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ACP InternistWeekly



In the News for the Week of October 22, 2013




Highlights

ACP issues clinical practice guideline on chronic kidney disease

ACP released a new clinical practice guideline this week on screening, monitoring and treatment of stage 1 to 3 chronic kidney disease (CKD). More...

Vitamin D didn't increase BMD in healthy, nonelderly adults

Vitamin D supplementation doesn't improve bone mineral density (BMD) in healthy adults, a new systematic review and meta-analysis concluded. More...


Test yourself

MKSAP Quiz: 3-month history of increasing fatigue and weight gain

A 38-year-old woman reports a 3-month history of increasing fatigue and weight gain. She underwent transsphenoidal surgery 4 years ago to remove a nonfunctioning pituitary macroadenoma, followed 4 months later by radiation therapy because of residual tumor. Following a review of medications, physical exam and lab tests, what is the most appropriate next diagnostic test? More...


Diabetes

ADA updates nutrition guidelines to address varied eating patterns

The American Diabetes Association (ADA) recently released new recommendations on nutrition therapy for adults with type 1 or type 2 diabetes. More...


Nephrology

Moderate to severe psoriasis may be associated with increased risk for chronic kidney disease

Moderate to severe psoriasis (more than 3% of body surface area affected) is associated with an increased risk of chronic kidney disease (CKD), independent of traditional risk factors such as diabetes and heart disease, a study found. More...


Reimbursement

New online tool lets practices enroll in EFT with multiple payers through a single, online process

CAQH has launched a new, universal electronic funds transfer (EFT) enrollment tool that facilitates the use of electronic payments between payers and clinicians by offering a single point of entry for adopting EFT. More...


From the College

ACP Masters elected Alpha Omega Alpha officers

John Tooker, MD, MBA, MACP, has been elected president of Alpha Omega Alpha, the national medical honor society, for 2014. Douglas S. Paauw, MD, MACP, has been named president-elect. 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


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ACP issues clinical practice guideline on chronic kidney disease

ACP released a new clinical practice guideline this week on screening, monitoring and treatment of stage 1 to 3 chronic kidney disease (CKD).

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The guideline was based on a systematic evidence review that evaluated the relevant English-language literature published from 1985 through November 2011. The clinical outcomes evaluated were all-cause mortality, cardiovascular mortality, composite renal outcomes, end-stage renal disease, quality of life, physical function and activities of daily living. The guideline was published online by Annals of Internal Medicine on Oct. 22.

ACP's recommendations are as follows:

  • Recommendation 1: ACP recommends against screening for CKD in asymptomatic adults without risk factors for CKD. (Grade: weak recommendation, low-quality evidence)
  • Recommendation 2: ACP recommends against testing for proteinuria in adults with or without diabetes who are currently taking an ACE inhibitor or an angiotensin II receptor blocker. (Grade: weak recommendation, low-quality evidence)
  • Recommendation 3: ACP recommends that clinicians select pharmacologic therapy that includes either an ACE inhibitor (moderate-quality evidence) or angiotensin II receptor blocker (high-quality evidence) in patients with hypertension and stage 1 to 3 CKD. (Grade: strong recommendation)
  • Recommendation 4: ACP recommends that clinicians choose statin therapy to manage elevated low-density lipoprotein in patients with stage 1 to 3 CKD. (Grade: strong recommendation, moderate-quality evidence)

The guideline authors also gave advice to clinicians on provision of high-value care in this population, noting that no evidence shows that screening improves clinical outcomes in adults without risk factors and that there is no proven benefit of screening in adults already taking ACE inhibitors or angiotensin II receptor blockers for microalbuminuria.

"In the absence of evidence that screening improves clinical outcomes, testing will add costs, owing to both the screening test and to additional follow-up tests (including those resulting from false-positive findings), increased medical visits, and costs of keeping or maintaining health insurance," the guideline authors concluded.


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Vitamin D didn't increase BMD in healthy, nonelderly adults

Vitamin D supplementation doesn't improve bone mineral density (BMD) in healthy adults, a new systematic review and meta-analysis concluded.

Researchers included 23 studies with more than 4,000 participants (all without metabolic bone disease; 92% women; average age, 59 years) that assessed the effects of supplementation with vitamin D3 or D2 on BMD. Mean baseline serum 25-hydroxyvitamin D concentration was less than 50 nmol/L (20 ng/mL) in 8 of the studies, and in 10 studies, participants took less than 800 IU of vitamin D per day. Results were published online by The Lancet on Oct. 11.

Bone mineral density was measured at 1 to 5 sites on the body in the included studies, and according to the review, there were 6 findings of significant benefit from supplementation and 2 of significant detriment; the rest were nonsignificant. The meta-analysis found that BMD was increased by calcium supplementation at only 1 measurement point, the femoral neck, and the benefit was small (weighted mean difference, 0.8%; 95% CI, 0.2% to 1.4%). There was significant heterogeneity among the trials (I2=67%).

The results are consistent with some prior meta-analyses that have found little reduction in fractures from vitamin D supplementation, the authors said. The results do conflict with some other reviews, but those studies gave patients calcium along with vitamin D, so the effects of the 2 supplements cannot be separated. This analysis's negative findings suggest that vitamin D does not work directly on bone cells to promote mineralization and that widespread use of vitamin D supplements for adults without risk factors for vitamin D deficiency is not justified, the authors said.

Individuals who actually have vitamin D deficiency may still benefit from supplementation, and further research is needed to improve the definition of vitamin D deficiency, the researchers recommended. Some clinicians have been targeting serum 25-hydroxyvitamin D concentrations greater than 75 nmol/L (30 ng/mL), they said, noting that their research findings and the 2010 Institute of Medicine report do not support this practice. The resources currently spent on measurement and supplementation of vitamin D levels could be better spent elsewhere, they concluded.

An accompanying comment agreed with the study's findings but noted that maintenance of vitamin D in the elderly (along with sufficient calcium intake) remains appropriate for prevention of hip fractures.



Test yourself


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MKSAP Quiz: 3-month history of increasing fatigue and weight gain

A 38-year-old woman reports a 3-month history of increasing fatigue and weight gain. She underwent transsphenoidal surgery 4 years ago to remove a nonfunctioning pituitary macroadenoma, followed 4 months later by radiation therapy because of residual tumor. She started taking hydrocortisone 14 months ago after adrenal insufficiency was diagnosed. The patient developed amenorrhea 1 year ago and began taking an oral contraceptive. Medications are hydrocortisone, norethindrone with ethinyl estradiol, and a multivitamin.

mksap.gif

On physical examination, blood pressure is 102/68 mm Hg, pulse rate is 64/min, and respiration rate is 12/min. Mild periorbital edema is noted. The skin is pale.

Laboratory studies:

Hemoglobin Normal
Sodium 134 mEq/L (134 mmol/L)
Prolactin 22 ng/mL (22 µg/L)
Thyroid-stimulating hormone 1.1 µU/mL (1.1 mU/L)

Which of the following is the most appropriate next diagnostic test?

A: Morning serum cortisol measurement
B: Serum free thyroxine (T4) measurement
C: Serum growth hormone measurement
D: Serum luteinizing hormone measurement

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


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Diabetes


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ADA updates nutrition guidelines to address varied eating patterns

The American Diabetes Association (ADA) recently released new recommendations on nutrition therapy for adults with type 1 or type 2 diabetes.

The recommendations, which were published by Diabetes Care on Oct. 9 and replace a set issued in 2008, note that "there is not a 'one-size-fits-all' eating plan for individuals with diabetes." In general, diabetes patients should eat a variety of nutrient-dense foods in appropriate portion sizes, with diet specifics individualized based on their personal and cultural preferences, health literacy and numeracy, access to food and willingness and ability to change. Both medical nutrition therapy and diabetes self-management education are recommended by the guidelines for patients with either type of diabetes.

The recommendations also included the following advice:

  • Evidence has not determined an ideal percentage or quantity of carbohydrates, protein or fat that patients with diabetes should consume, so choices should be individualized. Monitoring carbohydrate intake is key to achieving glycemic control, however.
  • Patients with diabetes should follow the same nutritional guidelines as the general public with regard to consumption of fiber and whole grains, foods containing long-chain omega-3 fatty acids, saturated and trans fats, sodium and cholesterol.
  • A Mediterranean-style diet is an effective alternative to a lower-fat, higher-carbohydrate eating pattern.
  • Substituting low-glycemic load foods for high-glycemic load foods may modestly improve glycemic control.
  • Patients with diabetes should limit or avoid sugar-sweetened beverages and drink alcohol only in moderation (1 drink per day for women, 2 for men).
  • There is no clear evidence to support supplementation with vitamins, minerals, omega-3, or cinnamon and other herbs for patients with diabetes.

The recommendations also include specific advice on coordinating food with different types of diabetes medications. The authors called for additional research on a number of topics, including Mediterranean-style, low-glycemic index and low-carbohydrate diets, as well as the effects of nonnutritive sweeteners.

"Nutrition interventions should emphasize a variety of minimally processed nutrient-dense foods in appropriate portion sizes as part of a healthful eating pattern and provide the individual with diabetes with practical tools for day-to-day food plan and behavior change that can be maintained over the long term," the recommendations concluded.



Nephrology


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Moderate to severe psoriasis may be associated with increased risk for chronic kidney disease

Moderate to severe psoriasis (more than 3% of body surface area affected) is associated with an increased risk of chronic kidney disease (CKD), independent of traditional risk factors such as diabetes and heart disease, a study found.

Researchers used a primary care electronic medical records database in the United Kingdom to identify 143,883 adults with psoriasis and match them to a control group of 689,702 patients without psoriasis, seen between 2003 and 2010.

Mild psoriasis was defined as disease affecting 2% or less of body surface area. Moderate disease was defined as 3% to 10% of body surface area affected. Severe to extensive disease was defined as more than 10% of body surface area affected or as receipt of phototherapy or oral or injectable biologic medications.

Study results appeared online Oct. 15 at BMJ.

Patients with psoriasis, particularly those with severe disease, were at greater risk of developing moderate to advanced (stage 3 to 5) CKD compared with control patients. For all patients with psoriasis, the hazard ratio (HR) was 1.05 (95% CI, 1.02 to 1.07); for mild disease, the HR was 0.99 (95% CI, 0.97 to 1.02); and for severe disease, the HR was 1.93 (95% CI, 1.79 to 2.08). Those with severe psoriasis were more than 4 times as likely to develop end-stage renal disease requiring dialysis (adjusted HR, 4.15; 95% CI, 1.70 to 10.11).

The researchers conducted a subgroup analysis of 8,731 psoriasis patients with measurements of affected body surface area and matched them to 87,310 patients without psoriasis. There was a greater risk of CKD in patients with moderate and severe disease in a dose-response effect. After adjustment for age, sex, cardiovascular disease, diabetes, hypertension, hyperlipidemia, body mass index, use of nonsteroidal anti-inflammatory drugs and duration of observation, the odds ratios of CKD were 0.89 (95% CI, 0.72 to 1.10) for mild disease, 1.36 (95% CI, 1.06 to 1.74) for moderate disease and 1.58 (95% CI, 1.07 to 2.34) for severe disease. The adjusted prevalence odds ratio of CKD was 0.90 (95% CI, 0.64 to 1.28) in patients with psoriasis of less than 2 years' duration and 1.24 (95% CI, 1.01 to 1.53) in patients with 10 or more years' duration.

The authors recommend closer monitoring for kidney problems in patients with moderate or severe disease. "Closer monitoring for renal insufficiency, such as routine screening urinalysis for microalbuminuria and serum creatinine and blood urea nitrogen testing, should be considered for patients with psoriasis affecting 3% or more of the body surface area. Increased screening efforts will allow for earlier detection and intervention to reduce the substantial morbidity and mortality associated with chronic kidney disease," they wrote. "Additionally, the risk versus benefit of potentially nephrotoxic drugs in patients with moderate to severe psoriasis should be carefully considered."



Reimbursement


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New online tool lets practices enroll in EFT with multiple payers through a single, online process

CAQH has launched a new, universal electronic funds transfer (EFT) enrollment tool that facilitates the use of electronic payments between payers and clinicians by offering a single point of entry for adopting EFT. The tool, free to clinicians, creates efficiencies for both payers and clinicians by eliminating the need to enroll in EFT separately for each health plan.

The CAQH enrollment tool allows clinicians to enter their EFT enrollment information into a single, secure, online utility and select the payers to which their information should be sent. Payers receive the enrollment information electronically from CAQH, enabling clinicians to complete the process once. In addition, clinicians can go into the tool at any time, make changes and easily distribute those changes to the applicable payers if needed.

Beginning January 2014, all payers, including Medicare, will be mandated to offer EFT under the requirements of the Patient Protection and Affordable Care Act. To access the CAQH EFT enrollment tool, or for more information, visit the tool website.

CAQH has designed a survey that takes less than 10 minutes to complete for ACP members interested in helping CAQH identify the challenges and improve implementation of EFT. The survey is available online.



From the College


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ACP Masters elected Alpha Omega Alpha officers

John Tooker, MD, MBA, MACP, has been elected president of Alpha Omega Alpha, the national medical honor society, for 2014. Douglas S. Paauw, MD, MACP, has been named president-elect.

Dr. Tooker is ACP's emeritus EVP and CEO and an adjunct professor of medicine at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. Dr. Paauw is a professor of medicine at the University of Washington School of Medicine in Seattle and holds the Rathmann Family Foundation Endowed Chair in Patient-Centered Clinical Education.

More information is available 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-20131022-cartoon.jpg

"That moment when you realize patient satisfaction has really gotten out of hand."

"Each button is wired to an electrical current. It's our version of the Skinner box."

"In regards to our smoking cessation program, I asked you to order venlafaxine, not a vending machine."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting ends on Monday, Oct. 28, with the winner announced in the Oct. 29 issue.


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MKSAP Answer and Critique



The correct answer is B: Serum free thyroxine (T4) measurement. This item is available to MKSAP 16 subscribers as item 57 in the Endocrinology & Metabolism section. More information is available online.

This patient most likely has central hypothyroidism and should have her serum free thyroxine (T4) level measured. Her hypopituitarism is a result of the radiation therapy she received as part of her treatment of a pituitary adenoma. Her symptoms are typical of hypothyroidism, and the signs and symptoms of central hypothyroidism are similar to those of primary hypothyroidism. However, the biochemical diagnosis of central hypothyroidism is established differently because patients may have either a low-normal to overtly low serum thyroid-stimulating hormone (TSH) level. Therefore, the diagnosis is made based on measurement of a low free T4 level in association with both a low to low-normal TSH level and clinical symptoms suggestive of hypothyroidism. This patient's mild hyponatremia may be caused by her hypothyroidism and should improve with T4 replacement. In a patient with central hypothyroidism who takes levothyroxine replacement therapy, the goal should be achievement of a normal free T4 level because monitoring the TSH value is not useful.

Measuring this patient's morning serum cortisol level is inappropriate management because she is receiving glucocorticoid replacement therapy for adrenal insufficiency, which guarantees that the cortisol level will be low.

A random measurement of the serum growth hormone (GH) level is not useful in the assessment of GH deficiency. A serum insulin-like growth factor 1 level would be useful for assessing GH production.

Measurement of this patient's serum luteinizing hormone level will not be useful because the oral contraceptive agent she is taking will have lowered her gonadotropin levels.

Key Point

  • The diagnosis of central hypothyroidism is made on the basis of the serum free thyroxine (T4) level.

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Test yourself

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?

Find the answer

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