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

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ACP InternistWeekly



In the News for the Week of 6-28-11




Highlights

High-dose statins associated with more diabetes risk

Higher-dose statin therapy increased patients' risk of developing diabetes more than moderate-dose regimens, a new meta-analysis found. More...

ACOG guidelines encourage use of IUDs, implants

Intrauterine devices and contraceptive implants are the most effective forms of reversible contraception available and are safe for almost all women, according to new guidelines from the American College of Obstetricians and Gynecologists. More...


Test yourself

MKSAP Quiz: a 5-day history of knee pain and swelling

A 69-year-old woman is evaluated for a 5-day history of pain and swelling in the right knee that developed after a prolonged period of gardening in her backyard. This week's MKSAP question asks readers to determine the most likely diagnosis. More...


Cardiology

Tool helps estimate heart failure patients' risk for low quality of life

Researchers have designed a simple tool to help recognize heart failure patients who, at the time of hospital discharge, are at high risk for death or a persistently unfavorable quality of life. More...


Stroke

43% of ischemic stroke patients discharged with high blood pressure

Forty-three percent of patients hospitalized with acute ischemic stroke were discharged with elevated blood pressure, and 33% had uncontrolled blood pressure six months later, a new analysis found. More...


FDA update

Warning about varenicline in patients with CVD

A warning will be added to smoking cessation aid varenicline (Chantix) to indicate that the drug may be associated with a small increased risk of certain cardiovascular adverse events in patients who have cardiovascular disease, the FDA announced last week. More...


From the College

ACP's John Tooker, MACP, blogs at KevinMD

John Tooker, MACP, ACP's associate executive vice president, continues his monthly column at KevinMD.com, one of the Web's most influential medical blogs. More...

Global health course featuring ACP leadership and policy in Italy this summer

ACP members are invited to participate in the European Genetics Foundation's summer course in Comparative Health: The Reforms of the Health Care Systems in a Globalized World, co-directed by ACP's associate executive vice president John Tooker, MACP, MBA, and featuring an array of international speakers. More...

ACP launches interactive benefit guide for members

ACP last week launched the Interactive Benefit Guide, a new tool to present the benefits of ACP membership. 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...

Editorial note: ACP InternistWeekly will not be published next week due to the Independence Day holiday.


Physician editor: Darren Taichman, FACP




Highlights


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High-dose statins associated with more diabetes risk

Higher-dose statin therapy increased patients' risk of developing diabetes more than moderate-dose regimens, a new meta-analysis found.

The analysis included five randomized controlled trials comparing intensive-dose statin therapy (80 mg of simvastatin or atorvastatin) with moderate-dose therapy. The trials had 32,752 participants, all of whom were without diabetes at baseline. Over the course of the trials, 2,749 people developed diabetes: 1,449 from the intensive group and 1,300 from the moderate-dose group. That difference worked out to two additional cases per 1,000 patient-years in the intensive group and an increased odds ratio for developing diabetes of 1.12 (95% CI, 1.04 to 1.22). However, patients in the intensive group were less likely to experience cardiovascular events (3,134 vs. 3,550, 6.5 fewer events per 1,000 patient-years, odds ratio of 0.84 [95% CI, 0.75 to 0.94]).

Researchers calculated that, with intensive therapy, the number needed to harm for diabetes incidence was 498, while the needed to treat to prevent a cardiovascular event was 155. The results confirm recent evidence of an increased incidence of diabetes with statin therapy and indicate a dose-dependent association, the authors said. However, the mechanism is still unknown and it's unclear whether the risk applies to all patients or only specific groups. The authors concluded, "Given that cardiovascular risk from diabetes is modest in the first decade after diagnosis, and as the benefit of statin therapy increases over time and in absolute terms with increasing age, net cardiovascular benefit in high-risk individuals will still strongly favor statin therapy."

They recommended that future research investigate the effect of intensive statins on patients with established diabetes, and that clinicians watch carefully for the development of diabetes in patients on intensive therapy. A registry could also be helpful in evaluating long-term effects of the regimen, the authors suggested. The study appeared the June 22/29 Journal of the American Medical Association.

The FDA recently recommended against starting patients on 80-mg doses of simvastatin due to the risk of myopathy.

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ACOG guidelines encourage use of IUDs, implants

Intrauterine devices (IUDs) and contraceptive implants are the most effective forms of reversible contraception available and are safe for almost all women, according to new guidelines from the American College of Obstetricians and Gynecologists (ACOG).

The specialty organization released a practice bulletin offering guidance on patient selection and clinical issues related to the three methods of long-acting reversible contraception: copper and levonorgestrel IUDs and the etonogestrel single-rod contraceptive implant. These methods are associated with lower pregnancy rates and lower costs than many other contraceptive methods but use of them is low in the United States, perhaps due to lack of knowledge, according to an ACOG press release.

All three methods have few contraindications, and almost all women, including adolescents and nulliparous women, are eligible for them, according to the guidelines. Insertion of the devices can occur at any point in the menstrual cycle. There may be an effect on menstrual bleeding (usually an increase with the copper IUD and a reduction with the levonorgestrel) and women should be so advised. For women at high risk of sexually transmitted infections, it is reasonable to screen for sexually transmitted infections and place an IUD on the same day, the guidelines said. All of the preceding recommendations were based on Level C evidence (consensus and expert opinion).

The guidelines offered two recommendations based on good and consistent scientific evidence (Level A): before IUD insertion, antibiotic prophylaxis for pelvic infection is not recommended, and insertion of a copper IUD is the most effective method of postcoital contraception (used within five days of unprotected intercourse).

Level B recommendations (limited or inconsistent scientific evidence) related to use of the devices around pregnancy. Immediately after childbirth, IUDs are safe and effective, as are implants in non-breast-feeding women. Women who are breast-feeding should wait four weeks for an implant. Insertion of either is safe and effective after abortion or miscarriage. The recommendations were published in the July 2011 Obstetrics & Gynecology.

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Test yourself


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MKSAP Quiz: a 5-day history of knee pain and swelling

A 69-year-old woman is evaluated for a 5-day history of pain and swelling in the right knee that developed after a prolonged period of gardening in her backyard. Her pain worsens when she walks and is relieved with rest. She has no morning stiffness.

On physical examination, temperature is normal, blood pressure is 128/72 mm Hg, pulse rate is 88/min, and respiration rate is 17/min. BMI is 32. The right knee has a moderate effusion but is not warm or erythematous. Range of motion of the right knee elicits pain. The remainder of the musculoskeletal examination is normal.

Plain radiographs of the right knee show osteophytes and medial joint-space narrowing. Arthrocentesis is performed, and synovial fluid analysis reveals 250 leukocytes/µL (88% lymphocytes, 12% macrophages).

Which of the following is the most likely diagnosis?

A) Bacterial arthritis
B) Crystal-induced arthritis
C) Fungal arthritis
D) Osteoarthritis

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

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Cardiology


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Tool helps estimate heart failure patients' risk for low quality of life

Researchers have designed a simple tool to help recognize heart failure patients who, at the time of hospital discharge, are at high risk for death or a persistently unfavorable quality of life.

Current prognostic models for heart failure patients focus only on death or readmissions, but quality-of-life (QoL) prognosis can help with shared decision-making between physicians and patients, noted the authors of the study, published online June 21 by Circulation: Cardiovascular Quality and Outcomes. Researchers analyzed data from 1,458 heart failure patients in the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) trial. Baseline data, including formal health status measures, were taken for these patients within 48 hours of hospital admission as well as one week and 24 weeks after hospital discharge. Health status was measured via the Kansas City Cardiomyopathy Questionnaire (KCCQ), a 23-item self-administered questionnaire for heart failure patients with scores ranging from 0 to 100. The primary end point of the analysis was a composite of all-cause death or unfavorable QoL (defined by KCCQ <45 at weeks one and 24 after discharge).

There were 478 deaths (32.8%) and another 192 patients (13.2%) who had persistently unfavorable QoL throughout follow-up. After adjustment for 23 covariates, independent predictors of the composite end point were:

  • low baseline KCCQ score (per 10-U increase in baseline QoL: risk ratio [RR], 0.82; 95% CI, 0.78 to 0.87),
  • high B-type natriuretic peptide (500 to 999 pg/mL: RR, 1.27 [95% CI, 1.05 to 1.53]; ≥1,000 pg/mL: RR, 1.41 [95% CI, 1.14 to 1.73], both compared with ≤500 pg/mL),
  • hyponatremia (sodium 135 mEq/L: RR, 1.30 [95% CI, 1.04 to 1.62] compared with sodium 135 to 145 mEq/L),
  • increased heart rate at discharge (per 10 bpm increase: RR, 1.08 [95% CI, 1.01 to 1.15]),
  • decreased systolic blood pressure at discharge (per 10 mm Hg increase: RR, 0.92 [95% CI, 0.88 to 0.97]),
  • absence of beta-blocker therapy at discharge (beta-blocker prescribed: RR, 0.80 [95% CI, 0.64 to 0.99]),
  • history of diabetes (HR, 1.18 [95% CI, 1.01 to 1.39]), and
  • history of arrhythmia (RR, 1.32 [95% CI, 1.08 to 1.60]).

A simplified predischarge heart failure score for later death or unfavorable QoL had moderate discrimination (c-statistic 0.72), the authors noted. Study limitations include that the findings come from a retrospective, post hoc analysis of patients enrolled in a clinical trial that excluded those with end-stage heart failure and an expected survival of less than six months, thus eliminating patients at the highest risk for adverse outcomes, the authors noted. The cohort was also limited to heart failure patients with reduced left ventricular ejection fraction, and those who were younger, mostly white and more likely to be male than community heart failure populations—though it also included patients with high comorbidity, the authors noted.

Still, the results should help physicians adhere to clinical practice guidelines that recommend discussing risk with heart failure inpatients. Providing a prognosis of QoL and death, rather than readmissions and death, gives information "that most directly relates to patients' concerns and experiences," the authors noted. This information can help patients and physicians make appropriate, personalized treatment decisions going forward, they said.

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Stroke


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43% of ischemic stroke patients discharged with high blood pressure

Forty-three percent of patients hospitalized with acute ischemic stroke were discharged with elevated blood pressure, and 33% had uncontrolled blood pressure six months later, a new analysis found.

Researchers examined a sample of patients (n=3,987) who had were admitted to a Veterans Affairs Medical Center for ischemic stroke in 2007. They analyzed blood pressure control (defined as <140/90 mm Hg) at discharge, and excluded those who had died, enrolled in hospice, or had unknown discharge disposition. Another 258 patients were excluded for missing race data, leaving 3,382 patients in 129 facilities for the first analysis. Researchers also examined all antihypertensive medications prescribed at admission and discharge, and compared to see if patients received a new prescription for a drug class at discharge. In a second analysis, they looked at blood pressure control within six months after stroke, excluding those who had died, were readmitted within 30 days, were lost to follow-up, or didn't have blood pressure or race recorded (n=1,915 in 125 facilities). Results were published online June 21 by Circulation: Cardiovascular Quality and Outcomes.

About sixty-three percent of the study population was white, and 98% were men. Forty-seven percent were younger than age 65, 29% had a history of cerebrovascular disease, and 37% had a history of cardiovascular disease. Among the stroke patients in the first analysis, 43% had their last documented blood pressure before discharge as above 140/90 mm Hg. Black race (adjusted odds ratio [OR], 0.77; 95% CI, 0.65 to 0.91), diabetes (OR, 0.73; 95% CI, 0.62 to 0.86), and hypertension history (OR, 0.51; 95% CI, 0.42 to 0.63) were associated with lower odds for controlled BP at discharge.

Of the stroke patients seen within six months of their index event, 32.8% still had uncontrolled blood pressure. By six months after the event, neither race nor diabetes was associated with blood pressure control, while history of hypertension continued to predict lower odds of control. For each 10-point increase in systolic blood pressure at discharge over 140 mm Hg, the odds of control six months after discharge decreased by 12%. Receipt of a new blood pressure medication at discharge wasn't associated with improved blood pressure control at six months, possibly because sicker patients are more likely to get new prescriptions and have poor control, the authors wrote.

The study data suggest that heightened efforts to improve management of hypertension at discharge and follow-up may benefit certain subgroups of patients, given that hypertension is causally involved in nearly 70% of all stroke cases and puts patients at risk for cardiovascular events, the authors said. Secondary prevention should include efforts to start risk factor control and antihypertensive medication before discharge. Future interventions could target those at highest risk for poorly controlled blood pressure, including those with a prior diagnosis of hypertension and multiple comorbidities, including diabetes, the authors said.

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FDA update


.
Warning about varenicline in patients with CVD

A warning will be added to smoking cessation aid varenicline (Chantix) to indicate that the drug may be associated with a small increased risk of certain cardiovascular adverse events in patients who have cardiovascular disease, the FDA announced last week.

The warning is based on FDA review of a placebo-controlled trial of varenicline in 700 smokers with cardiovascular disease. Quit rates were higher in patients taking the active drug but certain cardiovascular events, including angina pectoris, nonfatal myocardial infarction, need for coronary revascularization, and new diagnosis of peripheral vascular disease or admission for a procedure for the treatment of peripheral vascular disease, were reported more frequently in patients treated with varenicline. However, the study was not designed to have statistical power to detect differences between the arms on the safety endpoints, according to an FDA press release.

The FDA recommends that clinicians weigh the known benefits of the drug against potential risks when deciding whether to use it in smokers with cardiovascular disease, given that smoking is an independent and major risk factor for cardiovascular disease, and smoking cessation is of particular importance in this patient population. Patients should be counseled to seek medical attention if they experience new or worsening symptoms of cardiovascular disease while taking the drug.

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From the College


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ACP's John Tooker, MACP, blogs at KevinMD

John Tooker, MACP, ACP's associate executive vice president, continues his monthly column at KevinMD.com, one of the Web's most influential medical blogs. This month's post looks at the public comments on the proposed rule for the creation of accountable care organizations and what the comments might mean for the final rule.

Top


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Global health course featuring ACP leadership and policy in Italy this summer

ACP members are invited to participate in the European Genetics Foundation's (EGF) summer course in Comparative Health: The Reforms of the Health Care Systems in a Globalized World, co-directed by ACP's associate executive vice president John Tooker, MACP, MBA, and featuring an array of international speakers.

This post-graduate level course will be held Aug. 29 to Sept. 2, 2011 at the Euro Mediterranean University Center of Ronzano in Bologna, Italy, and will provide an up-to-date review of the field of comparative studies of health systems and medical care. ACP and its health care reform policies will be included in the course. More information and registration for the course are online.

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ACP launches interactive benefit guide for members

ACP last week launched the Interactive Benefit Guide, a new tool to present the benefits of ACP membership.

Available online in mobile Web and full Web formats, the guide presents benefits for Members and Fellows in an engaging, task-oriented format. The easy-to-navigate guide gives access to the many ACP programs and publications that support members' clinical needs and professional development. Information can be saved for future reference with the My Library feature. The College invites members to explore this new resource and ensure they are getting the most value from ACP membership.

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Cartoon caption contest


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Put words in our mouth

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

acpi-20110628-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) Osteoarthritis. This item is available to MKSAP 15 subscribers as item 10 in the Rheumatology section.

This patient most likely has osteoarthritis of the knee. Osteoarthritis may manifest as acute monoarticular arthritis and is usually noninflammatory. This condition is characterized by pain on activity that is relieved with rest and most commonly involves the proximal and distal interphalangeal and first carpometacarpal joints of the hands as well as the weight-bearing joints such as the knees and hips. Range of motion of the involved joint in patients with osteoarthritis is usually painful and may be limited. This patient's radiographic findings of joint-space narrowing and osteophytes are consistent with osteoarthritis. The synovial fluid leukocyte count in patients with osteoarthritis is typically between 200 and 2,000/µL and may be associated with a predominance of lymphocytes.

Bacterial, crystal-induced, and fungal arthritis also may manifest as monoarticular arthritis. However, these conditions typically are associated with inflammation and would typically cause morning stiffness, warmth, and erythema of the involved joint. Bacterial and fungal arthritis would most likely be associated with a synovial fluid leukocyte count of at least 10,000/µL with a predominance of neutrophils, and the synovial fluid leukocyte count in patients with bacterial arthritis often exceeds 100,000/µL. Finally, bacterial and crystal-induced arthritis often have an acute presentation, whereas fungal arthritis is usually chronic in nature at the time of presentation.

Key Point

  • The acute presentation of a noninflammatory monoarthritis involving a weight-bearing joint is suggestive of osteoarthritis.

Click here to return to the rest of ACP InternistWeekly.

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Test yourself

A 69-year-old woman is evaluated for a lump under her arm found on self-examination. She is otherwise healthy and has no other symptoms. Medical and family histories are unremarkable, and she takes no medications. A needle aspirate of the right axillary mass reveals adenocarcinoma. Bilateral mammography and breast MRI are normal. CT scan of the chest, abdomen, and pelvis demonstrates the enlarged axillary lymph node and no other abnormalities. What is the most appropriate initial treatment?

Find the answer

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