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

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ACP InternistWeekly



In the News for the Week of October 29, 2013




Highlights

Counseling before HIV testing didn't reduce later infection rates

Providing counseling about risk reduction at the time of HIV testing did not reduce patients' risk of later acquiring a sexually transmitted infection, according to a recent study. More...

Pulmonary and endocrine societies identify unnecessary tests

Several medical societies recently released lists of commonly performed pulmonary and endocrine tests and procedures that may not always be necessary, as part of the American Board of Internal Medicine Foundation's Choosing Wisely campaign. More...


Test yourself

MKSAP Quiz: 10-day history of malaise, discomfort and progressive jaundice

A 32-year-old woman is evaluated for a 10-day history of malaise, right upper quadrant discomfort, and progressive jaundice. She has had no recent travel outside of the United States, does not drink alcohol, and has no recent ingestions of drugs, including acetaminophen or herbal remedies. Up until this time, she has been healthy. She has a history of type 1 diabetes mellitus for which she takes insulin glargine and insulin detemir. Following a physical exam and lab results, what is the most likely diagnosis? More...


COPD

Telemonitoring for COPD may not affect exacerbation readmissions, quality of life

Telemonitoring in chronic obstructive pulmonary disease (COPD) patients at high risk for exacerbations did not affect hospital readmissions or improve quality of life, according to a new study. More...


Heart failure

End-stage renal disease uncommon in patients with systolic heart failure

End-stage renal disease (ESRD) is uncommon in outpatients with systolic heart failure, but certain factors can identify those at highest risk, according to a new study. More...


Education

Free webinar to help clinicians improve patients' medication adherence

A free webinar is being offered on Tuesday, Nov. 19, 2013, from 12 to 1 p.m. EST to help clinicians engage in frank conversations with patients to improve their medication adherence. More...


From the College

ACP members elected to Institute of Medicine membership

ACP President Molly Cooke, MD, FACP, and several other ACP members have been elected as Institute of Medicine (IOM) members. Election to the IOM is considered one of the highest honors in the fields of health and medicine and recognizes individuals who have demonstrated outstanding professional achievement and commitment to service. More...


Cartoon caption contest

And the winner is …

ACP InternistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption. More...


Physician editor: Philip Masters, MD, FACP



Highlights


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Counseling before HIV testing didn't reduce later infection rates

Providing counseling about risk reduction at the time of HIV testing did not reduce patients' risk of later acquiring a sexually transmitted infection, according to a recent study.

The AWARE clinical trial randomized 5,012 patients seen at 9 U.S. sexually transmitted disease clinics in 2010 to either brief evidence-based, patient-centered counseling (including negotiation of realistic and achievable risk-reduction steps) and a rapid HIV test or just a rapid HIV test with information. Results were published in the October 23/30 Journal of the American Medical Association.

Over the next 6 months, all participants were screened for Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum (syphilis), herpes simplex virus 2 and HIV, as well as Trichomonas vaginalis in women. The two groups showed no significant difference in disease incidence (adjusted risk ratio, 1.12; 95% CI, 0.94 to 1.33). The counseling group actually had slightly more incident cases of sexually transmitted infections than the information-only group (12.3% vs. 11.1%).

The researchers also surveyed the patients about their sexual behavior and did find some reductions in risky behaviors in the counseling group. The lack of an associated reduction in infection rates may mean that the magnitude of the behavior change was insufficient to affect disease rates or that the counseling group had a bias toward reporting reductions in risky behavior whether or not they actually occurred. Either way, actual biological outcomes are the most important result, the authors said. Overall incidence of sexually transmitted infections, the primary outcome of this study, was intended as a surrogate marker for HIV incidence, because an HIV-specific study would require too large a sample.

Prevention counseling significantly raises the cost of HIV testing, the authors noted. Given the lack of effect seen in this study, counseling at the time of testing is an inefficient use of health care resources, the authors concluded. Post-test counseling for patients who are HIV-positive remains essential, but clinics should consider reallocating resources from preventive risk-reduction counseling to conducting HIV tests in more patients, they said.

This study is one of the largest trials of prevention counseling and also benefits from inclusion of a broad study sample, use of rapid HIV testing, and a high follow-up rate, according to an accompanying editorial. The editorialists noted that the CDC explicitly removed its recommendation for prevention counseling as part of HIV testing in 2006. "Prevention counseling is staff-intensive, often perceived as onerous, and often not performed well," the editorialists wrote. Given these limitations, the study's findings, and the need for cost-efficient practice, preventive counseling should not be routinely provided with HIV testing, the editorial concluded.


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Pulmonary and endocrine societies identify unnecessary tests

Several medical societies recently released lists of commonly performed pulmonary and endocrine tests and procedures that may not always be necessary, as part of the American Board of Internal Medicine Foundation's Choosing Wisely campaign.

The pulmonary list was produced by a collaborative task force assembled by the American Thoracic Society (ATS) and the American College of Chest Physicians (ACCP).

Their 5 recommendations are:

  • Do not perform CT surveillance for evaluation of indeterminate pulmonary nodules at more frequent intervals or for a longer period of time than recommended by established guidelines.
  • Do not routinely offer pharmacologic treatment with advanced vasoactive agents approved only for the management of pulmonary arterial hypertension to patients with pulmonary hypertension resulting from left-sided heart disease or hypoxemic lung diseases (groups II or III pulmonary hypertension).
  • For patients recently discharged on supplemental home oxygen following hospitalization for an acute illness, do not renew the prescription without assessing the patient for ongoing hypoxemia.
  • Do not perform CT angiography to evaluate for possible pulmonary embolism in patients with a low clinical probability and negative results of a highly sensitive D-dimer assay.
  • Do not perform CT screening for lung cancer among patients at low risk for lung cancer.

The endocrine list was produced by a collaborative task force assembled by The Endocrine Society and the American Association of Clinical Endocrinologists (AACE).

Their 5 recommendations are:

  • Avoid routine multiple daily self-glucose monitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycemia.
  • Do not routinely measure 1,25-dihydroxyvitamin D unless the patient has hypercalcemia or decreased kidney function.
  • Do not routinely order a thyroid ultrasound in patients with abnormal thyroid function tests if there is no palpable abnormality of the thyroid gland.
  • Do not order a total or free T3 level when assessing levothyroxine (T4) dose in hypothyroid patients.
  • Do not prescribe testosterone therapy unless there is biochemical evidence of testosterone deficiency.

The Choosing Wisely campaign aims to promote conversations between physicians and patients by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm and truly necessary. To date, over 80 national and state medical specialty societies, regional health collaboratives and consumer partners, including ACP, have participated in the campaign, which has covered more than 250 tests and procedures. More information about the campaign is online.



Test yourself


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MKSAP Quiz: 10-day history of malaise, discomfort and progressive jaundice

A 32-year-old woman is evaluated for a 10-day history of malaise, right upper quadrant discomfort, and progressive jaundice. She has had no recent travel outside of the United States, does not drink alcohol, and has no recent ingestions of drugs, including acetaminophen or herbal remedies. Up until this time, she has been healthy. She has a history of type 1 diabetes mellitus for which she takes insulin glargine and insulin detemir. She has no other medical problems.

mksap.gif

On physical examination, temperature is 37.5 °C (99.5 °F), blood pressure is 106/68 mm Hg, pulse rate is 90/min, and respiration rate is 18/min. BMI is 24. Mental status is normal. Jaundice and scleral icterus are noted. Abdominal examination reveals tender hepatomegaly.

Laboratory studies:

INR 0.9 (normal range, 0.8-1.2)
Albumin 3.8 g/dL (38 g/L)
Alkaline phosphatase 220 units/L
Alanine aminotransferase 920 units/L
Aspartate aminotransferase 850 units/L
Total bilirubin 14.4 mg/dL (246.2 µmol/L)
Direct bilirubin 10.6 mg/dL (181.3 µmol/L)

Abdominal ultrasound demonstrates hepatic enlargement with edema surrounding the gallbladder. There is no biliary ductal dilatation. The portal vein and spleen are normal.

Which of the following is the most likely diagnosis?

A. Acute viral hepatitis
B. Fulminant liver failure
C. Hemochromatosis
D. Primary biliary cirrhosis

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


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COPD


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Telemonitoring for COPD may not affect exacerbation readmissions, quality of life

Telemonitoring in chronic obstructive pulmonary disease (COPD) patients at high risk for exacerbations did not affect hospital readmissions or improve quality of life, according to a new study.

Researchers in Scotland performed a researcher-blinded multicenter randomized, controlled trial to determine whether telemonitoring incorporated into existing clinical services was effective at improving COPD care. Patients who had been admitted to the hospital at least once for COPD in the year before randomization were assigned to receive telemonitoring or conventional self-monitoring. Those who had other significant lung disease, who could not provide informed consent or complete the study, or who had other social and clinical problems as identified by their general practitioner were excluded.

Patients in the telemonitoring group had telemonitoring equipment and a secure broadband link installed in their homes and received instruction on how to use them, as well as self-management education. They used a touch screen to transmit answers to a daily questionnaire about their symptoms and treatments and monitored their oxygen saturation; a symptom score was developed based on their data, with low scores being better and high scores being worse. The data were transmitted securely to the patients' clinical team for monitoring and review, and the team received alerts if data were not submitted or if patients scored a 4 or a 5. Each patient's monitoring clinician then decided on the next action to take, usually a telephone call to the patient to determine further management. Patients in the usual care group received the same clinical care as those in the intervention group, including self-management advice, since the researchers wanted to test only the effect of the telemonitoring technology.

The study's main outcome measure was time to hospital admission for COPD exacerbation 1 year after randomization, while secondary outcome measures included number and duration of hospital admissions and assessment by questionnaire of health-related quality of life, anxiety and/or depression, self-efficacy, knowledge and adherence to treatment. The study results were published online Oct. 17 by BMJ.

Study recruitment took place between May 21, 2009, and March 28, 2011. Two hundred fifty-six patients completed the study, 128 who were assigned to telemonitoring and 128 who were assigned to usual care. The mean age was 69.4 years, and 45% of the patients were men. Time to hospital admission did not differ between groups (adjusted hazard ratio, 0.98; 95% CI, 0.66 to 1.44), and the mean number of COPD admissions over 1 year was similar (1.2 admissions per person in the intervention group vs. 1.1 in the control group; P=0.59). The mean duration of COPD admissions over 1 year was also similar (9.5 days per person vs. 8.8 days, respectively; P=0.88). Health-related quality of life and other secondary outcome measures did not differ between groups.

The authors acknowledged that smaller clinically meaningful differences may not have been detected by their trial. In addition, they noted that most of the study patients did not live far from clinical care facilities and that telemonitoring may have a greater effect in more rural areas. However, they concluded that telemonitoring did not extend time to hospital admission and did not improve quality of life in patients with a history of hospitalization for COPD exacerbations. Positive effects in previous trials could have been related to enhanced clinical services in the intervention groups instead of to telemonitoring itself, they said.

"This trial suggests that the addition of telemonitoring to the management of high risk patients, over and above the backdrop of self management education and a good clinical service, is costly and ineffective," an accompanying editorial said. The editorialists stressed that the most effective components of self-management in COPD still need to be identified. "Perhaps we should be putting more emphasis on a more 'upstream' approach for preventing exacerbations," the editorialists wrote. "Exacerbations are usually caused by viruses, and interventions that incorporate simple public health approaches for infection control may be worth pursuing."



Heart failure


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End-stage renal disease uncommon in patients with systolic heart failure

End-stage renal disease (ESRD) is uncommon in outpatients with systolic heart failure, but certain factors can identify those at highest risk, according to a new study.

Although renal dysfunction is fairly common in patients with heart failure, it is not known how often it progresses to ESRD. Researchers used data from the Danish Heart Failure Clinics Network to determine the incidence of and identify predictors for ESRD in outpatients with systolic heart failure who were treated according to guidelines. Renal function was estimated by using the Chronic Kidney Disease Epidemiology Collaboration equation, and patients were divided according to estimated glomerular filtration rate (eGFR): group I, ≥60 mL/min/1.73 m2; group II, 30 to 59 mL/min/1.73 m2; group III, 15 to 29 mL/min/1.73 m2; and group IV, <15 mL/min/1.73 m2. The researchers used Cox hazard models for time to ESRD, death and a composite end point of ESRD or death. The study results were published online Oct. 18 by Circulation: Heart Failure.

Overall, 8,204 patients were included. The median patient age was 70 years, and 28% of patients were women. The median left ventricular ejection fraction was 30%; median eGFR was 68 mL/min/1.73 m2. Over a median follow-up of 3.7 years, 41 patients (1.2 per 1,000 patient-years) developed ESRD and 2,652 patients (84 per 1,000 patient-years) died. Time to ESRD was associated with worse baseline eGFR (groups II, III and IV; P<0.001 for all), uncontrolled hypertension (P=0.049), need for diuretics (P=0.023) and age younger than 60 years (P=0.016).

The authors noted that their results apply only to patients with systolic heart failure and mild to moderate symptoms and should not be generalized to those with more severe heart failure or those with heart failure and preserved ejection fraction. They also pointed out that the number of renal end points was small and that their study may have lacked power, among other limitations. However, they concluded that ESRD is uncommon overall in outpatients with systolic heart failure but that it is more likely in those with certain characteristics.

"Despite improved survival in systolic [heart failure], mortality risk is still a much larger clinical problem than risk of ESRD," the authors wrote. "eGFR-group, younger age, need for diuretics and uncontrolled hypertension are important risk factors for development of ESRD."



Education


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Free webinar to help clinicians improve patients' medication adherence

Have you ever suspected that some of your patients may not be taking their medicine as directed, but didn't know how to ask them? A free webinar is being offered on Tuesday, Nov. 19, 2013, from 12 to 1 p.m. EST to help clinicians engage in frank conversations with patients to improve their medication adherence.

This "Script Your Future" webinar is part of a public education campaign to raise awareness about medication adherence that is sponsored by the National Consumers League, a group with which ACP partners on special projects. Leading the webinar, ACP Member Ira Wilson, MD, chair of the Department of Health Services, Policy and Practice at Brown University in Providence, R.I., will discuss how to use a patient-centered approach to address the challenge of motivating patients and will address questions posed by Web participants.

To register for the webinar, go online. For more information about the "Script Your Future" campaign, visit the program website.



From the College


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ACP members elected to Institute of Medicine membership

ACP President Molly Cooke, MD, FACP, and several other ACP members have been elected as Institute of Medicine (IOM) members. Election to the IOM is considered one of the highest honors in the fields of health and medicine and recognizes individuals who have demonstrated outstanding professional achievement and commitment to service.

New members are elected by current active members through a selective process that recognizes individuals who have made major contributions to the advancement of the medical sciences, health care and public health. Congratulations to Dr. Cooke and ACP Members Katrina A. Armstrong, MD, FACP; Ashish K. Jha, MD, MPH; Gary S. Kaplan, MD, FACP; Nancy E. Lane, MD, MACP; Diane E. Meier, MD, FACP; Nirav R. Shah, MD, MPH, FACP; and James Owen Woolliscroft, MD, FACP.

The IOM announcement is online.



Cartoon caption contest


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And the winner is …

ACP InternistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

acpi-20131029-cartoon.jpg

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

This issue's winning cartoon caption was submitted by David M. Kast, DO, ACP Resident/Fellow Member. Thanks to all who voted! The winning entry captured 50.5% of the votes.

The runners-up were:

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

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


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MKSAP Answer and Critique



The correct answer is A. Acute viral hepatitis. This item is available to MKSAP 16 subscribers as item 5 in the Gastroenterology and Hepatology section. More information is available online.

The most likely diagnosis is acute viral hepatitis. This patient has marked hepatitis with jaundice and significant elevations of hepatic aminotransferases (greater than 15 times the upper limit of normal). In addition, the short duration of her symptoms suggests an acute onset. Elevation of aspartate aminotransferase and alanine aminotransferase to this severe degree is seen in acute viral hepatitis. Typically, the only other causes of this degree of liver chemistry test elevation are medication reactions/toxicity, autoimmune liver disease, ischemic hepatitis (referred to as "shock liver"), or acute bile duct obstruction.

Fulminant liver failure should always be a consideration in patients with acute hepatitis. However, fulminant liver failure is manifested by hepatic encephalopathy that occurs within 8 weeks of the onset of jaundice; this patient has normal mental status. In addition, laboratory studies demonstrate a normal INR and normal albumin level, confirming that this patient's liver function remains intact despite her liver inflammation.

Hemochromatosis is a chronic metabolic cause of chronic liver disease and is associated with much lower elevations of liver inflammation markers than are seen in this patient.

Primary biliary cirrhosis is an immune-mediated cause of chronic liver inflammation. This is not the correct diagnosis because the degree of elevation of aminotransferases vastly exceeds the levels seen in patients with primary biliary cirrhosis, who have elevated alkaline phosphatase and bilirubin levels disproportionately higher than the aminotransferase elevation.

Key Point

  • Acute viral hepatitis is characterized by jaundice and significant elevations of hepatic aminotransferases (greater than 15 times the upper limit of normal).

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Test yourself

A 48-year-old man is evaluated during a follow-up visit for urinary frequency. He reports no hesitancy, urgency, dysuria, or change in urine color. He has not experienced fevers, chills, sweats, nausea, vomiting, diarrhea, or other gastrointestinal symptoms. He feels thirsty very often; drinking water and using lemon drops seem to help. He has a 33-pack-year history of smoking. He has hypertension, chronic kidney disease, and bipolar disorder. Medications are amlodipine, lisinopril, and lithium. He has tried other agents in place of lithium for his bipolar disorder, but none has controlled his symptoms as well as lithium. What is the most appropriate treatment intervention for this patient?

Find the answer

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