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

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In the News

for the Week of 2-1-11



Highlights

Updated recommendations issued on antiviral agents for influenza

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices released updated recommendations last week for antiviral treatment in patients with confirmed or suspected influenza. More...

Financial incentives don't improve U.K. doctors' performance for hypertension care

A pay-for-performance initiative in the United Kingdom aimed at managing hypertension had no effect on clinical outcomes, a new study has found. More...


Test Yourself

MKSAP Quiz: Low back pain

A 32-year-old man is evaluated for a 10-year history of low back pain and stiffness that are alleviated with exercise and hot showers. In addition to starting an NSAID and physical therapy, what is the most appropriate treatment for this patient? More...


Diagnostics

ACP issues best practice advice on diagnostic imaging for low back pain

Routine imaging with X-ray or advanced imaging methods such as CT scan or MRI does not improve the health of patients with low back pain, a new paper from ACP advises. More...


Medical Licensing

AMA seeks to coordinate physician re-entry programs

The American Medical Association (AMA) announced new recommendations to improve the process for physicians who want to re-enter clinical medical practice after years in academic, business or personal pursuits. More...


Cardiology

Cognitive behavioral therapy improves outcomes in CHD

Cognitive behavioral therapy reduces the risk of repeat cardiac events in patients with coronary heart disease, a new trial found. More...


From ACP Internist

The next issue is online and in the mail

The next issue of ACP Internist features stories about potential overuse of CT scans, kidney transplantation, and practice efficiency. More...


From the College

Board of Governors Chair-elect announced

The Governors' Subcommittee on Nominations is pleased to announce that Thomas G. Tape, FACP, has been elected the Chair-elect Designee for the Board of Governors. More...

Governor-elect designees announced

ACP's Governors' Subcommittee on Nominations is pleased to announce the 2016 class of Governor-elect Designees. They will officially take office as Governors-elect after the business meeting in April 2011. 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, FACP




Highlights


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Updated recommendations issued on antiviral agents for influenza

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) released updated recommendations last week for antiviral treatment in patients with confirmed or suspected influenza.

The recommendations address use of antiviral agents for influenza prevention and treatment and include the following changes from previous recommendations:

  • Early antiviral treatment is recommended for patients with suspected influenza or clinically or laboratory-confirmed influenza who have severe, complicated, or progressive illness or require hospitalization, and for outpatients with confirmed or suspected influenza at higher risk for complications because of their age or underlying medical conditions.
  • Oseltamivir and zanamivir are recommended because almost all currently circulating influenza virus strains are sensitive to them.
  • Amantadine and rimantadine should not be used because of high resistance among circulating influenza A viruses.
  • Oseltamivir may be used for treatment or chemoprophylaxis in infants younger than 1 year when indicated.
  • Antiviral treatment within 48 hours of illness onset may be considered on the basis of clinical judgment for any outpatient with confirmed or suspected influenza but no known risk factors for severe illness.
  • Clinicians should monitor their local data on antiviral resistance, since patterns can change over time.

The new recommendations, which were published Jan. 21 in the CDC's Morbidity and Mortality Weekly Report , are available online.

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Financial incentives don't improve U.K. doctors' performance for hypertension care

A pay-for-performance initiative in the United Kingdom aimed at managing hypertension had no effect on clinical outcomes, a new study has found.

Researchers performed an interrupted time series study of patients in the United Kingdom who were diagnosed with hypertension between January 2000 and August 2007. In 2004, the U.K. had implemented the Quality and Outcomes Framework, a pay-for-performance program that offered physicians financial incentives, up to 25% of their income, for achieving targets indicating high-quality care for several chronic diseases. The researchers used data from the Health Improvement Network database to examine the effects of the pay-for-performance initiative on processes and outcomes of care for hypertension.

The researchers determined change in systolic and diastolic blood pressures, blood pressure monitoring, blood pressure control, and monthly treatment intensity at baseline and 36 months after the pay-for-performance program was implemented. Other main outcome measures included cumulative incidence of major hypertension-related outcomes and all-cause mortality in newly treated patients (defined as those who began treatment six months before the pay-for-performance began) and treatment-experienced patients (defined as those who started treatment before January 2001). The study results were published online Jan. 25 by BMJ.

Overall, data on 470,725 patients were analyzed. The authors found no change attributable to pay for performance in blood pressure monitoring frequency (level change, 0.85, 95% CI, −3.04 to 4.74, P=0.669; trend change,−0.01, 95% CI, −0.24 to 0.21, P=0.615), rate of blood pressure control (level change, −1.19, 95% CI, −2.06 to 1.09, P=0.109; trend change, −0.01, 95% CI, −0.06 to 0.03, P=0.569), or treatment intensity (level change, 0.67, 95% CI, −1.27 to 2.81, P=0.412; trend change, 0.02, 95% CI, −0.23 to 0.19, P=0.706). Pay for performance did not affect cumulative incidence of myocardial infarction, stroke, renal failure, heart failure, or all-cause mortality in either treatment-experienced or newly treated patients.

The study's limitations included its limited generalizability to other countries and the lack of a comparison group. However, the authors concluded that the pay-for-performance initiative implemented throughout the United Kingdom did not seem to affect processes or outcomes of care for hypertension. Hypertension care before the initiative began was already good and improving, the authors noted, and the performance thresholds may not have been set high enough to make the incentives effective. The results suggest that policymakers may have overestimated the effect of financial incentives on doctors' performance, the authors said. They recommended that resources currently directed toward pay for performance might be better spent on alternative approaches, for example, case management or comanagement.

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Test Yourself


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MKSAP Quiz: Low back pain

A 32-year-old man is evaluated for a 10-year history of low back pain and stiffness that are alleviated with exercise and hot showers. He does not have a history of skin, eye, or bowel disease. He has not had previous infections of the gastrointestinal or genitourinary systems.

mksap.jpg

On physical examination, vital signs are normal. The sacroiliac joints and lumbar spine are tender to palpation. There is complete loss of forward flexion in the lower spine. When standing upright against a wall, he is unable to touch the occiput to the wall.

Radiographs of the spine reveal complete fusion of the sacroiliac joints bilaterally and squaring of the vertebral bodies throughout the lumbar and thoracic spine.

In addition to starting an NSAID and physical therapy, which of the following is the most appropriate treatment for this patient?

A) Etanercept
B) Low-dose prednisone
C) Methotrexate
D) Sulfasalazine

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

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Diagnostics


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ACP issues best practice advice on diagnostic imaging for low back pain

Routine imaging with X-ray or advanced imaging methods such as CT scan or MRI does not improve the health of patients with low back pain, a new paper from ACP advises.

The College has released new best practice advice for diagnostic imaging for patients with low back pain in the paper "Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care" published in the Feb. 1 Annals of Internal Medicine.

ACP recommends that routine or advanced imaging studies should only be performed on higher-risk patients who have severe progressive neurologic deficits or signs or symptoms suggesting a serious or underlying medical condition. Decisions regarding repeat imaging for patients should be based on the development of new symptoms or changes in current symptoms.

Physicians should stop ordering imaging tests in patients with nonspecific low back pain as unnecessary imaging can lead to a series of additional unnecessary tests, follow-ups, and referrals, as well as invasive procedures that can be of limited or no benefit and may even be harmful.

Implementing these new recommendations will help physicians provide better care to patients with low back pain, reduce costs, improve outcomes, and limit patients' exposure to harm, the paper said.

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Medical Licensing


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AMA seeks to coordinate physician re-entry programs

The American Medical Association (AMA) announced new recommendations to improve the process for physicians who want to re-enter clinical medical practice after years in academic, business or personal pursuits.

Currently, every state has different re-entry requirements, and other barriers include high costs, limited information and resources, and a lack of standardized curricula and accreditation. The AMA issued 16 recommendations in five broad areas, including homogenizing regulatory policies across state medical boards, increasing the consistency of and possibly accrediting physician re-entry programs, studying the performance of re-entering physicians, funding the system and ensuring collaboration among all stakeholders.

The AMA's new recommendations are meant to help state medical licensing boards, the Federation of State Medical Boards, state and specialty societies and medical education programs develop and implement re-entry programs. National re-entry policy guidelines must be developed that are consistent and evidence-based, the AMA said in a press release. They should specify the length of time away from practice that necessitates participation in a re-entry process and how much clinical care constitutes active practice.

About 10,000 physicians could re-enter clinical practice in the U.S. each year, said AMA President Cecil B. Wilson, MACP. "Easing the re-entry process can help increase the physician workforce and improve access to care for patients. These new recommendations are aimed at helping ease a range of challenges physicians can face as they pursue re-entry," he said.

ACP Internist profiles physicians who have re-entered clinical practice, as well as the programs that certify physicians for practice after years of being away from clinical duties, in its February issue.

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Cardiology


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Cognitive behavioral therapy improves outcomes in CHD

Cognitive behavioral therapy (CBT) reduces the risk of repeat cardiac events in patients with coronary heart disease, a new trial found.

The Swedish study randomized 362 patients who had been hospitalized for a coronary heart disease event to usual care or usual care plus group CBT focused on stress. The CBT group met for 20 two-hour sessions during a year, after which the patients were followed for a mean of 94 months. Attendance at the CBT session varied, with a median rate of 85%. The study appears in the Jan. 24 Archives of Internal Medicine.

After adjustment for variables including traditional risk factors, patients in the CBT group were 41% less likely to have a recurrent cardiovascular disease event (hazard ratio, 0.59; 95% CI, 0.42 to 0.83; P=0.002) and 45% less likely to have a recurrent acute myocardial infarction (HR, 0.55; 95% CI, 0.36 to 0.85; P=0.007) than those receiving usual care. The therapy group also had a 28% lower risk of all-cause mortality, although this difference was not statistically significant.

There was also a strong dose-response effect between therapy group attendance and cardiovascular events. The proportion of patients having a first recurrent event increased almost linearly, from 53% among patients who attended all sessions to 73% in patients who attended marginally. Benefits of the therapy were similar in men and women. The number of patients needed to treat was 9 for any cardiovascular event and 10 for myocardial infarction.

The study authors concluded that CBT could be an effective addition to secondary preventive programs after myocardial infarction. One possible mechanism for the effect is decreased behavioral and emotional reactivity, leading to less psychophysiologic burden on the cardiovascular system, the authors speculated. Based on the findings of this and other studies, they suggested that interventions be at least 6 to 12 months long, be conducted in groups, and include specific techniques for altering behavior.

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From ACP Internist


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The next issue is online and in the mail

The next issue of ACP Internist features stories about:

ct_sm.jpg

How many are too many for CT scans? As many as one-third of the 70 million imaging tests ordered during the year may not be needed. Experts attempt to determine whether repeated radiation scanning doses could prove potentially yet unintentionally harmful.

Lack of kidneys for transplants raises debates. A shortage of transplantable organs has led to previously unthought-of issues that entangle ethics, policy, costs and clinical complications. Internists now must consider transplant tourists, long waits and "donation chains" as factors in their patient counseling.

Cut costs without cutting corners to keep the office efficient. Today's health care environment demands that physicians wring every last drop of efficiency from their practices. Here are five easy ways to accomplish that.

These stories and the MKSAP Quiz are online.

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From the College


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Board of Governors Chair-elect announced

The Governors' Subcommittee on Nominations is pleased to announce that Thomas G. Tape, FACP, has been elected the Chair-elect Designee for the Board of Governors. He will officially take office as Chair-elect in April 2011. Dr. Tape will become Chair at the close of the Annual Business Meeting in April 2012 and serve in that capacity for one year.

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Governor-elect designees announced

ACP's Governors' Subcommittee on Nominations is pleased to announce the 2016 class of Governor-elect Designees. They will officially take office as Governors-elect after the College's business meeting in April 2011. The list is available online.

Top




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.

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 A) Etanercept. This item is available to MKSAP 15 subscribers as item 71 in the Rheumatology section.

This patient most likely has ankylosing spondylitis, and the most appropriate treatment is therapy with an anti–tumor necrosis factor-α agent such as etanercept. This condition usually affects patients in the teenage years or 20s and manifests as chronic low back pain and stiffness that are alleviated with exercise.

This patient's clinical presentation is consistent with severe ankylosing spondylitis. As this condition progresses, spinal fusion and a resulting loss of spinal mobility may occur. An inability to touch a wall with the occiput when standing upright against the wall indicates a flexion deformity, and the distance between the wall and the occiput helps to measure the level of a patient's deformity. Radiographs of the spine in patients whose disease has progressed for several years typically reveal fusion of the sacroiliac joints as well as squaring of the vertebral bodies, which is caused by erosion of the corners of the vertebral bodies due to inflammation of the ligamentous attachments.

Conventional therapies such as NSAIDs are useful in relieving symptoms and in helping to maintain function in patients with ankylosing spondylitis but do not prevent progressive joint damage, bony ankylosis, physical deformity, or disability in patients with severe disease. Most patients treated with NSAIDs show significant relief of back pain within 48 hours of therapy with an optimal anti-inflammatory dose of NSAIDs and a prompt return of symptoms (within 48 hours) after discontinuation of the drug. Physical therapy and a regular exercise program have been shown to provide symptomatic relief, improve function, and increase the likelihood of a more functional posture as spinal fusion progresses. This intervention is therefore recommended in all patients with ankylosing spondylitis.

Until the advent of tumor necrosis factor-α inhibitors, no therapy had been shown to significantly and potentially affect progressive spinal fusion in patients with ankylosing spondylitis. Use of these agents usually is associated with a degree of symptomatic relief and improvement in inflammatory changes visible on MRI. To date, however, these agents have not been shown to impact progressive spinal changes.

Many of the agents used in rheumatoid arthritis, including methotrexate, sulfasalazine, and low-dose prednisone, are beneficial in the treatment of peripheral inflammatory arthritis associated with ankylosing spondylitis. However, these agents do not significantly affect spinal involvement in the spondyloarthropathies.

Key Point

  • Tumor necrosis factor-α inhibitors are indicated as first-line therapy for ankylosing spondylitis and usually are associated with a degree of symptomatic relief and improvement in inflammatory changes visible on MRI.

Click here to return to the rest of ACP InternistWeekly.

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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.

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Copyright 2011 by the American College of Physicians.

Test yourself

A 69-year-old woman is evaluated for a lump under her arm found on self-examination. She is otherwise healthy and has no other symptoms. Medical and family histories are unremarkable, and she takes no medications. A needle aspirate of the right axillary mass reveals adenocarcinoma. Bilateral mammography and breast MRI are normal. CT scan of the chest, abdomen, and pelvis demonstrates the enlarged axillary lymph node and no other abnormalities. What is the most appropriate initial treatment?

Find the answer

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