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

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ACP InternistWeekly



In the News for the Week of August 13, 2013




Highlights

Fear of malpractice suits prompts more tests, emergency department referrals

Medicare patients received more diagnostic tests and referrals to the emergency department when treated by physicians who worry more about malpractice liability, regardless of whether states have adopted common malpractice tort reforms, a study found. More...

Long-term use of calcium-channel blocker for hypertension associated with higher breast cancer risk

Long-term use of a calcium-channel blocker for hypertension was associated with about a 2.5 times higher risk of breast cancer, according to a study. More...


Test yourself

MKSAP Quiz: 6-month history of increased fatigue and decreased exercise tolerance

A 51-year-old man is evaluated for a 6-month history of increased fatigue and decreased exercise tolerance. He is otherwise well with no significant medical history. Following a physical exam and right hemicolectomy, what is the most appropriate management? More...


Infectious disease

Probiotics fail to prevent antibiotic-associated, C. difficile diarrhea in elderly

A multistrain preparation of lactobacilli and bifidobacteria failed to prevent antibiotic-associated diarrhea and/or Clostridium difficile diarrhea in elderly patients, a new study found. More...

Updated guidelines issued on post-HIV-exposure prophylaxis

Health care workers with any occupational exposure to HIV should immediately use a post-exposure prophylaxis regimen comprising three or more antiretroviral drugs, according to updated guidelines from the U.S. Public Health Service Commissioned Corps. More...


From the College

Two ACP Practice Advisor modules approved for MOC points

New components have been added to ACP Practice Advisor modules on diabetes and adult immunization to help physicians achieve 20 Self-evaluation of Practice Performance points towards Maintenance of Certification (MOC) through the American Board of Internal Medicine. ACP Practice Advisor is the online practice support tool formerly called Medical Home Builder. More...

ACP announces new Center for Patient Partnership in Healthcare

ACP has established a new Center for Patient Partnership in Healthcare (CPPH) to engage patients, families, and patient organizations in the design of patient-centered care delivery and development of educational material for patients. 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: Daisy Smith, MD, FACP



Highlights


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Fear of malpractice suits prompts more tests, emergency department referrals

Medicare patients received more diagnostic tests and referrals to the emergency department when treated by physicians who worry more about malpractice liability, regardless of whether states have adopted common malpractice tort reforms, a study found.

Funded by the National Institute for Health Care Reform, the study is based on a national sample of elderly Medicare fee-for-service beneficiaries with new complaints of chest pain, headache and lower back pain who within one week received diagnostic imaging services or other tests, were referred to the emergency department, or were admitted to a hospital. The data were linked through the Center for Studying Health System Change 2008 Health Tracking Physician Survey of nearly 30,000 Medicare Part A and B claims for one of those three complaints from 2007 to 2009.

Researchers assessed physicians' fears of malpractice lawsuits via five questions regarding their propensity to engage in defensive medicine, each ranked on a five-point Likert scale that ranged from "strongly agree" to "strongly disagree," which were then summed for a total score and classified into terciles. Next, researchers compared their findings with a state-by-state malpractice risk index, defined as malpractice claims per 1,000 physicians times the average dollar amount of the award, as well as whether the state capped malpractice awards.

Study results were published in the August Health Affairs.

Office-based physicians who reported higher levels of concern about malpractice had higher rates of use of diagnostic imaging for lower back pain and headache, were more likely to order advanced imaging for patients with headache and lower back pain and conventional imaging for patients with chest pain and lower back pain, and were less likely to use stress testing for patients with chest pain and more likely to refer them to the emergency department.

However, when researchers compared physicians' level of malpractice concern with objective state-level indicators of malpractice liability risk, such as whether a state caps economic damages, they found no consistent relationships. Models that tested the presence of caps showed that they were associated with greater use of some services, which researchers attributed to reverse causality: More concerns about malpractice and defensive medicine might make a state more likely to adopt a damage cap.

The researchers wrote, "Malpractice reform alone is unlikely to solve the problem of overuse of health care services, which has multiple drivers. Fee-for-service reimbursement provides a financial incentive to order more services. Patients' demands for services may be hard to resist. Finally, physicians may be averse to the risk of missing something and harming the patient—not just the risk of being sued when such harm occurs. Human beings' known tendency to overestimate the probability of rare but serious risks reinforces physicians' tendency to take excessive precautions."


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Long-term use of calcium-channel blocker for hypertension associated with higher breast cancer risk

Long-term use of a calcium-channel blocker for hypertension was associated with about a 2.5 times higher risk of breast cancer, according to a study.

Researchers conducted a population-based study among women ages 55 to 74 years in the three-county Seattle-Puget Sound metropolitan area. There were 880 women who had invasive ductal breast cancer, 1,027 who had invasive lobular breast cancer, and a control group of 856 who did not have cancer.

Results appeared online Aug. 5 in JAMA Internal Medicine.

Overall, antihypertensives were not associated with increased risk of either kind of breast cancer. However, current use of calcium-channel blockers for 10 or more years was associated with higher risks of both invasive ductal carcinoma (odds ratio [OR], 2.4; 95% CI, 1.2 to 4.9) and invasive lobular carcinoma (OR, 2.6; 95% CI, 1.3 to 5.3).

The study found that short-acting calcium-channel blockers might be particularly associated with cancer risk. Current users of short-acting calcium-channel blockers had an increased risk of invasive ductal carcinoma (OR, 3.7; 95% CI, 1.2 to 11.8) and a similar increased risk of invasive lobular carcinoma (OR, 3.6; 95% CI, 1.2 to 11.4) compared to non-users.

Current use of long-acting calcium-channel blockers was not associated with increased risk of either cancer, but the subgroup using them for 10 years or longer had elevated risks of invasive ductal carcinoma (OR, 2.7; 95% CI, 1.2 to 5.7) and invasive lobular carcinoma (OR, 2.5; 95% CI, 1.2 to 5.5). For short-acting agents, the effect of duration of use could not be assessed due to lack of power.

Current use of non-dihydropyridines for any duration was associated with a 60% increased risk of both invasive ductal carcinoma and invasive lobular carcinoma, but researchers noted that the risk estimate for invasive ductal carcinoma was within the limits of chance. Current use of dihydropyridines for 10 years or longer was associated with elevated risks of invasive ductal carcinoma (OR, 3.0; 95% CI, 1.0 to 8.9) and invasive lobular carcinoma (OR, 3.4; 95% CI, 1.1 to 9.9). Diuretics, β-blockers and angiotensin II antagonists were not associated with increased breast cancer risk.

"While some studies have suggested a positive association between calcium-channel blocker use and breast cancer risk, this is the first study to observe that long-term current use of calcium-channel blockers in particular are associated with breast cancer risk," the study concluded.

An editorial noted that study made a "convincing case" that long-term use of calcium-channel blockers increases the risk of breast cancer and should be followed up. Calcium-channel blockers were the ninth most commonly prescribed class of drugs in the U.S. in 2009, and breast cancer is the most commonly occurring cancer among women. An association that is confirmed between the two would make calcium-channel blockers a major modifiable risk factor.

However, the editorial cautioned, "Given these results, should the use of CCBs [calcium-channel blockers] be discontinued once a patient has taken them for 9.9 years? The answer is no, because these data are from an observational study, which cannot prove causality and by itself cannot make a case for change in clinical practice."



Test yourself


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MKSAP Quiz: 6-month history of increased fatigue and decreased exercise tolerance

A 51-year-old man is evaluated for a 6-month history of increased fatigue and decreased exercise tolerance. He is otherwise well with no significant medical history.

mksap.gif

On physical examination, temperature is 37.3 °C (99.1 °F), blood pressure is 115/75 mm Hg, pulse rate is 76/min, and respiration rate is 14/min. The abdomen is soft with no distention or organomegaly, and bowel sounds are normal. The remainder of the physical examination is normal.

Fecal occult blood testing results disclose brown, guaiac-positive stool.

Laboratory studies indicate a hemoglobin level of 8.4 g/dL (84 g/L) and a mean corpuscular volume of 80 fL.

Colonoscopy is performed, and a 5-cm mass is identified in the cecum. A biopsy of the mass reveals moderately differentiated adenocarcinoma. A contrast-enhanced CT scan of the chest, abdomen, and pelvis demonstrates the cecal mass and no evidence of metastatic disease. The patient undergoes a right hemicolectomy from which he recovers uneventfully. Final pathology reveals a tumor penetrating into the pericolonic fat, with 3 of 28 lymph nodes positive for cancer (T3N1M0; stage III). All margins of resection are clear of tumor.

Which of the following is the most appropriate management?

A: 5-Fluorouracil and leucovorin
B: 5-Fluorouracil, leucovorin, and oxaliplatin (FOLFOX)
C: Radiation therapy
D: Radiation therapy plus 5-fluorouracil followed by FOLFOX

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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Probiotics fail to prevent antibiotic-associated, C. difficile diarrhea in elderly

A multistrain preparation of lactobacilli and bifidobacteria failed to prevent antibiotic-associated diarrhea and/or Clostridium difficile diarrhea in elderly patients, a new study found.

In a randomized, double-blind, placebo-controlled trial, researchers assigned inpatients to receive either placebo or the multistrain preparation with a total of 6 × 1010 organisms, one per day for 21 days. The inpatients came from five U.K. facilities and were at least 65 years old. They had been exposed to one or more oral or intravenous antibiotics in the previous seven days or were about to start antibiotics.

The trial's main outcomes were occurrence of antibiotic-associated diarrhea (AAD) within eight weeks and C. difficile diarrhea (CDD) within 12 weeks of recruitment. Results were published online Aug. 8 by The Lancet.

AAD (including CDD) occurred in 10.8% of the inpatients in the microbial preparation group (n=1,470) and 10.4% of the inpatients in the placebo group (n=1,471); the difference was not significant between groups. CDD was an uncommon cause of AAD and occurred in 12 (0.8%) inpatients in the microbial preparation group and 17 (1.2%) inpatients in the placebo group. About 20% of participants had one or more serious adverse events, and the frequency of these events didn't differ by group, nor were they attributed to study factors. An analysis of secondary outcomes including diarrhea severity, length of hospital stay, frequency of abdominal symptoms and quality of life also showed no benefit for probiotics.

This trial indicates there is insufficient evidence to support routinely using probiotics to prevent AAD in older inpatients, the authors wrote. The prospects for future studies are hampered by a poor understanding of the pathophysiology of AAD, they added. Future trials should be done only "when there is supporting evidence that one or more specific microbes act against identified underlying pathophysiological mechanisms for AAD and CDD in a specific population group," they wrote.


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Updated guidelines issued on post-HIV-exposure prophylaxis

Health care workers with any occupational exposure to HIV should immediately use a post-exposure prophylaxis regimen comprising three or more antiretroviral drugs, according to updated guidelines from the U.S. Public Health Service Commissioned Corps.

Previously, the guidelines recommended assessing the level of risk associated with individual exposures in order to determine how many drugs to use for post-exposure prophylaxis (PEP). The guidelines also recommend taking a full four-week PEP regimen and undergoing close follow-up HIV testing that includes counseling and monitoring for drug toxicity. Follow-up appointments should start within 72 hours of exposure. These guidelines update the 2005 version and were published online Aug. 6 by Infection Control and Hospital Epidemiology.

If a newer, fourth-generation combination HIV p24 antigen-HIV antibody test is used for follow-up testing, the testing can be finished four months after exposure, the guidelines said. If a newer testing platform is not available, however, follow-up testing should continue until six months after exposure.

When a health care worker is exposed to HIV, he or she should seek expert consultation, though not at the expense of delaying treatment, the guidelines said. Consultation can be made with local experts or by calling the National Clinicians' Post-Exposure Prophylaxis Hotline at 888-448-4911.

Situations in which expert consultation is especially recommended include when an exposure report occurs ≥72 hours after exposure; when the exposure source is unknown; when the exposed person is pregnant, breastfeeding or has a serious illness; when the source virus is known or suspected to be resistant to antiretrovirals; and when the exposed person experiences toxicity from the initial PEP regimen.

The guidelines were developed by an interagency Public Health Service working group comprising representatives from the Centers for Disease Control and Prevention, National Institutes of Health, Food and Drug Administration and the Health Resources and Services Administration, in consultation with an external expert panel. They apply to a wide range of workers, including laboratory personnel, physicians, technicians, pharmacists, nurses, students, trainees, volunteers and emergency medical personnel.



From the College


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Two ACP Practice Advisor modules approved for MOC points

New components have been added to ACP Practice Advisor modules on diabetes and adult immunization to help physicians achieve 20 Self-evaluation of Practice Performance points towards Maintenance of Certification (MOC) through the American Board of Internal Medicine. ACP Practice Advisor is the online practice support tool formerly called Medical Home Builder.

ACP Practice Advisor offers 27 self-paced modules to help clinical practice teams improve patient care, streamline fundamental business operations, and identify and implement key features of the patient-centered medical home (PCMH). More than 2,000 practices nationwide have successfully used ACP Practice Advisor since it was first introduced as Medical Home Builder in 2009.


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ACP announces new Center for Patient Partnership in Healthcare

ACP has established a new Center for Patient Partnership in Healthcare (CPPH) to engage patients, families, and patient organizations in the design of patient-centered care delivery and development of educational material for patients.

The center's new director, Wendy Nickel, MPH, will be responsible for recruiting staff for the new center and establishing and overseeing its portfolio of projects. The CPPH will be guided by an Advisory Board for Patient Partnership in Healthcare chaired by Phyllis Guze, MD, MACP, immediate past chair of ACP's Board of Regents. The Advisory Board will include two representatives from patient organizations, a nurse, a physician assistant, and several physicians.

More information about the center is online.



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.

acpi-20130813-cartoon.jpg

"When I said 'What happens to my stone?' I didn't envision this."

"There was clearly a misunderstanding when I instructed my staff to provide topnotch care."

"I use it to determine what ICD-9 code to associate with your visit."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting ends on Monday, Aug. 19, with the winner announced in the Aug. 20 issue.


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MKSAP Answer and Critique



The correct answer is B: 5-Fluorouracil, leucovorin, and oxaliplatin (FOLFOX). This item is available to MKSAP 16 subscribers as item 115 in the Hematology and Oncology section. More information is available online.

This patient has stage III colon cancer with the tumor invading the pericolonic fat and three lymph nodes involved (T3N1M0), and the preferred treatment is a chemotherapy regimen of 5-fluorouracil (5-FU), leucovorin, and oxaliplatin (FOLFOX). Stage III colon cancer is potentially curable, and the rate of cure is statistically significantly increased by the use of adjuvant chemotherapy. 5-FU plus leucovorin was established as an appropriate standard adjuvant treatment for stage III colon cancer in the mid-1990s; however, in 2004, a large, randomized trial comparing adjuvant 5-FU plus leucovorin versus the FOLFOX regimen showed that the FOLFOX regimen led to a greater disease-free survival at both 3 and 5 years after surgery. Thus, the FOLFOX regimen, or some modification of it, is the current accepted standard for postoperative management of stage III colon cancer.

Because local recurrence is not a common event with colon cancer, and because it can be difficult to isolate the small bowel from the radiation field, radiation therapy, alone or in combination with chemotherapy, does not have a role in the routine management of stage III colon cancer (radiation to the small bowel can cause substantial toxicity). However, in the rectum, local recurrence is a greater problem, and it is far easier to isolate the small bowel out of the radiation field; therefore, the combination of radiation and chemotherapy, usually preoperatively, is routinely used in stage II and III rectal cancer.

Key Point

  • An adjuvant chemotherapy regimen of 5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX) has been shown to improve disease-free survival in patients with stage III colon cancer.

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Test yourself

A 66-year-old man comes for a preoperative evaluation before total joint arthroplasty of the left knee. He has a 25-year history of rheumatoid arthritis. He has had progressive pain in his left knee with activity, which limits his ability to hike. The patient has similar pain in the right knee, but it is less severe. He reports no recent morning stiffness. He is able to climb two or three flights of stairs without chest pain or shortness of breath. He has no other medical problems and reports no additional symptoms. Medications are methotrexate and folic acid. Following a physical exam and lab tests, what is the next best step in management?

Find the answer

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