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

Advertisement

ACP InternistWeekly



In the News for the Week of 12-6-11




Highlights

Self-testing, self-dosage for anticoagulation safe, suitable option for some patients, study indicates

Self-testing and self-dosage of oral anticoagulation may be safe and suitable for patients of all ages with suitable health care support as backup, according to a meta-analysis. More...

Osteoporosis screening strategies shown to be generally equal, effective

Several strategies to screen postmenopausal women for osteoporosis are about equally effective, and screening from ages 55 to 80 years was cost-effective, concluded the authors of a modeling study. More...


Test yourself

MKSAP Quiz: 3-month history of cervical lymphadenopathy

This week's quiz asks readers to evaluate a 42-year-old woman with progressive cervical lymphadenopathy, fatigue, night sweats, bilateral lower-extremity and abdominal wall edema, and weight gain. More...


Heart failure

Rule appears to improves diagnostic accuracy for new heart failure

Researchers developed a new rule for diagnosing heart failure, based on a study of primary care patients suspected of having the disease. More...


Gastroenterology

Antibiotics reduced dyspepsia symptoms for some primary care patients

Antibiotic treatment of Helicobacter pylori reduced symptoms of functional dyspepsia for some primary care patients, a new study found. More...


Medication safety

Two-thirds of adverse drug event hospitalizations in elderly linked to four drugs

Just four drugs were involved in more than two-thirds of the hospitalizations of older patients for adverse drug events from 2007 through 2009, a new analysis found. More...


CMS update

Medicare adds coverage for obesity screening

Last week CMS announced the addition of obesity screening to Medicare coverage for preventive services. More...

Medicare extends re-validation period

Medicare recently announced an extension of the deadline for physicians to re-submit their enrollment information by two years, to March 2015. More...

FAQs available for Primary Care Incentive Payment program

CMS has developed a new page of frequently asked questions about the new Primary Care Incentive Payment program (PCIP). More...


From the College

New guidance from ACP on eRx in 2012

New information about the Medicare Electronic Prescribing Incentive Program for 2012 is now available on the Running a Practice section of the College website. More...

College Fellow named Surgeon General of the Navy

Matthew L. Nathan, MC, USN, FACP, has been named the next Surgeon General of the Navy. More...

Fred Ralston Jr., MACP, blogs at KevinMD.com

Fred Ralston Jr., MD, MACP, ACP's immediate past president and a practicing internist in Fayetteville, Tenn., discusses challenges facing smaller practices at KevinMD.com. 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


.
Self-testing, self-dosage for anticoagulation safe, suitable option for some patients, study indicates

Self-testing and self-dosage of oral anticoagulation may be safe and suitable for patients of all ages with suitable health care support as backup, according to a meta-analysis.

Researchers searched the peer-reviewed literature for randomized trials that compared the effects of self-testing and/or self-dosage with control and dosage by physician or anticoagulation management clinic. Researchers included studies of adults on anticoagulant therapy for any indication, and then asked for individual patient data from all chosen trials. Primary outcomes were time to death, first major hemorrhage and first thromboembolic event.

Eleven trials contained data for 6,417 participants and 12,800 person-years of follow-up. Slightly more than half of participants had been randomly allocated to self-monitoring. Participants in the intervention groups were on average 1.7 years younger than those in the control groups (64.2 years vs. 65.9 years; P<0.0001). Ages ranged from 17 to 94 years, with 99 participants age 85 years or older. More than a third of participants had a mechanical heart valve insertion and more than half had atrial fibrillation. Results appeared online Dec. 1 at The Lancet.

A significant reduction in thromboembolic events was seen in the self-monitoring group (hazard ratio [HR], 0.51; 95% CI, 0.31 to 0.85; P=0.010). At one year, the number needed to treat to prevent one thromboembolic event was 78 (95% CI, 55 to 253), and by five years it was 27 (95% CI, 19 to 87). No significant changes in major hemorrhagic events (HR, 0.88; 95% CI, 0.74 to 1.06; P=0.18) or in deaths (0.82, 0.62 to 1.09; P=0.18) were apparent with self-monitoring.

Participants with a mechanical heart valve who self-monitored had significant reductions in thromboembolic events. At one year the number needed to treat to prevent one event was 55 (95% CI, 41 to 116), and by five years it was 24 (95% CI, 18 to 50). A significant reduction was seen in men but not in women, although the number of women was small (n=447) and this interaction was not significant (P=0.15). Men with a mechanical valve who were self-monitoring also had significantly fewer major hemorrhagic events, whereas women did not. However, the interaction test was not significant (P=0.25). Effects for atrial fibrillation and other indications were not significant.

Participants younger than 55 years of age who self-monitored had a striking reduction in thromboembolic events, the authors noted, while nonsignificant effects were shown in other age groups. In participants younger than 55 years, the number needed to treat was 21 (95% CI, 17 to 42) to prevent one thromboembolic event at one year. In the 99 patients older than 85 years, the analysis found no significant adverse effects of self-monitoring for all outcomes, and there was a reduction in mortality (HR, 0.44; 95% CI, 0.20 to 0.98; P=0.044). Little difference was seen between anticoagulation clinic care versus primary care for thromboembolic events, major hemorrhage, and mortality.

Mean time in therapeutic range tended to be better in the self-monitoring groups, the authors noted. Even when the time in therapeutic range showed worse control, the standard deviations were less, which suggests more stable control of oral anticoagulation. However, they cautioned, a full analysis was not part of the study design.

"Patients who self-tested and adjusted their doses had significantly lower rates of thromboembolic events, which suggests that patients should be given the opportunity, and provided with training, to undertake self-management," the authors concluded. "However, self-management does not mean that patients are left to fend for themselves: for instance, in one trial participants had 24 h back-up available, and good quality control measures are needed."

An editorial commented that the role of self-management itself will change in the advent of dabigatran and rivaroxaban, which do not require monitoring.

"... [S]elf-management (rather than self-testing) of treatment with vitamin K antagonists should be offered to patients with mechanical heart valves, especially those younger than 55 years. However, we do not see a place for self-monitoring in other areas of this treatment except for individual patients for whom access to routine usual anticoagulation care is restricted," the editorialists wrote.

Top


.
Osteoporosis screening strategies shown to be generally equal, effective

Several strategies to screen postmenopausal women for osteoporosis are about equally effective, and screening from ages 55 to 80 years was cost-effective, concluded the authors of a modeling study.

Although the "best" strategy was screening with dual-energy X-ray absorptiometry (DXA), treating if the T-score was −2.5 or less, and rescreening every five years, other strategies were just as effective for those who could not travel or did not have access to DXA, the authors concluded.

annals.jpg

The model compared the cost-effectiveness of nine osteoporosis screening strategies, including universal screening and treatment for those with osteoporosis according to bone mineral density (BMD) criteria, for postmenopausal women. The model began screening in five-year intervals from ages 55 to 80 years. Results appeared in the Dec. 6 Annals of Internal Medicine.

The model estimated quality-adjusted life-years (QALY), costs in 2010 U.S. dollars, and incremental cost-effectiveness ratios (ICERs) for the screening strategies. The ICERs represent cost per QALY gained for a particular strategy compared to another strategy. The model allowed direct comparison of multiple screening tests and sequences of tests, screening initiation ages, treatment thresholds and repeat screening intervals.

All of the most effective strategies involved screening starting at age 55, the authors said. Screening continued to be effective and cost-effective up to 80 years of age, and in general, quality-adjusted life-days gained with screening tended to increase with older age. In addition, strategies involving screening with DXA, rather than calcaneal quantitative ultrasonography (QUS) or Simple Calculated Osteoporosis Risk Estimation (SCORE) prescreening, were most effective, although the differences between strategies were on the order of quality-adjusted life-days.

The best strategy with an ICER less than $50,000 per QALY was initiating screening at 55 years of age using DXA, treating if the T-score was −2.5 or less, and rescreening every five years. If the model assumed a willingness to pay of $100,000 per QALY, screening at age 55 years with DXA, initiating treatment at a T-score of −2.0 or less, and rescreening every 10 years was the best strategy.

The most effective strategy across the starting ages was screening with DXA at age 55 years, treating at a T-score of −1.5 or less, and rescreening every five years. However, this strategy was very expensive, with an ICER of nearly $700,000 per QALY.

Several strategies involving SCORE prescreening or QUS prescreening were more cost-effective than strategies involving screening initiation with DXA, with ICERs less than $30,000 per QALY.

The authors noted that results do not indicate clear superiority of a repeated screening interval of five years versus every 10 years. Instead, it's likely that the best repeated screening interval may vary according to previous DXA T-scores.

"For women with limited access to DXA or those who prefer not to travel for DXA screening if possible, our findings show that the SCORE tool and QUS for prescreening are reasonable alternatives," the authors wrote. "Because other studies have shown the Osteoporosis Self-Assessment Tool and Osteoporosis Risk Assessment Instrument to perform similarly to the SCORE tool, we expect that these too may be acceptable alternatives."

An editorial commented that the analysis showed that DXA is cost-effective for women aged 55 to 64 years who have an average risk for fracture and a likelihood of having osteoporosis by BMD criteria. It also confirmed that other bone densitometry technologies, such as peripheral ultrasonography, are reasonable when central DXA is not available.

However, it is too soon to conclude that universal bone densitometry for all white women aged 55 to 64 years is cost-effective, the editorial stated. The model significantly overestimated rates of hip fracture for women aged 55 to 64 years and wrist fracture, according to the authors.

Instead, the editorial concluded, "We suspect that the 'truth' may lie somewhere between the base-case analyses and these sensitivity analyses. Additional studies with well-calibrated models examining the cost-effectiveness of universal bone densitometry for women aged 55 to 64 years compared with bone densitometry only for subsets with a higher pretest probability of osteoporosis selected with a prescreening measure are still needed."

Top




Test yourself


.
MKSAP Quiz: 3-month history of cervical lymphadenopathy

A 42-year-old woman is evaluated for a 3-month history of progressive cervical lymphadenopathy, fatigue, night sweats, bilateral lower-extremity and abdominal wall edema, and a 4.5-kg (10.0-lb) weight gain. History is significant for three episodes of weight gain and facial and lower-extremity edema lasting 4 weeks in her 20s and 30s. Her only current medication is a multivitamin.

mksap.jpg

After an evaluation and lymph node biopsy, she is diagnosed with stage IIIB Hodgkin lymphoma.

Laboratory studies:

Serum creatinine 1.3 mg/dL (114.9 µmol/L)
Urinalysis 2+ blood; 4+ protein; dysmorphic erythrocytes and occasional granular casts
Urine protein-creatinine ratio 9.25 mg/mg

On kidney ultrasound, the kidneys are 13.5 cm bilaterally and edematous. The corticomedullary junction is apparent, and there is no hydronephrosis.

Which of the following is the most likely cause of this patient's nephrotic syndrome?

A) Focal segmental glomerulosclerosis
B) IgA nephropathy
C) Membranous glomerular nephropathy
D) Minimal change disease

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

Top


.


Heart failure


.
Rule appears to improves diagnostic accuracy for new heart failure

Researchers developed a new rule for diagnosing heart failure, based on a study of primary care patients suspected of having the disease.

The cross-sectional study, which was published online Nov. 21 by Circulation, included 721 consecutive Dutch patients with suspected new-onset heart failure. All of the patients underwent a standardized diagnostic workup including a typical history and physical as well as chest X-ray, spirometry, electrocardiogram (ECG), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurement. Diagnosis of heart failure was confirmed by six-month follow-up data. Overall, 28.7% of the patients were determined to have heart failure.

The researchers found that heart failure could best be predicted using three items from the patient's history (age, coronary artery disease and loop diuretic use) plus six from the physical examination (pulse rate and regularity, displaced apex beat, rales, heart murmur and increased jugular vein pressure). Together, these factors had a c-statistic of 0.83 for predicting heart failure. Of the supplemental tests performed, NT-proBNP was found to be the most useful. It increased the c-statistic to 0.86 and resulted in a net reclassification improvement of 69% (P<0.0001). After developing a diagnostic rule based on these factors, the researchers validated it with two other datasets, which confirmed the rule's accuracy.

Application of the rule does still leave many patients (54.4% in the studied population) in an intermediate category of diagnostic uncertainty, but researchers believe the rule could be useful in quantifying the probability of heart failure in patients with suggestive symptoms. They noted that the results reinforce the importance of the history and physical and highlight the power of a relatively convenient test, the NT-proBNP. If the NT-proBNP is not available, however, the assessment of alternate diagnostic rules showed that ECG or chest X-ray could also be useful, the authors said.

Top




Gastroenterology


.
Antibiotics reduced dyspepsia symptoms for some primary care patients

Antibiotic treatment of Helicobacter pylori reduced symptoms of functional dyspepsia for some primary care patients, a new study found.

The trial randomized about 400 Brazilian patients with functional dyspepsia who had tested positive for H. pylori to treatment with either placebo or amoxicillin trihydrate and clarithromycin for 10 days. All patients also received omeprazole. Endoscopy and H. pylori testing were performed at the start and after 12 months. The primary outcome was at least 50% symptomatic improvement at 12 months as assessed by a disease-specific questionnaire. The results appeared in the Nov. 28 Archives of Internal Medicine.

At one year, the primary outcome was achieved in 49% of the antibiotics group compared to 36.5% of the control group (P=0.01). The patients in the antibiotic group were also more likely to report improvement in their global assessment of symptoms (78.1% vs. 67.5%; P=0.02). Their mean scores on the Medical Outcomes Study 36-Item Short Form Health Survey also increased more than controls' did (4.15 vs. 2.2; P=0.02).

This study may be the largest trial to date of H. pylori eradication as treatment for functional dyspepsia, the study authors said. Although the benefit to patients was relatively small, it is comparable to that shown by long-standing proton-pump inhibition, they noted. Antibiotic treatment also holds the advantage of being short term, and therefore potentially very cost-effective. The authors calculated a number needed to treat of 8.

The findings of this study are consistent with the results of a previous Cochrane review, according to an invited commentary published with the study. However, researchers have not uncovered the mechanism by which the antibiotics were successful in reducing dyspepsia, the commentary author noted. It's possible that the drugs work by treating a chronic inflammation in the patients' gastric mucosa, one that could be caused by organisms other than H. pylori, the author speculated. To study this theory, future trials could also try the antibiotic therapy in patients negative for H pylori.

Top




Medication safety


.
Two-thirds of adverse drug event hospitalizations in elderly linked to four drugs

Just four drugs were involved in more than two-thirds of the hospitalizations of older patients for adverse drug events from 2007 through 2009, a new analysis found.

Researchers used 2007-2009 data from the 58 hospitals that participate in the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance (NEISS-CADES) project to estimate the frequency and rate of emergency hospitalizations of adults aged 65 years and older. They also looked at the roles of specific medications in the hospitalizations, such as drugs designated as high-risk in the elderly by the 2011 Healthcare Effectiveness Data and Information Set (HEDIS) or as "potentially inappropriate" for use in older adults by the updated Beers criteria. Included cases involved hospitalizations for conditions that a clinician expressly attributed to use of a drug, or to a drug-specific adverse effect. Prescription and over-the-counter drugs, vaccines and dietary supplements were included in the analysis. Results were published in the Nov. 24 New England Journal of Medicine.

On the basis of 5,077 cases in the researchers' sample, they estimated that 99,628 elderly patients had emergency hospitalizations for adverse drug events. Four medications, taken alone or in combination, were linked to 67% of the cases: warfarin (33.3%), insulin (13.9%), oral antiplatelets (13.3%) and oral hypoglycemics (10.7%). Most hospitalizations involving warfarin (95.1%), insulin (99.4%) or oral hypoglycemics (99.1%) came from unintentional overdoses. Of hospitalizations attributed to warfarin, a second medication was implicated in 12.5% of visits, most commonly an antiplatelet (6.7%); of hospitalizations attributed to insulin, another medication was implicated in 15.4% of visits, most commonly an oral hypoglycemic (10.1%).

Medications dubbed high-risk by HEDIS were involved in just 1.2% of hospitalizations, while those dubbed potentially inappropriate by Beers criteria were involved in 6.6%. Forty-eight percent of adverse events involved patients aged 80 years or older, and the hospitalization rate was 3.5 times higher for adults 85 years or older versus those 65 to 69 years. Sixty-six percent of the hospitalizations were due to unintentional overdoses.

The analysis probably underestimated the number of emergency hospitalizations, the authors said, because NEISS-CADES data rely on emergency doctors' identification and documentation of adverse drug events, thus events confirmed during hospitalization or by patient interviews aren't likely to be captured. Overall, efforts to improve medication safety in older adults should focus on areas likely to yield the largest, and most measurable and clinically significant effects, such as management of antithrombotics and diabetes drugs, they said.

Top




CMS update


.
Medicare adds coverage for obesity screening

Last week CMS announced the addition of obesity screening to Medicare coverage for preventive services.

A beneficiary who screens positive for obesity based on BMI would be eligible for one face-to-face counseling visit every week for a month, then one face-to-fact visit every other week for the next five months, and then, depending on weight loss, a monthly visit for six additional months.

Additional information about how CMS came to this decision is available on the agency's website.

Top


.
Medicare extends re-validation period

Medicare recently announced an extension of the deadline for physicians to re-submit their enrollment information by two years, to March 2015.

Under a provision of the Affordable Care Act, physicians who enrolled in Medicare prior to March 25, 2011 are required to re-submit their enrollment information so that they can be re-validated under a new risk screening criteria. Physicians will receive a notice from their MAC letting them know that it is time to re-enroll, sometime between now and March 2015. Additional information is available from CMS.

Top


.
FAQs available for Primary Care Incentive Payment program

CMS has developed a new page of frequently asked questions about the new Primary Care Incentive Payment program (PCIP).

The page includes information on eligibility criteria and remittance notices. Additional information about the program is also available from the College on the Running a Practice section of the ACP website.

Top




From the College


.
New guidance from ACP on eRx in 2012

New information about the Medicare Electronic Prescribing Incentive Program for 2012 is now available on the Running a Practice section of the College website.

The incentive for e-prescribing will remain at 1% for 2012, with penalties beginning on 2012 claims for those who did not successfully e-prescribe or meet a hardship exemption. Physicians and other providers who do not become successful e-prescribers in 2012 will be subject to increasing penalties on their Medicare payments. Other changes to the program in the coming year include changing the definition of a group practice to require at least 25 participants, and expanding the list of qualifying systems to include ONC-certified EHR technology.

A complete summary of the program is online.

Top


.
College Fellow named Surgeon General of the Navy

Matthew L. Nathan, MC, USN, FACP, has been named the next Surgeon General of the Navy.

The Senate confirmed Dr. Nathan's appointment in mid-November, and the change-of-office ceremony took place on Nov. 18. Dr. Nathan, who was promoted to Vice Admiral, previously served as the Ninth Chief of the Navy Medical Corps and has also served as commander of the Walter Reed National Military Medical Center and Navy Medicine, National Capital Area. Dr. Nathan graduated from The Medical College of Georgia in 1981 and is a clinical professor of medicine at the Uniformed Services in Bethesda, Md. He has also received the American Hospital Association Excellence in Leadership award for the Federal Sector.

More information on Dr. Nathan's appointment is available online.

Top


.
Fred Ralston Jr., MACP, blogs at KevinMD.com

Fred Ralston Jr., MD, MACP, ACP's immediate past president and a practicing internist in Fayetteville, Tenn., continues his monthly column at KevinMD.com, one of the Web's leading destinations for provocative physician commentary. This month's post discusses some challenges facing smaller practices.

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-20111206-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 D) Minimal change disease. This item is available to MKSAP 15 subscribers as item 15 in the Nephrology section. More information about MKSAP 15 is available online.

This patient has minimal change disease secondary to Hodgkin lymphoma. Minimal change disease is a relapsing-remitting condition that may occur secondary to NSAID or lithium use, mononucleosis, or malignancy and may be the presenting symptom of Hodgkin lymphoma. Minimal change disease is characterized by sudden, massive proteinuria associated with a urine protein-creatinine ratio that may exceed 9 mg/mg. This condition also may cause mildly elevated blood pressure, hypoalbuminemia, and anasarca.

Proteinuria that develops after remission of Hodgkin lymphoma often indicates disease relapse. Therefore, close monitoring of the protein-creatinine ratio is indicated once remission is achieved to evaluate whether additional therapy is needed after chemotherapy and radiation therapy are completed.

In patients with solid tumors, the nephrotic syndrome is usually associated with membranous glomerular nephropathy; however, minimal change disease predominates in those with hematologic malignancies, particularly Hodgkin lymphoma.

Focal segmental glomerulosclerosis is the least frequently reported cause of the nephrotic syndrome in patients with hematologic malignancies and most often develops after transplantation or intense chemotherapy.

IgA nephropathy is not commonly associated with lymphoma or myeloproliferative disorders.

Key Point

  • Minimal change disease may be the presenting symptom of Hodgkin lymphoma and is characterized by sudden, massive proteinuria.

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 38-year-old man is evaluated for a mass in his right neck that he first noticed 2 weeks ago while shaving. The patient also reports experiencing a pressure sensation when swallowing solid foods for the past year and daily diarrhea for the past 2 months. His personal medical history is unremarkable. His younger brother has nephrolithiasis, and his father died of a hypertensive crisis and cardiac arrest at age 62 years while undergoing anesthesia induction to repair a hip fracture. Following a physical exam, lab studies, and a chest radiograph, what is the most likely diagnosis?

Find the answer

MKSAP 16 Holiday Special: Save 10%

MKSAP 16 Holiday Special:  Save 10%

Use MKSAP 16 to earn MOC points, prepare for ABIM exams and assess your clinical knowledge. For a limited time save 10% when you use priority code MKPROMO! Order now.

Maintenance of Certification:

What if I Still Don't Know Where to Start?

Maintenance of Certification: What if I Still Don't Know Where to Start?

Because the rules are complex and may apply differently depending on when you last certified, ACP has developed a MOC Navigator. This FREE tool can help you understand the impact of MOC, review requirements, guide you in selecting ways to meet the requirements, show you how to enroll, and more. Start navigating now.