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

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ACP InternistWeekly



In the News for the Week of August 21, 2012




Highlights

Treatment of mild hypertension is not associated with improved outcomes

Treating patients with mild hypertension for primary prevention does not significantly reduce their morbidity or mortality, according to a new Cochrane review. More...

Lung cancer risk model better predictor than smoking or family history

The Liverpool Lung Project risk model was a better predictor than smoking history or family history for determining whether to send a patient for computed tomography lung cancer screening, a study found. More...


Test yourself

MKSAP Quiz: managing systemic lupus erythematosus during pregnancy

This week's quiz asks readers to advise a 29-year-old pregnant woman with systemic lupus erythematosus. More...


Prostate cancer

Benefit of PSA screening diminished in an analysis of ERSPC data using QALYs

A new analysis quantified the effects of prostate-specific antigen (PSA) screening on men's quality of life. More...


Cardiology

CABG associated with nearly three times the stroke risk of PCI

Coronary revascularization by coronary artery bypass graft (CABG) compared with percutaneous coronary intervention (PCI) is associated with an increased risk of stroke, a meta-analysis found. More...

Warfarin associated with lower stroke, systemic thromboembolism risk in patients with both afib and CKD

The addition of chronic kidney disease (CKD) to atrial fibrillation is associated with an increased risk of stroke or systemic thromboembolism and bleeding. Warfarin treatment was associated with decreasing this risk, a new study found. More...


Hepatitis screening

CDC recommends hepatitis C screening for all patients born from 1945 to 1965

The Centers for Disease Control and Prevention recommends that all Americans born between 1945 and 1965 should have a one-time screening for hepatitis C, according to new recommendations published in Annals of Internal Medicine. More...


Influenza update

Next season's flu vaccine approved

The influenza vaccine formulation for the 2012-2013 season has been approved, the FDA announced last week. More...

Seasonal flu vaccine tool available

The HealthMap Vaccine Finder, a Web-based flu vaccine locator which helps physicians post their flu vaccine services, has been redesigned and is now available online. More...


Practice management

New rule to simplify electronic payment transactions

The Department of Health and Human Services has released a new rule meant to facilitate the ability of physician practices to receive claim payments electronically and reduce the burden and cost faced by practices in reconciling payments from their different payers. More...


From ACP Hospitalist

The August issue of ACP Hospitalist is online

The August issue of ACP Hospitalist is online and includes stories on patient-centered care, atrial fibrillation, and more. More...


From the College

Apply for the 2013 Health Policy Internship

Applications are now being accepted for the 2013 ACP Health Policy Internship program. 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: Daisy Smith, MD, FACP



Highlights


.
Treatment of mild hypertension is not associated with improved outcomes

Treating patients with mild hypertension for primary prevention does not significantly reduce their morbidity or mortality, according to a new Cochrane review.

The review included four randomized controlled trials with almost 9,000 participants, in which antihypertensive drugs were compared to placebo. Participants had no cardiovascular disease and mildly elevated blood pressure (systolic 140 to 159 mm Hg and/or diastolic 90 to 99 mm Hg).

The review was published by The Cochrane Library on Aug. 15.

Antihypertensive drug treatment for four or five years resulted in a nonsignificant decrease in mortality (relative risk [RR], 0.85; 95% CI, 0.63 to 1.15). Compared to those taking placebo, patients on antihypertensives also had similar risks of coronary heart disease (RR, 1.12; 95% CI, 0.80 to 1.57), stroke (RR, 0.51; 95% CI, 0.24 to 1.08) and total cardiovascular events (RR, 0.97; 95% CI, 0.72 to 1.32). Treated patients were more likely to withdraw from medication due to adverse effects, however; 9% of them did so (RR, 4.80; 95% CI, 4.14 to 5.57).

Study authors concluded that antihypertensives have not been proven to significantly reduce any primary prevention outcome in patients with mild hypertension. They noted that the nonsignificant decreases found for mortality and stroke allow for the possibility of benefit if a larger number of patients and events could be studied.

The authors noted that it is difficult to get more definitive data because mild hypertension is usually associated with a low risk of adverse events, but they called for a large randomized controlled trial in this patient population to better assess the risks and potentially find a cutoff point at which hypertension treatment provides benefit.

The review's findings conflict with current hypertension treatment guidelines in the U.S., Canada and Europe, the authors noted. If patients were aware of the evidence regarding drug treatment of mild hypertension, many might choose nondrug treatment, the review authors speculated. Physicians should also advise patients of the risk of adverse effects from treatment, they advised.


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Lung cancer risk model better predictor than smoking or family history

The Liverpool Lung Project risk model was a better predictor than smoking history or family history for determining whether to send a patient for computed tomography (CT) lung cancer screening, a study found.

annals.jpg

To evaluate the discrimination of the risk model and demonstrate its predicted benefit, researchers used data from three case-control and prospective cohort studies: the European Early Lung Cancer (EUELC) and Harvard case-control studies and the Liverpool Lung Project population-based prospective cohort (LLPC) study.

Results appeared in the Aug. 21 Annals of Internal Medicine.

The Liverpool Lung Project risk model had higher discriminative ability across the three data sets than smoking duration or family history of lung cancer, researchers reported. The Liverpool Lung Project model had modest discrimination in the EUELC data set (area under the curve [AUC], 0.67; 95% CI, 0.64 to 0.69) and good discrimination in both the Harvard (AUC, 0.76; 95% CI, 0.75 to 0.78) and LLPC (AUC, 0.82; 95% CI, 0.80 to 0.85) data sets.

The AUC for smoking duration, the strongest of the individual risk factors, was 0.63, 0.74, and 0.72 in the EUELC, Harvard, and LLPC data sets, respectively. The Liverpool Lung Project risk model had moderate overall calibration and improved accuracy at higher values of predicted risks, the authors noted.

At a threshold of 5% absolute risk, the model achieved a higher proportion of true-positive classifications than a screen-all strategy (2.3% higher for the LLPC data and 3% higher for the EUELC data) with the same proportion of false-positive classifications. The Liverpool Lung Project risk model provided greater net benefit than all alternative strategies at thresholds of absolute risk ranging from 3% to 15%.

Researchers wrote, "Identifying a single average risk threshold for a population is often difficult because of a lack of data on harms, benefits, and actual outcomes in a screened population. Unlike cardiovascular disease, for which a 10-year risk of 20% has been recommended to stratify patients as high-risk, no consensus is available in cancer screening."

Retrospective analysis of data from screening studies in Europe and the U.K. may help to standardize the risk threshold at which to recommend population-based CT screening, the authors concluded.



Test yourself


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MKSAP Quiz: managing systemic lupus erythematosus during pregnancy

A 29-year-old woman with systemic lupus erythematosus (SLE) is evaluated in the office after obtaining positive results on a home pregnancy test. She has a 1-month history of nausea but is otherwise asymptomatic. Her last menstrual period was 2 months ago. This is her first pregnancy. Her SLE is well controlled with hydroxychloroquine, and her last flare was 10 months ago.

mksap.jpg

On physical examination, temperature is 36.2 °C (97.2 °F), blood pressure is 110/72 mm Hg, pulse rate is 76/min, and respiration rate is 16/min. Physical examination is normal. A repeat pregnancy test is positive.

Laboratory studies:

Hemoglobin 12.1 g/dL (121 g/L)
Leukocyte count 5400/µL (5.4 × 109/L)
Platelet count 342,000/µL (342 × 109/L)
Serum creatinine 0.7 mg/dL (53.4 µmol/L)
Serum complement (C3 and C4) Normal
Antinuclear antibodies Titer of 1:2560
Anti-Ro/SSA antibodies Positive
Anti–double-stranded DNA antibodies Negative
Anti-Smith antibodies Positive
Urinalysis Normal

She seeks advice on how to manage her SLE during her pregnancy.

Which of the following is the most appropriate management of this patient?

A) Discontinue hydroxychloroquine
B) Recommend termination of pregnancy
C) Start prednisone
D) No change in management

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


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Prostate cancer


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Benefit of PSA screening diminished in an analysis of ERSPC data using QALYs

A new analysis quantified the effects of prostate-specific antigen (PSA) screening on men's quality of life.

Researchers used follow-up data from the European Randomized Study of Screening for Prostate Cancer (ERSPC) to predict how PSA screening would affect prostate cancer diagnoses, deaths, treatments and men's quality-adjusted life-years.

The results were published in the Aug. 16 New England Journal of Medicine.

The simulation found that if 1,000 men were PSA-screened annually between the ages of 55 and 69, the result would be nine fewer deaths from prostate cancer (a 28% reduction), 14 fewer men receiving palliative therapy (35% reduction) and a total gain of 73 life-years (an average of 8.4 life-years for every avoided death).

When the researchers adjusted those life-years to account for the negative effects of treatment and diagnosis, they concluded that 56 quality-adjusted life-years (QALYs) were gained by screening (range, −21 to 97). Adding men age 70 to 74 to the screening population would increase the overall number of life-years gained to 82, but would not change the number of QALYs.

Overdiagnosis of prostate cancer was the largest contributor to the difference between life-years and QALYs. The researchers called for development of strategies to reduce overdiagnosis and identify aggressive cancers, as well as consideration of comorbidity status in screening decisions. The current evidence is insufficient to make universal recommendations about PSA screening, they said.

"It is essential to await longer follow-up data from the ERSPC, as well as longer-term data on how treatment and active surveillance affect long-term quality of life," they wrote.

However, the study could "show the way to a resolution of the long-standing controversy about screening," according to an accompanying editorial. The study shows that the benefits and harms of screening can be quantified in a single measure and weighed based on how a man would value his life in various health states. Further research would be needed to assess this measure on a universal scale, but right now, shared decision making about PSA screening can allow for consideration of patients' potential gain or loss in quality-adjusted life, the editorial said.



Cardiology


.
CABG associated with nearly three times the stroke risk of PCI

Coronary revascularization by coronary artery bypass graft (CABG) compared with percutaneous coronary intervention (PCI) is associated with an increased risk of stroke, a meta-analysis found.

Researchers performed a meta-analysis of 19 trials in which 10,944 patients were randomized to either procedure. The primary end point was the 30-day rate of stroke. They also determined the rate of stroke at the midterm follow-up and investigated whether there was an interaction between either procedure and the extent of coronary artery disease on the relative risk of stroke.

Results appeared in the Aug. 21 issue of the Journal of the American College of Cardiology.

The 30-day rate of stroke was 1.20% after CABG compared with 0.34% after PCI (odds ratio, 2.94; 95% CI, 1.69 to 5.09; P<0.0001). Similar results were observed after a median follow-up of 12.1 months (1.83% vs. 0.99%; odds ratio, 1.67; 95% CI, 1.09 to 2.56; P=0.02).

The extent of coronary artery disease (single vessel vs. multivessel vs. left main) did not affect the relative increase in the risk of stroke observed with CABG compared with PCI at either 30 days (P=0.57 for interaction) or midterm follow-up (P=0.08 for interaction), the authors noted.

Similar findings were observed when results from 27 studies, including 33,980 patients enrolled in observational studies, were analyzed. Patients treated with CABG had an increased risk of stroke compared with PCI both at 30 days and at a median follow-up of 14.2 months. Patients treated with CABG have an excess of seven strokes for every 1,000 patients treated, the authors concluded.


.
Warfarin associated with lower stroke, systemic thromboembolism risk in patients with both afib and CKD

The addition of chronic kidney disease (CKD) to atrial fibrillation is associated with an increased risk of stroke or systemic thromboembolism and bleeding. Warfarin treatment was associated with decreasing this risk, a new study found.

Researchers collected data on all patients discharged from Danish hospitals with a diagnosis of nonvalvular atrial fibrillation between 1997 and 2008. Of the more than 130,000 patients studied, 2.7% had non-end-stage CKD and an additional 0.7% were on renal-replacement therapy at the time of hospitalization.

The study was published in the New England Journal of Medicine on Aug. 16.

The kidney disease and atrial fibrillation patients had a significantly increased risk of stroke or systemic thromboembolism compared to those with only atrial fibrillation (hazard ratio for non-end-stage group, 1.49; 95% CI, 1.38 to 1.59; hazard ratio for renal-replacement group, 1.83; 95% CI, 1.57 to 2.14). Taking warfarin appeared to reduce this risk (to a similar degree as in non-kidney-disease patients), but aspirin did not. The kidney disease group also had an increased risk of bleeding, which was further increased by both aspirin and warfarin.

The risk of stroke and thromboembolism was not affected by the severity of the kidney disease, the researchers noted, but the bleeding risk increased with larger doses of loop diuretics. Because warfarin was found both to reduce clot risk and increase bleeding risk, careful assessment is required to determine its likely effects in individual patients with kidney disease, the authors said. A clinical trial should be conducted to more precisely determine the effects of warfarin in these patients.

The authors also called for clinical trials of oral anticoagulants in patients with chronic kidney disease. Thus far, trials of these new drugs have largely excluded patients with kidney disease. The authors cautioned that their conclusions were limited by the observational nature of the trial and the availability of over-the-counter aspirin, among other factors.



Hepatitis screening


.
CDC recommends hepatitis C screening for all patients born from 1945 to 1965

The Centers for Disease Control and Prevention recommends that all Americans born between 1945 and 1965 should have a one-time screening for hepatitis C virus (HCV), according to new recommendations published in Annals of Internal Medicine.

annals.jpg

About 2.7 to 3.9 million people in the U.S. are infected with HCV and approximately 45% to 85% of those with HCV are unaware that they are infected. The CDC also recommends that all persons identified with HCV should receive a brief alcohol screening and intervention and be referred to the appropriate care and treatment services for HCV.

The full CDC statement is available online. ACP Internist's July/August issue offered full coverage of how to handle HCV patients in an office setting.



Influenza update


.
Next season's flu vaccine approved

The influenza vaccine formulation for the 2012-2013 season has been approved, the FDA announced last week.

Based on virus samples and global disease patterns, the strains selected for inclusion in the 2012-2013 flu vaccines are:

  • A/California/7/2009 (H1N1)-like virus
  • A/Victoria/361/2011 (H3N2)-like virus
  • B/Wisconsin/1/2010-like virus.

The H1N1 virus is the same as in the 2011-2012 influenza vaccines, but the other included strains differ from those in last year's vaccines, according to an FDA press release.

The manufacturers licensed to produce the 2012-2013 flu vaccines and the brand names of the vaccines for the upcoming flu season are:

  • Afluria, manufactured by CSL Limited;
  • Fluarix, manufactured by GlaxoSmithKline Biologicals;
  • FluLaval, manufactured by ID Biomedical Corporation;
  • FluMist, manufactured by MedImmune Vaccines Inc.;
  • Fluvirin, manufactured by Novartis Vaccines and Diagnostics Limited; and
  • Fluzone, Fluzone High-Dose and Fluzone Intradermal, manufactured by Sanofi Pasteur.

The CDC's Advisory Committee on Immunization Practices recommends that everyone six months of age and older receive an annual influenza vaccine.


.
Seasonal flu vaccine tool available

The HealthMap Vaccine Finder, a Web-based flu vaccine locator which helps physicians post their flu vaccine services, has been redesigned and is now available online.

The portal, offered by the U.S. Department of Health and Human Services, allows physicians to enter information on their vaccine services into the online database that can be accessed to by the public.

Although the website can be updated at any time, physicians are encouraged to submit their information by Aug. 22, before the public launch of the website on Aug. 27. The website will play a significant role in helping patients access clinicians committed to improving the public health of their communities.

More information is available online.



Practice management


.
New rule to simplify electronic payment transactions

The Department of Health and Human Services (HHS) has released a new rule meant to facilitate the ability of physician practices to receive claim payments electronically and reduce the burden and cost faced by practices in reconciling payments from their different payers.

Currently, electronic payment involves two separate sets of transactions: one to move the money to the bank account, and a separate transaction to send an explanation of the payment. It can be difficult for practices to match the two separate transactions to each other. The new rule establishes a set of standards that will allow practices to match automatically the two transactions with each other.

The new rule also establishes uniform guidelines across health plans regarding both the application process for practices to receive payments electronically and the format of "companion guides" explaining how practices can engage in these electronic payment transfers.

Most of the responsibility for the changes will be up to the health plans and practices can continue to receive these transactions on paper if they choose. The new rule is set to go into effect on Jan. 1, 2014. Additional information can be found on the HHS website.



From ACP Hospitalist


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The August issue of ACP Hospitalist is online

The August issue of ACP Hospitalist is online and includes stories about the following:

  • Patient-centered care: Not just a catchphrase. The Joint Commission began including patient-centered standards in accreditation decisions in July. The benefits of such care include, of course, gains in patient satisfaction, but research also suggests it can reduce readmissions. But what, exactly, does patient-centeredness mean in practice? This cover story looks at the concrete steps hospitals and hospitalists can take to ensure care is focused on the desires and best interests of patients and their families.
  • Afib initiative strives to close a quality gap. The connection between atrial fibrillation and stroke is often overlooked, but hospitalists should be aware that having one condition is good reason to check for the other. Our MKSAP Quiz also focuses on atrial fibrillation.
  • Present like a pro. It's not covered in medical school, but the ability to give a good presentation can make or break a career. Public speaking guru Scott Litin, MD, MACP, offers tips on how to wow the crowd, whether at a national meeting or in the halls of the hospital during rounds.


From the College


.
Apply for the 2013 Health Policy Internship

Applications are now being accepted for the 2013 ACP Health Policy Internship program.

The internship, which takes place in the spring of 2013, provides one Associate Member and one Medical Student Member with the opportunity to gain legislative knowledge and advocacy skills while working with the College's Washington office to prepare for ACP's annual Leadership Day. Applications are due by Oct. 22. Additional information can be found 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-20120821-cartoon.jpg

"Don't worry, sir, your condition is not 'hoop-less.'"

"… so they shortened it to Levitra, but really, the concept is the same."

"We usually refer 'floaters' to our ophthalmologist."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service.


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MKSAP Answer and Critique



The correct answer is D) No change in management. This item is available to MKSAP 15 subscribers as item 66 in the Rheumatology section.

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

This patient has systemic lupus erythematosus (SLE) and is in her first trimester of pregnancy, but her disease is well controlled with hydroxychloroquine. No change in treatment is warranted. She has had no symptoms of SLE for 10 months and currently has no signs of active disease, such as anemia, leukopenia, thrombocytopenia, hypocomplementemia, or anti–doubled-stranded DNA antibodies. She does have antinuclear, anti-Smith, and anti-Ro/SSA antibodies, but the presence of these autoantibodies does not vary with disease activity. Anti-Ro/SSA antibodies may be associated with congenital heart block in the fetus, and pregnant patients with these antibodies should undergo fetal echocardiography starting at 16 weeks of pregnancy.

Hydroxychloroquine is a U.S. Food and Drug Administration category C agent in pregnancy. However, this agent is useful for preventing SLE flares, and expert opinion considers use of this agent to be appropriate during pregnancy because the benefits outweigh the risks. Discontinuation of this agent is therefore not needed in this patient.

Patients with SLE whose disease has been quiescent for at least 6 months, during which time they either did not use medications for SLE or used medications that can safely be continued during pregnancy, generally have positive pregnancy outcomes. Therefore, there is no need to recommend termination of this patient's pregnancy.

Pregnancy may trigger SLE flares, and, if needed, prednisone can be used during pregnancy. However, the addition of prednisone would not be warranted in a patient with no signs of active SLE, and corticosteroids generally are not used prophylactically.

Key Point

  • Hydroxychloroquine is safe to use in pregnancy and is useful for preventing systemic lupus erythematosus flares.

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Test yourself

A 72-year-old woman is evaluated during a routine examination. She has very severe COPD with multiple exacerbations. She has dyspnea at all times with decreased exercise capacity. She does not have cough or any change in baseline sputum production. She is adherent to her medication regimen, and she completed pulmonary rehabilitation 1 year ago. She quit smoking 1 year ago. Her medications are a budesonide/formoterol inhaler, tiotropium, and an albuterol inhaler as needed. Following a physical and pulmonary exam, what is the most appropriate next step in management?

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