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

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ACP InternistWeekly



In the News for the Week of April 3, 2012




Highlights

Bariatric surgery procedures successfully used to treat diabetes

CHICAGO—Bariatric surgery procedures reduced obese patients' hemoglobin A1c levels more effectively than medical therapy and were associated with no life-threatening complications, reported a study presented at the annual meeting of the American College of Cardiology last week. More...

Hand, knee and hip osteoarthritis recommendations updated

Revised recommendations aimed at improving the treatment of patients with osteoarthritis of the hand, hip and knee were published by the American College of Rheumatology on March 27. More...


Test yourself

MKSAP Quiz: 1-year history of progressive exertional dyspnea

This week's quiz asks readers to determine the next step in management of a 54-year-old woman with a 1-year history of progressive exertional dyspnea. More...


Cardiology

Non-HDL cholesterol may be best marker of cardiovascular risk in statin-treated patients

Non-high-density lipoprotein cholesterol may be a better marker of cardiovascular risk in patients taking statins than low-density lipoprotein cholesterol or apolipoprotein B, according to a new study. More...


Dementia

Antipsychotics associated with MI in older patients with treated dementia

Antipsychotics are associated with a modestly increased risk for myocardial infarction (MI) in older patients also taking cholinesterase inhibitors for dementia, according to a new study. More...


Autoimmune diseases

Sjögren's criteria embrace multispecialty approach

Diagnosis and management of Sjögren's syndrome require participation by rheumatologists, ophthalmologists and oral medicine specialties, according to the first classification criteria endorsed by the American College of Rheumatology. More...


Drug updates

FDA revises recommendations for citalopram

The FDA has revised recommendations for the antidepressant citalopram (Celexa) to address doses in older patients and to urge caution in patients with certain heart conditions. More...

Bupivacaine, propofol could be easily confused, safety group warns

A medication safety coalition last week warned that local anesthetic bupivacaine (Exparel) looks similar to propofol, and its accidental use could cause serious adverse events and death. 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...

Reach exhibiting employers at Internal Medicine 2012 even if you're unable to attend

Looking for a job? Reach potential employers at Internal Medicine 2012, April 19-21, even if you are unable to attend the meeting. More...


From the College

ACP releases Immunization Advisor app

ACP has released the ACP Immunization Advisor, an app that will allow members to access the latest vaccine indications at their fingertips. More...

New ethics case study posted

The ACP Center for Ethics and Professionalism has posted a new case study, "Who Should Get What? Mammography and the Stewardship of Health Care Resources", on Medscape. More...

College Fellow named Dartmouth Medical School's senior associate dean for medical education

Richard J. Simons, MD, FACP, has been named senior associate dean for medical education and associate vice president for health affairs at Dartmouth Medical School in Hanover, N.H. More...

Chapter awardees announced

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

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


.
Bariatric surgery procedures successfully used to treat diabetes

CHICAGO—Bariatric surgery procedures reduced obese patients' hemoglobin A1c (HbA1c) levels more effectively than medical therapy and were associated with no life-threatening complications, reported a study presented at the annual meeting of the American College of Cardiology last week.

The trial included 150 patients, age 20 to 60 years, who had a diagnosis of type 2 diabetes, an HbA1c above 7% and a BMI of 27 to 43 kg/m2. Their average HbA1c was 9.2%. They were randomized to one of three groups: intensive medical therapy alone, medical therapy plus Roux-en-Y gastric bypass or medical therapy plus sleeve gastrectomy.

The study was presented at the ACC meeting and was published online by the New England Journal of Medicine on March 26.

The primary endpoint of the study was an HbA1c of 6% or lower. After a year of follow-up, 12% of patients in the medication group had achieved that goal, compared to 42% who underwent bypass and 37% who underwent sleeve gastrectomy. The bypass arm also had the lowest mean HbA1c: 6.4% versus 6.6% and 7.5% in the sleeve and medication alone groups, respectively. The surgery groups lost significantly more weight than the medical group (25 to 30 kg vs. 5 kg) and reduced their use of antihyperglycemic medications.

"All of the gastric bypass patients that reached the target did so without any medication. That's as close to a definition of remission as you can get," said lead study author Philip R. Schauer, MD.

Four patients had to undergo reoperation, but none died or suffered life-threatening complications. Further follow-up is necessary, but based on these results, bariatric surgery "represents a potentially useful strategy for management of uncontrolled diabetes," the study authors concluded. They noted that gastric bypass showed better results than sleeve gastrectomy on the study's various outcomes, but that the differences were not significant and the study wasn't powered to detect a difference between those groups.

By Stacey Butterfield, Associate Editor


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Hand, knee and hip osteoarthritis recommendations updated

Revised recommendations aimed at improving the treatment of patients with osteoarthritis (OA) of the hand, hip and knee were published by the American College of Rheumatology on March 27. They appear on the organization's website and in the April Arthritis Care & Research.

The revised recommendations are based on a systematic review of current evidence, coupled with the input of an expert panel. The specific recommendations were developed based on the quality of available evidence and an assessment of the balance of potential benefits and harms, and are reported in a manner intended to facilitate shared decision making that factors in the values and judgments of both patients and practitioners. Interventions with a "strong" recommendation are those it is believed that most informed patients would choose to pursue for treatment, while "conditional" recommendations are those it is believed a majority of informed patients would choose to pursue, but some would not, based on their preferences.

For hand OA, nonpharmacologic conditional recommendations are as follows:

  • Evaluate the ability to perform activities of daily living;
  • Instruct in joint protection techniques;
  • Provide assistive devices, as needed, to help patients perform daily living activities;
  • Instruct in use of thermal modalities; and
  • Provide splints for patients with trapeziometacarpal joint OA.

Pharmacologic conditional recommendations are as follows:

  • Use topical capsaicin; topical nonsteroidal anti-inflammatory drugs (NSAIDs), including trolamine salicylate; oral NSAIDs, including COX-2 selective inhibitors; and tramadol;
  • Do not use intraarticular therapies or opioid analgesics; and
  • Use topical rather than oral NSAIDs in patients age 75 years and older. For those younger than 75 years, there is no preference for using topical rather than oral NSAIDs.

For knee OA, cardiovascular (aerobic) and/or resistance land-based or aquatic exercise, as well as weight loss in overweight patients, is strongly recommended. Conditional recommendations for patients include the following:

  • Participate in self-management programs;
  • Receive manual therapy in combination with supervised exercise;
  • Receive psychosocial interventions;
  • Use medially directed patellar taping;
  • Wear medially wedged insoles if patients have lateral compartment OA;
  • Wear laterally wedged subtalar strapped insoles if patients have medial compartment OA;
  • Learn to use thermal agents;
  • Receive walking aids, as needed;
  • Do tai chi; and
  • Receive traditional Chinese acupuncture or be instructed in the use of transcutaneous electrical stimulation only if they are a knee replacement candidate who is unwilling or unable to undergo the procedure.

There are no recommendations for participating in balance exercises, wearing laterally wedged insoles, receiving manual therapy alone, wearing knee braces, or using laterally directed patellar taping.

It is conditionally recommended that patients with knee OA use acetaminophen, oral NSAIDs, topical NSAIDs, tramadol or intra-articular corticosteroid injections; that chondroitin sulfate, glucosamine and topical capsaicin should not be used; and that opioid analgesics should be reserved for patients who have an indication for total joint replacement but are either unwilling to or unable to undergo the procedure.

For hip OA, it is strongly recommended that patients should participate in aerobic and/or resistance exercise, aquatic exercise and lose weight, if overweight. Self-management programs and patient education and manual therapy in combination with supervised exercise are conditionally recommended. No recommendations were made for balance exercises, either alone or in combination with strengthening exercises, tai chi or receiving manual therapy alone.

It is conditionally recommended that patients with hip OA use acetaminophen, oral NSAIDs, tramadol or intra-articular corticosteroid injections but not use chondroitin sulfate and glucosamine. Opioid analgesics should be reserved for patients who have an indication for total joint replacement but are either unwilling to undergo or have contraindications to undergoing the procedure.

The update is the first in a decade and includes new recommendations for hand OA.



Test yourself


.
MKSAP Quiz: 1-year history of progressive exertional dyspnea

A 54-year-old woman is evaluated for a 1-year history of progressive exertional dyspnea. She does not smoke cigarettes or use illicit drugs. The patient has a history of obesity and has used various appetite suppressants but takes no other medications. She has no significant family or personal or medical history.

mksap.jpg

On physical examination, she is afebrile; the blood pressure is 100/60 mm Hg, the pulse rate is 98/min, the respiration rate is 20/min, and the BMI is 38 kg/m2. The lungs are clear on auscultation and percussion. There is a loud pulmonic component to S2, which is also split during inhalation and exhalation. Spirometry and plethysmography are normal.

Arterial blood gases are normal.

Ventilation/perfusion scan shows diffusely nonhomogeneous perfusion but no segmental or subsegmental regions of perfusion defect. Chest radiograph shows enlarged pulmonary arteries and enlarged right-sided heart chambers but no parenchymal abnormalities. Transthoracic echocardiography shows decreased cardiac output, right ventricular hypertrophy and dilation, and right atrial enlargement. The left ventricle is somewhat compressed by the intraventricular septum.

Which of the following is the most appropriate next step in the management of this patient?

A) High-resolution CT scan of the chest
B) Myocardial perfusion imaging
C) Right-heart catheterization
D) Therapeutic trial of enalapril
E) Transbronchial lung biopsy

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


.

Cardiology


.
Non-HDL cholesterol may be best marker of cardiovascular risk in statin-treated patients

Non-high-density lipoprotein cholesterol (non-HDL-C) may be a better marker of cardiovascular risk in patients taking statins than low-density lipoprotein cholesterol (LDL-C) or apolipoprotein B (apoB), according to a new study.

Researchers performed a meta-analysis of individual patient data from eight randomized, controlled trials of statin therapy that measured lipid and apolipoprotein levels in all participants at baseline and at one year. The goal of the study was to determine the association between non-HDL-C, LDL-C, and apoB and cardiovascular risk in statin-treated patients.

Studies were identified by a search of the literature through Dec. 31, 2011. The researchers determined hazard ratios (HRs) for risk of major cardiovascular events according to each 1-SD increase in LDL-C, non-HDL-C and apoB levels, with adjustment for established risk factors. Results appeared in the March 28 Journal of the American Medical Association.

Of 62,154 patients, 38,153 were assigned to receive statin therapy and had lipid and apolipoprotein levels available at baseline and at one year. Among this group, 158 had fatal myocardial infarctions, 1,678 had nonfatal myocardial infarctions, 615 had other fatal coronary artery disease events, 2,806 were hospitalized for unstable angina, and 1,029 had fatal or nonfatal strokes during follow-up.

Adjusted HRs for major cardiovascular events were 1.13 per 1-SD increase in LDL-C, 1.16 per 1-SD increase in non-HDL-C, and 1.14 per 1-SD increase in apoB. The HR for non-HDL-C was significantly higher than those for LDL-C (P=0.002) and apoB (P=0.02), but the HRs for LDL-C and apoB did not significantly differ (P=0.21) from one another.

The authors acknowledged that the eight trials had used different inclusion criteria and that the results may not apply to patients in clinical practice, among other limitations. However, they concluded that although three of the studied markers have a strong association with cardiovascular events, non-HDL-C's association appears to be the strongest.

"Given the fact that many other arguments for the clinical applicability of non–HDL-C and LDL-C are identical, non-HDL-C may be a more appropriate target for statin therapy than LDL-C," the authors wrote.



Dementia


.
Antipsychotics associated with MI in older patients with treated dementia

Antipsychotics are associated with a modestly increased risk for myocardial infarction (MI) in older patients also taking cholinesterase inhibitors for dementia, according to a new study.

Researchers in Quebec used data from a prescription claims database to perform a retrospective cohort study of patients 66 years of age and older who began treatment with cholinesterase inhibitors between Jan. 1, 2000, and Dec. 31, 2009. Patients in the cohort who began using antipsychotics during the study period were matched with a random sample of patients who were not taking antipsychotics. The goal of the study was to determine the association of MI with use of antipsychotics in patients with treated dementia. Results appeared online March 26 at Archives of Internal Medicine.

Among 37,138 patients with treated dementia, 10,969 (29.5%) began taking antipsychotics during the study period. These patients were matched with 10,969 patients who were not taking antipsychotics. Within one year, an MI occurred in 1.3% of those who were taking antipsychotics and 1.2% of those who were not. Compared with patients not taking antipsychotics, the hazard ratios for MI risk were 2.19 (95% CI, 1.11 to 4.32), 1.62 (95% CI, 0.99 to 2.65), 1.36 (95% CI, 0.89 to 2.08), and 1.15 (95% CI, 0.89 to 1.47), respectively, for the first 30 days, first 60 days, first 90 days, and first 365 days. In the case series study, which involved 804 MIs in patients starting antipsychotics, incidence rate ratios for 1 to 30 days, 31 to 60 days, and 61 to 90 days were 1.78 (95% CI, 1.26 to 2.52), 1.67 (95% CI, 1.09 to 2.56), and 1.37 (95% CI, 0.82 to 2.28), respectively.

The authors noted that the start date for antipsychotic therapy may not have been assessed correctly in all patients, among other limitations. However, they concluded that antipsychotics are associated with a modest increase in risk for MI among patients taking cholinesterase inhibitors for dementia, and that this risk is highest in the first month after antipsychotics are started.

An accompanying invited commentary stressed that previous research on this topic is inconsistent and that no biological mechanism can currently explain a relationship between antipsychotics and MI risk.

"Important lessons about the pathogenesis of cardiovascular disease may underlie the observed association between antipsychotic drug use and [acute MI] … but we must await further research to clarify the mechanisms contributing to this association," the commenting authors wrote. "Meanwhile, physicians should limit prescribing of antipsychotic drugs to patients with dementia and instead use other techniques when available, such as environmental and behavioral strategies, to keep these patients safe and engaged."



Autoimmune diseases


.
Sjögren's criteria embrace multispecialty approach

Diagnosis and management of Sjögren's syndrome require participation by rheumatologists, ophthalmologists and oral medicine specialties, according to the first classification criteria endorsed by the American College of Rheumatology.

The criteria appeared on the organization's website and in the April Arthritis Care & Research.

Patients must meet at least two out of three criteria to be classified as having Sjögren's syndrome:

  • positive serum anti-SSA/Ro and/or anti-SSB/La or positive rheumatoid factor and ANA titer ≥1:320;
  • labial salivary gland biopsy exhibiting focal lymphocytic sialadenitis with a focus score ≥1 focus/4 mm2;
  • keratoconjunctivitis sicca with ocular staining score ≥3 (assuming that individual is not currently using daily eye drops for glaucoma and has not had corneal surgery or cosmetic eyelid surgery in the last 5 years).

The criteria authors wrote, "The development of new biologic immunomodulating agents that are being considered in the treatment of SS [Sjögren's syndrome] increases the need and importance of developing stringent classification criteria that can be used in the context of clinical trials. The consequence of misclassifying someone without SS as a case would be serious given the potentially toxic side effects of these agents."

Furthermore, the distinction between primary and secondary forms of Sjögren's may now be obsolete, the authors continued. Because autoimmune conditions of the thyroid, liver, kidneys, and lungs can occur in Sjögren's patients, and many diseases have autoimmune mechanisms, "It seems of little use and risks potential confusion to distinguish in a given patient one autoimmune disease as secondary to another. Accordingly, the diagnosis of SS should be given to all who fulfill these criteria while also diagnosing any concurrent organ-specific or multiorgan autoimmune diseases, without distinguishing as primary or secondary."



Drug updates


.
FDA revises recommendations for citalopram

The FDA has revised recommendations for the antidepressant citalopram (Celexa) to address doses in older patients and to urge caution in patients with certain heart conditions.

Last August, the FDA issued a statement that citalopram shouldn't be used at doses greater than 40 mg/d due to the risk of potentially dangerous abnormalities in the heart's electrical activity. Current recommendations confirm the 40 mg/d limit, and also say the drug isn't recommended for patients taking other drugs that prolong the QT interval, or for those with congenital long QT syndrome, bradycardia, hypokalemia, hypomagnesemia, recent acute myocardial infarction, or uncompensated heart failure.

The maximum recommended dose is 20 mg/d for patients older than age 60, patients with hepatic impairment, those who are CYP2C19 poor metabolizers, or those who are taking concomitant cimetidine (Tagamet) or another CYP2C19 inhibitor. These factors lead to increased blood levels of citalopram, which increases the risk of QT interval prolongation and torsade de pointes, the agency said in a safety alert.


.
Bupivacaine, propofol could be easily confused, safety group warns

A medication safety coalition last week warned that local anesthetic bupivacaine (Exparel) looks similar to propofol, and its accidental use could cause serious adverse events and death.

Bupivacaine (Exparel) and propofol are both white emulsions used in similar settings and are packaged in vials that look similar. "When prepared in syringes these products essentially look identical," according to the alert by the National Alert Network, a coalition of members of the National Coordinating Council on Medication Error Reporting and Prevention.

If bupivacaine is accidentally administered intravenously instead of propofol, it may result in toxic blood concentrations and depressed cardiac conductivity and excitability. These may lead to atrioventricular block, ventricular arrhythmias, and cardiac arrest, the alert said. To date, there have been no reports of mix-ups of these two medications, it said.

To prevent the possibility of errors, the two products should be stored in separate areas and staff members should be reminded not to leave any medication or syringe unlabeled, it said. Directions for treatment of bupivacaine toxicity should be available in all surgical areas where bupivacaine is used; a checklist for treatment 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.


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Reach exhibiting employers at Internal Medicine 2012 even if you're unable to attend

Looking for a job? Reach potential employers at Internal Medicine 2012, April 19-21, even if you are unable to attend the meeting. Profiles will be included in one of two booklets based on your criteria and distributed only to employers who have submitted a job posting to the ACP Job Placement Center. The ACP Job Placement Center is a service available at Internal Medicine 2012, April 19-21, in New Orleans. The Center is located in the New Orleans Ernest N. Morial Convention Center, Booth #430.

New this year: All physicians who submit a Job Seeker's Profile will be e-mailed the Job Posting CD booklet so you can view the postings that were submitted at this year's meeting.

Profiles can be submitted online.



From the College


.
ACP releases Immunization Advisor app

ACP has released the ACP Immunization Advisor, an app that will allow members to access the latest vaccine indications at their fingertips.

Members can use the app to search by age or underlying medical circumstance, or browse the vaccine library to determine the vaccines their adult patients need. The latest immunization news and updates from ACP are also available.

Development of the ACP Immunization Advisor was made possible by unrestricted educational grants from Sanofi Pasteur, Merck Vaccines, and Pfizer, Inc. More information on the app is available online.


.
New ethics case study posted

The ACP Center for Ethics and Professionalism has posted a new case study, "Who Should Get What? Mammography and the Stewardship of Health Care Resources", on Medscape.

The case study explores the role of fundamental principles of medical professionalism such as the primacy of patient welfare, patient autonomy, and social justice in determining whether mammography should be done. CME credit is available for completion of the case study, which can be accessed online.


.
College Fellow named Dartmouth Medical School's senior associate dean for medical education

Richard J. Simons, MD, FACP, has been named senior associate dean for medical education and associate vice president for health affairs at Dartmouth Medical School in Hanover, N.H.

Dr. Simons, who is currently the vice dean for educational affairs at Penn State Milton S. Hershey Medical Center, received his medical degree in 1981 from Penn State College of Medicine and completed his internal medicine residency at the University of Michigan Hospital. He served as chief resident and instructor in the department of medicine at Penn State Milton S. Hershey Medical Center and completed a geriatrics fellowship at the University of North Carolina. He is board certified in both internal medicine and geriatrics.

A leader in medical education, Dr. Simons has served on committees for the National Board of Medical Examiners, the In-Service Training Exam for Internal Medicine, and the American Board of Internal Medicine. He will become a College Master at Internal Medicine 2012 later this month.

More information about Dr. Simons' appointment is online.


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Chapter awardees announced

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. In recognition of their outstanding service, exceptional individuals received chapter awards in the winter and spring 2012. The list is available online.



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-20120403-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 C) Right-heart catheterization. This item is available to MKSAP 15 subscribers as item 59 in the Pulmonology and Critical Care Medicine section. More information about MKSAP 15 is available online.

This patient has signs and symptoms of pulmonary hypertension and a history of use of appetite suppressants, which have been associated with pulmonary hypertension. Echocardiography has ruled out the presence of cardiac diseases associated with pulmonary hypertension. Pulmonary function testing has ruled out parenchymal obstructive and restrictive lung diseases, and ventilation/perfusion scanning has ruled out chronic thromboembolic pulmonary hypertension. Right-heart catheterization will confirm the presence of pulmonary arterial hypertension, measure pulmonary vascular resistance, determine the magnitude of right ventricular dysfunction, and guide therapy.

High-resolution CT scan is useful for the evaluation of pulmonary parenchymal disease, but the absence of parenchymal abnormalities on chest radiograph and the normal pulmonary function tests make interstitial disease unlikely. This patient's physiologic testing discloses no evidence of lung parenchymal disease. Myocardial perfusion imaging can help detect compromised coronary flow. However, the echocardiographic findings can be explained by right ventricular overload and do not suggest acute coronary disease.

Lung biopsy would add little to the diagnosis of pulmonary hypertension and entails a risk of bleeding in patients with pulmonary hypertension. Therapy with an angiotensin-converting enzyme (ACE) inhibitor may improve left ventricular function in patients with left ventricular systolic dysfunction. However, this patient's left ventricular dysfunction is attributable to compression from right ventricular hypertrophy and dilation. ACE inhibitors would not improve the pulmonary arterial resistance and might even cause dangerous decreases in this patient's blood pressure.

Key Point

  • In patients with pulmonary hypertension, right-heart catheterization will confirm the presence of pulmonary arterial hypertension, quantify pulmonary vascular resistance, determine the magnitude of right ventricular dysfunction, and guide therapy.

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Test yourself

This week's quiz asks readers to reevaluate a 55-year-old man during a follow-up examination for a wrist fracture and anemia.

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