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


In the News
for the Week of 5-18-10


  • Overuse of PPIs may raise risk of C. diff infections, fractures
  • Food allergies seem to proliferate, despite lack of evidence, definitions, tests

Test yourself with MKSAP 15

  • MKSAP Quiz: 3-week history of pain and swelling of right knee

Fracture risk

  • High-dose vitamin D may make falls, fractures more likely

Physician cost profiling

  • Physician cost profiling systems frequently come to different results

Regulatory news

  • CMS announces change to submission period for Medicare claims
  • CDC warns of Q fever in Iraq, Netherlands
  • FDA wants to know about 'bad' drug ads

From the College

  • New Doctor’s Dilemma™ app for iPhone

Cartoon caption contest

Physician editor: Darren Taichman, FACP


Overuse of PPIs may raise risk of C. diff infections, fractures

Widespread overuse of proton-pump inhibitors appears to increase patients’ risk of Clostridium difficile infections and fractures, several recent studies concluded.

One study, which analyzed data on more than 100,000 patients discharged from a tertiary care hospital over five years, found that the risk of nosocomial C. difficile infection increased among patients taking daily proton-pump inhibitors (PPIs) compared with those not taking the drugs (0.3% to 0.6%, respectively) and was highest among patients who took PPIs more than once a day (1.4%). Another retrospective study found that PPI use during C. difficile treatment was associated with a 42% increase in risk of recurrence of infection. Both studies appear in the May 10 Archives of Internal Medicine.

Three other studies in the same issue of Archives bring up other potential risks associated with overuse of PPIs. One study, based on Women’s Health Initiative data, looked at the impact of PPI use on fractures in postmenopausal women and concluded that PPIs were associated with an increased risk of spine, lower arm and total fractures (but not hip fracture). In addition, a meta-analysis demonstrated that higher doses of PPIs (equivalent to an 80-mg bolus followed by 8 mg/h for 72 hours or similar dose) were not more effective than lower doses in decreasing the rates of rebleeding, surgical intervention or mortality among patients with bleeding peptic ulcers.

A fifth study found that a guideline on appropriate PPI use decreased inpatient and discharge PPI therapy, but only among patients who were not taking the medication at admission. The overall rate of use was driven up by the high rate of outpatient PPI use at admission.

Overuse of PPIs can be tied to the prevalence of dyspepsia and the propensity of physicians to prescribe a pill rather than consider other possible treatments, said an accompanying editorial. However, for many patients the risks of PPIs may outweigh the benefits, the editorial continued, adding that PPIs are also thought to increase the risk of hospital- and community-acquired pneumonia.

While PPIs relieve symptoms of dyspepsia, they should not be routinely prescribed, especially in the absence of ulcer disease, esophagitis or severe gastroesophageal reflux disease, the editorialist said. Clinicians should offer alternative treatments for functional dyspepsia, prescribe short courses of treatment, and consider discontinuing therapy in asymptomatic patients. In addition, patients who know the risks may want to consider non-drug options such as waiting for symptoms to resolve over time and making behavioral changes.


Food allergies seem to proliferate, despite lack of evidence, definitions, tests

Overreporting and the lack of good definitions and diagnostic methods contribute to the appearance of more food allergies than may actually exist, according to a new study. Nearly one-third of people think they have food allergies, when less than a tenth actually do. And the treatments for food allergies not only lack evidence, but may actually create undernourishment in children.

Researchers conducted a systematic review of English-language articles indexed between January 1988 and September 2009, and reported their conclusions in the May 12 Journal of the American Medical Association.

Diagnostic tests were included if they had a prospective, defined study population, used food challenge as a standard and had enough data to calculate sensitivity and specificity. Researchers also included systematic reviews and randomized controlled trials. Of 12,378 citations, 72 met the criteria. Researchers reported findings for the foods that make up more than half of all food allergies: cow's milk, hen's egg, peanut, tree nut, fish and shellfish.

From the literature, researchers concluded:

  • Food allergies affect more than 1% or 2% but less than 10% of the U.S. population. It cannot be established if this rate is rising.
  • Food challenges, skin prick testing and serum food-specific IgE all play a role in diagnosis, but no test is easier than the others, nor are any tests more sensitive or specific enough to be recommended over another. Other proposed diagnostic tests lack enough evidence to prove value.
  • Elimination diets are the mainstay of therapy, despite having only one randomized controlled trial. Potential benefits need to be weighed against the potential nutritional risks of such a diet, particularly in children. More controlled studies in patients with non-anaphylactic symptoms are needed.
  • Immunotherapy may generate desensitization, but it's not licensed, it may not work long-term, and it may vary by food allergen.
  • Hydrolyzed infant formula may prevent cow's milk allergy, but there's no definition of a "high-risk infant" or of "hydrolyzed formula." Exclusive breastfeeding isn't proven to prevent atopic disease. Probiotics and breastfeeding or hypoallergenic formula may prevent food allergy, but their independent effects aren't clear.

Researchers wrote, "This systematic review of food allergies found that the evidence on the prevalence, diagnosis, management, and prevention of food allergies is voluminous, diffuse, and critically limited by the lack of uniformity for the diagnosis of a food allergy, severely limiting conclusions about best practices for management and prevention."


Test yourself with MKSAP 15

MKSAP Quiz: 3-week history of pain and swelling of right knee

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 28-year-old woman is evaluated for a 3-week history of pain and swelling of the right knee and ankle. For the past 6 weeks, she has had diffuse, crampy abdominal pain. For the past week, the pain has been accompanied by four to six daily episodes of bloody diarrhea and fecal urgency. She has lost approximately 1.5 kg (3.3 lb) since the onset of her symptoms. She has not noticed a rash or other joint or soft-tissue involvement. She has not traveled outside of her hometown and has a monogamous sexual relationship with her husband. She has no other medical problems and does not take any medications.

On physical examination, temperature is 37.7° C (99.9° F), blood pressure is 128/72 mm Hg, pulse rate is 98/min, and respiration rate is 18/min. The abdomen is soft and diffusely tender to palpation. Bowel sounds are normal, and there is no organomegaly. Rectal examination reveals tenderness of the rectal canal and stool associated with bright red blood. The right ankle and knee are swollen and slightly warm to the touch, and range of motion of these joints elicits pain. The remainder of the physical examination is normal.

Plain radiographs of the ankle and knee are normal. Arthrocentesis is performed. Synovial fluid analysis reveals a leukocyte count of 14,000/µL (92% polymorphonuclear cells, 8% macrophages).

Which of the following is the most likely cause of this patient’s joint symptoms?

A) Crystal-induced arthritis
B) Enteropathic arthritis
C) Gonococcal arthritis
D) Whipple disease

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


Fracture risk

High-dose vitamin D may make falls, fractures more likely

Annual high doses of vitamin D increased elderly women’s risk of falls and fracture, according to a new study.

The controlled trial recruited 2,256 community-dwelling women who were 70 or over and considered to be at high risk of fracture. For the next three to five years, the women received either a single dose of 500,000 IU of cholecalciferol or a placebo every winter. Data on falls and fractures (which were radiologically confirmed) were compared between the two groups; the results appeared in the May 12 Journal of the American Medical Association.

Contrary to the study’s hypothesis, women who received the vitamin D had significantly more fractures (171 in the intervention group vs. 135 in the placebo group) and falls (2,892 vs. 2,512). A post-hoc analysis found that the higher risk of falls was particularly acute immediately in the three months after the dose was given. There was also a trend toward more fractures in this period. A substudy looked at patients’ 25-hydroxycholecalciferol levels and found that they increased substantially a month after a dose, then gradually decreased, but remained an average of 41% higher than levels in the placebo recipients.

An accompanying editorial offered possible explanations for the results. It’s possible that the large dose triggered a protective reaction, causing blood and tissue levels of 1,25-dihydroxyvitamin D to decrease in the months immediately after the dose. Alternatively, the vitamin D could have resulted in other health benefits, such as improved mood, reduced pain or fewer flu infections, which caused the women to be more active, and therefore have more falls and fractures.

The study, which confirmed previous findings of a fracture risk with high vitamin D supplementation but was the first to show the risk of falls, should raise concerns about providing infrequent high doses of vitamin D, the authors of the study and the editorial agreed. The results cannot be directly translated to the practice of providing high-dose vitamin D throughout the year, but do suggest that the safety of that regimen should be studied, the study authors concluded.

The editorialists cautioned, however, that the study’s findings should not negate the importance of correcting vitamin D deficiency and insufficiency, and they recommended daily, weekly or monthly dosing of vitamin D3 as the appropriate treatment.


Physician cost profiling

Physician cost profiling systems frequently come to different results

Health plans using different cost profiling rules may assign the same physician into different tiers anywhere from 17% to 61% of the time.

Researchers applied one default rule and 11 alternatives to a claims database submitted to four commercial health plans (including managed care, preferred provider organizations and indemnity products) in Massachusetts. They then compared the effect of the alternatives on whether the care assigned to a physician was provided by that physician or by his or her colleagues and on cost categories to which each physician was assigned. They reported results in the May 18 Annals of Internal Medicine.

The study sample included 13,761 physicians who delivered 5.6 million episodes of care to 1.1 million patients. Among patients, 91% saw multiple physicians and 61% saw five or more physicians. Among episodes, 54% involved multiple physicians and 9% involved five or more physicians. The data set included more than 80% of the people with commercial health insurance in Massachusetts.

Methods to create cost profiles and assign physicians to cost categories closely followed those used by health plans. Researchers created standardized prices, constructed episodes of care, tallied the cost of each episode, assigned responsibility of care, calculated the expected cost profiles and placed physicians into categories: low (below 25th percentile), average (25th to 75th percentile), high (above 75th percentile) or low sample size (less than 30 episodes.)

Across the 12 attribution rules, the percentage of episodes that could be assigned to physicians ranged from 20% to 69%, and the percentage of physicians with a sample size less than 30 episodes ranged from 39% to 66%. The mean percentage of a physician’s billed professional costs that were included in the physician’s own cost profile ranged from 13% to 60%, and the mean percentage of professional costs included in a physician’s cost profile that were actually billed by that physician ranged from 37% to 73%.

To determine disagreement in cost categories, researchers included the 9,741 physicians (71%) from the sample who had 30 or more episodes under any of the 12 rules. Rates of disagreement between the default rule and alternate rules ranged from 17% to 61%. The highest disagreement rates were associated with patient-based (range of disagreement, 47% to 61%) and multiple-physician (range of disagreement, 35% to 53%) rules.

Researchers concluded that those who assign cost categories to physicians must be transparent about the rules they use to make decisions.

"Our results help to explain why some physicians question cost profile attribution rules," researchers wrote. "No more than 60% of a physician’s billed costs were included in cost profiles under any rule, and of the physician costs assigned to a physician, up to two thirds were billed by other physicians. These findings might make physicians less responsive to efforts to use cost profiles to decrease spending."


Regulatory news

CMS announces change to submission period for Medicare claims

Last week CMS informed physicians and other health care professionals that claims with a service date on or after Jan. 1, 2010 must be submitted for reimbursement no later than one calendar year after the date of service. While this likely provides sufficient time as internists typically submit claims promptly, the one-calendar-year submission deadline represents a shorter period than previously allowed by law.

This change is the result of the new health care reform legislation, the Patient Protection and Affordable Care Act. Additional information is available on the CMS Web site.


CDC warns of Q fever in Iraq, Netherlands

The CDC has issued a health advisory about increasing reports of Q fever in Iraq and the Netherlands. Physicians should consider Q fever in the differential diagnosis of patients who have traveled to those areas, the agency warned.

The most common clinical presentation of the disease is unexplained febrile illness, sometimes accompanied by pneumonia and/or hepatitis, although asymptomatic infections may also occur. Illness onset typically occurs within two to three weeks after exposure, according to the CDC advisory. The mortality rate for acute Q fever is 1% to 2%, and most patients with mild illness recover spontaneously within a few weeks, although antibiotic treatment will shorten the duration of illness and lessen the risk of complications. The primary mode of transmission of this zoonotic disease is inhalation of aerosols or dust contaminated by infected animals, most commonly cattle, sheep or goats.

Physicians seeing a patient—particularly military personnel or a civilian contractor—who has an illness consistent with Q fever and who has traveled to Iraq or the Netherlands within 30 days should perform appropriate laboratory testing. If a case of Q fever is probable or confirmed, a completed CDC Q fever case report form should be submitted to the state health department.


FDA wants to know about 'bad' drug ads

A new FDA program seeks to educate health care professionals who prescribe medications about what constitutes appropriate prescription drug promotion and advertising, and asks physicians to report any misleading prescription drug advertising that they encounter.

The FDA will promote its "Bad Ad" new program at major medical conferences starting this month and will partner with medical societies to distribute educational materials, according to a press release.

The program is an FDA-sponsored educational outreach effort administered by the agency’s Division of Drug Marketing, Advertising, and Communications (DDMAC), in the FDA’s Center for Drug Evaluation and Research. The FDA’s traditional regulatory activities for monitoring prescription drug promotion primarily have relied on review of promotional pieces submitted to the agency by sponsoring drug companies, industry complaints, and field surveillance at large medical conventions.

Health care professionals are encouraged to report a potential violation in drug promotion by sending an e-mail to or by calling 877-RX-DDMAC. Reports can be submitted anonymously; however, the FDA encourages clinicians to include contact information so that DDMAC officials can follow up, if necessary.


From the College

New Doctor’s Dilemma™ app for iPhone

A new iPhone app for ACP’s Doctor’s Dilemma is now available.

Doctor’s Dilemma tests knowledge in a variety of disciplines, such as allergy, endocrinology and gastroenterology. The game was designed for students and residents, but often proves to be a useful tool for seasoned physicians as well. There are over 25 games with questions for over 25 categories; new games are posted periodically. The new app is free and available online.


Cartoon caption contest

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







MKSAP Answer and Critique

The correct answer is B) Enteropathic arthritis. This item is available online to MKSAP 15 subscribers in the Rheumatology section, Item 23.

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’s joint symptoms are most likely caused by enteropathic arthritis. She has a 6-week history of crampy abdominal pain and the recent onset of bloody diarrhea and rectal urgency. She also has had weight loss. This clinical presentation raises suspicion for inflammatory bowel disease.

For the past 3 weeks, this patient also has had acute arthritis of the right knee and ankle accompanied by inflammatory features such as tenderness and swelling; her synovial fluid findings confirm the presence of an inflammatory process. The presence of acute oligoarticular arthritis involving the lower extremities in a patient with an inflammatory diarrheal illness is suggestive of enteropathic arthritis; enteropathic arthritis also may manifest as axial arthritis, such as a spondyloarthropathy.

Crystal-induced arthritis typically manifests as acute monoarticular arthritis and would be unlikely in a premenopausal woman.

Gonococcal arthritis may be associated with oligoarticular arthritis, and joint manifestations in this condition may be migratory. However, patients with gonococcal arthritis commonly have tenosynovitis and cutaneous involvement, which are not present in this patient. Furthermore, neither gonococcal nor crystal-induced arthritis would explain this patient’s diarrhea and abdominal pain.

Whipple disease is an extremely rare infectious syndrome caused by Tropheryma whippelii. The most common presenting symptom in affected patients is arthritis; other symptoms include diarrhea, malabsorption, and central nervous system and constitutional symptoms. Joint involvement is usually migratory and follows a chronic course.

Key Point

  • The presence of acute oligoarticular arthritis involving the lower extremities in a patient with inflammatory bowel disease is suggestive of enteropathic arthritis.

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Copyright 2010 by the American College of Physicians.


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