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

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ACP InternistWeekly



In the News for the Week of May 13, 2014




Highlights

First-year salaries up for primary care, specialty physicians

Primary care physicians reported $186,475 in median first-year guaranteed compensation when placed in a new practice, compared to $260,000 for specialists, an increase in first-year median guaranteed compensation for both groups of clinicians. More...

Aspirin for primary prevention should be better targeted, new study and FDA say

A recently published study and announcement from the FDA caution against wide use of aspirin for primary prevention of cardiovascular events. More...


Test yourself

MKSAP Quiz: 6-month history of diarrhea and bloating

A 51-year-old woman is evaluated for a 6-month history of diarrhea and bloating. She reports four to six loose stools per day, with occasional nocturnal stools. She has had a few episodes of incontinence secondary to urgency. She has not had melena or hematochezia but notes an occasional oily appearance to the stool. Following a physical exam and lab results, what is the most likely diagnosis? More...


Stroke

Guidelines issued on preventing stroke in patients with previous stroke and transient ischemic attack

The American Heart Association (AHA) and the American Stroke Association have released new guidelines on preventing stroke in patients who have survived an ischemic stroke or transient ischemic attack (TIA). More...


Women's health

Cervical cancer rates in older women may be higher than previously thought

Older women's rates of cervical cancer are significantly higher than previously thought, because past analyses have not adjusted for the prevalence of hysterectomy in this population, a new study found. More...

Age, bone mineral density may predict 5-year fracture risk after stopping bisphosphonate

When postmenopausal women stop bisphosphonate therapy, their age and hip bone mineral density (BMD) can help predict the likelihood of fractures over the next 5 years, a study found. More...


Geriatric medicine

Frailty score may help predict postop mortality risk in the elderly

A multidimensional frailty score helped predict postoperative mortality risk in elderly patients, according to a new study. More...


CMS update

Open payments registration begins June 1

On June 1, physicians and teaching hospital representatives can begin registering for the Open Payments program through the Centers for Medicare & Medicaid Services' (CMS) Enterprise Portal. More...


Health information technology

NCQA develops strategy to advance patient engagement using health IT tools

The National Committee for Quality Assurance (NCQA) released a report, "Building a Strategy to Leverage Health Information Technology to Support Patient and Family Engagement," that outlines a strategy to advance patient and family engagement in health care by leveraging new health information technology (IT). More...


Cartoon caption contest

And the winner is …

ACP InternistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption. More...


Physician editor: Philip Masters, MD, FACP



Highlights


.
First-year salaries up for primary care, specialty physicians

Primary care physicians reported $186,475 in median first-year guaranteed compensation when placed in a new practice, compared to $260,000 for specialists, an increase in first-year median guaranteed compensation for both groups of clinicians.

The findings come from the Medical Group Management Association's "Physician Placement Starting Salary Survey: 2014 Report Based on 2013 Data," which also found that 60% of physicians placed in a new practice reported receiving signing bonuses and 72% accepted paid relocation packages as part of their employment offers, increases from years past.

The Lower Midwest, the Southeast, and the Eastern Midwest regions reported having placed the most clinicians in jobs (17.34%, 16.97%, and 16.53%, respectively); however, 2 of these regions, the Eastern Midwest and the Southeast, also reported the highest percentages of physicians who relocated to other regions (16.98% and 15.86%, respectively). The North Atlantic had the third highest "relocated from" percentage, at 15.25%.

Physicians in the Southern geographic section report the highest first-year guaranteed compensation for both primary care and specialty care ($200,000 and $274,000, respectively). Specialty care physicians reported the lowest starting salary in the Midwest section at $246,048, whereas physicians in the Western section reported the lowest starting salary for primary care physicians ($180,000).

First-year guaranteed compensation for primary care physicians was $185,000 in physician-owned businesses, $192,554 from hospital- or integrated delivery service (IDS)-owned employers, and $160,000 in other employment models. Among subspecialists, the rates were $275,000 for physician-owned, $300,000 for hospital- or IDS-owned models, and $200,000 for other models.

When first-year physicians hired out of residency were compared to established physicians, primary care physicians reported similar starting salaries, with established physicians reporting only a 5.6% higher compensation. Specialty care physicians reported a much larger gap in compensation with established physicians: 31.2% higher median starting salary than new physicians.

The survey contained data on 5,318 clinicians in 567 medical organizations. All information was voluntarily provided.


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Aspirin for primary prevention should be better targeted, new study and FDA say

A recently published study and announcement from the FDA caution against wide use of aspirin for primary prevention of cardiovascular events.

The study evaluated coronary artery calcium (CAC) scoring as a method to determine which patients should take aspirin for primary prevention. Findings were based on more than 4,000 participants in the Multi-Ethnic Study of Atherosclerosis who were not on aspirin at baseline and were free of diabetes. Median follow-up was 7.6 years, and researchers calculated 5-year number needed to treat (NNT) and number need to harm (NNH) rates using an assumption that aspirin reduced event rates by 18% and increased major bleeding by 0.23%. Results were published online by Circulation: Cardiovascular Quality and Outcomes on May 6.

Study patients were stratified according to Framingham Risk Score (FRS) calculations of their risk of developing coronary heart disease in the next 10 years. Participants who had a CAC score of 100 or higher were found to benefit from aspirin, regardless of their FRS risk status. The NNT was 173 for patients with FRS <10% and 92 for those with FRS ≥10%. The NNH was 442 for all patients.

Patients who had a zero CAC score did not benefit from aspirin overall (NNT for <10%, 2,036; NNT for ≥10%, 808). However, researchers noted that women with elevated coronary risk according to traditional factors received a net benefit from aspirin.

About a quarter of the patients fell between the 2 categories, with a CAC of 1 to 99, and the study could not calculate definitive risk/benefit profiles for them. Patient preference should take a greater role in their treatment plans, the authors suggested. For many of the other patients, CAC score could change treatment recommendations regarding aspirin, the authors said. More than 10% of participants who don't qualify for aspirin under current American Heart Association guidelines had a CAC score ≥100, while over 30% of the participants who would be on aspirin were found to have a zero CAC score.

Cost and other effects of CAC testing (radiation, downstream testing, and psychological/behavioral effects) could pose issues with targeting aspirin in this way, the researchers noted, so the study results should be considered hypothesis-generating.

The FDA also recently took a position on use of aspirin for primary prevention. After denying a manufacturer request to change prescribing information to allow marketing of aspirin for prevention of heart attacks in patients with no history of cardiovascular disease, the agency announced to consumers that it "does not believe the evidence supports the general use of aspirin for primary prevention of a heart attack or stroke."

Evidence does support use in patients who have already had a heart attack or stroke or who have other evidence of coronary artery disease, such as angina or a history of a coronary bypass operation or coronary angioplasty, the agency said. However, additional clinical trials are underway that could provide new evidence for changing the indications for aspirin, according to the statement.



Test yourself


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MKSAP Quiz: 6-month history of diarrhea and bloating

A 51-year-old woman is evaluated for a 6-month history of diarrhea and bloating. She reports four to six loose stools per day, with occasional nocturnal stools. She has had a few episodes of incontinence secondary to urgency. She has not had melena or hematochezia but notes an occasional oily appearance to the stool. She has lost 6.8 kg (15.0 lb) during this time period. Results of a colonoscopy 1 year ago were normal. She has not had recent travel, antibiotic use, or medication changes. She does not think consumption of dairy products alters her symptoms. She has a history of systemic sclerosis for which she takes omeprazole for symptoms of gastroesophageal reflux disease.

mksap.gif

On physical examination, vital signs are normal. BMI is 22. Facial telangiectasias are present, and there is bilateral skin thickening of the hands. The abdomen is mildly distended, and bowel sounds are normal. Rectal examination is normal, with normal resting and squeeze tone. There are no palpable mass lesions.

Laboratory studies:

Hemoglobin 10.8 g/dL (108 g/L)
Mean corpuscular volume 104 fL
Serum electrolytes Normal
Folate 63 ng/mL (143 nmol/L)
Glucose Normal
Thyroid-stimulating hormone Normal
Vitamin B12 118 pg/mL (87 pmol/L)
Tissue transglutaminase antibody Normal

Stool cultures, including an ova and parasite examination, are normal.

Which of the following is the most likely diagnosis?

A: Celiac disease
B: Irritable bowel syndrome
C: Lactose malabsorption
D: Microscopic colitis
E: Small intestinal bacterial overgrowth

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


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Stroke


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Guidelines issued on preventing stroke in patients with previous stroke and transient ischemic attack

The American Heart Association (AHA) and the American Stroke Association have released new guidelines on preventing stroke in patients who have survived an ischemic stroke or transient ischemic attack (TIA).

The current guidelines are an update of the 2011 version and are intended for clinicians who manage secondary prevention in this population. The new guidelines have added sections on sleep apnea, aortic arch atherosclerosis, and nutrition, and the section on diabetes mellitus has been expanded to include prediabetes. In addition, substantial revisions were made to the sections on carotid stenosis, atrial fibrillation, prosthetic heart valves, pregnancy, and intracranial atherosclerosis, while a section on Fabry disease was removed. More emphasis is given to lifestyle and obesity as targets for risk reduction. The recommendations and levels of evidence were classified according to AHA and American College of Cardiology methods.

Some of the new recommendations are as follows:

  • All patients with TIA or stroke should be screened for obesity with measurement of body mass index (Class I recommendation; Level of Evidence C).
  • For patients who are able and willing to initiate increased physical activity, referral to a comprehensive, behaviorally oriented program is probably recommended (Class IIa recommendation; Level of Evidence C).
  • Patients with a history of ischemic stroke or TIA and signs of undernutrition should be referred for individualized nutritional counseling (Class I recommendation; Level of Evidence B).
  • A sleep study might be considered for patients with an ischemic stroke or TIA on the basis of the very high prevalence of sleep apnea in this population and the strength of the evidence that the treatment of sleep apnea improves outcomes in the general population (Class IIb recommendation; Level of Evidence B).
  • Rivaroxaban is reasonable for the prevention of recurrent stroke in patients with nonvalvular atrial fibrillation (Class IIa recommendation; Level of Evidence B).
  • For most patients with a stroke or TIA in the setting of atrial fibrillation, it is reasonable to initiate oral anticoagulation within 14 days after the onset of neurological symptoms (Class IIa recommendation; Level of Evidence B).
  • The combination of aspirin and clopidogrel might be considered for initiation within 24 hours of a minor ischemic stroke or TIA and for continuation for 90 days (Class IIb recommendation; Level of Evidence B).

The guidelines were published online by Stroke on May 1. An executive summary is also available.



Women's health


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Cervical cancer rates in older women may be higher than previously thought

Older women's rates of cervical cancer are significantly higher than previously thought, because past analyses have not adjusted for the prevalence of hysterectomy in this population, a new study found.

Researchers used self-reports of hysterectomy from the Behavioral Risk Factor Surveillance System to correct age-standardized and age-specific incidence rates of cervical cancer from the Surveillance, Epidemiology and End Results 18 registry from 2000 to 2009. Results were published by Cancer on May 12.

Removing women who have had hysterectomies from the denominator of the population at risk for cervical cancer (since removal of the cervix eliminates their risk) revealed that the rate of cervical cancer continues to increase with age after age 35-39, although at a slower rate, the study found. After correction, the highest cancer incidence rate was among 65- to 69-year-old women, with a rate of 27.4 cases per 100,000. By contrast, the highest uncorrected rate was 15.6 cases per 100,000 in women age 40 to 44 years. Correcting for hysterectomy had the greatest impact on risk among older black women, because they reported a high prevalence of hysterectomy.

Including women who have had hysterectomies when calculating cervical cancer rates results in substantial bias, the researchers concluded. Removing them from the calculation "resulted in higher age-standardized and age-specific cervical cancer incidence rates, a shift in the peak incidence to older women, and an increase in the disparity in cervical cancer incidence between black and white women in the United States," they wrote.

The study results are subject to limitations, including the possibility of recall bias in reports of hysterectomy, but they should lead to reconsideration of current screening recommendations, which call for cessation of routine cervical cancer screening at age 65, the authors said. Screening is more difficult after menopause, they acknowledged, but patients may benefit from it.


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Age, bone mineral density may predict 5-year fracture risk after stopping bisphosphonate

When postmenopausal women stop bisphosphonate therapy, their age and hip bone mineral density (BMD) can help predict the likelihood of fractures over the next 5 years, a study found.

The prospective Fracture Intervention Trial Long-term Extension (FLEX) study looked at 1,099 postmenopausal women age 61 to 86 years who were previously treated with 4 to 5 years of alendronate sodium, 5 or 10 mg/d. The women were randomized to either 5 more years of alendronate (60%) or placebo (40%) from 1998 through 2003. Women were offered a daily supplement of 500 mg of calcium and 250 IU of vitamin D.

This substudy specifically focused on the placebo group. The report appeared online May 5 at JAMA Internal Medicine.

Hip and spine dual-energy X-ray absorptiometry (DXA) were measured for 1 to 3 years of follow-up. Two biochemical markers of bone turnover, urinary type 1 collagen cross-linked N-telopeptide (NTX) and serum bone-specific alkaline phosphatase (BAP), were measured at baseline and after 1 and 3 years.

During 5 years of follow-up of the placebo group, 82 women had fractures after 1 year and 94 women (22%) had fractures over the entire time span. After adjustment for age, the risk of total hip fracture in women in the lowest tertile of baseline total hip BMD was higher than that in the other 2 tertiles (relative hazard ratio, 1.87; 95% CI, 1.20 to 2.92).

Results were similar for femoral neck BMD (relative hazard ratio, 2.17; 95% CI, 1.38 to 3.41). Older age was independently associated with a greater risk of fracture (relative hazard ratio, 1.54; 95% CI, 1.26 to 1.85 per 5-year increase) after stopping alendronate. Baseline levels of NTX (relative hazard ratio, 1.33; 95% CI, 0.84 to 2.10) and BAP (relative hazard ratio, 1.39, 95% CI, 0.89 to 2.17) were not associated with fracture outcomes.

The authors noted, "Women with greater total hip bone loss 2 or 3 years after discontinuation may be at increased risk of fracture, but these results need to be confirmed in other studies before routine measurement of BMD after discontinuation of alendronate therapy can be recommended."

In an invited commentary, editorialists noted the study is convincing because it relies on a clinical, symptomatic fracture outcome rather than surrogate measures such as rates of BMD loss or changes in bone turnover marker levels.

"In an era when we know much more about how to start alendronate therapy than how to stop it, the results of [the current study] suggest that identification of patients at high risk of fracture after treatment discontinuation is best accomplished by BMD measurement at the time of discontinuation rather than frequent short-term monitoring with BMD or bone turnover marker measurements after treatment discontinuation," they wrote.



Geriatric medicine


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Frailty score may help predict postop mortality risk in the elderly

A multidimensional frailty score helped predict postoperative mortality risk in elderly patients, according to a new study.

Researchers at a tertiary care center in Korea studied consecutive patients at least 65 years of age who were having intermediate-risk or high-risk elective surgery. Patients who had emergency surgery or who were classified as low risk for adverse outcomes after surgery according to American College of Cardiology/American Heart Association 2007 guidelines were excluded. The goal of the study was to develop a model that would predict adverse outcomes in elderly patients undergoing surgery. To that end, all patients received a comprehensive geriatric assessment, which involved burden of comorbidity, polypharmacy, physical function, psychological status, nutrition, and risk for postoperative delirium. Most received the assessment within a month prior to surgery, although 13 received it 1 to 3 months before surgery.

The study's main outcome measure was all-cause mortality at 1 year, while secondary outcomes were postoperative complications (unplanned ICU admissions, pneumonia, delirium, urinary tract infection, or acute pulmonary thromboembolism), length of stay, and discharge to a nursing facility if the patient had previously lived at home. The study results were published online May 7 by JAMA Surgery.

From Oct. 19, 2011, to July 31, 2012, 275 patients were included in the study. Mean age was 75.4 years, and 55% were men. Twenty-five patients (9.1%) died during a median follow-up of 13.3 months, 4 in the hospital after their surgery. At least 1 postsurgery complication occurred in 29 patients (10.5%), and 24 patients (8.7%) were discharged to nursing facilities. Patients who died were more likely to have malignant disease and low levels of serum albumin than those who did not. Higher mortality rates were associated with scores on the Charlson Comorbidity Index (a method of predicting mortality by weighting comorbid conditions), dependence in activities of daily living and instrumental activities of daily living, dementia, delirium risk, short midarm circumference, and malnutrition.

The researchers developed a frailty score based on these factors and found that it performed better when predicting rates of all-cause mortality than the American Society of Anesthesiologists score (area under the receiver-operating characteristic curve, 0.821 vs. 0.647; P=0.01). Based on the frailty score, patients were divided into those with a score greater than 5 and those with a score of 5 or lower, with a higher score indicating higher risk. Sensitivity was 84.0% and specificity was 69.2% for all-cause mortality. Patients with high-risk frailty scores had higher risk for death (hazard ratio, 9.01; P=0.003) and longer hospital stays (median, 9 vs. 6 days; P<0.001) after surgery.

The researchers noted that their study involved a single hospital and that the results therefore might not be generalizable to other settings. In addition, they pointed out that their model did not show statistical significance when predicting outcomes after surgery. However, they concluded that their score, which is based on a comprehensive geriatric assessment, is better than other conventional methods when predicting 1-year all-cause mortality rate after surgery, length of hospital stay, and risk for discharge to a nursing facility.

"This model may support surgical treatments for fit older patients at low risk of complications, and it may also provide an impetus for better management of geriatric patients with a high risk of adverse outcomes after surgery," the researchers concluded.



CMS update


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Open payments registration begins June 1

On June 1, physicians and teaching hospital representatives can begin registering for the Open Payments program through the Centers for Medicare & Medicaid Services' (CMS) Enterprise Portal. Open Payments is a federally run transparency program that will collect and make public information about financial relationships among the health care industry, physicians, and teaching hospitals.

Registration is voluntary but is required if physicians or teaching hospitals want to review and dispute the data reported about them. Physicians can learn more about Open Payments requirements by reviewing the CMS Program Overview for Physicians.

Registration for physicians and teaching hospitals will be conducted in 2 phases for this first Open Payments reporting year.

  • Phase 1 (begins June 1): Users can register in CMS' Enterprise Portal. This registration is required to obtain access to and review information submitted about oneself by industry during Phase 2.
  • Phase 2 (begins in July): Registered users in the Open Payments system can review and dispute data submitted by applicable manufacturers and applicable group purchasing organizations (GPOs) prior to public posting of the data. (Note: Any data that are disputed, if not corrected by industry, will still be made public but will be marked as disputed. Learn more about the review and dispute process online.)

CMS is offering several resources related to Open Payments, including continuing education materials, a brochure for patients, and a mobile app to help physicians track payments and other transfers of value they receive throughout the year.



Health information technology


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NCQA develops strategy to advance patient engagement using health IT tools

The National Committee for Quality Assurance (NCQA) released a report, "Building a Strategy to Leverage Health Information Technology to Support Patient and Family Engagement," that outlines a strategy to advance patient and family engagement in health care by leveraging new health information technology (IT).

ACP contributed input to the report, which illustrates how a variety of technology solutions, such as Web-based applications, mobile phones, remote sensing technologies, electronic health records, and other devices, can support patient engagement.

Read the report and watch a videotaped message about the initiative from ACP Executive Vice President and CEO Steven Weinberger, MD, FACP, on the NCQA website.



Cartoon caption contest


.
And the winner is …

ACP InternistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

acpi-20140513-cartoon.jpg

"We should have done a time-out."

This issue's winning cartoon caption was submitted by Allison R. Wilcox, MD, ACP Member. Thanks to all who voted! The winning entry captured 53.66% of the votes.

The runners-up were:

"This is one of those new 'head-to-head studies' patients."

"Confusion reigned when the students were told to observe from the foot of the operating room table."


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MKSAP Answer and Critique



The correct answer is E: Small intestinal bacterial overgrowth. This item is available to MKSAP 16 subscribers as item 55 in the Gastroenterology and Hepatology section. More information is available online.

This patient has many features of small intestinal bacterial overgrowth (SIBO), including diarrhea, bloating, and weight loss. In addition, she appears to have macrocytic anemia secondary to vitamin B12 deficiency in association with an elevated serum folate level, which is a classic pattern seen in SIBO (bacteria consume vitamin B12 and also synthesize folate). Patients with systemic sclerosis may be particularly at risk for SIBO because of intestinal dysmotility or small-intestinal diverticula. Common risk factors for SIBO include altered gastric acid (achlorhydria, gastrectomy), structural abnormalities (strictures, small-bowel diverticula, blind loops or afferent limbs), and intestinal dysmotility (diabetes mellitus, neuromuscular disorders). The diagnosis of SIBO can be established with hydrogen breath testing or upper endoscopy with small-intestinal cultures, if available.

Although celiac disease may cause diarrhea, weight loss, and bloating, this patient's normal tissue transglutaminase antibody and elevated serum folate level make this less likely than SIBO, especially given her risk factors for bacterial overgrowth.

Irritable bowel syndrome should not cause weight loss or nocturnal stools. These clinical findings represent alarm features in the evaluation of patients with diarrhea and abdominal pain or bloating, so it would be erroneous to diagnose irritable bowel syndrome with the presence of these findings.

Patients with lactose malabsorption in isolation should not have weight loss, so it would not explain this patient's clinical picture. Although patients with SIBO may have concomitant lactose intolerance, lactose restriction is discouraged before evaluating and treating the underlying problem, especially because this patient reports tolerance of lactose ingestion.

By definition, microscopic colitis is a disease with histologic changes limited to the colon, unless it occurs in the setting of celiac disease. Therefore, with a colonic disease, features of fat malabsorption and vitamin deficiencies should not be seen. Although patients with microscopic colitis may have mild degrees of weight loss due to volume depletion, this patient's weight loss is higher than what would typically be seen.

Key Point

  • Small intestinal bacterial overgrowth should be considered in patients presenting with diarrhea, bloating, or weight loss; vitamin B12 deficiency or an elevated serum folate level can be laboratory clues to the diagnosis.

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Test yourself

A 66-year-old man comes for a preoperative evaluation before total joint arthroplasty of the left knee. He has a 25-year history of rheumatoid arthritis. He has had progressive pain in his left knee with activity, which limits his ability to hike. The patient has similar pain in the right knee, but it is less severe. He reports no recent morning stiffness. He is able to climb two or three flights of stairs without chest pain or shortness of breath. He has no other medical problems and reports no additional symptoms. Medications are methotrexate and folic acid. Following a physical exam and lab tests, what is the next best step in management?

Find the answer

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