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

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In the News
for the Week of 3-8-11

Highlights

  • Guideline issued for diagnosis, treatment of interstitial cystitis/bladder pain syndrome
  • Antihypertensives lower risk for CVD patients without hypertension

Test yourself

  • MKSAP Quiz: 3-week history of fatigue, nausea, and poor appetite

Patient communication

  • Patients need to be told they are overweight, study finds
  • Drug adverse events affect patients' choices more than benefits

Cardiology

  • Clopidogrel may improve outcomes after CABG in patients with MI

Infectious disease

  • Central line infections in ICUs fell 58% between 2001 and 2009

FDA news

Education

  • Endocrine Society launches diabetes e-learning initiative

Internal Medicine 2011

  • ACP Job Placement Center calls for job seekers’ profiles

From the College

  • Members invited to take survey on specialty choice satisfaction
  • ACP receives grant from ABIM Foundation to improve care transitions
  • Rate ACP's mobile website

Cartoon caption contest

Physician editor: Darren Taichman, FACP


Highlights

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Guideline issued for diagnosis, treatment of interstitial cystitis/bladder pain syndrome

The American Urological Association recently released its first-ever clinical guideline on diagnosis and treatment of interstitial cystitis/bladder pain syndrome (IC/BPS).

A guideline panel conducted a systematic review of the literature to develop its recommendations. Eighty-six studies were analyzed. Because insufficient evidence was found on diagnosis, these recommendations are based on clinical principles and expert opinion. The full text of the guideline is available online.

The guideline panel recommended that clinicians assessing patients for IC/BPS should perform a careful history, physical examination and laboratory examination to identify characteristic symptoms (such as pain, bladder pressure and discomfort, lack of infection, and marked urinary urgency and frequency) and to rule out such disorders as overactive bladder or, in men, chronic prostatitis. Baseline voiding symptoms and pain levels should also be measured. The value of cystoscopy and urodynamic studies is uncertain, although these tests may be useful to identify bladder abnormalities in symptomatic patients and to rule out bladder cancer or urethral diverticula, the panel said.

The panel's recommendations for overall management include the following:

  • Type and level of initial treatment should be determined according to symptom severity, clinical judgment and patient preferences.
  • Multiple concurrent treatments may be of benefit for some patients, according to baseline symptom measurement and regular assessment.
  • Management of pain as well as its impact on quality of life should be regularly assessed.
  • If symptoms do not improve after multiple treatments are attempted, the clinician should reconsider the diagnosis.

First-line treatment should include education about IC/BPS and its available treatments (including that no one treatment is effective in most patients and that multiple treatments are often needed), self-care and behavioral modification, and stress management techniques, the panel said. The guideline provides an algorithm that covers recommended first-line through sixth-line treatments. It also lists treatments that should not be offered, including long-term oral antibiotics and glucocorticoids. An executive summary of the guideline is scheduled for future publication in the Journal of Urology.

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Antihypertensives lower risk for CVD patients without hypertension

In patients who had a clinical history of cardiovascular disease (CVD) but not hypertension, antihypertensive treatment was associated with decreased risk of stroke, congestive heart failure (CHF), composite CVD events and all-cause mortality, according to a meta-analysis.

To evaluate the effect of antihypertensive treatment on secondary prevention, researchers conducted a meta-analysis of 25 randomized, controlled trials reviewing outcomes of stroke, myocardial infarction (MI), CHF, composite CVD outcomes, CVD mortality and all-cause mortality. These studies totaled 64,162 participants (mean age range, 55 to 68 years; 76% men), all with blood pressure less than 140 mm Hg systolic, less than 90 mm Hg diastolic, or no clinical history of hypertension at baseline. Researchers reported results in the March 2 Journal of the American Medical Association.

Compared with controls, participants receiving antihypertensive medications had a pooled relative risk of 0.77 (95% CI, 0.61 to 0.98) for stroke, 0.80 (95% CI, 0.69 to 0.93) for MI, 0.71 (95% CI, 0.65 to 0.77) for CHF, 0.85 (95% CI, 0.80 to 0.90) for composite CVD events, 0.83 (95% CI, 0.69 to 0.99) for CVD mortality, and 0.87 (95% CI, 0.80 to 0.95) for all-cause mortality from random-effects models.

The corresponding absolute risk reductions per 1,000 persons were −7.7 (95% CI, −15.2 to −0.3) for stroke, −13.3 (95% CI, −28.4 to 1.7) for MI, −43.6 (95% CI, −65.2 to −22.0) for CHF events, −27.1 (95% CI, −40.3 to −13.9) for composite CVD events, −15.4 (95% CI, −32.5 to 1.7) for CVD mortality and −13.7 (95% CI, −24.6 to −2.8) for all-cause mortality.

Subgroup analyses showed little difference in the association of antihypertensive treatment among those with clinical history of MI or coronary artery disease, those with preexisting CHF, and those with history of diabetes or according to class of antihypertensive medication. Further, there was little change in the overall effect estimates by clinical history among those with MI or coronary artery disease, those with preexisting CHF, or according to class of antihypertensive medication, with the exception of diabetes. A limited number of trials conducted exclusively in patients with diabetes showed no statistically significant benefit of antihypertensive treatment.

The meta-analysis' strength is that it used only randomized, controlled trials with study characteristics very similar at baseline. Its weakness is that few studies reported outcomes for normotensive and prehypertensive patients.

"The results of this meta-analysis suggest that persons with these compelling indications but without hypertension may also benefit from reduced morbidity and mortality attributable to CVD events when treated with antihypertensive medications," the authors wrote. "In persons 40 years and older with prehypertension, more than 90% have at least 1 above-optimal risk factor, and more than 68% have at least 1 clinically high risk factor for heart disease or stroke. Although pharmacological treatment for all individuals in this population would not be economically feasible, a more reasonable strategy might be to identify groups within the prehypertensive population who would obtain the greatest benefit from early pharmacological intervention."

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Test yourself

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MKSAP Quiz: 3-week history of fatigue, nausea, and poor appetite

A 65-year-old woman is evaluated for a 3-week history of fatigue, nausea, and poor appetite. In the week before symptom onset, she had acute bronchitis with productive cough and fever. The patient has a 2-year history of osteoarthritis of the knees that requires intra-articular corticosteroid injections every 3 to 4 months; her last injection was 3 months ago. Her only other medication is acetaminophen.

On physical examination, the patient looks tired. Temperature is 37.5 °C (99.5 °F), blood pressure is 112/58 mm Hg, pulse rate is 92/min, respiration rate is 17/min, and BMI is 32. The patient has cushingoid features and central obesity. There are multiple ecchymoses on the upper and lower extremities. Decreased axillary and pubic hair is noted. There is bony hypertrophy and small effusions of the knees bilaterally but no evidence of warmth or erythema.

Laboratory studies:

Adrenocorticotropic hormone (a.m.) 9 pg/mL (1.98 pmol/L)
Cortisol (8 a.m.)
Initial measurement
1.4 µg/dL (38.6 nmol/L) (normal range, 5-25 µg/dL [138-690 nmol/L])
After cosyntropin stimulation 9.0 µg/dL (248.4 nmol/L)
Follicle-stimulating hormone 40 mU/mL (40 U/L)
Luteinizing hormone 35 mU/mL (35 U/L)
Prolactin 14 ng/mL (14 µg/L)
Thyroid-stimulating hormone 3.1 µU/mL (3.1 mU/L)
Thyroxine (T4), free 1.2 ng/dL (15.5 pmol/L)

Which of the following is the most likely cause of this patient’s current symptoms?

A) Adrenal adenoma
B) Exogenous corticosteroids
C) Pituitary microadenoma
D) Primary adrenal insufficiency

Click here to see the answer and critique for this question.

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Patient communication

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Patients need to be told they are overweight, study finds

Patients who have been told by a physician that they are overweight are significantly more likely to have attempted weight loss, according to a new study.

Researchers used data from the National Health and Nutrition Examination Survey, which included adults between 20 and 64 years old who had a BMI of at least 25. Patients' actual BMIs as well as their responses to questions about weight were collected and then analyzed using logistic regression. The results were published in the Feb. 28 Archives of Internal Medicine.

About 45% of patients who had a BMI of 25 or greater reported that a physician had told them they were overweight; among obese patients (BMI of 30 or more), the proportion was 66%. These patients were significantly more likely to consider themselves overweight than patients who hadn't discussed the subject with a doctor: Only 6% denied being overweight compared to 37% of those who hadn't been informed by their physicians. Among the obese subpopulation, the percentages were 3% and 19%, respectively. The patients were also twice as likely to report having attempted to lose weight in the past year if they had been told they were overweight (odds ratio, 2.51; 95% CI, 2.15 to 2.94).

Extrapolating from the data, study authors concluded that more than 74 million overweight Americans (including 23 million obese people) may never have been told that they are overweight by a doctor, although they noted that the self-reporting structure of the study doesn't account for patients who were told, but didn't listen or remember. The authors noted that physicians may fail to address this issue because they have limited time and low expectations about patients' ability to lose weight, but that the strong association found in this study between these conversations and weight-loss attempts should encourage physicians to talk to their patients about weight.

An accompanying commentary offered some strategies for these discussions. Physicians should inform patients that they are overweight in a straightforward manner by comparing their BMIs to standard definitions. Physicians should express concern rather than judgment and take measurement of other risk markers (lipids, glucose, blood pressure, abdominal circumference) in overweight patients, the commentary author advised. Although patients' ability to successfully lose weight without intensive interventions is uncertain, their awareness of the problem is a necessary first step, he concluded.

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Drug adverse events affect patients' choices more than benefits

Adverse events deter elderly people from taking drugs for primary prevention of myocardial infarction (MI), researchers report.

Researchers examined older persons' willingness to take medication for primary cardiovascular disease prevention according to benefits and harms by conducting in-person interviews with 356 older persons in three senior centers and one independent/assisted living facility. They reported results online Feb. 28 in the Archives of Internal Medicine.

Researchers outlined several scenarios. The first asked participants to consider that their risk for MI over the next five years was 20 in 100 and that this risk would be reduced to 14 in 100 with the medication. Subsequent scenarios varied the absolute reduction:

  • relative risk reduction increased to 50% (risk without medication: 20 in 100; risk with medication: 10 in 100);
  • baseline risk and relative risk reduction both increased (risk without medication: 50 in 100; risk with medication: 25 in 100) and
  • baseline risk decreased (risk without medication: 10 in 100; risk with medication: 7 in 100).

Most patients (88%) said they would take medication in the first scenario. Of participants who would not take it, 17% changed their preference if the absolute benefit was increased to 10 fewer persons with MI, and, of participants who would take it, 82% remained willing if the absolute benefit was decreased to 3 fewer persons with MI.

The questions were posed again with the addition of adverse effects:

  • mild daily fatigue and dizziness, either severe or not severe enough to interfere with daily life;
  • mild nausea, either severe or not severe enough to interfere with daily life and
  • fuzzy or slowed thinking, either severe or not severe enough to interfere with daily life.

Given the risk of mild fatigue, nausea, or fuzzy thinking, 48% to 69% were unwilling or uncertain about taking medication, and only 3% would take it with adverse effects severe enough to affect functioning.

Researchers wrote that "Guidelines need to recognize that adverse effects of medications, even when mild, are not 'side effects' but rather competing outcomes important in their own right. The decision about whether to take a medication should not be predicated on magnitude of benefit alone but rather on the balance of benefits and harms." Further, patients need to be allowed to determine when benefits are not outweighed by harms, and their decisions should be supported even when the clinician disagrees, the authors concluded.

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Cardiology

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Clopidogrel may improve outcomes after CABG in patients with MI

Clopidogrel may improve outcomes after coronary artery bypass grafting (CABG) for myocardial infarction (MI), a new study reports.

To evaluate the effect of clopidogrel on death and recurrent MI after CABG, Danish researchers examined data on patients admitted to the hospital with a first MI between 2002 and 2006 who underwent CABG within 180 days. They determined which patients received clopidogrel after discharge by looking at filled prescriptions. The main outcome measures were risk for death, recurrent MI or both. The study results appear in the March 8 Journal of the American College of Cardiology.

Study patients were followed for a mean of 466 ± 144 days. A total of 3,545 patients were included, 957 (27.0%) of whom received clopidogrel after CABG. Thirty-nine (4.1%) of those who received clopidogrel died or had a recurrent MI compared with 203 (7.8%) of those who did not receive clopidogrel (log-rank P=0.0003; hazard ratio, 0.59; 95% CI, 0.42 to 0.85). In a subgroup analysis of 945 patients matched by propensity score, 38 (4.0%) of those treated with clopidogrel died or had recurrent MI compared with 57 (6.0%) of those not treated with clopidogrel (log-rank P=0.05; hazard ratio, 0.67; 95% CI, 0.44 to 1.00). Rates of bleeding events after hospital discharge did not differ between groups.

The study was limited by its observational design, which did not allow the authors to definitively establish a causal relationship between clopidogrel and the primary outcomes. The authors also could not rule out selection bias. However, they concluded that clopidogrel treatment helped improve outcomes in patients with MI after CABG, but that the percentage of eligible patients who received clopidogrel treatment was low. They recommended that a randomized, controlled trial should be done to clarify the relationship between postoperative clopidogrel treatment and outcomes, and that more attention should be paid to prescribing clopidogrel at discharge in this group of patients.

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Infectious disease

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Central line infections in ICUs fell 58% between 2001 and 2009

Central line-associated bloodstream infections (CLABSIs) in ICUs dropped 58% between 2001 and 2009, the Centers for Disease Control and Prevention reported last week.

CDC researchers multiplied central line utilization and CLABSI rates by estimates of the total number of patient-days in ICUs, inpatient wards and outpatient hemodialysis facilities. They used the Healthcare Cost and Utilization Project's National Inpatient Sample and the Hospital Cost Report Information System to identify total inpatient days; CLABSI and central line use rates came from the National Nosocomial Infections Surveillance Systems for 2001 estimates (ICUs only) and from the National Healthcare Safety Network (NHSN) for 2009 estimates (ICUs and inpatient wards). Total number of outpatient hemodialysis patient-days in 2008 came from the U.S. Renal Data System; outpatient hemodialysis central line utilization data came from the Fistula First Breakthrough Initiative; and hemodialysis CLABSI rates were estimated from the NHSN. Results were published online March 1 by the CDC's Morbidity and Mortality Weekly Report.

ICU CLABSIs fell to about 18,000 cases in 2009 from about 43,000 cases in 2001. Reductions in infections caused by Staphylococcus aureus were greatest (73% reduction; rate ratio [RR], 0.27; 95% CI, 0.238 to 0.294), followed by those caused by Enterococcus species (55% reduction; RR, 0.45; 95% CI, 0.408 to 0.491), Candida species (46% reduction; RR, 0.54; 95% CI, 0.487 to 0.606) and gram-negative pathogens (37% reduction; RR, 0.63; 95% CI, 0.568 to 0.692). Overall, the decline in infections saved up to 6,000 lives and $414 million in potential excess health care costs in 2009, and an estimated $1.8 billion in cumulative excess health care costs since 2001. Still, a substantial number of CLABSIs occurred in inpatient wards and outpatient hemodialysis centers. While data for 2001 weren't available, there were an estimated 23,000 CLABSIs in inpatient wards in 2009 and 37,000 in outpatient hemodialysis centers in 2008.

Collaboration among health care facilities, professional societies and state and federal agencies to implement proven best practices for central line insertion has likely helped reduce CLABSIs in ICUs, the report concluded. Such efforts may have limited impact outside the ICU, where central lines are less frequently inserted, so extra prevention strategies should be developed, it said. "Implementation of CDC recommendations to maintain central lines, remove them promptly when they are no longer needed, and interrupt transmission of resistant bacteria will reduce CLABSIs further," the report said. Study limitations include that estimates were calculated rather than measured directly, and that differences between facilities reporting and not reporting data to CDC may have affected the accuracy of estimates.

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FDA news

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Unapproved prescription cough, cold, allergy meds pulled

The FDA ordered the market removal of a large number of prescription oral cough, cold, and allergy products last week.

The drugs had not been approved by the agency, but because the drugs’ labels do not disclose that they lack FDA approval, clinicians may have been unaware of the unapproved status of the drugs and continued to prescribe them, an FDA news release said. Over the past century, the laws outlining the requirements for drug approval have changed. In part as a result of these changes, many of the products targeted by this FDA action have been marketed without being approved under the current legal requirements.

There are numerous potential concerns about these products, FDA officials said. Some may contain risky combinations of ingredients, while others—marketed as timed-release—may release active ingredients too slowly, too quickly, or inconsistently. The agency has also received reports that some products have names that look or sound similar to other products. The FDA therefore concluded that the products pose unnecessary risk to consumers, especially given that approved prescription drugs and over-the-counter drugs that meet FDA standards are available to treat the same symptoms.

The companies that distribute these drugs have been ordered to stop production within 90 days and distribution within 180 days. A full list of the affected products is available online.

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Education

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Endocrine Society launches diabetes e-learning initiative

The Endocrine Society recently launched the Beta Cells in Diabetes e-learning initiative, an electronic resource that provides physicians with information about a physiology-based approach to type 2 diabetes care.

The Beta Cells in Diabetes initiative seeks to advance clinical care based on current knowledge about the pathophysiology of type 2 diabetes. The Endocrine Society has engaged leaders in primary care and endocrinology in an interactive resource that could change the way physicians manage patients. Join physicians from more than 100 countries and vote on which treatment option to give when one therapy fails or comment on the blog, where experts discuss topics such as vitamin D in type 2 diabetes or how the ACCORD trial affects patients. Visit the website for more information.

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Internal Medicine 2011

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ACP Job Placement Center calls for job seekers’ profiles

Physicians looking for a new job may submit a profile to the ACP Job Placement Center, a service available at Internal Medicine 2011, to be held April 7-9 in San Diego.

The center, located in the San Diego Convention Center’s Exhibit Hall, Booth #1601, provides physicians with tools to assist in job searches as well as the opportunity to meet with potential employers.

Profiles will be included in one of two booklets distributed only to Job Placement Center sponsors and exhibitors who have submitted a job posting that meets your criteria. After reviewing a profile, a recruiter may contact the physician to schedule a private on-site interview at the center. Profiles can be submitted online.

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From the College

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Members invited to take survey on specialty choice satisfaction

ACP is giving members access to a survey instrument currently in use in the United Kingdom that proposes the best and worst fits of medical specialties based on responses to a questionnaire regarding professional and personal preferences.

The survey is being piloted in the U.S. by the Acculturation Program of the Educational Commission for Foreign Medical Graduates (ECFMG) to determine whether the metrics used in the U.K. are equally valid for physicians in the U.S. This can only be done by gathering responses from large numbers of U.S. physicians who are already in various specialties. Your participation is voluntary and free of cost. To learn more about the project and how to participate, send an e-mail including your name and medical specialty to acculturation@ecfmg.org.

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ACP receives grant from ABIM Foundation to improve care transitions

ACP has been awarded a grant of $60,000 from the ABIM Foundation to support efforts in developing tools for primary care practices to improve care transitions for patients moving from the hospital to the home.

As part of ACP’s Medical Home Builder, the project, called IM-PACT, will work on improvements to coordination of care during inpatient stays and transitions from hospital to community-based care. The initiative will look at evidence-based transitions programs to identify common elements that relate to primary care and explore how primary care clinicians can optimize their practices in response.

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Rate ACP's mobile website

Have you visited www.acponline.org using a mobile device recently? If so, you could win $100 in the app store of your choice when you take our 5-minute survey about your experience.

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Cartoon caption contest

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Put words in our mouth

ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

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 B) Exogenous corticosteroids. This item is available to MKSAP 15 subscribers as item 64 in the Endocrinology and Metabolism section.

This patient has central adrenal insufficiency. Use of systemic corticosteroids is the most common cause of central adrenal insufficiency, with supraphysiologic dosages of exogenous corticosteroids causing disruption of hypothalamic/pituitary adrenocorticotropic hormone (ACTH) production. Consequently, the adrenal cortex atrophies. When subsequently challenged by stress, the hypothalamus and pituitary gland are unable to stimulate adequate adrenal production of cortisol. This central effect of exogenous corticosteroids can occur after only 3 weeks of suppressive therapy. The patient appears to have developed Cushing syndrome as a result of chronic systemic exposure to the intra-articular injections of corticosteroids. Despite her cushingoid features, however, she has clinical and biochemical evidence of adrenal insufficiency. Her low-normal serum ACTH level and her partial response to cosyntropin stimulation indicate that she has central (secondary) adrenal insufficiency. Patients with adrenal insufficiency often decompensate during concurrent illnesses. Because the rest of her pituitary function is normal, another cause of her loss of ACTH secretion is unlikely.

An adrenal adenoma could cause a suppressed ACTH level, cushingoid features, and central obesity, but her symptoms suggest glucocorticoid deficiency. Furthermore, an adrenal adenoma would cause an elevated, not suppressed, cortisol level.

A nonfunctioning pituitary adenoma is extremely unlikely in light of the isolated ACTH deficiency and the timing of symptom onset—3 months after exogenous corticosteroid administration. A functioning pituitary adenoma might produce excessive ACTH, but in that case both the ACTH and cortisol levels would be elevated, not suppressed as they are in this patient.

Primary adrenal insufficiency (Addison disease) is typically associated with low cortisol production and elevated ACTH levels.

Key Point

  • Secondary adrenal insufficiency due to exogenous corticosteroids may be associated with suppression of both adrenocorticotropic hormone and cortisol levels and with clinical findings of excess glucocorticoids.

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Copyright 2011 by the American College of Physicians.

Test yourself

A 66-year-old man comes for a preoperative evaluation before total joint arthroplasty of the left knee. He has a 25-year history of rheumatoid arthritis. He has had progressive pain in his left knee with activity, which limits his ability to hike. The patient has similar pain in the right knee, but it is less severe. He reports no recent morning stiffness. He is able to climb two or three flights of stairs without chest pain or shortness of breath. He has no other medical problems and reports no additional symptoms. Medications are methotrexate and folic acid. Following a physical exam and lab tests, what is the next best step in management?

Find the answer

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