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

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ACP InternistWeekly



In the News for the Week of 10-25-11




Highlights

Statins not associated with intracerebral hemorrhage, meta-analysis indicates

A recent meta-analysis found no evidence of an association between statins and intracerebral hemorrhage. More...

Essential tremor treatment guidelines updated

Propranolol and primidone remain the most successful and most frequently used drugs to treat essential tremor, while levetiracetam, 3,4-diaminopyridine, and flunarizine should not be used, according to updated guidelines by the American Academy of Neurology. More...


Test yourself

MKSAP Quiz: infertility

This week's quiz asks readers to evaluate a 25-year-old man with a 2-year history of infertility. More...


Diabetes

Guidelines recommend continuous monitoring for patients with type 1 diabetes

Continuous glucose monitoring is recommended for adults and children with type 1 diabetes in the outpatient setting, but not in the hospital, according to new guidelines from The Endocrine Society. More...


Gastroenterology

Men, women present differently for their reflux symptoms

Significant differences exist between how men and women experience symptoms of gastroesophageal reflux, and consequently, how they might present their diseases to their physicians. More...


Heart failure

U.S. hospitalizations for heart failure have declined, study finds

Hospitalizations for heart failure in the U.S. declined considerably from 1998 to 2008, according to a new study. More...


CMS update

Medicare will require clinicians to re-enroll

Due to new risk-screening criteria established as part of the Affordable Care Act, clinicians who enrolled in Medicare prior to March 25, 2011 will be required to re-enroll. More...

New Medicare ABN forms required Jan. 1

Beginning on Jan. 1, CMS will require physicians and other health care professionals to use the updated version of the Advanced Beneficiary Notice of Noncoverage (ABN) form that was released in May 2011. More...

CMS looking for innovation advisors

CMS is now accepting applications for a new Innovation Advisors Program to be run by the Center for Medicare and Medicaid Innovation. More...


From the College

Free resources available to ACP members for prescribing opioid medications

The National Institute on Drug Abuse offers free educational programs and resources on the prescribing of opioid medications for health care professionals. More...


Cartoon caption contest

And the winners are …

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. More...


Physician editor: Darren Taichman, MD, FACP



Highlights


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Statins not associated with intracerebral hemorrhage, meta-analysis indicates

A recent meta-analysis found no evidence of an association between statins and intracerebral hemorrhage (ICH).

Because a recent large, randomized controlled trial suggested a link between statin use and risk for ICH, the authors of the current study performed a large systematic review and meta-analysis of the existing literature to examine the potential association. They searched 17 electronic databases, manually screened bibliographies, reviewed proceedings abstracts, and consulted experts to find published and unpublished trials that included data on ICH and use of statins.

Studies were excluded if they combined statins with other classes of lipid-lowering drugs and if they only looked at ICH after thrombolysis for acute ischemic stroke. In the former case, however, the authors contacted study authors to determine whether data that analyzed statins separately were available. The authors calculated summary risk ratios and 95% CIs using DerSimonian-Laird random-effects models, and they analyzed the included studies separately by type (i.e., randomized trials, cohort studies and case-control studies). Results of the meta-analysis were published online Oct. 17 by Circulation.

Overall, data from 23 randomized trials and 19 observational studies, involving a total of 248,391 patients and 14,784 ICHs, were included. No association was seen between statins and ICH in randomized trials (risk ratio, 1.10; 95% CI, 0.86 to 1.41), cohort studies (risk ratio, 0.94; 95% CI, 0.81 to 1.10) or case-control studies (risk ratio, 0.60; 95% CI, 0.41 to 0.88). The case-control studies had substantial heterogeneity while the cohort studies and randomized trials did not. The authors performed sensitivity analyses according to characteristics of study design and patients as well as degree of cholesterol lowering, but the results did not markedly change.

The authors cautioned that their analysis did not allow access to individual patient data, that adherence to statin therapy was low in the observational studies, and that they could not determine the possible effect of statin use on different subtypes of ICH. However, they concluded that their large meta-analysis found no evidence indicating an association between ICH and statins, and noted that if such a risk does exist, it is probably small and does not outweigh statins' benefits. "Because risk factors for nonlobar [ICH] are similar to those for atherosclerotic events…, clinicians should continue to use treatment algorithms that base the initiation of statins on each individual's global risk for cardiovascular events," they wrote.

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Essential tremor treatment guidelines updated

Propranolol and primidone remain the most successful and most frequently used drugs to treat essential tremor, while levetiracetam, 3,4-diaminopyridine, and flunarizine should not be used, according to updated guidelines by the American Academy of Neurology.

Propranolol is the only FDA-approved medication for the condition, but 30% to 50% of patients with essential tremor (ET) will not respond to it or primidone, the authors noted. To assess other treatments, an expert panel conducted a search of the peer-reviewed literature between 2004 and 2010, selecting 252 controlled trials, observational studies, cohort studies, open-label trials or case series.

The guidelines and summary tables update the previous set released in 2005 on the medical and surgical management of essential tremor. They were published online Oct. 19 by Neurology.

Changes to conclusions and recommendations from the previous guideline include the following:

  • Levetiracetam and 3,4-diaminopyridine probably do not reduce limb tremor in ET and should not be considered;
  • Flunarizine possibly has no effect in treating limb tremor and may not be considered; and
  • There is insufficient evidence to support or refute the use of pregabalin, zonisamide or clozapine as treatment for essential tremor.

Findings unchanged from the previous guideline include:

  • Propranolol and primidone are established as effective;
  • Alprazolam, atenolol, gabapentin (monotherapy), sotalol and topiramate are probably effective;
  • Nadolol, nimodipine, clonazepam, botulinum toxin A, deep brain stimulation and thalamotomy are possibly effective; and
  • Gamma knife thalamotomy has insufficient evidence to support or refute its use.

Recent evidence suggests that essential tremor is likely a syndrome or family of diseases, "which adds a layer of complexity to matters," the authors wrote. "Furthermore, the sequence of molecular events that underlie these degenerative changes has yet to be elucidated, and until such a time, it will be difficult to design specific targets for pharmacotherapeutic intervention."

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Test yourself


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MKSAP Quiz: infertility

A 25-year-old man is evaluated for a 2-year history of infertility. He and his wife have been unable to conceive since marrying 2 years ago. Analysis of a semen sample provided 3 weeks ago during an infertility evaluation showed azoospermia. The patient has a strong libido and no history of erectile dysfunction. He has no other medical problems and exercises regularly. There is no family history of delayed puberty or endocrine tumors.

mksap.jpg

On physical examination, the patient appears very muscular. Temperature is normal, blood pressure is 142/85 mm Hg, pulse rate is 55/min, respiration rate is 14/min, and BMI is 22. Visual fields are full to confrontation. There is extensive acne but no gynecomastia or galactorrhea. Testes volume is 4 mL (normal, 18-25 mL) bilaterally. The penis appears normal.

Laboratory studies:

Follicle-stimulating hormone <0.1 mU/mL (0.1 U/L)
Luteinizing hormone <0.1 mU/mL (0.1 U/L)
Prolactin 12 ng/mL (12 µg/L)
Testosterone, total <50 ng/dL (1.7 nmol/L)

An MRI of the pituitary gland shows normal findings.

Which of the following is the most likely diagnosis?

A) Anabolic steroid abuse
B) Nonfunctioning pituitary macroadenoma
C) Primary testicular failure
D) Prolactinoma

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

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Diabetes


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Guidelines recommend continuous monitoring for patients with type 1 diabetes

Continuous glucose monitoring is recommended for adults and children with type 1 diabetes in the outpatient setting, but not in the hospital, according to new guidelines from The Endocrine Society.

A task force of experts from the society reviewed existing research to develop a clinical practice guideline on the use of continuous glucose monitoring. The guidelines, which were also reviewed by the Diabetes Technology Society and the European Society of Endocrinology, were published in the October Journal of Clinical Endocrinology and Metabolism.

In a strong recommendation based on high-quality evidence, the experts concluded that real-time continuous glucose monitoring (CGM) is appropriate for adults with type 1 diabetes as long as the patients have demonstrated that they can use the devices on a nearly daily basis. Additionally, CGM could be used short-term in any adult with diabetes to assist in management of hypoglycemia unawareness, to monitor the results of significant changes to a therapy regimen, or to detect nocturnal hypoglycemia, the dawn phenomenon, or postprandial hyperglycemia. The recommendations on short-term use were only a suggestion, because they are based on very low-quality evidence.

Similar recommendations were made for children over age 8. High-quality evidence supports the use of CGM if they have type 1 diabetes and an A1c below 7.0%. For those with higher A1c values, CGM is recommended if they are able to use it almost daily (based on moderate-quality evidence). No recommendations were made regarding children under age 8 due to a shortage of evidence.

The guideline writers also looked at inpatient use of CGM and concluded that it should not be used alone for glucose management in the intensive care unit or operating room, due to insufficient evidence of its accuracy and safety in those settings. The authors noted that ICU patients are less likely to be able to provide feedback about hypoglycemic symptoms and they expressed "concerns regarding potential danger in [CGM] use in guiding insulin administration in an acute-care setting, which outweighs the possible convenience and trend awareness that the technology provides." In conclusion, the guideline authors also noted that the proper use of CGM will depend on future findings regarding the costs and benefits of the technology.

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Gastroenterology


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Men, women present differently for their reflux symptoms

Significant differences exist between how men and women experience symptoms of gastroesophageal reflux, and consequently, how they might present their diseases to their physicians.

Researchers conducted face-to-face interviews among a random sample of individuals from the community and from patients seeking surgery for reflux in South Australia in the fall of 2006. Patients ages 15 to 95 answered questions on frequency and severity of heartburn and dysphagia, as well as medication use. Outcomes in men and women were compared for the community-dwelling population and for preoperative surgical candidates. Results appeared in the October Archives of Surgery.

Of the 2,973 community-dwelling interviewees, 1,277 (43%) were men and 1,696 (57%) were women. Women were more likely to never report having heartburn than men (52.1% vs. 46.8%, P=0.005). However, women who had heartburn were more likely to report a heartburn score of 4 or higher (54.0% vs. 44.7%, P=0.01) on a scale of 0 (no symptoms) to 10 (severe symptoms), and the mean heartburn score was also higher in women. A similar proportion of men and women took medicine to control their symptoms.

Among the surgical population, women were an average of seven years older than men at the time of surgery, had a higher preoperative body mass index, and had higher preoperative symptom scores for heartburn and dysphagia. No differences were noted between the sexes for average esophageal acid exposure measured by 24-hour pH monitoring and manometrically measured esophageal peristalsis. Men were more likely to have ulcerative esophagitis and Barrett's esophagus, but at surgery, were less likely to have a hiatal hernia.

"These findings suggest that men present for surgery with more advanced reflux disease, although this does not result in men reporting more severe symptoms," the researchers wrote. "The tendency to present with a higher grade of endoscopic esophagitis and lower resting LES (lower esophageal sphincter) pressure actually suggests that men present with more severe reflux disease, at least from the viewpoint of these objective measures of reflux."

The researchers felt that the differences might be partly explained by differences in the way men and women handle health concerns.

"It is widely recognized that males tend to ignore symptoms of illness and are more reluctant to engage in preventive health measures than are females," they wrote. "On the other hand, females probably take more interest in their health and might be more likely to report symptoms that many males might not worry about."

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Heart failure


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U.S. hospitalizations for heart failure have declined, study finds

Hospitalizations for heart failure in the U.S. declined considerably from 1998 to 2008, according to a new study.

Researchers analyzed data from all Medicare beneficiaries in the U.S. and Puerto Rico hospitalized at acute care hospitals from 1998 and 2008 with heart failure as a principal discharge diagnosis code. The goal of the study was to detect changes in rates of heart failure hospitalization and one-year mortality rates in the U.S. as a whole and by state or territory. Main outcome measures were changes in demographic characteristics and comorbid conditions as well as rates of hospitalization and one-year mortality. The study results appeared in the Oct. 19 Journal of the American Medical Association.

Overall, data from 55,097,390 Medicare beneficiaries were analyzed. After adjusting for age, sex and race, the authors found that the heart failure hospitalization rate decreased from 2,845 per 100,000 person-years in 1998 to 2,007 per 100,000 person-years in 2008 (P<0.001; relative decline, 29.5%). Heart failure hospitalization rates adjusted for age decreased during the study period among all categories of race and sex. For all race-sex categories, rate of decline was lowest among black men (4,142 to 3,201 per 100,000 person-years), even after adjustment for age (incidence rate ratio, 0.81; 95% CI, 0.79 to 0.84). One-year mortality rates adjusted for risk decreased from 31.7% to 29.6% from 1999 to 2008 (P<0.001; relative decline, 6.6%).

The authors noted that they only examined Medicare beneficiaries, that they could not determine whether changes in medical coding had affected their findings, and that they could not investigate differences in subtypes of heart failure, among other limitations. However, they concluded that overall risk-adjusted heart failure hospitalizations in the U.S. declined significantly from 1998 to 2008, primarily because fewer patients were being hospitalized (as opposed to a reduction in the frequency of hospitalizations), and that the rate of decline was lowest among black men.

The authors of an accompanying editorial applauded the study as the first to document improved heart failure hospitalization rates in the U.S. but noted that the event rate after discharge for a heart failure hospitalization "remains unacceptably high and requires immediate attention." The editorialists suggested exploring the following strategies for improvement:

  • Systematically assess and correct cardiac abnormalities;
  • Treat noncardiac comorbid conditions, such as hypertension, renal dysfunction and diabetes;
  • Increase use of underused therapies known to improve hospitalization rates, such as digoxin and eplerenone; and
  • Schedule postdischarge visits promptly, especially in high-risk patients.

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CMS update


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Medicare will require clinicians to re-enroll

Due to new risk-screening criteria established as part of the Affordable Care Act (ACA), clinicians who enrolled in Medicare prior to March 25, 2011 will be required to re-enroll.

Clinicians will receive a notice to re-enroll from their Medicare Administrative Contractors (MACs) sometime between now and March 2013 and should provide their enrollment information at that time. The process is being staggered so that MACs can better manage the information. Additional information is available on the CMS website.

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New Medicare ABN forms required Jan. 1

Beginning on Jan. 1, CMS will require physicians and other health care professionals to use the updated version of the Advanced Beneficiary Notice of Noncoverage (ABN) form that was released in May 2011.

The updated form can be identified by checking the lower left-hand corner for the release date, which should be 3/11. The new form can be found on the CMS website under "FFS Revised ABN."

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CMS looking for innovation advisors

CMS is now accepting applications for a new Innovation Advisors Program to be run by the Center for Medicare and Medicaid Innovation.

Under the program, 200 health care professionals will be chosen to implement and test new models of care delivery. Beginning in December, chosen advisors will work with the innovation center to test new models of care delivery in their own organizations and create partnerships to find new ideas that work and share the new ideas.

Employers may be eligible to receive financial support to facilitate a candidate's participation. Applications are being accepted through Nov. 15. Additional information can be found online.

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From the College


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Free resources available to ACP members for prescribing opioid medications

The National Institute on Drug Abuse offers free educational programs and resources on the prescribing of opioid medications for health care professionals.

The science-based resources are designed to help physicians identify patient drug use early and prevent it from escalating to abuse or addiction. Curriculum resources on drug abuse and addiction are also available at the NIDA's website.

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Cartoon caption contest


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And the winners are …

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. The vote was tied this week, with two winners who will share in the prize.

acpi-20111025-cartoon.jpg

"I asked you to put on an unna boot, not tuna boot."

—Submitted by John A. Magaldi, MD, FACP, from Torrington, Conn.

"Well, to the untrained eye, this may appear to be a red herring."

—Submitted by Steven W. Ressler, MD, ACP Member, from Scottsdale, Ariz.

Readers cast 91 ballots online to choose the winning entry. Thanks to all who voted! The winning entries each captured 40.7% of the votes.

The runner-up was:

"Clearly we can ALL benefit from tail coverage…."

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MKSAP Answer and Critique



The correct answer is A) Anabolic steroid abuse. This item is available to MKSAP 15 subscribers as item 9 in the Endocrinology and Metabolism section. More information about MKSAP 15 is available online.

This patient is most likely abusing anabolic steroids and possibly other performance-enhancing drugs. Anabolic steroid abuse should be suspected in a muscular man with normal libido, normal erectile function, atrophic testes, infertility, and low gonadotropin and testosterone levels. Fertility can be restored with abstinence from androgens and with gonadotropin injections.

A patient such as this one who has low levels of testosterone and gonadotropins might ordinarily be classified as having secondary hypogonadotropic hypogonadism. However, despite his low testosterone level, there is clinical evidence of adequate circulating androgens, including good muscle mass, normal libido, and erectile function. Therefore, despite the low testosterone and gonadotropin levels, pituitary macroadenoma and prolactinoma are unlikely diagnoses because they cannot explain the patient's clinical findings. An MRI of the sella turcica to exclude a pituitary tumor is unnecessary.

Common causes of primary testicular failure include Klinefelter syndrome, HIV infection, uncorrected cryptorchidism, previous use of cancer chemotherapeutic agents, irradiation, surgical orchiectomy, and previous infectious orchitis. Although each of these entities is a cause of low testosterone levels, each is also associated with elevated levels of gonadotropins (hypergonadotropic hypogonadism). Primary testicular failure is not a tenable diagnosis in this patient given the findings on clinical evaluation and the suppression of both follicle-stimulating hormone and luteinizing hormone levels.

Key Point

  • Anabolic steroid abuse should be suspected in a muscular man with atrophic testes, normal libido, normal erectile function, and a low testosterone level.

Click here to return to the rest of ACP InternistWeekly.

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