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ACP InternistWeekly



In the News for the Week of March 18, 2014




Highlights

Withholding, delaying antibiotics for simple respiratory infections had similar outcomes as immediate prescriptions

Not prescribing antibiotics or delaying prescriptions for uncomplicated acute sore throats and other respiratory infections resulted in fewer than 40% of patients using antibiotics and similar symptomatic outcomes versus offering immediate prescriptions, a study found. More...

Evidence doesn't support current guidelines on fat consumption

Dietary guidelines favoring high consumption of polyunsaturated fats and low consumption of saturated fats to reduce coronary risk are not supported by the available evidence, a recent meta-analysis found. More...


Test yourself

MKSAP Quiz: 3-week history of painful muscle spasms and twisting movements

A 24-year-old woman is evaluated for a 3-week history of painful muscle spasms and twisting movements in the neck and trunk. She says that her neck feels as if it is being pulled backward. She also reports general restlessness and an inability to keep still. Her medical history is notable for asthma, type 1 diabetes mellitus, and gastroparesis with reflux. The patient has no family history of neuropsychiatric disorders or liver disease. Medications are albuterol, insulin, omeprazole, and metoclopramide. Following findings from a physical exam, what is the most likely diagnosis? More...


Pulmonology

Thoracic society releases guidelines on pulmonary hypertension in sickle cell patients

The American Thoracic Society recently released clinical practice guidelines to help clinicians identify and manage patients with sickle cell disease who are at increased risk for death from pulmonary hypertension. More...


Infectious disease

Azithromycin, levofloxacin associated with increased cardiac risk versus amoxicillin

Azithromycin and levofloxacin were both associated with increased cardiac risk compared with amoxicillin, a recent study found. More...


DVT

Wells rule may not be accurate for excluding DVT in certain patients

The Wells rule may not be accurate for excluding deep venous thrombosis (DVT) in patients with cancer and those with previous DVT, according to a new study. More...


Internal Medicine 2014

It's not too late to submit a Job Seeker's Profile to the ACP Job Placement Center

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. More...


From the College

Deductibles and donuts change the flavor of health care

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. More...


Cartoon caption contest

Vote for your favorite entry

ACP InternistWeekly's cartoon caption contest continues. Readers can vote for their favorite caption to determine the winner. More...


Physician editor: Philip Masters, MD, FACP



Highlights


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Withholding, delaying antibiotics for simple respiratory infections had similar outcomes as immediate prescriptions

Not prescribing antibiotics or delaying prescriptions for uncomplicated acute sore throats and other respiratory infections resulted in fewer than 40% of patients using antibiotics and similar symptomatic outcomes versus offering immediate prescriptions, a study found.

Researchers in the United Kingdom conducted a pragmatic, randomized trial among 889 patients ages 3 years and over with acute respiratory tract infection (acute cold, influenza, sore throat, otitis media, sinusitis, croup or lower respiratory tract infection) who were recruited between March 2010 and March 2012 by 53 clinicians in 25 general practices.

Patients judged not to need immediate antibiotics were randomly assigned to 4 strategies of delayed prescription: recontact the clinic to request a prescription, be given a postdated prescription that could be filled later, allow the patient to pick up a prescription (collect) at the clinic at their discretion, or be given a valid prescription to be filled at the patient's choosing. During the trial, a strategy of no antibiotic prescription was added as another randomized comparison.

Symptom severity was self-measured and recorded for 2 weeks in symptom diaries at the end of each day until symptoms returned to normal. Symptoms included feeling generally unwell, sleep disturbance, fever, interference with normal activities, sore throat, cough, shortness of breath, facial or sinus pain, earache, and runny or blocked nose and were ranked from 0 (no problem) to 6 (as bad as it could be).

Results appeared online March 6 at BMJ.

Of the 889 patients, 333 (37%) were found to need immediate antibiotics and 556 (63%) entered the randomized trial. In the no-prescription and delayed-prescription groups, there was no significant effect of strategy on symptom severity (P=0.625), duration of illness (P=0.368), and small differences of 0.1°C in temperature control (P=0.035).

Antibiotic use did not differ significantly between strategies (P=0.292), with the lowest use (26%; 26 of 99 patients) reported in the no-prescription arm and an average of 37% (134 of 367 patients) taking antibiotics in the delayed arms, with rates varying from 33% (28 of 85 patients) in the collected-prescription arm to 39% (35 of 89 patients) in the group that received a prescription to fill if they chose. Belief in the effectiveness of antibiotics was strong and not significantly different among the groups (P=0.805). Patient satisfaction also did not differ significantly. Reconsultations during 1 month of follow-up and after that month were similar in all groups.

After inclusion of the nonrandomized immediate-prescription group, there was no significant effect of antibiotic prescribing strategy on symptom severity (P=0.543), duration (P=0.424), or temperature (P=0.176). Antibiotic use differed significantly (P<0.001), with 97% of patients (270 of 278 patients) reporting antibiotic use in the immediate arm. More patients in that group believed antibiotics were very effective (93% [168 of 180 patients]; P<0.01 compared to other groups) despite immediate prescription of antibiotics having no effect on symptom control or duration.

The researchers noted that if clear advice is given to patients, there is probably little difference between the different delayed-prescription strategies. Any strategy of delayed prescribing is likely to result in fewer than 40% of patients using antibiotics, they said.

"This finding contrasts both health professionals' behavior in commonly requiring immediate antibiotics, and the persistently strong beliefs patients have in the effectiveness of antibiotics," the authors wrote. "The different ways of using delayed prescription, when the same structured approach is used, had more similar outcomes than previous trial data suggest, although the collection approach performed well on most criteria."


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Evidence doesn't support current guidelines on fat consumption

Dietary guidelines favoring high consumption of polyunsaturated fats and low consumption of saturated fats to reduce coronary risk are not supported by the available evidence, a recent meta-analysis found.

Researchers reviewed 32 observational studies of fatty acids from dietary intake and 17 of fatty acid biomarkers, as well as 27 randomized, controlled trials of fatty acid supplementation. In total, their data included more than 600,000 people in 18 countries. They evaluated associations between fatty acids and coronary disease. Results were published in the March 18 Annals of Internal Medicine.

annals.jpg

In the observational trials, the relative risk (RR) for coronary disease between those consuming the most and the least of most types of fatty acid were not significantly different: 1.02 (95% CI, 0.97 to 1.07) for saturated; 0.99 (95% CI, 0.89 to 1.09) for monounsaturated; 0.93 (95% CI, 0.84 to 1.02) for long-chain, omega-3 polyunsaturated; and 1.01 (95% CI, 0.96 to 1.07) for omega-6 polyunsaturated. Higher consumption of trans fatty acids was associated with a RR of 1.16 (95% CI, 1.06 to 1.27).

Studies measuring circulating fatty acids revealed no significant differences in coronary risk and heterogeneity of associations between the fatty acids and coronary disease. Analysis of the randomized trial data revealed no significant differences in risk for coronary disease when supplementation with alpha-linolenic or long-chain, omega-3 polyunsaturated fats were compared to omega-6 polyunsaturated fats.

To explain their findings, the study authors noted that self-reports of fat consumption can be inaccurate but also said that circulating fatty acid levels can be significantly affected by how the body metabolizes the fats consumed. For example, the analysis found positive associations between coronary disease and circulating palmitic and stearic acids (which are only weakly associated with fat consumption) and a negative association with margaric acid (a saturated fat increased by milk and dairy consumption). This finding may suggest that saturated fats from milk or dairy could have less deleterious effects on coronary health than other types.

Overall, the findings are in line with current guidelines on avoidance of trans fats but do not support cardiovascular guidelines encouraging high consumption of polyunsaturated fats and low consumption of saturated fats, the authors concluded. "Nutritional guidelines on fatty acids and cardiovascular guidelines may require reappraisal," they wrote.



Test yourself


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MKSAP Quiz: 3-week history of painful muscle spasms and twisting movements

A 24-year-old woman is evaluated for a 3-week history of painful muscle spasms and twisting movements in the neck and trunk. She says that her neck feels as if it is being pulled backward. She also reports general restlessness and an inability to keep still. Her medical history is notable for asthma, type 1 diabetes mellitus, and gastroparesis with reflux. The patient has no family history of neuropsychiatric disorders or liver disease. Medications are albuterol, insulin, omeprazole, and metoclopramide.

mksap.gif

On physical examination, vital signs are normal. When the patient is seated, her neck pulls backward and her chin elevates; mild grimacing movements also are noted. On standing and walking, her trunk arches backward, sometimes with her arms pulling forward.

Which of the following is the most likely diagnosis?

A: Huntington disease
B: Juvenile Parkinson disease
C: Tardive dystonia
D: Wilson disease

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


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Pulmonology


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Thoracic society releases guidelines on pulmonary hypertension in sickle cell patients

The American Thoracic Society recently released clinical practice guidelines to help clinicians identify and manage patients with sickle cell disease who are at increased risk for death from pulmonary hypertension.

Many patients with sickle cell disease are now surviving long enough to develop pulmonary hypertension, with an estimated prevalence of 6% to 11%, the society stated in a press release.

The guidelines appear in the March 15 American Journal of Respiratory and Critical Care Medicine.

Recommendations include the following:

  • Mortality risk can be accurately determined noninvasively by measurement of the tricuspid regurgitant velocity (TRV) with Doppler echocardiography or by measurement of serum N-terminal pro-brain natriuretic peptide (NT-pro-BNP) levels and can be determined invasively by direct hemodynamic measurements via right-heart catheterization (RHC).
  • An increased risk for mortality is defined as a TRV=2.5 m/second, an NT-pro-BNP level=160 pg/mL, or RHC-confirmed pulmonary hypertension.
  • Patients found to have an increased mortality risk should be treated with hydroxyurea. Patients who do not respond to or are not candidates for hydroxyurea can be considered for chronic transfusion therapy.
  • Indefinite anticoagulant therapy rather than a limited duration of therapy should be used in patients with RHC-confirmed pulmonary hypertension, venous thromboembolism, and no additional risk factors for hemorrhage.
  • Patients with elevated TRV alone or elevated NT-pro-BNP alone should not be treated with targeted pulmonary arterial hypertension therapies, including prostanoid, endothelin receptor antagonist, and phosphodiesterase-5 inhibitor therapy.
  • Most patients with RHC-confirmed pulmonary hypertension should not be treated with targeted therapy.
  • A trial of either a prostanoid or an endothelin receptor antagonist may be performed in select patents with RHC-confirmed marked elevation of pulmonary vascular resistance, normal pulmonary capillary wedge pressure, and related symptoms.
  • Patients with RHC-confirmed marked elevation of pulmonary vascular resistance, normal pulmonary capillary wedge pressure, and related symptoms should not receive phosphodiesterase-5 inhibitor therapy as first-line treatment.

For more on sickle cell disease, read ACP Internist's coverage from April 2013, view a video from ACP's multimedia collection, or explore ACP's Smart Medicine module on the condition.



Infectious disease


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Azithromycin, levofloxacin associated with increased cardiac risk versus amoxicillin

Azithromycin and levofloxacin were both associated with increased cardiac risk compared with amoxicillin, a recent study found.

Researchers conducted a retrospective cohort study among U.S. veterans to determine whether azithromycin or levofloxacin would result in increased risk for cardiovascular death and cardiac arrhythmia versus amoxicillin. Patients between ages 30 and 74 who were treated at a Department of Veterans Affairs facility, including medical centers and outpatient clinics, between September 1999 and April 2012 and who received exclusive outpatient dispensing of amoxicillin, azithromycin, or levofloxacin were included. Amoxicillin and levofloxacin were usually dispensed for at least 10 days; azithromycin was usually dispensed for 5 days. The study's primary and secondary endpoints were all-cause mortality and serious cardiac arrhythmia. The study results were published in the March/April Annals of Family Medicine.

Throughout the study period, 979,380 patients were prescribed amoxicillin, 594,792 were prescribed azithromycin, and 201,798 were prescribed levofloxacin. The mean age of the cohort was 56.5 years; 71% of patients were white, 18.4% were black, and 88% were men. In the first 5 days of treatment, risk for death and serious arrhythmia was significantly higher in patients taking azithromycin compared with amoxicillin (hazard ratios, 1.48 [95% CI, 1.05 to 2.09] and 1.77 [95% CI, 1.20 to 2.62], respectively). Risks did not differ significantly between patients taking these 2 drugs on days 6 to 10. Patients taking levofloxacin also had a higher risk for death and serious cardiac arrhythmia than those taking amoxicillin during days 1 to 5 (hazard ratios, 2.49 [95% CI, 1.7 to 3.64] and 2.43 [95% CI, 1.56 to 3.79], respectively), but this increase in risk persisted during days 6 to 10 (hazard ratios, 1.95 [95% CI, 1.32 to 2.88] and 1.75 [95% CI, 1.09 to 2.82], respectively).

The authors noted that their results might have been affected by residual unmeasured confounding and that the differences in mortality may have reflected differences in the reasons for antibiotic use, among other limitations. However, they concluded that their results show an increase in cardiac risk with azithromycin and levofloxacin and support recent safety announcements from the FDA and from industry about these drugs. "There are usually multiple antibiotic choices available for older patients, especially those with cardiac comorbidities," the authors wrote. "Physicians may consider prescribing medications other than azithromycin and levofloxacin."



DVT


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Wells rule may not be accurate for excluding DVT in certain patients

The Wells rule may not be accurate for excluding deep venous thrombosis (DVT) in patients with cancer and those with previous DVT, according to a new study.

Researchers performed a meta-analysis of individual patient data to examine the accuracy of the Wells rule in excluding DVT in different subgroups of patients. Studies selected for the meta-analysis enrolled consecutive outpatients with suspected DVT, scored all of the variables of the Wells rule, and used an appropriate reference standard. Data from the 13 included studies were merged into a single dataset. The current study's main outcome measures were estimated differences in predicted probabilities of DVT according to the Wells rule, along with differing abilities to exclude DVT based on an unlikely Wells score and a negative D-dimer result. The study results were published online March 10 by BMJ.

Data from 10,002 outpatients were included in the study; no inpatients were included. A total of 1,864 patients (19%) had proximal DVT, 62% of patients were women, and the median patient age was 59 years. In the patient population overall, higher Wells rule scores were reliably associated with higher DVT risk. However, the actual probability of DVT was approximately 5% with a Wells rule score of −2, indicating that the Wells rule alone should not be used for DVT exclusion. Patients with cancer, those with suspected recurrent DVT, and, to a lesser extent, men had almost twofold higher predicted probabilities of DVT when the Wells rule score was low.

Patients with a Wells rule score of 1 or lower and a negative D-dimer results (29% of patients) were extremely unlikely to have DVT (probability, 1.2%; 95% CI, 0.7% to 1.8%). The authors noted that a failure rate of up to 2% is often considered the threshold of acceptability. Nine percent of patients with cancer had a Wells score of 1 or lower and negative D-dimer results, and this combination was associated with a 2.2% probability of DVT. The Wells rule combined with a negative D-dimer test result did not safely predict DVT in patients with suspected recurrent disease unless 1 point was added to the score.

The authors noted that the DVT assessor was not blinded in many of the included studies and that compression ultrasonography was often used as the reference standard although it is less reliable in assessing recurrent DVT events, among other limitations. They concluded that a low score on the Wells rule when combined with a negative D-dimer result can reliably exclude DVT in most patients. However, this combination was not found to be safe or efficient in patients with cancer. When the combination is used in patients with suspected recurrent DVT, the authors recommended that an extra point be added to the Wells score in this category, which preserves the ability to exclude DVT in this patient group.



Internal Medicine 2014


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It's not too late to submit a Job Seeker's Profile to the ACP Job Placement Center

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 (limit, 1 mini-CV per physician) will be eligible for a drawing for a $100 Amazon gift card on April 12. Winners will be contacted by e-mail.

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.



From the College


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Deductibles and donuts change the flavor of health care

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 this post, Dr. Ejnes looks at how "deductible season" has gotten longer and more active, as employers and insurers implement measures designed to control costs and increase patients' stake in how their health care dollars are spent.



Cartoon caption contest


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Vote for your favorite entry

ACP InternistWeekly's cartoon caption contest continues. Readers can vote for their favorite caption to determine the winner.

acpi-20140318-cartoon.jpg

"Another case of Peyronie's disease causing a reptile dysfunction."

"I keep telling you, Mr. S, you are OK. That's not a 'death rattle' that you are hearing."

"I hope your employer provided you with tail coverage."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting ends on Monday, March 24, with the winner announced in the March 25 issue.


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MKSAP Answer and Critique



The correct answer is C: Tardive dystonia. This item is available to MKSAP 16 subscribers as item 82 in the Neurology section. More information is available online.

This patient has developed tardive dystonia involving her neck and trunk that is most likely caused by the metoclopramide she is taking. The associated facial grimacing (a classic finding in tardive dyskinesia) and restlessness (akathisia) make the diagnosis of tardive dystonia certain because this constellation of symptoms does not occur in any other context. Tardive dystonia is a forceful, sometimes painful sustained contraction of muscles leading to twisted postures that must be distinguished from tardive dyskinesia, which consists of flowing, patterned choreic movements of the face. Both are caused by exposure to dopamine type 2 (D2) receptor antagonists, but the difference in the appearance of the movements has an important bearing on the treatment and prognosis. Tardive dystonia is more disabling than tardive dyskinesia and also harder to treat. The therapeutic approach includes a gradual discontinuation of the offending agent, treatment with anticholinergic or dopamine receptor-depleting agents, and the judicious use of botulinum toxin injections.

Huntington disease is a familial disorder causing generalized chorea, dementia, and behavioral changes. This patient does not exhibit these symptoms.

Juvenile Parkinson disease can cause parkinsonism in a child or young adult. This patient does not exhibit symptoms of parkinsonism.

Wilson disease causes copper accumulation in the basal ganglia and liver and may present as progressive parkinsonism or dystonia. Symptom onset is usually in childhood or teenage years. This patient does not have parkinsonism, Kayser-Fleischer rings, or a family history of neuropsychiatric or hepatic disease, which renders the diagnosis of Wilson disease unlikely.

Key Point

  • Tardive dystonia, a disorder whose classic findings include facial grimacing and akathisia, can be induced by dopamine receptor antagonists, such as metoclopramide and antipsychotic drugs.

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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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