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ACP InternistWeekly



In the News for the Week of June 24, 2014




Highlights

IDSA guidelines call for accurate diagnoses, fewer antibiotics for skin and soft-tissue infections

Skin and soft-tissue infections, even those caused by methicillin-resistant Staphylococcus aureus, are often minor and either heal on their own or can be easily treated without antibiotics, according to updated practice guidelines. More...

Beta-blockers before CABG not associated with better outcomes

Use of beta-blockers in patients who have not had a recent heart attack but are undergoing nonemergency coronary artery bypass grafting (CABG) surgery was not associated with better outcomes, a study found. More...


Test yourself

MKSAP Quiz: Progressive exertional leg discomfort

This week's quiz asks readers to determine the best diagnostic testing for a 68-year-old woman assessed for a 6-month history of progressive exertional leg discomfort, described as a "heaviness" involving both calves. More...


Women's health

Calcium and vitamin D supplementation associated with hypercalcemia, hypercalciuria in postmenopausal women

Postmenopausal women who take calcium and vitamin D supplements may be at higher risk for hypercalcemia and hypercalciuria, according to a new study. More...


Pulmonology

New guideline released on pharmacologic therapy for pulmonary arterial hypertension in adults

A new guideline was released last week on pharmacologic therapy for pulmonary arterial hypertension in adults. More...


FDA update

REMS no longer required to prescribe rosiglitazone

The requirement for prescribers of rosiglitazone to enroll in a Risk Evaluation and Mitigation Strategy (REMS) program has been eliminated by the FDA. 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


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IDSA guidelines call for accurate diagnoses, fewer antibiotics for skin and soft-tissue infections

Skin and soft-tissue infections (SSTIs), even those caused by methicillin-resistant Staphylococcus aureus (MRSA), are often minor and either heal on their own or can be easily treated without antibiotics, according to updated practice guidelines.

The guidelines, issued by the Infectious Diseases Society of America, are meant to help physicians make the correct diagnosis, establish the source and cause of the infection, determine its severity, and help physicians know when antibiotics are and are not necessary.

Emergency department visits due to SSTIs nearly tripled from 1.2 million in 1995 to 3.4 million in 2005, much of the increase driven by MRSA, the guideline noted. SSTIs account for more than 6 million visits to doctors' offices every year.

The guidelines appeared online June 19 in Clinical Infectious Diseases.

About half of SSTIs are caused by staph bacteria and are purulent, typically red, swollen, hot to the touch, and painful. Purulent infections are usually no larger than a few inches, have a focal point of infection, and are filled with pus. Most will clear on their own or should be treated with incision and draining alone, not antibiotics, the guidelines said.

Specifically, the guidelines recommend performing a Gram stain and culture of pus from carbuncles and abscesses, but treatment without these studies is reasonable in typical cases (evidence: strong, moderate). It is not recommended to perform a Gram stain and culture of pus from inflamed epidermoid cysts (evidence: strong, moderate). The guidelines recommend incision and drainage as primary therapy for inflamed epidermoid cysts, carbuncles, abscesses, and large furuncles (evidence: strong, high).

Use of antibiotics for S. aureus as an adjunct to incision and drainage should be based on whether there are symptoms of systemic inflammatory response syndrome, such as temperature higher than 38° C or less than 36° C, tachypnea more than 24 breaths per minute, tachycardia more than 90 beats per minute, or white blood cell count greater than 12,000 or less than 4,000 cells/μL (evidence: moderate).

Other SSTIs are caused by non-staph bacteria such as group A streptococcus, which produce toxins instead of pus and are more likely to be severe and even deadly, causing serious infections such as cellulitis, necrotizing fasciitis, or gangrene, the guideline stated. Non-purulent SSTIs do not have a focal point and continue to spread. Even mild or moderate non-purulent cases typically require antibiotic treatment, sometimes provided intravenously. These infections require speedy diagnosis, surgery to remove the infection, and antibiotic treatment. In the case of severe non-purulent SSTIs such as necrotizing fasciitis or group A streptococcus gangrene, the infected material should be removed surgically.

The guidelines contain a chart to help physicians quickly diagnose and treat the SSTI based on whether or not it is purulent; determine whether the infection is mild, moderate or severe; and recommend appropriate treatment. Again, physicians should be most concerned when a patient with any SSTI, whether purulent or not, has a fever higher than 38° C, a high white blood cell count, or a rapid heart rate; is breathing fast; or is immunocompromised.

The updated IDSA guidelines also provide extensive recommendations for:

  • treating SSTIs in immunocompromised patients, including those with HIV/AIDS or those who have had an organ transplant,
  • treating recurrent skin abscesses and cellulitis,
  • providing preferred management of surgical-site infections, and
  • treating animal bite wounds.

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Beta-blockers before CABG not associated with better outcomes

Use of beta-blockers in patients who have not had a recent heart attack but are undergoing nonemergency coronary artery bypass grafting (CABG) surgery was not associated with better outcomes, a study found.

Preoperative beta-blocker therapy is a national quality standard, the authors noted. They conducted a retrospective analysis of the Society of Thoracic Surgeons National Adult Cardiac database of U.S. hospitals performing cardiac surgery from 2008 to 2012. The study included 506,110 patients undergoing nonemergency CABG surgery who had not had a heart attack in the previous 21 days or any other high-risk symptoms.

Results appeared online June 16 at JAMA Internal Medicine.

Of the 506,110 patients, 86.2% received preoperative beta-blockers within 24 hours of surgery. A propensity-matched analysis included 138,542 patients. There was no difference between patients who did and did not receive preoperative beta-blockers in rates of:

  • operative mortality (1.12% vs. 1.17%; odds ratio [OR], 0.96; 95% CI, 0.87 to 1.06; P=0.38),
  • permanent stroke (0.97% vs. 0.98%; OR, 0.99; 95% CI, 0.89 to 1.10; P=0.81),
  • prolonged ventilation (7.01% vs. 6.86%; OR, 1.02; 95% CI, 0.98 to 1.07; P=0.26),
  • any reoperation (3.60% vs. 3.69%; OR, 0.97; 95% CI, 0.92 to 1.03; P=0.35),
  • renal failure (2.33% vs. 2.24%; OR, 1.04; 95% CI, 0.97 to 1.11; P=0.30), and
  • deep sternal wound infection (0.29% vs. 0.34%; OR, 0.86; 95% CI, 0.71 to 1.04; P=0.12).

Patients who received preoperative beta-blockers within 24 hours of surgery did have higher rates of new-onset atrial fibrillation than patients who did not (21.50% vs. 20.10%; OR, 1.09; 95% CI, 1.06 to 1.12; P<0.001), the authors wrote.

"[Beta]-blockers are an important and effective tool in the care of patients undergoing cardiac surgery in specific clinical scenarios," the authors wrote. "However, the empirical use of [beta]-blockers as recommended by the National Quality Forum (without physiologic goals i.e., adequate clinical drug levels) in all patients before CABG may not improve outcomes."

In an invited commentary, the editorialist states that, because of 5 limitations of the study, physicians should continue to adhere to American College of Cardiology/American Heart Association guidelines for preoperative beta-blockade in CABG surgery. Limitations include the following:

  • Short-term CABG mortality rates, which have decreased to about 1%, may no longer be a sufficiently sensitive outcome to assess the value of perioperative beta-blockade;
  • The study excluded 28% of patients with isolated CABG because of a myocardial infarction within 21 days before surgery, thus eliminating patients with ST-elevation myocardial infarction (STEMI) and non-STEMI;
  • Critical variables necessary to address the efficacy of perioperative beta-blockade are not present in the study, such the specific beta-blocker used, whether the patient was receiving long-term beta-blocker therapy, the exact timing and protocol for beta-blocker administration, and use of amiodarone hydrochloride;
  • Substantial differences were noted in the baseline characteristics of the beta-blocker and non-beta-blocker groups; and
  • Pharmacogenetic variation may affect the efficacy of preoperative beta-blockade.

"Important considerations include perioperative continuation of [beta]-blockade in patients receiving long-term therapy and administration and titration of [beta]-blockers to optimal heart rate and blood pressure in [beta]-blocker-naïve patients, initiated as long before surgery as possible (preferably weeks before in elective patients)," the commentary concluded.



Test yourself


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MKSAP Quiz: Progressive exertional leg discomfort

A 68-year-old woman is assessed for a 6-month history of progressive exertional leg discomfort, described as a "heaviness" involving both calves. The symptoms are relieved within 5 to 10 minutes of rest. She has noted the same limiting heaviness with bicycling. Medical history is significant for hypertension, type 2 diabetes mellitus, and hyperlipidemia; she does not smoke cigarettes. Medications are valsartan, hydrochlorothiazide, metformin, and rosuvastatin.

mksap.gif

On physical examination, the patient is afebrile. Blood pressure is 130/84 mm Hg in both arms. The highest right foot systolic pressure is 184 mm Hg; the highest left foot systolic pressure is 186 mm Hg. Pulse rate is 78/min and regular, and respiration rate is 14/min. BMI is 30. Distal pulses are diminished but equal bilaterally. Sensation to light touch is diminished bilaterally in the toes extending to the midfoot. No abdominal or femoral bruits are present. Deep tendon reflexes at the knees and ankles are 2+ and symmetric. Strength is 5/5 throughout in the lower extremities.

Which of the following is the most appropriate diagnostic test to evaluate her exertional leg pain?

A: Electromyography and nerve conduction studies
B: Exercise ankle-brachial index
C: Great toe pressure measurement
D: Lumbar MRI

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


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Women's health


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Calcium and vitamin D supplementation associated with hypercalcemia, hypercalciuria in postmenopausal women

Postmenopausal women who take calcium and vitamin D supplements may be at higher risk for hypercalcemia and hypercalciuria, according to a new study.

Researchers conducted a 1-year randomized, placebo-controlled trial in which postmenopausal women received 400 to 1,800 IU of vitamin D per day, as well as calcium citrate supplements. All of the women in the study had vitamin D insufficiency at baseline. Serum and 24-hour urine calcium were measured every 3 months while the women were taking supplements, and any result that exceeded the upper reference range was classified as hypercalcemia or hypercalciuria. The study's primary outcome measures were dose responses to serum 25-hydroxyvitamin D and serum parathyroid hormone after vitamin D supplementation. Secondary outcomes were serum and 24-hour urine calcium levels. The study results were published online June 16 by Menopause.

A total of 163 women age 57 to 90 years were randomly assigned to 1 of 8 study groups: 400 IU of vitamin D daily, 800 IU, 1,600 IU, 2,400 IU, 3,200 IU, 4,000 IU, 4,800 IU, or placebo. The study participants also received calcium supplementation to ensure an intake of 1,200 to 1,400 mg/d after 7-day food diaries were used to determine usual dietary calcium levels. All of the women in the study had been postmenopausal for at least 7 years, and all were white. Of the women who were randomly assigned, 147 completed the study protocol, 5 were lost to follow-up, and 11 stopped taking the study medications but were included in the analysis. Mean adherence to the study medications over 12 months was 94% for vitamin D and 91% for calcium.

Overall, 8.8% of women experienced hypercalcemia and 30.6% experienced hypercalciuria. Hypercalciuria was transient in half of patients and recurred in the other half. The researchers did not detect a relationship between hypercalcemia or hypercalciuria and dose of vitamin D, and an equal proportion of patients in the placebo group also experienced hypercalciuria. Eleven women experienced serious adverse events, but none appeared to be related to vitamin D use, and no patients developed symptomatic kidney stones. A weak relationship was found between 24-hour urine calcium level and 12-month serum 25-hydroxyvitamin D level.

The researchers acknowledged that their results might not apply to other age or ethnic groups and that they did not use fixed-dose calcium or include a placebo group who did not take calcium supplements. However, they concluded that hypercalcemia and hypercalciuria are common in postmenopausal women who take calcium and vitamin D supplements and that these events are not related to dose of vitamin D or to serum 25-hydroxyvitamin D level. It is unclear whether these events are related to calcium alone or to calcium plus vitamin D, the authors said.

"Further investigation is needed to better define individuals who are likely to develop hypercalciuria and hypercalcemia, but a high baseline 24-hour urine calcium level is one predictor of hypercalciuria," the authors wrote. "Before the start of calcium and vitamin D supplementation, it is advisable to measure blood and urine calcium levels and to perform a follow-up measurement within 3 months."



Pulmonology


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New guideline released on pharmacologic therapy for pulmonary arterial hypertension in adults

A new guideline was released last week on pharmacologic therapy for pulmonary arterial hypertension (PAH) in adults.

The CHEST guideline was developed by a 12-member expert panel and was based on systematic reviews of English-language studies published between 1990 and November 2013. The panel issued guideline recommendations when evidence was available to support them and consensus statements based on expert opinion when evidence was lacking.

The guideline is intended for all clinicians caring for adults with PAH, including cardiologists, primary care internists, pulmonologists, and rheumatologists. The panel stressed that the guideline covers only patients with PAH and that the recommendations do not apply to patients with other kinds of pulmonary hypertension, such as that due to left-sided heart disease or chronic hypoxemic lung disease. The guideline was published online June 17 by CHEST.

The guideline panel suggested that severity of a PAH patient's disease be evaluated systematically and consistently with a combination of World Health Organization (WHO) functional class, exercise capacity, and echocardiographic, laboratory, and hemodynamic variables to help inform therapeutic decisions. It also suggested that all PAH patients be evaluated at a center with expertise in PAH diagnosis whenever possible, ideally before therapy is initiated, and that collaborative, closely coordinated care be provided by local physicians as well as PAH experts.

The panel suggested that treatment-naïve patients without symptoms and those at increased risk for PAH should be monitored for symptoms that would warrant initiation of pharmacotherapy and that contributing causes of pulmonary hypertension, such as sleep apnea and systemic hypertension, should be treated aggressively. Symptomatic patients with PAH and no contraindications should have acute vasoreactivity testing using a short-acting agent at an experienced center, the panel suggested, and a trial of oral calcium-channel blocker therapy should be considered in those who demonstrate acute reactivity and have no right-heart failure or contraindications. The panel also made specific recommendations for PAH pharmacotherapy in patients with WHO functional class II, III, and IV symptoms.

The guideline panel suggested that pregnancy be avoided in patients with PAH. It also suggested that patients avoid exposure to high altitude and use supplemental oxygen as needed during altitude exposure or air travel in order to maintain an oxygen saturation above 91%. Patients with PAH should maintain current immunization against influenza and pneumococcal pneumonia, the panel suggested, and should avoid nonessential surgery. When surgery is necessary, the panel suggested, it should be performed at a pulmonary hypertension center with a multidisciplinary approach and careful monitoring.

"No approved therapy for PAH has been shown to prevent progression of the underlying pulmonary vascular disease," the guideline panel wrote. "PAH remains an incurable disease; currently clinicians attempt to manage it with pharmacotherapy. While we believe the outlook for a newly diagnosed patient with PAH has improved, it remains far from adequate or acceptable." The panel called on researchers to help fill the gaps in evidence regarding clinical questions about PAH.

The complete guideline is available free of charge online.

Read more about diagnosing PAH in the primary care setting in ACP Internist's April 2013 cover story.



FDA update


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REMS no longer required to prescribe rosiglitazone

The requirement for prescribers of rosiglitazone to enroll in a Risk Evaluation and Mitigation Strategy (REMS) program has been eliminated by the FDA.

The REMS sponsors are notifying clinicians of this change, which was first announced by the FDA in a November 2013 safety announcement. The change was based on data showing that rosiglitazone-containing drugs (Avandia, Avandamet, Avandaryl, and generics) do not show an increased risk of heart attack compared to metformin and sulfonylureas.

More information about the REMS is available online.



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-20140624-cartoon.jpg

"Honest, I have no money to give you! The copay and insurance premiums took me for all I had."

This issue's winning cartoon caption was submitted by David M. Casement, MD, ACP Member, from St. Paul, Minn. Thanks to all who voted! The winning entry captured 46.38% of the votes.

The runners-up were:

"Just a reflex whenever I see a masked man."

"My occupation? I test roller coasters."


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MKSAP Answer and Critique



The correct answer is C: Great toe pressure measurement . This item is available to MKSAP 16 subscribers as item 116 in the Cardiology section. More information is available online.

The most appropriate test to perform in this patient is measurement of the great toe pressure. The ankle-brachial index (ABI) is obtained by measuring the systolic pressures in the dorsalis pedis and posterior tibialis arteries on both sides. The ABI for each leg is the highest ankle pressure for that side divided by the highest brachial pressure (regardless of side). An ABI of 0.90 or lower establishes a diagnosis of peripheral arterial disease (PAD). In this patient, the ABI is greater than 1.40 bilaterally. An ABI above 1.40 suggests noncompressible vessels, which may reflect medial calcification but is not diagnostic of flow-limiting atherosclerotic disease. An ABI greater than 1.40 is associated with worse cardiovascular outcomes than a normal ABI. In such cases, an appropriate next step is to either measure great toe pressure or calculate a toe-brachial index (systolic great toe pressure divided by systolic brachial pressure). Vessels within the great toe rarely become noncompressible, and a great toe systolic pressure below 40 mm Hg or a toe-brachial index of less than 0.70 is consistent with PAD.

Although the patient probably has peripheral neuropathy based on the symmetric loss of sensation to light touch, it is unlikely to be related to the patient's exertional leg pain. Therefore, electromyography and nerve conduction studies would not be helpful at this point.

An ABI obtained immediately following symptom-limited exercise is useful when a high clinical suspicion for PAD remains despite a normal (1.00-1.40) or borderline resting ABI. A decrease of the ABI by 20% compared with the resting ABI is consistent with significant PAD. This patient's ABI is above the normal range; therefore, exercise ABI would not help to establish the diagnosis.

Although spinal stenosis can produce leg discomfort with walking, patients often describe discomfort with prolonged standing. The discomfort is relieved with lying down or with waist flexion. In this patient, the physical examination does not demonstrate motor or sensory loss that would support nerve root compression as the cause of her symptoms. Additionally, the position adopted for bicycling is less likely to provoke leg pain in patients with spinal stenosis, but can result in claudication due to arterial insufficiency. Lumbar MRI, therefore, is not indicated.

Key Point

  • In a patient with suspected peripheral arterial disease, an ankle-brachial index above 1.40 is noninterpretable; measurement of the great toe systolic pressure can establish the diagnosis.

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