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

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ACP InternistWeekly



In the News for the Week of 12-20-11




Highlights

Patients more eager to have open records than physicians

Most patients would like electronic access to their medical records, and a substantial proportion would also like to share that access with others, according to two new studies. More...

ADHD drugs appear to present no cardiovascular risks in adults

Attention-deficit/hyperactivity disorder medications were not associated with an increased risk of serious cardiovascular events among young and middle-aged adults, researchers found. More...


Test yourself

MKSAP Quiz: Confusion and agitation secondary to malignant hypertension

This week's quiz asks readers to evaluate a 67-year-old man who presents to the emergency department for confusion and agitation secondary to malignant hypertension. More...


Side effects

LABAs but not statins associated with leg cramps

Patients who begin taking a long-acting beta2-agonist or certain kinds of diuretics may have an increased risk of experiencing nocturnal leg cramps, a new study concluded. More...


Oncology

Muscular dystrophy patients appear more prone to some cancers

Patients with myotonic muscular dystrophy were at increased risk of cancer, both overall and specifically from malignancies of the endometrium, brain, ovary and colon, according to a Scandinavian registry study. More...


From the College

ACP launches Depression Care Guide

ACP's new free Depression Care Guide is an evidence-based, online resource that provides concise, practical information and strategies to enable physicians and other health professionals to reduce the treatment gaps that exist for depression care. More...

College joins Choosing Wisely campaign

ACP has joined other leading professional medical organizations in the Choosing Wisely campaign, which complements the College's High-Value, Cost-Conscious Care effort. More...


Cartoon caption contest

Vote for your favorite entry

ACP InternistWeekly's cartoon caption contest continues. Readers can vote for their favorite caption to determine the winner. More...

Editorial note: ACP InternistWeekly will not be published for the next two weeks due to the Christmas and New Year's holidays.


Physician editor: Darren Taichman, MD, FACP



Highlights


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Patients more eager to have open records than physicians

Most patients would like electronic access to their medical records, and a substantial proportion would also like to share that access with others, according to two new studies.

In the first study, more than 30,000 patients and 250 physicians were surveyed at primary care practices (located in Massachusetts, Pennsylvania and Washington state) participating in the OpenNotes research and demonstration project. The survey respondents were asked about their expectations and attitudes about physicians' notes being readable by patients. The surveys were conducted after physicians had decided whether or not to participate in the OpenNotes demonstration, but before they and their patients had experienced the system.

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Overall, across the three sites, 92% to 97% of patients and 69% to 81% of physicians participating in the project thought open visit notes were a good idea. Among nonparticipating physicians, only 16% to 33% thought it was a good idea. Participating physicians were more likely to anticipate improved communication than nonparticipants (74% to 92% vs. 45% to 67%), while nonparticipants expected greater worry among patients (88% to 92% vs. 50% to 58%) and more patient questions outside visits (83% to 84% vs. 36% to 50%). Only 12% to 16% of patients were concerned about greater worry and 22% anticipated sharing their visit notes with others, including other physicians.

Another study, also published in the Dec. 20 Annals of Internal Medicine, found an even higher rate of patient interest in sharing health records with others. These researchers surveyed more than 18,000 users of the Veterans Administration's electronic personal health record system. They found that 79% of respondents were interested in sharing access to their record—most often with a spouse (62%), followed by a non-VA clinician (25%), a child (23%), and another family member (15%). Participants were also asked what parts of their record they would like to share, and the most popular responses were medication lists, scheduled appointments and lab results.

The authors of the latter study noted that under current systems, sharing a limited amount of information from a personal health record is not easy. They called for health care systems to explore the possibilities of allowing patients to securely share their access in order to improve information exchange. The VA has recently completed a pilot of such a system, which was well received, they noted. The OpenNotes survey was also the first step in a pilot project, which will provide evidence about how the reality of open records compares to physicians' and patients' expectations. An accompanying editorial by physicians at MD Anderson Cancer Center said that patient access to records there has worked out well, although many questions remain about the long-term uses and effects of these systems.


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ADHD drugs appear to present no cardiovascular risks in adults

Attention-deficit/hyperactivity disorder (ADHD) medications were not associated with an increased risk of serious cardiovascular events among young and middle-aged adults, researchers found.

Researchers conducted a retrospective, population-based cohort study using electronic health care records from four study sites from 1986 through 2005, with additional covariate assessment using 2007 survey data. Participants were 25 through 64 years of age with dispensed prescriptions for methylphenidate (45% of current use), amphetamine (44%), atomoxetine (8%), and pemoline (3%). Each medication user (n=150,359) was matched to two nonusers by study site, birth year, sex and calendar year. Results appeared in the Dec. 14 Journal of the American Medical Association.

There was no evidence of an increased risk of serious cardiovascular events, including myocardial infarction (MI), sudden cardiac death (SCD), or stroke, associated with current use compared with nonuse or past use of ADHD medications. There was also no increased risk found with any specific medication or with longer duration of use. Results were similar when the study population was restricted to new users.

During 806,182 person-years of follow-up (median, 1.3 years per person), 1,357 cases of MI, 296 cases of SCD and 575 cases of stroke occurred. There were 107,322 person-years of current use (median, 0.33 year), with a crude incidence per 1,000 person-years of 1.34 (95% CI, 1.14 to 1.57) for MI, 0.30 (95% CI, 0.20 to 0.42) for SCD, and 0.56 (95% CI, 0.43 to 0.72) for stroke.

The multivariable-adjusted rate ratio (RR) of serious cardiovascular events for current use compared to nonuse of ADHD medications was 0.83 (95% CI, 0.72 to 0.96). Among new users of ADHD medications, the adjusted RR was 0.77 (95% CI, 0.63 to 0.94). The adjusted RR for events among current users compared to those whose prescriptions ended more than one year prior was 1.03 (95% CI, 0.86 to 1.24). For new users compared to those whose prescriptions ended more than one year prior, the adjusted RR was 1.02 (95% CI, 0.82 to 1.28).

An editorialist commented, "Perhaps the greatest clinical influence of [the study] will be in how clinicians counsel patients regarding the risks and benefits of ADHD medications. Now there is solid evidence—perhaps even some heartening news—that physicians can use to address concerns about cardiovascular risk."



Test yourself


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MKSAP Quiz: Confusion and agitation secondary to malignant hypertension

A 67-year-old man is evaluated in the emergency department for confusion and agitation secondary to malignant hypertension. Initial blood pressure is 230/130 mm Hg, and funduscopic examination reveals papilledema.

He is admitted to the intensive care unit, and therapy with nitroprusside by continuous infusion is begun; the therapy is titrated over the next 3 days. The encephalopathy and papilledema resolve with control of the blood pressure. However, he becomes more confused and lethargic. The physical examination is normal. He is afebrile, with a blood pressure of 100/70 mm Hg and a pulse rate of 60/min. He is oriented only to person. There are no focal findings on the neurologic examination and no evidence of nuchal rigidity.

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Arterial blood gases reveal: pH 7.2; Pco2 20 mm Hg; Po2 90 mm Hg (on ambient air). Venous Po2 is 72 mm Hg. Serum electrolyte panel shows: sodium, 140 mEq/L (140 mmol/L); potassium, 3.8 mEq/L (3.8 mmol/L); chloride, 90 mEq/L (90 mmol/L), and bicarbonate, 9 mEq/L (9 mmol/L).

Which of the following is the most likely cause of the patient's findings?

A) Cyanide toxicity
B) Delirium tremens
C) Hepatic encephalopathy
D) Hypoxic-ischemic encephalopathy
E) Wernicke encephalopathy

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


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Side effects


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LABAs but not statins associated with leg cramps

Patients who begin taking a long-acting beta2-agonist (LABA) or certain kinds of diuretics may have an increased risk of experiencing nocturnal leg cramps, a new study concluded.

The study used a database of prescribing information for about 4 million residents of British Columbia, Canada. Researchers looked at adults 50 years or older that had an index prescription for a diuretic, a statin or a LABA in 2000 to 2008 and then assessed the rate of quinine prescriptions (which they considered a marker for cramp treatment) for these patients in the years preceding and following the index prescription. The results were published online Dec. 12 by Archives of Internal Medicine.

Beginning treatment with a LABA was associated with the greatest increase in quinine use. The adjusted sequence ratio was 2.42, indicating that patients were 142% more likely to receive quinine in the year after initiating LABA treatment than the year before (P<0.001). Diuretics as a class also increased risk (adjusted sequence ratio, 1.47; P<0.001), but differences existed among the diuretic subclasses in their risk for cramps. Potassium-sparing diuretics had the greatest association with quinine use (adjusted sequence ratio, 2.12; P<0.001), followed by thiazide-like diuretics (adjusted sequence ratio, 1.48; P<0.001). Loop diuretics did not pose a statistically significantly increased risk (adjusted sequence ratio, 1.20; P=0.07). Statins were also not found to increase risk (adjusted sequence ratio, 1.16, P=0.004).

Overall, the study found that 60.3% of quinine users in the database had received at least one of the medications that were found to increase cramp risk (LABAs, potassium-sparing diuretics or thiazide-like diuretics) during a 13-year period. The authors noted that these findings extend and support the existing evidence linking these drugs to muscle cramping, which previously had been largely anecdotal.

If patients' cramps could be eliminated by nonuse of these drugs, the number needed to treat by discontinuing the drugs would be 1.7 for LABAs and 3.1 for thiazides, the authors calculated. They concluded that physicians should be aware of the epidemiological association between these drugs and cramp treatment, and be mindful that use of the drugs could worsen patients' nocturnal leg cramps.



Oncology


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Muscular dystrophy patients appear more prone to some cancers

Patients with myotonic muscular dystrophy were at increased risk of cancer, both overall and specifically from malignancies of the endometrium, brain, ovary and colon, according to a Scandinavian registry study.

Researchers identified 1,658 patients with a muscular dystrophy discharge diagnosis in national Swedish and Danish patient registries between 1977 and 2008, then linked them to their countries' respective cancer registries. Patients were followed from date of first muscular dystrophy diagnosis to first cancer diagnosis, death, emigration or exit from the cancer registry. Results appeared in the Dec. 14 Journal of the American Medical Association.

In the study, 104 patients with muscular dystrophy developed cancer, or 73.4 per 10,000 person-years with muscular dystrophy compared to an expected rate of 36.9 per 10,000 person-years in the general Swedish and Danish populations combined (standardized incidence ratio [SIR], 2.0; 95% CI, 1.6 to 2.4).

There were significant excess risks of cancer for several organ systems:

  • endometrium (n=11; observed rate, 16.1 per 10,000 person-years; SIR, 7.6; 95% CI, 4.0 to 13.2),
  • brain (n=7; observed rate, 4.9 per 10,000 person-years; SIR, 5.3; 95% CI, 2.3 to 10.4),
  • ovary (n=7; observed rate, 10.3 per 10,000 person-years; SIR, 5.2; 95% CI, 2.3 to 10.2), and
  • colon (n=10; observed rate, 7.1 per 10,000 person-years; SIR, 2.9; 95% CI, 1.5 to 5.1).

Cancer risks were similar in women and men after excluding genital organ tumors (SIR, 1.9; 95% CI, 1.4 to 2.5 vs. SIR, 1.8; 95% CI, 1.3 to 2.5, respectively; P=0.81 for heterogeneity; observed rates, 64.5 and 47.7 per 10,000 person-years in women and men, respectively). In age-stratified analyses of patients younger than 50 years old compared to those older than that, no statistically significant difference was observed in overall cancer risk (SIR, 2.2; 95% CI, 1.4 to 3.2 vs. SIR, 1.9; 95% CI, 1.6 to 2.4, respectively; P=0.58 for heterogeneity; observed rates, 25.7 and 165.6 per 10,000 person-years in the younger and older groups, respectively).

There was a significantly higher excess risk of endometrial cancer among women younger than 50 years (n=5; observed rate, 11.1 per 10,000 person-years; SIR, 35.6; 95% CI, 13.0 to 78.9) compared to women 50 years and older (n=6; observed rate, 25.8 per 10,000 person-years; SIR, 4.6; 95% CI, 1.9 to 9.5; P=0.003 for heterogeneity).

Clinical management of myotonic muscular dystrophy patients should include routine population-based cancer screening strategies, particularly for colon cancer, and careful assessment of therapy-related risks and benefits, the authors concluded.

They wrote, "The incidence rates for a number of the excess cancers are relatively low, despite their large relative risks. Screening for these uncommon cancers should not be implemented in the absence of demonstrated clinical utility. The evaluation of persistent central nervous system and abdominopelvic symptoms or dysfunctional uterine bleeding warrants clinical consideration with a higher prior probability of neoplasm, in light of our new findings."



From the College


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ACP launches Depression Care Guide

ACP's new free Depression Care Guide is an evidence-based, online resource that provides concise, practical information and strategies to enable physicians and other health professionals to reduce the treatment gaps that exist for depression care.

The guide focuses on team-based care, evaluation, psychiatric and medical comorbidity, self-management resources, and tools to help implement depression care. Multiple-choice questions are available to help clinicians test their knowledge on the care guide and earn applicable educational credit based on practice type. Access the ACP Depression Guide online.


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College joins Choosing Wisely campaign

ACP has joined other leading professional medical organizations in the Choosing Wisely campaign, which complements the College's High-Value, Cost-Conscious Care effort (HVCCC).

HVCCC aims to help physicians provide the best possible care to their patients while simultaneously reducing unnecessary health care costs. An initiative of the ABIM Foundation, the Choosing Wisely campaign has the goal of promoting thoughtful discussions among physicians, patients, and other stakeholders about how to use health care resources to improve quality of care.

Each participating organization will identify its own list of five tests or procedures that are sometimes practiced but that research shows may not be necessary for improved care. The lists will be unveiled in April 2012. More information on the campaign is available online.



Cartoon caption contest


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Vote for your favorite entry

ACP InternistWeekly's cartoon caption contest continues. Readers can vote for their favorite caption to determine the winner.

acpi-20111220-cartoon.jpg

"Sir, it appears that you may have Bieber fever."

"Don't tell my heart, my achy breaky heart … "

"Nooobody knooows, what's troublin' my spleen … "

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service.


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MKSAP Answer and Critique



The correct answer is A) Cyanide toxicity. This item is available to MKSAP 15 subscribers as item 41 in the Pulmonology and Critical Care section. More information about MKSAP 15 is available online.

Cyanide may cause toxicity through parenteral administration, smoke inhalation, oral ingestion, or dermal absorption. Sodium nitroprusside, when used in high doses or over a period of days, can produce toxic blood concentrations of cyanide. In most patients, cyanide release from sodium nitroprusside is slow enough that the body's innate detoxification mechanisms can eliminate the cyanide before it interferes with cellular respiration. However, patients with low thiosulfate reserves (for example, malnourished or postoperative patients) are at increased risk for developing symptoms, even with therapeutic dosing.

A severe anion gap metabolic acidosis, combined with a reduced arterial-venous oxygen gradient (less than 10 mm Hg due to venous hyperoxia), suggests the diagnosis of cyanide toxicity. Apnea may result in a combined metabolic and respiratory acidosis. The treatment of cyanide poisoning is empiric because laboratory confirmation can take hours or days. Treatment includes administration of both sodium thiosulfate and hydroxocobalamin.

Hepatic encephalopathy can cause confusion, respiratory alkalosis, and mild hypoxemia. Hypoxic-ischemic encephalopathy typically follows an obvious anoxic event such as cardiac arrest or drowning. This patient has no history of such a precipitating event. Wernicke encephalopathy is defined by confusion, ataxia, and ophthalmoplegia, but the full triad of findings is frequently absent. The first symptoms of alcohol withdrawal occur within 6 hours of the last drink and include tremors, diaphoresis, anxiety, headache, and gastrointestinal upset. None of these conditions are associated with an anion gap metabolic acidosis and a reduced arterial-venous oxygen gradient and are therefore unlikely causes of the patient's findings.

Key Point

  • Sodium nitroprusside when used in high doses or over a period of days can produce toxic blood concentrations of cyanide.

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Test yourself

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