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

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ACP InternistWeekly



In the News for the Week of June 19, 2012




Highlights

USPSTF issues draft recommendations on violence and abuse screening, vitamin D and calcium supplementation

The U.S. Preventive Services Task Force (USPSTF) has issued two draft guidance statements, one on screening for intimate partner violence and abuse of elderly and vulnerable adults and another on vitamin D and calcium supplementation to prevent cancer and osteoporotic fractures in adults. More...

Most hormonal contraceptives show little absolute risk of stroke or heart attack, study finds

A recent study found that the absolute risk of increased thrombotic stroke and myocardial infarction associated with the use of hormonal contraception was low, although the relative risks varied depending on whether higher doses were used. More...


Test yourself

MKSAP Quiz: chronic cutaneous lupus erythematosus

This week's quiz asks readers to evaluate a 38-year-old man with an 18-month history of chronic cutaneous lupus erythematosus. More...


Alzheimer's disease

Delirium may be associated with adverse outcomes in hospitalized patients with Alzheimer's disease

Patients with Alzheimer's disease who develop delirium during hospitalization are more likely to have adverse outcomes, according to a new study. More...


Statins

Lower energy, more exertional fatigue with statins

Statin treatment was associated with less energy and more exertional fatigue, according to a recent analysis. More...


Veterans' health care

Review examines optimal primary care for combat veterans

A new review by clinicians from the Veterans Administration outlines conditions common to returning combat veterans who served in Iraq and Afghanistan and provides management guidelines for optimal primary care. More...


Testing

Guidelines on peripheral arterial ultrasound and physiologic testing

New guidelines describe the appropriate uses of arterial ultrasound and physiological testing for patients with known or suspected peripheral vascular disorders. More...

American College of Radiology identifies five imaging studies to question

In support of making wise choices about medical care, ACP and a number of other organizations joined the ABIM Foundation's Choosing Wisely Campaign and provided a list of five recommendations that physicians and patients should question. More...


CMS update

Time running out on version 5010 deadline

As of July 1, practices must be transmitting claims using the version 5010 standards for electronic transactions. More...

ACO application deadline extended

CMS has announced that it will be re-opening the application period for the Advanced Payment Accountable Care Organization (ACO) model. More...


From ACP Hospitalist

Who's tops at your hospital?

ACP Hospitalist is seeking candidates for its fifth annual Top Hospitalists issue in November, which will feature the best and brightest in hospital medicine. More...


From the College

Annals of Internal Medicine launches new website

Annals of Internal Medicine has launched its website on a new digital platform to provide internal medicine specialists and subspecialists with a faster, more personalized Web experience across Annals, ACP Journal Club, In the Clinic, and PubMed, and a new multimedia library. 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: Daisy Smith, MD, FACP



Highlights


.
USPSTF issues draft recommendations on violence and abuse screening, vitamin D and calcium supplementation

The U.S. Preventive Services Task Force (USPSTF) has issued two draft guidance statements, one on screening for intimate partner violence and abuse of elderly and vulnerable adults and another on vitamin D and calcium supplementation to prevent cancer and osteoporotic fractures in adults.

In updating its 2004 recommendation on screening for violence and abuse, the Task Force recommended that clinicians screen women of childbearing age (14 to 46 years old) for intimate partner violence, and provide or refer women to intervention services when appropriate. This is a grade B recommendation (high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial).

The Task Force also found there isn't enough evidence to assess the balance of benefits and harms of screening all elderly people or adults with physical or mental dysfunction for abuse or neglect. It found no evidence on appropriate screening intervals.

The Task Force examined the accuracy of 14 screening tools for identifying intimate partner violence through an examination of randomized, controlled trials and other systematic reviews. Screening instruments with the highest levels of sensitivity and specificity for identifying intimate partner violence are:

  • HITS (Hurt, Insult, Threaten, Scream) (English and Spanish versions),
  • OAS/OVAT (Ongoing Abuse Screen/Ongoing Violence Assessment Tool),
  • STaT (Slapped, Threatened, and Throw),
  • HARK (Humiliation, Afraid, Rape, Kick),
  • CTQ-SF (Modified Childhood Trauma Questionnaire–Short Form) and
  • WAST (Woman Abuse Screen Tool).

The draft recommendations will be open for public comment through July 10.

For vitamin D and calcium, the Task Force found that there is insufficient evidence:

  • to assess the balance of the benefits and harms of vitamin D supplementation, with or without calcium, for the primary prevention of cancer in adults,
  • to assess the balance of the benefits and harms of combined vitamin D and calcium supplementation for the primary prevention of fractures in premenopausal women or in men or
  • to assess the balance of the benefits and harms of daily supplementation with >400 IU of vitamin D3 and 1,000 mg of calcium for the primary prevention of fractures in noninstitutionalized postmenopausal women.

The Task Force recommends against daily supplementation with ≤400 IU of vitamin D3 and 1,000 mg of calcium carbonate for the primary prevention of fractures in noninstitutionalized postmenopausal women. This is a grade D recommendation (There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits).

These draft recommendations will also be open for public comment through July 10.


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Most hormonal contraceptives show little absolute risk of stroke or heart attack, study finds

A recent study found that the absolute risk of increased thrombotic stroke and myocardial infarction (MI) associated with the use of hormonal contraception was low, although the relative risks varied depending on whether higher doses were used.

The 15-year historical cohort study appeared in the June 14 New England Journal of Medicine and followed nonpregnant Danish women ages 15 to 49 with no history of cardiovascular disease or cancer. Data on use of hormonal contraception, clinical end points, and potential confounders were obtained from four national registries.

More than 1.6 million women totaled more than 14 million person-years of observation, during which 3,311 thrombotic strokes (21.4 per 100,000 person-years) and 1,725 MIs (10.1 per 100,000 person-years) occurred.

The case fatality rate during the primary event or subsequent hospital stay was 1% for thrombotic stroke (34 of 3,311 women) and 10.8% for MI (186 of 1,725).

As compared with nonuse, current use of oral contraceptives that included ethinyl estradiol at a dose of 30 to 40 μg was associated with the following relative risks for thrombotic stroke and MI, respectively:

  • norethindrone, 2.2 (95% CI, 1.5 to 3.2) and 2.3 (95% CI, 1.3 to 3.9);
  • levonorgestrel, 1.7 (95% CI, 1.4 to 2.0) and 2.0 (95% CI, 1.6 to 2.5);
  • norgestimate, 1.5 (95% CI, 1.2 to 1.9) and 1.3 (95% CI, 0.9 to 1.9);
  • desogestrel, 2.2 (95% CI, 1.8 to 2.7) and 2.1 (95% CI, 1.5 to 2.8);
  • gestodene, 1.8 (95% CI, 1.6 to 2.0) and 1.9 (95% CI, 1.6 to 2.3) and
  • drospirenone, 1.6 (95% CI, 1.2 to 2.2) and 1.7 (95% CI, 1.0 to 2.6).

With ethinyl estradiol at a dose of 20 μg, the respective relative risks were:

  • desogestrel, 1.5 (95% CI, 1.3 to 1.9) for thrombotic stroke and 1.6 for MI (95% CI, 1.1 to 2.1);
  • gestodene, 1.7 (95% CI, 1.4 to 2.1) and 1.2 (95% CI, 0.8 to 1.9); and
  • drospirenone, 0.9 (95% CI, 0.2 to 3.5) and 0.0.

For transdermal patches, the relative risks were 3.2 for stroke (95% CI, 0.8 to 12.6) and 0.0 for MI; for a vaginal ring, the relative risks were 2.5 for stroke (95% CI, 1.4 to 4.4) and 2.1 for MI (95% CI, 0.7 to 6.5).

For women who smoked compared with those who did not, the relative risks of thrombotic stroke and MI were 1.57 (95% CI, 1.31 to 1.87) and 3.62 (95% CI, 2.69 to 4.87), respectively.

The authors concluded, "We estimate that among 10,000 women who use desogestrel with ethinyl estradiol at a dose of 20 μg for 1 year, 2 will have arterial thrombosis and 6.8 women taking the same product will have venous thrombosis. Although venous thrombosis is three to four times as frequent as arterial thrombosis among young women, the latter is associated with higher mortality and more serious consequences for the survivors. Therefore, these figures should be taken into account when prescribing hormonal contraception."

An editorial commented that five decades of research show that there is a small risk of arterial thrombotic events in women using combined estrogen-progestin hormonal contraceptives. The already small risk could be further reduced or eliminated by not smoking and by stopping hormonal contraceptive use if blood pressure rises.

"With the addition of the Danish data, evidence is now even stronger that progestin-only formulations of hormonal contraception have vascular risks that are undetectable with modern epidemiologic methods," the editorial states. "Although hormonal contraception is not risk-free, the evidence is convincing that the low and very low doses of ethinyl estradiol (<50 μg) in the combined estrogen-progestin contraceptives studied by Lidegaard and colleagues—whatever the progestin and whether delivered orally or by means of the patch or the ring—are safe enough."



Test yourself


.
MKSAP Quiz: chronic cutaneous lupus erythematosus

A 38-year-old man is evaluated for an 18-month history of chronic cutaneous lupus erythematosus. He has lesions on his face and scalp. He has been using topical sunscreen, but he finds it difficult to remember to apply it before leaving for work. He is also being treated with a corticosteroid lotion, and hydroxychloroquine was recently begun. Despite 4 months of therapy, new lesions continue to develop, and the old lesions have not healed. He admits to smoking 2 packs of cigarettes per day and drinking 6 to 10 beers per day. He has hypertension and hyperlipidemia. In addition to the corticosteroid lotion and hydroxychloroquine, his current medications are amlodipine, hydrochlorothiazide, simvastatin, and a multivitamin.

mksap.jpg

On physical examination, there are multiple erythematous lesions on the face and several on the scalp consistent with the diagnosis of discoid lupus erythematosus.

Which of the following is the next step in managing this patient's skin disease?

A) Initiate methotrexate
B) Initiate thalidomide
C) Recommend smoking cessation
D) Stop amlodipine
E) Stop hydrochlorothiazide

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


.

Alzheimer's disease


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Delirium may be associated with adverse outcomes in hospitalized patients with Alzheimer's disease

Patients with Alzheimer's disease who develop delirium during hospitalization are more likely to have adverse outcomes, according to a new study.

annals.jpg

Researchers performed a prospective cohort study of patients with Alzheimer's disease who were enrolled in the Massachusetts Alzheimer's Disease Research Center patient registry from 1991 to 2006. The goal of the study was to determine the association between hospitalization and delirium and risks for institutionalization, cognitive decline and death. The authors defined cognitive decline as a decrease of at least four points on the Blessed Information-Memory-Concentration test score. Adjusted relative risks (RRs) were calculated by using multivariate analysis. The study results appear in the June 19 Annals of Internal Medicine.

A total of 771 patients at least 65 years of age (mean age, 77.2 years) with a diagnosis of Alzheimer's disease were included in the study. Fifty-seven percent were women, and 95% were white. Over the study period, 367 patients (48%) were hospitalized and 194 (25%) developed delirium. Risks for death and institutionalization were higher in hospitalized patients than in nonhospitalized patients (adjusted RRs, 4.7 and 6.9, respectively) and were increased further in hospitalized patients who developed delirium (adjusted RRs, 5.4 and 9.3, respectively). Hospitalized patients who developed delirium also had an adjusted RR of 1.6 for cognitive decline. Overall, 21% of cognitive decline, 15% of institutionalizations, and 6% of deaths in hospitalized patients were determined to be associated with delirium.

The authors acknowledged that their study was nonrandomized, that some data were missing, and that ethnic minorities were not well represented, among other limitations. However, they concluded that delirium during hospitalization will lead to at least one adverse outcome in approximately one in eight patients with Alzheimer's disease. "Further investigation is greatly needed to determine whether prevention of hospitalization and delirium can decrease the attributable risk for death, institutionalization, and cognitive impairment in the vulnerable and increasing population of persons with [Alzheimer's disease]," the authors wrote.



Statins


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Lower energy, more exertional fatigue with statins

Statin treatment was associated with less energy and more exertional fatigue, according to a recent analysis.

Researchers used data from the University of California, San Diego Statin Study, which included 1,016 patients with low-density lipoprotein levels of 115 to 190 mg/dL and no cardiovascular disease or diabetes. The patients were randomized to daily 20-mg simvastatin, 40-mg pravastatin or placebo. The study participants rated their own change in energy and fatigue with exertion after six months of therapy. The results were published as an online research letter by the Archives of Internal Medicine on June 11.

The study found a significantly larger drop in energy among statin users compared to placebo recipients. The authors used patients' self-ratings to create an energy/exertional fatigue score, and they found a mean drop of −0.21 (P=0.005) in statin patients. Women had an even greater decrease in their mean scores (−0.39, P=0.01). The authors explained that such a drop could indicate 4 in 10 statin-taking women having worsening energy or fatigue, 2 in 10 finding either marker to be worse or much worse, or 1 in 10 having much worse energy and fatigue. Simvastatin appeared to be associated with greater mean drops in the energy/fatigue score than pravastatin.

The findings support previous case reports of statin side effects, the authors concluded. These effects could be important in statin-prescribing decisions, especially for healthier patients who have less expected benefit from the drugs. Lower levels of activity and exertional tolerance could lead to other adverse effects, the authors noted. They called for long-term trials to gather additional evidence and urged physicians to be alert to statin-taking patients' reports of worsened energy and fatigue.



Veterans' health care


.
Review examines optimal primary care for combat veterans

A new review by clinicians from the Veterans Administration (VA) outlines conditions common to returning combat veterans who served in Iraq and Afghanistan and provides management guidelines for optimal primary care.

The authors estimate that 1.44 million veterans of the Iraq and Afghanistan conflicts are currently eligible for VA services and that 772,000 have been cared for through the VA. Recent combat veterans are most prone to musculoskeletal problems, mental health conditions and "non-specific signs and symptoms," the authors wrote. Combat and deployment come with risks including combat injury, occupational exposures, and chronic health problems, along with mental health and psychosocial risks.

Primary care clinicians caring for returning veterans need to be alert to managing musculoskeletal pain, sleep disturbances, post-traumatic stress disorder, and traumatic brain injury, the authors wrote. The experts compiled a list of "pearls" for clinical management of post-combat veterans, including the following:

  • Address barriers to care.
  • Establish a strong connection (acknowledge military service, take military history, and place this in a visible, easy to access part of the chart).
  • Conduct a specialized review of systems, including combat exposures, blast exposures/concussive injuries, illness/injuries during deployments, tinnitus, dental concerns, chronic pain, sleep disturbance, tobacco, alcohol or substance abuse, depression screen, post-traumatic stress disorder screen and suicide assessment.
  • Involve all members of the health care team; construct an easy-to-follow, well-sequenced and synthesized plan.
  • De-stigmatize mental health care.
  • Follow patients closely.
  • Focus on function and reintegration.

The review, which also includes lists of online resources for clinicians and patients, was published by the Journal of General Internal Medicine and is available free of charge online.



Testing


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Guidelines on peripheral arterial ultrasound and physiologic testing

New guidelines describe the appropriate uses of arterial ultrasound and physiological testing for patients with known or suspected peripheral vascular disorders.

The criteria, which were released by a collaboration of several medical societies and published by the Journal of the American College of Cardiology on June 11, described 255 clinical scenarios. Of these, 117 were judged to be appropriate uses of noninvasive vascular testing, 84 were rated as uncertain, and 54 were found to be inappropriate. The scenarios cover non-coronary arterial disorders including atherosclerotic occlusive disease (i.e., carotid artery stenosis, lower- and upper-extremity peripheral arterial disease, renal and mesenteric artery occlusive disease), abdominal aortic aneurysms, fibromuscular dysplasia, vasospasm, arterial dissection and arterial trauma.

In general, testing was found to be appropriate when indicated by clinical signs and symptoms, as well as to establish a baseline after revascularization. Follow-up studies for patients with normal findings were generally rated as inappropriate.

The criteria are intended to help clinicians maximize use of the noninvasive vascular laboratory, identify evidence gaps in the field, and serve as a reference for policymakers, the authors said, acknowledging that many potential indications for testing are not included. They noted that this document included more indications for surveillance than appropriate use criteria for other cardiovascular imaging modalities, because optimal clinical management of peripheral vascular disorders requires periodic imaging surveillance.

The criteria were titled "Part I," and the authors wrote that appropriateness criteria for venous ultrasound and physiological testing are currently under development. The criteria were jointly released by the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American College of Radiology, American Institute of Ultrasound in Medicine, American Society of Echocardiography, American Society of Nephrology, Intersocietal Commission for the Accreditation of Vascular Laboratories, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Interventional Radiology, Society for Vascular Medicine, Society for Vascular Surgery, American Academy of Neurology, American Podiatric Medical Association, Society for Clinical Vascular Surgery, Society for Cardiovascular Magnetic Resonance and Society for Vascular Ultrasound.


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American College of Radiology identifies five imaging studies to question

In support of making wise choices about medical care, ACP and a number of other organizations joined the ABIM Foundation's Choosing Wisely Campaign and provided a list of five recommendations that physicians and patients should question.

As part of this effort, the American College of Radiology has identified the following list of five imaging studies that physicians and patients should question:

  • Don't do imaging for uncomplicated headache.
  • Don't image for suspected pulmonary embolism (PE) without moderate or high pre-test probability.
  • Avoid admission or preoperative chest X-rays for ambulatory patients with unremarkable history and physical exam.
  • Don't do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.
  • Don't recommend follow-up imaging for clinically inconsequential adnexal cysts.


CMS update


.
Time running out on version 5010 deadline

As of July 1, practices must be transmitting claims using the version 5010 standards for electronic transactions.

If your system is not using version 5010, your claims may not be paid after July 1. The new standards are being implemented in preparation for the transition to ICD-10 codes. Additional information about version 5010 is available on the College website.


.
ACO application deadline extended

CMS has announced that it will be re-opening the application period for the Advanced Payment Accountable Care Organization (ACO) model.

Under this model, applicants are provided with start-up funds to implement an ACO program. The program is focused on encouraging collaboration among small and rural physician practices to establish ACOs. A non-binding notice of intent is due by June 29. To participate in the Advanced Payment model, applicants must apply to both the Medicare Shared Savings Program and the Advanced Payment model.

The notice of intent form is available on the CMS website. Additional information about ACOs is also available on the College's website.



From ACP Hospitalist


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Who's tops at your hospital?

ACP Hospitalist is seeking candidates for its fifth annual Top Hospitalists issue in November, which will feature the best and brightest in hospital medicine.

Let us know what your colleagues have accomplished in 2012. Do they always go out of their way to educate patients or help new physicians? Did they take charge of a key quality or safety initiative? Maybe they are wizards at solving tricky diagnoses, or selfless about volunteer outreach. Whatever the contribution, if it helped further hospital medicine, we'd like to hear about it.

Recommending a physician is easy: Just visit our online form and tell us which hospitalists you think we should feature and why. We look forward to receiving your suggestions!

Note: ACP Hospitalist's Top Hospitalist issue is not part of the ACP National Awards Program. Self-nomination is not permitted. Candidates need not be ACP members. The selection process is not scientific. Editorial board members are solely responsible for determining those profiled in the Top Hospitalists issue.



From the College


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Annals of Internal Medicine launches new website

Annals of Internal Medicine has launched its website on a new digital platform to provide internal medicine specialists and subspecialists with a faster, more personalized Web experience across Annals, ACP Journal Club, In the Clinic, and PubMed, and a new multimedia library.

"Visitors can access information quickly and easily—whether it is the latest Annals articles or related commentary, CME, multimedia content, patient education materials, or teaching slides," said Christine Laine, MD, MPH, FACP, Annals' editor-in-chief and senior vice president at ACP. "The new design, information architecture, and site navigation are intended to make the user experience more efficient, effective, and engaging for busy internists."

The new website has a cleaner, more attractive design with new features, including:

  • Online first: streaming media of the latest clinical news before it is published in the journal's print edition.
  • Quick links: article-specific CME, slides, patient information, multimedia, and commenting and sharing features.
  • Smarter article collections: immediate access to collections organized by specialty, disease, and special topics.
  • Better search tools: More meaningful results, with screening and refining options.
  • Mobility: Automatic mobile-friendly display when accessing annals.org from any smartphone.

Annals of Internal Medicine is one of the top five most widely cited peer-reviewed medical journals in the world, with a current impact factor of 16.7. The journal has been published for 85 years. It accepts only about 7% of the original research studies submitted for publication. Follow Annals on Twitter and Facebook.



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-20120619-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) Recommend smoking cessation. This item is available to MKSAP 15 subscribers as item 8 in the Dermatology section. MKSAP 16 will release Part A on July 31. More information is available online.

Smoking is known to adversely affect the efficacy of therapy with antimalarial agents in patients with cutaneous lesions of lupus erythematosus. The mechanism of this phenomenon is not understood, but the products of cigarette smoking may interfere with antimalarial agents, lupus may be worsened by these chemicals, or both. Smoking cessation is therefore the most appropriate choice prior to initiating more aggressive and potentially toxic therapy.

Both methotrexate and thalidomide are treatments for cutaneous lupus erythematosus that is resistant to antimalarial agents, but smoking-cessation efforts should occur prior to the initiation of either of these more toxic alternatives.

Both amlodipine and hydrochlorothiazide are known to cause or exacerbate subacute cutaneous lupus erythematosus, but they have not been implicated as a cause of chronic cutaneous lupus erythematosus.

Key Point

  • Smoking interferes with therapy of cutaneous lupus erythematosus.

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Test yourself

A 76-year-old woman is evaluated for a 3-month history of left knee pain of moderate intensity that worsens with ambulation. She reports minimal pain at rest and no nocturnal pain. There are no clicking or locking symptoms. She has tried naproxen and ibuprofen but developed dyspepsia; acetaminophen provides mild to moderate relief. The patient has hypertension, hypercholesterolemia, and chronic stable angina. Medications are lisinopril, metoprolol, simvastatin, low-dose aspirin, and nitroglycerin as needed. Following a physical exam, lab results and radiograph, what is the next best step in management?

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