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ACP InternistWeekly



In the News for the Week of January 28, 2014




Highlights

USPSTF reviews evidence, updates recommendations on abdominal aortic aneurysm screening

The U.S. Preventive Services Task Force recently reviewed published evidence and issued new, slightly revised draft recommendations on screening for abdominal aortic aneurysm. More...

Critiques and explanations of new cholesterol guidelines published

Four new articles in Annals of Internal Medicine address the practice implications and controversy surrounding recent cholesterol treatment guidelines from the American College of Cardiology and the American Heart Association. More...


Test yourself

MKSAP Quiz: history of amenorrhea and galactorrhea

A 33-year-old woman is evaluated for a 5-month history of amenorrhea and a 3-month history of galactorrhea. She takes no medication. Vital signs and visual field findings are normal. Bilateral galactorrhea is noted. Serum prolactin level is markedly elevated. MRI shows a 1.5-cm sellar mass with suprasellar extension that impinges on the optic chiasm. What is the most appropriate initial treatment? More...


Multiple sclerosis

Vitamin D status associated with multiple sclerosis activity, progression

Higher vitamin D levels appear to be associated with reduced disease activity and a slower rate of disease progression in multiple sclerosis patients treated with interferon beta-1b, according to a study. More...


Health care attire

Recommendations on health care attire attempt to balance risk of cross-transmission with professional appearance

The Society for Healthcare Epidemiology of America recently issued recommendations on attire for health care personnel who work in non-operating-room settings. More...


CMS update

Deadline approaching to attest for 2013 EHR Incentive Program

Physicians and other eligible professionals must successfully attest by February 28 to receive an incentive payment for participation in the 2013 Medicare EHR Incentive Program. More...

CMS proposes rule change to Medicare Prescription Drug Program

CMS has issued proposed changes to the Medicare Prescription Drug Program and is asking for comments on the proposal by March 7. More...


Physician satisfaction

Yul Ejnes: How I changed my private practice glass from half empty to half full

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, discusses physician satisfaction at KevinMD.com. More...


From the College

College Fellow named National Coordinator for Health Information Technology

Karen B. DeSalvo, MD, FACP, has been named the next National Coordinator for Health Information Technology by the U.S. Department of Health and Human Services. More...


Cartoon caption contest

Put words in our mouth

ACP InternistWeekly wants readers to create captions for our new cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service. More...


Physician editor: Daisy Smith, MD, FACP



Highlights


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USPSTF reviews evidence, updates recommendations on abdominal aortic aneurysm screening

The U.S. Preventive Services Task Force recently reviewed published evidence and issued new, slightly revised draft recommendations on screening for abdominal aortic aneurysm (AAA).

The evidence review, published by Annals of Internal Medicine on Jan. 28, concluded that 1-time screening in men age 65 years or older was associated with decreased rate of AAA rupture and a 50% decrease in related mortality over 13 to 15 years, but not with a decline in all-cause mortality.

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In the 4 randomized, controlled trials analyzed, AAA prevalence varied from 4.0% to 7.7% in men. Most (70% to 82%) screen-detected aneurysms were less than 4 cm to 4.5 cm. Aneurysms measuring 5.5 cm or greater were detected in only 0.4% to 0.6% of the screened groups.

Screening was associated with more overall and elective surgeries but fewer emergency operations and lower 30-day operative mortality rates at up to 10- to 15-year follow-up.

In the single trial that recruited women (9,342 women, 59% of participants), screening had no benefit on AAA-related or all-cause mortality rates. Prevalence in women was 6 times lower than in men (1.3% vs. 7.6%). Most (30 out of 40) of the aneurysms were 3 cm to 3.9 cm.

The recommendation for women was the only change that the USPSTF's new draft recommendation made to the Task Force's 2005 recommendations on screening for AAA. Instead of a D recommendation against screening for AAA in all women, the new recommendation concludes that there is insufficient evidence to assess the harms and benefits of screening in women ages 65 to 75 years who have ever smoked. There is still a D recommendation against screening any women who never smoked.

The Task Force continues to recommend 1-time screening in men ages 65 to 75 years who have ever smoked (B recommendation) and continues to recommend that clinicians selectively offer screening to men ages 65 to 75 years who have never smoked (C recommendation). In the latter group, patients and clinicians should consider the balance of benefits and harms on the basis of evidence relevant to the patient's medical history, family history, other risk factors, and personal values.

The Task Force's draft recommendation is online and open to public comment.

"Deaths due to AAA represented less than 3% of all deaths," the review authors wrote. "We do not believe that the available data firmly support a reduction in all-cause mortality rates with AAA screening. It is important to note that although age is the strongest risk factor for AAA, competing causes of death and limited surgical candidacy due to comorbid conditions diminish the effectiveness of AAA screening."


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Critiques and explanations of new cholesterol guidelines published

Four new articles in Annals of Internal Medicine address the practice implications and controversy surrounding recent cholesterol treatment guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA).

The guidelines were released Nov. 12, 2013, by the Journal of the American College of Cardiology and Circulation and were covered in ACP InternistWeekly on Nov. 19. The Annals responses were published online Jan. 28.

annals.jpg

In the first Annals article, members of the panel that wrote the ACC/AHA guidelines provided a synopsis of the key features of the recommendations. They broke the guideline recommendations down into 8 areas: lifestyle, groups shown to benefit from statins, statin safety, decision making, estimation of cardiovascular disease risk, intensity of statin therapy, treatment targets, and monitoring of statin therapy.

An article in the Ideas and Opinions section highlighted some core concepts of the guidelines and discussed controversial aspects. The guidelines significantly changed previous practice by expanding their scope from prevention of coronary heart disease to atherosclerotic cardiovascular disease, including stroke, the authors said. The most controversial aspects were new risk assessment methods (including a calculator for 10-year risk) and discontinuation of treatment to a lipid target. To resolve concerns about these changes, the authors of this article suggested that clinicians could use an expanded definition of intermediate risk (5% to 15%) and refine treatment for patients in this group according to family history and coronary artery calcium score. While risk assessment should be the impetus for treatment, lipid measurements can still "serve as a marker of therapeutic response, promote adherence, motivate lifestyle improvements, and guide discussions about add-on pharmacological therapy," the authors said.

Another Ideas and Opinions piece praised the guidelines for discontinuing treatment to target but expressed concern about the lowering of risk thresholds for primary prevention. The authors would prefer that pharmacotherapy be initiated in patients whose risk is at least 10% or 15%, according to the new calculator. They recommend that patients in this risk category participate in shared decision making about statin treatment. The authors also disagreed with the guidelines' use of high-intensity statins. The authors proposed starting with moderate doses in most patients and using a shared decision-making approach to increase the dose.

Finally, an editorial analyzed why guidelines, including the ACC/AHA cholesterol recommendations, are controversial. Controversy could be reduced by including more stakeholders during development (such as through a public comment period); basing guidelines on formal, peer-reviewed, publicly available evidence reviews; providing education materials about supporting evidence for physicians and patients; and avoiding creation of a media event around release of a new guideline, the editorialist said.



Test yourself


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MKSAP Quiz: history of amenorrhea and galactorrhea

A 33-year-old woman is evaluated for a 5-month history of amenorrhea and a 3-month history of galactorrhea. The patient says her menstrual cycles were normal before onset of amenorrhea. She takes no medication.

mksap.gif

On physical examination, vital signs are normal. Visual field findings are normal. Bilateral galactorrhea is noted.

Results of laboratory studies show a serum luteinizing hormone level of 2 mU/mL (2 units/L), a prolactin level of 965 ng/mL (965 µg/L), and a free thyroxine level of 1.1 ng/dL (14 pmol/L). A serum β-human chorionic gonadotropin measurement is normal.

An MRI shows a 1.5-cm sellar mass with suprasellar extension that impinges on the optic chiasm.

Which of the following is the most appropriate initial treatment?

A: Dopamine agonist therapy
B: Oral contraceptive
C: Radiation therapy
D: Transsphenoidal surgical resection

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


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Multiple sclerosis


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Vitamin D status associated with multiple sclerosis activity, progression

Higher vitamin D levels appear to be associated with reduced disease activity and a slower rate of disease progression in multiple sclerosis (MS) patients treated with interferon beta-1b, according to a study.

The Betaferon/Betaseron in Newly Emerging multiple sclerosis For Initial Treatment (BENEFIT) study was originally designed to evaluate the impact of early versus delayed interferon beta-1b treatment in MS. From these data, researchers examined whether blood concentration of 25-hydroxyvitamin D was associated with disease activity and progression in patients with a first episode suggestive of MS.

Patients had blood serum levels taken to measure vitamin D status and MRI scans to measure disease progression for up to 5 years. Results appeared online Jan. 20 at JAMA Neurology.

During the 5 years of follow-up, 377 patients (81.3%) converted to MS defined by clinical criteria and MRI (McDonald et al MS criteria [MDMS]) and 216 (46.6%) converted to MS defined by purely clinical criteria (modified Poser et al criteria [CDMS]). Conversion rates decreased with increasing serum levels of vitamin D, more strongly after 6 months than before. Mean serum levels at 12 months predicted subsequent conversions to MDMS (P=0.02) and CDMS (P=0.05).

Higher serum vitamin D levels predicted reduced MS activity and slowed the rate of progression. A 50-nmol/L (20-ng/mL) increase in average serum levels within the first 12 months was associated with:

  • a 57% lower rate of new active MRI lesions between 12 and 60 months and a 63% lower rate between 24 and 60 months,
  • a 57% lower relapse rate (P=0.03),
  • a 25% lower yearly increase in T2 lesion volume (P<0.001), and
  • a 0.41% lower yearly loss in brain volume (P=0.07) from months 12 to 60.

Vitamin D levels greater than or equal to 50 nmol/L (20 ng/mL) at up to 12 months predicted lower disability on the Expanded Disability Status Scale (score, −0.17; P=0.004) during the next 4 years.

While more research is needed to assess what levels of vitamin D might be most beneficial, researchers noted, "The results of our study reveal a robust prognostic value of vitamin D levels measured early in the MS course and converge with previous epidemiological and biological evidence supporting a protective effect of vitamin D on the disease process underlying MS, and thus the importance of correcting vitamin D insufficiency, which affects about 50% of patients with MS in Europe and 20% in the United States."



Health care attire


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Recommendations on health care attire attempt to balance risk of cross-transmission with professional appearance

The Society for Healthcare Epidemiology of America recently issued recommendations on attire for health care personnel who work in non-operating-room settings.

The recommendations are intended to provide general guidance to the medical community. The writing group who developed the recommendations stated that any recommendations on health care attire should balance professional appearance, comfort and practicality with the potential for cross-transmission. The group noted that the evidence surrounding optimal health care attire is lacking and called for additional well-designed studies in this area.

The writing group recommended that health care facilities consider a "bare below the elbows" approach, defined as short sleeves, no wristwatches, no jewelry and no neckties during clinical practice. In institutions that mandate white coats for clinicians, the writing group recommended that each clinician have at least 2, as well as access to convenient, economical on-site laundry facilities. In addition, the group recommended that coat hooks be provided so that clinicians can remove their coats or other long-sleeved outer garments and hang them up before coming in contact with patients.

Ideally, apparel that comes into contact with the patient or the patient environment should be washed daily, the writing group said, and white coats worn while caring for patients should be washed at least once per week and when visibly dirty. The writing group noted that clinicians who don't care for many patients or who are infrequently involved in direct patient care may need to wash their white coats less often than other clinicians.

The writing group also recommended that clinicians wear closed-toe shoes with low heels and nonskid soles. ID badges should be clearly visible, and they and similar items, such as lanyards and cell phones, should be disinfected, replaced or eliminated after direct contact with the patient or the patient environment. The writing group noted that the current evidence did not support limitations on use of items such as neckties; however, the recommendations state that neckties should be secured by a white coat or some other mechanism if worn.

The writing group authors issued a caveat that all of these recommendations should be voluntary and that facilities adopting them should make a concerted effort to communicate them to both clinicians and patients and to provide appropriate education. The full expert guidance statement was published Jan. 16 by Infection Control and Hospital Epidemiology and is available free of charge online.



CMS update


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Deadline approaching to attest for 2013 EHR Incentive Program

Physicians and other eligible professionals must successfully attest by February 28 to receive an incentive payment for participation in the 2013 Medicare EHR Incentive Program.

For this program, physicians must attest to meaningful use of an EHR every year to receive the incentive and avoid the payment adjustment. Payment adjustments for those who do not successfully demonstrate meaningful use of an EHR system will begin on Jan. 1, 2015. Information and instructions on how the program works in each state can be found on the CMS website.


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CMS proposes rule change to Medicare Prescription Drug Program

CMS has issued proposed changes to the Medicare Prescription Drug Program and is asking for comments on the proposal by March 7.

The changes include strengthening fraud and abuse protections. They also include removing both antidepressant and immunosuppressant drugs from "protected" status in 2015. Protected status means that "all or substantially all" drugs within this class must be with the plan's formulary. CMS is also requesting information regarding the continued need to include antipsychotic drugs in a protected class through 2016. Antineoplastic, anticonvulsant and antiretroviral drugs will remain protected.

A summary of the proposed rule is available on the CMS website.



Physician satisfaction


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Yul Ejnes: How I changed my private practice glass from half empty to half full

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 discusses how to increase physician satisfaction and shares changes that improved his attitude toward private practice.



From the College


.
College Fellow named National Coordinator for Health Information Technology

Karen B. DeSalvo, MD, FACP, has been named the next National Coordinator for Health Information Technology by the U.S. Department of Health and Human Services.

Dr. DeSalvo, who was previously the health commissioner and senior health policy advisor for the City of New Orleans, took office on Jan. 13. She holds an MD and an MPH from Tulane University in New Orleans and received a master's in clinical epidemiology from Harvard School of Public Health in Boston. Dr. DeSalvo's full biography is available online.



Cartoon caption contest


.
Put words in our mouth

ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

acpi-20140128-cartoon.jpg

E‑mail all entries to acpinternist@acponline.org. ACP staff will choose finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.


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MKSAP Answer and Critique



The correct answer is A: Dopamine agonist therapy. This item is available to MKSAP 16 subscribers as item 64 in the Endocrinology and Metabolism section. More information is available online.

This patient has a macroprolactinoma, and administration of a dopamine agonist, such as cabergoline, is indicated as the initial treatment. Hyperprolactinemia can cause galactorrhea, oligomenorrhea, and amenorrhea in premenopausal women; erectile dysfunction in men; and decreased libido, infertility, and osteopenia in both sexes. Large tumors also may cause mass effects, which are often the presenting feature in men and postmenopausal women. This patient has amenorrhea and galactorrhea in the setting of a markedly elevated serum prolactin level. The MRI shows a pituitary mass greater than 1 cm that extends to the optic chiasm. These radiographic findings are consistent with a macroprolactinoma with chiasmal compression. The visual field examination indicates that the mass is not currently compressing the chiasm to the point of visual loss. Dopamine agonists normalize prolactin levels, correct amenorrhea and galactorrhea, and decrease tumor size by more than 50% in 80% to 90% of patients. They are used as first-line therapy, unless visual field loss is significant and progressive. Even with mild visual loss, dopamine agonists are usually used as first-line treatment. Cabergoline is generally more efficacious and better tolerated, although more expensive, than bromocriptine.

An oral contraceptive agent will replace gonadal corticosteroids and lead to menstruation but will not reduce tumor size. Simple replacement of estrogen with oral contraceptives is inappropriate therapy in this patient but may be preferable treatment in women with idiopathic hyperprolactinemia or microprolactinomas who do not desire fertility but are estrogen deficient. Because prolactinomas have estrogen receptors, tumor growth resulting from estrogen replacement therapy is possible. However, with the dosages routinely used in oral contraceptives, this growth is very uncommon.

Surgery is appropriate only in patients with resistance or intolerance to dopamine agonists, with a primarily cystic tumor, or with acute and unstable deterioration of vision. Radiation therapy, including stereotactic radiosurgery, is used even less commonly for prolactinomas but is indicated for macroprolactinomas that do not respond to either medical or surgical treatment.

Key Point

  • In a patient with a macroprolactinoma, administration of a dopamine agonist, such as cabergoline, is indicated as the initial treatment.

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Test yourself

A 63-year-old man is evaluated for pleuritic left-sided anterior chest pain, which has persisted intermittently for 1 week. The pain lasts for hours at a time and is not provoked by exertion or relieved by rest but is worse when supine. He reports transient relief with acetaminophen and codeine and occasionally when leaning forward. He has had a low-grade fever for 3 days, without cough or chills. Medical history is significant for acute pericarditis 7 months ago. Following a physical exam and electrocardiogram, what is the most appropriate management?

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