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

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ACP InternistWeekly



In the News for the Week of June 26, 2012




Highlights

Heart attacks may lead to PTSD, analysis finds

Posttraumatic stress disorder (PTSD) is relatively common among survivors of acute coronary syndrome and is associated with worse outcomes, according to a new meta-analysis. More...

Task Force recommends obesity screening in adults

The U.S. Preventive Services Task Force has issued a recommendation on screening for obesity in adults. More...


Test yourself

MKSAP Quiz: Routine follow-up of type 2 diabetes

This week's quiz asks readers to evaluate a 45-year-old woman with type 2 diabetes who is seen for routine follow-up. More...


Men's health

Guideline issued on managing osteoporosis in men

The Endocrine Society last week issued a clinical practice guideline on managing osteoporosis in men. More...


Perioperative care

Alcohol use disorder increases after bariatric surgery

Patients were more likely to report symptoms of alcohol use disorder two years after bariatric surgery than they were presurgery, a new study found. More...


Nephrology

Treatment for kidney failure may be less likely in older adults, study indicates

Older adults may not receive treatment for kidney failure as often as younger patients, according to a new study. More...


CDC update

Pneumonia vaccine gets yes vote for immunocompromised

Uses of the pneumococcal 13-valent conjugate vaccine (Prevnar 13) should be expanded to adults with immunocompromising conditions, according to a recent vote by the CDC's Advisory Committee on Immunization Practices (ACIP). More...


From the College

State medical boards preparing new Maintenance of Licensure framework

Patrick Alguire, MD, FACP, senior vice president of medical education at ACP, recently authored a paper "Maintenance of Licensure: Supporting a Physician's Commitment to Lifelong Learning," which details the upcoming changes to the Maintenance of Licensure (MOL) procedures for physicians. More...

ACP, New York chapter to collaborate to improve patient safety

ACP announced collaboration this month with the New York ACP chapter to extend New York's medical Near Miss Registry into a national patient safety reporting and professional educational program. More...

Call for nominations for the Robert Wood Johnson Foundation Young Leader Awards

The Robert Wood Johnson Foundation has established the Young Leader Awards: Recognizing Leadership for a Healthier America. Up to 10 awards will be given to young leaders, 40 years of age and under, who offer great promise for leading the way to improved health and health care for all Americans. 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...


Physician editor: Philip Masters, MD, FACP



Highlights


.
Heart attacks may lead to PTSD, analysis finds

Posttraumatic stress disorder (PTSD) is relatively common among survivors of acute coronary syndrome (ACS) and is associated with worse outcomes, according to a new meta-analysis.

The analysis covered 24 observational cohort studies including more than 2,000 patients who had ACS and were assessed for PTSD at least one month after the event. Overall, 12% of the patients had clinically significant symptoms of PTSD (95% CI, 9% to 16%), although rates varied widely among the studies. The variation could be explained by differing methods of screening, authors said; studies that used a screening questionnaire found higher rates of PTSD than those that used diagnostic interviews.

Three of the studies, totaling about 600 patients, assessed the relationship between PTSD and negative outcomes (mortality and/or ACS recurrence). Combined, the studies indicated a doubling of risk for these negative outcomes associated with clinically significant symptoms of PTSD (risk ratio, 2.00; 95% CI, 1.69 to 2.37). The overall meta-analysis also found that younger age was associated with higher PTSD rates, while a more recent study publication date was associated with lower risk (perhaps due to advances in treatment, the authors said). The results were published in the June PLoS One.

Extrapolating from their findings, study authors calculated that 168,000 ACS patients in the U.S. may develop PTSD each year. Their risk for mortality and recurrence is similar to the increased risk faced by depressed patients, they noted. Although the mechanism for this relationship is not known, increased inflammation associated with PTSD may have a negative effect on the heart, the authors speculated.

They called for additional research into treatments for ACS-induced PTSD, noting that only one treatment study (a trial of cognitive behavioral therapy) was identified in their search. A unified risk stratification strategy, using previously identified risk factors, is also needed, they concluded.


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Task Force recommends obesity screening in adults

The U.S. Preventive Services Task Force has issued a recommendation on screening for obesity in adults.

annals.jpg

To update its 2003 recommendation on screening for obesity and overweight in adults, the Task Force reviewed current evidence and identified new evidence that addressed previously noted gaps. Only nonsurgical interventions were considered. Unlike the 2003 recommendation, this update focuses on identifying obese adults (defined as having a body mass index ≥30 kg/m2) for intervention but not patients considered overweight (defined as having a body mass index of 25 to 29.9 kg/m2) because the separate effects of study interventions on overweight versus obesity could not be determined.

The Task Force recommended that clinicians screen for obesity in adults and that they should offer or refer those with a body mass index at or above 30 kg/m2 to receive intensive, multicomponent behavioral interventions. 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 noted that it found inadequate direct evidence about the effectiveness of behavioral interventions on long-term health outcomes such as death, cardiovascular disease and hospitalization.

The Task Force also published a separate recommendation on behavioral counseling to promote a healthy diet and physical activity to prevent cardiovascular disease in adults, noting that existing evidence shows a small benefit of such counseling in the primary care setting. "Clinicians may choose to selectively counsel patients rather than incorporate counseling in the care of all adults in the general population," the Task Force concluded. This is a grade C recommendation (for most individuals without signs or symptoms there is likely to be only a small benefit from this service).

Both recommendation statements were published online June 26 by Annals of Internal Medicine.



Test yourself


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MKSAP Quiz: Routine follow-up of type 2 diabetes

A 45-year-old woman is seen for routine follow-up. She has type 2 diabetes mellitus, diagnosed 5 years ago; initial treatment included metformin and glimepiride. A daily injection of insulin glargine was added to her regimen 1 year ago.

mksap.jpg

At present, her hemoglobin A1c value is 8.1%. Mean blood glucose values derived from the past 4 days of the patient's blood glucose log, which includes preprandial and postprandial values, are shown.

  • Breakfast: preprandial, 105 mg/dL (5.8 mmol/L); postprandial, 186 mg/dL (10.3 mmol/L)
  • Lunch: preprandial, 169 mg/dL (9.4 mmol/L); postprandial, 258 mg/dL (14.3 mmol/L)
  • Supper: preprandial, 146 mg/dL (8.1 mmol/L); postprandial, not measured.

Her mean bedtime blood glucose level is 278 mg/dL (15.4 mmol/L).

Which of the following changes should be made to this patient's medication regimen?

A) Add exenatide
B) Increase the insulin glargine dosage
C) Start insulin pump therapy
D) Stop glimepiride and add mealtime insulin aspart

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


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Men's health


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Guideline issued on managing osteoporosis in men

The Endocrine Society last week issued a clinical practice guideline on managing osteoporosis in men.

A task force of six experts and a methodologist analyzed systematic evidence reviews to reach consensus on its recommendations, which were reviewed in draft form by the Endocrine Society's clinical guidelines subcommittee and clinical affairs core committee, as well as representatives from related professional societies and Endocrine Society members. The Endocrine Society Council approved the final document.

The guideline's recommendations include the following:

  • Higher-risk men (those 70 years of age or older and those 50 to 69 years of age with such risk factors as low body weight, previous fractures during adulthood, and smoking) should be tested with central dual-energy X-ray absorptiometry (DEXA).
  • Contributing causes of osteoporosis should be detected via laboratory testing.
  • Clinicians should encourage adequate calcium and vitamin D intake, as well as weight-bearing exercise.
  • Patients should avoid smoking and excessive alcohol use.
  • Men 50 years of age and older who have had spine or hip fractures, men with T-scores of −2.5 or lower, and men at high fracture risk because of low bone mineral density and/or clinical risk factors should receive pharmacologic treatment.
  • Serial DEXA should be used to monitor treatment.

The detailed full text of the guideline, which was published in the June Journal of Clinical Endocrinology and Metabolism, is available free of charge online.



Perioperative care


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Alcohol use disorder increases after bariatric surgery

Patients were more likely to report symptoms of alcohol use disorder (AUD) two years after bariatric surgery than they were presurgery, a new study found.

The prospective cohort study included about 2,000 patients who underwent bariatric surgery at 10 U.S. hospitals. The prevalence of AUD was determined by the Alcohol Use Disorders Identification Test, administered preoperatively and one year and/or two years after surgery.

The percentage of patients with AUD symptoms one year after surgery was about the same as before surgery (7.3% vs. 7.6%) and the U.S. average (8.5%, or 6.5% if adjusted to match the mostly female study population). However, two years after surgery, the percentage with AUD was significantly higher: 9.6%. This increase was mostly seen among patients who received Roux-en-Y gastric bypass; they had double the risk of alcohol use disorder compared to patients who had laparoscopic adjustable gastric banding.

Several other risk factors for AUD after surgery were also identified: male sex; younger age; smoking, regular alcohol consumption or recreational drug use before surgery; and lower sense of belonging. Preoperative AUD was also a predictor of postoperative AUD, but more than half of patients who had the disorder after surgery did not report it preoperatively. The results were published in the June 20 Journal of the American Medical Association.

The researchers acknowledged that their cutoff for AUD was lower than some commonly used criteria: Patients were considered to have the disorder if they reported at least one symptom of alcohol-related harm or alcohol dependence. The authors also expressed concern about the levels of drinking reported by even patients who didn't have AUD—1 in 6 patients reported alcohol consumption at a potentially hazardous level by year two.

The authors speculated that increased alcohol sensitivity following Roux-en-Y surgery (as well as resumption of heavier drinking) could be responsible for the increase in AUD. Clinicians should educate potential bariatric surgery patients about the risk of AUD and conduct alcohol screening, and if necessary should refer for treatment, they said. The authors also called for longer-term research on AUD in bariatric surgery patients and investigation of the disorder's relationship to postoperative weight control.



Nephrology


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Treatment for kidney failure may be less likely in older adults, study indicates

Older adults may not receive treatment for kidney failure as often as younger patients, according to a new study.

Researchers in Alberta, Canada, performed a community-based cohort study to determine whether age was associated with treatment for kidney failure in patients who had an outpatient estimated glomerular filtration rate (GFR) measured between May 1, 2002, and March 31, 2008. At baseline, included patients had a GFR of at least 15 mL/min/1.73 m2 and did not need renal replacement therapy. Patient age groups were 18 to 44 years, 45 to 54 years, 55 to 64 years, 65 to 74 years, 75 to 84 years, and 85 years or older; eGFR groups were 90 mL/min/1.73 m2 or higher, 60 to 89 mL/min/1.73 m2, 45 to 59 mL/min/1.73 m2, 30 to 44 mL/min/1.73 m2, and 15 to 29 mL/min/1.73 m2.

The study's main outcome measures were adjusted rates of treatment for kidney failure, defined as dialysis or kidney transplant; untreated kidney failure, defined as progression to an eGFR less than 15 mL/min/1.73 m2 with no renal replacement therapy; and death. Results were published in the June 20 Journal of the American Medical Association.

Overall, 1,816,824 adults with a mean age of 48.2 years were included in the study. Less than half (44.3%) of the patients were men. Over a median of 4.4 years of follow-up, 97,451 (5.36%) patients died, 3,295 (0.18%) had treated kidney failure, and 3,116 (0.17%) had untreated kidney failure. Rates of kidney failure treatment were higher in younger patients than in older patients across all strata of eGFR. In patients who had had an eGFR of 15 to 29 mL/min/1.73 m2 at baseline, treatment rates for kidney failure were more than 10-fold higher in the youngest compared with the oldest patients (P<0.001). In addition, older patients consistently had higher rates of untreated kidney failure; among those with an eGFR of 15 to 29 mL/min/1.73 m2 at baseline, rates were more than fivefold higher in the oldest compared with the youngest patients (P<0.001). Less variation by age was observed in overall kidney failure rates (treated and untreated disease combined).

The authors acknowledged that they did not have information on why patients decided not to begin dialysis or on long-term prognosis, among other limitations. Regardless, they concluded that a large proportion of elderly patients may have advanced kidney disease because of high rates of untreated kidney failure. They called for future studies to examine dialysis initiation and shared decision making in this population.

The authors of an accompanying editorial noted that the study had "considerable strengths" but also pointed out that it didn't provide information on any alternative treatments and that the results may not be generalizable to patients in the United States. They agreed, however, that the results do indicate a potentially large burden of untreated kidney failure in older patients.

"It is of paramount importance to refine the current understanding of what constitutes appropriate treatment for kidney failure, which factors influence the decision-making process, and which methods are optimal for aligning treatment plans with patient goals and prognosis," the editorialists wrote. "Finding the right balance between overtreatment and undertreatment is challenging but necessary."



CDC update


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Pneumonia vaccine gets yes vote for immunocompromised

Uses of the pneumococcal 13-valent conjugate vaccine (Prevnar 13) should be expanded to adults with immunocompromising conditions, according to a recent vote by the CDC's Advisory Committee on Immunization Practices (ACIP).

The committee voted 14-0 in favor of expanding use to patients 19 and older with compromised immune systems due to conditions such as HIV infection, cancer and advanced kidney disease, Reuters reported last week.

In December 2011, the FDA granted expanded approval of the vaccine to all adults over 50. The ACIP is waiting for results from ongoing trials before developing a recommendation on routine use of the vaccine in adults over 50, according to a press release from Pfizer, the vaccine manufacturer. The recommendations of the ACIP become CDC policy after publication in the Morbidity and Mortality Weekly Report.



From the College


.
State medical boards preparing new Maintenance of Licensure framework

Patrick Alguire, MD, FACP, senior vice president of medical education at ACP, recently authored a paper "Maintenance of Licensure: Supporting a Physician's Commitment to Lifelong Learning," which details the upcoming changes to the Maintenance of Licensure (MOL) procedures for physicians.

In 2010, the Federation of State Medical Boards' House of Delegates voted to adopt a framework for MOL that would address concerns that current requirements for physicians are not sufficient when the knowledge and skills needed to practice medicine continue to grow exponentially. The new framework for MOL addresses those concerns through three components: reflective self-assessment; assessment of knowledge and skills; and performance in practice. Since implementation of MOL remains in the purview of state medical boards, some states may begin to adopt the new framework as early as 2014, and implementation may begin slowly and incorporate one component at time. The paper provides information on the new requirements and the probable timetable for implementation.


.
ACP, New York chapter to collaborate to improve patient safety

ACP announced collaboration this month with the New York ACP chapter to extend New York's medical Near Miss Registry into a national patient safety reporting and professional educational program. The announcement was made possible with ACP's Center for Quality's listing as an official Patient Safety Organization by the Agency for Healthcare Research and Quality on behalf of the U.S. Department of Health and Human Services.

"Near misses" are close calls or errors that are detected and corrected before resulting in patient harm. Over the last five years, New York's ACP chapter, under the leadership of Ethan Fried, MD, MACP, of St. Luke's Roosevelt Hospital, and a statewide advisory committee with the support of the New York State Department of Health's Patient Safety Center, pioneered the first statewide near-miss registry. In the initial phase, the near-miss investigators trained more than 3,000 internal medicine residents throughout the state.

In later phases of the registry and education program, it was extended to all physicians and allied health professionals. An educational program for health care professionals outlining patient safety, system barriers and steps to identify near-miss events was presented at more than 50 hospitals and professional societies across New York State.

"Our goal is to change the culture of health care into one that learns from mistakes and shares best practices in patient safety," Dr. Fried said.

Building on this effort, ACP has joined forces with New York chapter to expand the Near Miss Registry nationwide, including to outpatient health care practices. It will link registry reports of near misses to educational resources that will help clinical teams strengthen patient safety through data-driven system improvements shown to be effective.

Read more about the origins of the New York program online.


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Call for nominations for the Robert Wood Johnson Foundation Young Leader Awards

The Robert Wood Johnson Foundation (RWJF) has established the Young Leader Awards: Recognizing Leadership for a Healthier America. Up to 10 awards will be given to young leaders, 40 years of age and under, who offer great promise for leading the way to improved health and health care for all Americans. Each winner will receive an individual award of $40,000.

The Young Leaders Awards will recognize leaders who have demonstrated the characteristics needed to improve health and health care through leadership and innovation.

RWJF will accept third-party nominations only through July 16. Winners will be announced at a RWJF Oct. 25/26 conference in Princeton, N.J. For more information about the nomination process, requirements and a list of young leader characteristics, please visit the program's website.



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-20120626-cartoon.jpg

"To improve emergency room throughput we've replaced the front door with a CT scanner."

"I used to say it sounds like a garbage disposal but that hasn't seemed to help folks."

"Ticklish?"

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 D) Stop glimepiride and add mealtime insulin aspart. This item is available to MKSAP 15 subscribers as item 11 in the Endocrinology and Metabolism section. MKSAP 16 will release Part A on July 31. More information is available online.

This patient's medication regimen should be altered by stopping the glimepiride and initiating mealtime insulin aspart. Patients with type 2 diabetes mellitus experience progressive beta cell dysfunction, which eventually results in the requirement of insulin in most patients. Insulin therapy is typically begun with a single injection of a basal insulin, such as insulin glargine or insulin detemir, or two injections of neutral protamine Hagedorn (NPH) insulin. Over time, insulin secretion becomes progressively deficient, and postprandial glucose excursions can no longer be addressed by increasing the basal insulin dose. Such a scenario requires the addition of a rapid-acting insulin analogue before meals. Insulin lispro, insulin aspart, and insulin glulisine are typically used in this setting in dosages sufficient to prevent the glucose level from increasing more than 40 to 60 mg/dL (2.2 to 3.3 mmol/L) with each meal. Once this more intensive insulin regimen is initiated, ongoing use of a sulfonylurea, such as glimepiride, is no longer required.

Exenatide does reduce postprandial glucose levels and may be effective in doing so for this patient. However, exenatide was not initially approved for use with insulin. In 2011, a clinical trial on the use of exenatide with insulin glargine demonstrated that it was safe and effective, and the contraindication of basal insulin co-administration was subsequently removed from the product label. Regardless, the addition of prandial insulin to insulin glargine is still the preferred approach in this patient because of expense, lack of long-term safety data, and need for confirmatory clinical trials demonstrating efficacy of combination therapy with exenatide and insulin.

Increasing this patient's insulin glargine dosage will not address her prandial insulin requirements because glargine is a basal insulin and does not control postprandial glycemic peaks.

Continuous subcutaneous insulin infusion using an insulin pump is becoming a viable treatment option for patients with type 2 diabetes. Patients who may benefit from an insulin pump include those who have not been able to achieve glycemic goals on an intensified insulin regimen of multiple daily injections; have unacceptable rates of hypoglycemia when following insulin injection regimens that combine intermediate- or long-acting insulin (NPH, glargine) with prandial insulin; have a marked dawn phenomenon (increase in blood glucose levels during the early morning hours, i.e., 4:00 a.m. to 8:00 a.m.); or have erratic lifestyles (travel, shift work). Insulin pump therapy is premature at this juncture because this patient has not had a trial of an intensified insulin regimen of multiple daily injections.

Key Point

  • The addition of rapid-acting insulin analogues at mealtimes decreases postprandial glycemic excursions.

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Test yourself

A 66-year-old man is evaluated for vague abdominal pain of several months' duration and a 10-kg (22-lb) weight loss. He drinks alcohol socially but does not smoke. The patient is otherwise well, has good performance status, and takes no medications. Following a physical exam, lab studies, and a CT scan, what is the most appropriate initial management of this patient?

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