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

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ACP InternistWeekly



In the News for the Week of 11-8-11




Highlights

Aspirin may benefit patients at high risk for colorectal cancer

Patients at high risk for colorectal cancer because of Lynch syndrome, also called hereditary nonpolyposis colon cancer, may benefit from long-term daily aspirin therapy, according to a recent analysis. More...

Some recommended therapies may be underused in resistant hypertension

Physicians may be underprescribing certain guideline-recommended therapies for resistant hypertension, according to a new study. More...


Test yourself

MKSAP Quiz: pain, urinary frequency and dysuria

This week's quiz asks readers to evaluate a 52-year-old man with a 3-month history of perineal and suprapubic pain. More...


Cardiology

Revised PCI guidelines emphasize team approach to determining treatment

Guidelines on percutaneous coronary intervention (PCI) have been expanded to offer comprehensive and specific recommendations for every anatomic subgroup of patients with stable coronary artery disease. More...

Revised CABG guidelines update who to revascularize, how to do it

New guidelines for the management of patients undergoing coronary artery bypass graft surgery (CABG) address patient selection, the role of CABG versus percutaneous coronary interventions (PCI), and the use of aspirin and other platelet therapies before and after surgery. More...


Education

Patient website and infection control plan developed for outpatient oncology clinics

The Centers for Disease Control and Prevention is introducing two new educational resources as part of the Preventing Infections in Cancer Patients program. 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


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Aspirin may benefit patients at high risk for colorectal cancer

Patients at high risk for colorectal cancer because of Lynch syndrome, also called hereditary nonpolyposis colon cancer, may benefit from long-term daily aspirin therapy, according to a recent analysis.

Researchers evaluated data from the second Colorectal Adenoma/carcinoma Prevention Programme (CAPP2), a randomized, controlled trial examining aspirin chemoprevention in patients with Lynch syndrome. CAPP2 participants were randomly assigned to receive daily doses of 600 mg of aspirin or aspirin placebo or 30 g of resistant starch or starch placebo for a maximum of four years. The study's primary endpoint was colorectal cancer. Study results were published online Oct. 28 by The Lancet.

Participants were recruited into the study from Jan. 1, 1999 to March 10, 2005. A total of 861 people with Lynch syndrome were assigned to receive aspirin or aspirin placebo. At a mean of 55.7 months of follow-up, 18 of 427 participants in the aspirin group and 30 of 434 in the aspirin placebo group had developed primary colorectal cancer. In an intention-to-treat analysis of time to first colorectal cancer, the hazard ratio in the aspirin group was 0.63 (95% CI, 0.35 to 1.13; P=0.12), and in Poisson regression analysis, which considered more than one primary event, the incidence rate ratio was 0.56 (95% CI, 0.32 to 0.99; P=0.05). Participants who continued the intervention for two years had a hazard ratio of 0.41 (95% CI, 0.19 to 0.86; P=0.02) and an incidence rate ratio of 0.37 (95% CI, 0.18 to 0.78; P=0.008). The groups did not differ in adverse events during the intervention period, although information on adverse events after the intervention was not available.

The authors concluded that aspirin at a dose of 600 mg/d taken for a mean of 25 months reduced incidence of colorectal cancer in patients with Lynch syndrome. They called for additional studies to determine the best dose and duration of aspirin therapy for this indication; CAPP3 intends to examine these questions. An accompanying editorial pointed out that endpoints were not ascertained in a standardized manner and that the aspirin group could have had more postintervention adverse events and therefore more extensive colonoscopy than the nonaspirin group. However, the editorialists wrote, while the study does not allow definitive conclusions, the results "strongly support routine use of aspirin for patients with Lynch syndrome as an adjunct to intensive cancer surveillance."

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Some recommended therapies may be underused in resistant hypertension

Physicians may be underprescribing certain guideline-recommended therapies for resistant hypertension, according to a new study.

Researchers performed a retrospective cohort study using data from a medical claims database to analyze antihypertensive use in patients with resistant hypertension. Included patients had a diagnosis of hypertension according to ICD-9-CM criteria and had concurrently filled prescriptions for at least four antihypertensive agents during the study period (May 1, 2008 to June 30, 2009). Of the four agents, at least two had to be recommended as a first-line agent by the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7). Patients who had a diagnosis of heart failure were excluded. Recommended first-line agents included angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), beta-blockers, calcium-channel blockers, and diuretics. Chlorthalidone and aldosterone antagonists were considered evidence-based and recommended antihypertensive therapy, while therapy with an ACE inhibitor plus an ARB or with a combination of drugs from the same class was considered minimally efficacious. The study results were published early online Oct. 30 by Hypertension.

A total of 140,126 patients, 54.5% men, met the inclusion criteria. The mean age was 63.8 years. The most commonly prescribed drug classes were ACE inhibitors and/or ARBs (96.2%), diuretics (93.2%), calcium-channel blockers (83.6%) and beta-blockers (80%). Chlorthalidone and aldosterone antagonists were prescribed in 3.0% and 5.9% of patients, respectively, while 15.6% of patients were receiving both an ACE inhibitor and an ARB.

The authors noted that their study did not classify patients according to blood pressure measurements and that only a relatively short time had passed between publication of guidelines on resistant hypertension therapies and the beginning of the study, among other limitations. However, they concluded that while guideline-recommended first-line agents were frequently prescribed for resistant hypertension, other evidence-based therapies, such as chlorthalidone and aldosterone antagonists, were not used to full advantage. Also, they found that a significant proportion of patients was prescribed ineffective therapies, such an ACE inhibitor plus an ARB. They called for more research and better clinician education on optimal treatment for resistant hypertension.

An accompanying editorial labeled the problem one of "resistant prescribing" and called the gap between recommendations and clinical practice "unacceptably wide." He predicted that the population of patients with resistant hypertension will only continue to grow and said that clinicians need to understand their approach to current management in order to improve it. "Before attributing [resistant hypertension] to host factors beyond our control, we need to first ensure that we have not contributed to its presence by failing to use effective combinations and evidence-based therapies," he wrote.

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Test yourself


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MKSAP Quiz: pain, urinary frequency and dysuria

A 52-year-old man is evaluated for a 3-month history of perineal and suprapubic pain. He has experienced urinary frequency and dysuria for 4 to 6 weeks. The patient reports fatigue, insomnia, and low mood for the past 6 months. He has hypertension. Current medications are hydrochlorothiazide and acetaminophen as needed for pain.

mksap.jpg

On physical examination, temperature is normal, blood pressure is 138/80 mm Hg, and pulse rate is 78/min. BMI is 29. Abdominal examination is normal with mild suprapubic tenderness. The prostate is not enlarged; it is mildly tender without nodularity. Testicular examination is normal.

On laboratory study, urinalysis is normal, and urine culture is negative. Prostate-specific antigen level is 0.8 ng/mL (0.8 µg/L).

Which of the following is the most appropriate treatment for this patient?

A) Levofloxacin
B) Naproxen
C) Oxybutynin
D) Saw palmetto
E) Terazosin

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

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Cardiology


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Revised PCI guidelines emphasize team approach to determining treatment

Guidelines on percutaneous coronary intervention (PCI) have been expanded to offer comprehensive and specific recommendations for every anatomic subgroup of patients with stable coronary artery disease.

The revised guidelines were released by the American College of Cardiology Foundation, American Heart Association, and Society for Cardiovascular Angiography and Interventions on Nov. 7. The recommendations on revascularizing patients are based on improving both survival and symptoms. For example:

  • Use of drug-eluting stents to decrease the incidence of blood vessel renarrowing was given a Class I recommendation. This was balanced by a recommendation that before performing PCI, physicians must first evaluate patients to determine if they can tolerate and comply with dual antiplatelet therapy.
  • Aspirin recommendations are simplified by including a Class IIA recommendation ("it is reasonable") for using 81 mg of aspirin per day after PCI instead of higher maintenance doses.
  • Ticagrelor, a new P2Y12 inhibitor that was approved by the FDA after the release of the previous guidelines, received a Class I recommendation for a 180-mg loading dose and 90 mg twice daily for at least 12 months following PCI with a drug-eluting or bare-metal stent.

The 2011 guidelines expand and add recommendations on numerous other topics, including:

  • ethical aspects of PCI, including informed consent, self-referral, and potential conflicts of interest;
  • recommendations on statin therapy;
  • the use of vascular closure devices;
  • PCI in hospitals without on-site surgical backup; and
  • a Class I recommendation for monitoring and recording procedural radiation data.

The guidelines resulted from collaborations between committees specific to coronary artery bypass grafting, ST-elevated myocardial infarction (STEMI), stable ischemic heart disease, and unstable angina/non-STEMI guidelines. In addition to undergoing a more collaborative writing process, the committee members also added new concepts to the guidelines. A "heart team" approach was included as a Class I recommendation for patients with unprotected left main or complex CAD. Interventional cardiologists and cardiothoracic surgeons are encouraged to jointly review the patient, evaluate the pros and cons of each treatment option, and then present this information to the patient, along with their recommendation.

The guidelines also advocate using a SYNTAX score in decisions regarding treatment of patients with multivessel disease. This scoring system estimates the extent and complexity of CAD when the patient's angiography results are entered into a computer-based score calculator. While this calculation is complex, using the score to classify extent of disease more objectively may help guide decisions regarding whether to perform CABG or PCI.

The guidelines were published by the participating societies' respective journals: Journal of the American College of Cardiology, Circulation: Journal of the American Heart Association and Catheterization and Cardiovascular Interventions.

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Revised CABG guidelines update who to revascularize, how to do it

New guidelines for the management of patients undergoing coronary artery bypass graft surgery (CABG) address patient selection, the role of CABG versus percutaneous coronary interventions (PCI), and the use of aspirin and other platelet therapies before and after surgery.

The guideline writers, representing the American College of Cardiology Foundation and the American Heart Association, noted that use of PCI has expanded and physicians have become more skilled at it, driving changes in the recommendations. The 2011 guidelines state that PCI is a reasonable alternative to CABG in stable patients with left main coronary artery disease who have a low risk of PCI complications and an increased risk of adverse surgical outcomes. The guidelines also confirm the superiority of CABG compared to medical therapy and to PCI for most patients with three-vessel disease.

Preoperative and postoperative antiplatelet therapy were reexamined because the ability to inhibit platelet aggregation has improved, as more drugs have become available since the last set of guidelines was developed. Specifically, the 2011 guidelines note that aspirin should be administered to CABG patients preoperatively, and that in patients receiving elective CABG, clopidogrel and ticagrelor should be discontinued for at least five days before elective surgery (or at least 24 hours, if possible, for patients needing urgent CABG). Postoperatively, aspirin should be given within six hours of surgery (if it was not initiated preoperatively) and then continued indefinitely. Clopidogrel is a "reasonable alternative" in patients who are allergic to aspirin.

The new guidelines address numerous other issues, such as the appropriate choice of bypass graft conduit; the use of off-pump CABG versus traditional on-pump CABG; and CABG in specific patient subsets, such as those with diabetes.

The guidelines, like the revised PCI guidelines, stress the importance of a "heart team" approach in which the interventional cardiologist and the cardiac surgeon review the patient's condition, determine the pros and cons of each treatment option, and then present this information to the patient, allowing him or her to make a more informed decision.

The revised guidelines were based on a formal literature review of studies published in the past 10 years. The societies released the guidelines online on Nov. 7, and they will appear in the Dec. 6 issues of the Journal of the American College of Cardiology and Circulation: Journal of the American Heart Association.

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Education


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Patient website and infection control plan developed for outpatient oncology clinics

The Centers for Disease Control and Prevention is introducing two new educational resources as part of the Preventing Infections in Cancer Patients program.

The comprehensive program, first announced in 2009, provides information, action steps and tools for patients, their caregivers and their clinicians to reduce the risk of potentially life-threatening infections during chemotherapy. The new resources include an interactive website for cancer patients and caregivers, and a Basic Infection Control and Prevention Plan for Outpatient Oncology Settings.

The website, 3 Steps Toward Preventing Infections During Cancer Treatment, helps cancer patients assess their risk for developing neutropenia during chemotherapy. Cancer patients and caregivers complete a short online questionnaire about their risk factors and receive downloadable information about how to help lower their risk for infection and keep themselves healthy while receiving chemotherapy.

The Basic Infection Control and Prevention Plan for Outpatient Oncology Settings provides specific guidelines on injection safety, hand hygiene, environmental disinfection, and other related areas. The plan outlines how the guidelines should be applied in outpatient settings where cancer patients receive chemotherapy and ongoing treatment.

As part of the comprehensive program, the CDC produced a collection of posters and patient brochures and a fact sheet. Additionally, the CDC is reaching out to professional physician and patient advocacy organizations to help raise awareness of this serious health concern and the available resources.

Preventing Infections in Cancer Patients was developed by experts from the CDC's Division of Cancer Prevention and Control and the CDC's Division of Healthcare Quality Promotion in collaboration with scientists in the fields of oncology and infection control. The program was made possible by a grant from the biotechnology company Amgen, which also offers more information at its website.

More information and resources on the comanagement of cancer patients, including clinical resources, are highlighted in the November/December issue of ACP Internist.

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Cartoon caption contest


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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-20111108-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.

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MKSAP Answer and Critique



The correct answer is E) Terazosin. This item is available to MKSAP 15 subscribers as item 14 in the General Internal Medicine section. More information about MKSAP 15 is available online.

The most appropriate treatment for this patient is terazosin. This patient has chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). CP/CPPS is manifested by genitourinary/pelvic pain and voiding symptoms. There are no diagnostic physical or laboratory findings. Urine cultures are typically negative, and the presence or absence of leukocytes in the urine has limited clinical utility in diagnosis or in predicting treatment response.

α-Blockers have the most evidence of efficacy among pharmacologic therapies for the treatment of CP/CPPS. Several specific α-blockers have been evaluated in randomized clinical trials, including terazosin, in doses ranging from 1 to 5 mg/d. Other α-blockers tested in trials include tamsulosin and alfuzosin. Clinical response is often modest, however, and long-term efficacy is uncertain.

Current evidence does not support a bacterial cause of CP/CPPS. Although a 4- to 6-week trial of antibiotics is still commonly prescribed, there is a lack of clinical trial evidence supporting their use. In contrast to bacterial prostatitis, in which urinalysis and urine culture typically show signs of an infection, results of these tests are normal in CP/CPPS. Acute bacterial prostatitis is unlikely in this patient with an indolent course of symptoms and a prostate that on examination is only mildly rather than exquisitely tender.

NSAIDs are another class of drugs commonly recommended as empiric treatment, and there is preliminary evidence that inflammatory markers such as interleukin and tumor necrosis factor are elevated in patients with CP/CPPS. However, only one randomized controlled trial has been conducted, which showed modest benefits for rofecoxib, a COX-2 inhibitor. The efficacy of other NSAIDs has not been established.

Anticholinergic drugs such as oxybutynin are effective therapy for urge incontinence but are not indicated for other genitourinary syndromes.

Quercetin, a bioflavonoid found in red wine, onions, and other foods, has proven beneficial in one small trial, but other popular "prostate health" supplements, including saw palmetto, do not appear effective for CP/CPPS.

Key Point

  • α-Blockers may be effective in the treatment of chronic prostatitis/chronic pelvic pain syndrome.

Click here to return to the rest of ACP InternistWeekly.

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Test yourself

A 66-year-old man is evaluated for vague abdominal pain of several months' duration and a 10-kg (22-lb) weight loss. He drinks alcohol socially but does not smoke. The patient is otherwise well, has good performance status, and takes no medications. Following a physical exam, lab studies, and a CT scan, what is the most appropriate initial management of this patient?

Find the answer

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