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ACP InternistWeekly



In the News for the Week of October 1, 2013




Highlights

More primary care visits may lower colorectal cancer incidence, mortality

Medicare beneficiaries who see their primary care clinicians more often have lower colorectal cancer incidence and mortality rates and lower overall mortality, a study found. More...

Daily antibiotics appeared most effective for recurrent UTIs

Daily antibiotics appeared to be the most effective strategy for combating recurrent urinary tract infections (UTIs), according to a new analysis. More...


Test yourself

MKSAP Quiz: cyanotic congenital heart disease in Down syndrome

This week's quiz asks readers to diagnose a woman with cyanotic congenital heart disease and Down syndrome. More...


Screening

Repeat BMD screens unlikely to change osteoporosis management

Older patients who aren't being treated for osteoporosis may not benefit from frequent repetition of bone mineral density (BMD) testing, a new study found. More...


Infectious disease

Both nosocomial and community-based sources of C. difficile contribute to disease transmission

Genetically diverse, community-based sources of Clostridium difficile may play a larger role in nosocomial transmission than previously thought, a study found. More...


CMS update

CMS announces 2013-14 influenza vaccine payments

CMS has issued an update of payment allowances for seasonal influenza virus vaccines when payment is based on 95% of the average wholesale price. More...

Changes to local coverage determinations coming with ICD-10

As part of ICD-10, all local coverage determinations (LCDs) will be updated to reflect the appropriate ICD-10 codes. 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


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More primary care visits may lower colorectal cancer incidence, mortality

Medicare beneficiaries who see their primary care clinicians more often have lower colorectal cancer incidence and mortality rates and lower overall mortality, a study found.

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Researchers conducted a population-based, case-control study among Medicare patients ages 67 to 85 years diagnosed with colorectal cancer between 1994 and 2005 in U.S. Surveillance, Epidemiology, and End Results (SEER) regions. Primary care was defined as general practice, family medicine, primary care internal medicine, geriatric medicine, and obstetrics-gynecology.

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

Compared with people who had 0 or 1 primary care visit, those with 5 to 10 visits had less colorectal cancer (adjusted odds ratio [OR], 0.94; 95% CI, 0.91 to 0.96). A stratified analysis found that the association between primary care visits and lower colorectal cancer incidence occurred in patients with late-stage diagnosis and distal lesions, as well as in those diagnosed during years with greater Medicare coverage of colorectal cancer screening tests. There was a higher likelihood of diagnosis of early-stage cancer and proximal cancer with increased primary care visits.

Compared with people who had 0 or 1 primary care visit, those with 5 to 10 visits had less mortality (adjusted OR, 0.78; 95% CI, 0.75 to 0.82) and lower all-cause mortality (adjusted OR, 0.79; 95% CI, 0.76 to 0.82). A stratified analysis found that associations of primary care visits with fewer colorectal cancer deaths were stronger for patients with late- versus early-stage diagnosis, those with distal versus proximal lesions, and those diagnosed during years with greater Medicare coverage of screening tests.

Analyses that controlled for all covariates except colorectal cancer screening and polypectomy showed that having at least 2 primary care visits was associated with approximately 20% lower odds of all-cause mortality compared with 0 or 1 visit (adjusted OR, 0.79 to 0.82). This association was attenuated but not eliminated when colorectal cancer screening and polypectomy were added (adjusted OR, 0.88 to 0.92).

The researchers wrote, "In particular, primary care helps decrease CRC [colorectal cancer] by promoting screening and facilitating referrals for colonoscopy and polypectomy. Because a recommendation from primary care is one of the strongest predictors of adherence to CRC screening and several different options are available for CRC screening, access to primary care is important for counseling on these options. The move toward patient-centered medical homes will probably improve rates of CRC screening because of the model's emphasis on preventive care and tracking of tests in its patient population."


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Daily antibiotics appeared most effective for recurrent UTIs

Daily antibiotics appeared to be the most effective strategy for combating recurrent urinary tract infections (UTIs), according to a new analysis.

Researchers performed a systematic review of studies on managing UTIs in adult women who had more than 3 UTIs annually. For each management strategy studied by more than 2 adequate clinical trials, the researchers developed a Markov chain Monte Carlo model of recurrent UTI and simulated 2 separate cohorts, one in which patients had 3 UTIs per year and another in which patients had 8 UTIs per year. Treatment efficacy, costs to patients and payers and health-related quality of life were the main model outcomes. The study was published early online Sept. 24 by Clinical Infectious Diseases.

Overall, 5 strategies were addressed by more than 2 adequate clinical trials: daily antibiotic prophylaxis with nitrofurantoin (6 trials), daily prophylaxis with estrogen (5 trials), daily prophylaxis with cranberry (4 trials), acupuncture prophylaxis (2 trials) and symptomatic self-treatment (3 trials). Nitrofurantoin was the most effective method in the 3-UTI-per-year model, reducing the UTI rate to 0.4 per year, and was also the most expensive for payers, costing $821 per year. The other strategies saved the payers money, ranging from $319 per year for estrogen to $502 for acupuncture, and also resulted in cost savings per quality-adjusted life-year (QALY) gained but were not as clinically effective. In the 8-UTI-per-year model, the results were similar except for daily antibiotic prophylaxis, which yielded payer cost savings. Symptomatic self-treatment, meanwhile, was the only strategy to save money for patients ($70 per year) and also was the most favorable for cost per QALY gained (cost savings, $23,260 per QALY gained). Daily antibiotic therapy was the most cost-effective strategy for patients, while acupuncture was the least. In the 8-UTI-per-year model, findings were similar but antibiotic prophylaxis and estrogen prophylaxis also led to cost savings for patients.

The authors noted, among other limitations, that publication bias in the analyzed studies might have led to overestimates of efficacy for some of the therapies and that their model did not account for such factors as multidrug-resistant infections, medication adherence and toxicity. However, they concluded that while antibiotic use was the most effective strategy for recurrent UTIs, daily cranberry pills, daily estrogen and monthly acupuncture were also effective. Most of the regimens resulted in cost savings for payers and for patients, and all of the regimens improved health-related quality of life, with symptomatic self-treatment saving the most per QALY gained.

"Our findings provide clinically meaningful data to guide the physician-patient partnership in determining a preferred method of prevention for this common clinical problem," the authors wrote.



Test yourself


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MKSAP Quiz: cyanotic congenital heart disease in Down syndrome

A 31-year-old woman with cyanotic congenital heart disease is evaluated during a routine examination. She has Down syndrome and is accompanied by her guardian. She has never had cardiac surgery and has no symptoms.

mksap.gif

Her blood pressure is 110/80 mm Hg bilaterally. The cardiac apex is displaced. A left parasternal impulse is present. There is a normal S1. The pulmonic component of the S2 is increased. A grade 1/6 to 2/6 holosystolic murmur is noted at the left sternal border. There is no change with respiration. Digital cyanosis and clubbing are present. The rest of the examination is unremarkable.

The electrocardiogram demonstrates normal sinus rhythm with right axis deviation and right atrial enlargement. There is also right ventricular hypertrophy with a strain pattern. The chest radiograph demonstrates mild cardiac enlargement as well as enlargement of the central pulmonary arteries with reduced pulmonary vascularity.

Which of the following is the most likely diagnosis?

A: Aortic coarctation
B: Ebstein anomaly
C: Eisenmenger syndrome
D: Tetralogy of Fallot

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


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Screening


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Repeat BMD screens unlikely to change osteoporosis management

Older patients who aren't being treated for osteoporosis may not benefit from frequent repetition of bone mineral density (BMD) testing, a new study found.

The cohort study included 310 men and 492 women from the Framingham Osteoporosis Study who underwent femoral neck BMD scans twice between 1987 and 1999 and were followed for hip or major osteoporotic fractures for a median of 9.6 years. The mean age of the patients was 74.8 years. Results were published in the Sept. 25 Journal of the American Medical Association.

During follow-up, 76 participants had a hip fracture and 113 had a major osteoporotic fracture. The researchers found that decrease in BMD over an average of 3.7 years was independently associated with both types of fracture. At 10 years' follow-up, a BMD decrease 1 standard deviation greater than the average was associated with 3.9 excess hip fractures per 100 persons. However, adding BMD change to a risk prediction model based on baseline BMD did not meaningfully improve prediction of fractures, the study found. Only an insignificant percentage of patients were reclassified to a higher-risk group.

The authors concluded that repeating a BMD test after 4 years would rarely change management of osteoporosis, especially because the study participants with the greatest change in BMD were already high risk based on their baseline measurement. The results raise questions about the benefits of the current practice in the U.S. of repeating BMD every 2 years even in patients not being treated for osteoporosis, the authors said.

The authors cautioned that their results may not apply to patients different from those in the study, which excluded some older patients and was conducted in the pre-bisphosphonate era. Further research is needed to determine which patients might change fracture-risk category within a few years and therefore benefit from repeat BMD, they said. Inclusion of family history of fracture could be helpful, the authors suggested. Other limitations of the study included use of 2 different machines for measuring BMD and a mostly white population.



Infectious disease


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Both nosocomial and community-based sources of C. difficile contribute to disease transmission

Genetically diverse, community-based sources of Clostridium difficile may play a larger role in nosocomial transmission than previously thought, a study found.

Researchers performed whole-genome sequencing on isolates obtained from patients with C. difficile infection identified through health care or community settings in Oxfordshire, U.K., from September 2007 through March 2011. The researchers looked at single-nucleotide variants (SNVs) between the isolates. Genetic relationship was defined as ≤2 SNVs between the 2 isolates.

Results appeared in the Sept. 26 New England Journal of Medicine.

Of 957 sequenced isolates from patients with C. difficile infection, 333 (35%) were genetically related to at least 1 isolate from a previous case, and 428 (45%) had more than 10 SNVs. Of the 333 patients with genetically related isolates, 126 (38%) had ward contact with a previous genetically related case, 5 (2%) were linked only by possible ward-based contamination after the discharge or recovery of an infectious patient, 29 (9%) shared time in the same hospital but were never on the same ward, and 21 (6%) had both ward contamination and hospital-wide contact.

However, the remaining 152 patients (46%) had no hospital-based contact. Of these patients, 15 (10%) were patients at the same general medical practice, and 17 (11%) lived in the same postal-code district. Overall, 120 patients (36%) had no hospital or community contact with a previous genetically related case, and when researchers looked back at unlimited infectious, incubation, and ward-contamination periods, 68 patients (20%) still had no hospital or community contact.

The researchers noted that since 45% of cases had sufficient genetic diversity to represent transmission originating from sources other than the cases that were included in the study, and since distinct subtypes of infection continued to be identified throughout the study, there may be a considerable reservoir of C. difficile in the community.

The authors noted several changes to antibiotic prescribing habits across the U.K. during the study period, including the reduction in use of fluoroquinolones and cephalosporins.

"The incidence of genetically distinct C. difficile cases was similar to that of genetically related cases," the authors wrote. "This finding suggests that interventions to reduce susceptibility to disease in exposed patients (e.g., changes in the use of antibiotics or specific types of antibiotics), rather than just to reduce transmission of C. difficile from symptomatic patients, might have played a major role in reductions in the incidence of C. difficile infection in the region during the past 5 years."

An accompanying editorial noted that the study challenges the idea that symptomatic patients in hospitals account for most C. difficile transmission and infection.

"The findings will not alter recommendations that basic control measures are essential," the editorial stated. "Infrequent transmission from symptomatic patients in the study hospitals may in fact attest to the effectiveness of well-implemented control programs. The major implication of the study is that control of C. difficile will require that we move beyond the usual suspects (symptomatic patients in hospitals)."



CMS update


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CMS announces 2013-14 influenza vaccine payments

CMS has issued an update of payment allowances for seasonal influenza virus vaccines when payment is based on 95% of the average wholesale price. Specific payment rates are available on the CMS website.


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Changes to local coverage determinations coming with ICD-10

As part of ICD-10, all local coverage determinations (LCDs) will be updated to reflect the appropriate ICD-10 codes. The LCDs and their associated ICD-10 articles will receive new LCD/article reference numbers. CMS has said that the new numbers will be published on the Medicare Coverage Database (MCD) no later than April 10, 2014.

The new reference number could have an impact on Medicare Audit Contractors' (MAC) local systems, such as by changing their Medicare Summary Notice to capture the new number. However, CMS has determined that this number change will not mean that the policies are considered new policies. Instead, CMS considers this a coding revision that does not change the intent of coverage/noncoverage by an LCD. Therefore, if a MAC chooses to only translate ICD-9 codes to the appropriate ICD-10 code, the policy does not need to be vetted through their Carrier Advisory Committee or be sent through the public comment and notice process.

A MAC may choose to revise more than just the diagnosis codes. If so, it will need to follow the normal LCD development process outlined in the Medicare Program Integrity Manual, Publication 100-08, Chapter 13 (Local Coverage Determinations), available on the CMS website.



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-20131001-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 C: Eisenmenger syndrome. This item is available to MKSAP 16 subscribers as item 47 in the Cardiovascular Medicine section. More information is available online.

The physical examination, electrocardiographic, and chest radiograph findings all suggest the presence of Eisenmenger syndrome. Eisenmenger syndrome is a cyanotic congenital heart disease characterized by irreversible pulmonary vascular disease due to the presence of a long-standing cardiac shunt with eventual reversal of the shunt. This diagnosis is supported by the patient's cyanosis, clubbing, evidence of right ventricular hypertrophy, and decreased pulmonary vascularity on the chest radiograph.

Approximately half of persons with Down syndrome have congenital heart disease and approximately half of these have an atrioventricular septal defect. Up to 75% of complete atrioventricular septal defects are found in persons with Down syndrome. Unoperated, patients with complete atrioventricular septal defect develop progressive pulmonary hypertension, reversal of the shunt, and, ultimately, Eisenmenger physiology with associated cyanosis and irreversible pulmonary vascular disease. Although Eisenmenger syndrome is decreasing in frequency, affected patients represent a major proportion of adults with cyanotic congenital heart disease.

Patients with aortic coarctation generally have hypertension in the upper extremities, a systolic murmur, or continuous murmur in the region of the left infraclavicular area or over the left back. Lower extremity pulses are reduced and there is generally a delay between the palpated radial artery and the femoral artery pulse. The electrocardiogram in a patient with aortic coarctation usually demonstrates left ventricular hypertrophy. The chest radiograph demonstrates a "figure 3 sign" in the region of aortic narrowing and rib notching due to collateral blood flow.

Patients with Ebstein anomaly characteristically have variable degrees of right heart enlargement and features of severe tricuspid valve regurgitation. Cyanosis can result from a right-to-left shunt at the atrial level in patients with an atrial septal defect or a patent foramen ovale and severe tricuspid valve regurgitation. The characteristic electrocardiogram in Ebstein anomaly demonstrates very tall and peaked "Himalayan" P waves. The QRS duration is usually prolonged; a right bundle branch block pattern and preexcitation may be present. The chest radiograph shows right heart enlargement with a globular cardiac contour and clear lung fields. The pulmonary arteries generally appear small.

Patients with unoperated tetralogy of Fallot may present with features of cyanosis and clubbing. However, a patient with unrepaired tetralogy of Fallot will have a loud systolic murmur due to severe right ventricular outflow tract obstruction. The absence of a loud systolic murmur makes this diagnosis unlikely in this patient.

Key Point

  • Eisenmenger syndrome is a cyanotic congenital heart disease characterized by irreversible pulmonary vascular disease caused by a long-standing cardiac shunt with eventual reversal of the shunt.

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A 57-year-old woman is evaluated for a 2-week history of decreased exercise tolerance and substernal chest pain on exertion. She also has an 8-month history of macrocytic anemia. Following a physical exam, lab results, and electrocardiogram, what is the most likely diagnosis?

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