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

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ACP InternistWeekly



In the News for the Week of October 16, 2012




Highlights

HRT for 10 years appears to cut risk of heart failure and heart attack without increasing cancer, deep venous thrombosis or stroke

Women who take hormone replacement therapy (HRT) for 10 years after menopause may have a significantly reduced risk of mortality, heart failure and heart attack without any increased risk of cancer, deep venous thrombosis or stroke, a study found. More...

Rapid and point-of-care tests accurate for HCV

Rapid diagnostic tests and point-of-care tests for hepatitis C virus (HCV) are accurate enough to be used for first-line screening, according to a new study. More...


Test yourself

MKSAP Quiz: syncope and emotional stress

A 38-year-old man occasionally feels "skipped heart beats" during stressful emotional situations but has not had prolonged palpitations, presyncope, or syncope. He generally feels in good health. What is the most appropriate next test? More...


Women's health

Anticholinergic therapy and onabotulinumtoxinA appear equally effective for urgency urinary incontinence

Oral anticholinergic therapy and injection onabotulinumtoxinA appear to be equally effective for treating urgency urinary incontinence, according to a new trial. More...


Pulmonary embolism

Wells score, negative D-dimer test can rule out pulmonary embolism in primary care

A Wells score of 4 or lower and a negative qualitative D-dimer test result can safely and efficiently exclude pulmonary embolism in primary care, a study found. More...


Cardiology

Beta-blockers didn't benefit stable CAD patients

Taking beta-blockers did not reduce the risk of cardiovascular events for patients with no history or a remote history of myocardial infarction (MI), according to a recent study. More...


Meningitis

CDC offers updated guidance on national meningitis outbreak due to contaminated methylprednisolone

The CDC is offering updated guidance on the current national meningitis outbreak. More...


Immunization

Want to improve adult immunization rates? Get out of the way.

Yul Ejnes, MD, MACP, continues his column at KevinMD.com, sharing his strategies for improving adult immunization rates. More...

ACP offers resources to help raise adult immunization rates

Several resources are available to help physicians and health care professionals ensure that patients receive the correct immunizations in accordance with the Centers for Disease Control and Prevention's Recommended Adult Immunization Schedule. More...


Health care reform

Forum planned on incentive reforms

Mathematica's Center on Health Care Effectiveness will hold a forum in Washington, D.C., on Tuesday, Oct. 23, from 12:00 to 1:30 p.m. to discuss incentive reforms. More...


From the College

ACP, other groups release survey findings on electronic health records

ACP, the Bipartisan Policy Center, and Doctors Helping Doctors Transform Health Care developed a survey and analyzed 527 responses for the new report "Clinician Perspectives on Electronic Health Information Sharing for Transitions of Care." More...

ACP's EVP participates in the Voices for Primary Care Campaign

In recognition of National Primary Care Week 2012, Dr. Steven Weinberger, CEO and EVP of ACP, participated in the Voices for Primary Care photo sharing campaign. More...

FACP named 2012 MacArthur Fellow

Eric A. Coleman, MD, MPH, FACP, has been named a MacArthur Fellow for 2012. 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: Philip Masters, MD, FACP



Highlights


.
HRT for 10 years appears to cut risk of heart failure and heart attack without increasing cancer, deep venous thrombosis or stroke

Women who take hormone replacement therapy (HRT) for 10 years after menopause may have a significantly reduced risk of mortality, heart failure and heart attack without any increased risk of cancer, deep venous thrombosis or stroke, a study found.

Danish researchers carried out a randomized trial over 10 years with six years of additional follow-up on 1,006 white, healthy, recently menopausal women age 45 to 58. In the study, 504 received hormone replacement therapy and 502 didn't. Results appeared Oct. 9 at BMJ.

After 10 years, 16 women in the treatment group had either died of or were hospitalized for a heart attack or experienced heart failure, compared to 33 in the control group (hazard ratio [HR], 0.48; 95% CI, 0.26 to 0.87; P=0.015). Deaths were 15 in the treatment group compared with 26 in the control group (HR, 0.57; 95% CI, 0.30 to 1.08; P=0.084).

There was no increase in any cancer (36 in the treated group vs. 39 in the control group; HR, 0.92; 95% CI, 0.58 to 1.45; P=0.71) or breast cancer (10 in the treated group vs. 17 in the control group; HR, 0.58; 95% CI, 0.27 to 1.27; P=0.17) associated with HRT. This effect lasted for the 16 years of treatment and follow-up.

There were two cases of deep venous thrombosis in the treated group versus one in the control group (HR, 2.01; 95% CI, 0.18 to 22.16). There were 11 strokes in the treatment group compared to 14 in the control group (HR, 0.77; 95% CI, 0.35 to 1.70).

Researchers wrote, "With the longest duration of randomized treatment and complete and long-term follow up, the present study provides a unique opportunity to study the clinical implications of long term hormone therapy started in young postmenopausal women within three to 24 months of menopause when randomized."


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Rapid and point-of-care tests accurate for HCV

Rapid diagnostic tests and point-of-care tests for hepatitis C virus (HCV) are accurate enough to be used for first-line screening, according to a new study.

annals.jpg

Conventional laboratory tests for HCV infection are costly, and the wait for results can be long. Researchers performed a systematic review and meta-analysis to determine whether rapid diagnostic tests and point-of-care tests, which could save time and money, have acceptable accuracy. Studies that evaluated the diagnostic accuracy of rapid and point-of-care tests for detecting HCV in patients 18 years of age and older were included in the analysis. The results appear in the Oct. 16 Annals of Internal Medicine.

Nineteen studies were reviewed, and 18 were included in the meta-analysis. Studies were stratified by specimen type (oral fluid, whole blood, serum or plasma) or test type (rapid or point of care). High sensitivity was found for point-of-care tests of whole blood and serum or plasma (98.9% [95% CI, 94.5% to 99.8%] and 98.9% [95% CI, 96.8% to 99.6%], respectively), while sensitivity for rapid diagnostic tests of serum or plasma and point-of-care tests for oral fluid were 98.4% (95% CI, 88.9% to 99.8%) and 97.1% (95% CI, 94.7% to 98.4%), respectively. Point-of-care tests of whole blood and serum or plasma had the highest specificity (99.5% [95% CI, 97.5% to 99.9%] and 99.7% [95% CI, 99.3% to 99.9%], respectively), while rapid diagnostic tests of serum or plasma and point-of-care tests of oral fluid had specificities of 98.6% (95% CI, 94.9% to 99.6%) and 98.2% (95% CI, 92.2% to 99.6%), respectively.

The authors noted that test accuracy could have been affected by the use of different reference standards and by co-infection and that the tests used could not differentiate between chronic and acute infection, among other limitations. However, they concluded that point-of-care tests of blood and oral fluid and rapid diagnostic tests of serum or plasma are accurate enough to be used for HCV screening.

"In light of their accuracy and the urgent need to increase hepatitis C screening in marginalized and at-risk populations and in endemic HCV settings, these tests could play a substantial role in expanded global screening initiatives, which would eventually impact the control of HCV infection at the population level," they wrote.



Test yourself


.
MKSAP Quiz: syncope and emotional stress

A 38-year-old man is evaluated during a routine health examination. He exercises two or three days each week by jogging for 30 minutes without shortness of breath or chest discomfort. During stressful emotional situations, he occasionally feels "skipped heart beats" but has not had prolonged palpitations, presyncope, or syncope. He generally feels in good health. He has no history of medical problems and takes no medications. He has not had fever or chills.

mksap.gif

Physical examination shows normal temperature, blood pressure is 124/68 mm Hg, pulse rate is 64/min and regular, and respiration rate is 14/min. BMI is 23. Cardiac examination demonstrates a grade 2/6 early systolic crescendo-decrescendo murmur heard best at the lower left sternal border without radiation. Lungs are clear. Peripheral pulses are normal.

Electrocardiogram is normal.

Which of the following is the most appropriate next test?

A: Ambulatory electrocardiography
B: Transesophageal echocardiography
C: Transthoracic echocardiography
D: No additional testing

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


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Women's health


.
Anticholinergic therapy and onabotulinumtoxinA appear equally effective for urgency urinary incontinence

Oral anticholinergic therapy and injection onabotulinumtoxinA appear to be equally effective for treating urgency urinary incontinence, according to a new trial.

To compare these two treatments, researchers performed a double-blind, double placebo-controlled, randomized trial of women who reported having five or more episodes of idiopathic urgency urinary incontinence per three-day period. For six months, women were randomly assigned to receive an oral anticholinergic daily (5 mg of solifenacin with potential to escalate to 10 mg or subsequently switch to 60 mg of trospium XR if necessary) plus an intradetrusor saline injection, or to receive a single 100-U intradetrusor injection of onabotulinumtoxinA, a form of purified botulinum toxin type A, plus an oral placebo daily. Study participants kept three-day diaries of urinary incontinence episodes and submitted them monthly.

The study's primary outcome measure was reduction from baseline in mean urgency urinary incontinence episodes per day over six months, according to the diaries. Secondary outcomes were resolution of incontinence, catheter use, adverse events and quality of life. The study results were published Oct. 4 by the New England Journal of Medicine.

Two hundred forty-nine women were randomly assigned to a treatment group, 247 were treated, and data from 241 were included in the primary outcome analysis. At baseline, 41% reported never having received previous anticholinergic therapy. The baseline average of urgency urinary incontinence episodes was 5.0 per day, and the mean reduction per day over six months was 3.4 in the anticholinergic group and 3.3 in the onabotulinumtoxinA group (P=0.81). Both groups showed similar improvement in quality of life. Thirteen percent of women in the anticholinergic group and 27% in the onabotulinumtoxinA group reported complete resolution of urinary incontinence (P=0.0003). Dry mouth was more common in the anticholinergic group (46% vs. 31%; P=0.02), but catheter use at two months (0% vs. 5%; P=0.01) and urinary tract infections (13% vs. 33%; P<0.001) were less common.

The authors noted that they studied the effects of only one injection of one type of botulinum toxin A and that they could not discount the possibility of a placebo effect. However, they concluded that both treatments led to similar reductions in episodes of urgency urinary incontinence, with different side effects.

"The choice between these therapies should take into account the differing regimens and routes of administration and the side-effect profiles, including more frequent occurrence of dry mouth with anticholinergic medication and higher risks of intermittent catheterization and urinary tract infection with onabotulinumtoxinA," the authors wrote.



Pulmonary embolism


.
Wells score, negative D-dimer test can rule out pulmonary embolism in primary care

A Wells score of 4 or lower and a negative qualitative D-dimer test result can safely and efficiently exclude pulmonary embolism in primary care, a study found.

Researchers conducted a prospective cohort study among 300 primary care doctors in the Netherlands, providing them with study forms and written instruction on how to use the D-dimer test from July 2007 to December 2010.

Results appeared in the Oct. 9 BMJ.

There were 598 patients considered, with a mean age of 48 years, 71% of whom were women.

Venous thromboembolism was present in 73 patients (12.2%), with 68 cases of pulmonary embolism diagnosed immediately after referral. Four additional cases of pulmonary embolism and one deep venous thrombosis were found during three months of follow-up.

Overall, 422 patients had a Wells score of 4 or less and 237 had a score of less than 2. Venous thromboembolism was present in 21 (5%; 95% CI, 3.1% to 7.5%) and 7 (3%; 95% CI, 1.2% to 6%) of these patients, respectively. Venous thromboembolism occurred in 52 patients with a Wells score of greater than 4 (29.5%; 95% CI, 22.9% to 36.9%).

In total, 272 of the patients had both a Wells score of 4 or lower and a negative D-dimer test result, and only four of them were diagnosed with pulmonary embolism, a failure rate of 1.5% (95% CI, 0.4% to 3.7%). A failure rate of less than 2% is considered safe by most consensus statements, researchers noted. The combination of Wells score and D-dimer had a sensitivity of 94.5% and a specificity of 51%.

"Such a rule-out strategy makes it possible for primary care doctors to safely exclude pulmonary embolism in a large proportion of patients suspected of having the condition, thereby reducing the costs and burden to the patient (for example, reducing the risk of contrast nephropathy associated with spiral computed tomography) associated with an unnecessary referral to secondary care," the researchers concluded.



Cardiology


.
Beta-blockers didn't benefit stable CAD patients

Taking beta-blockers did not reduce the risk of cardiovascular events for patients with no history or a remote history of myocardial infarction (MI), according to a recent study.

The longitudinal, observational registry study included 14,000 stable patients with prior MI, 12,000 patients with coronary artery disease (CAD) and no history of MI and 19,000 patients with only risk factors for CAD. The primary outcome was cardiovascular death, nonfatal MI or nonfatal stroke. Secondary outcomes also included atherothrombotic events or a revascularization procedure. Results were published in the Oct. 3 Journal of the American Medical Association.

After a median follow-up of 44 months, cardiovascular event rates were similar between patients who had taken beta-blockers and those who hadn't among all three subgroups of patients. Those with prior MI had a slightly lower, but not significantly reduced, overall event rate if they took beta-blockers (489 [16.93%] vs. 532 [18.60%]; P=0.14). Participants on beta-blockers who had CAD and no MI actually had higher rates of the secondary outcome (odds ratio [OR], 1.14; P =0.01) and hospitalization (OR, 1.17; P=0.01) and the risk-factor-only group also saw no benefit from the beta-blockers. Patients who had a MI less than a year earlier did have a lower event rate if they took beta-blockers, however (OR, 0.77).

Study authors concluded that in these three patient groups, the use of beta-blockers was not associated with lower risk of cardiovascular events. They noted that these findings are consistent with recent guideline changes in which beta-blocker therapy has been downgraded. They noted that the benefits of beta-blockers have been extrapolated from patients with MI and heart failure to other patients with CAD or risk for developing it, without evidence to support these conclusions.

"Further research is warranted to identify subgroups that benefit from beta blocker therapy and the optimal duration of beta blocker therapy," the authors concluded.



Meningitis


.
CDC offers updated guidance on national meningitis outbreak due to contaminated methylprednisolone

The CDC is offering updated guidance on the current national meningitis outbreak.

As of Oct. 14, 2012, the CDC has reported 203 cases of fungal meningitis plus two peripheral joint infections, and 15 deaths. The outbreak is the result of three contaminated lots of methylprednisolone acetate, 80 mg/mL injection, prepared at the New England Compounding Center in Framingham, Mass. (lot numbers 05212012@68, 06292012@26, and 08102012@51).

A list of approximately 75 health care facilities in 23 states that received contaminated products is available online, as is updated information for clinicians and patients.

The CDC is urging clinicians to contact patients who have received an injection from one of the recalled lots to determine if they are having any symptoms of meningitis, and to notify the state health department of any patients undergoing evaluation for infection. Any suspected adverse events should be reported to the FDA's MedWatch program. The CDC has also advised that clinicians avoid using any products from the New England Compounding Center "out of an abundance of caution."

More information is available online.



Immunization


.
Want to improve adult immunization rates? Get out of the way.

Yul Ejnes, MD, MACP, immediate past chair of ACP's Board of Regents, a practicing internist in Cranston, R.I., and a member of ACP Internist's editorial board, continues his column at KevinMD.com, one of the Web's leading destinations for provocative physician commentary. In this month's post, Dr. Ejnes shares his strategies for improving adult immunization rates.


.
ACP offers resources to help raise adult immunization rates

Several resources are available to help physicians and health care professionals ensure that patients receive the correct immunizations in accordance with the Centers for Disease Control and Prevention's Recommended Adult Immunization Schedule.

ACP urges physicians and health care professionals to conduct an immunization review with patients during medical visits to assess whether patients' immunizations are up to date and to educate patients on the benefits of immunization. ACP's Adult Immunization Portal provides resources for clinicians such as the ACP Guide to Adult Immunization, ACP Immunization Advisor App, and the Medical Home Builder adult immunization model.



Health care reform


.
Forum planned on incentive reforms

Mathematica's Center on Health Care Effectiveness will hold a forum in Washington, D.C., on Tuesday, Oct. 23, from 12:00 to 1:30 p.m. to discuss incentive reforms.

The forum, titled "Paying Wisely: Using Incentive Reforms to Reduce Costs and Improve Patient Outcomes," will examine ways to promote evidence-based care through clinician payment reforms. Speakers will include Robert Berenson, MD, FACP, from the Urban Institute and Christine Cassel, MD, MACP, from the American Board of Internal Medicine.

The registration deadline for those attending in person is Oct. 19. The forum will also be available via Webinar. More information is online.



From the College


.
ACP, other groups release survey findings on electronic health records

ACP, the Bipartisan Policy Center, and Doctors Helping Doctors Transform Health Care developed a survey and analyzed 527 responses for the new report "Clinician Perspectives on Electronic Health Information Sharing for Transitions of Care."

Results from the survey revealed that an overwhelming majority of clinicians believe that electronic exchange of health information will have a positive impact on improving the quality of patient care, coordinating care, meeting the demands of new care models, and participating in third-party reporting and incentive programs. The full report is accessible online.


.
ACP's EVP participates in the Voices for Primary Care Campaign

In recognition of National Primary Care Week 2012, Dr. Steven Weinberger, CEO and EVP of ACP, participated in the Voices for Primary Care photo sharing campaign.

Primary Care Progress launched the campaign, which is focused on voicing the value of primary care in the U.S. health system. Primary Care Progress is a growing national grassroots network of energized primary care clinicians, trainees and primary care supporters coming together in local communities to engage in activities that reinvigorate the field of primary care.


.
FACP named 2012 MacArthur Fellow

Eric A. Coleman, MD, MPH, FACP, has been named a MacArthur Fellow for 2012.

Dr. Coleman, a professor in the Division of Health Care Policy and Research at the University of Colorado School of Medicine in Denver, is the creator of the well-known Care Transitions Program, which aims to help clinicians provide high-quality transitional care.

MacArthur Fellows are awarded unrestricted fellowships of $500,000 based on exceptional creativity, promise for future advances based on past accomplishments, and potential for subsequent creative work.

More information is available online.



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-20121016-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.


.


MKSAP Answer and Critique



The correct answer is D: No additional testing. This item is available to MKSAP 16 subscribers as item 3 in the Cardiology section.

MKSAP 16 released Part A on July 31. More information is available online.

No additional testing is needed for this patient. He has an asymptomatic benign systolic ejection murmur. The benign characteristics of the murmur include its intensity or grade (<3/6), timing (early and brief systolic), lack of radiation of the murmur, and the absence of additional abnormal heart sounds. The remainder of the physical examination and the electrocardiogram are normal, without any evidence of cardiac enlargement or dysfunction. In this common situation, the patient should be reassured, and no additional diagnostic testing is indicated.

Ambulatory electrocardiography, either continuously for 24 to 48 hours or as event-activated recordings, is not indicated. The patient's brief episodes of palpitations are sporadic and not associated with hemodynamic abnormalities. In patients with repetitive, frequent palpitations, ambulatory electrocardiography may be diagnostically useful.

Transesophageal echocardiography may be useful in patients with poor imaging by transthoracic study or to evaluate the feasibility of surgical repair when surgery is planned but is not indicated in this patient.

Transthoracic echocardiography is recommended for diagnosis of systolic murmurs grade 3/6 or greater in intensity, diastolic murmurs, continuous murmurs, holosystolic murmurs, late systolic murmurs, murmurs associated with ejection clicks, or murmurs that radiate to the neck or back. This patient's murmur does not have any of these characteristics.

Key Point

  • Echocardiography is not indicated for patients with brief, early systolic, low-intensity murmurs detected by physical examination without symptoms or associated findings of valvular or cardiac dysfunction.

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Test yourself

A 69-year-old woman is evaluated for a lump under her arm found on self-examination. She is otherwise healthy and has no other symptoms. Medical and family histories are unremarkable, and she takes no medications. A needle aspirate of the right axillary mass reveals adenocarcinoma. Bilateral mammography and breast MRI are normal. CT scan of the chest, abdomen, and pelvis demonstrates the enlarged axillary lymph node and no other abnormalities. What is the most appropriate initial treatment?

Find the answer

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