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ACP InternistWeekly



In the News for the Week of September 24, 2013




Highlights

ACP's sleep apnea guideline recommends weight loss and CPAP as initial therapies

All overweight and obese patients diagnosed with obstructive sleep apnea (OSA) should be encouraged to lose weight and use continuous positive-airway pressure (CPAP) or, if preferred, mandibular advancement devices, according to a new ACP guideline. More...

For substance abuse, chronic care management no better than usual care

Persons with substance abuse problems who received chronic care management, including relapse prevention counseling and medical, addiction and psychiatric treatment, were no more abstinent than those who received usual primary care, a study found. More...


Test yourself

MKSAP Quiz: 6-year history of Sjögren syndrome

A 56-year-old woman is evaluated during a follow-up visit for a 6-year history of Sjögren syndrome treated with low-dose hydroxychloroquine and cyclosporine eyedrops. She has had two episodes of cutaneous vasculitis, which resolved with corticosteroids. Following a physical exam and lab results, what is the most appropriate management? More...


Diabetes

Score predicts diabetes remission after Roux-en-Y surgery

Researchers created a new score, based on four variables, which can help predict whether a patient will have remission of type 2 diabetes after Roux-en-Y gastric bypass surgery. More...


Infectious disease

CDC: C. diff, CRE and drug-resistant Neisseria gonorrhoeae top list of bacterial threats to U.S. health

Clostridium difficile, carbapenem-resistant Enterobacteriaceae (CRE), and drug-resistant Neisseria gonorrhoeae are the most urgent bacterial threats to health in the U.S., the CDC said last week in a report. More...

MRSA declined between 2005 and 2011, especially hospital-onset infections

There were fewer invasive methicillin-resistant Staphylococcus aureus (MRSA) infections in the U.S. in 2011 than in 2005, and the reduction was greatest for health care-associated infections, a new study found. More...


From the College

Introducing ACP Smart Medicine, ACP's new Web-based, mobile-optimized clinical decision support tool

The American College of Physicians has released ACP Smart Medicine, a Web-based clinical decision support tool developed specifically for internal medicine physicians and containing 500 modules that provide guidance and information on a broad range of diseases and conditions. More...

ACP and AAIM release updated version of High Value Care Curriculum

ACP and the Alliance for Academic Internal Medicine (AAIM) have released a new version of their High Value Care Curriculum, a jointly developed instructional program to train resident physicians to be good stewards of limited health care resources. More...

I.M. a specialist

Yul Ejnes, MD, MACP, a past chair of ACP's Board of Regents, a practicing internist in Cranston, R.I., and a member of ACP Internist's editorial board, continues his monthly column at KevinMD.com in a post about what it means to be an internal medicine specialist. 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: Philip Masters, MD, FACP



Highlights


.
ACP's sleep apnea guideline recommends weight loss and CPAP as initial therapies

All overweight and obese patients diagnosed with obstructive sleep apnea (OSA) should be encouraged to lose weight and use continuous positive-airway pressure (CPAP) or, if preferred, mandibular advancement devices, according to a new ACP guideline.

annals.jpg

The guideline appeared in the Sept. 24 Annals of Internal Medicine and included the following recommendations:

  • Recommendation 1: All overweight and obese patients diagnosed with OSA should be encouraged to lose weight. (Grade: strong recommendation; low-quality evidence)
  • Recommendation 2: ACP recommends CPAP as initial therapy for patients diagnosed with OSA. (Grade: strong recommendation; moderate-quality evidence)
  • Recommendation 3: ACP recommends mandibular advancement devices as an alternative therapy to CPAP treatment for patients diagnosed with OSA who prefer mandibular advancement devices or for those with adverse effects associated with CPAP treatment. (Grade: weak recommendation; low-quality evidence)

The guideline was based on a literature search from 1966 to 2010, sponsored by the Agency for Healthcare Research and Quality, in which evidence showed that intensive weight-loss interventions reduce Apnea–Hypopnea Index scores and improve OSA symptoms. The reviewers also found moderate-quality evidence that CPAP was more effective than control treatments or sham CPAP but noted the absence of randomized trials evaluating long-term clinical outcomes, such as death or cardiovascular illness. Moderate-quality evidence showed that fixed and auto-CPAP have overall similar efficacy and adherence, and low-quality evidence showed that C-Flex CPAP (a proprietary system that provides pressure relief during active exhalation) and fixed CPAP were similarly efficacious, they noted.

The evidence showed that mandibular advancement devices could effectively lower Apnea–Hypopnea Index scores and reduce sleepiness but that CPAP more effectively reduced Apnea–Hypopnea Index and arousal index scores and increased the minimum oxygen saturation. Because adherence to CPAP is key to its effectiveness, physicians should consider patient preferences, potential reasons for nonadherence and costs before initiating therapy, the guideline advised.

The reviewers also looked at evidence on other OSA interventions, including positional therapy, oropharyngeal exercise, surgical interventions, pharmacologic therapy and atrial overdrive pacing, and found insufficient evidence of their overall or comparative efficacy. The guideline noted that pharmacologic therapy is not supported by evidence, so should not be prescribed, and that surgical treatments are associated with risks and serious adverse effects and thus should not be the initial treatment for OSA.


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For substance abuse, chronic care management no better than usual care

Persons with substance abuse problems who received chronic care management, including relapse prevention counseling and medical, addiction and psychiatric treatment, were no more abstinent than those who received usual primary care, a study found.

Researchers recruited 563 adult participants between September 2006 and September 2008 from a freestanding residential detoxification unit, from referrals to an urban teaching hospital and from advertisements. Alcohol dependence was determined by the Composite International Diagnostic Interview Short Form (CIDI-SF) and was defined as heavy drinking in the past 30 days (for men, 5 or more drinks on 1 occasion at least twice or 22 or more drinks per week in an average week; for women, 4 or more drinks on 1 occasion at least twice or 15 or more drinks per week). Drug dependence was defined based on the CIDI-SF and past 30-day misuse of cocaine, methamphetamine, or prescription amphetamines, or use of heroin or prescription opioids, the latter without a prescription, in larger amounts than prescribed, or for a longer period than prescribed.

Participants were randomized 1:1 to chronic care management or a control group. The chronic care management group received coordinated care from a primary care clinician, motivational enhancement therapy and relapse prevention counseling, as well as on-site medical, addiction, and psychiatric treatment, social work assistance and referrals to specialty addiction treatment and mutual help. The control group received a timely appointment and a list of addiction treatment resources, including a telephone number to arrange counseling.

Results appeared in the Sept. 18 JAMA.

At 12 months, researchers found no difference in abstinence from stimulants, opioids and heavy drinking between the care management and control groups (44% vs. 42%; adjusted odds ratio [OR], 0.84; 95% CI, 0.65 to 1.10; P=0.21). There were no significant differences over time in the alcohol and drug dependence subgroups except for fewer alcohol problems in the intervention group among those with alcohol dependence (mean score, 10.4 vs. 13.1 at 12 months; incidence rate ratio [IRR], 0.85; 95% CI, 0.72 to 1.00; P=0.048).

Among 369 patients with drug dependence and recent use of opioids, at 12 months the intervention was associated with a lower odds of opioid abstinence throughout follow-up (52% vs. 54%; OR, 0.71; 95% CI, 0.51 to 0.98) and had no effect on days of opioid use (mean, 16.7 vs. 14.0 days; IRR, 1.19; 95% CI, 0.94 to 1.52 in an analysis adjusted for baseline use). Among 364 patients with drug dependence and recent use of stimulants, at 12 months there were no significant intervention effects on stimulant abstinence (51% vs. 55%; OR, 0.77; 95% CI, 0.56 to 1.07) or days of stimulant use (mean, 11.0 vs. 12.4 days; IRR, 1.05; 95% CI, 0.81 to 1.37 in an analysis adjusted for baseline use). The authors did not detect differences in secondary outcomes of addiction severity, health-related quality of life, or drug problems.

The researchers noted that health care reforms in the U.S. include a focus on chronic care management in patient-centered medical homes. They wrote, "Even though CCM [chronic care management] is effective for a number of chronic conditions, it may be premature to assume that CCM will be the solution to improve the quality of care for and reduce costs of patients with addiction."

An accompanying editorial noted that the negative results provided a reason for future research. The study population, three-quarters of whom came from a detoxification unit and two-thirds of whom were addicted to more than 1 substance, had significant psychiatric and medical comorbidity and sometimes faced homelessness and incarceration. The editorialist wrote that a study focusing on patients who have either alcohol or drug dependence (but not both) might find different results.



Test yourself


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MKSAP Quiz: 6-year history of Sjögren syndrome

A 56-year-old woman is evaluated during a follow-up visit for a 6-year history of Sjögren syndrome treated with low-dose hydroxychloroquine and cyclosporine eyedrops. She has had two episodes of cutaneous vasculitis, which resolved with corticosteroids.

mksap.gif

On physical examination, temperature is 36.4 °C (97.6 °F), blood pressure is 116/64 mm Hg, pulse rate is 72/min, and respiration rate is 18/min. Oral mucous membranes are dry. There is a new firm, left parotid gland enlargement without tenderness or warmth, reported by the patient to be progressive over several months, with asymmetry of the parotid glands.

Laboratory studies at the time of diagnosis revealed elevated serum immunoglobulin levels; positive mixed monoclonal cryoglobulin levels; and positive rheumatoid factor, antinuclear antibodies, and anti-Ro/SSA antibodies.

Current laboratory studies:

Complete blood count Normal
Alkaline phosphatase Normal
Calcium Normal
Rheumatoid factor Negative
C3 Normal
C4 Decreased
Antinuclear antibodies Positive
Anti-Ro/SSA antibodies Positive

Which of the following is the most appropriate management?

A: Add pilocarpine
B: Add prednisone
C: Bone marrow biopsy
D: Increase hydroxychloroquine
E: Parotid gland biopsy

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


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Diabetes


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Score predicts diabetes remission after Roux-en-Y surgery

Researchers created a new score, based on four variables, which can help predict whether a patient will have remission of type 2 diabetes after Roux-en-Y gastric bypass surgery.

The score, which the researchers named the DiaRem score, was created based on a retrospective cohort study of 690 patients with type 2 diabetes who had the surgery at one hospital in 2004 to 2011. Patients were followed for partial or complete remission lasting at least 12 months after surgery. Partial remission was defined as hemoglobin A1c (HbA1c) less than 6.5% and fasting blood glucose less than 126 mg/dL, while complete remission was an HbA1c less than 6.0% with fasting blood glucose less than 100 mg/dL, both with no antidiabetic medication. Results were published by The Lancet Diabetes & Endocrinology on Sept. 13.

After examining 259 variables, researchers identified four that best predicted partial or complete remission in the 463 surgical patients (63%) who achieved either type of remission. Insulin use before surgery was the strongest predictor (patients who used insulin were least likely to have remission), so it was given the most weight (10 points in the 22-point score). Other factors that predicted remission were younger age, lower HbA1c and not taking the combination of both insulin-sensitizing agents (other than metformin) and sulfonylureas.

Among patients with the lowest scores, 88% had remission after surgery, compared to only 0.5% of the highest-scoring patients. The researchers validated their findings in two replication cohorts and concluded that their DiaRem score could be used preoperatively to predict diabetes remission after Roux-en-Y (but not other types of bariatric surgery). This study also found for the first time that, among patients who took insulin, use of incretin mimetics increased the chance of remission, a finding that needs further confirmation, the authors noted.

The score could help with treatment selection for diabetes and management of expectations in patients who are undergoing Roux-en-Y, an accompanying comment noted. However, more research is needed to validate the findings and assess the effects of surgery on other endpoints, including mortality. Clinicians should also remember that even patients who are unlikely to achieve diabetes remission from surgery may see significant benefits from the procedure, the comment concluded.



Infectious disease


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CDC: C. diff, CRE and drug-resistant Neisseria gonorrhoeae top list of bacterial threats to U.S. health

Clostridium difficile, carbapenem-resistant Enterobacteriaceae (CRE), and drug-resistant Neisseria gonorrhoeae are the most urgent bacterial threats to health in the U.S., the CDC said last week in a report.

The report, "Antibiotic Resistance Threats in the United States, 2013," categorizes 18 organisms as "urgent," "serious" or "concerning." The serious threats include: multidrug-resistant Acinetobacter and Pseudomonas aeruginosa; drug-resistant Campylobacter, non-typhoidal Salmonella, Salmonella typhi, Shigella, Streptococcus pneumoniae and tuberculosis; fluconazole-resistant Candida; extended-spectrum β-lactamase-producing Enterobacteriaceae; vancomycin-resistant Enterococcus; and methicillin-resistant Staphylococcus aureus. The concerning threats are vancomycin-resistant Staphylococcus aureus, erythromycin-resistant group A Streptococcus and clindamycin-resistant group B Streptococcus, the report said.

For each of the bacterial threats, the report includes an overview of the organism and associated health conditions, what the CDC is doing to combat the threat, recommendations for the health care community and for patients, and links to more resources. Generally, to fight the spread of resistance, the CDC is supporting four core actions:

  • Preventing infections from occurring and resistant bacteria from spreading
  • Tracking resistant bacteria
  • Improving antibiotic use
  • Promoting development of new antibiotics and new diagnostic tests for resistant bacteria

Antibiotic-resistant infections kill at least 23,000 people each year and make at least 2 million people ill, the report said. The CDC's Antibiotic Stewardship Drivers and Change Package includes several interventions for health care facilities and clinicians to help combat resistance, the report said.


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MRSA declined between 2005 and 2011, especially hospital-onset infections

There were fewer invasive methicillin-resistant Staphylococcus aureus (MRSA) infections in the U.S. in 2011 than in 2005, and the reduction was greatest for health care-associated infections, a new study found.

Researchers used data from the CDC's Emerging Infections Program-Active Bacterial Core surveillance program to compare MRSA incidence rates from January through December of 2005 and 2011. About 16.5 million people underwent surveillance in 2005 and about 19.4 million underwent surveillance in 2011, in both years from the same nine metropolitan areas. Cases were defined as hospital-onset if a culture was taken after hospital day 3. Health care-associated community onset (HACO) meant a culture was taken as an outpatient on or before hospital day 3 in a patient with a documented health care risk factor. Community-associated cases were the same as HACO cases except patients lacked a documented health care risk factor. Results were published online Sept. 16 by JAMA Internal Medicine.

From 2005 to 2011, hospital-onset infections decreased by 54.2%, HACO infections decreased by 27.7%, and community-associated infections decreased by 5.0%. The combined decrease of invasive MRSA infections was 31.2%, with an estimated 80,461 (95% CI, 69,515 to 93,914) infections in 2011 compared to 111,261 in 2005. In 2011, there were an estimated 48,353 HACO infections, 14,156 hospital-onset infections and 16,560 community-associated infections. Of the community-onset (nondialysis) infections in previously hospitalized patients, 64% occurred within three months after discharge, and 32% of these were admitted from long-term care facilities.

This is the first time since the CDC started tracking MRSA incidence that hospital-onset infections were fewer than community-associated infections, the authors noted. The reduction of hospital-onset infections could be due in part to greater awareness and implementation of infection-prevention measures, they wrote, adding that MRSA infections with community- or outpatient-onset "remain problematic."

An invited commenter agreed that the study showcased the need for a better understanding of how MRSA strains spread and start infection within the community. "Risks identified in the health care setting do not necessarily translate to those in the community," he noted.



From the College


.
Introducing ACP Smart Medicine, ACP's new Web-based, mobile-optimized clinical decision support tool

The American College of Physicians has released ACP Smart Medicine, a Web-based clinical decision support tool developed specifically for internal medicine physicians and containing 500 modules that provide guidance and information on a broad range of diseases and conditions.

Integrated with content from Annals of Internal Medicine, ACP JournalWise, and ACP's clinical practice guidelines, with a display that automatically adjusts to desktops, smartphones and tablets, the clinical recommendations in ACP Smart Medicine are evidence-based and rated based on the quality of the underlying evidence. Information is continually updated through triggered updates with new, relevant content and guidelines. Additionally, ACP High Value Care recommendations identify care activities that offer little benefit to patients.

ACP Smart Medicine also offers easy access to CME credit. Physicians can select modules from the list of content areas they have reviewed, answer a question and submit for CME credit.

ACP Smart Medicine is available as a free benefit to ACP members and can be purchased by non-members.


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ACP and AAIM release updated version of High Value Care Curriculum

ACP and the Alliance for Academic Internal Medicine (AAIM) have released a new version of their High Value Care Curriculum, a jointly developed instructional program to train resident physicians to be good stewards of limited health care resources.

The original 10-hour program, released in July 2012, has been updated and condensed into a 6-hour program, based on user feedback. The new version includes multimedia content and a toolbox for program directors so they can measure curricular impact and individual resident performance in high value care. The six 1-hour sessions include:

1. Eliminating Healthcare Waste and Over-ordering of Tests

2. Healthcare Costs and Payment Models

3. Utilizing Biostatistics in Diagnosis, Screening and Prevention

4. High Value Medication Prescribing

5. Overcoming Barriers to High Value Care

6. High Value Quality Improvement

The curriculum is free and available online.


.
I.M. a specialist

Yul Ejnes, MD, MACP, a past chair of ACP's Board of Regents, a practicing internist in Cranston, R.I., and a member of ACP Internist's editorial board, continues his monthly column at KevinMD.com.

In his latest post, Dr. Ejnes looks at what it means to be an internal medicine specialist.



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-20130924-cartoon.jpg

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

This issue's winning cartoon caption was submitted by Marshall C. Strother, a Medical Student Member. Thanks to all who voted! The winning entry captured 44.7% of the votes.

The runners-up were:

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

"I hear you have Rayn-auds."


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MKSAP Answer and Critique



The correct answer is E: Parotid gland biopsy. This item is available to MKSAP 16 subscribers as item 74 in the Rheumatology section. More information is available online.

Parotid gland biopsy is indicated for this patient who has Sjögren syndrome and progressive parotid swelling suggesting possible non-Hodgkin lymphoma. Patients with Sjögren syndrome have up to a 44-fold increased incidence of lymphoma, which may be confined to glandular tissue. Risk factors for the development of lymphoma include disappearance of rheumatoid factor, the presence of mixed monoclonal cryoglobulinemia, cutaneous vasculitis, and low C4 levels, all of which are seen in this patient. Although benign parotid gland swelling can occur and be unilateral or bilateral in patients with Sjögren syndrome, this patient's high-risk profile and new asymmetric parotid enlargement should prompt a biopsy to evaluate for extranodal lymphoma in the parotid gland. Extranodal marginal zone B-cell lymphomas of the mucosa-associated lymphoid tissue (MALT) are the most common lymphomas in patients with Sjögren syndrome, and salivary glands are the most common location; other extranodal sites include the stomach, nasopharynx, skin, liver, and lungs. The risk of nodal lymphoma is also increased in Sjögren syndrome. Although benign lymphadenopathy is a common disease manifestation, the presence of new or rapidly enlarging lymph nodes may indicate development of nodal lymphoma and should prompt biopsy.

Pilocarpine is effective for reducing dry mouth symptoms but is not used to treat parotid enlargement.

Prednisone is generally used to treat inflammatory symptoms of Sjögren syndrome, including arthritis, vasculitis, and cytopenias, but does not reduce parotid swelling or treat symptoms of keratoconjunctivitis sicca and xerostomia (dry eyes and dry mouth).

Patients with Sjögren syndrome often have elevated immunoglobulin levels with monoclonal gammopathy; stability of this during the patient's disease course, as well as normal hemoglobin, calcium, and alkaline phosphatase levels, suggests that bone marrow biopsy to evaluate for myeloma is not warranted. Extranodal lymphoma in Sjögren syndrome involves the bone marrow in less than 10% of patients.

Hydroxychloroquine is used to treat arthritis associated with Sjögren syndrome; however, it is unclear if this agent has efficacy in reducing sicca symptoms or parotid swelling.

Key Point

  • Patients with Sjögren syndrome have up to a 44-fold increased incidence of lymphoma, which may be confined to glandular tissue.

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Test yourself

A 59-year-old woman is evaluated for a 1-week history of increasing pain of the right foot. She recalls stepping on a nail about 1 month before her symptoms began. The patient has a 5-year history of heart failure secondary to idiopathic dilated cardiomyopathy. She has an implantable cardioverter-defibrillator, and her current medications are carvedilol, lisinopril, furosemide, and spironolactone. Following a physical examination and radiograph of the foot, what is the most appropriate next step to establish the diagnosis?

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