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

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ACP InternistWeekly



In the News for the Week of 7-19-11




Highlights

Updating family cancer history may change screening recommendations

Updating patients' family history of cancer during adulthood may lead to changes in recommended cancer screenings, according to a new study. More...

Low health literacy linked to poorer outcomes, use of health services

Patients with low health literacy are less likely to use health services and more likely to have poor health outcomes, according to a new study. More...


Test yourself

MKSAP Quiz: Stretch marks in a young man

This week's quiz asks readers to determine the cause of stretch marks in a 33-year-old man. More...


Infectious disease

CDC updates treatment, surveillance recommendations for gonorrhea

The Centers for Disease Control and Prevention has updated its recommendations for treatment and surveillance of Neisseria gonorrhoeae infection, according to a recent report. More...


Dementia

Antipsychotics still frequently prescribed for Parkinson patients

Despite FDA warnings, more than half of patients with Parkinson disease and psychosis were prescribed an antipsychotic in a new study. More...


Physician work hours

Most hospital-based specialists work longer hours than physicians in ambulatory settings

Specialists who care for more acutely ill patients work longer hours than those who care for more stable, chronically ill patients—though hospitalists are an exception, a new analysis found. More...


CMS update

CMS releases details on increased availability of the Pre-Existing Condition Insurance Plan

In July, the Obama Administration announced upcoming changes to the federal Pre-Existing Condition Insurance Plan that was established as part of the Affordable Care Act. New instructions are now available from CMS on how physicians may help their patients access this program. More...


FDA update

Concentration and dosing of Tamiflu changed

The concentration of oseltamivir phosphate (Tamiflu) oral suspension has been reduced, and labels and dosing have changed accordingly, the FDA announced last week. More...


From the College

Applications being accepted for ACP's Health Policy Internship Program

The College is now accepting applications for its Health Policy Internship Program for Associate and Student Members. 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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Updating family cancer history may change screening recommendations

Updating patients' family history of cancer during adulthood may lead to changes in recommended cancer screenings, according to a new study.

Researchers used data from the Cancer Genetics Network from 1999 to 2009 to determine how often changes in family history of cancer throughout adulthood could warrant changes in patients' own cancer screening. Included were 11,129 adults who had a personal history, family history, or both personal and family history of cancer. The study's main outcome measures were proportions of patients with clinically significant family histories and rate of change both retrospectively, defined as birth until enrollment in the network, and prospectively, defined as enrollment to last follow-up. The retrospective screening-specific analyses of colorectal, breast and prostate cancer included 9,861, 2,547 and 1,817 patients, while prospective analyses included 1,533, 617 and 163 patients, respectively. Median follow-up was 8 years. The study results appeared in the July 13 Journal of the American Medical Association.

In retrospective analyses, 2.1% and 7.1% of patients met high-risk criteria for colorectal cancer screening based on family history at age 30 years and at age 50 years, respectively. For breast cancer, percentages were 7.2% at 30 years and 11.4% at 50 years, while for prostate cancer percentages were 0.9% at 30 years and 2.0% at 50 years. Prospective analyses determined that 2 per 100 persons followed for 20 years met high-risk criteria for colorectal cancer screening based on updated family history between ages 30 and 50; for breast cancer and prostate cancer, these numbers were 6 and 8 per 100 persons followed for 20 years, respectively.

The authors noted that they didn't take personal medical history or previous cancer screening into account and did not consider criteria for genetic risk assessment, among other limitations. However, they found that between ages 30 and 50, there was a 5% chance that recommendations for colorectal cancer screening would change based on family history; they also found that 4% of women would become eligible for more intensive breast cancer screening with magnetic resonance imaging over the same period because of family history changes. The authors recommended that patients' family histories of cancer be updated every 5 to 10 years at minimum so that appropriate screening recommendations can be made.

An accompanying editorial recognized that family history is an important part of medical decision making but pointed out that risks, benefits and costs of screening must also be considered. "It is plausible but still unknown whether family history increases the likelihood that breast cancers, prostate cancers, or colon adenomas found by screening are clinically significant," the editorialist wrote. "An increase in the incidence of false-positive results and test-associated complications is a cost and potential harm of increased screening based on familial risk."

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Low health literacy linked to poorer outcomes, use of health services

Patients with low health literacy are less likely to use health services and more likely to have poor health outcomes, according to a new study.

Researchers performed a systematic review to determine whether low health literacy affects health outcomes, costs and disparities. Ninety-six studies of good or fair quality in 111 articles were examined, 98 dealing with health literacy, 22 dealing with numeracy (defined as the ability to use quantitative information for such tasks as interpreting food labels, measuring blood glucose levels and adhering to medication levels), and 9 dealing with both. The study, which was funded by the Agency for Healthcare Research and Quality, appears in the July 19 Annals of Internal Medicine.

annals.jpg

The authors found a consistent association between low health literacy and increased hospitalization, more use of emergency care, and less screening mammography and influenza vaccination. Low health literacy was also associated with reduced ability to take medications appropriately and to interpret labels and health messages correctly. Elderly patients with low health literacy were in worse overall health and had higher mortality rates. Racial disparities for some outcomes were linked to low health literacy, although the authors rated the available evidence as low. In addition, no firm conclusions could be drawn about the relationship between health outcomes and numeracy alone because of inadequate data.

The authors noted that they included only English-language studies and that they were unable to use Medical Subject Heading terms in their literature search. However, they concluded that low health literacy is associated with worse health outcomes and poorer use of health care services, and called on policymakers, clinicians and other stakeholders to find effective ways of addressing the problem.

The July/August issue of ACP Internist offers advice on communicating with patients who may have low health literacy.

Many related resources, including HEALTH TiPS for patients, are available online from ACP Foundation.

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Test yourself


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MKSAP Quiz: Stretch marks in a young man

A 33-year-old man is evaluated because of the recent appearance of stretch marks in his groin that extend to his thighs. He has a history of long-standing psoriasis that at times has involved much of his body, including his intertriginous areas. His topical treatments include tar-containing ointments, clobetasol propionate 0.05%, and calcipotriene 0.0005%; he has also undergone phototherapy. He is otherwise healthy.

On physical examination, scattered psoriasiform plaques are noted on the torso, elbows, knees, gluteal cleft, and scalp. There are pink, well-demarcated plaques in both axillae and in the inguinal folds. Purple striae extend from the inguinal creases onto the anterior thighs bilaterally. No moon facies or buffalo hump is present.

Which of the following treatments most likely resulted in this patient's cutaneous changes?

A. Calcipotriene
B. Clobetasol propionate
C. Phototherapy
D. Tar-containing ointment

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

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Infectious disease


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CDC updates treatment, surveillance recommendations for gonorrhea

The Centers for Disease Control and Prevention has updated its recommendations for treatment and surveillance of Neisseria gonorrhoeae infection, according to a recent report.

Cephalosporins are a mainstay of the CDC's recommended treatment for gonorrhea. However, in Asia and Europe, cephalosporin susceptibility has been decreasing and treatment failure has been increasing. The CDC reviewed current trends in the U.S. and found that minimum inhibitory concentrations (MICs) to cephalosporins, specifically cefixime and ceftriaxone, are rising, pointing to decreased cephalosporin susceptibility here as well, although overall prevalence of isolates with elevated MICs is currently low. The findings indicated that resistance to cefixime may emerge before resistance to ceftriaxone in the U.S., the CDC said. The report appeared in the July 8 Morbidity and Mortality Weekly Report and is available online.

The report's findings are limited because its data, from the Gonococcal Isolate Surveillance Project (GISP), include only men who attended publicly funded STD clinics, and because transient decreases in MIC susceptibility have been observed in GISP before, the CDC said. However, in light of the findings and the similar trends observed in other countries, the agency made the following recommendations:

  • For uncomplicated gonorrhea, treatment with 250 mg of ceftriaxone intramuscularly in single dose and 1 g of oral azithromycin in a single dose is usually most effective.
  • Clinicians treating patients for gonorrhea should remain alert to treatment failure, defined as persistent symptoms or positive results on a follow-up test despite treatment.
  • Clinicians should consider performing a test-of-cure with culture (preferred) or nucleic acid amplification tests (NAATs) in patients undergoing gonorrhea treatment, especially men in the western U.S. who have sex with men.
  • Patients taking cefixime who have treatment failure should be retreated with 250 mg of ceftriaxone intramuscularly and 2 g of azithromycin orally.
  • Clinicians caring for patients who experience treatment failure on ceftriaxone should consult with an infectious diseases expert and the CDC to determine retreatment. Such patients should also undergo tests-of-cure with culture (preferred) or NAAT within one week, and a culture specimen should be taken if the follow-up NAAT is positive.
  • Sex partners in the preceding two months of patients with ceftriaxone treatment failure should be tested for gonorrhea (culture preferred) and should receive empirical treatment with ceftriaxone, 250 mg intramuscularly, and azithromycin, 2 g orally.
  • Ceftriaxone treatment failures should be reported to local or state health departments within 24 hours.

"The eventual emergence of cephalosporin resistance remains likely," the CDC wrote. "Actions taken now could delay the spread of cephalosporin-resistant strains and mitigate the public health consequences."

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Dementia


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Antipsychotics still frequently prescribed for Parkinson patients

Despite FDA warnings, more than half of patients with Parkinson disease and psychosis were prescribed an antipsychotic in a new study.

Researchers used data from all Veterans Affairs facilities to assess trends in antipsychotic prescribing between 2002 and 2008. The study included 2,597 patients with Parkinson disease and psychosis and a comparison group of 6,907 patients with dementia and psychosis but not Parkinson disease. Results were published in the July Archives of Neurology.

In 2008, 50% of the patients with Parkinson disease and psychosis were prescribed an antipsychotic, a rate that was unchanged since 2002. Over the course of the entire study, quetiapine was the most frequently prescribed drug (66% of treated patients). The use of quetiapine increased over the course of the study, the researchers noted, even though all three placebo-controlled trials of the drug in Parkinson disease psychosis have been negative. Aripiprazole also increased in popularity, becoming the third most prescribed antipsychotic in these patients in 2008, even though research has shown poor tolerability, the authors said.

Almost 30% of treated patients received risperidone or olanzapine as their antipsychotic, and 7% got a high-potency typical antipsychotic. The study authors noted that typical and conventional antipsychotics are not recommended for use in patients with Parkinson disease because of the potential to exacerbate parkinsonism. The only drug that has demonstrated efficacy for the treatment of psychosis in these patients is clozapine, which was prescribed to fewer than 2% of the patients. Study authors noted several possible reasons for the low use, including the lengthy application process required to prescribe the drug, potential adverse events, and monitoring requirements.

They observed several other associations in the prescribing data. Patients diagnosed with Parkinson disease and dementia were more likely to receive antipsychotics than those without the conditions (despite FDA warnings about an association between the drugs and mortality in dementia patients), and younger Parkinson patients were particularly likely to be treated with antipsychotics.

The authors did note several limitations of their study, including that it may not be generalizable outside of the Veterans Affairs system. They called for additional research into the causes and effects of antipsychotic drug use in Parkinson patients.

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Physician work hours


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Most hospital-based specialists work longer hours than physicians in ambulatory settings

Specialists who care for more acutely ill patients work longer hours than those who care for more stable, chronically ill patients—though hospitalists are an exception, a new analysis found.

Researchers analyzed data from 6,381 physicians from the 2004-2005 Community Tracking Survey (CTS) who self-reported working 20 to 100 weekly work hours, and who worked at least 26 weeks per year. Work hours comprised all medically related activities, including direct patient care and administrative duties. The researchers analyzed 41 specialties with at least 20 respondents each, then separately analyzed the four broader categories of primary care, surgery, subspecialties of internal medicine and pediatrics, and other specialties. Control variables included region of residence, residence in areas with fewer than 200,000 people, foreign medical school graduation, practice ownership, academic employment, revenue from managed care, board certification status, age, sex and race. Results were published July 11 in Archives of Internal Medicine.

The mean annual hours worked were 2,524. In an adjusted regression analysis of the four broad categories, surgery had significantly more annual hours (303 hours vs. primary care; 95% CI, 219 to 387 hours), as did subspecialists in internal medicine and pediatrics (208 hours; 95% CI, 132 to 284 hours). The "other specialties" category had significantly fewer hours than primary care (−228 hours; 95% CI, −295 to −161 hours). In a separate adjusted linear regression analysis of the 41 specialties, those with the highest hours were vascular surgery (888 hours vs. family medicine; 95% CI, 446 to 1,330 hours), critical care internal medicine (689 hours; 95% CI, 350 to 1,029 hours), and neonatal and perinatal medicine (564 hours; 95% CI, 307 to 820 hours). Those with the lowest hours were pediatric emergency medicine (−440 hours vs. family medicine; 95% CI, −750 to −130 hours), occupational medicine (−360 hours; 95% CI, −527 to −193 hours), and dermatology (−346 hours; 95% CI, −574 to −117 hours).

In general, specialists with more acutely ill patients, or patients who need intensive monitoring, worked longer hours than physicians with stable, chronically ill patients. The latter tend to be in hospital settings and the former in ambulatory settings, the authors noted. Yet hospitalists and emergency medicine doctors are exceptions to the trend, as their jobs usually involve fixed, hourly shifts with limited work hours per day or month, they wrote. Generally, specialties with more work hours had lower physician job satisfaction ratings, and vice-versa, the authors said. Study limitations are that the CTS excluded radiologists, anesthesiologists and pathologists and that self-reported work hours didn't capture differences across day, swing or night shifts, or include on-call hours, they noted.

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CMS update


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CMS releases details on increased availability of the Pre-Existing Condition Insurance Plan

In July, the Obama Administration announced upcoming changes to the federal Pre-Existing Condition Insurance Plan (PCIP) that was established as part of the Affordable Care Act. New instructions are now available from CMS on how physicians may help their patients access this program. To be eligible, patients must be citizens or legal residents; have been without coverage for six months prior to their application; and have a pre-existing condition or have been denied coverage because of their health. Prior to the changes in July, applicants needed to have a denial letter from an insurance company to prove their pre-existing condition. Now a patient needs only a letter from a physician stating that he has or had a medical condition, disability or illness.

A sample letter template is available on ACP's website. Additional details about the plan and the changes can be found at the Learn More section of the PCIP website.

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FDA update


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Concentration and dosing of Tamiflu changed

The concentration of oseltamivir phosphate (Tamiflu) oral suspension has been reduced, and labels and dosing have changed accordingly, the FDA announced last week.

The concentration has been reduced from 12 mg/mL to 6 mg/mL, because the lower concentration is less likely to become frothy when shaken, which helps to ensure an accurate measurement, according to the FDA. The oral dosing device provided with the medication has also been changed to use milliliters instead of milligrams, and the dosing table on the medication package has been revised to include milliliter dosing based on the 6 mg/mL concentration.

Prescribers should use the new concentration and milliliter dosing for all future prescriptions of the medication, the FDA recommended. The manufacturer has instituted a voluntary take-back program to remove the 12 mg/mL medication from the marketplace, but some of the old product may remain in circulation this flu season. Patients should be warned about the possibility that they could receive either concentration to reduce the risk of medication errors, the FDA said.

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From the College


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Applications being accepted for ACP's Health Policy Internship Program

The College is now accepting applications for its Health Policy Internship Program for Associate and Student Members. This internship is a unique opportunity for one Associate and one Student Member to work directly with the College's Washington staff to develop their legislative knowledge and advocacy skills. The internship, geared toward participation in ACP's annual Leadership Day on Capitol Hill, will last for four weeks starting on May 1, 2012.

The application deadline is Sept. 12, 2011. Additional details are available on the College website.

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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-20110719-cartoon.jpg

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

This issue's winning cartoon caption was submitted by Jacob Hoover, ACP Member, from St. Louis, Mo. Readers cast 91 ballots online to choose the winning entry. Thanks to all who voted! The winning entry captured 34.1% of the votes.

The runners-up, tied with 33% of the vote each, were:

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

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

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MKSAP Answer and Critique



The correct answer is B. Clobetasol propionate. This item is available to MKSAP 15 subscribers as item 2 in the Dermatology section.

Clobetasol propionate 0.05% is an ultra–high-potency corticosteroid. Potential cutaneous complications associated with the use of topical corticosteroids include thinning of the skin, development of striae (stretch marks), development of purpura, pigmentary changes (hypo- or hyperpigmentation), acneiform eruptions, and increased risk of infections. Striae formation has been documented in 1% or more of patients using a mid-potency corticosteroid; the incidence may be higher with the use of more potent agents. The risk increases when corticosteroids are used for prolonged periods, are applied under occlusion, or are applied in skin folds where there is natural occlusion, as in this patient.

Calcipotriene, a vitamin D analog, inhibits proliferation of keratinocytes, normalizes keratinization, and inhibits accumulation of inflammatory cells (neutrophils and T-lymphocytes). Calcipotriene's efficacy is comparable to that of medium-strength topical corticosteroids, but the drug is not associated with the cutaneous side effects seen in this patient.

Phototherapy induces T-lymphocyte apoptosis and therefore decreases proinflammatory cytokines. The most commonly reported side effects include photoaging, cataracts, and skin cancer. Severe cutaneous atrophy with striae formation is not a side effect of phototherapy.

Topical tar compounds are frequently used as corticosteroid-sparing drugs for patients with refractory psoriasis and are associated with excellent results when combined with ultraviolet B phototherapy. Coal tar products do not result in thinning of the skin.

Key Point

  • Potential side effects of topical corticosteroids include development of striae and atrophy of the skin.

Click here to return to the rest of ACP InternistWeekly.

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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?

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