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

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In the News
for the Week of 2-23-10

Highlights

  • Aspirin associated with decreased risk for breast cancer recurrence and death
  • Classifying diabetic nephropathy should improve clinical management

Test yourself

  • MKSAP Quiz: depression medication

Cardiology

  • Statins associated with slightly higher diabetes risk
  • Genetic risk scores don’t predict cardiovascular disease in women

Health statistics

  • New report assesses health in every U.S. county

FDA update

  • Anemia drugs require risk management
  • Confusing Maalox product to be renamed

From ACP Hospitalist

From the College

  • America’s health care in state of decline, says ACP at annual briefing
  • ACP's Steven Weinberger, FACP, blogs at KevinMD
  • Call for fall 2010 Board of Governors resolutions

Cartoon caption contest

  • Vote for your favorite entry

Physician editor: Darren Taichman, FACP


Highlights

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Aspirin associated with decreased risk for breast cancer recurrence and death

Women with breast cancer who take aspirin after their diagnosis may be less likely to experience recurrence or die of the disease, a new study reports.

Researchers used data from the Nurses’ Health Study to perform a prospective observational study of aspirin use in 4,164 women diagnosed with stage I, II, or III breast cancer between 1976 and 2002. Patients were observed until June 2006 or until death. The study’s main outcome measure was risk for death from breast cancer, according to number of days that aspirin was taken per week. Aspirin use was first assessed 12 months after cancer diagnosis because it is contraindicated during chemotherapy. The study results were published online Feb. 16 by the Journal of Clinical Oncology.

During follow-up, 341 women died of breast cancer. The adjusted relative risks (RRs) for breast cancer death with one, two to five, and six to seven days of aspirin use per week versus no use were 1.07 (95% CI, 0.70 to 1.63), 0.29 (CI, 0.16 to 0.52) and 0.36 (CI, 0.24 to 0.54), respectively. The association was not affected by adjustment for stage, menopausal status, body mass index, or estrogen-receptor status. The adjusted RRs for recurrence were 0.91 (CI, 0.62 to 1.33), 0.40 (CI, 0.24 to 0.65), and 0.57 (CI, 0.39 to 0.82) for the same aspirin use categories compared with no use.

The study was limited because some data were obtained by self-report and because the authors did not have information on aspirin dose, among other factors. However, the authors concluded that aspirin may have a beneficial effect on survival after a breast cancer diagnosis. They called for additional studies on aspirin’s mechanism of action in this population, including a possible randomized trial.

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Classifying diabetic nephropathy should improve clinical management

A research committee has developed pathological classifications for diabetic nephropathy to create a uniform system to guide patient care, improve communication between clinicians and renal pathologists, and help researchers design better clinical studies.

Diabetic nephropathy is a major cause of end-stage renal disease, and diabetes rates are rising rapidly. While classifications already exist for several other kidney diseases, the group wanted to develop a uniform, easy-to-use classification system for diabetes with specific categories that discriminate lesions.

The consensus group published their classifications online in the Journal of the American Society of Nephrology.

They classified diabetic nephropathy due to type 1 and type 2 diabetes together because of the "substantial overlap" of histologic lesions and renal complications.

Class Description Criteria
I Mild or nonspecific light microscopy changes and mesangial expansion-proven glomerular basement membrane thickening Biopsy does not meet any of the criteria mentioned below for class II, III, or IV. Glomerular basement membrane >395 nm in women and >430 nm in men
IIa Mild mesangial expansion Biopsy does not meet criteria for class III or IV. Mild mesangial expansion in >25% of the observed mesangium
IIb Severe mesangial expansion Biopsy does not meet criteria for class III or IV. Severe mesangial expansion in >25% of the observed mesangium
III Nodular sclerosis (Kimmelstiel–Wilson lesion) Biopsy does not meet criteria for class IV. At least one convincing Kimmelstiel–Wilson lesion
IV Advanced diabetic glomerulosclerosis Global glomerular sclerosis in >50% of glomeruli. Lesions from classes I through III

The group did not state whether the classifications predict clinical outcomes. Other renal disease classifications do not, and the experts decided validation should be done in separate prospective studies that include protocol biopsies of patients with type 1 and type 2 diabetes who meet clearly defined clinical end points.

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Test yourself

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MKSAP Quiz: depression medication

A 37-year-old man is evaluated during a routine visit and reports feeling depressed. He meets the criteria for major depression and generalized anxiety disorder. The medical history is otherwise noncontributory.

The physical examination, including vital signs, is normal. Laboratory studies are unremarkable.

Which of the following is the most appropriate treatment option for this patient?

A) Paroxetine
B) Bupropion
C) Clonazepam
D) Risperidone

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

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Cardiology

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Statins associated with slightly higher diabetes risk

Taking a statin slightly increases patients’ risk of developing diabetes, according to a new meta-analysis.

The analysis included 13 randomized, controlled trials of statins with more than 90,000 participants, of whom more than 4,000 developed diabetes during a mean follow-up of four years. Patients on statins had a 9% increased risk for incident diabetes (odds ratio, 1.09, 95% CI, 1.02 to 1.17) compared to those taking placebo. The diabetes risk was highest in trials with older patients, and controlling for body mass index and change in low-density lipoprotein cholesterol did not eliminate the association between statins and diabetes. The study was published online by The Lancet on Feb. 17.

Study authors were not able to determine the mechanism of the increased risk or exclude a potential confounding factor, such as patients who were not taking statins and suffered cardiovascular events converting to a healthy lifestyle and thereby lowering their diabetes risk. The finding of increased risk merits further study, but should not change practice for patients with moderate or high cardiovascular risk, the study authors concluded.

Treating 255 patients with statins for four years would result in one additional case of diabetes, but based on other trial data, it would also prevent 5.4 major coronary events, the researchers calculated. The potential diabetes risk should be taken into account when considering statin therapy in low-risk patients, the authors said. Clinicians may also want to respond to the results by monitoring the glucose levels of older patients on statins, an accompanying comment suggested.

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Genetic risk scores don’t predict cardiovascular disease in women

Genetic risk scores constructed from the medical literature were not significantly associated with total cardiovascular disease (CVD) in women, according to a new study.

Researchers used data from the Human Genome Research Institute to create two genetic risk scores, the first including 101 single-nucleotide polymorphisms (SNPs) associated with CVD and its risk factors and the second including 12 SNPs associated with incident CVD. The scores were evaluated in 19,313 white women participating in the Women’s Genome Health Study, a subset of the Women’s Health Study. Main outcome measures were incident myocardial infarction, stroke, arterial revascularization and cardiovascular death. The study was published in the Feb. 17 Journal of the American Medical Association.

Seven hundred seventy-seven CVD events occurred during a median of 12.3 years of follow-up. Of these, 199 were myocardial infarctions, 203 were strokes, 63 were CVD deaths and 312 were revascularizations. After adjustment for age, both risk scores were associated with increased CVD risk but were unable to distinguish between women who were at risk for cardiovascular events and those who were not (c index, 0.52 for both scores). After adjustment for traditional CVD risk factors, such as total cholesterol and blood pressure, the association between both scores and CVD risk disappeared while an association between self-reported family history and CVD persisted.

The study was limited in part because the authors were not able to include rare alleles in their genetic scores. However, the results have clinical relevance because they reinforce the utility of traditional risk factors and the importance of family history in determining CVD risk, the authors wrote. They noted that although the scores they tested were not helpful for risk prediction, their findings point to areas for additional research that may improve genetic prediction in the future.

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Health statistics

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New report assesses health in every U.S. county

A new report from the Robert Wood Johnson Foundation has ranked the health of every county in the United States.

The counties are ranked within their states based on the rate of people dying before age 75, the percentage of people reporting fair or poor health, the number of days people reported being in poor physical or mental health, and the rate of low-weight births. The research also gathered data on a number of factors that could affect health, including smoking, obesity, binge drinking, access to primary care, high school graduation, violent crime, air pollution, liquor store density, unemployment and the number of children living in poverty.

The study found that healthier counties tended to have more residents who were educated and employed, with access to primary care, healthy food and recreational facilities. Suburban and urban counties were also more likely to be healthy than rural counties, reported the Feb. 17 BusinessWeek. The research found significant disparities, even among neighboring counties, with unhealthy counties having double or triple the rates of premature death compared to the healthier counties.

The report is intended to mobilize community leaders to take action to make their counties healthier, according to a press release. A previous similar project in Kansas, for example, motivated efforts to improve urban residents’ access to healthy food shopping. The county-by-county data are available online.

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FDA update

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Anemia drugs require risk management

Erythropoiesis-stimulating agents (ESAs), sold under the brand names Epogen, Procrit, and Aranesp, now require a risk management program for their prescription and use, the FDA announced last week.

The program, known as a risk evaluation and mitigation strategy (REMS), has been instituted in response to studies showing that ESAs can increase the risk of tumor growth and shorten survival in patients with cancer and increase the risk of heart attack, heart failure, stroke or blood clots in patients who use these drugs for other conditions, according to an FDA press release.

As part of the REMS, a medication guide explaining the risks and benefits of ESAs must be provided to all patients taking the drugs. In addition, manufacturer Amgen was required to develop the ESA APPRISE (Assisting Providers and Cancer Patients with Risk Information for the Safe use of ESAs) program, which will provide specific training and certification for health care professionals who prescribe ESAs to patients with cancer.

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Confusing Maalox product to be renamed

A new Maalox product could potentially confuse consumers and, if misused, result in serious side effects, the FDA warned.

Maalox Total Relief is an upset stomach reliever and anti-diarrheal medication, unlike other over-the-counter Maalox products, which are antacids. Bismuth subsalicylate, the active ingredient in Maalox Total Relief, is not appropriate for individuals with a history of gastrointestinal ulcer disease or a bleeding disorder or individuals who are taking certain medications, including oral antidiabetic drugs, anticoagulants, non-steroidal anti-inflammatory drugs and other anti-inflammatory drugs, an FDA press release said.

The manufacturer has agreed to change the name and packaging of Maalox Total Relief, with the new product expected to be available in September 2010. In the meantime, the company will conduct an educational outreach program and monitor adverse events related to the medication.

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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 College’s monthly magazine reporting on trends in hospital medicine. Featured in the current issue:

ACP HospitalistPost-discharge calls. A simple phone call to a recently discharged patient can go a long way towards clarifying issues like medication use or the need for outpatient follow-up. It can also help lower readmission rates and boost patient satisfaction. Learn about different strategies hospitalist programs have used to make post-discharge calls a routine practice in their facilities.

Team meetings. Hospitals can help lower readmission rates by having regular staff meetings to discuss the status of various patients. The combined input of physicians, nurses and other care team members can change the course of care—including the date of discharge—and ultimately lead to better outcomes. Daily meetings can also improve relationships among health team members, thus helping increase job satisfaction. Learn tips for how to make team meetings work at your hospital.

Hand hygiene success story. Learn how the Greater Baltimore Medical Center used a multi-pronged approach to reach 90% hand hygiene compliance in some units of the hospital.

The rock star hospitalist. San Francisco hospitalist Rupa Marya, MD, didn't want to pick between her two loves of medicine and music. So she didn't. Read about how the singer-doctor balances two very different careers.

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. To subscribe, request ACP Hospitalist using promo code GAD.

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From the College

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America’s health care in state of decline, says ACP at annual briefing

ACP reminded President Obama and Congress that there is an urgent need to move forward on health care reform at the annual State of the Nation’s Health Care briefing, held in Washington last week.

“The unfortunate truth is that by many measures, the state of America’s health care is in decline,” said Joseph W. Stubbs, FACP, president of ACP. “We have too many uninsured, too few primary care physicians, and the cost of health care is rising faster than we can afford.”

Additional information about the briefing was included in last Friday’s issue of the ACP Advocate. The report that was released at the briefing is also available on ACP’s Web site.

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ACP's Steven Weinberger, FACP, blogs at KevinMD

Steven Weinberger, FACP, ACP's 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 the issues surrounding resident work hours.

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Call for fall 2010 Board of Governors resolutions

The deadline for submitting new resolutions to be heard at the fall 2010 Board of Governors Meeting is March 23, 2010. In initiating a resolution, ACP members have an opportunity to focus attention at the ACP national level on a particular issue or topic that concerns them. Members must submit resolutions to their Governor and/or chapter council. A resolution becomes a resolution of the chapter once the chapter council approves it.

In accordance with the ACP Board of Governors Resolutions Process, resolutions should clearly distinguish the action requested within its resolved clause(s) as either a policy resolve ("Resolved that ACP policy…") or a directive, which requests action/study on an issue ("Resolved that the Board of Regents…"). If more than one action is proposed, each should have its own resolved clause. Please contact your Governor if you have any questions regarding the resolution format.

The Board of Governors votes on new resolutions, which are then presented to the Board of Regents for action. Members can use the Electronic Resolutions System (ERS) to monitor the status of resolutions. Visit your chapter Web site and link to the ERS under the "Advocacy" heading.

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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.

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting continues through 8 a.m. March 1, with the winner announced in the March 2 issue.

"Eye, eye, eye, such a problem!"
"Never allow a patient to juggle during a radiologic exam."
"The good news is that you have excellent depth perception."

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MKSAP answer and critique

The correct answer is A) Paroxetine. This item is available online to MKSAP 14 subscribers in the General Internal Medicine section, Item 120.

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 has major depression and generalized anxiety disorder and should receive paroxetine. All the selective serotonin reuptake inhibitors and the serotonin norepinephrine reuptake inhibitors are effective for depression and generalized anxiety disorder and have Food and Drug Administration (FDA) approval for these indications. Bupropion is a proven antidepressant and clonazepam is a proven anxiolytic, but neither is FDA-approved for treating depression and anxiety. The atypical antipsychotic agents, such as risperidone, olanzapine, and quetiapine, are sometimes added to antidepressant therapy to augment response in patients with treatment-resistant major depressive disorder but are not indicated as monotherapy for major depression and dysthymia or generalized anxiety disorder.

Patients with depression commonly have some symptoms of anxiety also, and approximately one-third meet the criteria for a concomitant anxiety disorder. Depressive symptoms often respond more quickly to treatment than do anxiety symptoms, and it is not uncommon for anxiety to be “unmasked” during the first few weeks of antidepressant treatment.

Key Points

  • All the selective serotonin reuptake inhibitors and the serotonin norepinephrine reuptake inhibitors are effective for depression and generalized anxiety disorder and have Food and Drug Administration approval for these indications.
  • Depressive symptoms often respond more quickly to treatment than do anxiety symptoms, and it is not uncommon for anxiety to be “unmasked” during the first few weeks of antidepressant treatment.

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 48-year-old man is evaluated during a follow-up visit for urinary frequency. He reports no hesitancy, urgency, dysuria, or change in urine color. He has not experienced fevers, chills, sweats, nausea, vomiting, diarrhea, or other gastrointestinal symptoms. He feels thirsty very often; drinking water and using lemon drops seem to help. He has a 33-pack-year history of smoking. He has hypertension, chronic kidney disease, and bipolar disorder. Medications are amlodipine, lisinopril, and lithium. He has tried other agents in place of lithium for his bipolar disorder, but none has controlled his symptoms as well as lithium. What is the most appropriate treatment intervention for this patient?

Find the answer

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