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

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ACP InternistWeekly



In the News for the Week of 5-17-11




Highlights

Choice of third oral diabetes drug can depend on each patient's needs

There is no clear choice for a third oral agent for controlling A1c levels above 7% following metformin and a sulfonylurea, researchers concluded from a meta-analysis of type 2 diabetics, so the best choice depends on the patient's need. More...

Physicians wary of commercially supported CME, but loath to cut it

Medical professionals are concerned about commercial bias from industry-supported continuing medical education programs, but they underestimate the costs of putting on such events and are unwilling to pay higher fees to offset or eliminate event costs. More...


Test yourself

MKSAP Quiz: Abdominal pain and loose stools in ulcerative colitis

A 32-year-old man is evaluated in the emergency department for a 5-day history of worsening crampy abdominal pain and eight to ten loose bowel movements a day. The patient has a 5-year history of ulcerative colitis treated with azathioprine and topical mesalamine, and recently had sinusitis that resolved with antibiotic therapy. What is the most appropriate next step in the management of this patient? More...


Cardiology

Short-term NSAIDs associated with increased myocardial infarction risk after previous heart attacks

Even short-term treatment with most nonsteroidal anti-inflammatory drugs was associated with increased risk of death and a subsequent myocardial infarction in patients with prior heart attacks, reports a national cohort population study from Denmark. More...


Pain management

Nerve blockade most effective option for managing pain after hip fracture

Nerve blockade is the most effective option for managing pain after hip fracture, according to a review funded by the Agency for Healthcare Research and Quality. More...


Gastroenterology

Colonoscopy may be more frequent than recommended in Medicare patients

Medicare patients may be receiving colonoscopies more frequently than recommended by guidelines, according to a new study. More...


Educational opportunities

National Health Service Corps scholarship application cycle opens

The 2011-2012 application cycle is now open for National Health Service Corps awards scholarships, offered each year to students pursuing careers in primary care. More...


From the College

ACP wants your opinion on virtual communities

ACP is investigating whether to provide members who have similar interests the opportunity to exchange ideas, information and experiences, and to stay connected with one another through online virtual communities and/or live meetings. 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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Choice of third oral diabetes drug can depend on each patient's needs

There is no clear choice for a third oral agent for controlling A1c levels above 7% following metformin and a sulfonylurea, researchers concluded from a meta-analysis of type 2 diabetics, so the best choice depends on the patient's need.

All the third-line agents decreased hemoglobin A1c levels about equally when added to metformin and a sulfonylurea, without any clear between-drug differences. Insulin was associated with more weight gain and hypoglycemia.

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Researchers looked at primary change in A1c level, change in weight, and frequency of severe hypoglycemia in 18 trials that included 4,535 participants. Compared with placebo, drug classes did not differ in effect on A1c level (reduction ranging from −0.70% [95% credible interval {CrI}, −1.33% to −0.08%] for acarbose to −1.08% [CrI, −1.41% to −0.77%] for insulin). Results appeared in the May 17 issue of Annals of Internal Medicine.

In a pooled analysis (9 trials), the addition of a third agent led to a mean reduction of −0.96% in A1c level with statistically significant between-study heterogeneity (I2=63.7%; P=0.005). Change in A1c level was seen with each drug, varying from -0.6% for acarbose to −1.15% for thiazolidinediones.

Weight increase was seen with insulins (2.84 kg [CrI, 1.76 to 3.90 kg]) and thiazolidinediones (4.25 kg [CrI, 2.76 to 5.66 kg]). Weight loss was seen with glucagon-like peptide-1 agonists (−1.63 kg [CrI, −2.71 to −0.60 kg]), but they also were associated with more severe hypoglycemic reactions than any other drug class except insulin. Insulins (human and analogue) caused twice the absolute number of severe hypoglycemic episodes than noninsulin antihyperglycemic agents.

"It is common in clinical practice to initiate insulin therapy after failure of therapies of 2 oral antihyperglycemic agents," the authors wrote. "In direct and network comparisons, insulins did not differ from other drug classes in their ability to decrease [hemoglobin] A1c levels, although the point estimate of effect was slightly greater for insulins in our analysis of trials directly comparing insulins with other drug classes."

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Physicians wary of commercially supported CME, but loath to cut it

Medical professionals are concerned about commercial bias from industry-supported continuing medical education (CME) programs, but they underestimate the costs of putting on such events and are unwilling to pay higher fees to offset or eliminate event costs.

Drug and device makers support up to 60% of accredited CME costs in the U.S., but in 2007, physicians spent an average of slightly more than $1,400 per year for CME. Commercial-free events would have cost about $3,500.

To assess clinician attitudes about commercially supported CME, researchers delivered a structured questionnaire to 1,347 participants at five live one-day educational courses designed for physicians and other clinicians (such as nurses, nurse practitioners, and physician assistants) delivered by the International AIDS Society-USA (IAS-USA) from January through June 2009. IAS-USA requires that commercially supported programs receive unrestricted educational grants from several companies with competing products.

Participants were recruited through morning podium announcements. Results appeared in the May 9 Archives of Internal Medicine.

Of 770 respondents (a 57% response rate), 378 (55%) were physicians; 242 (35%) were registered nurses, nurse practitioners, or physician assistants; and the rest had PhDs or other academic degrees.

Most (88%) believed that commercial support introduces bias, with greater amounts of support introducing greater risk of bias. Of 365 physicians who answered the question, 27 (7%) thought there was moderate or large potential bias in activities without commercial funding. As the funding increased, so did the level of suspicion: At 20% industry support, it was 156 of 341 physicians (46%); at 60% industry support, it was 273 of 343 (80%); and at 80% industry support, it was 300 of 351 (86%). Respondents also perceived greater potential bias from single-company support than from multicompany support.

Respondents also perceived significant potential bias from commercial support of the conference faculty. Most physicians (265 of 361 [73%]) perceived moderate to large bias from faculty members on commercial speakers' bureaus and from faculty receiving research support from industry (247 of 362 [68%]) compared with faculty who received no funding from pharmaceutical/medical device companies (18 of 361 [5%]).

Only 15%, however, supported elimination of commercial support from CME activities, and fewer than half (42%) of all attendees (169 of 369 physicians [46%], 125 of 307 others [41%]) were willing to pay increased registration fees to decrease or eliminate commercial support. Registration cost was reported as an important factor for physicians (286 of 372 [77%]) in choosing CME activities, and 208 of 370 (56%) agreed or strongly agreed that commercial support is essential for accredited CME and should not be eliminated.

Of the strategies listed to decrease costs, physicians most strongly supported using online instead of printed syllabi (203 of 366 [56%]), attending at a less desirable venue (184 of 365 [50%]) and cutting free food or snacks (180 of 364 [50%]). They also underestimated the actual costs of providing lunch and coffee at events. The least desirable strategies for decreasing costs were to provide fewer topics and speakers (41 of 363 [11%]) or to credit fewer CME hours (54 of 364 [15%]).

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Test yourself


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MKSAP Quiz: Abdominal pain and loose stools in ulcerative colitis

A 32-year-old man is evaluated in the emergency department for a 5-day history of worsening crampy abdominal pain and eight to ten loose bowel movements a day. The patient has a 5-year history of ulcerative colitis treated with azathioprine and topical mesalamine; before this episode, he had one or two bowel movements of well-formed stool a day. The patient had sinusitis recently, which resolved with antibiotic therapy. He has otherwise been healthy and has not traveled recently, had contact with sick persons, or been noncompliant with medication.

mksap.jpg

On physical examination, the temperature is 38.3 °C (101 °F), the blood pressure is 130/76 mm Hg sitting and 105/60 mm Hg standing, the pulse rate is 90/min sitting and 120/min standing, and the respiration rate is 18/min. The abdomen is diffusely tender without rebound or guarding. Laboratory studies reveal hemoglobin 12.3 g/dL (123 g/L), leukocyte count of 28,000/µL (28 × 109/L) with 15% band forms, and platelet count of 234,000/µL (234 × 109/L). Intravenous fluids are started and stool studies are obtained.

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

A) Increase dosage of azathioprine
B) Start oral vancomycin
C) Start oral mesalamine
D) Small-bowel radiographic series

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

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Cardiology


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Short-term NSAIDs associated with increased myocardial infarction risk after previous heart attacks

Even short-term treatment with most nonsteroidal anti-inflammatory drugs (NSAIDs) was associated with increased risk of death and a subsequent myocardial infarction (MI) in patients with prior heart attacks, reports a national cohort population study from Denmark.

Because patients may unavoidably receive NSAID treatment for a short period of time despite existing precautions in those with established cardiovascular disease, researchers studied the duration of NSAID treatment and cardiovascular risk. Patients 30 years of age or older admitted for a first MI from 1997 to 2006 and their subsequent NSAID use were identified using ICD codes and pharmacy records. Results appeared online May 9 in Circulation.

Of the 83,677 patients discharged alive after their first heart attack, 42.3% received NSAIDs during follow-up. There were 35,257 deaths or recurrent MIs.

NSAIDs were significantly associated with an increased risk of death/recurrent MI (hazard ratio [HR], 1.45) at the beginning of the treatment, and the risk persisted throughout the treatment course (HR, 1.55). Diclofenac was associated with the highest risk (HR, 3.26 for death/MI at day 1 to 7 of treatment). Rofecoxib was associated with increased risk of death after treatment from 7 to 14 days, while celecoxib was associated with increased risk of death after 14 to 30 days. Ibuprofen showed an increased risk when used for more than one week. Naproxen was not associated with an increased risk of death or MI for the entire treatment duration.

"It is noteworthy that a commonly used nonselective NSAID like diclofenac is associated with an even higher risk of death at the beginning of the course of treatment than the selective COX-2 inhibitor rofecoxib, which was withdrawn from the market in 2004," the authors wrote. But they later added that while naproxen had the lowest cardiovascular risk, it is associated with more gastrointestinal bleeding events.

"Our data challenge the current recommendations by the American Heart Association regarding NSAID treatment in patients with established cardiovascular disease," the authors concluded, "because we demonstrate that even short-term NSAID treatment is associated with increased cardiovascular risk in patients with prior MI; i.e., there essentially appears to be no safe therapeutic window for NSAID treatment. Therefore, the current approach of recommending short-duration treatment in patients with established cardiovascular disease who require NSAIDs may need revision."

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Pain management


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Nerve blockade most effective option for managing pain after hip fracture

Nerve blockade is the most effective option for managing pain after hip fracture, according to a review funded by the Agency for Healthcare Research and Quality.

To determine the benefits and harms of pain management options after hip fracture, researchers performed a systematic review of 83 studies published from January 1990 to December 2010, including randomized, controlled trials, nonrandomized controlled trials, and cohort studies. Included studies had to involve adults at least 50 years of age and examine a pain management intervention for hip fracture. Such interventions included nerve blockade, spinal anesthesia, systemic analgesia, traction, multimodal pain management, neurostimulation, rehabilitation, and complementary and alternative medicine. The study results were published early online May 17 by Annals of Internal Medicine.

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Study participants were mostly women (74%) and had a mean age ranging from 59 to 86 years. Thirty-one of the 83 studies excluded patients who had cognitive impairment or delirium. After review, the authors concluded that moderate evidence supported nerve blockade for relieving acute pain associated with hip fracture and preventing delirium. Preoperative traction was not found to reduce acute pain, but the evidence on this intervention was of low quality. The authors found insufficient evidence on the benefits and harms of spinal anesthesia, systemic analgesia, multimodal pain management, acupressure, relaxation therapy, transcutaneous electrical neurostimulation, and physical therapy for acute pain. They did conclude that according to the limited evidence available, acupressure, relaxation therapy, transcutaneous electrical nerve stimulation, and physical therapy seemed safe and might be effective for reducing pain.

The authors acknowledged that none of the included studies examined chronic pain outcomes or looked exclusively at nursing home residents or patients with cognitive impairment. In addition, they noted, systemic analgesics such as narcotics and NSAIDs were not adequately studied during the time period searched. However, the authors concluded that nerve blockade seems to be an effective method of controlling acute pain after hip fracture. Recommendations cannot be made on other interventions because of lack of evidence, they said.

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Gastroenterology


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Colonoscopy may be more frequent than recommended in Medicare patients

Medicare patients may be receiving colonoscopies more frequently than recommended by guidelines, according to a new study.

Expert guidelines recommend that colonoscopy be performed every 10 years in patients with normal findings on initial screening colonoscopy. Researchers studied a 5% national sample of Medicare patients from 2000 to 2008 to examine how frequently colonoscopy was repeated after a negative screening test. Colonoscopy was considered to be a negative screening examination if Medicare claims indicated only screening and if no follow-up procedure, such as a biopsy, fulguration or polypectomy, was done. Included patients were of average risk for colon cancer and had had screening colonoscopy between 2001 and 2003. The study results were published early online May 9 by Archives of Internal Medicine.

In the sample studied, 24,071 Medicare patients had a negative screening colonoscopy from 2001 to 2003. Of these, 46.2% had repeated colonoscopy in the next seven years, and of this group, 42.5% had no clear indication for early testing. Of patients who were 75 to 79 years old or at least 80 years old at the initial negative screening, 45.6% and 32.9%, respectively, had another colonoscopy within seven years.

Multivariable analyses found that patients who were male, had more comorbid conditions, and had colonoscopies performed by a high-volume colonoscopist or in an office were more likely to have early repeated tests without clear indications, while such testing was less likely in patients who were age 80 and older. Rates of early colonoscopy also varied widely by region.

The authors noted that their study was limited because information was not available on the quality of the first colonoscopy and because their results may not be generalizable to patients younger than 66 years of age or those covered by HMOs. However, they concluded that many Medicare patients receive screening colonoscopy more frequently than guidelines recommend. They pointed out that one-third of patients age 80 and older underwent screening colonoscopy without a clear indication, which is of concern because complications are more likely in older patients and they benefit less from the test. Older patients who had at least three comorbid conditions and were also therefore less likely to benefit from early removal of precancerous polyps were also more likely to be tested early.

The authors recommended that their analyses be applied to all Medicare data to help identify patterns of overuse and trigger chart audits. They also called for more patient involvement. "Given the increasing public interest in and ownership of cancer screening, public information campaigns that emphasize both the necessity for [colorectal cancer] screening as well as the dangers of overuse may prove beneficial in reducing overuse," they wrote.

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Educational opportunities


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National Health Service Corps scholarship application cycle opens

The 2011-2012 application cycle is now open for National Health Service Corps awards scholarships, offered each year to students pursuing careers in primary care. Students commit to serve in the Corps for two to four years in an underserved community located in a Health Professional Shortage Area (HSPA) upon their graduation and licensure. The deadline to apply is Thursday, June 9 at 5:00 p.m. EST.

The scholarship includes:

  • payment for tuition, required fees, and other reasonable educational costs,
  • monthly support stipend (taxable), and
  • assistance in finding a practice site.

National Health Service Corps Scholars commit to serve one year for each year of support (minimum of two years' service) at an approved site in a high-need HPSA soon after they graduate, serve a primary care residency (family medicine, general pediatrics, general internal medicine, obstetrics/gynecology or psychiatry for physicians and general or pediatric for dentists) and are licensed.

The application and program guidance are online, as are supporting documents.

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From the College


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ACP wants your opinion on virtual communities

ACP is investigating whether to provide members who have similar interests the opportunity to exchange ideas, information and experiences, and to stay connected with one another through online virtual communities and/or live meetings. Please let us know what you think by answering the seven questions in this short survey.

Top




Cartoon caption contest


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Put words in our mouth

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

acpi-20110517-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



This patient likely has Clostridium difficile antibiotic-associated colitis complicating his underlying inflammatory bowel disease. C. difficile is an anaerobic gram-positive rod that produces two toxins, both capable of damaging the mucosa of the colon and causing pseudomembranous colitis. Infectious diarrhea associated with C. difficile has emerged as a major public health concern and can be seen in patients with underlying inflammatory bowel disease. Whenever a patient with inflammatory bowel disease presents with a new flare, stool studies, including C. difficile toxin assay, should be done. This patient's recent history of antibiotic use greatly increases his risk of C. difficile infection. The fever, orthostasis, leukocytosis, and abdominal tenderness in the setting of chronic immunosuppression are all signs that he needs to be hospitalized for further investigations (for example, CT scan to rule out toxic megacolon) and to start empiric therapy. Optimal therapy is orally administered metronidazole or vancomycin and should be initiated promptly for severely ill patients.

It would be unwise to increase his immunosuppression either by adding prednisone or increasing the azathioprine in the setting of possible infection. There is no role for evaluation of the small-bowel mucosa with a small-bowel series in order to diagnose small-bowel inflammation.

Key Point

  • Infectious causes should be considered in exacerbations of diarrhea in patients with inflammatory bowel disease.

Click here to return to the rest of ACP InternistWeekly.

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Test yourself

A 76-year-old woman is evaluated for a 3-month history of left knee pain of moderate intensity that worsens with ambulation. She reports minimal pain at rest and no nocturnal pain. There are no clicking or locking symptoms. She has tried naproxen and ibuprofen but developed dyspepsia; acetaminophen provides mild to moderate relief. The patient has hypertension, hypercholesterolemia, and chronic stable angina. Medications are lisinopril, metoprolol, simvastatin, low-dose aspirin, and nitroglycerin as needed. Following a physical exam, lab results and radiograph, what is the next best step in management?

Find the answer

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