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

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In the News
for the Week of 3-16-10

Highlights

  • Hip fractures increase mortality five- to eightfold, more so in men
  • ACCP issues consensus statement on managing dyspnea in advanced heart or lung disease

Test yourself

  • MKSAP Quiz: severe head and neck pain

Mental health

  • Psychiatric tool adds disorders, guidance to primary care screening

Cardiology

  • Elective cardiac cath found to have low diagnostic yield

Practice patterns

  • Many hospitalists don't perform individual 'core competencies' in a given year

From the College

  • Health professionals to march for health care reform
  • Pay-for-performance models can support medical professionalism
  • ICD-10 summit to be held in April

Cartoon caption contest

Physician editor: Darren Taichman, FACP


Highlights

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Hip fractures increase mortality five- to eightfold, more so in men

Older adults are five to eight times as likely to die for any reason in the first three months after hip fracture, and although excess annual mortality decreases in the next two years, it does not return to the rate of age-matched peers even after 10 years of follow-up.

Also, at any given age, mortality after hip fracture is higher in men than in women, concluded a meta-analysis.

Researchers conducted the meta-analysis of 578,436 women and 154,276 men with hip fracture. They published results in the March 16 Annals of Internal Medicine.

Chosen studies all included a life-table analysis, and displayed the survival curves of the hip fracture group and age- and sex-matched control groups. Cohorts comprised the general population in 17 studies, Medicare enrollees in three studies, hospital control participants without hip fracture in two studies, and community-dwelling participants without hip fracture in two studies. Survival was documented from one to 15 years after injury.

Time-to-event meta-analyses showed that the relative hazard for all-cause mortality in the first three months after hip fracture was 5.75 (95% CI, 4.94 to 6.67) in women and 7.95 (CI, 6.13 to 10.30) in men. In both sexes, excess mortality after hip fracture depends largely on age, researchers concluded. Life-table methods showed that white women who have a hip fracture at age 80 have excess annual mortality compared to age-matched white women without a fracture of 8%, 11%, 18% and 22% at one, two, five and 10 years after injury, respectively. Men with a hip fracture at age 80 years have excess annual mortality of 18%, 22%, 26% and 20% at one, two, five and 10 years after injury, respectively.

Several factors may contribute to the marked increase in short-term relative mortality risk after hip fracture. These include:

  • postoperative events associated with hip surgery, such as pulmonary embolism,
  • infectious complications,
  • heart failure, or
  • cardiovascular or pulmonary complications.

Multiple comorbidities predisposing to fracture, such as dementia, chronic obstructive pulmonary disease, psychiatric conditions, cardiovascular disease, kidney disease and neurologic diseases, could also increase short-term mortality risks and merit further study, the authors said.

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ACCP issues consensus statement on managing dyspnea in advanced heart or lung disease

The American College of Chest Physicians has issued a consensus statement on the management of dyspnea in advanced heart or lung disease.

Dyspnea is a common problem in patients with advanced heart or lung disease, but its treatment is not consistent. The ACCP convened an expert panel of pulmonologists, cardiologists, nurses and palliative care specialists to summarize evidence and improve treatment. The panel looked at evidence regarding “dyspnea that persists at rest or with minimal activity and is distressful despite optimal therapy of advanced lung or heart disease.”

The panel focused on five categories: measurement of patient-reported dyspnea, oxygen therapy for relief of dyspnea, other nonpharmacologic therapies for relief of dyspnea, opioid medications for relief of dyspnea and ethical issues for relief of dyspnea at the end of life. Their recommendations included the following:

  • Patients should be asked to routinely and regularly rate the intensity of their breathlessness as part of a comprehensive care plan, and such ratings should be routinely documented in the medical record to help guide care.
  • Supplemental oxygen can help relieve dyspnea in patients who are hypoxemic at rest or during minimal activity.
  • Pursed-lip breathing and relaxation can be effective strategies for relief of dyspnea.
  • Oral and/or parenteral opioids can provide dyspnea relief.
  • Concerns about contributing to addiction and/or physical dependence should not limit effective treatment or palliation of dyspnea.

The consensus statement appears in the March CHEST.

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Test yourself

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MKSAP Quiz: severe head and neck pain

An 82-year-old woman is evaluated for a 2-week history of severe headaches and neck pain. She has stiffness and aching in her shoulders, neck and lower back.

On physical examination, the scalp is diffusely tender to palpation. Funduscopic examination is unremarkable, and she has carotidynia. On musculoskeletal examination, muscle strength testing is limited because of muscle pain. Biceps and triceps reflexes are 2+ and symmetrical.

Laboratory studies

Hemoglobin 10.7 g/dL (107 g/L)
Erythrocyte sedimentation rate 25 mm/h
Creatine kinase 184 U/L (3.07 µkat/L)

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

A) MRI of the head
B) Electromyography
C) Temporal artery biopsy
D) Doppler ultrasonography of the carotid artery

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

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Mental health

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Psychiatric tool adds disorders, guidance to primary care screening

A new tool offers valid, efficient and feasible psychiatric screening in a primary care setting for depression, anxiety, bipolar disorder and post-traumatic stress disorder, researchers said.

Available screening tools focus on specific types of depression or anxiety and provide little guidance for management. Researchers studied the My Mood Monitor (M-3) checklist, a one-page tool to screen for four psychiatric disorders in primary care. Results were reported in the March Annals of Family Medicine.

The M-3 is a self-reported symptom checklist that asks whether the patient has experienced symptoms of major depressive disorder (7 questions), generalized anxiety disorder (2 questions), panic disorder (2 questions), social anxiety disorder (1 question), post-traumatic stress disorder (4 questions), and obsessive compulsive disorder (3 questions) during the past two weeks. It also asks about a lifetime history of symptoms of bipolar spectrum disorder (4 questions). At the end of the symptom checklist, the M-3 poses four functional impairment questions.

Researchers enrolled a sample of 647 consecutive participants aged 18 years and older who were seeking primary care at a single academic family medicine clinic between July 2007 and February 2008. The clinic's 55 clinicians saw 18,000 patients annually, with a mean age of 45.7 years, 60% of whom were women. Nearly two-thirds of clinic patients were white (63%); the rest were black (30%) or another ethnicity (7%). Participants completed the M-3 in the waiting room. Within 30 days, a research assistant administered the Mini International Neuropsychiatric Interview (MINI) to participating patients by telephone as a diagnostic standard.

The M-3 modules had sensitivities of at least 0.82 and specificities of at least 0.70 for bipolar disorder, anxiety and PTSD. As a screen for any psychiatric disorder, sensitivity was 0.83 and specificity was 0.76. At the end of the clinic visits, participants and their physicians completed questionnaires assessing the feasibility of use. Patients took less than five minutes to complete the M-3 in the waiting room, and less than 1% reported not having time to complete it. Eighty-three percent of clinicians reviewed the checklist in 30 or fewer seconds, and 80% thought it was helpful in reviewing patients’ emotional health.

Guidelines suggest that depression screening should only be done in primary care settings that can then offer support or referral for care. Read more in the March issue of ACP Internist.

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Cardiology

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Elective cardiac cath found to have low diagnostic yield

Cardiac catheterization revealed obstructive coronary artery disease (CAD) in less than 40% of patients without previously diagnosed CAD who underwent the procedure, a new analysis found.

Using registry data from 663 U.S. hospitals, the study assessed almost 400,000 patients who underwent elective cardiac catheterization between 2004 and 2008. Of those patients, 37.6% had obstructive coronary disease, defined as stenosis of 50% or more of the left main coronary artery or 70% or more of a major epicardial vessel. Noninvasive testing had already been performed in 83.9% of the patients, but the study found that a positive result on a noninvasive test was only moderately predictive of obstructive disease, compared to patients who weren’t tested.

The study did confirm the predictive value of some traditional risk factors for coronary artery disease. Male sex (odds ratio, 2.70; 95% CI, 2.64 to 2.76), older age (odds ratio per 5 years, 1.29; CI, 1.28 to 1.30), insulin-dependent diabetes (odds ratio, 2.14; CI, 2.07 to 2.21), and dyslipidemia (odds ratio, 1.62; CI, 1.57 to 1.67) were all independent predictors of obstructive disease. The study was published in the March 11 New England Journal of Medicine.

Based on the results, study authors called for improvement of current decision-making strategies for the use of invasive angiography. Particular attention should be paid to the 30% of patients who had no symptoms, given that the primary benefit of catheterization is relief of symptoms, and therefore the benefit to these patients is uncertain, they said. Improvement strategies for patient selection for catheterization should include, but not be limited to, improvements to the quality of noninvasive testing, the authors concluded.

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Practice patterns

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Many hospitalists don't perform individual 'core competencies' in a given year

Though hospitalists perform more of the nine inpatient procedures designated as "core competencies" by the Society of Hospital Medicine (SHM) than non-hospitalists, only 11% perform all these procedures in a given year, a survey found.

Researchers analyzed data from a national survey mailed to internal medicine members of the American College of Physicians in 2004; 1,059 were eligible respondents. The survey asked whether respondents had performed any of 40 different bedside procedures in the last year, and the individual volume of those they had performed. Of the 40 procedures, researchers evaluated nine that have been designated as core competencies by SHM: electrocardiogram interpretation, chest X-ray interpretation, arthrocentesis, thoracocentesis, abdominal paracentesis, lumbar puncture, central line placement, endotracheal intubation and ventilator management. They defined hospitalists as respondents who spent more than 10 hours per week in clinical activity, and more than 40% of clinical time in hospital-based activity. The study was published online March 2 in the Journal of General Internal Medicine.

Nearly 17% of eligible respondents were classified as hospitalists (n=175). Eleven percent of hospitalists performed all nine SHM core procedures, compared with 3% of non-hospitalists (P<0.001). Hospitalists were significantly more likely than non-hospitalists to have performed each of the individual core procedures except electrocardiogram interpretation, arthrocentesis and chest X-ray interpretation. The hospitalists performed a median of four of the nine SHM core procedures in the previous year (interquartile range [IQR], two to six). They performed less than a median of six central line placements, thoracenteses, paracenteses, or lumbar punctures in the previous year.

Hospitalists who worked more than 45 hours per week performed more core procedures than those who worked fewer hours (P<0.001). Hospitalists spent a median of 40 hours per week in hospital-based patient care versus five hours per week for non-hospitalists (P<0.001); both types of physicians worked a median of 50 hours per week (IQR, 36 to 60 hours per week; P=0.32). There was no significant difference between hospitalists and non-hospitalists in terms of year of medical school graduation, hospital size or population of practice location.

There are several possible reasons why hospitalists don't perform more of the SHM core procedures, the authors said. Invasive diagnostic procedures may be less necessary than other procedures, given advances in diagnostic imaging techniques and clinical decision-making tools. Hospitalists also may opt to focus on cognitive and relational tasks, and refer certain patients to subspecialists, surgeons or radiologists, they said.

Also, reimbursement for some procedures may not match up with the time needed to perform them—a hypothesis partially supported by a non-significant trend showing that hospitalists whose incomes were less tied to productivity (e.g., salaried hospitalists) performed a wider variety of core procedures than those whose incomes were more contingent on productivity, the authors said. Study limitations include that data were self-reported and that respondents were ACP members, which may limit generalizability of results. The survey was also undertaken in 2004; practice patterns may have changed since then, the authors noted.

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From the College

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Health professionals to march for health care reform

ACP has lent its support to physicians and other health professionals who will be gathering in Washington to rally for health care reform on Monday, March 22. Participants will gather at Freedom Plaza near the White House and listen to a series of speakers before marching to the Capitol building. The Chair of ACP’s Board of Regents, Frederick E. Turton, FACP, will be among the speakers addressing the critical need for health care reform.

Information about how to participate is online.

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Pay-for-performance models can support medical professionalism

An expert panel convened by ACP has released a paper on the impact of pay-for-performance programs on medical professionalism. “Pay for Performance through the Lens of Medical Professionalism,” published in the March 16 Annals of Internal Medicine, indicates how properly designed models and programs can strengthen the relationship between physicians and patients, increasing the likelihood that physicians will deliver the best possible care. The ACP-led panel of experts included professionals in clinical medicine, law, management and health policy.

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ICD-10 summit to be held in April

The American Health Information Management Association’s second annual ICD-10 summit will be held April 12-13, 2010, in Washington, D.C.

The Annual ICD-10 Summit is the primary source for information, education and resources for preparedness and strategic implementation guidance. In 2010, the summit will explore the challenges and opportunities of the transition to the ICD-10-CM/PCS coding systems and the 5010 HIPAA transaction, featuring respected and well-known speakers, experts, industry leaders, and practitioners from all health care settings. ACP is a collaborating organization for this event. For more information, visit the summit Web site or AHIMA’s set of ICD-10 resources.

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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) Temporal artery biopsy. This item is available online to MKSAP 14 subscribers in the Rheumatology section, Item 11.

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.

The most appropriate next step in this patient's management is temporal artery biopsy. This patient most likely has giant cell arteritis, which is characterized by inflammation involving the extracranial branches of the carotid artery and typically affects the elderly population. Clinical manifestations of this condition include headaches, optic nerve ischemia, and accompanying polymyalgia rheumatica. Additional features that may occur in giant cell arteritis are scalp tenderness, carotidynia, and jaw claudication. Although the majority of patients with giant cell arteritis have an elevated erythrocyte sedimentation rate, this rate is low or normal in 10% to 24% of these patients.

The gold standard for diagnosing giant cell arteritis is temporal artery biopsy. Whenever possible, temporal artery biopsy should be performed before prednisone therapy is initiated, although some experts delay treatment for a few days until biopsy is obtained if symptoms are mild or there are no ocular manifestations. Nevertheless, immediate initiation of corticosteroid therapy is indicated if any visual symptoms occur. Corticosteroid therapy is less effective at recovering lost vision if treatment is not initiated promptly on the first day that symptoms develop.

Recent studies have shown that administering corticosteroid treatment for up to, and perhaps longer than, 2 weeks before temporal artery biopsy is performed does not affect biopsy results in patients with clinical suspicion for giant cell arteritis. Therefore, some experts recommend that corticosteroid therapy should precede biopsy in this setting.

Neither brain MRI nor ultrasonography of the carotid artery would help to evaluate the cause of this patient's proximal myalgias. This patient does not have muscle weakness or elevated levels of creatine kinase. Therefore, electromyography is not indicated.

Key Points

  • The gold standard for diagnosing giant cell arteritis is temporal artery biopsy.
  • The erythrocyte sedimentation rate in patients with giant cell arteritis usually is elevated but may be low or normal in 10% to 24% of patients.

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Copyright 2010 by the American College of Physicians.

Test yourself

A 66-year-old man comes for a preoperative evaluation before total joint arthroplasty of the left knee. He has a 25-year history of rheumatoid arthritis. He has had progressive pain in his left knee with activity, which limits his ability to hike. The patient has similar pain in the right knee, but it is less severe. He reports no recent morning stiffness. He is able to climb two or three flights of stairs without chest pain or shortness of breath. He has no other medical problems and reports no additional symptoms. Medications are methotrexate and folic acid. Following a physical exam and lab tests, what is the next best step in management?

Find the answer

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