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

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In the News
for the Week of 2-9-10

Highlights

  • Proteinuria predicts mortality in kidney patients
  • Federal government expands mental health parity coverage

Test yourself

  • MKSAP Quiz: diagnostics for viral hepatitis

Neurology

  • Antidepressant may help cognitive recovery after stroke

Menís health

  • Internists should follow up with prostate cancer patients receiving ADT

FDA update

  • Some H1N1 vaccine to expire next week
  • Didanosine gets labeling change
  • Hemodialysis system recalled

From the College

  • ACP EVP stays on with National eHealth Collaborative as board member
  • New trivia game by ACP on Facebook
  • Fellow chosen by New Jersey governor
  • For the record

Cartoon caption contest

Physician editor: Darren Taichman, FACP


Highlights

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Proteinuria predicts mortality in kidney patients

Proteinuria is a useful predictor of outcomes in patients with chronic kidney disease, a new study found.

The Canadian cohort study included more than 900,000 adults who had at least one outpatient serum creatinine measurement and did not require dialysis at baseline. Data were gathered in a 2002-2007 registry that included estimated glomerular filtration rates (eGFRs) and proteinuria measurements. The study was published in the Feb. 3 Journal of the American Medical Association.

Over the median follow-up of 35 months, 3% of the patients died. Although mortality rates were higher overall in patients with lower eGFRs, adjusted mortality rates were more than twice as high in patients with heavy proteinuria and eGFR of at least 60 mL/min/1.73 m2 compared to patients with normal protein excretion and eGFR of 45 to 59.9 mL/min/1.73 m2. Similar results were observed whether proteinuria was measured by urine dipstick or albumin-creatinine ratio. The study also found similar trends for the outcomes of hospitalization with acute myocardial infarction, end-stage renal disease and doubling of serum creatinine level.

Based on the results, it appears that patients with heavy proteinuria and normal eGFR have worse outcomes than those with moderately reduced eGFR and no proteinuria, the study authors concluded. Although current guidelines call for staging chronic kidney disease (CKD) based on eGFR, they should perhaps be revised, given that use of that measurement alone may miss clinically relevant gradients in risk. The authors also suggested that consideration be given to subdividing CKD stage 3, since their study found significant heterogeneity of risk among this population.

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Federal government expands mental health parity coverage

Group health plans will be required to provide coverage for mental and substance use disorders that is equivalent to their medical benefits under a new rule issued by the Obama administration.

The rule, which was jointly issued by the Departments of Health and Human Services, Labor and the Treasury last week, prohibits group health insurance plans from restricting access to care by limiting benefits and requiring higher patient contributions, according to an HHS press release. The rules implement the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).

MHPAEA expands on an earlier law, the Mental Health Parity Act of 1996, which required parity in aggregate lifetime and annual dollar limits between the categories of benefits and did not extend to substance use disorder benefits. The new law, which applied to employers of 50 or more workers, requires that any group plan that includes mental health and substance use disorder benefits along with standard medical and surgical coverage must treat them equally in terms of out-of-pocket costs, benefit limits and practices such as prior authorization and utilization review.

The mental health and substance use coverage must be based on the same level of scientific evidence used by the insurer for medical and surgical benefits. For example, a plan may not apply separate deductibles for treatment related to mental health or substance use.

The new rules will come into effect for plan years beginning on or after July 1, 2010. Comments on the interim final rules are being solicited for the next 90 days. Sections where further comments are being specifically sought include non-quantitative treatment limits, such as those that pertain to the scope and duration of covered benefits, drug formularies, and the coverage of step-therapies. Comments are also being specifically requested on the regulation's section on scope of benefits or continuum of care. Comments may be e-mailed through the federal rulemaking portal.

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Test yourself

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MKSAP Quiz: diagnostics for viral hepatitis

A 44-year-old man was recently found to have abnormal serologic test results for viral hepatitis when he attempted to donate blood. The patient is asymptomatic. He used injection drugs and drank alcohol excessively for two years 25 years ago but has not used either drugs or alcohol since. Medical history is otherwise unremarkable, and he takes no medications.

Physical examination discloses a BMI of 23, no stigmata of chronic liver disease, and a normal-sized liver.

Laboratory studies

Serum aspartate aminotransferase 53 U/L
Serum alanine aminotransferase 64 U/L
Serum alkaline phosphatase 89 U/L
Serum total bilirubin 0.9 mg/dL (15.39 Ķmol/L)
Hepatitis B surface antigen (HbsAg) Negative
Antibody to hepatitis B surface antigen (anti-HBs) Positive
IgG antibody to hepatitis B core antigen (IgG anti-HBc) Positive
IgM antibody to hepatitis B core antigen (IgM anti-HBc) Negative
Antibody to hepatitis C virus (anti-HCV) Positive

Abdominal ultrasonography is normal.

Which of the following diagnostic studies should be done next?

A) Hepatitis B e antigen (HBeAg)
B) Hepatitis B virus DNA (HBV DNA)
C) Hepatitis C virus RNA (HCV RNA)
D) IgM antibody to hepatitis A virus (IgM anti-HAV)

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

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Neurology

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Antidepressant may help cognitive recovery after stroke

Treatment with the antidepressant escitalopram may enhance cognitive recovery after stroke, according to a new study.

Researchers at the University of Iowa conducted a single-center study to determine if therapy with escitalopram would affect cognitive outcomes after stroke. Within three months of an index stroke, patients were assigned to a double-blind, placebo-controlled arm that compared escitalopram with placebo or a nonblinded arm involving problem-solving therapy, a psychological treatment that teaches patients how to deal with their problems. The main outcome measures were changes in several neuropsychological tests, including the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), performed at baseline and at the end of the intervention period. The study was funded by the National Institute of Mental Health and was published in the February Archives of General Psychiatry.

One hundred twenty-nine patients were randomly assigned--43 to escitalopram, 45 to placebo, and 41 to problem-solving therapy--but 12 withdrew before beginning treatment and seven withdrew after treatment began. Patients who were randomly assigned to problem-solving therapy were older than patients in the other two groups. At 12 months, the authors found that escitalopram had a significant effect on total RBANS score (adjusted mean change, 10.0 in the escitalopram group vs. 3.1 in the nonescitalopram groups; P<0.01) and RBANS delayed memory score (adjusted mean change, 11.3 in the escitalopram group vs. 2.5 in the nonescitalopram groups; P<0.01). Rates of adverse events did not differ among groups.

The authors acknowledged their study's limitations, including the limited generalizability of their findings and the difference in age between patients who received escitalopram and those who did not. However, they concluded that escitalopram was associated with improved global cognitive function, specifically verbal and visual memory, in patients who had had a stroke, independent of its effects on depression. "The utility of antidepressants in the process of poststroke recovery deserves to be further investigated," the authors wrote.

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Menís health

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Internists should follow up with prostate cancer patients receiving ADT

Studies that suggest a possible association between androgen-deprivation therapy (ADT) and an increased risk of cardiovascular events, including myocardial infarction and cardiovascular mortality, may be driving more consultations between patients, internists, endocrinologists and cardiologists.

To inform these consultations, a multispecialty group assembled a science advisory, a strictly informative paper that should not dictate clinical practice or supersede the clinical judgment of a physician. The paper was published online in the Feb. 1 Circulation.

ADT is widely used for prostate cancer. It's a mainstay for overt metastatic disease, and the standard of care for high-risk prostate cancer when combined with external-beam radiation therapy. ADT is also often used for prostate volume reduction in men before definitive local therapy with brachytherapy, or to treat rising prostate-specific antigen levels after definitive local treatment.

Observed cardiovascular effects noted in the literature include:

  • decreased lean body mass and increased fat mass,
  • increased serum cholesterol and triglyceride levels, and
  • increased fasting plasma insulin levels, a marker of insulin resistance in men with prostate cancer.

The advisory states that patients do not need to be referred to internists, endocrinologists or cardiologists for evaluation before starting ADT. They should see their primary care physician within three to six months after starting ADT to assess blood pressure, lipid profile and glucose level. However, no data guide further follow-up intervals.

The physician treating the patient for prostate cancer should decide whether to start ADT in patients with cardiac disease, and should weigh benefits against potential risks, specifically for patients with known coronary artery disease.

Cardiologists in particular should not feel compelled to perform any specific testing or coronary intervention before starting ADT. No data suggest that stress testing can predict potential future cardiac risks, or that revascularization before ADT would decrease future cardiovascular risk, the advisory says.

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FDA update

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Some H1N1 vaccine to expire next week

The expiration date for Sanofi Pasteurís 2009 H1N1 influenza vaccine in pre-filled syringes has been moved up to Feb. 15, 2010, the CDC announced last week.

The expiration date is being changed to ensure that the vaccine meets potency standards, according to the CDC. The vaccine does not pose any safety concerns and people who received vaccine from the lots with shortened shelf life do not need to take any action. The lots had previous expiration dates ranging from March to June 2011. The change does not include Sanofi Pasteurís 2009 H1N1 influenza vaccine in multi-dose vials. A full list of affected vaccine is online.

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Didanosine gets labeling change

Patients taking didanosine (Videx/Videx EC) have a newly recognized risk of non-cirrhotic portal hypertension, the FDA notified health care providers last week.

The medication, which is used to treat HIV infection, has been found to be associated with the liver problem based on reports submitted to the FDA's Adverse Event Reporting System. Because of the potential severity of portal hypertension, including death from hemorrhaging esophageal varices, the FDA has revised the warning and precautions section of the drug label.

The FDA believes the clinical benefits of didanosine for certain patients with HIV continue to outweigh its potential risks. The decision to use this drug, however, must be made on an individual basis between the treating physician and the patient, the agency said.

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Hemodialysis system recalled

The Aquarius Hemodialysis System is being recalled due to reports of clinically significant fluid imbalance and the potential for users to repeatedly override the fluid imbalance alarm, the FDA announced last week.

The class I recall includes model numbers GEF08200, GEF09500, GEF09600, GEF09700, and GEF09800, using software version 6.00.04. The product was distributed from July 12, 2007 through March 18, 2009. A software upgrade will be made to prevent users from bypassing the fluid balance alarm more than five times in a 20-minute period.

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From the College

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ACP EVP stays on with National eHealth Collaborative as board member

ACP Executive Vice President and CEO John Tooker, MBA, FACP, continues his commitment to the National eHealth Collaborative (NeHC) as one of nine newly elected members of the Board of Directors.

Dr. Tooker was one of three founding incorporators of NeHC, and served as the founding board chair until December 2009. The NeHC was created as the planned successor to the American Health Information Community (AHIC), a federal advisory committee to the U.S. Department of Health and Human Services (HHS) until 2008. The current objective of the NeHC as a public-private partnership is to improve individual and population health by developing a secure, interoperable, nationwide health information system. Present NeHC Board Chair Laura Adams said new board of director members were elected to better facilitate the level of engagement and collaboration among stakeholders that the organization feels is necessary to achieve its goals. The elected members will be introduced at a stakeholder forum on Feb. 22 in Washington, D.C. More information about the forum and the NeHC is available online.

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New trivia game by ACP on Facebook

Test your knowledge and have fun at the same time. Try out ACP's new Facebook trivia game, ďAre you an internist?Ē

The game features 10 questions derived from ACPís popular Medical Knowledge Self-Assessment Program (MKSAP). Take the quiz now, invite your friends and see how you rank. Check back monthly for updated questions.

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Fellow chosen by New Jersey governor

Last week, Poonam Alaigh, FACP, director of Horizon Blue Cross Blue Shield of New Jersey, was named commissioner of the New Jersey Health and Senior Services Department by Gov. Chris Christie.

Dr. Alaigh has previously served as national medical director for GlaxoSmithKline and is an assistant professor in the department of family practice at UMDNJ/Robert Wood Johnson University Medical School, according to the New Jersey Newsroom.

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For the record

The "Test yourself" item in last week's ACP InternistWeekly contained an error. The last sentence of the critique should have read "Thiazide-type diuretics should generally be used as initial therapy for most patients with hypertension, either alone or in combination with an angiotensin-converting enzyme inhibitor, an angiotensin receptor blocker, a Ŗ-blocker, or a calcium-channel blocker," not "and angiotensin receptor blocker Ö". The sentence has been corrected.

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Cartoon caption contest

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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 acpinternist@acponline.org. ACP staff will choose three finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.

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MKSAP answer and critique

The correct answer is C) Hepatitis C virus RNA (HCV RNA). This item is available online to MKSAP 14 subscribers in the Gastroenterology and Hepatology section, Item 12.

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.

Answer and Critique

This patient has elevated serum aminotransferase values and positive antibodies to hepatitis C virus (anti-HCV). In a patient with a history of injection drug use, these findings are highly suggestive of hepatitis C, and an HCV RNA study should be done to confirm the presence of viremia.

Positive tests for antibody to hepatitis B surface antigen (anti-HBs) and IgG antibody to hepatitis B core antigen (IgG anti-HBc) are consistent with immunity from prior infection, and determination of hepatitis B e antigen (HBeAg) and HBV DNA is therefore not necessary. Testing for IgM antibody to hepatitis A virus (IgM anti-HAV) is not indicated because acute hepatitis A tends to cause systemic symptoms, jaundice, and more marked elevations in serum aminotransferase values.

Key Points

  • Elevated serum aminotransferase values and a positive assay for antibody to hepatitis C virus (anti-HCV) in a patient with risk factors for HCV are highly suggestive of the presence of hepatitis C.
  • Patients with a positive assay for antibody to hepatitis C virus (anti-HCV) should be tested for HCV RNA to determine if viremia is present.

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.

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Copyright 2010 by the American College of Physicians.

Test yourself

A 57-year-old woman is evaluated for a 2-week history of decreased exercise tolerance and substernal chest pain on exertion. She also has an 8-month history of macrocytic anemia. Following a physical exam, lab results, and electrocardiogram, what is the most likely diagnosis?

Find the answer

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