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

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ACP InternistWeekly



In the News for the Week of February 25, 2014




Highlights

Standard blood glucose targets are lower than HbA1c goals require

A recent study determined the pre- and postprandial blood glucose levels that should be targeted to reach a specific HbA1c goal in patients with type 1 or type 2 diabetes. More...

Major elective surgery usually doesn't lead to long-term opioid use

About 3% of previously opioid-naive patients continued to use opioids for more than 90 days after major elective surgery, a study found. More...


Test yourself

MKSAP Quiz: severe abdominal pain of 2 days' duration

A 43-year-old man is evaluated in the hospital for severe abdominal pain of 2 days' duration. He is otherwise healthy except for the recent finding of pancytopenia. Family history is noncontributory. His only medication is a daily multivitamin. More...


Rheumatology

Rituximab may not benefit patients with primary Sjögren's syndrome

Rituximab offered some short-term benefits to patients with primary Sjögren's syndrome, but none by 24 weeks, a study found. More...


Geriatrics

Post-hip fracture function improved with home exercise program

An at-home exercise program modestly improved function and mobility in hip fracture patients, a recent study found. More...


Immunization

ACP, other medical groups urge physicians to strongly recommend HPV vaccination

ACP and 3 other national medical associations have issued a call urging physicians across the United States to educate their patients about the human papillomavirus (HPV) vaccine and to strongly recommend vaccination. More...


ACA update

Open enrollment for insurance exchanges ends March 31

The open enrollment period for coverage within the new federal and state-run health insurance exchanges (marketplaces) ends on March 31. More...


CMS update

Deadline extended for meaningful use attestation

The Centers for Medicare and Medicaid Services has announced an extension of the deadline for physicians and other health care professionals to attest to meaningful use in the Medicare electronic health record (EHR) incentive program. More...


Certification

ABIM seeks input on physician knowledge and skill assessment approaches

The American Board of Internal Medicine (ABIM) has convened a task force of experts within and outside the field of medicine to define what competencies physicians will need as the field continues to evolve and as a means to find the best ways to measure those competencies. More...


From the College

The high cost of 'free' unnecessary medical equipment

Yul Ejnes, MD, MACP, a member of ACP Internist's editorial board, continues his monthly column at KevinMD.com about durable medical equipment-related fraud and abuse. More...

ACP and MGMA collaborate on online cost survey

ACP and the Medical Group Management Association (MGMA) are working together to provide physicians an opportunity to participate in an exciting new streamlined MGMA 2014 Cost Survey. 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


.
Standard blood glucose targets are lower than HbA1c goals require

A recent study determined the pre- and postprandial blood glucose levels that should be targeted to reach a specific HbA1c goal in patients with type 1 or type 2 diabetes.

Researchers used data from participants in the hemoglobin A1c-Derived Average Glucose (ADAG) study, a multicenter observational study that included continuous glucose monitoring and self-monitoring blood glucose (SMBG) readings. Of the 470 patients included in this analysis, 237 had type 1 diabetes and 147 had type 2 diabetes. Their average fasting, premeal, postmeal and bedtime blood glucose readings were compared to their HbA1c levels.

Results were published online Feb. 10 by Diabetes Care.

The researchers found that an HbA1c of 5.5% to 6.49% was associated with an average fasting glucose of 122 mg/dL (95% CI, 117 to 127 mg/dL), an HbA1c of 6.5% to 6.99% was associated with 142 mg/dL fasting (95% CI, 135 to 150 mg/dL), an HbA1c of 7.5% to 7.99% was associated with 167 mg/dL (95% CI, 157 to 177 mg/dL), and an HbA1c of 8.0% to 8.5% was associated with 178 mg/dL (95% CI, 164 to 192 mg/dL). Postmeal average glucose was 139 mg/dL for patients with an HbA1c of 6.5% to 6.99% and 152 mg/dL for those with an HbA1c of 7.0% to 7.49%. Bedtime glucose was 153 mg/dL and 177 mg/dL in those HbA1c categories, respectively. Type 1 and type 2 diabetes patients were analyzed separately, but because their results were fairly similar, they were combined in the final analysis. (To convert glucose values to approximate equivalents in mmol/L, divide the mg/dL value by 18.)

The results show that "currently published SMBG targets are not consistent with the empirical data," the authors concluded. They noted that most SMBG targets are based on expert opinion or extrapolations from average daily glucose levels. Current recommendations typically target a fasting glucose of under 100 to 115 mg/dL, the authors noted, but this study shows that patients with an HbA1c of 5.5% to 6.49% have a fasting glucose of 122 mg/dL. For postprandial glucose, this study provides more specific numbers than the usual target of less than 180 mg/dL, they said.

Glucose monitoring schedules and goals are complex issues that should be decided based on individual factors, but these data may help patients and clinicians choose appropriate SMBG goals to achieve their selected HbA1c targets, the study authors said. They encouraged professional societies, clinicians and patients to consider these data in their future decision-making.


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Major elective surgery usually doesn't lead to long-term opioid use

About 3% of previously opioid-naive patients continued to use opioids for more than 90 days after major elective surgery, a study found.

Researchers conducted a retrospective cohort study in acute care hospitals in Ontario, Canada. Using several linked population-based administrative databases, they included 39,140 opioid-naive patients age 66 years or older who had 1 of 9 major elective surgeries from April 2003 to March 2010. Surgeries included cardiac, intrathoracic, intra-abdominal, and pelvic procedures.

Results appeared online Feb. 11 at BMJ.

Of the studied patients, 49.2% (n=19,256) were discharged from the hospital with an opioid prescription, and 3.1% (n=1,229) continued to receive opioids for more than 90 days after surgery.

The type of surgical procedure was highly associated with prolonged opioid use. Thoracic procedures had the highest risks (odds ratio [OR], 2.58 [95% CI, 2.03 to 3.28] for open thoracic procedures compared to open radical prostatectomies and 1.95 [95% CI, 1.36 to 2.78] for minimally invasive thoracic procedures). Major gynecological procedures were associated with even lower risks than radical prostatectomies (OR, 0.73 [95% CI, 0.55 to 0.98] for open gynecological procedures and 0.45 [95% CI, 0.33 to 0.62] for minimally invasive gynecological procedures).

Patient-related factors associated with significantly higher risks of prolonged opioid use included younger age; lower household income; specific comorbidities such as diabetes, heart failure and pulmonary disease; and use of certain drugs preoperatively, such as benzodiazepines, selective serotonin reuptake inhibitors and angiotensin-converting enzyme inhibitors.

The researchers noted that the figure of 3.1% represents a large absolute number of patients who continue to use opioids for more than 3 months after surgery, and a substantial overall public health concern at the population level.

Still, researchers wrote, "Patients can therefore be reassured that when people receive opioids appropriately to treat acute pain after major surgery, the majority do not experience prolonged use. Our findings therefore help inform patients' and clinicians' understanding of the risks of prolonged opioid use after major surgery, especially since patients' understandable fears about opioid dependence may be an important barrier to achieving adequate acute postsurgical pain relief."



Test yourself


.
MKSAP Quiz: severe abdominal pain of 2 days' duration

A 43-year-old man is evaluated in the hospital for severe abdominal pain of 2 days' duration. He is otherwise healthy except for the recent finding of pancytopenia. Family history is noncontributory. His only medication is a daily multivitamin. Following a physical exam and lab results, what test is most likely to establish the diagnosis?

mksap.gif

On physical examination, temperature is 36.2 °C (97.2 °F), blood pressure is 143/69 mm Hg, pulse rate is 86/min, and respiration rate is 12/min. The patient appears jaundiced. There is no splenomegaly. The remainder of the examination is normal.

Laboratory studies were as follows:

Haptoglobin Undetectable
Hemoglobin 10.4 g/dL (104 g/L)
Leukocyte count 3400/µL (3.4 × 109/L)
Platelet count 89,000/µL (89 × 109/L)
Reticulocyte count 7%
Total bilirubin 2.8 mg/dL (48 µmol/L)
Direct bilirubin 0.4 mg/dL (7 µmol/L)
Lactate dehydrogenase 775 units/L

His complete blood count and liver chemistry values from 1 year ago were normal.

A CT scan of the abdomen shows mesenteric vein thrombosis but no lymphadenopathy or splenomegaly.

Which of the following tests is most likely to establish the diagnosis?

A: Direct Coombs (antiglobulin) test
B: Factor V Leiden assay
C: Flow cytometric analysis for CD55 and CD59
D: Lupus anticoagulant and anticardiolipin antibody assay

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


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Rheumatology


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Rituximab may not benefit patients with primary Sjögren's syndrome

Rituximab offered some short-term benefits to patients with primary Sjögren's syndrome, but none by 24 weeks, a study found.

Researchers conducted a multicenter, double-blind, randomized, placebo-controlled trial to evaluate the efficacy and harms of rituximab in adults with recent-onset or systemic Sjögren's syndrome from March 2008 and January 2011. Coming from 14 university hospitals in France, participants were 120 patients with scores of 50 mm or greater (with 0 mm representing none to 100 mm being the worst) on at least 2 of 4 visual analogue scales (VAS) of global disease, pain, fatigue, and dryness, and less than 10 years' history of biologically active or systemic Sjögren's syndrome. Patients were randomized 1:1 to rituximab, 1 g at baseline and week 2, or to placebo.

annals.jpg

Results appeared in the Feb. 18 Annals of Internal Medicine.

Rituximab alleviated some symptoms, particularly fatigue, early in the trial but did not reduce symptoms or disease activity at 24 months. Decreases of at least 30 mm in at least 2 of the 4 VAS scores occurred in 9.1% of patients in the placebo group at 6 weeks, 17.0% at 16 weeks, and 22.0% at 24 weeks. The same measures were 22.4% at 6 weeks, 26.3% at 16 weeks, and 23.0% at 24 weeks in the rituximab group. The percentage was larger in the rituximab group only at week 6 (difference, 13.3 percentage points; 95% CI, 0.8 to 25.8 percentage points; P=0.036). For the primary outcome (decrease at week 24), the difference (1.0 percentage point; 95% CI, −16.7 to 18.7 percentage points) was not significant.

More infusion reactions occurred with rituximab than placebo, but no other differences in adverse events occurred. The researchers noted that although the data provide some support for the efficacy of rituximab reported in 2 previous preliminary studies, the size and duration of the benefit argue against using the drug to treat Sjögren's syndrome.

"Rituximab was associated with clinically significant improvements at week 6, suggesting transient efficacy that was not maintained throughout the 24-week period with our regimen," they wrote. "Fatigue was alleviated early, whereas effects on dryness were delayed."



Geriatrics


.
Post-hip fracture function improved with home exercise program

An at-home exercise program modestly improved function and mobility in hip fracture patients, a recent study found.

The trial included 232 functionally limited older adults who had completed traditional rehabilitation after a hip fracture between 2008 and 2012. They were randomized to either a 6-month exercise program taught in their homes by a physical therapist or a control program of in-home and telephone-based cardiovascular nutrition education. The exercise program focused on functionally oriented exercises, such as standing from a chair and climbing a step, and included no more than 4 visits from the physical therapist.

Patients' physical function was measured at baseline, 6 months and 9 months, and results were published in the Feb. 19 Journal of the American Medical Association.

At both 6- and 9-month assessments, the intervention group had clinically significant improvements in functional mobility compared to controls, as measured by the Short Physical Performance Battery. When assessed with the Activity Measure for Post-Acute Care instrument, the difference between groups was also statistically significant but did not meet the study's prespecified standard for clinical significance.

The study measured function using both patient-reported and physical performance measures, and while home exercise improved both types, the differences were greater in the performance-based measures, the researchers noted. "This finding suggests that it may be easier to improve a person's capacity to function than to change their actual level of function in daily life in the face of significant comorbidities," the authors said.

The most effective way to improve long-term functional outcomes for hip fracture patients would be extended rehabilitation, the authors noted, but costs are prohibitive, so patients are typically discharged from therapy with a written home exercise program. This study provides an alternative middle strategy, which gives patients more guidance on their at-home exercise. Future research should evaluate the cost-effectiveness of such a system in clinical practice, the authors concluded.



Immunization


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ACP, other medical groups urge physicians to strongly recommend HPV vaccination

ACP and 3 other national medical associations, the American Academy of Family Physicians, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, together with the Immunization Action Coalition and the Centers for Disease Control and Prevention, have issued a call urging physicians across the United States to educate their patients about the human papillomavirus (HPV) vaccine and to strongly recommend vaccination.

In a "Dear Colleague" letter issued earlier this month, medical and public health organizations emphasized to physicians that strong clinician recommendations are critical to increasing the rate of HPV vaccination and preventing HPV-associated cancers. Despite more than 7 years of vaccine monitoring showing overwhelming evidence of HPV vaccine safety and effectiveness, HPV vaccination rates are not improving while rates for other adolescent vaccines are.

In the U.S. alone, 79 million people are currently infected with HPV. Every year, 14 million are newly infected and 26,000 cancers attributable to HPV are diagnosed. Studies show that when a clinician strongly recommends HPV vaccination, patients are 4 to 5 times more likely to receive the HPV vaccine.

Read the complete "Dear Colleague" letter here.



ACA update


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Open enrollment for insurance exchanges ends March 31

The open enrollment period for coverage within the new federal and state-run health insurance exchanges (marketplaces) ends on March 31.

The next open enrollment period is scheduled to begin Nov. 15, unless an applicant qualifies for a special-circumstance enrollment period. Individuals who do not have health insurance, either through the exchange or some other means, may have to pay a penalty of either 1% of their income or $95 per adult, whichever is higher. The penalty will increase in future years.

More detailed patient information is available on healthcare.gov.

If you'd like guidance on where to direct patients who need help enrolling in the exchange, please visit ACP's enrollment website.



CMS update


.
Deadline extended for meaningful use attestation

The Centers for Medicare and Medicaid Services has announced an extension of the deadline for physicians and other health care professionals to attest to meaningful use in the Medicare electronic health record (EHR) incentive program.

Instead of Feb. 28, the new deadline will be March 31. Information about the new deadline is on the CMS EHR Incentive Program page.

Additional information on meaningful use and the EHR incentive program is available on the ACP website.



Certification


.
ABIM seeks input on physician knowledge and skill assessment approaches

The American Board of Internal Medicine (ABIM) has convened a task force of experts within and outside the field of medicine to define what competencies physicians will need as the field continues to evolve and as a means to find the best ways to measure those competencies.

ACP is being represented on the task force by Patrick Alguire, MD, FACP, senior vice president for medical education. The "Assessment 2020" Task Force will engage physicians, patients, assessment experts and other health care stakeholders in a conversation about assessment of the future and will help define what competencies physicians will need as the field of medicine continues to evolve and the best ways to measure those competencies.

For more information, visit the Task Force website. ABIM has also created the Assessment 2020 blog, which aims to engage the external community on a variety of topics in the area of assessment.

For information on ACP's resources to help earn points toward recertification, visit the College's website.



From the College


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The high cost of 'free' unnecessary medical equipment

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 durable medical equipment-related fraud and abuse and what physicians and patients can do to prevent it.

"Patients should keep in mind that not everything that Medicare covers is medically necessary, just as not everything that is medically necessary is covered by Medicare," Dr. Ejnes writes.


.
ACP and MGMA collaborate on online cost survey

ACP and the Medical Group Management Association (MGMA) are working together to provide physicians an opportunity to participate in an exciting new streamlined MGMA 2014 Cost Survey.

The survey gathers financial and other data that can help with managing costs, comparing physician and staff compensation, optimizing clinician and office staffing and managing practice finances. Participants in the survey will receive a free report comparing their own practice to benchmarks of their peers.

Your participation in this influential survey will make a difference to your ACP peers and the industry. Historically, internal medicine and small practices have been under-represented, and your participation can help to ensure that reliable benchmarks can be provided. The survey deadline is April 18. To participate, go online. Registration and participation are free and confidential.

If you have questions, please contact MGMA's Data Solutions toll-free at 877-275-6462, ext. 1895, or e-mail survey@mgma.com.



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-20140225-cartoon.jpg

"You've heard about the primary care shortage ... "

This issue's winning cartoon caption was submitted by Monica K. Martin, MD, ACP Member. Thanks to all who voted! The winning entry captured 40% of the votes.

The runners-up were:

"Let's stop the growth hormone injections. What do you think?"

"After a dramatic increase in the rate of hip fractures, the hospital decided to re-evaluate its bunk bed program."


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MKSAP Answer and Critique



The correct answer is C: Flow cytometric analysis for CD55 and CD5. This item is available to MKSAP 16 subscribers as item 60 in the Hematology and Oncology section. More information is available online.

The most appropriate test to establish a diagnosis is flow cytometric analysis for CD55 and CD59 on leukocytes or erythrocytes. This patient most likely has paroxysmal nocturnal hemoglobinuria (PNH), which is a primary acquired stem cell disorder characterized by a wide spectrum of clinical and laboratory findings, such as unprovoked venous thrombosis at an unusual location, hemolytic anemia, and mild to moderate pancytopenia. The diagnosis of PNH is made by flow cytometry, which can identify a subpopulation of erythrocytes or leukocytes lacking specific glycosylphosphatidylinositol-anchored surface proteins, such as CD55 or CD59.

The direct Coombs (antiglobulin) test is useful in the evaluation of autoimmune hemolysis. Autoimmune hemolytic anemia may be characterized by splenomegaly, spherocytic-shaped erythrocytes, reticulocytosis, elevated levels of unconjugated bilirubin and lactate dehydrogenase, and depressed levels of haptoglobin. Although this patient has some of these findings, he has no splenomegaly, and autoimmune hemolysis would not explain his pancytopenia or thrombosis.

Factor V Leiden is the most common inherited thrombophilic disorder and accounts for approximately half of the inherited thrombophilias in patients with venous thromboembolism. Although it may increase the risk for deep venous thrombosis, factor V Leiden would not explain this patient's pancytopenia or hemolysis.

The antiphospholipid syndrome is associated with an increased risk for venous and arterial thromboembolism. Common sites of thrombosis include the lower extremities but may also include the visceral veins. There is also a strong correlation between this syndrome and pregnancy loss. Antiphospholipid syndrome could explain the patient's unprovoked thrombosis but would not account for his pancytopenia or hemolysis.

Key Point

  • The diagnosis of paroxysmal nocturnal hemoglobinuria is established by flow cytometric analysis of CD55 and CD59 on leukocytes and erythrocytes.

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Test yourself

A 19-year-old man is evaluated for a sore throat, daily fever, frontal headache, myalgia, and arthralgia of 5 days' duration. He also has severe discomfort in the lower spine and a rash on his trunk and extremities. He returned from a 7-day trip to the Caribbean 8 days ago. The remainder of the history is noncontributory. Following a physical exam and lab studies, what is the most likely diagnosis?

Find the answer

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