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

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ACP InternistWeekly



In the News for the Week of August 14, 2012




Highlights

Antihypertensives associated with increased lip cancer risk

Antihypertensive drugs are linked to an increased risk for lip cancer, a new study has found. More...

Evidence insufficient on screening for age-related hearing loss, Task Force reports

Available evidence on screening for age-related hearing loss is insufficient to recommend for or against the practice in asymptomatic adults, the U.S. Preventive Services Task Force concluded this week. More...


Test yourself

MKSAP Quiz: 6-month history of cough

A 27-year-old man is evaluated for a 6-month history of cough, which is worse at night and after exposure to cold air. Often his cough is brought on by taking a deep breath or by laughter. What would likely provide the diagnosis of this patient's chronic cough? More...


Diabetes

Statins' benefits outweigh their association with diabetes incidence

Statins' benefits outweigh the risk of diabetes for patients taking the drugs for secondary prevention and those at high risk of major adverse coronary events, a study found. More...

Screening detected unknown diabetes in one-fourth of elective surgery patients

Among elective surgery patients, nearly one-fourth (24%) were diagnosed with previously unknown diabetes or pre-diabetes based on blood tests conducted while they were fasting pre-operatively, researchers found. More...

Intensive blood pressure targets didn't reduce mortality in type 2 diabetes

Intensive hypertension treatment slightly reduced the risk of stroke in type 2 diabetics, but had no effect on mortality or myocardial infarction, a new review found. More...


Practice management

Still time to participate in PQRS for 2012

A new reporting period for the Physician Quality Reporting System (PQRS) began on July 1, and there is still time to report and qualify for a bonus payment for 2012, even if you have not already begun reporting for this year. More...


From the College

New high-value, cost-conscious care curriculum available for internal medicine residents

ACP and the Alliance for Academic Internal Medicine have a curriculum for training internal medicine residents to practice high value, cost-conscious care to avoid overuse and misuse of tests and treatments that do not improve outcomes and may cause harm. More...


Cartoon caption contest

Put words in our mouth

ACP InternistWeekly wants readers to create captions for our new cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service. More...


Physician editor: Philip Masters, MD, FACP



Highlights


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Antihypertensives associated with increased lip cancer risk

Antihypertensive drugs are linked to an increased risk for lip cancer, a new study has found.

Researchers used data from the Kaiser Permanente Medical Care Program in northern California to examine whether an association existed between antihypertensive drugs, many of which are photosensitizing, and lip cancer. Data on cancer incidence and antihypertensive prescriptions dispensed between Aug. 1, 1994 and Feb. 29, 2008 were evaluated, and patients with lip cancer were matched with controls by age, sex and year of cohort entry.

Hydrochlorothiazide, triamterene, lisinopril, and nifedipine are photosensitizing drugs, while atenolol is not. The authors determined use of hydrochlorothiazide (with or without triamterene), lisinopril, nifedipine and atenolol two or more years before lip cancer diagnosis or the control index date and evaluated any association, focusing on duration of therapy. Matched case-control sets were analyzed using logistic regression while controlling for cigarette smoking.

The study results were published online Aug. 6 by Archives of Internal Medicine.

Overall, a total of 712 patients with lip cancer and 22,904 controls were included in the study. Approximately three-quarters of participants were men. Patients who had received an organ transplant, patients who had HIV infection, and patients who were not of non-Hispanic white ethnicity were excluded.

Compared with no use of antihypertensive therapy, odds ratios for developing lip cancer after five years of being prescribed a specific antihypertensive drug (taken with or without other antihypertensive agents) were 4.22 (95% confidence interval [CI], 2.82 to 6.31) for hydrochlorothiazide, 2.82 (95% CI, 1.74 to 4.55) for hydrochlorothiazide-triamterene, 1.42 (95% CI, 0.95 to 2.13) for lisinopril, 2.50 (95% CI, 1.29 to 4.84) for nifedipine, and 1.93 (95% CI, 1.29 to 2.91) for atenolol.

The authors performed a separate analysis of patients who received atenolol, excluding individuals who had received any of the other drugs, and found an odds ratio of 0.54 (95% CI, 0.07 to 4.08) for at least five years of exposure, which is consistent with its lack of photosensitizing properties. Risk seemed to increase with duration of use for hydrochlorothiazide, hydrochlorothiazide-triamterene, and nifedipine, while the risk with lisinopril appeared to be highest at one to five years of use. In multivariable analysis adjusted and unadjusted for cigarette smoking, use of hydrochlorothiazide, hydrochlorothiazide-triamterene, and nifedipine remained statistically significantly associated with lip cancer, while lisinopril's association was no longer statistically significant.

The authors acknowledged that they were not able to adjust for sun exposure, and that the database used in their study did not allow analysis of lip cancer risk by histological type (basal-cell, squamous-cell, or melanoma), among other limitations. They also stressed that their results do not establish a causal relationship and they called for further studies to confirm their findings.

However, they concluded that physicians who prescribe photosensitizing drugs should determine their patients' existing risk for lip cancer and make them aware of the importance of lip protection.

"Although not confirmed by clinical trials, likely preventive measures are simple: a hat with a sufficiently wide brim to shade the lips and lip sunscreens," they wrote.


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Evidence insufficient on screening for age-related hearing loss, Task Force reports

Available evidence on screening for age-related hearing loss is insufficient to recommend for or against the practice in asymptomatic adults, the U.S. Preventive Services Task Force (USPSTF) concluded this week.

annals.jpg

In 1996, the USPSTF recommended that physicians should periodically question older adults about their hearing, counsel them about hearing aids and provide referrals when appropriate. To update this recommendation, the USPSTF reviewed studies from 1950 through January 2010 on screening for age-related hearing impairment among adults age 50 years or older who did not yet have diagnosed hearing loss.

The new recommendation was published online Aug. 14 by Annals of Internal Medicine.

Evidence on the association between screening and improved health outcomes; the accuracy of screening methods; the benefits of early detection; the effectiveness of treatment; and the harms of screening and treatment was considered. The review did not consider congenital hearing loss, conductive hearing loss, or hearing loss due to occupational exposure or acute trauma.

Since the 1996 recommendation was developed, the USPSTF said, a randomized, controlled trial showed that screening for hearing loss does not seem to benefit patients without symptoms, and more research is needed before definitive conclusions can be reached. Therefore, the USPSTF concluded that current evidence is insufficient to assess the balance of benefits and harms of screening for hearing loss in asymptomatic adults 50 years of age and older.



Test yourself


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MKSAP Quiz: 6-month history of cough

A 27-year-old man is evaluated for a 6-month history of cough, which is worse at night and after exposure to cold air. Often his cough is brought on by taking a deep breath or by laughter. He does not have postnasal drip, wheezing, or heartburn. He has a strong family history of allergies.

Physical examination, chest radiograph, and spirometry are normal. He receives no benefit from a 3-month trial of gastric acid suppression therapy, intranasal corticosteroids, and an antihistamine-decongestant combination.

Which of the following would likely provide the diagnosis of this patient's chronic cough?

A) 24-Hour esophageal pH monitoring
B) Bronchoscopy
C) CT scan of the chest
D) CT scan of the sinuses
E) Trial of inhaled albuterol

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


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Diabetes


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Statins' benefits outweigh their association with diabetes incidence

Statins' benefits outweigh the risk of diabetes for patients taking the drugs for secondary prevention and those at high risk of major adverse coronary events, a study found.

Researchers used data from the Taiwan National Health Insurance Research Database (a universal, state-operated health program covering more than 98% of the population) and focused on men 45 years or older and women 55 years and older. There were 8,412 and 33,648 eligible subjects in the statin (30 days or more of use) and control groups (nonusers).

Controls were matched to statin users on a 4:1 ratio by age, sex, atherosclerotic comorbidities, and year of their entry. Study outcomes were diabetes, major adverse cardiovascular events (the composite of myocardial infarction and ischemic stroke), and in-hospital deaths.

Results were published online Aug. 8 by the Journal of the American College of Cardiology.

There were 5,754 cases of incident diabetes during the median follow-up of 7.2 years. Statin use increased diabetes rates (hazard ratio [HR], 1.15; 95% CI, 1.08 to 1.22; P<0.001). There were 769 myocardial infarctions, 2,961 ischemic strokes, and 3,484 in-hospital deaths in the total study population.

Statin users had fewer myocardial infarctions, (HR, 0.82; 95% CI, 0.68 to 0.98; P=0.028) and a trend toward fewer ischemic strokes (HR, 0.94; 95% CI, 0.86 to 1.03; P=0.176), leading to overall fewer major adverse cardiovascular events (HR, 0.91; 95% CI, 0.84 to 0.99; P=0.031) and in-hospital deaths (HR, 0.61; 95% CI, 0.55 to 0.67; P<0.001)

To evaluate the prognoses of diabetic subjects after exposure, four groups were created: nondiabetic controls (n=29,332), diabetic controls (n=4,316), diabetic patients with prior statin use (n=1,387) and nondiabetic patients with prior statin use (n=7,025). Major adverse cardiovascular events were 12, 21, 16 and 12 per 1,000 person-years, respectively, and the annual in-hospital mortality rates were 1.4%, 2.0%, 1.6% and 0.8%, respectively.

Overall risk-benefit analysis showed that statin treatment was favorable in high-risk (HR, 0.89; 95% CI, 0.83 to 0.95) and secondary prevention (HR, 0.89; 95% CI, 0.83 to 0.96) populations, the researchers reported. In general, treatment of statins prevented one fatal event in 202 subjects and led to one case of diabetes in 301 patients per year, concluded researchers.

Researchers cautioned that the incidence of diabetes in this study was 21 per 1,000 person-years, relatively more than what has been reported in other research. This, and reports of ethnic differences in diabetes occurrence and susceptibility to statins, may have resulted in overestimation of the potential risk for diabetes against the benefits of statins. Continuous surveillance for dysglycemia should be incorporated into care to optimize overall risk management, researchers added.


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Screening detected unknown diabetes in one-fourth of elective surgery patients

Among elective surgery patients, nearly one-fourth (24%) were diagnosed with previously unknown diabetes or pre-diabetes based on blood tests conducted while they were fasting pre-operatively, researchers found.

To assess whether diabetes testing could be incorporated into the elective surgical work-up, researchers conducted a prospective observational study among 275 patients undergoing elective total knee or hip arthroplasty or elective lumbar decompression and/or fusion who had a preoperative visit between December 2007 and November 2008 at a large Wisconsin academic medical center.

The mean patient age was 60.3 years, and 88% had a body-mass index greater than 25 kg/m2. All of the patients had insurance; 97% had a primary care provider, and 96.6% of patients had seen a primary provider within the past year. Fasting blood glucose was drawn immediately before surgery, and patients with preoperative fasting blood glucose greater than 100 mg/dL had another blood sample taken six to eight weeks postoperatively.

Results appeared online Aug. 7 at the Journal of Hospital Medicine.

In the study, 18% of patients had known diabetes or pre-diabetes, and 58% were normoglycemic. The other 24% were found to have previously unrecognized diabetes or impaired fasting glucose. Sixty-four percent of patients with fasting blood glucose greater than 100 mg/dL preoperatively remained elevated at their follow-up visit.

Researchers noted that with more than 1 million total knee and hip operations done in the U.S. annually, such screening could potentially identify more than a quarter-million previously unknown cases of diabetes or pre-diabetes. Considering that 70 million patients undergo ambulatory or inpatient procedures each year, if one quarter of them allowed for easy preoperative testing, then more than 4 million cases of diabetes and impaired fasting glucose could be found annually. Accountable care organizations may encourage such novel interventions, the authors noted.

Researchers said, "Remarkably, this statistic [24%] likely represents a 'best case scenario,' as the percent of undiagnosed patients is likely higher in uninsured patients, those without primary care visits, and those hospitalized for emergent or urgent reasons who, by definition, did not have an ambulatory preoperative evaluation, and who may also have greater severity of illness at baseline."


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Intensive blood pressure targets didn't reduce mortality in type 2 diabetes

Intensive hypertension treatment slightly reduced the risk of stroke in type 2 diabetics, but had no effect on mortality or myocardial infarction, a new review found.

Researchers conducted a meta-analysis of randomized trials comparing blood pressure treatment to intensive targets (upper limit 130 mmHg systolic and 80 mmHg diastolic) and standard targets (upper limit 140-160 mmHg and 85-100 mmHg diastolic) in patients with type 2 diabetes. The review covered five studies (including the UKPDS and ACCORD-BP trials) with more than 7,000 participants.

Results were published by the Archives of Internal Medicine on Aug. 7.

Using a random-effects model, the review authors found that patients treated to intensive targets did not significantly differ from standard-targeted patients in their rates of mortality (relative risk [RR], 0.76; 95% CI, 0.55 to 1.05) or myocardial infarction (RR, 0.93; 95% CI, 0.80 to 1.08). The intensive targets were associated with a decrease in the risk of stroke (RR, 0.65; 95% CI, 0.48 to 0.86). A pooled analysis of risk differences showed only a small absolute decrease in stroke risk (absolute risk, -0.01; 95% CI, -0.02 to -0.00) and no effect on mortality or myocardial infarction.

The researchers also looked at the benefits of standard blood pressure targets compared to historical treatment, defined as a blood pressure target higher than standard targets or as treatment in which a placebo or usual care was provided, and observed a much greater difference than they found between standard and intensive treatment. The number needed to treat to achieve benefit with intensive treatment is three-fold what it is for standard treatment compared to historical treatment, they calculated. They concluded that intensive blood pressure targets do not appear to reduce the risk of mortality or myocardial infarction.

Current guidelines recommend targets of 130/80 or less for patients with type 2 diabetes, the authors noted. Based on the review, they were not able to recommend a specific alternative target, but they suggested that their findings be considered in future guideline development.

According to an accompanying commentary, future guidelines are likely to suggest a target of 140/90 mmHg or less.

"Physicians need to understand and discuss these goals with their patients," the commentary author concluded.



Practice management


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Still time to participate in PQRS for 2012

A new reporting period for the Physician Quality Reporting System (PQRS) began on July 1, and there is still time to report and qualify for a bonus payment for 2012. If you have not already begun reporting for this year, there is still the option to use registry based reporting of one measures group to potentially qualify for an incentive payment equal to 0.5% of total Medicare Part B charges for the reporting period.

Additional information about PQRS and how to participate is available on the Running a Practice section of the ACP website.



From the College


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New high-value, cost-conscious care curriculum available for internal medicine residents

ACP and the Alliance for Academic Internal Medicine (AAIM) have developed and released a curriculum for training internal medicine residents to practice high value, cost-conscious care. The curriculum focuses on helping residents understand the potential benefits, harms and costs of medical interventions and enabling them to avoid overuse and misuse of tests and treatments that do not improve outcomes and may cause harm.

The curriculum is available for free download on a publicly accessible website. It is designed to engage residents and faculty in small group activities organized around actual patient cases that require careful analysis of the benefits, harms, and costs of intervention and the use of evidence-based, shared decision making. The flexible curriculum consists of 10 one-hour interactive sessions that can be incorporated into the existing conference structure of a program.

More information on ACP's High Value, Cost-Conscious Care Initiative is online.



Cartoon caption contest


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Put words in our mouth

ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

acpi-20120814-cartoon.jpg

E‑mail all entries to acpinternist@acponline.org. ACP staff will choose finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.


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MKSAP Answer and Critique



The correct answer is E) Trial of inhaled albuterol. This item is available to MKSAP 15 subscribers as item 93 in the Pulmonary and Critical Care Medicine section.

MKSAP 16 released Part A on July 31. More information is available online.

The patient has cough-variant asthma. A trial of inhaled albuterol could help control the patient's symptoms and confirm the diagnosis. The most common causes of chronic cough are asthma, postnasal drip syndrome (chronic sinusitis-rhinitis), and gastroesophageal reflux disease (GERD). Bronchoscopy and chest CT play no role in diagnosing cough due to these three causes. The diagnosis of cough-variant asthma is suggested by the presence of airway hyperresponsiveness and confirmed when cough resolves with asthma therapy.

Sensitivity to cold air is a clinical marker of airway hyperresponsiveness that can be confirmed with a methacholine challenge test. The methacholine challenge test has a negative predictive value of nearly 100% in the context of cough; this test is extremely useful in ruling out asthma, but because it has a poor positive predictive value, it is not very useful in patients with high prior probability of airway hyperresponsiveness. There is little about the character and timing of chronic cough due to GERD that distinguishes it from other conditions; in addition, it often can be "silent" from a gastrointestinal standpoint. However, the patient failed to benefit from 3 months of empiric gastric acid suppression therapy for GERD; therefore it is reasonable to rule out cough-variant asthma before pursuing 24-hour esophageal pH monitoring.

The patient does not have postnasal drip, purulent nasal secretions, sinus congestion, or other symptoms to suggest chronic or recurrent sinusitis and has not responded to treatment. Therefore, CT scan of the sinuses is not necessary. If the patient does not respond to albuterol, eosinophilic bronchitis should be considered as the cause of chronic cough, and bronchoscopy should be done to confirm that diagnosis.

Key Point

  • The diagnosis of cough-variant asthma is suggested by the presence of airway hyperresponsiveness and confirmed when cough resolves with a trial of inhaled albuterol.

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Test yourself

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

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