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

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ACP InternistWeekly



In the News for the Week of June 5, 2012




Highlights

Task force recommends exercise, vitamin D to prevent falls in elderly

The U.S. Preventive Services Task Force recommends exercise or physical therapy and vitamin D supplementation to prevent falls in at-risk community-dwelling adults aged 65 years or older. More...

IDSA diabetic foot infection guideline covers diagnosis and treatment

A new clinical practice guideline from the Infectious Diseases Society of America (IDSA) provides detailed instruction on diagnosis and treatment of diabetic foot infections. More...


Test yourself

MKSAP Quiz: 2-year history of enlargement and discomfort of the metacarpophalangeal joints

This week's quiz asks readers to evaluate a 62-year-old man for a two-year history of enlargement and discomfort of the metacarpophalangeal joints of both hands. More...


Women's health

Task force issues review, draft recommendations against hormone therapy for primary prevention

The U.S. Preventive Services Task Force has reviewed the latest evidence on using menopausal hormone therapy for primary prevention of chronic disease and has issued draft recommendations. More...


Bell's palsy

Prednisolone may reduce mild, moderate sequelae in Bell's palsy

Treatment with prednisolone may reduce mild and moderate sequelae of Bell's palsy, according to a new study. More...


Venous thromboembolism

Aspirin appears to reduce recurrence of VTE after stopping anticoagulants

Aspirin reduced the risk of venous thromboembolism (VTE) recurrence with no apparent increase in major bleeding in patients who had an initial unprovoked VTE and had discontinued anticoagulant treatment, a study found. More...


CMS update

Medicare to send Comparative Billing Reports to primary care clinicians to facilitate accurate billing

This June, CMS will be sending a Comparative Billing Report to a select group of 5,000 primary care clinicians, focusing on evaluation and management codes for office visits. More...

Medicare e-prescribing deadlines approaching on June 30

Two deadlines loom for the Medicare e-Prescribing Incentive Program. More...

Version 5010 compliance deadline is approaching

The enforcement discretion period for all HIPAA-covered entities to complete their upgrade to the version 5010 electronic standards ends on June 30. More...


From ACP Internist

The next issue is online and coming to your mailbox

June's edition of ACP Internist wraps up coverage from Internal Medicine 2012. More...


From the College

ACP joins Million Hearts Campaign

ACP has joined the Million Hearts Campaign, an initiative that aims to prevent a million heart attacks and strokes over the next five years. More...

Waste not, want not

Fred Ralston Jr., MD, MACP, a past president of ACP and a practicing internist in Fayetteville, Tenn., writes at KevinMD.com about current efforts to practice high-value, cost-conscious care. More...

Governance Committee seeks Regent and Treasurer candidates for 2013

ACP's Governance Committee, which oversees the process for nominating and electing Masters and Fellows of the College to the Board of Regents, is beginning the process of seeking Regents to join the Board in May 2013. The position of Treasurer will also open in 2013. More...


Cartoon caption contest

And the winner is …

ACP InternistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption. More...


Physician editor: Daisy Smith, MD, FACP



Highlights


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Task force recommends exercise, vitamin D to prevent falls in elderly

The U.S. Preventive Services Task Force (USPSTF) recommends exercise or physical therapy and vitamin D supplementation to prevent falls in at-risk community-dwelling adults aged 65 years or older.

annals.jpg

Exercise and vitamin D are Grade B recommendations, meaning there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. The recommendations and patient summary appeared online May 28 at Annals of Internal Medicine.

The USPSTF reviewed 18 studies of exercise or physical therapy in community-dwelling older adults and found these interventions to be associated with a statistically significant reduction in risk for falling (pooled relative risk [RR], 0.87; 95% CI, 0.81 to 0.94). The number needed to treat with exercise or physical therapy (for a median of approximately 12 weeks) to prevent one person from falling was 16. The benefit was greater in high-risk populations (pooled RR, 0.84; 95% CI, 0.78 to 0.91) than in low-risk populations.

Exercise or physical therapy trials included gait, balance or functional training (including a study on tai chi, strength or resistance exercise and general exercise. Treatment intensity (estimated in hours of contact) ranged from 2 to 80 hours.

The USPSTF reviewed nine trials of vitamin D supplementation and found an approximately 17% reduction in risk for falling during six to 36 months of follow-up and a number needed to treat of 10. Several of the studies targeted older adults who were vitamin D-deficient, and the effect of vitamin D supplementation was greater in these populations.

The trials studied a wide range of doses and durations for vitamin D supplementation. The median dose was 800 IU daily, and the median duration was 12 months. Data suggest that benefit from vitamin D supplementation occurs by 12 months; the efficacy of shorter treatment is unknown, the task force said.

The USPSTF does not recommend automatically performing an in-depth multifactorial risk assessment in conjunction with comprehensive management of identified risks to prevent falls because the likelihood of benefit is small. This is a Grade C recommendation, meaning it should be based on individual circumstances. Assessment would be of benefit to only a small group of patients without signs or symptoms, the task force concluded. Patients and clinicians should consider the balance of benefits and harms based on prior falls, comorbid medical conditions and patient values.


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IDSA diabetic foot infection guideline covers diagnosis and treatment

A new clinical practice guideline from the Infectious Diseases Society of America (IDSA) provides detailed instruction on diagnosis and treatment of diabetic foot infections.

The guideline notes that not all foot wounds in diabetic patients are infected. Infections should be diagnosed by the presence of at least two classic symptoms or signs of inflammation or purulent secretions, the IDSA said. Infections can then be classified into mild, moderate or severe. These classifications, along with vascular assessment, will help determine the need for hospitalization, surgery or amputation. Imaging is helpful in most cases, the guideline said, beginning with plain radiographs and progressing to magnetic resonance imaging if more information is needed.

Hospital admission is recommended for all patients with a severe infection, selected patients with a moderate infection with complicating features, patients unable to comply with outpatient treatment regimens, or patients who fail to improve on outpatient therapy. Before discharge, patients should be clinically stable; have any urgently needed surgery; achieve glycemic control; be able to manage outpatient self-care; and have a well-defined plan, an off-loading scheme, specific wound care instructions and planned follow-up.

For either in- or outpatient treatment, the guideline also provides instructions on culturing diabetic foot infections and prescribing antibiotics based on the results of cultures. Wounds with no evidence of infection do not require antibiotic therapy, and aerobic gram-positive cocci are the most common causative organisms of infections, the IDSA said.

Recommendations on how to diagnose and treat osteomyelitis are also included in the guideline. Multidisciplinary team care is recommended whenever possible, and the guideline includes advice on when to refer care to specialists. The appropriate use of surgical interventions (which are required for most diabetic foot infections) and best methods of wound care are also described in the guideline, which is presented as a series of questions and answers.

The guideline was published online May 22 by Clinical Infectious Diseases.



Test yourself


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MKSAP Quiz: 2-year history of enlargement and discomfort of the metacarpophalangeal joints

A 62-year-old man is evaluated for a two-year history of enlargement and discomfort of the metacarpophalangeal joints of both hands. He works as a bank manager and leads a sedentary lifestyle. He does not have morning stiffness. He was diagnosed with type 2 diabetes mellitus three months ago for which he takes metformin.

mksap.jpg

On physical examination, vital signs are normal. Examination of the skin reveals generalized hyperpigmentation. There is bony enlargement of the metacarpophalangeal joints bilaterally but no evidence of synovial proliferation. Range of motion of the hands is full, and he can make a strong fist. Examination of the proximal and distal interphalangeal joints, knees, and hips is normal.

Laboratory studies:

Hemoglobin A1c 7.3%
Erythrocyte sedimentation rate 13 mm/h
Glucose (fasting) 100 mg/dL (5.6 mmol/L)
Rheumatoid factor Negative
Anti–cyclic citrullinated peptide antibodies Negative

Hand radiographs show joint-space narrowing and hook-shaped osteophyte formation in the metacarpophalangeal joints. Radiographs of the hips and knees are normal. These imaging studies reveal no evidence of chondrocalcinosis.

Which of the following is the most likely diagnosis?

A) Calcium pyrophosphate deposition disease
B) Diabetic cheiroarthropathy (stiff hand syndrome)
C) Hemochromatosis
D) Primary osteoarthritis
E) Rheumatoid arthritis

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


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Women's health


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Task force issues review, draft recommendations against hormone therapy for primary prevention

The U.S. Preventive Services Task Force (USPSTF) has reviewed the latest evidence on using menopausal hormone therapy for primary prevention of chronic disease and has issued draft recommendations.

annals.jpg

The systematic review, which was published online by Annals of Internal Medicine on May 28, included randomized, controlled trials published between 2002 and late 2011 that focused on hormone therapy for primary prevention. In total, nine trials, including the Women's Health Initiative (WHI), met the criteria. The use of hormone therapy to treat menopausal symptoms was outside the scope of the review, the study authors noted.

After reviewing the trials, researchers concluded that estrogen taken with progestin and estrogen alone were both associated with reduced fracture risk but increased risk for stroke, thromboembolism, gallbladder disease and urinary incontinence. Estrogen plus progestin also increased the risk of breast cancer and dementia. However, estrogen alone decreased the risk of breast cancer.

The updated data from the WHI used in this analysis differ from initial findings, the reviewers noted. Follow-up data from the trial showed that the hormones' effect on breast cancer risk had become significant, while a decrease in colorectal cancer and an increase in coronary heart disease found with estrogen and progestin were no longer statistically significant.

Based on the review, the USPSTF issued two draft recommendations. It recommended against the use of combined estrogen and progestin for the prevention of chronic conditions in postmenopausal women and against the use of estrogen for the prevention of chronic conditions in postmenopausal women who have had a hysterectomy.

The task force noted that the recommendations apply to postmenopausal women considering hormone therapy for the primary prevention of chronic medical conditions, not women younger than age 50 years who have undergone surgical menopause or those considering hormone therapy for the management of menopausal symptoms. The recommendations are open for comment until June 26.



Bell's palsy


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Prednisolone may reduce mild, moderate sequelae in Bell's palsy

Treatment with prednisolone may reduce mild and moderate sequelae of Bell's palsy, according to a new study.

Researchers used data from a randomized, double-blind, placebo-controlled, multicenter trial with 12-month follow-up to compare four regimens for treatment of Bell's palsy. Eight hundred twenty-nine patients 18 to 75 years of age from 17 referral centers were randomly assigned to receive placebo plus placebo (206 patients); prednisolone, 60 mg/d for five days and a tapered dosage for five additional days, plus placebo (210 patients); valacyclovir hydrochloride, 1,000 mg three times daily for seven days, plus placebo (207 patients); or prednisolone plus valacyclovir (206 patients).

Patients were assigned to treatment within 72 hours of palsy onset. The study's main outcome measure was facial function after 12 months as determined by the Sunnybrook and House-Brackmann grading systems. The Sunnybrook system scores facial function on a scale of 0 (complete paralysis) to 100 (normal function), while the House-Brackmann system grades facial function on a scale of I (normal function) to VI (complete paralysis). The synkinesis portion of the Sunnybrook score, which ranges from 1 (mildest) to 15 (most severe), was also evaluated separately.

Overall, 184 of 829 patients had a Sunnybrook score below 90 at 12 months. Of these, 71 had received prednisolone and 113 had not (P<0.001). Ninety-eight patients had a Sunnybrook score less than 70, and of these 33 had received prednisolone and 65 had not (P<0.001). Patients who had received prednisolone and those who did not also had a statistically significant difference in House-Brackmann grades higher than I (P<0.001) and higher than II (P=0.01), but Sunnybrook scores less than 50 and House-Brackmann grades above III did not differ significantly according to prednisolone therapy (P=0.10 and P=0.80, respectively). In the 743 patients whose Sunnybrook score for synkinesis was evaluated separately, 96 had a score above 2 and 60 had a score above 4. In the former group, 33 patients had received prednisolone and 63 had not (P=0.001); in the latter group, 22 patients had received prednisolone and 38 had not (P=0.005).

The authors noted that they did not distinguish between complete and incomplete palsy at baseline and that their statistical comparisons may have been affected by the relatively small number of patients in the subgroup analyses. However, they concluded that treatment with prednisolone significantly reduced mild and moderate sequelae in patients with Bell's palsy at 12 months, although it did not affect the number of patients who developed severe sequelae. In addition, they noted, sequelae severity was not affected by valacyclovir alone, and prednisolone plus valacyclovir did not decrease the number of patients who developed sequelae when compared with prednisolone alone. The study results appeared in the May Archives of Otolaryngology—Head & Neck Surgery.



Venous thromboembolism


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Aspirin appears to reduce recurrence of VTE after stopping anticoagulants

Aspirin reduced the risk of venous thromboembolism (VTE) recurrence with no apparent increase in major bleeding in patients who had an initial unprovoked VTE and had discontinued anticoagulant treatment, a study found.

Researchers conducted a multicenter, double-blind trial among patients with first-ever unprovoked proximal deep venous thrombosis, pulmonary embolism or both who had completed six to 18 months of oral anticoagulant treatment with a target international normalized ratio (INR) of 2.0 to 3.0. VTE was considered to be unprovoked when it occurred in the absence of any known risk factor.

More than 400 patients were randomized to aspirin, 100 mg once daily, or placebo for two years. Randomization occurred within two weeks after vitamin K antagonists had been withdrawn. The primary efficacy outcome was recurrence of VTE, and the primary safety outcome was major bleeding.

An overt bleeding event was defined as major if it was fatal, if it occurred in a critical location (intracranial, intraspinal, intraocular, retroperitoneal, intraarticular, pericardial, or intramuscular [leading to a compartment syndrome]), or if it was associated with a decrease in hemoglobin level of at least 2.0 g/dL or required a transfusion of two or more units of whole blood or red cells. Clinically relevant, nonmajor bleeding was defined as any overt bleeding that required a medical intervention and did not meet any of the criteria for major bleeding.

Study results appeared in the May 24 New England Journal of Medicine.

From May 2004 through August 2010, VTE recurred in 71 patients (8.6% patients per year). Recurrent VTE was due to deep venous thrombosis in 44 patients (ipsilateral in 51% of cases) and to pulmonary embolism in 27 patients (fatal in 2 patients). In 77% of cases, recurrence took place in the absence of any known risk factor for VTE.

A recurrence in the form of pulmonary embolism was more common among patients who entered the study because of prior pulmonary embolism than among those who entered because of deep venous thrombosis (12.7% vs. 3.2%; hazard ratio, 5.52; 95% CI, 2.29 to 13.30; P<0.001).

Overall, VTE recurred in 28 of the 205 patients who received aspirin, as compared with 43 of the 197 patients who received placebo (6.6% vs. 11.2% per year; hazard ratio, 0.58; 95% CI, 0.36 to 0.93; P=0.02)

Over a median treatment period of 23.9 months, while taking the study drug, 23 patients in the aspirin group had a recurrence, as compared with 39 patients in the placebo group (5.9% vs. 11.0% per year; hazard ratio, 0.55; 95% CI, 0.33 to 0.92; P=0.02). Eleven of 83 patients in the aspirin group who entered the study because of pulmonary embolism had a recurrent event, as compared with 16 of 67 patients in the placebo group (6.7% vs. 13.5% per year; hazard ratio, 0.38; 95% CI, 0.17 to 0.88; P=0.02).

Among the patients who entered the study because of deep venous thrombosis, 17 of 122 in the aspirin group and 27 of 130 in the placebo group had a recurrent event (6.5% and 10.2% per year, respectively; hazard ratio, 0.65; 95% CI, 0.65 to 1.20; P=0.17).

Two episodes of nonfatal major bleeding occurred in the study, one in the placebo group (gastric ulcer) and one in the aspirin group (bowel angiodysplasia). Three patients in the aspirin group and three patients in the placebo group developed clinically relevant nonmajor bleeding (gingival bleeding and two cases of cutaneous hematomas in the aspirin group, hemorrhagic gastritis and two cases of musculoskeletal bleeding post-trauma in the placebo group). Five patients developed an adverse event that was attributed to the study drug and led to treatment withdrawal: gastric pain in three patients (two in the placebo group, one in the aspirin group), a cutaneous reaction in one patient (aspirin group), and renal failure in one patient (aspirin group).

The authors concluded that in patients with unprovoked VTE, aspirin therapy, begun after six to 18 months of oral anticoagulant treatment, reduced the rate of recurrence by about 40%, as compared with placebo. "This benefit is achieved with no apparent increase in the risk of major bleeding," they wrote.



CMS update


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Medicare to send Comparative Billing Reports to primary care clinicians to facilitate accurate billing

This June, CMS will be sending a Comparative Billing Report (CBR) to a select group of 5,000 primary care clinicians, focusing on evaluation and management (E/M) codes for office visits.

The CBR is a tool used by CMS to enhance coding accuracy and is not intended to be punitive or an indication of suspected fraud. The reports are being sent as part of CMS's effort to facilitate accurate billing. A recent study indicated that 8.4% of E/M services were being billed at the wrong code level—either too high or too low. The CBR is a confidential, educational tool to assist physicians and other health care professionals in a self-audit of their individual coding practices through a comparison to aggregated coding data from a related reference group.

The College provides a similar educational tool to its members. This tool compares a practice's overall coding pattern against the Medicare national average and provides a hypothetical estimate of the dollar difference between the current coding pattern and the national average. It is available to ACP members on the Running a Practice section of the College's website.


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Medicare e-prescribing deadlines approaching on June 30

Two deadlines loom for the Medicare e-Prescribing (eRx) Incentive Program.

First, there is still time to avoid a payment penalty in 2013 if you have not already submitted enough claims to qualify as a successful e-prescriber. To avoid the penalty, you must successfully submit at least 10 eRx claims by the end of June. If you are unable to use e-prescribing, you may be able to qualify for a hardship exemption from the payment penalties associated with this program. Those applications are also due by June 30.

Additional information is available on the ACP e-prescribing website.


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Version 5010 compliance deadline is approaching

There are a few things to keep in mind for submitting version 5010 claims. These tips could help practices avoid unnecessary rejections:

  • ZIP code: A complete 9-digit ZIP code must be included for the billing provider and service facility location.
  • Billing provider address: A physical address must be used for the billing provider address. (The pay-to address can still be a post office box.)
  • National Provider Identifier (NPI): For version 5010 claims, clinicians are only allowed to report an NPI, not a Social Security or tax ID number, as a primary identifier.

Additional details about these version 5010 tips are available on ACP's website.



From ACP Internist


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The next issue is online and coming to your mailbox

June's edition of ACP Internist wraps up coverage from Internal Medicine 2012.

acpi-20120605-internist.jpg

Making opiates safe, efficient in the office. Managing opiates can lead to a host of issues with patients, including pre-empting pain while ensuring communication of clear limits and preventing abuse. These challenges confound many internists, but clear-cut and easy guidelines can help achieve the best outcomes.

Diving into delicate patient conversations. Talking to patients about sensitive topics that have a major impact on their well-being can be difficult. Two physicians address ways to handle especially sensitive areas: sexual history and the inability to safely drive a car.

'PharManure' and some drugs to hate the most. Drugs that made one doctor's least-wanted list included those that increase costs without improving care.

These and other stories plus the latest MKSAP Quiz are now online.



From the College


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ACP joins Million Hearts Campaign

ACP has joined the Million Hearts Campaign, an initiative that aims to prevent a million heart attacks and strokes over the next five years.

The campaign seeks to empower Americans to make healthy choices, such as avoiding tobacco use and reducing sodium and trans-fat consumption, as well as to improve care for people who need medical treatment. The Million Hearts campaign focuses on the "ABCS": Aspirin for people at risk, Blood pressure control, Cholesterol management and Smoking cessation, addressing the major risk factors for cardiovascular disease. In addition to supporting the campaign, the College offers several resources related to heart attack and stroke prevention.


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Waste not, want not

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 discusses current efforts to practice high-value, cost-conscious care, an approach he first witnessed during his residency training in the early 1980s.


.
Governance Committee seeks Regent and Treasurer candidates for 2013

ACP's Governance Committee, which oversees the process for nominating and electing Masters and Fellows of the College to the Board of Regents, is beginning the process of seeking Regents to join the Board in May 2013. The position of Treasurer will also open in 2013.

The Governance Committee strives to represent the diversity within internal medicine on ACP's Board of Regents. Important general qualifications include commitment to ACP, dependability, leadership qualities, and the ability to represent the College in numerous and diverse arenas. Regent nominees must be Fellows or Masters of the College.

Candidates for Treasurer do not need to be current members of the Board of Regents, but will become a member of the Board upon election to Treasurer. The Treasurer will be a member of the Executive Committee of the Board of Regents and Chair of the Financial Policy and Audit Committee. Treasurer candidates should be experienced and/or comfortable with investments, pensions, insurance and financial management issues; have proven leadership ability in order to guide the Financial Policy and Audit Committee toward effective decision making; be willing to devote the time necessary to become familiar with the College's financial policies and practices; have the ability to work with College management; and possess the ability to make financial matters and recommendations understandable to persons with little or no financial background.

All candidates for Regent or Treasurer must submit a letter of nomination (not from the candidate) and two letters of support (from two individuals other than the nominator) by Aug. 1, 2012.

Letters of nomination should include the following sections:

  • Brief description of the nominee's current activities
  • Special attributes the candidate would bring to the Board of Regents in terms of the desired characteristics outlined above
  • Previous and current service in College related activities
  • Service in organizations other than the College (medical and non-medical)
  • Identification of two individuals who will write letters of support for the candidate

Letters of support do not need to have specific content or format but will be most useful if they focus on candidates' qualifications and how they would contribute to the Board of Regents and College.

Please send your confidential nominations no later than Aug. 1, 2012 to:

Governance Committee

ATTN: Mrs. Florence Moore

American College of Physicians

190 N. Independence Mall West

Philadelphia, PA 19106-1572

Fax: 215-351-2829

e-mail

Only candidates who submit a letter of nomination and two letters of support by Aug. 1, 2012, will be advanced to the Governance Committee for review. If you have any questions, please contact Florence Moore toll free at (800) 523-1546, ext. 2814, or direct at (215) 351-2814.



Cartoon caption contest


.
And the winner is …

ACP InternistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

acpi-20120605-cartoon.jpg

"Don't worry—this drug is safe. It was tested on humans."

This issue's winning cartoon caption was submitted by Jonah Feldman, MD, ACP Associate Member, from Winthrop-University Hospital in Mineola, N.Y. Thanks to all who voted! The winning entry captured 48.3% of the votes.

The runners-up were:

"No, I am a PRIMARY care physician."

"No, I will not prescribe you a banana bag."


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MKSAP Answer and Critique



The correct answer is C) Hemochromatosis. This item is available to MKSAP 15 subscribers as item 32 in the Rheumatology section. MKSAP 16 will release Part A on July 31. More information is available online.

This patient most likely has secondary osteoarthritis associated with hemochromatosis. Approximately 40% to 60% of patients with hemochromatosis develop an arthropathy with a presentation similar to that of osteoarthritis. The presence of symmetric pain and bony enlargement of the joints accompanied by radiographic findings of joint-space narrowing and osteophytes is consistent with osteoarthritis. However, primary osteoarthritis does not typically involve the metacarpophalangeal joints; if this occurs, suspicion should be raised for secondary osteoarthritis. Similarly, radiographs of the metacarpophalangeal joints may reveal hook-shaped osteophytes that are significantly different from radiographs of patients with primary osteoarthritis. Hemochromatosis arthropathy also may involve the proximal interphalangeal joints and, less frequently, the shoulders, hips, knees, and ankles. Finally, primary osteoarthritis usually affects patients with advanced age or who have occupations involving repetitive bending or manual labor.

Secondary osteoarthritis usually involves joints not affected by primary osteoarthritis. Secondary arthritis develops because of another condition, such as trauma, previous inflammatory arthritis, or metabolic disorders such as hemochromatosis or chondrocalcinosis. In this patient, the presence of skin hyperpigmentation and diabetes mellitus raises strong suspicion for hemochromatosis, which is particularly associated with involvement of the metacarpophalangeal joints in patients without primary osteoarthritis.

Symptoms of osteoarthritis that involve the second and third metacarpophalangeal joints also may be caused by calcium pyrophosphate deposition disease. However, radiographs of patients with this condition would typically reveal chondrocalcinosis, which occurs most frequently in the knees, symphysis pubis, and triangular fibrocartilage of the wrist.

Diabetic cheiroarthropathy (stiff hand syndrome) more commonly occurs in patients with long-standing diabetes. This condition manifests as joint stiffness, limited range of motion in the absence of pain, and skin thickening of the fingers, which is not compatible with this patient's presentation or radiographic findings.

Rheumatoid arthritis may involve the metacarpophalangeal joints in a symmetric pattern and may be present in patients without rheumatoid factor. This condition also may manifest as rheumatoid nodules (subcutaneous nodules that develop over bony prominences at sites such as the extensor surfaces of the hand) that may resemble the bony enlargement associated with osteoarthritis. However, rheumatoid arthritis is unlikely in the absence of morning stiffness and joint swelling.

Key Point

  • Secondary osteoarthritis usually involves joints not affected by primary osteoarthritis and develops because of another condition, such as trauma, previous inflammatory arthritis, or metabolic disorders such as hemochromatosis or chondrocalcinosis.

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Test yourself

A 42-year-old woman is evaluated for an 8-month history of crampy abdominal pain and three loose bowel movements per day. The pain is relieved by a bowel movement. There are no nocturnal bowel movements, and there is no blood or dark tarry material in the stool. She has not had fever, night sweats, or weight loss. She has a history of Hashimoto disease and is treated with levothyroxine. Following a physical exam, rectal exam, and lab tests, what is the most appropriate next step in management?

Find the answer

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