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

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In the News
for the Week of 4-13-10

Highlights

  • H1N1 rates debated in those vaccinated for seasonal flu
  • IOM links Gulf War service to several illnesses

Test yourself

  • MKSAP Quiz: worsening dysmenorrhea with pain
  • For the record

Opioid abuse

  • Hospitalizations for prescription drug poisoning increasing
  • OxyContin redesigned to reduce risk of abuse

Hematology

  • One-third of sickle cell patients rehospitalized within 30 days of discharge

Internal Medicine 2010

  • ACP Job Placement Center calls for physician profiles

From the College

Cartoon caption contest

Physician editor: Darren Taichman, FACP, PhD

Editor's note: ACP InternistWeekly readers will receive daily updates from Internal Medicine 2010 in Toronto April 22-24. There will be no issue on April 20 or April 27.


Highlights

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H1N1 rates debated in those vaccinated for seasonal flu

Possible confounding bias surrounds four Canadian studies that saw an increase in H1N1 influenza rates among those vaccinated for seasonal flu.

Investigators of a school outbreak of H1N1 in rural northern British Columbia in late spring 2009 noted those vaccinated against seasonal influenza had higher rates of illness characterized by fever and coughing. They sought to confirm this observation with three case-control investigations in Ontario and Quebec, as well as a transmission study in 47 Quebec households infected by H1N1. Results were reported April 6 in the online journal PLoS Medicine.

Among 1,226 lab-confirmed H1N1 cases and 1,505 controls, odds ratios for H1N1 infection requiring treatment increased between 1.4 and 2.5 in those who received seasonal flu vaccination.

The studies' observational nature makes potential confounding a significant concern, and patients may have altered their patterns of health-care seeking behavior, the authors wrote. But Canada's sentinel analysis protocols would have standardized for that. Accompanying commentary said although confounding plays a major part in interpreting observational studies, researchers fully described its impact in their research.

The commentary also noted that six other studies in the U.S., Australia and Mexico either showed no impact or a protective effect of H1N1 vaccination. Canada's sentinel system will provide more data soon, and "[T]his perplexing experience should teach us best how to react to disparate and conflicting studies and prepare us for the next public health crisis, so that we can better manage future alerts for unexpected risk factors," the authors noted.

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IOM links Gulf War service to several illnesses

The Institute of Medicine has found a causal relationship between service in the Persian Gulf War and post-traumatic stress disorder (PTSD). Other psychiatric disorders, gastrointestinal problems and multisymptom illness are also associated with deployment in the war, according to the evidence.

The review updates a 2006 IOM report on the health problems affecting Gulf War veterans and included data from several countries, including the United Kingdom and Australia. More than 250,000 of the 700,000 U.S. personnel who served in the war have since suffered from persistent, unexplained symptoms, an IOM press release noted.

According to the report, surveys and studies have found sufficient evidence that many veterans suffer from psychiatric disorders, including generalized anxiety disorder and abuse of substances, particularly alcohol, for at least 10 years after deployment. Irritable bowel syndrome and functional dyspepsia were also associated with deployment, but more research is needed to clarify the role of prior acute gastroenteritis and other comorbidities, the IOM found.

Limited evidence also suggested an association between Gulf War service and amyotrophic lateral sclerosis, sexual difficulties, fibromyalgia and chronic pain, and mortality from external causes, primarily motor vehicle accidents, soon after deployment. The experts were not able to determine what kind of chemical or other exposures could have caused the Gulf War illnesses, and they noted that it would be difficult if not impossible to do so after so much time has elapsed.

The IOM called for additional follow-up studies of Gulf War veterans to track the development of new health problems and genetic research to identify differences between veterans who have been affected by the illnesses and those who haven’t. Greater efforts should also be made to find treatments for multisystem illness, the report concluded.

An ACP Internist article addressed the impact of PTSD on combat veterans in September 2008.

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Test yourself

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MKSAP Quiz: worsening dysmenorrhea with pain

A 22-year-old woman is evaluated for dysmenorrhea, which has worsened over the past 3 years. Although the frequency of her periods is regular, her menstrual period lasts for 5 to 7 days. When menstruating, she sometimes misses work because of pain. Ibuprofen and naproxen do not resolve her symptoms and upset her stomach. She is not currently sexually active. Her medical history is unremarkable. Pelvic examination is normal.

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

A) Oral contraceptives
B) Depot-medroxyprogesterone acetate (DMPA)
C) Meclofenamate
D) Magnesium
E) Tramadol

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

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For the record

The answer to the "Test yourself" item in a recent edition of ACP InternistWeekly was initially incorrect. The correct answer is E, Migraine with aura, not C, Migraine without aura.

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Opioid abuse

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Hospitalizations for prescription drug poisoning increasing

Hospitalizations for overdoses of certain prescription drugs increased dramatically between 1999 and 2006, according to a new study.

Researchers used data from the Nationwide Inpatient Sample to examine U.S. hospitalizations for intentional and unintentional poisoning by prescription opioids, sedatives and tranquilizers. The study looked at the incidence and characteristics of such hospitalizations and compared them with hospitalizations for other poisonings in the same time period. The study results were published online April 6 by the American Journal of Preventive Medicine.

All hospitalizations due to overdoses of prescription opioids, sedatives and tranquilizers increased by 65% from 1999 to 2006, the researchers found. Unintentional poisonings involving these drugs increased by 37%, and intentional poisonings increased by 130%. Hospitalizations for poisonings by other drugs and substances increased by 33% over the same period; unintentional poisonings increased by 21%, and intentional poisonings increased by 57%.

The increase in number of poisonings was greatest for benzodiazepines (a difference of 10,379 hospitalizations between 1999 and 2006), while hospitalization for methadone poisoning saw the largest percentage increase (400%). Patients hospitalized for overdoses of prescription opioids, sedatives and tranquilizers compared with other drugs were more likely to be women, to be older than age 34, to be covered by Medicare, and to be seen at a rural or urban nonteaching hospital. Men were more likely to be hospitalized with unintentional poisoning, while intentional poisoning was more common in women.

The authors noted that their study had a retrospective design and used only the principal discharge diagnosis to classify poisoning cases, among other limitations. However, they concluded that it provides important information about U.S. hospitalizations for poisoning by prescription opioids, sedatives and tranquilizers, showing substantial increases in both intentional and unintentional overdoses.

Patients who overdose are hospitalized for an average of three days, they noted, giving future researchers an opportunity to gather more information and to help aid prevention. "Interviews with survivors could provide important additional details regarding the pathways to abuse of these drugs, the methods used to obtain the medications, the sequencing and combination of drugs that result in overdose, and the immediate precursors to these serious events," they wrote.

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OxyContin redesigned to reduce risk of abuse

A new formulation of OxyContin specially designed to help discourage misuse and abuse of the drug was approved last week by the FDA.

OxyContin is made to slowly release oxycodone to treat severe pain for an extended period of time. Because of the drug’s controlled-release properties, each tablet contains a large quantity of oxycodone, and under the previous formulation, abusers of the drug have been able to release high levels of oxycodone all at once.

The reformulated OxyContin is intended to prevent the opioid medication from being cut, broken, chewed, crushed or dissolved to release more medication. The new formulation may provide an incremental advantage over the current version and is likely to result in less abuse by snorting or injection, FDA officials said.

The drug still can be abused by simply ingesting larger doses than are recommended, and the manufacturer will be required to conduct a post-market study on the extent to which the new formulation reduces abuse and misuse, according to an FDA press release.

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Hematology

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One-third of sickle cell patients rehospitalized within 30 days of discharge

One-third of people with sickle cell disease are rehospitalized within 30 days of discharge, and 18- to 30-year-olds are particularly likely to be rehospitalized or have return visits to the emergency department, a new study found.

Researchers examined data on 21,112 patients from the 2005 and 2006 Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department (ED) Databases. Patients came from eight geographically diverse states—together comprising 33% of all people with sickle cell disease in the U.S.—and had had sickle cell-related treat-and-release ED visits or inpatient hospitalizations. Results were published in the April 7 Journal of the American Medical Association.

The 30-day rehospitalization rate was 33.4% (95% CI, 33.0% to 33.8%), while the 14-day rate was 22.1% (95% CI, 21.8% to 22.4%). In addition to rehospitalizations, 15% of hospital discharges were followed by a treat-and-release ED visit within 30 days (95% CI, 14.7% to 15.3%). Rehospitalization rates were highest for patients age 18 to 30 years, with 41.1% rehospitalized within 30 days (95% CI, 40.5% to 41.7%) and 28.4% within 14 days (95% CI, 27.8% to 29%). This age group was also more likely to go to the ED for treatment of pain, then be released. Medicaid patients, or those with other types of public insurance, had higher rates than privately insured or uninsured patients. A shorter length of stay wasn't greatly associated with rehospitalization.

Fourteen-day rehospitalization rates may seem a more appropriate time period to evaluate inpatient care, while 30-day rates may assess the quality of ambulatory care; however, two-thirds of those rehospitalized within 30 days were rehospitalized within 14 days, the authors noted. Preventing 14-day rehospitalizations "may require evaluation and intervention during the (original) hospitalization," they said.

The high utilization rate among 18- to 30-year-olds, compared to older age groups, probably reflects the fact that those with severe disease die earlier, leaving fewer people with severe disease as the population ages, they said. Identifying benchmarks can help with efforts to improve quality of care and reduce morbidity, they concluded.

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Internal Medicine 2010

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ACP Job Placement Center calls for physician profiles

Physicians looking for a new job may submit a Job Seeker's Profile to the ACP Job Placement Center, a service available at Internal Medicine 2010 in Toronto, Canada. The Center, located in the Metro Toronto Convention Centre’s Exhibit Hall, Booth 222, provides physicians with tools to assist in job searches as well as the opportunity to meet with potential employers.

Profiles are distributed to numerous employers participating in Internal Medicine 2010, which will be held April 22-24. After reviewing a profile, a recruiter may contact the physician to schedule a private on-site interview at the Convention Centre. Profiles can be submitted online.

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From the College

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Obama appoints ACP Fellow to new commission

Daniel Sulmasy, FACP, has been appointed to President Obama’s Commission for the Study of Bioethical Issues. Dr. Sulmasy holds the Kilbride-Clinton Chair in Medicine and Ethics in the Department of Medicine and Divinity School at the University of Chicago and is associate director of the MacLean Center for Clinical Medical Ethics. He is a former member of the ACP Ethics, Professionalism and Human Rights Committee.

The Commission for the Study of Bioethical Issues will advise the president on bioethical issues that may emerge from advances in biomedicine and related areas of science and technology. It will work with the goal of identifying and promoting policies and practices to ensure that scientific research, health care delivery, and technological innovation are conducted in an ethically responsible manner. Information about the commission and Dr. Sulmasy is online.

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National Healthcare Decisions Day to be held April 16

ACP joins more than 700 national, state and community organizations in support of National Healthcare Decisions Day, which will be held April 16. The initiative launched three years ago to encourage patient communication with clinicians. Its goal is to give all U.S. adults with decision-making capacity the information and opportunity to communicate and document their health care decisions. ACP offers several resources for advance health care planning, including an Ethics Manual, recommendations for physicians on relationships with family caregivers and a clinical guideline on palliative care, as well as other resources on end-of-life care. Information about National Healthcare Decisions Day and advance directives is available online.

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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 January, February and March 2010.

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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 finalists and post them for an online vote by readers. The finalists will be announced in the April 22 daily e-mail update from Internal Medicine 2010, and voting will remain open until May 3. The winner will be announced in the May 4 issue of ACP InternistWeekly.

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MKSAP answer and critique

The correct answer is A) Oral contraceptives. This item is available online to MKSAP 14 subscribers in the General Internal Medicine section, Item 93.

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 is likely experiencing primary dysmenorrhea, a term that describes menstrual cramping without a pathologic cause. The mainstay treatments are oral contraceptives, which generally reduce symptoms of primary dysmenorrhea, or NSAIDs. Meclofenamate would not necessarily be the next best choice for a patient who has experienced no relief using other NSAIDs. An individual patient may respond to one NSAID when others have not been effective. However, no evidence demonstrates the superiority of one NSAID over another.

Treatment of primary dysmenorrhea with depot-medroxyprogesterone acetate (DMPA) is an off-label use that can induce hypomenorrhea or amenorrhea, resulting in decreased dysmenorrhea. However, only about 50% of patients will become completely amenorrheic during the first year of use of this agent, with the remainder continuing to experience dysmenorrhea. Other alternative therapies, including magnesium, vitamin B6 (pyridoxine), vitamin E, and omega-3 fatty acids, have shown some benefit but have not been studied thoroughly enough to make a recommendation for use in this patient. Although tramadol may effectively reduce pain, it is not a good long-term solution.

Key Point

  • The mainstay of treatment for primary dysmenorrhea is oral contraceptives or NSAIDs.

Click here to go back to the rest of ACP InternistWeekly.

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Copyright 2010 by the American College of Physicians.

Test yourself

A 42-year-old woman is evaluated for an 8-month history of crampy abdominal pain and three loose bowel movements per day. The pain is relieved by a bowel movement. There are no nocturnal bowel movements, and there is no blood or dark tarry material in the stool. She has not had fever, night sweats, or weight loss. She has a history of Hashimoto disease and is treated with levothyroxine. Following a physical exam, rectal exam, and lab tests, what is the most appropriate next step in management?

Find the answer

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