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


In the News
for the Week of 2-8-11


  • Despite clear guidelines, rheumatoid arthritis prescriptions vary among Medicare managed care plans
  • New BPH guidelines address new drugs, watchful waiting, and when to try surgery

Test yourself

  • MKSAP Quiz: fatigue and exertional dyspnea


  • Breast cancer risk higher with hormone therapy started close to menopause, study indicates
  • Bevacizumab tied to higher rate of fatal adverse events
  • ASCO statement: Advanced cancer care should be tailored to patient preferences


  • Prognostic scores don't reliably predict early recurrence after minor stroke

From the College

  • ACP delivers State of the Nation’s Health Care report

Cartoon caption contest

Physician editor: Darren Taichman, FACP


Despite clear guidelines, rheumatoid arthritis prescriptions vary among Medicare managed care plans

More than one-third of Medicare managed care enrollees seen for rheumatoid arthritis did not receive recommended treatment with disease-modifying antirheumatic drugs (DMARDs), a study found. Variations by as much as 70% exist among health plans, with age, sex, race, income and geography also influencing DMARD receipt.

The Healthcare Effectiveness Data and Information Set (HEDIS) introduced quality measures on DMARDs in 2005. In a study in the Feb. 2 Journal of the American Medical Association, researchers analyzed HEDIS data for 93,143 patients 65 years or older with at least two diagnoses of rheumatoid arthritis within a year, from 2005 to 2008. "Two diagnoses" were defined as "at least 2 face-to-face physician encounters with different dates of service in an ambulatory or nonacute patient setting during the measurement year with any diagnosis of [rheumatoid arthritis]," as determined by ICD-9 codes. The average age of patients was 74 years; 75% were women and 82% were white.

Overall performance on the HEDIS measure for rheumatoid arthritis in the study sample was 63%. In 2005, 59% of the sample received a DMARD, increasing to 67% in 2008. The largest difference in performance on the HEDIS rheumatoid arthritis measure was based on age. Participants 85 years and older were 30% less likely to receive DMARDs compared with patients 65 to 69 years old. The difference may be due to age bias, increased prevalence of comorbidities that may represent contraindications to DMARD use, patient preferences against DMARD receipt, or a milder or different clinical course among older patients, researchers speculated.

Other patients less likely to receive a DMARD included men, individuals identified by race as black or other, individuals with low personal income, residents of lower socioeconomic status ZIP codes, and individuals in the Middle and South Atlantic regions. Also, patients living in a health professional shortage area had a 3% lower rate.

In addition, patients enrolled in a for-profit health plan had a 4% lower rate of DMARD receipt compared with patients enrolled in a not-for-profit health plan, the authors wrote. Performance varied among health plans from 16% to 87%. Possible explanations for these differences include availability or accessibility of specialty care or differences in the ability of the health plan to appropriately identify patients in the numerator and denominator for the measure.

“Given the enormous individual and societal costs associated with rheumatoid arthritis, and increasing substantial evidence that DMARDs can reduce these costs, variations in DMARD receipt based on demographics, socioeconomic status, and geography are unacceptable," the authors concluded. "Because optimizing DMARD use is the primary mechanism for decreasing the significant public health impact of rheumatoid arthritis in the United States, targeting educational and quality improvement interventions to patients who are underusing DMARDs and their clinicians will be important to eliminate these disparities."


New BPH guidelines address new drugs, watchful waiting, and when to try surgery

An updated clinical guideline on treatment of benign prostatic hyperplasia (BPH) from the American Urological Association (AUA) includes a detailed diagnostic algorithm to guide physicians in diagnosing and treating lower urinary tract symptoms (LUTS) secondary to BPH, as well as in-depth information on management of basic and complicated cases.

The full guideline, which updates the association's 2003 version, is online. The 2010 edition adds recommendations for the use of anti-cholinergic drugs and laser therapies. Additionally, the index patient age has been lowered to 45 years from 50 years, to better guide physicians in treating younger men who may be experiencing lower urinary symptoms.

Clinicians should not underestimate the effects of LUTS on patients' quality of life, according to the new guidelines. Traditionally, the primary goal has been to relieve bothersome LUTS. More recently, treatment has focused on changing disease progression and preventing complications. A variety of drug classes can be used, including alpha-adrenergic antagonists, 5-alpha-reductase inhibitors, anticholinergics and phytotherapeutics.

Physicians treating men with suspected cases of LUTS should obtain a relevant medical history, assess symptoms using the AUA Symptom Index and conduct a full physical examination, including a digital rectal exam. Laboratory tests should include a prostate-specific antigen test and a urinalysis to exclude infection or other causes for LUTS. Frequency and volume charts may also be useful in providing a diagnosis.

Patients with mild symptoms of LUTS secondary to BPH (AUA-SI score <8) and patients with moderate or severe symptoms (AUA-SI score ≥8) who are not bothered by their symptoms should be managed using a strategy of watchful waiting. It is also an appropriate option for men with moderate to severe symptoms who have not yet developed complications of LUTS and bladder output obstruction, such as renal insufficiency, urinary retention or recurrent infection. The guidelines also address at what stage to consider surgical options, as well as several new modalities.

Physicians should question patients about any planned cataract surgery prior to starting an alpha-blocker regimen, as men planning cataract surgery should avoid these drugs until after surgery has been completed. The risk of intraoperative floppy iris syndrome was substantial among men taking tamsulosin, ranging from about 43% to 90% in 10 retrospective and prospective studies. Men already taking the drugs should inform their ophthalmologists of their alpha-blocker regimen prior to surgery, the guidelines said.


Test yourself

MKSAP Quiz: fatigue and exertional dyspnea

A 31-year-old woman is evaluated for fatigue and exertional dyspnea. She reports no chest pain, palpitations, or syncope. She has no symptoms of collagen vascular disease. She has had no recent fevers, sick contacts, or weight gain. She smokes one pack of cigarettes per day and denies illicit drug use. Her family history is significant for a mother with mitral valve prolapse. She is on no medications and has never taken oral contraceptives.

On physical examination, temperature is normal, blood pressure is 122/60 mm Hg, and pulse is 80/min. BMI is 23. Cardiac examination reveals a point of maximal impulse that is undisplaced. A grade 2/6 lower left parasternal systolic murmur is heard that increases with inspiration but does not radiate. There are prominent jugular venous pulsations. There is 1+ pedal edema.

Leukocyte count is normal. An electrocardiogram shows evidence of right ventricular hypertrophy. A chest radiograph shows enlarged pulmonary arteries, right atrium, and right ventricle. A transthoracic echocardiogram demonstrates normal left ventricular size and function. The right ventricle is moderately enlarged. Aortic and mitral valve function are normal. There is moderate tricuspid regurgitation. No evidence of an interatrial shunt is seen by color Doppler imaging or following agitated saline contrast. Pulmonary pressure estimates are 60 to 65 mm Hg.

Which of the following is an appropriate next diagnostic test?

A) Cardiac magnetic resonance imaging
B) Stress echocardiogram
C) Transesophageal echocardiogram
D) Ventilation-perfusion lung scan

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



Breast cancer risk higher with hormone therapy started close to menopause, study indicates

Women who begin taking hormone therapy near menopause have a higher risk for breast cancer than those who start taking it later, a new study reports.

Researchers looked at the U.K. Million Women Study to examine whether the timing of hormone therapy initiation affected breast cancer risk. Data on 1,129,025 postmenopausal women with 4.05 million woman-years of follow-up were included. The study results were published early online Jan. 28 by the Journal of the National Cancer Institute and will appear in the Feb. 16 print issue.

A total of 15,759 cases of incident breast cancer occurred during follow-up, 7,107 (45%) in women currently using hormone therapy. The average age of participants was 56.6 years at study entry. Women who were currently using hormone therapy had a higher risk for breast cancer if they started therapy before or shortly after menopause. They were also at higher risk for breast cancer than those who had never taken hormone therapy, but the increased risk disappeared within a few years after therapy was discontinued. Those currently using estrogen alone had little if any increased risk if they had started therapy five or more years after menopause (relative risk, 1.05, 95% CI, 0.89 to 1.24) but statistically significant higher risk if they had started it before or within five years of menopause (relative risk, 1.43, 95% CI, 1.35 to 1.51). For those taking estrogen-progestin, the risk pattern relative to timing of therapy and menopause was similar (relative risk, 1.53, 95% CI, 1.38 to 1.70 and 2.04, 95% CI, 1.95 to 2.14, respectively), although the relative risk was higher in this group.

The authors noted that their results could have been affected by residual misclassification of hormone therapy use. However, they concluded that breast cancer risk varied significantly according to when hormone use began. Women who used estrogen-progestin compared with estrogen alone and those who began taking hormones close to menopause compared with at least five years afterward were at higher risk. An editorial cautioned that while the Women's Health Initiative also found a relationship between timing of hormone therapy initiation and breast cancer, there were differences regarding whether risk is altered according to the use of estrogen alone or estrogen-progestin combinations, and that further study is required.


Bevacizumab tied to higher rate of fatal adverse events

Compared to those taking chemotherapy alone, patients who took bevacizumab (Avastin) in combination with chemo- or biological therapy had more fatal adverse events, according to a new meta-analysis.

The analysis included 16 randomized controlled trials and 10,217 patients with a variety of advanced solid tumors. The overall incidence of fatal adverse events in the bevacizumab patients was 2.5%, which translated into a 46% higher risk compared to chemotherapy alone (P=0.01). The most common fatal adverse events were hemorrhage (23.5%), neutropenia (12.2%) and gastrointestinal tract perforation (7.1%), although the study authors also noted a relatively large number of unspecified causes.

The risk of fatal adverse events differed depending on which class of chemotherapeutic agents patients received. Platinum and taxanes appeared to pose a higher risk, although the difference was not statistically significant. The analysis also indicated the possibility of a dose-dependent effect, because the association between bevacizumab and fatal adverse events was statistically significant at a dose of 5.0 mg/kg per week, but not at a dose of 2.5 mg/kg per week. However, the difference in effect between the two doses was not statistically significant.

The study authors noted that the absolute risk of treatment-related mortality was low and they called for the risks of bevacizumab to be considered in the context of overall survival benefits. They also recommended some approaches for reducing the risk of fatal adverse events in patients taking the drug, including monitoring patients carefully for the most common adverse events, using prophylactic granulocyte colony-stimulating factor, adequately managing serious adverse events and selecting appropriate patients for therapy.

The last suggestion may pose a challenge, according to the author of an accompanying editorial, who noted that “few insights are available about specific subgroups of patients who may benefit” from bevacizumab. The editorialist concluded that the “jury is still out” on the drug, and noted that although the drug may benefit certain patients, as currently used it subjects many patients, and society in general, to high costs and toxic effects. The study and editorial were published in the Feb. 2 Journal of the American Medical Association.


ASCO statement: Advanced cancer care should be tailored to patient preferences

Physicians should start an open dialogue about palliative care and treatment with patients as soon as they are identified as having incurable cancer, according to guidelines by the American Society of Clinical Oncology.

Fewer than half of all cancer patients are enrolled in hospice care before their deaths, and of those who are enrolled, one-third are not enrolled until the last week of their lives, according to the policy statement published Jan. 24 in the Journal of Clinical Oncology.

The statement is meant to align patients’ personal goals and preferences with realistic conversations about evidence-based medicine, resources and potential outcomes.

The issues addressed include the following:

  • Anticancer therapy should be considered only when likely to result in significant clinical benefit. The priority should be placed on enhancing quality of life.
  • Patients should be well informed about their prognosis and treatment options, ensuring that they have opportunities to make their preferences and concerns regarding treatment and supportive care known.
  • Anticancer therapy should be discussed and offered when evidence supports a reasonable chance of providing meaningful clinical benefit.
  • Options to prioritize and enhance patients’ quality of life should be discussed when advanced cancer is diagnosed and throughout the course of illness, along with development of a treatment plan that includes goals of therapy.
  • Conversations about anticancer interventions should include information on likelihood of response, the nature of response, and the adverse effects and risks of any therapy. Direct costs related to time, toxicity, loss of alternatives, or financial impacts that can be anticipated should also be discussed to allow patients to make informed choices.
  • Patients with advanced cancer should be given the opportunity to participate in clinical trials or other forms of research.
  • When disease-directed options are exhausted, patients should be encouraged to transition to symptom-directed palliative care alone with the goal of minimizing physical and emotional suffering and ensuring that patients with advanced cancer are given the opportunity to die with dignity and peace of mind.

The statement also recommended raising awareness by:

  • emphasizing individualized care in medical education and training ("Quality palliative care should be incorporated into American Board of Internal Medicine training and certification");
  • recognizing the value of conversations about cancer as well as treatments of cancer ("Programs that use concurrent hospice care and chemotherapy may double the referrals to hospice and reduce end-of-life hospitalizations by more than half");
  • presenting patient-oriented information from the National Cancer Institute’s, ASCO’s, and patient advocacy group websites to start realistic discussions of care options; and
  • continuing basic research in advanced cancer care.



Prognostic scores don't reliably predict early recurrence after minor stroke

Leading prognostic scores don’t reliably predict risk for early recurrence after a minor stroke, a new study has indicated.

Researchers used data from the Oxford Vascular Study, a prospective, population-based study of all incident and recurrent stroke in Oxfordshire, United Kingdom, to examine the prognostic value of three stroke scores for early recurrence after minor stroke: the ABCD2 score, the Essen Stroke Risk Score and the Stroke Prognosis Instrument II. Strokes were considered minor if they scored 5 or lower on the National Institutes of Health Stroke Scale. The study was published online Jan. 27 by Stroke.

A total of 1,247 first events occurred from April 1, 2002 to March 31, 2007. Of these, 488 were transient ischemic attacks, 520 were minor strokes and 239 were major strokes. Patients were a mean age of 73 years (range, 24 to 98 years) when the first event occurred. One hundred forty-two recurrent strokes occurred within 90 days of the first event, 81 within 7 days and 111 within 30 days. Only the ABCD2 score was predictive of recurrence 7 and 90 days after minor stroke, and its predictive value was modest (area under the receiver operator curve, 0.64, 95% CI, 0.53 to 0.74, P=0.03 and 0.62, 95% CI, 0.54 to 0.70, P=0.004, respectively). The Essen Stroke Risk Score and the Stroke Prognosis Instrument II did not predict 7-day or 90-day risk. The authors examined the risk factors included in the ABCD2 score and found that only two, blood pressure above 140/90 mm Hg at first evaluation and large artery disease, predicted 90-day recurrence risk (hazard ratio, 2.75, 95% CI, 1.18 to 6.38, P=0.02 and 2.21, 95% CI, 1.00 to 4.88, P=0.05, respectively).

The authors noted that their estimates of stroke risk may have been imprecise because some patients with minor stroke don't seek medical care, and that relatively few outcomes were used to validate the scores for recurrence. However, they concluded that these three existing scores do not adequately predict early risk for recurrence after minor stroke. "More reliable early risk prediction after minor stroke is required," they wrote.


From the College

ACP delivers State of the Nation’s Health Care report

On Jan. 27, ACP presented the annual State of the Nation’s Health Care briefing at the National Press Club in Washington.

The College proposed specific ideas to encourage a bipartisan consensus to keep the essential changes made by the Affordable Care Act while making much-needed improvements. At the briefing, a new policy paper was also released, "How Can Our Nation Conserve and Distribute Health Care Resources Effectively and Efficiently?" The paper looks at how the U.S. health care system can move toward a more evidence-based approach to distributing limited resources. More information about the briefing and accompanying policy paper can be found in the latest issue of The ACP Advocate.


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.

E-mail all entries to ACP staff will choose finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.


MKSAP answer and critique

The correct answer is D) Ventilation-perfusion lung scan. This item is available to MKSAP 15 subscribers as item 88 in the Cardiology section.

The most appropriate diagnostic test for this patient is ventilation-perfusion lung scanning. This patient has tricuspid regurgitation and significant pulmonary hypertension with evidence of pressure overload on the right ventricle. Pulmonary hypertension with right ventricular enlargement and tricuspid valve annular dilation can lead to significant regurgitation of an otherwise normal tricuspid valve. Pulmonary hypertension may occur when abnormalities in left heart valvular or myocardial function (systolic or diastolic) cause pulmonary venous hypertension. Additional causes of pulmonary hypertension include chronic hypoxic pulmonary disorders (such as chronic obstructive pulmonary disease, interstitial lung disease, or sleep apnea) and chronic thromboembolic disease. Pulmonary hypertension may occur in association with anorectic drug use, HIV infection, chronic liver disease, or collagen vascular disease. In the absence of identifiable risk factors, pulmonary hypertension may be idiopathic. A diagnosis of idiopathic primary pulmonary arterial hypertension requires exclusion of secondary and associated causes of pulmonary hypertension. Additionally, right heart catheterization is needed to confirm the presence of pulmonary hypertension, exclude elevated left-sided filling pressures, and demonstrate elevated pulmonary vascular resistance.

Numerous diagnostic tests may be used to evaluate a patient with suspected pulmonary hypertension. Pulmonary function tests are needed to identify and characterize underlying lung disease. Ventilation-perfusion scanning is used to evaluate patients for chronic thromboembolic disease. A normal scan has greater than 90% sensitivity in excluding chronic thromboembolic disease and a similarly high specificity. Although helpful in the evaluation of acute pulmonary embolism, CT angiography is not known to be sufficiently sensitive for detection of chronic thromboembolism. Blood tests are performed to evaluate potential liver disease, HIV infection, or collagen vascular disease. A right heart catheterization confirms the presence of pulmonary hypertension and allows for calculation of pulmonary vascular resistance. Some patients require left heart catheterization as well.

Cardiac magnetic resonance (CMR) imaging is useful when evaluating primary myocardial abnormalities (such as an infiltrative disease), evaluating ventricular volumes, or assessing three-dimensional imaging of congenital heart disease. In this patient, transthoracic images do not suggest congenital heart disease. CMR imaging would not be the next imaging study of choice.

Exertional dyspnea may be an angina equivalent and stress echocardiography could be considered. However, the patient’s age, relative paucity of cardiovascular risk factors, and abnormal transthoracic echocardiogram findings (right ventricular enlargement and pulmonary hypertension) argue against an ischemic cause for her symptoms. A ventilation-perfusion lung scan is the appropriate next diagnostic test.

Transesophageal echocardiography to evaluate for tricuspid valve vegetations would be indicated if there were a strong clinical suspicion for endocarditis. This patient’s clinical presentation, with an absence of corroborating history, fever, or an elevated leukocyte count, does not suggest endocarditis.

Key Point

  • Pulmonary hypertension may lead to right ventricular enlargement, tricuspid valve annular dilation, and regurgitation in an otherwise normal tricuspid valve.

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A 67-year-old man is evaluated for a recent diagnosis of primary hyperparathyroidism after an elevated serum calcium level was incidentally detected on laboratory testing. Medical history is significant only for hypertension, and his only medication is ramipril. Following a physical exam and lab studies, what is the most appropriate management of this patient?

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