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

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ACP InternistWeekly



In the News for the Week of June 25, 2013




Highlights

Treatment for prostate symptoms doesn't appear to increase risk for advanced prostate cancer

Treating prostate symptoms with 5α-reductase inhibitors (5-ARIs) does not appear to increase risk for advanced prostate cancer, a new study indicates. More...

USPSTF recommends hepatitis C screening for baby boomers and high-risk patients

All patients born between 1945 and 1965 should be screened for hepatitis C virus (HCV), as should all high-risk patients, the U.S. Preventive Services Task Force recently recommended. More...


Test yourself

MKSAP Quiz: worsening heart failure

A 78-year-old man was admitted to the hospital 5 days ago for worsening heart failure. There were bibasilar crackles and dullness to percussion at both posterior lung bases. Jugular venous distention, an S3, and lower extremity edema were present. Chest radiograph revealed cardiomegaly, vascular congestion, and moderate-sized bilateral pleural effusions. What is the most likely cause of this patient's pleural effusion? More...


Infectious disease

CDC offers recommendations on doxycycline shortage

In response to recent shortages of the antibiotic doxycycline, the CDC issued recommendations to clinicians about appropriate use of the drug when availability is limited. More...

CDC updates vaccination guide for measles, mumps, rubella

The Advisory Committee on Immunization Practices (ACIP) published three revisions to its guidelines for vaccinating against measles, mumps and rubella (MMR). More...


Stroke

Simple score may help predict early stroke mortality

A simple score based on four variables easily obtainable at the point of care may help predict inpatient and 7-day mortality after acute stroke, a study found. More...


Contraception

CDC updates recommendations on contraceptive use

The Centers for Disease Control and Prevention issued selected practice recommendations on contraceptive use last week as a companion to its 2010 recommendations on medical eligibility for contraception. More...


Practice management

CCHIT develops tool to help ACOs achieve goals

The Certification Commission for Health Information Technology (CCHIT) has developed an assessment and planning tool called the CCHIT Accountable Care Organization (ACO) Health Information Technology (HIT) Framework to help ACOs anticipate the costs and resources needed to start and maintain a successful HIT infrastructure. More...


From ACP Hospitalist

Who's tops at your hospital?

ACP Hospitalist is seeking candidates for its sixth annual Top Hospitalists issue in November. More...


From the College

In the U.S. or Bangladesh or South Africa, physicians face similar nonclinical issues

Yul Ejnes, MD, MACP, continues his monthly column at KevinMD.com, this time explaining how nonclinical issues faced by U.S. physicians are, surprisingly, shared by doctors around the world. 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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Treatment for prostate symptoms doesn't appear to increase risk for advanced prostate cancer

Treating prostate symptoms with 5α-reductase inhibitors (5-ARIs) does not appear to increase risk for advanced prostate cancer, a new study indicates.

In 2011, the FDA issued a safety announcement warning that 5-ARIs, which are used to treat prostate symptoms, might increase risk of more serious prostate cancer. The warning was based on two randomized, clinical trials finding that chemoprevention with 5-ARIs substantially reduced risk for prostate cancer at biopsy but also appeared to increase risk for more severe disease (i.e., a Gleason score of 8-10).

To determine the association between 5-ARI treatment for lower urinary tract symptoms related to prostate enlargement and risk for prostate cancer, especially more severe disease, researchers in Sweden performed a population-based case-control study of men who were diagnosed with prostate cancer in 2007-2009. Data on cancer diagnosis and 5-ARI use were obtained from several national databases. Risk for prostate cancer was the main outcome measure. The study results were published online by BMJ on June 18.

A total of 26,735 cases and 133,671 matched controls were selected for the study, with five controls randomly selected per case. The mean age was 69.3 years, and men who had disease with lower Gleason scores tended to be younger than those with higher scores. Overall, 7,815 men, 1,499 cases and 6,316 controls, had taken 5-ARIs, and 412 had done so before being diagnosed with higher-grade disease (Gleason score 8-10).

The researchers found that prostate cancer risk decreased as a whole with increased exposure to 5-ARIs (odds ratio [OR], 0.72; P<0.001 for trend in men treated for >3 years). Risk for cancer with Gleason scores of 2 to 6 and 7 also decreased with increased exposure (P<0.001 for trend in both comparisons). However, risk for disease with a Gleason score of 8 to 10 did not appear to change due to 5-ARI exposure (ORs, 0.96 for 0 to 1 year of exposure, 1.07 for 1 to 2 years of exposure, 0.96 for 2 to 3 years of exposure, and 1.23 for >3 years of exposure; P=0.46 for trend).

The researchers acknowledged that the study follow-up was relatively short and that data on prostate-specific antigen testing and digital rectal exam results at initiation of 5-ARI therapy were not available, among other limitations. However, they concluded that treatment with 5-ARIs decreased overall risk for prostate cancer and did not appear to be associated with increased risk for severe disease. "Our data, together with previous studies, suggest that the net balance between benefit and harm for 5-ARI use is favourable in men with lower urinary tract symptoms based on prostatic enlargement," they wrote.


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USPSTF recommends hepatitis C screening for baby boomers and high-risk patients

All patients born between 1945 and 1965 should be screened for hepatitis C virus (HCV), as should all high-risk patients, the U.S. Preventive Services Task Force recently recommended.

annals.jpg

The recommendations, published by Annals of Internal Medicine on June 25, concluded that one-time screening of patients born 1945-1965 is moderately certain to provide moderate benefit (a B recommendation). Patients in this age group may have undergone blood transfusions before 1992 or have a long-ago history of other risk factors. A risk-based approach could miss a substantial proportion of HCV-infected persons in this cohort, the USPSTF said.

As for high-risk patients, past or present injection drug use and a blood transfusion before 1992 were identified as the most significant risk factors meriting screening (also moderately certain to be of moderate benefit). Other risk factors include long-term hemodialysis, being born to an HCV-infected mother, incarceration, intranasal drug use, getting an unregulated tattoo, and other percutaneous exposures, but the relative significance of these risks may differ by location and other factors, the Task Force noted. It recommended periodic screening of patients who continue to be high risk but noted that the optimal frequency of screening is unknown.

The new recommendations represent a significant change from those issued in 2004, when the USPSTF recommended against screening for HCV infection in adults not at increased risk and found insufficient evidence to recommend for or against screening in adults at high risk. However, in 2011, the FDA approved two new anti-HCV medications that demonstrated improved efficacy when used in combination with older antiviral therapies for patients with genotype 1, and other treatments are under study that may decrease the morbidity and mortality associated with HCV infection when used in affected patients identified through screening. The new recommendations are based on two systematic reviews of screening for and treatment of HCV infection in asymptomatic adults, especially focused on research published since 2004.

Anti-HCV antibody testing is recommended for initial screening. If negative, no further testing is necessary. If positive, this test should be followed by polymerase chain reaction testing for HCV RNA. Positive polymerase chain reaction testing for HCV RNA indicates current HCV infection. It should be opt-out screening, in which patients are informed orally or in writing that HCV testing will be performed unless they decline. Before HCV screening, patients should receive an explanation of HCV infection, how it can and cannot be acquired, the meaning of positive and negative test results, and the benefits and harms of treatment, as well as an opportunity to ask questions and to decline testing.

The USPSTF noted that the new recommendations match current CDC recommendations. An accompanying editorial suggested that the Affordable Care Act will facilitate implementation of these recommendations, as it requires preventive services with an A or B recommendation from the USPSTF to be covered by private health plans without patient cost.



Test yourself


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MKSAP Quiz: worsening heart failure

A 78-year-old man was admitted to the hospital 5 days ago for worsening heart failure.

mksap.gif

On physical examination at admission, temperature was normal, blood pressure was 150/88 mm Hg, pulse rate was 108/min, and respiration rate was 22/min. There were bibasilar crackles and dullness to percussion at both posterior lung bases. Jugular venous distention, an S3, and lower extremity edema were present. Chest radiograph revealed cardiomegaly, vascular congestion, and moderate-sized bilateral pleural effusions. He was managed with furosemide and lisinopril. On the fourth hospital day, thoracentesis on the right was performed for further relief of dyspnea.

Pleural fluid analysis demonstrates a pleural fluid to serum lactate dehydrogenase (LDH) ratio of 61%, a pleural fluid LDH that is 46% of the upper limit of serum LDH, and a pleural fluid to serum total protein ratio of 0.51. Pleural fluid cultures and cytology are negative. The serum to pleural fluid total protein gradient is 3.3 g/dL (33 g/L).

Which of the following is the most likely cause of this patient's pleural effusion?

A: Heart failure
B: Malignancy
C: Pneumonia
D: Pulmonary embolism

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


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Infectious disease


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CDC offers recommendations on doxycycline shortage

In response to recent shortages of the antibiotic doxycycline, the CDC issued recommendations to clinicians about appropriate use of the drug when availability is limited.

According a health advisory of June 12, the CDC recommends the following:

  • Doxycycline should be used to treat suspected rickettsial infections; no alternatives can be recommended that have the same proven degree of efficacy in limiting fatal outcome. Because treatment delay can result in adverse or fatal outcome, planning for doxycycline availability is essential.
  • Doxycycline is the recommended drug for prophylaxis of Lyme disease; alternatives have not been tested for efficacy. Clinicians should be judicious in its use following a tick bite.
  • Doxycycline should still be used for the prophylaxis and treatment of malaria according to the standard recommendations.
  • Alternatives exist for the treatment of sexually transmitted diseases and Lyme disease. Clinicians should use clinical judgment in making treatment and prophylactic decisions.

Doxycycline is currently available from most manufacturers, and no manufacturers are currently reporting shortages of intravenous doxycycline hyclate or oral suspension doxycycline calcium, according to the FDA. The agency has received reports of shortage from some, but not all, manufacturers of some dosages and forms of doxycycline hyclate and doxycycline monohydrate.

Clinicians should ensure they have access to doxycycline for the listed indications, and advance planning is essential to ensure treatment is not delayed, the CDC said. Those who encounter difficulty ordering doxycycline or increased pricing from their usual suppliers should contact alternate distributors, drug manufacturers, or their state health department to inquire about other procurement options. For additional information about the availability of doxycycline, visit the FDA Drug Shortage website or the American Society of Health-System Pharmacists website.


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CDC updates vaccination guide for measles, mumps, rubella

The Advisory Committee on Immunization Practices (ACIP) published three revisions to its guidelines for vaccinating against measles, mumps and rubella (MMR).

The ACIP removed documentation of physician-diagnosed disease as an acceptable criterion for evidence of immunity for measles and mumps and included laboratory confirmation of disease as acceptable evidence of immunity for MMR.

In addition, it expanded recommendations for vaccination to all HIV-infected people older than one year who do not have evidence of current severe immunosuppression. It recommended revaccinating people with perinatal HIV infection who were vaccinated before establishment of effective antiretroviral therapy (ART) with two appropriately spaced doses of MMR vaccine once effective ART has been established. ACIP also changed the recommended timing of the two doses of MMR vaccine for HIV-infected people to age 12 through 15 months and 4 through 6 years.

For measles postexposure prophylaxis, the ACIP expanded recommendations for use of immune globulin administered intramuscularly (IGIM) to include infants (from birth to 6 months old) exposed to measles. It increased the recommended dose of IGIM for immunocompetent people. The ACIP also recommended intravenous immune globulin for severely immunocompromised people and pregnant women without evidence of measles immunity who are exposed to measles.

The new recommendations were published online June 14 by Morbidity and Mortality Weekly Report. (The ACIP adopted the revisions in October 2012.)

Unchanged recommendations include two doses of MMR vaccine for children (at 12 to 15 months and 4 to 6 years). Two doses are recommended for adults at high risk for exposure and transmission (e.g., students attending colleges, health care personnel, and international travelers) and one dose for other adults aged 18 years or older. For prevention of rubella, one dose of MMR vaccine is recommended for people aged 12 months and older.



Stroke


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Simple score may help predict early stroke mortality

A simple score based on four variables easily obtainable at the point of care may help predict inpatient and 7-day mortality after acute stroke, a study found.

Four variables—the Stroke subtype, the Oxfordshire Community Stroke Project Classification, the Age, and the prestroke Rankin stroke—comprise the SOAR score. It is an 8-point scale (0–7), with each of the variables scored as 0, 1 or 2 points, taken when the patient is admitted.

To validate the SOAR score's ability to predict inpatient and 7-day mortality, British researchers used data from 3,547 stroke patients (92% ischemic) treated at eight National Health Service hospital trusts in the Anglia Stroke and Heart Clinical Network between September 2008 and April 2011.

Results appeared online June 18 at Stroke.

The best predictive value was observed for the cut-off score of 3 or above. The area under the receiver-operator curve was 0.80 (95% CI, 0.78 to 0.82) for inpatient mortality and 0.82 (95% CI, 0.79 to 0.84) for 7-day mortality.

Researchers noted that, unlike other scores, SOAR can be applied to both ischemic and hemorrhagic stroke. It can be calculated by both clinical and nonclinical staff for administrative purposes once the clinical assessment has been made, since all four factors were fixed during admission.

Still, researchers cautioned, "Although the sensitivity and specificity of the SOAR score are reasonable when cut-off point ≥3 is used, the positive predictive value was less impressive (only 23% with a SOAR score of 3 died) and this may result in some patients being assigned a misleading prognosis. As a result, clinical judgment still has a role in prognostication as the score has yet to be tested against clinical judgment."



Contraception


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CDC updates recommendations on contraceptive use

The Centers for Disease Control and Prevention issued selected practice recommendations on contraceptive use last week as a companion to its 2010 recommendations on medical eligibility for contraception.

The recommendations cover intrauterine contraception, implants, injectables, combined hormonal contraceptives, progestin-only pills, the standard-days method, and male sterilization, among other topics. They are based on the World Health Organization's 2012 global family planning guidance but have been adapted for a U.S. audience or because of new evidence. Specifically, they include new guidance on the use of the combined contraceptive patch and vaginal ring and address four new subject areas: effectiveness of female sterilization, extended use of combined hormonal methods and bleeding problems, regular contraception after use of emergency contraception, and determination of when contraception is no longer needed.

Compared with the World Health Organization's guidance, the CDC recommendations also include changes to the grace period for reinjection with depot medroxyprogesterone acetate, different recommendations for tests and exams before initiating contraception and for managing bleeding irregularities, and a modified algorithm for missed doses of the contraceptive pill. The recommendations were published in Morbidity and Mortality Weekly Report on June 14. ACP Internist published an article on contraceptive methods in our June issue.



Practice management


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CCHIT develops tool to help ACOs achieve goals

The Certification Commission for Health Information Technology (CCHIT) has developed an assessment and planning tool called the CCHIT Accountable Care Organization (ACO) Health Information Technology (HIT) Framework to help ACOs anticipate the costs and resources needed to start and maintain a successful HIT infrastructure.

The ACO HIT Framework offers a step-by-step guide that allows users to assess what steps they need to take to achieve the four key HIT requirements: 1) share information, 2) collect data, 3) support patient safety, and 4) ensure privacy and security protection. The Framework will help users formulate a structured plan to incorporate changes into their current HIT infrastructure or fulfill them using outside entities.

For more information about this resource, visit the CCHIT website.



From ACP Hospitalist


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Who's tops at your hospital?

ACP Hospitalist is seeking candidates for its sixth annual Top Hospitalists issue in November, which will feature the best and brightest in hospital medicine. Let us know what your colleagues have accomplished in 2013. Did they take charge of a key quality or safety initiative? Do they always go out of their way to educate patients or help new physicians? Maybe they are amazing at tricky diagnoses, or selfless about volunteer outreach. Whatever the contribution, if it helped further hospital medicine, we'd like to hear about it.

Recommending a physician is easy: Just visit our online form and tell us which physicians you think we should feature and why. We look forward to receiving your suggestions!

Note: ACP Hospitalist's Top Hospitalist issue is not part of the ACP National Awards Program. Self-nomination is not permitted. Candidates need not be ACP members. The selection process is not scientific. Editorial board members are solely responsible for determining those profiled in the Top Hospitalists issue.



From the College


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In the U.S. or Bangladesh or South Africa, physicians face similar nonclinical issues

Yul Ejnes, MD, MACP, a past chair of ACP's Board of Regents, a practicing internist in Cranston, RI, and a member of ACP Internist's editorial board, continues his monthly column at KevinMD.com. In his latest post, Dr. Ejnes shares his experience learning that nonclinical issues faced by U.S. physicians are, surprisingly, shared by doctors around the world.



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-20130625-cartoon.jpg

"Oh great, another super bug."

This issue's winning cartoon caption was submitted by Cy Anderson, MD, ACP Member. Thanks to all who voted! The winning entry captured 51% of the votes.

The runners-up were:

"You must be the new stool culture testing technician."

"... and make sure you stay off the Web."


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MKSAP Answer and Critique



The correct answer is A: Heart failure. This item is available to MKSAP 16 subscribers as item 74 in the Pulmonology and Critical Care section. More information is available online.

The most likely cause of this patient's pleural effusion is heart failure. This patient presents with classic findings of decompensated heart failure. In this patient, pleural fluid analysis is consistent with an exudate by total protein criteria only (pleural fluid to serum total protein ratio of 0.51), with a transudative lactate dehydrogenase ratio. Pleural fluid differentiation into transudative or exudative categories by modified Light criteria is almost 100% sensitive but only 83% specific for an exudative process, and specificity further declines in the setting of a transudative process with concurrent diuretic therapy, such as in this patient. In this setting, determining the albumin or total protein gradient is useful in confirming the clinical suspicion that the effusions are in fact due to heart failure alone. A serum to pleural fluid albumin gradient greater than 1.2 g/dL (12 g/L) or a serum to pleural fluid total protein gradient greater than 3.1 g/dL (31 g/L) are equally consistent with a transudative process under these circumstances.

Pleural effusions due to malignancy tend to be unilateral with exudative chemical characteristics, and up to two-thirds are lymphocyte predominant. The effusion in this patient is most consistent with a transudate, in which case the lymphocyte predominance is of no clinical significance.

Pneumonia is associated with an exudative pleural effusion, which is not present in this patient. In addition, the absence of fever reduces the probability of a parapneumonic effusion. Although the results of the pleural fluid analysis may increase or decrease the posttest probability that the effusion is exudative, a low clinical suspicion of an exudate should not be affected by borderline test results.

Pleural effusions due to pulmonary embolus are small and unilateral, with 86% resulting in only blunting of the costophrenic angle. Pleural fluid analysis is not helpful in establishing the diagnosis; however, it is almost always consistent with an exudative process.

Key Point

  • Heart failure is the most common cause of transudative effusions, but diuresis can cause borderline exudative chemical characteristics; a serum to pleural fluid albumin gradient greater than 1.2 g/dL (12 g/L) or a serum to pleural fluid total protein gradient greater than 3.1 g/dL (31 g/L) is equally consistent with a transudative process under these circumstances.

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Test yourself

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?

Find the answer

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