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

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ACP InternistWeekly



In the News for the Week of 8-16-11




Highlights

Rise in antidepressant prescriptions questioned

Prescriptions for antidepressants given by nonpsychiatrists to patients without a specific psychiatric disorder increased more than 12% in 12 years, leading to the drug class becoming the third most commonly prescribed, a study found. More...

Practical strategies should guide doctors' talks about weight

A new scientific statement offers advice on communicating evidence-based strategies about weight loss to overweight and obese patients. More...


Test yourself

MKSAP Quiz: increasing fatigue of 2 months' duration

This week's quiz asks readers to evaluate a 58-year-old man for increasing fatigue of 2 months' duration. More...


Anticoagulation

Rivaroxaban noninferior to warfarin for stroke, embolism in atrial fibrillation

Rivaroxaban was noninferior to warfarin for the prevention of stroke or systemic embolism in patients with atrial fibrillation, a study found. More...


Women's health

Soy isoflavone tablets don't prevent menopausal symptoms, bone loss

Daily supplementation with soy isoflavone tablets had no effect on menopausal symptoms or bone loss, a new study has indicated. More...


Hip fracture

Mortality with later hip fracture surgery linked to medical reasons for delay

Late hip fracture surgery carries a higher mortality risk than early surgery, but mostly because of underlying medical reasons for the delay, according to a new study. More...


CMS update

Incentive payments for 2010 now available

Incentive payments for CMS' 2010 Medicare Electronic Prescribing (eRx) Incentive Program have begun for eligible professionals who met the criteria for successful reporting. Distribution of 2010 payments is scheduled to be completed by the end of this month. More...


From the College

Call for spring 2012 Board of Governors resolutions

The deadline for submitting new resolutions to be heard at the spring 2012 Board of Governors meeting is Monday, Oct. 17, 2011. More...

ACP's EVP in upcoming Discovery Channel series

Steven Weinberger, FACP, will appear in a Discovery Channel CME series that begins airing on Saturday, Aug. 20. More...


For the record

Clarification to a previous issue

In last week's ACP InternistWeekly, a story on thromboprophylaxis referred to vitamin K agonists instead of vitamin K antagonists. 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


.
Rise in antidepressant prescriptions questioned

Prescriptions for antidepressants given by nonpsychiatrists to patients without a specific psychiatric disorder increased more than 12% in 12 years, leading to the drug class becoming the third most commonly prescribed, a study found.

Research in the August Health Affairs reported that antidepressant prescriptions by doctors who didn't record a specific psychiatric disorder increased from 59.5% of all prescriptions by nonpsychiatrists in 1996 to 72.7% in 2007.

Researchers reviewed data on patients age 18 or older from the 1996-2007 Centers for Disease Control and Prevention's National Ambulatory Medical Care Surveys, a national sample of more than 233,000 office-based visits. In a pattern described as consistent with primary care physicians delivering basic mental health services, 45.8% of visits to nonpsychiatrist physicians were to primary care doctors, compared to 54.2% to other nonpsychiatrist physicians. But 8.7% of visits to a primary care doctor resulted in a psychiatric diagnosis compared to 1.6% of visits to other nonpsychiatrists (P<0.001).

Antidepressants were prescribed in 9.3% of primary care visits and 3.6% of visits to other nonpsychiatrists. Only 44% of primary care visits that resulted in a prescription for antidepressants included a psychiatric diagnosis, compared to 12.8% of visits to other nonpsychiatrists.

The proportion of antidepressants prescribed for patients without a psychiatric diagnosis increased from 2.5% of all visits to nonpsychiatrists to 6.4% between 1996 and 2007. For primary care visits, antidepressant prescribing grew from 3.1% to 7.1%. For other nonpsychiatrists besides primary care, visits without a psychiatric diagnosis grew from 1.9% to 5.8%. In contrast, antidepressants prescribed with a psychiatric diagnosis increased from 1.7% to 2.4%.

Patients who received antidepressants without a psychiatric diagnosis were more likely to be age 50 or older, and less likely to be men, members of a racial or ethnic minority, new patients, or paying for the visit themselves, researchers noted. These patients also tended to have diabetes, heart disease, or multiple medical conditions; have excessive fatigue and headaches; or report nonspecific pain or abnormal sensations.

Researchers said the growing use of antidepressants for broader conditions, such as boosting moods, relieving mild anxiety, or improving sleep, raises worrisome questions about whether the drugs are being inappropriately prescribed.

"We do not yet have proof that inappropriate use of antidepressants is increasing, but the change in prescribing trends is worrisome. The trends suggest that some primary care physicians overestimate the effectiveness of antidepressant medications in treating mild conditions, and that insufficient communication is occurring between primary care physicians and psychiatrists," the authors wrote.

The study recommended:

  • taking steps to better educate physicians on how to recognize mental disorders and what the evidence shows about the long-term benefits and limits of antidepressants;
  • reforming insurers' drug formularies to help rein in inappropriate antidepressant prescribing; and
  • reducing fragmented care to improve the delivery of mental health services and foster better collaboration among clinicians.

"Prescribing antidepressants without a psychiatric diagnosis is especially common in medical practices that prescribe the medications to a larger percentage of their patients," the authors concluded. "Yet paradoxically, a large proportion of patients with common mental disorders do not receive needed treatment because their primary care providers do not detect their conditions."

The study also suggested that patients discuss with their physicians whether antidepressants are the right treatment, and for physicians to seek alternative treatments.

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Practical strategies should guide doctors' talks about weight

A new scientific statement offers advice on communicating evidence-based strategies about weight loss to overweight and obese patients.

The statement by the American Heart Association, which was published early online Aug. 8 by Circulation, divided strategies into three categories:

  • appropriate ways to talk about body weight and readiness to change,
  • collaboration among different clinicians, and
  • information technology to deliver weight management programs.

The scientific statement concluded that because many weight management interventions involve understanding and applying detailed and sometimes complex information, the health literacy of patients should be taken into account in the design and selection of interventions. The statement suggested that clinicians refer to weight in a nonjudgmental, respectful and unhurried manner and assess readiness and ability to change behaviors before starting a specific strategy. It also recommended validated tools that assess behavior, including the Eating Pattern Questionnaire, the Starting the Conversation tool, and the WAVE and REAP-S tools.

Internet-based and other new technologies for weight loss have insufficient evidence to warrant their use in busy clinical settings, but they were included in the scientific statement because they have the potential to impact large numbers of participants and are relatively easy to recommend, administer, or refer to in such settings, the authors said. A subsequent scientific statement on adiposity will address assessing patients for overweight and obesity.

Future research should:

  • Include diverse populations in the enrollment.
  • Develop large studies that include technologically based interventions. Attrition rates from technology-based studies are very high, so there is a need to develop effective strategies to keep patients engaged in using technology tools for the long-term.
  • Further evaluate collaborative approaches. Longer study durations are needed to evaluate the effectiveness of the chronic care model as a framework for weight management interventions.
  • Explore the potential of electronic health records to identify, assess and deliver obesity interventions.

A recent article in ACP Internist discussed talking to patients about obesity.

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Test yourself


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MKSAP Quiz: increasing fatigue of 2 months' duration

A 58-year-old man is evaluated for increasing fatigue of 2 months' duration. The patient has hypertension and hyperlipidemia treated with lisinopril and atorvastatin. A sister has hypothyroidism.

On physical examination, temperature is normal, blood pressure is 135/80 mm Hg, pulse rate is 72/min, and respiration rate is 18/min. There is no lymphadenopathy or peripheral edema. The spleen is palpable 4 cm below the left costal margin.

Laboratory studies:

Hemoglobin 12.1 g/dL (121 g/L)
Leukocyte count 55,200/µL (55.2 × 109/L)
Platelet count 105,000/µL (105 × 109/L)
mksap.jpg

A peripheral blood smear shows an increased number of granulocytic cells in all phases of development but no Auer rods in the blasts. Bone marrow examination shows hypercellular marrow (80% cellularity) with marked granulocytic hyperplasia, a left shift in the granulocytes, and 3% myeloblasts. Cytogenetic testing reveals a BCR/ABL translocation.

Which of the following is the most appropriate next step in managing this patient?

A) Administration of imatinib
B) HLA typing of the patient and his sister
C) Leukapheresis
D) Observation with monthly follow-up office visits

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

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Anticoagulation


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Rivaroxaban noninferior to warfarin for stroke, embolism in atrial fibrillation

Rivaroxaban was noninferior to warfarin for the prevention of stroke or systemic embolism in patients with atrial fibrillation, a study found.

A randomized, double-blind, double-dummy, event-driven trial assigned 14,264 patients from 1,178 sites in 45 countries, with nonvalvular atrial fibrillation documented by electrocardiography and at moderate-to-high risk for stroke, to receive either rivaroxaban (20 mg daily or 15 mg daily in patients with creatinine clearance of 30 to 49 mL/min) or dose-adjusted warfarin (target international normalized ratio, 2.0 to 3.0). The authors reported funding from Johnson & Johnson and Bayer. Results appeared in the Aug. 10 New England Journal of Medicine.

The per-protocol, as-treated primary analysis was designed to determine whether rivaroxaban was noninferior to warfarin for the primary end point of ischemic or hemorrhagic stroke or systemic embolism. In that analysis, the primary end point occurred in 188 patients in the rivaroxaban group (1.7% per year) and in 241 in the warfarin group (2.2% per year) (hazard ratio in the rivaroxaban group, 0.79; 95% CI, 0.66 to 0.96; P<0.001 for noninferiority).

In the intention-to-treat analysis, the primary end point occurred in 269 patients in the rivaroxaban group (2.1% per year) and in 306 patients in the warfarin group (2.4% per year) (hazard ratio, 0.88; 95% CI, 0.74 to 1.03; P<0.001 for noninferiority; P=0.12 for superiority).

There were no significant differences in rates of major and clinically relevant bleeding. Bleeding occurred in 1,475 patients in the rivaroxaban group (14.9% per year) and in 1,449 in the warfarin group (14.5% per year) (hazard ratio, 1.03; 95% CI, 0.96 to 1.11; P=0.44). Intracranial hemorrhage rates were significantly lower (hazard ratio, 0.67; 95% CI, 0.47 to 0.93; P=0.02) in the rivaroxaban group, as were rates of fatal bleeding (0.2% vs. 0.5%; P=0.003).

Editorialists wrote, "For the management of atrial fibrillation, oral alternatives to warfarin have arrived. Their simplicity of use is attractive, and they appear to have an efficacy similar to that of warfarin, with the proviso that comparisons seem to depend on how easily the patient can be treated with warfarin." However, the editorialists continued, "An important concern that these clinical trials do not address is the absence of antidotes to rapidly reverse the anticoagulant effects of either rivaroxaban or dabigatran in the case of life-threatening hemorrhage or surgery."

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Women's health


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Soy isoflavone tablets don't prevent menopausal symptoms, bone loss

Daily supplementation with soy isoflavone tablets had no effect on menopausal symptoms or bone loss, a new study has indicated.

Researchers performed a single-center, randomized, placebo-controlled, double-blind, clinical trial to determine whether taking 200 mg of soy isoflavones daily would help prevent bone loss and menopausal symptoms in women 45 to 60 years of age who were within five years of menopause and had bone mineral density T scores of at least −2.0 in the lumbar spine or total hip.

Study participants were randomly assigned to receive daily soy isoflavone tablets, 200 mg, or placebo. The study's main outcome measure was change in bone mineral density (lumbar spine, femoral neck, total hip) at two years, while secondary outcomes assessed menopausal symptoms. The study results appear in the Aug. 8/22 Archives of Internal Medicine.

Two hundred forty-eight women were randomly assigned to receive soy isoflavones (n=122) or placebo (n=126). Of those, 23 (18.8%) in the soy isoflavones group and 43 (34.1%) in the placebo group were lost to follow-up, leaving 182 women who completed the study. Some of these 182 patients (11.2% in the soy isoflavone group and 15.6% in the placebo group) stopped taking the study drug but continued to participate in all or most outcome assessments. At two years, the authors found no significant differences in bone mineral density changes in women assigned to soy compared with those assigned to placebo (spine, −2.0% vs. −2.3%; total hip, −1.2% vs. −1.4%; femoral neck, −2.2% vs. −2.1%). Hot flashes (48.4% vs. 31.7%; P=0.02) and constipation (31.2% vs. 20.6%; P=0.06) were significantly more common in the soy group than in the placebo group, but no other menopausal symptoms or adverse events differed significantly.

The authors acknowledged that their study had a substantial dropout rate, significantly higher in the placebo group than in the soy isoflavone group, and that the relatively small bone loss in the control group might have made it difficult to detect a treatment effect, among other limitations. They concluded, however, that 200 mg of soy isoflavones taken daily did not affect bone loss or menopausal symptoms in this study population.

An accompanying invited commentary pointed out the lack of effect of soy isoflavones in other studies, including two recent meta-analyses, and noted that certain nonhormonal therapies such as gabapentin may be effective for symptom relief in some women. "Perhaps efforts should be directed away from the hope of a one-size-fits-all therapy for menopausal symptoms toward using existing treatments to target the symptoms that disturb patients most," the commentary authors wrote.

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Hip fracture


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Mortality with later hip fracture surgery linked to medical reasons for delay

Late hip fracture surgery carries a higher mortality risk than early surgery, but mostly because of underlying medical reasons for the delay, according to a new study.

Researchers in Spain performed a prospective cohort study at a university hospital's hip fracture unit to determine how delayed surgery for hip fracture affected outcomes. A total of 2,250 consecutive elderly patients with hip fracture were included. The study's main outcome measures were time to surgery, reasons for delayed surgery, adjusted in-hospital mortality, and complication risk. The results appear in the Aug. 16 Annals of Internal Medicine.

annals.jpg

All study patients were admitted to the hospital's hip fracture unit between August 2003 and September 2008. All were 65 years of age or older (mean age, 83.6 years), and the median time to hip surgery was 72 hours. Fifty-six patients (2.5%) had surgery immediately, 311 (13.8%) had surgery within 24 hours of admission, and 1,459 patients (64.9%) had surgery more than 48 hours after admission.

The most common reasons for delaying surgery longer than 48 hours were lack of operating rooms (60.7%) and acute medical problems (33.1%). Ninety-eight patients died (4.35%), while 1,031 (45.9%) had at least one postsurgical in-hospital medical complication. In patients clinically unstable at admission, these rates were 13.7% and 74.2%, respectively.

Longer time to surgery was associated with higher mortality rates and higher rates of medical complications. When the authors adjusted for age, dementia, chronic comorbidities and functionality, they found that these associations no longer persisted for delays of 120 hours or less but did persist for delays longer than 120 hours. When the authors adjusted for acute medical conditions as a cause of the delay, the risks were attenuated (P=0.06 for time effect on mortality; P=0.031 for time effect on medical complications).

The authors noted that reasons for clinical unsuitability for surgery varied, that all patients in their study received daily geriatric care, and that no patients were followed after discharge. They also pointed out that the most common reason for delayed surgery was lack of an operating room, highlighting the need for organizational improvements. However, they concluded that the association between late surgery for hip fracture and higher morbidity and mortality is mostly caused by medical reasons rather than by the delay itself. Very long delays in surgery continued to be associated with worse outcomes regardless of the reason for the delays.

An accompanying editorial noted that hip fracture patients are usually "medically complex," that "medical reasons for delaying surgery are the rule rather than the exception," and that clinicians should not delay surgery based on the current study's results.

"Although hip fracture is typically regarded as a surgical condition, the poor underlying health status of the patient population, coupled with the effects of hip fracture on functional status and existing comorbid conditions, means that nonsurgical aspects of care are critical to optimizing clinical outcomes," the editorialists wrote.

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CMS update


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Incentive payments for 2010 now available

Incentive payments for CMS' 2010 Medicare Electronic Prescribing (eRx) Incentive Program have begun for eligible professionals who met the criteria for successful reporting. Distribution of 2010 payments is scheduled to be completed by the end of this month.

Effective January 2010, CMS revised the way incentive payment information is communicated to eligible professionals receiving electronic remittance advices. CMS has instructed Medicare contractors to use a new indicator, LE, for incentive payments instead of LS. LE will appear on the electronic remittance.

To further clarify the type of incentive payment issued (PQRI or eRx incentive), CMS created a four-digit code to indicate the type of incentive and reporting year. For the 2010 eRx incentive payments, the 4-digit code is RX10. This code will be displayed on the electronic remittance advice along with the LE indicator. For example, eligible professionals will see LE to indicate an incentive payment, along with RX10 to identify that payment as the 2010 eRx incentive payment. The paper remittance advice will read, "This is an eRx incentive payment." The year will not be included in the paper remittance.

Physicians who have questions about the status of their eRx incentive payments during the distribution timeframe should contact their Provider Contact Center. The Contact Center Directory is available on the CMS website.

The QualityNet Help Desk is available Monday through Friday from 7:00 a.m. to 7:00 p.m. CST at 1-866-288-8912 or via e-mail. The help desk can also assist with program- and measure-specific questions.

A CMS resource is available online to help eligible professionals understand the 2010 eRx incentive payments.

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From the College


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Call for spring 2012 Board of Governors resolutions

The deadline for submitting new resolutions to be heard at the spring 2012 Board of Governors meeting is Monday, Oct. 17, 2011.

Initiating a resolution provides ACP members an opportunity to focus attention at the ACP national level on a particular issue or topic that concerns them. When drafting a resolution, don't forget to consider how it fits within ACP's Mission and Goals. In addition, be sure to use the College's Strategic Plan to guide you when proposing a resolution topic. Members must submit resolutions to their Governor and/or chapter council. A resolution becomes a resolution of the chapter once the chapter council approves it.

In accordance with the ACP Board of Governors Resolutions Process, resolutions should clearly distinguish the action requested within its resolved clause(s) as either a policy resolve ("Resolved that ACP policy…") or a directive, which requests action/study on an issue ("Resolved that the Board of Regents…"). If more than one action is proposed, each should have its own resolved clause. Please contact your Governor if you have any questions regarding the resolution format.

The Board of Governors votes on new resolutions, which are then presented to the Board of Regents for action. Members are encouraged to use the Electronic Resolutions System (ERS) to research the status of past resolutions before proposing a new resolution. Visit your chapter website and link to the ERS under the "Advocacy" heading.

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ACP's EVP in upcoming Discovery Channel series

Steven Weinberger, FACP, will appear in a Discovery Channel CME series that begins airing on Saturday, Aug. 20.

"Comparative Effectiveness Research: Plans, Promises, and Pitfalls" is designed to educate health care workers about what comparative effectiveness research is and its potential impact on them and their patients, as well as the evolving work on study design, interpretation, and future research needs with a particular focus on areas that would most directly affect physicians. Check your local listings for the exact air time.

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For the record


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Clarification to a previous issue

In last week's ACP InternistWeekly, a story on thromboprophylaxis referred to vitamin K agonists instead of vitamin K antagonists. The Web version has been corrected.

Top




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-20110816-cartoon.jpg

"You say niacin gives you a flushing problem?"

"I'm not sure there's a CPT code for this, but here goes…."

"Of course, the informed consent form is a little longer if you want me to use this one…."

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) Administration of imatinib. This item is available to MKSAP 15 subscribers as item 8 in the General Hematology and Oncology section. More information about MKSAP 15 is available online.

This patient requires administration of imatinib. Chronic myeloid leukemia (CML) is the prototype of the myeloproliferative syndromes. It results from a balanced translocation between chromosomes 9 and 22 [t(9;22) the Philadelphia chromosome] creating a unique gene designated BCR-ABL, which codes a 210-kDa protein (p210) that functions as tyrosine kinase. The t(9;22) is not only diagnostic of CML, it is also the causative genetic event and a therapeutic target. The diagnosis of CML in this patient is based upon the presence of the BCR/ABL oncogene, peripheral blood smear findings showing increased granulocytes with a marked left shift and early erythrocyte precursors, and hypercellular bone marrow with marked myeloid proliferation. Patients with chronic-phase CML initially have less than 10% blasts in their bone marrow and peripheral blood. However, as the disease progresses, the blast count increases and is associated with an accelerated phase consisting of up to 20% blasts. A blast crisis may occur when the blast count is greater than 20%. Imatinib is a tyrosine kinase inhibitor that can lead to a complete cytogenetic remission in 70% of patients with CML and is most effective when used in the chronic phase of the disease. The optimal duration of therapy, long-term benefits, and toxicity of imatinib mesylate are under investigation. Imatinib has replaced hematopoietic stem cell transplantation (HSCT) as the initial treatment of patients with CML.

The best results for HSCT occur in patients with HLA-identical sibling donors. HSCT is curative for CML and was once the primary treatment option for patients with appropriately matched donors. However, HSCT is associated with significant morbidity and mortality and should be used only in very young patients with CML or in those who are resistant to the available tyrosine kinase inhibitors such as imatinib. Performing HLA typing in this patient and his sister to determine matching for HSCT is therefore not indicated at this time.

Leukapheresis is used to control the leukocytosis in patients with acute myeloid leukemia when the blast count is greater than 50,000/µL (50 × 109/L). Patients with acute myeloid leukemia may have an elevated leukocyte count, but most leukocytes are circulating myeloblasts, and the blasts may contain Auer rods (clumped lysozymes that appear as azurophilic cytoplasmic rods). Auer rods are not present in patients with CML.

Because treatment of patients with CML is most effective when initiated in the chronic phase, close observation is inappropriate at this time.

Key Point

  • Imatinib is a tyrosine kinase inhibitor that can lead to a complete cytogenetic remission in 70% of patients with chronic myeloid leukemia (CML); it is most effective when used in the chronic phase of CML.

Click here to return to the rest of ACP InternistWeekly.

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Test yourself

A 48-year-old man is evaluated during a follow-up visit for urinary frequency. He reports no hesitancy, urgency, dysuria, or change in urine color. He has not experienced fevers, chills, sweats, nausea, vomiting, diarrhea, or other gastrointestinal symptoms. He feels thirsty very often; drinking water and using lemon drops seem to help. He has a 33-pack-year history of smoking. He has hypertension, chronic kidney disease, and bipolar disorder. Medications are amlodipine, lisinopril, and lithium. He has tried other agents in place of lithium for his bipolar disorder, but none has controlled his symptoms as well as lithium. What is the most appropriate treatment intervention for this patient?

Find the answer

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