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ACP InternistWeekly



In the News for the Week of 4-19-11




Highlights

Treatment guidelines offered for painful diabetic neuropathy

New expert guidelines on treatment of painful diabetic neuropathy have evaluated the evidence base and identified some recommended medications. More...

Starting cART earlier may increase AIDS-free survival time

Starting combined antiretroviral therapy in HIV patients earlier may stave off symptoms, prevent HIV transmission and prolong AIDS-free survival without affecting mortality, according to an observational study that used pooled data from 12 large cohorts. More...


Test yourself

MKSAP Quiz: Irregular menses and infertility

What constitutes best management for a 24-year-old woman evaluated for irregular menses and infertility? More...


Sexually transmitted infections

Asymptomatic herpes patients can spread virus

People with asymptomatic herpes simplex virus shed the virus less often than those with symptomatic disease, but they still pose significant risk of transmission, according to a new study. More...


FDA update

C. diff and dengue tests cleared by FDA

New tests that can assist with diagnosis of Clostridium difficile and dengue fever were recently cleared for marketing, the FDA announced. More...


CMS update

New preventive care charts from Medicare

The Centers for Medicare and Medicaid Services has published three new charts for physicians about preventive services covered by Medicare. More...

Survey on physician interest in the EHR meaningful use incentive

The HIMSS health information technology organization is conducting a survey to gauge physician interest in Medicare incentives for meaningful use of a qualified electronic health record system. More...


From the College

Earn both CME credits and MOC points with MKSAP 15

MKSAP 15 can now be used for AMA PRA Category 1 Credits™ and Self-Evaluation of Medical Knowledge points required under the ABIM's Maintenance of Certification program. More...

ACP signs advisory letter urging pertussis vaccination outreach

ACP has joined the American Nurses Association, along with many other nursing, pediatric and physician organizations, to urge clinicians to encourage patients who have any contact with newborns and infants to get vaccinated for pertussis. More...

Potential Governor-elect candidates solicited

ACP will conduct elections for the Class of 2017 in September 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


.
Treatment guidelines offered for painful diabetic neuropathy

New expert guidelines on treatment of painful diabetic neuropathy have evaluated the evidence base and identified some recommended medications.

The guidelines were developed by a panel representing the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine and the American Academy of Physical Medicine and Rehabilitation and were published online by Neurology on April 11.

The strongest evidence (Level A) was found to support offering pregabalin for relief of painful diabetic neuropathy. The guidelines also listed a number of treatments that are supported by Level B recommendations, and are probably effective so should be considered, including gabapentin, sodium valproate, amitriptyline, venlafaxine, duloxetine, dextromethorphan, morphine sulfate, tramadol, oxycodone, capsaicin and isosorbide dinitrate spray. The guideline writers noted that there was not sufficient evidence to prefer any of the listed antidepressants or opioids over another. Level C recommendations were made for adding venlafaxine to gabapentin and considering the Lidoderm patch.

A review of nonpharmacologic treatments was also conducted, and the experts made a Level B recommendation in favor of considering percutaneous electrical nerve stimulation. There was insufficient evidence on amitriptyline plus electrotherapy, and the other studied treatments (electromagnetic field treatment, low-intensity lasers, and Reiki therapy) should probably not be considered, the guidelines said.

Insufficient evidence was also found for topiramate, desipramine, imipramine, fluoxetine, vitamins, α-lipoic acid and the combination of nortriptyline and fluphenazine. Drugs that should probably not be considered for treatment of painful diabetic neuropathy include oxcarbazepine, lamotrigine, lacosamide, clonidine, pentoxifylline and mexiletine, according to the guidelines. In their recommendations for future research, the guideline authors called for longer, head-to-head trials of treatments with greater focus on quality of life, physical function and cost-effectiveness. A formalized process for rating pain scales is also needed, they said.

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Starting cART earlier may increase AIDS-free survival time

Starting combined antiretroviral therapy (cART) in HIV patients earlier may stave off symptoms, prevent HIV transmission and prolong AIDS-free survival without affecting mortality, according to an observational study that used pooled data from 12 large cohorts.

Clinical guidelines differ on when to start cART. European guidelines and the World Health Organization recommend starting cART in asymptomatic people whose CD4 cell count is less than 0.350 × 109 cells/L, while U.S. guidelines from the International AIDS Society-USA panel and from the Department of Health and Human Services recommend a level of 0.500 × 109 cells/L.

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Researchers reviewed prospective observational data from the HIV-CAUSAL Collaboration and dynamic marginal structural models to compare cART initiation strategies for 20,971 HIV-infected, therapy-naive people who had not yet undergone treatment. Patients had a baseline CD4 cell count above 0.500 × 109 cells/L and no previous AIDS-defining illnesses. In the study, 8,392 patients' CD4 cell counts subsequently decreased to 0.200 to 0.499 × 109 cells/L.

The study population was from HIV clinics in Europe and the U.S. Veterans Health Administration system. CART initiation was defined as the date on which a person started three or more antiretroviral drugs, two ritonavir-boosted protease inhibitors, or a nonnucleoside reverse-transcriptase inhibitor and a boosted protease inhibitor. The study was funded by the National Institutes of Health, and results appear in the April 19 Annals of Internal Medicine.

Outcomes were all-cause mortality and a combined end point of AIDS-defining illness or death. Compared with initiating cART at the CD4 cell count threshold of 0.500 × 109 cells/L, the mortality hazard ratio was 1.01 (95% CI, 0.84 to 1.22) for the 0.350 threshold and 1.20 (95% CI, 0.97 to 1.48) for the 0.200 threshold. Estimates showed little mortality change as the CD4 threshold increased from 0.300 to 0.500. The corresponding hazard ratios were 1.38 (95% CI, 1.23 to 1.56) and 1.90 (95% CI, 1.67 to 2.15), respectively, for the combined end point of AIDS-defining illness or death.

Delaying cART initiation until the CD4 cell count decreased below 0.350 would result in a 38% increase in the incidence of AIDS-defining illness or death, compared with a threshold of 0.500. The authors wrote that 48 patients would need to start cART when their CD4 cell count decreased below 0.500 rather than 0.350 to prevent one new case of an AIDS-defining illness or death during the first five years. However, randomized, controlled trials are needed to validate this observational series, the authors concluded.

The authors of an accompanying editorial suggested that expanded use of cART could substantially curtail future HIV infections, as decreasing viral load decreases transmission risk. "Encouraging results from clinical studies, modeling studies, real-world observations, and public health reporting have led to a sense that the HIV epidemic can be controlled by expanding the indications for cART," the editorialists wrote. "Unfortunately, in the current fiscal reality, the 'test and treat everyone' strategy seems to require more resources than are available."

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Test yourself


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MKSAP Quiz: Irregular menses and infertility

A 24-year-old woman is evaluated for irregular menses and infertility. She reports having had normal puberty but having irregular menses until she started taking an oral contraceptive pill. She has been unable to become pregnant since marrying 1 year ago despite regular intercourse and discontinuing the oral contraceptive pill; during the past year, she has menstruated three times. The patient has never had acne or facial hair. She was a track athlete in high school and college and still enjoys distance running, typically running 50 miles per week. There is no family history of infertility or an endocrine disorder.

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On physical examination, blood pressure is 100/68 mm Hg, pulse rate is 52/min, and BMI is 16. Visual fields are full to confrontation. The patient has small breasts without galactorrhea and no facial hair or acne. Pubic hair is normal.

Laboratory studies:

Human chorionic gonadotropin Negative for pregnancy
Prolactin 16 ng/mL (16 µg/L)
Follicle-stimulating hormone 2 mU/mL (2 U/L)
Thyroid-stimulating hormone 1.2 µU/mL (1.2 mU/L)

Which of the following is the most appropriate next step in management?

A) Clomiphene therapy
B) Pelvic ultrasonography
C) Progestin withdrawal challenge
D) Weight gain and decreased exercise

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

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Sexually transmitted infections


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Asymptomatic herpes patients can spread virus

People with asymptomatic herpes simplex virus (HSV) shed the virus less often than those with symptomatic disease, but they still pose significant risk of transmission, according to a new study.

The study included 498 patients who were seropositive for HSV-2. The participants collected swabs of their genital secretions for at least 30 days. In the 410 patients who had symptomatic disease, the virus was detected in 20% of samples. In the 88 people with asymptomatic cases, virus was found in 10% of samples. Although patients with symptoms had more subclinical shedding of virus, the amount of virus detected during these episodes was similar in people with and without symptoms. The study authors concluded that asymptomatic patients shed virus less frequently, but that the difference is attributable to their having less frequent genital lesions.

The study highlights the risk of disease transmission by people with unrecognized infections, the researchers noted. Although this study categorized patients as symptomatic or asymptomatic, disease manifestations actually vary along a broad continuum. The majority of people found to be seropositive do not have a history of genital herpes, but a substantial proportion of apparently asymptomatic patients will recognize recurrences after they've been diagnosed and educated, the authors said. The results were published in the April 13 Journal of the American Medical Association.

One of the purposes of this study was to address uncertainty about proper management of asymptomatic patients. The authors concluded that best practices should include anticipatory guidance with regard to genital symptoms and education about transmission risk. Proven methods of reducing transmission include condom use, daily valacyclovir therapy and disclosure of positive status. However, the strategies are only effective in diagnosed patients, who are a minority of the HSV-2 positive population, noted the authors, who called for a rethinking of current testing and control programs.

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FDA update


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C. diff and dengue tests cleared by FDA

New tests that can assist with diagnosis of Clostridium difficile and dengue fever were recently cleared for marketing, the FDA announced.

The Cepheid Xpert C. difficile/Epi assay is designed to rapidly detect the toxin B gene associated with C. difficile infection. The test determines if C. difficile is in a patient's stool and whether it is the epidemic 027/NAP1/BI strain. The assay is automated and works on the Cepheid GeneXpert Dx System, which consists of an instrument that houses single-use disposable cartridges, a personal computer, and software that allows tests to be run and viewed quickly. The test is intended for use as an aid in diagnosis. The detection of the 027/NAP1/B1 strain is for epidemiological purposes only and should not be used to determine or monitor treatment, according to an FDA press release.

The DENV Detect IgM Capture ELISA test is the first test to help diagnose dengue fever or dengue hemorrhagic fever, reported an FDA press release. The test detects antibodies to dengue virus in blood samples from patients who have signs and symptoms of dengue and will be available for use in clinical laboratories. Diagnostic testing for dengue is complicated by the fact that an IgM antibody response to the dengue virus infection is not detectable until 3 to 5 days after the onset of fever, so a test result can be negative even though a person has dengue. Most reported dengue cases in the continental U.S. occur in people returning from Latin America, the Caribbean and Southeast Asia.

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CMS update


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New preventive care charts from Medicare

The Centers for Medicare and Medicaid Services has published three new charts for physicians about preventive services covered by Medicare.

  • The ABCs of Providing the Initial Preventive Physical Examination (IPPE) is a quick reference chart that includes a list of the elements of the IPPE along with coverage and coding information.
  • The ABCs of Providing the Annual Wellness Visit (AWV) is a chart that lists the elements of the AWV along with coverage and coding information.
  • The Medicare Preventive Services Quick Reference chart provides coverage, coding and payment information on other preventive services covered by Medicare.

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Survey on physician interest in the EHR meaningful use incentive

The HIMSS health information technology organization is conducting a survey to gauge physician interest in Medicare incentives for meaningful use of a qualified electronic health record (EHR) system.

The survey, posted to the AmericanEHR Partners website, asks how physicians are already responding or are planning to respond to the program.

More information on the meaningful use incentive is available on the College website.

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From the College


.
Earn both CME credits and MOC points with MKSAP 15

MKSAP 15 can now be used for AMA PRA Category 1 Credits™ and Self-Evaluation of Medical Knowledge points required under the ABIM's Maintenance of Certification (MOC) program.

It's no longer necessary to complete separate MKSAP modules to receive the credits and points. Physicians can apply for up to 80 Self-Evaluation of Medical Knowledge points by submitting completed MKSAP CME test records directly to the ABIM through MKSAP's online submission form. Any MKSAP 15 and MKSAP 15 Update 1 and 2 CME tests completed in the past will apply for physicians currently eligible for MOC. For more information, and to view the video about the new process, visit the MKSAP MOC webpage.

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ACP signs advisory letter urging pertussis vaccination outreach

ACP has joined the American Nurses Association (ANA), along with many other nursing, pediatric and physician organizations, to urge clinicians to encourage patients who have any contact with newborns and infants to get vaccinated for pertussis.

The letter is part of an effort to stem a nationwide outbreak, and advises vaccination for several groups that previously had not been recommended to receive the vaccine. The advisory letter, which outlines new Centers for Disease Control and Prevention recommendations for pertussis immunization, is on the ANA's website.

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Potential Governor-elect candidates solicited

ACP will conduct elections for the Class of 2017 in September 2011. The College is currently preparing a solicitation mailing for the voting membership (two-year Associates, Members, Fellows, and Masters) of each chapter asking them to send in nominees to the chair of their local Nominations Committee. The following chapters/regions are holding elections this year:

Alaska, Arizona, Northern California, Southern California Region III, Colorado, Connecticut, Hawaii, Illinois Downstate, Mississippi, New York Long Island, Oregon, Tennessee, Texas Northern, Utah, Venezuela and US Army (appointed).

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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-20110419-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 D) Weight gain and decreased exercise. This item is available to MKSAP 15 subscribers as item 66 in the Endocrinology and Metabolism section.

This patient should stop or reduce exercising and gain some weight to restore normal menses and fertility. Hypothalamic amenorrhea (or oligomenorrhea, in this patient's case) involves disordered gonadotropin release and may be the result of a tumor or infiltrative lesion (such as lymphoma or sarcoidosis) but more commonly is functional. The usual functional causes are stress, excessive loss of body weight or fat, excessive exercise, or some combination thereof; BMI is typically less than 17. Diagnosis of functional hypothalamic amenorrhea is one of exclusion, and the minimal evaluation includes a pregnancy test and measurement of serum prolactin, thyroid-stimulating hormone, and follicle-stimulating hormone levels to rule out prolactinoma, thyroid problems, and ovarian failure, respectively. If a functional etiology is still suspected, decreased exercise, improved nutrition, and attention to emotional needs are helpful adjuncts to restore normal menses and fertility.

Although clomiphene can be used to induce ovulation and pelvic ultrasonography can be used to assess reproductive anatomy, the pretest probability of functional hypothalamic amenorrhea is sufficiently high that conservative treatment should be recommended first.

If results of the initial laboratory assessment are normal, the next step in evaluation of patients with amenorrhea is the progestin withdrawal challenge. Menstrual flow on progestin withdrawal indicates relatively normal estrogen production and a patent outflow tract. However, this patient already has occasional menses, so even if she does have progestin withdrawal bleeding, the test result would be of limited value.

Key Point

  • Functional hypothalamic amenorrhea, which is usually caused by excessive loss of body weight or fat or excessive exercise, is a diagnosis of exclusion.

Click here to return to the rest of ACP InternistWeekly.

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Test yourself

A 48-year-old man is evaluated during a follow-up visit for urinary frequency. He reports no hesitancy, urgency, dysuria, or change in urine color. He has not experienced fevers, chills, sweats, nausea, vomiting, diarrhea, or other gastrointestinal symptoms. He feels thirsty very often; drinking water and using lemon drops seem to help. He has a 33-pack-year history of smoking. He has hypertension, chronic kidney disease, and bipolar disorder. Medications are amlodipine, lisinopril, and lithium. He has tried other agents in place of lithium for his bipolar disorder, but none has controlled his symptoms as well as lithium. What is the most appropriate treatment intervention for this patient?

Find the answer

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