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

Advertisement

ACP InternistWeekly



In the News for the Week of 2-14-12




Highlights

Not all doctors fully disclose errors, pharma ties, bad prognoses, survey finds

A significant proportion of physicians do not completely agree that they should disclose serious medical errors or financial relationships with drug and device companies to patients, according to a recent survey. In addition, one-tenth of survey respondents had told patients something that was not true in the previous year. More...

Updated guidelines released on antithrombotic therapy, thrombosis prevention

The American College of Chest Physicians released updated guidelines last week on antithrombotic therapy and prevention of thrombosis. More...


Test yourself

MKSAP Quiz: 6-month history of abdominal pain

This week's quiz asks readers to evaluate a 35-year-old woman with a 6-month history of right upper quadrant abdominal pain. More...


Nephrology

One glomerular filtration rate equation may offer better tradeoffs than the other, review indicates

While neither of the two main equations for calculating glomerular filtration rates (GFRs) is universally better, the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation may be more useful for patients in North America, Europe and Australia, a study concluded. More...


Infectious disease

Cefpodoxime found inferior to ciprofloxacin as cystitis treatment

Cefpodoxime is not an effective treatment option for acute uncomplicated cystitis, a new study concluded. More...


Parkinson's disease

Tai chi appears to help balance in mild to moderate Parkinson's

Tai chi may help improve balance in patients with mild to moderate Parkinson's disease, according to a new study. More...


FDA update

Proton-pump inhibitors to carry warning about C. diff

The FDA warned last week that proton-pump inhibitors (PPIs) may be associated with an increased risk of Clostridium difficile–associated diarrhea (CDAD). More...


From the College

On Valentine's Day, internists say what they love about Annals of Internal Medicine

On Valentine's Day, dozens of internists are explaining what they love about Annals of Internal Medicine. More...

Create a video on weight loss tips

ACP and Discovery Channel are sponsoring a contest for physicians to submit brief videos on successful strategies for helping patients lose weight. Three finalists will win a free trip to Internal Medicine 2012. More...

How medical ethics principles affect daily patient care

Is medical ethics an important aspect of real world medical practice today? Or a quaint notion for the history books based on "Mom and apple pie" generalisms? 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...

Editorial note: ACP InternistWeekly will not be published next week due to the Presidents' Day holiday.


Physician editor: Philip Masters, MD, FACP



Highlights


.
Not all doctors fully disclose errors, pharma ties, bad prognoses, survey finds

A significant proportion of physicians do not completely agree that they should disclose serious medical errors or financial relationships with drug and device companies to patients, according to a recent survey. In addition, one-tenth of survey respondents had told patients something that was not true in the previous year.

Researchers surveyed 1,891 physicians in internal medicine, family practice, pediatrics, cardiology, general surgery, anesthesiology and psychiatry nationwide in 2009 to find out if they followed the standards on communication laid out by the American Board of Internal Medicine Foundation's Charter on Medical Professionalism. That charter was coauthored by the American College of Physicians and later endorsed by more than 100 groups worldwide, as well as the Accreditation Council for Graduate Medical Education. The survey excluded osteopaths, residents and those who practiced in federally owned hospitals.

Results appeared in the February 2012 Health Affairs.

Nearly 20% of physicians said they had not fully disclosed an error to a patient in the previous year because they feared the admission would trigger a malpractice case. More than 55% of physicians said they often or sometimes described a patient's prognosis in a more positive manner than warranted and 35% did not completely agree that they should disclose all financial ties with drug- and devicemakers to patients.

Women physicians were more likely to report fully describing benefits and risks, disclosing financial relationships, and never having told an untruth in the prior year. Race or ethnicity was significantly associated with never telling a lie and never disclosing confidential information: Underrepresented minorities were more likely than white or Asian respondents to report attitudes consistent with the charter. International medical graduates were less likely than U.S. grads to have told a patient something untrue or to have disclosed confidential patient information in the past year.

General surgeons and pediatricians were most likely to completely support disclosing all serious medical errors to patients, while cardiologists and psychiatrists were least likely (P<0.001). Anesthesiologists, general surgeons and pediatricians were most likely to report never having described patients' prognoses in more positive terms than warranted, while internists and psychiatrists were least likely (P<0.05). Cardiologists and general surgeons were most likely to report never having told patients an untruth in the previous year, while pediatricians and psychiatrists were least likely (P<0.001). Physicians in universities or medical centers were more likely to completely agree with the need to report all serious medical errors than physicians in solo or two-person practices (78.1% vs. 60.5%; P=0.03).

Even though the survey was anonymous, it likely underestimated the rate at which physicians do not comply with the professionalism charter, the study authors speculated. "The survey results suggest that many physicians do not completely support the charter requirements related to communication with patients. An alternative interpretation is that treating support for the charter precepts as 'black or white'—physicians either do or do not completely endorse and adhere to these principles—fails to recognize complexities of patient physician communication in everyday practice," they wrote.

"Despite the relative clarity and unambiguous language of the charter precepts, many factors can affect how and what physicians communicate to patients," the authors continued. "Some might argue that knowing when to breach or bend these rules when individual patients require a different approach constitutes clinical wisdom and true patient-centeredness."


.
Updated guidelines released on antithrombotic therapy, thrombosis prevention

The American College of Chest Physicians released updated guidelines last week on antithrombotic therapy and prevention of thrombosis.

The new guidelines are an update of the organization's previous edition, which was published in 2008, and differ in several important ways, according to the authors. For example, the new guidelines adhere to a more rigorous methodological standard for assessing and interpreting study results, attempt to use clinically meaningful end points (when available) to draw conclusions regarding diagnosis and therapy, and report conclusions and recommendations in a form more useful to clinicians. In addition, each panel of experts responsible for developing the guidelines included a practicing clinician who was not involved in research, with the goal of making the recommendations more relevant to routine clinical practice. Input on appropriate resource use was also sought from experts in the field when determining the strength or weakness of recommendations.

The guidelines, which appear as a supplement to the February Chest, cover the following areas of prevention, diagnosis and treatment in extensive detail:

  • evidence-based management of anticoagulant therapy;
  • prevention of venous thromboembolism (VTE) in nonsurgical patients;
  • prevention of VTE in nonorthopedic surgical patients;
  • prevention of VTE in orthopedic surgery patients;
  • perioperative management of antithrombotic therapy;
  • diagnosis of deep venous thrombosis;
  • antithrombotic therapy for VTE disease;
  • treatment and prevention of heparin-induced thrombocytopenia;
  • antithrombotic therapy for atrial fibrillation;
  • antithrombotic and thrombolytic therapy for valvular disease;
  • antithrombotic and thrombolytic therapy for ischemic stroke;
  • primary and secondary prevention of cardiovascular disease;
  • antithrombotic therapy in peripheral artery disease;
  • VTE, thrombophilia, antithrombotic therapy and pregnancy; and
  • antithrombotic therapy in neonates and children.

The guidelines' executive summary, introduction, and explanation of methodology are available free of charge online.



Test yourself


.
MKSAP Quiz: 6-month history of abdominal pain

A 35-year-old woman is evaluated for a 6-month history of right upper quadrant abdominal pain that has slowly increased in intensity and is worse on deep inspiration. The patient is otherwise well, and her only medication is an oral contraceptive pill that she has taken for 15 years. She drinks alcohol socially but has no history of heavy alcohol use, injection drug use, or blood transfusion.

mksap.jpg

On physical examination, vital signs are normal; BMI is 26. There is slight hepatomegaly with mild discomfort on deep palpation in the right upper quadrant and mid-epigastrium. There is no jaundice or ascites. The lungs are clear. Complete blood count and serum biochemistry studies, including aminotransferases, bilirubin, and α-fetoprotein, are normal. Ultrasonography shows a solitary hyperechoic 9-cm lesion in the right lobe of the liver. CT scan shows a well-demarcated lesion with peripheral enhancement after injection of intravenous contrast; there is no central scar. Liver biopsy specimen reveals sheets of hepatocytes, with no bile ducts or Kupffer cells.

Which of the following is the most likely diagnosis?

A) Focal nodular hyperplasia
B) Hepatic adenoma
C) Hepatocellular carcinoma
D) Simple hepatic cyst

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


.

Nephrology


.
One glomerular filtration rate equation may offer better tradeoffs than the other, review indicates

While neither of the two main equations for calculating glomerular filtration rates (GFRs) is universally better, the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation may be more useful for patients in North America, Europe and Australia, a study concluded.

annals.jpg

Researchers compared the CKD-EPI equation to the Modification of Diet in Renal Disease (MDRD) equation to review their performance and to inform the selection of a single equation by laboratories and clinicians. A systemic review of the literature from 1999 to October 2011 found cross-sectional studies in adults that compared the equations' performances.

Results appeared online Feb. 6 at Annals of Internal Medicine.

In adult populations in North America, Europe or Australia, researchers reviewed 12 studies comprising 12,898 patients. The CKD-EPI equation was more accurate than the MDRD equation in 10 studies and less accurate in two studies. Bias ranged from 14.6 to −22 mL/min per 1.73 m2. The CKD-EPI equation was less biased than the MDRD equation in seven studies and more biased in five studies. In six of the 10 studies that reported a measure of precision, the CKD-EPI equation was more precise than the MDRD equation. Precision of the MDRD was better or the same in the other four studies. In five studies, performance measures were consistently better for the CKD-EPI than for the MDRD. In two studies, both of which were conducted in kidney transplant recipients, performance measures were better for the MDRD.

In adult populations in Asia and Africa, eight studies examined GFR estimations. In six studies, the MDRD or CKD-EPI equation was modified by adding or removing a coefficient to improve performance or a new equation was developed using the same variables. Comparing the performance of equations across studies was difficult because locally derived equations were generally not tested in other studies or populations. In these studies, the unmodified MDRD and CKD-EPI equations were less accurate than they were in the studies in North America, Europe and Australia. Coefficients developed in one ethnic or racial population did not improve equation accuracy in a study of another ethnic or racial population.

"The observed and expected differences in performance by range of GFR suggest that we cannot optimize the performance of any equation for all clinical populations across a wide range of GFRs," the authors wrote. "Because the goal is to select a single estimating equation for routine use by clinical laboratories, the tradeoff of optimizing performance at either higher or lower GFR ranges must be accepted. Because the difference in bias (on the raw scale) between the equations is greater at higher GFRs, using the CKD-EPI equation would lead to smaller average bias in clinical populations with a wide range of GFRs."

Applying the CKD-EPI rather than the MDRD would potentially allow more efficient use of resources in caring for patients with lower estimated GFR, the authors noted. And it would allow reporting of estimated GFR as a numerical value throughout the full range, rather than limit it to lower values (for example, <60 mL/min per 1.73 m2, as currently recommended for the MDRD in the United States). However, using the CKD-EPI equation would slightly increase overestimation at lower GFRs. Nephrologists and others caring for patients with low GFR would need to be aware of this limitation, the authors concluded.



Infectious disease


.
Cefpodoxime found inferior to ciprofloxacin as cystitis treatment

Cefpodoxime is not an effective treatment option for acute uncomplicated cystitis, a new study concluded.

In a double-blind trial, researchers randomized 300 women, ages 18 to 55, with acute uncomplicated cystitis to three days of treatment with either cefpodoxime or ciprofloxacin. Patients were given 250 mg of ciprofloxacin orally twice daily or 100 mg of cefpodoxime proxetil orally twice daily. Overall clinical cure, defined as not requiring more antibiotics at a 30-day follow-up visit, was the primary outcome.

In an intent-to-treat analysis in which patients lost to follow-up (who totaled 32) were considered cured, the clinical cure rate was 93% for ciprofloxacin compared to 82% for cefpodoxime (difference, 11%; 95% CI, 3% to 18%). When the patients lost to follow-up were assumed to not be cured, the cure rates were 83% for ciprofloxacin versus 71% for cefpodoxime (difference, 12%; 95% CI, 3% to 21%). An even greater difference was seen in microbiological cure rate: 96% for ciprofloxacin and 81% for cefpodoxime (difference, 15%; 95% CI, 8% to 23%). More women in the cefpodoxime group were also found to have vaginal colonization with Escherichia coli at their follow-up visit (40% vs. 16%).

The study authors concluded that cefpodoxime did not meet their clinical criteria for noninferiority to ciprofloxacin (which was set at a 10% margin before the study began). The research was undertaken, they explained, because although fluoroquinolones such as ciprofloxacin are highly efficacious for acute cystitis, guidelines have recommended that the drugs be reserved for more serious conditions to slow the development of fluoroquinolone resistance. Cefpodoxime was thought to have potential as a safe and effective fluoroquinolone-sparing option, but the findings of this study do not support its use as a first-line treatment, the authors concluded.

The risk of gram-negative extended-spectrum beta-lactamase resistance is another potential concern about cefpodoxime, the researchers noted. Given these limitations of the drug, they recommended that physicians follow existing guidelines and consider nitrofurantoin, trimethoprim-sulfamethoxazole and fosfomycin as treatments for uncomplicated cystitis before resorting to fluoroquinolones or beta-lactams. The study was published in the Feb. 8 Journal of the American Medical Association.



Parkinson's disease


.
Tai chi appears to help balance in mild to moderate Parkinson's

Tai chi may help improve balance in patients with mild to moderate Parkinson's disease, according to a new study.

Researchers in Oregon performed a randomized, controlled trial to assess whether tai chi could help improve postural control in Parkinson's disease. Patients whose disease was rated as stage 1 to 4 on the Hoehn and Yarhr scale (range, 1 to 5, with higher scores indicating more severe disease) were randomly assigned to perform tai chi, resistance training, or stretching in 60-minute exercise sessions twice a week for 24 weeks. The study's primary outcomes were changes from baseline in the limits of stability test, which measures maximum excursion and directional control on a scale of 0% to 100%; secondary outcomes examined gait, strength, functional reach, scores on timed up-and-go tests, falls, and motor scores on the Unified Parkinson's Disease Rating Scale. The study results appeared in the Feb. 9 New England Journal of Medicine.

One hundred ninety-five patients were randomly assigned to one of the three study groups, with each group assigned 65 patients. One hundred sixty-four patients (84%) had stage 2 or higher disease, and the mean age in each study group was approximately 69 years. Approximately 37% of all patients were women. One hundred seventy-six patients completed the interventions as assigned, and complete data on all outcome measures were available for 185 patients at follow-up. No significant differences in demographics or primary outcomes were noted between patients who did and did not complete the trial.

At 24 weeks, maximum excursion and directional control were both consistently better in the tai chi group than in the resistance training and stretching groups (between-group difference in change from baseline, 5.55 percentage points and 11.98 percentage points, respectively, for maximum excursion and 10.45 percentage points and 11.38 percentage points, respectively, for directional control). Patients in the tai chi group also had better results on all secondary outcomes than did patients in the stretching group and had better stride length and functional reach than the resistance training group. Fall incidence was lower in the tai chi group compared with the stretching group but not the resistance training group. Effects of tai chi remained evident three months after the intervention, and serious adverse events were not seen.

The authors acknowledged that their trial could not be blinded and did not involve a no-exercise control group. However, they concluded that tai chi seems to be an effective way to improve postural stability and functional ability in patients with mild to moderate Parkinson's disease and also showed benefit for fall reduction compared with stretching. The lack of adverse events, they noted, indicates that tai chi is a potentially safe and useful intervention in this population.



FDA update


.
Proton-pump inhibitors to carry warning about C. diff

The FDA warned last week that proton-pump inhibitors (PPIs) may be associated with an increased risk of Clostridium difficile–associated diarrhea (CDAD).

Physicians should consider a diagnosis of CDAD in patients taking PPIs who develop diarrhea that does not improve, the FDA said. They should also advise patients who take PPIs to seek immediate care from a health care professional if they experience watery stool that does not go away, abdominal pain and fever. In general, the lowest dose and shortest duration of PPI therapy appropriate to the patient's condition should be prescribed.

The FDA is currently working with PPI manufacturers to modify drug labels to provide information about the risk of CDAD. Affected medications include:

  • rabeprazole sodium (Aciphex),
  • dexlansoprazole (Dexilant),
  • esomeprazole magnesium (Nexium, Vimovo),
  • omeprazole (Prilosec, Zegerid),
  • lansoprazole (Prevacid) and
  • pantoprazole sodium (Protonix).

The risk of CDAD in users of H2 receptor blockers is also under review by the FDA, according to the agency's MedWatch alert.



From the College


.
On Valentine's Day, internists say what they love about Annals of Internal Medicine

On Valentine's Day, dozens of internists are explaining what they love about Annals of Internal Medicine.

Some examples:

"I love it because it's so relevant to what I do. It really covers the broad array of general internal medicine."

acpi-20120214-annals-love.jpg

"You can always find clinical pearls that you can use in your practice…."

"It helps me to be a better doctor."

Watch their fun and informative interviews online to see if you recognize your friends and colleagues.


.
Create a video on weight loss tips

ACP and Discovery Channel are sponsoring a contest for physicians to submit brief videos on successful strategies for helping patients lose weight. Three finalists will win a free trip to Internal Medicine 2012. The entry deadline is March 9, 2012.

More information is online.


.
How medical ethics principles affect daily patient care

Is medical ethics an important aspect of real world medical practice today? Or a quaint notion for the history books based on "Mom and apple pie" generalisms?

Fred Ralston Jr., MD, MACP, ACP's immediate past president and a practicing internist in Fayetteville, Tenn., and Lois Snyder, JD, director of ACP's Center for Ethics & Professionalism, discuss these issues on KevinMD.com, one of the Web's leading destinations for provocative physician commentary.



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-20120214-cartoon.jpg

"I didn't think this is what you meant by balloon angioplasty."

This issue's winning cartoon caption was submitted by Bridget M. McCandless, MD, FACP, from Kansas City, Mo. Thanks to all who voted! The winning entry captured 56% of the votes.

The runners-up were:

"You might feel a little pressure."

"Doctor, might I benefit from a proton-pump inhibitor?"


.


MKSAP Answer and Critique



The correct answer is B) Hepatic adenoma. This item is available to MKSAP 15 subscribers as item 102 in the Gastroenterology and Hepatology section. More information about MKSAP 15 is available online.

This patient likely has hepatic adenoma, which is associated with oral contraceptive use and occurs most commonly in women between the ages of 20 and 45 years. These lesions are usually solitary and occur most frequently in the right lobe. Diagnosis of hepatic adenoma depends on a lesion occurring in the proper clinical setting, with imaging showing a hyperechoic lesion on ultrasonography and peripheral arterial enhancement on a contrast-enhanced CT scan. MRI shows hyperintensity on both T1- and T2-weighted images. Surgical resection should be considered for patients with symptomatic hepatic adenomas.

The absence of a central scar makes focal nodular hyperplasia less likely than adenoma, although only one third of focal nodular hyperplastic lesions have a central scar. The lack of bile ducts and Kupffer cells on the biopsy specimen would effectively exclude focal nodular hyperplasia, in which such findings are prominent. The solid nature of the lesion on imaging excludes the diagnosis of simple hepatic cyst. The MRI in hepatocellular carcinoma usually shows high intensity on T2-weighted imaging and low intensity on T1-weighted images. Biopsy is generally not needed to make the diagnosis. In addition, the normal serum α-fetoprotein concentration, absence of cirrhosis, and biopsy findings make hepatocellular carcinoma highly unlikely.

Key Point

  • Hepatic adenomas show a hyperechoic lesion on ultrasonography and peripheral arterial enhancement on a contrast-enhanced CT scan.

Click here to return to the rest of ACP InternistWeekly.

Top




About ACP InternistWeekly

ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.

To add your e-mail address to your member record and to begin receiving ACP InternistWeekly, please click here.

Copyright © by American College of Physicians.

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

What will you learn from your Annals Virtual Patient?

Reviews of the World's Top Medical Journals—FREE to ACP Members! Annals Virtual Patients is a unique patient care simulator that mirrors real patient care decisions and consequences. CME Credit and MOC Points are available. Start off with a FREE sample case. Start your journey now.

Products and Resources for Patients

Products and Resources for PatientsACP has developed easy- to-use materials designed to help educate your patients on self-management of a wide variety of common health conditions. Order yours today!