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

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ACP InternistWeekly



In the News for the Week of February 12, 2013




Highlights

Biennial vs. annual mammography in older women doesn't appear to alter disease-stage diagnoses

Women age 66 to 89 years who undergo biennial screening mammography have similar risk of advanced-stage disease and lower cumulative risk of a false-positive mammography study than those who are screened annually, regardless of comorbidity, a study found. More...

Angina not associated with mortality in diabetes patients with coronary artery disease

Patients with type 2 diabetes and stable coronary artery disease had similar risk of cardiovascular events and death, regardless of whether they had angina or angina-like symptoms, a study found. More...


Test yourself

MKSAP Quiz: 2-day history of severe muscle weakness

A 67-year-old woman is evaluated for a 2-day history of severe muscle weakness. The patient experienced significant weight gain and developed hypertension and type 2 diabetes mellitus 2 years ago. She also reports developing muscle weakness of the lower extremities 6 months ago. Following a physical exam and bloodwork, what tests should be performed to reveal the cause of her diabetes? More...


Cardiology

PAD patients improved walking ability on ramipril

Ramipril improved ability to walk in patients with peripheral artery disease and intermittent claudication, a new study found. More...


End-of-life care

More at-home deaths in Medicare patients, but also more end-of-life ICU stays

More Medicare patients died at home in 2009 than in 2000, but there was also an increase in intensive care use during the last 30 days of life, a new study found. More...


From ACP Internist

ACP Internist is online and coming to your mailbox

The next issue of ACP Internist is online, featuring stories about eating disorders, patient self-management and skin cancer. More...


Internal Medicine 2013

ACP's Job Placement Center offers career opportunities during Internal Medicine 2013

Submit a Job Seeker's Profile (Mini CV) to reach exhibiting and attending employers at Internal Medicine 2013 even if you're unable to be at the meeting. More...


Education

ACP launches MKSAP 16 Digital

ACP recently launched MKSAP 16 Digital, a version of MKSAP that offers the ability to access and save work in multiple places. 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 Presidents' Day holiday.


Physician editor: Philip Masters, MD, FACP



Highlights


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Biennial vs. annual mammography in older women doesn't appear to alter disease-stage diagnoses

Women age 66 to 89 years who undergo biennial screening mammography have similar risk of advanced-stage disease and lower cumulative risk of a false-positive mammography study than those who are screened annually, regardless of comorbidity, a study found.

Researchers sought to evaluate the impact of biennial versus annual mammographic screening in older women, and specifically whether the stage of disease detected using this screening pattern would be affected by the presence of comorbid illness in this population.

Data were prospectively collected on 2,993 older women age 66 to 89 with invasive breast cancer or ductal carcinoma in situ and 137,949 older women without breast cancer who underwent mammography from January 1999 to December 2006, and were then matched to Medicare claims. The presence of comorbid illness in both groups was quantified using the Charlson index, a method that assigns a weighted score to specific medical conditions and provides an indicator of disease burden; patients with a Charlson score of 0 in the study were considered to have no comorbid illness present.

Study results were published online Feb. 5 by the Journal of the National Cancer Institute.

The proportion of women with adverse tumor characteristics was similar among patients screened annually and biennially, and there were no more adverse tumor characteristics at diagnosis associated with less frequent screening. Additionally, there was no association of tumor stage in patients with comorbid illness versus those without comorbidities as assessed by the Charlson index, in contrast with previous studies.

Cumulative probability of a false-positive result over 10 years of screening in women at the lower age range of the study group (66 to 74 years) was higher among those screened annually than among those screened biennially regardless of comorbidity: 48% (95% CI, 46.1% to 49.9%) of women screened annually would have a false-positive result compared with 29.0% (95% CI, 28.1% to 29.9%) of those screened biennially.

Among women at the higher age range of the study group (75 to 89 years) with comorbidity, the rate of false-positives was 48.4% (95% CI, 46.1% to 50.8%) with annual screening and 27.4% (95% CI, 26.5% to 28.4%) with biennial screening. Slightly lower estimates were obtained for women in this age group with no comorbidity.

Researchers noted that there are 4.9 million U.S. women age 66 to 89 years with comorbidities and 14.3 million women without comorbidities. They concluded, "If these women undergo annual instead of biennial mammography, this could result in approximately one million additional false-positive examinations and 0.29 million additional false-positive biopsy recommendations among women with comorbidity plus 2.86 million additional false-positive examinations and 0.86 million additional false-positive biopsy recommendations among women without comorbidity. Thus, if older women undergo annual screening without consideration of the presence of comorbidity, it could result in substantial morbidity from screening mammography."

The authors also noted that a randomized, controlled trial of mammography in older women is unlikely to be performed, and therefore more high-quality observational studies that look at additional measures of comorbidity and breast cancer mortality "may facilitate improved understanding of the benefits and harms of different screening mammography frequencies among older women and, ultimately, inform clinical and policy decisions about the appropriate use of screening in this growing population."


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Angina not associated with mortality in diabetes patients with coronary artery disease

Patients with type 2 diabetes and stable coronary artery disease (CAD) had similar risk of cardiovascular events and death, regardless of whether they had angina or angina-like symptoms, a study found.

Researchers performed a post hoc analysis in 2,364 patients with diabetes and CAD enrolled in the BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial to determine the occurrence of death and a composite outcome of death, myocardial infarction and stroke during a five-year follow-up.

Results appeared in the Journal of the American College of Cardiology on Feb. 11.

There were 1,434 patients with angina, 506 with angina equivalents and 424 with neither condition. All patients received optimal medical therapy of lifestyle management and medication to maintain hemoglobin A1c levels less than 7%, low-density lipoprotein less than 100 mg/dL, and blood pressure of 130/80 mm Hg or less. The cumulative five-year death rates (total deaths, 316) were 12% in patients with angina, 14% in angina equivalents and 10% in neither (P=0.3), and composite cardiovascular outcome rates (total events, 548) were 24% in angina, 24% in angina equivalents and 21% in neither (P=0.5).

Compared to patients who had neither condition, the hazard ratios (HRs) for death, adjusted for confounders, were not different in the groups with angina (HR, 1.11; 99% CI, 0.81 to 1.53) and angina equivalents (HR, 1.17; 99% CI, 0.81 to 1.68). The same was true of cardiovascular events in patients with angina (HR, 1.17; 99% CI, 0.92 to 1.50) and angina equivalents (HR, 1.11; 99% CI, 0.84 to 1.48). Researchers noted that these findings suggest that these patients can be similarly managed in terms of risk stratification and preventive therapies.

An editorialist noted that given rising rates of diabetes and of health care costs, clinicians should carefully assess the risk, benefit and cost of widespread screening for CAD.

"Given the rapidly escalating epidemic of type 2 diabetes, the costs of widespread CAD screening of low-risk asymptomatic patients with diabetes would likely outweigh the minor clinical benefit," stated the editorial. "For now, we should certainly optimize risk factor management for all patients with diabetes, and we will need more prospective cost-effectiveness studies to determine an optimal risk stratification strategy for patients with diabetes at risk for CAD."



Test yourself


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MKSAP Quiz: 2-day history of severe muscle weakness

A 67-year-old woman is evaluated for a 2-day history of severe muscle weakness. The patient experienced significant weight gain and developed hypertension and type 2 diabetes mellitus 2 years ago. She also reports developing muscle weakness of the lower extremities 6 months ago. Her diabetes is only partially controlled by metformin; her blood glucose measurements at home are usually greater than 250 mg/dL (13.9 mmol/L).

Other medications are hydrochlorothiazide, lisinopril, amlodipine, and metoprolol.

mksap.gif

Physical examination shows a woman who appears chronically ill. Blood pressure is 154/92 mm Hg, and other vital signs are normal; BMI is 40. Skin examination is notable for facial hirsutism. Central obesity, mild proximal muscle weakness, and 2+ peripheral edema are noted.

Results of laboratory studies show a serum creatinine level of 1.3 mg/dL (115 µmol/L), a plasma glucose level of 144 mg/dL (8.0 mmol/L), and a serum potassium level of 2.9 mEq/L (2.9 mmol/L).

Which of the following tests should be performed to reveal the cause of her diabetes?

A) Adrenal CT
B) C-peptide measurement
C) Glutamic acid decarboxylase antibody titer
D) Pancreatic MRI
E) 24-hour urine free cortisol excretion

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


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Cardiology


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PAD patients improved walking ability on ramipril

Ramipril improved ability to walk in patients with peripheral artery disease and intermittent claudication, a new study found.

The trial randomized 212 Australians with peripheral artery disease (mean age, 65.5) to 24 weeks of treatment with 10 mg of ramipril per day or placebo. At the start and end of treatment, they were given a standard treadmill test, the Walking Impairment Questionnaire (WIQ) and the Short-Form 36 Health Survey (SF-36). Results appeared in the Feb. 6 Journal of the American Medical Association.

Compared to the placebo group, ramipril was associated with a 75-second increase in mean pain-free walking time (95% CI, 60 to 89 seconds) and a 255-second increase in maximum walking time (95% CI, 215 to 295 seconds). The ramipril patients also had significantly greater improvements in their WIQ scores for median distance, speed and stair climbing. There was also a significant increase in their physical functioning, according to the SF-36.

The improvements in walking found in this study were greater than those reported with the conventional therapies for peripheral artery disease, the authors said. They noted that angiotensin-converting enzyme (ACE) inhibition has not been specifically recommended for intermittent claudication and that this is the first trial to demonstrate improved walking performance with ramipril. They also acknowledged that their study excluded patients for a number of factors, including poorly controlled hypertension and other major comorbid conditions, so the generalizability of the results is not clear.

An accompanying editorial noted that the study population was limited to Australian citizens and the results need to be confirmed in ethnically diverse populations, since variations in the ACE genotype might affect response. The editorialist also pointed out that prior trials of ramipril, as well as other ACE inhibitors, for this application have had mixed results, and that the mechanism of action is unclear.



End-of-life care


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More at-home deaths in Medicare patients, but also more end-of-life ICU stays

More Medicare patients died at home in 2009 than in 2000, but there was also an increase in intensive care use during the last 30 days of life, a new study found.

The retrospective cohort study included a random 20% sample of Medicare fee-for-service beneficiaries (more than 800,000 patients) who died in 2000, 2005 or 2009. Researchers compared these patients' sites of death, places of care in the last 30 days, hospice use and health care transitions at the end of life. Results appeared in the Feb. 6 Journal of the American Medical Association.

Between 2000 and 2009, the percentage of patients dying in acute care hospitals dropped from 32.6% to 24.6%. The percentage of patients in hospice at the time of death also changed significantly, from 21.6% to 42.2%. However, the study also found an increase in the use of the intensive care unit (ICU) in the final 30 days, from 24.3% of deaths in 2000 to 29.2% in 2009. The researchers noted an increase in health care transitions at the end of life too, especially in the last three days (10.3% of patients in 2000 versus 14.2% in 2009). Specifically focusing on the patients who used hospice in 2009, they found that 28.4% of them had been in for three days or less and, of those, 40.3% had come from the ICU.

Previous reports have also shown that more elderly patients are dying at home, but this study shows that these patients are not necessarily receiving less aggressive care, the authors concluded. The finding that hospice admissions were short and followed ICU stays suggests that the increasing use of hospice may not reduce resource utilization. Although the study was not able to collect data on patient preferences, the authors speculated that the observed patterns of care were not the result of patient choice and could be improved.

An accompanying editorial also called for greater attention to patient preferences and goals, as well as provision of active treatments such as intravenous fluids or antibiotics outside the hospital whenever possible. Set criteria for ICU admissions, based on likely benefit and life expectancy, could also be helpful in reducing inappropriate and costly care, the editorialist said.



From ACP Internist


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ACP Internist is online and coming to your mailbox

The next issue of ACP Internist is online, featuring stories about:

acpi-20130212-internist.jpg

Eating disorders. Internists are often the first clinicians to see signs of an eating disorder, with the rapid or extreme changes in weight apparent both in person and from the history recorded in a patient's chart. But primary care clinicians may sometimes be afraid to ask about the problem because they are unsure how to handle what they might learn.

Patient self-management. Time-pressed physicians are adopting a team approach as they grapple with helping their patients improve their health. Referred to as "patient self-management," the sometimes time-consuming process can be handled directly by physicians or through trained coaches.

Skin cancer. While it isn't recommended that primary care physicians perform whole-body skin exams for skin cancer, they can and should be alert for skin lesions with malignant features. An easy acronym and other tips and tricks can make this easier.

Also, Test Yourself with the MKSAP Quiz in which a 35-year-old man is evaluated for a 2-year history of intermittent retrosternal chest pain, and take our poll on how often issues of gun violence are raised in your clinical practice.



Internal Medicine 2013


.
ACP's Job Placement Center offers career opportunities during Internal Medicine 2013

Looking for a job? Submit a Job Seeker's Profile (Mini CV). Reach exhibiting and attending employers at Internal Medicine 2013 even if you're unable to be at the meeting. Your profile will be included in one of two booklets based on your criteria and distributed only to employers who have submitted a job posting to the Job Placement Center.

The Job Placement Center, located in the San Francisco Moscone Center Exhibit Hall, South Hall A-C, Booth #1639, provides physicians with tools to assist in job searches as well as the opportunity to meet with potential employers.

Submit your profile online today.



Education


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ACP launches MKSAP 16 Digital

ACP recently launched MKSAP 16 Digital, a version of MKSAP that offers the ability to access and save work in multiple places.

Physicians using MKSAP Digital can achieve their study goals with the flexibility to work from an iPad or other tablet, a computer or a smartphone. Regardless of where MKSAP 16 Digital is accessed, answers can be submitted to an online account so they are always accessible.

MKSAP 16 Digital features related content links, enabling users to quickly find areas related to the question answered. The fully integrated, sophisticated search engine within the MKSAP 16 online application allows users to search for specific content in the 11 subspecialty topics, the questions, or both simultaneously. Lists of completed answers, incorrect answers and unanswered questions are viewable in one place for easy organization. Downloadable apps also allow users to work on the questions while offline.

For more information on MKSAP 16 Digital and the MKSAP product line, visit the website.



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-20130212-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 E) 24-Hour urine free cortisol excretion. This item is available to MKSAP 16 subscribers as item 6 in the Endocrinology and Metabolism section.

MKSAP 16 released Part A on July 31, 2012, and Part B on Feb. 1, 2013. More information is available online.

Measurement of the 24-hour excretion of urine free cortisol is the most appropriate next test in this patient to determine the cause of her diabetes mellitus. Various secondary causes of diabetes exist, most involving other endocrinopathies, effects of medications, pancreatic diseases, or genetic conditions. Cushing syndrome is one of these secondary causes of diabetes. The most common cause of Cushing syndrome is corticosteroid therapy, followed by the secretion of adrenocorticotropic hormone (ACTH) by a pituitary adenoma (Cushing disease) and the hyperfunctioning of an adrenocortical adenoma. In this patient, the combination of diabetes, hypertension, central obesity, hypokalemia, proximal muscle weakness, and edema strongly suggests the presence of Cushing syndrome. The diagnosis can be confirmed by several tests, including measurement of 24-hour excretion of urine free cortisol, an overnight dexamethasone suppression test, or a midnight salivary cortisol measurement.

Adrenal CT is appropriate after Cushing syndrome is diagnosed, especially when it is non–ACTH dependent, to identify the type of adrenal condition responsible. This test would be premature in this patient in whom the diagnosis has not been confirmed.

Residual beta-cell function can be assessed by measuring the C-peptide level, which is often high-normal in early type 2 diabetes because of insulin resistance. Similarly, measuring the glutamic acid decarboxylase antibody titer is useful to confirm the presence of autoimmune (type 1) diabetes when no other evidence exists. However, the C-peptide level will not indicate the cause of diabetes in this patient, and measuring the glutamic acid decarboxylase level also is unlikely to be helpful because she does not have type 1 diabetes.

Pancreatic imaging could be considered when signs and symptoms (such as abdominal or back pain, jaundice, or chronic diarrhea) suggest that an underlying pancreatic disorder is the cause of diabetes. This patient has none of these signs or symptoms, and thus a pancreatic MRI is unlikely to be revealing.

Key Point

  • Cushing syndrome is a likely cause of diabetes mellitus in a patient with hypertension, central obesity, and hypokalemia.

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Test yourself

A 66-year-old man comes for a preoperative evaluation before total joint arthroplasty of the left knee. He has a 25-year history of rheumatoid arthritis. He has had progressive pain in his left knee with activity, which limits his ability to hike. The patient has similar pain in the right knee, but it is less severe. He reports no recent morning stiffness. He is able to climb two or three flights of stairs without chest pain or shortness of breath. He has no other medical problems and reports no additional symptoms. Medications are methotrexate and folic acid. Following a physical exam and lab tests, what is the next best step in management?

Find the answer

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