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

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In the News
for the Week of 4-6-10

Highlights

  • Modeling study suggests diabetes screening cost-effective starting between 30 and 45
  • States' medical boards increased disciplinary actions in 2009

Test yourself

  • MKSAP Quiz: aching in joints of hands and knees

Prostate cancer

  • BPH drug may lower prostate cancer incidence, effect on mortality unknown

Breast cancer

  • Survivors of childhood cancer treated with chest radiation may benefit from early breast cancer surveillance

Advance directives

  • Nearly one-third of older adults need end-of-life decisions made but lack ability

From ACP Internist

  • The next issue of ACP Internist is online and coming to your mailbox

Internal Medicine 2010

  • ACP Job Placement Center calls for physician profiles

Upcoming meetings

  • ICD-10 summit to be held next week
  • Joint Commission to hold conference on quality, safety in June

Cartoon caption contest

Physician editor: Vincenza Snow, FACP


Highlights

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Modeling study suggests diabetes screening cost-effective starting between 30 and 45

It is cost-effective to screen asymptomatic patients for type 2 diabetes beginning between the ages of 30 and 45 and repeating the test every three to five years, according to a computer model.

The study used data from a representative sample of the U.S. population to create a simulated population of 325,000 people 30 years of age without diabetes. Diabetes incidence, health care costs associated with screening and treatment, and potential complications (including myocardial infarction, stroke and microvascular complications) were simulated for the following 50 years of the hypothetical patients’ lives. A number of different screening strategies were put into the model—screens starting at different ages, occurring at different frequencies, or triggered by a diagnosis of hypertension.

Compared to not screening, all of the strategies reduced the incidence of myocardial infarction and microvascular complications and increased the number of quality-adjusted life-years (QALYs). There was little to no effect on stroke incidence. The screening strategies varied more in their cost per QALY. Screening at frequent intervals (every six months starting at 30 or every year starting at 45) or late-onset screening (every three years starting at 60) was associated with a cost of more than $15,000 per QALY.

Screening patients who were already being treated for hypertension had the lowest cost per QALY, but less effect on microvascular outcomes because fewer cases of diabetes were diagnosed. The most cost-effective strategies appeared to be those that started screening patients between 30 and 45 and repeated screening every three to five years, the researchers concluded. Such strategies were associated with a cost per QALY of $10,500 or less. The study was published online by The Lancet on March 30.

The cost of these screenings could be minimized further by conducting the screening in conjunction with other recommended care, such as lipid screening, the authors noted. Although the model is limited by being a simulation, the study’s results are applicable to real life, the study authors said, concluding that screening every three to five years starting between 30 and 45 would be cost-effective for the U.S. population.

The study did not address the American Diabetes Association’s current recommendations, which suggest screening 30- to 45-year-olds only if they have risk factors, an accompanying comment noted. (The study authors did mention that a risk assessment before screening could improve cost-effectiveness.) The results of the simulation do provide further evidence that diabetes screening should be combined with screening for hypertension and lipids, the comment concluded.

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States' medical boards increased disciplinary actions in 2009

The Federation of State Medical Boards reported a 6% increase in disciplinary actions in 2009 overall among state medical boards. The annual report summarizing disciplinary actions against physicians by 70 medical and osteopathic boards in U.S. states and territories recorded 5,721 actions taken against doctors in 2009, an increase of 342 from 2008. The year 2008 saw an increase of 60 over 2007.

Because of the wide variations between state medical boards in terms of composition, funding, size and levels of proof required, the report is most useful in comparing variations within each state over time, instead of comparisons among the states.

However, each year the federation issues a Composite Action Index, an average of disciplinary actions that weights the severity of actions taken, such as license revocations and suspensions.

While most states were fairly consistent, some states saw wider variations in the numbers of disciplinary actions taken between 2009 and 2008. New Hampshire's actions more than doubled from 7 (against 7 doctors) to 16 (against 16 doctors). South Dakota's also rose from 7 (against 7 doctors) to 16 (against 15 doctors). Nebraska increased to 69 (against 65 doctors) from 32 (against 29 doctors). Florida's Board of Osteopathic Medicine handed out 16 actions (against 16 doctors) in 2009, compared to 54 (against 46 doctors) in 2008.

Other states' boards issues fewer actions. Idaho handed out 19 actions (against 16 doctors) in 2009, compared to 29 actions (against 28 doctors) in 2008. South Carolina handed out 20 actions (against 20 doctors) in 2009, compared to 56 actions (against 54 doctors) in 2008.

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Test yourself

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MKSAP Quiz: aching in joints of hands and knees

A 28-year-old woman develops a 2-month history of aching in the joints in her hands and knees. Her fingertips turn white and become numb with exposure to cold. In addition, she has experienced postprandial and occasional burning nocturnal chest discomfort for the past 3 months. She does not have shortness of breath, exertional chest pain, or digital ulcers. Medical history is unremarkable, and family history is remarkable only for an aunt with systemic lupus erythematosus. She takes no medications.

On physical examination, pulse rate is 78/min, respiration rate is 18/min, and blood pressure is 100/60 mm Hg. There is skin thickening of the face, chest, abdomen, arms, hands, and feet. Lungs are clear to auscultation, and cardiac examination reveals a normal S1 and S2 with no gallops or murmurs. Abdominal examination is unremarkable with no organomegaly. There is no evidence of synovitis, but flexion contractures are present at the proximal interphalangeal joints and elbows. The wrists have reduced flexion. Tendon friction rubs are present around the ankles.

The complete blood count, basic metabolic profile, and urinalysis are normal. Antinuclear antibody assay is positive (titer of 1:640; speckled pattern), and an anti-double-stranded DNA antibody assay is negative.

In addition to a calcium-channel blocker trial, which of the following is the most appropriate management for this patient?

A) Prednisone
B) Omeprazole
C) Intravenous pulse cyclophosphamide
D) Azathioprine

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

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Prostate cancer

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BPH drug may lower prostate cancer incidence, effect on mortality unknown

Dutasteride (Avodart) reduced the risk of prostate cancers and precursor lesions and improved outcomes related to benign prostatic hyperplasia (BPH) among men, a study concluded.

The Reduction by Dutasteride of Prostate Cancer Events (REDUCE) study was done in collaboration with the drug's maker, GlaxoSmithKline. The four-year, multicenter, randomized, double-blind, placebo-controlled, parallel-group study compared dutasteride, 0.5 mg daily, to placebo in men 50 to 75 years of age with a prostate-specific antigen (PSA) level of 2.5 to 10.0 ng/mL and one negative prostate biopsy (6 to 12 cores) within six months before enrollment. Results were reported in the April 1 New England Journal of Medicine.

Cancer was detected via biopsy or surgery in 659 of the 3,305 men in the dutasteride group and 858 of 3,424 men in the placebo group (relative risk reduction, 22.8%; 95% CI, 15.2 to 29.8; P<0.001). Among the 6,706 men who underwent a needle biopsy, there were 220 tumors with a Gleason score of 7 to 10 among 3,299 men in the dutasteride group and 233 among 3,407 men in the placebo group (P=0.81). In the placebo group, men with prostate cancer were withdrawn from the study, so during years 3 and 4, there were 12 tumors with a Gleason score of 8 to 10 in the dutasteride group, as compared with only 1 in the placebo group (P=0.003).

Researchers wrote that while dutasteride therapy may have played a role in reducing the number of cancers with Gleason scores of 8 to 10, more men in the placebo group may have had their tumors upgraded had the study protocols not required they be withdrawn. Researchers also said the data support the idea that the difference in the number of cancers with a Gleason score of 8 to 10 was due in part to dutasteride therapy.

However, an accompanying editorial cautioned that dutasteride (and finasteride, another drug in the 5a-reductase inhibitors class) do not prevent prostate cancer, but only shrink tumors that have a low potential for mortality. "The use of these drugs for prevention may be somewhat risky," the editorial continued. "Because PSA levels are suppressed, men may have a false sense of security, and if prostate cancer ever develops, the diagnosis may be delayed until they have high-grade disease that may be difficult to cure."

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Breast cancer

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Survivors of childhood cancer treated with chest radiation may benefit from early breast cancer surveillance

Women treated with chest radiation for cancer as children or young adults may benefit from early surveillance for breast cancer, according to a new study.

Researchers performed a meta-analysis of 11 trials to examine the incidence of and excess risk for breast cancer in women after chest radiation for pediatric or young adult cancer, as well as the clinical characteristics of their cancers and the possible benefits and harms of surveillance in this group. The study results were published in the April 6 Annals of Internal Medicine.

After chest radiation for cancer early in life, women have a substantially elevated risk for breast cancer, the study found (standardized incidence ratio, 13.3 to 55.5; cumulative breast cancer incidence by age 40 to 45, 13% to 20%). Higher doses of radiation were associated with higher cancer risk. Although evidence on the characteristics and outcomes of breast cancer in this group was limited, both seemed similar to the general population.

The authors acknowledged that their results were limited by study heterogeneity, varied study design, and small sample size. However, they concluded that women who receive chest radiation for childhood or young adult cancer are at substantially elevated risk for early breast cancer and that the risk does not seem to plateau with age. Early detection appeared to have benefit in this group because those who received diagnoses of early-stage breast cancer were likely to have favorable outcomes. The authors pointed out that more research is needed to weigh the potential benefits and harms of the additional radiation exposure involved when mammograms are started early.

In related news, a study published online March 29 by the Journal of Clinical Oncology found that in women with early-stage breast cancer, those who had mastectomies were less likely to receive subsequent radiation than those who had breast-conserving surgery, even when radiation was strongly indicated. The researchers found that patients' willingness to receive radiation and surgeon involvement in the decision heavily influenced treatment.

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Advance directives

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Nearly one-third of older adults need end-of-life decisions made but lack ability

About 30% of older adults near the end of life needed decisions made about medical treatment but lacked such decision-making capacity, a new study found, and most of those with advance directives got the care they had specified.

Using data from the Health and Retirement Study, researchers studied 3,746 adults age 60 years or older who had died between 2000 and 2006 and for whom a proxy answered study questions after the patient died. Outcomes included whether the patient had completed a living will or durable power of attorney, maintained decision-making capacity, and needed decision making at the end of his or her life. Data were also collected on care preferences of subjects who completed a living will, and researchers compared these preferences with the outcomes of surrogate decision making. Results were published in the April 1 New England Journal of Medicine.

Forty-two-and-a-half percent of study patients needed decision making, and of these, 70.3% lacked the capacity to make decisions for themselves. Within this subgroup, 67.6% of patients had advance directives, 6.8% had only a living will, 21.3% had only appointed a durable power of attorney, and 39.4% had both prepared a living will and appointed a durable power of attorney. Among those patients who had completed living wills and stated preferences for or against all care possible, there was strong agreement between their preference and the care received (P<0.001). Eighty-three percent of those who requested limited care, and 97.1% of those who requested comfort care, got care consistent with these preferences. Those who requested all care possible were more likely to get it than those who didn't request it (adjusted odds ratio, 22.62; 95% CI, 4.45 to 115), but 7.1% (n=30) of those who didn't indicate an all-care preference got it anyway, and 50% (n=5) of those who wanted all care didn't receive it.

While the results suggest more than a quarter of older adults may need surrogate decision making before death, the data also indicate it's difficult to predict who will need this decision making, the authors noted. The fact that so many older adults have advance directives suggests they find them acceptable, familiar, available and valuable, they said. A causal relationship can't be inferred, but the findings do suggest advance directives influence end-of-life decisions, they added. Of those patients who wanted aggressive care but didn't receive it, the decisions may have been overridden by their surrogates, or such care may not have been an option. Overall, the study suggests the health care system should ensure clinicians receive the time and reimbursement needed to help patients plan for the end of life, the authors concluded.

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From ACP Internist

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The next issue of ACP Internist is online and coming to your mailbox

The April issue of ACP Internist features the following articles:

Array of symptoms can point to celiac. Celiac disease incidence has risen since the 1950s, so alert internists listen to the symptoms, get to the basis, and make accurate attributions to make the right diagnosis. A constellation of symptoms can point to a common underlying condition.

EHR era ushers in stricter privacy, security. Offices feeling confident about HIPAA compliance now face HITECH, which involves increased demands meant to secure confidential information in a digital age. As the demands have increased, so have the penalties.

Mindful Medicine: Seeing the whole diagnostic picture. For a year, one patient saw specialist after specialist and received a different diagnosis each time. Like the story of the blind men and the elephant, specialists often see the patient through only one component of training, as anchoring and availability sneak into their thinking.

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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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Upcoming meetings

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ICD-10 summit to be held next week

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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Joint Commission to hold conference on quality, safety in June

The Joint Commission will hold its annual Conference on Quality and Patient Safety June 23-25 in Chicago. The conference will focus on ways for organizations to improve quality and reduce errors, contain costs, increase productivity and execution, and build leaders throughout their organization.

Information, including registration instructions, is available on The Joint Commission Web site. An early bird registration discount of $100 is available until May 24. The Joint Commission is an independent organization that accredits and certifies more than 17,000 health care organizations and programs in the U.S.

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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 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 B) Omeprazole. This item is available online to MKSAP 14 subscribers in the Rheumatology section, Item 28.

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.

Combination therapy with a proton-pump inhibitor, such as omeprazole, and a calcium-channel blocker is the most appropriate treatment in this clinical scenario. This patient has aggressive new-onset diffuse cutaneous systemic sclerosis with extensive skin involvement. Therapy for scleroderma involves systematic management of end-organ involvement. Therefore, therapy with a proton-pump inhibitor or, alternately, a histamine-2 receptor antagonist is indicated to treat this patient's symptoms of gastroesophageal reflux. In addition, a calcium-channel blocker is indicated to manage this patient's Raynaud's phenomenon.

Because scleroderma is not characterized by an inflammatory disorder, neither high-dose corticosteroids nor immunosuppressive agents are used in this setting. Moreover, even moderate-dose corticosteroid therapy may be associated with normotensive renal crisis in patients with scleroderma. In one study of 140 patients with “scleroderma renal crisis,” 11% of these patients had normal blood pressure but a rapid decline in renal function. These patients also were more likely to have microangiopathic hemolytic anemia and thrombocytopenia and were more likely to receive higher doses of prednisone during the 2 months immediately preceding renal crisis. Low-dose corticosteroids are indicated to treat inflammatory arthritis associated with scleroderma if first-line therapy is not effective. This patient has aggressive skin involvement, but no treatments for skin involvement in scleroderma are documented in clinical trials to be disease modifying. Therefore, cyclophosphamide and azathioprine would not be appropriate in this patient.

Key Points

  • There is no treatment for scleroderma that is disease modifying.
  • Therapy for scleroderma involves systematic management of end-organ involvement.
  • In patients with scleroderma, high-dose corticosteroid therapy may be associated with normotensive renal crisis.

Click here to return to the rest of ACP InternistWeekly.

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Copyright 2010 by the American College of Physicians.

Test yourself

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