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

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ACP InternistWeekly



In the News for the Week of December 4, 2012




Highlights

Upper endoscopy may be overused in patients with reflux, guidelines committee says

Routine use of upper endoscopy for most patients with gastroesophageal reflux disease (GERD) does not improve patient health, is associated with preventable harms, and may lead to unnecessary interventions and costs, according to an ACP clinical policy paper. More...

6-minute walk test, exercise testing provide similar prognostic value in patients with chronic heart failure

The 6-minute walk test performed similarly to cardiopulmonary exercise testing in patients with heart failure, according to a new study. More...


Test yourself

MKSAP Quiz: 1-month history of headaches and blurred vision

A 65-year-old man is evaluated for a 1-month history of headaches and blurred vision, early satiety, and itching that occurs after showering. He has a 90-pack-year smoking history. Following physical, cardiopulmonary and neurologic examinations, what is the most appropriate next step in diagnosis? More...


Cardiology

Digoxin associated with higher mortality in afib patients

Digoxin was associated with a significant increase in all-cause mortality in patients with atrial fibrillation, regardless of gender and whether they had had heart failure, a study found. More...


Postoperative care

Three to six months of warfarin associated with better survival after bioprosthetic aortic valve replacement

Warfarin therapy after bioprosthetic aortic valve replacement was associated with reduced rates of thromboembolic events and mortality, a new study found. More...


Education

CMS webinar on blood pressure control to be held today

The Centers for Medicare and Medicaid Services will host an educational Million Hearts™ webinar today titled "Power Enough to Make a Difference: Promising Practices for Blood Pressure Control in Clinical Settings." More...


Patient-centered medical home

ACP's Medical Home Builder available at discounted rate to federally qualified health centers

ACP and the National Association of Community Health Centers (NACHC) have collaborated on a national effort to help federally-qualified health centers improve care by offering ACP's Medical Home Builder 2.0 at a discounted rate. More...


From the College

2013-14 Chair-elect, Board of Regents selected

At their November meeting, the Board of Regents elected Robert M. Centor, MD, FACP, of Huntsville, Ala., the 2013-14 Chair-elect of the Board of Regents. More...

Nominate candidates for upcoming Council of Associates and Council of Student Members elections

ACP's Council of Associates (COA) and Council of Student Members (CSM) are seeking candidates to fill vacant seats with terms to begin at Internal Medicine 2013. More...

Reminder: ACP Member Census

ACP needs to hear from you regardless of your current status as a physician to participate in the 2013 ACP Member Census. 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: Daisy Smith, MD, FACP



Highlights


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Upper endoscopy may be overused in patients with reflux, guidelines committee says

Routine use of upper endoscopy for most patients with gastroesophageal reflux disease (GERD) does not improve patient health, is associated with preventable harms, and may lead to unnecessary interventions and costs, according to an ACP clinical policy paper.

annals.jpg

The policy paper from the ACP Clinical Guidelines Committee appeared in the Dec. 4 Annals of Internal Medicine.

Upper endoscopy is indicated in men and women with:

  • heartburn and alarm symptoms (dysphagia, bleeding, anemia, weight loss and recurrent vomiting),
  • typical GERD symptoms that persist despite a therapeutic trial of four to eight weeks of twice-daily proton-pump inhibitor therapy,
  • severe erosive esophagitis after a two-month course of proton-pump inhibitor therapy to assess healing and rule out Barrett's esophagus (recurrent endoscopy after this follow-up examination is not indicated in the absence of Barrett's esophagus), or
  • history of esophageal stricture and recurrent symptoms of dysphagia.

Upper endoscopy may be indicated:

  • in men older than 50 years with chronic GERD symptoms (symptoms for more than five years) and additional risk factors (nocturnal reflux symptoms, hiatal hernia, elevated body mass index, tobacco use, and intra-abdominal distribution of fat) to detect esophageal adenocarcinoma and Barrett's esophagus,
  • for surveillance evaluation in men and women with a history of Barrett's esophagus,
  • in men and women with Barrett's esophagus and no dysplasia. In these patients, surveillance examinations should occur at intervals no more frequently than three to five years. More frequent intervals are indicated in patients with Barrett's esophagus and dysplasia.

"Endoscopy has revolutionized the diagnosis and management of gastrointestinal illness," the guidelines committee wrote. "However, inappropriate use has the potential to add cost with no benefit. Data suggest that upper endoscopy in the setting of GERD symptoms is useful only in a few, well-circumscribed situations, as previously reviewed. Avoidance of repetitive, low-yield endoscopy that has little effect on clinical management or health outcomes will improve patient care and reduce costs."

An accompanying editorial stated, "The importance of this guidance is underscored by the cumulative financial and clinical burden of endoscopy in 2012. Gastroesophageal reflux disease afflicts more than 100 million U.S. adults and costs our health system more than $9 billion annually. It is related distantly to EAC [esophageal adenocarcinoma], a rare but deadly cancer that is increasing in annual incidence. Primary care physicians must decide how best to manage patients in a manner that provides an excellent experience but balances attention to the improvement of population health and one that uses resources efficiently."

ACP's Performance Measurement Committee (PMC) also recently reviewed performance measures related to the use of upper endoscopy in patients with GERD that are currently endorsed by the National Quality Forum (NQF). The PMC does not support the use of the measure "NQF 0622: GERD–Upper Endoscopy Study in Adults with Alarm Symptoms." The PMC's goal is to provide guidance on measures that are not evidence-based and should be avoided and recommend measures that are evidence-based and clinically meaningful.


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6-minute walk test, exercise testing provide similar prognostic value in patients with chronic heart failure

The 6-minute walk test performed similarly to cardiopulmonary exercise testing in patients with heart failure, according to a new study.

Data from the HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) trial were used to compare the prognostic efficacy of both tests in outpatients who had chronic systolic heart failure and were in stable condition (New York Heart Association class II and III, ejection fraction ≤35%). Study end points were all-cause mortality or hospitalization and all-cause mortality alone over 2.5 years of mean follow-up as predicted by distance on the 6-minute walk test or cardiopulmonary exercise testing (peak oxygen consumption [VO2] and ventilatory equivalents for exhaled carbon dioxide [VE/VCO2] slope). The study results were published online Nov. 21 by the Journal of the American College of Cardiology.

Overall, 2,054 patients had exercise testing and performed the 6-minute walk test at baseline. Patients' median age was 59 years, and most (71%) were men. Sixty-four percent had class II heart failure and 36% had class III/IV heart failure.

C-indices for distance on the 6-minute walk test were 0.58 and 0.65 in unadjusted models and 0.62 and 0.72 in adjusted models for predicting all-cause mortality or hospitalization and all-cause mortality alone, respectively. Corresponding C-indices for peak VO2 were 0.61 and 0.68 in unadjusted models and 0.63 and 0.73 in adjusted models, while C-indices for VE/VCO2 slope were 0.56 and 0.65 in unadjusted models and 0.61 and 0.71 in adjusted models. C-indices did not change appreciably when both exercise testing variables were combined. In adjusted models, 6-minute walk distance and exercise testing variables were found to have similar prognostic value.

The authors noted that HF-ACTION was an exercise training trial and that its exercise intervention may have affected their findings, among other limitations. However, they concluded that both the 6-minute walk test and cardiopulmonary exercise testing had similar value in predicting all-cause hospitalization and mortality and all-cause mortality alone in outpatients with stable heart failure.

They did note that each test's results had only a modest prognostic effect when added to prediction models that use other major demographic and clinical covariates. Nevertheless, they wrote, "these data suggest that a [6-minute walk] test may be substituted for [cardiopulmonary exercise] testing as an inexpensive, practical clinical tool to help gauge prognosis in the large and growing [heart failure] population."

The author of an accompanying editorial noted that according to the study results, the 6-minute walk test may be preferred for clinical research studies on heart failure and can help clinicians diagnose the cause of patients' dyspnea or fatigue. It may also be useful for determining progress of therapy or clinical course in some patients with heart failure or pulmonary arterial hypertension, he observed.

"However," the editorialist wrote, "predicting adverse events in heart failure … largely rests on clinical and demographic variables." The current study, he concluded, "demonstrate[s] that prediction of prognosis was little enhanced by adding the results of either the [6-minute walk] or the [cardiopulmonary exercise] test."



Test yourself


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MKSAP Quiz: 1-month history of headaches and blurred vision

A 65-year-old man is evaluated for a 1-month history of headaches and blurred vision, early satiety, and itching that occurs after showering. He has a 90-pack-year smoking history. He has no history of cardiopulmonary or sleep disorders, no other medical problems, and he takes no medications.

mksap.gif

On physical examination, temperature is normal, blood pressure is 160/90 mm Hg, pulse rate is 90/min, and respiration rate is 18/min. BMI is 35 kg/m2. Oxygen saturation is 97% with the patient breathing ambient air and does not decrease with exertion. His face is erythematous, and engorged retinal veins are noted on funduscopic examination. Cardiopulmonary and neurologic examinations are normal. Abdominal examination shows splenomegaly.

Laboratory studies:

Hemoglobin 19 g/dL (190 g/L)
Leukocyte count 13,500/µL (13.5 × 109/L); normal differential
Platelet count 595,000/µL (595 × 109/L)

The findings on the complete blood count are confirmed. The remaining laboratory studies, including liver chemistry tests, are normal.

Which of the following is the most appropriate next step in diagnosis?

A: BCR-ABL gene analysis
B: Bone marrow biopsy
C: JAK2 V617F mutational analysis
D: Polysomnography

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


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Cardiology


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Digoxin associated with higher mortality in afib patients

Digoxin was associated with a significant increase in all-cause mortality in patients with atrial fibrillation, regardless of gender and whether they had had heart failure, a study found.

To determine the relationship between digoxin and mortality in patients with atrial fibrillation, researchers assessed patients enrolled in the AF Follow-Up Investigation of Rhythm Management (AFFIRM) trial. Analyses were conducted in all patients and in subsets according to the presence or absence of heart failure, as defined by a history of heart failure and/or an ejection fraction less than 40%.

Results appeared online Nov. 27 in the European Heart Journal.

Digoxin was associated with an increase in all-cause mortality (estimated hazard ratio [EHR], 1.41; 95% CI, 1.19 to 1.67; P<0.001), cardiovascular mortality (EHR, 1.35; 95% CI, 1.06 to 1.71; P=0.016), and arrhythmic mortality (EHR, 1.61; 95% CI, 1.12 to 2.30; P=0.009). The all-cause mortality was increased with digoxin in patients without or with heart failure (EHR, 1.37; 95% CI, 1.05 to 1.79; P=0.019 and EHR, 1.41; 95% CI, 1.09 to 1.84; P=0.010, respectively). There was no significant interaction between digoxin and gender for all-cause (P=0.70) or cardiovascular (P=0.95) mortality.

These findings call into question the widespread use of digoxin in patients with atrial fibrillation, researchers wrote. Recent studies put its use at between 35% and 70% of these patients, despite limited safety data and controversy over its use.

"Digoxin may seem appealing for patients with AF [atrial fibrillation] and HF [heart failure], in whom positive inotropic effects and improved neurohormonal responses are desired," the researchers wrote. "Digoxin may also be beneficial during SR [sinus rhythm] by reducing the heart rate as suggested in an analysis of the Dig trial. However, in our analysis, digoxin was associated with a 41% increase in mortality for patients with HF."



Postoperative care


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Three to six months of warfarin associated with better survival after bioprosthetic aortic valve replacement

Warfarin therapy after bioprosthetic aortic valve replacement was associated with reduced rates of thromboembolic events and mortality, a new study found.

Researchers used data on more than 4,000 patients from the Danish National Patient Registry who had surgical aortic valve replacement (AVR) with biological prostheses in 1997-2009. The study looked at whether warfarin was prescribed, and if so, when the prescription was discontinued. The mean follow-up was 6.57 years. Results were published in the Nov. 28 Journal of the American Medical Association.

Patients who took warfarin had significantly lower risk of stroke (2.69 per 100 person-years vs. 7 per 100 person-years; adjusted incidence rate ratio [IRR], 2.46) and thromboembolic events (3.97 vs. 13.07 per 100 person-years; IRR, 2.93) than those who were not taking it. The warfarin group also had fewer cardiovascular deaths: The comparison was 3.83 versus 31.74 per 100 person-years (IRR, 7.61) for deaths 30 to 89 days after surgery and 2.08 versus 6.50 per 100 person-years (IRR, 3.51) for deaths 90 to 179 days after surgery.

The results suggest a benefit to using warfarin during the initial three months after surgery which may extend to six months, the study authors concluded. They noted that their study was limited by lack of data about achieved international normalized ratios and potential confounding by comorbidities, but given these results and the lack of randomized data, they called for review of existing guidelines to consider the extension of warfarin treatment for patients receiving bioprosthetic AVR.

Current guidelines on this question are conflicting, noted an accompanying editorial. The American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology recommend three months of warfarin, and the ACC/AHA recommends adding aspirin. The American College of Chest Physicians recommends aspirin alone.

This study does not resolve the dilemma of whether to use aspirin (or the emerging option of novel oral anticoagulants), but it should change warfarin prescribing practices, the editorialist concluded, noting that "the optimal duration of therapy appears to be 6 months."



Education


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CMS webinar on blood pressure control to be held today

The Centers for Medicare and Medicaid Services will host an educational Million Hearts™ webinar today titled "Power Enough to Make a Difference: Promising Practices for Blood Pressure Control in Clinical Settings."

The webinar will take place today, Dec. 4, from 3:00 p.m. to 4:30 p.m. EST. It will showcase effective approaches to improving blood pressure control across the population. Leading experts will share their success stories, effective strategies, and lessons learned.

This event will be a "Virtual Meeting." Attendees will need a computer, Internet access, and a phone line to participate. Registration is available online.

Million Hearts™ is a national initiative that was launched by the U.S. Department of Health and Human Services in September 2011 to prevent one million heart attacks and strokes by 2017. ACP is a Million Hearts™ partner.



Patient-centered medical home


.
ACP's Medical Home Builder available at discounted rate to federally qualified health centers

ACP and the National Association of Community Health Centers (NACHC) have collaborated on a national effort to help federally-qualified health centers improve care by offering ACP's Medical Home Builder 2.0 at a discounted rate.

Qualified centers will also have the opportunity to join an online community within the Medical Home Builder to support the NACHC Patient Centered Medical Home Institute. Participating centers can check online to find out when access to Medical Home Builder 2.0 will be available.



From the College


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2013-14 Chair-elect, Board of Regents selected

At their November meeting, the Board of Regents elected Robert M. Centor, MD, FACP, of Huntsville, Ala., the 2013-14 Chair-elect of the Board of Regents.

Dr. Centor will assume position of Chair at the conclusion of the Annual Business Meeting at Internal Medicine 2014 in Orlando, Fla. More information about Dr. Centor will be provided in the March issue of ACP Internist when the results of the election of the new Treasurer, Regents and President-elect are reported.


.
Nominate candidates for upcoming Council of Associates and Council of Student Members elections

ACP's Council of Associates (COA) and Council of Student Members (CSM) are seeking candidates to fill vacant seats with terms to begin at Internal Medicine 2013. If you know of an ACP member in your chapter, medical school or residency program who has demonstrated leadership skills and a passion for internal medicine, please pass this information along to him or her for consideration.

At time of election, COA candidates must be Associate members and CSM candidates must be current Medical Student members. For available positions, deadline information and more details, please see the COA Call for Nominations or the CSM Call for Nominations. or contact us by e-mail.


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Reminder: ACP Member Census

If the College has your e-mail address on file, you should have recently received an online request from ACP's executive vice president and CEO, Steven Weinberger, MD, FACP, to participate in the 2013 ACP Member Census.

ACP needs to hear from you regardless of your current status as a physician so that the College can develop programs and direct communications that are most relevant to its members. Please check your e-mail and take five minutes today to ensure that your membership record is up to date. Complete the profile between Nov. 19 and Jan. 20 and you will be automatically entered to win one of 50 $100 ACP Gift Certificates.



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-20121204-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.


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MKSAP Answer and Critique



The correct answer is C: JAK2 V617F mutational analysis. This item is available to MKSAP 16 subscribers as item 6 in the Hematology/Oncology section.

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

The most appropriate next step in the management of this patient is to obtain a JAK2 V617F analysis. Polycythemia vera (PV) should be suspected in patients with an increased hemoglobin level or hematocrit and an oxygen saturation greater than 92%. The suspicion for PV is increased in patients with other manifestations of the disease, including erythromelalgia (a burning sensation in the palms and soles, possibly caused by platelet activation), plethora, warm water-induced pruritus, and thrombotic and bleeding symptoms. Previously, diagnosis of PV relied on detection of an increased red blood cell mass in the absence of other causes of secondary erythrocytosis. Assessment of red cell mass is no longer available at most laboratories. However, an elevated red cell mass can be identified indirectly by the presence of a hemoglobin level greater than 18.5 g/dL (185 g/L) in men or greater than 16.5 g/dL (165 g/L) in women. Concomitant leukocytosis (often with basophilia) and thrombocytosis further support the diagnosis. The diagnosis of PV can be confirmed with a JAK2 V617F analysis in patients with elevated hemoglobin or hematocrit levels and no evidence of conditions that may cause secondary erythrocytosis. This mutation is found in more than 97% of patients with PV.

The BCR-ABL (Philadelphia chromosome) is associated with chronic myeloid leukemia (CML). The diagnosis of CML requires the identification of this oncogene in a patient who has a leukoerythroblastic peripheral blood smear (increased granulocytes with a marked left shift plus early erythrocyte precursors) and hypercellular bone marrow with marked myeloid proliferation. These findings are not present in this patient.

Bone marrow biopsy is usually reserved for patients in whom a myeloproliferative disorder is suspected but in whom JAK2 mutation testing results are negative. Bone marrow findings usually show a hypercellular marrow with clusters of abnormal megakaryocytes. Increased reticulin fibrosis may also be seen. These findings are nonspecific but can be used to confirm the suspicion of a myeloproliferative neoplasm.

Polysomnography (a sleep study) can be performed in patients in whom nocturnal oxygen desaturation secondary to obstructive sleep apnea is suspected as a cause of secondary erythrocytosis; however, obstructive sleep apnea is not associated with postbathing pruritus, splenomegaly, leukocytosis, or thrombocythemia, all of which are present in this patient.

Key Point

  • Identification of the JAK2 V617F mutation in patients with a hemoglobin level greater than 18.5 g/dL (185 g/L) in men or greater than 16.5 g/dL (165 g/L) in women, with concomitant leukocytosis, thrombocytosis, and hepatosplenomegaly, is diagnostic of polycythemia vera.

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Test yourself

A 66-year-old man comes for a preoperative evaluation before total joint arthroplasty of the left knee. He has a 25-year history of rheumatoid arthritis. He has had progressive pain in his left knee with activity, which limits his ability to hike. The patient has similar pain in the right knee, but it is less severe. He reports no recent morning stiffness. He is able to climb two or three flights of stairs without chest pain or shortness of breath. He has no other medical problems and reports no additional symptoms. Medications are methotrexate and folic acid. Following a physical exam and lab tests, what is the next best step in management?

Find the answer

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