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

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ACP InternistWeekly



In the News for the Week of September 18, 2012




Highlights

After-hours physician access associated with lower patient expenditures

Patients who could visit their doctors on nights and weekends spent 10% less on health care than those without extended-hours access, a study found. More...

Hypothyroidism guidelines recommend case-finding testing, treatments, when to consult an endocrinologist

New guidelines on managing hypothyroidism in adults have been issued by the American Association of Clinical Endocrinologists and the American Thyroid Association. More...


Test yourself

MKSAP Quiz: spontaneous hypokalemia and hypertension

A 59-year-old man is evaluated for recently discovered spontaneous hypokalemia and hypertension. The patient had normal blood pressure at a visit 1 year ago. He has no symptoms and takes no medications. What is the most appropriate initial treatment? More...


Cardiology

NSAIDs associated with increased cardiovascular risk up to five years post-MI

Taking NSAIDs increases cardiovascular risk for heart attack survivors as long as five years after the attack, a new study found. More...


Transitions of care

Hospital-initiated transition interventions may improve stroke, MI outcomes

Transition-of-care interventions initiated in the hospital can help improve outcomes in adult patients with stroke and myocardial infarction (MI), according to a new study. More...

Interventions at hospital discharge may improve transitions to primary care, but more research is needed

Certain interventions at hospital discharge appear to help improve handoffs to primary care, but more research is needed to determine how and why, a new study indicates. More...


CMS update

Open enrollment for Part D starts Oct. 15

Remind patients that the open enrollment period for Medicare Part D coverage will run from Oct. 15 to Dec. 7. More...


Initiatives

New Patient Care Program aims to engage patients and reduce costs

The Gordon and Betty Moore Foundation recently launched a Patient Care Program that seeks to eliminate all preventable harms to patients and reduce complications and patient readmissions that could be averted. More...


Education

Free educational tools available for diagnosis, treatment of lupus

Free educational resources are available through the American College of Rheumatology's Lupus Initiative to reduce health disparities for patients disproportionately affected by lupus based on race, ethnicity and gender. More...


From the College

ACP's director of clinical policy elected to chair Guidelines International Network

Amir Qaseem, MD, PhD, MHA, FACP, director of clinical policy at ACP, was elected as the chair of the Guidelines International Network (G-I-N). 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: Daisy Smith, MD, FACP



Highlights


.
After-hours physician access associated with lower patient expenditures

Patients who could visit their doctors on nights and weekends spent 10% less on health care than those without extended-hours access, a study found.

Researchers analyzed data from more than 33,000 people age 18 to 90 who responded to the 2000-2008 Medical Expenditure Panel Surveys. Respondents answered yes or no to having access to extended hours from a usual source of care in two successive years.

Results appeared in the September/October Annals of Family Medicine.

Total expenditures were 10.4% lower (95% CI, 7.2% to 13.4%) among patients reporting access to extended hours in both years compared to those who had it neither year. Adjustment for year 2 prescription drug expenditures and, to a lesser extent, office visit-related expenditures (but not total prescriptions or office visits, or emergency and inpatient expenditures) attenuated this relationship.

Although patients reporting access to extended hours were less likely to visit the emergency department, this didn't account for lower expenditures, since such visits were a small part of overall health care costs in year 2 of the study, the researchers noted. Instead, after-hours access may be a marker of primary care practices that take a cost-conscious approach. Also, practices offering extended access may attract patients less likely to seek brand-name drugs and discretionary testing, the researchers said.


.
Hypothyroidism guidelines recommend case-finding testing, treatments, when to consult an endocrinologist

New guidelines on managing hypothyroidism in adults have been issued by the American Association of Clinical Endocrinologists and the American Thyroid Association.

Published in Thyroid, the guidelines comprise 52 evidence-based recommendations. Among them are the following:

  • Serum thyroid-stimulating hormone (TSH) is the single best screening test for primary thyroid dysfunction in outpatient care, but it is not sufficient in hospitalized patients or when central hypothyroidism is present or suspected.
  • The standard treatment for hypothyroidism is replacement with L-thyroxine (T4).
  • The decision to treat subclinical hypothyroidism, when the serum TSH is less than 10 mIU/L, should be tailored to the individual patient.

The authors wrote that while there is no consensus about population screening for hypothyroidism, evidence supports case-finding for hypothyroidism in patients with autoimmune diseases such as type 1 diabetes, pernicious anemia, a first-degree relative with autoimmune thyroid disease, a history of neck radiation to the thyroid gland, a prior history of thyroid surgery or dysfunction, an abnormal thyroid examination, psychiatric disorders, and patients taking amiodarone or lithium.

Most physicians can diagnose and treat hypothyroidism, the experts said, but an endocrinologist should be consulted for:

  • children and infants,
  • patients who cannot maintain a euthyroid state,
  • women who are pregnant or planning to become pregnant,
  • patients with cardiac disease,
  • patients with a goiter, nodule, or other structural changes in the thyroid gland,
  • patients with other endocrine disease such as adrenal and pituitary disorders,
  • patients with unusual thyroid function test results, or
  • patients whose disorders have unusual causes.


Test yourself


.
MKSAP Quiz: spontaneous hypokalemia and hypertension

A 59-year-old man is evaluated for recently discovered spontaneous hypokalemia and hypertension. The patient had normal blood pressure at a visit 1 year ago. He has no symptoms and takes no medications.

mksap.jpg

On physical examination, temperature is 36.9 °C (98.4 °F), blood pressure is 148/96 mm Hg, pulse rate is 58/min, respiration rate is 18/min, and BMI is 25. Examination findings are otherwise unremarkable.

The serum potassium level is 2.9 mEq/L (2.9 mmol/L) with increased urine potassium losses. After correction of the hypokalemia, the serum aldosterone level is 28.7 ng/dL (792 pmol/L) and the serum aldosterone to plasma renin activity ratio is 287. The serum aldosterone level is not suppressible with a high-sodium diet.

A CT scan of the adrenal glands shows minimal bilateral enlargement, with no identifiable masses or nodules.

Which of the following is the most appropriate initial treatment?

A) Bilateral adrenalectomy
B) Lisinopril
C) Spironolactone
D) Triamterene

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


.

Cardiology


.
NSAIDs associated with increased cardiovascular risk up to five years post-MI

Taking NSAIDs increases cardiovascular risk for heart attack survivors as long as five years after the attack, a new study found.

The observational study used data on about 100,000 Danish patients hospitalized with a first-time myocardial infarction (MI) between 1997 and 2009. Their use of nonsteroidal anti-inflammatory drugs (NSAIDs) over the following five years was determined from pharmacy registries. Results were published by Circulation on Sept. 10.

Overall, 44% of the patients were prescribed NSAIDs at some point in the five years following MI. There were 36,747 deaths and 28,603 coronary deaths or nonfatal MIs among the whole study population during that period. Researchers found that patients taking an NSAID, compared to those who didn't, had a similarly increased risk of death at one year after MI (hazard ratio [HR], 1.59; 95% CI, 1.49-1.69) and at five years out (HR, 1.63; 95% CI, 1.52-1.74). They also had a higher risk of coronary death or nonfatal MI after one year (HR, 1.30; 95% CI, 1.22-1.39) and five years (HR, 1.41; 95% CI, 1.28-1.55).

Researchers concluded that taking NSAIDs was associated with an increased cardiovascular risk for these patients, regardless of the time elapsed since their MI. "It would seem prudent to limit NSAID use among patients with cardiovascular disease and to get the message out to clinicians taking care of these patients that NSAIDs are potentially harmful," they wrote.

Naproxen was associated with the lowest cardiovascular risk in the study, suggesting it might be the preferred NSAID if treatment cannot be avoided, the authors said. However, gastrointestinal bleeding is an additional risk with that drug. The authors called for additional research into the cardiovascular effects of NSAIDs but suggested that in the meantime, the drugs should be avoided or used cautiously in all patients who have had an MI.



Transitions of care


.
Hospital-initiated transition interventions may improve stroke, MI outcomes

Transition-of-care interventions initiated in the hospital can help improve outcomes in adult patients with stroke and myocardial infarction (MI), according to a new study.

Researchers performed a systematic review of studies published from January 2000 to March 2012 to examine whether transitional care interventions led to benefit or harms in patients who were hospitalized for acute stroke or MI. Observational studies or trials were included if they were in English, compared transitional and usual care in adults with the conditions of interest, and reported patient, caregiver, process or systems outcomes within one year of discharge from the hospital. Data were extracted on study design, population, quality, intervention, and patient- and system-level outcomes. Results were published in the Sept. 18 Annals of Internal Medicine.

annals.jpg

The review included 62 articles involving 44 studies, 27 of acute stroke and 17 of MI. A total of four intervention categories were studied: hospital-initiated support (14 trials), patient and family education (7 trials), community-based support (20 trials) and chronic disease management (3 trials). Sixty-eight percent of the studies were judged to be of fair quality.

All of the transitions were from a hospital or from inpatient rehab to patients' homes. Moderate-strength evidence indicated that hospital-initiated support reduced length of stay for acute stroke, and low-strength evidence indicated that it reduced mortality for MI. Evidence was insufficient to determine the benefits and harms of the other types of transitional care interventions.

The authors acknowledged that few of the included studies were of high quality, that the usual care group was not often well defined, and that only six of the studies were done in the United States, among other limitations. However, they concluded that according to the available evidence, hospital-initiated transitional care can lead to improvements in certain outcomes for patients with acute stroke or MI. They called for more studies in this area, especially in U.S. settings.

"As the U.S. population ages and the number of patients who have MI or stroke increases, it is imperative to have transitional care interventions proven to be effective in improving functional outcomes, facilitating transfer of care from a hospital-based system to a community-based system, and preventing rehospitalization and adverse events," the authors wrote.


.
Interventions at hospital discharge may improve transitions to primary care, but more research is needed

Certain interventions at hospital discharge appear to help improve handoffs to primary care, but more research is needed to determine how and why, a new study indicates.

Researchers performed a systematic review of randomized, controlled trials published from January 1990 to March 2011 to examine interventions intended to improve the transition between hospital discharge and primary care. All trials involved transitions from the hospital to primary care or to home and were restricted to adult patients (excluding pregnant women) without a psychiatric diagnosis. Data were extracted on study objectives, setting and design, intervention, and outcomes, and studies were categorized by quality, sample size, intervention characteristics, outcome, direction of effects and statistical significance. Results were published in the Sept. 18 Annals of Internal Medicine.

annals.jpg

A total of 36 studies were included in the review. Of these, 25 (69.4%) showed a statistically significant effect favoring the intervention and 34 (94.4%) involved multicomponent interventions. Medication reconciliation, electronic generation of discharge summaries, discharge planning, shared follow-up between hospital- and community-based clinicians, electronic discharge notifications, and Web-accessible discharge summaries for primary care clinicians were found to be effective. Effective interventions had statistically significant effects on reducing hospital use (e.g., rehospitalizations or emergency department visits), improving care continuity (e.g., medication reconciliation or completeness of discharge summary) and improving patient status (e.g., quality of life or satisfaction) after discharge.

The authors were not able to perform a meta-analysis of the data because of the substantial heterogeneity in the interventions and study characteristics. In addition, most of the included studies had different goals and did not include thorough descriptions of each intervention component. Therefore, the authors concluded that although many interventions at hospital discharge appear to positively impact the transition to primary care, the available data do not allow them to draw firm conclusions about which interventions are most helpful.

"Our review … outlines a rich area for several key research questions, including developing a clearer description of the interventions, using uniform and valid outcome measures, and attending to the care provider's attitudes and training in developing effective handover interventions," they wrote.



CMS update


.
Open enrollment for Part D starts Oct. 15

Remind your patients that the open enrollment period for Medicare Part D coverage will run from Oct. 15 to Dec. 7.

Additional information about Part D plans and the coverage they offer is available on the CMS website. Also, physicians who wish to promote the program in their offices can order a promotional poster.



Initiatives


.
New Patient Care Program aims to engage patients and reduce costs

The Gordon and Betty Moore Foundation recently launched a Patient Care Program that seeks to eliminate all preventable harms to patients and reduce complications and patient readmissions that could be averted.

The program will also focus on engaging patients and their families in their own health care by developing an approach focused on team-based care, as well as processes and technology designed to be supportive of patient engagement while reducing health care costs. The foundation was established to advance environmental conservation, scientific research, and patient care. More information on the Patient Care Program is available online.



Education


.
Free educational tools available for diagnosis, treatment of lupus

Free educational resources are available through the American College of Rheumatology's Lupus Initiative, a national education initiative funded by the U.S. Department of Health and Human Services Office of Minority Health, to reduce health disparities for patients disproportionately affected by lupus based on race, ethnicity and gender. A series of CME lectures for clinicians as well as materials that can be used with their patients are available online.



From the College


.
ACP's director of clinical policy elected to chair Guidelines International Network

Amir Qaseem, MD, PhD, MHA, FACP, director of clinical policy at ACP, was elected as the chair of the Guidelines International Network (G-I-N).

The network is composed of 86 organizations and 107 individual members representing 45 countries from all continents. The G-I-N's mission is to lead, strengthen and support collaboration and work within the guideline development, adaptation and implementation community throughout the world. As chair, Dr. Qaseem will focus on increasing global visibility of G-I-N, delivering value of G-I-N to current members, increasing G-I-N membership, and improving the financial growth and stability of G-I-N. More information on Dr. Qaseem's appointment is 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-20120918-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 C) Spironolactone. This item is available to MKSAP 15 subscribers as item 97 in the Endocrinology and Metabolism section.

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

Spironolactone therapy should be initiated in this patient. He has biochemical findings suggestive of primary hyperaldosteronism. The initial clue to the diagnosis is the unprovoked hypokalemia and urine potassium renal losses. The results of laboratory studies show an elevated serum aldosterone level and suppressed plasma renin activity, which are suggestive of hyperaldosteronism. The diagnosis is usually confirmed by using a salt load to find out if aldosterone secretion is nonsuppressible and therefore autonomous. After primary hyperaldosteronism is biochemically confirmed, the cause should be defined. CT of the adrenal glands is an excellent way to localize an adrenal adenoma. This patient's CT scan does not show an aldosterone-secreting adrenal adenoma but rather suggests bilateral adrenal hyperplasia. The treatment of choice in such instances is an aldosterone receptor–blocking agent, such as the nonselective agent spironolactone or the more selective agent eplerenone. Besides blocking aldosterone receptors, spironolactone usually lowers blood pressure and keeps it down. The combination of spironolactone with a thiazide diuretic may provide even better control and allow for smaller doses of spironolactone. If additional antihypertensive therapy is needed, calcium-channel blockers or angiotensin-converting enzyme inhibitors may be used.

Bilateral adrenalectomy is unnecessary and inappropriate in this patient with bilateral adrenal enlargement. Such treatment would make him dependent on permanent glucocorticoid and perhaps mineralocorticoid replacement therapy.

Beginning lisinopril therapy is unlikely to control the patient's hypertension or address his primary hyperaldosteronism as well as an aldosterone blocker will.

Triamterene is a commonly used potassium-sparing diuretic that does not block the effects of aldosterone on the kidney. Using it will not be sufficient in this patient with hyperaldosteronism.

Key Point

  • Primary hyperaldosteronism caused by bilateral adrenal hyperplasia is best treated medically with a nonselective (spironolactone) or more selective (eplerenone) aldosterone-blocking agent.

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A 19-year-old man is evaluated for a sore throat, daily fever, frontal headache, myalgia, and arthralgia of 5 days' duration. He also has severe discomfort in the lower spine and a rash on his trunk and extremities. He returned from a 7-day trip to the Caribbean 8 days ago. The remainder of the history is noncontributory. Following a physical exam and lab studies, what is the most likely diagnosis?

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