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

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In the News
for the Week of 6-15-10

Highlights

  • A1cs are higher in black patients
  • American Board of Internal Medicine sanctions physicians over exam questions

Test yourself

  • MKSAP Quiz: thyroid nodule

NSAID use

  • Diclofenac linked to increased cardiovascular risks

Alzheimer's disease

  • No evidence supports modifying lifestyle to slow Alzheimer's progression

H1N1 influenza pandemic

  • Oseltamivir prophylaxis worked, but drug may pose reinfection risks

Hepatology

  • Hepatocellular carcinoma surveillance suboptimal in cirrhosis patients

Patient-centered medical home

  • Medicare soliciting states for new PCMH demonstration
  • Primary care collaborative holds working group meeting

Cartoon caption contest

Physician editor: Darren Taichman, FACP


Highlights

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A1cs are higher in black patients

Levels of hemoglobin A1c are higher in black patients than white, found a new study that could affect methods of screening and monitoring diabetes.

The cross-sectional analysis included 1,581 patients from the Screening for Impaired Glucose Tolerance study and 1,967 from the National Health and Nutrition Examination Survey (NHANES III). A1c levels were compared between black and white patients involved in the trials. The study was published in the June 15 Annals of Internal Medicine.

Black patients had higher average A1c levels, whether they had diabetes, prediabetes or normal glucose tolerance. The difference between the racial groups became greater as glucose intolerance increased; levels were only about 0.2% higher in nondiabetic blacks, but almost 0.5% higher in diabetics. These differences were found even after adjustment for a number of factors, including age, sex, body mass index, education and income. Because none of the patients had previously been diagnosed with diabetes or prediabetes, treatment decisions are unlikely to have confounded the results.

The study confirms previous research that found differences in A1c levels by race, independent of glycemia. The mechanism for the difference is unknown, although study authors speculated on possible physiologic or genetic explanations and recommended that more research be done in this area.

In the meantime, they urged clinicians to recognize the limitations of using A1c to assess glycemic control both in the general population and in individual patients. Greater emphasis on home glucose-monitoring data may be helpful, the authors suggested. Physicians may also want to keep the findings in mind when considering current American Diabetes Association recommendations to diagnose diabetes based on A1c level, noted an accompanying editorial.

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American Board of Internal Medicine sanctions physicians over exam questions

The American Board of Internal Medicine (ABIM) will sanction 139 physicians for soliciting or sharing confidential questions from board certification examinations, it announced last week. ABIM also brought legal action against five physicians it alleged were the most egregious offenders.

The physicians involved took the Arora Board Review, a test-preparation course for board certification. They were encouraged to relay questions to the company immediately after taking ABIM exams and were given ABIM questions obtained from other physicians, ABIM has alleged. When registering for ABIM exams, physicians agree in writing not to discuss the exam content and sign a "pledge of honesty" that they will not disclose, copy, or reproduce any portion of the exam material. ABIM also warns physicians that it will severely penalize anyone who divulges exam content. ABIM asserts that exam questions are copyrighted property of ABIM, and unauthorized dissemination of them is in violation of copyright law and professional ethical medical standards.

“Sharing test questions from memory is a serious problem that threatens the integrity of all standardized testing. Test takers need to know that this kind of ‘brain dumping’ is grossly unethical,” said Christine K. Cassel, MACP, ABIM’s president and CEO, in a press release. “Ethics are critical to the practice of medicine and are the foundation of a successful doctor-patient relationship. We will not tolerate unethical behavior from physicians seeking board certification.”

ABIM has taken the following actions, according to its press release:

  • The physicians involved will have their board certification suspended for up to five years, based on the seriousness of their offense.
  • Physicians involved who have not achieved certification will not be admitted to sit for a certification exam for at least one year, based on the seriousness of their offense.
  • Certification will be revoked for any physician who organized, collected and distributed ABIM exam questions.
  • Physicians who took the Arora Board Review course will receive a letter expressing concern about their failure to notify ABIM about any questionable activities involving solicitation or receipt of exam questions.

ABIM may impose additional sanctions or escalate sanctions if new evidence is obtained in the ongoing investigation.

"Honesty and integrity must govern all aspects of medicine, including our relationships with patients, with the public, and with each other," said ACP President J. Fred Ralston, FACP. "These physicians must be held accountable for these serious breaches of ethics and professionalism, and for fracturing the trust society grants our profession."

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Test yourself

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MKSAP Quiz: thyroid nodule

A 35-year-old woman comes to the office for her annual physical examination. The patient says she feel well. She has no pertinent personal or family medical history and takes no medications.

On physical examination, vital signs are normal. Palpation of the thyroid gland suggests the presence of a nodule. All other findings of the general physical examination are normal.

Laboratory studies show a thyroid-stimulating hormone level of 1.3 µU/mL (1.3 mU/L) and a free thyroxine (T4) level of 1.3 ng/dL (16.8 pmol/L).

An ultrasound of the thyroid gland reveals a normal-sized gland with a 2-cm hypoechoic right midpole nodule.

Which of the following is the most appropriate next step in management?

A) Fine-needle aspiration biopsy of the nodule
B) Measurement of anti-thyroperoxidase and anti-thyroglobulin antibody titers
C) Neck CT with contrast
D) Thyroid scan with technetium
E) Trial of levothyroxine therapy

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

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NSAID use

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Diclofenac linked to increased cardiovascular risks

Diclofenac and rofecoxib were associated with increased cardiovascular mortality and morbidity and should be used with caution in most individuals, whereas naproxen may have a safer cardiovascular risk profile, Danish researchers concluded.

The researchers used their country's nationwide administrative registers to identify more than 1 million people (mean age, 39 years) who were receiving a nonsteroidal anti-inflammatory drug (NSAID), and were without hospitalizations for the previous five years or prescriptions for other cardiac drugs or analgesics for the previous two years. Results were released early online and will appear in the July issue of Circulation: Cardiovascular Quality and Outcomes.

During the study period, 56,305 individuals died, 2,204 of whom were taking an NSAID. The nonselective NSAID diclofenac (brand names include Voltaren or Cataflam) was associated with an increased risk of cardiovascular death (odds ratio [OR], 1.91; 95% CI, 1.62 to 2.42). The selective cyclooxygenase-2 inhibitor rofecoxib (Vioxx) also was associated with an increased risk (OR, 1.66; 95% CI, 1.06 to 2.59).

Ibuprofen had an increased risk of fatal or nonfatal stroke (OR, 1.29; 95% CI, 1.02 to 1.63), but naproxen (Aleve) was not associated with increased cardiovascular risk (OR for cardiovascular death, 0.84; 95% CI, 0.50 to 1.42).

Diclofenac had a dose-dependent increase of coronary death or nonfatal MI, and fatal or nonfatal stroke, which researchers found concerning because it is used in high doses more often than the other drugs. Diclofenac has a high COX-2-inhibiting selectivity, and researchers hypothesized that it may share this trait with rofecoxib, which was withdrawn from the market in 2004.

"Our results confirm this association in healthy individuals, and it is particularly worrying that diclofenac exerts the same risk for cardiovascular adverse events as rofecoxib," the authors wrote. "This is a major public health concern because diclofenac is one of the most widely used NSAIDs worldwide and in some countries dispensed as an over-the-counter drug."

Study strengths include its size and completeness, which was the entire population of Denmark. All NSAID use was tracked, with the exception of low-dose over-the-counter sales of ibuprofen, and a sensitivity analysis for this did not change the results. Limitations include the study's observational nature and a lack of information about the exact reason for beginning NSAID treatments, which may cause confounding by indication.

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Alzheimer's disease

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No evidence supports modifying lifestyle to slow Alzheimer's progression

No evidence of even moderate scientific quality links the risk for Alzheimer's disease to any modifiable factor such as diet, drugs, demographics, co-morbidity or environmental exposure, according to a consensus statement.

While promising research is under way on numerous factors, published evidence is weak or inconclusive, according to a consensus statement written by a panel of the National Institutes of Health and published early online by Annals of Internal Medicine.

The panel considered evidence from 127 observational studies, 22 randomized, controlled trials and 16 systematic reviews to draw conclusions and make recommendations for further research.

While some lifestyle factors such as a Mediterranean-style diet, omega-3 fatty acids and physical and leisure activities were associated with a lower risk of cognitive decline, available evidence is too weak to justify strongly recommending them to patients.

No consistent associations were found for other vitamins; fatty acids; metabolic syndrome; blood pressure; plasma homocysteine level; obesity and body mass index; antihypertensive medications; nonsteroidal anti-inflammatory drugs; gonadal steroids; or exposures to solvents, electromagnetic fields, lead or aluminum.

Likewise, some factors, such as the gene marker apolipoprotein E, depression and metabolic syndromes, were associated with a higher risk of cognitive decline, yet evidence was also limited. Stronger evidence showed that people who smoke or have diabetes are at an increased risk for cognitive decline.

While the researchers could not draw firm conclusions about modifiable risk factors, they added that a large amount of promising research on medication, diet, exercise, and cognitive engagement is under way. The panel recommended that future research:

  • use rigorous, consensus-based diagnostic criteria; further develop brain imaging techniques to pinpoint pathological changes; and delineate the natural progression of Alzheimer's disease;
  • develop an objective, consensus-based definition of mild cognitive impairment to further aid research;
  • collect data from caregivers in a systematic way;
  • involve large-scale, long-term population-based studies using precise, well-validated exposure and outcome measures to generate strong evidence on biological, behavioral, lifestyle, dietary, socioeconomic, and clinical factors;
  • include women and men from socioeconomically and ethnically diverse populations to examine the incidence and prevalence of Alzheimer's disease and cognitive decline in these groups and specific subgroups; and
  • create a large, multicenter registry, following the models of cancer, that would greatly expand opportunities for research and surveillance.

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H1N1 influenza pandemic

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Oseltamivir prophylaxis worked, but drug may pose reinfection risks

Treatment with an antiviral agent may decrease a patient’s protection against reinfection in a subsequent pandemic, although a combination of early detection and "ring" protection can truncate epidemics in close quarters.

Epidemiology and containment strategies from the 2009 influenza A (H1N1) pandemic, especially regarding the use of oseltamivir (Tamiflu), were assessed in two new studies from Hong Kong and Singapore, published in the June 10 New England Journal of Medicine.

The Hong Kong study included 99 patients who were seen at outpatient clinics for acute respiratory illness and who had positive results on a rapid test for influenza A. In addition, nasal and throat swabs were collected from all members of the patients’ households during three visits over the next seven days. Samples were also taken from a subgroup of patients to test for antibody responses to both the pandemic and seasonal influenza A viruses.

Overall, the epidemiology of the viruses appeared similar; secondary attack rates, viral shedding, and the course of illness showed insignificant differences between the pandemic disease and the seasonal one. However, the study did find one potential difference between these strains. Almost half (44%) of the patients received oseltamivir, and those patients had reduced antibody titers to the pandemic strain compared to patients who hadn’t received drug treatment.

Combined with some recent case reports, this finding could indicate that treatment with an antiviral agent may decrease a patient’s protection against reinfection in a subsequent pandemic, the study authors said. This could be true of pandemic influenza but not seasonal influenza because immune systems have already been primed to respond to seasonal flu by exposure to previous, closely related strains, the authors explained.

The Singapore study analyzed the effectiveness of oseltamivir as a prophylactic strategy during H1N1 outbreaks in military camps. During four outbreaks, a total of 1,110 personnel received prophylaxis. Three out of the four outbreaks showed significant reductions in infection rates after the prophylaxis was instituted. The anti-flu effort also isolated infected patients and segregated affected military units.

The study authors concluded that early detection (which was accomplished in three of the outbreaks through education and daily monitoring for symptoms) and "ring" prophylaxis (defined as "geographically targeted containment") with antiviral drugs can effectively truncate the spread of an epidemic.

The strategy may be appropriate in areas where vaccine supply is limited or unavailable, or in situations where the vaccine is a poor match with the circulating virus. Aggressive prophylaxis could be particularly useful in long-term care facilities, schools, prisons or military camps, the study authors said. However, an accompanying editorial cautioned that compliance and oseltamivir resistance could pose problems. Vaccination should remain as the primary prevention tool for influenza, the editorialist wrote.

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Hepatology

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Hepatocellular carcinoma surveillance suboptimal in cirrhosis patients

Recommended surveillance for hepatocellular carcinoma is too low in patients with cirrhosis, especially those treated by internists or family doctors, according to a new study.

Risk for hepatocellular carcinoma (HCC) is elevated in patients with cirrhosis, and most cases are diagnosed at an advanced stage. Guidelines from consensus conferences and professional organizations have called for regular surveillance for HCC in cirrhosis patients.

Researchers performed a population-based cohort study using data from Medicare patients in the Surveillance, Epidemiology, and End Results (SEER) Registry to determine the use of HCC surveillance in this group. Patients were categorized as receiving regular surveillance (annual alpha-fetaprotein [AFP] test or ultrasound during at least two of the three years before HCC diagnosis), inconsistent surveillance (at least one AFP test or ultrasound for surveillance during the three years before HCC diagnosis) or no surveillance. Results will appear in the July Hepatology.

Overall, study authors identified 1,873 HCC patients with a previous diagnosis of cirrhosis. Mean age at diagnosis of HCC was 74.9 years, 65.7% of patients were men, and 81.8% were white. In the three years before HCC was diagnosed, 17% of patients underwent regular surveillance, 38% received inconsistent surveillance and 45% received no surveillance. Among a subset of 541 patients who had received a cirrhosis diagnosis at least three years before their HCC diagnosis, 29% got routine surveillance, 33% got inconsistent surveillance and 38% got no surveillance. Approximately 52% of patients who received regular surveillance had both AFP tests and ultrasound, while 46% received only an AFP test and 2% received only ultrasound.

Regular surveillance was associated with living in an urban area and having a higher income. Patients seen by a gastroenterologist/hepatologist or by a physician with an academic affiliation were 4.5-fold and 2.8-fold more likely to receive regular surveillance, respectively, than those who were seen by an internist or a family practitioner only.

The authors acknowledged that surveillance tests could have been misclassified and that tests could have been ordered but not performed, among other limitations. They also pointed out that rates of surveillance may be improving, because the study used data from 1994 to 2002 while the two most important guidelines on HCC management were released in 2001 and 2005. Nevertheless, they concluded that rates of recommended HCC surveillance are low in patients with established cirrhosis, and that physician specialty and practice type are strongly associated with surveillance.

"Future studies are needed to evaluate the knowledge, attitudes, and barriers for HCC surveillance and to develop appropriate, targeted interventions to increase the dissemination of this practice," they wrote.

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Patient-centered medical home

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Medicare soliciting states for new PCMH demonstration

The Centers for Medicare and Medicaid Services (CMS) is seeking applications from states that wish to participate in the new Multi-payer Advanced Primary Care Practice Demonstration project. States eligible to apply are those with state-based patient-centered medical home (PCMH) projects that involve private payers and the state Medicaid program. Medicare beneficiaries will be able to join the PCMH project in the states that CMS selects, with the agency funding their participation.

The project is one of three different programs CMS is conducting to test the model of care. The demonstration will be the first project to include all major payers in the participating sites, thereby increasing resources for practices to transition to the PCMH model. ACP is pleased that CMS has initiated this project as it has urged the agency to have Medicare join with other payers.

The deadline for applications is August 3. Physicians who are involved with PCMH projects at the state level should encourage the conveners to apply. CMS will select up to six different states to participate in this project. Additional information about the demonstration project is available on the CMS website.

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Primary care collaborative holds working group meeting

The Patient-Centered Primary Care Collaborative will hold its Stakeholders' Working Group Meeting on July 22 in Washington, D.C.

The meeting will focus on the patient-centered medical home (PMCH) in the community, addressing such topics as the employers' role and the role of federal initiatives. Case studies from practices and pilots will also be presented. The meeting's keynote speakers will be Mary Wakefield, RN, PhD, administrator of the Health Resources and Services Administration for the U.S. Department of Health and Human Services, and Anthony Rodgers, deputy administrator and director of the Center for Strategic Planning at CMS.

ACP is a member of the Patient-Centered Primary Care Collaborative. Registration information is available online.

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Cartoon caption contest

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Put words in our mouth

ACP Internist continues its cartoon caption contest this week. 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 A) Fine-needle aspiration biopsy of the nodule. This item is available online to MKSAP 15 subscribers in the Endocrinology and Metabolism section, Item 16.

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.

Fine-needle aspiration biopsy is the most appropriate next step in the evaluation of this patient. Whereas screening for thyroid nodules with ultrasonography is not recommended, ultrasonography is an excellent modality for assessing the thyroid gland when anatomic abnormalities are suspected clinically. Ultrasonography allows identification of nodules, whether palpable or not, and of nodule characteristics, such as echogenicity, vascular pattern, and presence of calcifications. Fine-needle aspiration is the mainstay in the evaluation of such thyroid nodules in euthyroid patients and has an excellent sensitivity and specificity for detecting cancer. Ultrasonography-guided fine-needle aspiration would be preferred in this patient because the nodule was not definitively palpated on examination.

Nodules can harbor malignancy regardless of the presence or absence of autoimmune disease. Therefore, determination of anti-thyroperoxidase antibody and anti-thyroglobulin antibody titers in this patient is unlikely to be helpful.

Ultrasonography is superior to CT in the evaluation of thyroid nodules, except when there is a goiter with substantial substernal extension. This patient has no such goiter. Because the thyroid nodule has been verified on an ultrasound, further imaging is unnecessary before obtaining a tissue sample.

Thyroid scanning has no role in the initial workup of thyroid nodules because both benign and malignant nodules tend to be hypofunctional or “cold” on a thyroid scan. Thyroid scanning may be helpful when the thyroid-stimulating hormone (TSH) level is suppressed (which this patient’s is not) to assess for a hyperfunctioning (“hot”) nodule that does not require fine-needle aspiration biopsy. Hyperfunctioning nodules are rarely malignant.

Suppression of the TSH level with levothyroxine has fallen out of favor in the management of benign nodular thyroid disease because most randomized prospective trials have shown no net reduction in nodule size, and concerns are increasing about the adverse effects of iatrogenic thyrotoxicosis. Suppressive therapy is generally now reserved for patients with a cancer diagnosis.

Key Point

  • Fine-needle aspiration is the mainstay in evaluation of nontoxic thyroid nodules.

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Copyright 2010 by the American College of Physicians.

Test yourself

A 66-year-old man comes for a preoperative evaluation before total joint arthroplasty of the left knee. He has a 25-year history of rheumatoid arthritis. He has had progressive pain in his left knee with activity, which limits his ability to hike. The patient has similar pain in the right knee, but it is less severe. He reports no recent morning stiffness. He is able to climb two or three flights of stairs without chest pain or shortness of breath. He has no other medical problems and reports no additional symptoms. Medications are methotrexate and folic acid. Following a physical exam and lab tests, what is the next best step in management?

Find the answer

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