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

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ACP InternistWeekly



In the News for the Week of November 13, 2012




Highlights

Aspirin didn't reduce recurrent VTE but did reduce major vascular events

Low-dose aspirin may have therapeutic benefit for patients who have completed initial anticoagulant therapy for an unprovoked venous thromboembolism (VTE) even though the rate of recurrent VTE was not significantly reduced in a recent study. More...

Statins may be associated with reduced cancer-related mortality

Statins may be associated with reduced cancer-related mortality, a new study has found. More...


Test yourself

MKSAP Quiz: recurring pain and swelling of the knee

A 42-year-old woman is evaluated for recurring pain and swelling of the left knee and right ankle that began 5 months ago. Based on a physical exam, lab results and radiographs, what is the most appropriate treatment for this patient? More...


Infectious disease

Probiotics reduced C. diff infections, review finds

Giving probiotics to patients taking antibiotics reduced the risk of Clostridium difficile-associated diarrhea (CDAD), according to a new review. More...


Stroke

Stroke risk may be higher up to 12 weeks after hip replacement, study finds

Risk for stroke is elevated up to 12 weeks after total hip replacement, according to a new study. More...


Medication safety

ACP supports acetaminophen awareness and education campaign

The College has lent its support to Know Your Dose, a public awareness campaign from the Acetaminophen Awareness Coalition that educates patients on how to appropriately use medicines containing acetaminophen to prevent unintentional overdose. More...


Practice tools

ACP and WellPoint provide free access to Medical Home Builder 2.0

ACP and WellPoint are collaborating to provide free licensed access to Medical Home Builder 2.0 to physician practices in 14 states that participate in WellPoint's affiliated health plan's patient-centered primary care programs, beginning in January 2013. More...


Internal Medicine 2013

Poster competition announced for ACP Medical Student Members and Associates at Internal Medicine 2013

ACP will feature a National Poster Competition for ACP Medical Student Members and Associates at Internal Medicine 2013, which will be held in San Francisco April 11-13. More...


Cartoon caption contest

And the winner is …

ACP InternistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption. More...


Physician editor: Daisy Smith, MD, FACP



Highlights


.
Aspirin didn't reduce recurrent VTE but did reduce major vascular events

Low-dose aspirin may have therapeutic benefit for patients who have completed initial anticoagulant therapy for an unprovoked venous thromboembolism (VTE) even though the rate of recurrent VTE was not significantly reduced in a recent study.

The trial included more than 800 patients who had a first unprovoked VTE and completed treatment with heparin followed by warfarin for at least six weeks (most for at least three months). They were randomized to either 100 mg of aspirin per day or placebo for up to four years. Results were published online by the New England Journal of Medicine on Nov. 4.

The rate of recurrent VTE was lower in the aspirin group, but the difference was not statistically significant (6.5% per year on placebo vs. 4.8% per year on aspirin; hazard ratio, 0.74; 95% CI, 0.52 to 1.05; P=0.09). Aspirin did significantly decrease a prespecified composite outcome: The rate of VTE, myocardial infarction, stroke or cardiovascular death was 5.2% per year with aspirin compared to 8.0% on placebo (hazard ratio, 0.66; P=0.01). The groups had similar rates of major or clinically relevant nonmajor bleeding episodes (0.6% per year with placebo vs. 1.1% per year with aspirin; P=0.22).

The authors concluded that although aspirin didn't significantly reduce VTE, it did significantly reduce major vascular events, providing a net clinical benefit. They noted that recruitment and retention of fewer patients than planned led to the trial being underpowered to detect an effect on VTE. When the results were combined with those of another recent, similar trial, a statistically significant reduction in VTE of 32% was found (P=0.007).

Based on the findings of the current study, the authors calculated that for every 1,000 patients treated with aspirin for a year, there would be 17 fewer VTEs, 28 fewer major thrombotic events and five additional nonfatal bleeding episodes. Aspirin is less effective than warfarin but may be more attractive to patients for long-term use, they concluded.

An accompanying editorial agreed, noting that in addition to the lesser expense and freedom from monitoring, aspirin is more easily reversible and provides extra protection against arterial thrombosis. It seems to be a "reasonable option" for patients who have completed initial anticoagulation, the editorialist concluded.


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Statins may be associated with reduced cancer-related mortality

Statins may be associated with reduced cancer-related mortality, a new study has found.

Researchers from Denmark examined national data on mortality among patients who were diagnosed with cancer between 1995 and 2007 and were followed until date of death or Dec. 31, 2009. The objective of the study was to determine whether statin use started before a diagnosis of cancer was associated with better cancer-related mortality. Mortality among patients who had taken statins before diagnosis (n=18,721) was compared with mortality among those who had not (n=277,204). The study results appeared in the Nov. 8 New England Journal of Medicine.

The study involved 1,072,503 person-years of follow-up, during which 162,067 patients died of cancer, 14,489 died of cardiovascular causes, and 19,038 died of other causes. Overall, patients who had used statins had multivariable-adjusted hazard ratios of 0.85 (95% CI, 0.83 to 0.87) for death from any cause and 0.85 (95% CI, 0.82 to 0.87) for death from cancer compared with patients who had not used statins.

The researchers also assessed the relationship by recommended defined daily statin dose, or the assumed average maintenance dose per day. When this variable was considered, the adjusted hazard ratios for death from any cause and death from cancer were 0.82 and 0.83 for a defined dose of 0.01 to 0.75 per day, 0.87 and 0.87 for a defined dose of 0.76 to 1.50 per day, and 0.87 and 0.87 for a defined dose above 1.50 per day. Statin use was associated with lower cancer-related mortality in patients with 13 of 27 types of cancer. For the remaining 14 types, the confidence intervals for the multivariable-adjusted hazard ratios overlapped 1.

The authors noted that the available data on cancer characteristics such as size and metastasis were incomplete and that statin use before diagnosis could have indicated higher health awareness, among other potential limitations. However, they concluded that statin use at cancer diagnosis was associated with up to a 15% reduction in risk for cancer-related death. They called for clinical trials to determine whether statin use improves survival in cancer patients.

An accompanying editorial called for caution in interpreting the study results and suggested additional research examining existing statin trials before clinical trials are performed. The editorialist also suggested that population studies verifying the current findings and basic science studies looking at statins' mechanisms of action should be performed.

"Clinicians want to understand whether the cardiovascular and cancer effects of statins are due to overlapping or independent mechanisms, how the effects differ according to the individual agent and dose or are mediated by genes, and whether the effects correlate with the degree of lipid lowering," he wrote.



Test yourself


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MKSAP Quiz: recurring pain and swelling of the knee

A 42-year-old woman is evaluated for recurring pain and swelling of the left knee and right ankle that began 5 months ago. At that time, she also had an episode of conjunctivitis as well as dysuria, both of which resolved spontaneously. The joint pain and swelling persisted, and aspiration of the left knee was performed, which revealed leukocytosis without evidence of crystals or bacteria. She started naproxen, which provided some relief; 1 month later, she switched to indomethacin, but there was no improvement. She then began corticosteroid joint injections, which initially provided relief, but now the pain and swelling have recurred. Six months ago she also had an episode of nonbloody diarrhea of 5 days' duration that resolved spontaneously.

mksap.gif

On physical examination, vital signs are normal. Cutaneous examination is normal. There is no evidence of conjunctivitis or iritis. Musculoskeletal examination reveals swelling, tenderness, and warmth of the left knee and right ankle.

Rheumatoid factor, antinuclear antibody, and anti–cyclic citrullinated peptide antibody testing is negative. Lyme disease serology results are negative. Chlamydia trachomatis and Neisseria gonorrhoeae test results are negative.

Radiographs of the left knee and right ankle are normal.

Which of the following is the most appropriate treatment for this patient?

A: Colchicine
B: Glucosamine
C: Nitrofurantoin
D: Sulfasalazine

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


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Infectious disease


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Probiotics reduced C. diff infections, review finds

Giving probiotics to patients taking antibiotics reduced the risk of Clostridium difficile-associated diarrhea (CDAD), according to a new review.

Reviewers included 20 trials with more than 3,800 adult or pediatric patients who were receiving antibiotics and were randomized to a specified probiotic or placebo or no treatment control. They found that probiotics reduced the incidence of CDAD by 66% (pooled relative risk, 0.34 [95% CI, 0.24 to 0.49]). Results were published online by Annals of Internal Medicine on Nov. 13.

annals.jpg

Assuming a 5% incidence of CDAD in patients taking antibiotics (the median risk in the studies' control groups), probiotic prophylaxis would prevent 33 cases of CDAD per 1,000 patients, the researchers calculated (95% CI, 25 to 38). Adverse events were lower in the probiotic-treated patients (9.3% vs. 12.6% of controls) and no trial reported a serious adverse event attributable to probiotics. Using multiple species of probiotics rather than a single species appeared to result in larger effects, but the finding was not consistent across studies, so further research is needed on this issue.

The authors concluded that moderate-quality evidence suggests a large reduction in CDAD from probiotic prophylaxis. A larger sample size would be required to rate the quality of evidence as better than moderate, they noted. The review was limited by missing data on CDAD status in some patients. However, the authors conducted a stringent assessment of the worst-plausible assumptions with regard to that missing data and found the results still robust.

"Given the low cost of probiotics and the moderate-quality evidence suggesting the absence of important adverse effects, there seems little reason not to encourage the use of probiotics in patients receiving antibiotics who are at appreciable risk for CDAD," the authors concluded.



Stroke


.
Stroke risk may be higher up to 12 weeks after hip replacement, study finds

Risk for stroke is elevated up to 12 weeks after total hip replacement, according to a new study.

Researchers in Denmark performed a nationwide cohort study to determine the timing of stroke after total hip replacement surgery. Patients who had had a primary total hip replacement were matched by age, sex and region with three controls who had not had total hip or knee replacement surgery. The effects of comorbid conditions and medications on the timing of stroke were also assessed. The study results were published early online Nov. 6 by Stroke.

A total of 66,583 patients and 199,995 controls were included in the study. Mean age in both groups was 71.9 years, and most of the study population (63.1%) was female. Previous use of cardiovascular drugs was slightly more likely and prevalence of previous cerebrovascular disease was modestly higher in total hip replacement patients than controls, while use of pain relievers was substantially higher. Compared with matched controls, patients who had total hip replacement had a 4.7-fold increased risk for ischemic stroke and a 4.4-fold increased risk of hemorrhagic stroke in the first two weeks after surgery. This elevated risk persisted for a total of six weeks and 12 weeks, respectively. Risk for ischemic stroke was 70% lower in patients who took antiplatelet agents after hospital discharge. Statistical power was too low to detect significant effect modification for hemorrhagic stroke.

The authors noted that they did not have data available on body mass index, which may affect stroke risk, or on use of antithrombotic agents during hospitalization, among other limitations. However, they concluded that risk for ischemic and hemorrhagic stroke appeared to be elevated for at least six and at least 12 weeks, respectively, after total hip replacement and that risk assessment for stroke in individual patients undergoing this procedure should be considered during this time period. Although use of antiplatelet therapy appeared to substantially lower postoperative risk for ischemic stroke, the authors wrote that "this seemingly protective effect should be interpreted with caution, given the observational design and the lack of information on inpatient antithrombotic use."



Medication safety


.
ACP supports acetaminophen awareness and education campaign

The College has lent its support to Know Your Dose, a public awareness campaign from the Acetaminophen Awareness Coalition that educates patients on how to appropriately use medicines containing acetaminophen to prevent unintentional overdose. Information cards, posters and talking points to use with patients are available online.



Practice tools


.
ACP and WellPoint provide free access to Medical Home Builder 2.0

ACP and WellPoint are collaborating to provide free licensed access to Medical Home Builder 2.0 to physician practices in 14 states that participate in WellPoint's affiliated health plan's patient-centered primary care programs, beginning in January 2013.

Medical Home Builder 2.0, ACP's online practice management tool, helps primary care practices improve clinical quality, streamline fundamental business operations, and identify and implement key features of the patient-centered medical home. More information is available online.



Internal Medicine 2013


.
Poster competition announced for ACP Medical Student Members and Associates at Internal Medicine 2013

ACP will feature a National Poster Competition for ACP Medical Student Members and Associates at Internal Medicine 2013, which will be held in San Francisco April 11-13. Enter for a chance to win recognition among your peers. National winners and finalists receive complimentary registration to the meeting. The deadline for entries is Dec. 3, 2012. For more information, please visit the ACP website.



Cartoon caption contest


.
And the winner is …

ACP InternistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

acpi-20121113-cartoon.jpg

"Some refer to my practice as fee-for-service, but I prefer the term à la carte."

This issue's winning cartoon caption was submitted by Ashwini Davison, MD, ACP Member. Readers cast 126 ballots online to choose the winning entry. Thanks to all who voted! The winning entry captured 44.4% of the votes.

The runners-up were:

"Since opening my concierge practice, I'm able to offer many new service options. I see the sigmoidoscopy paired with a nice pinot grigio has caught your eye."

"I recommend the liver."


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MKSAP Answer and Critique



The correct answer is D: Sulfasalazine. This item is available to MKSAP 16 subscribers as item 2 in the Rheumatology section.

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

Treatment with sulfasalazine is appropriate for this patient with reactive arthritis. Reactive arthritis is characterized by the presence of inflammatory arthritis that manifests within 2 months of an episode of bacterial gastroenteritis or nongonococcal urethritis or cervicitis in a genetically predisposed patient. Approximately one third of patients manifest the classic triad of arthritis, urethritis, and conjunctivitis. Reactive arthritis is usually self-limited and remits within 6 months without causing erosive damage; approximately 25% of patients develop a chronic persistent arthritis that can be refractory to treatment with NSAIDs. This patient has reactive arthritis related to an episode of gastroenteritis. NSAIDs and corticosteroids have been ineffective in improving her condition. Data on the use of disease-modifying antirheumatic drugs in reactive arthritis are limited; however, sulfasalazine has been shown to have some efficacy in patients with chronic reactive arthritis and may be beneficial for this patient. The benefits of sulfasalazine in peripheral musculoskeletal manifestations of other forms of spondyloarthritis, including psoriatic arthritis, inflammatory bowel disease–associated arthritis, and ankylosing spondylitis, also support the use of sulfasalazine in reactive arthritis.

Colchicine is used to control inflammation in patients with crystal-associated arthritis as well as some autoinflammatory syndromes but is not used for patients with reactive arthritis.

Glucosamine may have a limited role in pain relief in some patients with osteoarthritis but has not been studied or suggested for use in patients with reactive arthritis.

Despite the association between reactive arthritis and bacterial infection, antibiotics are indicated primarily for acute infection and generally are of dubious benefit for reactive joint disease. In some studies, a 3-month trial of minocycline or a similar agent was shown to improve the clinical course of reactive arthritis, particularly when this condition was associated with Chlamydia trachomatis infection. There is no role for nitrofurantoin in the treatment of this patient.

Key Point

  • Treatment with sulfasalazine is appropriate for a patient with chronic reactive arthritis who does not respond to NSAIDs or corticosteroids.

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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?

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