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

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ACP InternistWeekly



In the News for the Week of December 10, 2013




Highlights

ACP policy paper calls for tighter management of prescription drugs

The American College of Physicians recommended 10 clinical and administrative changes that will make it harder for prescription drugs, such as those prescribed for pain, sleep disorders and weight loss, to be abused or diverted for sale on the street. More...

IDSA issues vaccination guideline for immunocompromised patients

Most people with compromised immune systems should receive the flu shot and other vaccinations, noted a new guideline released by the Infectious Diseases Society of America (IDSA). More...


Test yourself

MKSAP Quiz: 3-month history of night sweats, weight loss, increasing cough

A 70-year-old man is evaluated for a 3-month history of night sweats, weight loss, and increasing cough. He is a retired miner, and his medical history is significant for a diagnosis of pulmonary silicosis made 15 years ago based on exposure history and characteristic chest radiographic findings. He is a lifelong nonsmoker. Following a physical exam and a chest radiograph that shows multiple small nodules that appear throughout all lung zones, what is the most appropriate next step in management? More...


Hematology

ACP recommends conservative use of transfusions and erythropoiesis-stimulating agents in patients with heart disease

Red blood cell transfusions should be restricted to cases of severe anemia in patients with heart disease, the American College of Physicians recommended in a clinical practice guideline published in Annals of Internal Medicine. More...


Cardiology

Elevated heart rate at discharge may be associated with adverse outcomes, readmissions in heart failure patients

Heart failure patients with elevated heart rates at hospital discharge may be at higher risk for all-cause and cardiovascular mortality and for 30-day readmission for heart failure and cardiovascular disease, according to a new study. More...

New oral anticoagulants may slightly decrease all-cause mortality when compared to warfarin, meta-analysis suggests

In patients with atrial fibrillation, the advantages of all 4 new oral anticoagulants over warfarin seem to outweigh the risks, a new meta-analysis found. More...


Health insurance

Help your patients enroll in ACA health insurance marketplaces

ACP can help you provide your patients with information about how to enroll in your state's new health insurance marketplace. More...


CME

Don't miss the latest videos from The Consult Guys

Physicians who enjoy a dose of laughter while earning their CME credits won't want to miss the latest videos from The Consult Guys, the popular monthly video series released by Annals of Internal 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...


Physician editor: Daisy Smith, MD, FACP



Highlights


.
ACP policy paper calls for tighter management of prescription drugs

The American College of Physicians recommended 10 clinical and administrative changes that will make it harder for prescription drugs, such as those prescribed for pain, sleep disorders and weight loss, to be abused or diverted for sale on the street.

annals.jpg

ACP's Health and Public Policy Committee developed the position paper to guide prescribers and policymakers faced with the challenge of deterring prescription drug abuse while maintaining patient access to appropriate treatment.

In a new policy paper that appeared online first on Dec. 10 in Annals of Internal Medicine, ACP strongly advocated for physician, patient and public education on the harms of medical and nonmedical use of prescription drugs. For the treatment of pain, ACP recommended that physicians consider the full array of treatments available before prescribing opioids.

While maximum dosage and duration of therapy limitations may not be appropriate for all patients, ACP recommended the establishment of evidence-based, nonbinding guidelines to inform treatment. ACP also supported the establishment of a national Prescription Drug Monitoring Program so that prescribers and dispensers can check with their own and neighboring states before writing and filling prescriptions for substances with high potential for abuse. Until such a program is implemented, ACP supports standardizing existing programs through the federal National All Schedules Prescription Electronic Reporting program.

Other recommendations include:

  • a comprehensive national policy on prescription drug abuse containing education, monitoring, proper disposal and enforcement elements.
  • efforts to educate physicians, patients, and the public on the appropriate medical uses of controlled drugs and the dangers of both medical and nonmedical use of prescription drugs.
  • a balanced approach to permit safe and effective medical treatment using controlled substances and efforts to reduce prescription drug abuse. However, educational, documentation and treatment requirements toward this goal should not impose excessive administrative burdens on prescribers or dispensers.
  • encouragement for patients identified as at significant risk for prescription drug abuse to participate in a drug monitoring program and undergo random drug testing. Physicians may be required to report suspected cases of drug abuse but should not be mandated to conduct random drug testing without the patient's consent. The financial cost of mandatory drug testing should be borne by the authority requiring the testing; neither the patient nor the physician should bear the financial cost of random drug testing mandated by a third-party authority.
  • consideration of patient-clinician treatment agreements as a tool for the treatment of pain.
  • electronic prescription for controlled substances in all states.

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IDSA issues vaccination guideline for immunocompromised patients

Most people with compromised immune systems should receive the flu shot and other vaccinations, noted a new guideline released by the Infectious Diseases Society of America (IDSA).

Written to address a void in comprehensive recommendations for vaccinations of all different types of immunocompromised patients, the IDSA's "Clinical Practice Guideline for the Vaccination of the Immunocompromised Host" appeared online Dec. 5 in Clinical Infectious Diseases. The new guideline is designed to help primary care physicians and specialists who treat immunocompromised patients, as well as vaccinating people who live with immunocompromised patients.

The guideline is meant to provide one-stop shopping for clinicians caring for children and adults with compromised immune systems and includes recommendations and evidence for vaccinations ranging from influenza; chicken pox; hepatitis A; measles, mumps and rubella; pneumococcus; and herpes zoster.

The guideline notes most immunocompromised patients 6 months or older should receive the annual flu shot but should not receive the live attenuated influenza vaccine that comes in the form of a nasal spray. However, patients who are receiving intensive chemotherapy or who have received anti-B-cell antibodies in the previous 6 months are unlikely to benefit.

Other recommendations include the following:

  • Specialists should share responsibility with the primary care clinician for ensuring that appropriate vaccinations are given to patients and members of their households (strong recommendation, low-quality evidence).
  • Vaccines should be given before planned immunosuppression if feasible (strong recommendation, moderate evidence).
  • Live vaccines should be administered 4 or more weeks before immunosuppression (strong recommendation, low evidence) and should be avoided within 2 weeks of beginning immunosuppression (strong recommendation, low evidence).
  • Inactivated vaccines should be administered 2 or more weeks before immunosuppression (strong recommendation, moderate evidence).
  • Immunocompetent individuals who live with immunocompromised patients can safely receive inactivated vaccines based on the CDC/Advisory Committee on Immunization Practices' annually updated recommended vaccination schedules for children and adults.
  • Healthy immunocompetent individuals who live with immunocompromised patients should receive live vaccines based on the CDC annual schedule for combined measles, mumps, and rubella vaccines (strong recommendation, moderate evidence); rotavirus vaccine in infants aged 2 to 7 months (strong recommendation, low evidence); varicella vaccine (strong recommendation, moderate evidence); and zoster vaccine (strong recommendation, moderate evidence).

Other recommendations were made for international travel, varicella and zoster vaccines, and congenital immune deficiencies, as well as in populations of patients with HIV, cancer and hematopoietic stem-cell transplants.



Test yourself


.
MKSAP Quiz: 3-month history of night sweats, weight loss, increasing cough

A 70-year-old man is evaluated for a 3-month history of night sweats, weight loss, and increasing cough. He is a retired miner, and his medical history is significant for a diagnosis of pulmonary silicosis made 15 years ago based on exposure history and characteristic chest radiographic findings. He is a lifelong nonsmoker.

mksap.gif

On physical examination, temperature is 37.9 °C (100.2 °F), blood pressure is 120/65 mm Hg, pulse rate is 84/min, and respiration rate is 22/min. Pulmonary examination reveals diffuse inspiratory crackles throughout all lung zones, unchanged from previous examinations.

Pulmonary function tests demonstrate mild obstruction with no change from 1 year ago. Chest radiograph shows multiple small nodules that appear throughout all lung zones but are upper-lobe predominant. There is no significant change in comparison with previous imaging studies.

Which of the following is the most appropriate next step in management?

A: High-resolution CT of the chest
B: Lung biopsy
C: Prednisone
D: Tuberculosis testing

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


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Hematology


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ACP recommends conservative use of transfusions and erythropoiesis-stimulating agents in patients with heart disease

Red blood cell transfusions should be restricted to cases of severe anemia in patients with heart disease, the American College of Physicians recommended in a clinical practice guideline published in Annals of Internal Medicine.

annals.jpg

ACP also recommends against using erythropoiesis-stimulating agents (ESAs) in patients with mild to moderate anemia and congestive heart failure (CHF) or coronary heart disease (CHD) because the harms, including increased risks of thromboembolic events and stroke, outweigh the benefits.

To develop the guideline, ACP conducted a systemic review to answer 3 questions related to the treatment of anemia in patients with CHF or CHD:

  • What are the health benefits and harms of treating anemia with red blood cell transfusions?
  • What are the health benefits and harms of treating anemia with ESAs?
  • What are the health benefits and harms of using iron to treat iron deficiency with or without anemia?

Among a combined review of medical and surgical patients, low-quality evidence from 6 studies showed no mortality benefit for liberal red blood cell transfusion (hemoglobin level >10 g/dL) compared with restrictive red blood cell transfusion (hemoglobin level <10 g/dL) (relative risk [RR], 0.94; 95% CI, 0.61 to 1.42; I2=16.8%).

Low-quality evidence showed that liberal red blood cell transfusions were associated with fewer cardiovascular events (RR, 0.64; 95% CI, 0.38 to 1.09; I2=0.0%), although the data were not statistically significant.

There was not enough evidence to determine the effect of red blood cell transfusions on exercise tolerance and duration or the effect of red blood cell transfusions on quality of life. There were only sparse reports of harms for red blood cell transfusions for anemic patients with heart disease.

Among a group of only nonsurgical patients, low-quality evidence from 3 trials showed no mortality benefit with a higher red blood cell transfusion threshold in nonsurgical patients with acute myocardial infarction (MI) or known ischemic heart disease. Evidence was insufficient to determine the effect of red blood cell transfusions on exercise tolerance and duration or on quality of life.

Among a group of only surgical patients, low-quality evidence from 3 studies assessed short-term mortality in hip fracture and vascular surgery patients treated with liberal red blood cell transfusion (hemoglobin trigger, 10 g/dL) compared with restrictive transfusion (hemoglobin trigger, 8 to 9 g/dL). There was no difference in outcomes (RR, 1.35; 95% CI, 0.80 to 2.25; I2=0.0%). Observational studies did not find a mortality benefit with aggressive transfusion.

Subgroup analysis in 1 study in vascular surgery patients found an increase in MI in patients transfused at a hemoglobin level of 9 g/dL or more compared with those transfused at hemoglobin levels ranging from 7 to 9 g/dL. Low-quality evidence from 2 studies did not find a statistically significant difference between liberal and restrictive red blood cell transfusion protocols in cardiovascular complications of MI (RR, 0.60; 95% CI, 0.34 to 1.03; I2=0.0%). There was not enough evidence to determine the effect of red blood cell transfusions on exercise tolerance and duration or on quality of life.

High-quality evidence showed that ESA treatment did not improve mortality in anemic patients with stable CHF. Pooled data from 11 studies of patients with CHF or CHD (hemoglobin target levels, 12 to 15 g/dL) suggested an increased risk for mortality (RR, 1.07; 95% CI, 0.98 to 1.16; I2=0.0%) for patients receiving ESA treatment compared with control patients.

High-quality evidence showed that ESAs do not affect cardiovascular events in patients with stable CHF. Pooled data from 7 studies showed no difference in the risk for cardiovascular events when comparing ESA treatment with control (RR, 0.94; 95% CI, 0.82 to 1.08; I2=41.5%). Hemoglobin target levels ranged from 9.0 to 15.0 g/dL in the studies.

Moderate-quality evidence showed that ESA treatment had no effect on exercise tolerance and duration in patients with stable CHF. Pooled data from 9 studies showed that treatment with ESAs in patients with CHF (hemoglobin target levels, 12.0 to 15.0 g/dL) resulted in improved New York Heart Association functional class scores compared with control patients (mean difference, −0.77; 95% CI, −1.12 to −0.32; I2=96%). However, the results were generally inconsistent and the studies were highly heterogeneous.

The guideline was released in conjunction with ACP's efforts to encourage high-value care. In related news, the American Society of Hematology released its Choosing Wisely® list of 5 tests and treatments that physicians and patients should question.

The 5 items are as follows:

  • Avoid liberal red blood cell transfusion.
  • Avoid thrombophilia testing in adults in the setting of transient major thrombosis risk factors.
  • Avoid inferior vena cava filters except in specified circumstances.
  • Avoid plasma or prothrombin complex concentrate in the nonemergent reversal of vitamin K antagonists.
  • Limit routine CT surveillance following curative-intent treatment of non-Hodgkin lymphoma.

The list appeared online first Dec. 4 in the society's journal, Blood. The Choosing Wisely® campaign is led by the American Board of Internal Medicine Foundation in collaboration with leading medical societies in the U.S., including the American College of Physicians.



Cardiology


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Elevated heart rate at discharge may be associated with adverse outcomes, readmissions in heart failure patients

Heart failure patients with elevated heart rates at hospital discharge may be at higher risk for all-cause and cardiovascular mortality and for 30-day readmission for heart failure and cardiovascular disease, according to a new study.

Researchers looked at whether heart rate at hospital discharge was associated with mortality at 30 days and 1 year or with outcomes after hospitalization. They used data from the EFFECT-HF trial, a population-based retrospective chart review of patients at least 18 years of age who were admitted to acute care hospitals with heart failure in Ontario, Canada, from 1999 to 2001 and 2004 to 2005.

Patients were included in the current study if they met the modified Framingham heart failure criteria at presentation, if their discharge summary included a primary diagnosis of heart failure, and if they remained in normal sinus rhythm while they were hospitalized. All-cause 30-day and 1-year mortality were the primary outcomes. Secondary outcomes included cardiovascular death and readmission for heart failure, ischemic heart disease and cardiovascular disease. Results were published early online Dec. 2 by Circulation: Heart Failure.

Overall, 9,097 patients with heart failure were included in the study, almost half of whom (47.1%) were men. Patients were classified as having discharge heart rates of 40 to 60 beats/min (n=1,333), 61 to 70 beats/min (n=2,170), 71 to 80 beats/min (n=2,631), 81 to 90 beats/min (n=1,700) or greater than 90 beats/min (n=1,263).

Compared with the reference group (61 to 70 beats/min), those with discharge heart rates in the 2 highest categories had significantly increased all-cause 30-day mortality (adjusted odds ratios, 1.59 for 81 to 90 beats/min and 1.56 for >90 beats/min; P=0.003 and 0.007, respectively). Patients in these 2 categories also had a higher risk for cardiovascular death at 30 days (adjusted odds ratios, 1.59 and 1.65, respectively; P=0.017 for both comparisons).

The highest heart rate, over 90 beats/min, was also associated with higher cardiovascular death and all-cause mortality at 1 year (adjusted odds ratios, 1.47 and 1.41; P=0.005 and <0.001, respectively) compared with the reference category of 40 to 60 beats/min. Those in the highest heart rate category also had more 30-day readmissions for heart failure and cardiovascular disease (adjusted hazards ratios, 1.26 and 1.29; P=0.0021 and 0.004, respectively).

The authors noted that their study did not prove causality and that discharge heart rates were determined from a single reading, among other limitations. However, they concluded that higher heart rates at discharge in heart failure patients were associated with higher risk for all-cause and cardiovascular death for 1 year, as well as a higher risk for readmission for heart failure and cardiovascular disease within 30 days.

"Our study suggests that heart rate, an eminently modifiable prognostic marker, merits attention in the transition from hospital to ambulatory care in the community," the authors wrote. "Future studies are needed to define the beneficial impacts of both pharmacologic and non-pharmacologic heart rate lowering interventions and to determine if target ranges exist to guide therapy."


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New oral anticoagulants may slightly decrease all-cause mortality when compared to warfarin, meta-analysis suggests

In patients with atrial fibrillation, the advantages of all 4 new oral anticoagulants over warfarin seem to outweigh the risks, a new meta-analysis found.

Researchers searched Medline between Jan. 1, 2009, and Nov. 19, 2013, for phase 3 trials of atrial fibrillation patients who were randomized to take new oral anticoagulants (n=42,411) or warfarin (n=29,272). Included trials also reported both safety and efficacy outcomes. The new oral anticoagulants were dabigatran (110 mg and 150 mg), rivaroxaban, apixaban and edoxaban (30 mg and 60 mg). The main outcomes were stroke and systemic embolic events, hemorrhagic stroke, ischemic stroke, myocardial infarction, major bleeding, gastrointestinal bleeding, intracranial hemorrhage, and all-cause death. Results were published online Dec. 4 by Lancet.

Patients who took the new drugs had 19% fewer strokes or systemic embolic events than those who took warfarin (relative risk [RR], 0.81; 95% CI, 0.73 to 0.91; P<0.0001). This result was due in large part to a reduction in hemorrhagic stroke (RR, 0.49; 95% CI, 0.38 to 0.64; P<0.0001). Patients who took the new oral anticoagulants also had less all-cause mortality (RR, 0.90; 95% CI, 0.85 to 0.95; P=0.0003) and intracranial hemorrhage (RR, 0.48; 95% CI, 0.39 to 0.59; P<0.0001); however, they had greater gastrointestinal bleeding (RR, 1.25; 95% CI, 1.01 to 1.55; P=0.04). Patients on the 2 low-dose new anticoagulant regimens had a better bleeding profile but more ischemic strokes than those taking warfarin, and their overall reduction in stroke or systemic embolic events wasn't significantly different from warfarin (RR, 1.03; 95% CI, 0.84 to 1.27; P=0.75).

This meta-analysis "support(s) the premise that compared with warfarin, new oral anticoagulants, as a class, reduce all-cause mortality by about 10% …," the authors wrote. The analysis doesn't answer the question of which new drug is best, an editorial noted, suggesting that "ultimately, the drug could be fitted to the patient, or the patient to the drug, dependent on a focus on safety or efficacy, and on other patient factors, such as renal function and drug compliance."

Researchers in a second study sought to determine the long-term safety and efficacy of edoxaban compared to warfarin in 21,105 patients with moderate- to high-risk atrial fibrillation and followed patients for a median of 2.8 years. They found that both drugs didn't differ significantly in terms of stroke or systemic embolism but that edoxaban was associated with significantly lower rates of major bleeding (3.43% with warfarin vs. 2.75% with high-dose edoxaban and 1.61% with low-dose edoxaban; hazard ratios, 0.80 and 0.47; P<0.001 for both comparisons). Edoxaban patients also had lower mortality from cardiovascular causes (3.17% vs. 2.74% and 2.71%; hazard ratios, 0.86 and 0.85; P=0.01 for both comparisons). The study was published Nov. 28 by the New England Journal of Medicine.

A third study reported additional results from the ROCKET AF trial (which found that rivaroxaban and warfarin carried similar risks for stroke/systemic embolism and major/nonmajor clinically relevant bleeding). The new analysis focused on factors that placed patients at greater risk for major bleeding, regardless of whether they took rivaroxaban or warfarin. The risk factors were older age, current or prior smoking, male sex, mild anemia, diastolic blood pressure of at least 90 mm Hg, prior gastrointestinal bleeding, and aspirin use at baseline. The study was published online Dec. 4 by the Journal of the American College of Cardiology.



Health insurance


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Help your patients enroll in ACA health insurance marketplaces

People looking for coverage starting Jan. 1, 2014, have until Dec. 23, 2013, to enroll through the health insurance marketplaces, also known as exchanges. ACP can help you provide your patients with information about how to enroll in your state's new health insurance marketplace. On our enrollment resources webpage you'll find answers to questions your patients may be asking about enrolling or health care reform in general. Also find state-specific information about the new coverage programs and contact information for the marketplace in your area. While Dec. 23 is the deadline to have coverage be effective in January, enrollment in the exchanges will continue through March for people who still need to sign up.



CME


.
Don't miss the latest videos from The Consult Guys

Physicians who enjoy a dose of laughter while earning their CME credits won't want to miss the latest videos from The Consult Guys, the popular monthly video series released by Annals of Internal Medicine. Learn how Geno Merli, MD, MACP, and Howard Weitz, MD, MACP, solve the conundrum of Green Urine?!? and effectively treat A Pain in the Back in these short, educational videos.

The Consult Guys offer a new topic each month, and some of the videos feature "stumper" questions submitted by internal medicine physicians. Each video is accompanied by resources cited in the video and slide sets, as well as the opportunity to earn CME credit.

Physicians can download the videos online or via the Annals iPad app.



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-20131210-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 D: Tuberculosis testing. This item is available to MKSAP 16 subscribers as item 31 in the Pulmonology and Critical Care section. More information is available online.

The most appropriate next step in management is evaluation for tuberculosis with purified protein derivative testing and sputum testing for acid-fast bacilli. Silicosis is a spectrum of pulmonary disease related to inhalation of crystalline silicon dioxide (silica). Silica is the most abundant mineral on earth, and the most common form is quartz. Any occupation that disturbs the earth's crust or uses or processes silica-containing rock or sand has potential risks. A number of other medical conditions are associated with silicosis and are believed to be due to immune dysfunction induced by silicon exposure. This includes an increased susceptibility to tuberculosis and autoimmune diseases such as systemic sclerosis, rheumatoid arthritis, and systemic lupus erythematosus. A recent investigation by the Centers for Disease Control and Prevention examined silicosis mortality rates associated with respiratory tuberculosis between the years of 1968 and 2006. Of the reported deaths, tuberculosis was on 14% of the death certificates. Seventy-three percent of these patients were older than 65 years, and greater than 99% were male. There has been a steady decline in the total number of deaths related to silicosis and concomitant tuberculosis infection. This is likely attributable to prevention and control measures to prevent silica dust exposure as well as to appropriately treat and contain tuberculosis.

A high-resolution chest CT would provide more detailed structural information concerning this patient's lung disease and might be abnormal if he has tuberculosis, but it would not be the appropriate next study to evaluate for that potential diagnosis.

In patients with a known exposure and characteristic radiographic findings, lung biopsy is generally not needed to establish the diagnosis of silicosis. Additionally, in this patient with a long-standing diagnosis, stable clinical course, and no radiographic changes from his stable baseline, a lung biopsy is not currently indicated.

Corticosteroids have been used in some trials to attempt to modulate the immune reaction to silica and may be of some benefit, particularly in patients with acute or severe disease; however, it is not considered an established therapy for chronic silicosis. In addition, it would be inappropriate therapy until tuberculosis is excluded as a cause of this patient's systemic symptoms.

Key Point

  • Silicosis is a spectrum of pulmonary disease related to inhalation of crystalline silicon dioxide (silica), and it is associated with an increased risk for tuberculosis.

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Test yourself

A 42-year-old woman is evaluated for an 8-month history of crampy abdominal pain and three loose bowel movements per day. The pain is relieved by a bowel movement. There are no nocturnal bowel movements, and there is no blood or dark tarry material in the stool. She has not had fever, night sweats, or weight loss. She has a history of Hashimoto disease and is treated with levothyroxine. Following a physical exam, rectal exam, and lab tests, what is the most appropriate next step in management?

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