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

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ACP InternistWeekly



In the News for the Week of March 11, 2014




Highlights

New guidelines on valvular heart disease released

Cardiology experts released new updated guidelines on the management of valvular heart disease (VHD) last week. More...

Warfarin associated with better 1-year outcomes for patients with CKD who experience acute MI with afib

Giving warfarin to acute myocardial infarction (MI) patients with atrial fibrillation who have chronic kidney disease (CKD) was associated with better 1-year outcomes than not giving warfarin, a study found. More...


Test yourself

MKSAP Quiz: routine follow-up visit for diabetes and hyperlipidemia

A 59-year-old woman is evaluated during a routine follow-up visit. She was recently diagnosed with type 2 diabetes mellitus and hyperlipidemia. She feels well. Medications are metformin, atorvastatin, and aspirin. Following a physical exam and lab results, what is the most appropriate diagnostic test to perform next? More...


Prostate cancer

Radical prostatectomy may offer advantages over watchful waiting

Men with prostate cancer may survive longer with radical prostatectomy than watchful waiting, especially if they are younger than 65 years of age at diagnosis, a study suggested. More...

Surgery performs better than radiotherapy for non-metastatic prostate cancer

Surgery was associated with better survival than radiotherapy in men with non-metastatic prostate cancer, according to a large observational study with follow-up as long as 15 years. More...


Hyponatremia

European societies release guideline on diagnosis, treatment of hyponatremia

Three European societies recently released a clinical practice guideline on the diagnosis and treatment of hyponatremia. More...


Resources

New tool available for integrating primary care and public health

A new tool to integrate primary care and public health called "A Practical Playbook: Public Health & Primary Care Together" is now available online. More...


From the College

College Master, Fellow receive Heinz Awards

A College Master and a College Fellow were recently named recipients of the 19th Heinz Awards. More...


For the record

Correction to a previous issue

An item in last week's ACP InternistWeekly required correction. 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


.
New guidelines on valvular heart disease released

Cardiology experts released new updated guidelines on the management of valvular heart disease (VHD) last week.

The American Heart Association/American College of Cardiology (AHA/ACC) guideline on VHD was last updated in 2008, and among the changes in the 2014 version are new stages of disease severity for categorizing the disease:

  • Stage A: at risk for VHD
  • Stage B: progressive VHD
  • Stage C: asymptomatic, severe VHD
  • Stage D: severe, symptomatic VHD

The new guideline lowers the threshold for intervention for some patient populations (such as those with severe asymptomatic aortic stenosis or mitral regurgitation) and provides a new scoring system for evaluating surgical and interventional risk. The score is based on the patient's frailty, major organ system compromise, procedure-specific impediments and the Society of Thoracic Surgeons predicted risk of mortality score.

Other additions in the latest version of the guideline include discussion of transcatheter aortic valve replacement and heart valve team care. The format has also changed to include decision pathway diagrams and summary tables, which will make the guideline easier to use at the point of care, according to a press release.

In addition to the AHA and ACC, the American Association for Thoracic Surgery, American Society for Echocardiography, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons collaborated on the guideline development. It will be published in the Journal of the American College of Cardiology and Circulation.

The full guideline and an executive summary were released online March 3.


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Warfarin associated with better 1-year outcomes for patients with CKD who experience acute MI with afib

Giving warfarin to acute myocardial infarction (MI) patients with atrial fibrillation who have chronic kidney disease (CKD) was associated with better 1-year outcomes than not giving warfarin, a study found.

Swedish researchers used national registry data from 2003-2010 to conduct an observational, prospective cohort study on 24,317 patients, all consecutive survivors of an acute MI with atrial fibrillation and known serum creatinine. They used estimated glomerular filtration rate (eGFR) to classify chronic kidney disease stages and prescription data from the registry to determine warfarin treatment (dosage information was not available). Outcomes were a composite end point of death, readmission from MI, or ischemic stroke within a year of discharge; readmission due to bleeding within a year of discharge; and the aggregate of the first 2 outcomes. Results were published March 5 by JAMA.

Twenty-two percent of patients (n=5,292) were prescribed warfarin at discharge, and 52% of patients had chronic kidney disease (CKD) of stage 3 or higher (eGFR <60 mL/min/1.73 m2). Compared with those not prescribed warfarin, patients who took warfarin had a lower risk of the first composite outcome in each CKD stratum for event rates per 100 person-years, as follows:

  • eGFR >60: event rate, 28.0 for warfarin vs. 36.1 for no warfarin; adjusted hazard ratio (HR), 0.73 (95% CI, 0.65 to 0.81);
  • eGFR 30-60: event rate, 48.5 for warfarin vs. 63.8 for no warfarin; HR, 0.73 (95% CI, 0.66 to 0.80);
  • eGFR 15-30: event rate, 84.3 for warfarin vs. 110.1 for no warfarin; HR, 0.84 (95% CI, 0.70-1.02); and
  • eGFR 15: event rate, 83.2 for warfarin vs. 128.3 for no warfarin; HR, 0.57 (95% CI, 0.37-0.86).

The reduced risk in the composite outcome was driven largely by a lower mortality risk. The crude absolute risk differences were 5.8% for death, 2.2% for MI, and 1.8% for stroke in the entire cohort. Warfarin in each stratum was associated with lower hazards of the aggregate outcome, and the risk of bleeding (n=1202 events) was not significantly higher in patients treated with warfarin in any CKD stratum, measured by event rates per 100 person-years.

The results "may suggest not denying warfarin to patients with atrial fibrillation after a myocardial infarction because of compromised renal function," the authors wrote, but they added that the results are observational and thus don't offer conclusive guidance.

Editorialists agreed and added that confounding due to indication for selecting warfarin is especially relevant to a post-MI cohort. As well, they noted that Sweden has excellent international normalized ratio (INR) quality control, and warfarin benefits might be attenuated in countries with inferior INR control, such as the U.S. "These data support the use and continuation of warfarin therapy among patients with CKD with excellent INR control," they concluded.



Test yourself


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MKSAP Quiz: routine follow-up visit for diabetes and hyperlipidemia

A 59-year-old woman is evaluated during a routine follow-up visit. She was recently diagnosed with type 2 diabetes mellitus and hyperlipidemia. She feels well. Medications are metformin, atorvastatin, and aspirin.

mksap.gif

Physical examination findings and vital signs are normal. BMI is 27.

Laboratory studies reveal a serum creatinine level of 0.9 mg/dL (79.6 µmol/L), an estimated glomerular filtration rate of >60 mL/min/1.73 m2, and normal urinalysis results.

Which of the following is the most appropriate diagnostic test to perform next?

A: 24-Hour urine collection for protein
B: Kidney ultrasonography
C: Spot urine albumin–creatinine ratio
D: No additional testing

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


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Prostate cancer


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Radical prostatectomy may offer advantages over watchful waiting

Men with prostate cancer may survive longer with radical prostatectomy than watchful waiting, especially if they are younger than 65 years of age at diagnosis, a study suggested.

Between 1989 and 1999, researchers in the Scandinavian Prostate Cancer Group Study Number 4 randomly assigned 695 men with early prostate cancer to watchful waiting or radical prostatectomy. The men, treated at 14 centers in Sweden, Finland, and Iceland, were followed through 2012 for death from any cause, death from prostate cancer, the risk of metastases, and initiation of androgen-deprivation therapy. Results appeared in the March 6 New England Journal of Medicine.

The cumulative incidence of death after 18 years of the study was 56.1% in the radical-prostatectomy group and 68.9% in the watchful-waiting group, a difference of 12.7 percentage points (95% CI, 5.1 to 20.3 percentage points). This corresponded to a relative risk of death in the radical-prostatectomy group of 0.71 (95% CI, 0.59 to 0.86; P<0.001).

During 23.2 years of follow-up, 200 of 347 men in the surgery group and 247 of the 348 men in the watchful-waiting group died, an absolute difference of 11 percentage points (95% CI, 4.5 to 17.5 percentage point). Of the deaths, 63 in the surgery group and 99 in the watchful-waiting group were due to prostate cancer (relative risk, 0.56; 95% CI, 0.41 to 0.77; P=0.001).

The cumulative incidence of distant metastases at 18 years of follow-up was 26.1% in the radical-prostatectomy group and 38.3% in the watchful-waiting group, a difference of 12.2 percentage points (95% CI, 5.1 to 19.3 percentage points). Relative risk of distant metastases in the radical-prostatectomy group was 0.57 (95% CI, 0.44 to 0.75; P<0.001).

The cumulative incidence of the use of androgen-deprivation therapy at 18 years was 42.5% in the radical-prostatectomy group and 67.4% in the watchful-waiting group, a difference of 25.0 percentage points (95% CI, 17.7 to 32.3 percentage points). Relative risk of the use of androgen-deprivation therapy in the radical-prostatectomy group was 0.49 (95% CI, 0.39 to 0.60; P<0.001).

Among men who were younger than 65 years of age at diagnosis, there was a reduction of 25.5 percentage points in overall mortality, 15.8 percentage points in death from prostate cancer, and 15.8 percentage points in the risk of metastases with surgery compared to waiting. There was no significant reduction in mortality with surgery among men 65 years of age or older at diagnosis. There was a significant absolute reduction of 8.9 percentage points in the risk of metastases.

The large proportion of long-term survivors in the watchful-waiting group who never required palliative treatment provides support for active surveillance as an alternative in adequately selected groups, the researchers noted. "However, the overall long-term disease burden is also a reminder that factors other than survival should be considered when counseling men with localized prostate cancer; the risk of metastases and ensuing palliative treatments also affect quality of life," they wrote.


.
Surgery performs better than radiotherapy for non-metastatic prostate cancer

Surgery was associated with better survival than radiotherapy in men with non-metastatic prostate cancer, according to a large observational study with follow-up as long as 15 years.

Researchers in Sweden conducted an observational study from 1996 to 2010 among 34,515 men primarily treated for prostate cancer with surgery (n=21,533) or radiotherapy (n=12,982). Patients were categorized by risk group (low, intermediate, high and metastatic), age and Charlson comorbidity score.

Results appeared in BMJ.

Among men with non-metastatic prostate cancer, treatment with radiotherapy was associated with a significantly higher propensity score-adjusted prostate cancer mortality than surgery (subdistribution hazard ratio, 1.76; 95% CI, 1.49 to 2.08). There was no discernible difference in treatment effect among men with metastatic disease, the authors noted. Subgroup analyses showed more clear benefits of surgery among younger and fitter men with intermediate and high-risk disease, and a sensitivity analyses confirmed the main findings.

The researchers noted that younger men and those with less comorbidity who have intermediate- or high-risk localized prostate cancer might see a greater benefit from surgery. The authors wrote, "… our study suggests that surgery might result in improved outcomes compared with radiotherapy in terms of survival for men with non-metastatic prostate cancer, and that radiotherapy seems at least equivalent, and may be superior, to surgery for men with metastatic disease."



Hyponatremia


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European societies release guideline on diagnosis, treatment of hyponatremia

Three European societies recently released a clinical practice guideline on the diagnosis and treatment of hyponatremia.

The guideline, which was developed by the European Society of Intensive Care Medicine, the European Society of Endocrinology, and the European Renal Association-European Dialysis and Transplant Association, focused on diagnosis and treatment of hyponatremia in adults and is intended to support clinical decision making in all health care professionals caring for inpatients and outpatients with this disorder. The guideline steering committee developed clinical questions about the diagnosis and differential diagnosis of hyponatremia, as well as acute and chronic treatment of hypotonic hyponatremia. Overall evidence for the guideline recommendations was graded from A, or high, to D, or very low, and recommendations were classified as strong (1) or weak (2). The guideline was published online by the European Journal of Endocrinology.

The guideline defined mild hyponatremia as a serum sodium concentration between 130 and 135 mmol/L, moderate hyponatremia as a serum sodium concentration between 125 and 129 mmol/L, and profound hyponatremia as a serum sodium concentration less than 125 mmol/L. Acute hyponatremia was defined as that existing less than 48 hours, and chronic hyponatremia was defined as that existing for at least 48 hours. The guideline defined moderately symptomatic hyponatremia as "any biochemical degree of hyponatremia in the presence of moderately severe symptoms of hyponatremia" and severely symptomatic hyponatremia as "any biochemical degree of hyponatremia in the presence of severe symptoms of hyponatremia."

In addition to recommendations on diagnosis, the guideline offered detailed recommendations for first-hour and follow-up management of acute or chronic hyponatremia with severe symptoms, as well as diagnostic assessment and treatment recommendations for hyponatremia with moderately severe symptoms and acute hyponatremia without severe or moderately severe symptoms. Recommendations on general management of chronic hyponatremia without severe or moderately severe symptoms were also given, along with recommendations for managing this disorder in patients with expanded extracellular fluid, patients with syndrome of inappropriate antidiuresis, and patients with reduced circulating volume. The guideline also offered recommendations on what clinicians can do if hyponatremia is corrected too rapidly.

The complete guideline, which includes algorithms for diagnosis and management, is available free of charge online.



Resources


.
New tool available for integrating primary care and public health

A new tool to integrate primary care and public health called "A Practical Playbook: Public Health & Primary Care Together" is now available online.

The Playbook, developed by the CDC, Duke Community and Family Medicine, and the de Beaumont Foundation, is an interactive, Web-based tool that helps primary care clinicians and public health groups find productive ways to work together to better manage chronic diseases. The project's goal is to increase the quality of care while keeping health care costs in check.

ACP's state of Washington Governor, Carrie A. Horwitch, MD, MPH, FACP, is on the National Advisory Committee.



From the College


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College Master, Fellow receive Heinz Awards

A College Master and a College Fellow were recently named recipients of the 19th Heinz Awards.

Abraham Verghese, MD, MACP, received an award in the category of Arts and Humanities for his critically acclaimed work as a writer of fiction and nonfiction. Sanjeev Arora, MBBS, FACP, received an award in the category of Public Policy for his work with Project ECHO, a model that uses videoconferencing and case-based learning to connect front-line primary care physicians with specialists.

The Heinz Awards were established by Teresa Heinz and the Heinz Family Foundation to honor the memory of the late U.S. Senator John Heinz. More information on the 19th Heinz Awards is available online.

See the September 2011 ACP Internist for more on Project ECHO.



For the record


.
Correction to a previous issue

An item in last week's ACP InternistWeekly required correction.

The recommended apixaban dosing to reduce risk for stroke or subsequent stroke in patients with nonvalvular atrial fibrillation who are thought to require oral anticoagulants should have been as follows:

  • apixaban, 5 mg twice daily (if serum creatinine <1.5 mg/dL) or 2.5 mg twice daily (in patients with a serum creatinine >1.5 and <2.5 mg/dL and body weight <60 kg or age ≥80 years or both).

In addition, the recommended dose of triflusal should have been 600 mg, not 500 mg. The errors have been corrected.



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-20140311-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 C: Spot urine albumin–creatinine ratio. This item is available to MKSAP 16 subscribers as item 73 in the Nephrology section. More information is available online.

A spot urine albumin–creatinine ratio is indicated to evaluate this patient for chronic kidney disease (CKD). She has type 2 diabetes mellitus, a population that is at risk for CKD, and testing for microalbuminuria is appropriate. The National Kidney Foundation and the American Diabetes Association recommend annual testing to assess urine albumin excretion in patients with type 1 diabetes of 5 years' duration and in all patients with type 2 diabetes starting at the time of diagnosis by measuring the albumin–creatinine ratio. Microalbuminuria is defined as an albumin–creatinine ratio of 30 to 300 mg/g; diagnosis requires an elevated albumin–creatinine ratio on two of three random samples obtained over 6 months. Patients with diabetes and microalbuminuria are at increased risk for progression of CKD and cardiovascular disease. Use of ACE inhibitors or angiotensin receptor blockers delays progression in patients with proteinuric kidney disease or in patients with diabetes and microalbuminuria, underscoring the importance of early detection.

The gold standard for measuring urine protein excretion is a 24-hour urine collection. However, this test is cumbersome and unreliable if not collected correctly. Patients have a difficult time accurately collecting urine for 24 hours, in addition to keeping it on ice. Therefore, the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) recommends use of urinary ratios on random urine samples as an alternative method of estimating proteinuria in the clinical assessment of kidney disease. Furthermore, a 24-hour urine collection may not diagnose low-grade microalbuminuria.

Kidney ultrasonography can be performed once a diagnosis of CKD is made but should not be used to screen for CKD.

Although this patient has an estimated glomerular filtration rate of >60 mL/min/1.73 m2 and normal urinalysis results, she has diabetes and should therefore be evaluated for CKD.

Key Point

  • The National Kidney Foundation and the American Diabetes Association recommend annual testing to assess urine albumin excretion in patients with type 1 diabetes mellitus of 5 years' duration and in all patients with type 2 diabetes starting at the time of diagnosis by measuring the albumin–creatinine ratio.

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Test yourself

A 69-year-old woman is evaluated for a lump under her arm found on self-examination. She is otherwise healthy and has no other symptoms. Medical and family histories are unremarkable, and she takes no medications. A needle aspirate of the right axillary mass reveals adenocarcinoma. Bilateral mammography and breast MRI are normal. CT scan of the chest, abdomen, and pelvis demonstrates the enlarged axillary lymph node and no other abnormalities. What is the most appropriate initial treatment?

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