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

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ACP InternistWeekly



In the News for the Week of May 6, 2014




Highlights

Massachusetts health care reform associated with improved health outcomes in adults

Health care reform in Massachusetts, which has been considered a model for the Affordable Care Act, was associated with reduced all-cause mortality and deaths from causes potentially affected by access to health care, according to a new study. More...

New methadone safety clinical practice guideline released

New guidelines for prescribing methadone for opioid addiction and pain management offer advice for primary care and specialty providers about safety and electrocardiogram monitoring to identify patients at high risk for cardiac problems. More...


Test yourself

MKSAP Quiz: 3-month history of irregular menses

A 32-year-old woman is evaluated for increased hair growth on the face and chest and a 3-month history of irregular menses. She has a 5-year history of hypothyroidism. Her only medication is levothyroxine. Terminal hair growth of the upper lip, chin, sides of the face, and middle of the chest is noted. Pelvic examination reveals clitoromegaly. What is the most appropriate next diagnostic test? More...


Gastroenterology

Pathology of nonalcoholic fatty liver disease improves after bariatric surgery

Bariatric surgery improved nonalcoholic fatty liver disease (NAFLD) in obese patients, according to a study presented at Digestive Disease Week. More...


Blood pressure

Hypertension may be underdiagnosed in rheumatoid arthritis patients

Patients with rheumatoid arthritis are nearly 30% less likely to be diagnosed with hypertension than those without the disease, a study found. More...


Infectious Disease

Physician resources available for MERS

The first case of Middle East Respiratory Syndrome (MERS) has been reported in the United States. This issue has been followed closely by the Centers for Disease Control (CDC) and the Department of Health and Human Services (HHS) over the past several months, as its arrival in the U.S. and its 30% mortality rate have raised the level of attention and concern. More...


From the College

Lessons learned during an unplanned EHR downtime

Yul Ejnes, MD, MACP, continues his monthly column at KevinMD.com in a column that describes the pros and cons of electronic health records after he went without his for longer than expected. More...

ACP to host its first national conference in India in September 2014

The College will host its first national conference in New Delhi, India, Sept. 5-6, 2014, at the Le Meridien hotel. The conference focus is "The Burden of Non-Communicable Diseases," and it will feature both U.S.-based and India-based physicians as faculty speakers. More...

ACP offers resources to help with CMS physician payment data release

In response to CMS's recent release of physician payment data, ACP has created a Frequently Asked Questions document for physicians responding to patient inquiries or needing a reference tool on the data release. More...

Jock Murray, MD, MACP, inducted into the Canadian Medical Hall of Fame

Former ACP Regent T.J. (Jock) Murray, MD, MACP, was inducted into the Canadian Medical Hall of Fame (CMHF). More...


From ACP Internist

ACP Internist is online and coming to your mailbox

The latest issue of ACP Internist is online and coming to your mailbox. Top stories include portable ultrasound, medical nonadherence, and cognitive strategies for being a better doctor. 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: Daisy Smith, MD, FACP



Highlights


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Massachusetts health care reform associated with improved health outcomes in adults

Health care reform in Massachusetts, which has been considered a model for the Affordable Care Act, was associated with reduced all-cause mortality and deaths from causes potentially affected by access to health care, according to a new study.

annals.jpg

Researchers compared mortality rates before and after introduction of health care reform in Massachusetts counties with rates among a control group in counties in other states to determine whether the Massachusetts law affected outcomes. The pre-reform period was defined as 2001 to 2005, while the post-reform period was defined as 2007 to 2010. The primary outcome measures were annual county-level all-cause mortality in age-, sex-, and race-specific cells (n=146,825) obtained from the CDC's Compressed Mortality File. Secondary outcomes were deaths from causes that could be affected by access to health care, insurance coverage, access to care, and self-reported health. Data on coverage, health care access, and self-reported health were obtained from the CDC's Behavioral Risk Factor Surveillance System and the Census Bureau's Current Population Survey. The study involved adults 20 to 64 years of age.

Results appeared in the May 6 Annals of Internal Medicine.

Researchers found that Massachusetts health care reform was associated with a significant decrease in all-cause mortality versus the control group (−2.9%; P=0.003; absolute decrease, 8.2 deaths per 100,000 adults). Deaths from causes that could be affected by access to health care, such as cardiovascular disease and cancer, also saw a significant decrease (−4.5%; P<0.001). Counties that had lower household incomes and higher proportions of uninsured persons before health care reform experienced greater changes.

In secondary analyses, post-reform counties in Massachusetts had significant gains in coverage, access to care, and self-reported to health. The researchers calculated that approximately 830 adults needed to gain health insurance to avoid 1 death annually.

The study's design was nonrandomized and the data may have been affected by unmeasured confounders, the authors noted. However, they concluded that health reform in Massachusetts was associated with reduced all-cause mortality and reductions in deaths from causes that could be affected by access to health care.

"Although this analysis cannot demonstrate causality, the results offer suggestive evidence that the Affordable Care Act—modeled after the Massachusetts law—may impact not only coverage and access but also mortality," the authors wrote. However, they said, the Massachusetts results might not be generalizable to the country as a whole, "which underscores the need to monitor closely the Affordable Care Act's effect on coverage, access, and population health across all states."

The author of an accompanying editorial said that the study adds to a large body of existing evidence that suggests insurance has a positive effect on health and that it seems reasonable to concluded that coverage expansion benefits health by facilitating health care access.

"What is unreasonable and, in my view, unconscionable is to leverage a selective reading of the evidence on the benefits of health insurance in an argument to deny assistance to Americans who cannot afford to purchase basic coverage," the editorialist concluded.


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New methadone safety clinical practice guideline released

New guidelines for prescribing methadone for opioid addiction and pain management offer advice for primary care and specialty providers about safety and electrocardiogram monitoring to identify patients at high risk for cardiac problems.

The American Pain Society convened an expert panel that reviewed more than 3,700 scientific abstracts under the direction of the Oregon Evidence-based Practice Center to develop the new methadone safety guideline, which appeared online at The Journal of Pain.

According to the guideline, clinicians should perform an individualized medical and behavioral risk evaluation to assess risks and benefits of methadone (strong recommendation, low-quality evidence). Careful patient selection for methadone is essential and should be based on a thorough history, review of medical records, and physical examination. Assessment results can be used to stratify patients based on their risk for substance abuse, drug interactions, arrhythmias.

The guidelines recommend educating and counseling patients before prescribing methadone about the indications for treatment and goals of therapy, availability of alternative therapies, and specific plans for monitoring therapy, adjusting doses, and dealing with potential adverse effects (strong recommendation, low-quality evidence).

Clinicians should do an electrocardiogram (ECG) before starting methadone in patients with risk factors for QTc interval prolongation, and consider doing an ECG before starting methadone in patients not known to be at higher risk. Buprenorphine is an option for patients being treated for opioid addiction who have risk factors for prolonged QTc intervals.

Clinicians should begin methadone at low doses based on the indication for treatment and prior opioid exposure status, titrate doses slowly, and monitor patients for sedation (strong recommendation, moderate-quality evidence). Methadone should be withheld if there is evidence of sedation.

When used to treat opioid addiction, clinicians should start methadone at no more than 30 to 40 mg once daily, titrated by no more than 10 mg/d and no more frequently than every 3 to 4 days. When used to treat chronic pain in adults on relatively low doses of other opioids (such as <40–60 mg/d of morphine or equivalent), clinicians should start methadone at 2.5 mg tid, with initial dose increases of no more than 5 mg/d every 5 to 7 days. When used to treat chronic pain and switching to methadone from higher doses of another opioid, clinicians can start methadone therapy at a dose 75% to 90% less than the calculated equianalgesic dose and at no higher than 30 to 40 mg/d, with initial dose increases of no more than 10 mg/d every 5 to 7 days.

Clinicians can consider those patients previously prescribed methadone, but who have not currently taken opioids for 1 to 2 weeks, as opioid-naïve when restarting methadone (strong recommendation, low-quality evidence).

Clinicians should conduct urine drug screens before starting methadone and at regular intervals in patients prescribed methadone for opioid addiction (strong recommendation, low-quality evidence). Also, patients prescribed methadone for chronic pain who have risk factors for drug abuse should undergo urine drug testing before starting methadone and at regular intervals thereafter. Clinicians can consider urine drug testing in all patients regardless of assessed risk status (strong recommendation, low-quality evidence).



Test yourself


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MKSAP Quiz: 3-month history of irregular menses

A 32-year-old woman is evaluated for increased hair growth on the face and chest and a 3-month history of irregular menses. She has a 5-year history of hypothyroidism. Her only medication is levothyroxine.

mksap.gif

On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 110/72 mm Hg, and pulse rate is 80/min; BMI is 26. Terminal hair growth of the upper lip, chin, sides of the face, and middle of the chest is noted. No acanthosis nigricans or galactorrhea is detected. Palpation of the abdomen reveals no masses. Pelvic examination reveals clitoromegaly.

Laboratory studies:

Dehydroepiandrosterone sulfate 2.78 µg/mL (7.5 µmol/L)
Prolactin 17 ng/mL (17 µg/L)
Total testosterone 279 ng/dL (9.7 nmol/L)
Thyroid-stimulating hormone 1.5 µU/mL (1.5 mU/L)

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

A: Adrenal CT
B: Free testosterone measurement
C: Pituitary MRI
D: Transvaginal ultrasonography

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


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Gastroenterology


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Pathology of nonalcoholic fatty liver disease improves after bariatric surgery

Bariatric surgery improved nonalcoholic fatty liver disease (NAFLD) in obese patients, according to a study presented at Digestive Disease Week.

Researchers had a pathologist review liver biopsies of 152 patients who underwent bariatric surgery between 1998 and 2013 (82% women, mean pre-op body-mass index 52 kg/m2). For each patient, a biopsy taken during the bariatric procedure was compared to one taken during a subsequent abdominal operation, which was on average 29 months after the index procedure. The study was presented as an abstract at the meeting.

The post-op biopsies showed that steatosis resolved in 70% of the 118 patients who had it initially. Chronic portal inflammation resolved in 32% of cases (32 of 99 patients) and steatohepatitis resolved in 88% (44 of 50 patients). Fibrosis of any grade resolved in 21% of cases and improved in another 23%. Most significantly, the researchers noted, Grade 2 or 3 (bridging) fibrosis resolved or improved in 65% of the patients who had it (Grade 2: 16 of 52 cases resolved, 16 improved; Grade 3: 1 of 10 cases resolved, 7 improved).

"What we found surprised us," the study's lead author said at a press conference. "These findings suggest that bariatric surgery should be considered as the treatment of choice for NAFLD patients with a body mass index greater than 35 and obesity-related comorbidities or patients with a body mass index of greater than 40."

The findings may be particularly relevant to patients who haven't had success with traditional interventions such as medications and dieting, he added.



Blood pressure


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Hypertension may be underdiagnosed in rheumatoid arthritis patients

Patients with rheumatoid arthritis are nearly 30% less likely to be diagnosed with hypertension than those without the disease, a study found.

Researchers studied adult patients with and without rheumatoid arthritis/inflammatory arthritis from a large academic multispecialty practice. All were seen regularly in primary care and met clinical guideline hypertension criteria but lacked prior hypertension diagnosis/treatment.

Results appeared online at Arthritis Care & Research.

Among 14,974 patients with undiagnosed hypertension, 201 (1.3%) had rheumatoid arthritis. Patients with rheumatoid arthritis patients had equal numbers of primary care visits and more total medical visits compared to patients without the condition (5.4 compared to 2.3, including on average of 2.6 rheumatology visits annually). The likelihood of hypertension diagnosis was 36% in rheumatoid arthritis patients compared to 51% without rheumatoid arthritis (HR=0.71; 95% CI, 0.55 to 0.93).

Researchers noted that patients with comorbid diabetes or hyperlipidemia were more likely to be diagnosed with hypertension (hazard ratios [HR] 1.27 and 1.09, respectively). Patients between the ages of 60 and 79 years had the highest rate of diagnosis (HR=1.42; 95% CI, 1.31 to 1.54), black patients had the next (HR=1.28; 95% CI, 1.14 to 1.44), and current smokers had a lower rate of hypertension diagnosis (HR=0.88; 95% CI, 0.82 to 0.96).

Given that rheumatoid arthritis patients have a 50% to 60% increased incidence of cardiovascular disease (CVD) events and premature death, hypertension diagnosis should be a key step in managing the condition, the authors noted.

"Patients with diabetes and hyperlipidemia also experienced higher diagnosis, likely reflecting concordant CVD risk perceptions, and well-known, guideline-driven practices for CVD risk management," the authors wrote. "RA (rheumatoid arthritis) patients, in contrast, may be suffering from the lack of provider awareness regarding RA as a concordant CVD risk. Lower hypertension diagnosis in active smokers was particularly concerning given that health care providers should be more vigilant to traditional CVD risk factors like hypertension in patients who smoke."



Infectious Disease


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Physician resources available for MERS

The first case of Middle East Respiratory Syndrome (MERS) has been reported in the United States. This issue has been followed closely by the Centers for Disease Control (CDC) and the Department of Health and Human Services (HHS) over the past several months, as its arrival in the U.S. and its 30% mortality rate have raised the level of attention and concern.

Comprehensive resources for physicians and health care professionals on MERS and the coronavirus that causes it are available through the CDC website, including a direct link to the "Interim Guidance for Health Professionals."



From the College


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Lessons learned during an unplanned EHR downtime

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 describes the pros and cons of electronic health records he observed during a time when his EHR was unavailable for longer than expected.


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ACP to host its first national conference in India in September 2014

The College will host its first national conference in New Delhi, India, Sept. 5-6, 2014, at the Le Meridien hotel. The conference focus is "The Burden of Non-Communicable Diseases," and it will feature both U.S.-based and India-based physicians as faculty speakers.

The meeting program for the ACP India National Conference will include updates in:

  • hypertension,
  • diabetes,
  • gastroenterology and hepatology,
  • hematology and oncology,
  • infectious diseases, and
  • cardiology.

These updates will be presented in a panel format comprised of 1 U.S. and 1 Indian speaker per session. A pre-session focusing on Gerontology issues will be held on Sept. 4, 2014, in collaboration with Fortis Hospital, Gurgaon.

The conference is open to all who are interested, and physicians are encouraged to inform their colleagues about this event. More information and registration rates are available on the ACP India website.


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ACP offers resources to help with CMS physician payment data release

In response to CMS's recent release of physician payment data, ACP has created a Frequently Asked Questions document for physicians responding to patient inquiries or needing a reference tool on the data release.

CMS has also provided an interactive search tool to obtain physician Medicare payment data. The new tool allows users to search for a health care provider by name, address or National Provider Identifier (NPI). The tool, which is query-based, provides information about the services of a specific provider to Medicare beneficiaries. This information includes the number of services provided, the number of beneficiaries treated, and the average payment and costs of such services.


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Jock Murray, MD, MACP, inducted into the Canadian Medical Hall of Fame

Former ACP Regent T.J. (Jock) Murray, MD, MACP, was inducted into the Canadian Medical Hall of Fame (CMHF).

Dr. Murray was 1 of 6 physicians honored by the CMHF at a gala event held on April 24, 2014, at Queen's University in London, Ontario, Canada. The CMHF celebrates the work of health leaders and medical innovators who demonstrate excellence in the field of medicine. Dr. Murray was acknowledged as a world leader in multiple sclerosis research and care.

Dr. Murray served 2 terms as chair of the ACP Board of Regents and is a former chair of the Board of Governors. He received his ACP Mastership and Chair Emeritus title in 1998, and is a recipient of ACP's Nicholas Davies Award, the Stengel Award, and the ACP Laureate Award from the Atlantic ACP Chapter.

More information about Dr. Murray and his prestigious award is online.



From ACP Internist


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ACP Internist is online and coming to your mailbox

The latest issue of ACP Internist is online and coming to your mailbox. Top stories include:

acpi-20140506-internist.jpg

Portable ultrasound scopes out a new role. Enthusiasts argue that point-of-care ultrasonography extends the scope of the physical exam far beyond what can be auscultated through a stethoscope. Detractors worry about overdiagnosis and a loss of medical skills that have intrinsic value. Both sides seek balance when considering how to use this new technology.

Treat the epidemic of medical nonadherence. Multiple diseases and multiple medications, among other factors, lead to many patients not following their prescribed regimens. Experts are examining why in an effort to help improve nonadherence rates that can reach 50% by some estimates.

Cognitive strategies take good physicians to greatness. On-the-job learning, feedback, simulation, and deliberate practice can take a good clinician to the next level.

More conference coverage and Test Yourself with the MKSAP Quiz are available online.



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-20140506-cartoon.jpg

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

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

"We should have done a time-out."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting ends on May 12, with the winner announced in the May 13 issue.


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MKSAP Answer and Critique



The correct answer is D: Transvaginal ultrasonography. This item is available to MKSAP 16 subscribers as item 62 in the Endocrinology and Metabolism section. More information is available online.

The most appropriate next diagnostic test is transvaginal ultrasonography to examine this patient's ovaries. Her history and physical examination findings are consistent with hyperandrogenism. Her total testosterone level is elevated, and her dehydroepiandrosterone sulfate (DHEAS) level is normal. In healthy women, the ovaries and adrenal glands contribute equally to testosterone production. However, a testosterone level greater than 200 ng/dL (6.9 nmol/L) in a woman with rapid onset of hyperandrogenic symptoms (increased hirsutism in a short period of time and clitoromegaly) suggests an ovarian neoplasm, which is best diagnosed with a transvaginal ultrasound.

Dehydroepiandrosterone is produced primarily in the adrenal glands and is sulfated in the adrenal glands, liver, and small intestine to become DHEAS. Levels greater than 7.0 micrograms/mL (18.9 micromoles/L) strongly suggest an adrenal source of androgens. In this patient, whose DHEAS level is only 2.9 micrograms/mL (7.8 micromoles/L), imaging of the adrenals would be the next step only if the transvaginal ultrasound showed no ovarian neoplasm.

A free testosterone measurement is not needed because this patient's history and physical examination findings do not suggest an abnormality in her sex hormone–binding globulin level that would make the total testosterone measurement suspect.

Because elevated androgen levels in women have either an ovarian or an adrenal source, a pituitary MRI would not be useful in this patient.

Key Point

  • In a woman with rapid onset of hyperandrogenic symptoms, especially if her testosterone level is greater than 200 ng/dL (6.9 nmol/L), an ovarian neoplasm is likely and is best diagnosed with a transvaginal ultrasound.

Click here to return to the rest of ACP InternistWeekly.

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Test yourself

A 38-year-old man is evaluated for a mass in his right neck that he first noticed 2 weeks ago while shaving. The patient also reports experiencing a pressure sensation when swallowing solid foods for the past year and daily diarrhea for the past 2 months. His personal medical history is unremarkable. His younger brother has nephrolithiasis, and his father died of a hypertensive crisis and cardiac arrest at age 62 years while undergoing anesthesia induction to repair a hip fracture. Following a physical exam, lab studies, and a chest radiograph, what is the most likely diagnosis?

Find the answer

MKSAP 16 Holiday Special: Save 10%

MKSAP 16 Holiday Special:  Save 10%

Use MKSAP 16 to earn MOC points, prepare for ABIM exams and assess your clinical knowledge. For a limited time save 10% when you use priority code MKPROMO! Order now.

Maintenance of Certification:

What if I Still Don't Know Where to Start?

Maintenance of Certification: What if I Still Don't Know Where to Start?

Because the rules are complex and may apply differently depending on when you last certified, ACP has developed a MOC Navigator. This FREE tool can help you understand the impact of MOC, review requirements, guide you in selecting ways to meet the requirements, show you how to enroll, and more. Start navigating now.