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ACP InternistWeekly



In the News for the Week of August 7, 2012




Highlights

No reason for higher HbA1c threshold to diagnose diabetes in blacks

Retinopathy occurs at lower hemoglobin A1c (HbA1c) levels in blacks than in whites, so there is no reason to recommend a higher HbA1c threshold for diagnosing diabetes in blacks, a study concluded. More...

Metastatic disease reduced in PSA screening era, study indicates

Prostate-specific antigen (PSA) screening reduced the number of men presenting with metastatic prostate cancer, a new study found. More...


Test yourself

MKSAP Quiz: 4-month history of tremor

This week's quiz asks readers to evaluate a 53-year-old woman with a 4-month history of tremor. More...


Endocrinology

Screen for cardiovascular risk factors in Cushing's patients who use glucocorticoids

People who use glucocorticoids and exhibit iatrogenic Cushing's syndrome should be aggressively targeted for early screening and management of cardiovascular risk factors, a study found. More...


Education

Course offered on healing health care disparities through education

Medical educators are invited to attend a two-day course featuring interactive methods for achieving the recently mandated integration of cross-cultural care into medical school and residency programs. More...

Handbook offers practical guidance on preventive health records

The Agency for Healthcare Research and Quality recently released a guide titled "An Interactive Preventive Care Record (IPHR): A Handbook for Using Patient-Centered Personal Health Records To Promote Prevention." More...


Antibiotics

Context affects physicians' antimicrobial prescribing decisions, study finds

Context can play a role in whether physicians decide to prescribe antimicrobials, according to a new study. More...


From the College

ACP, SGIM release paper on the ethics of the patient-centered medical home

ACP, in collaboration with the Society of General Internal Medicine (SGIM), recently released the position paper "The Patient-Centered Medical Home: An Ethical Analysis of Principles and Practice." 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


.
No reason for higher HbA1c threshold to diagnose diabetes in blacks

Retinopathy occurs at lower hemoglobin A1c (HbA1c) levels in blacks than in whites, so there is no reason to recommend a higher HbA1c threshold for diagnosing diabetes in blacks, a study concluded.

Recent studies have indicated that at the same blood glucose levels, black patients have higher HbA1C levels than white patients. This distinction has led some experts to propose setting a higher HbA1C threshold for diagnosing diabetes in black patients

To compare the relationships between HbA1c level and the prevalence of retinopathy in non-Hispanic black and white adults, researchers conducted a cross-sectional study from data in the National Health and Nutrition Examination Survey (NHANES) from 2005 through 2008. The study included 2,804 whites and 1,008 blacks age 40 years or older who were examined for the prevalence of retinopathy. Results appeared in the Aug. 7 Annals of Internal Medicine.

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The weighted crude prevalence (±SE) of retinopathy was 6.3% ± 0.5% for whites and 13.1% ± 1.1% for blacks. In whites, the adjusted prevalence of retinopathy was significantly higher beginning at HbA1c levels of 6%-6.4%, compared with HbA1c levels less than 5.5% (the reference category).

Among black adults, those with HbA1c levels of 5.5% to 5.9% had significantly higher risk for prevalent retinopathy than those with HbA1c levels less than 5.5%, according to the study. The adjusted risk difference for retinopathy for blacks with HbA1c levels of 5.5% to 5.9% was similar to that of whites with HbA1c levels of 6% to 6.4%.

Researchers noted that if the diagnostic threshold of HbA1c were lowered from the current adopted level of 6.5% to 6%, an estimated additional 1.8 million black and 7.6 million white U.S. adults aged 40 years or older would be diagnosed with diabetes, of whom 0.2 million blacks and 0.8 million whites would be anticipated to have diabetic retinopathy at the time of examination. For both blacks and whites, this translates to diagnosing nine additional cases of diabetes to detect one additional case of prevalent diabetic retinopathy.

If the diagnostic threshold for diabetes were lowered from 6.5% to 5.5%, an additional 5.7 million blacks and 39.0 million whites would be diagnosed with diabetes, among which there would be 0.5 million cases of retinopathy among blacks and 2.2 million cases among whites. This new diagnostic threshold would result in diagnosing 11 additional cases of diabetes among blacks and 18 additional cases among whites to detect one additional case of diabetic retinopathy.

The authors wrote, "The results of our study suggest that the risk for diabetic retinopathy is higher for blacks at any given HbA1c level between 5.0% and 7.0% ... Therefore, our findings argue against increasing the HbA1c diagnostic threshold for blacks."


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Metastatic disease reduced in PSA screening era, study indicates

Prostate-specific antigen (PSA) screening reduced the number of men presenting with metastatic prostate cancer, a new study found.

Researchers used data from the Surveillance, Epidemiology and End Results (SEER) registry to calculate the incidence of metastatic prostate cancer in 2008 and compared it to annual incidence rates from the early 1980s, before PSA screening was performed. They calculated how many cases of metastatic disease would be expected in the registry population in 2008 based on the 1980s data and came up with 2,277. However, according to the SEER data, only 739 cases were actually observed in 2008, an expected-to-observed ratio of 3.1.

Extrapolated to the total U.S. population, these calculations indicate that about 25,000 men would have been expected to present with metastatic prostate cancer in 2008, compared to the approximately 8,000 that actually did. The researchers concluded that these findings show an apparent benefit to PSA screening. They also found that the benefit increased with age until age 85. The study was published online by Cancer on July 30.

Although the study controlled for age and race, there is still a risk of residual confounding, even by some currently unknown risk factor, the authors cautioned. A second limitation is the issue of lead-time effects. PSA screening could potentially change the age at which a patient presents with metastatic cancer without changing the length of his symptom-free or overall survival. The current study also did not consider the risks of overdiagnosis and overtreatment, the authors noted.

The study was not able to assess the optimal ages to start and stop screening, but the authors concluded that the data showed a significant decline in metastatic cancer attributable to PSA screening. "We believe that these estimates must be taken into consideration (bearing in mind the limitations of observational data) when public health policy-level recommendations are made regarding PSA screening," they concluded.



Test yourself


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MKSAP Quiz: 4-month history of tremor

A 53-year-old woman is evaluated in the office for a 4-month history of tremor. The tremor affects both upper extremities and is present "most of the time." She has a 15-year history of type 2 diabetes mellitus; she also has a history of hypertension, gastroparesis, and chronic kidney disease. Medications are insulin glargine, insulin lispro, lisinopril, hydrochlorothiazide, and metoclopramide.

mksap.jpg

On examination, she has diminished pedal pulses. Speech, language, and mental status are normal. Cranial nerve function is normal, although a paucity of facial expression is noted. Movements are slow, and there is mild bilateral upper and lower extremity rigidity. Deep tendon reflexes are normal, as are results of manual muscle strength testing. Sensory examination reveals distal sensory loss. She had a mildly stooped posture but no postural instability. A 4-Hz resting tremor in both upper extremities is noted, as is a prominent postural tremor.

Which of the following is the most likely diagnosis?

A) Dementia with Lewy bodies
B) Drug-induced parkinsonism
C) Multiple system atrophy
D) Parkinson disease

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


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Endocrinology


.
Screen for cardiovascular risk factors in Cushing's patients who use glucocorticoids

People who use glucocorticoids and exhibit iatrogenic Cushing's syndrome should be aggressively targeted for early screening and management of cardiovascular risk factors, a study found.

Researchers conducted a cohort study comparing British patients prescribed systemic glucocorticoids who had a diagnosis of iatrogenic Cushing's syndrome (n=547) with two other groups: those prescribed glucocorticoids with no diagnosis of iatrogenic Cushing's syndrome (n=3,231) and those not prescribed systemic glucocorticoids (n=3,282). Results appeared online July 30 at BMJ.

A total of 417 cardiovascular events occurred in 341 patients among the 424 U.K. general practices in the study. The adjusted overall hazard ratio of a cardiovascular event was 2.74 (95% CI, 2.06 to 3.62) for those prescribed glucocorticoids with Cushing's syndrome compared with the group prescribed glucocorticoids without Cushing's syndrome. Patients prescribed glucocorticoids with iatrogenic Cushing's syndrome also had a higher adjusted hazard ratio of any cardiovascular event (4.16; 95% CI, 2.98 to 5.82) compared with those not prescribed glucocorticoids.

Results were similar when people with a history of cardiovascular events (n=1,004) were excluded from the analyses. Adjusted hazard ratios of all cardiovascular events were 2.56 (95% CI, 1.66 to 3.94) for the steroid/Cushing's group compared to steroid/no Cushing's patients and 4.26 (95% CI, 2.49 to 7.29) compared with the group not prescribed glucocorticoids.

The authors concluded that a glucocorticoid-induced cushingoid appearance should no longer be considered as a minor adverse event. "It has been reported by patients as the most distressing adverse event affecting daily living and is associated with some features of the metabolic syndrome. Furthermore, we found that it is associated with a higher risk of cardiovascular events, particularly heart failure and coronary heart disease. It is therefore essential that patients prescribed glucocorticoids who develop iatrogenic Cushing's syndrome are assessed for cardiovascular risk and monitored regularly in both primary care and secondary care for early prevention of cardiovascular diseases," they wrote.



Education


.
Course offered on healing health care disparities through education

Medical educators are invited to attend a two-day course featuring interactive methods for achieving the recently mandated integration of cross-cultural care into medical school and residency programs.

The course is offered by Harvard Medical School in Boston, Oct. 12-13, 2012. ACP is endorsing this course, allowing ACP members to enjoy a $50 discount on registration. More information is online.


.
Handbook offers practical guidance on preventive health records

The Agency for Healthcare Research and Quality recently released a guide titled "An Interactive Preventive Care Record (IPHR): A Handbook for Using Patient-Centered Personal Health Records To Promote Prevention."

The guide provides practical steps for health care professionals to follow when deploying IPHRs as components of electronic health records and walks professionals through the practical challenges associated with deployment of IPHRs. The handbook is available online.



Antibiotics


.
Context affects physicians' antimicrobial prescribing decisions, study finds

Context can play a role in whether physicians decide to prescribe antimicrobials, according to a new study.

Researchers performed a 5.5-year retrospective cohort study in a Midwestern primary care network to determine whether contextual factors were associated with decisions to prescribe antimicrobials for febrile respiratory illness. Specifically, they wanted to test whether the publicity and educational efforts surrounding the H1N1 influenza pandemic in the spring and fall of 2009 made physicians more likely to consider a viral cause of febrile respiratory illness, and less likely to prescribe an antibiotic, than during a typical flu season. The study also examined whether physicians' own recent experiences would have an impact on prescribing decisions. All patients who presented with febrile respiratory illness during influenza seasons between 2006 and 2011 at 26 outpatient practices were included in the study. The results appeared in the Aug. 7 Annals of Internal Medicine.

annals.jpg

Overall, the study examined 28,301 unique patient encounters for febrile respiratory illness among 69 physicians. In 12,795 cases (45.2%), patients were prescribed an antibiotic. During the seasonal influenza period, an antibiotic was prescribed in 47.5% of patient encounters, while during the pandemic influenza period, an antibiotic was prescribed in 39.2% of patient encounters (P<0.001). The authors performed multivariable adjustment for patient and physician characteristics and found that antibiotic prescribing remained lower in the pandemic period than in the seasonal period (odds ratio, 0.72). Physicians were also less likely to prescribe an antibiotic if they had seen more patients with febrile respiratory illness in the previous week; the odds ratios were 0.93 for two to three patients seen, 0.84 for four to six patients seen, 0.71 for seven to 11 patients seen and 0.57 for at least 12 patients seen, compared with the reference range of zero to one patient seen.

The authors acknowledged that their study was retrospective and focused on only one geographic area. However, they concluded that epidemiologic variables and the number of recent febrile respiratory illness cases seen affected whether a physician was likely to prescribe an antimicrobial for a patient presenting with this condition. "Even controlling for physician characteristics and the patients' presentation, the epidemiologic context of the visit, and the physician's recent experience with [febrile respiratory illness] (personal context) seemed to strongly influence prescribing of therapy," the authors wrote. "Our work suggests that tools that increase physicians' awareness of context may help to drive much-needed improvements in prescribing."

The authors of an accompanying editorial pointed out that the study was not able to answer some important questions, including the kind of epidemiologic knowledge clinicians accessed and how it affected their clinical reasoning and their encounters with patients. "Answers to these questions are certainly beyond the scope of [the current study's] methods, but they would be invaluable in helping us understand exactly where and how to intervene when designing strategies to reduce unnecessary prescriptions," the editorialists wrote. "To change practices, we need to understand not only which contextual factors shape them but how and why."

In a related study in another journal, Canadian researchers found that patients with acute respiratory infections who consulted about treatment with a physician trained in shared decision making were less likely to choose antibiotics than those receiving usual care. The study was published online July 30 by CMAJ.



From the College


.
ACP, SGIM release paper on the ethics of the patient-centered medical home

ACP, in collaboration with the Society of General Internal Medicine (SGIM), recently released the position paper "The Patient-Centered Medical Home: An Ethical Analysis of Principles and Practice."

In the paper, published in the Journal of General Internal Medicine, ACP and SGIM explore the ethical dimensions of the patient-centered medical home (PCMH) and highlight some of the practical choices and implications of PCMH design that should be considered when implementing the PCMH model of care. More details about the paper are available online.



Cartoon caption contest


.
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-20120807-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.


.


MKSAP Answer and Critique



The correct answer is B) Drug-induced parkinsonism. This item is available to MKSAP 15 subscribers as item 35 in the Neurology section.

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

Drug-induced parkinsonism is the most likely diagnosis in this patient. This disorder has classically been associated with neuroleptic medications but can occur with any dopamine-blocking medications, including metoclopramide. Although metoclopramide causes drug-induced parkinsonism in one third of all patients using it, the disorder is particularly underdiagnosed in such patients. Establishing a diagnosis of drug-induced parkinsonism is critical because stopping dopamine-blocking medications can reverse or improve parkinsonian features in these patients.

Cognitive impairment in conjunction with parkinsonism occurs in patients with dementia with Lewy bodies, but the latter diagnosis is unlikely in this patient, given her apparently normal cognition.

Multiple system atrophy is a heterogeneous, progressive, and ultimately fatal neurodegenerative disorder associated with parkinsonian features and with cerebellar and autonomic signs and symptoms of variable severity. Early multiple system atrophy would be a consideration in this patient if she were not on a medication known to induce signs and symptoms of parkinsonism. The parkinsonism in some patients with early multiple system atrophy cannot be distinguished from Parkinson disease and may even be responsive initially to levodopa. Most patients with multiple system atrophy, however, have bilateral parkinsonian signs and lack significant tremor, findings that are atypical of Parkinson disease.

Parkinson disease should be part of the differential diagnosis but is an unlikely cause of the symptoms in this patient. Although there are parkinsonian signs and symptoms, there are several atypical features that should prompt consideration of an alternative diagnosis. The presence of symmetric signs and symptoms (tremor and rigidity) and the postural tremor in this patient suggest a condition other than Parkinson disease. Other features that suggest an alternative condition in patients with parkinsonian signs and symptoms include early falls, rapid progression, poor or waning levodopa response, dementia, early autonomic failure, and ataxia. Moreover, this patient is taking metoclopramide, a medication known to cause parkinsonism.

Key Point

  • Drug-induced parkinsonism is a potential complication of dopamine-blocking medications, including metoclopramide.

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A 69-year-old woman is evaluated for a lump under her arm found on self-examination. She is otherwise healthy and has no other symptoms. Medical and family histories are unremarkable, and she takes no medications. A needle aspirate of the right axillary mass reveals adenocarcinoma. Bilateral mammography and breast MRI are normal. CT scan of the chest, abdomen, and pelvis demonstrates the enlarged axillary lymph node and no other abnormalities. What is the most appropriate initial treatment?

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