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ACP InternistWeekly



In the News for the Week of July 24, 2012




Highlights

Start ART in all HIV-infected adults, expert panel says

All adults with HIV should receive antiretroviral therapy (ART) regardless of CD4 cell count, according to the 2012 International Antiviral Society-USA panel recommendations. More...

Tailor prostate screening based on life expectancy, ASCO recommends

A provisional clinical opinion from the American Society of Clinical Oncology (ASCO) recommends against prostate-specific antigen screening for men with a life expectancy of 10 years or less. More...


Test yourself

MKSAP Quiz: 12-hour history of bilateral lower-extremity paralysis

This week's quiz asks readers to evaluate a 38-year-old man admitted to the hospital for a 12-hour history of bilateral lower-extremity paralysis. More...


Neurology

Interferon beta may not help disability progression in MS patients

Treatment with interferon beta does not appear to affect progression to disability in patients with relapsing-remitting multiple sclerosis (MS), according to a new study. More...


Cardiology

Focused update released on management of unstable angina, non-ST-segment- elevation MI

The American College of Cardiology Foundation/American Heart Association released a focused update last week to their guidelines on management of unstable angina and non-ST-segment-elevation myocardial infarction. More...


Hypertension

Hematocrit may predict mortality, study finds

Hematocrit measurements can predict long-term mortality in patients with hypertension, a recent study found. More...


Lyme disease

Free CME course offered on Lyme disease

The Infectious Diseases Society of America (IDSA) is offering a free online course on Lyme disease. More...


Social media

A Senate intern turned internist seeks solutions to better patient care

This month at KevinMD.com, Fred Ralston Jr., MD, MACP, a past president of ACP and a practicing internist in Fayetteville, Tenn., discusses meeting with elected representatives about our health care system. More...


From the College

Call for spring 2013 Board of Governors resolutions

The deadline for submitting new resolutions to be heard at the spring 2013 Board of Governors meeting is Sept. 26, 2012. More...

ACP releases annual report from the Executive Vice President

The 2011-2012 ACP Report of the Executive Vice President—a review of the past year's accomplishments, programs, initiatives and collaborations—is now available on ACP's website. More...

The Doctors Company announces five-year anniversary of the Tribute Plan

The Doctors Company, ACP's exclusively sponsored medical liability carrier, announced the five-year anniversary of its Tribute Plan last week. 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


.
Start ART in all HIV-infected adults, expert panel says

All adults with HIV should receive antiretroviral therapy (ART) regardless of CD4 cell count, according to the 2012 International Antiviral Society-USA panel recommendations.

Experts updated the previous 2010 guidelines based on observational cohort data finding all HIV-positive patients may benefit from ART and data from a randomized controlled trial showing that ART reduces the likelihood of spreading HIV. The findings were presented at the International AIDS Conference in Washington, D.C., on Sunday and appear in the July 25 Journal of the American Medical Association.

There is no CD4 cell count threshold at which starting therapy is contraindicated, but the strength of the recommendation and the quality of the evidence supporting therapy increase as the CD4 cell count decreases and in patients who are pregnant, have hepatitis B or C, are older than 60 years, or have HIV-associated nephropathy. Ongoing monitoring of patients' CD4 cell count, HIV-1 RNA levels, ART adherence, HIV-drug resistance, and quality-of-care indicators is recommended.

Because any drug regimen to treat HIV is lifelong, therapy choices should consider patient convenience and tolerability. Recommended initial therapy is still a combination of two nucleoside reverse transcriptase inhibitors and a potent third agent (generally a nonnucleoside reverse transcriptase inhibitor, a ritonavir-boosted protease inhibitor, an integrase strand transfer inhibitor, or, rarely, an agent that blocks the CC chemokine receptor 5).

In the same issue of JAMA, in a study evaluating screening for cervical disease in women with HIV, researchers reported that HIV-infected and uninfected women with a normal Pap test and a negative test result for oncogenic human papillomavirus (HPV) DNA at study enrollment had a similar risk of cervical precancer and cancer after five years of follow-up. Additional observational studies or a randomized clinical trial may be necessary before clinical guideline committees consider whether to expand current recommendations regarding HPV co-testing to HIV-infected women, according to the study authors.

"More broadly, the current investigation highlights the potential for a new era of molecular testing, including HPV as well as other biomarkers, to improve cervical cancer screening in HIV-infected women," the authors wrote.


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Tailor prostate screening based on life expectancy, ASCO recommends

A provisional clinical opinion from the American Society of Clinical Oncology (ASCO) recommends against prostate-specific antigen (PSA) screening for men with a life expectancy of 10 years or less.

The provisional opinion recommends a discussion between physicians and patients about the appropriateness of PSA screening. The opinion was published online July 16 by the Journal of Clinical Oncology.

The experts based their recommendations on a 2011 Agency for Healthcare Research and Quality systematic review. Results were driven primarily by the two largest randomized, controlled trials in the analysis, both with evidence rated as fair quality: the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial and 11-year follow-up results for the European Randomized Study of Screening for Prostate Cancer.

The recommendations are as follows:

  • In men with a life expectancy of 10 years or less, general screening for prostate cancer with PSA should be discouraged, because harms seem to outweigh potential benefits.
  • In men with a life expectancy greater than 10 years, physicians should discuss whether PSA testing for prostate cancer screening is appropriate, based on consideration of complications from unnecessary biopsy, surgery or radiation treatment.

"Screening with PSA may identify prostate cancers earlier, but better screening approaches are needed, such as risk stratification for screening and assessing individualized risk for prostate cancer," the authors wrote. "It is well established that a patient's age and level of comorbidity need to be considered when deciding whether to screen for prostate cancer."

This recommendation differs from that of the U.S. Preventive Services Task Force, which recently recommended against using the test for prostate cancer screening in men of all ages in the general population.



Test yourself


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MKSAP Quiz: 12-hour history of bilateral lower-extremity paralysis

A 38-year-old man is admitted to the hospital for a 12-hour history of bilateral lower-extremity paralysis. The patient is an injection drug user. Over the past week, he developed lower back pain, which progressed to pain and numbness radiating down both lower extremities. On the day of admission, he was unable to walk but continued to use injection drugs.

mksap.jpg

On physical examination, vital signs, including temperature, are normal. Cardiac examination reveals a regular rhythm and a grade 2/6 holosystolic murmur heard at the apex and radiating to the axilla. Neurologic examination demonstrates 0/5 strength in both lower extremities and absent sensation in both legs.

Emergent MRI of the spine shows evidence of osteomyelitis of the L1 and L2 vertebrae, diskitis of the L1-L2 disk space, and an epidural fluid collection compressing the spinal cord. Three blood cultures are drawn, and empiric therapy with vancomycin and ceftazidime is initiated.

In addition to continuing antimicrobial therapy, which of the following is the most appropriate management?

A) CT-guided aspiration of the epidural fluid collection
B) Electromyography of the lower extremities
C) Emergent laminectomy
D) Lumbar puncture

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


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Neurology


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Interferon beta may not help disability progression in MS patients

Treatment with interferon beta does not appear to affect progression to disability in patients with relapsing-remitting multiple sclerosis (MS), according to a new study.

Researchers performed a retrospective cohort study of 1995-2008 data from patients in British Columbia, Canada, to determine the relationship between interferon beta, a common MS treatment, and disability progression. Patients who had relapsing-remitting MS and were treated with interferon beta (n=868) were compared with a contemporary cohort eligible for treatment by the study criteria who were not exposed to interferon beta (n=829) and a historical cohort who would have been eligible for treatment by the study criteria before interferon beta was available in Canada (n=959). The study's main outcome measure was the time from baseline, defined as the point of eligibility for interferon beta treatment, to a confirmed, sustained score of 6 on the Expanded Disability Status Scale (EDSS). The EDSS ranges from 0 to 10; higher scores indicate greater disability. A person with a score of 6 requires a cane, crutch or brace to walk 100 meters. The study also looked at the association between interferon beta treatment and the hazard of disease progression. Results appeared in the July 18 Journal of the American Medical Association.

The median active follow-up times, from first to last EDSS measurement, were 5.1 years for the interferon beta cohort, 4.0 years for the contemporary cohort, and 10.8 years for the historical cohort. Overall, 10.8%, 5.3% and 23.1% of patients in each cohort, respectively, reached a sustained EDSS score of 6. The authors adjusted for sex, age, disease duration and EDSS score and found no association between interferon beta treatment and a statistically significant difference in reaching an EDSS score of 6 (hazard ratios, 1.30 compared with the contemporary cohort and 0.77 compared with the historical cohort; P=0.14 and 0.07, respectively). These results did not change after additional adjustment for comorbid conditions and socioeconomic status or after propensity score adjustment.

The authors noted that they were not able to test different types of interferon beta drugs separately and did not take adverse events of treatment into account, among other study limitations. However, they concluded that in patients with relapsing-remitting MS, interferon beta does not appear to slow progression to disability, which they called the "ultimate goal" of MS treatment. Their findings question whether interferon beta should be used routinely for this indication, they wrote, although they stressed that the treatment may still benefit an as-yet-identified subset of patients.

An accompanying editorial called the study an important contribution to the literature but pointed out that "Lacking evidence of treatment effect is not proof of lacking effect." The editorialists noted that the study may have been underpowered and that the results could be biased against interferon because a significant proportion of the contemporary cohort may have had disease mild enough to disqualify them from treatment consideration.

The editorialists said that neurologists will probably continue to prescribe interferon beta for relapsing-remitting MS based on existing evidence pointing to short-term benefits. "However, the rigorously collected data [in the current study] reinforce the conclusion that the associations between use of interferons and long-term disability, although plausible, remain unproven," the editorialists wrote.



Cardiology


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Focused update released on management of unstable angina, non-ST-segment- elevation MI

The American College of Cardiology Foundation/American Heart Association released a focused update last week to their guidelines on management of unstable angina and non-ST-segment-elevation myocardial infarction (NSTEMI). The guidelines were originally issued in 2007 and were last updated in March 2011. This update replaces the March 2011 update.

The guideline writing committee looked at research on newly approved oral antiplatelets, including ticagrelor, and offered guidance on how to incorporate them into clinical practice, as well as comparisons of the different agents in various settings. The focused update covers the following areas:

  • antiplatelet/anticoagulant therapy in patients with likely or definite unstable angina/NSTEMI,
  • initial invasive versus initial conservative strategies,
  • long-term medical therapy and secondary prevention,
  • special considerations in diabetes and chronic kidney disease and
  • quality of care and outcomes for unstable angina/NSTEMI.

The update will be published in the Aug. 14 Circulation. The full text is available online.



Hypertension


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Hematocrit may predict mortality, study finds

Hematocrit measurements can predict long-term mortality in patients with hypertension, a recent study found.

The cohort study included more than 10,000 Scottish patients who were seen at a hypertension clinic. Hematocrit was measured at their initial clinic visits and at follow-up visits for up to 35 years. Overall, men had higher median hematocrit than women (0.44 vs. 0.41). The lowest mortality risk was seen in men with a hematocrit between 0.421 and 0.440 and in women between 0.381 and 0.400. In general, the researchers concluded that a hematocrit above 0.44 was associated with increased risk of death for hypertensive men or women.

The sexes differed in the pattern and causes of mortality, however. In general, men had an increased risk of death with hematocrit below 0.42, with a J-shaped pattern for cardiovascular mortality, but their risk for non-cardiovascular mortality had a linear relationship with hematocrit. Women had a lower threshold at which their mortality risk was increased (0.38) and a U-shaped pattern for non-cardiovascular mortality.

The study also found that patients with higher hematocrit at baseline had higher blood pressure on treatment, but that higher hematocrit was associated with increased mortality risk whether or not patients achieved blood pressure targets. Given the limitations of the data, researchers weren't able to determine whether more aggressive blood pressure management would lower the mortality risk of patients with high hematocrit.

Still, they concluded that hypertensive patients with hematocrit levels in the higher risk ranges should be targeted for aggressive blood pressure management and other cardiovascular risk reduction. Hematocrit levels should be considered an important risk predictor in these patients, the authors said. They called for additional research to assess the differing relationships between hematocrit and mortality in men and women, and to develop management strategies for high hematocrit levels. The study was published online July 16 by Hypertension.



Lyme disease


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Free CME course offered on Lyme disease

The Infectious Diseases Society of America (IDSA) is offering a free online course on Lyme disease.

The interactive course consists of a series of case studies and is based on the IDSA guideline "The Clinical Assessment, Treatment and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis and Babesiosis." The case studies are designed to educate clinicians regarding the proper diagnosis and treatment of Lyme disease and also provide an opportunity to better understand the IDSA guideline. The course was developed in partnership with the Centers for Disease Control and Prevention.

Each case in the course is accredited for 0.25 CME credit. To receive CME credit, the learner must complete at least four of the six cases, score 70% correct or higher on the post-test, and complete the evaluation.

The course is available online.



Social media


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A Senate intern turned internist seeks solutions to better patient care

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 shows how meeting with elected representatives to discuss the challenges facing our nation's health care system merges with the joy of helping one patient at a time.



From the College


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Call for spring 2013 Board of Governors resolutions

The deadline for submitting new resolutions to be heard at the spring 2013 Board of Governors meeting is Sept. 26, 2012. Initiating a resolution provides ACP members an opportunity to focus attention at the ACP national level on a particular issue or topic that concerns them. When drafting a resolution, don't forget to consider how well it fits within ACP's Mission and Goals. In addition, be sure to use the College's Strategic Plan to guide you when proposing a resolution topic. Members must submit resolutions to their Governor and/or chapter council. A resolution becomes a resolution of the chapter once the chapter council approves it.

In accordance with the ACP Board of Governors Resolutions Process, resolutions should clearly distinguish the action requested within a resolved clause(s) as either a policy resolve ("Resolved that ACP policy…") or a directive, which requests action/study on an issue ("Resolved that the Board of Regents…"). If more than one action is proposed, each should have its own resolved clause. Please contact your Governor if you have any questions regarding the resolution format.

The Board of Governors votes on new resolutions, which are then presented to the Board of Regents for action. Members are encouraged to use the Electronic Resolutions System (ERS) to research the status of past resolutions before proposing a new resolution. Visit your chapter website and link to the ERS under the "Advocacy" heading.


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ACP releases annual report from the Executive Vice President

The 2011-2012 ACP Report of the Executive Vice President—a review of the past year's accomplishments, programs, initiatives and collaborations—is now available on ACP's website.

The report reviews the College's accomplishments and activities over the past year. As part of ACP's ongoing effort to reduce paper and to be environmentally responsible, the report has been produced in a digital format. You can use the interactive table of contents to jump to specific sections, access detailed content throughout the report, access video and scroll forward and back through the report with ease.

A video message from CEO and EVP Steven Weinberger, MD, FACP, is also available online.


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The Doctors Company announces five-year anniversary of the Tribute Plan

The Doctors Company, ACP's exclusively sponsored medical liability carrier, announced the five-year anniversary of its Tribute Plan last week.

The Tribute Plan is a significant financial benefit that rewards doctors for their loyalty to The Doctors Company and for their dedication to outstanding patient care. Since the plan's inception, more than 1,300 Tribute awards have been distributed, and over 22,700 members of The Doctors Company have qualified for awards when they retire from the practice of medicine.

Additional information about the program—including a special Tribute Plan five-year anniversary video featuring details about Tribute, perspectives from members of The Doctors Company, and commentary from Richard E. Anderson, MD, FACP, the company's chairman and CEO—is available online.



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-20120724-cartoon.jpg

"So your staff informed me that you suddenly had an opening this morning, which was such a relief 'cause I was like, 'Me too.'"

"These new bariatric surgeries are getting ridiculous."

"But ibuprofen is working great for my arthritis!"

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 C) Emergent laminectomy. This item is available to MKSAP 15 subscribers as item 72 in the Infectious Disease section. MKSAP 16 will release Part A on July 31. More information is available online.

This patient has a spinal epidural abscess and vertebral osteomyelitis. Given his history of injection drug use, he likely has infective endocarditis with continuous bacteremia, leading to seeding of his lumbar spine and development of the epidural fluid collection. The likely infecting organisms are Staphylococcus aureus and gram-negative bacilli, and appropriate empiric antimicrobial therapy has been initiated.

Patients with spinal epidural abscess and neurologic dysfunction require urgent laminectomy with decompression and drainage, although surgery is not likely to be a viable therapeutic option in patients who have experienced complete paralysis of longer than 24 to 36 hours' duration; some experts, however, would perform surgical therapy in patients in whom complete paralysis has lasted fewer than 72 hours. Given that this patient's symptoms of paralysis lasted only 12 hours prior to presentation, emergent laminectomy is indicated to attempt to reverse the neurologic deficits.

CT-guided aspiration would likely identify the causative microorganism (approximately 90% of cultures are positive) but would be inadequate to treat the neurologic dysfunction. Electromyography would offer no other information and would not further guide the management of this patient.

Lumbar puncture for cerebrospinal fluid examination is not necessary and will not contribute to the management of this patient. Typical findings include an elevated protein level and pleocytosis, and Gram stain and cultures are negative in more than 75% to 80% of patients.

Key Point

  • Emergent laminectomy should be performed in patients with spinal epidural abscess and neurologic dysfunction of less than 24 to 36 hours' duration.

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Test yourself

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

Find the answer

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