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

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ACP InternistWeekly



In the News for the Week of April 30, 2013




Highlights

Alternative methods OK to try for lowering blood pressure, consensus statement says

Behavioral therapy, biofeedback and exercise regimens may be useful adjuvants for lowering blood pressure, but they have varying degrees of evidence support, according to a consensus statement from the American Heart Association. More...

Task Force issues HIV screening recommendations

All adolescents and adults age 15 to 65 should be screened for HIV infection, the U.S. Preventive Services Task Force said. More...


Test yourself

MKSAP Quiz: evaluation during fourth week of pregnancy

A 27-year-old woman is evaluated during the fourth week of an uneventful pregnancy. She has a 3-year history of primary hypothyroidism due to Hashimoto thyroiditis that is treated with levothyroxine, 125 µg/d. Following a physical exam and lab results, what is the most appropriate management? More...


Influenza

CDC issues antiviral recommendations for H7N9 influenza

The Centers for Disease Control and Prevention last week issued recommendations on antiviral treatment for avian influenza A(H7N9). More...


Heart failure

ACC/ACR release recommendations on imaging in heart failure

Recommendations on the appropriate use of imaging in heart failure patients were released by the American College of Radiology and the American College of Cardiology Foundation last week. More...


Diabetes

Medication choices, treatment escalation covered by new algorithm

A comprehensive algorithm for the management of diabetes was released last week by the American Association of Clinical Endocrinologists and the American College of Endocrinology. More...


CMS update

Contact your state Medicaid office to qualify for enhanced primary care payments

Primary care and related specialty physicians will see an increase in their Medicaid payments this year to make them at least equivalent to Medicare payments. More...

Let us know about problems with transition care codes

ACP has been receiving some reports of problems with payment for claims for the transitional care management services. Here's what to do if you have experienced a problem using these new codes. More...


Medical education

ACP, advisory board endorse Internal Medicine Milestones for residents

The Internal Medicine Education Redesign Advisory Board, with representation from multiple medical organizations, including ACP, has endorsed the release of Internal Medicine Milestones for use in the ACGME Next Accreditation System (NAS). More...

IMpact newsletter features profile of husband/wife internists

The April issue of IMpact, ACP's electronic newsletter for student members, includes a multimedia slideshow featuring husband and wife internists, Larry Kaplan, MD, FACP, and Rosalind Kaplan, MD, FACP. 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


.
Alternative methods OK to try for lowering blood pressure, consensus statement says

Behavioral therapy, biofeedback and exercise regimens may be useful adjuvants for lowering blood pressure, but they have varying degrees of evidence support, according to a consensus statement from the American Heart Association.

The consensus statement, as well as a suggested management algorithm and recommendations for individual approaches in clinical practice, was published online April 22 at Hypertension.

Among behavioral therapies, Transcendental Meditation (TM), other meditation techniques, yoga, and other relaxation therapies generally had modest, mixed, or no consistent evidence demonstrating their efficacy. TM may be considered in clinical practice to lower blood pressure (BP), according to the statement. "Because of many negative studies or mixed results and a paucity of available trials, all other meditation techniques (including MBSR [Mindfulness-Based Stress Reduction]) received a Class III, no benefit, Level of Evidence C recommendation," the experts concluded.

Biofeedback approaches also generally had modest, mixed, or no consistent evidence demonstrating their efficacy. The statement said that for these techniques, "a paucity of data precludes making recommendations for implementing a specific methodology to treat high BP in clinical practice. On the other hand, no significant health risks were reported among the trials." Of the noninvasive procedures and devices evaluated, device-guided breathing had greater evidence support than acupuncture.

Exercise-based regimens, including aerobics (found by the analysis to be useful or effective, with sufficient evidence support), should be performed by most individuals to reduce BP if clinically appropriate and not contraindicated, the statement said: "We recommend following existing Joint National Committee guidelines to perform aerobic physical activity at least 30 minutes per day most days of the week."

Dynamic resistance training can lower arterial BP by a modest degree, although the evidence base lacks trials of individuals with hypertension, the group found. "However, there is no evidence of harm … Hence, there is no rationale to contraindicate resistance training for most individuals with mild stage I hypertension."

A clear yet relatively small cardiovascular benefit of isometric handgrip resistance training has emerged, including modest improvements in BP, with a regimen of several intermittent bouts of handgrip contractions at 30% maximal strength lasting two minutes each for a total of 12 to 15 minutes per session, at least three times per week over 8 to 12 weeks, the experts noted.

The statement concluded that it would be reasonable to recommend "these alternative approaches as long as they are used under appropriate circumstances and guidance by a health care provider. It is also important to re-emphasize that many of the reviewed alternative therapies (eg, resistance and aerobic exercise, yoga, meditation, acupuncture) may provide a range of health or psychological benefits beyond BP lowering or cardiovascular risk reduction."


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Task Force issues HIV screening recommendations

All adolescents and adults age 15 to 65 should be screened for HIV infection, the U.S. Preventive Services Task Force said.

annals.jpg

The Task Force's current recommendation statement, published early online April 30 by Annals of Internal Medicine, expands on its statement from 2005, which strongly recommended HIV screening in all adolescents and adults at increased risk for infection and in all pregnant women. The Task Force continues to strongly recommend screening in these groups but now also includes all adolescents and adults age 15 to 65 who are not known to be at increased HIV risk. Its recommendations for pregnant women include those who present in labor and have not been tested and those whose HIV status is not known.

To develop the current recommendations, the Task Force reviewed evidence on the effectiveness of HIV treatment in HIV-infected patients with CD4 cell counts above 0.200 × 109 cells/L; the effects of screening, counseling and use of antiretroviral therapy on risk behaviors and risk for HIV transmission; and the cardiovascular harms of antiretroviral therapy over the long term. The current recommendations are Grade A recommendations, meaning that the Task Force recommends the service and there is high certainty that the net benefit is substantial.

The authors of an accompanying editorial questioned the Task Force's focus on the timing of antiretroviral therapy initiation and its potential cardiac risk. However, they noted that the Task Force's recommendations are now mostly in agreement with the 2006 guidelines from the CDC, which call for testing all people between 13 and 64 years of age, and that an increasing consensus has emerged on population-based screening for HIV.



Test yourself


.
MKSAP Quiz: evaluation during fourth week of pregnancy

A 27-year-old woman is evaluated during the fourth week of an uneventful pregnancy. She has a 3-year history of primary hypothyroidism due to Hashimoto thyroiditis that is treated with levothyroxine, 125 µg/d. She also takes prenatal vitamins and iron sulfate.

mksap.gif

On physical examination, temperature is 37.1 °C (98.8 °F), blood pressure is 128/80 mm Hg, pulse rate is 95/min, and respiration rate is 18/min and regular; BMI is 25. She has a mild fine hand tremor. Lung, cardiac, and skin examination findings are normal. The thyroid gland is smooth and slightly enlarged without a bruit or nodules.

Laboratory studies show a serum thyroid-stimulating hormone level of 4.2 µU/mL (4.2 mU/L) and a serum free thyroxine (T4) level of 1.6 ng/dL (21 pmol/L).

Which of the following is the most appropriate management?

A: Increase the levothyroxine dosage by 10% now
B: Increase the levothyroxine dosage by 30% now
C: Repeat thyroid function tests in 5 weeks
D: Repeat thyroid function tests in the second trimester

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


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Influenza


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CDC issues antiviral recommendations for H7N9 influenza

The Centers for Disease Control and Prevention last week issued recommendations on antiviral treatment for avian influenza A(H7N9).

The recommendations apply to confirmed and probable cases of H7N9 infection and to cases under investigation. The CDC noted that the recommendations are based on currently available information, as well as the current lack of a vaccine for this virus, the severity of H7N9 disease, and the fact that current human-to-human virus transmission is limited but could increase in the future. The CDC said that clinicians should consider H7N9 influenza in patients with acute febrile respiratory illness who have "an appropriate recent travel or exposure history."

The CDC recommended that all confirmed cases, probable cases, and H7N9 cases under investigation should receive antiviral treatment with a neuraminidase inhibitor as early as possible, even if it is more than 48 hours after onset of illness. In addition, it said, laboratory testing and initiation of antiviral treatment should occur simultaneously, and treatment shouldn't be delayed for laboratory confirmation of influenza or H7N9 infection.

The CDC also directed clinicians to consult its "Antiviral Drugs: Dosage" document for additional guidance, including dosage recommendations by age group. The CDC said oseltamivir is recommended for treatment of persons of any age, while zanamivir is recommended for children age 7 and older.

All of the recommendations, including additional recommendations for uncomplicated illness in outpatients and for hospitalized patients, are available online.

In a separate study, published early online April 24 by the New England Journal of Medicine, researchers examined data from 82 patients with H7N9 infection in China and found no epidemiologic relation in most cases. The median patient age was 63 years (range, 2 to 89 years), 73% of patients were male, and 84% lived in urban areas.

Approximately three-quarters of the 77 patients for whom data were available had been exposed to live animals, especially chickens. Seventeen patients (21%) died, with a median illness duration of 11 days. The researchers also examined 1,689 close contacts of case-patients, of whom 1,251 completed a seven-day monitoring period. Among these close contacts, 19 (1.5%) developed respiratory symptoms but none tested positive for the H7N9 virus.

The researchers could not rule out human-to-human transmission because H7N9 cases were found in two family clusters. However, they said that their results "suggest that the risk of secondary H7N9 virus transmission, including to health care personnel, is low at this time."



Heart failure


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ACC/ACR release recommendations on imaging in heart failure

Recommendations on the appropriate use of imaging in heart failure patients were released by the American College of Radiology and the American College of Cardiology Foundation last week.

This first joint effort on the subject covered the use of imaging for initial diagnosis and evaluation, decisions about revascularization and device implantation, and long-term follow-up, among other indications. The writing group reviewed available literature, presented common clinical scenarios and came to recommendations on the use of 11 possible tests, including rest and rest/stress tests for echo, radionuclide imaging and cardiac magnetic resonance (CMR) imaging, as well as cardiac CT and invasive cardiac catheterization. Resting electrocardiograms and chest X-rays were not included, since they were considered part of routine care.

For patients being initially evaluated for potential or suspected heart failure, the experts recommended echo and CMR and saw no role for stress cardiovascular testing, cardiac CT or invasive angiography. If the only information needed is ejection fraction, radionuclide ventriculography may also be useful. Once heart failure has been diagnosed, the preferred imaging strategies are stress testing, angiography with CT or invasive cardiac catheterization, the experts said.

To select patients for device therapy, echo and CMR are useful, as is cardiac CT. Most such patients do not need a stress evaluation or invasive cardiac catheterization, according to the recommendations. If patients have a change in clinical status (including device activation), reevaluation of left ventricular function is appropriate, but routine follow-up of ejection fraction is rarely appropriate, with the possible exception of echocardiography. In general, patients with changing or worsening symptoms should be tested similarly to those being initially evaluated. If there are additional concerns of ischemia, stress testing is reasonable. For patients with no change in symptoms, testing is rarely appropriate, the experts concluded.

Heart failure patients vary greatly in presentation, so the recommendations should be used in conjunction with sound clinical judgment, the authors noted. They believe that implementation of the criteria could lead to high-quality and efficient care but also noted that the evidence in this area is rapidly evolving and the document will likely need to be updated. The recommendations were published early online by the Journal of the American College of Cardiology on April 23.



Diabetes


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Medication choices, treatment escalation covered by new algorithm

A comprehensive algorithm for the management of diabetes was released last week by the American Association of Clinical Endocrinologists and the American College of Endocrinology.

The full document includes treatment algorithms for care of the overweight or obese patient and the patient with prediabetes as well as for achieving glycemic control, modifying cardiovascular risk factors and adding or intensifying insulin treatment in patients with diabetes. Goals for glycemic control are also listed: hemoglobin A1c of 6.5% or less for healthy patients without concurrent illness and low risk of hypoglycemia, and individualized targets for patients with concurrent illness and hypoglycemia risk.

The document also contains a profile of antidiabetic medications, listing their risk for hypoglycemia and effects on body weight, renal function, gastrointestinal symptoms, cardiovascular disease, heart failure and bone health.

The algorithm was published in the March/April issue of Endocrine Practice.



CMS update


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Contact your state Medicaid office to qualify for enhanced primary care payments

Primary care and related specialty physicians will see an increase in their Medicaid payments this year to make them at least equivalent to Medicare payments.

To ensure that you receive this increase, you must contact your state Medicaid office. Each state has a different timeline and procedure for physicians to fulfill an "attestation" requirement to receive the payment increases. In some states, physicians may still be able to qualify for payments retroactive to the beginning of the year; however, you need to start the attestation process as soon as possible. Additional information about the enhanced payments is on the College's website.


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Let us know about problems with transition care codes

ACP has been receiving some reports of problems with payment for claims for the transitional care management services. ACP has been working with CMS staff on this issue but needs additional details about the problems that have been experienced.

If you have experienced a problem using these new codes, please contact Debra Lansey in the ACP Health Policy and Regulatory Affairs Department with the details of your claim. Send an e-mail that includes:

  • the name of your Medicare carrier or commercial insurer,
  • the date of the patient's hospital/facility discharge,
  • the diagnosis on hospital/facility discharge,
  • the TCM claim billing date,
  • the date of the face-to-face visit,
  • the diagnosis on the TCM claim,
  • the carrier's stated reason for claim denial and
  • any other info related to the denial or lack of processing.


Medical education


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ACP, advisory board endorse Internal Medicine Milestones for residents

The Internal Medicine Education Redesign Advisory Board, with representation from multiple medical organizations, including ACP, has endorsed the release of Internal Medicine Milestones for use in the ACGME Next Accreditation System (NAS).

Internal Medicine Milestones is a document that provides medical education programs with a competency-based system for evaluating resident physicians and reporting results of their performance reviews to the ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies that describe the development of competence from an early learner up to and beyond that expected for unsupervised practice.

According to the advisory board, the Milestones document not only serves a vital role in transitioning to a competency-based system for graduate medical education, it also increases the transparency of performance expectations and provides residents with a valuable tool for self-assessment.


.
IMpact newsletter features profile of husband/wife internists

The April issue of IMpact, ACP's electronic newsletter for student members, includes a multimedia slideshow featuring husband and wife internists, Larry Kaplan, MD, FACP, and Rosalind Kaplan, MD, FACP. The slideshow is part of IMpact's physician profiles series titled "My Kind of Medicine: Real Lives of Practicing Internists." The monthly profiles highlight the careers of selected ACP members, revealing why they chose internal medicine and what they enjoy most about their careers. To see the slideshow and hear the Kaplans speak about their careers, visit the IMpact website.



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-20130430-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



Answer and critique

The correct answer is B: Increase the levothyroxine dosage by 30% now. This item is available to MKSAP 16 subscribers as item 13 in the Endocrinology 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's levothyroxine dosage should be increased by 30% now, and the thyroid function tests should be repeated in 2 to 4 weeks. Pregnancy is known to increase levothyroxine requirements in most patients receiving thyroid replacement therapy, and this expected increase should be anticipated by increasing her levothyroxine dosage. The levothyroxine dosage is typically increased in the first (and sometimes in the second) trimester of pregnancy, with a possible total increase of 30% to 50%. During the first trimester, the goal thyroid-stimulating hormone (TSH) level is less than 2.5 microunits/mL (2.5 milliunits/L) because first-trimester serum TSH levels between approximately 0.1 and 2.5 microunits/mL (0.1 to 2.5 milliunits/L) are associated with fewer maternal and fetal complications. In contrast, the upper range of normal for nonpregnant patients is approximately 4.5 to 5.0 microunits/mL (4.5 to 5.0 milliunits/L). In pregnant women with hypothyroidism, thyroid function testing should be frequent, preferably every 4 weeks, to protect the health of mother and fetus and to avoid pregnancy complications. When serum TSH values are inappropriately elevated, the dosage of levothyroxine is increased, and free thyroxine (T4) and TSH levels are monitored every 2 to 4 weeks. The fetus is largely dependent on transplacental transfer of maternal thyroid hormones during the first 12 weeks of gestation. The presence of maternal subclinical or overt hypothyroidism may be associated with subsequent fetal neurocognitive impairment, increased risk of premature birth, low birth weight, increased miscarriage rate, and even an increased risk of fetal death.

Continuing the current levothyroxine dosage is inappropriate in this patient because her TSH level is already too high (4.2 microunits/mL [4.2 milliunits/L]). TSH levels generally should be 0.1 to 2.5 microunits/mL (0.1 to 2.5 milliunits/L) in the first trimester, 0.2 to 3.0 microunits/mL (0.2 to 3.0 milliunits/L) in the second, and 0.3 to 3.0 microunits/mL (0.3 to 3.0 milliunits/L) in the third.

Key Point

  • Early in pregnancy, levothyroxine requirements are increased in most patients with hypothyroidism by 30% to 50%.

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A 76-year-old woman is evaluated for a 3-month history of left knee pain of moderate intensity that worsens with ambulation. She reports minimal pain at rest and no nocturnal pain. There are no clicking or locking symptoms. She has tried naproxen and ibuprofen but developed dyspepsia; acetaminophen provides mild to moderate relief. The patient has hypertension, hypercholesterolemia, and chronic stable angina. Medications are lisinopril, metoprolol, simvastatin, low-dose aspirin, and nitroglycerin as needed. Following a physical exam, lab results and radiograph, what is the next best step in management?

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