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

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ACP InternistWeekly



In the News for the Week of October 8, 2013




Highlights

Long-term follow-up of WHI indicates menopausal hormone therapy not helpful for chronic disease prevention

Hormone therapy after menopause is not effective for chronic disease prevention, according to a new analysis of long-term follow-up data from the Women's Health Initiative (WHI). More...

Exercise may be as effective as drugs for some mortality outcomes, study finds

Exercise may be as effective as drug therapy in providing mortality benefits for certain conditions, according to a new study. More...


Test yourself

MKSAP Quiz: Recurrent pruritic rash on the hands

A 32-year-old woman is evaluated for a recurrent pruritic rash on her hands. She works as a dental hygienist and notices that it improves when she goes on vacation. Topical corticosteroids alleviate the rash, but it quickly recurs. Following a physical exam, what test should be done next? More...


Delirium

Longer inpatient delirium time associated with worse cognition a year later

Inpatients who spent more time in delirium had worse cognition and executive function scores at 3 and 12 months, a new study found. More...


Migraine

Migraineurs may have more risk of hemorrhagic stroke

People with migraine may have an increased risk of hemorrhagic stroke, especially women younger than 45, a meta-analysis found. More...


Immunization

ACP resources available to help boost adult immunizations

With flu season approaching, now is the time for physicians to recommend flu shots to their patients and assess their vaccine needs. More...


EHRs

AmericanEHR allows clinicians to rate EHRs and submit feedback

AmericanEHR has released over 3 years' worth of feedback on electronic health records (EHRs) that clinicians have submitted outlining firsthand experiences with certified EHR systems. More...


From ACP Internist

ACP Internist is now online and coming to your mailbox

The October issue of ACP Internist is online, featuring stories on how the states have become divided over Medicaid and how internists can handle diabetic foot care. More...


From the College

ACP's Quality Improvement Network now recruiting practices for ACPNet: Diabetes

ACP's Quality Improvement (QI) Network is recruiting practices to enroll in ACPNet: Diabetes, a QI initiative that provides physicians free access to PQRSwizard, ABIM-approved MOC practice performance (part IV) credit, and ACP's Practice Advisor (formerly the Medical Home Builder). More...

ACP announces new Leadership Academy

The ACP Leadership Academy is ACP's new leadership development program designed to provide early-career internists with the skills and knowledge necessary to become leaders in medicine. 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...

Editorial note: ACP InternistWeekly will not be published next week due to the Explorer's Day holiday.


Physician editor: Philip Masters, MD, FACP



Highlights


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Long-term follow-up of WHI indicates menopausal hormone therapy not helpful for chronic disease prevention

Hormone therapy after menopause is not effective for chronic disease prevention, according to a new analysis of long-term follow-up data from the Women's Health Initiative (WHI).

Researchers presented an overview of findings from 2 WHI trials of hormone therapy with extended postintervention follow-up. In the trials, women who had an intact uterus received conjugated equine estrogen (CEE), 0.625 mg/d, plus medroxyprogesterone acetate (MPA), 2.5 mg/d, or placebo. Women who had had a hysterectomy received CEE alone at the same dosage or placebo. The intervention phase of the CEE plus MPA trial was 5.6 years, while the intervention phase of the CEE-only trial lasted 7.2 years; there were 13 years of cumulative follow-up until Sept. 30, 2010. In the current analysis, the primary efficacy outcome was coronary heart disease (CHD) and the primary safety outcome was invasive breast cancer. In addition, a global index of monitored clinical events included time to first event for CHD, invasive breast cancer, stroke, pulmonary embolism, colorectal cancer, hip fracture and death from all other causes, plus endometrial cancer in the CEE plus MPA group. The study was published in the Oct. 2 Journal of the American Medical Association.

Overall, 27,347 postmenopausal women 50 to 79 years of age were enrolled in the study at 40 U.S. centers. A total of 8,506 women received CEE plus MPA and 8,102 received placebo, while 5,310 women received CEE alone and 5,429 received placebo. For the CEE plus MPA intervention, 196 CHD cases occurred in the CEE plus MPA group and 159 occurred in the placebo group (hazard ratio [HR], 1.18; 95% CI, 0.95 to 1.45); the numbers of breast cancer cases were 206 and 155, respectively (HR, 1.24; 95% CI, 1.01 to 1.53). Patients in the intervention group also had increased risk for stroke, pulmonary embolism, dementia (if ≥65 years of age), gallbladder disease and urinary incontinence but decreased risk for hip fractures, diabetes and vasomotor symptoms. Most risks and benefits dissipated during cumulative postintervention follow-up with the exception of risk for breast cancer, which remained elevated in the intervention group (434 cases vs. 323 cases; HR, 1.28; 95% CI, 1.11 to 1.48).

The CEE-only intervention yielded more balanced risk and benefits. Two hundred four CHD cases and 104 invasive breast cancer cases occurred in the intervention group versus 222 cases and 135 cases in the placebo group; the HR for CHD was 0.94 (95% CI, 0.78 to 1.14), while the HR for invasive breast cancer was 0.79 (95% CI, 0.61 to 1.02). A cumulative total of 168 breast cancer cases was diagnosed in the CEE-only group versus 216 in the placebo group (HR, 0.79; 95% CI, 0.61 to 1.02). Other outcomes in the CEE-only intervention were similar to those seen in the CEE plus MPA intervention.

Neither of the interventions appeared to affect all-cause mortality. Women 50 to 59 years of age had more favorable outcomes with CEE only for all-cause mortality, myocardial infarction and the global index. The range of absolute risks of adverse events with CEE plus MPA as measured by the global index per 10,000 women annually was 12 excess cases in women age 50 to 59 and 51 excess cases in women age 70 to 79. Outcomes related to quality of life were mixed for both interventions. Younger women age 50 to 54 years in the CEE plus MPA and CEE-only groups who were having hot flashes, night sweats or both at study enrollment (n=979) reported substantial improvement in symptoms at 1 year, while among the entire cohort, women taking either study regimen had less sleep disturbance but more breast tenderness than those taking placebo. Those taking CEE plus MPA were also less likely than those taking placebo to report joint pain.

The authors noted that because the WHI trials each examined only 1 hormone dose, type and route of administration, the results may not be generalizable to other hormone preparations, and that 20% of surviving study participants did not give consent for extended follow-up, among other limitations. However, they concluded, the current WHI findings don't support the use of either intervention for chronic disease prevention. They noted that the risks of CEE plus MPA outweighed the benefits for women of all studied ages, that younger women with hysterectomy had a more favorable risk-to-benefit ratio with CEE alone, and that increased stroke and venous thrombosis risk persisted with both regimens.

"Even though hormone therapy is a reasonable option for the management of moderate to severe menopausal symptoms among generally healthy women during early menopause, the risks associated with hormone therapy, in conjunction with the multiple testing limitations attending subgroup analyses, preclude a recommendation in support of its use for disease prevention even among younger women," the authors wrote. "Current findings also suggest caution when considering hormone therapy treatment in older age groups, even in the presence of persistent vasomotor symptoms, given the high risk of CHD and other outcomes associated with hormone therapy use in this setting."


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Exercise may be as effective as drugs for some mortality outcomes, study finds

Exercise may be as effective as drug therapy in providing mortality benefits for certain conditions, according to a new study.

Researchers performed a meta-epidemiological study of meta-analyses involving randomized, controlled trials that compared the effect of exercise and drug interventions on mortality with each other or with a control (defined as a placebo or usual care). A random-effects network meta-analysis was used to combine study-level death outcomes; the current study's main outcome measure was mortality. The results were published online Oct. 1 by BMJ.

An initial search of Medline and the Cochrane Database of Systematic Reviews found 4 exercise and 12 drug meta-analyses. A separate Medline search found 3 recent exercise trials that had been published between 2008 and 2012 and were not included in any of the 4 meta-analyses. When these meta-analyses and trials were incorporated, the current review included 305 trials involving 339,274 participants. Of these, 14,716 participants were randomly assigned to a physical activity intervention in 57 trials. There was evidence of the effectiveness of exercise on mortality for 4 conditions: secondary prevention of coronary heart disease, stroke rehabilitation, heart failure treatment and diabetes prevention. The authors found no statistically detectable differences between exercise and drug interventions for secondary prevention of coronary heart disease or diabetes prevention. Physical activity was more effective than drugs for stroke rehabilitation (odds ratios, 0.09 [95% credible interval, 0.01 to 0.70] for exercise vs. anticoagulants and 0.10 [95% credible interval, 0.01 to 0.62] for exercise vs. antiplatelets), but diuretics were more effective than exercise for heart failure treatment (odds ratio, 4.11 for exercise vs. diuretics [95% credible interval, 1.17 to 24.76]).

The authors noted that their findings regarding stroke rehabilitation and heart failure should be interpreted with care because data were scarce and from different study settings. They also pointed out that exercise interventions were defined differently in different trials and that some of the meta-analyses of drug interventions were outdated, among other limitations. However, they said that their study was the first to compare the effects of exercise and drugs on mortality and that it "highlights the need to perform randomised trials on the comparative effectiveness of exercise and drug interventions." They suggested that since funding for additional exercise trials may be limited, regulators might consider requiring pharmaceutical companies to test new drugs against an exercise intervention. "In cases where drug options provide only modest benefit, patients deserve to understand the relative impact that physical activity might have on their condition," the authors wrote.



Test yourself


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MKSAP Quiz: Recurrent pruritic rash on the hands

A 32-year-old woman is evaluated for a recurrent pruritic rash on her hands. She works as a dental hygienist and notices that it improves when she goes on vacation. Topical corticosteroids alleviate the rash, but it quickly recurs.

mksap.gif

On physical examination, she has scaling, erythematous patches on her dorsal hands, fingers, and wrists. She has scaling, peeling, and scabbed erosions on several fingertips.

Which of the following tests should be done next?

A: Patch testing
B: Potassium hydroxide (KOH) preparation
C: Prick testing
D: Radioallergosorbent testing

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


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Delirium


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Longer inpatient delirium time associated with worse cognition a year later

Inpatients who spent more time in delirium had worse cognition and executive function scores at 3 and 12 months, a new study found.

In a multicenter, prospective cohort study, researchers examined 821 patients with respiratory failure, cardiogenic shock or septic shock in surgical and medical ICUs. Inpatients were evaluated for delirium (using the Confusion Assessment Method for the ICU) and level of consciousness (using the Richmond Agitation-Sedation Scale) every day until day 30 or hospital discharge.

Separate researchers, who were unaware of the patients' hospital courses, then assessed the patients' global cognition at 3 and 12 months after discharge using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and the Trail Making Test, Part B. The researchers used linear regression to examine any associations between duration of delirium, use of analgesic and sedative agents, and outcomes. Results were published online Oct. 3 by the New England Journal of Medicine.

Six percent of patients had cognitive impairment at baseline, and 74% developed delirium while in the hospital. At 3 months, 40% of patients scored 1.5 SDs below the mean in global cognition, similar to scores of patients who have moderate traumatic brain injury. Twenty-six percent of patients had scores 2 SDs below the mean, similar to scores of patients with mild Alzheimer disease.

At 12 months, 34% and 24% of patients had scores at 1.5 and 2 SDs below the mean, respectively. A longer duration of delirium was independently associated with lower global cognition at 3 and 12 months (P=0.001 and P=0.04, respectively), as well as lower executive functioning (P=0.004 and P=0.007 at 3 and 12 months, respectively). Cognitive impairment wasn't associated with analgesic or sedative drug use, and deficits occurred in both older and younger patients.

Though the results were similar to previous studies showing cognitive deficits in ICU survivors, this study is different in that it enrolled a large sample of patients with a broad age range and diverse diagnoses, and detailed data were collected about delirium and sedative exposure as risk factors, the authors noted. A limitation, however, was that researchers couldn't test patients' cognition before their emergent illness, though the researchers did attempt to account for this via exclusions, stratification and statistical adjustments, they added.

Editorialists wrote that the study "unequivocally establishes that critical illness promotes the development of new and clinically important cognitive impairment, regardless of age, burden of coexisting conditions and diagnosis at hospital admission." The results highlight the important of monitoring for delirium in the ICU and intervening, as well as practicing wake-up and mobility protocols, they wrote.



Migraine


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Migraineurs may have more risk of hemorrhagic stroke

People with migraine may have an increased risk of hemorrhagic stroke, especially women younger than 45, a meta-analysis found.

Researchers reviewed the literature through March 2013 for case-control and cohort studies with a clear definition of the diagnostic criteria for migraine and hemorrhagic stroke to find 8 studies (4 case-control and 4 cohort studies) involving a total of 1,600 hemorrhagic strokes.

Results appeared online Oct. 1 at Stroke.

The overall pooled adjusted effect estimate of hemorrhagic stroke in subjects with any migraine versus control subjects was 1.48 (95% CI, 1.16 to 1.88; P=0.002), with moderate statistical heterogeneity (I2=54.7%; P value for Q test=0.031). The increase in hemorrhagic stroke associated with migraine with aura (1.62; 95% CI, 0.87 to 3.03; P=0.129) was not significant.

Compared with control subjects, the risk of hemorrhagic stroke was greater in women with any migraine (1.55; 95% CI, 1.16 to 2.07; P=0.003), as well as female migraineurs under 45 years old (1.57; 95% CI, 1.10 to 2.24; P=0.012).

Researchers noted that only 2 studies reported data for men, so a direct comparison of the risk in women with the risk in men was not possible. The analysis could not determine the effects of migraines with or without aura because only 2 cohort studies and 1 case-control study collected data on the risk of hemorrhagic stroke according to migraine type. The group of patients who had migraines with aura was a smaller subgroup and the effect size estimate was higher than that for migraine without aura, so the meta-analysis may not have sufficient power to detect an association, the study authors noted. Also, an analysis based on only 8 studies may limit the conclusiveness of the results. Finally, the mechanisms underlying the association between migraine and hemorrhagic stroke are uncertain.

"Consequently, no alert should be given to migraineurs because no changes to their current standard treatments are needed," the authors wrote. "Indeed, to date, the best recommendation for physicians treating subjects with migraine is to continue to focus carefully on those factors that could increase their risk of vascular events."



Immunization


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ACP resources available to help boost adult immunizations

With flu season approaching, now is the time for physicians to recommend flu shots to their patients and assess their vaccine needs.

ACP urges physicians and health care professionals to conduct an immunization review during medical visits to assess whether patients' immunizations are up to date and to educate patients on the benefits of immunization. Although many factors influence low rates of adult immunization in the U.S., research indicates that a physician's recommendation is a powerful motivator for adults to get vaccinated against serious diseases like influenza, tetanus, whooping cough, shingles, hepatitis A and B, and pneumococcal disease.

Several resources are available to help physicians and health care professionals ensure that patients receive the correct immunizations in accordance with the CDC's Recommended Adult Immunization Schedule. For resources and information, visit ACP's website.



EHRs


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AmericanEHR allows clinicians to rate EHRs and submit feedback

AmericanEHR has released over 3 years' worth of feedback on electronic health records (EHRs) that clinicians have submitted outlining firsthand experiences with certified EHR systems.

AmericanEHR.com has also introduced new community features, including the ability for verified physicians and EHR vendors to interact and openly discuss the challenges posed with EHRs and health information technology.

AmericanEHR collects EHR feedback during its "EHR Satisfaction Survey," which is open to all physicians, physician assistants, and nurse practitioners. Users are able to sort EHR feedback by EHR product, and each submission is tagged with the specialty and clinical setting of the clinician rater. Over 4,800 EHR ratings have been published on AmericanEHR.com to date, and new ratings are constantly added as new users register and participate. Visit online to view the new features and comment.



From ACP Internist


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ACP Internist is now online and coming to your mailbox

The October issue of ACP Internist is online, featuring stories on the following:

acpi-20131008-cover.jpg
  • Changes to Medicaid divide states, doctors. States get the final say in whether to expand their Medicaid programs and how to accomplish that. The resulting disparities have prompted physicians to get involved to secure access for their patients and funding for themselves, their practices and their hospitals.
  • Diabetic foot care begins with bare feet. Internists can head up a care team that intervenes early and often in preventing the ulcerations, pressure points and neuropathies that can progress to infection and possibly amputation.
  • President's Message: Maintenance of Certification is needed, but it needs to change. ACP President Molly Cooke, MD, FACP, writes that the College will continue to press for a process that ensures physicians remain up-to-date on clinical knowledge, but in a much less burdensome way than the current methods.

Don't miss Test Yourself with the MKSAP Quiz, info on C. difficile in the outpatient setting, and our new acrostic puzzle feature, Crossed Words, which challenges readers to unlock clues placed horizontally in rows to reveal an answer written vertically.



From the College


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ACP's Quality Improvement Network now recruiting practices for ACPNet: Diabetes

ACP's Quality Improvement (QI) Network is recruiting practices to enroll in ACPNet: Diabetes, a QI initiative that provides physicians free access to PQRSwizard, ABIM-approved MOC practice performance (part IV) credit, and ACP's Practice Advisor (formerly the Medical Home Builder). Participants will also be entered into a lottery to win free registration for Internal Medicine 2014 in Orlando, Fla.

ACPNet: Diabetes will be launched with a webinar on Nov. 11, 2013, at 7 p.m. EST. This program will help physicians review their diabetes performance and understand how the ACPNet tools can help. After the webinar, physicians can upload baseline and follow-up data from 25 of their diabetic patient charts online, which will be used to automatically calculate diabetes performance measures. The data will be transferred automatically for PQRS and MOC—physicians only have to provide the information once to meet Medicare reimbursement and MOC requirements.

The program's MedConcert platform includes hundreds of resources for improving diabetes care with ongoing opportunities for coaching calls. Overall, participants can gain access to the full benefits of participation in a matter of several hours over the course of 3 to 6 months.

The registration deadline for this program is Oct. 31, 2013. Physicians can register online. For more information, please contact ACPQI@acponline.org.


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ACP announces new Leadership Academy

The ACP Leadership Academy is ACP's new leadership development program designed to provide early-career internists with the skills and knowledge necessary to become leaders in medicine.

The program's first offerings will be live and online courses offered in partnership with the American College of Physician Executives (ACPE), the nation's largest health care organization for physician leaders. These courses are eligible for CME credit through the ACPE and were selected to provide episodic leadership training for members wanting to brush up on a specific content area. Participants can put these courses toward earning a nationally recognized leadership certificate from the ACPE and can also roll course credits into advanced degree programs from accredited universities. ACP members will receive a 15% discount on approved courses.

In addition to these courses, in coming months, the ACP Leadership Academy will begin offering additional, informal leadership development opportunities via other College-wide vehicles to enhance the formal coursework.

The new ACP Leadership Academy replaces ACP's Leadership Enhancement and Development (LEAD) program. Members currently pursuing an ACP LEAD Certificate must declare their intent to complete the requirements by e-mailing ACP by Dec. 31, 2013. To earn a LEAD certificate, you must participate in 5 out of 7 LEAD activities and complete your application by June 30, 2014. Former ACP LEAD certificate recipients and members who have completed some but not all of the requirements for a LEAD certificate may transfer up to 22 credits toward completion of the prerequisites for ACPE's certificate by June 30, 2014. To determine how many credits you may transfer, please e-mail ACP by Dec. 31, 2013. Applications for ACP's LEAD certificate or transfer of credits will not be accepted after this date.

More information, including a list of courses and LEAD transition information, is online.



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-20131008-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 A: Patch testing. This item is available to MKSAP 16 subscribers as item 41 in the Dermatology section. More information is available online.

Patch testing is done to determine if a patient's eczema is from a contact allergy. Allergic contact dermatitis (ACD) is a type IV or delayed hypersensitivity reaction caused by allergen-specific T-lymphocytes. The first reaction to an antigen may occur several weeks after exposure, but subsequent reactions usually develop within 24 to 48 hours of reexposure. Reactions often become more intense with repeated exposure. ACD is usually intensely itchy. In acute reactions, the skin is red, edematous, weepy, and crusted, and there may be vesicles or bullae. Chronic exposure results in a chronic eczema. Pruritus is prominent. The hands are a common site for allergic contact dermatitis, especially in health care workers. Exposure history and pattern of the rash may provide clues as to the causal allergen. Epicutaneous patch testing is the gold standard for diagnosis of ACD. Patch testing should be performed to evaluate recurrent or recalcitrant dermatitis. Patch testing is performed by applying a number of standardized chemicals on small discs to the patient's back. It typically requires three visits within a 1-week period. Patients should diligently avoid any identified allergens. Topical corticosteroids are used for pruritus and inflammation. Systemic corticosteroids may be used for severe cases for 2 to 3 weeks but should not be a long-term therapy.

The potassium hydroxide (KOH) test is a common bedside diagnostic test performed on skin scrapings to detect fungi or yeast. An expanding, ringlike lesion with a slightly scaly, erythematous, advancing edge and central clearing suggests a fungal infection, findings that are not present in this patient.

Prick testing and radioallergosorbent testing (RAST) are useful in diagnosing immediate-type hypersensitivity reactions; however, these tests are less appropriate in the setting of ACD, which is a delayed-type hypersensitivity reaction.

Key Point

  • Epicutaneous patch testing is the gold standard for diagnosis of allergic contact dermatitis and should be performed to evaluate recurrent or recalcitrant dermatitis.

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Test yourself

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?

Find the answer

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