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

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ACP InternistWeekly



In the News for the Week of April 22, 2014




Highlights

Review of anti-flu drugs find little benefit, side effects, flaws in approval processes

Two Cochrane systematic reviews on flu relief drugs, which for the first time considered clinical study reports in addition to published studies, concluded that the medicines didn't have much impact on the course of symptoms. More...

High-energy shock-wave therapy may be effective for shoulder pain, function

High-energy extracorporeal shock-wave therapy (ESWT) is effective for improving pain and shoulder function in chronic calcific shoulder tendinitis and can result in complete resolution of calcifications, a meta-analysis found. More...


Test yourself

MKSAP Quiz: pleuritic left-sided anterior chest pain

A 63-year-old man is evaluated for pleuritic left-sided anterior chest pain, which has persisted intermittently for 1 week. The pain lasts for hours at a time and is not provoked by exertion or relieved by rest but is worse when supine. He reports transient relief with acetaminophen and codeine and occasionally when leaning forward. He has had a low-grade fever for 3 days, without cough or chills. Medical history is significant for acute pericarditis 7 months ago. Following a physical exam and electrocardiogram, what is the most appropriate management? More...


Infectious disease

Rapid hepatitis C testing identified infections in high-risk population

Rapid testing for hepatitis C virus (HCV) at agencies for people with drug dependence identified many previously unrecognized infections, a recent study found. More...


Anticoagulant therapy

Adding aspirin or NSAID to anticoagulant doubles bleeding risk

Taking aspirin or an NSAID while on anticoagulant therapy significantly increases the risk of bleeding in patients who have had a venous thromboembolism (VTE), a recent study found. More...


Warnings and alerts

Educational update issued on alpha-blockers and cataract surgery

The American Society of Cataract and Refractive Surgery and the American Academy of Ophthalmology recently issued a joint educational update on complications of cataract surgery associated with systemic alpha-blockers. More...


Women's health

ACOG invites public comment on proposed definitions from April 2 to June 4

The American College of Obstetricians and Gynecologists (ACOG) is leading an initiative to standardize language used across organizations in the area of women's health care and is seeking feedback from interested stakeholders in an online Public Comment forum, April 2 to June 4. More...


High-value care

ACP and Consumer Reports hold second annual patient empowerment expo

The second annual patient empowerment expo, co-sponsored by ACP and Consumer Reports Health, was held on Saturday, April 12, in Orlando, Fla. More...


From the College

Governance Committee seeks Regent candidates for 2015

The Governance Committee oversees the process for nominating and electing Masters and Fellows of the College to the Board of Regents (BOR) and is beginning the process of seeking Regents to join the Board in May 2015. More...

On Being a Doctor, volume 4, now available

On Being a Doctor, volume 4, is the latest collection of prose and poetry that vividly captures the feelings and experiences of doctors and patients. More...

The Doctors Company announces 2014 dividend for ACP members

The Doctors Company, the nation's largest physician-owned medical malpractice insurer and the exclusively sponsored carrier for ACP, has announced a $23 million dividend, which is made possible by the excellent claims experience of The Doctors Company's members. 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


.
Review of anti-flu drugs find little benefit, side effects, flaws in approval processes

Two Cochrane systematic reviews on flu relief drugs, which for the first time considered clinical study reports in addition to published studies, concluded that the medicines didn't have much impact on the course of symptoms.

The studies and accompanying editorials appeared online April 10 at BMJ.

In the first study, oseltamivir (Tamiflu) reduced the time to first alleviation of symptoms in adults by 16.8 hours (95% CI, 8.4 to 25.1 hours; P<0.001). While there was no effect in children with asthma, there was an effect in otherwise-healthy children (mean difference, 29 hours; 95% CI, 12 to 47 hours; P=0.001). There was no difference in hospital admissions in adults (risk difference, 0.15%; 95% CI, −0.91% to 0.78%, P=0.84).

Oseltamivir in adults increased the risk of nausea (risk difference, 3.66%; 95% CI, 0.90% to 7.39%; number needed to treat to harm [NNTH], 28; 95% CI, 14 to 112) and vomiting (risk difference, 4.56%; 95% CI, 2.39% to 7.58%; NNTH, 22; 95% CI, 14 to 42). In children, oseltamivir increased vomiting (risk difference, 5.34%; 95% CI, 1.75% to 10.29%; NNTH, 19; 95% CI, 10 to 57).

In prophylaxis studies, oseltamivir increased the risk of psychiatric adverse events during the combined "on-treatment" and "off-treatment" periods (risk difference, 1.06%; 95% CI, 0.07% to 2.76%; NNTH, 94; 95% CI, 36 to 1,538). Also, there was a dose-response effect on psychiatric events in 2 treatment trials, at doses of 75 mg and 150 mg twice daily (P=0.038). In prophylaxis studies, oseltamivir increased the on-treatment risks of headaches (risk difference, 3.15%; 95% CI, 0.88% to 5.78%; NNTH, 32; 95% CI, 18 to 115), renal events with treatment (risk difference, 0.67%; 95% CI, −0.01% to 2.93%), and nausea during treatment (risk difference, 4.15%; 95% CI, 0.86% to 9.51%; NNTH, 25; 95% CI, 11 to 116).

The authors wrote, "Given that oseltamivir is now recommended as an essential medicine for the treatment of seriously ill patients or those in higher risk groups with pandemic influenza, the issues of mode of action, lack of sizeable benefits, and toxicity are of concern. This is made worse by the record and stated intentions of governments to distribute oseltamivir to healthy people to prevent complications and interrupt transmission on the basis of a published evidence base that has been affected by reporting bias, ghost authorship, and poor methods. We believe these findings provide reason to question the stockpiling of oseltamivir, its inclusion on the [World Health Organization] list of essential drugs, and its use in clinical practice as an anti-influenza drug."

The second study found that zanamivir (Relenza) reduced the time to symptomatic improvement in adults, but not in children, and the difference might have stemmed from symptom relief medication. For adults, zanamivir reduced the time to first alleviation of symptoms of influenza-like illness by 0.60 day (95% CI, 0.39 to 0.81 day; P<0.001), or a 10% reduction in mean duration of symptoms from 6.6 days to 6.0 days. Time to first alleviation of symptoms was shorter in all participants when any relief drugs were allowed compared with no use.

In prophylaxis studies, symptomatic influenza in individuals was significantly reduced, with event rates lowered from 3.26% to 1.27%, (number needed to treat, 51; 95% CI, 40 to 103). The prophylactic effect on asymptomatic influenza cases was not significant in individuals or in households. Prophylaxis in adults reduced unverified pneumonia (0.32%, 95% CI, 0.09% to 0.41%; number needed to treat, 311, 95% CI, 244 to 1,086) but had no effect on pneumonia in children or on bronchitis or sinusitis in adults or children.

The authors concluded that "zanamivir is no more effective in relieving symptoms than commonly used over the counter symptomatic drugs (such as paracetamol or NSAIDs)." No further clinical trials of zanamivir are warranted, they added.

An editorialist criticized the drug approval process and government decisions to stockpile oseltamivir despite the lack of evidence. "The review's conclusion should lead to serious soul searching among policy makers," the editorial stated. A second editorialist wrote, "For now, health professionals can communicate the available evidence to anyone contemplating taking oseltamivir and zanamivir for prophylaxis or treatment, with confidence that nothing is hidden from view. Many patients may consider the risk of adverse effects to more than offset the prospect of shortening symptoms by half a day. For those who pay out of pocket, the additional costs may also be a deterrent."


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High-energy shock-wave therapy may be effective for shoulder pain, function

High-energy extracorporeal shock-wave therapy (ESWT) is effective for improving pain and shoulder function in chronic calcific shoulder tendinitis and can result in complete resolution of calcifications, a meta-analysis found.

annals.jpg

Researchers reviewed results from 28 randomized, controlled trials comparing high-energy (energy flux density ≥ 0.28 mJ/mm2) versus low-energy (energy flux density < 0.28 mJ/mm2) ESWT or placebo. Results appeared in the April 15 Annals of Internal Medicine.

The quality of trials varied in several respects and was generally low, with the number of patients ranging from 20 to 144 participants and trial durations ranging from 3 to 12 months. Six trials were double-blinded, 15 were single-blinded, and 7 did not report blinding. Withdrawal rates ranged from 0% to 33%, with 3 trials reporting a withdrawal rate of more than 20%. The trials had numerous sources of heterogeneity and bias, and 14 devices and a variety of regimens were used.

Compared with placebo, high-energy ESWT seemed to improve shoulder pain, function, and calcifications, whereas low-energy ESWT seemed to improve only function. The reduction in calcification was significantly greater after high-energy ESWT than after placebo treatment, while results for low-energy ESWT were inconclusive.

Eight calcific tendinitis trials directly compared high-energy ESWT with low-energy. For pain outcomes, the available studies did not demonstrate superiority of high-energy over low-energy ESWT. However, high-energy ESWT improved shoulder function significantly more than low-energy ESWT. High-energy ESWT seemed to be more efficient than low-energy ESWT in resolving shoulder calcium deposits.

The most commonly reported adverse events related to ESWT were petechiae, small bruises and hematomas, local erythema, and acute pain. Patients who received high- or medium-energy ESWT reported more adverse events than those who received low-energy ESWT or placebo. No serious adverse events occurred in any of the included studies.

The safety and efficacy of ESWT, coupled with its noninvasiveness, may suggest it as an alternative to surgery, the researchers concluded. "Extracorporeal shock-wave therapy is emerging as an innovative treatment for musculoskeletal disorders. As our understanding of its physiologic effects advance and more controlled homogeneous studies are conducted to further define the most effective dosing parameters and administration technique, ESWT may be a promising approach to treating chronic soft-tissue disorders," they wrote.



Test yourself


.
MKSAP Quiz: pleuritic left-sided anterior chest pain

A 63-year-old man is evaluated for pleuritic left-sided anterior chest pain, which has persisted intermittently for 1 week. The pain lasts for hours at a time and is not provoked by exertion or relieved by rest but is worse when supine. He reports transient relief with acetaminophen and codeine and occasionally when leaning forward. He has had a low-grade fever for 3 days, without cough or chills. Medical history is significant for acute pericarditis 7 months ago. He was treated at that time with ibuprofen and had rapid resolution of his symptoms. His only current medications are acetaminophen and codeine.

mksap.gif

On physical examination, temperature is 37.8 °C (100.0 °F), blood pressure is 132/78 mm Hg, pulse rate is 98/min, and respiration rate is 16/min. No jugular venous distention is noted. A two-component pericardial friction rub is heard over the left side of the sternum. Pulsus paradoxus of 6 mm Hg is noted. Lung auscultation reveals normal breath sounds with no wheezing. No pedal edema is present.

Electrocardiogram demonstrates sinus rhythm and no ST-segment shift.

Which of the following is the most appropriate management?

A: Azathioprine
B: Chest CT
C: Colchicine and aspirin
D: Pericardiectomy
E: Prednisone

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


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Infectious disease


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Rapid hepatitis C testing identified infections in high-risk population

Rapid testing for hepatitis C virus (HCV) at agencies for people with drug dependence identified many previously unrecognized infections, a recent study found.

The division of public health in Wisconsin conducted a pilot program from October 2012 to October 2013, in which rapid HCV testing was offered at 4 agencies that typically offer HCV and HIV testing, syringe exchange, counseling, and other harm reduction services. Results were published in the April 11 Morbidity and Mortality Weekly Report.

In total, 1,255 people received the rapid HCV test, and 20% of the results were positive. Of those positive tests, 72% had not been previously reported. A blood specimen was collected from 78% (192 patients) of the patients with positive rapid tests for further testing (the other 54 participants either refused venipuncture or a vein could not be accessed). Almost all (190) of the blood specimens were also tested for HCV antibody using enzyme immunoassays, and no false-positive results from the rapid HCV test were found. Most (183) of the blood samples were also tested using reverse transcription–polymerase chain reaction, which indicated active infection in 70% of the HCV cases.

The pilot project also found that 53% of participants said they had not been tested previously for HCV and another 10% didn't remember being tested. The majority of participants reported having injected drugs within the past 6 months, and the average number of persons with whom they reported injecting drugs was 5.4 (range, 0 to 100). Two-thirds of the study participants also reported having shared drug injection equipment, and 42% had shared equipment within 6 months of testing.

The results show that rapid tests could be a powerful tool for screening for HCV, conveying prevention information, and initiating treatment, the study authors concluded. The finding that patients frequently shared equipment is concerning, especially considering that these patients were participating in a syringe-exchange service. It indicates the importance of prevention messages that emphasize the risk of HCV transmission from any sharing of injection equipment, not just syringes, the authors said.



Anticoagulant therapy


.
Adding aspirin or NSAID to anticoagulant doubles bleeding risk

Taking aspirin or an NSAID while on anticoagulant therapy significantly increases the risk of bleeding in patients who have had a venous thromboembolism (VTE), a recent study found.

Researchers conducted a prospective analysis of observational data from the EINSTEIN trials, which compared anticoagulant treatment with oral rivaroxaban with initial enoxaparin followed by vitamin K antagonist (VKA) therapy in more than 8,000 patients with deep venous thrombosis or pulmonary embolism between 2007 and 2009. The researchers looked at days of aspirin or NSAID use while patients were on one of the anticoagulants and instances of clinically relevant or major bleeding. Results were published April 14 by JAMA Internal Medicine.

Taking NSAID or aspirin while on an anticoagulant significantly increased the risk of either type of bleeding compared to taking an anticoagulant alone. With NSAIDs, there were 37.5 clinically relevant bleeding events and 6.5 major bleeds per 100 patient-years compared to 16.6 and 2.0, respectively, in those not taking NSAIDs (hazard ratio [HR] for clinically relevant bleeding events, 1.77; 95% CI, 1.46 to 2.14 and HR for major bleeds, 2.37; 95% CI, 1.51 to 3.75). For patients on aspirin, the risk of clinically relevant bleeding was 36.6 per 100 patient-years, compared to 16.9 per 100 patient-years not on aspirin (HR, 1.70; 95% CI, 1.38 to 2.11). Major bleeding rates were 4.8 per 100 patient-years in aspirin-taking patients compared to 2.2 during aspirin nonuse (HR, 1.50; 95% CI, 0.86 to 2.62).

The authors concluded that in patients on anticoagulant therapy due to a VTE, concomitant use of an NSAID or aspirin is associated with about a doubling of the risk of bleeding. They noted that bleeding rates were similar on either of the anticoagulant regimens (rivaroxaban or enoxaparin-VKA) and that the study wasn't powered to determine whether use of selective COX-2 NSAIDs reduced the risk of bleeding.

Even though the study protocol discouraged physicians from using NSAIDs or aspirin, 22% of the participating patients took NSAIDs at some point during follow-up. Combined with the exclusion of patients with increased bleeding risk from the trial, this indicates that the study results may actually underestimate the bleeding risk of combining these drugs in practice. The study authors urged physicians "to combine anticoagulation with either NSAID or aspirin therapy with caution and only if genuinely indicated, with no similarly effective and safer alternative treatment available."



Warnings and alerts


.
Educational update issued on alpha-blockers and cataract surgery

The American Society of Cataract and Refractive Surgery and the American Academy of Ophthalmology recently issued a joint educational update on complications of cataract surgery associated with systemic alpha-blockers.

Patients taking systemic alpha-blockers, especially tamsulosin, are more likely to experience severe intraoperative floppy iris syndrome (IFIS), or sudden iris prolapse and pupil constriction during cataract surgery. The joint educational update is based on 2 new studies published in April. The first study, published in the April Ophthalmology, found that compared with alfuzosin, tamsulosin, an alpha-blocker selective for the alpha 1-A receptor subtype, was more likely to cause severe IFIS. The second study, published in the April Journal of Cataract & Refractive Surgery, found that 35% percent of primary care physicians surveyed knew that alpha-blockers affect cataract surgery and half of this group (17%) took this into account when deciding on treatment.

The 2 organizations recommend that physicians prescribing nonemergent alpha-blocker treatment should consider whether patients have cataracts and may need surgery. Patients who have known cataracts may want to have surgery earlier or start therapy with a nonselective alpha-blocker. Alpha-blockers have no other ocular adverse effects, and patients who have already had cataract surgery do not need special considerations, the organizations noted in a press release.

The full educational update is available online.



Women's health


.
ACOG invites public comment on proposed definitions from April 2 to June 4

The American College of Obstetricians and Gynecologists (ACOG) is leading an initiative to standardize language used across organizations in the area of women's health care and is seeking feedback from interested stakeholders in an online Public Comment forum, April 2 to June 4.

The reVITALize Gynecology Data Definitions Initiative is the result of collaborative efforts of more than 60 leaders in women's health care who convened at a December 2013 reVITALize Gynecology National Stakeholder Conference. The initiative seeks to standardize gynecology data definitions for performance measurement, registries, observational research, and electronic health records.

Currently, more than 100 proposed data element definitions across 6 separate categories are available for review. To learn more about the initiative or provide feedback on proposed definitions, go online.



High-value care


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ACP and Consumer Reports hold second annual patient empowerment expo

The second annual patient empowerment expo, co-sponsored by ACP and Consumer Reports Health, was held on Saturday, April 12, in Orlando, Fla.

The expo, "Your Health: Fact, Not Fiction," was a free event offered to area residents and was designed to help attendees learn how to be informed consumers of health care services and products. The expo featured physician speakers from both ACP and Consumer Reports, health screenings, and presentations on how to avoid the most common medication mistakes and which screening tests may be unnecessary.

John Whyte, MD, MPH, FACP, director of professional affairs and stakeholder engagement at the Food and Drug Administration, delivered the keynote speech, "High Value Care from the Patient's Perspective," and a second presentation, "How to Live (and Want) to be 100!"

More about ACP's High Value Care initiative is online.



From the College


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Governance Committee seeks Regent candidates for 2015

The Governance Committee oversees the process for nominating and electing Masters and Fellows of the College to the Board of Regents (BOR) and is beginning the process of seeking Regents to join the Board in May 2015.

The Governance Committee will strive to represent the diversity within internal medicine on ACP's Board of Regents. Important general qualifications include commitment to ACP, dependability, leadership qualities, and the ability to represent the College in numerous and diverse arenas. Regent nominees must be Fellows or Masters of the College.

All candidates for Regent must submit a letter of nomination (not from the candidate) and 2 letters of support from 2 individuals (other than the nominator) by Aug. 1, 2014.

Letters of nomination should include the following sections:

  • brief description of the nominee's current activities,
  • special attributes the candidate would bring to the BOR in terms of the desired characteristics outlined above,
  • previous and current service in College related activities,
  • service in organizations other than the College (medical and non-medical), and
  • identification of 2 individuals who will write letters of support for the candidate

Letters of support do not need to have specific content or format, but will be most useful if they focus on the candidate's qualifications and how they would contribute to the BOR and College.

Please send your confidential nominations, no later than Aug. 1, 2014, to:

Governance Committee

ATTN: Mrs. Florence Moore

American College of Physicians

190 N. Independence Mall West

Philadelphia, PA 19106-1572

Fax: 215-351-2829

e-mail: fmoore@acponline.org

Only candidates who submit a letter of nomination and 2 letters of support by Aug. 1, 2014, will be advanced to the Governance Committee for review.

If you have any questions, please contact Florence Moore toll free at (800) 523-1546, ext. 2814, or direct at (215) 351-2814.


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On Being a Doctor, volume 4, now available

On Being a Doctor, volume 4, is the latest collection of prose and poetry that vividly captures the feelings and experiences of doctors and patients.

Published by ACP, the fourth edition of On Being a Doctor is a softcover book compiled from pieces originally published in Annals of Internal Medicine, between 2007 and 2013. The book is a collection of more than 100 stories, essays, and poems in 9 sections ranging from "Those Who Are Our Patients" and "Balancing the Personal and the Professional" to "The Doctor Becomes a Patient" and "Death and Dying."

On Being a Doctor, volume 4, is edited by Annals of Internal Medicine Editor-in-Chief Christine Laine, MD, MPH, and Annals of Internal Medicine Associate Editor Michael LaCombe, MD, MACP. To order the book, go online, or call ACP Customer Service at 800-523-1546, extension 2600 (M-F, 9:00 a.m.-5:00 p.m. ET). A digital version of the book will soon be available.


.
The Doctors Company announces 2014 dividend for ACP members

The Doctors Company, the nation's largest physician-owned medical malpractice insurer and the exclusively sponsored carrier for ACP, has announced a $23 million dividend, which is made possible by the excellent claims experience of The Doctors Company's members.

Since 1976, The Doctors Company has paid more than $310 million in dividends, and 2014 marks the ninth year in a row that the company has awarded dividends. The 2014 dividend credit, approved by The Doctors Company's Board of Governors, will provide a premium reduction of 5% to eligible members of ACP. Dividend distributions will appear as premium reductions effective with renewals on or after July 1, 2014. More information about The Doctors Company is 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-20140422-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: Colchicine and aspirin. This item is available to MKSAP 16 subscribers as item 26 in the Cardiovascular Medicine section. More information is available online.

This patient most likely has recurrent pericarditis, and colchicine in combination with aspirin is the first-line treatment. He has pleuritic chest pain that is worse when supine and partially relieved by leaning forward and evidence of a pericardial friction rub. These findings are consistent with pericarditis. Lack of ST-segment elevation on electrocardiography does not exclude pericarditis. Seven months ago, he was diagnosed with acute pericarditis and treated with ibuprofen.

In patients with recurrent pericarditis who have not benefited from colchicine plus aspirin and who have not benefited from or cannot tolerate corticosteroid therapy, current guidelines support the use of alternative immunosuppressive therapy with azathioprine or cyclophosphamide. However, these third-line agents are not indicated in this patient who has yet to be treated with colchicine and aspirin.

Chest CT is useful for assessment of pericardial thickness when constrictive pericarditis is suspected on the basis of right heart failure (jugular venous distention, pedal edema, hepatic congestion). This patient has no such findings, and chest CT is not required.

In patients with acute or recurrent pericarditis, pericardiectomy does not prevent recurrent disease and is only indicated in patients who develop constrictive pericarditis.

Corticosteroids should generally be avoided for both acute and recurrent pericarditis because they increase the risk for recurrences. Prednisone is indicated in selected patients with recurrent pericarditis, such as those with pericarditis related to connective tissue disease and those with pericarditis refractory to colchicine and NSAIDs.

Key Point

  • Colchicine plus aspirin is the first-line treatment for recurrent pericarditis.

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