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

Advertisement

ACP InternistWeekly



In the News for the Week of 6-7-11




Highlights

Smoking associated with PAD in women, even decades after stopping

Smoking significantly increased the risk for symptomatic peripheral artery disease in women in a dose-dependent manner. While quitting reduces risk, it remains elevated compared with women who never smoked. More...

Screening may not decrease ovarian cancer mortality rates, study finds

Screening for ovarian cancer with CA-125 tests and transvaginal ultrasound may not reduce mortality rates. More...


Test yourself

MKSAP Quiz: Follow up of advanced multiple myeloma

A 50-year-old woman with advanced multiple myeloma diagnosed 6 months ago undergoes a follow-up visit. Treatment includes daily oral thalidomide and pulse dexamethasone. What treatment will optimize disease-free and overall survival? More...


Hepatitis C

Model helps improve HCV care in underserved populations

A model developed to improve care for persons with complicated medical conditions in underserved areas helped provide safe, effective treatment for hepatitis C virus infection. More...


Cancer screening

Screen childhood cancer survivors for digestive, genitourinary neoplasms in adulthood

Childhood cancer survivors who develop subsequent primary neoplasms in adulthood are most likely to experience digestive and genitourinary cancers, so screening should focus on these two areas to reduce overall incidence. More...


CMS update

Proposed changes to e-prescribing program announced

CMS recently released a proposed rule that would update the Electronic Prescribing Incentive Program. More...

New opportunities to learn about ACOs

CMS has recently announced several new opportunities for physicians and other health care professionals to learn about the new accountable care organization model of care. More...

National Version 5010 Testing Day approaching

CMS will provide an opportunity for physicians and Medicare Administrative Contractors to come together on June 15 to test their progress in transitioning to version 5010. More...


From ACP Internist

The next issue is online and coming to your mailbox

The June issue of ACP Internist is online, featuring stories about evaluating knee injuries, palliative care and incorporating well visits for Medicare patients. More...


From the College

ACP's John Tooker, MACP, blogs at KevinMD

John Tooker, MACP, continues his monthly column at KevinMD.com on the subject of "How accountable care is a team sport." More...

Fostering Excellence in Internal Medicine Campaign exceeds goal

The College thanks ACP members for contributing to the Fostering Excellence in Internal Medicine Campaign 2010-2011. 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. More...


Cartoon caption contest

Vote for your favorite entry

ACP InternistWeekly's cartoon caption contest continues. Readers can vote for their favorite captions to determine the winner. More...


Physician editor: Darren Taichman, FACP




Highlights


.
Smoking associated with PAD in women, even decades after stopping

Smoking significantly increased the risk for symptomatic peripheral artery disease (PAD) in women in a dose-dependent manner, a new study found. Those who quit reduced their risk, but it remained elevated compared with women who never smoked.

annals.jpg

Researchers conducted a prospective cohort study using data from 39,825 participants in the Women's Health Study with no cardiovascular disease who were followed for a median of 12.7 years and surveyed about their past and current smoking habits. Results appeared in the June 7 Annals of Internal Medicine.

Current smokers were asked the average number of cigarettes they smoked per day at study entry and were asked again annually for five years, and three more times during the observational follow-up. On the basis of their answers, women were classified as never smokers, former smokers, current smokers who smoked fewer than 15 cigarettes per day, or current smokers who smoked 15 or more cigarettes per day.

Pack-years of cigarette smoking were calculated by multiplying the midpoint of the total number of years smoked by the average number of cigarettes smoked per day on the baseline questionnaire. For women who had quit smoking before enrollment, researchers subtracted the midpoint of the age category when they reported quitting smoking from their age at enrollment.

In the study, 178 confirmed PAD events occurred, defined as intermittent claudication or lower-extremity artery revascularization. Self-reported PAD was confirmed by interview and medical records. Across the four smoking categories (never, former, <15 cigarettes/d, and ≥15 cigarettes/d), age-adjusted incidence rates of PAD were 0.12, 0.34, 0.95, and 1.63 per 1,000 person-years of follow-up, respectively. Multivariate adjustment had little effect on this relationship. Adjusted hazard ratios for PAD compared to women who had never smoked were 3.14, 8.93 and 16.95, respectively.

Lifetime exposure showed a strong dose-response relationship. In age-adjusted models, hazard ratios among women whose lifetime exposure was fewer than 10, 10 to 29, or 30 or more pack-years were 2.3, 6.43 and 11.06, respectively, compared with women who never smoked. Compared with current smokers, the adjusted hazard ratios for fewer than 10 years, 10 to 20 years, more than 20 years, or lifelong abstinence were 0.39, 0.28, 0.16 and 0.08, respectively.

"Although our data show no particular threshold below which smoking does not confer an increased risk, women who indicated at least 10 pack-years of smoking exposure had a particularly steep risk increase," the authors wrote. They continued that while it's better not to have started smoking, the message to stop is still important. "For patients and their physicians, our findings suggest that long-term smoking cessation substantially reduces the risk for symptomatic PAD, whereas the residual risk even among former smokers who abstain for at least 20 years underscores the importance of primary efforts for smoking prevention."

Top


.
Screening may not decrease ovarian cancer mortality rates, study finds

Screening for ovarian cancer with CA-125 tests and transvaginal ultrasound may not reduce mortality rates, a new study suggests.

To determine the effect of ovarian cancer screening on mortality, researchers from the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening trial randomly assigned women to an intervention group (screening with CA-125 and transvaginal ultrasound at baseline, annual transvaginal ultrasound for three additional years, and annual CA-125 for five additional years) or a usual care group (usual medical care with no annual screening). The study was conducted at 10 U.S. screening centers from November 1993 to July 2001. The primary outcome measure was death from ovarian cancer, and secondary outcome measures were incidence of ovarian cancer and complications of screening and diagnostic tests. The study was published early online June 4 by the Journal of the American Medical Association.

Study participants ranged in age from 55 to 74 years at study entry and were followed for a median of 12.4 years (range, 10.9 to 13.0 years). Overall, 39,105 women were assigned to the intervention group and 39,111 were assigned to the usual care group. Two hundred twelve women in the intervention group and 176 in the usual care group were diagnosed with ovarian cancer (5.7 per 10,000 person-years and 4.7 per 100,000 person-years, respectively; rate ratio [RR], 1.21; 95% CI, 0.99 to 1.48), and 118 and 100 women, respectively, died of the disease (3.1 per 10,000 person-years vs. 2.6 per 10,000 person-years; RR for mortality, 1.18; 95% CI, 0.82 to 1.71).

A total of 3,285 women in the intervention group had false-positive results on screening; of these, 1,080 had surgical follow-up, and of these, 163 had one or more serious complications, defined as infection, direct surgical complications, cardiovascular or pulmonary complications, or other. In the usual care group, 2,914 women died of causes other than ovarian, colorectal and lung cancer versus 2,924 women in the intervention group (76.2 per 10,000 person-years vs. 76.6 per 10,000 person-years; RR, 1.01; 95% CI, 0.96 to 1.06).

The authors acknowledged that their study did not collect data on all aspects of treatment, such as type of systemic therapy. They also noted that although the study was powered to detect a mortality reduction of 35%, smaller effect sizes could also be considered worthwhile from a public health perspective, and that the screening tests studied might be more useful if different cutoffs were used to define positive results. However, they concluded that in the U.S., the screening strategy used in the PLCO trial "does not reduce disease-specific mortality in women at average risk for ovarian cancer but does increase invasive medical procedures and associated harms."

Top




Test yourself


.
MKSAP Quiz: Follow up of advanced multiple myeloma

A 50-year-old woman with advanced multiple myeloma diagnosed 6 months ago undergoes a follow-up visit. Treatment includes daily oral thalidomide and pulse dexamethasone. The patient now feels well.

mksap.jpg

Laboratory studies indicate a serum monoclonal protein concentration of 3.0 g/dL (30 g/L). Hemoglobin concentration, serum calcium level, and renal function studies are normal. A bone marrow aspirate shows reduction in plasma cells from 50% to 10%.

Which of the following is the most appropriate treatment to optimize this patient's disease-free and overall survival?

A) Autologous stem cell transplantation
B) Continuation of oral thalidomide
C) Initiation of parenteral bisphosphonates
D) Initiation of oral melphalan

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

Top


.


Hepatitis C


.
Model helps improve HCV care in underserved populations

A model developed to improve care for persons with complicated medical conditions in underserved areas helped provide safe, effective treatment for hepatitis C virus (HCV) infection, a new study has found.

Physicians in New Mexico developed the Extension for Community Healthcare Outcomes (ECHO) model to train primary care clinicians in rural or other underserved locations in providing appropriate care for complex medical problems. ECHO uses teleconferencing to train, support and advise clinicians via case presentations and lectures. Twenty-one sites in New Mexico, 16 rural communities and 5 prisons, currently use the ECHO model to treat HCV infection. The authors conducted a prospective cohort study to evaluate the safety and efficacy of ECHO-based treatment compared with treatment at the University of New Mexico's HCV clinic. Sustained virologic response, defined as undetectable HCV RNA 24 weeks after treatment stopped, was used as the primary end point. The study was published online June 1 by the New England Journal of Medicine.

Patients were eligible for the study if they were 18 to 65 years of age; had HCV RNA evidence of infection; hadn't been treated for HCV infection before Sept. 7, 2004; and began treatment between Sept. 7, 2004 and Feb. 29, 2008 if they had HCV genotype 1 or 4 infection or between Sept. 7, 2004 and Aug. 15, 2008 if they had HCV genotype 2 or 3 infection. Patients in the ECHO group were more likely to be male and Hispanic, while patients in the university clinic group were older. Most patients (about 56% in each group) had HCV genotype 1 infection. A definitive treatment outcome was determined for all patients by Dec. 31, 2009.

Four hundred seven patients were enrolled in the study, 146 who were treated at the university clinic and 261 who were treated at ECHO sites. Overall, 57.5% of patients treated at the university clinic and 58.2% of those treated at ECHO sites had a sustained virologic response to treatment (between-group difference, 0.7 percentage point; 95% CI, −9.2 to 10.7 percentage points; P=0.89). After the authors adjusted for differences in patient characteristics, the rate of sustained virologic response did not differ significantly for the ECHO sites compared with the university clinic (adjusted odds ratio, 1.04; 95% CI, 0.67 to 1.60). Rates of serious adverse events were 13.7% in university clinic patients and 6.9% in ECHO patients (P=0.02). University clinic patients were also more likely to have a serious adverse event that led to treatment withdrawal (8.9% vs. 4.2%; P=0.05).

The authors pointed out that they did not compare ECHO patients with patients receiving standard treatment in the same areas, and that ethical concerns precluded random assignment of rural and prison clinicians to use of the ECHO model or care without ECHO support. Patients could also not be randomly assigned to a treatment group.

Nevertheless, the authors concluded that the ECHO model of care led to effective treatment of HCV infection in patients living in underserved areas, comparable to the care provided at an academic medical center.

"By implementing this model, other states and nations can potentially treat many more patients infected with HCV than are currently receiving treatment, thereby reducing the enormous burden of illness and associated mortality," the authors wrote. They also noted that the model could be adapted and used to improve care for other chronic health conditions.

Top




Cancer screening


.
Screen childhood cancer survivors for digestive, genitourinary neoplasms in adulthood

Childhood cancer survivors who develop subsequent primary neoplasms in adulthood are most likely to experience digestive and genitourinary cancers, so screening should focus on these two areas to reduce overall incidence, a British study found.

Researchers conducted the British Childhood Cancer Survivor Study, a population-based cohort of 17,981 patients diagnosed with cancer before age 15 who lived for at least 5 years from 1940 and 1991 and were followed through December 2006. Results appeared online June 8 in the Journal of the American Medical Association

The study found 1,354 subsequent primary neoplasms in 1,222 patients after a median follow-up of 24.3 years (mean, 25.6 years). The most commonly observed subsequent primary neoplasms were of the central nervous system (n=344), of which 105 were gliomas; nonmelanoma skin (n=278); digestive (n=105); genitourinary (n=100); breast (n=97); and bone (n=94).

Subsequent primary neoplasms occurred most frequently in survivors who were originally diagnosed with a central nervous system neoplasm (n=338), leukemia (n=271), Hodgkin's lymphoma (n=157), heritable retinoblastoma (n=131), and Wilms tumor (n=104).

Researchers compared standardized incidence ratios (SIRs), absolute excess risks (AERs), and cumulative incidence of subsequent primary neoplasms. The overall SIR was 3.9 (AER, 16.8 per 10,000 person-years). The AER at older than 40 years was highest for digestive (AER, 5.9 per 10,000 person-years) and genitourinary (AER, 6.0 per 10,000 person-years) subsequent primary neoplasms. These two types of cancer accounted for 36% of the total AER. The cumulative incidence of colorectal cancer for survivors treated with direct abdominopelvic irradiation was 1.4% by age 50 years, comparable with the 1.2% risk in individuals with at least two first-degree relatives affected by colorectal cancer.

When broken down by organ system:

  • The SIR for genitourinary neoplasms was the lowest (SIR, 1.9; AER, 1.3/10,000 person-years).
  • The SIR for a breast neoplasm was 2.2 times more than expected (AER, 1.4/ 10,000 person-years) and highest following Hodgkin's lymphoma (SIR, 8.9; AER, 7.8/10,000 person-years).
  • The SIR for a digestive neoplasm was 4.6 times more than expected (AER, 2.2/10,000 person-years).
  • The SIR for a glioma neoplasm was 6.5 times more than expected (AER, 2.4/10,000 person-years).
  • The highest overall SIR was observed for bone neoplasms (SIR, 30.5; AER, 2.5/10,000 person-years).

Efforts to reduce development of subsequent primary neoplasms in childhood cancer survivors should focus on the digestive and genitourinary systems, the authors wrote. The results also provide evidence for routine colonoscopy in this population, they added.

Most childhood cancer survivors aren't routinely screened as adults, Annals of Internal Medicine reported last year. Women treated with chest radiation as children would benefit from breast cancer screening in adulthood, Annals also reported. Learn more about managing this patient population and how to encourage screening in ACP Internist's September 2010 cover article on the subject.

Top




CMS update


.
Proposed changes to e-prescribing program announced

CMS recently released a proposed rule that would update the Electronic Prescribing (eRx) Incentive Program.

The changes would expand the number of clinicians able to qualify for a hardship exemption to the program and potentially allow them to avoid penalties. The changes are still in proposed form, and will not likely be in effect until this fall, so physicians who are able to comply with the eRx requirements should still attempt to do so.

The new hardship exemptions are:

  • Eligible professionals who register to participate in the EHR Incentive Programs and adopt certified EHR technology.
  • Inability to electronically prescribe due to local, state, or federal law or regulation, such as prescriptions for controlled substances.
  • Limited prescribing activity.
  • Insufficient opportunities to report the electronic prescribing measure due to limitations of the measure's denominator.

The eRx Incentive Program was first implemented by Medicare in 2009. In 2009 and 2010, physicians who successfully participated in the program earned an incentive payment. While clinicians using eRx in 2011 will still receive an incentive payment, this is the first year that clinicians who have not implemented an eRx system may be subject to a penalty. Additional information about the program and what clinicians need to do to comply is available on the Running a Practice section of the ACP website.

Top


.
New opportunities to learn about ACOs

CMS has recently announced several new opportunities for physicians and other health care professionals to learn about the new accountable care organization (ACO) model of care.

In June, CMS will hold two Open Door Forum calls about two of the newly announced initiatives:

  • The Pioneer ACO Model, Tuesday, June 7, 2011 at 12:00 p.m. eastern time. Dial 1-866-501-5502, Conference ID 70961782.
  • The Advance Payment Initiative, Tuesday, June 14, 2011 at 2:00 p.m. eastern time. Dial 1-866-501-5502, Conference ID 71725238.

Over the course of the year, CMS will also be hosting four accelerated development learning sessions throughout the country at which physicians and other health care professionals interested in forming ACOs can learn more about the process in person. The first session will take place June 20 to 22 in Minneapolis. Subsequent sessions will be held in September in San Francisco, in October in Atlanta and in November in Philadelphia. Registration is now open for the June session.

Additional information about ACOs can be found on the ACP website.

Top


.
National Version 5010 Testing Day approaching

CMS will provide an opportunity for physicians and Medicare Administrative Contractors (MACs) to come together on June 15 to test their progress in transitioning to version 5010.

Version 5010 is the new set of electronic standards that practices need to have in place in order to eventually transition to ICD-10. To continue to receive payments, all practices will need to be using version 5010 by Jan. 1, 2012. Additional information about the testing day is available on the CMS website.

For more information about version 5010, ICD-10 and preparations for the transition, please visit ACP's Running a Practice website.

Top




From ACP Internist


.
The next issue is online and coming to your mailbox

The June issue of ACP Internist is online, featuring stories about:

acpi-20110607-cover.jpg

Evaluating 'weekend warrior' knee injuries. Knee injuries are a common complaint in the primary care setting. Many diagnostic tests can be performed in under a minute, sparing unneeded referrals to orthopedists.

Palliative care. Three stories outline ways to involve palliative care earlier, clarify its value to the public, and discuss prognosis with patients.

Well visits not just for kids anymore. Medicare now reimburses for annual physical exams, so prepare your office, your patients and yourself for the best way to incorporate this into your practice.

More stories and the MKSAP Quiz, in which a 48-year-old woman is evaluated for a rash on her legs, arthralgia and myalgia, low-grade fever and fatigue of 4 weeks' duration, can be found online.

Top




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. This month's topic is "How accountable care is a team sport."

Top


.
Fostering Excellence in Internal Medicine Campaign exceeds goal

The College would like to thank ACP members for contributing to the Fostering Excellence in Internal Medicine Campaign 2010-2011. Through your support, we exceeded our goal of raising $100,000.

Contributions will help continue our work to ensure the future of internal medicine and our mission to:

  • Support internal medicine interest groups at medical schools throughout the United States.
  • Provide every medical student with electronic access to Annals of Internal Medicine at no cost to them.
  • Ensure that medical students can attend the Internal Medicine meeting with no registration fee.

Top


.
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.

Top




Cartoon caption contest


.
Vote for your favorite entry

ACP InternistWeekly's cartoon caption contest continues. Readers can vote for their favorite captions to determine the winner.

acpi-20110607-cartoon.jpg

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

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

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

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting ends on Monday, June 13, with the winner announced in the June 14 issue.

Top


.


MKSAP Answer and Critique



The correct answer is A) Autologous stem cell transplantation. This item is available to MKSAP 15 subscribers as item 50 in the Hematology and Oncology section.

Thalidomide plus dexamethasone is standard first-line chemotherapy for patients younger than 65 years who are candidates for autologous stem cell transplantation. The overall response rate to this chemotherapy is approximately 65% to 75%. In patients who do have a favorable hematologic response to initial therapy, several randomized clinical trials have shown improvement in both overall and disease-free survival if these patients are subsequently treated with autologous stem cell transplantation. Patients who have no contraindications to intensive therapy with thalidomide and dexamethasone and autologous stem cell transplantation should therefore be offered this treatment as the best option to improve overall and disease-free survival.

Continuation of thalidomide with or without dexamethasone cannot be recommended, although clinical trials are evaluating the effectiveness of this agent as maintenance therapy after stem cell transplantation. Thalidomide has not been studied in this setting and is not approved for this indication. Furthermore, it is unknown whether thalidomide confers a survival advantage compared with autologous stem cell transplantation for patients with advanced multiple myeloma who have responded to initial therapy. Although parenteral bisphosphonates may reduce or prevent skeletal complications in patients with multiple myeloma, they do not improve disease-free survival.

Oral melphalan should not be used in patients who are potential candidates for stem cell transplantation because this treatment can impair the future collection of peripheral stem cells necessary for stem cell transplantation.

Key Point

  • Autologous stem cell transplantation following high-dose chemotherapy can improve overall and disease-free survival in patients with multiple myeloma.

Click here to return to the rest of ACP InternistWeekly.

Top




About ACP InternistWeekly

ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.

To add your e-mail address to your member record and to begin receiving ACP InternistWeekly, please click here.

Copyright © by American College of Physicians.

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

Have questions about the new ABIM MOC Program?

Have questions about the new ABIM MOC Program?

ACP explains the ABIM requirements and offers many free solutions to earn MOC points.

One Click to Confidence - Free to members

One Click to Confidence - Free to members ACP Smart Medicine is a new, online clinical decision support tool specifically for internal medicine. Get rapid point-of-care access to evidence-based clinical recommendations and guidelines. Plus, users can easily earn CME credit. Learn more