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

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ACP InternistWeekly



In the News for the Week of July 31, 2012




Highlights

Shift work associated with vascular events

People who work any schedule other than a standard day or evening shift have an increased risk of major vascular events, according to a meta-analysis. More...

Mortality reduced in states that expanded Medicaid

Expansions in eligibility for Medicaid were associated with lower all-cause mortality among adults, according to a new study. More...


Test yourself

MKSAP Quiz: Older man with progressive fatigue

This week's quiz asks readers to evaluate a 62-year-old man for a 2-month history of progressive fatigue, dyspnea on exertion, anorexia, and nausea. More...


Perioperative medicine

MI risk higher after total hip, knee replacement

Patients who have total hip or total knee replacement surgery are at higher risk for myocardial infarction (MI) afterward, according to a new study. More...


Testing

USPSTF updates guidance on screening electrocardiography

The U.S. Preventive Services Task Force (USPSTF) recently updated its recommendations on screening for coronary heart disease using electrocardiography. More...


Resources

Disability benefits questionnaires for veterans available

The Department of Veterans Affairs has created a series of disability benefits questionnaires to speed the processing of disability compensation and pension claims and alleviate a current backlog of veterans' disability benefit claims. More...


From the College

New module on chronic pain available on Medical Home Builder 2.0

A new Chronic Pain Management module has been added to the Medical Home Builder 2.0, ACP's online tool that enables clinicians and staff members to measure and, where needed, improve patient care and office workflow based on the Patient-Centered Medical Home model. More...

ACP announces Colombia Chapter

ACP is pleased to announce the establishment of a new ACP Colombia Chapter. 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: Philip Masters, MD, FACP



Highlights


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Shift work associated with vascular events

People who work any schedule other than a standard day or evening shift have an increased risk of major vascular events, according to a meta-analysis.

Canadian researchers assessed 34 observational studies with more than 2 million participants. The included studies used prospective cohorts, retrospective cohorts or case controls to compare shift workers (those who worked all evenings or nights, or irregular, mixed or rotating shifts) to either daytime workers or the general population. Results were published by BMJ on July 26.

All of the shift work schedules except evening shifts were associated with a higher risk of coronary events. Shift workers had a 23% higher risk of myocardial infarction (risk ratio [RR], 1.23; 95% CI, 1.15 to 1.31) and a 5% higher risk of stroke (RR, 1.05; 95% CI, 1.01 to 1.09). The risk of any coronary event was also increased (RR, 1.24; 95% CI, 1.10 to 1.39), but no association with mortality risk was found in the studies that assessed all-cause or cardiovascular mortality.

With its basis on observational data, the analysis cannot prove causality, the study authors noted. Shift workers have previously been found to have lower socioeconomic status and engage more in unhealthy behaviors, such as smoking, than daytime workers. However, the studies within this analysis that adjusted for socioeconomic status had similar findings to the overall results, the authors said, and other research has found that adjustment for unhealthy behavior does not eliminate the apparent risk of shift work.

Given these findings, and regardless of causality, shift workers and their physicians should be vigilant about modifying cardiovascular risk factors, the authors concluded. Screening and education programs can identify risk factors and possibly forestall or prevent disease. Modification of schedules may also improve the health of these workers, the authors said, although more research is needed to assess long-term effects of such strategies and to identify the workers at highest risk.


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Mortality reduced in states that expanded Medicaid

Expansions in eligibility for Medicaid were associated with lower all-cause mortality among adults, according to a new study.

Researchers compared three states that expanded adult Medicaid eligibility (New York, Maine and Arizona) with neighboring states that did not expand coverage (Pennsylvania, New Hampshire, Nevada and New Mexico). The study population was between the ages of 20 and 64 and they were followed for five years before and after the expansions (1997 to 2007). The primary outcome was all-cause mortality, and secondary outcomes were insurance coverage, delaying care because of costs and self-reported health (measured by two large population surveys).

Overall, the population covered by Medicaid expanded by 24.7% in the studied states. That expansion was associated with a 6.1% reduction in mortality, or 19.6 fewer deaths per 100,000 adults. The reductions were greatest among older adults (35- to 64-year-olds), nonwhites and residents of poorer counties. The study also found a 15% decrease in the states' uninsured population, a 21% drop in patients reporting delayed care because of costs, and 3% more patients reporting excellent or very good health. The results were published by the New England Journal of Medicine on July 25.

The improvements in the secondary outcomes may not be sufficient to account for the large change in mortality, the researchers acknowledged. The 6% drop in mortality could be achieved if Medicaid coverage reduced mortality risk by 30% and the 1-year risk of death were 1.9%, they calculated. This would indicate that the new Medicaid enrollees were sicker than the general population, a finding that was supported by new enrollees being older, more likely to be minorities and more likely to be in fair or poor health.

However, the study was limited by its nonrandomized design and so cannot prove causality, the authors cautioned. Insurance coverage also increased during the study period in non-Medicaid populations and mortality declined (to a lesser degree) among the elderly. Another limitation is that the results were largely driven by the largest included state, New York. Still, the authors concluded that expansion of Medicaid coverage may reduce mortality among adults, and they urged policymakers to be aware of this effect when making changes to the insurance program.



Test yourself


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MKSAP Quiz: Older man with progressive fatigue

A 62-year-old man is evaluated for a 2-month history of progressive fatigue, dyspnea on exertion, anorexia, and nausea. He has no other medical problems and takes no medications.

mksap.jpg

On physical examination, temperature is normal, blood pressure is 157/88 mm Hg, pulse rate is 86/min, and respiration rate is 22/min. BMI is 31. The conjunctivae are pale. On cardiopulmonary examination, the point of maximal impulse is displaced laterally. There is dullness to percussion at both lung bases. Abdominal examination reveals no organomegaly. There is bilateral lower-extremity edema. Neurologic examination reveals mild asterixis.

Laboratory studies:

Hemoglobin 7.2 g/dL (72 g/L)
Total protein 9.8 g/dL (98 g/L)
Calcium 10.2 mg/dL (2.5 mmol/L)
Phosphorus 6.8 mg/dL (2.2 mmol/L)
Serum parathyroid hormone 92 pg/mL (92 ng/L)
Blood urea nitrogen 98 mg/dL (35.0 mmol/L)
Serum creatinine 9.8 mg/dL (866.3 µmol/L)
Urinalysis 2+ protein
Urine protein-creatinine ratio 5 mg/mg

Serum and urine protein electrophoreses are positive for a monoclonal IgG κ spike. On kidney ultrasound, both kidneys are 13.5 cm and there is increased bilateral echogenicity. There is no evidence of obstruction. Chest radiograph shows cardiomegaly and bilateral pleural effusions.

Which of the following is the most appropriate next step in this patient's management?

A) Chemotherapy
B) Hemodialysis and plasmapheresis
C) Hemodialysis, plasmapheresis, and chemotherapy
D) Plasma exchange and chemotherapy.

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


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Perioperative medicine


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MI risk higher after total hip, knee replacement

Patients who have total hip or total knee replacement surgery are at higher risk for myocardial infarction (MI) afterward, according to a new study.

Researchers performed a retrospective cohort study using data from national registries in Denmark to compare the timing of MI in patients who had total knee or total hip replacement with that of matched controls. Patients who had a primary total knee or total hip replacement surgery from Jan. 1, 1998 through Dec. 31, 2007 were each matched by age, sex and geographic region with three controls who had not had surgery. Controls and patients were all followed for acute MI. Hazard ratios (HRs) were calculated and adjusted for disease and medication history. The study results were published online July 23 by Archives of Internal Medicine.

A total of 95,227 patients were included in the study, 66,524 who had total hip replacement and 28,703 who had total knee replacement. They were matched with 286,165 controls. Total hip patients had a mean age of 71.9 years, and 39.6% were men; total knee patients had a mean age of 67.2 years, and 37.6% were men. Within the first two weeks after surgery, total hip patients and total knee patients had a higher risk for MI compared with controls (adjusted HRs, 25.5 and 3.09, respectively). Total hip patients continued to have an elevated risk two to six weeks after surgery (adjusted HR, 5.05), but risk in total knee patients did not differ from controls after two weeks had passed. Total hip patients had an absolute six-week risk for MI of 0.51%, compared with 0.21% in total knee patients.

The authors noted that they did not have data on other risk factors for acute MI, such as body mass index and smoking; inpatient use of anticoagulant medications; or use of general anesthesia, among other limitations. However, they concluded that compared with controls, patients who undergo total hip or total knee replacement surgery have a much higher risk for acute MI within the first two postoperative weeks. "Risk assessment of [acute] MI should be considered during the first 6 weeks after THR surgery and during the first 2 weeks after TKR surgery," the authors wrote.

An accompanying commentary pointed out that cardiac risk is higher in general after surgery and said that physicians must actively work to decrease that risk. "It is important for physicians caring for patients in the perioperative period to recognize the potential for cardiac morbidity and mortality and then appropriately use the armamentarium of medical therapies we now have to reduce cardiac risk, prevent perioperative MIs, and prevent cardiac deaths," the commentary author wrote.



Testing


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USPSTF updates guidance on screening electrocardiography

The U.S. Preventive Services Task Force (USPSTF) recently updated its recommendations on screening for coronary heart disease (CHD) using electrocardiography (ECG).

According to the current recommendations, asymptomatic adults at low risk for CHD events should not be screened with resting or exercise ECG. For asymptomatic patients at intermediate or high risk, the evidence is insufficient to balance benefits and harms of ECG screening, the USPSTF found. The recommendations were published in Annals of Internal Medicine on July 31.

annals.jpg

The recommendations are an update of the task force's 2004 recommendations, which came to the same conclusions. The task force said that for low-risk patients, ECG screening is unlikely to provide additional information beyond that available from conventional risk assessment methods, such as the Framingham ATP III calculator. Higher-risk patients should receive risk factor modification, regardless of ECG findings. Potential harms from screening include unnecessary invasive procedures, overtreatment and labeling.

The recommendation not to screen low-risk patients was a D recommendation, made with moderate certainty. No organizations currently recommend ECG screening for low-risk patients, but "anecdotally, it is performed with some frequency," the task force noted.

ACP has recommended against the use of both resting and exercise ECG screening for patients at low risk for CHD as part of the College's High Value Cost-Conscious Care Initiative, and against the use of exercise ECG screening for patients at low risk for CHD in its contribution to the ABIM Foundation's Choosing Wisely campaign. Both of these efforts are focused on fostering the appropriate use of clinical tests to improve patient care while reducing the potential risks and costs associated with low-yield interventions.



Resources


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Disability benefits questionnaires for veterans available

The Department of Veterans Affairs has created a series of disability benefits questionnaires to speed the processing of disability compensation and pension claims and alleviate a current backlog of veterans' disability benefit claims.

The department is soliciting physicians' help in filling out the questionnaires, with the hope that the growing number of claims will move more quickly and efficiently through the system, ultimately helping veterans get the care they need.

The Disability Benefits Questionnaire program is part of the Joining Forces Campaign, a national initiative championed by First Lady Michelle Obama and Dr. Jill Biden that aims to give service members and their families opportunities and support in the areas of wellness, employment and education. ACP has joined the Joining Forces Campaign and supports the program's goals of helping to meet the neurological and psychological needs of service members and their families.



From the College


.
New module on chronic pain available on Medical Home Builder 2.0

A new Chronic Pain Management module has been added to the Medical Home Builder 2.0, ACP's online tool that enables clinicians and staff members to measure and, where needed, improve patient care and office workflow based on the Patient-Centered Medical Home model.

The Chronic Pain Management module explains how to develop and maintain office procedures to guide the care of patients with chronic pain, helping to minimize risk while ensuring that patients receive optimum care. More information on the Chronic Pain Management module on the Medical Home Builder 2.0 is available online.


.
ACP announces Colombia Chapter

ACP is pleased to announce the establishment of a new ACP Colombia Chapter.

The Asociación Colombiana de Medicina Interna (ACMI) submitted a formal request to establish an ACP chapter in Colombia and formed a steering committee to lead this initiative. The ACP Board of Regents has approved the proposal to establish a chapter and Roberto Esguerra, MD, FACP, has been appointed Interim Governor. Dr. Esguerra will oversee leadership for the new chapter and will serve as the point of contact between College staff and ACP members in Colombia. More information about the Colombian chapter is available online.



Cartoon caption contest


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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-20120731-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.'"

This issue's winning cartoon caption was submitted by Joseph Brett West, MD, ACP Associate Member, Phoenix, Ariz. Thanks to all who voted! The winning entry captured 49.4% of the votes.

The runners-up were:

"But ibuprofen is working great for my arthritis!"

"These new bariatric surgeries are getting ridiculous."


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MKSAP Answer and Critique



The correct answer is C) Hemodialysis, plasmapheresis, and chemotherapy. This item is available to MKSAP 15 subscribers as item 44 in the Nephrology section.

MKSAP 16 releases Part A today. More information is available online.

This patient has multiple myeloma, which is characterized by kidney failure, anemia, proteinuria, and a monoclonal protein in the plasma and urine. This patient's bilaterally enlarged kidneys also are consistent with multiple myeloma. The most appropriate next step is hemodialysis, plasmapheresis, and chemotherapy.

The most common cause of kidney failure in multiple myeloma is myeloma kidney, which manifests as chronic kidney failure that results from tubular injury and intratubular cast formation and obstruction. This patient's light chain excretion is characteristic of myeloma cast nephropathy. Initial management in patients with myeloma cast nephropathy should include volume expansion, alkalinization of the urine, discontinuation of nephrotoxic agents, and avoidance of radiocontrast agents. In this patient with evidence of fluid overload and no hypercalcemia, volume expansion is not necessary and may be hazardous.

The goal of therapy for patients with myeloma kidney is to remove the light chains as quickly as possible by decreasing their production with chemotherapy and enhancing their removal with plasmapheresis. Dialysis also is appropriate for patients with symptomatic uremia. The 2-month mortality rate of patients with multiple myeloma who undergo dialysis is 30%, but those who survive have a median life expectancy of 2 years. Hemodialysis or peritoneal dialysis can be performed, but the same catheter used for plasmapheresis can be used for hemodialysis.

Finally, approximately 10% of patients with myeloma kidney who undergo plasmapheresis recover kidney function and do not require chronic dialysis. Furthermore, this intervention is associated with minimal side effects.

Key Point

  • Chemotherapy and plasmapheresis are indicated for patients with myeloma kidney and may be accompanied by dialysis in those with symptomatic uremia.

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Test yourself

A 50-year-old man is evaluated in follow-up for a recent diagnosis of cirrhosis secondary to nonalcoholic steatohepatitis. He has a history of asthma, type 2 diabetes mellitus, hyperlipidemia, and obesity. His current medications are inhaled fluticasone, montelukast, insulin glargine, insulin lispro, simvastatin, and lisinopril. Following a physical exam, lab studies, and upper endoscopy, what is the most appropriate treatment?

Find the answer

MKSAP 16 Holiday Special: Save 10%

MKSAP 16 Holiday Special:  Save 10%

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Maintenance of Certification:

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Maintenance of Certification: What if I Still Don't Know Where to Start?

Because the rules are complex and may apply differently depending on when you last certified, ACP has developed a MOC Navigator. This FREE tool can help you understand the impact of MOC, review requirements, guide you in selecting ways to meet the requirements, show you how to enroll, and more. Start navigating now.