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ACP InternistWeekly



In the News for the Week of March 12, 2013




Highlights

GERD guidelines establish diagnosis, management options

The American Gastroenterological Society issued guidelines for the diagnosis and management of gastroesophageal reflux disease (GERD). More...

'Information overload' may cause missed EHR alerts

Electronic health records (EHRs) routinely alert clinicians to abnormal test results, but there is potential for these alerts to be missed, according to a new study. More...


Test yourself

MKSAP Quiz: hospitalization for fever, chills, hypotension and dyspnea

A 64-year-old woman is hospitalized for a 2-day history of fever and chills and a 1-day history of hypotension and dyspnea. Medical history is significant for adenocarcinoma of the colon diagnosed 3 weeks ago for which she had a partial colectomy. Her course was complicated by the development of a polymicrobial intra-abdominal abscess. Following a physical exam and lab results, what is the most appropriate treatment option for this patient? More...


Asthma

Combined maintenance and rescue therapy in one inhaler appears effective in moderate to severe asthma

Combining maintenance and rescue therapy in one inhaler appears to be effective in patients with uncontrolled asthma, according to two new studies. More...


Infectious disease

Rare but resistant and deadly strains of Enterobacteriaceae increasing

Rare but deadly strains of carbapenem-resistant Enterobacteriaceae (CRE) are on the rise, stated a report. More...


From ACP Internist

The March issue of ACP Internist is online and coming to your mailbox

The March issue of ACP Internist features stories on anemia, empathy's role in treatment and pulmonary embolisms. More...


Ethics

New ACP case study addresses ethics in a health emergency

"Stewardship of Health Care Resources: Allocating Mechanical Ventilators during Pandemic Influenza," a new case study from ACP's Ethics, Professionalism and Human Rights Committee, is available online for CME credit. More...


Opioid safety

ACP receives grant on safety when prescribing opioids

ACP and its curriculum partner, Pri-Med, have been awarded an educational grant from a company to develop and implement a training program that educates clinicians about safety and efficacy when prescribing opioids. More...


Cartoon caption contest

And the winner is …

ACP InternistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption. More...


Physician editor: Daisy Smith, MD, FACP



Highlights


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GERD guidelines establish diagnosis, management options

The American Gastroenterological Society issued guidelines for the diagnosis and management of gastroesophageal reflux disease (GERD), "arguably the most common disease encountered by the gastroenterologist," according to the authors. "It is equally likely that the primary care providers will find that complaints related to reflux disease constitute a large proportion of their practice."

The full recommendations and evidence for them appeared in the March The American Journal of Gastroenterology and are also free online.

GERD should be defined as symptoms or complications resulting from the reflux of gastric contents into the esophagus or beyond, into the oral cavity (including larynx) or into the lung, according to the guidelines. This definition includes symptoms with or without erosions on endoscopic examination.

Following are all strong recommendations, with levels of evidence graded as "high" (implying that further research was unlikely to change the authors' confidence in the estimate of the effect) or "moderate" (further research would be likely to have an impact on the confidence in the estimate of effect):

Diagnosis

  • GERD can be established in the setting of typical symptoms of heartburn and regurgitation. Empiric medical therapy with a PPI is recommended (moderate level of evidence).
  • Barium radiographs should not be performed to diagnose GERD (high level of evidence).
  • Upper endoscopy is not required in the presence of typical GERD symptoms. It is recommended in the presence of alarm symptoms and for screening patients at high risk for complications. Repeat endoscopy is not indicated in patients without Barrett's esophagus in the absence of new symptoms (moderate level of evidence).
  • Routine biopsies from the distal esophagus are not recommended specifically to diagnose GERD (moderate level of evidence).
  • Ambulatory reflux monitoring is not required in the presence of short- or long-segment Barrett's esophagus to establish a diagnosis of GERD (moderate level of evidence).

Management

  • An 8-week course of proton-pump inhibitors (PPIs) is the therapy of choice for symptom relief and healing of erosive esophagitis, with no differences between the different PPIs (high level of evidence).
  • Delayed-release PPIs should be administered 30 to 60 minutes before meals (moderate level of evidence).
  • Maintenance PPI therapy should be given to patients who continue to have symptoms after stopping PPIs and in patients with complications including erosive esophagitis and Barrett's esophagus (moderate level of evidence).

Surgical options

  • Surgery is a treatment option for long-term therapy in GERD (high level of evidence).
  • Surgery is generally not recommended in patients who do not respond to PPIs (high level of evidence).
  • Preoperative ambulatory pH monitoring is mandatory in patients without evidence of erosive esophagitis. All patients should undergo preoperative manometry to rule out achalasia or scleroderma-like esophagus (moderate level of evidence).
  • Surgery is as effective as medical therapy for carefully selected patients with chronic GERD when performed by an experienced surgeon (high level of evidence).

Risks associated with PPIs

  • Patients with osteoporosis can remain on PPIs, except in patients with other risk factors for hip fracture (moderate level of evidence).
  • PPIs can be a risk factor for Clostridium difficile infections (moderate level of evidence).
  • PPIs do not need to be altered in concomitant clopidogrel users because the evidence does not support an increased risk for cardiovascular events (high level of evidence).

Asthma, chronic cough, and laryngitis

  • GERD can be considered as a potential co-factor in patients with asthma, chronic cough, or laryngitis. Careful evaluation for non-GERD causes should be undertaken in all of these patients (moderate level of evidence).
  • A diagnosis of reflux laryngitis should not be made based solely upon laryngoscopy findings (moderate level of evidence).
  • Surgery should generally not be performed to treat extraesophageal symptoms of GERD in patients who do not respond to acid suppression with a PPI (moderate level of evidence).

Also, the authors noted, the Los Angeles classification system should be used when describing the endoscopic appearance of erosive esophagitis. Symptoms in patients with Barrett's esophagus can be treated in a similar fashion to patients with GERD who do not have Barrett's esophagus. Patients with Barrett's esophagus found during endoscopy should undergo periodic surveillance according to guidelines.

The guidelines also review potential adverse events associated with PPI therapy, as well as lifestyle factors associated with GERD.


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'Information overload' may cause missed EHR alerts

Electronic health records (EHRs) routinely alert clinicians to abnormal test results, but there is potential for these alerts to be missed, according to a new study.

To examine what factors might predict missed test results in an EHR, researchers performed a cross-sectional survey of primary care clinicians working in the Veterans Affairs system from June through November 2010. The clinicians were asked their perceptions of the technical aspects of their EHR, such as ease of use and content of alerts, and about relevant social factors that might affect EHR use, such as workflow. Clinicians were asked if they received more alerts than they considered effectively manageable or too many alerts, obscuring those that were considered most important.

The study's primary outcomes were based on clinicians' answers to two survey items reflecting potential for missed results ("The alert notification system in Computerized Patient Record System as currently implemented makes it possible for practitioners to miss test results") and personal history of missed results ("In the past year, I missed abnormal lab or imaging test results that led to delayed patient care"). Correlation coefficients were examined for significant relationships between social and technical factors and the primary outcomes, and multivariate analysis was then performed. The study results were published online in a research letter by JAMA Internal Medicine on March 4.

A total of 5,001 practitioners were invited to participate in the study, and 2,590 (51.8%) responded to the survey. The respondents reported receiving a median of 63 EHR alerts each day, and 86.9% said that the number of alerts they received was excessive. A total of 69.6% said they received more alerts than they could manage effectively, and 55.6% said that the current EHR notification system was structured to allow clinicians to miss results. Personally missed test results that resulted in delayed care were reported by 29.8% of respondents.

The authors found that clinicians who perceived their EHR as easy to use were less likely to report a potential for missed results and a personal history of missed results (odds ratios, 0.52 [95% CI, 0.32 to 0.86] and 0.64 [95% CI, 0.43 to 0.96], respectively). Clinicians who were more concerned about electronic handoffs, defined as "routing alerts to the EHR of a surrogate covering practitioner," were more likely to report potential for missed results and personal missed results (odds ratios, 2.00 [95% CI, 1.38 to 2.39] and 1.86 [95% CI, 1.28 to 2.69], respectively). Missed results leading to delayed patient care were more likely in clinicians who reported receiving more alerts than were manageable (odds ratio, 2.20 [95% CI, 1.37 to 3.52]). The authors noted that neither of the primary outcomes were related to the number of alerts clinicians reported receiving each day.

The authors stressed that the data on alerts received were self-reported and that their study could not assess causation. However, they concluded that their results may indicate EHR "information overload" among clinicians, which could cause important clinical information to be missed. They also noted that both social and technical factors affected the primary outcomes and said that both should be considered in future studies. "An isolated reduction in alert numbers without attention to the broader [primary care practitioner] experience related to information overload might be insufficient to improve outcomes," they wrote.



Test yourself


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MKSAP Quiz: hospitalization for fever, chills, hypotension and dyspnea

A 64-year-old woman is hospitalized for a 2-day history of fever and chills and a 1-day history of hypotension and dyspnea. Medical history is significant for adenocarcinoma of the colon diagnosed 3 weeks ago for which she had a partial colectomy. Her course was complicated by the development of a polymicrobial intra-abdominal abscess. After drainage of the abscess, she received hyperalimentation through a central line catheter and ceftriaxone and metronidazole for 7 days.

On physical examination, temperature is 39.0 °C (102.2 °F), blood pressure is 90/60 mm Hg, pulse rate is 120/min, and respiration rate is 20/min. There are erythema and purulent drainage at the site of a right subclavian central venous catheter. The rest of the examination is normal.

Laboratory studies indicate a leukocyte count of 16,000/µL (16 × 109/L). Serum creatinine level is 3.6 mg/dL (318.2 µmol/L) compared with a value of 1.2 mg/dL (106.1 µmol/L) at admission. Two sets of blood cultures obtained 2 days ago are growing yeast.

In addition to central venous catheter removal, which of the following is the most appropriate treatment option for this patient?

A) Caspofungin
B) Conventional amphotericin B
C) Fluconazole
D) Liposomal amphotericin B
E) Voriconazole

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


.

Asthma


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Combined maintenance and rescue therapy in one inhaler appears effective in moderate to severe asthma

Combining maintenance and rescue therapy in one inhaler appears to be effective in patients with uncontrolled asthma, according to two new studies published last week in Lancet Respiratory Medicine. Both studies looked at different Single Maintenance and Reliever Therapy (SMART) regimens that combined a single inhaled corticosteroid with a long-acting β2 agonist. This therapy has been approved in other countries but is not currently approved in the United States.

The first study, an industry-funded double-blind, randomized, controlled trial, randomly assigned 1,714 patients to receive beclometasone-formoterol as needed (n=857) or salbutamol as needed (n=859) in addition to maintenance therapy with beclometasone-formoterol. All patients underwent a two-week run-in period during which they received beclometasone and formoterol in one daily inhalation plus salbutamol via a pressurized metered-dose inhaler as required. Eight hundred fifty-two patients in the beclometasone-formoterol group and 849 in the salbutamol group were analyzed. The study's primary outcome was time to first severe exacerbation, defined as hospital admission or emergency department visit or systemic steroid use for at least three consecutive days.

Two hundred fifty-one patients reported 326 severe exacerbations during the 48-week study period. Patients who received beclometasone-formoterol for maintenance and rescue therapy had significantly greater time to the first exacerbation (209 days vs. 134 days) and a risk reduction of 36% (hazard ratio, 0.64; 95% CI, 0.49 to 0.82; P<0.0005) compared with the other group. The beclometasone-formoterol group also had fewer days with mild asthma exacerbations. Both therapies were well tolerated and few patients experienced serious adverse events.

"Our findings further support the notion of a single inhaled corticosteroid and a rapid-onset, long-acting β2 agonist combination for maintenance and relief in patients with moderate to severe asthma," the authors concluded.

The second trial looked at the efficacy and safety of SMART with budesonide-formoterol over 24 weeks in patients at risk for severe asthma. Patients were randomly assigned to receive budesonide-formoterol (n=151) or a standard fixed-dose regimen of budesonide-formoterol plus salbutamol (n=152). The primary outcome measure was the proportion of patients in each group who had at least one high-use β-agonist episode.

Overall, the two groups did not differ significantly in the primary outcome (56% vs. 45%, respectively; relative risk, 1.24; 95% CI, 0.99 to 1.56; P=0.058). However, patients in the SMART group had fewer days of high use (mean, 5.1 days vs. 8.9 days; P=0.01) and fewer severe asthma exacerbations (35 vs. 66; P=0.004). The authors concluded that SMART "has a favourable risk-to-benefit profile compared with standard maintenance treatment and can be recommended for use in adults at risk for severe asthma."

The author of an accompanying commentary noted that although SMART has been considered controversial, these two studies provide convincing additional evidence to support its use. However, he cautioned that more research is needed because it is unclear which patients would benefit from each type of asthma treatment.



Infectious disease


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Rare but resistant and deadly strains of Enterobacteriaceae increasing

Rare but deadly strains of carbapenem-resistant Enterobacteriaceae (CRE) are on the rise, stated a report in the March 5 news brief from MMWR.

Last year, 4.6% of acute care hospitals reported at least one CRE infection (short-stay hospitals, 3.9%; long-term acute care hospitals, 17.8%). CRE strains were defined as E. coli, Klebsiella pneumoniae, Klebsiella oxytoca, Enterobacter cloacae, or Enterobacter aerogenes that were not susceptible to imipenem, meropenem or doripenem.

The proportion of Enterobacteriaceae that were resistant increased from 1.2% in 2001 to 4.2% in 2011 in the National Nosocomial Infection Surveillance system (NNIS)/National Healthcare Safety Network (NHSN) and from 0% in 2001 to 1.4% in 2010 in The Surveillance Network–USA (TSN). Most of the increase was observed in Klebsiella species (from 1.6% to 10.4% in NNIS/NHSN).

During the first six months of 2012, among the 3,918 U.S. acute care hospitals performing surveillance for either catheter-associated urinary tract infections or central-line-associated bloodstream infections in any part of their hospital, 181 (4.6%) reported one or more infections with CRE, 145 (3.9%) in short-stay hospitals and 36 (17.8%) in long-term acute care hospitals. Hospitals most affected were larger facilities and teaching hospitals in the Northeast.

To determine characteristics of CRE culture-positive episodes, researchers used data collected during the internally funded pilot of a population-based CRE surveillance project conducted through the Centers for Disease Control and Prevention's Emerging Infections Program (EIP) at three sites (Atlanta; Minneapolis-St. Paul; and Portland, Ore. metropolitan areas). Laboratories were asked for reports of CRE, defined as Enterobacteriaceae from sterile-site and urine cultures that were nonsusceptible to imipenem, meropenem or doripenem and resistant to all third-generation cephalosporins such as ceftriaxone, cefotaxime and ceftazidime. CRE-positive clinical cultures were classified as hospital-onset if the culture was taken from a hospital inpatient after the third day of admission. A health care exposure was defined as a recent hospitalization, long-term care admission, surgery, dialysis, or the presence of an indwelling device in the two days before the positive culture.

During the 5-month EIP project pilot, 72 CRE were identified in 64 patients, 56 patients with one positive culture and eight with two. Most came from the Atlanta metropolitan area (n=59), followed by Minneapolis-St. Paul (n=10) and Portland (n=3). Most CRE were Klebsiella species (n=49) followed by Enterobacter species (n=14) and E. coli (n=9). The most common source was urine (89%), followed by blood (10%). Most isolates were from cultures collected outside of acute care hospitals (47 of 71); however, most of these community-onset isolates were from patients with health care exposures (41 of 47), particularly recent hospitalizations (72%).

Although CRE are increasing in prevalence, their distribution is limited, the researchers noted. But resistant strains are associated with mortality rates exceeding 40%, which is significantly higher than mortality rates observed for carbapenem-susceptible Enterobacteriaceae.

"The high proportion of [long-term acute care hospitals] with CRE in 2012 highlights the need to expand prevention outside of short-stay acute-care hospitals into settings that, historically, have had less developed infection prevention programs," the researchers wrote. "Additional research is needed to clarify unanswered questions, including assessing which CRE prevention strategies are most effective and investigating new prevention approaches such as decolonization. Fortunately, many regions are in a position to prevent the further emergence of these organisms if they act aggressively."



From ACP Internist


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The March issue of ACP Internist is online and coming to your mailbox

The March issue of ACP Internist features the following stories:

acpi-20130312-internist.jpg

Start with bloodwork to diagnose anemia. Anemia is fairly common, but its many etiologies complicate diagnosis. It affects more than one in five black and Hispanic people, one in 10 seniors and one in five of those over the age of 85. Learn how to fine-tune the diagnosis to best help patients.

New research links empathy to outcomes. Everyone wants to have a physician who understands what he or she is feeling, but it's not just about human contact; better clinical outcomes can result from physician empathy.

Decision-making rules for diagnosing PE may save lives. Early detection of pulmonary embolism is critical, which puts the primary care internist on the front lines of preventing a patient's continual deterioration that culminates in death. Patients are as likely to present in the office with symptoms as they are at the emergency department.

Take our poll on what factors are the primary driver of patient readmissions to the hospital within 30 days. And Test Yourself with the MKSAP Quiz on the most appropriate diagnostic test for a 45-year-old woman evaluated in the emergency department for headache and impaired consciousness.



Ethics


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New ACP case study addresses ethics in a health emergency

"Stewardship of Health Care Resources: Allocating Mechanical Ventilators during Pandemic Influenza," a new case study from ACP's Ethics, Professionalism and Human Rights Committee, is available online for CME credit.

The case study examines the ethical issues presented when limited critical health resources must be allocated during a health emergency. CME credit is available through Medscape for completion of this and other ACP case studies in the professionalism case study series, which are available online.



Opioid safety


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ACP receives grant on safety when prescribing opioids

ACP and its curriculum partner, Pri-Med, have been awarded an educational grant by the REMS Program Companies, a group of manufacturers of extended-release and long-acting (ER/LA) opioids, to develop and implement a training program that educates clinicians about safety and efficacy when prescribing opioids.

The grant will incorporate elements of the FDA's recently approved guideline program, "Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics," and will mark the first time that an FDA-required REMS program has included a continuing medical education (CME) component. The educational program will deliver critical training for primary care clinicians who prescribe ER/LA opioids in an effort to safely and effectively manage patients with chronic pain.

The initiative will be launched on June 15, 2013, through a certified, online curriculum that will be available online through ACP and Pri-Med.



Cartoon caption contest


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And the winner is …

ACP InternistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

acpi-20130312-cartoon.jpg

"Are you part of the rabbit response team?"

This issue's winning cartoon caption was submitted by James Baumgartner, MD, ACP Member. Thanks to all who voted! The winning entry captured 65.5% of the votes.

The runners-up were:

"I'm all ears."

"I think your problem is carotenemia."


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MKSAP Answer and Critique



The correct answer is A) Caspofungin. This item is available to MKSAP 16 subscribers as item 3 in the Infectious Diseases section.

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

This patient should be treated with caspofungin. She has fungemia, which is most likely caused by Candida species. The most likely source is the central venous catheter, the site of which shows obvious signs of infection including erythema and purulent drainage. She has multiple risk factors for candidemia, including exposure to broad-spectrum antibiotics and having received parenteral nutrition via a central venous catheter. In addition to catheter removal, it is essential that antifungal therapy be instituted promptly. Because she is severely ill, the therapy of choice is an echinocandin agent. The Infectious Diseases Society of America guidelines do not distinguish among the echinocandins; therefore, any of them (caspofungin, anidulafungin, or micafungin) would be appropriate.

Amphotericin B or a lipid formulation of amphotericin B is an alternative choice if there is intolerance to or limited availability of other antifungal agents. This patient has kidney failure, which would be exacerbated by either formulation of amphotericin B.

Fluconazole is recommended for patients who are less critically ill than this patient and who have had no recent exposure to azole antifungal agents. When this patient becomes clinically stable, she can be transitioned from receiving an echinocandin to fluconazole if the isolate is likely to be susceptible to fluconazole.

Voriconazole is effective for the treatment of candidemia, but it offers little advantage over fluconazole and is recommended as step-down oral therapy for selected patients with candidiasis caused by Candida krusei or voriconazole-susceptible Candida glabrata.

Key Point

  • Antifungal therapy with an echinocandin agent (caspofungin, anidulafungin, or micafungin) is the treatment of choice for critically ill patients with candidemia.

Click here to return to the rest of ACP InternistWeekly.

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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?

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