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

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In the News
for the Week of 1-25-11

Highlights

  • USPSTF updates osteoporosis screening guidelines for men, women
  • Nonrespiratory causes of death becoming more common in oxygen-dependent COPD

Test yourself

  • MKSAP Quiz: a 1-week history of paresthesias

Geriatrics

  • Updated guidelines issued for fall prevention in the elderly

Prostate cancer

  • Behavioral therapy reduces incontinence after radical prostatectomy

FDA update

Practice resources

  • Toolkit assists with claims process

From ACP Hospitalist

  • The next issue is online

From the College

  • Depression quality improvement program seeks participants
  • Call for fall 2011 Board of Governors resolutions
  • Clinical skills proposals for Internal Medicine 2012 wanted

Cartoon caption contest

Physician editor: Darren Taichman, FACP


Highlights

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USPSTF updates osteoporosis screening guidelines for men, women

Osteoporosis screening is appropriate in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman, according to updated recommendations from the U.S. Preventive Services Task Force.

The article was released early online on Jan. 17 by Annals of Internal Medicine.

Based on the FRAX tool, a 65-year-old white woman with no other risk factors has a 9.3% 10-year risk for an osteoporotic fracture and should be screened. (Clinicians also should consider each patient's values and preferences and use clinical judgment when discussing screening, the guidelines noted.) White women between the ages of 50 and 64 years with equivalent or greater 10-year fracture risks based on specific risk factors are also recommended for screening. That would include, for example:

  • a 50-year-old current smoker with a BMI less than 21 kg/m2, daily alcohol use, and parental fracture history,
  • a 55-year-old woman with a parental fracture history,
  • a 60-year-old woman with a BMI less than 21 kg/m2 and daily alcohol use, and
  • a 60-year-old current smoker with daily alcohol use.

Evidence is lacking about optimal intervals for repeated screening, the guidelines found. The choice of treatment should take into account the patient's clinical situation and the tradeoff between benefits and harms. Clinicians should provide education about how to minimize drug side effects. Treatments include adequate calcium and vitamin D intake and weight-bearing exercise, as well as FDA-approved therapies to reduce fracture risk in women with low bone mineral density and no previous fractures, including bisphosphonates, parathyroid hormone, raloxifene, and estrogen.

The USPSTF expanded its review to include men, but concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men (I statement). Men most likely to benefit from screening have a 10-year risk for osteoporotic fracture equal to or greater than that of a 65-year-old white woman without risk factors. Because of the lack of relevant studies, the USPSTF found inadequate evidence that drug therapies reduce the risk for fractures in men who have no previous osteoporotic fractures. The USPSTF identified the absence of randomized trials of primary fracture prevention in men who have osteoporosis as a critical gap in the evidence.

The recommendations in women apply to all racial and ethnic groups because the harms of the screening tests are usually small, the consequences of failing to identify and treat women who have low bone mineral density are considerable, and the optimal alternative age at which to screen nonwhite women is uncertain. The quantity and quality of data on osteoporotic fracture risk other than hip fracture are much less for Asian, American Indian or Alaska Native, Hispanic, and black women than for whites. The FRAX tool also predicts 10-year fracture risks for black, Asian, and Hispanic women in the United States. In general, estimated fracture risks in nonwhite women are lower than those for white women of the same age.

A patient summary is available online and the text will be published in the March 1 issue of Annals of Internal Medicine.

ACP Internist published an article in 2008 on the College's guidelines for osteoporosis screening in men.

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Nonrespiratory causes of death becoming more common in oxygen-dependent COPD

Mortality rates due to nonrespiratory causes have increased over time in patients receiving long-term oxygen therapy for chronic obstructive pulmonary disease (COPD), according to a recent study.

Swedish researchers performed a prospective study of 7,628 patients with COPD (4,027 women, 3,601 men) who started long-term oxygen therapy between Jan. 1, 1987 and Dec. 31, 2004. Patients were followed until the end of the study, until oxygen therapy was stopped, or until death. The goal of the study was to determine whether mortality rates and causes of death have changed as more older people and more women with severe COPD have begun receiving long-term oxygen therapy. The study's primary end point was cause of death according to the Swedish National Causes of Death Register. The study results were published online Jan. 7 by the American Journal of Respiratory and Critical Care Medicine.

Median follow-up was 1.7 years (range, 0 to 18 years). Overall, 5,457 patients (71.5%) died during the study, with a 1.6% (95% CI, 0.9% to 2.2%; P<0.001) annual increase in crude overall mortality rate. Seventy-one percent of deaths were due to respiratory causes, 16% were due to circulatory causes, 7.6% were due to cancer and 1.1% were due to digestive organ disease. The absolute risk for death increased by 2.8% annually (95% CI, 1.3% to 4.3%; P<0.001) for circulatory disease and by 7.8% (95% CI, 1.9% to 14.0%; P=0.009) for digestive organ disease but decreased by 2.7% annually (95% CI, 2.0% to 3.3%; P<0.001) for respiratory disease and by 3.4% (95% CI, 1.1% to 5.7%; P=0.004) for lung cancer.

The authors cautioned that their mortality estimates are based on death certificate data and that estimates of cause-specific mortality could have been affected by changes in such factors as diagnostics and coding. However, they concluded that both overall mortality rates and mortality rates due to nonrespiratory causes have increased over time in patients with oxygen-dependent COPD. "The present study supports the important prognostic role of co-morbidity in oxygen-dependent COPD and shows that mortality has increased for non-respiratory causes, such as cardiovascular disease," the authors wrote.

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Test yourself

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MKSAP Quiz: a 1-week history of paresthesias

A 53-year-old woman is evaluated in the office for a 1-week history of paresthesias that began symmetrically in the feet and progressed to involve the distal legs and, more recently, the hands. She says she is unsteady when walking, has lower limb weakness, and has difficulty going upstairs. The patient has no history of pain or bowel or bladder impairment. Personal and family medical history is noncontributory, and she takes no medications.

On physical examination, vital signs are normal. Weakness of distal lower extremity muscles is noted, with stocking-glove sensory loss and areflexia. Deep tendon reflexes are absent. Plantar responses are flexor, and gait is unsteady. No sensory level is present across the thorax. Mental status, language, and cranial nerve function are normal.

Complete blood count results, erythrocyte sedimentation rate, serum creatinine and creatine kinase levels, and liver chemistry test results are normal.

A chest radiograph shows no abnormalities.

Which of the following is the most appropriate next diagnostic test?

A) Electromyography
B) MRI of the spinal cord
C) Serologic testing for West Nile virus
D) Sural nerve biopsy

Click here to see the answer and critique for this question.

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Geriatrics

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Updated guidelines issued for fall prevention in the elderly

The American Geriatrics Society and British Geriatrics Society announced updated guidelines recently on preventing falls in elderly patients.

The guidelines, which were published in the Journal of the American Geriatrics Society on Jan. 13, update the societies' 2001 guidelines on this topic. New recommendations include the following:

  • All fall prevention interventions in community-dwelling older persons should include exercise to improve balance, gait and strength, such as physical therapy or tai chi.
  • Multifactorial fall risk assessment should evaluate the feet and footwear, patients' fear of falling, and patients' assessment of their functional ability.
  • Home safety should be determined during fall risk assessment.
  • Necessary cataract surgery should be expedited in older women at risk for falls.
  • All current medications should be reviewed and minimized or withdrawn if possible.

The guidelines were developed by an expert panel and were based on a systematic review of studies published from May 2001 and April 2008. Randomized, controlled trials published between April 2008 and July 2009 were also reviewed but did not change the recommendations, the American Geriatrics Society said in a press release.

The full guidelines, which include a fall risk assessment algorithm, are available online.

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Prostate cancer

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Behavioral therapy reduces incontinence after radical prostatectomy

Behavioral training programs that included pelvic floor muscle training, bladder control strategies and fluid management resulted in a significant reduction in incontinence following radical prostatectomy, according to a study in the Jan. 12 Journal of the American Medical Association. Biofeedback and pelvic floor electrical stimulation provided no additional benefit.

The multisite randomized, controlled trial involved 208 community-dwelling men ages 51 through 84 years with incontinence persisting one to 17 years after radical prostatectomy from 2003 to 2008. Participants were stratified by site (one university and two VA medical centers), and by incontinence type (stress, urgency, or mixed) and severity (less than five, five to 10, or more than 10 episodes per week). Then, participants were randomized to three groups: eight weeks of behavioral therapy (pelvic floor muscle training and bladder control strategies); behavioral therapy plus in-office, dual-channel electromyograph biofeedback and daily home pelvic floor electrical stimulation (behavior plus); or delayed treatment, which served as the control group. Participants completed seven-day bladder diaries.

The researchers found that at eight weeks, those in the behavioral therapy group had an average reduction of incontinence episodes of 55% (95% CI, 44% to 66%; from 28 to 13 episodes per week), which was significantly greater than the 24% reduction (95% CI, 10% to 39%; from 25 to 21 episodes per week) reported by the control group. Those in the behavior-plus group experienced an average reduction of 51% (95% CI, 37% to 65%; from 26 to 12 episodes per week). Reductions were significant for both treatment groups (P=0.001), and there was no significant difference in incontinence reduction between the treatment groups (P=0.69).

Improvements lasted one year in the active treatment groups, which saw a 50% reduction (13.5 episodes per week) in the behavioral group and a 59% reduction (9.1 episodes per week) in the behavior-plus group. At the end of the eight-week treatment period, 15.7% of men in the behavior therapy group, 17.1% in the behavior-plus group, and 5.9% in the control group achieved complete continence.

Based on the study’s results and the small number needed to treat (n=10), the researchers concluded, “Behavioral therapy should be offered to men with persistent postprostatectomy incontinence because it can yield significant, durable improvement in incontinence and quality of life, even years after radical prostatectomy.”

An editorial countered that behavioral therapy "likely requires considerable patient and clinician time and effort to implement and is associated with limited benefit” and suggested that "A better strategy would be primary prevention: increased utilization of active surveillance among patients with lower-risk disease and selective application of aggressive interventions in patients with worse prognostic variables.”

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FDA update

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Prescription acetaminophen gets new limit, warnings

Prescription drugs that contain combinations of acetaminophen and other medications will be required to contain no more than 325 mg of acetaminophen per tablet or capsule, the FDA recently announced.

The limit will be phased in over the next three years. In addition, a boxed warning on the potential for severe liver injury and a warning on the potential for allergic reactions (e.g., swelling of the face, mouth, and throat; difficulty breathing; itching; or rash) will be added to the labels of these drugs.

Acetaminophen is one of the most commonly used drugs in the United States, and between 1998 and 2003 it was the leading cause of acute liver failure in the country, with 48% of acetaminophen-related cases (131 of 275) associated with accidental overdose, the FDA announcement said. The new regulations are intended to reduce the risk of severe liver injury and allergic reactions associated with acetaminophen, as well as making it less likely that patients will overdose if they mistakenly take too many doses of acetaminophen-containing products.

Clinicians should educate patients about the importance of reading all prescription and over-the-counter (OTC) labels to ensure they are not taking multiple acetaminophen-containing products, the FDA advised. Patients should also be advised not to drink alcohol while taking acetaminophen and not to exceed the maximum total daily dose of 4 g/d. Dosing of combination medications will not need to change in response to the reformulations. For example, if a product that previously contained 500 mg of acetaminophen with an opioid and was prescribed as 1 to 2 tablets every 4 to 6 hours is reformulated to contain 325 mg of acetaminophen, the dosing instructions can remain unchanged, the FDA said.

OTC products containing acetaminophen are not affected by this action, and the FDA is continuing to evaluate ways to reduce the risk of acetaminophen-related liver injury from OTC products, according to the announcement.

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Practice resources

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Toolkit assists with claims process

The American Medical Association’s “Heal the Claims Process” campaign offers a toolkit of educational resources and tools that can help physician practices streamline the internal claims process. This free toolkit includes resources such as:

  • Prepare that claim,” which helps practices review the efficiency of current internal claims processes, and offers sample forms and policies that you can adapt to fit the specific needs of your practice.
  • Follow that claim,” which follows a claim as it moves along the claims submission and health insurer process. Understanding this flow can help address the delay, denial and reduced payment tactics used by third-party payers.
  • Appeal that claim,” which can help reduce a practice’s administrative burden by delivering a step-by-step course of action to appeal an underpaid, delayed or inappropriately denied claim.

Go online to learn more about the “Heal the Claims Process” campaign.

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From ACP Hospitalist

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The next issue is online

The January issue of ACP Hospitalist is online. Don't miss stories on:

Making nice with PCPs. Learn the strategies hospitalist practices use to maintain strong connections to their referring PCPs, and how this benefits both doctors and patients.

Improving sepsis diagnosis. Detect the subtle early symptoms and order tests appropriately.

Retooling the M&M conference. New meetings focus less on finger-pointing and more on uncovering systemic problems.

These features and more, including Test Yourself with the MKSAP Quiz: Sepsis, are now online.

Are you involved in hospital medicine? Then you should be getting ACP Hospitalist and ACP HospitalistWeekly. Click here to subscribe.

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From the College

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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 mgannon@acponline.org.

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Call for fall 2011 Board of Governors resolutions

The deadline for submitting new resolutions to be heard at the fall 2011 Board of Governors meeting is Wednesday, March 23, 2011. Initiating a resolution provides ACP members an opportunity to focus attention at the ACP national level on a particular issue or topic that concerns them. Members must submit resolutions to their Governor and/or chapter council. A resolution becomes a resolution of the chapter once the chapter council approves it.

In accordance with the ACP Board of Governors Resolutions Process, resolutions should clearly distinguish the action requested within its resolved clause(s) as either a policy resolve (“Resolved that ACP policy…”), or a directive, which requests action/study on an issue (“Resolved that the Board of Regents…”). If more than one action is proposed, each should have its own resolved clause. Please contact your Governor if you have any questions regarding the resolution format.

The Board of Governors votes on new resolutions, which are then presented to the Board of Regents for action. Members can use the Electronic Resolutions System (ERS) to monitor the status of resolutions. Visit your chapter website and link to the ERS under the “Advocacy” heading.

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Clinical skills proposals for Internal Medicine 2012 wanted

The Clinical Skills Subcommittee (CSSC) is now accepting proposals for Internal Medicine 2012, to be held April 19-21, 2012. The CSSC welcomes all proposals but places a priority on interactive workshops that focus on the acquisition or improvement of physical examination skills, communication skills, and procedural skills. The CSSC is most interested in workshops that have a high likelihood of changing physician behavior using proven teaching techniques or new and innovative teaching strategies that have yet to be tested.

Proposals are due May 1, 2011. For more information, contact Patrick C. Alguire, FACP, at palguire@acponline.org.

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Cartoon caption contest

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And the winner is …

ACP InternistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

"This is not quite what I meant by androgen blockade."

This issue's winning cartoon caption was submitted by John Allan, ACP Associate Member. Readers cast 113 ballots online to choose the winning entry. Thanks to all who voted! The winning entry captured 59.3% of the votes.

The runners-up were:

"Given how you feel, Erik, maybe watchful waiting is a better way to go."

"I'll be gentler than the TSA agent."

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MKSAP answer and critique

The correct answer is A) Electromyography. This item is available to MKSAP 15 subscribers as item 19 in the Neurology section.

This patient should undergo electromyography (EMG). She has a rapidly progressive disorder affecting the peripheral nervous system, most compatible with a clinical diagnosis of Guillain-Barré syndrome. Patients with Guillain-Barré syndrome typically develop paresthesias distally in the lower extremities that are followed by limb weakness and gait unsteadiness. In addition to sensory loss and limb weakness, deep tendon reflexes are characteristically absent or markedly reduced. The diagnosis is confirmed by EMG, which usually shows a demyelinating polyradiculoneuropathy. Cerebrospinal fluid (CSF) analysis characteristically shows albuminocytologic dissociation, whereby the spinal fluid cell count is normal but the spinal fluid protein level is elevated. CSF analysis may also yield normal results early in the course of the disease. However, a normal CSF cell count is useful in excluding other infectious conditions, such as polyradiculoneuropathies associated with HIV and cytomegalovirus infection, infection due to West Nile virus, and carcinomatous or lymphomatous nerve root infiltration. By definition, symptoms in patients with Guillain-Barré syndrome peak within 4 weeks of onset. Poor prognostic features include rapid symptom progression, respiratory failure, EMG evidence of axonal degeneration, and advanced age. Intravenous immune globulin and plasma exchange are equally efficacious in the treatment of Guillain-Barré syndrome.

MRI of the spinal cord would be inappropriate as the next diagnostic test. The patient’s presentation of distal extremity sensory loss with areflexia suggests a disorder of the peripheral nervous system. A spinal cord lesion (myelopathy) would be an unlikely cause of the symptoms noted on clinical examination. The absence of bowel or bladder impairment, the lack of a sensory level across the thorax, and the upper and lower limb areflexia argue against a central nervous system disorder affecting the spinal cord.

West Nile virus infection should be considered in every patient with symptoms of extremity weakness that begin acutely and progress over days to weeks. However, the presence of paresthesias and sensory loss on examination are not typical of West Nile virus infection. This enteroviral illness affects the anterior horn cells, causing limb weakness in the absence of sensory loss. Most cases of West Nile virus infection cause only minor symptoms that are indistinguishable from those of other viral illnesses.

Biopsy of the sural nerve is considered in the diagnostic evaluation of patients with a marked peripheral neuropathy of unknown cause. The sural nerve is a sensory nerve that supplies sensation to the lateral distal leg and lateral aspect of the foot. Sural nerve biopsy is appropriate in patients with suspected vasculitis or amyloidosis and occasionally in patients with chronic inflammatory demyelinating polyradiculoneuropathy; it is also used to exclude neuropathic conditions resulting from neoplastic infiltration or other inflammatory conditions, such as sarcoidosis. Symmetric signs and symptoms and diffuse areflexia are not typical of vasculitis. The acute onset and rapid symptom progression would argue against amyloidosis, chronic inflammatory demyelinating polyradiculoneuropathy, or other infiltrating peripheral nerve disorders. Sural nerve biopsy is not necessary in patients with suspected Guillain-Barré syndrome.

Key Point

  • Guillain-Barré syndrome is a disorder associated with rapidly progressive extremity weakness, paresthesias, and areflexia.

Click here to return to the rest of ACP InternistWeekly.

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About ACP InternistWeekly

ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.

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Copyright 2011 by the American College of Physicians.

Test yourself

A 72-year-old woman is evaluated during a routine examination. She has very severe COPD with multiple exacerbations. She has dyspnea at all times with decreased exercise capacity. She does not have cough or any change in baseline sputum production. She is adherent to her medication regimen, and she completed pulmonary rehabilitation 1 year ago. She quit smoking 1 year ago. Her medications are a budesonide/formoterol inhaler, tiotropium, and an albuterol inhaler as needed. Following a physical and pulmonary exam, what is the most appropriate next step in management?

Find the answer

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