In the News
for the Week of 1-11-11
- MKSAP Quiz: progressive dysphagia for solids and liquids
- Gait speed associated with survival in older adults
- Systolic blood pressure variability predicts stroke risk
- Colonoscopy effectively screens for both left- and right-sided colorectal cancer, study finds
From ACP Internist
- January issue in print and online
From the College
- Depression quality improvement program seeks participants
- Fall chapter awardees announced
- ACP's John Tooker, MACP, blogs at KevinMD
- College Fellow chosen as New York's next health commissioner
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Editorial note: ACP InternistWeekly will not be published next week due to the Martin Luther King Jr. Day holiday.
New guidelines set out MRSA treatments
The Infectious Diseases Society of America released its first set of guidelines on the treatment of methicillin-resistant Staphylococcus aureus (MRSA) last week.
The guidelines were developed by an expert panel of infectious disease specialists and cover MRSA infections associated with health care facilities (HA-MRSA) as well as those acquired in the community (CA-MRSA). The guidelines note that the “so-called CA-MRSA isolates” are genetically distinct from HA-MRSA and susceptible to many non-ß-lactam antibiotics. Recommendations are provided on the appropriate treatment—both antibiotic and non-drug—of skin and soft-tissue infections, from simple abscesses seen in the outpatient setting to complicated infections in hospitalized patients.
The guidelines also discuss management of recurrent MRSA skin and soft-tissue infections, recommending education on personal hygiene for all patients, with decolonization and oral therapy reserved for patients in which other measures are unsuccessful. Appropriate antibiotic and other therapy for MRSA bacteremia and infective endocarditis, MRSA pneumonia, and MRSA infections in bones, joints and the central nervous system are also covered in the guidelines, which will appear in the Feb. 1 issue of Clinical Infectious Diseases. Local variations in epidemiology should be considered by physicians implementing the guidelines, the authors noted.
The guidelines provide advice on vancomycin therapy, including the limitations of vancomycin susceptibility testing. If testing indicates a vancomycin minimum inhibitory concentration (MIC) of less than or equal to 2 µg/mL, the patient’s clinical response should determine use of vancomycin. If the MIC is greater than 2 µg/mL, an alternative drug should be used. The guidelines recommend dosing and monitoring vancomycin according to a previous consensus statement from the IDSA and other groups. The new guidelines have been endorsed by the Pediatric Infectious Diseases Society, the American College of Emergency Physicians and the American Academy of Pediatrics..
CDC issues guidance on rapid influenza tests
Rapid influenza tests can be useful in diagnosis and treatment, but they often yield false-negative results, the CDC recently cautioned.
In a guidance statement released in December, the CDC outlined the appropriate use of rapid influenza tests for the 2010-2011 influenza season. The tests are easy to use and yield results in 15 minutes or less, making them helpful for confirmation of outbreaks, especially in institutional settings. However, they have limited sensitivity and predictive value, the agency said. Because of the high risk for false-negative results, a patient who tests negative but has signs and symptoms of flu should not be excluded from antiviral treatment. Testing is not always necessary in all patients, especially in a community known to already be affected by influenza. The CDC listed the following factors as potential influences on rapid-test accuracy:
- clinical signs and symptoms of influenza,
- prevalence of influenza in the population tested,
- time from illness onset to collection of respiratory specimens for testing,
- type of respiratory specimen tested, and
- accuracy of the test compared to a reference test, such as reverse transcriptase polymerase chain reaction or viral culture.
To minimize false results, the CDC recommends that clinicians collect specimens as early as possible after illness onset (ideally within four days), follow manufacturer’s instructions on acceptable specimens and appropriate handling, and confirm negative results with a reference test if a laboratory-confirmed diagnosis is needed.
The full guidance statement, which includes additional information on test interpretation and clinical algorithms to assist in decision making, is available online.
MKSAP Quiz: progressive dysphagia for solids and liquids
A 56-year-old woman is evaluated for a 3-year history of progressive dysphagia for solids and liquids; she has had a 6.8-kg (15-lb) weight loss during this time. The dysphagia was initially intermittent, but recently swallowing almost all food or drink causes a feeling of chest tightness and discomfort with increasingly frequent regurgitation of undigested food. The dysphagia is sometimes alleviated by standing upright. Her medical history is significant only for hypertension, and her medications include lisinopril and a multivitamin.
On physical examination, the patient appears uncomfortable and restless; she is thin but does not have thenar wasting. She is afebrile; the blood pressure is 142/92 mm Hg, the pulse rate is 96/min, and the respiration rate is 22/min. The BMI is 23.
Barium esophagography shows a dilated esophagus with an air/fluid level and tapered narrowing of the distal esophagus. Esophagogastroduodenoscopy shows a dilated esophagus with retained food and a tight lower esophageal sphincter, which allowed passage of the endoscope.
Which of the following is the most likely diagnosis?
B) Diffuse esophageal spasm
C) Peptic stricture
D) Scleroderma esophagus
Click here or scroll to the bottom of the page for the answer and critique.
Gait speed associated with survival in older adults
Gait speed, age and sex may be all that are needed to predict survival in older adults, the authors of a new analysis concluded.
Researchers conducted a pooled analysis of nine cohort studies conducted between 1986 and 2000, using individual data from 34,485 community-dwelling older adults aged 65 years or older who were followed between six and 21 years. They reported results in the Jan. 5 Journal of the American Medical Association.
There were 17,528 deaths in the studied population. The overall five-year survival rate was 84.8% (95% CI, 79.6% to 88.8%) and the 10-year survival rate was 59.7% (95% CI, 46.5% to 70.6%). Faster gait speed was associated with survival in all studies (pooled hazard ratio per 0.1 m/s, 0.88; 95% CI, 0.87 to 0.90; P<0.001). At age 75, predicted 10-year survival across the range of gait speeds ranged from 19% to 87% in men and from 35% to 91% in women.
In the pooled sample, median survival for the age groups 65 through 74 years was 12.6 years for men and 16.8 for women; for 75 through 84 years, 7.9 years for men and 10.5 years for women; and for 85 years or older, 4.6 years for men and 6.4 years for women. As gait speed increased, so did predicted years of remaining life for each sex and age group, with a gait speed of about 0.8 m/s at the median life expectancy at most ages for both sexes. Gait speeds of 1.0 m/s or higher consistently predicted longer than expected survival.
Gait speed was "especially informative" after age 75, the authors wrote. In men, the probability of five-year survival at age 85 ranged from 0.3 to 0.88 and the probability of 10-year survival ranged from 0.18 to 0.86. In women, the probability of five-year survival remained greater than 0.5 until advanced age, but 10-year survival at age 75 ranged from 0.34 to 0.92 and at age 80 years from 0.22 to 0.86. Further adjustment for body mass index, smoking, systolic blood pressure, diseases, prior hospitalization, and self-reported health did not change the results (overall hazard ratio, 0.90; 95% CI, 0.89 to 0.91; P<0.001).
The authors wrote, "Gait speed could be considered a simple and accessible summary indicator of vitality because it integrates known and unrecognized disturbances in multiple organ systems, many of which affect survival. In addition, decreasing mobility may induce a vicious cycle of reduced physical activity and deconditioning that has a direct effect on health and survival."
Researchers predict that gait speed could be used:
- to identify those with a high probability of living for 5 or 10 more years, who may be appropriate targets for long-term preventive interventions,
- to identify patients at increased risk of early mortality and to target potentially modifiable risks,
- to monitor declines over time that might signal a new health problem,
- to stratify risks from surgery or chemotherapy, and
- to assess medical and behavioral interventions for their effect on gait speed in clinical trials.
An editorial concluded that gait speed is a useful research tool and may become a useful clinical one. However, the editorialist cautioned, “Functional limitations, cognitive impairment, hearing or visual problems, and balance or postural disorders may render the test more time-consuming than expected.”.
Systolic blood pressure variability predicts stroke risk
Short-term, visit-to-visit variability in systolic blood pressure was associated with increased all-cause mortality, researchers reported.
Researchers used data from 956 patients in the third National Health and Nutrition Examination Survey. In that study, three consecutive blood pressure readings were taken during three separate study visits from 1988 to 1994. The first of the three was done at home. The second was recorded at a mobile exam center within one month, and the third was recorded between 1 and 48 days (median, 17) after the second.
Visit-to-visit blood pressure variability for each participant was defined using the standard deviation and coefficient of variation based on the mean of the second and third measurements from each visit. All-cause mortality was assessed through Dec. 31, 2006. The median follow-up was 14 years, during which time 240 (25.1%) of patients died. Results appeared online Jan. 3 in Hypertension.
The mean of the standard deviation for systolic blood pressure across visits was 7.7 mm Hg. After multivariable adjustment, older age, female gender, history of myocardial infarction, higher mean systolic blood pressure and pulse pressure, and use of angiotensin-converting enzyme (ACE) inhibitors were associated with higher standard deviation in systolic blood pressure.
After adjustment for age; sex; race/ethnicity; history of myocardial infarction; mean systolic blood pressure and pulse pressure; and ACE inhibitor, beta-blocker, calcium-channel blocker and thiazide-type diuretic use, the hazard ratio for all-cause mortality was 1.57 (95% CI, 1.07 to 2.18) and 1.50 (95% CI, 1.03 to 2.18) for the middle and highest versus lowest tertile of standard deviation of systolic blood pressure (P=0.064 for trend). The hazard ratio was 1.55 (95% CI, 1.09 to 2.22) and 1.49 (95% CI, 1.05 to 2.10) for the middle and highest versus lowest tertiles of coefficient of variation of systolic blood pressure (P=0.040 for trend).
An editorial in the same issue explained, "It should be emphasized that this intermediate BP variability may help the practicing physician to optimize antihypertensive treatment more than the long-term one because information can be collected quickly rather than after months or years, when the damage of inconsistent BP control has progressed and treatment modifications may come too late."
Colonoscopy effectively screens for both left- and right-sided colorectal cancer, study finds
Screening colonoscopy helps reduce incidence of both left- and right-sided colorectal cancer, according to a recent study.
Clinical studies have shown that screening colonoscopy helps reduce incidence of colorectal cancer by detecting precancerous lesions, but the test's effectiveness in community settings has been less clear, especially for right-sided disease. German researchers performed a population-based case-control study to examine the association between previous colonoscopy and colorectal cancer risk. Data were collected via the medical record and self-report on lifetime history of risk factors and preventive factors for colorectal cancer. The researchers calculated the odds ratios for colorectal cancer associated with undergoing colonoscopy in the previous 10 years, adjusted for several factors including sex, age, and family history. The study appears in the Jan. 4 Annals of Internal Medicine.
Overall, researchers gathered data on 1,688 case-patients who had colorectal cancer (41.8% women) and 1,932 controls (42.7% women), all of whom were age 50 or older (mean age, 69 and 70 years, respectively). Those who had had colonoscopy in the previous 10 years had a 77% lower risk for colorectal cancer. Adjusted odds ratios were 0.23 (95% CI, 0.19 to 0.27) for any colorectal cancer, 0.44 (95% CI, 0.35 to 0.55) for right-sided colorectal cancer and 0.16 (95% CI, 0.12 to 0.20) for left-sided colorectal cancer. Colonoscopy was associated with a strong reduction in risk for all stages of cancer and for all ages, with the exception of right-sided colorectal cancer in those 50 to 59 years of age. Risk reduction was greater among those 70 and older for right-sided but not left-sided disease.
The authors noted that their results could have been affected by residual confounding and selection bias because of the study's observational design. However, they concluded that colonoscopy, followed by polypectomy, is associated with substantial reduction in risk for colorectal cancer in the community. Although risk reduction in their study was strongest for left-sided disease, it was also significant for right-sided disease at more than 50%.
An accompanying editorial pointed out that while some factors related to colonoscopy's effectiveness, such as patients' age and sex, can't be changed, others, such as laxative preparation, can be controlled. More research should be done to determine why colonoscopy is not as effective in the right colon, the editorialist noted, but "it would be a mistake to conclude that 'less effective' is the same as 'ineffective.'" The current study "offer[s] reassurance that colonoscopy can provide substantial protection against right- and left-sided [colorectal cancer]," the editorialist concluded.
From ACP Internist.
January issue in print and online
The next issue of ACP Internist is online and coming to your mailbox. Included in this issue are:
Miserable symptoms mark chronic sinusitis. Distinctive clues can lead internists to deliver the right treatment for chronic sinusitis, an illness that can feel as symptomatically miserable as many life-threatening conditions.
PCPs, hospitalists work at communication. Closer relationships between primary care physicians and hospitalists and resulting improvements in patient care are achievable.
When you look, but don't see the diagnosis. In the latest Mindful Medicine installment, gradual yet significant change in a woman's appearance, first noticed by a daughter she hadn't seen for a year, leads to the diagnosis of a common yet frequently missed ailment.
Also, don't miss the latest Test Yourself with the MKSAP Quiz.
From the College.
Depression quality improvement program seeks participants
Physicians are invited to participate in ACP’s new quality improvement program on depression.
This free Web-based program offers physicians the chance to earn up to 30 performance improvement CME credits and credit toward American Board of Internal Medicine Part 4 Maintenance of Certification. This program will help physicians to analyze their own practice patterns, evaluate actual practice data in identifying gaps and learn how to implement clinical quality improvement tools and techniques.
Participants will also communicate with national experts via conference call to interact and receive guidance on practice improvement. The program is done for free without leaving the office. Physicians will be asked to complete both a survey and a set of chart abstractions twice during the program and will be given access to a Web-based educational module on depression.
The first 50 physicians to enroll in the program will be entered into a raffle to win either MKSAP 15 or Internal Medicine 2011 registration. If you are interested in participating in this program, please contact Meghan Gannon at email@example.com..
Fall chapter awardees announced
Chapters honor Members, Fellows, and Masters of ACP who have demonstrated by their example and conduct an abiding commitment to excellence in medical care, education, research, or service to their community, their chapter, and ACP. In recognition of their outstanding service, these exceptional individuals received chapter awards..
ACP's John Tooker, MACP, blogs at KevinMD
John Tooker, MACP, ACP's Associate Executive Vice President, continues his monthly column at KevinMD.com, one of the Web's most influential medical blogs. This month's column looks at the role of clinical decision support for new delivery models..
College Fellow chosen as New York's next health commissioner
Nirav R. Shah, FACP, has been chosen by New York Gov.-elect Andrew Cuomo to be the state's next health commissioner, the Associated Press recently reported.
Dr. Shah, who is currently an internist at Bellevue Hospital Center, associate investigator at the Geisinger Center for Health Research and assistant professor at NYU Langone Medical Center, will replace Richard Daines, FACP.
Cartoon caption contest.
Vote for your favorite entry
ACP InternistWeekly's cartoon caption contest continues. Readers can vote for their favorite captions to determine the winner.
"This is not quite what I meant by androgen blockade."
"Given how you feel, Erik, maybe watchful waiting is a better way to go."
"I'll be gentler than the TSA agent."
Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting ends on Monday, Jan. 24, with the winner announced in the Jan. 25 issue..
MKSAP answer and critique
The correct answer is A) Achalasia. This item is available to MKSAP 15 subscribers as item 15 in the Gastroenterology and Hepatology section.
The patient’s history is typical for achalasia, an uncommon but important primary motility disorder of the esophagus. The barium study and endoscopic appearance described are typical for achalasia, but the diagnosis is confirmed manometrically with esophageal motility studies. The manometric diagnosis of achalasia usually includes an elevated lower esophageal sphincter pressure, failure of the lower esophageal sphincter to relax with swallowing, and diminished or absent peristalsis of the esophageal body.
Diffuse esophageal spasm typically presents with noncardiac chest pain. The diagnosis of diffuse esophageal spasm is made manometrically by the finding of more than 20% of swallows having simultaneous contractions in the distal esophagus. Peptic stricture would present with dysphagia, but would typically show a longer, non-tapered stricture on barium esophagography. Furthermore, peptic strictures seldom present with megaesophagus, as seen in this patient. Scleroderma esophagus leads to loss of esophageal motility and often severe reflux or distal esophageal strictures, not a dilated esophagus.
Treatment of achalasia is usually pneumatic dilatation of the esophagus or surgical myomectomy, the latter of which can be done laparoscopically. Pneumatic dilatation, even in experienced hands, is associated with a 5% to 10% risk of esophageal perforation. Botulinum toxin injection can afford relief of achalasia in patients who are not considered candidates for endoscopic or surgical interventions.
- Achalasia is a primary motility disorder of the esophagus and requires manometric diagnosis.
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Copyright 2010 by the American College of Physicians.
A 67-year-old man is evaluated for a 6-month history of worsening exertional dyspnea. He has severe COPD, previously with minimal exertional symptoms, but now notes activity-limiting shortness of breath when walking short distances. He does not have chest pain, gastrointestinal symptoms, or sleep-related symptoms. Medical history is otherwise unremarkable. Medications are a twice-daily fluticasone/salmeterol inhaler and an as-needed albuterol/ipratropium metered-dose inhaler. He has a 55-pack-year smoking history but quit when COPD was diagnosed. Following a physical exam, chest radiograph, and transthoracic echocardiogram, what is the most appropriate diagnostic test to perform next?
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