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


In the News
for the Week of 8-24-10


  • Health care reform’s effects on physicians described
  • Early palliative care improves quality of life in patients with metastatic lung cancer

Test yourself

  • MKSAP Quiz: progressive right knee pain


  • Increased suicide risk, but not overall mortality, with fibromyalgia
  • Tai chi helps with fibromyalgia


FDA update

From ACP Foundation

  • Video HEALTH TiPS on opioid pain medications available

Cartoon caption contest

  • Vote for your favorite entry

Physician editor: Darren Taichman, FACP


Health care reform’s effects on physicians described

Health care reform will increase the appeal of primary care as a career and push physicians toward practice integration or hospital employment, according to a new paper by White House officials.

The article, released online yesterday by Annals of Internal Medicine, addresses the opportunities and challenges of the Affordable Care Act. The authors—Robert Kocher, MD, Ezekiel Emanuel, FACP, and Nancy-Ann M. DeParle, JD—note that in addition to increasing patient access to physicians through expansion of insurance coverage, the act includes a number of provisions affecting physician practice.

The implementation of electronic health records—and their use in patient tracking, teamwork and patient outcome orientation—will be encouraged by $25 billion in incentives, the article noted. The new law also moves away from the fee-for-service system by establishing patient-centered medical homes and accountable care organizations, as well as pilots of bundled payments. These changes will drive greater integration of the health care system, with physicians either organizing themselves into larger groups or joining hospitals, the article predicted.

Physicians will also be encouraged to practice in primary care by a 10% bonus for qualified primary care physicians and increased funding for the National Health Service Corps. Additional funding for medical education and provisions to reduce administrative paperwork should also have a positive effect on the primary care system, the article noted.

The failure of the reform plan to fix the sustainable growth rate formula is disappointing, but this limitation should not distract physicians from the provisions that can benefit them and their patients, the officials advised.


Early palliative care improves quality of life in patients with metastatic lung cancer

Introducing palliative care soon after diagnosis of metastatic non-small-cell lung cancer improves quality of life, mood and possibly survival, while decreasing aggressive end-of-life care, according to a new study.

Researchers at Massachusetts General Hospital performed an unblinded randomized, controlled trial that assigned patients with a new diagnosis of non-small-cell lung cancer to receive standard care or early palliative care plus standard care. Those assigned to early palliative care met with a clinician from the palliative care team within three weeks of study enrollment and a minimum of once a month thereafter; patients could schedule additional visits at their own or their clinicians' discretion. The palliative care visits were used to assess physical and psychosocial symptoms, outline care goals, help patients make decisions about treatment and coordinate care. Patients who were assigned to standard care didn't meet with the palliative care team unless they, their family or their oncologist requested a visit.

The study measured quality of life at baseline and at 12 weeks with the Functional Assessment of Cancer Therapy–Lung (FACT-L) scale, which ranges from 0 to 136. Patients' mood was measured at baseline and at 12 weeks using the Hospital Anxiety and Depression Scale. The authors also looked at the type and amount of end-of-life care that patients received, according to electronic medical records. The study results appear in the Aug. 19 New England Journal of Medicine.

Seventy-four patients were assigned to the standard care group, and 77 were assigned to receive early palliative care. One hundred seven patients (86%) survived to 12 weeks and completed the study assessments. Patients in the early palliative care group had better quality of life at 12 weeks than those receiving standard care (mean FACT-L score, 98.0 vs. 91.5; P=0.03) and were also less likely to report depressive symptoms (16% vs. 38%; P=0.05). Patients receiving palliative care were less likely to receive aggressive end-of-life care (33% vs. 54%; P=0.05) but had longer median survival after diagnosis (11.6 months vs. 8.9 months; P=0.02).

The authors pointed out that their study involved highly trained clinicians at a single facility, as well as only one disease, limiting its generalizability. Among other limitations, the patients were not ethnically diverse and all parties were aware of the study group assignments. However, the authors concluded that early palliative care can improve quality of life and perhaps survival in patients recently diagnosed with metastatic non-small-cell lung cancer, and that it may also lead to more appropriate end-of-life care.

An accompanying editorial noted that the study challenged conventional ideas about palliative care, which is often considered an alternative to standard care rather than an adjunct. The editorialists said that the findings on improved survival need to be replicated and pointed out that improved quality of life in the early palliative care group might be due simply to increased time and attention from clinicians rather than to any specific interventions. However, they called the study "an important step in confirming the beneficial outcomes of a simultaneous care model that provides both palliative care and disease-specific therapies beginning at the time of diagnosis." Palliative care should be made "an essential and routine component of evidence-based, high-quality care for the management of serious illness," they concluded.


Test yourself

MKSAP Quiz: progressive right knee pain

A 72-year-old woman is evaluated for a 1-year history of progressive pain in the right knee. The pain is most acute along the medial aspect of the joint, worsens with activity, and is relieved with rest. She has no stiffness in the morning and has had no swelling. She also has not experienced locking or giving way of this joint.

On physical examination, vital signs are normal. There is bony enlargement of the proximal and distal interphalangeal joints. There is no evidence of a right knee effusion. Passive flexion and extension of the right knee are painful.

Laboratory studies, including complete blood count, erythrocyte sedimentation rate, and C-reactive protein, are normal. Radiograph of the right knee also is normal.

In addition to acetaminophen as needed, which of the following is the most appropriate next step in this patient’s management?

A) Arthroscopy
B) Aspiration of the knee
C) MRI of the knee
D) Physical therapy

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



Increased suicide risk, but not overall mortality, with fibromyalgia

Patients who have been diagnosed with fibromyalgia have about the same mortality risk as the general population, but their risk of suicide or accidental death is elevated, according to a new study.

The analysis included more than 8,000 patients who had been seen by a physician for fibromyalgia between 1974 and 2009. They were compared to a control set of more than 12,000 patients with osteoarthritis as well as death rates for the general U.S. population, adjusted for age and sex. The results were published online by Arthritis Care & Research last week.

During the study period, 539 of the fibromyalgia patients died. The mortality rate was not significantly different from that of the osteoarthritis patients or the U.S. general population. However, the fibromyalgia patients were more than three times more likely than average to commit suicide and they had a 45% increased risk of accidental death. Patients who met the American College of Rheumatology’s 2010 criteria for fibromyalgia—which would indicate greater severity of symptoms—did have an increased overall risk of death (hazard ratio, 1.62, 95% CI 1.19 to 2.21).

The study’s results confirm previous European research finding no increased mortality for fibromyalgia patients, but differ from studies that have found increased deaths in patients who had widespread pain, which were attributed to cancer. This study found no increased cancer mortality in fibromyalgia patients.

The increase in suicide risk could actually be even higher than calculated, because other research has found that about 20% of accidental deaths may actually be suicides, the authors of the study noted. The authors did not suggest any possible explanations for the suicide risk and they cautioned that the study should not be understood to suggest that fibromyalgia causes suicide, since the findings are associative, not causative.


Tai chi helps with fibromyalgia

Fibromyalgia patients who participated in tai chi classes had less pain and improved quality of life, according to a new randomized trial.

Half of the 66 patients participating in the study were assigned to 12 weeks of twice-weekly Yang-style tai chi. The other patients received wellness education and stretching for the same time period. The end points of the study were changes in the Fibromyalgia Impact Questionnaire (FIQ) score and physical and mental components of the Medical Outcomes Study 36-Item Short-Form Health Survey.

Patients in the tai chi group showed significant improvements in their overall FIQ score, as well as in measures used to assess pain, sleep quality, depression and quality of life. The gains had been sustained at 24-week follow-up, leading the study authors to conclude that tai chi may be a useful treatment for fibromyalgia. The study was published in the Aug. 19 New England Journal of Medicine.

The results confirm previous nonrandomized trials that have found benefit in tai chi, the authors said. They noted a few limitations to the study: The classes were all conducted by one tai chi master, and the absence of a sham tai chi made double-blinding of the study impossible.

Since the mechanism by which tai chi works is unknown and likely complex, trying to construct a sham version would not be worthwhile, according to an accompanying editorial. The editorialist recommended that future research replicate the study with more patients and longer follow-up and compare it to other therapies such as yoga. In the meantime, physicians can reasonably support their fibromyalgia patients’ interest in tai chi, although it may be premature to prescribe it, the editorial concluded.



Plasma renin activity helps predict response to antihypertensive medications

Plasma renin activity along with pretreatment blood pressure can help predict a patient's response to atenolol and hydrochlorothiazide both as monotherapy and add-on therapy for primary hypertension, according to a new study.

Researchers looked at predictors of blood pressure response to therapy with atenolol followed by hydrochlorothiazide or vice versa in 363 men and women 65 years of age or younger who had primary hypertension. One hundred fifty-two patients were black, and 211 were white. Most (76%) stopped taking previous antihypertensive drugs before beginning the study regimens, and the remainder (24%) had not previously been treated for hypertension. Patients were randomly assigned to receive one of the following regimens:

  • atenolol, 50 mg/d, titrated to 100 mg/d if blood pressure remained above 120/70 mm Hg, followed by hydrochlorothiazide, 12.5 mg/d, titrated to 25 mg/d similarly or
  • hydrochlorothiazide, 12.5 mg/d, titrated to 25 mg/d if blood pressure remained above 120/70 mm Hg, followed by atenolol, 50 mg/d, titrated to 100 mg/d similarly.

Patients measured their average blood pressure at home before and after each study drug was administered using a study-provided sphygmomanometer. They were told to check their blood pressure while seated twice after getting out of bed in the morning and twice at night right before going to bed. Blood pressure readings were also recorded in a physician's office on patients' home machines during study visits (before randomization, after monotherapy and before the add-on drug was started, and after add-on therapy concluded). The study results were published early online Aug. 19 by American Journal of Hypertension.

The authors found that plasma renin activity and blood pressure before treatment consistently predicted patients' systolic and diastolic responses to the study drugs, both as monotherapy and as add-on therapy. Patients with higher plasma renin activity had a larger response to atenolol and a smaller response to hydrochlorothiazide, independent of age, race or other characteristics. Based on their results, the authors wrote, measuring plasma renin activity and blood pressure before add-on treatment with atenolol and hydrochlorothiazide can help predict degree of response in patients with primary hypertension. However, "whether marginal benefits demonstrated relative to hypertension specialists' care or as demonstrated in our study relative to race and age outweigh costs may be arguable," they concluded.


FDA update

Hypotension drug faces withdrawal

The FDA proposed to withdraw approval of midodrine hydrochloride (ProAmatine), a drug used to treat orthostatic hypotension, because required post-approval studies to verify the clinical benefit of the medication have not been done.

Patients who currently take this medication should not stop taking it but should consult their health care professional about other treatment options, advised the FDA announcement. The agency is working with the drug’s manufacturers to develop an expanded-access program to allow patients who currently receive the drug (which is produced under its brand name and as a generic) to continue to receive it. This is the first time the FDA has issued such a notice for a drug approved under its accelerated approval regulations.


From ACP Foundation

Video HEALTH TiPS on opioid pain medications available

The ACP Foundation recently released two new video HEALTH TiPS on how to take opioid pain medication and how to use an opioid pain medication patch. Video HEALTH TiPS are very brief videos made with real patients, physicians and other health professionals. The videos provide patients with information and skills they need to know. To view the videos, go to the ACP Foundation website.


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.

"Did you say you were a little horse? Or a little hoarse?"
"I think we need to up your dose of Lasix."
"I’ll need to take a look with my oatoscope."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting continues through Monday, August 30, with the winner announced in the August 31 issue.


MKSAP answer and critique

The correct answer is D) Physical therapy. This item is available to MKSAP 15 subscribers as item 38 in the Rheumatology module.

This patient has osteoarthritis of the knee. The most appropriate next step in her management is referral for physical therapy, which is an appropriate first-line management option for patients with this condition. Quadriceps muscle training in particular has been shown to reduce pain in this population group. Use of over-the-counter acetaminophen or an NSAID on an as-needed basis also may benefit this patient.

Arthroscopy and MRI of the knee would most likely reveal abnormalities of the articular cartilage not visible on plain radiography but are not needed to establish the diagnosis of osteoarthritis. Similarly, aspiration of the knee joint would be warranted in patients with an effusion to obtain a synovial fluid leukocyte count but is not needed to establish a diagnosis; furthermore, this patient does not have an effusion.

Key point

  • Physical therapy is an appropriate first-line management option for patients with osteoarthritis of the knee, and quadriceps muscle training in particular has been shown to reduce pain in this setting.

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Copyright 2010 by the American College of Physicians.

Test yourself

A 28-year-old man is evaluated for pain on the radial aspect of the right wrist that occurs with use of the thumb. The pain has been present for 2 weeks. He has never had this pain before and has not had any trauma. He works as a computer programmer and plays video games for 3 to 4 hours each night when he gets home from work. Following a physical exam, what is the most likely diagnosis?

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