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ACP InternistWeekly



In the News for the Week of 4-26-11




Highlights

AHA statement designates optimal triglyceride levels

The American Heart Association has defined the optimal upper limit for fasting triglycerides as 100 mg/dL, while elevated levels are still defined as 150 mg/dL or higher, according to a new scientific statement. More...

New Alzheimer's guidelines redefine stages, set biomarkers for future research

New guidelines on Alzheimer's disease describe new stages, including a pre-clinical stage, and suggest new biomarkers for research purposes. More...


Test yourself

MKSAP Quiz: severe knee pain and swelling

A 78-year-old man with a 15-year history of osteoarthritis is evaluated for severe pain and swelling of the left knee of 4 days' duration. What is the most appropriate treatment for this patient? More...


Women's health

Drospirenone contraceptives associated with more VTE

Oral contraceptives containing drospirenone are associated with a higher risk of venous thromboembolism than those with levonorgestrel, according to two new studies. More...


Cardiology

Beta-blocker use after hospital discharge appears beneficial in severe acute heart failure

Patients with severe acute heart failure appear to benefit from beta-blocker therapy after hospital discharge, a new study reports. More...


FDA news

Opioid manufacturers told to develop physician, patient education

As part of a new federal effort to reduce prescription drug abuse in the U.S., the FDA will begin requiring a Risk Evaluation and Mitigation Strategy (REMS) for all extended-release and long-acting opioid medications. More...


From the College

Winner announced in ACP's Recruit-a-Colleague Program

Everard N. Barton, FACP, of Mona Kingston, Jamaica, has been selected as the winner in the 2010-2011 Recruit-a-Colleague Program grand prize drawing for a trip to Internal Medicine 2012 in New Orleans, La. More...

ICD-10/version 5010 readiness assessment available

ACP is making available to its members a readiness assessment tool developed by CMS to gauge the health care industry's awareness of, and preparation for, the transition to ICD-10 and version 5010. 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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AHA statement designates optimal triglyceride levels

The American Heart Association has defined the optimal upper limit for fasting triglycerides as 100 mg/dL, while elevated levels are still defined as 150 mg/dL or higher, according to a new scientific statement.

However, 100 mg/dL should not be targeted by medical therapy because studies have not shown the benefit of using drugs to reach this level, the statement concluded.

The statement includes a suggested algorithm for screening and managing elevated triglyceride levels, and advises initially using nonfasting levels for screening. The statement complements recent American Heart Association scientific statements on childhood and adolescent obesity and dietary sugar intake. While the statement is not intended to serve as a specific guideline, it will influence future evidence-based guidelines. The statement was published online April 18 in Circulation.

A nonfasting level of less than 200 mg/dL is commensurate with a normal (<150 mg/dL) or optimal (<100 mg/dL) fasting triglyceride level and requires no further testing, according to the statement. Nonfasting triglyceride levels are not used in the definition of metabolic syndrome and should not be used to calculate low-density lipoprotein cholesterol by the Friedewald formula.

Fasting samples can be categorized as borderline high (150 to 199 mg/dL), high (200 to 499 mg/dL), or very high (≥500 mg/dL). Treatment should focus on intensive therapeutic lifestyle change, which can reduce triglycerides by 50%. The statement notes that weight loss of 5% to 10% could lower triglycerides by 20%. A low carbohydrate diet that reduces sugars and fructose while increasing unsaturated fat intake may lower triglyceride levels another 10% to 20%. Eliminating trans fats, restricting saturated fats and increasing marine-based omega-3 fatty acids, in addition to aerobic activity, help triglyceride-lowering efforts.

Medication's role in triglyceride levels lacks evidence from clinical trials, according to the statement. First, clinicians should rule out medications such as hormone therapy and conditions such as diabetes as potential causes of high triglycerides. Women of reproductive age who develop hypertriglyceridemia while taking oral contraceptive therapy should consider contraceptive products that contain less estrogen, or other sforms of birth control. Postmenopausal women with hypertriglyceridemia who require postmenopausal hormone preparations may consider transdermal preparations that blunt the triglyceride increases seen in oral drugs.

Triglyceride-lowering medications to prevent pancreatitis in those with triglyceride levels above 500 mg/dL are a reasonable addition to intensive therapeutic lifestyle change, according to the statement. Those with a history of triglyceride-induced pancreatitis should keep triglyceride levels well controlled through lifestyle and drugs.

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New Alzheimer's guidelines redefine stages, set biomarkers for future research

New guidelines on Alzheimer's disease describe new stages, including a pre-clinical stage, and suggest new biomarkers for research purposes.

The National Institute on Aging and the Alzheimer's Association issued three papers that update the last set of guidelines from 1984. The new guidelines were published online and will appear in the May issue of Alzheimer's and Dementia: The Journal of the Alzheimer's Association:

Three stages identified by the new criteria are pre-clinical Alzheimer's disease, mild cognitive impairment due to Alzheimer's disease, and dementia due to Alzheimer's disease. Pre-clinical Alzheimer's disease is marked by measurable changes in biomarkers that indicate the earliest signs of disease, before symptoms such as memory loss and confusion about time or place are noticeable. While the criteria and guidelines identify this as a stage of Alzheimer's disease, they do not establish diagnostic criteria. Rather, they propose additional research into what tests might confirm that a person is in this or another stage of the disease, such as brain imaging strategies and spinal fluid proteins.

The definition of mild cognitive impairment due to Alzheimer's disease includes mild changes in memory and thinking that are noticeable to the person and to family members and friends and that can be measured, but that do not affect daily function. The guidelines define four levels of certainty for ruling out other causes and arriving at a diagnosis of mild cognitive impairment due to Alzheimer's disease. Markers of this stage include beta-amyloid accumulation in the brain and biomarkers showing that nerve cells in the brain are injured or actually degenerating.

Dementia due to Alzheimer's disease includes memory, thinking and behavioral symptoms that impair a person's ability to function in daily life, the workgroup concluded. The workgroup stressed that its recommendations on pre-clinical Alzheimer's disease currently have no clinical utility and are intended only for research purposes.

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Test yourself


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MKSAP Quiz: severe knee pain and swelling

A 78-year-old man with a 15-year history of osteoarthritis is evaluated for severe pain and swelling of the left knee of 4 days' duration. He also has hypertension, type 2 diabetes mellitus, and chronic kidney disease. Medications are glyburide, lisinopril, and low-dose aspirin.

mksap.jpg

On physical examination, vital signs are normal. He is unable to bear weight on the left leg because of pain. The left knee is swollen and warm, and range of motion of this joint is limited and elicits pain. There are no tophi.

Laboratory studies:

Leukocyte count 15,600/µL (15.6 × 109/L) (90% polymorphonuclear cells, 10% lymphocytes)
Glucose (random) 210 mg/dL (11.7 mmol/L)
Serum creatinine 2.2 mg/dL (167.9 µmol/L)
Serum uric acid 10.7 mg/dL (0.63 mmol/L)
Urinalysis Normal

Arthrocentesis of the left knee is performed. Synovial fluid leukocyte count is 24,000/µL (90% polymorphonuclear cells, 10% lymphocytes). Polarized light microscopy reveals intra- and extracellular monosodium urate crystals. Gram stain is negative.

Which of the following is the most appropriate treatment for this patient?

A) Allopurinol
B) Colchicine
C) Ibuprofen
D) Intra-articular methylprednisolone
E) Prednisone

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

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Women's health


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Drospirenone contraceptives associated with more VTE

Oral contraceptives containing drospirenone are associated with a higher risk of venous thromboembolism than those with levonorgestrel, according to two new studies.

In the first study, 186 newly diagnosed idiopathic cases of venous thromboembolism (VTE) were identified among American women aged 15 to 44 who had received an oral contraceptive containing either drospirenone or levonorgestrel. These cases were matched to 681 controls. A case-control analysis found that drospirenone was associated with a more than twofold higher risk of VTE compared to levonorgestrel. The study also included a cohort analysis finding that incident rates for VTE were 30.8 per 100,000 patient-years with drospirenone and 12.5 per 100,000 patient-years with levonorgestrel.

After adjusting for age, researchers found an increased VTE incidence rate of 2.8 (95% CI, 2.1 to 3.8) with drospirenone compared to levonorgestrel. The increased risk remained when findings were adjusted for risk factors including being a new user of the pill, being obese and having a history of menstrual disorders. The findings differ from some prior research on drospirenone, the authors noted, possibly because the other studies have included non-idiopathic VTE and additional contraceptives shown to carry higher VTE risk, such as cyproterone and desogestrel.

A second similar study, also published online by BMJ on April 21, included 61 cases of idiopathic VTE and 215 matched controls from the United Kingdom General Practice Database. This study found an increased odds ratio for VTE of 3.3 associated with drospirenone compared to levonorgestrel after adjustment for body mass index. The crude incidence rate was 23.0 VTEs per 100,000 patient-years with drospirenone and 9.1 per 100,000 patient-years for levonorgestrel.

Based on their results and other studies finding no clear evidence of additional benefits (such as treatment of acne or premenstrual syndrome) from drospirenone, the authors of the second study concluded that the older contraceptive, levonorgestrel, should be women's first-line choice for oral contraception. The authors of the U.S. study agreed that drospirenone contraceptives (which are sold under the brand name Yasmin) should not be the first choice, as they do not appear to be as safe as levonorgestrel with respect to VTE. They called for additional studies and a systematic review to confirm their findings.

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Cardiology


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Beta-blocker use after hospital discharge appears beneficial in severe acute heart failure

Patients with severe acute heart failure appear to benefit from beta-blocker therapy after hospital discharge, a new study reports.

Researchers performed a post hoc analysis of data from the SURVIVE trial to determine whether maintaining or starting beta-blocker therapy during hospitalization for severe acute heart failure would affect long- or short-term survival after discharge. Patients in the SURVIVE trial all had severe heart failure, defined as inadequate response to intravenous diuretic or vasodilators and at least one of the following characteristics: oliguria not related to hypovolemia, dyspnea at rest or need for mechanical ventilation, or hemodynamic impairment with pulmonary artery catheter use plus requirement for intravenous inotropic support. Outcome measures were all-cause mortality 31 and 180 days after discharge with or without beta-blocker use at study entry and/or at discharge. The study results were published in the May Critical Care Medicine.

A total of 1,104 patients survived to hospital discharge and had data available on beta-blocker use. The 549 patients who were taking beta-blockers at study entry and at discharge had statistically significantly lower mortality rates at 31 days and 180 days (P<0.001 for both) than the 259 patients who were not taking beta-blockers at either time point. When the association was adjusted for age and comorbid conditions, the P values were 0.006 at 30 days and 0.003 at 180 days. In unadjusted analyses but not in adjusted analyses, the 40 patients who were taking beta-blockers at study entry but not at discharge had a higher mortality risk than those taking beta-blockers at both time points. The 259 patients who were not taking beta-blockers at either time point and patients taking beta-blockers only at study entry had a similar mortality risk.

The authors noted that the study was retrospective and that data on beta-blocker use did not include information on aspects such as dose, among other limitations. Prospective trials are needed, they said, to determine whether and how the discharge dose of beta-blockers affects outcomes and whether any beta-blocker is superior to others. However, they concluded that beta-blocker therapy at hospital admission and discharge improves both long- and short-term outcomes in patients with severe acute heart failure, and that withdrawing such therapy at hospital admission has a detrimental effect. The author of an accompanying editorial agreed, writing, "There is solid support for prescribing b-blockers, titrating to maximal tolerated doses, and continuing therapy even during acute exacerbations in patients with heart failure."

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FDA news


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Opioid manufacturers told to develop physician, patient education

As part of a new federal effort to reduce prescription drug abuse in the U.S., the FDA will begin requiring a Risk Evaluation and Mitigation Strategy (REMS) for all extended-release and long-acting opioid medications.

The new REMS plan focuses primarily on educating doctors about proper pain management, patient selection and other requirements, and improving patient awareness about how to use the drugs safely. "The prescriber education component of this Opioid REMS balances the need for continued access to these medications with stronger measures to reduce their risks," said FDA Commissioner Margaret A. Hamburg, MD.

Although doctor training is not mandatory under the REMS plan, other federal agencies are working to get Congress to link mandatory physician training to the already required Drug Enforcement Administration registration number for prescribing controlled substances, according to an FDA press release.

Doctor training, patient counseling, and other risk reduction measures developed by opioid makers as part of the REMS are expected to become effective by early 2012. They will be required for drugs including hydromorphone, oxycodone, morphine, oxymorphone, methadone, transdermal fentanyl and transdermal buprenorphine.

Elements of the overall federal plan, which is called Epidemic: Responding to America's Prescription Drug Abuse Crisis, include:

  • expansion of state-based prescription drug monitoring programs,
  • recommending convenient and environmentally responsible ways to remove unused medications from homes,
  • supporting education for patients and clinicians, and
  • reducing the number of "pill mills" and doctor-shopping through law enforcement.

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From the College


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Winner announced in ACP's Recruit-a-Colleague Program

Everard N. Barton, FACP, of Mona Kingston, Jamaica, has been selected as the winner in the 2010-2011 Recruit-a-Colleague Program grand prize drawing for a trip to Internal Medicine 2012 in New Orleans, La.

More information about the Recruit-a-Colleague Program is online.

Top


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ICD-10/version 5010 readiness assessment available

ACP is making available to its members a readiness assessment tool developed by CMS to gauge the health care industry's awareness of, and preparation for, the transition to ICD-10 and version 5010.

The survey measures industry progress toward key milestones. Your participation is voluntary, and responses are anonymous and will not be linked to your identity or e-mail address. To participate in this 15-minute web survey by April 29, 2011, please click here.

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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-20110426-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) Intra-articular methylprednisolone. This item is available to MKSAP 15 subscribers as item 5 in the Rheumatology section.

This patient has gout, which manifests as acute, intermittent attacks of severe pain, redness, and swelling of a joint accompanied by intracellular urate crystals seen on polarized light microscopy of the synovial fluid. The most appropriate treatment for this patient is an intra-articular corticosteroid injection. Early attacks of gout are typically monoarticular and usually involve a joint in the lower extremities, particularly the first metatarsophalangeal joint. Affected joints may be exquisitely tender to the touch and have a painful range of motion. Gout also is associated with an inflammatory synovial fluid leukocyte count during an acute attack and an elevated serum uric acid level, although many patients with hyperuricemia do not develop gout.

Intra-articular corticosteroid injection has been shown to rapidly treat acute gout. This therapy is particularly useful in patients in whom NSAIDs or oral or parenteral corticosteroids are contraindicated. Furthermore, local injection therapy with a corticosteroid only minimally affects glycemic control. However, infectious arthritis must be excluded before this treatment is administered.

Allopurinol would help to decrease this patient's uric acid level. However, use of uric acid–lowering agents during an acute attack does not ameliorate the attack of gout and may prolong an attack or cause a more frequent attack rate. Furthermore, allopurinol may cause a rare but serious hypersensitivity syndrome in patients who have renal insufficiency. Therefore, this agent should be used with caution starting at a low dose in this population group.

Effective treatment of acute attacks of gout involves high-dose therapy with NSAIDs, corticosteroids, or colchicine. Immediately initiating NSAID treatment at anti-inflammatory doses is most likely more important than the specific agent used. However, NSAIDs are contraindicated in this patient because of his chronic kidney disease.

Colchicine is most effective for the treatment of acute gout when used within the first 24 hours of symptom onset but would be less efficacious in this patient, whose symptoms began 4 days ago. This agent is associated with potential bone marrow toxicity, particularly in patients with renal insufficiency.

Corticosteroids may be given orally, intramuscularly, or by intra-articular injection. These agents have similar efficacy to NSAIDs, but a high-dose oral or parenteral corticosteroid may exacerbate this patient's diabetes mellitus and is therefore relatively contraindicated.

Key Point

  • Intra-articular injections of corticosteroids have been shown to be effective in the treatment of acute gout attacks and are useful in patients who cannot take NSAIDs or oral and parenteral corticosteroids.

Click here to return to the rest of ACP InternistWeekly.

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A 72-year-old woman is evaluated during a routine examination. She has very severe COPD with multiple exacerbations. She has dyspnea at all times with decreased exercise capacity. She does not have cough or any change in baseline sputum production. She is adherent to her medication regimen, and she completed pulmonary rehabilitation 1 year ago. She quit smoking 1 year ago. Her medications are a budesonide/formoterol inhaler, tiotropium, and an albuterol inhaler as needed. Following a physical and pulmonary exam, what is the most appropriate next step in management?

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