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

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ACP InternistWeekly



In the News for the Week of January 8, 2013




Highlights

ADA recommendations increase blood pressure target to below 140 mm Hg systolic in diabetic patients

A higher maximum systolic blood pressure target for diabetics is one of the most significant changes in the American Diabetes Association's 2013 Standards of Medical Care. More...

Quadruple dose of influenza vaccine may offer HIV patients better protection

HIV-infected patients who received a quadruple dose of seasonal influenza vaccine had a higher antibody response and greater seroconversion rate than did those who received a standard dose, with similar rates of adverse events, a study found. More...


Test yourself

MKSAP Quiz: Follow-up of ulcerative colitis

A 38-year-old man is evaluated during a routine examination. He was diagnosed with ulcerative colitis 10 years ago and is currently asymptomatic. His last colonoscopy, performed at the time of diagnosis, showed mildly active extensive colitis extending to the hepatic flexure. Physical and abdominal examinations are normal. What is the most appropriate colonoscopy interval for this patient? More...


Insomnia

Non-benzodiazepine hypnotics provide slight benefit in insomnia

Non-benzodiazepine hypnotics help adults with insomnia fall asleep slightly sooner, a new meta-analysis found. More...


Gastroenterology

More restrictive blood transfusion rates may be better for upper GI bleeds

A blood transfusion threshold of 7 g/dL of hemoglobin significantly improved outcomes in patients with acute upper gastrointestinal bleeding compared to 9 g/dL, a study found. More...


Anticoagulation

Adding antiplatelet agents to dabigatran, warfarin elevates major bleeding risk

The risk of major bleeding is increased when antiplatelet drugs are added to either dabigatran or warfarin, a new subgroup analysis confirmed. More...


Business of medicine

2nd annual Business of Medicine Summit to be held Feb. 23-24

The Jefferson School of Population Health and the Institute for Continuing Healthcare Education are sponsoring the second annual Business of Medicine Summit: Healthy Practice, Healthy Patients, on Feb. 23-24. More...


CMS update

Medicaid's increased primary care payments take effect

Primary care and related subspecialty physicians participating in their state's Medicaid program will receive enhanced payments for designated services beginning in 2013. 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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ADA recommendations increase blood pressure target to below 140 mm Hg systolic in diabetic patients

A higher maximum systolic blood pressure target for diabetics is one of the most significant changes in the American Diabetes Association's 2013 Standards of Medical Care.

The standards, which are revised annually, are based on the most current scientific evidence and provide guidance on treating children and adults with all types of diabetes. They were published online Dec. 20, 2012, and in a special supplement to the January 2013 Diabetes Care.

Several changes were made to the recommendations for 2013, the most significant being an increase in the systolic blood pressure goal for many people with diabetes from less than 130 mm Hg to less than 140 mm Hg. The revision was based on several new meta-analyses showing little additional benefit from lower targets, according to a press release. However, lower targets may still be appropriate for some patients, for example those who are younger or have a higher risk of stroke, the recommendations noted.

Another recommendation change affects hospitalized patients who have not been previously diagnosed with diabetes. If such patients have risk factors for diabetes and exhibit hyperglycemia during hospitalization, physicians should consider obtaining a hemoglobin A1c test, the standards now say. The standards have also been updated to reflect new recommendations from the Centers for Disease Control and Prevention on hepatitis B vaccination. Diabetic patients age 19 to 59 should be vaccinated, and vaccination should be considered for those 60 and over.

Recommendations on self-monitoring of blood glucose for patients who take multiple doses of insulin per day have also changed. Previously, the recommendations called for self-monitoring three or more times a day. The 2013 standards specify that these patients should test their blood glucose prior to meals and snacks, occasionally after eating, at bedtime, before exercise, when hypoglycemia is suspected or has occurred and prior to critical tasks such as driving.

The new recommendations also contain changes regarding diabetes self-management education, screening and treatment of cardiovascular risk factors in prediabetes, and emphasizing statin therapy over specific low-density lipoprotein cholesterol goals. A summary of the revisions and an executive summary of the standards are online.


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Quadruple dose of influenza vaccine may offer HIV patients better protection

HIV-infected patients who received a quadruple dose of seasonal influenza vaccine had a higher antibody response and greater seroconversion rate than did those who received a standard dose, with similar rates of adverse events, a study found.

annals.jpg

Researchers conducted a randomized, double-blind, controlled trial at the Hospital of the University of Pennsylvania in Philadelphia from October 2010 to March 2011. In the study, 190 adults with HIV were randomly assigned to receive either a standard dose (15 μg of antigen per strain, n=93) or a high dose (60 μg/strain, n=97) of the influenza trivalent vaccine. Seroprotection was defined as antibody titers of 1:40 or greater on the hemagglutination inhibition assay 21 to 28 days after vaccination.

Results appeared in the Jan. 1 Annals of Internal Medicine.

Seroprotection rates after vaccination were higher in the high-dose group for three strains of flu: H1N1 (96% vs. 87%; treatment difference, 9 percentage points; 95% CI, 1 to 17 percentage points; P=0.029), H3N2 (96% vs. 92%; treatment difference, 3 percentage points; 95% CI, −3 to 10 percentage points; P=0.32), and influenza B (91% vs. 80%; treatment difference, 11 percentage points; 95% CI, 1 to 21 percentage points; P=0.030).

There was no significant difference in the local or systemic reactions between the two groups and no serious adverse events related to vaccine administration. The most frequent local adverse events were pain and tenderness at the injection site. The most frequent systemic adverse effect was myalgia, followed by malaise and headache. However, although seroprotection rates were increased with a higher vaccine dose, researchers noted that their study did not assess the effectiveness of the vaccine in preventing clinical influenza, which would require more study participants.

"A strategy with a single HD [high-dose] immunization is much easier to implement than a multiple-dose schedule," the authors wrote. "Although a higher dose is 1 route to the protection of this vulnerable population, other strategies may also be explored in the future, such as alternative vaccines, the use of adjuvants, or new schedule strategies."



Test yourself


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MKSAP Quiz: Follow-up of ulcerative colitis

A 38-year-old man is evaluated during a routine examination. He was diagnosed with ulcerative colitis 10 years ago and is currently asymptomatic. His last colonoscopy, performed at the time of diagnosis, showed mildly active extensive colitis extending to the hepatic flexure. There is no family history of colon cancer or colon polyps. His only medication is mesalamine.

mksap.gif

On physical examination, vital signs are normal. Abdominal examination is normal. Laboratory studies, including a complete blood count, liver chemistry studies, and C-reactive protein, are normal.

Which of the following is the most appropriate colonoscopy interval for this patient?

A: Colonoscopy now and every 1 to 2 years
B: Colonoscopy now and every 5 years
C: Colonoscopy every 5 years starting at age 40
D: Colonoscopy every 10 years starting at age 40

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


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Insomnia


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Non-benzodiazepine hypnotics provide slight benefit in insomnia

Non-benzodiazepine hypnotics help adults with insomnia fall asleep slightly sooner, a new meta-analysis found.

Researchers used data from 13 double-blind, placebo-controlled trials submitted to the FDA. The studies included three drugs (eszopiclone, zaleplon and zolpidem), 65 different drug-placebo comparisons and more than 4,000 participants. Results were published in the Jan. 2 print issue of BMJ and online Dec. 17, 2012.

In the meta-analysis, the drugs were associated with statistically significant, but slight, improvements in the time it took to fall asleep. According to polysomnography, participants fell asleep 22 minutes sooner (95% CI, 11 to 33 minutes) on the drugs than placebo, and subjective reports from patients showed a perceived benefit of seven minutes of sleep latency reduction from the drugs. Not enough data were collected on secondary outcomes for the analysis to draw firm conclusions.

The researchers did find that more benefit was seen in studies that included zolpidem, were published earlier, used larger doses, had longer duration of treatment, and had more younger and/or female patients. They also noted that a strong placebo response was found in the studies: If both the drug effect and placebo effect were included, participants fell asleep an average of 42 minutes sooner.

These findings indicate that placebo response may be a major contributor to the effectiveness of these drugs, the authors concluded. The small effect achieved by the drugs alone should be balanced against the harms of the drugs (including adverse effects, tolerance and addiction), which were not considered in this analysis, they concluded.

An accompanying editorial recommended that cognitive and behavioral therapy for insomnia be considered either in place of or in combination with pharmaceutical treatments. The findings "highlight the need to reduce reliance on hypnotic drugs as sole treatments for insomnia," the editorialist said.



Gastroenterology


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More restrictive blood transfusion rates may be better for upper GI bleeds

A blood transfusion threshold of 7 g/dL of hemoglobin significantly improved outcomes in patients with acute upper gastrointestinal bleeding compared to 9 g/dL, a study found.

Researchers randomly assigned 444 patients with severe acute upper gastrointestinal bleeding to a restrictive transfusion strategy (transfusion when hemoglobin fell below 7 g/dL with a target range post-transfusion of 7 to 9 g/dL) and 445 patients to a liberal strategy (transfusion when hemoglobin fell below 9 g/dL with a target range post-transfusion of 9 to 11 g/dL). Safety and efficacy of both strategies were compared.

Results appeared in the Jan. 3 New England Journal of Medicine.

A total of 225 patients assigned to the restrictive strategy did not receive transfusions compared with 65 assigned to the liberal strategy (51% vs. 15%; P<0.001). The restrictive-strategy group had a higher survival rate at six weeks compared to the liberal-strategy group (95% vs. 91%; hazard ratio [HR] for death with restrictive strategy, 0.55; 95% CI, 0.33 to 0.92; P=0.02).

Deaths attributed to unsuccessfully controlled bleeding occurred in three patients in the restrictive-strategy group and in 14 patients in the liberal-strategy group (0.7% vs. 3.1%; P=0.01). Complications of treatment were the cause of death in one patient in the restrictive-strategy group and two in the liberal-strategy group. Hemorrhage was controlled and death was due to associated diseases in 19 patients in the restrictive-strategy group and 25 in the liberal-strategy group.

Less bleeding occurred in the restrictive-strategy group compared with the liberal-strategy group (10% vs. 16%; P=0.01), and there were fewer adverse events (40% vs. 48%; P=0.02). Further bleeding was significantly lower with the restrictive strategy group after adjustment for baseline risk factors (HR, 0.68; 95% CI, 0.47 to 0.98). Length of hospital stay was shorter in the restrictive-strategy group than in the liberal-strategy group.

Patients who had bleeding associated with a peptic ulcer had a slightly higher probability of survival with the restrictive strategy than with the liberal strategy (HR, 0.70; 95% CI, 0.26 to 1.25). Patients with cirrhosis and Child-Pugh class A or B disease in the restrictive-strategy group had a significantly higher probability of survival (HR, 0.30; 95% CI, 0.11 to 0.85), but those with cirrhosis and Child-Pugh class C disease did not (HR, 1.04; 95% CI, 0.45 to 2.37).

Researchers noted that improvement in survival rates observed with the restrictive transfusion strategy "was probably related to a better control of factors contributing to death, such as further bleeding, the need for rescue therapy, and serious adverse events. All these factors were significantly reduced with the restrictive strategy."



Anticoagulation


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Adding antiplatelet agents to dabigatran, warfarin elevates major bleeding risk

The risk of major bleeding is increased when antiplatelet drugs are added to either dabigatran or warfarin, a new subgroup analysis confirmed.

Researchers performed a post-hoc analysis of an earlier trial showing that a 150-mg dose of dabigatran was superior and a 110-mg dose was non-inferior to warfarin for preventing stroke and systemic embolism in atrial fibrillation patients. In the subgroup analysis, researchers compared the safety and efficacy of the 110-mg and 150-mg doses of dabigatran to warfarin in subgroups of patients with and without concomitant aspirin or clopidogrel treatment. Results were published online Dec. 27 by Circulation.

Nearly 7,000 of the original study's 18,113 patients received an antiplatelet medication at some point during the study. Eight hundred and twelve patients took both aspirin and clopidogrel, 5,789 took aspirin alone, and 351 took clopidogrel alone. A history of prior myocardial infarction or coronary artery disease, hypertension, paroxysmal atrial fibrillation, male sex and diabetes were more common among patients on antiplatelet therapy.

Use of concomitant antiplatelet agents was associated with a higher rate of major bleeding (4.4% vs. 2.6%), regardless of whether patients took warfarin or either dose of dabigatran (overall hazard ratio [HR], 2.01; 95% CI, 1.79 to 2.25). The absolute risk of bleeding was lowest with the 110-mg dose of dabigatran (3.9% per year), followed by the 150-mg dose of dabigatran (4.4% per year) and warfarin (4.8% per year) in those who also took antiplatelet drugs (P=0.05 for 110-mg dabigatran vs. warfarin; P=0.38 for 150-mg dabigatran vs. warfarin).

Risk of major bleeding was higher among patients on dual antiplatelet therapy vs. those taking a single antiplatelet agent (HR, 2.31 vs. 1.60; P<0.001 for trend in all treatment groups), with absolute risk lowest with 110-mg dabigatran. Similar trends were seen with major, minor and extracranial bleeding, but not intracerebral hemorrhage, which had a low event rate.

Tandem use of antiplatelet and anticoagulant therapy is common, the authors noted, and this analysis suggests the relative risk of bleeding is similar for dabigatran and warfarin. The risk rose 50% with one antiplatelet medication and doubled with two, they noted. Because absolute (not relative) rates of bleeding seemed lower with 110 mg of dabigatran, however, this dose may be preferable "in patients in whom bleeding risk is of concern, such as those requiring dual antiplatelet therapy," the authors wrote.

Editorialists wrote that the 110-mg dose of dabigatran might be a safer alternative in patients who require low-dose aspirin in particular. Regardless, treatment with both agents "needs to be highly personalized, taking into account the thrombotic and bleeding risk of each individual patient," the editorialists wrote.

Separately, the U.S. Food and Drug Administration warned in late December that patients with mechanical heart valves should not use dabigatran to prevent major stroke or blood clots. Researchers recently stopped a trial of mechanical heart valve patients in Europe because the patients taking dabigatran were more likely than those taking warfarin to experience strokes, heart attacks and blood clots that formed on the valves. They also had more bleeding after valve surgery. Physicians should transition all patients with mechanical heart values who take dabigatran to another medication, the alert said.



Business of medicine


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2nd annual Business of Medicine Summit to be held Feb. 23-24

The Jefferson School of Population Health and the Institute for Continuing Healthcare Education are sponsoring the second annual Business of Medicine Summit: Healthy Practice, Healthy Patients, on Feb. 23-24.

In collaboration with Medical Economics and in consultation with the American College of Physicians, the 1.5-day meeting in Philadelphia will cover timely and important topics such as health policy issues, practice efficiencies, meaningful use and risk management.

Michael Barr, MD, MBA, FACP, ACP's senior vice president of the Medical Practice, Professionalism and Quality Division, will emcee the program. Registration and more information can be found on the Business of Medicine website.



CMS update


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Medicaid's increased primary care payments take effect

Primary care and related subspecialty physicians participating in their state's Medicaid program will receive enhanced payments for designated services beginning in 2013.

Participating physicians should contact their state Medicaid office immediately to find out how to fulfill the "attestation" requirement. The increased payments, which are at least equivalent to payments under Medicare, are fully funded for 2013 and 2014 by the federal government to encourage physician participation in Medicaid. The Kaiser Family Foundation recently released a policy brief that includes a chart reflecting the estimated percent increase in payment for each state. The Centers for Medicare and Medicaid Services (CMS) also recently released a series of FAQs pertaining to this enhanced payment provision.



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-20130108-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 A: Colonoscopy now and every 1 to 2 years. This item is available to MKSAP 16 subscribers as item 9 in the Gastroenterology and Hepatology section.

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

The most appropriate management for this patient is colonoscopy now and every 1 to 2 years. Patients with ulcerative colitis with disease extending beyond the rectum are at an increased risk of colorectal cancer. Cancer risk has been widely reported to be between 0.5% and 1% per year after having extensive disease for 10 years or more. The exact risk for an individual patient is uncertain and is probably based on the duration and extent of disease, severity of inflammation, and other personal factors. Based on this increased cancer risk, routine surveillance colonoscopy with biopsies every 1 to 2 years is warranted beginning 8 to 10 years after diagnosis. Because cancers associated with ulcerative colitis tend to arise from the mucosa as opposed to the usual adenoma-cancer sequence, biopsies are taken from flat mucosa throughout the colon and are evaluated for dysplastic changes. A finding of flat, high-grade dysplasia is grounds for recommending colectomy owing to the high rate of concomitant undetected cancer. A finding of flat, low-grade dysplasia warrants colectomy or continued surveillance colonoscopy at more frequent intervals.

Colonoscopy now for this patient is appropriate, but the interval should be every 1 to 2 years rather than every 5 years. For persons without ulcerative colitis but with a family history of colorectal cancer in a first-degree relative, screening is initiated either at age 40 years or beginning 10 years earlier than the diagnosis of the youngest affected family member. Colonoscopy every 10 years starting at age 40 is not appropriate for this patient.

Key Point

  • Patients with ulcerative colitis with disease extending beyond the rectum should undergo routine surveillance colonoscopy with biopsies every 1 to 2 years beginning 8 to 10 years after diagnosis.

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A 66-year-old man comes for a preoperative evaluation before total joint arthroplasty of the left knee. He has a 25-year history of rheumatoid arthritis. He has had progressive pain in his left knee with activity, which limits his ability to hike. The patient has similar pain in the right knee, but it is less severe. He reports no recent morning stiffness. He is able to climb two or three flights of stairs without chest pain or shortness of breath. He has no other medical problems and reports no additional symptoms. Medications are methotrexate and folic acid. Following a physical exam and lab tests, what is the next best step in management?

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