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

Advertisement

ACP InternistWeekly



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




Highlights

Minorities bring med school applications to all-time high

First-time applicants to medical school reached an all-time high in 2011, increasing by 2.6% over last year to about 32,700 students, according to the Association of American Medical Colleges. More...

Screening X-rays don't reduce lung cancer mortality

Annual screening with chest radiographs over a four-year period did not reduce lung cancer mortality compared with usual care, according to researchers analyzing results of the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial. More...


Test yourself

MKSAP Quiz: 5-day history of abdominal pain

This week's quiz asks readers to evaluate a 32-year-old man who visits the emergency department for a 5-day history of worsening crampy abdominal pain and frequent loose bowel movements. More...


Low back pain

Yoga may be beneficial in chronic low back pain

Yoga improved chronic low back pain compared to usual care, a new randomized trial has shown. More...


Women's health

Some newer progestogens double thromboembolism risk

Women taking oral contraceptives containing drospirenone or desogestrel had twice the risk of venous thromboembolism as women taking levonorgestrel pills, a new Danish study found. More...


Education

Upcoming conference examines patient-centered policy, practice

The ERCI Institute and the FDA will co-organize an upcoming conference titled "Patient-Centeredness in Policy and Practice," to be held Nov. 29-30 in Silver Spring, Md. More...

Resources to guide appropriate imaging available online

The American College of Radiology offers several ways to access its criteria for appropriate imaging online. More...


Drug update

Preliminary trial results show triple-drug regimen may be harmful for idiopathic pulmonary fibrosis

Therapy with a combination of prednisone, azathioprine and N-acetylcysteine may be harmful in patients with idiopathic pulmonary fibrosis, the National Institutes of Health announced last week. More...


CMS update

Last chance to avoid eRx penalty

Today is the last day to apply for a hardship exemption for the Medicare e-Prescribing program. More...


From ACP Internist

The November/December issue is online and coming to your mailbox

The November/December issue of ACP Internist is now online and coming to your mailbox, featuring stories on medical residency, HIV, and more. More...


From the College

Election results announced for Board of Governors Chair-elect Designee

The Governors' Subcommittee on Nominations is pleased to announce that Susan T. Hingle, MD, FACP, has been elected the Chair-elect Designee for the Board of Governors. More...


Cartoon caption contest

Put words in our mouth

ACP InternistWeekly wants readers to create captions for our new cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service. More...


Physician editor: Darren Taichman, MD, FACP




Highlights


.
Minorities bring med school applications to all-time high

First-time applicants to medical school reached an all-time high in 2011, increasing by 2.6% over last year to about 32,700 students, according to the Association of American Medical Colleges. Total applicants rose by 2.8% to nearly 44,000, with gains across most major racial and ethnic groups for a second year in a row.

The growth comes at a time when there is a growing need for doctors and a serious physician shortage, and the applicant pool is increasingly diverse, the AAMC reported last week in a press release.

The total number of applicants and enrollees from most major racial and ethnic groups increased in 2011:

  • After a slight decrease (0.2%) in 2010, black applicants increased by 4.8% while enrollees increased by 1.9%.
  • Hispanic applicants increased by 5.8% and enrollees increased by 6.1%.
  • Asian applicants increased by 3.8% and enrollees increased by 3.3%.
  • First-time female applicants increased by 3% to nearly 16,000, and first-time male applicants grew nearly 2% to about 16,700 in 2011. The percentage of male (53%) and female (47%) enrollees remained steady from last year.
  • Native American applicants and enrollees decreased from 200 to 169 and 191 to 157, respectively.

The overall academic credentials of applicants remained strong, the AAMC reported, with an average GPA of 3.5 and an MCAT exam score of 29. The majority of applicants reported slightly increased rates of premedical experiences in community service and medical research, with 82.5% reporting community service experience in medical and clinical settings, 68.4% reporting nonclinical community service, and 73% reporting experience in research.

Total enrollment increased by 3% over last year, with more than 19,000 students in the 2011 entering class. Medical schools have steadily been increasing their class sizes since the AAMC called for a 30% increase in enrollment in 2006 to help alleviate anticipated physician workforce shortages. There has been a 16.6% enrollment increase over 2002, the base year used in calculating the 30% goal. Current projections indicate that medical schools are on target to reach the 30% enrollment increase by 2017.

The majority of this year's growth came from existing schools while a smaller portion came from first-year enrollees at medical education programs established in the past decade, the AAMC reported.

Top


.
Screening X-rays don't reduce lung cancer mortality

Annual screening with chest radiographs over a four-year period did not reduce lung cancer mortality compared with usual care, according to researchers analyzing results of the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial.

The PLCO trial is a randomized, controlled trial of 154,901 smokers and nonsmokers 55 through 74 years of age. Of this group, 77,445 were assigned to annual screenings and 77,456 were assigned to usual care between November 1993 and July 2001. Results appeared online Oct. 26 in the Journal of the American Medical Association.

Participants randomized to the intervention group were offered a posterior-anterior chest radiograph at baseline and then annually for three more years. If a nodule, mass, infiltrate, or other abnormality considered suspicious for lung cancer was noted, patients were advised to seek diagnostic evaluation from their own physicians. PLCO screening center staff obtained medical records related to diagnostic follow-up.

Participants in the usual care group were offered no interventions and received their usual medical care. All diagnosed cancer, deaths, and causes of death were ascertained through 13 years of follow-up or until Dec. 31, 2009.

Cumulative lung cancer incidence rates through 13 years of follow-up were 20.1 per 10,000 person-years in the intervention group and 19.2 per 10,000 person-years in the usual care group (rate ratio [RR]; 1.05, 95% CI, 0.98 to 1.12). Although incidence rates were dependent on smoking history (3.1 for never smokers, 23 for former smokers, 83 for current smokers), the RRs for incidence were similar according to smoking history: 1.06 for never smokers, 1.12 for former smokers, and 1.00 for current smokers. A total of 1,213 lung cancer deaths were observed in the intervention group compared with 1,230 in usual care group through 13 years (mortality RR, 0.99; 95% CI, 0.87 to 1.22). Researchers concluded that annual chest radiographic screening for up to four years did not have an effect on cumulative lung cancer mortality during 13 years of follow-up.

The PLCO data were then analyzed in an ancillary analysis with another trial, the National Lung Screening Trial (NLST), which compared chest radiographs with spiral computed tomography (CT) screening. The authors noted that because the NLST did not have a usual care group, examining its findings alongside the PLCO study was critical to addressing the benefit and harms of CT compared with usual care.

The findings from the NLST, which demonstrated a 20% mortality benefit (RR, 0.80) for screening with low-dose spiral CT compared with chest radiograph, were compared with the findings for chest radiograph versus usual care for the PLCO subgroup that would have been eligible for NLST. Through the approximate six-year period, the mortality RR in the NLST-eligible PLCO cohort was 0.94 (95% CI, 0.81 to 1.10). The study authors wrote, "Although there were some modest differences between the 2 cohorts, it seems reasonable to consider the chest radiograph vs usual care comparison in the NLST-eligible cohort in PLCO to be an adequate surrogate for such a comparison within NLST."

An accompanying editorialist commented that the results of the PLCO lung cancer study convincingly indicate that using chest radiography to screen for lung cancer is not effective. "The study is important for putting this question to rest and providing strong empirical grounds for comparing low-dose CT to a real-world alternative: usual care," the editorialist wrote.

Top




Test yourself


.
MKSAP Quiz: 5-day history of abdominal pain

A 32-year-old man is evaluated in the emergency department for a 5-day history of worsening crampy abdominal pain and eight to ten loose bowel movements a day. The patient has a 5-year history of ulcerative colitis treated with azathioprine and topical mesalamine; before this episode, he had one or two bowel movements of well-formed stool a day. The patient had sinusitis recently, which resolved with antibiotic therapy. He has otherwise been healthy and has not traveled recently, had contact with sick persons, or been noncompliant with medication.

mksap.jpg

On physical examination, the temperature is 38.3 °C (101 °F), the blood pressure is 130/76 mm Hg sitting and 105/60 mm Hg standing, the pulse rate is 90/min sitting and 120/min standing, and the respiration rate is 18/min. The abdomen is diffusely tender without rebound or guarding. Laboratory studies reveal hemoglobin 12.3 g/dL (123 g/L), leukocyte count of 28,000/µL (28 × 109/L) with 15% band forms, and platelet count of 234,000/µL (234 × 109/L). Intravenous fluids are started and stool studies are obtained.

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

A) Increase dosage of azathioprine
B) Start oral vancomycin
C) Start oral mesalamine
D) Small-bowel radiographic series

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

Top


.


Low back pain


.
Yoga may be beneficial in chronic low back pain

Yoga improved chronic low back pain compared to usual care, a new randomized trial has shown.

Researchers in the United Kingdom performed a parallel-group randomized, controlled trial from April 2007 to March 2010 at 13 facilities not affiliated with the U.K.'s National Health Service. Three hundred thirteen adults with chronic or recurrent low back pain were randomly assigned to receive yoga (n=156) or usual care (n=157). All participants were given an educational booklet on back pain, and the intervention group was offered a 12-class yoga program given by 12 teachers over a three-month period. The yoga classes were adapted for low back pain and became more challenging as time progressed (a video is available online). Outcome measures, assessed via mailed questionnaire, were Roland-Morris Disability Questionnaire (RMDQ) scores (ranging from 0, indicating best, to 24, indicating worst) as well as pain, pain self-efficacy, and general health measures at three, six and 12 months. The results appear in the Nov. 1 Annals of Internal Medicine.

annals.jpg

Seventy-seven percent of participants had current low back pain at randomization. Of the 156 patients assigned to yoga classes, 93 (60%) went to three or more of the first six sessions and at least three of the remaining sessions. Back function was significantly better in the yoga group than in the usual care group at three, six, and 12 months (adjusted mean RMDQ scores, 2.17 points, 1.48 points, and 1.57 points lower for yoga vs. usual care, respectively; P<0.001, P=0.011, and P=0.007, respectively). Back pain was similar in both groups at all three time points, while pain self-efficacy scores were higher in the yoga group at three and six months but not at 12 months. Adverse events, most commonly increased pain, were reported by two of the 157 usual care participants and 12 of the 156 yoga participants.

The authors noted that data were missing for the primary outcome (i.e., three-month RMDQ scores) in both groups and cautioned against comparing their findings directly with those from other randomized trials of exercise and manipulation for low back pain. However, they concluded that a 12-week yoga program in adults with chronic or recurrent low back pain yielded greater improvement than did usual care.

Another study, published early online Oct. 24 by Archives of Internal Medicine, compared the effects of yoga, stretching, and a self-care book on chronic low back pain in adults. In that study, 228 adults were assigned to 12 weekly yoga classes (n=93), stretching exercises (n=91), or a self-care book (n=45). The primary outcomes were back function as measured on a modified 23-point version of the Roland Disability Questionnaire and bothersomeness of pain on an 11-point scale at 12 weeks, with outcomes assessed at baseline and at six, 12, and 26 weeks. All patients were recruited from the Puget Sound area of Washington state.

At 12 weeks, after adjustment for baseline values, the yoga group had better outcomes in function and symptoms (mean differences, −2.5 points and −1.1 points, respectively) than the self-care group (P<0.001 for both comparisons). The yoga group continued to have better function at 26 weeks than the self-care group (mean difference, −1.8 points; P<0.001), but yoga was never found to be superior to stretching. The authors noted that because yoga and stretching yielded similar outcomes, the benefits of yoga were probably due to its physical rather than mental aspects. Limitations of the study included its use of participants from a single site and the lack of follow-up past 26 weeks. However, the authors concluded that compared to self-care, yoga can improve function and symptoms for several months in patients with low back pain.

An invited commentary accompanying the Archives article said the results show that exercise in patients with low back pain is "safe and moderately beneficial" and that clinicians can safely refer such patients to yoga classes or physical therapy. The commentary author called for more comparative effectiveness research on low back pain to help guide recommendations on policy and clinical practice.

The American College of Physicians recently published a guideline on diagnostic imaging for low back pain as part of its high-value, cost-conscious care initiative.

Top




Women's health


.
Some newer progestogens double thromboembolism risk

Women taking oral contraceptives containing drospirenone or desogestrel had twice the risk of venous thromboembolism (VTE) as women taking levonorgestrel pills, a new Danish study found.

The cohort study, which was an expansion of previous work by the researchers, included more than 8 million woman-years of observation from Danish national registries. More than 4,000 first-ever VTE events were included, about two-thirds of them confirmed as certain. The results were published online Oct. 25 by BMJ.

Compared to women not taking hormonal contraception, the relative risk of confirmed VTE was 2.9 for women on ethinylestradiol with levonorgestrel (95% CI, 2.2 to 3.8), 6.4 with drospirenone (95% CI, 5.4 to 7.5), 6.6 with desogestrel (95% CI, 5.6 to 7.8) and 6.2 with gestodene (a progestogen not available in the U.S.). A lower dose of estrogen (20 mg vs. 30 mg) did not reduce VTE risk for women taking drospirenone. When levonorgestrel replaced non-use as a reference standard, the risk of confirmed VTE with the other progestogens was about double. The study found no increase in VTE risk with intrauterine devices or progestogen-only pills.

Based on the sixfold increased VTE risk found to be associated with the hormones, the researchers calculated that the risk of VTE for women on drospirenone, desogestrel or gestodene is 10 per 10,000 woman-years. They noted that 2,000 women would have to switch to levonorgestrel to prevent one VTE in one year.

The author of an accompanying editorial complimented the thoroughness of the study and predicted that many clinicians will choose to minimize risk by prescribing levonorgestrel whenever possible. However, he cautioned that the risk of VTE should not be exaggerated, noting that oral contraceptives are, in general, remarkably safe.

Top




Education


.
Upcoming conference examines patient-centered policy, practice

The ERCI Institute and the FDA will co-organize an upcoming conference titled "Patient-Centeredness in Policy and Practice," to be held Nov. 29-30 in Silver Spring, Md.

ACP's EVP and CEO, Steven E. Weinberger, MD, FACP, will present at the conference, which will examine research that promotes and evaluates the effectiveness of moving the health care system toward patient-centeredness. Other speakers and moderators include Margaret Hamburg, MD, FACP, commissioner of the FDA; Carolyn Clancy, MD, MACP, director of the Agency for Healthcare Research and Quality; and Jeffrey Shuren, MD, JD, director of the Center for Devices and Radiological Health. The conference will attempt to determine what patient-centeredness means, which programs to develop it are working, whether patient-centeredness has staying power, and whether a business case supports it.

The conference is free, but advance registration is required and space is limited. More information and registration are available online.

Top


.
Resources to guide appropriate imaging available online

The American College of Radiology offers several ways to access its criteria for appropriate imaging online.

The ACR Appropriateness Criteria, which were developed to help physicians make appropriate decisions about imaging and treatment, are available in their entirety on the American College of Radiology's website and via an online search engine.

In addition, physicians can purchase a mobile app offering point-of-care access to the criteria.

More information, including a guidance document for safe magnetic resonance imaging and a white paper on radiation dose in medicine, is also available online.

Top




Drug update


.
Preliminary trial results show triple-drug regimen may be harmful for idiopathic pulmonary fibrosis

Therapy with a combination of prednisone, azathioprine and N-acetylcysteine may be harmful in patients with idiopathic pulmonary fibrosis, the National Institutes of Health announced last week.

The NIH was conducting a three-arm multicenter clinical trial to evaluate treatments for idiopathic pulmonary fibrosis and found that outcomes were worse in patients receiving the triple-drug regimen than in those receiving placebo. Compared with the placebo group, the triple-drug group had higher rates of mortality (11% vs. 1%), hospitalization (29% vs. 8%) and adverse events (31% vs. 9%). Adherence rates were also lower in the triple-drug group than in the placebo group (78% vs. 98%), while tests of lung function did not differ.

Based on these results, the Data Safety and Monitoring Board recommended that the triple-therapy arm of the trial be stopped, and the NIH has complied. The arms of the trial in which patients receive either N-acetylcysteine alone or placebo will continue, the NIH said.

It is very important to note that these are only preliminary reports and that firm conclusions must await peer-reviewed data. The study co-chair cautioned that patients currently taking these medications should consult with their physicians before stopping therapy. More information is available online.

Top




CMS update


.
Last chance to avoid eRx penalty

Today is the last day to apply for a hardship exemption for the Medicare e-Prescribing program.

Under the 2011 Medicare Electronic Prescribing Incentive Program, clinicians who do not successfully use an eRx system during 2011 will be subject to a payment penalty on their 2012 Medicare payments. However, under a change to the rule published earlier this fall, clinicians who are not able to use an eRx system may be eligible for an exemption. Additional guidance about who may apply and how to apply is available online.

Top




From ACP Internist


.
The November/December issue is online and coming to your mailbox

The November/December issue of ACP Internist features the following stories:

acpi-20111101-internist.jpg

Building the medical home starts in school. Four medical schools revamped their residency programs to include concepts of the patient-centered medical home. The changes resulted in better teamwork, better continuity of care, and more intense clinical rotations.

HIV comes of age as disease of mid-to-late life. Protease inhibitors revolutionized management of HIV, morphing it from a death sentence to a chronic, manageable condition. Medical issues have since grown more complex as doctors consider how HIV interacts with aging and how aging interacts with these sometimes toxic drugs used to control the virus.

It's tough to navigate return from cancer care to primary care. An Institute of Medicine report suggests that patients are becoming lost in transitions between oncology and primary care. Educating physicians is a key to overcoming many of the barriers.

These and the next installment of the MKSAP Quiz, on progressive worsening of fatigue and forgetfulness, are now online.

Top




From the College


.
Election results announced for Board of Governors Chair-elect Designee

The Governors' Subcommittee on Nominations is pleased to announce that Susan T. Hingle, MD, FACP, has been elected the Chair-elect Designee for the Board of Governors.

She will officially take office as Chair-elect in April 2012. Dr. Hingle will become Chair at the close of the Annual Business Meeting in April 2013 and serve in that capacity for one year.

Top




Cartoon caption contest


.
Put words in our mouth

ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

acpi-20111101-cartoon.jpg

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.

Top


.


MKSAP Answer and Critique



The correct answer is B) Start oral vancomycin. This item is available to MKSAP 15 subscribers as item 10 in the Gastroenterology and Hepatology section. More information about MKSAP 15 is available online.

This patient likely has Clostridium difficile antibiotic-associated colitis complicating his underlying inflammatory bowel disease. C. difficile is an anaerobic gram-positive rod that produces two toxins, both capable of damaging the mucosa of the colon and causing pseudomembranous colitis. Infectious diarrhea associated with C. difficile has emerged as a major public health concern and can be seen in patients with underlying inflammatory bowel disease. Whenever a patient with inflammatory bowel disease presents with a new flare, stool studies, including C. difficile toxin assay, should be done. This patient's recent history of antibiotic use greatly increases his risk of C. difficile infection. The fever, orthostasis, leukocytosis, and abdominal tenderness in the setting of chronic immunosuppression are all signs that he needs to be hospitalized for further investigations (for example, CT scan to rule out toxic megacolon) and to start empiric therapy. Optimal therapy is orally administered metronidazole or vancomycin and should be initiated promptly for severely ill patients.

It would be unwise to increase his immunosuppression either by adding prednisone or increasing the azathioprine in the setting of possible infection. There is no role for evaluation of the small bowel mucosa with a small-bowel series in order to diagnose small-bowel inflammation.

Key Point

  • Infectious causes should be considered in exacerbations of diarrhea in patients with inflammatory bowel disease.

Click here to return to the rest of ACP InternistWeekly.

Top




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.

To add your e-mail address to your member record and to begin receiving ACP InternistWeekly, please click here.

Copyright © by American College of Physicians.

Test yourself

A 76-year-old woman is evaluated for a 3-month history of left knee pain of moderate intensity that worsens with ambulation. She reports minimal pain at rest and no nocturnal pain. There are no clicking or locking symptoms. She has tried naproxen and ibuprofen but developed dyspepsia; acetaminophen provides mild to moderate relief. The patient has hypertension, hypercholesterolemia, and chronic stable angina. Medications are lisinopril, metoprolol, simvastatin, low-dose aspirin, and nitroglycerin as needed. Following a physical exam, lab results and radiograph, what is the next best step in management?

Find the answer

Have questions about the new ABIM MOC Program?

Have questions about the new ABIM MOC Program?

ACP explains the ABIM requirements and offers many free solutions to earn MOC points.

One Click to Confidence - Free to members

One Click to Confidence - Free to members ACP Smart Medicine is a new, online clinical decision support tool specifically for internal medicine. Get rapid point-of-care access to evidence-based clinical recommendations and guidelines. Plus, users can easily earn CME credit. Learn more