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ACP InternistWeekly



In the News for the Week of November 19, 2013




Highlights

New cardio guidelines change statin use, CVD risk assessment

The American Heart Association (AHA) and American College of Cardiology (ACC) issued 4 new cardiovascular disease prevention guidelines last week on cholesterol treatment, cardiovascular risk assessment, lifestyle management and management of overweight and obesity. More...

Available evidence does not support adverse effects of statins on cognition

The available published evidence does not seem to support a link between statins and cognitive impairment, despite an FDA warning to that effect, according to a new systematic review. More...


Test yourself

MKSAP Quiz: 5-week history of spots in the mouth and throat

A 33-year-old woman is evaluated for a 5-week history of whitish spots in the mouth and the back of the throat and discomfort with swallowing solid foods. This is her first episode of these symptoms. She has had no mouth pain, trouble ingesting liquids or pills, nausea, vomiting, diarrhea, fever, chills, sweats, or skin problems. She has a 3-year history of HIV infection and also has moderately severe asthma, which is now well controlled with inhaled medications that were recently prescribed. Whitish plaques are seen on the palate and posterior pharynx. What is the most appropriate management of this patient? More...


Diabetes

Geriatrics society updates guideline for older diabetes patients

Several changes to recommended care for diabetes patients over age 65, including less use of aspirin therapy, were made in a guideline update from the American Geriatrics Society (AGS). More...


Men's health

Tamsulosin for BPH associated with hospitalizations for hypotension

Tamsulosin for benign prostatic hyperplasia (BPH) may be associated with about twice the rate of severe hypotension requiring hospitalization during the first 8 weeks of treatment and the first 8 weeks after restarting treatment, researchers found. More...


Geriatrics

Simple screening tool assesses frailty in elderly patients with acute coronary syndrome

The highest category of scores for the Edmonton Frail Scale (EFS) in elderly patients with acute coronary syndrome was associated with increased comorbidity, longer lengths of stay, and fewer procedures and was independently associated with mortality, a study found. More...


HIV

Updated guidelines released for management of HIV in primary care

The HIV Medicine Association of the Infectious Diseases Society of America (IDSA) released updated guidelines last week on management of HIV in primary care. More...


CMS update

Deadline for eRx incentive approaching

Physicians and other eligible professionals have until Dec. 31 to report at least 25 successful electronic prescribing (eRx) transactions to earn a 0.5% bonus on total allowed charges for professional services covered by the Medicare Part B Physician Fee Schedule during 2013. More...


Internal Medicine 2014

Register now for ACP's national poster competition

ACP Resident/Fellow Members and Medical Student Members are encouraged to enter ACP's national poster competition. More...


From the College

Practicing high-value care and overcoming patients' concerns

Yul Ejnes, MD, MACP, continues his monthly column at KevinMD.com about obstacles to practicing high-value care and the strategies to help patients understand when a particular test or treatment is not likely to improve health. More...

Governor-elect election results announced

The Governors' Subcommittee on Nominations is pleased to announce the Governor-elect Designees. More...


From ACP Hospitalist

The latest issue is online

The November issue of ACP Hospitalist is online. 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: Philip Masters, MD, FACP



Highlights


.
New cardio guidelines change statin use, CVD risk assessment

The American Heart Association (AHA) and American College of Cardiology (ACC) issued 4 new cardiovascular disease prevention guidelines last week on cholesterol treatment, cardiovascular risk assessment, lifestyle management and management of overweight and obesity.

The cholesterol guideline made substantial changes to recommendations about statin use, moving away from specific cholesterol targets and likely increasing the number of patients taking the drugs, according to a press release.

Moderate- or high-intensity statin therapy is recommended for patients who have:

  • clinical cardiovascular disease (CVD),
  • an LDL cholesterol level of 190 mg/dL or higher,
  • type 1 or type 2 diabetes and are between 40 and 75 years of age with an LDL cholesterol level of 70 to 189 mg/dL, or
  • an estimated 10-year risk of CVD of 7.5% or higher (as estimated using the Pooled Cohort Equations) and are between 40 and 75 years with an LDL cholesterol level of 70 to 189 mg/dL.

The second guideline introduced a new method for assessing cardiovascular risk that was broadened from current measures (such as the Framingham risk score) to include assessment of stroke risk, lifetime CVD risk and gender- and ethnicity-specific risk, a press release said. The New Pooled Cohort Equations were derived from a broad group of National Heart, Lung, and Blood Institute-sponsored community-based cohort studies (including Framingham) to better estimate cardiovascular risk and are appropriate for use in non-Hispanic whites and African-Americans from ages 40 to 79. A risk calculator is available. (The new risk calculator has created some controversy.) The guideline also identified 4 additional measures as potentially helpful when patients or clinicians are still uncertain after using the equations: family history of premature CVD, coronary artery calcium score, high-sensitivity C-reactive protein levels and ankle-brachial index.

The third guideline focuses on lifestyle management and strongly recommends a heart-healthy dietary pattern as the first step to lower risk of CVD. Specifically, Americans should limit saturated fat, trans fat and sodium and emphasize fruits, vegetables and whole grains, while including low-fat dairy products, poultry, fish and nuts and limiting red meat, sweets and sugar-sweetened beverages. Physical activity should average 40 minutes of moderate- to vigorous-intensity aerobic exercise 3 to 4 times a week. Further details are available in a press release.

A final guideline, developed in collaboration with The Obesity Society, offered advice on tailoring treatment recommendations for overweight and obese patients. Clinicians should calculate patients' body mass index (BMI) annually or more frequently and, for patients who need to lose weight, should develop individualized weight loss plans that include a moderately reduced-calorie diet, increased physical activity and behavioral strategies. Adults with a BMI of 40 or higher, or 35 or higher with 2 other cardiovascular risk factors, should be advised that bariatric surgery may provide significant health benefits, a press release noted.

The expert panels that wrote the reports were convened by the National Heart, Lung, and Blood Institute of the National Institutes of Health. The full reports were published on the websites of the ACC and the AHA and will appear in future print issues of the Journal of the American College of Cardiology and Circulation. The obesity guideline will also appear in Obesity: Journal of The Obesity Society.


.
Available evidence does not support adverse effects of statins on cognition

The available published evidence does not seem to support a link between statins and cognitive impairment, despite an FDA warning to that effect, according to a new systematic review.

annals.jpg

Researchers searched PubMed, Embase, and the Cochrane Library through October 2012 for randomized, controlled trials (RCTs) and cohort, case-control and cross-sectional studies that assessed cognition in patients taking statins. They also searched FDA databases from January 1986 through March 2012 to identify reports of adverse events related to statins. Their study was meant to address whether the available published literature indicates that statins impair cognitive function and whether the FDA's postmarketing surveillance databases indicate a higher cognitive risk with statins than with other drugs commonly used for cardiovascular disease.

Results of the review, which received no external funding, were published in the Nov. 19 Annals of Internal Medicine.

A total of 57 studies (19 RCTs, 26 cohort studies, 6 case-control studies and 6 cross-sectional studies) were selected, and of these, 27 (3 RCTs, 16 cohort studies, 4 case-control studies and 4 cross-sectional studies) were included in meta-analyses. Criteria for the lowest risk of bias were met in 4 RCTs, 4 cohort studies and 2 case-control studies. However, most of the RCTs didn't provide enough information to judge the risk of bias from such factors as sequence generation, allocation concealment and selective outcome reporting. Poor representativeness and inadequate follow-up were seen in 11 cohort studies each, while 8 cohort studies had limited comparability. Three of the case-control studies, meanwhile, had limited exposure ascertainment.

Based on these data, the review authors found that low-quality evidence suggested no increase in Alzheimer's disease incidence with statin use. In addition, no difference was seen in procedural memory, attention or motor speed related to statin use. According to moderate-quality evidence, statins did not appear to increase incidence of dementia or mild cognitive impairment or change global cognitive scores, executive function, declarative memory, processing speed or visuoperception. The rate of cognitive-related adverse events in the FDA postmarketing databases was low for statins and was similar to rates reported for other common cardiovascular drugs.

The authors acknowledged that no highly powered RCTs were available for most outcomes and that the strength of the evidence in their study was therefore moderate or low. They also noted that the results for several outcomes were imprecise and inconsistent, that risk of bias was present, and that data on high-dose statins were especially limited. However, they concluded that the currently available evidence does not support the theory that statins have negative cognitive effects. "Larger and better-designed studies are needed to draw unequivocal conclusions about the effect of statins on cognition," they wrote.



Test yourself


.
MKSAP Quiz: 5-week history of spots in the mouth and throat

A 33-year-old woman is evaluated for a 5-week history of whitish spots in the mouth and the back of the throat and discomfort with swallowing solid foods. This is her first episode of these symptoms. She has had no mouth pain, trouble ingesting liquids or pills, nausea, vomiting, diarrhea, fever, chills, sweats, or skin problems. She has a 3-year history of HIV infection and also has moderately severe asthma, which is now well controlled with inhaled medications that were recently prescribed. Her medications are tenofovir, emtricitabine, raltegravir, and inhaled fluticasone and salmeterol.

mksap.gif

On physical examination, her vital signs are normal. Whitish plaques are seen on the palate and posterior pharynx. The remainder of the physical examination is normal. Her last CD4 cell count was 458/µL. The HIV RNA viral load is undetectable.

Which of the following is the most appropriate management of this patient?

A: Clotrimazole troches
B: Fluticasone cessation
C: Intravenous amphotericin B
D: Nystatin swish-and-swallow
E: Oral fluconazole

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


.

Diabetes


.
Geriatrics society updates guideline for older diabetes patients

Several changes to recommended care for diabetes patients over age 65, including less use of aspirin therapy, were made in a guideline update from the American Geriatrics Society (AGS).

"The American Geriatrics Society Guidelines for Improving the Care of Older Adults with Diabetes Mellitus: 2013 Update" were based on high-quality research and developed by an expert panel of clinicians and researchers in the fields of medicine, nursing and pharmacy. An abridged version of the full guidelines was published in the Journal of the American Geriatrics Society on Nov. 12.

The update included several changes from the AGS's 2003 guideline. Aspirin is no longer recommended for the primary prevention of cardiovascular disease (CVD) in older diabetics, due to new evidence on the risk of bleeding. Daily aspirin therapy (81 mg to 325 mg) is still recommended for patients with diabetes and known CVD, however. Recommendations on using statins to treat dyslipidemia were revised to put less focus on targeting specific lipid levels.

The recommendations on glycemic control were also revised to encourage more personalization of blood glucose goals, based on patients' functional status, comorbidities and life expectancy. According to the update, hemoglobin A1c (HbA1c) targets for older adults should generally be 7% to 8%, but a lower target (7% to 7.5%) may be appropriate for healthier, more functional adults, and a higher target (8% to 9%) may be appropriate for less healthy patients with limited life expectancy. Lowering HbA1c to less than 6.5% is associated with potential harm in older adults with diabetes, the guideline update said.

The update also strengthened recommendations about lifestyle modification, calling for regular dietary counseling of all older diabetes patients and at least 150 minutes of moderate-intensity aerobic exercise per week, as well as resistance exercise, for older diabetes patients with normal cognition and functional status.

Other topics covered by the guideline update include smoking cessation, hypertension treatment, glycemic control monitoring and medications, and polypharmacy, as well as screening for foot problems, nephropathy, depression, cognitive impairment, urinary incontinence, fall risk and pain.



Men's health


.
Tamsulosin for BPH associated with hospitalizations for hypotension

Tamsulosin for benign prostatic hyperplasia (BPH) may be associated with about twice the rate of severe hypotension requiring hospitalization during the first 8 weeks of treatment and the first 8 weeks after restarting treatment, researchers found.

To characterize the risk of hypotension requiring hospitalization among men ages 40 to 85 who were treated with tamsulosin (Flomax), researchers designed a population-based, retrospective cohort study based on claims data from a private insurer database comprising 102 U.S. health care plans for more than 68 million patients from January 2001 through June 2011.

Researchers looked at all men who received tamsulosin or a 5α reductase inhibitor (5ARI) after a minimum of 6 months of enrollment to test a between-patient methodology, and then a self-controlled case series to test within-patient methodology. Results appeared online Nov. 5 at BMJ.

Among 383,567 new users of study drugs (tamsulosin, n=297,596; 5ARI, n=85,971), there were 2,562 hospitalizations for severe hypotension. Rates of hypotension were higher for tamsulosin (42.4 events per 10,000 person-years) than for 5ARIs (31.3 events per 10,000 person-years). The cohort analysis found an increased rate of hypotension in the tamsulosin group during weeks 1 to 4 (rate ratio [RR], 2.12; 95% CI, 1.29 to 3.04) and weeks 5 to 8 (RR, 1.51; 95% CI, 1.04 to 2.18). There was no significant increase during weeks 9 to 12 (RR, 1.34; 95% CI, 0.97 to 1.84).

After tamsulosin was restarted, rates of hypotension also increased at weeks 1 to 4 (RR, 1.84; 95% CI, 1.46 to 2.33) and 5 to 8 (RR, 1.85; 95% CI, 1.45 to 2.36), although the risk increase during weeks 9 to 12 was not significant (RR, 1.34; 95% CI, 0.97 to 1.84). Rates of hypotension increased during maintenance treatment (RR, 1.19; 95% CI, 1.07 to 1.32).

The researchers noted that the self-controlled case series yielded similar results as the cohort analysis. After new drug treatment was started, hypotension risk rose during weeks 1 to 4 of new use (RR, 2.56; 95% CI, 2.15 to 3.05), weeks 5 to 8 (RR, 1.66; 95% CI, 1.30 to 2.11) and weeks 9 to 12 (RR, 1.54; 95% CI, 1.19 to 2.01). After treatment was restarted, hypotension rose during weeks 1 to 4 (RR, 1.58; 95% CI, 1.24 to 2.01) and weeks 5 to 8 (RR, 1.60; 95% CI, 1.25 to 2.05) and during maintenance drug treatment (RR, 1.38; 95% CI, 1.21 to 1.57).

Lower rate ratios for hypotension in the later time blocks of 5 to 8 weeks or 9 to 12 weeks may represent hypotension risk among patients who tolerated the drug during earlier periods, the researchers noted. They added that patients who are adherent to tamsulosin may also achieve better control of lower urinary tract symptoms, which could result in a lower risk of falls. The researchers advised physicians to counsel patients about the drug's apparent "first dose phenomenon."



Geriatrics


.
Simple screening tool assesses frailty in elderly patients with acute coronary syndrome

The highest category of scores for the Edmonton Frail Scale (EFS) in elderly patients with acute coronary syndrome was associated with increased comorbidity, longer lengths of stay, and fewer procedures and was independently associated with mortality, a study found.

The Edmonton Frail Scale is a user-friendly screening interview that requires less than 5 minutes to administer and was designed for nongeriatricians. The scale is derived from 9 factors: cognition (drawing a clock diagram); general health status (hospital admissions and a general description); functional independence (activities of daily living); social support (individuals who can help); medication use (5 or more prescriptions, remembering to take them); nutrition (weight loss); mood (sadness or depression); unexpected urinary incontinence; and functional performance on the timed "get up and go" test.

Scores range from 0 (not frail) to 17 (very frail). Researchers seeking to assess the scale's use in acute coronary syndrome administered it as part of a pilot study of 183 consecutive patients 65 years or older who were admitted to a single center in Edmonton, Alberta, Canada.

Results appeared online Oct. 30 in the Canadian Journal of Cardiology.

Patient scores ranged from 0 to 13. Patients with higher scores were older, with more comorbidities, longer lengths of stay (EFS 0 to 3: mean, 7.0 days; EFS 4 to 6: mean, 9.7 days; and EFS ≥7: mean, 12.7 days; P=0.03), and decreased procedure use. Crude mortality rates at 1 year were 1.6% for EFS 0 to 3, 7.7% for EFS 4 to 6, and 12.7% for EFS ≥7 (P=0.05).

After adjustment for baseline risk differences using a "burden of illness" score, the hazard ratio for mortality for EFS ≥7 compared with EFS 0 to 3 was 3.49 (95% CI, 1.08 to 7.61; P=0.002).

The researchers noted the advantages and disadvantages of simple screening tools in the context of frailty. The complexity of some other methods makes simple tools attractive to clinicians, they wrote. Even if some nuances are lost, simple tools can still be predictive. In addition, the EFS has been validated in multiple settings. Still, the authors noted that this was a pilot study designed to assess the tool's use in acute coronary syndrome.

The researchers wrote, "Further work is needed to determine whether the use of a validated frailty instrument to better delineate some of the 'unmeasured factors' involved in medical decision making in elderly patients with cardiovascular disease would provide more transparent and refined discussions of risk and the opportunity for interventions to improve this risk in this important, often disadvantaged, population."



HIV


.
Updated guidelines released for management of HIV in primary care

The HIV Medicine Association of the Infectious Diseases Society of America (IDSA) released updated guidelines last week on management of HIV in primary care.

The evidence-based guidelines, which replace those issued in 2009, were developed by an expert panel and are intended for clinicians who care for patients infected with HIV. Because people with HIV are living longer, the guidelines include information on optimal preventive care, such as screening for diabetes, osteoporosis, colon cancer and other disorders. Patients whose HIV infection is controlled should now have viral levels monitored every 6 to 12 months rather than every 3 to 4 months, the new guidelines state. The guidelines also recommend that patients with HIV infection be vaccinated against pneumococcal infection, influenza, varicella and hepatitis A and B.

The guidelines include an expanded section on sexually transmitted diseases and a new section on metabolic abnormalities, the latter replacing separate, previously published guidelines on dyslipidemia. The guidelines feature tables on routine immunizations and routine health care maintenance in HIV-infected adults, as well as several tables outlining recommendations for the initial assessment of an HIV-infected patient (history, review of systems and physical exam, and initial laboratory and other tests) and a table detailing potential reactions between antiretroviral drugs and statins.

The full text of the guidelines, which were published early Nov. 14 by Clinical Infectious Diseases, is available online.



CMS update


.
Deadline for eRx incentive approaching

Physicians and other eligible professionals have until Dec. 31 to report at least 25 successful electronic prescribing (eRx) transactions to earn a 0.5% bonus on total allowed charges for professional services covered by the Medicare Part B Physician Fee Schedule during 2013.

Submissions can be through claims or approved registry or electronic health record (EHR) systems. Eligible professionals reporting through the Group Practice Reporting Option must meet different defined criteria to earn the bonus, which is based on the size of the group. The eRx incentive is only available to clinicians who do not earn an EHR (meaningful use) incentive in the same year.

Eligible professionals who have not earned the eRx bonus in 2012, or who have not submitted at least 10 successful eRx transactions through claims by June 30, 2013, will be assessed a 2% penalty on their Medicare Part B charges in 2014. This payment adjustment can only be avoided if the eligible professional qualifies for one of the eRx Incentive Program's automatic exemptions or if the eligible professional was recognized as a participant in the Meaningful Use program by June 30, 2013.

More detailed information can be obtained on ACP's Running a Practice webpage.



Internal Medicine 2014


.
Register now for ACP's national poster competition

ACP Resident/Fellow Members and Medical Student Members are encouraged to enter ACP's national poster competition.

National winners and finalists receive complimentary registration to Internal Medicine 2014, ACP's annual scientific meeting (April 10-12, 2014, in Orlando), where entries are featured. The deadline for submissions is Dec. 1, 2013. For more information, visit the ACP website.



From the College


.
Practicing high-value care and overcoming patients' concerns

Yul Ejnes, MD, MACP, a past chair of ACP's Board of Regents, a practicing internist in Cranston, R.I., and a member of ACP Internist's editorial board, continues his monthly column at KevinMD.com.

In his latest post, Dr. Ejnes looks at the obstacles to practicing high-value care and the strategies to help patients understand when a particular test or treatment is not likely to improve health.


.
Governor-elect election results announced

The Governors' Subcommittee on Nominations is pleased to announce the Governor-elect Designees (GEDs) for the chapters below. The GEDs will start their terms as Governors-elect after the Annual Business Meeting in April 2014.

Class of 2019

Alabama Chapter

Gustavo R. Heudebert, MD, FACP

Alberta Chapter

Narmin Kassam, MD, FACP

Arkansas Chapter

Omar T. Atiq, MD, FACP

British Columbia

Dawn E. Dewitt, MD, FACP

Georgia Chapter

Walter J. Moore, MD, FACP

Iowa Chapter

Scott A. Vogelgesang, MD, FACP

Japan Chapter

Fumiaki Ueno, MD, MACP

Minnesota Chapter

John B. Bundrick, MD, FACP

Missouri Chapter

Richard W. Burns, MD, FACP

Nevada Chapter

Evan M. Klass, MD, FACP

New York Manhattan/Bronx Region

Lawrence M. Phillips, MD, FACP

North Carolina Chapter

Peter R. Lichstein, MD, FACP

North Dakota Chapter

Neville M. Alberto, MD, FACP

Ohio Chapter

Michael J. Tan, MD, FACP

Oklahoma Chapter

Michael S. Bronze, MD, FACP

Ontario Chapter

Alexander Ross Morton, MB ChB, FACP

Pennsylvania Eastern Region

David L. George, MD, FACP

Quebec Chapter

Nadine Lahoud, MD, FACP

Rhode Island Chapter

Audrey R. Kupchan, MD, FACP

Saudi Arabia Chapter

Maha M. Al Saud, MBBS, FACP

Texas Southern Region

George E. Crawford, MD, MACP

US Navy Region

Cmdr. Michael P. Keith, MC, USN, FACP

Vermont Chapter

Jan K. Carney, MD, FACP

West Virginia Chapter

John Thomas Dorsey III, MD, FACP



From ACP Hospitalist


.
The latest issue is online

The November issue of ACP Hospitalist is online and includes stories on the following.

Top Hospitalists. Our sixth annual Top Docs issue profiles the best and brightest of your colleagues in hospital medicine from east to west, urban and rural areas, and academic and community hospitals.

Syncope units. Syncope accounts for nearly half a million hospital admissions per year, yet only about half of patients admitted for syncope are actually discharged with the condition as their primary diagnosis. Syncope units aim to make diagnosis more precise, use fewer tests and shorten length of stay.

The Brief Case. This collection of interesting patient cases submitted by hospitalist readers includes an account of drug-induced eosinophilic pneumonia, vancomycin-induced thrombocytopenia, and vesicular rash in a patient with myasthenia gravis.



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.

acpi-20131119-cartoon.jpg

"I hear dead people."

"This concierge medicine gig is getting a little out of control."

"When hospice doctors round late ..."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting ends on Monday, Nov. 25, with the winner announced in the Nov. 26 issue.


.


MKSAP Answer and Critique



The correct answer is E: Oral fluconazole. This item is available to MKSAP 16 subscribers as item 52 in the Infectious Disease section. More information is available online.

This patient should be treated with oral fluconazole. She has evidence of oral candidiasis (thrush), with typical white plaques on visual inspection and symptoms of dysphagia indicating esophageal involvement. Although oral candidiasis has been typically associated with advanced immunosuppression in patients with HIV (CD4 cell counts <200/microliter), it may occur with higher CD4 cell counts in the setting of other risk factors, such as inhaled corticosteroids or broad-spectrum antibiotics.

Although isolated oral disease can be treated with topical agents such as nystatin or clotrimazole, this patient's swallowing symptoms suggest concurrent esophageal disease. Esophageal candidiasis requires systemic therapy such as fluconazole, which can be administered orally as long as the patient can swallow pills.

Although this patient's inhaled corticosteroids may have predisposed her to oral candidiasis, the most appropriate management is to treat the candidal disease and not to discontinue the inhaled corticosteroids, which are an important part of the successful management of her asthma.

This patient has no history of previous treatment with fluconazole and is therefore unlikely to have fluconazole-resistant Candida.

Amphotericin B is an intravenous treatment, is associated with increased toxicity, and is not as convenient as oral therapy; consequently, it is not warranted as initial treatment of esophageal candidiasis.

Key Point

  • Oral candidiasis with esophageal involvement is characterized by whitish plaques on the oral mucosa and difficulty swallowing; treatment with a systemic agent such as fluconazole is required.

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