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

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ACP InternistWeekly



In the News for the Week of March 26, 2013




Highlights

High-dose statins associated with more admissions for acute kidney injury

Higher-dose statin therapy was associated with more hospital admissions for acute kidney injury than lower-intensity treatment, a study found. More...

Neurologists offer guidelines on diagnosing sports concussions

Updated recommendations on evaluating and managing sports-related concussions were released by the American Academy of Neurology (AAN) last week. More...


Test yourself

MKSAP Quiz: 2-week history of bilateral leg weakness, urinary incontinence

A 19-year-old woman is admitted to the hospital because of a 2-week history of bilateral leg weakness and numbness accompanied by urinary incontinence that began after a viral gastrointestinal illness of 3 days' duration. She has no personal or family medical history of note and takes no medication. Following a physical exam and lab results, what is the most appropriate next step in treatment? More...


Diabetes

Metformin appears safe for heart failure patients, analysis finds

Metformin appears to be a safe option for glycemic control in heart failure patients, according to a recent meta-analysis. More...


High-value care

ED visits are usually for emergencies rather than 'primary care'

Use of presenting complaint is ineffective in determining whether emergency department (ED) visits could have been treated by a primary care visit instead, a recent study found. More...


CDC update

CDC expands HIV awareness and anti-stigma campaign

The CDC has expanded its "Let's Stop HIV Together" campaign to include new participants, more materials in both Spanish and English, and HIV awareness and testing information in Spanish through a new website. More...


From the College

ACP renames Associates and Young Physicians membership groups

In November 2012, the Board of Regents approved recommendations supported by the Councils of Associates and Young Physicians to change their names and references to their membership groups to Resident/Fellow Members and Early Career Physicians, respectively. More...


From ACP Hospitalist

The March issue of ACP Hospitalist is online

The March issue of ACP Hospitalist is online. Featured stories include reframing readmissions, successful ward teams and patient identification errors. More...


Cartoon caption contest

Put words in our mouth

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


Physician editor: Philip Masters, MD, FACP



Highlights


.
High-dose statins associated with more admissions for acute kidney injury

Higher-dose statin therapy was associated with more hospital admissions for acute kidney injury than lower-intensity treatment, a study found.

Although the effect seemed to be strongest in the first 120 days after initiation of statin treatment, increased risk of admission remained elevated for at least two years, researchers noted.

To quantify an association between acute kidney injury and use of higher-dose statins (defined as ≥10 mg of rosuvastatin, ≥20 mg of atorvastatin and ≥40 mg of simvastatin) versus lower-dose statins, researchers conducted a retrospective observational analysis including more than 2 million patients age 40 years or older who were newly treated with statins from January 1997 through April 2008 in the U.S., United Kingdom and Canada. Each person hospitalized for acute kidney injury was matched with 10 controls.

Results appeared online March 19 at BMJ.

Among 2,008,003 patients without chronic kidney disease, there were 4,691 hospitalizations for acute kidney injury within 120 days of treatment. Among 59,636 patients with chronic kidney disease, there were 1,896 hospitalizations.

In patients without chronic kidney disease, current users of higher-dose statins were 34% more likely to be hospitalized with acute kidney injury within 120 days after starting treatment (fixed-effect rate ratio, 1.34; 95% CI, 1.25 to 1.43) than lower-dose statin users. Users of higher-dose statins with chronic kidney disease had a 10% increase in admission rate (fixed-effect rate ratio, 1.10; 95% CI, 0.99 to 1.23), a nonsignificant difference compared to lower-dose statin users.

Researchers noted that clinicians should consider this potential risk before prescribing high-dose statins when treatment with a lower dose is an option. In previous studies of statins, more intensive statin treatment in secondary prevention was associated with a 0.3% reduction in absolute risk in major coronary events per year of treatment. But these previous studies could have overstated statins' efficacies in typical clinical practice, and mostly involved comparisons of a low dose of a statin to its highest possible dose, the authors said.

"In reality, clinicians would not choose between, for example, 10 mg of atorvastatin and 80 mg of atorvastatin," researchers wrote. "Given what is likely to be a small magnitude of incremental cardiovascular benefit of high potency statins over low potency statins in reality, a pressing question is how to identify patients for whom the risk-benefit balance for high potency statin treatment is unfavorable."

An editorial noted, "Despite extensive experience with the use of statins over many years, optimization of doses to derive benefit but minimize risk is still evolving. The results of the current study indicate that a randomized controlled trial is needed to compare the adverse effects of high and low potency statins."


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Neurologists offer guidelines on diagnosing sports concussions

Updated recommendations on evaluating and managing sports-related concussions were released by the American Academy of Neurology (AAN) last week.

The guideline authors reviewed the literature from 1955 to 2012 to update a 1997 AAN practice parameter and assess risk factors, diagnostic tools, interventions and risk for complications related to concussions. The evidence-based guideline update was published online by Neurology on March 18.

According to the guidelines, the Post-Concussion Symptom Scale and Graded Symptom Checklist are likely to accurately identify sports-related concussions and may be administered by trained personnel, nurses or physicians. The Standardized Assessment of Concussion is also likely to identify concussions in early stages postinjury. Neuropsychological testing could, as well, but requires a neuropsychologist for accurate interpretation. The Balance Error Scoring System identifies concussions with low to moderate diagnostic accuracy, the guidelines said.

CT imaging should not be used to diagnose sports-related concussions but may be used to rule out more serious traumatic brain injury in athletes who have loss of consciousness, post-traumatic amnesia, persistently altered mental status, focal neurological deficits, evidence of skull fracture or signs of clinical deterioration.

Patients who have been diagnosed with a concussion are more likely to suffer postconcussion impairments if they have ongoing clinical symptoms, concussion history or a younger age (high school age or younger concussion patients should be managed more conservatively than older athletes, the guidelines noted). Athletes should be prohibited from returning to play or practice until a licensed health care professional has judged that the concussion has resolved and the athlete is asymptomatic off medication.

Data are insufficient to show that any intervention enhances recovery or diminishes long-term sequelae postconcussion, although, based on research in mild traumatic brain injury, clinicians might provide cognitive restructuring (brief psychological counseling that consists of education, reassurance and reattribution of symptoms) to shorten the duration of subjective symptoms and diminish the risk for chronic postconcussion syndrome, the guidelines said.

An accompanying editorial noted that neurologists have become much more closely involved in maintaining the health and safety of professional athletes in recent years and will play an essential part in responses to the public health problem of sports-related concussions.



Test yourself


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MKSAP Quiz: 2-week history of bilateral leg weakness, urinary incontinence

A 19-year-old woman is admitted to the hospital because of a 2-week history of bilateral leg weakness and numbness accompanied by urinary incontinence that began after a viral gastrointestinal illness of 3 days' duration. She has no personal or family medical history of note and takes no medication.

mksap.gif

On physical examination, temperature is 36.7 °C (98.1 °F), blood pressure is 96/55 mm Hg, and pulse rate is 66/min. Bilateral leg weakness, loss of sensation below the umbilicus, and hyperreflexia in the lower extremities are noted.

Laboratory studies are as follows:

Vitamin B12 455 pg/mL (336 pmol/L)
HIV antibodies Negative
Human T-lymphotropic virus antibodies Negative
Cerebrospinal fluid (CSF)
Leukocyte count 45/µL (45 × 106/L)
Glucose 57 mg/dL (3.2 mmol/L)
Protein 65 mg/dL (650 mg/L)
Polymerase chain reaction No evidence of herpes simplex virus or varicella zoster virus

A T2-weighted MRI of the thoracic spine reveals hyperintensity in the thoracic cord at the T9 level, which enhances with administration of gadolinium. Cultures for acid-fast bacilli and CSF bacteria are negative.

High-dose intravenous methylprednisolone is administered. After 5 days, symptoms have not improved.

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

A: Glatiramer acetate
B: Increased dosage of methylprednisolone
C: Methotrexate
D: Plasmapheresis

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


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Diabetes


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Metformin appears safe for heart failure patients, analysis finds

Metformin appears to be a safe option for glycemic control in heart failure patients, according to a recent meta-analysis.

The analysis included nine observational studies of the association between metformin and morbidity and mortality in patients with diabetes and heart failure, the majority of which were published in 2010. According to the analysis, patients on metformin had about 20% lower mortality than controls, who were most commonly taking sulfonylurea drugs: 23% versus 37% (P<0.001). A small but not statistically significant reduction in all-cause hospitalizations was also found in the metformin patients compared to controls.

The researchers also looked at the subgroups of patients who had reduced left ventricular ejection fraction (LVEF) or chronic kidney disease, and in both cases, metformin was associated with slightly reduced mortality (pooled adjusted risk estimates, 0.91 and 0.81, respectively). No increased risk of lactic acidosis was found in metformin patients. The results were published online by Circulation Heart Failure on March 18.

Despite historical concerns about its use in heart failure patients, metformin appears to be at least as safe as other glucose-lowering treatments for these patients (including the high-risk groups with reduced LVEF and kidney disease) and should be the treatment of choice, the study authors concluded. This finding supports both current guidelines from medical specialty societies and recent decisions by the FDA and Canadian regulators to remove a black-box contraindication about using metformin in heart failure patients.

The authors did acknowledge a risk of confounding because the evidence is based entirely on observational trials, but they said that randomized trials in this patient population are rare and not likely to be expanded. However, a number of studies in animal models of heart failure have suggested potential benefits of metformin, the authors noted.



High-value care


.
ED visits are usually for emergencies rather than 'primary care'

Use of presenting complaint is ineffective in determining whether emergency department (ED) visits could have been treated by a primary care visit instead, a recent study found.

Efforts to optimize utilization of emergency care resources have focused on identifying patients presenting to EDs who might be appropriately evaluated and treated in other settings, such as primary care clinics. To determine whether patients who could have been treated in a primary care setting could have been identified on initial triage in the ED, researchers modified an established algorithm used to classify ED discharge diagnoses into those that needed emergency care and those that might have been appropriately treated in a primary care setting. The algorithm was then applied to nearly 35,000 records in the 2009 National Hospital Ambulatory Medical Care Survey (NHAMCS), with each representing a unique ED visit.

For the visits with discharge diagnoses considered primary care-treatable conditions, the presenting complaints at triage were compiled into a list of "non-emergent complaints." The data set was then reexamined, and all visits with "non-emergent" chief complaints at triage were reviewed to assess whether the presenting complaint could be used to identify patients with primary care-treatable conditions. Results appeared in the March 20 Journal of the American Medical Association.

The study found that discharge diagnoses were not easily determined by evaluating the presenting complaints. The primary care-treatable patients (who made up 6.3% [95% CI, 5.8% to 6.7%] of the total ED population) presented with the same complaints seen for 88.7% (95% CI, 88.1% to 89.4%) of all ED visits.

Of the patients with non-emergent complaints, a total of 11.1% (95% CI, 9.3% to 13.0%) of these visits were identified at triage as needing immediate or emergency care, and 12.5% (95% CI, 11.8% to 14.3%) required hospital admission. Among admitted patients, 11.2% (95% CI, 9.5% to 12.9%) went to a critical care unit, 22.9% (95% CI, 18.4% to 27.4%) required step-down or telemetry monitoring, 3.4% (95% CI, 2.5% to 4.3%) required the operating room, and 7.0% (95% CI, 5.7% to 8.4%) were admitted to an observation unit.

Also, 3.7% (95% CI, 3.4% to 4.1%) of these patients had been seen in the same ED within the last 72 hours, and 2.1% (95% CI, 1.7% to 2.5%) had been discharged from a hospital within the past seven days.

Further complicating matters was that 79.7% patients (95% CI, 78.2% to 81.3%) had at least one abnormal triage vital sign recorded:

  • respiratory rate (61.8%; 95% CI, 59.9% to 63.8%),
  • blood pressure (34.2%; 95% CI, 32.7% to 35.8%),
  • abnormal heart rate (21.8%; 95% CI, 20.8% to 22.8%)
  • hypoxia (6.6%; 95% CI, 5.3% to 7.9%), or
  • hypo- or hyperthermia (6.1%; 95% CI, 5.5% to 6.7).

Thus, it may not be possible, based on presenting complaints, to accurately identify emergency visits that could have been treated by primary care instead in order to limit or deny payments for these visits, the researchers concluded.

The researchers wrote, "Attempting to discourage patients from using the ED based on the likelihood that they would have nonemergency diagnoses risks sending away patients who require emergency care. The majority of Medicaid patients, who stand to be disproportionately affected by such policies, visit the ED for urgent or more serious problems."



CDC update


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CDC expands HIV awareness and anti-stigma campaign

The CDC has expanded its "Let's Stop HIV Together" campaign to include new participants, more materials in both Spanish and English, and HIV awareness and testing information in Spanish through a new website.

ACP is a member of the CDC's "HIV Screening Standard Care" campaign's clinical workgroup to help physicians make HIV testing a standard part of the medical care they provide to their patients, which ACP recommends. Both campaigns are part of the CDC's "Act Against AIDS" initiative. ACP has HIV resources available online.



From the College


.
ACP renames Associates and Young Physicians membership groups

In November 2012, the Board of Regents approved recommendations supported by the Councils of Associates and Young Physicians to change their names and references to their membership groups to Resident/Fellow Members and Early Career Physicians, respectively.

The recommendations were developed to better reflect the current professional identity of each membership group. The Council of Resident/Fellow Members will represent internists who are in an internal medicine residency training program or in a subspecialty fellowship training program. The Council of Early Career Physicians will continue to represent physicians who are within 16 years of graduating medical school, regardless of age.

Over the next couple of months, ACP staff will be updating all print and Web communication references from Associates and Young Physicians to Resident/Fellow Members and Early Career Physicians. Changes to the Council names and these membership groups will not be reflected in materials for Internal Medicine 2013. Please contact Joanne Ey in the Executive Office with any questions.



From ACP Hospitalist


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The March issue of ACP Hospitalist is online

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

Reframing readmissions. Could the experience of hospitalization itself be contributing to readmissions? Experts debate the validity of "post-hospital syndrome" and discuss what can be done to make a hospital stay less stressful for patients.

Successful ward teams. To create a well-functioning ward team, members must invest time up front getting to know one another and establishing common goals and guidelines. To keep the team running well, communication and prompt conflict resolution are key.

Patient identification errors. Sometimes the simplest solutions are the best. Read how one Colorado hospital drastically reduced ID errors by using photos of patients in their electronic medical records system.



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-20130326-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: Plasmapheresis. This item is available to MKSAP 16 subscribers as item 9 in the Neurology 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 undergo plasmapheresis. She has had an episode of postinfectious idiopathic transverse myelitis, as suggested by her examination findings of bilateral leg weakness, loss of sensation below the umbilicus, and hyperreflexia in the lower extremities; her laboratory results showing leukocytosis in the cerebrospinal fluid; and the evidence of inflammation indicated by the contrast enhancement on her MRI. The presence of a sensory spinal cord level and hyperreflexia on examination localize her disorder to the spinal cord, which rules out Guillain-Barré syndrome. Transverse myelitis presumably results from an autoimmune process. First-line treatment for this disorder is high-dose corticosteroids, such as methylprednisolone, to which this patient did not respond. For corticosteroid-refractory transverse myelitis, the best available evidence supports the use of plasmapheresis and/or cyclophosphamide as rescue treatment.

Glatiramer acetate is a disease-modifying agent used in the treatment of multiple sclerosis (MS). Thought to modulate immune responses relevant to MS pathophysiology, glatiramer acetate is well tolerated and reduces the relapse rate by approximately one third. It has no role in the treatment of acute transverse myelitis.

The patient is already receiving a high-dose corticosteroid, and no medical evidence suggests that increasing the dosage would be beneficial.

Although methotrexate has anti-inflammatory effects, it also is not an established treatment for corticosteroid-refractory transverse myelitis.

Key Point

  • The best available evidence supports the use of plasmapheresis and/or cyclophosphamide as rescue treatment for corticosteroid-refractory transverse myelitis.

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Test yourself

A 72-year-old woman is evaluated during a routine examination. She has very severe COPD with multiple exacerbations. She has dyspnea at all times with decreased exercise capacity. She does not have cough or any change in baseline sputum production. She is adherent to her medication regimen, and she completed pulmonary rehabilitation 1 year ago. She quit smoking 1 year ago. Her medications are a budesonide/formoterol inhaler, tiotropium, and an albuterol inhaler as needed. Following a physical and pulmonary exam, what is the most appropriate next step in management?

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