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ACP InternistWeekly



In the News for the Week of 8-2-11




Highlights

New clinical guideline issued on diagnosis, management of stable COPD

Several collaborating medical societies, including the American College of Physicians, released new guidelines this week on the diagnosis and management of stable chronic obstructive pulmonary disease. More...

Antibiotics better than cranberry extract to prevent recurring urinary tract infections

Prophylactic antibiotics are more effective than cranberry capsules in preventing recurrent urinary tract infections, but they do increase antibiotic resistance, Dutch researchers concluded. More...


Test yourself

MKSAP Quiz: 3-month history of GI bloating and discomfort

This week's quiz asks readers to evaluate a 64-year-old man with a 3-month history of gastrointestinal bloating and mid-epigastric discomfort. More...


Pulmonology

Pneumothorax common after transthoracic lung biopsy, study finds

Patients who undergo transthoracic lung biopsy of a pulmonary nodule may be likely to develop pneumothorax, although hemorrhages are not common, a new study reports. More...


Cardiology

Apixaban associated with more bleeding, no change in ischemic events

A phase 3 trial of apixaban, a new factor Xa inhibitor, was halted after the drug was found to increase major bleeding in patients taking it after acute coronary syndrome. More...


Inpatient care

Hospitalist care associated with higher costs, more medical utilization after discharge

Though hospitalist care is associated with shorter inpatient length of stay and lower hospital costs, these are offset by higher medical utilization and costs after discharge, a new study found. More...


FDA update

Linezolid and methylene blue cause problems with psychiatric medications

Linezolid and methylene blue can cause serious reactions in patients who are taking serotonergic psychiatric medications, the FDA warned last week. More...


From the College

College Regent wins medical professionalism prize

Molly Cooke, FACP, a Regent of the College, has been named a winner of the American Board of Internal Medicine Foundation Professionalism Article Prize for an article published last year in the New England Journal of Medicine. More...


Cartoon caption contest

Put words in our mouth

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


Physician editor: Darren Taichman, FACP




Highlights


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New clinical guideline issued on diagnosis, management of stable COPD

Several collaborating medical societies, including the American College of Physicians (ACP), released new guidelines this week on the diagnosis and management of stable chronic obstructive pulmonary disease (COPD).

The guideline, which updates and expands on a 2007 ACP guideline on this topic, was developed by a panel with members from ACP, the American College of Chest Physicians, the American Thoracic Society, and the European Respiratory Society, and represents an official, joint guideline from all four organizations. The panel helped develop key questions related to COPD diagnosis and management and evaluated related evidence reviews and tables to arrive at its recommendations, which were approved by unanimous vote. The guideline was published in the Aug. 2 Annals of Internal Medicine.

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The guideline recommendations are as follows:

  • Spirometry should be obtained to diagnose airflow obstruction in patients with respiratory symptoms (strong recommendation, moderate-quality evidence) but should not be used to screen for airflow obstruction in individuals without respiratory symptoms (strong recommendation, moderate-quality evidence).
  • For stable COPD patients with respiratory symptoms and FEV1 between 60% and 80% predicted, possible treatment with inhaled bronchodilators is suggested (weak recommendation, low-quality evidence).
  • For stable COPD patients with respiratory symptoms and FEV1 less than 60% predicted, treatment with inhaled bronchodilators is recommended (strong recommendation, moderate-quality evidence).
  • Clinicians should prescribe monotherapy using either long-acting inhaled anticholinergics or long-acting inhaled β-agonists for symptomatic patients with COPD and FEV1 less than 60% predicted (strong recommendation, moderate-quality evidence), and should base the choice of specific monotherapy on patient preference, cost, and adverse effect profile.
  • Clinicians may administer combination inhaled therapies (long-acting inhaled anticholinergics, long-acting inhaled β-agonists, or inhaled corticosteroids) for symptomatic patients with stable COPD and FEV1 less than 60% predicted (weak recommendation, moderate-quality evidence).
  • Clinicians should prescribe pulmonary rehabilitation for symptomatic patients with an FEV1 less than 50% predicted (strong recommendation, moderate-quality evidence) and may consider pulmonary rehabilitation for symptomatic or exercise-limited patients with an FEV1 more than 50% predicted (weak recommendation, moderate-quality evidence).
  • Clinicians should prescribe continuous oxygen therapy in patients with COPD who have severe resting hypoxemia (Pao2 ≤55 mm Hg or Spo2 ≤88%) (strong recommendation, moderate-quality evidence).

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Antibiotics better than cranberry extract to prevent recurring urinary tract infections

Prophylactic antibiotics are more effective than cranberry capsules in preventing recurrent urinary tract infections (UTIs), but they do increase antibiotic resistance, Dutch researchers concluded.

The double-blind, randomized noninferiority trial recruited 221 premenopausal women with at least three self-reported recurring UTIs in the previous year from all over the Netherlands. Women were randomized to 12-month prophylaxis with 480 mg of trimethoprim-sulfamethoxazole once daily (plus one placebo pill), or 500 mg of cranberry capsules twice daily. The amount of type A proanthocyanidins in the cranberry extract was 9.1 mg/g. Primary end points were the mean number of symptomatic UTIs, the proportion of patients with at least one symptomatic UTI, the median time to the first UTI, and development of antibiotic resistance of Escherichia coli.

The women were asked to collect urine and feces samples monthly from the start of the study to three months after the final prophylactic dose, and to complete a questionnaire about UTI symptoms, adverse events, infections other than UTIs, and other antibiotic use. Results appeared in the July 25 Archives of Internal Medicine.

Antibiotics worked better, with a mean of four clinical recurrences in the cranberry group compared to 1.8 in the antibiotic group (P=0.02) in the 12 months of follow-up. While 78.2% of patients in the cranberry group reported at least one symptomatic UTI, 71.1% did so in the antibiotic group. Median time to the first symptomatic UTI was four months for the cranberry extract and eight months for the antibiotic group.

However, after one month, in the cranberry group, 23.7% of fecal and 28.1% of asymptomatic bacteriuria E. coli isolates were resistant to trimethoprim-sulfamethoxazole, whereas in the antibiotic group, 86.3% of fecal and 90.5% of isolates were resistant. There were also increased resistance rates for trimethoprim, amoxicillin, and ciprofloxacin in E. coli after one month in the antibiotic group. After the antibiotic was stopped, resistance returned to baseline levels after three months. The authors concluded that that the potential benefit of antibiotics should be weighed against the greater development of antibiotic resistance.

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Test yourself


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MKSAP Quiz: 3-month history of GI bloating and discomfort

A 64-year-old man is evaluated for a 3-month history of abdominal bloating and mid-epigastric discomfort associated with a 6.8-kg (15-lb) weight loss. The patient has no significant medical history and takes no medications.

mksap.jpg

On physical examination, vital signs are normal, and the only significant finding is mild epigastric tenderness.

Laboratory studies:

Complete blood count Normal
Aspartate aminotransferase 55 U/L
Alanine aminotransferase 67 U/L
Amylase 184 U/L
Lipase 382 U/L

(A mobile quick reference of normal lab values is available for download online.)

Helical CT scan of the abdomen shows a 2.8-cm pancreatic body mass. There are no liver lesions and no invasion into surrounding major vessels. Endoscopic ultrasonography confirms the presence of an approximately 3-cm lesion without vascular invasion. A fine-needle aspiration specimen is positive for adenocarcinoma.

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

A) Combined radiation therapy and chemotherapy
B) Distal pancreatectomy
C) Palliative care consultation
D) Pancreatic enzyme supplementation

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

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Pulmonology


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Pneumothorax common after transthoracic lung biopsy, study finds

Patients who undergo transthoracic lung biopsy of a pulmonary nodule may be likely to develop pneumothorax, although hemorrhages are not common, a new study reports.

Researchers performed a cross-sectional analysis of the 2006 State Ambulatory Surgery Databases and State Inpatient Databases from the Healthcare Cost and Utilization Project in California, Florida, Michigan and New York, with the goal of determining population-based estimates of complication risks after transthoracic needle biopsy of a pulmonary nodule. The main outcome measures were percentages of biopsies followed by a hemorrhage, any pneumothorax, or pneumothorax requiring a chest tube, along with adjusted odds ratios by biopsy characteristic. The study results were published in the Aug. 2 Annals of Internal Medicine.

annals.jpg

Data were analyzed for 15,865 adults who had transthoracic needle biopsy of a pulmonary nodule. Hemorrhages occurred in 1.0% of biopsies (95% CI, 0.9% to 1.2%), and of patients with hemorrhage, 17.8% (95% CI, 11.8% to 23.8%) required a blood transfusion. Pneumothorax occurred in 15.0% of patients (95% CI, 14.0% to 16.0%), and 6.6% (95% CI 6.0% to 7.2%) of all biopsies resulted in pneumothorax requiring a chest tube. Hemorrhage and pneumothorax with a chest tube were associated with longer lengths of stay (P<0.001) and respiratory failure requiring mechanical ventilation (P=0.020) compared with no complications. Risk for complications was higher in patients between 60 and 69 years of age compared with younger and older patients, as well as in patients who smoked and patients with chronic obstructive pulmonary disease.

The authors noted that the data they used cannot be linked to other sources to provide information on, for example, long-term risks and benefits, and that some complications may have been undercoded. However, they concluded that transthoracic biopsy of a pulmonary nodule may be associated with significant harms. "For many patients, including those with a low risk for cancer, those who are too frail to undergo cancer treatment, or those with a high risk for cancer who should proceed directly to surgery, this procedure may be unnecessary," they wrote. "Before exposing patients to potential harm from [computed tomography]-guided biopsy, physicians must ensure that patients understand the risks."

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Cardiology


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Apixaban associated with more bleeding, no change in ischemic events

A phase 3 trial of apixaban, a new factor Xa inhibitor, was halted after the drug was found to increase major bleeding in patients taking it after acute coronary syndrome.

The double-blind trial included more than 7,000 patients who had recent acute coronary syndrome and at least two risk factors for recurrent ischemic events and were receiving standard antiplatelet therapy. The participants were randomized to receive either apixaban, 5 mg twice daily, or placebo, and the primary end point was cardiovascular death, myocardial infarction or ischemic stroke. However, after a median follow-up of 241 days, the trial was stopped due to differences between groups in the primary safety outcome—major bleeding. Such bleeding occurred in 1.3% (46 people) of those who received apixaban, compared to 0.5% (18 people) of those on placebo (hazard ratio, 2.59; P=0.001). There were also more intracranial and fatal bleeds in the active group.

No significant difference was found between the groups in rates of cardiovascular death, myocardial infarction or ischemic stroke. The combined outcome occurred in 7.5% of apixaban users compared to 7.9% of placebo users (P=0.51). The study authors noted that phase 2 trials of apixaban and another factor Xa inhibitor, rivaroxaban, had found increases in bleeding but also reductions in ischemic events. The early discontinuation of this trial—at a lower number of ischemic events than expected—leaves some uncertainty about whether a benefit to the drug could have been found in this study, they said.

The results could also be different in other patient populations, the study authors suggested. This trial included high-risk patients, many with diabetes, heart failure or renal insufficiency, but no differences were seen among the subgroups in the study, such as those receiving aspirin plus clopidogrel versus aspirin alone or those who had or didn't have revascularization.

Still, the results of this trial, combined with those of other interventions, such as vitamin K antagonists, "raise doubt about whether meaningful incremental efficacy can be achieved with an acceptable risk of bleeding by combining a long-term oral anticoagulant with both aspirin and a P2Y12-receptor antagonist in patients with coronary disease," the authors concluded. The study was funded by Bristol-Myers Squibb and Pfizer and was published online by the New England Journal of Medicine on July 24.

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Inpatient care


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Hospitalist care associated with higher costs, more medical utilization after discharge

Though hospitalist care is associated with shorter inpatient length of stay and lower hospital costs, these are offset by higher medical utilization and costs after discharge, a new study found.

In an observational cohort study, researchers analyzed hospital admissions from January 2001 to November 2006 in a representative national sample of 5% of Medicare beneficiaries. Researchers looked at claims for hospital stays, outpatient facility use and physician services. They included only admissions for patients with an identified primary care physician (PCP) before admission, in order to better compare patients cared for by hospitalists versus PCPs. Admissions of patients cared for by both, or neither, were excluded. The main analysis included hospitals with at least 20 admissions cared for by hospitalists and 20 by PCPs during the study period, leaving a final cohort of 58,125 admissions at 454 hospitals. Outcomes of interest were length of stay, hospital charges, discharge location and physician visits, rehospitalization, emergency department visits, and Medicare spending in the 30 days after discharge. Results were published in the Aug. 2 Annals of Internal Medicine.

annals.jpg

Among patients cared for by hospitalists, length of stay was 0.64 day less (5.17 days vs. 5.82 days; P<0.001) and hospital charges were $282 lower ($15,019 vs. $15,301; P<0.001) than among those cared for by PCPs. Medicare costs 30 days after discharge were $332 higher for patients seen by hospitalists, however ($3,279 vs. $2,947; P<0.001). Patients under hospitalist care also:

  • were less likely to be discharged to home (70.6% vs. 76%; odds ratio [OR], 0.82; 95% CI, 0.78 to 0.86),
  • were more likely to have emergency department visits within 30 days of discharge (20.7% vs. 17.8%; OR, 1.18; 95% CI, 1.12 to 1.24),
  • were more likely to be readmitted within 30 days post-discharge (19% vs. 17.4%; OR, 1.08; 95% CI, 1.02 to 1.14),
  • had fewer visits with their PCPs within 30 days post-discharge (0.62 visits vs. 0.79; P<0.001) and
  • had more nursing facility visits within 30 days post-discharge (0.58 vs. 0.52; P<0.001).

Study limitations included that only patients on Medicare with an identified PCP and a medical diagnosis were included, thus results might not be generalizable to other kinds of patients. Still, the study's findings indicate that the apparent savings in hospital costs due to hospitalist care is in fact a shifting (and increase) of costs to the post-discharge period, the authors wrote. "If applied to the approximate 25% of Medicare admissions cared for by hospitalists, this represents more than $1.1 billion in additional Medicare costs annually," they wrote. Hospitalists may be more prone to behaviors that promote cost shifting, they added, but current efforts toward bundling of payments should reduce incentives for these behaviors.

While the findings raise the question of whether hospitalists discharge their patients "more quickly but less appropriately," such that they bounce back, the results must be interpreted cautiously, as the study examined hospitalizations before the time when 30-day readmissions was a quality benchmark, the authors of an accompanying editorial noted. As for why hospitalist care is associated with greater use of postdischarge services, it may be because hospitalists are under pressure to shorten length of stay, and thus discharge sicker patients, or that they lack knowledge of outpatient services, they wrote. Ultimately, many questions remain unanswered, and more studies that follow patients through their course of care are needed, they concluded.

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FDA update


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Linezolid and methylene blue cause problems with psychiatric medications

Linezolid and methylene blue can cause serious reactions in patients who are taking serotonergic psychiatric medications, the FDA warned last week.

The agency has received reports of serious central nervous system reactions in patients who were taking a serotonergic psychiatric medication when they received either linezolid or methylene blue. Although the exact mechanism of this drug interaction is unknown, linezolid and methylene blue inhibit the action of monoamine oxidase, so it is believed that the combination of drugs causes high levels of serotonin to build up in the brain, known as serotonin syndrome. Signs and symptoms of serotonin syndrome include mental changes (confusion, hyperactivity, memory problems); muscle twitching; excessive sweating, shivering or shaking; diarrhea; trouble with coordination; and fever.

The FDA recommends that methylene blue or linezolid generally not be given to patients taking serotonergic drugs. However, there are some conditions that may be life-threatening or require urgent treatment with the drugs. For methylene blue, those exceptions may include when it is used in the emergency treatment of methemoglobinemia, ifosfamide-induced encephalopathy, or cyanide poisoning. For linezolid, exceptions may include treatment of vancomycin-resistant Enterococcus faecium infections or nosocomial pneumonia and complicated skin and skin structure infections, including cases caused by methicillin-resistant Staphylococcus aureus.

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From the College


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College Regent wins medical professionalism prize

Molly Cooke, FACP, a Regent of the College, has been named a winner of the American Board of Internal Medicine (ABIM) Foundation Professionalism Article Prize for an article published last year in the New England Journal of Medicine.

The ABIM Foundation Professionalism Article Prize honors articles that showcase the role of medical professionalism as highlighted in the 2002 "Medical Professionalism in the New Millennium: A Physician Charter," authored by the ABIM Foundation, the ACP Foundation, and the European Federation of Internal Medicine.

Dr. Cooke's article "Cost Consciousness in Patient Care—What Is Medical Education's Responsibility?" was named the winner in the Medical Education and Training category. It and the other two winning articles, in the categories of Commentary/Perspective and Professionalism and Practice, were selected from over 100 others. Articles were considered if they were published in English-language, peer-reviewed journals between Jan., 1 2010 and Dec. 31, 2010. A selection committee of physicians, experts in medical practice and education, and patients judged the articles on clarity of writing, thoroughness, methodology, and contributions to the field and society.

More information about the award is available online.

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Cartoon caption contest


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Put words in our mouth

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

acpi-20110802-cartoon.jpg

E‑mail all entries to acpinternist@acponline.org. ACP staff will choose finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.

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MKSAP Answer and Critique



The correct answer is B) Distal pancreatectomy. This item is available to MKSAP 15 subscribers as item 34 in the Gastroenterology and Hepatology section.

At the time of diagnosis, about 80% to 85% of pancreatic cancers are unresectable because of distant metastases or invasion or encasement of the major blood vessels. Treatment of pancreatic cancer that has not metastasized nor spread to the local vasculature is surgical resection, with distal pancreatectomy being the preferred procedure for lesions of the pancreatic body. Evaluation of whether the tumor is resectable preoperatively is performed with a combination of helical CT of the abdomen and endoscopic ultrasonography. Even with surgery and complete resection of the tumor, the 5-year survival rate is only 10% to 30%.

Concurrent radiation therapy and chemotherapy alone delay disease progression and may improve survival in patients with localized unresectable pancreatic cancer but will not provide a cure in patients with localized resectable pancreatic cancer. Pancreatic enzymes are used in patients with chronic pancreatitis or after pancreatic surgery to treat pancreatic malabsorption. In this otherwise healthy patient with a localized lesion and a potential for curative resection, palliative care is not indicated.

Key Point

  • Surgery is the only treatment that provides a potential cure in patients with localized pancreatic cancer, with a 5-year survival rate of 10% to 30%.

Click here to return to the rest of ACP InternistWeekly.

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Test yourself

A 72-year-old woman is evaluated during a routine examination. She has very severe COPD with multiple exacerbations. She has dyspnea at all times with decreased exercise capacity. She does not have cough or any change in baseline sputum production. She is adherent to her medication regimen, and she completed pulmonary rehabilitation 1 year ago. She quit smoking 1 year ago. Her medications are a budesonide/formoterol inhaler, tiotropium, and an albuterol inhaler as needed. Following a physical and pulmonary exam, what is the most appropriate next step in management?

Find the answer

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