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

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ACP InternistWeekly



In the News for the Week of May 7, 2013




Highlights

Azithromycin not associated with increased cardiovascular risk in the general population

Azithromycin was not associated with an increased risk of death from cardiovascular causes in a general population of young and middle-aged adults, a Danish study found. More...

Starting salaries rise for primary care doctors in 2012

Primary care physicians reported $180,000 in median first-year guaranteed compensation, up from $175,000 in 2011, a salary survey noted. More...


Test yourself

MKSAP Quiz: Fever and abdominal pain

A 45-year-old man is admitted to the hospital for a 2-day history of fever and abdominal pain. His medical history is notable for cirrhosis due to chronic hepatitis C, esophageal varices, ascites, and minimal hepatic encephalopathy. Abdominal ultrasound discloses cirrhosis, splenomegaly, and ascites. His albumin level is consistent with spontaneous bacterial peritonitis. What is the most appropriate treatment? More...


Diabetes

Mortality, hospitalization may be similar with sitagliptin versus other oral antidiabetics

Sitagliptin was associated with similar rates of hospital admission and mortality as other glucose-lowering drugs, according to a recent study of patients with type 2 diabetes. More...


Osteoarthritis

Total knee arthroplasty may be associated with weight gain

Patients who undergo knee arthroplasty may be at risk for weight gain in the five years after surgery, according to a new study. More...


Cardiology

Guidance released on use of new oral anticoagulants in nonvalvular afib

The European Heart Rhythm Association published guidance last week on using new oral anticoagulants in patients with nonvalvular atrial fibrillation. More...


FDA update

New limitations on tolvaptan due to liver injury risk

The labeling for tolvaptan (Samsca) has been revised due to observation of increased risk of liver injury in recent trials, the FDA announced last week. More...


CMS update

Medicare revises limits for recovery audit program

As of April 15, new limits apply to additional document requests for Medicare providers, except for physicians and suppliers. More...


Practice management

ACP can help you with the new transitional care codes

The ACP website offers detailed resources that can help you figure out the new CPT codes for transitional care management. More...


From the College

Governance Committee seeks Regent candidates for 2014

The Governance Committee oversees the process for nominating and electing Masters and Fellows of the College to the Board of Regents and is beginning the process of seeking Regents to join the Board in May 2014. 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: Daisy Smith, MD, FACP



Highlights


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Azithromycin not associated with increased cardiovascular risk in the general population

Azithromycin was not associated with an increased risk of death from cardiovascular causes in a general population of young and middle-aged adults, a Danish study found.

Researchers conducted a nationwide historical cohort study involving Danish adults in a registry database, ages 18 to 64, from 1997 through 2010. They estimated rate ratios for death from cardiovascular causes, comparing 1,102,050 uses of azithromycin to no use of antibiotic agents (matched in a 1:1 ratio according to propensity score) and 1,102,419 uses of azithromycin to 7,364,292 uses of penicillin V.

Results appeared in the May 2 New England Journal of Medicine.

Risk of death from cardiovascular causes significantly increased with current use of azithromycin compared to no antibiotic use (rate ratio [RR], 2.85; 95% CI, 1.13 to 7.24). There was no significantly increased risk with recent or past use. The risk of noncardiovascular death was also higher with current use of azithromycin compared to no antibiotic (RR, 1.60; 95% CI, 1.00 to 2.54).

However, when compared to penicillin V in an unadjusted analysis, azithromycin was not significantly associated with an increased risk of death from cardiovascular causes during current use (RR, 0.78; 95% CI, 0.47 to 1.28) or recent or past use. In an analysis adjusted for propensity scores, azithromycin was not associated with a significantly increased risk of death from cardiovascular causes during current use (RR, 0.93; 95% CI, 0.56 to 1.55), recent use (RR, 0.75; 95% CI, 0.34 to 1.62) or past use (RR, 0.92; 95% CI, 0.60 to 1.42) compared with penicillin V.

Researchers wrote, "[O]ur findings indicate that the risk of cardiac toxic effects associated with azithromycin may not be generalizable but may rather be limited to high-risk populations. The implications of these findings for clinical decision making are reassuring; they indicate that for the general population of patients seen in office practice, azithromycin can be prescribed without concern about an increased risk of death from cardiovascular causes, whereas the benefits of therapy need to be weighed against the risk of death from cardiovascular causes among patients with a high baseline risk of cardiovascular disease."

An accompanying editorial from the FDA noted that in March the agency revised the azithromycin product labels to reflect other study results that showed azithromycin can prolong the QT interval.

"Pharmacologic and epidemiologic data point to lethal arrhythmias as a potential consequence of QT-interval prolongation with use of azithromycin, other macrolides, and fluoroquinolones," the researchers wrote. "This possibility should give clinicians pause when they're considering prescribing antibacterial drugs, especially for patients with preexisting cardiovascular risk factors or clinical conditions in which antibacterial drug therapy has limited benefits."


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Starting salaries rise for primary care doctors in 2012

Primary care physicians reported $180,000 in median first-year guaranteed compensation, up from $175,000 in 2011, a salary survey noted.

MGMA's "Physician Placement Starting Salary Survey: 2013 Report Based on 2012 Data" reported that medical practices feel the pressure to recruit physicians and offer competitive benefits amid concerns over the physician workforce shortage, expected to reach more than 90,000 physicians by 2020 and 130,000 by 2025.

In an effort to recruit physicians, practices may be offering benefits such as first-year, postresidency or postfellowship signing bonuses, paid relocation expenses, loan forgiveness, paid vacations, and continuing medical education, the organization said in a press release.

The report also assessed physician movement around the country. Physicians reported that they were most likely to relocate within their region. Physicians in the Midwest (including Illinois, Indiana, Michigan, Minnesota, Ohio and Wisconsin) reported the most relocations away from the region. Physicians reported the fewest placements to the West (including Colorado, Montana, North Dakota, South Dakota, Utah and Wyoming).

The MGMA report contains data on 5,225 clinicians in 629 medical organizations.



Test yourself


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MKSAP Quiz: Fever and abdominal pain

A 45-year-old man is admitted to the hospital for a 2-day history of fever and abdominal pain. His medical history is notable for cirrhosis due to chronic hepatitis C, esophageal varices, ascites, and minimal hepatic encephalopathy. His medications are furosemide, spironolactone, nadolol, lactulose, zinc, vitamin A, and vitamin D.

mksap.gif

On physical examination, temperature is 36.5 °C (97.7 °F), blood pressure is 100/50 mm Hg, pulse rate is 84/min, and respiration rate is 20/min. BMI is 28. Abdominal examination discloses distention consistent with ascites. The abdomen is nontender to palpation.

Laboratory studies

Hemoglobin 10 g/dL (100 g/L)
Leukocyte count 3500/µL (3.5 × 109/L)
Platelet count 70,000/µL (70 × 109/L)
INR 1.5 (normal range, 0.8-1.2)
Albumin 2.5 g/dL (25 g/L)
Alkaline phosphatase 220 units/L
Alanine aminotransferase 30 units/L
Aspartate aminotransferase 40 units/L
Total bilirubin 4 mg/dL (68.4 µmol/L)
Creatinine 1.8 mg/dL (159 µmol/L)
Urinalysis Normal

Abdominal ultrasound discloses cirrhosis, splenomegaly, and ascites. The portal and hepatic veins are patent, and there is no hydronephrosis. Diagnostic paracentesis discloses a cell count of 2000/µL with 20% neutrophils, a total protein level of 1 g/dL (10 g/L), and an albumin level of 0.7 g/dL (7 g/L), consistent with spontaneous bacterial peritonitis.

Which of the following is the most appropriate treatment?

A: Cefotaxime
B: Cefotaxime and albumin
C: Furosemide and spironolactone
D: Large-volume paracentesis

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


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Diabetes


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Mortality, hospitalization may be similar with sitagliptin versus other oral antidiabetics

Sitagliptin was associated with similar rates of hospital admission and mortality as other glucose-lowering drugs, according to a recent study of patients with type 2 diabetes.

The observational, retrospective study used a database of commercial insurance claims to find more than 72,000 U.S. patients who began taking an oral antidiabetic drug between 2004 and 2009. They were followed until death, termination of insurance or the end of 2010. The study's composite endpoint was all-cause hospital admission and all-cause mortality. Results were published by BMJ on April 25.

Of the 72,738 patients, 11% took sitagliptin; of those, 91% took it in combination with at least one other antidiabetic agent. In the total study population, 11% of patients had ischemic heart disease and 9% had diabetes complications when their first diabetes drug was prescribed. Sitagliptin users were slightly more likely to have diabetes complications and to use insulin at the start of treatment. Overall, 20% of the studied patients died or were admitted to the hospital, and sitagliptin users had a similar rate of this outcome compared with other patients (adjusted hazard ratio [HR] 0.98; 95% CI, 0.91 to 1.06), even if they had ischemic heart disease (HR, 1.10; 95% CI, 0.94 to 1.28) or estimated glomerular filtration rate below 60 mL/min (HR, 1.11; 95% CI, 0.88 to 1.41).

The results of this first population-based study of a dipeptidyl peptidase-4 (DPP-4) inhibitor's effect on mortality and hospitalization are consistent with previous observational studies showing that sitagliptin isn't associated with increased acute pancreatitis. However, the results don't confirm recent meta-analyses finding a major reduction in adverse cardiac events in patients on the drug, the study authors noted. That could be due to the higher baseline risk of patients taking sitagliptin in the current study. The study's observational nature and relatively short follow-up were two limitations.

Definitive conclusions about the safety of sitagliptin in patients with cardiovascular disease will only be possible after the conclusion of a large, currently ongoing trial, the study authors noted. Still, the results of this observational study support current recommendations for use of sitagliptin and indicate that the drug seems to be safe in patients with diabetes. "Given the current controversy about other antidiabetic agents, most notably the thiazolidinediones, this is important information for patients and for clinicians," the study authors wrote.



Osteoarthritis


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Total knee arthroplasty may be associated with weight gain

Patients who undergo knee arthroplasty may be at risk for weight gain in the five years after surgery, according to a new study.

Researchers used data from a Mayo Clinic knee joint registry and a population-based sample of controls from the same region in Minnesota to study whether patients who had total knee arthroplasty (TKA) had a higher risk of clinically important weight gain, defined as at least 5% of baseline body weight, in the first five years postsurgery. The Mayo Clinic registry, which originated in 1971, collects data on follow-up outcomes at two and five years from patients who had TKA at Mayo. The study included patients who had primary TKA from Jan. 1, 1995, to Dec. 31, 2005. Patients who had had bariatric surgery or any cancer besides basal-cell carcinoma two years or less before or up to five years after the index TKA were excluded, as were patients who did not provide informed consent and those who had bilateral TKA on the same day. The study results appeared in the May Arthritis Care & Research.

A total of 1,122 TKAs in 917 patients were included in the study. Most of the patients (64% in both the TKA and control groups) were women. Thirty percent of patients who had TKA experienced clinically important weight gain in the five years after surgery compared with 19.7% of controls (multivariable-adjusted odds ratio, 1.6; 95% CI, 1.2 to 2.2). Patients who underwent at least one other arthroplasty procedure in the follow-up period were even more likely to gain weight than controls (odds ratio, 2.3; 95% CI, 1.6 to 3.2). A multivariable logistic regression model that included only TKA patients found that younger patients and patients who lost more weight in the five years before surgery also had higher risk for clinically important weight gain after surgery. Body mass index at baseline was not related to risk for later weight gain.

The authors acknowledged that one-third of the study patients and almost half of the controls were missing five-year data on weight and that they did not know the reasons for subjects' weight changes. However, they concluded that their study shows an association between TKA and clinically important weight gain soon after the procedure, especially in patients younger than age 70 and in those who lost a greater amount of weight before surgery. These findings are relevant for primary care physicians managing patients post-TKA, the authors said.

"Multidisciplinary weight loss/maintenance interventions particularly directed to those TKA patients who are younger and have lost considerable weight prior to surgery should be considered," the authors wrote. "Given the challenges of losing or maintaining weight over the long term, research efforts should target this subgroup of patients."



Cardiology


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Guidance released on use of new oral anticoagulants in nonvalvular afib

The European Heart Rhythm Association (EHRA) published guidance last week on using new oral anticoagulants in patients with nonvalvular atrial fibrillation (AF).

The guide was funded by industry through unrestricted educational grants and covers use of dabigatran, rivaroxaban and apixaban, as well as one other drug, edoxaban, that has yet to be approved in the U.S. or Europe. The goal, the authors said, was "to coordinate a unified way of informing physicians on the use of [new oral anticoagulants]" and to serve as an adjunct to the European Society of Cardiology's AF guidelines.

A working group reviewed available evidence and developed advice on the following concrete clinical scenarios:

  • practical start-up and follow-up plans for patients taking new oral anticoagulants,
  • measurement of the drugs' anticoagulant effects,
  • drug-drug interactions and pharmacokinetics,
  • how to switch between anticoagulant regimens,
  • how to ensure compliance,
  • how to handle dosing errors,
  • use in patients with chronic kidney disease,
  • how to handle a suspected overdose without bleeding, or a clotting test that indicates a risk of bleeding,
  • management of bleeding complications,
  • management of a planned surgical intervention or ablation,
  • management of an urgent surgical intervention,
  • use in patients with AF and coronary artery disease,
  • cardioversion in a patient taking a new anticoagulant,
  • management of patients presenting with acute stroke while taking a new anticoagulant, and
  • comparison of new anticoagulants and vitamin K antagonists in patients with AF and a malignancy.

The guide was published in the May 5 Europace.

Additional information, including an executive summary and downloadable cards for patients, is available at the guide's accompanying website, which the authors said will be continually updated as new evidence becomes available.



FDA update


.
New limitations on tolvaptan due to liver injury risk

The labeling for tolvaptan (Samsca) has been revised due to observation of increased risk of liver injury in recent trials, the FDA announced last week.

According to the new label, tolvaptan should not be used for longer than 30 days and should not be used in patients with underlying liver disease, including cirrhosis, because it can cause liver injury, potentially requiring liver transplant or death. It's also recommended that clinicians discontinue the drug in patients with symptoms of liver injury. These changes are due to liver injuries found in large clinical trials evaluating tolvaptan for use in patients with autosomal-dominant polycystic kidney disease, according to an FDA press release.



CMS update


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Medicare revises limits for recovery audit program

As of April 15, new limits apply to additional document requests (ADRs) for Medicare providers, with the exceptions of physicians and suppliers.

Recovery Audit Contractors (RACs) can now request as few as 20 medical records per 45-day period; the previous minimum was 35 medical records. Recovery auditors may request up to 20 records per 45 days from providers whose calculated limit is 19 additional documentation requests or fewer. Medical record request limits are calculated by taking 2% of all claims submitted during the previous calendar year and dividing by eight. The maximum amount of RAC medical record requests remains at 400 per 45-day period.

More information is available from CMS.



Practice management


.
ACP can help you with the new transitional care codes

The ACP website offers detailed resources that can help you figure out the new CPT codes for transitional care management.

Below is a list of articles that discuss the care components of the codes, the time constructs for the postdischarge contact with the patient, the face-to-face visit, and the 30-day care period.



From the College


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Governance Committee seeks Regent candidates for 2014

The Governance Committee (GC) oversees the process for nominating and electing Masters and Fellows of the College to the Board of Regents (BOR) and is beginning the process of seeking Regents to join the Board in May 2014.

The Governance Committee will strive to represent the diversity within internal medicine on ACP's Board of Regents. Important general qualifications include commitment to ACP, dependability, leadership qualities, and the ability to represent the College in numerous and diverse arenas. Regent nominees must be Fellows or Masters of the College.

All candidates for Regent must submit a letter of nomination (not from the candidate) and two letters of support (from two individuals other than the nominator) by Aug. 1, 2013.

Letters of nomination should include the following sections:

  • brief description of the nominee's current activities,
  • special attributes the candidate would bring to the BOR in terms of the desired characteristics outlined above,
  • previous and current service in College-related activities,
  • service in organizations other than the College (medical and nonmedical) and
  • identification of two individuals who will write letters of support for the candidate.

Letters of support do not need to have specific content or format but will be most useful if they focus on the candidate's qualifications and how he or she would contribute to the BOR and the College.

Please send your confidential nominations, no later than Aug. 1, 2013, to:

Governance Committee

ATTN: Mrs. Florence Moore

American College of Physicians

190 N. Independence Mall West

Philadelphia, PA 19106-1572

Fax: 215-351-2829

e-mail: fmoore@acponline.org

Only candidates who submit a letter of nomination and two letters of support by Aug. 1, 2013, will be advanced to the Governance Committee for review.

If you have any questions, please contact Florence Moore toll-free at (800) 523-1546, ext. 2814, or direct at (215) 351-2814.



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-20130507-cartoon.jpg

E‑mail all entries to acpinternist@acponline.org. ACP staff will choose finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.


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MKSAP Answer and Critique



The correct answer is B: Cefotaxime and albumin. This item is available to MKSAP 16 subscribers as item 3 in the Gastroenterology and Hepatology section. More information is available online.

The most appropriate treatment is cefotaxime and albumin. The diagnosis of spontaneous bacterial peritonitis (SBP) is made in the setting of a positive ascitic fluid bacterial culture and/or an elevated ascitic fluid absolute polymorphonuclear (PMN) cell count (≥250/microliter) without evidence of secondary causes of peritonitis. Patients with negative cultures have the same clinical presentation and outcomes compared with those with positive cultures. Intravenous cefotaxime or a similar third-generation cephalosporin is the treatment of choice for SBP. Three of the most common isolates are Escherichia coli, Klebsiella pneumoniae, and pneumococci. Oral fluoroquinolone treatment may be indicated in ambulatory patients with stable hepatic and kidney function and ascitic fluid absolute PMN cell count of 250/microliter or greater. While a significant number of hospitalized patients with SBP recover, it has been shown that kidney failure associated with SBP increases the risk for mortality. The use of cefotaxime plus intravenous albumin at 1.5 g/kg on admission and 1 g/kg on day 3 has been shown to decrease in-hospital mortality by 20% in patients with serum creatinine values of 1.5 mg/dL (133 micromoles/L) or greater, as in this patient. Patients with advanced liver disease, including those with a serum total bilirubin of 4 mg/dL (68.4 micromoles/L) or greater, as seen in this patient, also benefit from intravenous albumin to prevent kidney failure associated with SBP.

The use of cefotaxime alone in this patient is not appropriate, because the risk for progressive kidney dysfunction could still exist in the absence of intravenous albumin.

Oral diuretics such as furosemide and spironolactone should be withheld in patients with ascites and SBP to minimize the risk of worsening kidney function.

There is no evidence that large-volume paracentesis improves outcomes in patients with SBP; in fact, it may worsen kidney function owing to excessive fluid shifts.

Key Point

  • In patients with spontaneous bacterial peritonitis, the concomitant use of intravenous albumin with antibiotic therapy is associated with a survival benefit compared with antibiotic therapy alone.

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Test yourself

A 63-year-old man is evaluated for pleuritic left-sided anterior chest pain, which has persisted intermittently for 1 week. The pain lasts for hours at a time and is not provoked by exertion or relieved by rest but is worse when supine. He reports transient relief with acetaminophen and codeine and occasionally when leaning forward. He has had a low-grade fever for 3 days, without cough or chills. Medical history is significant for acute pericarditis 7 months ago. Following a physical exam and electrocardiogram, what is the most appropriate management?

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