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

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ACP InternistWeekly



In the News for the Week of November 5, 2013




Highlights

ACE inhibitors may be better than other antihypertensives for diabetes patients

Angiotensin-converting enzyme (ACE) inhibitors were found to possibly improve outcomes for patients with diabetes more than other antihypertensives, a recent meta-analysis found. More...

Score may determine when patients should seek treatment for strep throat

A score to diagnose group A streptococcal (GAS) pharyngitis that can be calculated by patients at home could save hundreds of thousands of visits annually by identifying the need for testing or treatment, a study found. More...


Test yourself

MKSAP Quiz: 10-year history of hot flushes

A 61-year-old woman is evaluated for hot flushes, which have been persistent for the last 10 years. They occur at least 7 times per day, last for approximately 60 seconds, and are associated with severe sweating, palpitations, and occasional nausea. She is awakened several times per night. Following a review of medicines and herbal supplements, taking her medical history, and a physical exam, what is the most appropriate treatment? More...


Burnout

Hospitalists no more prone to burnout than outpatient doctors, analysis finds

The common belief that hospitalists are more likely to experience burnout than outpatient physicians doesn't appear to be true, a new meta-analysis suggests. More...


Cardiology

Short-term dual antiplatelet therapy noninferior to long-term after drug-eluting stent placement

Three months of dual antiplatelet therapy after placement of a drug-eluting stent was noninferior to 12 months of therapy, according to a new study. More...

AHA scientific statement targets atherosclerotic cardiovascular disease

The American Heart Association recently issued a statement on secondary prevention of atherosclerotic cardiovascular disease (ASCVD) in the elderly. More...


Ethics

New ethics case study offers guidance on care of cognitively impaired patients

Preventive Health Screening, Ethics, and the Cognitively Impaired Patient is a new ACP ethics case study available online for CME credit. More...

Ethical duties in "Talking with Patients about Other Clinicians' Errors"

A recent New England Journal of Medicine Sounding Board article examined clinicians' ethical duty to address others' medical errors with patients and examines possible solutions for both physicians and institutions. More...


From the College

Physicians can earn CME online with ACP Clinical Shorts

ACP Clinical Shorts are short educational videos that clinicians can order to earn CME using their computers or mobile devices. Subscribers to ACP Clinical Shorts will receive one year of unlimited access to 28 videos. More...


Cartoon caption contest

Put words in our mouth

ACP InternistWeekly wants readers to create captions for our new cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service. More...


Physician editor: Philip Masters, MD, FACP



Highlights


.
ACE inhibitors may be better than other antihypertensives for diabetes patients

Angiotensin-converting enzyme (ACE) inhibitors were found to possibly improve outcomes for patients with diabetes more than other antihypertensives, a recent meta-analysis found.

In the systematic review and Bayesian network meta-analysis, researchers included 63 randomized, controlled trials with more than 36,000 participants who all had diabetes. All of the studies had follow-up of at least a year and reported outcomes of all-cause mortality, need for dialysis or doubling of serum creatinine. Studied drugs included ACE inhibitors, angiotensin receptor blockers (ARBs), alpha-blockers, beta-blockers, calcium channel blockers and diuretics. Results were published by BMJ on Oct. 24.

Of the studied drugs, only ACE inhibitors significantly reduced the risk of serum creatinine doubling compared to placebo (odds ratio, 0.58; 95% credible interval, 0.32 to 0.90). Only beta-blockers significantly increased patients' mortality risk (odds ratio, 7.13; 95% credible interval, 1.37 to 41.39). The researchers also looked at the drug classes compared to each other individually, and found that, although the differences were not statistically significant, ACE inhibitors had a probability of being superior to ARBs on all three outcomes.

The effect of combination therapy on mortality risk was also examined. Although no combination significantly outperformed placebo on this outcome, the analysis found that an ACE inhibitor plus a calcium channel blocker had the greatest probability (73.9%) of being the best treatment to reduce mortality, followed by ACE inhibitor plus diuretic at 12.5%, ACE inhibitors at 2.0%, calcium channel blockers at 1.2% and ARBs at 0.4%.

The results show superior effects with ACE inhibitors compared to other hypertension treatments for diabetic patients, the researchers concluded. Especially considering the lower cost of these drugs, they should be the first-line choice. If adequate control is not achieved with ACE inhibitors alone, adding a calcium channel blocker might be the preferred treatment, the authors recommended.

They cautioned that the number of patients in the trials prohibited evaluation of some other combination therapies (including ARBs plus any of the other drug classes), and that only 1.7% of the studied patients took an ACE inhibitor plus a calcium channel blocker, so the generalizability of that finding is uncertain. Future research should further compare ACE inhibitors and ARBs, they said, noting that some guidelines suggest that their effects are equivalent.


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Score may determine when patients should seek treatment for strep throat

A score to diagnose group A streptococcal (GAS) pharyngitis that can be calculated by patients at home could save hundreds of thousands of visits annually by identifying the need for testing or treatment, a study found.

annals.jpg

To help patients decide when to visit a clinician for the evaluation of sore throat, researchers conducted a retrospective cohort study among 71,776 patients aged 15 years or older who visited a retail health clinic from September 2006 to December 2008 with pharyngitis and were tested for GAS pharyngitis.

Researchers created a score using information from patient-reported clinical variables plus the incidence of local disease. The home score (actual range, 8 to 62; possible range 0 to 100) is based on demographic, historical, and biosurveillance data only, and not on a physical exam. The presence of fever or cough, the patient's age and the proportion of positive tests recently in the area were the factors in the score. Researchers compared the home score with the Centor score and other traditional risk assessment methods.

Results appeared in the Nov. 5 issue of Annals of Internal Medicine.

Among the 48,089 retail health visits of patients ages 15 years or older in the derivation set, 11,614 (24%) tested positive for GAS pharyngitis. In the validation set, 5,728 of 23,687 (24%) tested positive. Researchers found that using a home score of 10 as a cutoff had a sensitivity of 0.99 and a specificity of 0.04, with a negative predictive value of 0.90. They calculated that if patients aged 15 years or older with sore throat did not visit a clinician below this cutoff, 230,000 visits could be avoided annually in the U.S., and only 8,500 patients with GAS pharyngitis would be missed.

Researchers wrote, "Even without information from physical examination findings, the home score approaches the accuracies and overall performances of the existing validated scores. Clinicians could use the home score to interact with patients online or over the telephone. There may also be circumstances in which it would be safe for patients themselves to be guided by a home score application."

An editorial noted some concerns, including that the biosurveillance data used in the model assumes an even prevalence across an entire community and that the study equated the presence of GAS in the upper respiratory tract with streptococcal infection, but they aren't the same.

A second editorial pointed out that while reducing clinic visits and health care costs for unneeded treatments is admirable, biosurveillance and other aspects of implementing this score carry their own burdens and costs. More practical strategies include a change in testing protocol to avoid testing patients with a very low risk for GAS pharyngitis, and using recommended generic antibiotics instead of more expensive ones, the author said.

"Acute pharyngitis has a typical duration of 3 to 5 days," the second editorialist wrote. "Patients clinically improve each day. We should clarify that the evaluation of patients whose symptoms have worsened requires a different approach. Such patients have a separate differential diagnosis that physicians should consider; therefore, we should always caution our patients that they should return if their symptoms—especially fever, rigors, sweats, or unilateral neck swelling—worsen."



Test yourself


.
MKSAP Quiz: 10-year history of hot flushes

A 61-year-old woman is evaluated for hot flushes, which have been persistent for the last 10 years. They occur at least 7 times per day, last for approximately 60 seconds, and are associated with severe sweating, palpitations, and occasional nausea. She is awakened several times per night. She has tried herbal medications, including soy and black cohosh, but has not experienced any benefit. She has hypertension, type 2 diabetes mellitus, and hyperlipidemia. Five years ago, she developed deep venous thrombosis after hip replacement surgery. Her current medications are ramipril, metformin, atorvastatin, calcium, and vitamin D.

mksap.gif

On physical examination, vital signs are normal. BMI is 29. The remainder of the examination is normal.

Which of the following is the most appropriate treatment?

A: Citalopram
B: Oral estrogen therapy
C: Oral estrogen/progesterone therapy
D: Topical (vaginal) estrogen
E: Venlafaxine

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


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Burnout


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Hospitalists no more prone to burnout than outpatient doctors, analysis finds

The common belief that hospitalists are more likely to experience burnout than outpatient physicians doesn't appear to be true, a new meta-analysis suggests.

Researchers searched 5 medical databases and found 54 studies from 1974 to 2012 that measured burnout in inpatient and/or outpatient physicians in the U.S. and countries with a hospitalist-like care model. The studies comprised 5,318 outpatient physicians and 1,301 inpatient physicians, with 15 studies offering direct comparisons between in- and outpatient doctors, and 28 studies using the same measure of burnout. Burnout, as distinguished from depression, stress and job dissatisfaction, was defined as a state in which "emotional exhaustion, depersonalization, and a low sense of personal accomplishment combine to negatively affect work life," but not personal life, the researchers wrote.

Emotional exhaustion was significantly higher in outpatient than inpatient physicians (mean difference, 3 points; 95% CI, 0.05 to 5.94; P=0.046), but there was no significant difference between doctor types in feelings of depersonalization and low personal accomplishment. Subgroup analysis found that U.S. outpatient physicians had a higher sense of personal accomplishment in double-armed studies than U.S. hospitalists (mean difference, 2.38 points; 95% CI, 1.22 to 3.55; P<0.001), though this difference wasn't evident when single-armed studies were included in the analysis. Results were published online Oct. 25 by the Journal of Hospital Medicine.

The higher prevalence of shift work among hospitalists may allow them to better balance their work and personal lives than outpatient doctors, which could explain why the latter report more emotional exhaustion, the researchers wrote. Inpatient medicine also may provide more opportunity for teamwork and collegiality, which has been correlated with lower burnout, they added. A lack of depersonalization among hospitalists is encouraging, they noted, as some have expressed concern that depersonalization is a byproduct of the hospital medicine model.

The trend toward a greater sense of personal accomplishment among outpatient physicians may be due to the fact that hospital medicine tends to have younger physicians who "may not have had time to develop a sense of accomplishment," the researchers wrote. The lack of longitudinal patient care, and the higher provision of end-of-life care, may also reduce hospitalists' sense of accomplishment compared to outpatient doctors, they added.



Cardiology


.
Short-term dual antiplatelet therapy noninferior to long-term after drug-eluting stent placement

Three months of dual antiplatelet therapy after placement of a drug-eluting stent was noninferior to 12 months of therapy, according to a new study.

The OPTIMIZE trial, a randomized, open-label, active-controlled noninferiority study performed at 33 sites in Brazil, involved patients with stable coronary artery disease or a history of low-risk acute coronary syndrome who were undergoing percutaneous coronary intervention with a drug-eluting stent. After the procedure, patients were randomly assigned to receive aspirin, 100 to 200 mg/d, and clopidogrel, 75 mg/d, for 3 months or 12 months.

The study's primary end point was net adverse clinical and cerebral events (NACCE), defined as a composite of all-cause death, myocardial infarction (MI), stroke or major bleeding. The secondary end points were major adverse cardiac events, or MACE (defined as a composite of all-cause death, MI, emergent coronary artery bypass graft surgery, or target lesion revascularization), and definite or probable stent thrombosis as defined by the Academic Research Consortium. Study results were published online Oct. 31 by the Journal of the American Medical Association.

Between April 2010 and March 2012, 1,563 patients were assigned to short-term dual antiplatelet therapy and 1,556 were assigned to long-term therapy. Thirty-seven percent of patients were women; mean age was 61.3 years in the short-term group and 61.9 years in the long-term group. Clinical follow-up was performed at 1, 2, 6 and 12 months, and 76 patients declined or were lost to follow-up. Most patients received zotarolimus-eluting stents.

Overall, 93 patients in the short-term group and 90 patients in the long-term group had NACCE (6.0% vs. 5.8%, respectively; risk difference, 0.17; 95% CI, −1.52 to 1.86; P=0.002 for noninferiority). At 1 year, 8.3% of patients in the short-term group and 7.4% of patients in the long-term group developed MACE (hazard ratio, 1.12; 95% CI, 0.87 to 1.45). Between 91 and 360 days, no statistically significant association was seen between duration of therapy and NACCE, MACE, or stent thrombosis.

The researchers concluded that in patients undergoing percutaneous coronary intervention with zotarolimus-eluting stents, short-term dual antiplatelet therapy was noninferior to longer dual antiplatelet therapy for death, MI, stroke and major bleeding and did not increase stent thrombosis risk. However, they noted that second-generation drug-eluting stents show lower rates of stent thrombosis than first-generation stents, so it was not possible to determine whether all patients with drug-eluting stents could benefit from short-term dual antiplatelet therapy. Also, there were relatively low event rates observed, hinting that the study might not have been powered to detect small differences in ischemic and bleeding events after 90 days. The overall event rate for NACCE was 6% versus 9%, even though the rate of MACE was about 8%, which may have affected the statistical power to rule out a small degree of excess risk.

Another limitation included that the study population was mostly made up of patients with stable coronary artery disease or history of low-risk acute coronary syndrome. In addition, combining efficacy and safety within a single composite outcome might have masked important differences. Finally, randomization occurred at the time of the index procedure, which differs from clinical practice, when physicians and patients may need to decide on the duration of dual antiplatelet therapy before the decision to revascularize because it may be a factor in deciding whether to use a drug-eluting stent.


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AHA scientific statement targets atherosclerotic cardiovascular disease

The American Heart Association recently issued a statement on secondary prevention of atherosclerotic cardiovascular disease (ASCVD) in the elderly.

The statement was prompted by a number of factors, including the aging of the population, and recent increases in incidence of stroke and peripheral artery disease, costs of treatments, and randomized, controlled trials of treatments. It is intended to clarify the benefits and risks of secondary prevention measures, and to increase the application of proven secondary prevention therapies in older patients. While the statement considered all patients ages 65 and older, it emphasized patients ages 75 and older, who have more pronounced age-associated challenges.

The statement appeared online Oct. 28 in Circulation.

Among the many considerations addressed by the statement, some included:

  • CHD in older adults. Providers must maintain a high index of suspicion for coronary heart disease in older patients, and should implement appropriate diagnostic and therapeutic strategies that comply with guidelines and with individual patient circumstances and preferences.
  • Stroke. Control of hypertension and hyperlipidemia have shown strong and consistent reduction in new and recurrent stroke risk, although the data on patients who are 80 or older are limited. Smoking cessation has similar benefits, and within 5 years of smoking cessation, the risk of stroke declines to that of people who never smoked.
  • PAD. The ankle-brachial index (ABI) remains the best screening test for PAD because of its simplicity, wide availability, low risk and low cost. While an ABI less than 0.9 suggests PAD, an ABI or more than 1.3 is more common in patients because of calcified, noncompressible arteries. Because of the high prevalence of asymptomatic PAD in older adults, those with claudication or atypical leg symptoms, as well as those with known coronary heart disease or previous stroke, should undergo ABI testing.
  • Obesity. Although both obesity and ASCVD are highly prevalent among seniors, there are considerably fewer data for older patients than for younger ones. And, the effect of weight loss interventions on achieving long-term weight reduction in older adults has been modest.

"Given the greater attributable risk associated with ASCVD in older adults in relation to morbidity, mortality, and decreased QOL, physical function, and personal independence, as well, beside higher health care costs, older patients are particularly likely to benefit from secondary prevention strategies," the statement concluded. "Nonetheless, risks attributable to these therapies also increase for seniors in comparison with the younger populations on which evidence-based secondary prevention standards were based. Secondary prevention pharmacological, invasive, and lifestyle interventions are all technically feasible in older and younger adults with ASCVD, as well, but their risk-to-benefit ratios vary significantly."



Ethics


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New ethics case study offers guidance on care of cognitively impaired patients

Preventive Health Screening, Ethics, and the Cognitively Impaired Patient is a new ACP ethics case study available online for CME credit. The case study presents the ethical issues in decision making regarding screening tests for patients with cognitive impairment and is designed to help primary care physicians, geriatricians, neurologists and other physicians who care for patients with intellectual disabilities.

CME credit is available through Medscape for completion of this and other ACP case studies in the professionalism case study series, which is online.


.
Ethical duties in "Talking with Patients about Other Clinicians' Errors"

A recent New England Journal of Medicine Sounding Board article examined clinicians' ethical duty to address others' medical errors with patients and examines possible solutions for both physicians and institutions.

Topics addressed include post-error communication methods, meeting patients' and families' needs and new approaches to colleague-to-colleague reporting of errors. A helpful reference table describes common situations involving other clinicians and offers strategy and rationale for each clinical situation.

ACP's Ethics, Human Rights and Professionalism staff contributed to the initial workgroup that was convened and the subsequent development of the article. Sources cited in the article include the ACP Ethics Manual, an ACP case study on professionalism and the ACP paper "Medical Professionalism in the New Millennium: A Physician Charter."



From the College


.
Physicians can earn CME online with ACP Clinical Shorts

ACP Clinical Shorts are short educational videos that clinicians can order to earn CME using their computers or mobile devices. Each Clinical Short video is less than 15 minutes long and provides concise answers to challenging clinical situations. After viewing a video, users answer a three-question quiz, and then submit online for CME credit. Beginning Dec. 15, 2013, Clinical Shorts subscribers can earn up to 28 MOC Points.

Subscribers to ACP Clinical Shorts will receive one year of unlimited access to 28 videos. Register now for your one-year subscription.



Cartoon caption contest


.
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-20131105-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.


.


MKSAP Answer and Critique



The correct answer is E: Venlafaxine. This item is available to MKSAP 16 subscribers as item 60 in the General Internal Medicine section. More information is available online.

This 61-year-old woman with cardiovascular risk factors and a history of deep venous thrombosis should be started on a nonhormonal therapy for her hot flushes. Certain antidepressants, including serotonin-norepinephrine reuptake inhibitors such as venlafaxine, are effective nonhormonal medications for reducing menopausal vasomotor symptoms.

Approximately 10% of menopausal women experience hot flushes for 7 to 10 years after the cessation of menses. This patient is continuing to experience frequent and severe hot flushes which have been refractory to conservative therapy and are decreasing her quality of life; thus, pharmacologic therapy is warranted. Systemic estrogen therapy is the most effective treatment for the relief of menopausal hot flushes and must be coadministered with progesterone in women with an intact uterus. However, combined estrogen and progesterone therapy has been shown to increase the risk of several adverse outcomes, including coronary heart disease, stroke, invasive breast cancer, and venous thromboembolism. The North American Menopause Society guideline notes that women older than 60 years who experienced natural menopause at the median age and have never used hormone therapy will have elevated baseline risks of cardiovascular disease, venous thromboembolism, and breast cancer; hormone therapy, therefore, should not be initiated in this population without a compelling indication and only after appropriate counseling and attention to cardiovascular risk factors. Moreover, this patient has a history of deep venous thrombosis, which is an absolute contraindication to initiating hormone therapy.

Several nonhormonal medications have been found to be effective for the treatment of menopausal hot flushes. Notably, there is a significant placebo effect: in most studies, approximately one-third of women will experience relief of hot flushes, even if they do not receive active treatment. In numerous studies, venlafaxine, administered at doses of 37.5 mg/d to 150 mg/d, decreases hot flush severity and frequency in approximately 60% of patients (as compared with 30% who experienced benefit with placebo treatment). Paroxetine is similarly beneficial; in contrast, few studies have shown efficacy with fluoxetine or citalopram. Gabapentin and clonidine are two additional nonhormonal treatments that reduce hot flushes, but attendant side effects may limit their use in some patients.

Vaginal estrogen therapy is typically used for the isolated treatment of vaginal dryness, pruritus, and dyspareunia. Treatment with vaginal estrogen tablets will improve local vaginal symptoms, but will not improve menopausal vasomotor symptoms.

Key Point

  • Owing to cardiovascular and thromboembolic risks, systemic hormone therapy is not recommended for treatment of menopausal vasomotor symptoms in women older than 60 years who experienced menopause at the median age.

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Test yourself

A 50-year-old man is evaluated in follow-up for a recent diagnosis of cirrhosis secondary to nonalcoholic steatohepatitis. He has a history of asthma, type 2 diabetes mellitus, hyperlipidemia, and obesity. His current medications are inhaled fluticasone, montelukast, insulin glargine, insulin lispro, simvastatin, and lisinopril. Following a physical exam, lab studies, and upper endoscopy, what is the most appropriate treatment?

Find the answer

MKSAP 16 Holiday Special: Save 10%

MKSAP 16 Holiday Special:  Save 10%

Use MKSAP 16 to earn MOC points, prepare for ABIM exams and assess your clinical knowledge. For a limited time save 10% when you use priority code MKPROMO! Order now.

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Maintenance of Certification: What if I Still Don't Know Where to Start?

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