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

Advertisement

ACP InternistWeekly



In the News for the Week of 9-13-11




Highlights

Residents' burnout, exhaustion and debt affect their medical learning

Burnout and educational debt are associated with lower scores among residents taking the Internal Medicine In-Training Examination. And some of the lower-scoring students are unable to catch up with their peers by the end of residency, according to a new study. More...

TNF agents for rheumatic diseases associated with increased skin cancer risk

Tumor necrosis factor inhibitors used to treat rheumatoid arthritis are associated with an increased risk of skin cancer but not lymphoma, according to a meta-analysis. More...


Test yourself

MKSAP Quiz: gradual onset and progression of memory loss

This week's quiz asks readers to evaluate gradual memory loss in an 81-year-old man. More...


Neurology

Medication better than brain stent for stroke prevention

Medical therapy outperformed stenting for secondary prevention of stroke in patients with intracranial arterial stenosis, a new study found. More...


Cardiology

Complication rates of ICDs higher in the elderly, but mainly due to comorbidities

Elderly patients have higher rates of complications after implantable cardioverter defibrillator placement compared with younger patients, but mainly due to increased comorbid conditions, and the risks of the procedure are still acceptable, a new study has found. More...


Infectious disease

Transfusion-related babesiosis of concern in the U.S., study finds

Rates of babesiosis related to blood transfusions are of concern in the U.S., according to a recent study from the Centers for Disease Control and Prevention. More...


CMS update

Changes finalized to eRx program

Last week, the Centers for Medicare and Medicaid Services announced a new final rule, making changes to the Electronic Prescribing Incentive Program for 2011. More...

Medicare will require clinicians to re-enroll

Due to new risk-screening criteria established as part of the Affordable Care Act, clinicians who enrolled in Medicare before March 25, 2011 will be required to re-enroll. More...


From ACP Internist

The next issue of ACP Internist is online

September's issue of ACP Internist features stories on disaster response, Alzheimer's disease and hepatitis management, among others. More...


From the College

Only 4 weeks left to apply for ACP's Health Policy Internship Program

There is still time to send in your application for ACP's Health Policy Internship Program for Associate and Student Members. More...

ACP Immunization Portal now available

ACP has launched the ACP Immunization Portal, a Web-based guide to adult immunization designed to help health care professionals develop a systematic process to incorporating immunization procedures into their day-to-day practice. More...

Course for educators offered on healing health care disparities through education

Medical faculty, residents and fellows are invited to attend a two-day course presenting interactive educational methods for achieving the recently mandated integration of cross-cultural care into medical school and residency programs. 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, MD, FACP




Highlights


.
Residents' burnout, exhaustion and debt affect their medical learning

Burnout and educational debt are associated with lower scores among residents taking the Internal Medicine In-Training Examination (IM-ITE). And some of the lower-scoring students are unable to catch up with their peers by the end of residency, according to a new study.

To measure how well-being correlates with medical knowledge during residency, researchers used 2008 and 2009 IM-ITE scores and the 2008 IM-ITE survey. There were 16,394 residents surveyed, representing 74.1% of all eligible internal medicine residents, including U.S. and international medical graduates. Results appeared in the Sept. 7 Journal of the American Medical Association.

Overall quality of life was measured by self-assessment on a scale of 1 ("As bad as it can be") to 5 ("As good as it can be"). Low quality of life was defined as the lowest two categories. Burnout was assessed using two measures adapted from a longer survey. Emotional exhaustion was assessed by the question, "How often do you feel burned out from your work?" and depersonalization by the question, "How often do you feel you've become more callous toward people since you started your residency?" Each question was answered on a 7-point Likert scale with response options ranging from "never" to "daily."

About 15% of residents classified their quality of life as "as bad as it can be" or "somewhat bad" (99% CI, 14.1% to 15.6%). At least weekly symptoms of emotional exhaustion were reported by 7,394 residents (45.8% [99% CI, 44.8% to 46.8%]). Weekly symptoms of depersonalization were reported by 4,541 (28.9% [99% CI, 27.9% to 29.8%]). Overall, at least one symptom of burnout was present in 8,343 of 16,192 residents (51.5% [99% CI, 50.5% to 52.5%]). Greater educational debt was associated with the presence of at least one symptom of burnout (61.5% of those with debt more than $200,000 vs. 43.7% of those with no debt; odds ratio, 1.72 [99% CI, 1.49 to 1.99]; P<0.001).

Decreased quality of life and increased frequency of burnout symptoms were associated with lower IM-ITE scores, most notably in the 242 residents (1.5%) reporting quality of life that was "as bad as it can be" (mean score, 57.6 vs. 60.3 for residents reporting quality of life "as good as it can be" [difference, 2.7 points; 99% CI, 1.2 to 4.3; P<0.001]). IM-ITE scores also were lower for the 600 residents (3.7%) with daily feelings of emotional exhaustion (mean score, 57.8 vs. 62.0 for residents never feeling burned out from work [difference, 4.2 points; 99% CI, 2.5 to 5.9; P<0.001]).

Residents reporting debt greater than $200,000 had mean IM-ITE scores 5.0 points (99% CI, 4.4 to 5.6; P<0.001) lower than those with no debt. As a point of comparison, these differences were as large as the increases normally seen as residents progress from their first to second postgraduate year (4.1 points; 99% CI, 3.9 to 4.3) and their second to third postgraduate year (2.6 points; 99% CI, 2.4 to 2.8).

Burnout was less common among international medical graduates than among U.S. medical graduates (45.1% vs. 58.7%; odds ratio, 0.70 [99% CI, 0.63 to 0.77]; P<0.001). This effect persisted after adjusting for debt. Researchers suggested that international medical graduates in the U.S. may be more resilient because they've already successfully completed a complex and highly competitive selection process for U.S. residency positions. The study authors also noted that all members of the study cohort began training after duty hour limits went into effect in 2003, so burnout remains an issue despite these regulations.

Top


.
TNF agents for rheumatic diseases associated with increased skin cancer risk

Tumor necrosis factor inhibitors (TNFi) used to treat rheumatoid arthritis are associated with an increased risk of skin cancer but not lymphoma, according to a meta-analysis.

To assess the risk of malignancy in patients with rheumatoid arthritis treated with TNFi, researchers did a meta-analysis of published literature and, to reduce publication bias, included conference abstracts published by three rheumatology medical societies.

Twenty-one full texts and eight abstracts met the inclusion criteria of prospective, observational studies of more than 100 patients receiving TNFi for rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis. No retrospective studies were included. The studies included 40,000 patients and almost 150,000 cumulative years of exposure. Results appeared in the September Annals of the Rheumatic Diseases.

The pooled estimate among seven studies that included relative risk for all-site malignancy was 0.95 (95% CI, 0.85 to 1.05) for patients treated with TNFi compared to non-exposed patients. Two studies reported there was no evidence that longer exposure to TNFi agents increased the risk of malignancy.

In patients with previous malignancies, there was a higher risk of a new/recurring malignancy, the researchers noted. The overall incidence of malignancy in patients with rheumatoid arthritis ranged from 3.88 (95% CI not reported) per 1,000 patient-years to 9.34 (95% CI, 8.19 to 10.60) per 1,000 patient-years in the included studies. But in two studies among patients with previous malignancy, rates were much higher: 25.3 (95% CI 13.4 to 43.2) per 1,000 patient-years and 45.5 (95% CI 20.8 to 86.3) per 1,000 patient-years. This risk was not higher in patients who had been exposed to TNFi compared to those who hadn't, although researchers noted the confidence intervals were wide.

Results from four studies showed that patients treated with TNFi have a significantly increased risk of developing a non-melanoma skin cancer (1.45, 95% CI, 1.15 to 1.76). In addition, patients are at an increased risk of developing melanoma, as the pooled estimate from two studies was 1.79 (95% CI, 0.92 to 2.67). The pooled estimate for the risk of lymphoma was 1.11 (95% CI, 0.70 to 1.51).

"This systematic review and meta-analysis provides reassurance to physicians and patients that the treatment of RA patients with TNFi does not increase the risk of malignancy, particularly lymphoma," the authors wrote. "However, it does appear to increase the risk of skin cancer, including melanoma. The [confidence intervals], however, do not preclude an effect of treatment on the risk for specific malignancies, and researchers should be encouraged to publish additional analyses to add to the evidence base."

Top




Test yourself


.
MKSAP Quiz: gradual onset and progression of memory loss

An 81-year-old man is evaluated for the gradual onset and progression of memory loss over the past year. He says he has difficulty recalling the names of familiar people, has misplaced his wallet on numerous occasions, and is slower to find his car in large, crowded parking lots. He continues to manage his finances, travel with his wife, and perform the activities of daily living without difficulty. He has borderline hyperlipidemia that is managed by diet alone. A paternal uncle developed Alzheimer dementia at age 74 years. His only medications are aspirin and a daily multivitamin.

mksap.jpg

On physical examination, temperature is 36.7 °C (98.1 °F), blood pressure is 126/82 mm Hg, pulse rate is 68/min, respiration rate is 14/min, and BMI is 26. His level of alertness, speech, and gait are normal. He scores 26/30 on the Folstein Mini–Mental State Examination, losing all three points on the recall portion and one point on the orientation section for incorrectly stating today's date.

Results of a complete blood count, serum vitamin B12 measurement, thyroid function tests, and a basic metabolic panel are normal.

An MRI of the brain without contrast shows no abnormalities.

Which of the following is the most likely diagnosis at this time?

A) Alzheimer dementia
B) Dementia with Lewy bodies
C) Frontotemporal dementia
D) Mild cognitive impairment
E) Vascular dementia

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

Top


.


Neurology


.
Medication better than brain stent for stroke prevention

Medical therapy outperformed stenting for secondary prevention of stroke in patients with intracranial arterial stenosis, a new study found.

The trial included 451 patients with recent transient ischemic attack or stroke attributed to stenosis of 70% to 99% of the diameter of a major intracranial artery. They were randomized to either aggressive medical management alone or aggressive medical management plus percutaneous transluminal angioplasty and stenting with the Wingspan stent system (a device approved by the FDA under humanitarian and research exceptions). The medical management consisted of 325 mg of aspirin daily, 75 mg of clopidogrel daily for 90 days, antihypertensive medication with a target systolic blood pressure less than 140 mmHg, rosuvastatin with an LDL target less than 70 mg/dL, and a lifestyle modification program to manage other risk factors.

Enrollment was stopped early because the 30-day rate of stroke or death was significantly higher in the stent group: 14.7% versus 5.8% (P=0.002). The study's primary end point was stroke or death within 30 days, or after revascularization for the qualifying lesion, or stroke in the same territory sometime after 30 days. At one year, this outcome had occurred in 20% of the stent group and 12.2% of the medical management patients (P=0.009), leading authors to conclude that medical management is superior. The results were published online Sept. 7 by the New England Journal of Medicine.

The results contradicted researchers' hypotheses; stroke and death rates were both higher than expected in the stent group and lower than expected in the medication group. Earlier trials of the stent had found 30-day stroke or death rates under 10%, perhaps because patients in this trial had greater stenosis and more recent symptoms. The findings may also indicate that the medical management applied in the study is highly effective, the authors speculated. It may be difficult to duplicate all components of the medication plan in clinical practice, but some elements, such as clopidogrel with aspirin for 90 days and management of blood pressure and LDL cholesterol, should be adopted, the authors said. They plan to continue following the enrolled patients to assess long-term outcomes.

An accompanying editorial noted that the study shows not only the effectiveness of medical therapy, but also the challenges of intracranial revascularization compared to revascularization of extracranial carotid stenoses as well as the importance of the FDA and CMS in situations like this one. The decision by CMS not to reimburse for the Wingspan device for purposes other than research assisted with trial recruitment and prevented overuse of unproven technology, the editorialist said.

Top




Cardiology


.
Complication rates of ICDs higher in the elderly, but mainly due to comorbidities

Elderly patients have higher rates of complications after implantable cardioverter defibrillator (ICD) placement compared with younger patients, but mainly due to increased comorbid conditions, and the risks of the procedure are still acceptable, a new study has found.

Researchers used data from the National Cardiovascular Data Registry's ICD Registry to try to determine ICD complication rates by decade of age in elderly patients. Previous studies, they said, have used only one age cutoff to define "elderly" and may not have detected differences in complication rates among patients in their sixties, seventies, eighties and nineties. A total of 150,264 patients who received ICDs for primary prevention between January 2006 and December 2008 were included. The study's primary end point was any adverse event or death in the hospital, while the secondary end points were major and minor adverse events and length of stay. The study results were published online Aug. 30 by Circulation: Cardiovascular Quality and Outcomes.

Of the study patients, 91,863 (61%) were 65 years of age or older. Patients in this age group were more likely than younger patients to have diabetes, atrial fibrillation, congestive heart failure, renal disease, and coronary artery disease. A total of 3.4% of the entire study cohort experienced a complication after ICD implantation: 2.8% of patients younger than 65, 3.1% of patients 65 to 69 years old, 3.5% of patients 70 to 74 years old, 3.9% of patients 75 to 79 years old, 4.5% of patients 80 to 84 years old, and 4.5% of patients at least 85 years old. In multivariate analysis after adjustment for clinical covariates, the authors found that the risk for any adverse event or death compared with patients younger than 65 was 1.14 (95% CI, 1.03 to 1.25) in those 75 to 79 years old, 1.22 (95% CI, 1.10 to 1.36) in those 80 to 84 years old, and 1.15 (95% CI, 1.01 to 1.32) in those 85 years old and older. Age did not predict complications as well as some other factors did, including sex, renal failure, stage IV heart failure, atrial fibrillation, second- or third-degree atrioventricular block, and biventricular ICD placement.

The study examined only adverse events that occurred in the hospital and did not include complications related to leads, among other limitations. However, the authors concluded, "Older patients had a modestly increased—but acceptably safe—risk of periprocedural complications and in-hospital mortality, driven mostly by increased comorbidity." The authors stressed that their findings do not indicate that elderly patients should not receive ICDs but rather provide data on complication rates by age that will help improve informed decision making.

Top




Infectious disease


.
Transfusion-related babesiosis of concern in the U.S., study finds

Rates of babesiosis related to blood transfusions are of concern in the U.S., according to a recent study from the Centers for Disease Control and Prevention.

Babesiosis is transmissible through tick bite or blood transfusion. While tickborne transmission mainly occurs in seven states in the Northeast and upper Midwest, transfusion-associated cases can occur anywhere. Depending on a patient's age and general health, Babesia infection can range from asymptomatic to severe, leading to nonspecific flu-like symptoms, hemolytic anemia, and complications such as multiorgan dysfunction and death. No screening test is currently approved for blood donors, and donors without symptoms may not know they have the infection.

annals.jpg

To examine rates of transfusion-associated Babesia infection in the U.S. since 1979, the authors reviewed data from the CDC, health departments, blood collection and transfusion services, other health professionals, and the medical literature. One hundred fifty-nine cases of Babesia infection were identified, 139 of which (86%) were found to be transfusion-related. These infections occurred during all four seasons of the year in 19 states, with a mean patient age of 65 years (range, 1 to 94 years). Eighty-seven percent of the cases occurred in the seven main babesiosis-endemic states, and 77% of cases occurred between 2000 and 2009.

The authors acknowledged that they had no follow-up data on the identified cases, and that some of the cases may have been related to tickborne transmission. However, they concluded that babesiosis should be considered in patients with unexplained fever or hemolytic anemia, regardless of region or time of year, and that donor-screening strategies should be developed to decrease the risk for transfusion-related transmission.

"The increasing recognition of transfusion cases strengthens the impetus for screening strategies that mitigate the transmission risk, including testing approaches implemented under FDA-approved protocols and longer-term strategies with development of a high-throughput Babesia screening assay," the authors wrote. Their findings were published early online Sept. 5 by Annals of Internal Medicine.

Top




CMS update


.
Changes finalized to eRx program

Last week, the Centers for Medicare and Medicaid Services (CMS) announced a new final rule, making changes to the Electronic Prescribing Incentive Program for 2011.

Under the new rule, an additional type of eRx system will qualify for the program, and the types of hardship exemptions available for clinicians who cannot e-prescribe have also been expanded. Under the 2011 program, clinicians who do not successfully use an eRx system during 2011 will be subject to a payment penalty on their 2012 Medicare payments. Clinicians who may qualify for an exemption have by Nov. 1, 2011 to apply. Additional information is available on the College website.

Top


.
Medicare will require clinicians to re-enroll

Due to new risk-screening criteria established as part of the Affordable Care Act, clinicians who enrolled in Medicare before March 25, 2011 will be required to re-enroll.

Clinicians will receive a notice to re-enroll from their Medicare administrative contractor (MAC) sometime between now and March 2013 and should provide their enrollment information at that time. The process is being staggered so that MACs can better manage the information. Additional information is available on the CMS website.

Top




From ACP Internist


.
The next issue of ACP Internist is online

September's issue of ACP Internist features stories on the following:

acpi-20110913-japan.jpg

Internists healing tsunami's aftereffects. Six months after an earthquake and tsunami, Japan's populace and its clinicians are sizing up the long-term health effects. Don't miss our survey on disaster preparedness closer to home.

Alzheimer's markers make diagnosis tougher. Diagnostic advances are identifying Alzheimer's disease and its precursors much earlier. The bad news is that, for now at least, these improvements may only create more dilemmas for general internists.

Hepatitis management. Check out ACP Internist's stories on hepatitis management efforts, including a national program to educate all clinicians, and a state-by-state effort that applies telemedicine and long-distance expertise to consult on cases.

These stories and the next MKSAP Quiz on diabetic ketoacidosis are online.

Top




From the College


.
Only 4 weeks left to apply for ACP's Health Policy Internship Program

There is still time to send in your application for ACP's 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 participating in ACP's annual Leadership Day on Capitol Hill, will last for four weeks starting on May 1, 2012.

The application deadline has been extended to Oct. 14. Additional details are available on the College website.

Top


.
ACP Immunization Portal now available

ACP has launched the ACP Immunization Portal, a Web-based guide to adult immunization designed to help health care professionals develop a systematic process to incorporating immunization procedures into their day-to-day practice.

The portal provides resources on quality improvement principles in immunization, resources for practical application, and recommendations for adult vaccines, as well as information for administering vaccines to special populations. The Immunization Portal can be accessed online.

Top


.
Course for educators offered on healing health care disparities through education

Medical faculty, residents and fellows are invited to attend a two-day course presenting interactive educational methods for achieving the recently mandated integration of cross-cultural care into medical school and residency programs.

The course is offered by Harvard Medical School in coordination with ACP. It will take place in Boston on Oct. 14 and 15. ACP members receive a $50 discount on registration. More information is available online.

Top




Cartoon caption contest


.
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-20110913-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.

Top


.


MKSAP Answer and Critique



The correct answer is D) Mild cognitive impairment. This item is available to MKSAP 15 subscribers as item 30 in the Neurology section. More information about MKSAP 15 is available online.

This patient has mild cognitive impairment (MCI), which denotes abnormal cognitive decline that is not severe enough to produce disability. His self-reported memory loss, which is confirmed by his performance on the Folstein Mini–Mental State Examination, is his only symptom; there are no other signs of dementia. Memory loss is nonspecific and is part of many dementia syndromes. However, the lack of any functional impairment in this patient makes MCI the most likely diagnosis at this time. Although there are no universally accepted criteria for MCI, the disorder has been defined as a memory abnormality corroborated by objective memory impairment on standardized tests, without general cognitive impairment or an effect on functional independence. The rate of progression to dementia is approximately 10% to 15% per year.

Alzheimer dementia is the most common cause of MCI involving memory loss. Because this patient has no functional disabilities and thus does not meet the criteria for frank dementia, Alzheimer dementia is an incorrect diagnosis at this point. He may eventually develop the disease, given that the conversion rate of MCI to dementia is roughly 10% to 15% per year and that, at autopsy, approximately 80% of patients originally diagnosed with MCI have Alzheimer dementia.

Early-stage symptoms that are characteristic of frontotemporal dementia include changes in behavior and personality, such as increasing apathy, disinhibition, or perseverative (repetitive to an exceptional degree) fixations. This patient has exhibited no such changes.

The onset of dementia with Lewy bodies could also be characterized by memory loss. Besides clearly not having dementia of any sort at this stage of his illness, this patient lacks any of the other symptoms of dementia with Lewy bodies, such as parkinsonism, visual hallucinations, psychomotor slowing, and dream enactment behavior.

Typical manifestations of vascular dementia include psychomotor slowing, a stepwise progression, and a history of stroke, none of which pertain to this patient.

Key Point

  • Mild cognitive impairment denotes abnormal cognitive decline that is not severe enough to produce disability.

Click here to return to the rest of ACP InternistWeekly.

Top




About ACP InternistWeekly

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

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

Copyright © by American College of Physicians.

Test yourself

A 42-year-old woman is evaluated for an 8-month history of crampy abdominal pain and three loose bowel movements per day. The pain is relieved by a bowel movement. There are no nocturnal bowel movements, and there is no blood or dark tarry material in the stool. She has not had fever, night sweats, or weight loss. She has a history of Hashimoto disease and is treated with levothyroxine. Following a physical exam, rectal exam, and lab tests, what is the most appropriate next step in management?

Find the answer

ACP JournalWise

Reviews of the World's Top Medical Journals—FREE to ACP Members!

New CME Option: Internal Medicine 2014 RecordingsACP JournalWiseSM is mobile optimized with optional email alerts! Get access to reviews from over 120 of the world’s top medical journals alerting you to the highest quality, most clinically relevant new articles based on your preferred areas of specialty. ACP Members register your FREE account now!

New CME Option: Internal Medicine 2014 Recordings

New CME Package

New CME Option: Internal Medicine 2014 RecordingsIncludes 75 of the most popular sessions in internal medicine and the subspecialties. Stream the sessions, answer brief quizzes and earn CME credit. See details.