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


In the News
for the Week of 5-25-10


  • Thoracic meeting features research on pulmonary diseases and ICU
  • Vitamin B12 declines in patients taking metformin

Test yourself with MKSAP 15

  • MKSAP Quiz: weight loss, heat intolerance and tremor

Primary care

  • Flexible anxiety treatment delivers better than usual care

Infectious disease

FDA update


  • Late registration for hospice and palliative medicine exam closes June 1

From the College

  • ACP's Steven Weinberger, FACP, blogs at KevinMD
  • Governance policy committee seeks regent candidates for 2010
  • Forum on health information exchange scheduled

Cartoon caption contest

  • Vote for your favorite entry

Physician editor: Darren Taichman, FACP

Editorial note: ACP InternistWeekly will not be published next week due to the Memorial Day holiday.


Thoracic meeting features research on pulmonary diseases and ICU

NEW ORLEANS—Researchers at the annual meeting of the American Thoracic Society presented findings in the organization’s areas of focus: pulmonary diseases, critical care and sleep.

  • Two studies of patients with chronic obstructive pulmonary disease (COPD) looked at the effects of exercise. One trial found that being active on a regular basis was more closely associated with patients' functional status than their maximal exercise tolerance, indicating the importance of encouraging patients to be regularly active, researchers said. Another study found that obese COPD patients benefit as much from pulmonary rehabilitation as thinner patients.

  • Asthma researchers found that patients could reduce their use of corticosteroids through an online self-management program and that consumption of a high-fat, fast-food meal increases airway inflammation. A follow up of adult survivors of childhood asthma may also indicate a link between the pediatric disease and later development of COPD. New basic science was also presented about the effects of estrogen on the lung, which may have potential to affect treatment of menstrual or pre-menstrual asthma.

  • In critical care, a comparison of Pennsylvania hospitals' public reporting of central-line bloodstream infections and ventilator-associated pneumonia with mortality rates found no association between reported rates and mortality in at-risk patients. The study author theorized that hospitals are gaming the system and recommended more auditing of public reports. In another Pennsylvania study, uninsured ICU patients were more likely to die and less likely to get a number of procedures—central lines, tracheostomies and acute hemodialysis—regardless of where they were treated, indicating that disparities in care are not caused by variations among hospitals.

  • Testing for obstructive sleep apnea can be conducted effectively in patients’ homes instead of the lab, according to a study from the Veterans Administration. The practice, which is commonly used in Europe, could potentially reduce costs of testing. Another study found clinical benefit to treating patients with obstructive sleep apnea, even if they don’t report daytime sleepiness. Cardiac events and new cases of hypertension were reduced in patients who used continuous positive airway pressure at least four hours per night.

—Stacey Butterfield


Vitamin B12 declines in patients taking metformin

Taking metformin increased the chances of developing vitamin B12 deficiency, according to a new study of type 2 diabetics on insulin.

The Dutch trial randomized 390 patients to receive either 850 mg of metformin or a placebo three times a day for 4.3 years. Their levels of vitamin B12, folate and homocysteine were measured at baseline and 4, 17, 30, 43 and 52 months. The metformin group showed a persistent, progressive decrease in B12 concentrations, with a mean decrease of 19% compared to the placebo group. At the end of the study, patients taking metformin were 7% more likely to be B12-deficient (less than 150 pmol/L) and 11% more likely to have a low level (15 to 220 pmol/L).

The metformin patients also had lower folate concentrations than placebo recipients, although both groups showed an overall increase and the difference between groups was eliminated after adjustments for body mass index and smoking. There was also an increase in homocysteine levels in the metformin group that was not statistically significant across the whole group, but showed that patients who were B12-deficient had higher concentrations of homocysteine (a mean of 23.7 µmol/L compared to 14.9 µmol/L in patients with normal B12 levels). The study was published online by BMJ.

Based on the findings, study authors concluded that regular measurement of B12 concentrations should be considered for patients on long-term metformin treatment. They noted that deficiencies are relatively easy and cheap to treat effectively and safely. However, an editorial that accompanied the study noted several questions that should be answered before such screening becomes routine practice: The study did not determine whether the patients with low levels of B12 suffered any adverse effects of their deficiency, or whether these findings apply to type 2 diabetics not treated with insulin.

It’s also possible that simple dietary counseling could solve the problem of B12 deficiency, the editorialists said. If counseling is found to be insufficient, then researchers should conduct randomized trials that screen for deficiency among all type 2 diabetics (not just those on insulin) and look at outcomes and costs of screening and treatment.


Test yourself with MKSAP 15

MKSAP Quiz: weight loss, heat intolerance and tremor

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 55-year-old man is evaluated for a 4-month history of weight loss, heat intolerance, tremor and hyperdefecation and a 1-week history of dry eyes that are sensitive to light and frequently injected. He reports no blurred or double vision but does relate having been previously diagnosed with a “thyroid condition” and having a severe allergic reaction to methimazole therapy. The patient currently takes no medications.

On physical examination, blood pressure is 140/88 mm Hg, pulse rate is 120/min, respiration rate is 18/min, and BMI is 22. Pupils are equal, round, and reactive to light and accommodation; extraocular movements are intact. Mild bilateral conjunctival injection and periorbital edema are noted. There is no chemosis, but some slight lid lag and proptosis are present. Examination of the neck reveals a smooth thyroid gland that is three times its normal size. Cardiac examination shows tachycardia and a regular rhythm. There is a 3+ upper extremity tremor bilaterally.

Laboratory studies show a serum thyroid-stimulating hormone level of 0.01 µU/mL (0.01 mU/L) and a serum free thyroxine (T4) level of 3.8 ng/dL (49.0 pmol/L).

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

A) Immediate thyroidectomy
B) Orbital decompression surgery
C) Prednisone and radioactive iodine ablation
D) Radioactive iodine ablation alone

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


Primary care

Flexible anxiety treatment delivers better than usual care

Treating anxiety-related disorders with or without depression via a flexible treatment regimen in a primary care setting may result in greater improvement in anxiety symptoms, depression symptoms, functional disability, and quality of care during 18 months of follow-up, according to study results.

Researchers conducted a randomized controlled effectiveness trial of Coordinated Anxiety Learning and Management (CALM) compared with usual care in 17 primary care clinics in four U.S. cities. Patients were referred to the study by their internists or family practitioners and all had anxiety disorders (panic, generalized anxiety, social anxiety, or post-traumatic stress).

CALM allows patients to choose cognitive behavioral therapy (CBT), medication, or both. It includes real-time Web-based outcomes monitoring to optimize treatment decisions, and a computer-assisted program to optimize delivery of CBT by nonexpert care managers who also assisted primary care clinicians in promoting adherence and optimizing medications.

Between June 2006 and April 2008, 1,004 patients with anxiety disorders (with or without major depression) received treatment for three to 12 months. Blinded follow-up assessments at six, 12 and 18 months after baseline were completed in October 2009 using a 12-item Brief Symptom Inventory (BSI-12) score. Secondary outcomes included response (>50% reduction from pretreatment BSI-12 score) or remission (total BSI-12 score <6).

A significantly greater improvement in global anxiety symptoms was found for CALM over usual care, measured by medication, counseling or referral to a mental health specialist. The mean differences in BSI-12 between groups were −2.49 (95% CI, −3.59 to −1.40), −2.63 (95% CI, −3.73 to −1.54), and −1.63 (95% CI, −2.73 to −0.53) at six, 12 and 18 months, respectively.

At 12 months, response and remission rates (CALM vs. usual care) were 63.66% (95% CI, 58.95% to 68.37%) versus 44.68% (95% CI, 39.76% to 49.59%), and 51.49% (95% CI, 46.60% to 56.38%) versus 33.28% (95% CI, 28.62% to 37.93%), with a number needed to treat of 5.27 (95% CI, 4.18 to 7.13) for response and 5.50 (95% CI, 4.32 to 7.55) for remission. The number needed to treat was within the range of other treatments considered effective, and effects lasted for at least a year, study authors concluded. The study was published in the May 19 Journal of the American Medical Association.

Flexibility in the number and types of session, criteria for continuing therapy, targeting multiple disorders, and effectiveness across a range of primary care settings suggest the model could be applied elsewhere. Study limitations include a patient population referred by their doctors, one-third of whom had failed at least one drug regimen and who were relatively well-educated. Because the treatment was a blend, it is not known which components resulted in efficacy.


Infectious disease

Antibiotic resistance lasts up to a year

Antibiotic resistance is greatest in the month after treatment but may last for up to a year, possibly driving high levels of resistance in the community, a meta-analysis concluded. Longer treatment courses and multiple treatment courses were associated with higher rates of resistance.

British researchers analyzed 24 published studies of antibiotic resistance in primary care patients, who were mainly treated for respiratory or urinary infections. The paper appeared online May 18 in BMJ.

Of the studies, 22 involved patients with symptomatic infection and two involved healthy volunteers. Nineteen were observational studies (two prospective) and five were randomized.

Five studies of urinary tract bacteria (14,348 participants) found the pooled odds ratio (OR) for resistance was 2.5 (95% CI, 2.1 to 2.9) within two months of antibiotic treatment and 1.33 (95% CI, 1.2 to 1.5) within 12 months. Seven studies of respiratory tract bacteria (2,605 participants) found pooled ORs of 2.4 (95% CI, 1.4 to 3.9) within two months and 2.4 (95% CI, 1.3 to 4.5) within 12 months.

Researchers found a dose-response relationship for amoxicillin and trimethoprim. Also, longer duration and multiple courses of antibiotics were associated with higher resistance rates. The authors concluded that the only way to avoid the resistance is to avoid using antibiotics whenever possible.

An accompanying economic analysis said that although new antibiotics are needed, the research pipeline is nearly devoid of promising new alternatives. Financial incentives and medical-legal changes could persuade drug companies to develop new lines. But until new drugs are developed, said an editorial, steps must be taken to conserve existing medications.


FDA update

Metronidazole injection recalled

A voluntary nationwide recall has been issued for all lots of metronidazole injection, USP 500 mg/100 mL, manufactured by Claris Lifesciences and distributed by Sagent, the FDA announced last week.

No adverse patient events have been reported but two lots of metronidazole injection were recently found to be non-sterile. Non-sterility of an antimicrobial administered via the intravenous route has the potential to result in infections, which could be fatal, especially in patients who are immunocompromised, noted the FDA alert.

The lot numbers being recalled, A090742, A090743, A090744, A090745, A090746, A090769, A090770, A090771, A090772, A090773, A090774, A090775, A090776, A090968, A091014, A000013, A000016 and A000019, were distributed to hospitals, wholesalers and distributors nationwide from February through May 2010. Metronidazole injection is an intravenous antimicrobial product used to treat infections and is supplied in a single-dose plastic container.


Rotarix OK for use again

The FDA revised its recommendations on rotavirus vaccines last week, rescinding an earlier recommendation that the Rotarix vaccine be avoided.

The warning against Rotarix was issued as a precaution when DNA from porcine circovirus type 1 (PCV1) was found in the vaccine. After evaluation of laboratory results, a review of the scientific literature and input from experts, the FDA has determined that clinicians and health care professionals should resume the use of Rotarix and continue the use of RotaTeq. The benefits of the vaccines outweigh the theoretical risk of PCV1, according to the new FDA alert.



Late registration for hospice and palliative medicine exam closes June 1

Internists who are interested in taking this year's hospice and palliative medicine exam but have not yet registered must do so by June 1.

After hospice and palliative medicine was recognized as a subspeciality in 2006, the American Board of Medical Specialties confirmed a five-year "grandfathering" period in which physicians with the required number of clinical hours may take the certification exam without first completing a 12-month fellowship program. The second exam within the grandfathering period is scheduled for Nov. 16, 2010, and late registration closes June 1. The third and final exam within the grandfathering period will take place in fall 2012.

More information on the exam is available online from the American Academy of Hospice and Palliative Medicine.


From the College

ACP's Steven Weinberger, FACP, blogs at KevinMD

Steven Weinberger, FACP, ACP's deputy executive vice president and senior vice president for medical education and publishing, continues his monthly column at, one of the Web's most influential medical blogs. This month's column looks at the principles that should guide relationships between medical societies and commercial entities.


Governance policy committee seeks regent candidates for 2010

The Governance Policy Committee (GPC) oversees the process for nominating and electing Masters and Fellows of the College to the Board of Regents (BOR) and is beginning the process of seeking Regents to join the Board in May 2011.

The GPC will strive to represent the diversity within internal medicine on ACP’s Board of Regents. Important general qualifications include commitment to ACP, dependability, leadership qualities, and the ability to represent the College in numerous and diverse arenas. Regent nominees must be Fellows or Masters of the College.

Regent candidates must submit a letter of nomination (not from the candidate) and two letters of support (from two individuals other than the nominator) by August 1.

Letters of nomination should include the following sections:

  • brief description of the nominee’s current activities,
  • special attributes the candidate would bring to the BOR in terms of the desired characteristics outlined above,
  • previous and current service in College-related activities,
  • service in organizations other than the College (medical and non-medical), and
  • identification of two individuals who will write letters of support for the candidate.

Letters of support do not need to have specific content or format, but will be most useful if they focus on the candidate’s qualifications and how they would contribute to the BOR and College.

Send confidential nominations to:

Governance Policy Committee
ATTN: Mrs. Florence Moore
American College of Physicians
190 N. Independence Mall West
Philadelphia, PA 19106-1572
Fax: 215-351-2829

Only candidates who submit a letter of nomination and two letters of support by August 1 will be advanced to the GPC for review.

If you have any questions, please contact Florence Moore toll free at (800) 523-1546, ext. 2814, or direct at (215) 351-2814.


Forum on health information exchange scheduled

ACP is a strategic partner in the upcoming eHealth Initiative's National Forum on Health Information Exchange, to be held July 22, 2010 at the Omni Shoreham Hotel in Washington, D.C.

The forum will convene health information technology coordinators and health information exchanges from dozens of states to discuss the challenges and strategies related to operating a sustainable health information exchange. During the event, the eHealth Initiative will release the results of its 7th Annual Survey of Health Information Exchange (HIE). Experts and HIE leaders from the field will be on hand to engage in interactive discussions surrounding the findings.

Health information exchange representatives are encouraged to attend this event free of charge (in exchange for their participation in the 2010 Health Information Exchange Survey). More information and registration are online.


Cartoon caption contest

Vote for your favorite entry

ACP InternistWeekly's cartoon caption contest continues. Readers can vote for their favorite caption to determine the winner.









"You've lost weight, but that didn't really change your BMI."
"Odd ... it says here that your co-pay is an arm and a leg."
"My HMO says I can be capitated here."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting continues through Monday, June 7, with the winner announced in the June 8 issue.


MKSAP 15 answer and critique

The correct answer is C) Prednisone and radioactive iodine ablation. This item is available online to MKSAP 15 subscribers in the Endocrinology and Metabolism section, Item 46.

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 should receive prednisone and radioactive iodine ablation concomitantly. He has active Graves disease and mild Graves ophthalmopathy. Because he also has a history of a severe allergic reaction to methimazole, a retrial of antithyroidal drugs is not recommended. Although thyroidectomy is a viable treatment for hyperthyroidism resulting from Graves disease, patients are typically first made euthyroid with antithyroidal drugs preoperatively, which is not an option with this patient.

Graves disease is complicated by Graves ophthalmopathy in approximately 5% to 10% of patients. Graves ophthalmopathy is an autoimmune disease of the retro-orbital tissues that may present with proptosis and periorbital edema. Patients may report irritation in the eyes, tearing, ocular pain, and changes in vision. Vision loss may occur. A persistent thyrotoxic or hypothyroid state appears to exacerbate eye disease activity, so patients should be made euthyroid as soon as possible. However, the use of radioactive iodine to treat hyperthyroidism can exacerbate thyroid-associated eye disease, especially in patients with significant preexisting ophthalmopathy at the time of ablation. Prednisone can mitigate this negative effect. A periablative course of prednisone is thus appropriate in patients with mild ophthalmopathy who are being considered for ablation therapy.

Orbital decompression surgery is reserved for patients with severe ophthalmopathy that has not responded to medical treatment. Furthermore, the patient would first need to be made euthyroid before any such surgery. Decompression surgery is thus inappropriate in this patient.

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Copyright 2010 by the American College of Physicians.


Test yourself

A 67-year-old man is evaluated for a recent diagnosis of primary hyperparathyroidism after an elevated serum calcium level was incidentally detected on laboratory testing. Medical history is significant only for hypertension, and his only medication is ramipril. Following a physical exam and lab studies, what is the most appropriate management of this patient?

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