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

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ACP InternistWeekly



In the News for the Week of 7-12-11




Highlights

Modeling study finds benefit in personalized mammogram schedules

Personalized mammography schedules based on women's individual risk factors could be more beneficial and cost-effective than generalized recommendations, according to a new modeling study. More...

Non-aspirin NSAIDs associated with risk for atrial fibrillation or flutter, study finds

Nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) and selective cyclooxygenase (COX)-2 inhibitors may be associated with increased risk for atrial fibrillation or flutter, according to a new study. More...


Test yourself

MKSAP Quiz: treating coronary artery disease

A 52-year-old man is evaluated regarding treatment of his coronary artery disease. He had a myocardial infarction 8 years ago and was treated with a coronary stent placed in his right coronary artery. One month ago, he noted worsening of his exertional angina. What is the most appropriate treatment for this patient? More...


E-prescribing

E-prescriptions may be vulnerable to error, study finds

About 10% of electronically generated prescriptions in a recent study included at least one error, and one-third of these mistakes had potential for harm. More...


Heart failure

Nesiritide not effective for acute heart failure, study finds

Nesiritide is not an effective treatment for acute decompensated heart failure, according to a new controlled trial. More...


Pulmonary embolism

Outpatient pulmonary embolism treatment not inferior to inpatient management, study finds

Outpatient care for pulmonary embolism (PE) can safely and effectively be used in place of inpatient care in patients with low risk of death, according to a new study. More...


From the College

Executive Vice President's annual report and video message now online

The 2010-2011 Report of the Executive Vice President has been mailed with the July/August issue of ACP Internist and is now available on ACP's website. More...

ACP urges White House, congressional leaders to agree on debt ceiling

Last Thursday, the College sent a letter to President Obama, Vice President Biden and congressional leaders urging them to reach a debt ceiling agreement in time to avert disruption of care for Medicare and Medicaid patients. 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 (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. 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


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Modeling study finds benefit in personalized mammogram schedules

Personalized mammography schedules based on women's individual risk factors could be more beneficial and cost-effective than generalized recommendations, according to a new modeling study.

Researchers applied a Markov model to data from the Surveillance, Epidemiology and End Results program, the Breast Cancer Surveillance Consortium, and other reports from the medical literature. The study included U.S. women between ages 40 and 79 who had an initial mammogram at age 40 and breast density between 1 and 4, according to the Breast Imaging and Reporting Data System (BI-RADS) categories. The researchers calculated the cost per quality-adjusted life-year (QALY) gained from screening, and considered screening programs cost-effective if a QALY was gained for $100,000 or less.

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Their findings confirmed current guidelines recommending biennial screening for most women between the ages of 50 to 74. However, for women in that age range with BI-RADS category 1 density, no previous breast biopsies and no family history, the model found that less frequent screening (every three to four years) may be more appropriate, based on cost-effectiveness and potential harms.

For younger women (between ages 40 and 49), the study supported individual screening strategies, based on the results of an initial mammogram at age 40. If that initial screening indicated a BI-RADS category of 1 or 2 and the woman had no other risk factors, mammography could be resumed at age 50, the authors said. For women with higher density and/or risk factors, biennial screening was cost-effective. Annual screening was not found to be cost-effective for any group, according to the model. These results do not apply to women who carry the BRCA1 or BRCA2 mutations, the study noted.

Based on the study's results, the authors concluded that mammogram recommendations should be personalized based on age, breast density, history of breast biopsy and family history of breast cancer. They suggested that BI-RADS categories be included in mammography reports to assist primary care physicians. The authors noted that their conclusions are projected from a national perspective (such as payers and guideline writers), and that individual women may also want to base their decisions on personal feelings about the benefits and harms of screening.

The potential of a personalized screening approach is exciting, but further research is needed and limitations remain, according to an accompanying editorial. Such an approach could be difficult to communicate, and the study's findings were based on film rather than digital mammography, the editorialists noted. The study and editorial appeared in the July 5 Annals of Internal Medicine.

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Non-aspirin NSAIDs associated with risk for atrial fibrillation or flutter, study finds

Nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) and selective cyclooxygenase (COX)-2 inhibitors may be associated with increased risk for atrial fibrillation or flutter, according to a new study.

Researchers performed a population-based case-control study of patients in a Danish database to examine the relationship between non-aspirin nonselective NSAIDs (ibuprofen, naproxen, ketoprofen, dexibuprofen, piroxicam, and tolfenamic acid) or selective COX-2 inhibitors and atrial fibrillation or flutter. A total of 32,602 patients who had had a first inpatient or outpatient diagnosis of atrial fibrillation or flutter between 1999 and 2008 (54% men, mean age 75 years) were compared with 325,918 age- and sex-matched controls. The study's main outcome measures were current NSAID use (defined as use at the time of admission) or recent NSAID use (defined as use before admission); current use was further defined as new (first NSAID prescription filled within 60 days before diagnosis) or long-term. The study was published online July 4 by BMJ.

Overall, 2,925 case-patients and 21,871 controls were classified as current users of non-aspirin NSAIDs (9% vs. 7%). When compared with no NSAID use, the incidence rate ratios for the association between current drug use and atrial fibrillation or flutter were 1.33 (95% CI, 1.26 to 1.41) and 1.50 (95% CI, 1.42 to 1.59) for nonselective non-aspirin NSAIDs and COX-2 inhibitors, respectively. After adjustment for age, sex, and risk factors, the incidence rate ratios were 1.17 (95% CI, 1.10 to 1.24) and 1.27 (95% CI, 1.20 to 1.34), respectively, among current users versus 1.46 (9%% CI, 1.33 to 1.62) and 1.71 (95% CI, 1.56 to 1.88), respectively, among new users.

The authors noted that their study did not include data on lifestyle factors such as body size and that their results may have been affected by confounding, among other limitations. Nevertheless, they concluded that use of non-aspirin NSAIDs was associated with an increased risk for atrial fibrillation or flutter, especially among new users, who had a 40% to 70% increase in relative risk. COX-2 inhibitors were associated with a higher risk than nonselective non-aspirin NSAIDs, and elderly patients appeared to be at highest risk. New treatment with COX-2 inhibitors seemed to be associated with higher risk in patients with chronic kidney disease or rheumatoid arthritis (adjusted incidence rate ratios, 2.87 [95% CI, 1.53 to 5.38] and 2.49 [95% CI, 1.40 to 4.42], respectively). The authors wrote that their study "adds evidence that atrial fibrillation or flutter need to be added to the cardiovascular risks under consideration when prescribing NSAIDs."

The author of an accompanying editorial reiterated the authors' cautions regarding potential confounding and pointed out that the association between NSAID use and atrial fibrillation need not be due to a cause-and-effect relationship. He concluded that clinicians should be cautious in applying the current study's results in clinical practice. "However," he wrote, "NSAIDs (non-selective NSAIDs and COX-2 inhibitors) should continue to be used very cautiously in older patients with a history of hypertension or heart failure, who are already at high risk for adverse effects of these drugs, regardless of whether an association between NSAIDs and atrial fibrillation actually exists."

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Test yourself


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MKSAP Quiz: treating coronary artery disease

A 52-year-old man is evaluated regarding treatment of his coronary artery disease. He had a myocardial infarction 8 years ago and was treated with a coronary stent placed in his right coronary artery. Over the last 8 years he did well with medical therapy, with only mild episodes of exertional angina that resolved with rest or sublingual nitroglycerin. One month ago, he noted worsening of his exertional angina. Coronary angiography showed 50% stenosis of the left main coronary artery, severe disease (75% stenosis) of the left circumflex artery, severe disease (70% stenosis) of the proximal left anterior descending artery, and in-stent restenosis (80%) of the stent within the right coronary artery. Left ventricular systolic function is mildly reduced (ejection fraction 50%). His medical therapy was increased, and he has remained pain-free with activity. He is active and is a construction worker.

Medical history is notable for diabetes mellitus, hyperlipidemia, and hypertension. Current medications are aspirin, ramipril, atorvastatin, metoprolol, isosorbide mononitrate, diltiazem, and metformin.

Physical examination shows a well-developed man who appears comfortable. Blood pressure is 110/60 mm Hg and heart rate is 60/min. BMI is 28. Neck examination demonstrates a right carotid bruit and no jugular venous distention. Cardiac examination reveals normal heart sounds and no murmurs. Lungs are clear bilaterally and there is no peripheral edema.

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

A) Coronary artery bypass graft surgery
B) Enhanced external counterpulsation
C) Percutaneous coronary intervention
D) Start ranolazine

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

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E-prescribing


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E-prescriptions may be vulnerable to error, study finds

About 10% of electronically generated prescriptions in a recent study included at least one error, and one-third of these mistakes had potential for harm.

Researchers conducted a retrospective cohort study of 3,850 e-prescriptions received by a commercial outpatient pharmacy chain across three states over four weeks in 2008. All the prescriptions were from ambulatory care clinicians. A panel reviewed them for medication errors, potential adverse drug events, and rate of prescribing errors by type and by prescribing system. Results were published online June 29 by the Journal of the American Medical Informatics Association.

Of the 3,850 prescriptions, 452 (11.7%) contained 466 errors, of which 163 (35%) were potential adverse drug events. Of the potential adverse drug events, 95 (58.3%) were significant, 68 (41.7%) were serious and none were life-threatening.

The most common cause for error was omitted information (60.7% of total errors and 50.9% of potential adverse drug events). The most likely omissions were duration, dose, or frequency. Omitted dose was the most likely error to result in a potential adverse drug event, and accounted for 35% of all potential adverse drug events. Other types of errors were information that was unclear (16.1% of total errors, 19.6% of potential adverse drug events), conflicting (15.7% of total errors, 16.0% of potential adverse drug events), or clinically incorrect (7.5% of total errors, 13.5% of potential adverse drug events).

There was a significant variation by prescribing system in the types of prescribing errors (P<0.001) and the potential for adverse drug events (P<0.002). Prescribing error rates ranged from 5.1% (95% CI, 0.3% to 9.9%) to 37.5% (95% CI, 23.5% to 51.5%) among the different systems.

The researchers noted that the error rates seen with e-prescribing in their study were similar to those reported in the literature for handwritten prescriptions. They suggested some computer-based and clinician-based strategies to minimize the errors associated with computer-generated prescriptions. Computer-based strategies include forcing functions, specific drug decision-support systems such as maximum dose checkers, and calculators. Clinician-based strategies may include rigorous vendor selection, increased financial incentives and better training.

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Heart failure


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Nesiritide not effective for acute heart failure, study finds

Nesiritide is not an effective treatment for acute decompensated heart failure, according to a new controlled trial.

The study randomized more than 7,000 patients who were hospitalized with acute heart failure to receive either nesiritide or placebo for 24 to 168 hours in addition to standard care. End points were change in dyspnea and rehospitalization or death within 30 days. The results were published in the July 7 New England Journal of Medicine.

Patients taking nesiritide reported improved dyspnea at both six hours (44.5% vs. 42.1%, P=0.03) and 24 hours (68.2% vs. 66.1%, P=0.007), but these differences did not meet the study's prespecified minimum for statistical significance. Very little difference was seen between the groups in rehospitalization or death (9.4% on nesiritide vs. 10.1% on placebo, P=0.31), death at 30 days (3.6% on nesiritide vs. 4.0% on placebo) or worsening renal function (defined as a >25% decrease in estimated glomerular filtration rate, 31.4% on nesiritide vs. 29.5% on placebo, P=0.11). However, nesiritide did significantly increase rates of hypotension in patients who took it: 26.6% versus 15.3% (P<0.001).

Based on the results, study authors concluded that "nesiritide cannot be recommended for routine use in the broad population of patients with acute heart failure." They noted that their findings are consistent with results of the trial that led to FDA approval of nesiritide a decade ago. That study included about 500 patients and showed that the drug significantly improved dyspnea at 3 hours, but made little difference at 24 hours

The current study contradicted widespread assumptions about both the effectiveness of nesiritide in relieving dyspnea and its potential to harm patients by reducing survival and renal function, the authors noted. The results show the need for rigorously designed, adequately powered trials of new medications, the authors said. An accompanying editorial expanded on this conclusion, saying that "the FDA should be provided the full regulatory authority to require definitive trials and withdraw a drug if the sponsor does not conduct a far-reaching clinical end-point trial."

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Pulmonary embolism


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Outpatient pulmonary embolism treatment not inferior to inpatient management, study finds

Outpatient care for pulmonary embolism (PE) can safely and effectively be used in place of inpatient care in patients with low risk of death, according to a new study.

Researchers conducted an open-label, randomized, non-inferiority trial at 19 emergency departments in Switzerland, France, Belgium and the U.S., between February 2007 and June 2010. Subjects were 18 years of age or older with acute, symptomatic and objectively verified PE and a low death risk, defined as a risk class of I or II on the pulmonary embolism severity index. This index is a clinical prognostic model that assigns risk according to an overall point score obtained by adding the patient's age in years to points assigned to other applicable predictors (male sex, history of or active cancer, heart failure, chronic lung disease, pulse ≥110 beats/min, systolic blood pressure <100 mm Hg, respiratory rate ≥30 breaths/min, temperature below 36 degrees Celsius, altered mental status, and arterial oxygen saturation <90%). Higher scores indicate a higher risk class.

Researchers defined PE as the acute onset of dyspnea or chest pain, together with a new contrast filling defect on spiral computed tomography or pulmonary angiography, a new high-probability ventilation-perfusion lung scan, or documentation of a new proximal deep vein thrombosis either by venous ultrasonography or contrast venography. Patients with at least one of the following characteristics were excluded: arterial hypoxemia, systolic blood pressure below 100 mm Hg, chest pain requiring parenteral opioids, active bleeding, high risk of bleeding (stroke during the preceding 10 days, gastrointestinal bleeding during the preceding 14 days or <75,000 platelets per mm3), severe renal failure (creatinine clearance <30 mL/min according to the Cockcroft-Gault equation), extreme obesity (body mass >150 kg), history of heparin-induced thrombocytopenia or allergy to heparins, therapeutic oral anticoagulation at the time of PE diagnosis, any barriers to treatment adherence or follow-up (e.g., current alcohol abuse or illicit drug use), pregnancy, imprisonment, diagnosis of PE more than 23 hours before screening, or previous enrollment in the trial.

In the study, 344 consecutive adults were randomized to initial outpatient (discharged from the hospital <24 hours after randomization) or inpatient treatment with subcutaneous enoxaparin (≥5 days) followed by oral anticoagulation (≥90 days). The primary outcome was symptomatic, recurrent venous thromboembolism (VTE) within 90 days. Safety outcomes included major bleeding within 14 or 90 days and mortality within 90 days. Results appeared in the July 2 The Lancet.

In the primary analysis, one of 171 outpatients, a woman with cervical cancer who initially had bilateral segmental PE, developed recurrent VTE within 90 days, compared with none of 168 inpatients (95% upper confidence limit [UCL], 2.7%; P=0.011). Researchers pointed out that this UCL suggests that the true outpatient event rate is not likely to exceed the true inpatient event rate by more than 2.7%.

One patient in each treatment group died within 90 days (95% UCL, 2.1%; P=0.005), and two of 171 outpatients and no inpatients had major bleeding within 14 days (95% UCL, 3.6%; P=0.031). By 90 days, three outpatients but no inpatients had developed major bleeding (95% UCL, 4.5%; P=0.086).

The major bleeds were intramuscular hematomas occurring on days 3 and 13 (one patient had insertion of a vena cava filter). One additional outpatient developed major bleeding within 90 days (menometrorrhagia on day 50).

Outpatients had a mean of 3.4 fewer days of initial hospital stay, with similar hospital readmission rates, emergency department visits, and outpatient visits to doctors to the inpatient group. Outpatients had 2.6 more days of treatment with low-molecular-weight heparin than inpatients.

Researchers wrote, "Although we showed non-inferiority for outpatient treatment with respect to major bleeding at 14 days, we did not achieve non-inferiority at 90 days because of an additional bleeding episode that occurred 50 days after randomization. However, given this time latency, it is unlikely that this bleeding event was related to randomization to outpatient treatment."

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From the College


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Executive Vice President's annual report and video message now online

The 2010-2011 Report of the Executive Vice President has been mailed with the July/August issue of ACP Internist and is now available on ACP's website, as well as on the Regents' Information Center (RIC) and the Governors' Information Center (GIC).

The EVP report is a review of the year's events at the College, including new programs, initiatives, mobile technologies, and clinical resources.

A video message from Dr. Weinberger is also available on the ACP website.

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ACP urges White House, congressional leaders to agree on debt ceiling

Last Thursday, the College sent a letter to President Obama, Vice President Biden and congressional leaders urging them to reach a debt ceiling agreement in time to avert disruption of care for millions of Medicare and Medicaid patients. In the letter, the College offers principles for the agreement to preserve patient access and reduce health care spending. The letter is available online.

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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.

The cost of the course has been reduced to 550 Euro due to philanthropic sponsorship. In addition, fellowships are available; young interested participants should submit their applications before July 15. More information and registration for the course are online.

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Cartoon caption contest


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Vote for your favorite entry

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

acpi-20110712-cartoon.jpg

"Some patients bring a tape recorder, but I see you've got your parrot."

"Sorry, I'm an internist, not an 'aye' doctor."

"I'm afraid you've had a HARRRRR-T attack."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service.

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MKSAP Answer and Critique



The correct answer is A) Coronary artery bypass graft surgery. This item is available to MKSAP 15 subscribers as item 2 in the Cardiovascular Medicine section.

This patient has several indications for coronary artery bypass graft surgery. He has stenosis of the left main coronary artery and multivessel coronary artery disease with mildly reduced left ventricular systolic function. Coronary artery bypass grafting is indicated in patients with left main coronary artery disease, severe three-vessel disease with reduced left ventricular systolic function, and severe three-vessel disease with involvement of the proximal left anterior descending artery. In addition, patients with diabetes mellitus and multivessel disease also derive benefit from coronary artery bypass graft surgery. In this setting, surgery would not only relieve angina and improve quality of life, but it would also prolong life expectancy. Patients achieve a significant clinical benefit when the left internal mamillary artery graft is used as the bypass conduit for lesions within the left anterior descending artery system.

Enhanced external counterpulsation (EECP) is an acceptable treatment for patients with medically refractory angina who are not candidates for revascularization. However, the patient presented is a candidate for coronary artery bypass graft surgery, and this should be performed prior to considering alternative options such as EECP.

Although percutaneous coronary intervention may occasionally be used for patients with multivessel coronary artery disease who are not appropriate candidates for surgery, it would not be the best choice for this patient. This patient is young and active, and he does not have any clear contraindications for surgery.

Ranolazine can be useful in patients with chronic stable angina on maximal medical therapy. However, this patient has severe obstructive coronary artery disease that requires revascularization. In patients who have failed to benefit from revascularization and remain symptomatic on maximal medical therapy, ranolazine can be considered.

Key Point

  • Coronary artery bypass graft surgery is recommended for patients with diabetes mellitus and multivessel disease.

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Test yourself

A 50-year-old man is evaluated in follow-up for a recent diagnosis of cirrhosis secondary to nonalcoholic steatohepatitis. He has a history of asthma, type 2 diabetes mellitus, hyperlipidemia, and obesity. His current medications are inhaled fluticasone, montelukast, insulin glargine, insulin lispro, simvastatin, and lisinopril. Following a physical exam, lab studies, and upper endoscopy, what is the most appropriate treatment?

Find the answer

MKSAP 16 Holiday Special: Save 10%

MKSAP 16 Holiday Special:  Save 10%

Use MKSAP 16 to earn MOC points, prepare for ABIM exams and assess your clinical knowledge. For a limited time save 10% when you use priority code MKPROMO! Order now.

Maintenance of Certification:

What if I Still Don't Know Where to Start?

Maintenance of Certification: What if I Still Don't Know Where to Start?

Because the rules are complex and may apply differently depending on when you last certified, ACP has developed a MOC Navigator. This FREE tool can help you understand the impact of MOC, review requirements, guide you in selecting ways to meet the requirements, show you how to enroll, and more. Start navigating now.