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

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ACP InternistWeekly



In the News for the Week of February 26, 2013




Highlights

Task Force advises against vitamin D, calcium for primary prevention of fractures in postmenopausal women

The U.S. Preventive Services Task Force recommended against taking daily supplementation of 400 IU or less of vitamin D3 and 1,000 mg or less of calcium for the primary prevention of fractures in community-dwelling postmenopausal women. More...

Specialty organizations highlight lists of common tests and interventions that should be questioned

Several medical organizations released lists of tests or procedures that might be overused in clinical practice, as part of the Choosing Wisely initiative of the American Board of Internal Medicine Foundation. More...


Test yourself

MKSAP Quiz: lack of interest in sexual intercourse

A 54-year-old woman is evaluated during a routine examination. She is very concerned by her lack of interest in sexual intercourse. She used to enjoy intercourse and does not know why she feels this way now. She has been menopausal for the past 2 years. Following a normal physical examination, what is the most likely diagnosis? More...


Opioids and overdoses

Opioids implicated in the majority of pharmaceutical overdose deaths

Opioids are a major contributor to drug overdose deaths, either when taken alone or in combination with other drugs, a new research letter said. More...


Anticoagulation

Dabigatran noninferior to warfarin for preventing VTE recurrence

In patients who had a previous venous thromboembolism (VTE), dabigatran prevented recurrence about as well as warfarin and caused fewer bleeding events, according to two new manufacturer-sponsored trials of extended treatment. More...


From ACP Hospitalist

The latest issue of ACP Hospitalist is online

The February issue of ACP Hospitalist is online, featuring stories on determining who belongs in the ICU, grooming residents to lead, and caring for cancer patients. More...


Patient-centered care

NCQA offers specialty practices early adopter opportunity

The National Committee for Quality Assurance (NCQA) is releasing in March the Patient Centered Specialty Recognition Program to recognize those non-primary care practices that engage in processes that promote high-quality, patient-centered, integrated care. More...

PCORI now accepting applications

The Patient-Centered Outcomes Research Institute (PCORI) is accepting applications for its current advisory panels until Monday, March 4. More...


CMS update

CMS issues final physician sunshine rule

CMS has issued a final rule requiring manufacturers of drugs, devices, and biological and medical supplies to report payments or gifts of $10 or more made to physicians, hospitals and other health care professionals. The rule also requires reporting of physician ownership and investment activities in applicable manufacturers and group purchasing organizations. More...

Deadline approaching for new PQRS requirements

The Physician Quality Reporting System (PQRS) reporting regulations are changing. More...


From the College

Medicine up in the air inflates patient expectations

Yul Ejnes, MD, MACP, immediate 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 column at KevinMD.com, about how advertising and marketing for benign conditions can contribute to unrealistic patient expectations. 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


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Task Force advises against vitamin D, calcium for primary prevention of fractures in postmenopausal women

The U.S. Preventive Services Task Force recommended against taking daily supplementation of 400 IU or less of vitamin D3 and 1,000 mg or less of calcium for the primary prevention of fractures in community-dwelling postmenopausal women.

annals.jpg

This is a D recommendation (recommended against; there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefit). This recommendation does not apply to the treatment of persons with osteoporosis or vitamin D deficiency. The recommendation appears in the Feb. 26 Annals of Internal Medicine.

Also, the Task Force concluded that evidence is insufficient to assess the balance of the benefits and harms of daily supplementation with greater than 400 IU of vitamin D3 and greater than 1,000 mg of calcium for the primary prevention of fractures (I statement).

To make the recommendation, the Task Force considered six randomized trials conducted in community-dwelling adults. No statistically significant reduction in fractures was observed in these studies (pooled relative risk, 0.89; 95% CI, 0.76 to 1.04).

The largest trial of fracture outcomes included in the meta-analysis was the Women's Health Initiative, which enrolled 36,282 healthy postmenopausal women ages 50 to 79. The intervention group received 400 IU of vitamin D3 and 1,000 mg of calcium daily compared to a placebo group.

In the study, there was no statistically significant reduction in hip fracture (hazard ratio [HR], 0.88; 95% CI, 0.72 to 1.08) or total fractures (HR, 0.96; 95% CI, 0.91 to 1.02). However, the Task Force could not generalize the results of the Women's Health Initiative beyond the specific dose, preparation and population studied. Nearly 30% of study participants were already taking 500 mg or more of calcium daily before the start of the trial.

The Task Force has previously concluded in a separate recommendation that vitamin D supplementation is effective for community-dwelling adults aged 65 years or older who are at increased risk for falls (B recommendation; recommended. There is high certainty that the net benefit is moderate or that there is moderate certainty that the net benefit is moderate to substantial).

The Task Force also reported there is adequate evidence that supplementation with 400 IU or less of vitamin D3 and 1,000 mg or less of calcium increases the incidence of renal stones, although the magnitude is small. The Women's Health Initiative noted a statistically increased incidence of renal stones in women taking supplemental vitamin D and calcium. One woman was diagnosed with a urinary tract stone for every 273 women who received supplementation over a 7-year follow-up period.


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Specialty organizations highlight lists of common tests and interventions that should be questioned

Several medical organizations released lists of tests or procedures that might be overused in clinical practice, as part of the Choosing Wisely initiative of the American Board of Internal Medicine Foundation.

In 2012, nine groups supporting the initiative, including ACP, released lists of five commonly used tests or procedures whose necessity should be questioned and discussed. The most recent release added more specialty societies' recommendations to that collection, along with some of the original societies expanding their lists.

Several of the groups' new recommendations may be relevant to internists' practice, including:

American Academy of Family Physicians

  • Don't screen for carotid artery stenosis in asymptomatic adult patients.
  • Don't screen women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer.
  • Don't screen women younger than 30 years of age for cervical cancer with HPV testing, alone or in combination with cytology.

American Academy of Hospice and Palliative Medicine

  • Don't recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding.
  • Don't delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment.
  • Don't leave an implantable cardioverter-defibrillator activated when it is inconsistent with the patient/family goals of care.
  • Don't recommend more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis.
  • Don't use topical lorazepam (Ativan), diphenhydramine (Benadryl), haloperidol (Haldol) ("ABH") gel for nausea.

American Geriatrics Society

  • Don't use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.
  • Avoid using medications to achieve hemoglobin A1c <7.5% in most adults age 65 and older; moderate control is generally better.
  • Don't use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium.
  • Don't use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.

New lists were also released by the American Academy of Neurology, American Academy of Ophthalmology, American Academy of Otolaryngology–Head and Neck Surgery Foundation, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American College of Rheumatology, American Society for Clinical Pathology, American Society of Echocardiography, American Urological Association, Society for Vascular Medicine, Society of Cardiovascular Computed Tomography, Society of Hospital Medicine, Society of Nuclear Medicine and Molecular Imaging and the Society of Thoracic Surgeons. All of the recommendations are available online.



Test yourself


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MKSAP Quiz: lack of interest in sexual intercourse

A 54-year-old woman is evaluated during a routine examination. She is very concerned by her lack of interest in sexual intercourse. The patient feels like she "just doesn't want to be touched." She used to enjoy intercourse and does not know why she feels this way now, but she acknowledges that it is causing tremendous stress in her marriage. She has been menopausal for the past 2 years. She uses lubrication for intercourse, which is successful in reducing discomfort. She has no previous history of menstrual irregularities, pelvic surgeries, sexual trauma, or sexually transmitted infections. She currently takes calcium and vitamin D supplements daily.

mksap.gif

On physical examination, external genitalia are normal, with no pain with vulvar palpation or with speculum insertion. The vaginal walls are pale with decreased rugae and petechial hemorrhages. Decreased vaginal lubrication is noted. The remainder of the physical examination is normal.

Which of the following is the most likely diagnosis?

A) Dyspareunia
B) Hypoactive sexual desire disorder
C) Sexual aversion disorder
D) Vaginismus

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


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Opioids and overdoses


.
Opioids implicated in the majority of pharmaceutical overdose deaths

Opioids are a major contributor to drug overdose deaths, either when taken alone or in combination with other drugs, a new research letter said.

Researchers examined 2010 data from the National Vital Statistics System multiple cause-of-death file, which is based on death certificates. Results were published in the Feb. 20 Journal of the American Medical Association.

There were 38,329 drug overdose deaths in the U.S., of which 57.7% involved pharmaceuticals and 24.6% involved unspecified drugs. Seventy-four percent of the pharmaceutical-related overdose deaths were unintentional, 17% were suicides and 8.4% were of undetermined intent.

The drugs most commonly involved in pharmaceutical-related overdose deaths, either alone or in combination with other pharmaceuticals, were opioids (75.2%), benzodiazepines (29.4%), antidepressants (17.6%) and antiepileptic and antiparkinsonism drugs (7.8%).

Opioids were involved in 77% of deaths that also involved benzodiazepines, 65.5% of deaths that involved antiepileptic and antiparkinsonism medications, 58% of deaths that involved antipsychotic and neuroleptic drugs, 57.6% of deaths involving antidepressants, 56.5% of deaths involving other analgesics, antipyretics, and antirheumatics; and 54.2% of deaths involving other psychotropic drugs.

The analysis is limited by the fact that 25% of death certificates analyzed didn't specify the drugs involved in the overdose, the authors noted, meaning the numbers in the analysis are undercounts. The analysis does confirm the large role that opioids play in pharmaceutical overdose deaths, as well as the "frequent involvement of drugs typically prescribed for mental health conditions such as benzodiazepines, antidepressants and antipsychotics," they wrote.

The authors concluded that it's important for clinicians to appropriately screen for, identify and manage mental health disorders, as well as use prescription drug monitoring programs and electronic health records when possible.



Anticoagulation


.
Dabigatran noninferior to warfarin for preventing VTE recurrence

In patients who had a previous venous thromboembolism (VTE), dabigatran prevented recurrence about as well as warfarin and caused fewer bleeding events, according to two new manufacturer-sponsored trials of extended treatment.

The results of both trials were published together in the Feb. 21 New England Journal of Medicine.

In the first double-blind trial, almost 3,000 patients with VTE, who were thought to be at high risk of recurrence, completed three months of initial therapy and then were randomized to warfarin or twice-daily dabigatran at a dose of 150 mg. The length of study treatment ranged from six to 36 months.

Recurrent VTE occurred in 1.8% of dabigatran patients compared to 1.3% of warfarin patients, a finding that met the study's prespecified threshold for noninferiority. The dabigatran patients had fewer major bleeds and fewer major or clinically relevant bleeds, but only the latter combined outcome showed a statistically significant difference.

In the second double-blind trial, about 1,300 similar patients were randomized to the same dabigatran treatment or to placebo. The dabigatran group had many fewer VTE recurrences (0.4% vs. 5.6%; hazard ratio, 0.08; P<0.001) than the placebo group, but more major (0.3% vs. 0) and major or clinically relevant (5.3% vs. 1.8%) bleeds.

The study authors concluded that dabigatran was effective in extended treatment of VTE and carried a lower risk of major or clinically relevant bleeding than warfarin, but a higher one than placebo. They noted that the efficacy of dabigatran compared to placebo was similar to that shown by rivaroxaban and warfarin in other studies.

However, the study was not able to resolve concerns about an association between dabigatran and acute coronary syndromes (ACS). In the first trial, ACS occurred in 13 (0.9%) dabigatran patients and 3 (0.2%) warfarin patients, and it occurred in one patient in each of the groups in the placebo trial.

Based on results like these, targeted anticoagulants are an appealing alternative to warfarin, according to an accompanying editorial, which noted that dabigatran has not yet been FDA-approved for extended treatment of VTE. However, the editorialist cautioned, there are still questions and concerns about these new drugs, including the current lack of an antidote and the challenge of selecting appropriate patients for treatment.



From ACP Hospitalist


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The latest issue of ACP Hospitalist is online

The February issue of ACP Hospitalist is online. Featured stories include the following:

acpi-20130226-hospitalist.jpg

Who belongs in the ICU? Some experts are beginning to question how the nation's critical care beds are being used. While little guidance exists for admission and transfer decisions, experts have many ideas on the best ways to make use of costly ICU care.

Grooming residents to lead. Recognizing that residents need to know more than just clinical skills, some hospitals and health systems are teaching them about business and management as well.

Caring for cancer patients. Hospitalists working in perioperative settings are increasingly involved in decisions regarding the care of cancer patients who undergo surgery as part of their treatment. It's thus become more important than ever to know about the effects of cancer treatments on organ systems and the potential risks of surgery unique to cancer patients.



Patient-centered care


.
NCQA offers specialty practices early adopter opportunity

The National Committee for Quality Assurance (NCQA) is releasing in March the Patient Centered Specialty Recognition Program to recognize those non-primary care practices that engage in processes that promote high-quality, patient-centered, integrated care.

The program was developed to complement NCQA's Patient Centered Medical Home (PCMH) recognition program and it implements the recommendations included in an American College of Physicians (ACP) policy paper on the role of the "medical neighborhood" within the PCMH care model.

Interested practices may become "early adopters" of this program if they apply by March 19. Benefits include program discounts, free access to related educational events and the designation of a point of contact to provide guidance in the process. More information is available on the NCQA website.


.
PCORI now accepting applications

The Patient-Centered Outcomes Research Institute (PCORI) is accepting applications for its current advisory panels until Monday, March 4.

The panels focus on Addressing Disparities; Assessment of Prevention, Diagnosis, and Treatment Options; Improving Healthcare Systems; and Patient Engagement and will assist PCORI to identify research priorities and refine research project agendas.

PCORI was established as part of the Affordable Care Act (ACA) to help encourage comparative effectiveness research so that physicians have the best possible evidence in order to make more informed patient-care decisions. Applications are due by 5 p.m. Eastern on March 4 and must be submitted online. More information is on the PCORI website.



CMS update


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CMS issues final physician sunshine rule

CMS has issued a final rule requiring manufacturers of drugs, devices, and biological and medical supplies to report payments or gifts of $10 or more made to physicians, hospitals and other health care professionals. The rule also requires reporting of physician ownership and investment activities in applicable manufacturers and group purchasing organizations.

The Physicians Payments Sunshine act requires reporting on a yearly basis and also requires reporting of ownership or investment interests of physicians or their immediate family members in these companies.

Data will start being collected on Aug. 1. The final rule exempts speakers and attendees of accredited CME programs; manufacturers of over-the-counter drugs and class I and II medical devices; educational material intended for use by patients; discounts or rebates; and samples for patient use. Physicians will have an opportunity to review and correct their reports before they are posted online.

Additional information is available from CMS.


.
Deadline approaching for new PQRS requirements

The Physician Quality Reporting System (PQRS) reporting regulations are changing.

The 2012 reporting year will be the last year to participate in PQRS and receive an incentive payment of 0.5% of the total allowed charges for Physician Fee Schedule covered services, without risk of penalty. The deadline for report submission is March 14, 2013.

The PQRIwizard is an online tool, similar to tax preparation software, designed to help physicians and other eligible professionals quickly and easily participate in the PQRS requirements. ACP members can purchase the PQRIwizard at a discounted rate. More information on the fee schedule is available online, as is information on the PQRIwizard.



From the College


.
Medicine up in the air inflates patient expectations

Yul Ejnes, MD, MACP, immediate 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 column at KevinMD.com, one of the Web's leading destinations for provocative physician commentary.

In this month's post, Dr. Ejnes looks from 39,000 feet at how advertising and marketing for benign conditions can contribute to unrealistic patient expectations, making the practice of evidence-based medicine that much more difficult.



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-20130226-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 B) Hypoactive sexual desire disorder. This item is available to MKSAP 16 subscribers as item 5 in the General Internal Medicine section.

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

The most likely diagnosis is hypoactive sexual desire disorder (HSDD). Female sexual dysfunction, defined as sexual difficulties that are persistent and personally distressing to the patient, affects up to 35% of sexually active women and is common among middle-aged women. HSDD is defined as a persistent lack of desire for or receptiveness to sexual activity or a persistent lack of sexual thoughts. HSDD is one of the most common causes of female sexual dysfunction, and prevalence ranges from 12% to 19%. Natural and surgical menopause may contribute to the development of HSDD, as the associated decline in testosterone levels may decrease sexual motivation and desire. There is no FDA-approved medication for the treatment of female HSDD; individual and couples sex therapy or psychotherapy may be beneficial.

Dyspareunia is persistent urogenital pain that occurs around intercourse and is not related exclusively to inadequate lubrication or vaginismus. Several conditions may cause dyspareunia, including interstitial cystitis, pelvic adhesions, infections, endometriosis, pelvic venous congestion, and vulvodynia. Treatment is aimed at correcting the underlying abnormality. This patient's absence of sexual pain, history of previously normal sexual intercourse, and lack of symptoms and signs associated with any of the aforementioned conditions (no urinary symptoms, no history of pelvic surgeries or sexually transmitted infections) make dyspareunia an unlikely etiology for her current sexual problems.

Sexual aversion disorder is a persistent or recurrent aversive response to any genital contact with a sexual partner. Physiologic responses often accompany these feelings, with associated nausea and shortness of breath. Frequently there is a history of a painful or traumatic sexual event. Although this patient is avoiding intercourse, this is related to low sexual desire and motivation. Patients with sexual aversion disorder avoid intercourse because of feelings of revulsion and disgust.

Vaginismus is involuntary and recurrent spasm of the outer third of the vaginal musculature that interferes with vaginal penetration. Pain may accompany this involuntary spasm, and there is often associated avoidance and anticipatory fear of penetration. Prevalence ranges between 1% and 6%. On examination, this patient easily tolerated insertion of the vaginal speculum without any evidence of muscular spasm, although it should be noted that some women experience vaginismus only during sexual activity (situation-specific).

Key Point

  • Hypoactive sexual desire disorder, a common cause of female sexual dysfunction, is defined as a persistent lack of desire for or receptiveness to sexual activity or a persistent lack of sexual thoughts.

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A 57-year-old woman is evaluated for a 2-week history of decreased exercise tolerance and substernal chest pain on exertion. She also has an 8-month history of macrocytic anemia. Following a physical exam, lab results, and electrocardiogram, what is the most likely diagnosis?

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