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

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ACP InternistWeekly



In the News for the Week of May 14, 2013




Highlights

Fish oil not associated with cardiovascular benefits

Patients with cardiovascular risk factors who took n-3 polyunsaturated fatty acids daily appeared to have no reduction in cardiovascular mortality or morbidity, according to a new study. More...

Task Force recommends screening all adults for alcohol misuse

Clinicians should screen all adults 18 and over, including pregnant women, for alcohol misuse and should provide brief behavioral counseling interventions to patients engaged in risky or hazardous drinking, the U.S. Preventive Services Task Force recently announced. More...


Test yourself

MKSAP Quiz: nursing home evaluation for incontinence

A 78-year-old woman living in a nursing home is evaluated for incontinence. Over the past year, she has had progressive decline in her cognitive status and now spends most of the day in bed. She requires coaxing to join the other residents in their communal meals and requires assistance for eating and bathing. Medical history is significant for dementia and depression treated with citalopram. What is the most appropriate management of this patient? More...


Lung cancer

ACCP recommends screening for lung cancer in high-risk patients

The American College of Chest Physicians recommends screening high-risk patients for lung cancer, according to an updated clinical practice guideline released last week. More...


Hepatitis C

More follow-up testing needed for positive hepatitis C antibody tests

Clinicians should perform an RNA hepatitis C virus test to more definitively diagnose patients after a positive antibody test, the Centers for Disease Control and Prevention recommended. More...


FDA update

Valproate contraindicated for migraines in pregnant women

Valproate sodium and related products, valproic acid and divalproex sodium, are now contraindicated for prevention of migraine headaches in pregnant women, the FDA announced last week. More...


CMS update

Problems with the CMS ACO exclusivity provision

ACP has been working to address a problem with the "exclusivity provision" of the Medicare Shared Saving Accountable Care Organization Program. More...

Palmetto GBA reminds physicians to send redetermination requests to Appeals Department

Last week, a Medicare contractor noted an increasing trend of clinicians sending redetermination requests to its Medical Review Department after their additional development requests resulted in a denied claim. More...

Deadline approaching to avoid eRx penalty

Under the 2013 Electronic Prescribing (eRx) Incentive Program, physicians must successfully report as an electronic prescriber by June 30 to avoid a 2% penalty on Medicare payments in 2014. More...

CMS call on open payments

CMS has scheduled a call for physicians and other health care professionals about the National Physician Payment Transparency Program. 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...


Physician editor: Philip Masters, MD, FACP



Highlights


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Fish oil not associated with cardiovascular benefits

Patients with cardiovascular risk factors who took n-3 polyunsaturated fatty acids daily appeared to have no reduction in cardiovascular mortality or morbidity, according to a new study.

Researchers in Italy performed a double-blind, placebo-controlled clinical trial that randomly assigned general-practice patients with atherosclerotic vascular disease or more than one cardiovascular risk factor but no myocardial infarction to receive 1 g of n-3 fatty acids daily or olive oil as a placebo. The goal of the study was to determine the potential benefit of n-3 fatty acids in this patient subgroup.

The initial primary end point was cumulative death, nonfatal myocardial infarction and nonfatal stroke, but because of a lower-than-anticipated event rate, it was revised at one year to be time to death or hospital admission related to cardiovascular causes. Secondary end points included the initial primary end point; a composite of time to death from cardiovascular causes, nonfatal myocardial infarction or nonfatal stroke; death due to coronary heart disease; and sudden death due to cardiac causes. The results were published in the May 9 New England Journal of Medicine.

Overall, 12,513 patients cared for by 860 general practitioners were enrolled in the study, and 12,505 were included in the intention-to-treat analysis. A total of 61.5% of the patients were men, and the mean patient age was 64 years. In the intention-to-treat analysis, 6,239 patients received n-3 fatty acids and 6,266 received placebo. At a median follow-up of five years, 1,478 patients (11.8%) had experienced the primary end point, 733 in the n-3 fatty acids group and 745 in the placebo group (11.7% vs. 11.9%; adjusted hazard ratio with n-3 fatty acids, 0.97; 95% CI, 0.88 to 1.08; P=0.58). Rates of all of the secondary end points were also similar between groups.

The authors concluded that in this study population, n-3 fatty acids had no effect on cardiovascular morbidity and mortality. They noted that their results differ from those of previous trials, which found a benefit mainly from reducing sudden deaths related to cardiac causes. "It is conceivable that the effects of n-3 fatty acids become manifest primarily in patients who are particularly prone to ventricular arrhythmic events (e.g., those with a myocardial scar or left ventricular dysfunction)," the authors wrote. They noted that research into the safety profile of n-3 fatty acids in the latter population could be useful.


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Task Force recommends screening all adults for alcohol misuse

Clinicians should screen all adults 18 and over, including pregnant women, for alcohol misuse and should provide brief behavioral counseling interventions to patients engaged in risky or hazardous drinking, the U.S. Preventive Services Task Force recently announced.

These recommendations differ from the 2004 statement in that the Task Force redefined alcohol misuse to include a broader spectrum of drinking habits from risky to dependent, rather than limiting the definition to just risky, hazardous or harmful drinking.

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Although pregnant women are included, this recommendation is related to decreasing risky or hazardous drinking, not to complete abstinence, which is recommended for all pregnant women. These recommendations do not apply to persons who are actively seeking evaluation or treatment for alcohol misuse.

The Grade B recommendation appeared online first May 14 at Annals of Internal Medicine.

The Task Force found adequate evidence that brief behavioral counseling interventions are effective in reducing heavy drinking episodes in adults engaging in risky or hazardous drinking. These interventions also reduce weekly alcohol consumption rates and increase adherence to recommended drinking limits.

The most effective interventions were 10 to 15 minutes per contact delivered by primary care physicians with some additional support from a nurse or health educator. Limited evidence suggests that brief behavioral counseling interventions are generally ineffective as singular treatments for alcohol abuse or dependence. The Task Force did not formally evaluate other interventions (pharmacotherapy or outpatient treatment programs) for alcohol abuse or dependence, but the benefits of specialty treatment are well established and recommended for persons meeting the diagnostic criteria for alcohol dependence.

The Task Force emphasized that evidence on the effectiveness of brief behavioral counseling interventions in the primary care setting remains largely restricted to persons engaging in risky or hazardous drinking. Evidence is lacking to recommend an optimal screening interval. The Task Force also found insufficient evidence to make recommendations for screening or behavioral interventions for adolescents.

The Task Force considers three tools the instruments of choice for screening for alcohol misuse in the primary care setting: the Alcohol Use Disorders Identification Test (AUDIT), the abbreviated AUDIT-Consumption (AUDIT-C), and single-question screening (for example, the National Institute on Alcohol Abuse and Alcoholism recommends asking, "How many times in the past year have you had 5 [for men] or 4 [for women and all adults older than 65 years] or more drinks in a day?").



Test yourself


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MKSAP Quiz: nursing home evaluation for incontinence

A 78-year-old woman living in a nursing home is evaluated for incontinence. Over the past year, she has had progressive decline in her cognitive status and now spends most of the day in bed. She requires coaxing to join the other residents in their communal meals and requires assistance for eating and bathing. When accompanied by an aide or family member, she is able to walk slowly to the bathroom without leakage and to urinate. Medical history is significant for dementia and depression treated with citalopram.

mksap.gif

She is a frail, elderly woman in no acute distress. On physical examination, temperature is normal, blood pressure is 132/88 mm Hg, and pulse rate is 68/min. BMI is 23. Her score on the Mini-Mental State Examination is 14/30. Her gait is slow and she requires assistance. Abdominal examination is without suprapubic fullness. Rectal examination reveals normal sphincter tone. Results of urinalysis are normal.

Which of the following is the most appropriate management of this patient?

A: Cystoscopy
B: Indwelling Foley catheter
C: Pelvic floor muscle training
D: Prompted voiding
E: Tolterodine

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


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Lung cancer


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ACCP recommends screening for lung cancer in high-risk patients

The American College of Chest Physicians recommends screening high-risk patients for lung cancer, according to an updated clinical practice guideline released last week.

The guideline, "Diagnosis and Management of Lung Cancer, 3rd edition," was published as a supplement to the May Chest and was developed through systematic review of all available evidence by an expert panel. The last edition of the guideline, published in 2007, did not recommend screening for lung cancer because the evidence at the time did not support it. New evidence, however, indicates that a structured, organized screening program can reduce lung cancer deaths, the ACCP said in a press release.

The guideline suggests that patients ages 55 to 74 who smoke or have smoked for at least 30 pack-years and either continue to smoke or have quit in the past 15 years be screened annually with low-dose computed tomography. The guideline stresses, however, that such screening should be done "only in settings that can deliver the comprehensive care provided to National Lung Screening Trial participants."

The guideline does not recommend screening at-risk patients with chest radiography once or at regular intervals, nor does it suggest regular screening with sputum cytology in this group. In addition, the guideline said, computed tomography screening is not suggested in patients with fewer than 30 pack-years of smoking, those younger than age 55 or older than age 74, those who stopped smoking more than 15 years ago, or those with severe comorbid conditions that would preclude attempts at curative treatment or limit life expectancy.

In addition to screening, the guideline covers chemoprevention of lung cancer, treatment of tobacco use, evaluation of pulmonary nodules, initial evaluation of patients with lung cancer, establishing a diagnosis, staging, treatment, among other topics. An executive summary is available online.



Hepatitis C


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More follow-up testing needed for positive hepatitis C antibody tests

Clinicians should perform an RNA hepatitis C virus (HCV) test to more definitively diagnose patients after a positive antibody test, the Centers for Disease Control and Prevention (CDC) recommended

The CDC updated its guidance this month because of the availability of commercial HCV antibody tests, evidence that many people with positive HCV antibody tests aren't being evaluated for current infection, and development of antiviral agents with improved efficacy.

Testing for HCV begins with a rapid or laboratory-conducted assay for HCV antibody in blood, the guidance states. A reactive result indicates current HCV infection, resolved past HCV infection or a false positive.

A reactive result should be followed by nucleic acid testing (NAT) for HCV RNA in one of four ways:

  • Blood from a subsequent venipuncture is submitted for HCV NAT if the blood sample collected is reactive for HCV antibody during initial testing.
  • From a single venipuncture, two specimens are collected in separate tubes: one tube for initial HCV antibody testing and a second tube for HCV NAT if the HCV antibody test is reactive.
  • The same sample of venipuncture blood used for initial HCV antibody testing, if reactive, is reflexed to HCV NAT without another blood draw for NAT.
  • A separate venipuncture blood sample is submitted for HCV NAT if the OraQuick HCV Rapid Antibody Test for initial testing of HCV antibody has used fingerstick blood.

If HCV RNA is not detected, that indicates either past, resolved HCV infection or false HCV antibody positivity. Testing to distinguish between true positivity and biologic false positivity may be done with a second HCV antibody assay that is different from the first assay used. Biologic false positivity is unlikely when multiple tests are used on a single specimen.

In addition to the new guidance, surveillance data on positive test results for HCV infection, reported to CDC from eight U.S. sites from 2005 to 2011, were analyzed in the MMWR.

Of 217,755 newly reported people, 107,209 (49.2%) were HCV antibody positive only, and 110,546 (50.8%) had a positive HCV RNA result that confirmed current HCV infection. In both groups, persons were most likely to have been born from 1945 to 1965 (58.5% of those who were HCV antibody positive only; 67.2% of those who were HCV RNA positive). The CDC amended testing recommendations in 2012 to include one-time HCV testing for everyone born from 1945 to 1965 regardless of other risk factors.



FDA update


.
Valproate contraindicated for migraines in pregnant women

Valproate sodium and related products, valproic acid and divalproex sodium, are now contraindicated for prevention of migraine headaches in pregnant women, the FDA announced last week.

Valproate's pregnancy category for migraine use will be changed from "D" (the potential benefit of the drug in pregnant women may be acceptable despite its potential risks) to "X" (the risk of use in pregnant women clearly outweighs any possible benefit of the drug). The change is based on evidence from a recent study that these medications decreased IQ scores in children whose mothers took them while pregnant, the FDA said.

Valproate products will remain in pregnancy category D for treating epilepsy and manic episodes associated with bipolar disorder.



CMS update


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Problems with the CMS ACO exclusivity provision

ACP has been working to address a problem with the "exclusivity provision" of the Medicare Shared Saving (MSS) Accountable Care Organization (ACO) Program.

The provision limits practices to being involved as a formal participant in only one MSS ACO if they submit claims for a set of defined "primary care" codes. This has become a problem particularly for specialty and subspecialty practices in areas where there is more than one approved MSS program. ACOs may try to steer their patients to specialists who are participants with their own MSS. A webinar explaining this issue in further detail is available online.

If you have experienced a problem regarding this "exclusivity" issue, ACP asks that you do the following:

  • Notify CMS directly at ShareSavingsProgram@cms.hhs.gov describing any instances in which an MSS program is inappropriately informing their patients that they can only see physicians and other health care professionals within their specific system
  • Please contact ACP by e-mail with the subject line MSS PROGRAM describing any other related concerns you have. The College is specifically interested in instances where this situation has significantly decreased a practice's patient panel.

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Palmetto GBA reminds physicians to send redetermination requests to Appeals Department

Last week, Palmetto GBA (a Medicare contractor) noted an increasing trend of clinicians sending redetermination requests to its Medical Review Department after their additional development requests (ADRs) resulted in a denied claim.

Palmetto is reminding physicians that redetermination requests should be sent to the Appeals Department, not to the Medical Review Department. They also noted that if the requests are mistakenly sent to the medical review staff without the redetermination request form, staff cannot forward the documentation to Appeals without the form. Physicians have 12 days to file an appeal after a claim has been denied.


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Deadline approaching to avoid eRx penalty

Under the 2013 Electronic Prescribing (eRx) Incentive Program, physicians must successfully report as an electronic prescriber by June 30 to avoid a 2% penalty on Medicare payments in 2014.

Additional information about the incentive program and resources to help practices avoid the payment penalty are available on the Running a Practice section of the College's website.


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CMS call on open payments

CMS has scheduled a call for physicians and other health care professionals about the National Physician Payment Transparency Program.

This program, originating from the Affordable Care Act, requires pharmaceutical and medical device companies to publicly report payments made to physicians and teaching hospitals. The CMS call will be held Wednesday, May 22, from 2:30 to 4 p.m. Eastern Time and will provide an overview of the program and what physicians need to know about it. You can register online at the CMS Upcoming National Provider Calls registration website. Additional information about the program is also available on the CMS website.



Cartoon caption contest


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Vote for your favorite entry

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

acpi-20130514-cartoon.jpg

"I guess we're too late. He's already flat-lining."

"I had something else in mind when I asked for an outline of the patient's condition."

"Yeah, I guess it would bother most people, but an office with a window is an office with a window."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting ends on Monday, May 20, with the winner announced in the May 21 issue.


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MKSAP Answer and Critique



The correct answer is D: Prompted voiding. This item is available to MKSAP 16 subscribers as item 33 in the General Internal Medicine section. More information is available online.

This patient would be best managed by establishing a prompted voiding protocol. Urinary incontinence affects more than 50% of nursing home patients and is associated with significant morbidity and cost. Most of these patients have limited mobility or significant cognitive impairment, leading to a high prevalence of functional incontinence, defined as simply not getting to the toilet quickly enough. In a systematic review of 14 randomized controlled studies involving 1,161 nursing home patients, the use of prompted voiding (periodically asking the patient about incontinence, reminding the patient to go to the toilet, and providing praise for maintaining continence and using the toilet) was associated with modest short-term improvement in urinary incontinence.

History, focused examination, and urinalysis are often adequate to classify urinary incontinence. Postvoid residual urine volume determination is most useful if overflow incontinence due to outlet obstruction or a flaccid neurogenic bladder is suspected. Detailed urologic evaluations, such as cystoscopy and urodynamic testing, are unnecessary in uncomplicated urinary incontinence.

An indwelling Foley catheter is not advised as a first-line measure to manage urinary incontinence owing to an increased risk of urinary tract infection, resultant antibiotic treatment, and the development of antibiotic complications and resistance.

Pelvic floor muscle training is effective for stress incontinence, which may be coexistent in this patient, but successful implementation requires a cooperative and cognitively intact patient who can understand and participate in the exercise program.

Tolterodine, a selective anticholinergic antimuscarinic medication, is primarily indicated for urge incontinence and is of no benefit in functional incontinence. In addition, adverse side effects, such as dry mouth and worsening cognitive function, render its use in this patient ill advised.

Key Point

  • Prompted voiding is an effective management strategy for patients with functional urinary incontinence.

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Test yourself

A 48-year-old man is evaluated during a follow-up visit for urinary frequency. He reports no hesitancy, urgency, dysuria, or change in urine color. He has not experienced fevers, chills, sweats, nausea, vomiting, diarrhea, or other gastrointestinal symptoms. He feels thirsty very often; drinking water and using lemon drops seem to help. He has a 33-pack-year history of smoking. He has hypertension, chronic kidney disease, and bipolar disorder. Medications are amlodipine, lisinopril, and lithium. He has tried other agents in place of lithium for his bipolar disorder, but none has controlled his symptoms as well as lithium. What is the most appropriate treatment intervention for this patient?

Find the answer

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