've never seen a case of palmar fasciitis."

ACP InternistWeekly's cartoon caption contest continues next week.

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MKSAP answer and critique

The correct answer is A) Decrease prednisone dosage. This item is available to MKSAP 15 subscribers as item 58 in the Rheumatology section.

This patient most likely has corticosteroid-induced myopathy, and the most appropriate next step in his management is to decrease the prednisone dosage. He has progressive muscle weakness, but the significant decrease in his creatine kinase level suggests that his dermatomyositis is well controlled. Improvement in muscle strength typically is preceded by improvement in the creatine kinase level, but the discrepancy between this patientís findings on laboratory studies and symptoms is highly suggestive of a secondary cause for his weakness.

Corticosteroid-induced myopathy should be suspected in patients with polymyositis or dermatomyositis treated with corticosteroids who develop progressive weakness despite significant improvement in muscle enzyme levels. This patientís cushingoid features also are consistent with this condition.

The most appropriate management of a patient whose clinical presentation raises concern for corticosteroid-induced myopathy is to decrease the corticosteroid dosage and closely monitor the creatine kinase level for elevations. If corticosteroid-induced myopathy is causing this patientís symptoms, his muscle weakness should begin to resolve 3 to 4 weeks after his prednisone dosage is decreased.

Increasing the azathioprine dosage would not be warranted in a patient with dermatomyositis whose creatine kinase level is not significantly elevated. Furthermore, this intervention would not directly address this patientís underlying corticosteroid-induced myopathy.

Cyclosporine is an adjunct or substitute for methotrexate and azathioprine in patients in whom these agents are ineffective in the treatment of myositis or in those who cannot tolerate these agents. This patient is tolerating azathioprine, and there is therefore no need to add or substitute cyclosporine.

Methotrexate is effective in the treatment of inflammatory myositis and is an alternative steroid-sparing drug to azathioprine. However, the patientís condition is responsive to his current medication regimen of corticosteroids and azathioprine, and substituting methotrexate is not likely to offer any advantage to a patient with corticosteroid-induced myopathy.

Key Point

  • Corticosteroid-induced myopathy should be suspected in patients with polymyositis or dermatomyositis treated with corticosteroids who develop progressive weakness despite significant improvement in muscle enzyme levels.

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Copyright 2010 by the American College of Physicians.

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