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

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ACP InternistWeekly



In the News for the Week of 3-6-12




Highlights

ACP issues guideline on colorectal cancer screening

A new guidance statement developed by ACP offers recommendations on when to screen patients for colorectal cancer. More...

AIDS care panel issues new HIV guidelines

The International Association of Physicians in AIDS Care (IAPAC) has issued new guidelines on improving adherence to antiretroviral therapy (ART). More...


Test yourself

MKSAP Quiz: Appropriate management of mediastinal germ cell tumor

This week's quiz asks readers about management of a 45-year-old man previously treated for a mediastinal germ cell tumor. More...


Cancer screening

Primary care physicians often misinterpret cancer screening statistics, study indicates

Primary care physicians often misinterpret statistics about the benefits of cancer screening, according to a new study. More...


Vitamins and supplements

Too much or too little selenium associated with higher mortality

Selenium supplements are beneficial to people with low levels of the mineral, but those with levels over 122 µg/L do not obtain improvement in mortality or other outcomes from supplementation, according to a new review of available studies on selenium. More...


Women's health

Imaging for breast pain increases procedures but not cancer detection

Treating women with breast pain by performing imaging increased the odds of further tests and visits, a study found. More...


FDA update

Statin warnings on liver enzymes, blood glucose revised

The warning labels on statin medications are being changed, the FDA announced last week. More...


CMS update

Error with hypertension code for PQRS

CMS has recently realized that claims submitted for the 2012 Physician Quality Reporting System Measure #235, "Hypertension: Plan of Care" are being rejected or denied. More...


Education

Free, interactive online training series on post-traumatic stress disorder

The Home Base Program, in collaboration with the Veterans Administration's National Center for Posttraumatic Stress Disorder (PTSD), is offering a new 14-part training series, "From the War Zone to the Home Front: Supporting the Mental Health of Veterans and Families." More...


From ACP Internist

ACP Internist is now online and coming to your mailbox

The March issue of ACP Internist addresses the latest in internal medicine. More...


From the College

ACP CEO joins National Commission on Physician Payment Reform

Dr. Steven Weinberger, executive vice president and CEO of ACP, has been appointed to the National Commission on Physician Payment Reform, an independent commission that will assess how physicians are paid and how pay incentives are linked to patient care. 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...


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: Philip Masters, MD, FACP



Highlights


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ACP issues guideline on colorectal cancer screening

A new guidance statement developed by ACP offers recommendations on when to screen patients for colorectal cancer.

annals.jpg

The College's clinical guidelines committee based the recommendations on a review of existing U.S. guidelines for colorectal cancer screening. Existing guidelines (from organizations such as the American Cancer Society, American College of Radiology, American College of Gastroenterology and U.S. Preventive Services Task Force) recommend initiating screening in average-risk adults between 40 and 50 years of age depending on ethnicity, but they differed on the method of screening, the committee found. Based on the review, the ACP experts issued four guidance statements:

  • Guidance Statement 1: ACP recommends that clinicians perform individualized assessment of risk for colorectal cancer in all adults.
  • Guidance Statement 2: ACP recommends that clinicians screen for colorectal cancer in average-risk adults starting at the age of 50 years and in high-risk adults starting at the age of 40 years or 10 years younger than the age at which the youngest affected relative was diagnosed with colorectal cancer.
  • Guidance Statement 3: ACP recommends using a stool-based test, flexible sigmoidoscopy, or optical colonoscopy as a screening test in patients who are at average risk. ACP recommends using optical colonoscopy as a screening test in patients who are at high risk. Clinicians should select the test based on the benefits and harms of the screening test, availability of the screening test, and patient preferences.
  • Guidance Statement 4: ACP recommends that clinicians stop screening for colorectal cancer in adults over the age of 75 years or in adults with a life expectancy of less than 10 years.

The statement also notes that the screening interval for average-risk patients is 10 years for colonoscopy, five years for other endoscopic and radiologic tests, annually for fecal occult blood tests, and uncertain for stool DNA panels. Computed tomography colonography is another option supported by some guidelines, but the U.S. Preventive Services Task Force found insufficient evidence on its benefits and harms.

The recommendations are intended to highlight "how clinicians can contribute to delivering high-value, cost-conscious health care," the statement said. Evidence shows that screening more frequently than recommended does not improve outcomes and contributes to avoidable health care costs, the authors noted. The guidance statement was published in the March 6 Annals of Internal Medicine.


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AIDS care panel issues new HIV guidelines

The International Association of Physicians in AIDS Care (IAPAC) has issued new guidelines on improving adherence to antiretroviral therapy (ART).

To help clinicians monitor and support adherence to ART in HIV-infected patients, IAPAC convened a panel of experts who conducted a systematic review of 325 randomized, controlled trials and observational studies. Members of the panel drafted recommendations and then graded the overall quality of evidence for and strength of each.

The panel made a total of 37 recommendations in the following categories:

  • entry into and retention in HIV medical care,
  • monitoring ART adherence,
  • interventions to improve ART adherence,
  • adherence tools for patients,
  • education and counseling interventions,
  • health system and service delivery interventions and
  • special populations (including pregnant women, patients with substance use or mental health disorders, incarcerated or homeless patients, and children and adolescents).

The panel also called for further cost-effectiveness research on ART as well as research in areas where evidence was insufficient to make recommendations, such as in patients with HIV infection and one or more comorbid conditions.

The full recommendations were published early online March 6 by Annals of Internal Medicine.



Test yourself


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MKSAP Quiz: Appropriate management of mediastinal germ cell tumor

Seven years ago, a 45-year-old man was diagnosed with a biopsy-proven mediastinal germ cell tumor. The patient was treated with combination chemotherapy (bleomycin, etoposide, and cisplatin) and had a complete radiographic response. He has been disease-free since completing therapy, and follow-up serum tumor marker measurements, chest radiographs, and CT scans of the abdomen and pelvis have been normal.

mksap.jpg

Which of the following is the most appropriate management at this time?

A) Age- and sex-appropriate screening
B) Audiometry
C) Exercise stress test
D) Pulmonary function tests
E) Renal ultrasonography

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


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Cancer screening


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Primary care physicians often misinterpret cancer screening statistics, study indicates

Primary care physicians often misinterpret statistics about the benefits of cancer screening, according to a new study.

annals.jpg

Researchers used an Internet survey to conduct a parallel-group, randomized trial of a national sample of U.S. primary care physicians. The physicians were selected from a Harris Interactive research panel, and the trial was randomized only for order effect. The study's objective was to determine whether primary care physicians understand which screening statistics indicate whether cancer screening saves lives. Physicians were given scenarios about two hypothetical screening tests; in the first scenario, the test was described as improving five-year survival rates and increasing early detection, while in the second, it was described as decreasing cancer mortality and incidence. The study's main outcome measures were physicians' general knowledge of screening statistics and their recommendations and perception of screening benefit in each of the scenarios. The results appeared in the March 6 Annals of Internal Medicine.

The study surveyed 297 primary care physicians in 2010 who practiced in both inpatient and outpatient settings and 115 physicians in 2011 who practiced in outpatient settings only. Most physicians (77%) were men, and most (81%) were age 40 or older. The researchers found that physicians were more likely (69% vs. 23%; P<0.001) to recommend a test based on irrelevant evidence (a five-year survival rate that increased from 68% to 99%) than one based on relevant evidence (a cancer mortality reduction from 2 to 1.6 in 1,000 persons). Most physicians did not see a difference between the irrelevant and relevant statistics, with 76% and 81%, respectively, stating that each type proved screening saves lives (P=0.39). Forty-seven percent of physicians erroneously responded that finding more cancer cases in screened versus unscreened populations proves that screening saves lives.

The study authors acknowledged that their results were based on hypothetical scenarios rather than actual clinical practice, and that the scenarios did not include potential harms of screening. However, they concluded that primary care physicians' knowledge of the benefit of cancer screening is lacking. "To better understand the true contribution of specific tests, physicians need to be made aware that in the context of screening, survival and early detection rates are biased metrics and that only decreased mortality in a randomized trial is proof that screening has a benefit," the authors wrote.



Vitamins and supplements


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Too much or too little selenium associated with higher mortality

Selenium supplements are beneficial to people with low levels of the mineral, but those with levels over 122 µg/L do not obtain improvement in mortality or other outcomes from supplementation, according to a new review of available studies on selenium.

A large majority of the U.S. population already meets the 122 µg/L cutoff, according to the review. Conclusions appeared online at The Lancet on Feb. 29.

Prospective studies included in the review found a relationship between low overall mortality and high selenium concentrations, while low selenium was an independent predictor of all-cause mortality in other studies. However, the author noted, "Such studies are prone to confounding since plasma selenium concentrations are higher in fit and well-nourished elderly people than in those who are frail, poorly nourished and unwell."

Selenium has immunostimulant effects, including enhancing proliferation of activated T cells and other effects, the review said. But evidence outside of in vitro and animal studies is scarce, the reviewer noted. Only one study looked at a functional outcome, in which patients taking supplements cleared an oral, live, attenuated poliovirus more rapidly than those given placebos.

While selenium has cardiometabolic effects, randomized trials have not shown a cardioprotective effect, the reviewer noted. However, a meta-analysis of 25 observational studies showed a significant inverse association between selenium concentrations and risk of coronary heart disease, particularly in low-selenium populations.

Prospective studies have shown some benefit on the risk of bladder, colorectal, liver, esophageal, gastric, thyroid and prostate cancers. In particular, prostate cancer studies showed "more significant protective associations are consistently detected between selenium and risk of advanced, rather than localised or low-grade, prostate cancer," especially among smokers, the author wrote.

Evidence is conflicting between studies looking at selenium concentrations and glucose metabolism, the review concluded. Lower selenium concentrations seen in the studies might be an effect of diabetes, or high selenium levels might have an effect on insulin signaling processes.

The reviewer wrote, "The crucial factor that needs to be emphasized is the inextricable U-shaped link with selenium status: additional selenium intake (e.g. from food fortification or supplements) may well benefit people with low status. However, people of adequate or high status could be affected adversely and should not take selenium supplements."



Women's health


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Imaging for breast pain increases procedures but not cancer detection

Treating women with breast pain by performing imaging increased the odds of further tests and visits, a study found.

To determine if initial imaging for breast pain reduces subsequent clinical utilization, researchers conducted a retrospective cohort study at one hospital-based breast health practice, following women referred for breast pain from 2006 to 2009. Results appeared online Jan. 31 at the Journal of General Internal Medicine.

Initial imaging was defined as a physician-ordered diagnostic mammogram, ultrasound, or magnetic resonance imaging (MRI) within three months of the visit; screening mammograms were excluded. Clinical services utilization included additional imaging tests, biopsies or another visit to a breast specialist.

Breast pain accounted for 32% of new patient referrals seen by internal medicine breast providers. The mean age was 39±13 years, and 60% of the women were less than 40 years old. In the study, 25% of women were referred for diagnostic imaging at first visit.

The results found that 98% of women who received imaging initially had additional clinical services utilization, versus 26% of women who did not receive imaging (P<0.0001). After adjustment for clinical breast exam results, age, family history and clinician, women who received initial imaging had 25 times higher odds of using subsequent clinical services (95% CI, 16.7 to 38.6).

Women with normal clinical breast exams who received initial imaging had 23.8 (95% CI, 12.9 to 44.0) times the odds of further clinical utilization than women who did not receive initial imaging, after controlling for age, family history and clinician. They had 10.4 (95% CI, 5.5 to 19.2) times the odds of receiving additional imaging, 3.7 (95% CI, 1.1 to 12.2) times the odds of receiving a biopsy, and 2.3 (95% CI, 1.4, 3.9) times the odds of having additional visits.

The authors concluded, "While initial imaging in women with breast pain has been recommended for reassurance purposes, there is significant increased subsequent utilization in women who receive initial imaging, without increased diagnostic yield."



FDA update


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Statin warnings on liver enzymes, blood glucose revised

The warning labels on statin medications are being changed, the FDA announced last week.

The recommendation for routine monitoring of liver enzymes in patients taking statins was removed. The labels now recommend that liver enzyme tests be performed before starting statin therapy and as clinically indicated thereafter. The FDA has concluded that serious liver injury with statins is rare and unpredictable in individual patients, and that routine periodic monitoring of liver enzymes does not appear to be effective in detecting or preventing serious liver injury.

Warnings will be added about the potential for generally non-serious and reversible cognitive side effects (rare cases of which have been reported) and increased blood glucose and glycosylated hemoglobin levels. However, the FDA continues to believe that the cardiovascular benefits of statins outweigh these small increased risks, according to the agency's drug safety update.

Affected drugs include atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor, Altoprev), pitavastatin (Livalo), pravastatin (Pravachol), rosuvastatin (Crestor) and simvastatin (Zocor), as well as combination products lovastatin/niacin extended-release (Advicor), simvastatin/niacin extended-release (Simcor), and simvastatin/ezetimibe (Vytorin).

The label for lovastatin has received additional updates, including new contraindications and dose limitations when it is taken with certain medications that can increase the risk for myopathy/rhabdomyolysis.



CMS update


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Error with hypertension code for PQRS

CMS has recently realized that claims submitted for the 2012 Physician Quality Reporting System Measure #235, "Hypertension: Plan of Care" are being rejected or denied.

Due to a CMS error, the G-codes for this claims/registry measure are not being accepted. The codes (G8675, G8676, G8677, G8678, G8679, G8680, and 4050F) will be reactivated in April 2012. Until then, CMS is recommending that physicians who planned to report this measure on their claims either consider reporting alternate measures in place of it or reporting the measure for more than 50% of their eligible visits for the remainder of the year to ensure their average for the year is above the 50% needed to qualify. ACP has recommended to CMS that it first attempt to correct the claims to capture the submitted G-codes before asking physicians to overreport or use alternate measures.



Education


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Free, interactive online training series on post-traumatic stress disorder

The Home Base Program, in collaboration with the Veterans Administration's National Center for Posttraumatic Stress Disorder (PTSD), is offering a new 14-part training series, "From the War Zone to the Home Front: Supporting the Mental Health of Veterans and Families."

The educational series on veterans and PTSD will help clinicians diagnose and treat PTSD and traumatic brain injury (TBI) with traditional and complimentary evidence-based therapy. Clinicians will also learn to recognize the emotional stress in spouses, parents, and children of veterans with PTSD and TBI. Participants can earn up to 1 CME/CE credit per session. More information about the series is available online.



From ACP Internist


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ACP Internist is now online and coming to your mailbox

The March issue of ACP Internist addresses the latest in internal medicine:

acpi-20120306-internist.jpg

Diagnosing a disorder with few symptoms. Hypercalcemia can have absent, few or nondifferential symptoms, but the condition can indicate the presence of major diseases such as breast cancer. Experts review how to quickly make a diagnosis.

Open access medical records require an open mind by doctors. Patients have always been able to review their records, but making this a routine practice has most patients enthused and some physicians worried. Learn how some primary care practices are applying open access to medical records to improve patient communication and compliance. And, tell us whether you'd ever allow open-access medical records in your practice at our latest poll.

Many malaria prophylaxis options, but none perfect. Malaria research is turning from short-term prophylaxis for travelers to efforts toward elimination and eradication. Drug costs and new ethics rules for research are key drivers of this new direction.

Also, Test yourself with the MKSAP Quiz on a 60-year-old man who is evaluated for a growing and bleeding skin lesion on his right wrist.



From the College


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ACP CEO joins National Commission on Physician Payment Reform

Dr. Steven Weinberger, executive vice president and CEO of ACP, has been appointed to the National Commission on Physician Payment Reform, an independent commission that will assess how physicians are paid and how pay incentives are linked to patient care. The commission, sponsored by the Society of General Internal Medicine, is composed of physician and non-physician leaders in health care delivery, health policy, and health care economics. As a member of the commission, Dr. Weinberger will join others in offering a wide range of perspectives in efforts to provide a road map of cost-conscious payment changes that will help rein in health care spending while optimizing patient care. More information on the commission is available online.


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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.



Cartoon caption contest


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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-20120306-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 A) Age- and sex-appropriate screening. This item is available to MKSAP 15 subscribers as item 55 in the Hematology and Oncology section. More information about MKSAP 15 is available online.

Although bleomycin may be associated with pulmonary toxicity and cisplatin has known ototoxic effects, no delayed cardiovascular effects are associated with this patient's chemotherapeutic regimen that would require surveillance beyond age- and sex-appropriate screening. Screening recommendations for survivors of germ cell cancer are no different than those for the general population, and, for this patient, include periodic lipid screening (every five years), annual blood pressure measurement (or at each office visit), and counseling regarding tobacco use.

Because his risk for cardiovascular risk is not increased, an exercise stress test is not indicated in this patient.

Cisplatin therapy is related to high-tone hearing loss, but in most patients, this long-term complication presents predominantly asymptomatically. Audiometry screening in asymptomatic individuals is not recommended because it has little impact on subsequent management.

Although this patient does remain at risk for late-onset bleomycin-induced lung injury, pulmonary function tests are not advised in the absence of symptoms. Whether the patient should wear a Medic-alert bracelet warning of the dangers of high Fio2 during subsequent surgery is debatable.

Although dose-related nephrotoxicity may occur during cisplatin therapy, there is no risk for late renal injury or renal neoplasia, and screening renal ultrasonography is not recommended.

Key Point

  • Nothing beyond age- and gender-based screening is recommended for long-term germ cell cancer survivors who received cisplatin or bleomycin chemotherapy.

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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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