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

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ACP InternistWeekly



In the News for the Week of August 20, 2013




Highlights

Diastolic blood pressure below 70 mm Hg associated with higher mortality in chronic kidney disease

Achieving ideal systolic blood pressure (SBP) at the expense of lower-than-ideal diastolic blood pressure (DBP) could be harmful in adults with chronic kidney disease (CKD), noted a study. More...

Nontreatment, undertreatment of psoriasis and psoriatic arthritis still prevalent

Nontreatment and undertreatment of psoriasis and psoriatic arthritis appear to still be a significant problem in the United States, according to a study. More...


Test yourself

MKSAP Quiz: 1-day history of fever, headache, myalgia

A 35-year-old woman is evaluated for a 1-day history of fever, headache, myalgia, arthralgia, and neck stiffness. The patient is sexually active. She had a similar episode 2 years ago, at which time results of cerebrospinal fluid (CSF) analysis showed lymphocytic meningitis. All culture results were negative, and her symptoms resolved over the next 3 days. Examination of the CSF shows a leukocyte count of 90/µL (90 × 106/L) with 95% lymphocytes, a glucose level of 68 mg/dL (3.8 mmol/L), and a protein level of 70 mg/dL (700 mg/L). A Gram-stained CSF specimen is negative. Which diagnostic study will most likely establish the cause of this patient's meningitis? More...


Diabetes

Oral fluoroquinolones associated with increased dysglycemia risk in diabetics

Diabetic patients taking oral fluoroquinolones could have a higher risk for severe dysglycemia, according to a new study. More...


Rheumatology

Novel drug plus DMARDs may improve control of rheumatoid arthritis

Tofacitinib improved disease control in patients with active rheumatoid arthritis despite treatment with nonbiologic disease-modifying, anti-rheumatic drugs (DMARDs) compared to placebo, a study found. More...


From ACP Hospitalist

The August issue is online and coming to your mailbox

The August issue of ACP Hospitalist is online and includes a cover article on green hospitals, an installment of The Brief Case, and extensive coverage of the Hospital Medicine 2013 annual conference. More...


Initiatives

Million Hearts® Hypertension Control Challenge

Million Hearts® began a competitive challenge called The Million Hearts® Hypertension Control Challenge to identify practices, physicians and health systems that have demonstrated exceptional achievements in controlling hypertension. More...


Medical education

Apply for ACP's 2014 Washington internship

Applications are now being accepted for the College's Health Policy Internship for Resident/Fellow and Medical Student Members. More...


From the College

Robert H. Moser, MD, MACP, former College EVP, dies at 90

Robert H. Moser, MD, MACP, former Executive Vice President of ACP, died of pancreatic cancer on Aug. 6, 2013, in Tucson, Ariz. He was 90. 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


.
Diastolic blood pressure below 70 mm Hg associated with higher mortality in chronic kidney disease

Achieving ideal systolic blood pressure (SBP) at the expense of lower-than-ideal diastolic blood pressure (DBP) could be harmful in adults with chronic kidney disease (CKD), noted a study.

annals.jpg

A review of U.S. veterans with CKD found that SBP of 130 to 159 mm Hg and DBP of 70 to 89 mm Hg were associated with the lowest mortality rates.

Researchers looked at a retrospective cohort of 651,749 U.S. veterans with non-dialysis-dependent CKD and more than 18.5 million blood pressure measurements at all U.S. Department of Veterans Affairs health care facilities between 2005 and 2012.

All possible combinations of SBP and DBP were examined in 96 categories from lowest (<80/<40 mm Hg) to highest (>210/>120 mm Hg), in 10-mm Hg increments.

Results appeared in the Aug. 20 Annals of Internal Medicine.

Patients with SBP of 130 to 159 mm Hg combined with DBP of 70 to 89 mm Hg had the lowest adjusted mortality rates, and those in whom both SBP and DBP were concomitantly very high or very low had the highest mortality rates, researchers wrote. Patients with moderately elevated SBP combined with DBP no less than 70 mm Hg had consistently lower mortality rates than did patients with ideal SBP combined with DBP less than 70 mm Hg. Results were consistent in subgroups of patients with normal and elevated urinary microalbumin-creatinine ratios.

The researchers noted that paradigms emphasize treating the higher of the SBP or DBP readings, which ignores the potential negative effects of low pressures that are linked with their normal or elevated counterparts. In addition, they said, it is common in CKD for patients to have elevated SBP combined with low DBP.

They wrote, "Nearly one third (32.5%) of the patients in our cohort had SBP greater than 140 mm Hg and DBP less than 70 mm Hg at some point during the observation period. Our granular analyses of BP categories indicated that categories of lower SBP–DBP combinations are associated with lower mortality rates only as long as the DBP component remains greater than approximately 70 mm Hg."

An editorial noted that the observational data do not address causality and that "remarkable attenuation" in the adjusted analyses raises the specter of residual confounding.

The editorial stated, "It may not be the BP combination per se but the characteristics of the persons with that combination that lead to greater mortality rates. Also, the assumption outlined previously and implied by [the study authors] (that DBP and SBP move in tandem with treatment) may not necessarily be the case. Translating these findings into practice is challenging."


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Nontreatment, undertreatment of psoriasis and psoriatic arthritis still prevalent

Nontreatment and undertreatment of psoriasis and psoriatic arthritis appear to still be a significant problem in the United States, according to a study.

Researchers surveyed a random sample from a National Psoriasis Foundation database of more than 76,000 patients with psoriatic diseases from January 2003 through December 2011.

Results appeared online Aug. 14 at JAMA Dermatology.

There were 5,604 patients with psoriasis or psoriatic arthritis. Overall, 52.3% of patients with psoriasis and 45.5% of patients with psoriatic arthritis reported that they were dissatisfied with their treatment, according to study results.

During the survey years, the percentage of mild psoriasis patients who were untreated ranged from 36.6% to 49.2%; for moderate psoriasis, the range was 23.6% to 35.5%, and for severe psoriasis, the range was 9.4% to 29.7%.

Among those receiving treatment, those treated with topical agents alone included 29.5% of patients with moderate psoriasis and 21.5% of patients with severe psoriasis.

The most frequently used phototherapy was UV-B, which increased from less than 8.5% in 2003 to 33.2% in 2004. This rate held steady through the spring of 2005 and decreased to a mean of 11.2% from the fall of 2005 to the spring of 2011.

Methotrexate was the most commonly used oral agent, ranging from 9.8% to 14.5% from 2003 through 2011. From 2003 to 2009, acitretin use ranged from 0.7% to 4.2%, rising to 22.6% of patients in 2011. Cyclosporine was used in 0.5% to 2.3% of patients.

Top reasons for stopping biological agents included side effects, lack of efficacy and an inability to get insurance coverage.

The researchers noted that in 2011 almost half of patients with mild psoriasis, one-quarter of patients with moderate psoriasis, and almost one-tenth of patients with severe psoriasis didn't receive any treatment and that these figures among members of the National Psoriasis Foundation are likely more conservative than those among the general population.

They wrote, "Undertreatment also represents a significant problem. Approximately 30% of patients with moderate psoriasis and about 20% of patients with severe psoriasis receive topical medication alone. With the availability of multiple immune modulatory agents, ensuring that patients are offered these therapeutic options is paramount to improving patient outcomes."



Test yourself


.
MKSAP Quiz: 1-day history of fever, headache, myalgia

A 35-year-old woman is evaluated for a 1-day history of fever, headache, myalgia, arthralgia, and neck stiffness. The patient is sexually active. She had a similar episode 2 years ago, at which time results of cerebrospinal fluid (CSF) analysis showed lymphocytic meningitis. All culture results were negative, and her symptoms resolved over the next 3 days.

mksap.gif

On physical examination, temperature is 38.3 °C (101.0 °F), blood pressure is 110/70 mm Hg, pulse rate is 90/min, and respiration rate is 12/min. There are no oral or genital ulcers. There is mild neck stiffness. Remaining physical examination findings, including mental status evaluation and complete neurologic examination, are normal. Funduscopic examination is normal.

Examination of the CSF shows a leukocyte count of 90/µL (90 × 106/L) with 95% lymphocytes, a glucose level of 68 mg/dL (3.8 mmol/L), and a protein level of 70 mg/dL (700 mg/L). A Gram-stained CSF specimen is negative.

Which of the following diagnostic studies will most likely establish the cause of this patient's meningitis?

A: CSF cytology
B: CSF IgM assay for West Nile virus
C: CSF polymerase chain reaction for herpes simplex virus type 2
D: MRI of the brain

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


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Diabetes


.
Oral fluoroquinolones associated with increased dysglycemia risk in diabetics

Diabetic patients taking oral fluoroquinolones could have a higher risk for severe dysglycemia, according to a new study.

Researchers performed a population-based inception cohort study of diabetic outpatients in Taiwan from January 2006 to November 2007 who were new users of oral levofloxacin, ciprofloxacin, moxifloxacin, cephalosporins and macrolides. The main outcome measures were emergency department visits or hospitalization for dysglycemia 30 days after antibiotic therapy was initiated. The study results were published online Aug. 14 by Clinical Infectious Diseases.

The study included 78,433 diabetic patients who were taking a fluoroquinolone, 12,564 taking ciprofloxacin, 4,221 taking moxifloxacin, 11,766 taking levofloxacin, 20,317 taking cephalosporins, and 29,565 taking macrolides. Two hundred fifteen hyperglycemic events and 425 hypoglycemic events occurred during the study period. Those taking moxifloxacin had an absolute risk of 6.9 per 1,000 persons for hyperglycemia and 10.0 per 1,000 persons for hypoglycemia; for those taking macrolides, the risks were 1.6 and 3.7 per 1,000 persons, respectively. Adjusted odds ratios for hyperglycemia with levofloxacin, ciprofloxacin and moxifloxacin compared to macrolides were 1.75, 1.87, and 2.48, while adjusted odds ratios for hypoglycemia were 1.79, 1.46, and 2.13, respectively. Hypoglycemia risk was significantly higher with moxifloxacin than with ciprofloxacin, as well as with moxifloxacin and concomitant insulin.

The authors noted that data on rare events were obtained from an electronic database and might therefore be incomplete. Among other limitations, they also pointed out that reverse causality could have been present, since severe infection can cause dysglycemia. However, they concluded that based on their results, diabetic patients taking fluoroquinolones, especially moxifloxacin, could potentially be at higher risk for severe dysglycemia. "Clinicians should consider these risks when treating patients with diabetes and prescribe fluoroquinolones cautiously," the authors wrote.



Rheumatology


.
Novel drug plus DMARDs may improve control of rheumatoid arthritis

Tofacitinib improved disease control in patients with active rheumatoid arthritis despite treatment with nonbiologic disease-modifying, anti-rheumatic drugs (DMARDs) compared to placebo, a study found.

annals.jpg

Researchers conducted a one-year, double-blind, randomized trial at 114 centers in 19 countries among 792 patients with active rheumatoid arthritis despite taking nonbiologic DMARDs, primarily methotrexate.

Patients were randomly assigned to receive oral tofacitinib, 5 mg or 10 mg twice daily, or placebo. Patients randomly assigned to placebo advanced at month 3 to tofacitinib, 5 mg or 10 mg twice daily if they did not respond at an earlier assessment. All patients advanced to active treatment at month 6.

Results appeared in the Aug. 20 Annals of Internal Medicine.

Nearly half of patients receiving placebo (n=78, 49.1%) did not have a response at month 3 and advanced to tofacitinib, 5 mg (n=38) and 10 mg (n=40) twice daily. There were 80 (25.4%) patients assigned to 5-mg and 58 (18.2%) patients assigned to 10-mg twice-daily tofacitinib who also had no response at month 3. Forty-three patients (27%) receiving placebo met the American College of Rheumatology (ACR20) criteria at month 3.

Compared to placebo, the ACR20 response rates at month 6 were greater for the 5-mg twice-daily tofacitinib (treatment difference, 21.2%; 95% CI, 12.2% to 30.3%; P<0.001) and 10-mg twice-daily tofacitinib (25.8%; 95% CI, 16.8% to 34.8%; P<0.001) groups.

Improvements from baseline in Health Assessment Questionnaire Disability Index scores at month 3 were greater (P<0.001) for the active treatment groups compared with placebo. In addition, more patients in the active treatment groups than the placebo group had a Disease Activity Score for 28-joint counts based on an erythrocyte sedimentation rate of less than 2.6 at month 6 (P=0.005 for 5-mg twice-daily tofacitinib; P<0.001 for 10-mg twice-daily tofacitinib).

During months 0 to 12, the adverse event rate per 100 patient-years was 171.9 (95% CI, 152.5 to 193.8) in the 5-mg twice-daily tofacitinib group, 175.7 (95% CI, 155.8 to 198.2) in the 10-mg twice-daily tofacitinib group, and 342.3 (95% CI, 281.1 to 416.9) in the combined placebo group.

Serious adverse event rates were 6.9 per 100 patient-years (95% CI, 4.6 to 10.5) for the 5-mg twice-daily tofacitinib group, 7.3 (95% CI, 4.8 to 11.0) in the 10-mg twice-daily tofacitinib group, and 10.9 (95% CI, 4.9 to 24.2) in the combined placebo group.

The most common adverse events in the tofacitinib groups were upper respiratory tract infections. The exposure-adjusted event rate (new events per 100 patient-years of exposure) was 12.3 in the 5-mg group and 14.6 in the 10-mg group, compared to 12.6 in the combined placebo group. The next most common adverse event in the tofacitinib groups was nasopharyngitis, with a rate of 7.1 in the 5-mg group and 5.6 in the 10-mg groups compared to 21.6 in the combined placebo group.

The researchers concluded that when used in combination with various nonbiologic DMARDs, primarily methotrexate, 5 mg and 10 mg of tofacitinib twice daily rapidly reduced signs and symptoms of rheumatoid arthritis and improved physical function compared with placebo.



From ACP Hospitalist


.
The August issue is online and coming to your mailbox

The August issue of ACP Hospitalist is online and includes a cover article on green hospitals, an installment of The Brief Case, and extensive coverage of the Hospital Medicine 2013 annual conference.

acpi-20130820-cover.jpg

Fixing patients and the planet. Clinicians, administrators and others at more than 700 hospitals have committed to health and environmental sustainability through the Healthier Hospitals Initiative.

Hospital Medicine 2013 coverage. Session recaps from this May 2013 conference include stories on non-evidence-based medicine, infectious diseases and patient satisfaction, among others.

Cases from The Ohio State University Medical Center. The Brief Case installment includes summaries of patients who had hypereosinophilia, pulmonary embolism presenting as syncope, and a Chiari network.



Initiatives


.
Million Hearts® Hypertension Control Challenge

Million Hearts® is a national initiative that aims to prevent a million heart attacks and strokes in five years. To help achieve its goal, Million Hearts® began a competitive challenge called The Million Hearts® Hypertension Control Challenge to identify practices, physicians and health systems that have demonstrated exceptional achievements in controlling hypertension. Those achieving control rates greater than 70% are eligible to enter the 2013 Million Hearts® Hypertension Control Challenge.

In 2012, Million Hearts® recognized Kaiser Permanente Colorado and Ellsworth Medical Clinic in Wisconsin as Hypertension Control Champions for their success in achieving greater than 80% control among their patient populations with high blood pressure.

More information about the 2013 Challenge is online. The Challenge is open through Sept. 9, 2013.



Medical education


.
Apply for ACP's 2014 Washington internship

Applications are now being accepted for the College's Health Policy Internship for Resident/Fellow and Medical Student Members.

The internship represents an opportunity for one Resident/Fellow Member and one Medical Student Member to develop legislative knowledge and advocacy skills by working directly with the College's Washington staff. The internship will last for four weeks starting on April 28 and ending with ACP's 2014 Leadership Day. The deadline to apply is Oct. 11. More information is online.



From the College


.
Robert H. Moser, MD, MACP, former College EVP, dies at 90

Robert H. Moser, MD, MACP, former Executive Vice President of ACP, died of pancreatic cancer on Aug. 6, 2013, in Tucson, Ariz. He was 90.

Dr. Moser graduated from Georgetown University Medical Center in 1948. During his career he was chief of medicine at Walter Reed Army Medical Center in Washington, D.C.; William Beaumont Army Medical Center in El Paso, Texas; and Tripler Army Medical Center in Honolulu.

From 1977 to 1986, Dr. Moser served as the Executive Vice President of ACP, where he created a division of public policy to carry the message of internal medicine to the public. He became a Master in 1985 and received the Alfred Stengel Memorial Award in 1988 for service to the College. He is survived by his wife, Linda, his remaining son, Jonathan (a second son, Steven, passed away in 2005), and four grandchildren.

A full obituary is online.



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-20130820-cartoon.jpg

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

This issue's winning cartoon caption was submitted by two winners, Panagiota V. Caralis, MD, FACP, and Jonas B. Green, MD, ACP Member. Thanks to all who voted! The winning entry captured 66.7% of the votes.

The runners-up were:

"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."


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MKSAP Answer and Critique



The correct answer is C: CSF polymerase chain reaction for herpes simplex virus type 2. This item is available to MKSAP 16 subscribers as item 24 in the Infectious Disease section. More information is available online.

This patient most likely has benign recurrent lymphocytic meningitis, and the most appropriate study to confirm the diagnosis is cerebrospinal fluid (CSF) polymerase chain reaction for herpes simplex virus type 2 (HSV-2). Benign recurrent lymphocytic meningitis, formerly known as Mollaret meningitis, is most often caused by HSV-2, although some cases have been associated with HSV-1 and Epstein-Barr virus. Patients usually experience 2 to 3 to at least 10 episodes of meningitis (most often characterized by headache, fever, and stiff neck) that last for 2 to 5 days and are followed by spontaneous recovery. About 50% of patients may also have transient neurologic manifestations, such as seizures, hallucinations, diplopia, cranial nerve palsies, or an altered level of consciousness. Disease occurs in patients without symptoms or signs of genital or cutaneous infection. Nucleic acid amplification tests, such as CSF polymerase chain reaction to detect the DNA of HSV-2, will establish the diagnosis. Patients usually recover without therapy; it is not clear whether antiviral agents alter the course of mild infection.

Given the recurrent nature of this patient's illness, it is unlikely to be caused by a malignancy. Cytologic studies are therefore unnecessary at this time. Cytology may reveal Mollaret cells, which are large atypical monocytes, but they are not seen in all cases, and their presence does not establish the etiologic diagnosis.

The recurrent episodes that this patient has experienced also make West Nile virus infection unlikely.

MRI of the brain would be appropriate if the patient had the clinical presentation of encephalitis (fever, hemicranial headache, language and behavioral abnormalities, memory impairment, cranial nerve deficits, and seizures), which is most often caused by HSV-1 rather than HSV-2.

Key Point

  • Herpes simplex virus type 2 is the most common cause of benign recurrent lymphocytic meningitis, and the diagnosis is established by cerebrospinal fluid polymerase chain reaction.

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Test yourself

A 38-year-old man is evaluated for a mass in his right neck that he first noticed 2 weeks ago while shaving. The patient also reports experiencing a pressure sensation when swallowing solid foods for the past year and daily diarrhea for the past 2 months. His personal medical history is unremarkable. His younger brother has nephrolithiasis, and his father died of a hypertensive crisis and cardiac arrest at age 62 years while undergoing anesthesia induction to repair a hip fracture. Following a physical exam, lab studies, and a chest radiograph, what is the most likely diagnosis?

Find the answer

MKSAP 16 Holiday Special: Save 10%

MKSAP 16 Holiday Special:  Save 10%

Use MKSAP 16 to earn MOC points, prepare for ABIM exams and assess your clinical knowledge. For a limited time save 10% when you use priority code MKPROMO! Order now.

Maintenance of Certification:

What if I Still Don't Know Where to Start?

Maintenance of Certification: What if I Still Don't Know Where to Start?

Because the rules are complex and may apply differently depending on when you last certified, ACP has developed a MOC Navigator. This FREE tool can help you understand the impact of MOC, review requirements, guide you in selecting ways to meet the requirements, show you how to enroll, and more. Start navigating now.