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ACP InternistWeekly



In the News for the Week of 6-14-11




Highlights

Vitamin D guidelines advise on dietary intake, screening for deficiency

New guidelines from the Endocrine Society offer recommendations on evaluation, treatment and prevention of vitamin D deficiency. More...

Major medical societies update performance measures for coronary artery disease, hypertension

New performance measures for adults with coronary artery disease and hypertension are meant to provide a patient-centered focus and give practitioners and institutions tools to measure and improve care quality. More...


Test yourself

MKSAP Quiz: 6-month history of progressive weakness

A 61-year-old man is evaluated in the office for a 6-month history of progressive weakness of the lower extremities. This week's MKSAP Quiz asks readers to determine the best diagnostic test for this patient. More...


Dermatology

Plantar wart treatment options equally effective

Cryotherapy and salicylic acid had similar, and low, rates of success in treating plantar warts, a new study found. More...


Kidney disease

Reduced kidney function, albuminuria strongly associated with atrial fibrillation

Patients with kidney damage, manifested as microalbuminuria or macroalbuminuria, or decreased kidney function had a higher atrial fibrillation risk, researchers concluded. More...


FDA update

Simvastatin to carry warning about myopathy

The cholesterol-lowering medication simvastatin will be required to carry a warning about the risk of muscle injury or myopathy, the FDA announced last week. More...


From the College

College Fellow recognized for humanism in medicine

Susan Hingle, FACP, recently received the Leonard Tow Humanism in Medicine Award from the Arnold P. Gold Foundation. More...

Former College president appointed to MedPAC

The U.S. Government Accountability Office recently announced that William J. Hall, MACP, will be one of two new members of the Medicare Payment Advisory Commission. More...

ACP offers low back pain guidelines pocket card and digital version

ACP and the International Guidelines Center have released a new Low Back Pain GUIDELINES Pocketcard™, adapted from ACP's guidelines and best practice advice. More...

Subjects sought for study of chronic kidney disease in adult type 2 diabetes patients

The National Kidney Foundation is looking for primary care physicians and their patients to participate in a multi-site cross-sectional study to estimate the prevalence of chronic kidney disease in adult type 2 diabetes patients. More...


Cartoon caption contest

And the winner is …

ACP InternistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption. More...


Physician editor: Darren Taichman, FACP




Highlights


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Vitamin D guidelines advise on dietary intake, screening for deficiency

New guidelines from the Endocrine Society offer recommendations on evaluation, treatment and prevention of vitamin D deficiency.

The guidelines, which were prepared by an expert task force guided by systematic evidence reviews, call for screening for vitamin D deficiency in at-risk individuals (including African-American, Hispanic and obese patients as well as those with conditions, medications or histories that put them at greater than normal risk) but not the population as a whole. The serum circulating 25-hydroxyvitamin D [25(OH)D] assay is recommended as the method of screening over the serum 1,25-dihydroxyvitamin D [1,25(OH)2D] assay. Deficiency is defined as a 25(OH)D level below 20 ng/mL.

To treat or prevent deficiency, the guidelines recommend vitamin D2 or D3. Adults who are deficient can be treated with 50,000 IU of D2 or D3 once a week for eight weeks or 6,000 IU daily, to achieve a 25(OH)D level above 30 ng/mL, after which they should receive maintenance therapy of 1,500 to 2,000 IU per day. Patients who are obese, have malabsorption syndromes, or take medications affecting vitamin D metabolism should take a higher dose: at least 6,000 to 10,000 IU per day, followed by maintenance therapy of 3,000 to 6,000 IU per day. For patients with extrarenal production of 1,25(OH)2D, the guidelines suggest serial monitoring of that level and serum calcium during treatment with vitamin D. They also recommend as-needed treatment and serum calcium monitoring for patients with primary hyperparathyroidism.

Adults up to age 70 should consume at least 600 IU of vitamin D per day, the guidelines say. Those over 70 should get at least 800 IU/day. However, maintaining a 25(OH)D level above the target of 30 ng/mL may require supplementation of vitamin D in the amount of 1,500 to 2,000 IU/day, the guidelines said. They called for two to three times as much vitamin D to be consumed by patients who are obese or take anticonvulsants, glucocorticoids, antifungals or medications for AIDS. The maintenance tolerable upper limit for vitamin D in healthy adults is 4,000 IU per day, although that may be exceeded under medical supervision to correct deficiency, the guidelines noted.

Prescribing vitamin D supplements for fall prevention is recommended, but giving patients more than the recommended daily amounts in order to prevent cardiovascular disease or death or to improve quality of life is not advised by the guidelines. The guidelines were published in the July 2011 Journal of Clinical Endocrinology and Metabolism. More on vitamin D and calcium supplementation is available from ACP Internist.

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Major medical societies update performance measures for coronary artery disease, hypertension

New performance measures for adults with coronary artery disease (CAD) and hypertension are meant to provide a patient-centered focus and give practitioners and institutions tools to measure and improve care quality.

The new measures from the American College of Cardiology Foundation (ACCF), the American Heart Association, and the American Medical Association's Physician Consortium for Performance Improvement (AMA-PCPI) update a set released by the three groups in 2005, and are a significant departure from them. Specifically, the new measures consider not just whether cardiac risk factors are treated but whether they are controlled to target levels. The measures appeared online June 13 at the Journal of the American College of Cardiology.

Screening for diabetes in patients with CAD was retired as a measure. While the writing committee recognized the significance of diabetes in patients with CAD, the measure was found to be difficult to implement and was not widely used. Another work group is expected to release new diabetes screening guidelines that could be a significant change from the current ones.

The 10 performance measures comprise both revisions of five measures from the 2005 set and five new measures. Measures in the updated set for coronary artery disease include:

Blood pressure control. Prescribe at least two antihypertensive medications in patients who have not reached a target blood pressure of less than 140/90 mm Hg.

Lipid control. Document a plan of care, which includes at minimum the prescription of a statin, for patients who cannot lower their LDL cholesterol below 100 mg/dL.

Symptom and activity assessment. Evaluate patients' activity level and the corresponding presence or absence of angina symptoms.

Symptom management. Document a plan of care to manage angina symptoms.

Tobacco use, screening, cessation and intervention. Screen patients for tobacco use, and provide tobacco-cessation counseling for users.

Antiplatelet therapy. Prescribe aspirin or clopidogrel for patients.

Beta-blocker therapy. Physicians should prescribe beta-blocker therapy for patients with prior myocardial infarction or a left ventricular ejection fraction of less than 40%.

ACE inhibitor/ARB therapy. Physicians should prescribe an ACE inhibitor or ARB for patients with diabetes or left ventricular ejection fraction of less than 40%.

Cardiac rehabilitation patient referral. Refer patients who have had an acute heart attack, a coronary artery bypass graft surgery, stenting, cardiac valve surgery or cardiac transplantation to an early outpatient cardiac rehabilitation program.

To treat hypertension, the new measures call for a target of under 140/90 mm Hg, and prescription of at least two antihypertensive medications for patients who have not met that.

These measures are meant to resolve some of the methodological issues associated with performance measures at the individual practitioner or practice level resulting from the socioeconomic and clinical heterogeneity of patient populations and the relatively small number of patients treated by any one practitioner or group. This measures set attempts to resolve those issues with the blood pressure and lipid control measures, as well as the symptom assessment and management measures.

The performance measures were based on updated practice guidelines and were designed to harmonize with other national measure sets. Before being used in accountability programs, including public reporting or pay-for-performance programs, they will undergo testing developed by the AMA-PCPI and by the ACCF PINNACLE Registry.

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Test yourself


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MKSAP Quiz: 6-month history of progressive weakness

A 61-year-old man is evaluated in the office for a 6-month history of progressive weakness of the lower extremities. He says he has difficulty rising from a seated position and walking up stairs and also has episodes of dry eyes, dry mouth, and erectile dysfunction. The patient reports no ptosis, diplopia, dysphagia, or dyspnea. He has a 15-year history of hypertension and a 42 pack-year smoking history. Family history is unremarkable. His only medication is hydrochlorothiazide.

On physical examination, vital signs are normal. Manual muscle strength testing shows weakness in the proximal upper and lower limb muscles. Deep tendon reflexes are absent diffusely. Plantar responses are flexor. A sensory examination shows no abnormalities, and cranial nerve function is normal.

Laboratory studies show normal serum levels of sodium, potassium, calcium, creatinine, glucose, and creatine kinase. Results of liver chemistry studies are also normal.

Which of the following is the best diagnostic test for this patient?

A) Measurement of acetylcholine receptor antibody level
B) Measurement of parathyroid hormone level
C) Measurement of voltage-gated P/Q-type calcium channel antibody level
D) Muscle biopsy

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

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Dermatology


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Plantar wart treatment options equally effective

Cryotherapy and salicylic acid had similar, and low, rates of success in treating plantar warts, a new study found.

The trial included 240 patients aged 12 and over seen by a health care professional in the United Kingdom for treatment of a plantar wart. They were randomized to receive either cryotherapy with liquid nitrogen by a clinician, up to four treatments two or three weeks apart, or self-treatment with 50% salicylic acid daily for a maximum of eight weeks. The primary outcome was complete clearance of the warts at 12 weeks, but the study also looked at clearance at six months according to patient report. The results were published online by BMJ on June 7.

The study found similar rates of clearance at 12 weeks in the two groups (17/119 or 14% for salicylic acid vs. 15/110 or 14% for cryotherapy, difference 0.65%, 95% CI –8.33 to 9.63). The results did not change when adjusted for age, previous treatment and type of wart. At six months, patients reported similar rates of clearance (31% for salicylic acid vs. 34% for cryotherapy, difference –3.15%, 95% CI –16.31 to 10.02). The study also found no difference between groups in time to clearance or the number of warts at 12 weeks.

Study authors concluded that the odds of clearance appear to be similar with either treatment. They noted that cryotherapy is associated with higher cost, so that salicylic acid might be preferable. However, the study used a higher strength of salicylic acid than is typical in front-line treatment for warts, so cryotherapy might be superior to lower concentrations of the acid, the authors said. The study also found a much lower overall cure rate than most previous research, perhaps because it included patients with more resistant types of warts and those who had already tried self-treatment, the researchers speculated.

Given the low cure rates found in this study, patients may have done just as well without any intervention, concluded the authors of an accompanying editorial. Around two-thirds of warts clear within two years without treatment, the editorialists said. They suggested that future research must look for treatments that are safe, painless and do not increase morbidity, as well as investigating the possibility that HPV-subtype-specific treatment will be more effective than current strategies.

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Kidney disease


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Reduced kidney function, albuminuria strongly associated with atrial fibrillation

Patients with kidney damage, manifested as microalbuminuria or macroalbuminuria, or decreased kidney function had a higher atrial fibrillation (AF) risk, researchers concluded.

An elevated risk of AF was observed even among individuals with mildly decreased kidney function measured by cystatin C-based glomerular filtration rate (eGFRcys), independent of lifestyle factors, cardiovascular disease, sex, race or hypertension.

In the Atherosclerosis Risk in Communities (ARIC) Study, 10,328 men and women ages 45 to 64 were recruited from four geographically disparate U.S. regions from 1996 to 1998. Participants had four exams, a baseline and three more three years apart. Results appeared online June 6 at Circulation.

Atrial fibrillation was ascertained through the end of 2007 by hospital discharge codes and death certificates. During a median follow-up of 10.1 years, 788 atrial fibrillation cases occurred.

Lower levels of eGFRcys were associated with a higher risk of AF, even after adjustment for potential confounders. Compared to patients with eGFRcys of at least 90 mL • min–1 • 1.73 m–2, patients with National Kidney Foundation classification eGFRcys levels of 60 to 89, 30 to 59, and 15 to 29 mL • min–1 • 1.73 m–2 had multivariable hazard ratios for AF of 1.3, 1.6 and 3.2 (P for trend<0.0001), respectively.

Microalbuminuria and macroalbuminuria were associated with a higher risk, as well. Compared with patients with an albumin-to-creatinine ratio (ACR) less than 30 mg/g, those with an ACR of 30 to 299 mg/g had twice the risk of AF, and for an ACR of 300 mg/g or greater, the risk was increased 3.2 times.

Risk of AF was particularly elevated in those with both low eGFRcys and macroalbuminuria (hazard ratio, 13.1, comparing individuals with ACR≥300 mg/g and eGFRcys of 15 to 29 mL • min–1 • 1.73 m–2 and those with ACR<30 mg/g and eGFRcys≥90 mL • min–1 • 1.73 m–2).

"Given the growing burden of CKD in the general population and the potential for its prevention, future studies should focus on understanding the specific mechanisms underlying this association," the authors wrote. "Furthermore, strategies for the prevention of AF will have to consider CKD as a preventable risk factor for AF in addition to other well-established risk factors."

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FDA update


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Simvastatin to carry warning about myopathy

The cholesterol-lowering medication simvastatin will be required to carry a warning about the risk of muscle injury or myopathy, the FDA announced last week.

The warning is based on an FDA safety review finding that 80 mg, the highest approved dose of the drug, has been associated with an elevated risk of myopathy. The review, which included the Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine and adverse event reports, showed that patients taking simvastatin, 80 mg daily, had an increased risk of muscle injury compared to patients taking lower doses of simvastatin or other statins. The risk of muscle injury is highest during the first year of treatment, is often the result of interactions with certain other medicines, and is frequently associated with a genetic predisposition for simvastatin-related muscle injury, according to an FDA news release.

According to the new label, simvastatin, 80 mg, should be used only in patients who have been taking that dose for 12 months or more and have not experienced any muscle toxicity. Patients who are unable to adequately lower their cholesterol on 40 mg of simvastatin should not be given an 80-mg dose. Instead, they should try an alternative treatment, the FDA said. The label also lists new contraindications and dose limitations for when simvastatin is taken with certain other medications that interact to increase the level of simvastatin in the body.

Simvastatin is sold under the brand name Zocor and as a single-ingredient generic product. It is also sold in combination with ezetimibe as Vytorin and in combination with niacin as Simcor.

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From the College


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College Fellow recognized for humanism in medicine

Susan Hingle, FACP, recently received the Leonard Tow Humanism in Medicine Award from the Arnold P. Gold Foundation. The award is given annually to one graduating medical student and one faculty member at participating medical schools nationwide, in recognition of outstanding compassion in delivering care; respect for patients, their families, and health care colleagues; and clinical excellence.

Dr. Hingle is an associate professor of clinical medicine, clerkship director, associate residency program director, and associate doctoring director at the Southern Illinois University School of Medicine in Springfield. More information about the award is available online.

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Former College president appointed to MedPAC

The U.S. Government Accountability Office recently announced that William J. Hall, MACP, will be one of two new members of the Medicare Payment Advisory Commission (MedPAC).

Dr. Hall is a geriatrician and professor of medicine at the University of Rochester School of Medicine, where he directs the Highland Hospital Center for Healthy Aging. Dr. Hall was president of the College in 2001-2002. The other new member of the commission is Willis D. Gradison Jr., MBA, a scholar in residence in the Health Sector Management Program at Duke University's Fuqua School of Business. Their terms will expire in 2014.

Congress established MedPAC in 1997 to analyze access to care, cost and quality of care, and other key issues affecting Medicare, according to a GAO press release. MedPAC advises Congress on payments to health plans participating in the Medicare Advantage program and clinicians in Medicare's traditional fee-for-service programs.

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ACP offers low back pain guidelines pocket card and digital version

ACP and the International Guidelines Center have released a new Low Back Pain GUIDELINES Pocketcard™, adapted from ACP's guidelines and best practice advice.

The Pocketcard™ is packed with essential information on assessment, diagnosis and management to be used in clinical decision-making, teaching, and quality and performance initiatives. The eGuidelineViewer™, the digital version of the GUIDELINES Pocketcard™, is available for desktop or tablet platforms.

ACP members can receive 10% off the purchase of the Pocketcard™ and eGuidelineViewer™ by using the discount code DCACP11. To order the Pocketcard™, go here. To order the eGuidelineViewer, go here.

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Subjects sought for study of chronic kidney disease in adult type 2 diabetes patients

The National Kidney Foundation is looking for primary care physicians and their patients to participate in a multi-site cross-sectional study to estimate the prevalence of chronic kidney disease in adult type 2 diabetes patients.

Patients and physicians will be compensated for their time. Commitment is one office visit for each participant. Those who are interested can learn more online.

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Cartoon caption contest


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And the winner is …

ACP InternistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

acpi-20110614-cartoon.jpg

"I wanted to evaluate your prostate, not evaluate you prostrate."

This issue's winning cartoon caption was submitted by David Y. Gelman, ACP Member. Readers cast 82 ballots online to choose the winning entry. Thanks to all who voted! The winning entry captured 58.5% of the votes.

The runners-up were:

"In an orthopod's office, you can hide, but you can't run."

"I believe in a patient-centered medical home, but you don't need to do the floors."

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MKSAP Answer and Critique



The correct answer is C) Measurement of voltage-gated P/Q-type calcium channel antibody level. This item is available to MKSAP 15 subscribers as item 10 in the Neurology section.

This patient most likely has Lambert-Eaton myasthenic syndrome, as suggested by his history of proximal upper and lower limb weakness, the presence of autonomic symptoms (dry eyes/mouth, erectile dysfunction), and the finding of absent deep tendon reflexes on examination. These are characteristic signs and symptoms of the syndrome. Lambert-Eaton myasthenic syndrome is a neuromuscular junction disorder caused by disordered calcium channel function on the presynaptic nerve terminal. In most patients with this disorder, antibodies to voltage-gated P/Q-type calcium channel receptors exist. Lambert-Eaton myasthenic syndrome is typically a paraneoplastic syndrome, caused by or associated with an underlying malignancy, particularly small cell lung cancer. The diagnosis of Lambert-Eaton myasthenic syndrome precedes the clinical diagnosis of cancer in up to 50% of affected patients; therefore, in patients with newly diagnosed Lambert-Eaton myasthenic syndrome, a thorough search for an underlying cancer should be performed. If no evidence of malignancy is found, these patients should be evaluated serially for occult malignancy. In addition to elevated levels of voltage-gated P/Q-type calcium channel antibodies, the diagnosis can be confirmed through electrodiagnostic studies, particularly repetitive nerve stimulation studies, which show an increase in the muscle action potential (increment) after brief exercise.

Elevated levels of antibodies against acetylcholine receptors are present in 90% of patients with generalized myasthenia gravis. Myasthenia gravis is an autoimmune disorder that results in neuromuscular transmission failure, causing weakness of limb and cranial muscles. The diagnosis is confirmed through electrodiagnostic testing, including repetitive nerve stimulation studies and, in some patients, single-fiber electromyography. The presence of an elevated acetylcholine receptor antibody level may provide additional confirmatory evidence supporting the diagnosis of myasthenia gravis. In this patient, the absence of any bulbar signs or symptoms, such as ptosis, visual symptoms (blurred vision or diplopia), or dysphagia, in conjunction with absent deep tendon reflexes, would argue against myasthenia gravis.

Hyperparathyroidism, either primary or secondary, can result in proximal limb weakness. The normal calcium level in this patient would argue against a significant parathyroid disorder. Additionally, absent deep tendon reflexes would not be expected in a patient with hyperparathyroidism. Measurement of the parathyroid hormone level is therefore not indicated.

Muscle biopsy is not likely to offer any additional diagnostic information in this patient with normal serum creatine kinase levels. Muscle biopsy is indicated primarily in patients with suspected inflammatory myopathies, such as polymyositis, dermatomyositis, or inclusion body myositis, and in certain hereditary myopathic disorders. Symptom onset in the seventh decade argues against a hereditary myopathy, as does the normal creatine kinase level. Although serum creatine kinase levels can be normal in patients with inclusion body myositis, deep tendon reflexes are typically normal, and weakness is most prominent in quadriceps and deep finger flexor muscles.

Key Point

  • The diagnosis of Lambert-Eaton myasthenic syndrome, a neuromuscular junction disorder that causes progressive proximal muscle weakness and areflexia, precedes the clinical recognition of cancer in up to 50% of patients.

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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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