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

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ACP InternistWeekly



In the News for the Week of September 17, 2013




Highlights

Studies examine effectiveness of financial incentives in primary care

Two randomized trials suggest that certain financial incentives may be associated with some clinical improvements in primary care, although both the study authors and editorialists said that additional research is needed. More...

Episodic migraines associated with obesity, especially in younger women

Episodic migraines (≤14 headache days/month) are associated with obesity, with the strongest relationships among those younger than 50 years, of white race and of female sex, a study found. More...


Test yourself

MKSAP Quiz: 6-month history of increasing daily cough

A 45-year-old man is evaluated for a 6-month history of increasing daily cough, sputum production, and dyspnea on exertion. He has been employed as a coal miner for 10 years. He has never smoked and does not have a history of diabetes mellitus, hypertension, or hyperlipidemia. Pulmonary examination reveals mildly decreased breath sounds bilaterally with no wheezes, crackles, or rhonchi. Cardiac examination and chest radiograph are normal. What is the most appropriate next step in management? More...


Smoking cessation

Varenicline appears efficacious for smoking cessation in patients treated for current or past depression

Varenicline appeared to help patients with stably treated current or past depression stop smoking without increasing depression or anxiety, according to a new industry-funded study. More...

E-cigarettes facilitated quitting as well as patches

Electronic cigarettes, both with and without nicotine, helped smokers quit about as well as nicotine patches did, a recent New Zealand study found. More...


From the College

ACP releases new policy paper addressing principles for organizing clinical care teams

ACP sets the framework for a team-based model of health care in a new policy paper published in Annals of Internal Medicine. More...

"The Consult Guys" video series delivers laughs and CME credits

Annals of Internal Medicine is offering physicians an opportunity to laugh while they learn with "The Consult Guys," a monthly video series that features two prominent physicians who use humor to address and solve clinical problems. More...

Less than a month left to 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...


Cartoon caption contest

Vote for your favorite entry

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


Physician editor: Philip Masters, MD, FACP



Highlights


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Studies examine effectiveness of financial incentives in primary care

Two randomized trials suggest that certain financial incentives may be associated with some clinical improvements in primary care, although both the study authors and editorialists said that additional research is needed.

The first study, published in the Sept. 11 Journal of the American Medical Association, was a cluster-randomized trial of 12 Veterans Affairs outpatient clinics, involved 83 primary care physicians and 42 nonphysicians and looked at the effect of individual-level financial incentives, practice-level financial incentives, both kinds of incentives, or no incentives on hypertension care. Five performance periods and a 12-month washout period were included.

Total payments over the course of the study were $4,270 for combined incentives, $2,672 for the individual incentives, and $1,648 for the practice-level incentives. Only the individual-incentive group saw a significantly greater increase in blood pressure control or in appropriate response to uncontrolled blood pressure compared with the control group. No incentive, however, affected use of guideline-recommended medications or increased hypotension incidence, and the effect of incentives was not sustained after the washout period.

The second study, published in the same issue of JAMA, was a cluster-randomized trial of small primary care clinics, all of which had electronic health records. Clinics in the incentive group were paid for each patient whose care met performance criteria for aspirin or thrombotic prescriptions, blood pressure control, cholesterol control, and smoking cessation. Payments were higher for patients who had comorbid conditions, those who had Medicaid, and those who were uninsured. Maximum payments during the study, which ran from April 2009 through March 2010, were $200 per patient and $100,000 per clinic.

Greater adjusted absolute improvement in appropriate antithrombotic prescription, blood pressure control and smoking cessation was seen among the 42 incentive clinics compared with the 42 control clinics. Medicaid and uninsured patients did better on all variables at incentive clinics, with the exception of cholesterol control. The authors concluded that the incentive program modestly improved certain measures of cardiovascular care but noted that studies longer than a year are needed.

An accompanying editorial said that both studies contribute to the field of knowledge regarding the role of financial incentives in quality improvement but noted that it is not clear how much such incentives can actually affect health care costs. The findings, said the editorialists, seem to suggest that differences in performance may be related to "systematic shortcomings" rather than differences in individual clinician performance.

The two trials "provide a great opportunity to ask the question of how to best use the limited but expensive primary care physician workforce in the most effective manner in the evolving health care delivery system," the editorialists wrote. "But this question also suggests that a clear understanding of system-level goals and responsibilities is needed to enable the transformation of clinical care."


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Episodic migraines associated with obesity, especially in younger women

Episodic migraines (≤14 headache days/month) are associated with obesity, with the strongest relationships among those younger than 50 years, of white race and of female sex, a study found.

Researchers studied 3,862 adult participants of both black and white race interviewed in the National Comorbidity Survey Replication. Results were published online Sept. 11 by Neurology.

In the study, 188 participants had episodic migraine. The unadjusted prevalence estimate of obesity was 32.2% among those with episodic migraine and 26% among controls (P=0.18). After adjustment for age, sex, race, poverty, smoking, diabetes and depression, the adjusted odds of episodic migraine were greater in individuals who were obese compared with those of normal weight (odds ratio [OR], 1.81; 95% CI, 1.27 to 2.57; P=0.001).

There were no significant increases in the mean headache frequency in participants with episodic migraine based on obesity status. Compared with normal-weight people, the odds of episodic migraine were greater in obese people who were younger than 50 (OR, 1.86; 95% CI, 1.20 to 2.89; P for trend ≤0.008), white (OR, 2.06; 95% CI, 1.41 to 3.01; P for trend ≤0.001), or female (OR, 1.95; 95% CI, 1.38 to 2.76; P for trend ≤0.001).

The authors noted that:

  • the odds of lower-frequency episodic migraine increased by 83% to 89% in obese people compared to those with normal weight;
  • the odds of migraine were not increased in obese individuals 50 years and older;
  • although the odds of episodic migraine increased with obesity in both black and white participants, the odds of episodic migraine were twofold higher when analyses were limited to only white obese participants; and
  • the odds of episodic migraine were not increased in obese men in the study, although it may be that the relationship is merely stronger in women than men.

The researchers wrote, "These findings suggest that clinicians treating patients with EM [episodic migraine] should promote healthy lifestyle choices regarding diet and exercise routines, as well as take particular care in their choices of medications prescribed to their patients with EM given that many can affect weight positively or negatively."



Test yourself


.
MKSAP Quiz: 6-month history of increasing daily cough

A 45-year-old man is evaluated for a 6-month history of increasing daily cough, sputum production, and dyspnea on exertion. He has been employed as a coal miner for 10 years. He has never smoked and does not have a history of diabetes mellitus, hypertension, or hyperlipidemia. His family history is negative for cardiopulmonary disease.

mksap.gif

On physical examination, vital signs are normal. Pulmonary examination reveals mildly decreased breath sounds bilaterally with no wheezes, crackles, or rhonchi. Cardiac examination is normal.

A chest radiograph is normal.

Which of the following is the most appropriate next step in management?

A: Annual chest radiography
B: High-resolution CT of the chest
C: PET chest imaging
D: Pulmonary function studies

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


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Smoking cessation


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Varenicline appears efficacious for smoking cessation in patients treated for current or past depression

Varenicline appeared to help patients with stably treated current or past depression stop smoking without increasing depression or anxiety, according to a new industry-funded study.

annals.jpg

Varenicline is a nicotinic receptor partial agonist that has demonstrated efficacy in assisting some patients with smoking cessation. However, several studies have suggested that varenicline may be associated with adverse neuropsychiatric symptoms, raising concerns about its use in patients with mood disorders or other psychiatric conditions.

To evaluate both efficacy and safety, researchers performed a phase 4 multicenter, randomized, double-blind trial in adult smokers who had stably treated current or past major depression but had not had a recent cardiovascular event. The goal of the trial was to compare the effect of varenicline versus placebo on smoking cessation as well as on mood and anxiety levels.

Patients were randomly assigned to receive varenicline, 1 mg twice daily, or placebo for 12 weeks. Follow-up without treatment lasted for 40 weeks. The study's primary outcome was continuous abstinence rate confirmed by carbon monoxide testing for weeks 9 to 12, while secondary outcomes included continuous abstinence rate during the nontreatment follow-up, mood, anxiety, and suicidal ideation/behavior. The study was funded by Pfizer and appeared in the Sept. 17 Annals of Internal Medicine.

Two hundred fifty-six patients were assigned to receive varenicline and 269 were assigned to receive placebo. Participants had smoked for an average of 26.7 years and had smoked an average of 22 cigarettes per day in the past month. Most patients (62.7%) were women. Overall, 68.4% of the varenicline group and 66.5% of the placebo group finished the study. Patients who took varenicline had higher continuous abstinence rates than those who took placebo at weeks 9 to 12 (35.9% vs. 15.6%; odds ratio [OR], 3.35; P<0.001), weeks 9 to 24 (25.0% vs. 12.3%; OR, 2.53; P<0.001) and weeks 9 to 52 (20.3% vs. 10.4%; OR, 2.36; P=0.001). The two groups did not have any clinically relevant differences in suicidal ideation or behavior, overall worsening of depression or overall worsening of anxiety.

A total of 72.3% of varenicline participants and 66.9% of placebo participants reported adverse effects, most of which were rated mild or moderate. Nausea, which was reported by 27.0% of the varenicline group and 10.4% of the placebo group, was the most common overall, and the most common adverse effects causing treatment discontinuation were depression (2.0% in the varenicline group and 1.1% in the placebo group) and depressed mood (0% in the varenicline group and 1.5% in the placebo group). Two patients in the varenicline group had serious psychiatric adverse effects (i.e., psychotic disorder, depression, and suicidal ideation) and four placebo participants had intentional self-injury, depression and suicidal ideation, agitation, and depression. Two patients died during the nontreatment phase, both in the varenicline group; their deaths were considered unrelated to the study treatment.

The authors acknowledged that some data were missing because of attrition and that the study had limited power to detect differences between groups in rare events. In addition, the study did not include patients who smoked and had untreated depression, those with co-occurring psychiatric episodes, or those taking mood stabilizers or antipsychotics. However, they concluded that treatment with varenicline improved smoking cessation rates in patients who had stably treated current or past depression and did not increase depression or anxiety.

"With 350 million individuals having [depression] worldwide and because many smokers who seek treatment have a lifetime history of [major depression disorder], these results have the potential to reduce morbidity and mortality in many smokers," the authors wrote. They stressed that clinicians should use caution, however, when treating smoking cessation in depressed patients with "more complex psychiatric presentations."


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E-cigarettes facilitated quitting as well as patches

Electronic cigarettes, both with and without nicotine, helped smokers quit about as well as nicotine patches did, a recent New Zealand study found.

A total of 657 adult smokers who wanted to quit were randomized in 4:4:1 ratio to e-cigarettes with 16 mg of nicotine, a daily 21-mg nicotine patch or placebo e-cigarettes with no nicotine, from one week before quit day to 12 weeks after. They were also offered access to telephone support thorough the national quitline, and smoking abstinence at six months was verified by exhaled breath carbon monoxide measurement. The controlled trial, which was funded by the Health Research Council of New Zealand, ran from September 2011 to July 2013. Results were published online by The Lancet Sept. 7.

At six months, abstinence rates were insignificantly different among the groups, at 7.3% in nicotine e-cigarette users, 5.8% in patch users and 4.1% in placebo e-cigarette users. Overall cessation rates were substantially lower than the researchers had expected, so the study was underpowered to detect a difference between the quitting aids. There were no significant differences between groups in adverse events, either.

The study authors concluded that e-cigarettes were modestly effective and might be as effective as nicotine patches for achieving cessation. One strength of the study was its real-world setting, but a limitation was the use of first-generation e-cigarettes, which delivered less nicotine than promised by their labeling. The authors called for research into second-generation e-cigarettes and the effects of longer-term use.

An accompanying comment noted that the e-cigarettes also appeared to have helped study participants who didn't cease smoking reduce their tobacco cigarette consumption and that, as a replacement for tobacco cigarettes, e-cigarettes could "ultimately lead to the disappearance of combustible tobacco products and to the end of the epidemic of smoking-related disease and death." Based on this study, "health professionals will now hopefully feel easier about recommending e-cigarettes to smokers, or at least condoning their use," the commenter concluded.



From the College


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ACP releases new policy paper addressing principles for organizing clinical care teams

ACP sets the framework for a team-based model of health care in a new policy paper published in Annals of Internal Medicine.

ACP offers more than a dozen principles to encourage and enable clinicians to work together effectively in dynamic clinical care teams. The paper, "Principles Supporting Dynamic Clinical Care Teams," outlines a process for creating more nimble, adaptable partnerships that encourage teamwork, collaboration and smooth transitions of responsibility to ensure the needs of patients are met at each step of the way.

The paper reaffirms support of the "Joint Principles of the Patient-Centered Medical Home" while recognizing that the current model of health care delivery will need to change to meet the coming demand of patients.


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"The Consult Guys" video series delivers laughs and CME credits

Annals of Internal Medicine is offering physicians an opportunity to laugh while they learn with "The Consult Guys," a monthly video series that features two prominent physicians who use humor to address and solve clinical problems.

"The Consult Guys," a derivative of the popular course "Consult Talk" offered at ACP's annual scientific meeting, features Drs. Geno Merli and Howard Weitz addressing a variety of clinical issues. The videos are accompanied by resources cited in the video, slide sets, and the opportunity to earn CME credit. Some videos will feature "stumper" questions submitted by internal medicine physicians.

The monthly series kicks off with two entertaining videos presenting clinical conundrums in the area of cardiology. New videos will be added each month in which The Consult Guys address clinical issues while using humor to deliver educational pearls related to the practice of internal medicine.

Physicians can access The Consult Guys online or use the Annals iPad app to download the videos.


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Less than a month left to 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 through 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.



Cartoon caption contest


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Vote for your favorite entry

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

acpi-20130917-cartoon.jpg

"This is just universal precaution for anyone with a combination of priapism and urinary incontinence."

"I frankly don't understand these new isolation guidelines, either."

"I hear you have Rayn-auds."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting ends on Monday, Sept. 23, with the winner announced in the Sept. 24 issue.


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MKSAP Answer and Critique



The correct answer is D: Pulmonary function studies. This item is available to MKSAP 16 subscribers as item 50 in the Pulmonology and Critical Care Medicine section. More information is available online.

The most appropriate diagnostic test to perform next is pulmonary function testing, specifically with measurement of spirometry, lung volumes, and DLCO. Exposure to coal dust in occupational settings may lead to a spectrum of clinical conditions ranging from asymptomatic deposition of coal particles without an inflammatory response (anthracosis) to complicated pulmonary disease with massive pulmonary fibrosis caused by the activation of inflammatory mediators in response to inhaled coal dust. Impairment of lung function in individuals exposed to coal dust is also significantly accelerated in smokers. Autopsy studies have shown that the extent of emphysema was significantly greater in ever-smokers who were miners in comparison with the never-smoker, non-miner population. In addition, the extent of emphysema was sixfold greater in those who were never-smoker miners compared with never-smoker non-miners. Documentation of declines in FEV1 in coal miners provides strong evidence for the development of obstructive lung disease in workers exposed to significant coal dust. As a result, symptomatic patients should undergo pulmonary function testing to identify obstructive physiology, whether or not they have a smoking history. This allows for earlier interventions such as bronchodilator therapy, avoidance of further exposure, and the opportunity for continued monitoring.

In asymptomatic patients with a history of coal exposure in whom baseline radiographs have been obtained, radiographic studies should be repeated every 5 years to monitor for progressive lung disease. These studies should be performed more frequently in patients who develop symptoms. However, initiating routine surveillance alone in this symptomatic patient without further evaluation would not be appropriate.

Although coal miners are at increased risk for interstitial lung diseases, this patient presents with bronchitic symptoms and a normal chest radiograph. Before pursuing CT imaging, pulmonary function testing should be performed to differentiate between obstructive and restrictive physiology.

The role of PET scanning for the diagnosis and surveillance of lung disease associated with coal exposure has not been established. Because of its high sensitivity for detection of inflammation, its use in assessing malignancy in coal-exposed patients is limited owing to high false-positive rates.

Key Point

  • Studies have shown that workers exposed to significant coal dust have a high risk for the development of obstructive lung disease.

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Test yourself

A 42-year-old woman is evaluated for an 8-month history of crampy abdominal pain and three loose bowel movements per day. The pain is relieved by a bowel movement. There are no nocturnal bowel movements, and there is no blood or dark tarry material in the stool. She has not had fever, night sweats, or weight loss. She has a history of Hashimoto disease and is treated with levothyroxine. Following a physical exam, rectal exam, and lab tests, what is the most appropriate next step in management?

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