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

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ACP InternistWeekly



In the News for the Week of March 4, 2014




Highlights

PCMH pilot demonstrated minimal quality improvement, no cost savings

A pilot project found that implementation of a medical home practice model improved quality only minimally and did not reduce health care costs or utilization. More...

Statin challenges may allow some with myalgia to continue their regimen

In patients who had had myalgia while taking statins, double-blind, crossover comparisons objectively determined whether the drug was truly causing the problem and allowed the patients to continue therapy, a proof-of-concept study found. More...


Test yourself

MKSAP Quiz: 2-week history of nonproductive cough and fever

A 35-year-old man is evaluated for a 2-week history of nonproductive cough and fever. He has a 20-year history of asthma. Three weeks ago, he visited friends in Indiana. He has no dyspnea, hemoptysis, or worsening of his baseline asthma symptoms. His only medication is an albuterol inhaler as needed. Following a physical exam, lab results and a chest radiograph, what is the most appropriate management? More...


Hypertension

Antihypertensive drugs associated with risk for serious fall injuries in elderly patients

Antihypertensive drugs may be associated with a higher risk for serious fall injuries in elderly adults, according to a new study. More...


Stroke

Guideline update issued on prevention of stroke in nonvalvular afib

The American Academy of Neurology recently issued a guideline update on preventing stroke in patients with nonvalvular atrial fibrillation (NVAF). More...


Cardiology

Depression a risk factor for adverse outcomes in ACS patients

Depression should be considered as a risk factor for adverse outcomes in patients with acute coronary syndrome (ACS), according to a new scientific statement from the American Heart Association (AHA). More...


CMS update

Reminder of ICD-10 testing this week

From March 3 to 7, CMS is offering the opportunity to test ICD-10 codes to give billing companies, clearinghouses, and physicians and other clinicians a chance to see whether their claims using ICD-10 codes will work. More...


Education

Population Health Colloquium to be held this month in Philadelphia

The Jefferson School of Population Health will hold its 14th Population Health Colloquium from March 17-19 at the Loews Hotel in Philadelphia. More...


Internal Medicine 2014

ACP to conduct Annual Business Meeting

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. More...


From ACP Internist

The latest issue of ACP Internist is online and coming to your mailbox

The next issue of ACP Internist is online and coming to your mailbox. Featured in this month's issue are stories about e-cigarettes, lung cancer screening recommendations, and the potential of GERD as a cause of pulmonary diseases. More...


Cartoon caption contest

Put words in our mouth

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


Physician editor: Daisy Smith, MD, FACP



Highlights


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PCMH pilot demonstrated minimal quality improvement, no cost savings

A pilot project found that implementation of a medical home practice model improved quality only minimally and did not reduce health care costs or utilization.

The project involved 32 primary care practices in southeastern Pennsylvania, followed from 2008 to 2011. During the project, the pilot practices received technical assistance to develop new tools such as disease registries and were financially rewarded by the 6 participating payers for achieving medical home recognition from the National Committee for Quality Assurance (NCQA). Using claims data, researchers compared changes in quality, utilization and costs for about 64,000 patients in the pilot practices with 56,000 patients from 29 similar practices that hadn't volunteered for the pilot.

Although the practices successfully achieved NCQA recognition, their performance improved significantly on only 1 of 11 studied quality measures: nephropathy screening diabetes (82.7% vs. 71.7%). The pilots' patients didn't reduce their use of hospital, emergency department or ambulatory care services, or total health care costs, over the 3 years. Results were published in the Feb. 26 Journal of the American Medical Association.

The study authors noted that one explanation may be that practices volunteering for a pilot project might have had little room for improvement in their quality of care. The project's focus on NCQA recognition also might have distracted from other possible improvements, including those that would have reduced costs and utilizations. The practices weren't given incentives or feedback related to their patients' utilization of care; a quarter of the practices didn't receive hospital discharge summaries. The study authors concluded that "medical home interventions may need further refinement."

Supporters of the patient-centered medical home (PCMH) model shouldn't be too disappointed by the results of the study, according to an accompanying editorial. The lack of effect found in the study may indicate that PCMH interventions need to be focused on a more specific patient population. Intensive interventions should be targeted at patients with a history of high utilization and cost, the editorialist suggested.

"Before confidently promoting the PCMH as a core component of health care reform, it is necessary to better understand which features and combination of features of the PCMH are most effective for which populations and in what settings," the editorial said.


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Statin challenges may allow some with myalgia to continue their regimen

In patients who had had myalgia while taking statins, double-blind, crossover comparisons objectively determined whether the drug was truly causing the problem and allowed the patients to continue therapy, a proof-of-concept study found.

annals.jpg

Eight patients recruited from a tertiary lipid clinic in Canada who had previously tried and discontinued statin therapy due to myalgia were given either their statin or a placebo for up to 3 weeks, followed by 3-week washout periods.

Researchers determined weekly visual analogue scale (VAS) scores (range, 0 to 100 mm) for myalgia and for specific symptoms, pain interference scores, and pain severity scores during the 3-week treatment periods. Results appeared in the March 4 Annals of Internal Medicine.

Seven patients completed 3 treatment pairs, and 1 completed 2 treatment pairs after the first trial was interrupted by an acute medical condition. For each trial, no statistically significant differences were seen between statin and placebo in the VAS myalgia score, symptom-specific VAS score, pain interference score, and pain severity score.

After the conclusion of the trial, 1 patient's follow-up low-density lipoprotein cholesterol level was below the recommended target and the person did not continue on a statin. Five of the 7 remaining patients requiring statin therapy resumed and have continued to receive the statin for a median follow-up of 10 months (range, 5 to 18 months).

The researchers wrote that management of statin-related myalgia has primarily focused on continuing to administer a statin, if possible, by statin rechallenge, statin switching, or alternate dosing schedules. However, results are often confounded by other pains induced by fibromyalgia, arthritis, or a job with varying levels of physical exertion.

The researchers wrote, "Our findings show that not all patients developing myalgia during open-label statin treatment have true statin-related myopathy."



Test yourself


.
MKSAP Quiz: 2-week history of nonproductive cough and fever

A 35-year-old man is evaluated for a 2-week history of nonproductive cough and fever. He has a 20-year history of asthma. Three weeks ago, he visited friends in Indiana. He has no dyspnea, hemoptysis, or worsening of his baseline asthma symptoms. His only medication is an albuterol inhaler as needed.

mksap.gif

On physical examination, temperature is 38.0 °C (100.4 °F), blood pressure is 130/70 mm Hg, pulse rate is 88/min, and respiration rate is 16/min. Crackles are heard in both lungs.

Laboratory studies show a normal leukocyte count and serum creatinine level.

Chest radiograph reveals patchy pulmonary infiltrates with mild hilar lymphadenopathy.

Which of the following is the most appropriate management?

A: Lipid amphotericin B
B: Fluconazole
C: Itraconazole
D: No treatment

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


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Hypertension


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Antihypertensive drugs associated with risk for serious fall injuries in elderly patients

Antihypertensive drugs may be associated with a higher risk for serious fall injuries in elderly adults, according to a new study.

Researchers used data from the Medicare Current Beneficiary Survey to perform a competing risk analysis in community-living hypertensive adults older than age 70 over 3 years of follow-up. Intensity of exposure to antihypertensive medications was based on the standardized daily dose of each class used by each patient. The study's main outcome measures were serious fall injuries (hip and other major fractures, traumatic brain injuries, and joint dislocations) as determined by CMS claims. The results were published online Feb. 24 by JAMA Internal Medicine.

A total of 4,961 patients were included in the study. The mean age was 80.2 years, and 61.5% were women. Overall, 697 patients (14.1%) did not receive antihypertensive medications, 2,711 (54.6%) received moderate-intensity antihypertensive treatment, and 1,553 (31.3%) received high-intensity antihypertensive treatment. Five hundred three patients had had a previous fall injury. Renin-angiotensin system blockers were the most common antihypertensive drug taken (56.6%), followed by diuretics (54.2%), beta-blockers (45.9%), and calcium-channel blockers (34.2%). Three hundred forty-nine patients (7.0%) took other classes of antihypertensive drugs. Among the patients taking antihypertensive drugs, 1,265 (28.3%) took 1 class, 1,599 (35.8%) took 2 classes and 1,607 (35.9%) took 3 or more classes. The propensity-score matched subcohort included 2,849 patients, 662 (95%) of those not taking medication for hypertension, 1,455 (53.7%) of the moderate-intensity group, and 732 (47.1%) of the high-intensity group.

Over the 3-year follow-up, 446 patients (9.0%) had serious fall injuries and 837 (16.9%) died. Compared with nonusers of antihypertensive drugs, the moderate-intensity and high-intensity groups had adjusted hazard ratios for serious fall injury of 1.40 (95% CI, 1.03 to 1.90) and 1.28 (95% CI, 0.91 to 1.80), respectively. Differences in adjusted hazard ratios did not reach statistical significance across groups, but results were similar in the subcohort of patients matched for propensity scores. Among patients with a history of previous fall injuries, adjusted hazard ratios were 2.17 (95% CI, 0.98 to 4.80) for the moderate-intensity group and 2.31 (95% CI, 1.01 to 5.29) for the high-intensity group.

The researchers noted that they did not find a cause-and-effect relationship in their study, nor a dose-response relationship between intensity or number of drug classes and fall injury risk. In addition, no particular class of antihypertensives was associated with increased risk. The researchers also acknowledged that data on hypertension onset and duration of antihypertensive treatment were not available, among other limitations. However, they concluded that based on their results, antihypertensive medications seem to be associated with increased risk for fall injury among hypertensive elderly patients. "The potential harms vs benefits of antihypertensive medications should be weighed in deciding to continue treatment with antihypertensive medications in older adults with multiple chronic conditions," they wrote.

The authors of an accompanying editorial agreed that the study's findings increase the evidence supporting an association between antihypertensive medications and increased risk for fall injuries but pointed out that undertreatment of systolic hypertension might also cause harm. Without more direct data, they said, clinicians should base treatment decisions on individual functional status, life expectancy, and preferences and should discuss risks and benefits "candidly" with each patient.

"When antihypertensive drug treatment is indicated, using the lowest dose possible to achieve a target blood pressure makes good sense," the editorialists wrote. "Most important, clinicians should pay greater attention to fall risk in older adults with hypertension in an effort to prevent injurious falls, particularly among adults with a previous injury."



Stroke


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Guideline update issued on prevention of stroke in nonvalvular afib

The American Academy of Neurology recently issued a guideline update on preventing stroke in patients with nonvalvular atrial fibrillation (NVAF).

The guideline update reviewed the evidence published since 1998, when the Academy's last guideline on this topic was issued, and focused on how often various technologies identify previously undetected NVAF in patients with cryptogenic stroke, as well as which therapies including antithrombotic medications reduce stroke risk and severity and have the lowest risk of hemorrhage. The guideline panel based its practice recommendations on the strength of the evidence according to systematic review, principles of care, benefits and harms, costs, intervention availability, and patients' preferences.

The panel concluded that cardiac rhythm monitoring probably detects occult NVAF in patients who have recently had a cryptogenic stroke. In addition, it found that dabigatran, rivaroxaban and apixaban are probably at least as effective as warfarin for stroke prevention but confer a lower hemorrhage risk. Triflusal added to acenocoumarol appears to be more effective than acenocoumarol monotherapy in reducing risk for stroke, the panel noted. Clopidogrel plus aspirin, meanwhile, appears to be less effective than warfarin for stroke prevention with a lower intracranial bleeding risk; this combination also appears to reduce stroke risk more than aspirin alone but with a higher risk for major hemorrhage. Aspirin and apixaban have similar bleeding risk, but the latter appears to be more effective in reducing risk for stroke, the panel said.

Based on its findings, the panel recommended that clinicians choose one of the following regimens to reduce risk for stroke or subsequent stroke in patients with NVAF who are thought to require oral anticoagulants (Level B recommendation):

  • warfarin, with a target international normalized ratio of 2.0 to 3.0;
  • dabigatran, 150 mg twice daily (in patients with a creatinine clearance >30 mL/min);
  • rivaroxaban, 15 mg/d (in patients with a creatinine clearance of 30 to 49 mL/min) or 20 mg/d;
  • 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);
  • triflusal, 600 mg, plus acenocoumarol, with a target international normalized ratio of 1.25 to 2.0 (for patients at moderate risk for stroke; this choice is mainly for those in developing countries).

The panel noted that clinicians might obtain outpatient cardiac rhythm studies in patients with cryptogenic stroke but no known NVAF in order to identify occult NVAF (Level C recommendation). In addition, the panel said, clinicians should prescribe dabigatran, rivaroxaban, or apixaban to patients with NVAF who require anticoagulant medication and have a high risk for intracranial bleeding (Level B recommendation).

Clinicians should offer oral anticoagulation routinely to NVAF patients older than 75 if they have no history of recent unprovoked bleeding or intracranial hemorrhage (Level B recommendation); oral anticoagulation can also be offered to NVAF patients with dementia or occasional falls, but patients or family members should be told that the risk-benefit ratio is not known in those whose dementia is moderate or severe or in those who fall very frequently, the panel said (Level B recommendation).

A summary of the guideline, which was published Feb. 24 by Neurology, is available online.



Cardiology


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Depression a risk factor for adverse outcomes in ACS patients

Depression should be considered as a risk factor for adverse outcomes in patients with acute coronary syndrome (ACS), according to a new scientific statement from the American Heart Association (AHA).

To support the recommendation, the AHA writing group conducted a systematic review of the literature on depression and adverse outcomes after ACS. In total, 53 studies and 4 meta-analyses were included. Thirty-two of the studies assessed the association between depression and all-cause mortality after ACS, and 21 of them suggested that depression was a risk factor. Twelve studies looked specifically at cardiac mortality, and 8 of them found depression to be a risk factor. When a composite of fatal and nonfatal cardiac events was the endpoint, 17 of 22 studies showed that depression increased risk. The meta-analyses varied but generally found an association between depression and worse outcomes.

The reviewers noted that the studies were heterogeneous, with differences in inclusion criteria, depression assessment, depression subtypes, and risk adjustment. However, they concluded that there is sufficient evidence to support the AHA (and other health organizations) elevating depression to the status of a risk factor for adverse outcomes in ACS. The scientific statement was published by Circulation on Feb. 24.

Evidence is lacking on whether depression treatment improves survival in ACS patients, the writing group noted, although worsening depression is associated with worsening outcomes. They called for more research into the risks and benefits of screening and treatment of depression in ACS patients. Future research should also identify the highest-risk subtypes of depression, the role of other psychiatric conditions, and the biobehavioral mediators of depression's effect on cardiac outcomes, the statement said.



CMS update


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Reminder of ICD-10 testing this week

From March 3 to 7, CMS is offering the opportunity to test ICD-10 codes to give billing companies, clearinghouses, and physicians and other clinicians a chance to see whether their claims using ICD-10 codes will work.

As of Oct. 1, physicians and other covered entities will be required to use the ICD-10 code set in all standard transactions covered by HIPAA, including claims. CMS will offer an additional claims testing week in early May. Additional information about testing for the ICD-10 code set is available from CMS. Advice and information about the transition to ICD-10 is also available on the ACP website.



Education


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Population Health Colloquium to be held this month in Philadelphia

The Jefferson School of Population Health will hold its 14th Population Health Colloquium from March 17-19 at the Loews Hotel in Philadelphia.

The 3-day conference focuses on implementing and practicing population-based health care, bringing together leading experts and highlighting the most innovative initiatives, programs, and solutions being implemented around the country and abroad.

The colloquium is a hybrid event with onsite and online participants, co-located with the 6th National Medical Home Summit. Population health and patient-centered care are at the heart of the Affordable Care Act (ACA). The program will offer continuing education opportunities, a preconference event on "Preparing for Implementation of the ACA," and a postconference session on "Super-Utilizers."

Registration and full conference information can be found online.



Internal Medicine 2014


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ACP to conduct Annual Business Meeting

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 meeting will be held at the Orange County Convention Center in Orlando, Fla., on Saturday, April 12, from 12:45 to 1:45 p.m., with outgoing 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


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The latest issue of ACP Internist is online and coming to your mailbox

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

acpi-20140304-internist.jpg

Debate ignites over safety of e-cigarettes.E-cigarettes can open doors into the subject of quitting tobacco use. Although the devices lack any hard data to support their use, they can offer doctors a chance to explore with patients other options for smoking cessation.

Lung cancer screening guideline debated. New screening recommendations for low-dose CT for smokers will prove to be trickier to follow than most preventive care guidelines, experts say. Learn what issues to consider, where to refer patients, and how to deal with the results.

Consider GERD in patients with pulmonary diseases. Because not all presentations of lung diseases include gastroesophageal reflux disease (GERD)'s more commonly recognized symptoms, such as heartburn and regurgitation, it is easy to miss GERD as a contributing factor. Internists should be on the lookout for "red flags" such as dysphagia or weight loss.

These stories, Test Yourself with the MKSAP Quiz, and more are available online.



Cartoon caption contest


.
Put words in our mouth

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

acpi-20140304-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 D: No treatment. This item is available to MKSAP 16 subscribers as item 30 in the Infectious Disease section. More information is available online.

This patient has mild pulmonary histoplasmosis, which is self-limiting and requires no treatment in a healthy host. In those who become ill, the incubation period is 7 to 21 days, and most have symptoms by day 14. Histoplasmosis is common in states bordering the Ohio River Valley and the lower Mississippi River. Infection may be asymptomatic, but the diagnosis should be considered in any patient with pulmonary and systemic symptoms following potential exposure in a geographically endemic area. In most symptomatic patients, disease is mild and resolves without therapy within 1 month. In a few patients, particularly those with immunocompromise (such as HIV infection) or other concurrent illnesses, severe pneumonia with respiratory failure may result.

Histoplasmosis may also cause chronic infection, including pulmonary and mediastinal masses, cavitary lesions, central nervous system involvement, pericarditis, and arthritis and arthralgia. Antifungal treatment is indicated for severe or moderately severe acute pulmonary, chronic pulmonary, disseminated, and central nervous system histoplasmosis or for those patients whose symptoms do not improve within 1 month. Evidence of effectiveness, however, is lacking to support this recommendation.

If treatment is indicated for acute pulmonary histoplasmosis, the treatment of choice is itraconazole. Lipid formulations of amphotericin B are indicated for more severe forms of pulmonary histoplasmosis. Fluconazole has been used for treatment of histoplasmosis, but it is less effective than itraconazole. Fluconazole resistance has also been noted in some patients who have not responded to therapy.

Key Point

  • Mild forms of histoplasmosis do not require treatment, whereas more severe forms may be treated with amphotericin B or one of the newer triazole antifungal agents.

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Test yourself

A 42-year-old woman is evaluated for an 8-month history of crampy abdominal pain and three loose bowel movements per day. The pain is relieved by a bowel movement. There are no nocturnal bowel movements, and there is no blood or dark tarry material in the stool. She has not had fever, night sweats, or weight loss. She has a history of Hashimoto disease and is treated with levothyroxine. Following a physical exam, rectal exam, and lab tests, what is the most appropriate next step in management?

Find the answer

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