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

Advertisement

ACP InternistWeekly



In the News for the Week of April 2, 2013




Highlights

Statin discontinuation is common but may have no clinical basis, study indicates

Many patients discontinue statins because of reported adverse events, but most can tolerate the drugs long-term if therapy is restarted, according to a new study. More...

Higher Framingham scores predict cognitive decline

The Framingham risk scores predicted cognitive decline in late middle age slightly more accurately than a score specifically designed to predict dementia in a recent study. More...


Test yourself

MKSAP Quiz: Asthma exacerbation in a 35-year-old woman

This week's quiz asks readers to evaluate a 35-year-old woman who presents to an urgent care center for an acute exacerbation of asthma. More...


Pulmonology

Macrolide antibiotics reduce exacerbations but increase antimicrobial resistance in non-cystic fibrosis bronchiectasis

The macrolide antibiotics erythromycin and azithromycin each appear to reduce exacerbations in patients with non-cystic fibrosis bronchiectasis but may also lead to increased antimicrobial resistance, according to two new studies in the March 27 Journal of the American Medical Association. More...


Readmissions

Score can predict readmission risk

A prediction score can identify before discharge the likelihood of a potentially avoidable 30-day readmission, a new study suggests. More...


Practice management

ICD-10 summit to be held in April

The American Health Information Management Association's 2013 ICD-10 CM/PCS and Computer-Assisted Coding Summit will be held April 22-24 at the Hilton Baltimore in Maryland. More...

ACP and MGMA-ACMPE collaborate on online cost survey

ACP members have a unique opportunity to participate in a new, abbreviated cost survey developed by ACP and MGMA-ACMPE. More...


Internal Medicine 2013

ACP Annual Business Meeting to be held

All members are encouraged to attend ACP's Annual Business Meeting to be held during Internal Medicine 2013. More...


Advocacy

ACP website features new online policy library and redesigned advocacy section

ACP has redesigned the advocacy section of its website to make it easier to view and find content about ACP's advocacy and public policy efforts. More...


From ACP Internist

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

The April issue of ACP Internist features stories on pulmonary hypertension, work-life balance and more. More...


Cartoon caption contest

Vote for your favorite entry

ACP InternistWeekly's cartoon caption contest continues. Readers can vote for their favorite caption to determine the winner. More...

Editor's note: ACP InternistWeekly readers will receive daily updates from Internal Medicine 2013 in San Francisco on April 11-13. There will be no issue of ACP InternistWeekly on April 9 or April 16.


Physician editor: Philip Masters, MD, FACP



Highlights


.
Statin discontinuation is common but may have no clinical basis, study indicates

Many patients discontinue statins because of reported adverse events, but most can tolerate the drugs long-term if therapy is restarted, according to a new study.

Researchers performed a retrospective cohort study to examine the reasons for statin discontinuation, particularly statin-related adverse events, in routine care. Adults seen at practices affiliated with Brigham and Women's Hospital and Massachusetts General Hospital in Boston who were prescribed a statin between Jan. 1, 2000, and Dec. 31, 2008, were included. Data on reasons for statin discontinuation were obtained from electronic medical records and electronic clinician notes. The study appeared in the April 2 Annals of Internal Medicine.

annals.jpg

The study included 107,835 patients, 38.7% of whom had a history of coronary artery disease. Atorvastatin was the most common statin taken. A total of 57,292 patients discontinued statins at least temporarily, and of these, 39,568 (69.1%) had a reason for the discontinuation recorded in the electronic medical record. A documented statin-related event occurred in 18,778 patients (17.4%); of these, 11,124 discontinued statin therapy at least temporarily, and of that group, 6,579 were rechallenged with a statin over the next year. Most of the patients who were rechallenged (92.2%) were still on statin therapy 12 months after the statin-related event took place. A total of 2,721 patients were challenged with the same statin they had discontinued, and of these, 1,295 were receiving the same drug 12 months later, 996 at the same or a higher dose.

The authors acknowledged that their study was retrospective, used secondary data that could have been incomplete or misinterpreted, and examined patients affiliated with only two academic medical centers, among other limitations. However, they concluded that while patients often report statin-related events and discontinue statin therapy because of them, most are able to restart statins and remain on them long-term. "This suggests that many of the statin-related events may have other causes, are tolerable, or may be specific to individual statins rather than the entire drug class," they wrote.

An accompanying editorial pointed out that part of the problem with statin therapy is that it is lifelong. "This is a tall order for many persons, and it is not surprising that discontinuation rates are relatively high," the editorialist wrote. He suggested that two questions be considered when developing strategies to improve statin adherence: Why do patients discontinue them, and in what proportion do real side effects, or statin intolerance, prevent therapy continuation? Since treatment guidelines are becoming "increasingly 'aggressive'" in recommending statins for primary prevention, the editorialist wrote, adherence will probably continue to be problematic. "With little doubt, good adherence to preventive therapies carries the potential for greatly reducing population prevalence of atherosclerotic cardiovascular disease," he wrote. "Better strategies to promote statin adherence are essential to realizing this potential."


.
Higher Framingham scores predict cognitive decline

The Framingham risk scores predicted cognitive decline in late middle age slightly more accurately than a score specifically designed to predict dementia in a recent study.

Researchers used data from the Whitehall II study, a longitudinal British cohort study. More than 7,000 study participants, with a mean age of 55.6 years at baseline, were assessed using the Framingham general cardiovascular disease risk score, the Framingham stroke risk score and the Cardiovascular Risk Factors, Aging and Dementia (CAIDE) risk score. To determine the incidence of cognitive decline, participants were given cognitive tests on reasoning, memory, verbal fluency, vocabulary and global cognition at three times over 10 years.

Patients who were at higher risk according to the Framingham scores also showed greater cognitive decline in all the tests except memory. Higher risk according to the CAIDE score was associated with decline in reasoning, vocabulary and global cognitive scores, but the Framingham scores had slightly stronger associations with overall 10-year cognitive decline, the study found. Diabetes, a factor in both Framingham scores, was found to be the biggest independent predictor of cognitive decline. Results were published in Neurology on April 2.

All three risk scores predicted cognitive decline, the study authors concluded. One explanation for the slight difference in accuracy might be the CAIDE score's inclusion of education, a factor that affects the risk of dementia but not the rate of cognitive decline. The Framingham scores also had more risk categories than the CAIDE for certain factors (for example, five systolic blood pressure ranges instead of two), which could make them more sensitive.

In addition to their greater predictive value, the Framingham scores might be more practical for primary prevention of cognitive decline, the authors suggested. A risk evaluation specifically for dementia could induce anxiety in patients, and the addition of another risk score is unlikely to be appealing to busy physicians. The Framingham scores are already used frequently in practice to alert patients to their risk for heart disease and stroke, so "in the future, they could also be told that they may be at higher risk of cognitive decline," the authors said.



Test yourself


.
MKSAP Quiz: Asthma exacerbation in a 35-year-old woman

A 35-year-old woman is evaluated in an urgent care center for an acute exacerbation of asthma. She has a history of frequent asthma exacerbations requiring unscheduled visits; however, between these exacerbations, her examination and pulmonary function studies have been unremarkable. Her current medications are inhaled budesonide and inhaled albuterol.

mksap.gif

On physical examination, she is in moderate distress with audible inspiratory and expiratory wheezing. Temperature is 37.0 °C (98.6 °F), pulse rate is 110/min, and respiration rate is 26/min. Monophonic inspiratory and expiratory wheezing is heard predominantly in the central lung fields. Other than tachycardia, the cardiac examination and remainder of the physical examination are normal.

She receives intravenous methylprednisolone and three nebulized albuterol-ipratropium bromide treatments. On follow-up evaluation 1 hour later, she still has wheezing, tachycardia, and tachypnea and is in moderate respiratory distress. Oxygen saturation is 96% breathing ambient air.

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

A: Chest radiograph
B: Intravenous magnesium sulfate
C: Laryngoscopy
D: Levofloxacin

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


.

Pulmonology


.
Macrolide antibiotics reduce exacerbations but increase antimicrobial resistance in non-cystic fibrosis bronchiectasis

The macrolide antibiotics erythromycin and azithromycin each appear to reduce exacerbations in patients with non-cystic fibrosis bronchiectasis but may also lead to increased antimicrobial resistance, according to two new studies in the March 27 Journal of the American Medical Association.

The Bronchiectasis and Low-dose Erythromycin Study (BLESS) randomly assigned 117 patients with non-cystic fibrosis bronchiectasis and a history of at least two infective exacerbations in the previous year to receive 400 mg of erythromycin twice daily (n=59) or placebo (n=58) for one year. At the study's end, protocol-defined pulmonary exacerbations were significantly lower in the erythromycin group than in the placebo group (mean, 1.29 vs. 1.97 per patient per year; incidence rate ratio, 0.57; P=0.003), as were 24-hour sputum production and measured decline in lung function. However, the proportion of macrolide-resistant oropharyngeal streptococci was also higher among patients taking erythromycin (median change, 27.7% vs. 0.04%; P<0.001).

In the Bronchiectasis and Long-term Azithromycin Treatment (BAT) study, 83 patients with non-cystic fibrosis bronchiectasis and at least three lower respiratory tract infections in the previous year were randomly assigned to receive 250 mg of azithromycin daily (n=43) or placebo (n=40) for one year. The analysis was modified intention-to-treat. At the end of the study, the azithromycin group had 0 mean exacerbations (interquartile range, 0 to 1) while the placebo group had 2 (interquartile range, 1 to 3) (P<0.001). Change in forced expiratory volume in the first second of expiration measured in three-month intervals increased in the azithromycin group but decreased in the placebo group. Forty percent of the azithromycin group and 5% of the placebo group reported gastrointestinal adverse events; no patients discontinued the study because of them. The macrolide resistance rate was 88% in the azithromycin group versus 26% in the placebo group.

The authors of an accompanying editorial noted that few previous randomized, controlled trials have examined macrolide treatment for non-cystic fibrosis bronchiectasis and said the current studies help provide "a good evidence base for an effective therapy for bronchiectasis." However, they pointed out that both trials were limited because they focused only on antibiotic resistance in known pathogens and didn't use quantitative cultures to determine whether the decreased exacerbation rates in the macrolide groups were due to decreased total sputum bacterial load or decreased density in individual species.

The editorialists said that based on these trials, erythromycin and azithromycin both effectively reduce exacerbations in patients with bronchiectasis and yield similar rates of antibiotic resistance. "Macrolides offer an important and now evidence-based treatment for bronchiectasis and, if used carefully, may help to improve [quality of life] and reduce health care costs for patients with bronchiectasis," they wrote.

They also pointed out, however, that macrolides can adversely affect hearing and liver function and can prolong the QTc interval. Physicians should consider macrolide therapy only in patients with non-cystic fibrosis bronchiectasis who have had at least two exacerbations in the previous year, they said. They recommended obtaining a sputum culture, performing an electrocardiogram, and testing hearing and liver function before starting treatment and periodically thereafter, and withholding or discontinuing macrolide therapy in patients with abnormal results. They also recommended careful monitoring of antibiotic resistance to common respiratory pathogens in individuals and community-wide.



Readmissions


.
Score can predict readmission risk

A prediction score can identify before discharge the likelihood of a potentially avoidable 30-day readmission, a new study suggests.

In a retrospective cohort study, researchers analyzed all patient discharges from medical services at Brigham and Women's Hospital in Boston between July 2009 and June 2010. They identified potentially avoidable 30-day readmissions using a computerized algorithm based on administrative data and analyzed these cases to develop a prediction score that could be used prospectively to identify factors that place patients at high risk for readmission. Results were published online March 25 by JAMA Internal Medicine.

Readmissions were considered to be unavoidable if they were planned or if they were unforeseen due to newly developed conditions unrelated to known diseases during the index hospitalization. Avoidable readmissions were related to a previously coded medical condition or resulted from a treatment complication. The researchers looked at readmissions to Brigham and Women's as well as Massachusetts General Hospital and Faulkner Hospital; all three are affiliated with the Partners HealthCare network.

Among 10,731 eligible discharges, 2,398 (22.3%) were followed by a 30-day readmission. Of these, 879 (8.5% of all discharges) were identified as potentially avoidable. Researchers randomly divided these potentially avoidable admissions and those not followed by a 30-day readmission (n=8,333) into a derivation and validation set to determine the prediction score.

The prediction score identified seven independent factors, referred to with the acronym HOSPITAL: Hemoglobin at discharge, discharge from an Oncology service, Sodium level at discharge, Procedure during the index admission, Index Type of admission, number of Admissions during the last 12 months and Length of stay. The HOSPITAL score had good calibration and fair discriminatory power (C statistic, 0.71).

It was surprising that none of the most frequent comorbidities in readmitted patients were retained as a factor in the final model, the researchers noted. "The hypothesis that comorbidities or causes of admission do not matter as much as illness severity or clinical instability is attractive and has intuitive appeal," they wrote. The HOSPITAL score, which can be used for all patients regardless of their main admission cause, enables physicians to target intensive transitions-of-care interventions to those who might benefit the most from them, they concluded.

However, an invited commenter noted that more research is needed on how to most effectively help patients at risk of readmission, since currently recommended interventions are resource intensive. One intervention that doesn't seem to work is having inpatient clinicians communicate directly with outpatient clinicians at discharge, another study in the March 15 JAMA Internal Medicine found. Fifty-four percent of inpatient clinicians don't attempt to directly communicate with the outpatient physician during discharge at all, and even among those who did, no reduction in readmissions was associated with direct communication, the study found.



Practice management


.
ICD-10 summit to be held in April

The American Health Information Management Association's 2013 ICD-10 CM/PCS and Computer-Assisted Coding (CAC) Summit will be held April 22-24 at the Hilton Baltimore in Maryland.

The summit provides a forum for health care leaders to develop strategies for successful ICD-10-CM/PCS transition and effective use of CAC. Participants will learn methods to improve coding workflow and achieve high-quality data accuracy that will ultimately help them operate more efficiently and improve patient care.

ACP is a collaborating organization for this event, and ACP members who register to attend the summit receive a 10% discount off the cost of their registration. To receive the discount, ACP members must use this code when registering: ICDSUMACP. More information about this conference is available at AHIMA's website.


.
ACP and MGMA-ACMPE collaborate on online cost survey

ACP members have a unique opportunity to participate in a new, abbreviated cost survey developed by ACP and MGMA-ACMPE.

This survey gathers financial and practice data to help your practice manage costs such as physician and staff compensation, optimize clinician and office staffing, and review practice finances. Participating practices will receive a free report that compares their own practice to benchmarks from similar practices.

Please participate in this influential survey. Your time and effort will not only help your practice but will also make a difference to your ACP peers by providing valid benchmark information that currently does not exist for small and medium-sized groups.

The survey deadline is April 19. To participate, go online.

If you have questions, please contact MGMA-ACMPE's Data Solutions toll-free at 877-275-6462, ext. 1895, or by e-mail.



Internal Medicine 2013


.
ACP Annual Business Meeting to be held

All members are encouraged to attend ACP's Annual Business Meeting to be held during Internal Medicine 2013. Current College Officers will retire from office and incoming Officers, new Regents and Governors-elect will be introduced.

The meeting will be held on Saturday, April 13, 2013, at the Moscone Center in San Francisco from 12:45 p.m. to 1:45 p.m., with David L. Bronson, MD, FACP, ACP President, presiding. Dennis R. Schaberg, MD, MACP, will present the Annual Report of the Treasurer. A key feature of the meeting is the presentation of ACP's priorities for 2013-14 by Executive Vice President and Chief Executive Officer Steven E. Weinberger, MD, FACP. Members will have the opportunity to ask questions following Dr. Weinberger's presentation.



Advocacy


.
ACP website features new online policy library and redesigned advocacy section

ACP has redesigned the advocacy section of its website to make it easier to view and find content about ACP's advocacy and public policy efforts.

The new advocacy page includes a tabbed menu for ACP's positions on important public policy issues, a legislative action center, state health policy resources, and upcoming advocacy events. It also features a new searchable policy library so visitors to the site can access ACP's public policy, clinical, educational and ethics recommendations.



From ACP Internist


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

The April issue of ACP Internist features the following stories:

acpi-20130402-internist.jpg

Learn to see signs of an often fatal disease. Pulmonary arterial hypertension can be recognized and treated. But it remains a diagnosis that is often missed, and the delay can lead to a rapidly progressing and fatal outcome. Learn the signs beyond a patient who reports "being out of breath."

Work-life balance easily upset, tough to ignore. Doctors sometimes struggle with their own poor health choices, as busy days in the office are carried home. Burnout, depression and stress can lead to smoking, drinking and weight gain. Find a balance that works.

Probiotics have potential, though definitive evidence is lacking. Probiotics are gaining some rationale for use—not for everything, but for preventing antibiotic-associated diarrhea and Clostridium difficile infections in hospitals. But many products on the market don't live up to their own hype.

Patients with diabetes experience vision loss at ever-earlier ages. Just as diabetes is affecting younger populations, so are its consequences. Childhood obesity can translate into diabetic retinopathy in patients in their 20s, which requires a response from the primary care community.

Take our poll and tell us about your own work-life balance. And Test Yourself with the MKSAP Quiz on the most appropriate management for a 35-year-old woman with platelet clumping on a peripheral blood smear revealed on a routine exam.



Cartoon caption contest


.
Vote for your favorite entry

ACP InternistWeekly's cartoon caption contest continues. Readers can vote for their favorite caption to determine the winner.

acpi-20130402-cartoon.jpg

"Ugh. . .I bet the out-of-network fees are going to be astronomical."

"I thought an 'ET consult' would be some new scan."

"You guys were the closest primary care docs taking Medicare I could find."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting ends on Monday, April 22, with the winner announced in the April 23 issue.


.


MKSAP Answer and Critique



The correct answer is C: Laryngoscopy. This item is available to MKSAP 16 subscribers as item 35 in the Pulmonary and Critical Care Medicine section.

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

The most appropriate next step in management is laryngoscopy. Patients with vocal cord dysfunction (VCD) have inspiratory and expiratory wheezing, respiratory distress, and anxiety. During attacks, VCD can be difficult to distinguish from asthma. Potential clues include sudden onset and abrupt termination of the attacks, lack of response to asthma therapy, prominent neck discomfort, lack of hypoxemia, and lack of hyperinflation on chest radiography. The distinction between the two conditions can be more difficult when patients have asthma as well as VCD. Laryngoscopy in symptomatic patients can reveal characteristic adduction of the vocal cords during inspiration. Alternatively, a flow-volume loop (in which the patient is asked to take a deep breath and then exhale while the inspiratory and expiratory flows are recorded) may be useful. In patients with VCD, the inspiratory limb of the flow-volume loop is "cut off" owing to narrowing of the extrathoracic airway (at the level of the vocal cords) during inspiration. The expiratory flows are preserved. Recognizing VCD is essential to avoid treating patients with repeat courses of systemic corticosteroids and other therapies for severe asthma while delaying the start of therapies targeted at VCD. These include speech therapy, relaxation techniques, and treatment of underlying causes such as anxiety, postnasal drip, and gastroesophageal reflux.

Chest radiograph in patients with acute asthma is not indicated unless the patient does not respond to initial therapy, has severe exacerbations, has clinical evidence of a concurrent illness (such as fever to suggest pneumonia, or crackles and leg edema to suggest heart failure), has evidence of a complication (subcutaneous air, asymmetric breath sounds that may suggest pneumothorax), or requires hospitalization.

Intravenous magnesium sulfate can be considered in acute asthma exacerbations, but it has no role in treating VCD.

There is no indication for antibiotics in this patient even if an acute asthma exacerbation were suspected.

Key Point

  • Potential clues for vocal cord dysfunction include sudden onset and abrupt termination of attacks, lack of response to asthma therapy, prominent neck discomfort, and lack of hypoxemia.

Click here to return to the rest of ACP InternistWeekly.

Top




About ACP InternistWeekly

ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.

To add your e-mail address to your member record and to begin receiving ACP InternistWeekly, please click here.

Copyright © by American College of Physicians.

Test yourself

A 50-year-old man is evaluated in follow-up for a recent diagnosis of cirrhosis secondary to nonalcoholic steatohepatitis. He has a history of asthma, type 2 diabetes mellitus, hyperlipidemia, and obesity. His current medications are inhaled fluticasone, montelukast, insulin glargine, insulin lispro, simvastatin, and lisinopril. Following a physical exam, lab studies, and upper endoscopy, what is the most appropriate treatment?

Find the answer

MKSAP 16 Holiday Special: Save 10%

MKSAP 16 Holiday Special:  Save 10%

Use MKSAP 16 to earn MOC points, prepare for ABIM exams and assess your clinical knowledge. For a limited time save 10% when you use priority code MKPROMO! Order now.

Maintenance of Certification:

What if I Still Don't Know Where to Start?

Maintenance of Certification: What if I Still Don't Know Where to Start?

Because the rules are complex and may apply differently depending on when you last certified, ACP has developed a MOC Navigator. This FREE tool can help you understand the impact of MOC, review requirements, guide you in selecting ways to meet the requirements, show you how to enroll, and more. Start navigating now.