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

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ACP InternistWeekly



In the News for the Week of April 10, 2012




Highlights

Drugs offer small benefit for urgency urinary incontinence in women

Drugs can help relieve urinary incontinence in women, but the benefit is small and side effects can lead to discontinuation of treatment, according to a new study. More...

Infection, other factors may increase risk for VTE hospitalization

Infection, treatment with erythropoiesis-stimulating agents, and blood transfusion may increase risk for hospitalization due to venous thromboembolism (VTE), according to a new study. More...


Test yourself

MKSAP Quiz: 3-month history of increasing fatigue

This week's quiz asks readers to evaluate a 78-year-old woman with a 3-month history of increasing fatigue. More...


Ophthalmology

Fluoroquinolones associated with retinal detachment

Current users of oral fluoroquinolones are nearly five times more likely to have a retinal detachment than nonusers, although the absolute risk was small, a study found. More...

Bisphosphonates associated with scleritis, uveitis

First-time use of oral bisphosphonates is associated with increased risk for uveitis and scleritis, according to a retrospective cohort study. More...


Conference coverage

Keynote speaker addresses record number of attendees at Hospital Medicine 2012

SAN DIEGO—Hospital Medicine 2012, the annual meeting of the Society of Hospital Medicine, brought more than 2,500 hospitalists to San Diego this week for the largest ever gathering of inpatient-based clinicians. More...


CMS update

Still time to avoid an eRx penalty in 2013

There is still time to avoid a Medicare e-prescribing penalty payment in 2013. More...

CMS releases fact sheet to help with version 5010 transition

Because clinicians have been reporting issues with version 5010 claims processing and payment, CMS has issued a fact sheet with guidance about how to troubleshoot the issues. More...

Change announced to Trailblazer audit demand letters

In response to concern that demand letters for recovery audit reviews would be overlooked among the different letters coming from Medicare Administrative Contractors (MACs), Trailblazer announced that it will test sending the letters on a different color of paper. More...


Surveys

Survey on medical profession available

ACP is making available to its members a survey sponsored by The Physicians Foundation. The focus of the survey is to compile a "state of the union" of the medical profession, examining physician morale, practice plans, and practice metrics. More...


Internal Medicine 2012

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...


From the College

Attend a chapter meeting

Clinicians can enhance their clinical skills and knowledge and network with colleagues at local ACP chapter meetings. 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...

Editor's note: ACP InternistWeekly readers will receive daily updates from Internal Medicine 2012 in New Orleans on April 19-21. There will be no issue on April 17 or April 24.


Physician editor: Philip Masters, MD, FACP



Highlights


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Drugs offer small benefit for urgency urinary incontinence in women

Drugs can help relieve urinary incontinence in women, but the benefit is small and side effects can lead to discontinuation of treatment, according to a new study.

Researchers performed a systematic review to examine the safety and efficacy of drugs available in the U.S. for urgency urinary incontinence in women. MEDLINE and the Cochrane Central Register of Controlled Trials were searched from 1966 to November 2011 for published randomized, controlled English-language trials that examined efficacy and quality of life. Clinically important improvement was defined as a reduction of 50% or more in frequency of urinary incontinence, while harms were defined as the totality of all possible adverse consequences of an intervention. The study was funded by the Agency for Healthcare Research and Quality and was published early online April 9 by Annals of Internal Medicine.

annals.jpg

A total of 94 trials were included in the study. In pooled analyses, continence rates per 1,000 women treated were 130 (95% CI, 58 to 202) with fesoterodine, 85 (95% CI, 40 to 129) with tolterodine, 114 (95% CI, 64 to 163) with oxybutynin, 107 (95% CI, 58 to 156) with solifenacin and 114 (95% CI, 83 to 144) with trospium. Rates of discontinuation due to adverse effects per 1,000 women treated were 31 (95% CI, 10 to 56) with fesoterodine, 63 (95% CI, 12 to 127) with oxybutynin, 18 (95% CI, 4 to 33) with trospium and 13 (95% CI, 1 to 26) with solifenacin.

The authors acknowledged that reporting bias may have affected their study and that evidence was limited or insufficient in some areas. However, they concluded that benefits from drug treatment of urgency urinary incontinence are small and that discontinuation of treatment because of side effects is common. "Since all drugs for urgency [urinary incontinence] have comparable effectiveness, therapeutic choices should consider the harms profile, and women should be informed about all possible adverse effects," the authors noted.


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Infection, other factors may increase risk for VTE hospitalization

Infection, treatment with erythropoiesis-stimulating agents, and blood transfusion may increase risk for hospitalization due to venous thromboembolism (VTE), according to a new study.

Researchers used data from the Health and Retirement Study, a nationally representative, ongoing, longitudinal study of Americans at least 51 years of age, to perform a case-crossover study examining risk factors for VTE hospitalization. Data from the study were linked with Medicare files for hospital and nursing home stays and emergency department, outpatient and home health visits from 1991 to 2007. The authors compared exposures to potential risk factors in the 90 days before hospital admission in patients admitted with a principal diagnosis of deep venous thrombosis or pulmonary embolism to the same patients' exposures during the four previous 90-day periods. A 90-day washout period was observed between the risk and comparison periods. The main outcome was hospitalization for VTE. The study results were published early online April 3 by Circulation.

A total of 16,781 patients with 399 index VTE hospitalizations were included. The most common predictor of hospitalization for VTE was infection (52.4% of risk periods), with adjusted incidence rate ratios (IRRs) of 2.90 (95% CI, 2.13 to 3.94) for all infection, 2.63 (95% CI, 1.90 to 3.63) for infection without a previous stay in a hospital or skilled nursing facility and 6.92 (95% CI, 4.46 to 10.72) for infection with a previous stay in a hospital or skilled nursing facility. An association was also seen between VTE hospitalization and treatment with erythropoiesis-stimulating agents (IRR, 9.33; 95% CI, 1.19 to 73.42) and blood transfusion (IRR, 2.57; 95% CI, 1.17 to 5.64). Major surgeries, fractures, immobility and chemotherapy also appeared to contribute to VTE hospitalization risk.

The authors acknowledged that their study database was relatively small and that information on oral medications was not available, among other limitations. However, they concluded that infection, erythropoiesis-stimulating agents and blood transfusion are associated with increased risk for VTE hospitalization and that risk prediction algorithms should be updated to include these factors.

An accompanying editorial called for additional studies using "more robust" data sets to confirm and expand on these findings, especially in younger patients, but agreed that "acute infection, particularly a more severe infection that requires hospitalization, should be considered a trigger for acute VTE." The study's findings "provide evidence suggesting that blood transfusion and treatment with erythropoiesis-stimulating agents should now be considered as possible triggers for acute VTE in non-cancer patients," the editorialist added.



Test yourself


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MKSAP Quiz: 3-month history of increasing fatigue

A 78-year-old woman has a 3-month history of increasing fatigue. She has no other medical problems and does not take any medications.

mksap.jpg

On physical examination, temperature is normal, blood pressure is 130/80 mm Hg, pulse rate is 72/min, and respiration rate is 16/min. The patient appears pale. Examination is unremarkable.

Laboratory studies:

Hemoglobin 7.8 g/dL (78 g/L)
Leukocyte count 2800/µL (2.8 × 109/L)
Absolute neutrophil count 1200/µL (1.2 × 109/L) (normal >1500/µL [1.5 × 109/L])
Platelet count 560,000/µL (560 × 109/L)
Erythropoietin 600 mU/mL (600 U/L)

Bone marrow examination shows hypercellular marrow with erythroid hyperplasia and dysplasia of the erythroid and granulocyte series. Megakaryocytes are increased with many hypolobulated cells. Iron stores are normal. Cytogenetic studies show deletion of the long arm of chromosome 5 [del(5q-)].

Which of the following is the most appropriate treatment?

A) Azacitidine
B) Danazol
C) Lenalidomide
D) Granulocyte colony-stimulating factor and recombinant erythropoietin

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


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Ophthalmology


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Fluoroquinolones associated with retinal detachment

Current users of oral fluoroquinolones are nearly five times more likely to have a retinal detachment than nonusers, although the absolute risk was small, a study found.

To examine the association between use of oral fluoroquinolones and the risk of developing a retinal detachment, researchers conducted a nested case-control study of patients in British Columbia, Canada, who had visited an ophthalmologist between January 2000 and December 2007.

Current users were those with a prescription that overlapped the index date. A recent user was defined as having a prescription 1 to 7 days prior to the index date, and a past user was defined as having a prescription 8 to 365 days before the index date.

As an additional control, researchers also examined the risk of retinal detachment against two drug classes not associated with retinal detachment: oral β-lactam antibiotics (all oral penicillins and cephalosporins) and short-acting β-agonists.

Results appeared in the April 4 Journal of the American Medical Association.

Among the cohort of 989,591 patients, 4,384 cases of retinal detachment and 43,840 corresponding controls were identified. Current use of fluoroquinolones was associated with a higher risk of developing a retinal detachment (3.3% of cases vs. 0.6% of controls; adjusted rate ratio [ARR], 4.50; 95% CI, 3.56 to 5.70). Neither recent use (0.3% of cases vs. 0.2% of controls; ARR, 0.92; 95% CI, 0.45 to 1.87) nor past use (6.6% of cases vs. 6.1% of controls; ARR, 1.03; 95% CI, 0.89 to 1.19) was associated with a retinal detachment.

There was no evidence of an association between retinal detachments and β-lactam antibiotics (ARR, 0.74; 95% CI, 0.35 to 1.57) or short-acting β-agonists (ARR, 0.95; 95% CI, 0.68 to 1.33).

The absolute increase in the risk of a retinal detachment associated with fluoroquinolones was 4 per 10,000 person-years. The number needed to harm was 2,500 for any use of fluoroquinolones.

The retina is attached to the cortical vitreous by collagen fibers, and fluoroquinolones have been shown to interfere with collagen synthesis. Just two doses of oral ciprofloxacin can reach antibacterial concentration in the vitreous, the authors noted. Although the absolute risk is small, fluoroquinolones are a commonly prescribed drug and 40% of people who experience a detachment could permanently lose at least some visual acuity, they noted.


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Bisphosphonates associated with scleritis, uveitis

First-time use of oral bisphosphonates is associated with increased risk for uveitis and scleritis, according to a retrospective cohort study.

Because of published reports of ocular inflammation with bisphosphonate use, researchers conducted a retrospective cohort study among residents of British Columbia who had visited an ophthalmologist from 2000 to 2007. The cohort included 10,827 first-time users of bisphosphonates and 923,320 nonusers who were followed for scleritis or uveitis to the time of their first inflammatory ocular adverse event, death, termination of insurance or the end of the study period.

Results appeared early online April 2 at CMAJ.

First-time users of bisphosphonates had an elevated risk of uveitis (adjusted relative risk [RR], 1.45, 95% CI, 1.25 to 1.68) and scleritis (adjusted RR, 1.51; 95% CI, 1.34 to 1.68) compared with nonusers. The results of the sensitivity analysis in which use of nonsteroidal anti-inflammatory drugs was added to the definition for scleritis did not change the results. Numbers needed to harm were 1,100 for uveitis and 370 for scleritis.

The authors noted that the release of inflammatory mediators is believed to be the possible mechanism for bisphosphonate-induced inflammatory events. Alendronate and risedronate are nitrogen-based aminobisphosphonates and are considered more potent than non-aminobisphosphonates.

"The risk of inflammatory ocular adverse events, including scleritis and uveitis, is not highlighted in most package inserts included with oral bisphosphonates," the authors wrote. "Our study highlights the need for clinicians to inform their patients about the signs and symptoms of scleritis and uveitis, so that prompt treatment may be sought and further complications averted. Patients taking oral bisphosphonates must be familiar with the signs and symptoms of these conditions, so that they can seek immediate assessment by an ophthalmologist."



Conference coverage


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Keynote speaker addresses record number of attendees at Hospital Medicine 2012

SAN DIEGO—Hospital Medicine 2012, the annual meeting of the Society of Hospital Medicine, brought more than 2,500 hospitalists to San Diego this week for the largest ever gathering of inpatient-based clinicians.

After three days of scientific sessions, Robert Wachter, MD, FACP, closed out the meeting with an address on "The Great Physician 2012," in which he warned attendees about significant changes in store for physicians but also reassured them that hospitalists are well-positioned to lead the future of medicine.

He noted many positives of contemporary hospitalist practice, including improved quality and safety and potential for cost-cutting, but he also discussed potentially negative aspects, especially related to an increasing focus on technology. Hospitalists should be "constantly asking ourselves what we have lost in terms of our relationship with patients" because of computers, Dr. Wachter said. He also expressed concern that physicians' body of skills and knowledge could shrink due to their reliance on technology and instant access to information, asking "Is Google making us stupider?"

Dr. Wachter encouraged hospitalists not to let ongoing efforts toward better teamwork distract from the need for strong leadership within the hospital. "Teamwork is absolutely vital and yet I've been to a lot of institutions that seem to be really good at teamwork, but what they're missing is leadership. I think we've got to be a little careful about going too far in the 'Kumbaya' direction," he said.

Dr. Wachter will become chair of the American Board of Internal Medicine (ABIM) later this year, and he discussed the challenges of assessing the competence of current and future internists. Other forums for physician assessment (such as HealthGrades) may make the public less concerned about board certification, while the increasing complexity of practice—for example, the need to judge a doctor's team behavior, systems thinking, and professionalism as well as clinical knowledge—makes assessment more difficult.

He predicted that a component of the ABIM exam will allow physicians to use the Internet to answer questions within the next five to ten years, although he also expects part of the exam to continue to rely on memorized knowledge. "It's vital that we don't ditch all of the old competencies," he said. He closed his speech by reassuring hospitalists that these changes will not be too much for them to handle. "If any field is going to sort out how to be this new great physician while holding onto the parts of the old great physician that have enduring value, it will be us," he said.

By Stacey Butterfield, Associate Editor



CMS update


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Still time to avoid an eRx penalty in 2013

There is still time to avoid a Medicare e-prescribing penalty payment in 2013. Clinicians who did not become successful e-prescribers by the end of 2011 can still submit claims to qualify during the first six months of 2012. To avoid the penalty, clinicians must successfully submit at least 10 eRx claims by the end of June. Clinicians who are not able to use e-prescribing may be able to qualify for a hardship exemption; applications for the exemption also must be submitted by June 30.

Additional information is available on the ACP website.


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CMS releases fact sheet to help with version 5010 transition

CMS recently announced that it will delay enforcement of the version 5010 transaction standards until June 30. Because clinicians have been reporting issues with version 5010 claims processing and payment, CMS has also issued a fact sheet with guidance about how to troubleshoot the issues. The fact sheet is available online. Additional information about the transition to version 5010 and ICD-10 is available on the College website.


.
Change announced to Trailblazer audit demand letters

In response to concern that demand letters for recovery audit reviews would be overlooked among the different letters coming from Medicare Administrative Contractors (MACs), Trailblazer announced that it will test sending the letters on a different color of paper.

The color will be visible through the envelope window. TrailBlazer will be making the change during the month of April and will follow with more details when they become available.



Surveys


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Survey on medical profession available

ACP is making available to its members a survey sponsored by The Physicians Foundation. The focus of the survey is to compile a "state of the union" of the medical profession, examining physician morale, practice plans, and practice metrics.

The Physicians Foundation is a nonprofit, grant-making organization whose stated purpose is to advance the work of practicing physicians and to improve the quality of health care for all Americans. Your participation in the survey is voluntary. Responses are anonymous and will not be linked to your identity or e-mail address. The survey is available online.



Internal Medicine 2012


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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.



From the College


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Attend a chapter meeting

Clinicians can enhance their clinical skills and knowledge and network with colleagues at local ACP chapter meetings. ACP members and nonmembers alike can gain insight into recent medical advances, discuss local and national issues affecting internal medicine, and learn about the benefits of membership. ACP chapter meetings will help clinicians meet not only their needs as a general internist, subspecialty internist, family practitioner, fellow in subspecialty training, allied health practitioner, or resident, but also the needs of the patients they serve. More information about upcoming meetings, CME offerings and registration is available 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-20120410.jpg

"I'm not sure why you feel a sense of impending doom."

"Just as I suspected: ST-rex segment elevation."

"I know what you mean. There aren't very many of us solo practitioners around either."

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 C) Lenalidomide. This item is available to MKSAP 15 subscribers as item 15 in the Hematology and Oncology section. More information about MKSAP 15 is available online.

This patient should receive lenalidomide. Myelodysplastic syndromes (MDS) are clonal disorders of the hematopoietic stem cells that occur predominantly in patients older than 50 years and are characterized by ineffective hematopoiesis and peripheral cytopenia. Dysplasia of erythroid, granulocytic, or megakaryocytic lineages in a patient with a hypercellular bone marrow and low peripheral blood counts suggests MDS. Detection of clonal abnormalities commonly involving chromosomes 3, 5, 7, 8, and 17 supports the diagnosis. This patient has the 5q- syndrome (interstitial deletion of the long arm of chromosome 5), which is a subtype of MDS, characterized by an elevated platelet count and anemia. Most patients are elderly women who have an indolent course associated with transfusion-dependent anemia, a low incidence of neutropenia and thrombocytopenia, and a low rate of transformation to acute myeloid leukemia. This subtype of MDS responds favorably to lenalidomide, an analogue of thalidomide, which results in resolution of the anemia in two thirds of patients. Lenalidomide is U.S. Food and Drug Administration-approved for patients with the 5q- syndrome, but they must register with the "Revassist" program, and they must complete an informed consent to ensure that they understand the need to minimize fetal exposure. Lenalidomide can cause neutropenia and infections, and blood counts must be monitored closely.

Patients with classic MDS treated with azacitidine have better outcomes than patients who receive supportive care only. In these patients, azacitidine therapy significantly delays leukemic transformation and significantly improves quality of life. Azacitidine is not as effective as lenalidomide for a patient with the 5q- syndrome. Danazol has been used to treat the anemia associated with MDS. However, danazol has a low response rate and many side effects (especially masculinizing effects in women) and is therefore not recommended as first-line therapy. In selected patients with MDS, co-administration of erythropoietin and granulocyte colony-stimulating factor has a synergistic effect in increasing hemoglobin levels and decreasing transfusion requirements, particularly in patients requiring less than 2 units of packed erythrocytes per month and in those with serum erythropoietin levels less than 500 U/L.

Key Point

  • Patients with the 5q- syndrome have a subtype of myelodysplastic syndrome that responds to lenalidomide.

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Test yourself

A 63-year-old man is evaluated for pleuritic left-sided anterior chest pain, which has persisted intermittently for 1 week. The pain lasts for hours at a time and is not provoked by exertion or relieved by rest but is worse when supine. He reports transient relief with acetaminophen and codeine and occasionally when leaning forward. He has had a low-grade fever for 3 days, without cough or chills. Medical history is significant for acute pericarditis 7 months ago. Following a physical exam and electrocardiogram, what is the most appropriate management?

Find the answer

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Have questions about the new ABIM MOC Program?

ACP explains the ABIM requirements and offers many free solutions to earn MOC points.

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