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

Advertisement

ACP InternistWeekly



In the News for the Week of January 14, 2014




Highlights

Smoking cessation rates no higher when bupropion added to varenicline treatment

Combined treatment with varenicline and bupropion sustained-release (SR) was negligibly more effective than varenicline alone in helping smokers quit, a recent study found. More...

Internationally developed gout guidelines seek to improve clinical practice

Ten recommendations for the diagnosis and management of patients with gout have been developed by a multinational group with the aim of improving daily clinical practice. More...


Test yourself

MKSAP Quiz: 3- to 4-month history of diffuse, intractable itching

A 72-year-old man is evaluated for a 3- to 4-month history of diffuse, intractable itching involving most of the body. He uses emollients regularly. He cannot identify any precipitating causes. Following a physical exam, what is the most appropriate next step in management? More...


Risk assessment

Herpes zoster may be an independent risk factor for vascular disease

Herpes zoster was an independent risk factor for vascular disease, particularly in subjects affected before age 40, a study found. More...


Influenza

Shortage of oral oseltamivir reported

The FDA warned clinicians about a temporary shortage of the oral suspension form of oseltamivir phosphate (Tamiflu) last week. More...


Ethics

Spanish translation of ACP's Ethics Manual, Sixth Edition, now available

The Spanish translation of ACP's Ethics Manual, Sixth Edition, is now available online. More...


Education

Register now for 2014 Annual HIMSS Conference

The 2014 Annual Healthcare Information Management Systems Society (HIMSS) Conference and Exhibition will be held in Orlando, Fla., Feb. 23 to 27, 2014, at the Orange County Convention Center. More...


From the College

Call for fall 2014 Board of Governors resolutions

The deadline for submitting new resolutions to be heard at the fall 2014 Board of Governors Meeting is March 19, 2014. 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...

Editorial note: ACP InternistWeekly will not be published next week due to Martin Luther King Jr. Day holiday.


Physician editor: Philip Masters, MD, FACP



Highlights


.
Smoking cessation rates no higher when bupropion added to varenicline treatment

Combined treatment with varenicline and bupropion sustained-release (SR) was negligibly more effective than varenicline alone in helping smokers quit, a recent study found.

The controlled trial randomized 506 adult smokers in the Midwestern U.S. to 12 weeks of varenicline and bupropion SR or varenicline and placebo. The study was conducted between October 2009 and April 2013; outcomes were biochemically confirmed prolonged abstinence (no smoking since 2 weeks after quit date) and abstinence for the past 7 days, measured at week 12, week 26 and week 52. Results were published in the Jan. 8 Journal of the American Medical Association, a tobacco-themed issue.

Only 315 patients (62% of the initial group) completed the 12 weeks of therapy. Of those who finished, the combination group had slightly higher rates of prolonged abstinence at 12 weeks (53.0% vs. 43.2% on varenicline alone; odds ratio [OR], 1.49; 95% CI, 1.05 to 2.12; P=0.03), but there was no significant difference in 7-day abstinence (56.2% vs. 48.6%; P=0.09). The results were similar at 26 weeks: Prolonged abstinence was 36.6% on combination therapy and 27.6% on varenicline (OR, 1.52; 95% CI, 1.04 to 2.22; P=0.03), but no significant difference was found in smoking over the previous 7 days (38.2% vs. 31.9%; P=0.14). At 52-week follow up, the groups showed no significant difference on either measure, with about a quarter of patients having successfully quit.

The groups did differ in some adverse events. Patients on combination therapy reported more anxiety (7.2% vs. 3.1%; P=0.04) and depressive symptoms (3.6% vs. 0.8%; P=0.03). Researchers noted that use of bupropion SR for tobacco dependence has previously been found to increase anxiety. The patients on combination treatment who successfully quit had less weight gain at week 12 than those on monotherapy, the authors noted. This suggests that combination therapy could be a good option for patients whose concern about weight gain could impede their smoking cessation.

The authors noted several limitations to the study, including the high dropout rate, which could have led to over- or underestimation of the treatment effects. Patients with serious medical or psychiatric illnesses were also excluded from the study, so the results may not be generalizable to all smokers. The study authors concluded by calling for more research on the role of combination treatment in smoking cessation.


.
Internationally developed gout guidelines seek to improve clinical practice

Ten recommendations for the diagnosis and management of patients with gout have been developed by a multinational group with the aim of improving daily clinical practice.

The 10 recommendations appeared in the February Annals of the Rheumatic Diseases:

  1. Identification of monosodium urate crystals should be performed to definitively diagnose gout; if not possible, a diagnosis of gout can be supported by classical clinical features (such as podagra, tophi, rapid response to colchicine) and/or characteristic imaging findings.
  2. In patients with gout, measure renal function and assess cardiovascular risk factors.
  3. Treat acute gout with low-dose colchicine (up to 2 mg daily), NSAIDs and/or intra-articular, oral or intramuscular glucocorticoids.
  4. Patients should reduce excess body weight, exercise, stop smoking, and avoid excess alcohol and sugar-sweetened drinks.
  5. Allopurinol should be the first-line urate-lowering therapy, followed by uricosurics or febuxostat. Uricase as monotherapy should only be considered in patients with severe gout after all other therapies have failed or are contraindicated. Urate-lowering therapy, except uricase, should be started as a low dose and then increased to achieve a target serum urate level.
  6. Patient education on flare is essential and prophylaxis, of colchicine up to 1.2 mg daily, should be considered. NSAIDs or low-dose glucocorticoids can be used if colchicine is contraindicated or not tolerated.
  7. Patients with mild-moderate renal impairment can consider allopurinol, with close monitoring for adverse events, starting at a daily dose of 50 to 100 mg that can be titrated up to achieve a target serum for uric acid. Febuxostat and benzbromarone can be used as alternative drugs without dose adjustment.
  8. Treat to target serum urate level below 0.36 mmol/L (6 mg/dL) and the eventual absence of gout attacks and resolution of tophi. Monitor serum urate level, frequency of gout attacks and tophi size.
  9. Tophi should be treated medically by achieving a sustained reduction in serum uric acid, preferably below 0.30 mmol/L (5 mg/dL). Surgery is only indicated in cases such as nerve compression, mechanical impingement or infection.
  10. Pharmacological treatment of asymptomatic hyperuricemia is not recommended.

"Even though gout is a potentially curable disease, its management is far from optimal in both primary care and rheumatology clinics," the authors wrote. "The quality of care provided to gout patients needs to improve."



Test yourself


.
MKSAP Quiz: 3- to 4-month history of diffuse, intractable itching

A 72-year-old man is evaluated for a 3- to 4-month history of diffuse, intractable itching involving most of the body. He uses emollients regularly. He cannot identify any precipitating causes. He was relatively healthy before the onset of the itch but now feels chronically fatigued. The itch is relentless. He has used topical hydrocortisone and oral diphenhydramine without relief from the itching. Medical history is pertinent only for a 25 pack-year history of smoking, and his only medication is aspirin.

mksap.gif

On physical examination, his skin is generally well hydrated. Scattered punctate and linear excoriations are present on the upper shoulders, arms, upper back, thighs, and legs. The skin on the midback between the scapulae is normal. No primary skin lesions or icterus is seen.

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

A: Complete blood count, comprehensive metabolic profile, and thyroid function studies
B: Epicutaneous patch testing
C: Prednisone
D: Skin biopsy

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


.

Risk assessment


.
Herpes zoster may be an independent risk factor for vascular disease

Herpes zoster was an independent risk factor for vascular disease, particularly in subjects affected before age 40, a study found.

The retrospective population cohort study looked at 106,601 herpes zoster cases from among 3.6 million active patients collected over 23.7 years. These were matched 1:2 to 213,202 controls by age, sex and general practice from the THIN (The Health Improvement Network) general practice database in the United Kingdom.

Researchers looked at the risks of stroke, transient ischemic attack (TIA), and myocardial infarction (MI), and then adjusted for vascular risk factors such as body mass index, smoking, cholesterol, hypertension, diabetes, ischemic heart disease and atrial fibrillation, among other conditions, for up to 24 years (median, 6.3 years) after herpes zoster occurred.

Results were published ahead of print on Jan. 2 by Neurology.

Risk factors for vascular disease were significantly increased in the patients with herpes zoster compared with controls. For TIA, the adjusted hazard ratio (AHR) was 1.15 (95% CI, 1.09 to 1.21) and for MI it was 1.10 (95% CI, 1.05 to 1.16). For stroke, the AHR was 1.02 (95% CI, 0.98 to 1.07).

The increases in risk were particularly large in cases where herpes zoster occurred in patients under 40 years old: The AHRs were 2.42 for stroke (95% CI, 1.34 to 4.36), 1.49 for TIA (95% CI, 1.04 to 2.15) and 1.74 for MI (95% CI, 1.13 to 2.66). The researchers noted that patients under 40 were significantly less likely to be asked about vascular risk factors than were older patients (P<0.001).

The researchers noted that irrespective of age, conditions that predispose to vascular disease, including lifestyle factors such as smoking and obesity, were significantly more common in the patients with herpes zoster, although that finding may also have resulted from better recording of risk factors in this population. In older patients, better ascertainment of vascular risk factors and earlier intervention could have explained the lower stroke risk after herpes zoster.

"Overall, these data add to the growing body of evidence linking VZV [varicella zoster virus], a ubiquitous pathogen that establishes persistent infection in more than 95% of individuals, to vascular disease," the researchers wrote. "Immunization with the licensed zoster vaccine has been shown to significantly reduce the incidence of herpes zoster as well as significantly decrease the severity of neuropathic complications. Population studies are now needed to evaluate whether immunization to prevent herpes zoster could also reduce the incidence of vascular events including stroke, TIA and MI."



Influenza


.
Shortage of oral oseltamivir reported

The FDA warned clinicians about a temporary shortage of the oral suspension form of oseltamivir phosphate (Tamiflu) last week.

Due to increased demand, the manufacturer experienced delays in manufacturing the oral suspension of the drug (6 mg/mL; 60 mL). Additional supplies were expected to be available by mid-January, according to an FDA drug shortage posting.

In the interim, pediatric patients over 1 year of age can be dosed correctly using the 30-mg and 45-mg capsules of the drug. For patients who cannot swallow capsules, the capsules can be opened and the contents may be mixed with chocolate syrup or some other thick, sweet liquid, the FDA advised. Instructions for compounding a suspension are also available on the manufacturer's website.



Ethics


.
Spanish translation of ACP's Ethics Manual, Sixth Edition, now available

The Spanish translation of ACP's Ethics Manual, Sixth Edition, is now available online. ACP's Ethics Manual, Sixth Edition, is the foundation of College ethics policy, addressing challenging real-world ethical dilemmas that confront physicians, patients and researchers.

The sixth edition of the manual, published in January 2012 in Annals of Internal Medicine, offers new or expanded sections, including treatment without interpersonal contact; confidentiality and electronic health records; therapeutic nondisclosure; genetic testing; health system catastrophes; boundaries and privacy; social media and online professionalism and more. A case method for medical ethics decision making is also included.

Opportunities to earn CME and Maintenance of Certification (MOC) credit are available with the English version of the manual. To view the text of the Spanish translation, visit the College website.



Education


.
Register now for 2014 Annual HIMSS Conference

The 2014 Annual Healthcare Information Management Systems Society (HIMSS) Conference and Exhibition will be held in Orlando, Fla., Feb. 23 to 27, 2014, at the Orange County Convention Center. More than 35,000 health care industry professionals are expected to attend to discuss health IT issues and explore innovative solutions for their organizations.

ACP has endorsed the Physician's IT Symposium and Meaningful Use Workshop offered at this year's event. The conference will offer more than 300 peer-reviewed sessions, including workshops and roundtables, and preconference symposia on clinical and business intelligence, health information technology and rural care, health information exchanges, ICD-10, interoperability, mobile health, nursing informatics and more.

Hillary Clinton leads a keynote roster that also includes Mark Bertolini, chairman, CEO and president of AETNA. For more information about HIMSS14 and to register, visit the conference website.



From the College


.
Call for fall 2014 Board of Governors resolutions

The deadline for submitting new resolutions to be heard at the fall 2014 Board of Governors Meeting is March 19, 2014.

Initiating a resolution provides ACP members an opportunity to focus attention at the ACP national level on a particular issue or topic that concerns them. When drafting a resolution, don't forget to consider how well it fits within ACP's Mission and Goals. In addition, be sure to use the College's Strategic Plan to guide you when proposing a resolution topic. Members must submit resolutions to their Governor and/or chapter council. A resolution becomes a resolution of the chapter once the chapter council approves it.

In accordance with the ACP Board of Governors Resolutions Process, resolutions should clearly distinguish the action requested within its resolved clause(s) as either a policy resolve ("Resolved that ACP policy…"), or a directive, which requests action/study on an issue ("Resolved that the Board of Regents…"). If more than one action is proposed, each should have its own resolved clause. Please contact your Governor if you have any questions regarding the resolution format.

The Board of Governors votes on new resolutions, which are then presented to the Board of Regents for action. Members are encouraged to use the Electronic Resolutions System (ERS) to research the status of past resolutions before proposing a new resolution. Visit your chapter website and follow the link to the ERS under the "Advocacy" heading.



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.

acpi-20140114-cartoon.jpg

"It definitely sounds guttural."

This issue's winning cartoon caption was submitted by Steve B. Kalish, MD, FACP. Thanks to all who voted! The winning entry captured 67.9% of the votes.

The runners-up were:

"Dr. Smith can tell just by auscultating when a patient is circling the drain."

"Always an innovator, Dr. Brown was ready when he encountered 'distant' heart sounds."


.


MKSAP Answer and Critique



The correct answer is A: Complete blood count, comprehensive metabolic profile, and thyroid function studies. This item is available to MKSAP 16 subscribers as item 66 in the Dermatology section. More information is available online.

Serologic tests to evaluate common causes of itch are appropriate, including a complete blood count, serum chemistries, iron studies, and thyroid studies. A serum protein electrophoresis can be considered. This patient has an itch that is not explained by a rash, and this is a concern for an underlying systemic or neurogenic cause. Important causes of systemic itching include malignancy (particularly lymphoma), cholestatic liver disease, chronic kidney disease, thyroid disease, iron deficiency, certain medications (opiates), and HIV infection. Patients with this type of itch have no primary skin findings but can develop excoriations and even an eczematous dermatitis from repeated scratching. Evaluation for an underlying cause of itch is appropriate whenever the degree of itch seems to exceed the identifiable dermatitis. In patients with pulmonary symptoms or at risk for lung cancer, a chest radiograph may help evaluate for an occult malignancy. Other imaging studies should be considered based on history and findings on physical examination. Patients with this type of itch should undergo age- and sex-appropriate cancer screening, if they are not up-to-date.

Epicutaneous patch testing is the diagnostic gold standard for allergic contact dermatitis; however, this diagnosis should not be considered in the absence of an eczematous dermatitis. Treatment with systemic corticosteroids could mask symptoms and result in an inappropriate or delayed diagnosis. A skin biopsy is unlikely to help establish a diagnosis in the absence of any relevant skin findings.

Key Point

  • Diffuse itching in the absence of a rash requires a thorough evaluation of an underlying systemic cause.

Click here to return to the rest of ACP InternistWeekly.

Top




About ACP InternistWeekly

ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.

To add your e-mail address to your member record and to begin receiving ACP InternistWeekly, please click here.

Copyright © by American College of Physicians.

Test yourself

A 72-year-old woman is evaluated during a routine examination. She has very severe COPD with multiple exacerbations. She has dyspnea at all times with decreased exercise capacity. She does not have cough or any change in baseline sputum production. She is adherent to her medication regimen, and she completed pulmonary rehabilitation 1 year ago. She quit smoking 1 year ago. Her medications are a budesonide/formoterol inhaler, tiotropium, and an albuterol inhaler as needed. Following a physical and pulmonary exam, what is the most appropriate next step in management?

Find the answer

New Leadership Webinars

New Leadership Webinars

The ACP Leadership Academy is offering FREE webinars covering the core tenets of leadership, leadership in hospital medicine, finance, and more.

Join ACP Today!

Join ACP Today!

ACP membership connects you with like-minded colleagues and provides access to a variety of clinical resources, practice tools, and ways to earn MOC and CME.