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

Advertisement

ACP InternistWeekly



In the News for the Week of May 8, 2012




Highlights

Med school slots continuing to increase, AAMC says

Increases in medical school enrollment are likely to almost meet the 30% target set by the Association of American Medical Colleges (AAMC) in 2006, according to new projections. More...

No compelling reason for warfarin over aspirin for reduced LVEF, study indicates

There was no significant overall difference in the primary outcome between warfarin and aspirin among patients with reduced left ventricular ejection fraction (LVEF) who were in sinus rhythm, researchers reported. More...


Test yourself

MKSAP Quiz: Evaluation of a type 1 diabetic patient after a marathon

This week's quiz asks readers to evaluate a 22-year-old man with type 1 diabetes who has just run a marathon. More...


Heart failure

Titrating beta-blockers likely improves outcomes in HF patients with systolic dysfunction

Titrating beta-blocker doses up to a carvedilol equivalent of 50 mg/d appears to have benefit in patients with heart failure (HF) and systolic dysfunction, according to a new study. More...


Prevention and counseling

Counsel young patients about skin cancer prevention

Young patients with fair skin should be counseled about reducing their exposure to ultraviolet radiation to reduce the risk of skin cancer, according to a new recommendation statement from the U.S. Preventive Services Task Force. More...

Screening for domestic violence works, but outcomes don't change

Screening instruments accurately identify women experiencing intimate partner violence, potentially boosting the chances of addressing it during a clinical exam. But improvement in health outcomes varies widely among populations, researchers found. More...


From the College

ACP, Annals, Consumer Reports collaborate on high value care resources

ACP and Annals of Internal Medicine are collaborating with Consumer Reports to create a series of High Value Care resources to help patients understand the benefits, harms and costs of tests and treatments for common clinical issues. More...

If I were health care king

Fred Ralston Jr., MD, MACP, a past president of ACP and a practicing internist in Fayetteville, Tenn., reflects at KevinMD.com on what he would do if declared health care king. More...

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

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


.
Med school slots continuing to increase, AAMC says

Increases in medical school enrollment are likely to almost meet the 30% target set by the Association of American Medical Colleges (AAMC) in 2006, according to new projections.

According to a survey conducted by the AAMC's Center for Workforce Studies, first-year medical school enrollment is projected to reach 21,376 in the school year 2016-2017, a 29.6% increase over enrollment in 2002-2003, just short of the 30% increase by 2015 that the AAMC had called for.

Most of that growth (58%) will occur in the 125 schools that were already accredited in 2002. Schools that have been accredited since then will provide 25% of the increase, and the remainder (17%) will come from schools that are currently in applicant or candidate status with the Liaison Committee on Medical Education. More than half (56%) of the enrollment growth has already occurred, with 2,850 of the 4,888 slots available by 2011.

About 40% of the schools reported targeting their increases at underserved populations. Enrollment in Doctor of Osteopathic Medicine (DO) programs has risen particularly rapidly. First-year DO enrollment in 2016-2017 is projected to be 6,179, about double what it was in 2002-2003.

The survey also identified some concerns among medical school administrators:

  • 52% are concerned about the effects of the economic environment on enrollment,
  • 74% are concerned about the supply of qualified primary care preceptors, and
  • 53% are concerned about the supply of specialty preceptors.

The increase in medical students also raises concerns about the supply of residency slots. "If the number of entry level residency positions does not continue to increase, we may face a day when some qualified graduates of U.S. medical schools and osteopathic schools will be unable to find residency positions," the survey authors wrote.


.
No compelling reason for warfarin over aspirin for reduced LVEF, study indicates

There was no significant overall difference in the primary outcome between warfarin and aspirin among patients with reduced left ventricular ejection fraction (LVEF) who were in sinus rhythm, researchers reported.

A reduced risk of ischemic stroke with warfarin was offset by an increased risk of major hemorrhage, among other tradeoffs noted in the study.

Researchers designed a cooperative, double-blind, multicenter clinical trial at 168 centers in 11 countries looking at warfarin use with a target international normalized ratio of 2.0 to 3.5 or 325 mg of aspirin per day in patients with a documented LVEF of 35% or lower. The trial was sponsored by the National Institutes of Health (NIH). Researchers followed 2,305 patients for up to six years and looked for the primary outcome of time to ischemic stroke, intracerebral hemorrhage or death from any cause. Results appeared online May 2 at the New England Journal of Medicine.

Overall, 622 patients (27%) had one of the three primary outcomes (531 deaths [85.4%], 84 ischemic strokes [13.5%], and 7 intracerebral hemorrhages [1.1%]). There were 7.47 events per 100 patient-years in the warfarin group and 7.93 events per 100 patient-years in the aspirin group (hazard ratio with warfarin, 0.93; 95% CI, 0.79 to 1.10; P=0.40).

There was a constant and significant benefit with warfarin compared to aspirin for the rate of ischemic stroke (HR, 0.52; 95% CI, 0.33 to 0.82; P=0.005). There was no significant difference between the groups for the first event in the composite of death, ischemic stroke, intracerebral hemorrhage, myocardial infarction, or hospitalization for heart failure (HR with warfarin, 1.07; 95% CI, 0.93 to 1.23; P=0.33). Rates of myocardial infarction and hospitalization for heart failure did not differ significantly between the two groups.

The rate of major hemorrhage was significantly higher with warfarin than with aspirin (1.78 events per 100 patient-years with warfarin vs. 0.87 event per 100 patient-years with aspirin; adjusted rate ratio, 2.05; 95% CI, 1.36 to 3.12; P<0.001). However, the rates of intracerebral and intracranial hemorrhages combined did not differ significantly according to treatment group (0.27 event per 100 patient-years in the warfarin group and 0.22 event per 100 patient-years in the aspirin group; P=0.82). Major gastrointestinal bleeding occurred more frequently in the warfarin group (0.94 event per 100 patient-years vs. 0.45 event per 100 patient-years in the aspirin group; P=0.01).

The authors wrote, "Given the finding that warfarin did not provide an overall benefit and was associated with an increased risk of bleeding, there is no compelling reason to use warfarin rather than aspirin in patients with a reduced LVEF who are in sinus rhythm."

Editorialists commented that "The careful conduct of this blinded trial, in which patients in the warfarin group had good control of INR levels (mean time in the therapeutic range after a 6-week period of dose adjustment, 62.6%) and which included more than 600 primary outcome events, has provided clinicians with clear answers. ... The lack of an effect of warfarin on mortality suggests that most of the deaths in these patients with heart failure, who had severe impairment of left ventricular function, are unrelated to thromboembolism and, instead, are most likely due to pump failure or ventricular arrhythmias."



Test yourself


.
MKSAP Quiz: Evaluation of a type 1 diabetic patient after a marathon

A 22-year-old man comes for a routine evaluation. He has a history of type 1 diabetes mellitus and began taking insulin glargine and insulin lispro 8 years ago. Two days ago, he participated in a marathon race.

mksap.jpg

On physical examination, temperature is 36.4 °C (97.5 °F), blood pressure is 112/70 mm Hg, pulse rate is 60/min, and respiration rate is 15/min. BMI is 24 kg/m2. Funduscopic examination is normal. There is normal sensation in the extremities.

Laboratory studies:

Hemoglobin A1c 5.8%
Urinalysis Normal
Urine albumin-creatinine ratio 100 mg/g

In addition to refraining from heavy exercise, which of the following is the most appropriate next step in this patient's management?

A) Begin losartan
B) Perform kidney biopsy
C) Repeat urine albumin-creatinine ratio in 1 year
D) Repeat urine albumin-creatinine ratio in 2 weeks

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


.

Heart failure


.
Titrating beta-blockers likely improves outcomes in HF patients with systolic dysfunction

Titrating beta-blocker doses up to a carvedilol equivalent of 50 mg/d appears to have benefit in patients with heart failure (HF) and systolic dysfunction, according to a new study.

Researchers analyzed results from HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) to determine whether beta-blocker dose at baseline was associated with outcomes in patients with ambulatory HF and systolic dysfunction.

The 2,331 patients in HF-ACTION were randomly assigned to exercise training versus usual care and were followed for a median of 2.5 years. The relationship between beta-blocker dose and all-cause mortality, all-cause hospitalization and secondary cardiovascular endpoints was analyzed with and without adjustment for outcome-associated variables. Although different agents were used by the participating centers in the study, beta-blocker dose at baseline was standardized by converting these different treatments into equivalent doses of carvedilol for evaluation; baseline daily dose was then analyzed in dose groups (0 mg/d, 1 to 13 mg/d, 14 to 25 mg/d, 26 to 50 mg/d, and 51 to 100 mg/d) and as a continuous variable.

The study was published online May 2 by the Journal of the American College of Cardiology.

Most of the study patients (approximately 95%) were receiving a beta-blocker. A significant inverse relationship was found between beta-blocker dose and all-cause death or hospitalization, with a linear benefit seen up to 50 mg daily. Other cardiovascular endpoints were not found to be associated with beta-blocker dose in adjusted analyses. At three months, beta-blocker dose was also significantly associated with change in peak VO2. Higher beta-blocker doses did not appear to increase bradycardia.

The authors acknowledged that their study was a post hoc analysis and excluded patients who were not ambulatory and those with preserved systolic function. They also pointed out that dose conversions are not a perfectly accurate method of comparison and that higher doses of beta-blockers may be less tolerable in sicker patients.

However, they concluded that a significant inverse relationship existed between beta-blocker dose and all-cause death or all-cause hospitalization, even after adjustment, and that bradycardia did not increase with higher doses.

"These data support the current clinical guideline recommendations that [beta-blocker] therapy should be titrated to moderate-to-high doses as used in randomized, controlled clinical trials," they wrote.



Prevention and counseling


.
Counsel young patients about skin cancer prevention

Young patients with fair skin should be counseled about reducing their exposure to ultraviolet radiation to reduce the risk of skin cancer, according to a new recommendation statement from the U.S. Preventive Services Task Force (USPSTF).

annals.jpg

The statement was based on a targeted literature search for new evidence on sun protection and skin cancer. Based on the results, the USPSTF recommended that primary care clinicians counsel fair-skinned patients age 10 to 24 years about protecting themselves from the sun. This group was targeted because most trials of skin cancer counseling only include people with fair skin, and more evidence of counseling's effectiveness is available in this population than in older or younger patients.

For patients older than 24, the USPSTF concluded that the evidence is insufficient to assess the benefits and harms of counseling about preventing skin cancer. It's unknown whether counseling changes these patients' behavior and there is less clear evidence that behavior change would reduce their risk for skin cancer, the statement said.

For counseling younger patients, the most effective interventions focused their messages on cancer prevention or appearance. Appearance-focused intervention included self-guided booklets, videos on photoaging, peer counseling sessions, and ultraviolet facial photography to demonstrate the patient's existing skin damage. The USPSTF statement noted that none of these interventions are associated with any known risks or harms.

The statement replaced the USPSTF's 2003 recommendation, which found insufficient evidence on skin cancer counseling at any age. This new review found significant studies conducted in young persons describing a consistent picture of moderate behavior change, the task force noted. The statement was published online by Annals of Internal Medicine on May 8.


.
Screening for domestic violence works, but outcomes don't change

Screening instruments accurately identify women experiencing intimate partner violence, potentially boosting the chances of addressing it during a clinical exam. But improvement in health outcomes varies widely among populations, researchers found.

annals.jpg

Fortunately, potential adverse effects such as discomfort, loss of privacy, emotional distress, and concerns about further abuse appear to have a minimal impact on most women.

The evidence showed that women assigned to screening versus usual care did not have statistically significant improvements in intimate partner violence or health outcomes. However, more women in the screened group discussed intimate partner violence with their clinician (44% vs. 8%).

Researchers reviewed English-language trials of the effectiveness of screening and interventions, diagnostic accuracy studies of screening instruments, and studies of any design about adverse effects. The review is an update for the U.S. Preventive Services Task Force recommendation on screening women for intimate partner violence and appeared online May 8 at Annals of Internal Medicine.

One large cluster randomized, controlled trial met review criteria. It looked at 6,743 women aged 18 to 64 years who were randomly assigned to screening or nonscreening groups. The primary outcomes were exposure to abuse and quality of life in the 18 months after screening.

Reviewers noted that women with positive screenings were not offered a specific intervention and few screen-positive women had discussions about intimate partner violence with their clinicians during their clinic visits. Women who were randomly assigned to the nonscreening group were provided with information cards of locally available resources for women with intimate partner violence. Women in the nonscreening group had extensive questioning about intimate partner violence over the 18 months of the trial.

The 12-month prevalence of intimate partner violence at the initial clinic visit was 13% and 12% in the screened and nonscreened groups, respectively. During follow-up, women in both groups accessed additional health care services; had reduced recurrence, post-traumatic stress disorder symptoms, and alcohol problems; and had improved scores for quality of life, depression, and mental health. None of these results were statistically significantly different between groups.

Fifteen studies evaluated the diagnostic accuracy of 13 screening instruments. Five instruments demonstrated high accuracy in identifying women with current or recent intimate partner violence, and an instrument with two questions accurately identified women with histories of childhood abuse. Positive responses on the Partner Violence Screen predicted verbal aggression and violence during the four months after screening.

Six trials evaluated interventions to reduce intimate partner violence. Results consistently showed that counseling provided benefits such as reducing intimate partner violence and improving birth outcomes for pregnant women, reducing intimate partner violence for new mothers, and reducing pregnancy coercion and unsafe relationships for women in family-planning clinics.

Few studies reported adverse effects of screening and interventions. A large randomized, controlled trial of screening indicated no differences, while descriptive studies generally indicated low levels of adverse effects related to screening.



From the College


.
ACP, Annals, Consumer Reports collaborate on high value care resources

ACP and Annals of Internal Medicine are collaborating with Consumer Reports to create a series of High Value Care resources to help patients understand the benefits, harms and costs of tests and treatments for common clinical issues. The resources, derived from ACP's evidence-based clinical practice recommendations published in Annals of Internal Medicine, support the College's High Value, Cost-Conscious Care Initiative. Two patient brochures about diagnostic imaging for low back pain and oral medication for type 2 diabetes are the initial resources released in the collaboration and are available in both English and Spanish, and more resources will be developed in the future. More information on the collaboration is available online.


.
If I were health care king

Fred Ralston Jr., MD, MACP, a past president of ACP 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 outlines changes to the health care system that would benefit doctors and patients everywhere.


.
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


.
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-20120508-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.


.


MKSAP Answer and Critique



The correct answer is D) Repeat urine albumin-creatinine ratio in 2 weeks. This item is available to MKSAP 15 subscribers as item 15 in the Nephrology section. More information about MKSAP 15 is available online.

Annual measurement of the urine albumin excretion is indicated for patients with type 1 diabetes mellitus. However, because this patient's albumin excretion was abnormal, repeat testing in less than 1 year is warranted in order to determine whether his proteinuria is transient or persistent. Fever and exercise can cause a transient increase in protein excretion, and this patient's participation in a marathon 2 days ago may explain his proteinuria. Repeat urinalyses should be performed twice within the next 6 months, and the presence of microalbuminuria (defined as a urine albumin-creatinine ratio between 30 and 300 mg/g) would be confirmed if two of the three urine samples are positive. Therefore, in this patient, repeat urinalysis in 2 weeks is reasonable.

Kidney biopsy is not indicated unless the presence of proteinuria has been established.

Microalbuminuria is the first detectable manifestation of diabetic nephropathy and typically occurs 5 to 15 years after the diagnosis of type 1 diabetes mellitus, but a diagnosis of microalbuminuria has not yet been confirmed in this patient. Diabetic nephropathy also is typically associated with hypertension and diabetic retinopathy, which are absent in this patient. Treatment for diabetic nephropathy with an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker is not appropriate at this time.

Key Point

  • Because factors such as fever and exercise can cause a transient increase in protein excretion, patients with type 1 diabetes mellitus who have abnormal findings on annual measurement of the urine albumin excretion should undergo repeat urinalyses twice within the next 6 months; positive findings on two of the three urine samples would confirm a diagnosis of microalbuminuria (defined as a urine albumin-creatinine ratio between 30 and 300 mg/g).

Click here to return to the rest of ACP InternistWeekly.

Top




About ACP InternistWeekly

ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.

To add your e-mail address to your member record and to begin receiving ACP InternistWeekly, please click here.

Copyright © by American College of Physicians.

Test yourself

A 19-year-old man is evaluated for a sore throat, daily fever, frontal headache, myalgia, and arthralgia of 5 days' duration. He also has severe discomfort in the lower spine and a rash on his trunk and extremities. He returned from a 7-day trip to the Caribbean 8 days ago. The remainder of the history is noncontributory. Following a physical exam and lab studies, what is the most likely diagnosis?

Find the answer

ACP Clinical Shorts

Expert Education on Your Schedule

Short videos deliver highly focused answers to challenging clinical situations seen in practice and are a terrific way to earn CME credit on-the-goShort videos deliver highly focused answers to challenging clinical situations seen in practice and are a terrific way to earn CME credit on-the-go. See more.

New: Free Modules from ACP Practice Advisor!

New: Free Modules from ACP Practice Advisor!

Keep your practice moving in the right direction. ACP Practice Advisor is offering four modules that you and your staff can try for free. Get to know the premier online practice management tool at no risk. Explore the modules.