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

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ACP InternistWeekly



In the News for the Week of February 4, 2014




Highlights

ACIP adult vaccine schedule updated for 2014

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) just announced its recommended 2014 adult immunization schedule. More...

Home stool test will detect most colorectal cancers

Fecal immunochemical tests (FITs) have high accuracy, high specificity and moderately high sensitivity and can detect about 4 out of 5 colorectal cancers, according to an evidence review. More...


Test yourself

MKSAP Quiz: persistent heartburn and regurgitation

A 50-year-old man is evaluated for persistent heartburn and regurgitation despite taking a high-dose proton-pump inhibitor twice a day for 6 months. His symptoms have improved, but he continues to have symptoms many times a week. He has not had dysphagia, chest pain or weight loss. He has significantly modified his diet. His only medication is esomeprazole, 40 mg twice a day, which he takes as directed. Endoscopy reveals persistent esophagitis and a moderately large hiatal hernia. His BMI is 34. What is the most appropriate next step in treatment? More...


Heart failure

Memory problems common, under-recognized in older heart failure patients

Many more elderly patients with heart failure have cognitive impairment than their treating cardiologists realize, a recent study found. More...


Women's health

Postmenopausal HRT associated with higher acute pancreatitis risk, study finds

Postmenopausal women taking hormone replacement therapy (HRT) may be at higher risk for acute pancreatitis, according to a new study. More...


Tools and resources

Three medical societies offer expert advice online to treat hepatitis C

A new website offers up-to-date guidance for the treatment of hepatitis C virus (HCV) infection, including sections on testing and linkage to care; initial treatment and retreatment options, and unique populations such as individuals with HIV, cirrhosis or liver transplant. More...


Internal Medicine 2014

Submit a profile to the ACP Job Placement Center by March 8

Looking for a job? ACP's Job Placement Center offers career opportunities during Internal Medicine 2014. More...

ACP Annual Business Meeting to be held during Internal Medicine 2014

All members are encouraged to attend ACP's Annual Business Meeting to be held during Internal Medicine 2014. More...


From ACP Internist

The next issue of ACP Internist is online

The next issue of ACP Internist is online and coming to your mailbox, including stories on patients refusing treatment and addressing psoriasis symptoms. More...


From the College

Share your story or recommend a mentor or colleague

Each month, in ACP's Medical Student Member newsletter IMpact, the My Kind of Medicine article features the career of an internal medicine specialist or subspecialist. Share your own story. 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: Philip Masters, MD, FACP



Highlights


.
ACIP adult vaccine schedule updated for 2014

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) just announced its recommended 2014 adult immunization schedule.

annals.jpg

The full schedule was published in the Feb. 4 Annals of Internal Medicine and on the CDC's website. The ACIP includes ACP and 16 other medical societies. The recommendations are intended to guide physicians and other clinicians about the appropriate vaccines for their adult patients.

The recommendations, which were approved in October 2013, include changes for several vaccines:

  • Influenza. Recommendations on the recombinant influenza (RIV) and inactivated influenza (IIV) vaccines now indicate that RIV or IIV can be used among persons with hives-only allergy to eggs and RIV can be used in persons age 18 to 49 with egg allergy of any severity.
  • Haemophilus influenza type b (Hib). The recommendations were updated to note that vaccination of patients with HIV is no longer recommended because their risk of Hib is low. Adults who have had a successful hematopoietic stem-cell transplant should receive a 3-dose series of Hib vaccine 6 to 12 months after the transplant regardless of prior Hib vaccination status.
  • Health care workers. Notes about health care personnel were removed from the HPV and zoster recommendations. Being a health care worker is not a specific indication for either vaccine. The vaccines should be given to those who meet the age and other indications.
  • Human papillomavirus (HPV). Information was added to clarify the timing between the second and third doses. The second dose should be administered 4 to 8 weeks (minimum interval of 4 weeks) after the first dose; the third dose should be administered 24 weeks after the first dose and 16 weeks after the second dose (minimum interval of 12 weeks).
  • Pneumonia. The recommendation was updated to remind clinicians that pneumococcal conjugate vaccine (PCV13) should be administered before the pneumococcal polysaccharide vaccine (PPSV23) in persons for whom both vaccines are recommended.
  • Meningitis. The meningococcal vaccine recommendation was edited to clarify which persons need 1 or 2 doses of vaccine and which should receive meningococcal conjugate (MenACWY-D) versus the meningococcal polysaccharide (MenACWY-CRM). MenACWY-D is preferred for those age 55 years or younger as well as for adults age 56 years or older who were vaccinated previously with MenACWY-D or for whom multiple doses are anticipated. Two doses (of MenACWY-D) are recommended at least 2 months apart to adults with functional asplenia or persistent complement component deficiencies. (HIV infection is not an indication for routine vaccination with MenACWY-D.) A single dose of vaccine is recommended for military recruits, persons at risk during an outbreak attributable to a vaccine serogroup, and travelers to countries in which disease is hyperendemic or epidemic. MenACWY-CRM is preferred for adults age 56 years or older who have not received MenACWY-D previously and who require a single dose only.
  • Tetanus, diphtheria, acellular pertussis (Tdap) and tetanus, diphtheria (Td). Tdap and Td vaccine recommendations were edited to harmonize with the language used in the pediatric immunization schedule. A single dose of Tdap vaccine is recommended for previously unvaccinated persons age 11 years or older, and Td booster should be administered every 10 years thereafter.

A study in the same issue of Annals reported U.S. primary care physicians' perspectives on adult vaccines. The survey of general internists and family physicians found that most don't assess vaccination status at every visit and that the biggest barriers to vaccination are financial. Vaccination rates could be improved by more communication between physicians and alternate vaccinators, more use of electronic tools, and removal of policy-related barriers, the authors concluded.


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Home stool test will detect most colorectal cancers

Fecal immunochemical tests (FITs) have high accuracy, high specificity and moderately high sensitivity and can detect about 4 out of 5 colorectal cancers, according to an evidence review.

annals.jpg

Researchers reviewed 19 published studies of 8 different brands of FITs to determine their diagnostic accuracy for colorectal cancer and to identify factors affecting their performance characteristics. (Two brands have been discontinued and are no longer produced in the United States.)

Results appeared in the Feb. 4 Annals of Internal Medicine.

The overall accuracy of FIT was 95% (95% CI, 93% to 97%). Among the pooled results, on average, the FITs were sensitive (0.79; 95% CI, 0.69 to 0.86) to colorectal cancers with only one round of testing. The tests were also highly specific (0.94; 95% CI, 0.92 to 0.95). The positive likelihood ratio was 13.10 (95% CI, 10.49 to 16.35), and the negative likelihood ratio was 0.23 (95% CI, 0.15 to 0.33). (A positive likelihood ratio greater than 5 and a negative likelihood ratio less than 0.2 provide strong diagnostic evidence to rule in or rule out diagnoses.)

No brand performed markedly better than another, although the confidence intervals were fairly wide for sensitivity. The authors cautioned that only 2 brands had several studies that could be pooled in a subgroup analyses and that there was only 1 study comparing brands head-to-head. While most of the FITs required collection of only 1 stool sample, brands that required 2 or 3 stool samples were no more accurate than those requiring only 1 sample.

The authors noted that FIT type could be customized to different-sized care settings without significant variability in accuracy, allowing health systems wishing to optimize use to balance tradeoffs between increasing sensitivity by lowering the cutoff threshold for a positive test and the resulting increase in the number of positive test results.

A FIT cutoff value less than 20 µg/g had the best combination of sensitivity (89%) and specificity (91%) for colorectal cancer and the lowest negative likelihood ratio (0.16) compared with the subgroups with cutoff values of 20 to 50 µg/g and greater than 50 µg/g. However, studies using a 1-sample FIT with cutoff values less than 20 µg/g had positivity rates that were generally greater than those for 1-sample FITs at cutoff values of 20 to 50 µg/g.

"Considering the lack of colonoscopy resources across the world, identifying an optimal cutoff value for defining a positive result deserves considerable attention because this number can influence both the number of cancer cases detected as well as the number of colonoscopies needed in a [colorectal cancer] screening program," the authors wrote.



Test yourself


.
MKSAP Quiz: persistent heartburn and regurgitation

A 50-year-old man is evaluated for persistent heartburn and regurgitation despite taking a high-dose proton-pump inhibitor twice a day for 6 months. His symptoms have improved, but he continues to have symptoms many times a week. He has not had dysphagia, chest pain or weight loss. He has significantly modified his diet. His only medication is esomeprazole, 40 mg twice a day, which he takes as directed.

mksap.gif

Physical examination is notable for a BMI of 34. The remainder of the physical examination is normal.

Endoscopy reveals persistent esophagitis and a moderately large hiatal hernia.

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

A: Add twice-daily sucralfate
B: Fundoplication
C: Increase dose of esomeprazole
D: Radiofrequency ablation

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


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Heart failure


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Memory problems common, under-recognized in older heart failure patients

Many more elderly patients with heart failure have cognitive impairment than their treating cardiologists realize, a recent study found.

Researchers at multiple sites in France studied 912 ambulatory heart failure patients age 70 or above treated by cardiologists between January and November 2009. On average, the patients' heart failure had been diagnosed 4.4 years earlier and mean ejection fraction was 43.6%. Patients in the study were given the delayed recall Memory Impairment Screen (MIS-D). Results were published online by the American Journal of Cardiology in January.

The 291 participating cardiologists suspected that 109 patients (12% of the total) had memory impairment. However, results on the MIS-D revealed that 45.6% of the patients had memory impairment (95% CI, 42.4% to 48.8%) and 23.4% had severe memory impairment (95% CI, 20.6% to 26.1%). The study found an association between greater memory impairment and more severe heart failure class. However, this finding was no longer significant when adjusted for older age, lower education level, depression, history of stroke, renal failure and less physical activity (all independent predictors of impairment).

Researchers concluded that memory impairment is common among older patients with heart failure and that screening tools such as the MIS-D could help identify patients at risk. Identification of these patients is important because management of their disease requires "complex pharmacological therapy, diet and fluid restrictions, monitored physical activity and patient education that can be difficult to understand, remember and manage for patients with cognitive impairment," the authors wrote.

The mechanism for the association between impairment and heart failure is not known, the study authors said, although they offered 3 possibilities: common risk factors such as hypertension, diabetes or dyslipidemia; focal brain vascular lesions or chronic ischemia; and decreased cardiac output leading to inadequate cerebral perfusion. Regardless of the cause, better identification of impairment could allow physicians to take steps (such as pill boxes or nurse visits) to improve heart failure patients' ability to care for themselves.



Women's health


.
Postmenopausal HRT associated with higher acute pancreatitis risk, study finds

Postmenopausal women taking hormone replacement therapy (HRT) may be at higher risk for acute pancreatitis, according to a new study.

Researchers performed a prospective study of postmenopausal women who participated in the Swedish Mammography Cohort. All women took a baseline questionnaire in 1997 that asked about HRT use. The study cohort was compared with the Swedish National Patient Register to assess hospital admissions due to acute pancreatitis through 2010. The study results were published online by CMAJ on Jan. 27.

A total of 31,494 women ranging in age from 48 to 83 years were included in the study. Total follow-up was 389,456 person-years, and in that time, 237 cases of incident acute pancreatitis were identified. Forty-two percent of women used HRT at baseline and 12% had used it in the past. Among those who were currently taking HRT at baseline, 6,795 (52%) were taking systemic therapy, 4,148 (32%) were using local therapy and 2,170 (17%) were using both. Age-standardized incidence rates of acute pancreatitis were 71 cases per 100,000 person-years in women who had ever used HRT and 52 cases per 100,000 person-years in those who had never done so. The multivariable-adjusted relative risk among ever users was 1.57 (95% CI, 1.20 to 2.05) versus never users. The researchers did not find a difference in risk between current and past use, but women who took systemic therapy and those who took HRT for over 10 years appeared to have higher risk (relative risks, 1.92 [95% CI, 1.38 to 2.66] and 1.87 [95% CI, 1.11 to 3.17], respectively).

The authors acknowledged that their study relied on self-reported information on HRT and that information on the type of HRT used was lacking, among other limitations. However, based on their results, they concluded that postmenopausal HRT is associated with a higher risk for acute pancreatitis in this population and that more research, including research on the role of HRT preparation, dose and route of administration, is needed. "If these findings are confirmed by other studies, the risk of acute pancreatitis should be considered when hormone replacement therapy is prescribed," they wrote.



Tools and resources


.
Three medical societies offer expert advice online to treat hepatitis C

A new website offers up-to-date guidance for the treatment of hepatitis C virus (HCV) infection, including sections on testing and linkage to care; initial treatment and retreatment options, and unique populations such as individuals with HIV, cirrhosis or liver transplant.

A panel of 26 liver disease and infectious disease specialists and a patient advocate developed evidence-based consensus recommendations for the screening, treatment and management of patients with HCV. This guidance is intended for clinicians who treat the disease and others who need updated information about best practices. The site will be updated to keep pace with improved diagnostic tools and new drug options as they are approved by the FDA.

The website is meant to help clinicians figure out optimal treatment despite the rapid pace of drug development. For example, in the past 3 months, 2 new medications became available for treating HCV and more are expected.

The website is a collaboration of the American Association for the Study of Liver Diseases, the Infectious Diseases Society of America and the International Antiviral Society-USA.



Internal Medicine 2014


.
Submit a profile to the ACP Job Placement Center by March 8

Looking for a job? ACP's Job Placement Center offers career opportunities during Internal Medicine 2014, to be held April 10-12 in Orlando, Fla. Submit a Job Seeker's Profile (mini-CV) to be included in 1 of 2 booklets based on your criteria. Your profile is guaranteed to be distributed to participating employers who submit a job posting to the center. You do not have to attend the meeting to submit a profile.

All physicians who submit a Job Seeker's Profile by March 8 (limit, 1 mini-CV per physician) will be eligible for 2 drawings for a $100 Amazon gift card. The first drawing will be held on March 10. The second drawing will be on April 12. Winners will be contacted by e-mail. You do not have to attend Internal Medicine 2014 to be eligible for the drawings.

The Job Placement Center, located in the Orange County Convention Center, Exhibit Hall B2, Booth #1075, provides physicians with tools to assist in job searches, as well as the opportunity to meet with potential employers.

Submit your profile online today.


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ACP Annual Business Meeting to be held during Internal Medicine 2014

All members are encouraged to attend ACP's Annual Business Meeting to be held during Internal Medicine 2014. Current College Officers will retire from office and incoming Officers, new Regents and Governors will be introduced.

The business meeting will be held at the Orange County Convention Center, Orlando, Fla., on Saturday, April 12, from 12:45 p.m. to 1:45 p.m. with ACP president Molly Cooke, MD, FACP, presiding.

Robert A. Gluckman, MD, FACP, will present the Annual Report of the Treasurer. A key feature of the meeting is the presentation of ACP's priorities for 2014-2015 by Executive Vice President and Chief Executive Officer Steven E. Weinberger, MD, FACP. Members will have the opportunity to ask questions following Dr. Weinberger's presentation.



From ACP Internist


.
The next issue of ACP Internist is online

The next issue of ACP Internist is online and coming to your mailbox. Featured in this month's issue are:

acpi-20140204-internist.jpg

Look for reasons if patients refuse advice. Refusal can be frustrating for physicians, who likely see their medical advice as contributing toward healing and improving quality of life. But patients reserve the right to make informed decisions about their care, even if these decisions run counter to what's been recommended.

Psoriasis symptoms can be tough to address. A recent survey showed that many psoriasis patients are not satisfied with their care, reporting inadequate relief from such symptoms as itching and scaling. Learn more about clues to diagnosis and suggestions on treating and managing symptoms of both mild and more severe disease.

More stories, the latest MKSAP Quiz, and our blog are all online.



From the College


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Share your story or recommend a mentor or colleague

Each month, in ACP's Medical Student Member newsletter IMpact, the My Kind of Medicine article features the career of an internal medicine specialist or subspecialist. These stories about positive role models help to inspire students to pursue careers in internal medicine. Share your story, or recommend a colleague's story, today. Selected physicians will be interviewed by ACP staff and profiled in an upcoming issue of IMpact.



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-20140204-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 B: Fundoplication. This item is available to MKSAP 16 subscribers as item 52 in the Gastroenterology and Hepatology section. More information is available online.

This patient should be offered fundoplication. He continues to have persistent gastroesophageal reflux disease (GERD) manifested by esophagitis despite high-dose proton-pump inhibitor (PPI) therapy. Patients with persistent symptoms despite PPI therapy should be assessed for adherence to medication regimens and correct administration (30 to 45 minutes before a meal). Patients should also be assessed for other symptoms that may indicate alternative diagnoses such as eosinophilic esophagitis, heart disease, or achalasia. The next step in evaluation should be endoscopy; if endoscopy is unrevealing, 24-hour ambulatory pH testing should be performed. In this patient, esophagitis on endoscopy indicates persistent uncontrolled GERD despite maximal medical therapy. The notable endoscopic findings make it unnecessary to perform an ambulatory reflux study. The best treatment is surgical fundoplication, which has been shown to be effective in controlling excessive distal esophageal acid exposure. The best outcomes are observed in patients whose symptoms respond to medical therapy and who have few comorbidities. Relief of symptoms with surgery is significant but not always long-lasting; more than half of patients who have surgery for GERD resume regular PPI therapy 10 to 15 years after surgery. Side effects of surgery, which include dysphagia, gas-bloat syndrome, and diarrhea, occur in approximately 25% of patients.

Increasing the dose of esomeprazole or adding sucralfate would not lead to long-term healing of esophagitis and symptom relief in this 50-year-old patient, given that doses of greater than 80 mg of esomeprazole per day do not lead to appreciably increasing acid suppression. Sucralfate is prescribed for short-term use as an adjunct to PPI therapy.

Endoscopic antireflux procedures such as radiofrequency ablation have not been shown to achieve significant long-term reduction in esophageal acid exposure and remain experimental at this time.

Key Point

  • Fundoplication is a therapeutic option for confirmed gastroesophageal reflux disease that is refractory to proton-pump inhibitor therapy.

Click here to return to the rest of ACP InternistWeekly.

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