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

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In the News
for the Week of 5-11-10

Highlights

  • Internal medicine a 'stepping stone' to other careers
  • Type of antidepressant doesn't seem to affect suicide, suicide attempts in adults

Test yourself with MKSAP 15

  • MKSAP Quiz: ear pain following URI

Oncology

  • Younger whites only group to see more noncardia stomach cancer

Cardiology

  • New drug-eluting stents outperform old ones except in diabetics
  • Early follow-up reduces heart failure readmissions

FDA update

  • Infusion pumps to be recalled and destroyed
  • Children’s medications recalled by McNeil

From ACP Internist

  • Follow KevinMD on ACP Internist and ACP Hospitalist

Educational opportunities

  • National Health Services Corps offering primary care scholarships
  • HRSA offers primary care training grants

Cartoon caption contest

Physician editor: Darren Taichman, FACP


Highlights

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Internal medicine a 'stepping stone' to other careers

Nine percent of internists board-certified between 1990 and 1995 no longer work in general internal medicine or a subspecialty.

"Where Have All the General Internists Gone?", a survey published by the Journal of General Internal Medicine and conducted by ACP and the American Board of Internal Medicine (ABIM), also found that:

  • a significantly larger proportion of general internists (17%) than internal medicine subspecialists (4%) left practice at mid-career (P<0.001);
  • although most are satisfied with their career choice, a significantly lower proportion of general internists (70%) than internal medicine subspecialists (77%) were satisfied with their career; and
  • more general internists and internal medicine subspecialists who left internal medicine are satisfied with their career (87%) than those still working in internal medicine (74%).

Study authors analyzed responses from a national mailed random sample of physicians originally certified by ABIM in general internal medicine or an internal medicine subspecialty. Of 3,583 eligible survey recipients, 2,058 (57%) returned usable responses. The proportion of general internists who had left internal medicine in 2006 (19%) was not significantly different from the 21% who left in 2004 (P=0.45). The proportion of general internists who left internal medicine was not significantly different in earlier (1990-92; 19%) versus later (1993-95; 15%) certification cohorts (P=0.15).

Two factors contributing to the primary care physician shortage include decreasing numbers of medical students pursuing careers in general internal medicine and general internists leaving their practices for other careers in and out of medicine. Existing research reviewed by the authors suggests that general internists may be particularly discontent and more likely to leave internal medicine due to a widening income gap between primary care physicians and many subspecialists, increasing demands, growing expectations and accountability for providing high-quality care, and payment based on the ability to perform in a challenging environment.

Authors made no conclusions that general internists left internal medicine in greater proportion than subspecialists because they were dissatisfied. Instead, internal medicine's general nature provides more career options in and outside of medicine. Authors suggested increasing support for primary care training programs, increasing Medicaid and Medicare reimbursements to primary care physicians, and expanding pilot testing and start-ups of patient-centered medical homes.

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Type of antidepressant doesn't seem to affect suicide, suicide attempts in adults

Risk for suicide and suicide attempts does not appear to differ among different types of antidepressants, according to a new study.

In 2004, the FDA issued an advisory warning of possible increased suicide risk in children and adolescents taking antidepressants. While a subsequent meta-analysis of trials in adults found no such increase in risk, individual drugs could not be studied. The authors performed a cohort study using population-based health care utilization data from British Columbia, Canada, to examine rates of death by suicide or self-harm-related hospitalization in patients taking antidepressants. The goal of the study was to examine the risk associated with individual antidepressant agents. The study results appear in the May Archives of General Psychiatry.

Data were available for 287,543 adults 18 years of age or older with a diagnosis of depression. Over half (56.2%) were women, while 2.8% reported substance abuse, 1.6% reported anxiety and sleep disorders, 1.6% reported psychotic disorder, and 5.6% reported other mental disorders. Rates of suicide or hospitalization due to self-harm ranged from 4.41 events per 1,000 patient-years to 9.09 events per 1,000 patient-years, most of which occurred within six months of treatment initiation.

The authors found no difference in risk for suicide or suicide attempts for specific drugs when compared with fluoxetine hydrochloride. Hazard ratios were as follows: citalopram hydrobromide, 1.00 (95% CI, 0.63 to 1.57); fluvoxamine maleate, 0.98 (95% CI, 0.63 to 1.51); paroxetine hydrochloride, 1.02 (95% CI, 0.77 to 1.35); and sertraline hydrochloride, 0.75 (95% CI, 0.53 to 1.05).

The authors also looked at drug classes and found that serotonin-norepinephrine reuptake inhibitors, tricyclic agents, and other newer and atypical agents all conferred similar risk compared with selective serotonin reuptake inhibitors.

The study's definitions of completed and attempted suicide were imperfect, the authors acknowledged, noting that coroners may misclassify suicide as "other injuries" in up to 10% of cases. The authors also did not have data on patients who were treated in emergency departments for injuries due to suicide attempts and then released. However, the authors concluded that risk for suicide and suicide attempts among adults is similar across all classes of antidepressants as well as for individual drugs. "Treatment decisions should be based on efficacy, and clinicians should be vigilant in monitoring after initiating therapy with any antidepressant agent," they wrote.

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Test yourself with MKSAP 15

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MKSAP Quiz: ear pain following URI

EDITOR'S NOTE: ACP InternistWeekly now features questions from MKSAP 15. See the Answer and Critique for this question for important information about MKSAP 15.

A 45-year-old man is evaluated because of the acute onset of right ear pain. The patient was well until 10 days ago, when he developed symptoms of an upper respiratory tract infection, including nasal congestion and a nonproductive cough. Although these symptoms are resolving, pain and some loss of hearing in the right ear first occurred last night. He does not have fever, sore throat, or drainage from the ear. Medical history is unremarkable. The patient has no allergies and takes no medications.

On physical examination, vital signs, including temperature, are normal. The right tympanic membrane is erythematous, opacified, and immobile, but the external auditory canal is normal. The left ear and posterior pharynx are normal. Examination of the chest is unremarkable.

Which of the following is the best initial antibiotic choice in this patient?

A) Amoxicillin
B) Amoxicillin-clavulanate
C) Azithromycin
D) Ceftriaxone

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

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Oncology

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Younger whites only group to see more noncardia stomach cancer

Noncardia gastric cancer declined among all race and age groups for the past three decades, except for whites aged 25 to 39 years, according to cancer registration data.

Researchers conducted a descriptive study with age-period-cohort analysis of cancer registration data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program. They analyzed noncardia primary cancers of the stomach, excluding leukemia, lymphoma, mesothelioma, or Kaposi sarcoma, in patients ages 25 to 84 years who were grouped into five-year intervals. Race was categorized as white, black, or other (including unspecified). Socioeconomic status was inferred from prevalence of poverty in the county of residence. The study results appear in the May 5 Journal of the American Medical Association.

From 1977 through 2006, there were 83,225 adults with incident primary gastric cancer, including 39,003 noncardia cases. Overall, age-standardized annual incidence per 100,000 population declined during the study period from 5.9 (95% CI, 5.7 to 6.1) to 4.0 (95% CI, 3.9 to 4.1) in whites, from 13.7 (95% CI, 12.5 to 14.9) to 9.5 (95% CI, 9.1 to 10.0) in blacks, and from 17.8 (95% CI, 16.1 to 19.4) to 11.7 (95% CI, 11.2 to 12.1) in other races.

Among whites, age-specific trends varied significantly between older and younger groups (P<0.001 for interaction by age). Incidence per 100,000 declined significantly from 19.8 (95% CI, 19.0 to 20.6) to 12.8 (95% CI, 12.5 to 13.1) for ages 60 to 84 years and from 2.6 (95% CI, 2.4 to 2.8) to 2.0 (95% CI, 1.9 to 2.1) for ages 40 to 59 years. However, it increased significantly from 0.27 (95% CI, 0.19 to 0.35) to 0.45 (95% CI, 0.39 to 0.50) for ages 25 to 39 years, while falling or remaining stable among all age groups of blacks and other races. Age-period-cohort analysis confirmed a significant increase in younger whites (P<0.001).

Among whites, when broken down into successive birth-year cohorts, age-specific incidence decreased through the 1947 cohort, then progressively increased for the 1952 and subsequent cohorts. Specifically, incidence declined by 1.6% per year over the 1932 to 1942 cohorts, then increased by 2.2% per year over the 1952 to 1962 cohorts. The difference between these slopes before and after the 1947 mid-year of birth was 3.9% per year (95% CI, 2.1% to 5.6%; P<0.001 for the slope contrast). The same effect was seen in white men and white women, centered around the 1947 year of birth.

Researchers conjectured the trends are due to changes in Helicobacter pylori infection patterns, the emergence of a new carcinogenic process exposed by the eradication of H. pylori in gastric mucosa, the Epstein-Barr virus' link to a subset of gastric cancer, changes to gastric microbial flora, or the changing role of diet, particularly increasing salt intake.

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Cardiology

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New drug-eluting stents outperform old ones except in diabetics

Second-generation drug-eluting stents that released everolimus lowered rates of stent thrombosis and restenosis compared to paclitaxel-eluting stents, a new trial found.

The trial randomized 3,687 patients to receive one or the other drug-eluting stent without routine follow-up angiography. Over the next year, rates of cardiac death, target-vessel myocardial infarction and ischemia-driven target-lesion revascularization (combined as target-lesion failure) were compared between the two groups. The study was published in the May 6 New England Journal of Medicine.

Everolimus-eluting stents performed significantly better than paclitaxel-eluting ones on the composite endpoint of target-lesion failure (4.2% vs. 6.8% of patients; relative risk, 0.62, 95% CI, 0.46 to 0.82; P=0.001). The newer stents also significantly reduced the risk of ischemia-driven target-lesion revascularization (P=0.001), myocardial infarction (1.9% vs. 3.1%, P=0.02) and stent thrombosis (0.17% vs. 0.85%, P=0.004). Study authors noted that the rate of stent thrombosis was among the lowest ever reported for a drug-eluting stent. The everolimus stents also showed a benefit that didn’t reach the point of significance in reducing cardiac death and target-vessel myocardial infarction.

The newer stents did not show any significant benefit in patients with diabetes, however, which suggests that the mechanism of restenosis and/or the response to antiproliferative agents may differ in diabetic patients, said an accompanying editorial. Therefore, the paclitaxel-eluting stent may be more appropriate for these patients, the editorialist concluded.

In patients without diabetes, more data about cost-effectiveness are needed to determine whether the higher cost of the everolimus-eluting stents (about $300 extra) is justified by the reduction in adverse events, the editorialist concluded. He also called for additional research on the stents’ effect on stent thrombosis and MI when prasugrel instead of clopidogrel is used as anti-platelet therapy.

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Early follow-up reduces heart failure readmissions

Having a follow-up appointment with a physician within a week of being discharged from a hospital with a diagnosis of heart failure appears to reduce a patient’s risk of readmission, according to a comparison of hospitals.

The observational analysis used data from the OPTIMIZE-HF and Get with the Guidelines programs to compare how many of the hospitals’ heart failure patients saw a physician within a week of leaving the hospital.

The study population included more than 30,000 patients treated at 225 hospitals between 2003 and 2006. The hospitals were divided into quartiles based on follow-up rates; those results were then compared with rates of readmission within 30 days. To control for individual patient factors that might confound the association between follow-up and outcomes, hospital-wide statistics were analyzed. The results were published in the May 5 Journal of the American Medical Association.

Overall, more than 20% of the patients were readmitted within the month. Most patients also didn’t have a follow-up appointment within a week. The median percentage across the hospitals was only 38.3%. In the quartile of hospitals with the worst follow-up rates, the readmission rate was 23.3% in 30 days, compared to just under 21% in the other three quartiles.

The study also found that most patients had their follow-up appointment with a general internist; less than 10% saw a cardiologist within a week. The vast majority of patients (94%) also did have an outpatient appointment scheduled while they were in the hospital, although the study did not look at how soon those appointments were.

The findings highlight the need for improved coordination of care between inpatient and outpatient settings, the study authors concluded. They noted that the narrowing of the scope of medical practice makes this coordination more difficult, but they suggested the models of care using nurse practitioners or physician assistants could improve access to timely follow-up care. The authors also said that early follow-up after discharge could be used in the future as a marker of quality in heart failure performance measure sets.

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FDA update

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Infusion pumps to be recalled and destroyed

The FDA last week ordered Baxter Healthcare Corp. to recall and destroy all of its Colleague Volumetric Infusion Pumps.

In the past several years, the pumps had been associated with more than 56,000 reports of adverse events and subject to several class I recalls, according to an FDA press release. Changes to the pumps have not resolved the problems, and the FDA believes there may be as many as 200,000 of the pumps currently in use.

Therefore, the FDA has ordered Baxter to recall and destroy all Colleague infusion pumps, reimburse customers for the value of the recalled devices, and assist in finding a replacement for these customers. Hospitals and other users of the pumps will be receiving further instructions and information from Baxter and the FDA.

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Children’s medications recalled by McNeil

A number of infant and children’s liquid medications have been voluntarily recalled by McNeil Consumer Healthcare.

The recall includes Tylenol, Motrin, Zyrtec, and Benadryl products and was instituted due to manufacturing deficiencies that may affect the quality, purity or potency of the medications. Some of the products included in the recall may contain a higher concentration of active ingredient than specified; others contain inactive ingredients that may not meet internal testing requirements; and others may contain tiny particles, according to an FDA press release.

The agency described the risk of serious events resulting from the deficiencies as remote, but recommended that consumers discontinue use of the medication. Generic versions of the recalled products could be used instead, the FDA advised. Any adverse events should be reported to the FDA MedWatch program and refunds for the affected products are available from McNeil.

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From ACP Internist

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Follow KevinMD on ACP Internist and ACP Hospitalist

Kevin Pho, MD, aka KevinMD, now posts on the ACP Internist and ACP Hospitalist blogs. Voted best medical blog in 2008, and with over 29,000 subscribers and 21,000 Twitter followers, KevinMD.com is the Web's definitive site for influential health commentary. Follow Toni Brayer, FACP, Rob Lamberts, ACP Member and the entire Get Better Health network through ACP's news publications online.

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Educational opportunities

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National Health Services Corps offering primary care scholarships

The National Health Services Corps (NHSC) is accepting applications for its 2010 scholarship program.

The primary care scholarship includes payment for tuition, required fees and other reasonable educational costs, and a monthly stipend. In 2010, 125 scholarships will be awarded. NHSC is a network of more than 10,000 primary care health care professionals and sites serving the most medically underserved regions of the country. The deadline for applications is June 1. More information is available online.

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HRSA offers primary care training grants

The Health Resources and Services Administration (HRSA) recently announced funding opportunities for health professions education programs in primary care.

Information on the new opportunities is available at the HRSA’s Web site, and conference calls were recently held to explain the programs. Recordings of the conference calls are available until May 21. Call (800) 937-9698 for information about physician faculty development in primary care, (800) 627-8064 for residency training in primary care or (866) 350-7003 for predoctoral training in primary care. Opportunities to obtain funding for academic administrative units and joint degree programs are also open. Applications for funding are due May 21, 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 online for an online vote by readers. The winner will appear in an upcoming edition.

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MKSAP 15 answer and critique

The correct answer is A) Amoxicillin. This item is available online to MKSAP 15 subscribers in the General Internal Medicine section, Item 2.

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 best initial antibiotic for this patient is amoxicillin. Although otitis media is the most frequent bacterial infection in children, it is much less common in adults. In most cases of acute otitis media, a viral upper respiratory tract infection precedes the ear infection. Eustachian tube obstruction occurs secondary to inflammation. Bacteria subsequently enter the middle ear by means of a compliant eustachian tube, aided by other factors, including nose blowing, sniffing, and negative middle ear pressure. The microbiology of otitis media in adults is similar to that of children: Streptococcus pneumoniae, 21% to 63%; Haemophilus influenzae, 11% to 26%; Staphylococcus aureus, 3% to 12%; and Moraxella catarrhalis, 3%. Thirty percent of bacterial cultures of the middle ear show no growth.

Antibiotic therapy should be reserved for patients in whom evidence of purulent otitis exists. There are no antibiotic treatment trials in adults. Guidelines for antibiotic use are the same in children and adults. Amoxicillin is the recommended initial antibiotic because of its proven efficacy, safety, relatively low cost, and narrow spectrum of activity. If symptoms do not improve after 48 to 72 hours of amoxicillin therapy, initiation of amoxicillin-clavulanate, cefuroxime, or ceftriaxone is recommended. Alternative agents for patients with penicillin allergy are oral macrolides (azithromycin, clarithromycin). Patients should not use nasal decongestants or antihistamines. Follow-up of these patients is not necessary unless symptoms persist or progress.

Key Point

  • Amoxicillin is the recommended antibiotic for treating acute otitis media in adults because of its proven efficacy, safety, relatively low cost, and narrow spectrum of activity.

Click here to return to the rest of ACP InternistWeekly.

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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 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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