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ACP InternistWeekly



In the News for the Week of 9-20-11




Highlights

Nonaspirin NSAIDs associated with renal cell cancer

Nonaspirin nonsteroidal anti-inflammatory drugs were associated with an elevated risk of renal cell cancer, especially among those who took them for a long time, while aspirin and acetaminophen were not associated with such risk, an analysis found. More...

Statins after stroke not associated with intracerebral hemorrhage

Taking statins following an ischemic stroke was not associated with an increased risk of intracerebral hemorrhage, researchers found. More...


Test yourself

MKSAP Quiz: fatigue and decreased exercise capacity

This week's quiz asks readers to evaluate fatigue and decreased exercise capacity in a 72-year-old woman. More...


Women's health

Fewer than 3 doses of HPV vaccine still effective

Two doses of the human papillomavirus vaccine appeared to protect women against infection as well as the recommended three doses, a recent study found. More...

Introduction of mammography screening may increase breast surgery rates

Mammography screening may increase rates of breast surgery, including mastectomy, according to a new study. More...


FDA update

Ondansetron contraindicated in patients with QT prolongation

The antinausea drug ondansetron (Zofran) will carry a new warning about the risk of abnormal heart rhythms, the FDA announced last week. More...


CMS update

ACP offers new guidance on Medicare bundled payments initiative

A summary and guidance for physicians who may be interested in participating in CMS's new Bundled Payments for Care Improvement Initiative are now available from ACP. More...


Health insurance

HealthCareandYou.org to host a Web chat on new insurance limits

On Thursday, Sept. 22, HealthCareandYou.org will host a Web-based chat focused on the changes the Affordable Care Act will make to annual and lifetime limits on health insurance coverage. More...


From the College

Fred Ralston Jr., MD, MACP, blogs at KevinMD.com

Fred Ralston Jr., MD, MACP, ACP's immediate past president and a practicing internist in Fayetteville, Tenn., blogs at KevinMD.com on payment and practice trends. 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, MD, FACP




Highlights


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Nonaspirin NSAIDs associated with renal cell cancer

Nonaspirin nonsteroidal anti-inflammatory drugs (NSAIDs) were associated with an elevated risk of renal cell cancer, especially among those who took them for a long time, while aspirin and acetaminophen were not associated with such risk, an analysis found.

Researchers examined the relationship between analgesic use and renal cell cancer using data from the Nurses' Health Study (beginning in 1990) and the Health Professionals Follow-up Study (beginning in 1986). Results appeared in the Sept. 12 Archives of Internal Medicine.

During a follow-up of 16 years among 77,525 women (1,106,683 person-years) and 20 years among 49,403 men (807,017 person-years), there were 333 renal cell cancer cases (153 women and 180 men). Aspirin and acetaminophen use was not associated with renal cell cancer risk. However, regular use of nonaspirin NSAIDs was associated with an increased renal cell cancer risk (pooled multivariate relative risk [RR], 1.51; 95% CI, 1.12 to 2.04) at baseline compared with nonregular use. The absolute risk differences for the users versus nonusers of nonaspirin NSAIDs were 9.15 per 100,000 person-years in women and 10.92 per 100,000 person-years in men.

There was also a dose-response relationship. Compared with nonregular use, the pooled multivariate RRs were 0.81 (95% CI, 0.59 to 1.11) for NSAID use less than 4 years, 1.36 (0.98 to 1.89) for 4 to less than 10 years, and 2.92 (1.71 to 5.01) for 10 or more years (P<0.001 for trend).

Researchers mutually adjusted for the three types of analgesics in a multivariate model. The positive association between nonaspirin NSAIDs and renal cell cancer risk remained essentially unchanged. The pooled multivariate RR was 3.00 (95% CI, 1.74 to 5.18) for those who used nonaspirin NSAIDs 10 or more years compared to nonusers.

Researchers also examined nonconsecutive versus consecutive use. In women, the RRs for nonconsecutive and consecutive use were 4.01 (95% CI, 1.98 to 8.29; 11 cases) and 2.40 (CI 0.72 to 7.95; 3 cases), respectively. All of the men taking NSAIDs for 10 or more years were nonconsecutive users. After prevalent users of nonaspirin NSAIDs at baseline were excluded, few cases remained among those with 4 or more years of use. When men taking NSAIDs for 4 to 10 years and 10 years or more were combined as a group, no significant association was found.

In women, there was a linear increase in renal cell cancer risk with increasing frequency of use. Compared with nonuse, the RRs were 1.08 (95% CI, 0.67 to 1.74), 1.30 (0.71 to 2.39), and 1.86 (1.19 to 2.90) for use of 1 to 4 days per month, 5 to 14 days per month, and more than 15 times per month, respectively.

Because some participants used more than one analgesic, researchers evaluated the associations among individuals who used one medication exclusively by excluding those who also took other analgesics. The results were essentially similar. The pooled multivariate RR was 1.57 (95% CI, 1.07 to 2.33) for those who exclusively used nonaspirin NSAIDs compared with those who did not.

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Statins after stroke not associated with intracerebral hemorrhage

Taking statins following an ischemic stroke was not associated with an increased risk of intracerebral hemorrhage, researchers found.

Canadian researchers conducted a retrospective, propensity-matched, cohort study among patients age 66 years and older who were admitted to any Ontario hospital with a primary diagnosis of acute ischemic stroke from July 1994 to March 2008. The primary study outcome was time to intracerebral hemorrhage, defined as a hospitalization or emergency department visit within 120 days of hospital discharge. A total of 17,872 patients (8,936 statin users and 8,936 matched controls) were followed for a median of 4.2 years. Results appeared in the Sept. 12 Archives of Neurology.

In the primary analysis comparing statin users with nonusers, there were 213 episodes of intracerebral hemorrhage, with a slightly lower rate in statin-treated patients than in matched controls (2.94 vs. 3.71 episodes per 1,000 patient-years, respectively). The hazard ratio (HR) for statin exposure was 0.87 (95% CI, 0.65 to 1.17) compared to nonuse. There was no effect found when considering the variables of age, sex, socioeconomic status, major comorbidities, or therapy with antiplatelets or anticoagulants. Patients were also examined by dosage, with doses defined as high when the prescription contained the maximum allowable dose in the product monograph and all other doses defined as low. Patients who took high or low doses of statins had intracerebral hemorrhage risks similar to those not taking statins (HR, 1.33; 95% CI, 0.30 to 5.96; and HR, 0.86; 95% CI, 0.64 to 1.16, respectively). There was no association between statins and fatal hemorrhagic stroke (HR, 0.96; 95% CI, 0.63 to 1.45).

The authors said the study supports current practice, whereby more than 80% of patients discharged from the hospital after ischemic stroke are prescribed statin therapy. An accompanying editorial stated, however, that until more evidence clarifies the association between statins and intracerebral hemorrhages, modifiable risks such as high blood pressure should be carefully controlled in patients taking statins. Other risks, such as history of intracerebral hemorrhage or use of antithrombotic therapy and cerebral microbleeds, should also be carefully considered when prescribing statins, it said.

"The clinical decision to administer a statin following intracerebral hemorrhage remains a challenging one with available evidence tilting in the direction of withholding such therapy, especially when there is a history of lobar brain hemorrhage," the editorialist wrote. Input from patients and family members, once they have been told about possible bleeding risks with statins, is useful in making the decision, he added.

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Test yourself


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MKSAP Quiz: fatigue and decreased exercise capacity

A 72-year-old woman is evaluated for fatigue and decreased exercise capacity. The patient has severe chronic obstructive pulmonary disease, which was first diagnosed 10 years ago, and was hospitalized for her second exacerbation 1 month ago. She is a former smoker, having stopped smoking 5 years ago. She has no other significant medical problems, and her medications are albuterol as needed, an inhaled corticosteroid, a long-acting bronchodilator, and oxygen, 2 L/min by nasal cannula.

On physical examination, vital signs are normal. Breath sounds are decreased, and there is 1+ bilateral pitting edema. Spirometry done 1 month ago showed an FEV1 of 28% of predicted, and blood gases measured at that time (on supplemental oxygen) showed pH 7.41, Pco2 43 mm Hg, and Po2 64 mm Hg; DLco is 30% of predicted. There is no nocturnal oxygen desaturation. Chest radiograph at this time shows hyperinflation. CT scan of the chest shows homogeneous distribution of emphysema.

Which of the following would be the most appropriate management for this patient?

A) Lung transplantation
B) Lung volume reduction surgery
C) Nocturnal assisted ventilation
D) Pulmonary rehabilitation

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

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Women's health


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Fewer than 3 doses of HPV vaccine still effective

Two doses of the human papillomavirus (HPV) vaccine appeared to protect women against infection as well as the recommended three doses, a recent study found.

Researchers in Costa Rica evaluated the efficacy of fewer than three doses of the Cervarix HPV 16/18 vaccine as part of a larger study testing the vaccine against a control hepatitis A vaccine. The majority of the women in the study (2,957 in the HPV group and 3,010 controls) received three doses. For various reasons, the most common being pregnancy and colposcopy, the remaining women received only one or two doses. In total, 802 women (422 HPV and 380 control) got two shots and 384 (196 HPV and 188 control) only got one. The participants were followed for a median of 4.2 years to see if they developed HPV 16 or 18 infections that persisted for 10 months or more.

The study found that the efficacy of the HPV vaccine was 80.9% in those who received three doses (95% CI, 71.1% to 87.7%) compared to 84.1% in the two-dose group (95% CI, 50.2% to 96.3%) and 100% in the participants getting one dose (95% CI, 66.5% to 100%). The study authors concluded that two doses, and possibly even one dose, of the vaccine may be as protective as three doses. The results were published online Sept. 9 in the Journal of the National Cancer Institute.

The authors did note some limitations of the results, including that three doses appeared to offer greater cross-protection against other HPV types than the other regimens, although the differences were not statistically significant. The duration of protection also remains to be seen, as well as the applicability to other populations, since the trial population was largely comprised of sexually active women age 18 to 25 years.

An accompanying editorial called for additional research addressing larger populations and disease end points such as cervical intraepithelial neoplasia grade 3 or higher. If this study's findings are confirmed, using fewer doses could allow more women to be vaccinated, especially in the low-resource settings where cervical cancer causes the greatest disease burden, the editorialist concluded.

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Introduction of mammography screening may increase breast surgery rates

Mammography screening may increase rates of breast surgery, including mastectomy, according to a new study.

Norwegian researchers performed a comparative analysis from a national cancer registry to determine whether the introduction of mammography screening throughout the country affected rates of surgical breast cancer treatment. In Norway, mammography screening for women age 50 to 69 years began in four counties in 1996 and was introduced into the remaining 15 counties sequentially between 1999 and 2004.

Population-based data were examined from 1993 to 2008 for women 40 to 79 years of age who underwent surgical treatment for invasive breast cancer or ductal carcinoma in situ. The study's main outcome measures were rates of breast surgery, defined as mastectomy plus breast-conserving treatment, and rates of mastectomy alone for women age 40 to 49 years, 50 to 69 years, and 70 to 79 years. The authors also calculated changes in rates of breast surgery between 1993-1995 (prescreening), 1996-2004 (introduction of screening), and 2005-2008 (screening) in women who were invited to screening and those who were not. The study results were published online Sept. 13 by BMJ.

From the prescreening to the screening period, the annual breast surgery rate in the invited age group (50 to 69 years) increased from 180 to 305 per 100,000 women (hazard ratio, 1.70; 95% CI, 1.62 to 1.78). In younger noninvited women (age 40 to 49 years), the increase was smaller, from 133 to 144 per 100,000 women yearly (hazard ratio, 1.08; 95% CI, 1.00 to 1.16), and in older noninvited women (age 70 to 79 years), the rate decreased from 227 to 214 per 100,000 women yearly (hazard ratio, 0.92; 95% CI, 0.86 to 1.00).

Rates of mastectomy alone decreased between the prescreening and screening periods in invited and noninvited women but increased from 156 per 100,000 women in the prescreening period to 167 per 100,000 women in the introduction of screening period among those 50 to 69 years of age (hazard ratio, 1.09; 95% CI, 1.03 to 1.14). In younger noninvited women over this same period, mastectomy rates decreased from 109 to 91 per 100,000 women annually (hazard ratio, 0.83; 95% CI, 0.78 to 0.90). Women in the invited group had a 31% higher mastectomy rate than those in the noninvited younger group (hazard ratio, 1.31; 95% CI, 1.20 to 1.43).

The authors acknowledged that their study could not adjust for factors other than introduction of mammography screening, such as tumor stage and size, and that choice of surgery may have been influenced by geographic differences. However, they concluded that in Norwegian women age 50 to 69 years, increased rates of both breast cancer surgery and mastectomy alone were associated with mammography screening.

Although mastectomy rates in Norway have recently decreased because of changes in surgical policy, they wrote, these decreases have mainly been seen in unscreened age groups. "A potential benefit of mammography screening—a reduction in mastectomy rates and an increase [in] the use of less invasive surgery—was not corroborated by our results," the authors wrote.

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FDA update


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Ondansetron contraindicated in patients with QT prolongation

The antinausea drug ondansetron (Zofran) will carry a new warning about the risk of abnormal heart rhythms, the FDA announced last week.

The drug may increase the risk of prolongation of the QT interval of the electrocardiogram, which can lead to abnormal and potentially fatal arrhythmias, including torsade de pointes, according to an FDA press release.

Patients at particular risk for developing torsade de pointes include those with underlying heart conditions, such as congenital long QT syndrome, those who are predisposed to low levels of potassium and magnesium in the blood, and those taking other medications that lead to QT prolongation.

The label had previously warned about QT interval prolongation, but the new warning urges physicians to avoid the use of ondansetron in patients with congenital long QT syndrome. In addition, ECG monitoring is recommended in patients with electrolyte abnormalities (e.g., hypokalemia or hypomagnesemia), congestive heart failure, and bradyarrhythmias or patients taking concomitant medications that prolong the QT interval.

The FDA is also requiring the drug manufacturer to conduct a thorough study to determine the degree to which ondansetron may cause QT interval prolongation, and promises to update the public when more information becomes available.

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CMS update


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ACP offers new guidance on Medicare bundled payments initiative

A summary and guidance for physicians who may be interested in participating in CMS's new Bundled Payments for Care Improvement Initiative are now available from ACP.

The new program is designed to encourage better coordinated care by aligning multiple payments related to a single episode of care. Physicians and other providers who choose to participate in the program may benefit from any cost savings generated by the program.

More information is on the College website.

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Health insurance


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HealthCareandYou.org to host a Web chat on new insurance limits

On Thursday, Sept. 22, HealthCareandYou.org will host a Web-based chat focused on the changes the Affordable Care Act will make to annual and lifetime limits on health insurance coverage.

Those interested in participating may send in their questions ahead of time on the HealthCareandYou website.

HealthCareandYou is a coalition devoted to providing the public with easy-to-understand information about the health care reform law. ACP is one of the founding members.

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From the College


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Fred Ralston Jr., MD, MACP, blogs at KevinMD.com

Fred Ralston Jr., MD, MACP, ACP's immediate past president and a practicing internist in Fayetteville, Tenn., continues his monthly column at KevinMD.com, one of the Web's leading destinations for provocative physician commentary. This month's post looks at current and future payment and practice trends in medicine.

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Cartoon caption contest


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Vote for your favorite entry

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

acpi-20110920-cartoon.jpg

"And they say the solo practitioner is dead."

"You don't mind if I play this while the med student practices abdominal percussion?"

"I thought you wanted to know if you were healthy enough for sax. My bad."

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 D) Pulmonary rehabilitation. This item is available to MKSAP 15 subscribers as item 10 in the Pulmonary and Critical Care Medicine section. More information about MKSAP 15 is available online.

This patient who is on maximum medical treatment for chronic obstructive pulmonary disease (COPD) and is still symptomatic would benefit from pulmonary rehabilitation. Comprehensive pulmonary rehabilitation includes patient education, exercise training, psychosocial support, and nutritional intervention as well as the evaluation for oxygen supplementation. Referral should be considered for any patient with chronic respiratory disease who remains symptomatic or has decreased functional status despite otherwise optimal medical therapy.

Pulmonary rehabilitation increases exercise capacity, reduces dyspnea, improves quality of life, and decreases health care utilization. Reimbursement for pulmonary rehabilitation treatment remains an impediment to its widespread use.

The effect of lung volume reduction surgery is larger in patients with predominantly nonhomogeneous upper-lobe disease and limited exercise performance after rehabilitation. The ideal candidate should have an FEV1 between 20% and 35% of predicted, the DLco no lower than 20% of predicted, hyperinflation, and limited comorbidities. There is no indication for nocturnal assisted ventilation because she does not have daytime hypercapnia and worsening oxygen desaturation during sleep.

Lung transplantation should be considered in patients hospitalized with COPD exacerbation complicated by hypercapnia (Pco2 greater than 50 mm Hg) and patients with FEV1 not exceeding 20% of predicted and either homogeneous disease on high-resolution CT scan or DLco less than 20% of predicted who are at high risk of death after lung volume reduction surgery. Lung transplantation is, therefore, not an option for this patient.

Key Point

  • Pulmonary rehabilitation in patients with advanced lung disease can increase exercise capacity, decrease dyspnea, improve quality of life, and decrease health care utilization.

Click here to return to the rest of ACP InternistWeekly.

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Test yourself

A 46-year-old woman is evaluated before undergoing a dental cleaning procedure involving deep scaling. She has a history of mitral valve prolapse without regurgitation and also had methicillin-resistant Staphylococcus aureus (MRSA) aortic valve endocarditis 10 years ago treated successfully with antibiotics. The patient notes an allergy to penicillin characterized by hypotension, hives, and wheezing. The remainder of the history is noncontributory. Following a physical and cardiopulmonary examination, what is the most appropriate prophylactic regimen for this patient before her dental procedure?

Find the answer

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