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

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ACP InternistWeekly



In the News for the Week of 2-7-12




Highlights

Physicians self-report overuse of ovarian cancer screening while recommended cancer screening remains underused

Many physicians report screening low- and medium-risk women for ovarian cancer despite evidence-based guidelines recommending against routine screening, a new study found. More...

ACIP expands indications for Tdap, HPV, hepatitis B vaccinations

The Advisory Committee on Immunization Practices (ACIP) released its sixth annual review of the recommended Adult Immunization Schedule last week. More...


Test yourself

MKSAP Quiz: management of diabetes mellitus

This week's quiz asks readers about management of diabetes mellitus in a 78-year-old woman who resides in a nursing home. More...


Diabetes

ACP: Best practice for diabetes is diet, then metformin, then any second drug

New diabetes guidelines from the American College of Physicians recommend prescribing a drug when lifestyle changes don't lower hyperglycemia. Specifically, start with metformin first and then add any second oral agent. More...


Blood pressure

Different blood pressure in each arm may be associated with increased risk for vascular disease

Patients who have significant differences in systolic blood pressure between their right and left arms may be at increased risk of vascular disease, a new study found. More...


FDA update

Contraceptive pills recalled

Twenty-eight lots of oral contraceptives have been recalled by manufacturer Pfizer because some blister packs may contain an inexact count of inert or active-ingredient tablets and the tablets may be out of sequence. More...


From ACP Internist

The February issue is online and coming to your mailbox

February's issue of ACP Internist looks at clinical and practice management issues. More...


Internal Medicine 2012

ACP Job Placement Center calls for job seekers' profiles

Physicians looking for a new job may submit a job seeker's profile to the ACP Job Placement Center, a service available at Internal Medicine 2012, to be held April 19-21 in New Orleans. More...


From the College

Are your claims being affected by version 5010?

There have been reports of physician practices having issues with submitting claims related to the transition to version 5010. More...

ACP Annual Business Meeting to be held

All members are encouraged to attend ACP's Annual Business Meeting to be held during Internal Medicine 2012. Current College Officers will retire from office and incoming Officers, new Regents and Governors-Elect will be introduced. More...

Chapter awardees for 2011-2012

Chapters honor Members, Fellows, and Masters of ACP who have demonstrated by their example and conduct an abiding commitment to excellence in medical care, education, research, or service to their community, their chapter, and ACP. 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: Daisy Smith, MD, FACP



Highlights


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Physicians self-report overuse of ovarian cancer screening while recommended cancer screening remains underused

Many physicians report screening low- and medium-risk women for ovarian cancer despite evidence-based guidelines recommending against routine screening, a new study found.

Researchers sent 3,200 family physicians, general internists and obstetrician-gynecologists a questionnaire with vignettes about women's annual examinations. The responses of 1,088 physicians were included in the study. Physicians were asked about their use of transvaginal ultrasonography (TVU) and cancer antigen 125 (CA-125), neither of which is recommended as an effective screening tool by current guidelines. The results appear in the Feb. 7 Annals of Internal Medicine.

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When asked about their screening practices for low-risk women, 28% of the physicians said they would order the tests at least sometimes, and 65.4% would use them for women at medium risk for ovarian cancer. Smaller percentages reported routinely using the tests for these patients (6% for low-risk women and 24% for medium-risk). However, a full third of the surveyed physicians believed that the TVU or CA-125 was an effective screening test.

Evidence-based reviews have documented that both tests cause more harm than benefit, the study authors noted. Multiple professional societies and the U.S. Preventive Services Task Force (USPSTF) have publicly concluded that ovarian cancer screening incurs more risk than benefit for low- and medium-risk women, the researchers added. Extrapolating their findings over the population of the U.S., they concluded that as many as 1.2 million women may be unnecessarily screened at a potential cost of $18 to $360 million.

Younger physicians, those in group practices, and physicians who listed the USPSTF as one of their main sources of screening recommendations were less likely to screen excessively, the study found. The authors noted that the USPSTF has issued more declarative guidelines on the subject than other organizations. The American Cancer Society, for example, does not publish ovarian cancer screening guidelines. The authors called for wider dissemination of guidelines and interventions that encourage interaction between diverse physicians to remedy this problem.

In contrast, screening rates for several other types of cancer are still falling short of Healthy People 2020 targets, according to an analysis from the Centers for Disease Control and Prevention, published in the Jan. 27 Morbidity and Mortality Weekly Report.

The USPSTF recommends mammography every two years for women 50 to 74, and the goal is to have 81.1% of eligible patients screened by 2020. However, according to the 2010 National Health Interview Survey (NHIS), the breast cancer screening rate was only 72.4%, which represented no improvement over year 2000 statistics. For cervical cancer, the recommendation was a Pap test every three years for women 21 to 65, and the goal was screening 93% of the population. The 2010 NHIS found a rate of 83%, which was a slight drop from 2000.

Colorectal cancer screening rates improved over the decade but still fell short of the goal of 70.5%. Overall, 58.6% of respondents between the ages of 50 and 75 met the recommendation of having 1) annual high-sensitivity fecal occult blood testing (FOBT), 2) sigmoidoscopy every five years combined with FOBT every three years, or 3) colonoscopy every 10 years. Asian people were less likely to have received any type of screening and Hispanic patients were less likely to have received cervical or colorectal screening. The researchers called for overall improvements in the use of the tests as well as efforts targeted at particularly underscreened populations.


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ACIP expands indications for Tdap, HPV, hepatitis B vaccinations

The Advisory Committee on Immunization Practices (ACIP) released its sixth annual review of the recommended Adult Immunization Schedule last week.

The recommendations appeared online at Annals of Internal Medicine on Jan. 31.

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Important changes include that pregnant women should preferentially receive tetanus, diphtheria and pertussis (Tdap) vaccination after 20 weeks' gestation, instead of the previous recommendation that the vaccine be given postpartum. Other adults who are in close contact with children less than one year old should still get a one-time dose of Tdap vaccine.

The human papillomavirus (HPV) vaccine recommendation now includes routine vaccination of males ages 11 to 12 years, with catch-up vaccination recommended for males ages 13 to 21. HPV vaccine also is recommended for previously unvaccinated males aged 22 to 26 years who are immunocompromised, who test positive for HIV infection or who have sex with men.

ACIP also voted in October 2011 to recommend hepatitis B vaccine for diabetic adults younger than age 60, as soon as possible after diabetes is diagnosed. It can also be considered for diabetics 60 years or older based on a patient's likely need for assisted blood glucose monitoring, likelihood of acquiring hepatitis B and likelihood of immune response to vaccination.

Influenza vaccination was revised to clarify that all persons aged 6 months or older can receive trivalent injectable vaccine and that health care workers who care for persons requiring a protected environment should receive it. Health care workers younger than 50 who have no contraindications may receive either the live attenuated or trivalent forms of the vaccine.

The recommended Adult Immunization Schedule has been approved by ACIP, ACP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists and the American College of Nurse-Midwives.



Test yourself


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MKSAP Quiz: management of diabetes mellitus

A 78-year-old woman who resides in a nursing home is seen for management of her diabetes mellitus. The patient's blood glucose log shows levels ranging between 40 and 400 mg/dL (2.2 and 22.2 mmol/L). She otherwise feels well. She has been on insulin for more than 25 years after first taking oral agents for several years following her initial diagnosis. The patient has hypothyroidism treated with levothyroxine and remote history of Graves disease treated with radioactive iodine. Her diabetes is currently treated with neutral protamine Hagedorn (NPH) insulin, 25 units twice daily; the dosage has been gradually increased over the past 3 weeks.

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The only pertinent finding on physical examination is her lean body habitus (BMI of 19.3 kg/m2).

Results of routine laboratory studies are all within the normal range. An anti-glutamic acid decarboxylase antibody titer is positive.

Which of the following is the most likely diagnosis?

A) Late-onset autoimmune diabetes of adulthood
B) Maturity-onset diabetes of the young
C) Type 1 diabetes mellitus
D) Type 2 diabetes mellitus

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


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Diabetes


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ACP: Best practice for diabetes is diet, then metformin, then any second drug

New diabetes guidelines from the American College of Physicians recommend prescribing a drug when lifestyle changes don't lower hyperglycemia. Specifically, start with metformin first and then add any second oral agent.

annals.jpg

The three recommendations are:

  • Add oral pharmacologic therapy in patients diagnosed with type 2 diabetes when diet, exercise and weight loss fail to improve hyperglycemia (Grade: strong recommendation; high-quality evidence). There are no best data on when to start drugs, so consider life expectancy, whether there are vascular complications, and the risk for adverse events.
  • Prescribe monotherapy with metformin for initial pharmacologic therapy to treat most patients with type 2 diabetes (Grade: strong recommendation; high-quality evidence). It's cheaper than most other drugs, is more effective, has fewer side effects and does not result in weight gain.
  • Add a second agent to metformin to treat patients with persistent hyperglycemia when lifestyle modifications and monotherapy with metformin fail to control hyperglycemia (Grade: strong recommendation; high-quality evidence). Adding a second drug can lower hyperglycemia by about 1 more percentage point. No evidence supports using one combination therapy over another.

The guideline is based on a 2011 review of the literature from 1966 through April 2010. It expands on a 2007 evidence report from the Agency for Healthcare Research and Quality that discussed drug therapy's effect on mortality, microvascular and macrovascular outcomes, intermediate outcomes and adverse effects. The 2011 review focuses on head-to-head comparisons and includes direct comparisons for monotherapy and dual therapy regimens. The College's recommendations appear in the Feb. 7 Annals of Internal Medicine.

In developing the recommendations, experts considered outcomes including all-cause mortality, cardiovascular morbidity and mortality, cerebrovascular morbidity, neuropathy, nephropathy and retinopathy.

Most diabetes medications reduced A1c levels to a similar degree, the authors noted. In most cases, metformin was more effective than other medications as a monotherapy and when used in combination therapy to reduce A1c levels, body weight, and plasma lipid levels. But it was difficult to draw conclusions about the comparative effectiveness of type 2 diabetes medications on all-cause and cardiovascular mortality, cardiovascular and cerebrovascular morbidity, and microvascular outcomes because of low-quality or insufficient evidence, the guideline writers said.

High-quality evidence shows that the risk for hypoglycemia with sulfonylureas exceeds the risk with metformin or thiazolidinediones and that the combination of metformin plus sulfonylureas is associated with six times more risk for hypoglycemia than the combination of metformin plus thiazolidinediones, the authors noted.

Moderate-quality evidence shows that the risk for hypoglycemia with metformin and thiazolidinediones is similar. But metformin is associated with an increased risk for gastrointestinal side effects, thiazolidinediones are associated with an increased risk for heart failure, and rosiglitazone and pioglitazone are contraindicated in patients with serious heart failure.



Blood pressure


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Different blood pressure in each arm may be associated with increased risk for vascular disease

Patients who have significant differences in systolic blood pressure between their right and left arms may be at increased risk of vascular disease, a new study found.

The meta-analysis included 20 studies that compared blood pressure (BP) between patients' arms. Five studies used angiography and found that among patients with subclavian stenosis, the mean difference in systolic BP between arms was 36.9 mm Hg. In these invasively tested patients, a difference of 10 mm Hg or more was strongly associated with subclavian stenosis (risk ratio, 8.8). In the other, noninvasive studies included in the analysis, a difference of 10 mm Hg or more was associated with increased risk of peripheral vascular disease (risk ratio, 2.4; sensitivity, 32%; specificity, 91%).

When the cutoff for difference in systolic BP between arms was increased to 15 mm Hg, the analysis found patients who met that cutoff were more likely to have preexisting cerebrovascular disease (risk ratio, 1.6; sensitivity, 8%; specificity, 93%), cardiovascular mortality (hazard ratio, 1.7) and all-cause mortality (hazard ratio, 1.6). The findings were published online by The Lancet on Jan. 30.

The study authors concluded that a difference in systolic BP of 10 mm Hg or higher or 15 mm Hg or higher is associated with peripheral vascular disease, although with low sensitivity but high specificity, in both community- and hospital-recruited patient cohorts. This finding might be useful for identifying patients in need of further vascular assessment, they said, noting a cutoff of a 15 mm Hg difference would lead to further assessment for fewer than 5% of overall patients.

Although the study concluded that a 15 mm Hg difference could be a useful indicator of mortality risk, this finding was gathered from populations with a high baseline cardiovascular risk and so is not necessarily generalizable to lower-risk patients, the authors said. They recommended that these findings be incorporated into future guidelines but also be clarified by further research into normal versus excessive BP differences between arms.

A comment accompanying the study noted that international hypertension guidelines have already recommended measurement of BP in both arms. One obstacle to effective implementation is that patients are twice as likely to show differences between arms if their BP is measured sequentially rather than simultaneously. The commentary authors recommended measurement of BP in both arms, ideally simultaneously, to accurately diagnose hypertension, but they noted that the low sensitivity found in this study means that the practice has little value as a screening tool for peripheral vascular disease.



FDA update


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Contraceptive pills recalled

Twenty-eight lots of oral contraceptives have been recalled by manufacturer Pfizer because some blister packs may contain an inexact count of inert or active-ingredient tablets and the tablets may be out of sequence.

The recall includes 14 lots of Lo/Ovral®-28 (norgestrel and ethinyl estradiol) tablets and 14 lots of generic norgestrel and ethinyl estradiol tablets. As a result of this packaging error, the daily regimen for these oral contraceptives may be incorrect and could leave women without adequate contraception and at risk for unintended pregnancy, the FDA warned.

Consumers who have been using the affected product should begin using a non-hormonal form of contraception immediately, notify their physicians and return the product to the pharmacy. A list of affected lot numbers is online.



From ACP Internist


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The February issue is online and coming to your mailbox

February's issue of ACP Internist looks at clinical and practice management issues.

acpi-20120207-internist.jpg

Scribes: A write way and a wrong way. Should doctors delegate their dictation, or is taking one's own notes during an exam an integral part of the practice of medicine? Be sure to voice your opinion in our poll.

Sleep disorder may be overlooked on exams. Experts want the surgeon general to consider sleep habits as another vital sign. They say sleep has that much impact on chronic conditions such as hypertension, diabetes and atrial fibrillation.

Lessen the burdens of Medicare's home health requirements. Patients now need face-to-face exams to qualify for home health care, but the paperwork required can be a stumbling block. Simple tips can help physicians overcome the hurdles.

Don't miss a story on how to build an inexpensive thoracentesis simulator from pork ribs and the latest MKSAP Quiz on managing new-onset atrial fibrillation.



Internal Medicine 2012


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ACP Job Placement Center calls for job seekers' profiles

Physicians looking for a new job may submit a job seeker's profile to the ACP Job Placement Center, a service available at Internal Medicine 2012, to be held April 19-21 in New Orleans. The Center, located in the New Orleans Ernest N. Morial Convention Center, Booth 430, provides physicians with tools to assist in job searches as well as the opportunity to meet with potential employers.

Profiles will be included in one of two booklets based on job seekers' criteria and distributed only to Job Placement Center sponsors and exhibitors who have submitted a job posting. After reviewing a profile, a recruiter may contact the physician to schedule a private on-site interview at the Center. Profiles can be submitted online.



From the College


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Are your claims being affected by version 5010?

There have been reports of physician practices having issues with submitting claims related to the transition to version 5010.

The AMA has compiled a complaint sheet for physicians experiencing issues with claims due to this or other aspects of HIPAA. Physicians are encouraged to submit a complaint form if they have experienced any problems due to the version 5010 transition.

For more information about the transition to version 5010, please visit the Running a Practice section of the ACP website.


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ACP Annual Business Meeting to be held

All members are encouraged to attend ACP's Annual Business Meeting to be held during Internal Medicine 2012. Current College Officers will retire from office and incoming Officers, new Regents and Governors-Elect will be introduced.

The meeting will be held on Saturday, April 21, 2012 at the New Orleans Ernest N. Morial Convention Center from 12:45 p.m. to 1:45 p.m., with Virginia L. Hood, MBBS, MPH, FACP, ACP President, presiding. Dennis R. Schaberg, MD, MACP, will present the Annual Report of the Treasurer. A key feature of the meeting is the presentation of ACP's priorities for 2012-13 by Executive Vice President and Chief Executive Officer Steven E. Weinberger, MD, FACP. Members will have the opportunity to ask questions following Dr. Weinberger's presentation.


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Chapter awardees for 2011-2012

Chapters honor Members, Fellows, and Masters of ACP who have demonstrated by their example and conduct an abiding commitment to excellence in medical care, education, research, or service to their community, their chapter, and ACP.

Awardees have a long history of excellence and peer approval in the specialty of internal medicine. In recognition of their outstanding service, many exceptional individuals received chapter awards in the fall and winter 2011-2012. A full list of award winners is online.



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-20120207-cartoon.jpg

"You might feel a little pressure."

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

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

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service.


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MKSAP Answer and Critique



The correct answer is A) Late-onset autoimmune diabetes of adulthood. This item is available to MKSAP 15 subscribers as item 2 in the Endocrinology and Metabolism section. More information about MKSAP 15 is available online.

This patient most likely has late-onset autoimmune diabetes of adulthood (LADA). Diabetes mellitus is categorized into several types. Most affected patients have type 2 diabetes, and a minority (5% to 10%) have type 1 diabetes. Patients with type 2 diabetes are usually overweight, if not frankly obese. Type 1 diabetes results from autoimmune destruction of pancreatic beta cells and results in absolute insulin deficiency, whereas type 2 is marked by insulin resistance and relative insulin deficiency. Type 1 diabetes is classically seen in younger patients, usually in children, teens, and young adults. However, type 1 diabetes can be diagnosed at any age. When diagnosed in older persons, especially those in whom hyperglycemia was once controlled with oral agents, this form of diabetes is referred to as LADA. In persons with LADA, beta cell destruction over time leads to the requirement for insulin therapy, as in type 1 diabetes. LADA typically occurs in leaner persons after glycemic control has become more labile and there is clear insulin dependency. Autoimmune markers (anti-islet cell autoantibodies) are present, including anti-glutamic acid decarboxylase antibody, the detection of which can confirm the diagnosis.

Maturity-onset diabetes of the young is typically diagnosed in adolescents or young adults and usually is marked by mild hyperglycemia, often with a strong family history of diabetes.

Key Point

  • Diabetes mellitus in older, lean patients with anti-islet cell autoantibodies is termed late-onset autoimmune diabetes of adulthood.

Click here to return to the rest of ACP InternistWeekly.

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Test yourself

A 72-year-old woman is evaluated during a routine examination. She has very severe COPD with multiple exacerbations. She has dyspnea at all times with decreased exercise capacity. She does not have cough or any change in baseline sputum production. She is adherent to her medication regimen, and she completed pulmonary rehabilitation 1 year ago. She quit smoking 1 year ago. Her medications are a budesonide/formoterol inhaler, tiotropium, and an albuterol inhaler as needed. Following a physical and pulmonary exam, what is the most appropriate next step in management?

Find the answer

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