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

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ACP InternistWeekly



In the News for the Week of March 20, 2012




Highlights

Residency match numbers level off for internal medicine

The number of U.S. medical student seniors at medical schools choosing internal medicine residencies leveled off in 2012 after two years of significant increases, according to results from the 2012 Match Day. More...

New guidelines call for longer screening interval for cervical cancer

Guidelines on cervical cancer screening released separately this week by the U.S. Preventive Services Task Force and the American Cancer Society agree on most recommendations, but contain a few differences. More...


Test yourself

MKSAP Quiz: ED visit for agitated person

This week's quiz asks readers to evaluate a 32-year-old man who presents to the emergency department disoriented, combative and agitated. More...


Prostate cancer

European study finds prostate cancer mortality reduced by PSA screening

Prostate-specific antigen (PSA)-based screening significantly reduced mortality from prostate cancer but did not affect all-cause mortality, according to two more years of follow-up results in the European Randomized Study of Screening for Prostate Cancer. More...


Diabetes

Phone calls from peer mentors improved veterans' hemoglobin A1c levels

A peer mentoring program improved diabetic African-American veterans' hemoglobin A1c levels more than financial incentives did, a recent study found. More...


Chronic kidney disease

Harms of antiplatelet therapy may outweigh benefits in chronic kidney disease

Antiplatelet therapy may have uncertain benefits that could be outweighed by bleeding risk in patients with chronic kidney disease, according to a new study. More...


CMS update

Version 5010 enforcement again delayed

Last Thursday, CMS announced that it would again delay enforcement of the version 5010 transactions standards for electronic claims. This time the delay will extend until June 30. More...

Medicare holding call on Initial Preventive Physical Exam and Wellness Visit

On Wednesday, March 28, CMS will be holding a conference call about what physicians need to know about the Initial Preventive Physical Exam (the "Welcome to Medicare" visit) and the Annual Wellness Visit. More...

Are you having problems with eRx?

Have you been subject to a Medicare eRx payment penalty despite a pending application for a hardship exemption? More...


Education

Arnold P. Gold Foundation to hold biennial conference

The Arnold P. Gold Foundation will hold its biennial conference and 10th anniversary celebration this fall. More...


From ACP Internist

Take our poll on open records access

Tell us whether you'd ever consider implementing open access medical records in your office. More...


From ACP Hospitalist

The March issue is now online

The March issue of ACP Hospitalist is now online, with stories about substance abuse in physicians, a novel transitions-of-care program, and cardiac monitoring. More...


From the College

Evaluating risk and screening for colorectal cancer

Fred Ralston Jr., MD, MACP, ACP's immediate past president and a practicing internist in Fayetteville, Tenn., discusses colorectal cancer screening this month at KevinMD.com, one of the Web's leading destinations for provocative physician commentary. More...


Cartoon caption contest

And the winner is …

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


Physician editor: Philip Masters, MD, FACP



Highlights


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Residency match numbers level off for internal medicine

The number of U.S. medical student seniors at medical schools choosing internal medicine residencies leveled off in 2012 after two years of significant increases, according to results from the 2012 Match Day.

The 2012 National Resident Matching Program (NRMP) report, released on March 16, showed that 2,941 U.S. medical school seniors matched internal medicine, nearly unchanged from the 2,940 who matched in the field in 2011.

"After seeing increases in 2010 and 2011 for the internal medicine residency match for U.S. medical students, we are disappointed that there was not a bigger increase this year," said Virginia L. Hood, MBBS, MPH, FACP, ACP's president. "We remain concerned about the need to significantly increase the nation's internal medicine and primary care physician workforce to meet the needs of an aging population requiring care for chronic and complex illnesses."

The 2012 match numbers include students who will ultimately enter a subspecialty of internal medicine, such as cardiology or gastroenterology. Currently, about 20% to 25% of internal medicine residents eventually choose to specialize in general internal medicine, compared with 54% in 1998. Internal medicine enrollment numbers decreased from 2007 to 2009 (2,680 in 2007; 2,660 in 2008; and 2,632 in 2009).

"The numbers of U.S. medical students choosing internal medicine residencies are still well below the numbers of a generation ago," said Steven Weinberger, MD, FACP, ACP's executive vice president and CEO.

In 1985, 3,884 U.S. medical school graduates chose internal medicine residency programs.

"ACP also remains concerned about the rising cost of medical education and the resulting financial burden on medical students and residents, particularly those who choose careers in general internal medicine," Dr. Weinberger said. "Our nation needs to continue to reform the payment system and help internal medicine residents recognize their societal contribution to providing primary care for complex patients."

ACP's full press release on the internal medicine Match Day 2012 results is available online.

Visit ACP's Match Day site to hear Katrina Armstrong, MD, FACP, chief of the division of internal medicine at the University of Pennsylvania's Perelman School of Medicine in Philadelphia, describe Penn Medicine's Match Day experience, and visit ACP Internist's blog to read about one medical student's experience with the Match.


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New guidelines call for longer screening interval for cervical cancer

Guidelines on cervical cancer screening released separately this week by the U.S. Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS) agree on most recommendations, but contain a few differences.

annals.jpg

Both sets of guidelines recommend that routine screening for average-risk women not be initiated until age 21. Women 21 to 29 years of age should be screened using cytology every three years, according to the guidelines. Both sets of guidelines also recommend against screening women over age 65 if they have had adequate prior negative screens. Screening is also not recommended in women who have had a hysterectomy and don't have a history of high-grade precancerous lesions or cervical cancer.

For women age 30 to 65, the guidelines from the ACS (which were co-sponsored by the American Society for Colposcopy and Cervical Pathology and the American Society for Clinical Pathology) make a "preferred" recommendation of human papillomavirus (HPV) and cytology co-testing every five years. Screening with cytology alone every three years instead is "acceptable." The USPSTF recommends choosing between cytology every three years or co-testing every five years based on whether a woman wants to lengthen the screening cycle. The ACS guidelines also add on a specific recommendation for HPV-vaccinated women: They should be screened at the same intervals as unvaccinated women of the same age.

Both guidelines were published online March 14, the USPSTF set in Annals of Internal Medicine and the ACS set in CA: A Cancer Journal for Clinicians. An editorial in Annals noted that clinicians and patients may be reluctant to follow these recommendations for less frequent screening. However, both sets of guidelines "clearly state that more frequent screening causes significant harm in terms of short-term psychological stress, vaginal bleeding and infection, and potential adverse pregnancy outcomes," the editorialists wrote.

Because many women have used annual cervical cancer screening as an opportunity to address any other health issues and concerns, physicians and health care systems will have to develop new systems for making sure that such issues are still addressed, the editorialists added. The authors also urged promotion of HPV vaccination and expanding screening to reach the most vulnerable populations.



Test yourself


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MKSAP Quiz: ED visit for agitated person

A 32-year-old man is brought to the emergency department after becoming disoriented, combative, and agitated earlier that day. He is accompanied by a friend, who states that the patient has a history of alcohol and drug abuse, including inhalants.

mksap.jpg

On physical examination, the patient is uncooperative and slightly disoriented. Temperature is normal, blood pressure is 140/88 mm Hg, and pulse rate is 98/min. The remainder of the examination is normal.

Laboratory studies:

Fasting glucose 110 mg/dL (6.1 mmol/L)
Sodium 142 mEq/L (142 mmol/L)
Potassium 4.1 mEq/L (4.1 mmol/L)
Chloride 109 meg/L (109 mmol/L)
Bicarbonate 23 mEq/L (23 mmol/L)
Blood urea nitrogen 18 mg/dL (6.4 mmol/L)
Plasma osmolality 320 mosm/kg H2O (320 mmol/kg H2O)
Serum creatinine 1.1 mg/dL (97.2 µmol/L)
Serum ketones Positive
Urinalysis Trace glucose; 4+ ketones

Arterial blood gas studies (with the patient breathing ambient air):

pH 7.4
Pco2 44 mm Hg
Po2 92 mm Hg

Which of the following is the most likely cause of this patient's clinical presentation?

A) Alcoholic ketoacidosis
B) Diabetic ketoacidosis
C) Ethylene glycol
D) Isopropyl alcohol
E) Toluene

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


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Prostate cancer


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European study finds prostate cancer mortality reduced by PSA screening

Prostate-specific antigen (PSA)-based screening significantly reduced mortality from prostate cancer but did not affect all-cause mortality, according to two more years of follow-up results in the European Randomized Study of Screening for Prostate Cancer (ERSPC).

ERSPC involved 182,160 men between the ages of 50 and 74 in eight European countries. Men randomly assigned to the screening group were offered PSA-based screening, whereas those in the control group were not. Screening was carried out every four years (every two years in Sweden). The primary outcome was mortality from prostate cancer. A positive test result, defined as a PSA value of 3.0 ng/mL or more, was an indication for sextant prostatic biopsies. Study results appeared in the March 15 New England Journal of Medicine.

There were 299 deaths from prostate cancer in the screening group and 462 in the control group, with death rates of 0.39 and 0.50 per 1,000 person-years, respectively. Overall, a rate ratio of 0.79 (95% CI, 0.68 to 0.91; P=0.001), was found for prostate cancer mortality between the screened group and unscreened. The absolute difference in mortality amounted to 0.10 death per 1,000 person-years, or 1.07 deaths per 1,000 men randomized.

After correction for selection bias and noncompliance, an adjusted rate ratio of 0.71 (95% CI, 0.58 to 0.86) was found. Rate ratios for the period of 1 to 9 years and the period of 1 to 11 years were 0.85 (95% CI, 0.71 to 1.03) and 0.79 (95% CI, 0.67 to 0.92), respectively.

To prevent one death from prostate cancer in 11 years of follow-up, 1,055 men would need to be invited for screening (NNI) and 37 cancers would need to be detected (NND). The NNI and NND varied considerably according to the length of follow-up at all centers (NNI range, 936 to 2,111; NND range, 33 to 80) and at the three largest centers (NNI range, 194 to 1,825; NND range, 8 to 42). There was no significant difference in all-cause mortality between the screened and unscreened groups.

The authors wrote that reduction in prostate-cancer mortality needs to be balanced against the disadvantages of early detection of prostate cancer, with overdiagnosis estimated to occur in approximately half of screening-detected cancers. "More information on the balance of benefits and adverse effects, as well as the cost-effectiveness, of prostate-cancer screening is needed before general recommendations can be made," they wrote.

The results contradict those of the U.S.-based Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial, probably reflecting differences in the studies' respective populations and protocols, an editorialist said. For example, screening-detected cancers were treated differently. In the European screening group, men diagnosed with prostate cancer were more likely to have been treated at an academic center than were men in the control group.

"We are left with an unsatisfactory situation, in which many practitioners will think there are insufficient data to recommend abandoning PSA screening for prostate cancer," the editorialist wrote. "However, the findings of the PLCO trial are more applicable to the situation in the United States, since the ERSPC was conducted in a largely PSA-naive population. Therefore, an intensification of PSA screening would be unwise, and I think it would be advisable to follow the preliminary recommendations of the U.S. Preventive Services Task Force."



Diabetes


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Phone calls from peer mentors improved veterans' hemoglobin A1c levels

A peer mentoring program improved diabetic African-American veterans' hemoglobin A1c (HbA1c) levels more than financial incentives did, a recent study found.

annals.jpg

The six-month randomized controlled trial included 118 African-American veterans age 50 to 70 years who had been treated at the Philadelphia Veterans Affairs Medical Center and had an HbA1c of 8% or higher. One-third of the group was assigned to usual care: notification of their HbA1cs and recommendations about HbA1c goals. The second group was offered a financial incentive: $100 if they reduced their HbA1c levels by 1% and $200 if they decreased them by 2% or hit the goal of 6.5%. The members of the final group were each assigned a mentor, another African-American veteran of similar age who had formerly had poor glycemic control but now had an HbA1c of 7.5% or less. The mentor was asked (and paid $20) to talk to the patient over the phone at least once per week.

After six months, HbA1c had decreased most in the peer mentoring group. Their average HbA1c dropped from 9.8% to 8.7%, a mean change of −1.07% (95% CI, −1.84% to −0.31%) compared to the control group (whose HbA1cs decreased only from 9.9% to 9.8%). The financial incentive group saw a non-significant drop in HbA1c, from 9.5% to 9.1%, or −0.45% compared to controls (CI, −1.23% to 0.32%). Researchers concluded that peer mentorship improved glucose control in this cohort of African-American veterans with diabetes. The results were published in the March 20 Annals of Internal Medicine.

The authors noted that the mentors and patients communicated most in the first month of the program, having an average of four calls between each pair, and their conversations dropped off to a mean of two calls in the sixth month. All communication was conducted over the phone, and both patients and mentors reported that they would have appreciated face-to-face introductions. Despite this, the program was effective and could be useful, particularly in rural or suburban settings where in-person group support is inconvenient, the authors suggested. They also noted that the program was very cost-effective compared to many other possible interventions.

However, further research would be needed to determine whether the program would be effective in a broader population, since the participants were likely to already have a culture of camaraderie from their shared experiences and background. The authors also proposed future experimentation with transitioning successful mentees into mentors, which could improve their own glucose control as well as their new mentees'.



Chronic kidney disease


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Harms of antiplatelet therapy may outweigh benefits in chronic kidney disease

Antiplatelet therapy may have uncertain benefits that could be outweighed by bleeding risk in patients with chronic kidney disease (CKD), according to a new study.

annals.jpg

Researchers performed a systematic review and meta-analysis to determine how antiplatelet therapy affected cardiovascular events and mortality and bleeding rates in CKD patients. They searched the Embase and Cochrane databases through November 2011 to find 40 randomized trials in adult CKD patients that compared antiplatelet agents with standard care, no treatment, or placebo. Nine of the included trials reported on 9,969 patients with CKD who had acute coronary syndromes or were undergoing percutaneous coronary intervention; all of these data were post hoc analyses of CKD patients from larger trials. The remaining 31 trials reported on 11,701 CKD patients with stable cardiovascular disease or no cardiovascular disease. The study results were published in the March 20 Annals of Internal Medicine.

In the nine trials involving post hoc analyses, glycoprotein IIb/IIIa inhibitors or clopidogrel added to standard care increased serious bleeding compared with standard care alone, but had little or no effect on all-cause or cardiovascular mortality or myocardial infarction rates in patients with acute coronary syndromes. In the 31 trials of patients with CKD and stable or no cardiovascular disease, antiplatelet agents compared with placebo or no treatment protected against myocardial infarction but did not necessarily improve mortality rates and they increased rates of minor bleeding. All of these findings were based mainly on low-quality evidence.

The authors noted that their conclusions were based on trial-level rather than individual-patient data, that the available data overall were limited, and that the included trials were of different durations and used different definitions of bleeding outcomes, among other limitations. However, they concluded that the evidence supporting antiplatelet therapy in patients with CKD is of low quality. "Bleeding hazards and lack of clear efficacy in reducing cardiovascular morbidity and mortality need to be acknowledged when patients with CKD are being counseled about acute or long-term antiplatelet therapy," they wrote.



CMS update


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Version 5010 enforcement again delayed

Last Thursday, CMS announced that it would again delay enforcement of the version 5010 transactions standards for electronic claims. This time the delay will extend until June 30.

The new standards, which are being implemented in preparation for the transition to the ICD-10 code set, were scheduled to begin on Jan. 1. In December, CMS announced that it would delay enforcement until the end of March, and with this latest announcement, enforcement will begin six months after originally scheduled.

More information about version 5010 and the delay are available on the Running a Practice section of the ACP website.


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Medicare holding call on Initial Preventive Physical Exam and Wellness Visit

On Wednesday, March 28, CMS will be holding a conference call about what physicians need to know about the Initial Preventive Physical Exam (the "Welcome to Medicare" visit) and the Annual Wellness Visit.

The call will discuss which patients are eligible, when to perform the service, who can perform the service, and how to code and bill for each service. The call will be 2:30 to 4:00 p.m. Eastern time. Interested participants can register online.


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Are you having problems with eRx?

Have you been subject to a Medicare eRx payment penalty despite a pending application for a hardship exemption?

If you have been unable to resolve the situation with CMS, ACP has developed a complaint form that you can use to let us know about your problem. More information about problems that physicians have been experiencing appeared in the last issue of ACP Advocate.

If you're being affected, please take a moment to fill out the form to let us know about your situation.



Education


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Arnold P. Gold Foundation to hold biennial conference

The Arnold P. Gold Foundation will hold its biennial conference and 10th anniversary celebration this fall.

The theme of the conference is "Building on a Decade of Humanism in Action," with a focus on patient-centered, compassionate care. Featured speakers will include Jerome Groopman, MD, FACP, and Pamela Hartzband, MD, FACP, ACP Internist columnists and authors of "Your Medical Mind: How to Decide What Is Right for You." The conference will take place Oct. 4-6 in Chicago. More information is available online.



From ACP Internist


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Take our poll on open records access

Large health systems have begun experimenting with using electronic health records to provide more convenient access for patients, a move that worries some primary care physicians while other physicians and their patients have embraced it. Take our poll and tell us whether you'd ever consider implementing open access medical records in your office.



From ACP Hospitalist


.
The March issue is now online

The March issue of ACP Hospitalist is now online, with stories about substance abuse in physicians, a novel transitions-of-care program, and cardiac monitoring.

Substance abuse in physicians is no more common than in the general public, but it can be harder to spot. Learn the warning signs of abuse, and what you can do if you think a colleague is affected.

Oregon Health & Science University helped improve care transitions by paying community clinics to serve as medical homes for low-income patients, and designing a low-cost hospital-based formulary. Read about other features of this unique program.

Continuous cardiac monitoring for ED patients with chest pain might seem prudent, but it can lead to inappropriate use of resources. Learn when—and when not—to use telemetry with patients.



From the College


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Evaluating risk and screening for colorectal cancer

Fred Ralston Jr., MD, MACP, ACP's immediate past president and a practicing internist in Fayetteville, Tenn., continues his column at KevinMD.com, one of the Web's leading destinations for provocative physician commentary. In this month's post, Dr. Ralston reminds physicians to evaluate their patients' risk for colorectal cancer and about the importance of screening.



Cartoon caption contest


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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-20120320-cartoon.jpg

"Thank you, Mr. Jones. We will now proceed with the wallet biopsy."

This issue's winning cartoon caption was submitted by David S. Silverman, MD, ACP Member, from Rotorua, New Zealand. Thanks to all who voted! The winning entry captured 42.9% of the votes.

The runners-up were:

"It's part of our effort to update the practice's technology."

"Our office manager is pretty aggressive about collecting co-pays at the time of visit."


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MKSAP Answer and Critique



The correct answer is D) Isopropyl alcohol. This item is available to MKSAP 15 subscribers as item 8 in the Nephrology section. More information about MKSAP 15 is available online.

This patient most likely has isopropyl alcohol poisoning. Manifestations of this condition resemble those in ethanol intoxication and include inebriation and a depressed mental status. Isopropyl alcohol ingestion causes acetone production, which results in ketones in the blood and urine. However, because bicarbonate is not consumed during acetone production, metabolic acidosis is absent in this setting. Isopropyl alcohol poisoning is characterized by an increased osmolal gap in the setting of positive serum and urine ketones. The osmolal gap is the difference between the measured and calculated osmolality, with the calculated osmolality obtained using the following formula:

Plasma Osmolality (mosm/kg H2O) = 2 × Serum Sodium (mEq/L) + Blood Urea Nitrogen (mg/dL)/2.8 + Glucose (mg/dL)/18

This patient's calculated plasma osmolality is 296 mosm/kg H2O (296 mmol/kg H2O) and the calculated osmolal gap is 24 mosm/kg H2O (24 mmol/kg H2O), whereas the normal osmolal gap is approximately 10 mosm/kg H2O (10 mmol/kg H2O). An elevated osmolal gap suggests the presence of an unmeasured osmole and is most commonly caused by ethanol. The osmolal gap is also elevated in the presence of ethylene glycol, methanol, and isopropyl alcohol. However, isopropyl alcohol does not cause an elevated anion gap metabolic acidosis (methanol and ethylene glycol poisoning) and is not associated with retinal abnormalities (methanol poisoning) or kidney failure (ethylene glycol poisoning).

This patient's confusion and disorientation are consistent with ethylene glycol poisoning, diabetic ketoacidosis, and alcoholic ketoacidosis; however, these conditions would be associated with an anion gap metabolic acidosis. Toluene, an industrial solvent that can be abused as an inhalant, may cause confusion and disorientation in addition to metabolic acidosis, hypokalemia, hypophosphatemia, rhabdomyolysis, and elevated creatine kinase level. The absence of metabolic acidosis and hypokalemia makes toluene poisoning unlikely.

Key Point

  • Isopropyl alcohol poisoning is characterized by an increased osmolal gap in the setting of positive serum and urine ketones and does not cause metabolic acidosis.

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Test yourself

A 69-year-old woman is evaluated for a lump under her arm found on self-examination. She is otherwise healthy and has no other symptoms. Medical and family histories are unremarkable, and she takes no medications. A needle aspirate of the right axillary mass reveals adenocarcinoma. Bilateral mammography and breast MRI are normal. CT scan of the chest, abdomen, and pelvis demonstrates the enlarged axillary lymph node and no other abnormalities. What is the most appropriate initial treatment?

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