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ACP InternistWeekly



In the News for the Week of April 23, 2013




Highlights

CT scans ordered for other reasons may also detect osteoporosis

Computed tomography scans ordered for other reasons may be an acceptable method of detecting osteoporosis without exposing a patient to additional radiation, according to a new study. More...

Chronic pain syndromes appear common after ischemic stroke

Chronic pain syndromes appear to be common in patients who have had an ischemic stroke, according to a new study. More...


Test yourself

MKSAP Quiz: gradually progressive knee pain

A 52-year-old man is evaluated for a 5-year history of gradually progressive left knee pain. He has 20 minutes of morning stiffness, which returns after prolonged inactivity. He has minimal to no pain at rest. He reports no clicking or locking of the knee. Over the past several months, the pain has limited his ambulation to no more than a few blocks. Following a physical exam and radiograph, what is the most appropriate next diagnostic step? More...


Diabetes

Consensus statement offers strategies for preventing hypoglycemia

Consequences of hypoglycemia and strategies to prevent this condition in patients with diabetes were discussed in a recent consensus statement from the American Diabetes Association (ADA) and The Endocrine Society. More...


Prostate cancer

Emphasize potential prostate biopsy and cancer treatment outcomes when discussing risks, benefits of PSA testing

One-third of men age 65 and older with abnormal prostate-specific antigen (PSA) levels elect to have a prostate biopsy, yet once cancer is detected most men undergo immediate treatment regardless of advanced age and multiple comorbidities, a study found. More...


Non-physician providers

Role of non-physician providers in patient care

Yul Ejnes, MD, MACP, continues his column at KevinMD.com, about the role of non-physician providers in patient care. 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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CT scans ordered for other reasons may also detect osteoporosis

Computed tomography scans ordered for other reasons may be an acceptable method of detecting osteoporosis without exposing a patient to additional radiation, according to a new study.

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In a cross-sectional study at one U.S. academic medical center, researchers used computed tomography (CT) scans performed for other clinical indications to compare bone mineral density (BMD) assessment on CT versus dual-energy X-ray absorptiometry (DXA). CT-attenuation values of trabecular bone between the T12 and L5 vertebral levels were measured in Hounsfield units (HU), with emphasis on the L1 measures. BMD was measured by DXA as the reference standard. The study results appeared in the April 16 Annals of Internal Medicine.

A total of 1,867 adults (2,063 CT-DXA pairs) had CT and DXA during a six-month period. Most patients (81%) were women, and the mean age was 59.2 years.

Patients with osteoporosis on DXA had significantly lower CT-attenuation values at all vertebral levels (P<0.001). A CT-attenuation threshold of 160 HU or less at the L1 vertebra was found to be 90% sensitive and a threshold of 110 HU was found to be over 90% specific for distinguishing between osteoporosis and osteopenia and normal BMD. At L1 CT-attenuation thresholds less than 100 HU, positive predictive values for osteoporosis were 68% or more, while negative predictive values were above 99% at a threshold above 200 HU. One hundred nineteen patients had at least one moderate to severe vertebral fracture, and of these, 62 (52.1%) had false-negative DXA results while 97% had an L1 or mean T12 to L5 vertebral attenuation of 145 HU or lower.

The authors noted that the potential benefits and costs of the different CT-attenuation thresholds were not assessed and that DXA is itself not a perfect reference standard for osteoporosis. However, they concluded, "abdominal CT images obtained for other reasons that include the lumbar spine can be used to identify patients with osteoporosis or normal BMD without additional radiation exposure or cost."

The authors of an accompanying editorial said they believed the current results would be best used to identify patients who are at high risk for fracture because of densitometric or clinical osteoporosis. They noted that this approach may seem conservative but is justified because a significant proportion of CT scans already report incidental findings, many of which are never followed up. "Systematically adding more information to reports already replete with incidental findings that are not being acted on should be undertaken with trepidation," the editorialists wrote.

They also said that tolerance for false-positive results should be low and that a threshold yielding 90% specificity, a positive likelihood ratio of 6 and a post-test probability of approximately 70% should be used.

"Although sensitivity would suffer," they wrote, "radiologists and patients would be assured low rates of false-positive results and minimization of issues related to testing cascades and potential liability (for radiologists) and of harms related to additional radiation, labeling, and the 'hassle factor' (for patients)."

The editorialists said that the authors of the current study had established the evidence to justify this use of conventional CT imaging and that "it is now up to the rest of us to safely and cost-effectively translate this new knowledge into everyday clinical practice."


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Chronic pain syndromes appear common after ischemic stroke

Chronic pain syndromes appear to be common in patients who have had an ischemic stroke, according to a new study.

As part of the PRoFESS (Prevention Regimen for Effectively avoiding Second Stroke) trial, participants who reported having chronic pain after their stroke but no history of pain before their stroke were given a standardized chronic pain questionnaire at the next-to-last follow-up visit. Mean follow-up for PRoFESS was 2.5 years.

The researchers used multivariable logistic regression to determine risk factors for poststroke pain, pain subtypes, and any relation between poststroke pain and cognitive and functional decline. Cognitive decline was defined as a reduction of three points or more in Mini-Mental State Examination score (range, 0 to 30), and functional decline was defined as an increase of one or more points on the modified Rankin scale score (range, 0 to 5).

Study results were published early online April 4 by Stroke.

Of 15,754 participants, 1,665 (10%) reported having new chronic pain after their stroke. Four hundred thirty-one (2.7%) reported central pain, 238 (1.5%) reported peripheral neuropathic pain, 208 (1.3%) reported pain from spasticity, and 136 (0.9%) reported pain from shoulder subluxation. Eighty-six participants (0.6%) reported having more than one type of pain. More severe stroke, female sex, alcohol intake, statin use, depressive symptoms, diabetes, antithrombotic drugs, and peripheral vascular disease were all found to predict poststroke pain. All types of chronic pain syndrome showed an association with increased disability and dependence, while functional decline appeared to be associated with peripheral neuropathy, spasticity and shoulder subluxation.

The authors noted that they were not able to determine which pain medications participants used during the trial, that the trial excluded patients with intracerebral hemorrhage, and that they measured pain at only one point in time, among other limitations. However, they concluded that chronic pain syndromes appear to be common after ischemic stroke and have a negative effect on cognition and functional dependence. They called for clinical trials to investigate ways of preventing pain syndromes after stroke.



Test yourself


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MKSAP Quiz: gradually progressive knee pain

A 52-year-old man is evaluated for a 5-year history of gradually progressive left knee pain. He has 20 minutes of morning stiffness, which returns after prolonged inactivity. He has minimal to no pain at rest. He reports no clicking or locking of the knee. Over the past several months, the pain has limited his ambulation to no more than a few blocks.

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On physical examination, vital signs are normal. BMI is 25. The left knee has a small effusion and some fullness at the back of the knee; the knee is not erythematous or warm. Range of motion of the knee elicits crepitus. There is medial joint line tenderness to palpation, bony hypertrophy, and a moderate varus deformity. There is no evidence of joint instability on stress testing.

Radiographs of the knee reveal bone-on-bone joint-space loss and numerous osteophytes.

Which of the following is the most appropriate next diagnostic step for this patient?

A: CT of the knee
B: Joint aspiration
C: MRI of the knee
D: No diagnostic testing

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


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Diabetes


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Consensus statement offers strategies for preventing hypoglycemia

Consequences of hypoglycemia and strategies to prevent this condition in patients with diabetes were discussed in a recent consensus statement from the American Diabetes Association (ADA) and The Endocrine Society.

The statement updated a 2005 ADA workgroup report. Experts from both specialty organizations considered data from recent clinical trials and other studies and also used expert opinion to develop their conclusions. The statement was published in Diabetes Care and also appeared in the Journal of Clinical Endocrinology and Metabolism on April 15.

The consensus statement confirmed previous definitions of hypoglycemia and noted several challenges of accurately measuring blood glucose (such as the inaccuracies of point-of-care meters in critical care settings). Although hypoglycemia occurs more frequently in patients with type 1 diabetes, the greater prevalence of type 2 diabetes means that most episodes occur in type 2 patients, the consensus authors noted. Recent evidence (including the ACCORD, ADVANCE and VADT trials) indicates that hypoglycemia may negatively affect mortality and cognitive function, especially in patients with type 2 disease.

Elderly patients are particularly vulnerable to hypoglycemia, the consensus statement noted. Therefore, for these patients, the experts recommended careful education and regular reinforcement regarding the symptoms and treatment of hypoglycemia, assessment of functional status to properly apply individualized goals, avoidance of arbitrary short-acting insulin sliding scales and glyburide, simplification of complex regimens, and education about hypoglycemia for caregivers and staff in long-term care facilities.

In general, glycemic targets should be based on a patient's age, life expectancy, comorbidities, preferences and an assessment of how hypoglycemia might impact his or her life, the statement said. For healthy adults with diabetes, a reasonable goal might be the lowest hemoglobin A1c level that does not cause severe hypoglycemia, preserves awareness of hypoglycemia and doesn't result in an unacceptable number of hypoglycemic episodes. For patients with long-standing disease and advanced complications or limited life expectancy, the goals may be relaxed.

Strategies to prevent hypoglycemia include patient education (for both the patient and any domestic companions, possibly including interviewing to help identify precipitating factors of hypoglycemic episodes), dietary interventions (such as carrying carbohydrates at all times), exercise management, medication adjustment (substitution of rapid-acting insulin for regular insulin or other oral agents for sulfonylureas), and glucose monitoring. Clinicians should also assess the risk of hypoglycemia at every visit with patients on insulin or insulin secretagogues (an example questionnaire is provided in the consensus statement) and carefully review the patient's glucose log for date, time and circumstances of any hypoglycemia episodes.



Prostate cancer


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Emphasize potential prostate biopsy and cancer treatment outcomes when discussing risks, benefits of PSA testing

One-third of men age 65 and older with abnormal prostate-specific antigen (PSA) levels elect to have a prostate biopsy, yet once cancer is detected most men undergo immediate treatment regardless of advanced age and multiple comorbidities, a study found.

To quantify 5-year outcomes following a PSA screening result exceeding 4.0 ng/mL, researchers conducted a longitudinal cohort study among 295,645 men 65 years or older in the national Veterans Affairs health care system.

Results appeared online April 15 at JAMA Internal Medicine.

In total, 25,208 of the men (8.5%) had an index PSA level higher than 4.0 ng/mL. During the five-year follow-up period, 8,313 of those men (33.0%) underwent at least one prostate biopsy, of which 5,220 (62.8%) were diagnosed with prostate cancer and 4,284 (82.1% of diagnosed cases) were treated for it. While prostate biopsy rates decreased with advancing age and worsening comorbidity (P<0.001), once cancer was found, treatment rates exceeded 75% even among men 85 years or older, those with a Charlson-Deyo Comorbidity Index of 3 or higher, and those having low-risk cancer.

Among men with biopsy-detected cancer, the risk of death from other causes increased with advancing age and worsening comorbidity (P<0.001). There were 468 men (5.6%) who had complications within seven days after prostate biopsy. Complications of prostate cancer treatment included new urinary incontinence in 584 men (13.6%) and new erectile dysfunction in 588 men (13.7%).

Data on outcomes in clinical practice should inform treatment and screening decisions, the authors noted. They wrote, "[D]ecisions to pursue PSA screening should include individualized discussion about when to pursue biopsy and treatment because these steps substantially affect downstream outcomes of screening in clinical practice."

A research letter in the same issue of JAMA Internal Medicine evaluated whether receiving an inconclusive result from PSA screening, compared with undergoing no test, motivated more individuals to undertake a prostate biopsy.

Researchers recruited 727 men ages 40 to 75 and randomized them to one of four hypothetical situations based on PSA results. In the first situation, "no PSA," participants were given information about the risks and benefits of prostate biopsies and asked whether they would have a biopsy and the certainty of their decision. In the other three situations, participants were given information about PSA tests, as well as about prostate biopsies, and were then asked to imagine that they'd received normal, elevated or inconclusive results. Participants were then asked about whether they would undergo a biopsy and the certainty of their decision.

Significantly more men said that they would undergo a prostate biopsy if they received an inconclusive PSA test result (40%) than if they had no PSA test (25%; χ2=8.80; P=0.003). Those assigned an elevated PSA test result were more likely to state that they would undergo a biopsy (62%) compared with those who had no PSA test (χ2=47.76; P<0.001) and compared with those assigned an inconclusive PSA test result (χ2=17.89; P<0.001), although 38% of men with an elevated PSA test result still would not opt for a biopsy.

Those assigned a normal PSA test result were less likely to state that they would undergo a biopsy (13%) compared with those who had no PSA test (χ2=8.47; P=0.004), demonstrating some, but not total, reassurance from receiving a normal PSA test result. They were also less likely to state that they would undergo a biopsy than those assigned an inconclusive PSA test result (χ2=35.85; P<0.001) and those assigned an elevated PSA test result (χ2=97.80; P<0.001).

The research letter's authors wrote, "These results suggest that the ubiquitous use of simple but unreliable screening tests may lead to consequences beyond the initial cost and patient anxiety of inconclusive results; they could also lead to investigation momentum."

On April 9 in Annals of Internal Medicine, ACP issued new recommendations emphasizing that doctors should discuss with men ages 50 to 69 the limited benefits and substantial harms of the PSA before screening for prostate cancer.

There are substantial harms associated with prostate cancer screening and treatment that doctors should convey to patients, ACP said, including the following:

  • The PSA test result may be high because of an enlarged prostate but not because of cancer. Or, it may be low even though cancer is present.
  • If a prostate biopsy is needed, it is not free from risk. The biopsy involves multiple needles being inserted into the prostate under local anesthesia, and there is a small risk of infection or significant bleeding as well as risk of hospitalization.
  • If cancer is diagnosed, it will often be treated with surgery or radiation, which carries risks, including a small risk of death with surgery, loss of sexual function (approximately 37% higher risk), and loss of control of urination (approximately 11% higher risk) compared to no surgery.

ACP recommends against PSA testing in average-risk men younger than 50, in men older than 69, or in men who have a life expectancy of less than 10 to 15 years, because the harms of prostate cancer screening outweigh the benefits for these patients. For men younger than 50, the harms such as erectile dysfunction and urinary incontinence may carry even more weight relative to any potential benefit.

ACP developed this guidance statement for clinicians by assessing current prostate cancer screening guidelines developed by other organizations.



Non-physician providers


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Role of non-physician providers in patient care

Yul Ejnes, MD, MACP, a 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 at the role of non-physician providers in patient care.



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-20130423-cartoon.jpg

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

This issue's winning cartoon caption was submitted by Kenneth Lin, MD, ACP Member, who practices practice primary care med/peds at the Palo Alto Medical Foundation in Redwood City, Calif. Thanks to all who voted! The winning entry captured 50% of the votes.

The runners-up were:

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

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


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MKSAP Answer and Critique



The correct answer is D: No diagnostic testing. This item is available to MKSAP 16 subscribers as item 3 in the Rheumatology section.

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

No additional diagnostic testing is indicated for this patient who has osteoarthritis, which is a clinical diagnosis. According to the American College of Rheumatology's clinical criteria, knee osteoarthritis can be diagnosed if knee pain is accompanied by at least three of the following features: age greater than 50 years, stiffness lasting less than 30 minutes, crepitus, bony tenderness, bony enlargement, and no palpable warmth. These criteria are 95% sensitive and 69% specific but have not been validated for clinical practice. Additional diagnostic testing is not appropriate, because it has no impact on the management of advanced disease.

CT of the knee is very sensitive for pathologic findings in bone and can be used to look for evidence of an occult fracture, osteomyelitis, or bone erosions. However, none of these are suspected in this patient.

Small- to moderate-sized effusions can occur in patients with osteoarthritis, and the fluid is typically noninflammatory. Joint aspiration in this patient without evidence of joint inflammation and evident osteoarthritis is not useful diagnostically but is often done in the context of intra-articular corticosteroid injection or viscosupplementation.

MRI is useful to evaluate soft-tissue structures in the knee such as meniscal tears. Patients with meniscal tears may report a clicking or locking of the knee secondary to loose cartilage but often have pain only on walking, particularly going up or down stairs. Patients with degenerative arthritis often have MRI findings that indicate meniscus tears. These tears are part of the degenerative process but do not impact management; arthroscopic knee surgery for patients with osteoarthritis provides no clinical benefit. The one exception may be in patients with meniscal tears that result in a free flap or loose body, producing painful locking of the joint. These symptoms are not present in this patient.

Key Point

  • Osteoarthritis is diagnosed clinically and does not require advanced imaging to establish the diagnosis.

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Test yourself

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