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

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ACP InternistWeekly



In the News for the Week of December 11, 2012




Highlights

Even many residents in primary care training programs not planning to enter primary care

Most internal medicine residents, even those in primary care residencies, don't plan to practice general internal medicine, a recent survey found. More...

Tamoxifen for 10 years may halve breast cancer mortality during the second decade after diagnosis

Continuing tamoxifen for 10 years rather than stopping at five years reduces recurrence and mortality in estrogen receptor-positive early breast cancer, particularly after year 10, a study found. More...


Test yourself

MKSAP Quiz: New patient with Parkinson diagnosis

A 50-year-old man is seen for a new-patient evaluation. He reports a recent diagnosis of Parkinson disease. From a list of symptoms, which is most suggestive of atypical parkinsonism syndrome? More...


Infectious disease

IDSA guidelines aim to reduce death, disability and cost of prosthetic joint infections

Multispecialty physician teams need to work together to reduce disability, death and costs associated with the ever-growing number of prosthetic joint infections, said the first guidelines on the topic released by the Infectious Diseases Society of America (IDSA). More...

Benzodiazepines associated with community-acquired pneumonia

Benzodiazepines are associated with risk for and death from community-acquired pneumonia (CAP), according to a new study. More...


Men's health

Longer antibiotic treatment associated with more recurrence of male UTIs

Antibiotic treatment longer than a week was associated with worse outcomes for men with urinary tract infections (UTIs) compared to shorter therapy, a new study found. More...


CMS update

CMS to hold call on Medicaid pay parity tomorrow

The Centers for Medicare and Medicaid Services (CMS) will be holding a National Provider Call to discuss increased payments beginning in 2013 for primary care services. More...

Planning for potential Medicare pay cuts

ACP has posted a page on the Running a Practice section of the College website with information about the status of the fiscal cliff negotiations in Congress and advice on planning for the potential that the cuts are not averted. More...


FDA update

Ondansetron 32-mg dose pulled from market

The 32-mg, single intravenous dose of ondansetron hydrochloride (Zofran) has been pulled from the market due to its cardiac risks, the FDA recently announced. More...


From the College

Former ACP Japan chapter Governor receives prestigious awards

Former ACP Japan chapter Governor Kiyoshi Kurokawa, MD, MACP, who led the Fukushima Nuclear Accident Independent Investigation Commission, has been honored with two recent awards. More...


Cartoon caption contest

Vote for your favorite entry

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


Physician editor: Philip Masters, MD, FACP



Highlights


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Even many residents in primary care training programs not planning to enter primary care

Most internal medicine residents, even those in primary care residencies, don't plan to practice general internal medicine, a recent survey found.

U.S. internal medicine residents were surveyed about their career plans while taking the Internal Medicine In-Training Examination (IM-ITE). Data were gathered from more than 57,000 residents who responded to the survey in 2009-2011. About a third of the responses came from third-year residents. Results were published in the Dec. 5 Journal of the American Medical Association.

Overall, 21.5% of the residents reported plans to practice general internal medicine (GIM). Residents in primary care residency programs were more likely to choose GIM than those in categorical internal medicine residency programs (39.6% vs. 19.9%), but a subspecialty career was the most common plan for both groups (52.5% of primary care residents, 65.3% of categorical residents). Among primary care residents, there was a significant difference between the plans of U.S. medical school graduates and international medical graduates (IMGs). More than half (57.3%) of primary care IMGs were planning to subspecialize, compared to only 27.3% of U.S. grads.

The study also found that female residents were more likely than male residents to ever report a plan of a GIM career (26.7% vs. 17.3%) and to stick with that plan over the course of their training (62.4% of women reporting a GIM plan in their first year also reported one in their third year vs. 47.2% of men). The study showed that many residents change their mind about career plans, both for and against GIM, the authors noted.

This is the first study to find that even primary care residents are commonly opting for subspecialty careers, the authors added. Thus, expanding medical school enrollment or primary care residency slots might not significantly increase the supply of GIM physicians. Further investigation of the causes and potential solutions to IMG primary care residents' lack of interest in GIM may be important, however, since they fill the majority of the residency slots in primary care training programs, the authors said.

An accompanying editorial noted that the field of hospital medicine is an additional contributor to the shortage of general internists in primary care; 9.3% of the third-year residents reported plans to be a hospitalist. The editorial called for protection and realignment of graduate medical education funding.


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Tamoxifen for 10 years may halve breast cancer mortality during the second decade after diagnosis

Continuing tamoxifen for 10 years rather than stopping at five years reduces recurrence and mortality in estrogen receptor-positive early breast cancer, particularly after year 10, a study found.

To assess the effects of continuing tamoxifen to 10 years instead of stopping at five years, researchers looked at data from nearly 13,000 women enrolled globally in the Adjuvant Tamoxifen: Longer Against Shorter (ATLAS) trial. Women with early breast cancer who had completed five years of treatment with tamoxifen were randomized 1:1 to continue tamoxifen to 10 years or stop treatment.

Results appeared online Dec. 5 at The Lancet.

Among women with estrogen receptor-positive early breast cancer, 10 years of treatment with tamoxifen reduced:

  • the risk of breast cancer recurrence (617 recurrences in 3,428 women allocated to continue vs. 711 recurrences in 3,418 controls, P=0.002),
  • breast cancer mortality (331 deaths vs. 397 deaths, P=0.01), and
  • overall mortality (639 deaths vs. 722 deaths, P=0.01).

Researchers noted that reductions in adverse breast cancer outcomes appeared to be less extreme in the first decade of treatment compared to the second decade. The recurrence rate ratio (RR) during years five to nine was 0.90 (95% CI, 0.79 to 1.02) compared to 0.75 (95% CI, 0.62 to 0.90) after 10 years. The breast cancer mortality RR was 0.97 (95% CI, 0.79 to 1.18) during years five to nine and 0.71 (95% CI, 0.58 to 0.88) after 10 years. The cumulative risk of recurrence during years five to 14 was 21.4% for women allocated to continue versus 25.1% for controls. Breast cancer mortality during years five to 14 was 12.2% for women allocated to continue versus 15% for controls (absolute mortality reduction, 2.8%).

Treatment allocation seemed to have no effect on breast cancer outcomes among 1,248 women with estrogen receptor-negative disease and an intermediate effect among 4,800 women with unknown estrogen-receptor status. Among all 12,894 women, mortality without recurrence from causes other than breast cancer was similar in both groups (691 deaths without recurrence in 6,454 women allocated to continue versus 679 deaths in 6,440 controls; RR, 0.99; 95% CI, 0.89 to 1.10; P=0.84).

Researchers noted that this study, taken together with results from previous trials, suggest that 10 years of tamoxifen can approximately halve breast cancer mortality during the second decade after diagnosis.

There are side effects to note, researchers wrote. Tamoxifen increased the incidence of endometrial cancer in postmenopausal women who had not had a hysterectomy. Although there is little risk in premenopausal women, risk calculation shows that five years of adjuvant tamoxifen carries an absolute 15-year endometrial cancer risk of about 2% to 3%, and that 10 years is associated with an additional 2% risk by year 15. However, the death rate from endometrial cancer is about one-tenth of the incidence rate, so the excess of uterine cancer mortality is greatly outweighed by the decrease in breast cancer mortality, the authors said.

An editorial noted that other trials of tamoxifen are still under way, and a meta-analysis of all trials could result in changing the standard of care to 10 years of tamoxifen. "This change should open up a whole new era of clinical trials to assess the benefit of extended adjuvant endocrine therapy of breast cancer," the editorialist wrote.



Test yourself


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MKSAP Quiz: New patient with Parkinson diagnosis

A 50-year-old man is seen for a new-patient evaluation. He reports a recent diagnosis of Parkinson disease made after a 2-year history of stiffness in his right arm, a tendency to posture when walking, an awkward and stiffly inverted step when using the right leg, but no tremor. During this period, his voice became softer and slightly high pitched.

mksap.gif

The patient lost his sense of smell 10 years ago and has a 2-year history of diplopia when reading, a 9-month history of urinary urgency and impotence, and no history of dementia, depression, or psychosis. He has been taking high-dose levodopa replacement therapy since diagnosis without improvement in symptoms.

Which of the following features in the patient's history is most suggestive of an atypical parkinsonism syndrome?

A: Absence of a tremor
B: Diplopia
C: Impotence
D: Loss of olfaction
E: Poor response to levodopa

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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IDSA guidelines aim to reduce death, disability and cost of prosthetic joint infections

Multispecialty physician teams need to work together to reduce disability, death and costs associated with the ever-growing number of prosthetic joint infections, said the first guidelines on the topic released by the Infectious Diseases Society of America (IDSA).

The guidelines appeared online at the IDSA website and in the Dec. 7 Clinical Infectious Diseases.

Joint infections require multidisciplinary teams, including an orthopedist and an infectious disease specialist, as well as other specialists on a case-by-case basis, the guidelines advise. For instance, if the patient is older and has heart disease, an internist should be involved, and if the surgical wound is difficult to close, a plastic surgeon should be consulted.

In rural areas with few specialists, doctors should consider consulting with infectious disease specialists or orthopedists at referral centers.

Physicians should suspect a prosthetic joint infection in a patient who has any of the following:

  • persistent wound drainage in the skin over the joint replacement,
  • sudden onset of a painful prosthesis, or
  • ongoing pain after the prosthesis has been implanted, especially if there had been no pain for several years or if there is a history of prior wound healing problems or infections.

The following guidelines apply in patients with prosthetic joint infections:

  • Those with a well-fixed prosthesis without an open wound to the skin who had surgery less than 30 days previously are likely candidates for debridement, which means reopening the incision and cleaning out the wound.
  • Those who have more extensive infection that has affected the bone and tissue may need to have the prosthesis replaced, either in the same surgery in which the prosthesis is removed or in a later surgery.
  • Patients who cannot walk and who have limited bone stock, poor soft tissue coverage and infections due to highly resistant organisms may need to have the implants permanently removed. In some cases the joint may need to be fused.
  • Amputation of the limb may be necessary, but only as a last resort. Prior to amputation, the patient should be referred to a center with specialist experience in prosthetic joint infections if his or her condition allows.

Four to six weeks of intravenous or highly bioavailable oral antibiotic therapy is almost always necessary to treat prosthetic joint infections, according to the guidelines.


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Benzodiazepines associated with community-acquired pneumonia

Benzodiazepines are associated with risk for and death from community-acquired pneumonia (CAP), according to a new study.

Researchers in the United Kingdom performed a nested case-control study of data from the Health Improvement Network, a database of primary care patients, to determine whether an association existed between CAP and therapy with benzodiazepines. They hypothesized that benzodiazepines might increase CAP risk because of their potential effects on immune function. The authors also examined the effects of zopiclone, a nonbenzodiazepine that has a similar mechanism of action. The study's primary end points were risk of CAP and mortality from CAP at 30 days and over the long term, a median follow-up of 2.8 years. The study results were published online on Dec. 5 by Thorax.

A total of 4,964 cases and 29,697 controls were included in the study. Cases were patients whose medical records indicated a diagnosis of pneumonia between July 1, 2001 and July 1, 2002. Approximately 54% of both cases and controls were women. The authors used conditional logistic regression to detect an association between drug use and CAP and then used Cox regression to determine the drugs' effects on mortality among the 4,964 cases.

An association was found between benzodiazepine use and increased pneumonia risk (odds ratio, 1.54; 95% CI, 1.45 to 1.67) and between use of diazepam, lorazepam or temazepam and increased CAP incidence. No such individual association was seen with chlordiazepoxide, but an increased risk was also associated with zopiclone. Thirty-day mortality (hazard ratio, 1.22; 95% CI, 1.06 to 1.39) and long-term mortality (hazard ratio, 1.32; 95% CI, 1.19 to 1.47) appeared to be higher in patients with CAP who had taken benzodiazepines. Each of the four benzodiazepines studied also appeared to individually affect long-term mortality, but zopiclone did not. Only diazepam and lorazepam appeared to individually affect 30-day mortality.

The authors noted that unmeasured confounders and selection bias may have affected their results and that their findings do not prove a cause-and-effect relationship between benzodiazepines and CAP, among other limitations. However, they concluded that benzodiazepines and zopiclone appear to be associated with higher risk for and death from CAP. "Given the widespread use of benzodiazepine drugs," they wrote, "further studies are required to evaluate their safety in the context of infection."



Men's health


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Longer antibiotic treatment associated with more recurrence of male UTIs

Antibiotic treatment longer than a week was associated with worse outcomes for men with urinary tract infections (UTIs) compared to shorter therapy, a new study found.

The observational study included more than 30,000 men with UTIs treated as outpatients in the Veterans Affairs system during fiscal year 2009. The most commonly used antimicrobials were ciprofloxacin (62.7% of infections) and trimethoprim-sulfamethoxazole (26.8% of infections). Most of the patients (65%) received more than seven days of antibiotics (usually 10 days), but 35% received shorter treatment (usually seven days). Results were published online by Archives of Internal Medicine on Dec. 3.

Overall, 9.9% of the index infections were followed by a late recurrence (at least 30 days later) and 4.1% had an early recurrence (less than 30 days). There was no difference in the risk of early recurrence between the shorter and longer treatment groups, but patients treated for seven days or more had an increased risk of late recurrence (10.8% vs. 8.4%; P<0.001). This difference remained significant after multivariate analysis, with an odds ratio (OR) of 1.20 (95% CI, 1.10 to 1.30). Longer treatment was also associated with higher rates of Clostridium difficile infection in the next year (0.5% vs. 0.3%), although this finding was not significant after multivariate analysis (OR, 1.42; 95% CI, 0.97 to 2.07).

The study authors acknowledged that the study was limited by its observational nature and that some unmeasured factor, such as more patients with catheters receiving longer therapy, could have confounded the results. Still, the findings raise questions about the value of longer treatment for UTIs in male outpatients, the authors said. They called for randomized trials directly comparing longer and shorter treatment for these infections.

An accompanying editorial noted that most research and guidelines on UTIs focus on female patients. Although this retrospective study doesn't establish that longer treatment causes recurrence or C. difficile infection, the findings have biologic plausibility, the editorialist wrote. "We recommend a culture shift in antibiotic prescribing practices for men with bacteriuria from 'more is better' to 'less is more,'" the editorial concluded.



CMS update


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CMS to hold call on Medicaid pay parity tomorrow

The Centers for Medicare and Medicaid Services (CMS) will be holding a National Provider Call at 4:00 p.m. Eastern on Wednesday, Dec. 12, to discuss increased payments beginning in 2013 for primary care services delivered by designated primary care physicians and other health care professionals participating within their state Medicaid programs.

For call-in information, please visit the Running a Practice section of ACP's website and click on the More News headline under News and Updates.


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Planning for potential Medicare pay cuts

ACP has posted a page on the Running a Practice section of the College website with information about the status of the fiscal cliff negotiations in Congress and advice on planning for the potential that the cuts are not averted.

Please check back for updates on this page as we move closer to the Jan. 1 deadline.

To learn more about the current negotiations in Washington, please see last Friday's issue of ACP Advocate.



FDA update


.
Ondansetron 32-mg dose pulled from market

The 32-mg, single intravenous dose of ondansetron hydrochloride (Zofran) has been pulled from the market due to its cardiac risks, the FDA recently announced.

The agency had previously warned that this dose of the anti-nausea drug should be avoided due to the risk of QT-interval prolongation, which can lead to torsades de pointes. Now, the pre-mixed 32-mg solutions, which also contain either dextrose or sodium chloride, are being recalled by the branded and generic manufacturers.

The FDA continues to recommend an intravenous regimen of 0.15 mg/kg administered every four hours for three doses to prevent chemotherapy-induced nausea and vomiting, but no single intravenous dose should exceed 16 mg, according to the agency's drug safety communication.



From the College


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Former ACP Japan chapter Governor receives prestigious awards

Former ACP Japan chapter Governor Kiyoshi Kurokawa, MD, MACP, who led the Fukushima Nuclear Accident Independent Investigation Commission, has been honored with two recent awards. Dr. Kurokawa was chosen for the list of 100 Top Global Thinkers by Foreign Policy and also received the 2012 Scientific Freedom and Responsibility Award from the American Association for the Advancement of Science. ACP congratulates Dr. Kurokawa on these well-deserved and prestigious awards.



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-20121211-cartoon.jpg

"This is not the best way to get your LDL to drop."

"OK, OK, I'll order a stool FIT instead!"

"Sorry, our waiting room got downsized."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting ends on Monday, Dec. 17, with the winner announced in the Dec. 18 issue.


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MKSAP Answer and Critique



The correct answer is E: Poor response to levodopa. This item is available to MKSAP 16 subscribers as item 3 in the Neurology section.

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

The sign most suggestive of an atypical parkinsonism syndrome in this patient is the absence of response to high-dose levodopa replacement. Parkinson disease remains a clinical diagnosis that is based on a cardinal set of clinical features, including resting tremor, bradykinesia, rigidity, and postural instability; the tremor, bradykinesia, and rigidity are asymmetric. Sustained levodopa responsiveness is expected in Parkinson disease and helps confirm the clinical diagnosis. All patients with suspected parkinsonism should have an adequate trial of levodopa. A lack of response indicates that the neurodegenerative process extends substantially beyond the nigrostriatal pathway and involves other basal ganglion structures. In the absence of a standard, convenient, readily affordable diagnostic test for Parkinson disease, the diagnosis depends on the response to levodopa.

The absence of a tremor should raise the suspicion of atypical parkinsonism, although tremor is absent in up to 30% of patients with classic idiopathic Parkinson disease, as confirmed by autopsy. Therefore, the absence of a tremor is less suggestive of an atypical parkinsonism syndrome than is the lack of response to levodopa replacement.

Convergence insufficiency is a common finding in patients with Parkinson disease, causing diplopia while reading, and is not suggestive of atypical parkinsonism.

Many patients with Parkinson disease have autonomic dysfunction, including constipation, urinary urgency and incontinence, impotence, orthostasis, and temperature instability. Therefore, the presence of impotence in this patient does not exclude Parkinson disease as a diagnosis. When autonomic symptoms are especially severe and overshadow the motor signs of the disorder, further autonomic testing may be indicated, and a diagnosis of the atypical parkinsonism syndrome of multiple system atrophy, autonomic type, may be made.

The absence of olfaction is a frequent finding in Parkinson disease, sometimes preceding the onset of motor signs by many years, and has not been associated with atypical parkinsonism syndromes.

Key Point

  • Absence of a response to levodopa is most suggestive of an atypical parkinsonism syndrome.

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