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

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ACP InternistWeekly



In the News for the Week of July 22, 2014




Highlights

Little benefit, many harms from niacin, study finds

Taking niacin didn't significantly reduce vascular events and did cause a variety of serious side effects for high-risk patients, a new study found. More...

History of ischemic stroke raises risk of adverse events after noncardiac surgery

A history of ischemic stroke, especially within the previous 9 months, was associated with a higher risk of adverse events after noncardiac surgery, a new study found. More...


Test yourself

MKSAP Quiz: 2-week history of decreased exercise tolerance

A 57-year-old woman is evaluated for a 2-week history of decreased exercise tolerance and substernal chest pain on exertion. She also has an 8-month history of macrocytic anemia. Following a physical exam, lab results, and electrocardiogram, what is the most likely diagnosis? More...


Autoimmune disease

Hydroxychloroquine for Sjögren syndrome does not appear effective

Hydroxychloroquine did not improve symptoms of primary Sjögren syndrome during 24 weeks of treatment compared with placebo, according to a study. More...


Infection control

Hand hygiene recommendations released

Several professional societies, including the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America, recently released recommendations on preventing health care-associated infections through hand hygiene. More...


Education

ACP to host first national conference in India in September 2014

The American College of Physicians will host its first national conference in New Delhi, India, Sept. 5-6 at the Le Méridien 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...


High-value care

Article cites ACP and other groups for efforts to promote high-value care

According to an article published in the July 16 Journal of the American Medical Association (JAMA), professional organizations like ACP are the groups best positioned to engage physicians in qualitative efforts to improve the value of health care. More...


From the College

Call for spring 2015 Board of Governors resolutions

The deadline for submitting new resolutions to be heard at the spring 2015 Board of Governors meeting is Sept. 24. 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


.
Little benefit, many harms from niacin, study finds

Taking niacin didn't significantly reduce vascular events and did cause a variety of serious side effects for high-risk patients, a new study found.

More than 25,000 patients with vascular disease were included in the Heart Protection Study 2-Treatment of HDL to Reduce the Incidence of Vascular Events (HPS2-THRIVE). They were randomized to either placebo or 2 g of extended-release niacin and 40 mg of laropiprant, a highly selective prostaoid DP(1) receptor antagonist that decreases flushing but has no affect on lipids, daily. The median follow-up was 3.9 years, and the primary outcome was first major vascular event. Results were published in the July 17 New England Journal of Medicine (NEJM).

At follow-up, patients in the niacin group did have lower LDL cholesterol (average difference, 10 mg/dL) and higher HDL cholesterol (average difference, 6 mg/dL). However, the difference in major vascular events was not significant (13.2% on niacin vs. 13.7% on placebo; rate ratio, 0.96; 95% CI, 0.90 to 1.03). The niacin group had significantly higher rates of a number of serious side effects, including disturbances in diabetes control, new diabetes diagnoses, and problems with the gastrointestinal, musculoskeletal, and skin systems. Infections and bleeding rates were also significantly higher in the niacin group.

The latter 2 adverse effects were unexpected, researchers noted, while the others were in line with previous research. In response to these new findings about adverse effects, the authors of a previous trial of niacin (AIM-HIGH) published a letter in the same issue of NEJM about side effects found in their study. They concluded that the data have certain similarities, especially regarding infections, but that the excess in bleeding was not definitively confirmed, and the difference in drug formulations between the trials should be remembered.

Given the side effects and small benefit for patients in the current study, niacin's only possible usefulness may be in particular patient groups, the HPS2-THRIVE authors concluded. An accompanying editorial went further, saying that "niacin must be considered to have an unacceptable toxicity profile for the majority of patients, and it should not be used routinely," although it could possibly benefit very high-risk patients who have contraindications to statins, need a fourth-line agent, or have severe hypertriglyceridemia. The ineffectiveness of niacin, along with the results of other studies using agents that raise HDL cholesterol, also undermines the hypothesis that increasing HDL cholesterol in isolation is of benefit in reducing cardiovascular events.


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History of ischemic stroke raises risk of adverse events after noncardiac surgery

A history of ischemic stroke, especially within the previous 9 months, was associated with a higher risk of adverse events after noncardiac surgery, a new study found.

Danish researchers used national registry data of all elective noncardiac surgeries (n=481,183 surgeries) performed in patients aged 20 years or older in 2005-2011. Using ICD-10 codes, they identified patients with prior ischemic stroke; they didn't include patients with hemorrhagic stroke or transient ischemic attack. Patients whose last stroke occurred more than 5 years before surgery weren't included.

The researchers divided patients into subgroups based on time elapsed between stroke and surgery. The groups were no prior stroke, stroke within less than 3 months, stroke within 3 to less than 6 months, stroke within 6 to less than 12 months, and stroke 12 or more months before surgery. The primary outcomes were all-cause mortality and major adverse cardiovascular events (MACE) up to 30 days after surgery. MACE was a combination of nonfatal acute myocardial infarction, nonfatal ischemic stroke, and cardiovascular death. Results were published online July 16 by the Journal of the American Medical Association.

Among patients with prior stroke (n=7,137), the crude incidence rate of MACE was 54.4 per 1,000 patients, compared to patients without prior stroke (n=474,046) for whom the MACE incidence rate was 4.1 per 1,000. Regardless of time between ischemic stroke and surgery, a prior ischemic stroke was associated with an adjusted 1.8- and 4.8-fold increased relative risk of 30-day mortality and 30-day MACE, respectively, compared with patients without prior stroke.

There also was a strong time-dependent relationship between previous stroke and adverse postoperative outcome, with patients who had a stroke less than 3 months before surgery at especially high risk. Compared to patients without stroke, odds ratios for MACE were 14.23 (95% CI, 11.61 to 17.45) for patients with stroke less than 3 months before surgery, 4.85 (95% CI, 3.32 to 7.08) for stroke 3 to less than 6 months prior, 3.04 (95% CI, 2.13 to 4.34) for stroke 6 to less than 12 months prior, and 2.47 (95% CI, 2.07 to 2.95) for stroke 12 months or more prior. In those same subgroups, 30-day mortality risks followed a similar pattern; odds ratios were 3.07 (95% CI, 2.30 to 4.09), 1.97 (95% CI, 1.22 to 3.19), 1.45 (95% CI, 0.95 to 2.20), and 1.46 (95% CI, 1.21 to 1.77), respectively. Risks for MACE and death were elevated but level after 9 months. MACE risk didn't vary by whether the surgery itself was low-, intermediate- or high-risk.

Studies looking into the optimal timing of surgery in patients with prior stroke are scarce, the authors noted. These results suggest patients should be considered at higher risk of adverse 30-day outcomes after noncardiac surgery until 9 months after stroke, the authors concluded. Given that low- and intermediate-risk surgeries appeared to pose the same risk of MACE as high-risk surgeries, "it seems important to take a history of recent stroke seriously, including in the context of minor surgical procedures," the authors wrote.



Test yourself


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MKSAP Quiz: 2-week history of decreased exercise tolerance

A 57-year-old woman is evaluated for a 2-week history of decreased exercise tolerance and substernal chest pain on exertion. She also has an 8-month history of macrocytic anemia.

mksap.gif

On physical examination, temperature is 36.7 °C (98.0 °F), blood pressure is 137/78 mm Hg, pulse rate is 104/min, and respiration rate is 17/min. BMI is 25. The patient has pale conjunctivae. Cardiopulmonary and neurologic examination findings are normal.

Initial laboratory studies indicate a hemoglobin level of 7.4 g/dL (74 g/L), a mean corpuscular volume of 104 fL, a serum vitamin B12 level in the low-normal range, and a normal red cell folate level. Subsequent testing indicates elevated serum homocysteine and methylmalonic acid levels.

An electrocardiogram is normal.

Which of the following is the most likely diagnosis?

A: Cobalamin deficiency
B: Combined folate and cobalamin deficiency
C: Folate deficiency
D: Transcobalamin II deficiency

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


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Autoimmune disease


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Hydroxychloroquine for Sjögren syndrome does not appear effective

Hydroxychloroquine did not improve symptoms of primary Sjögren syndrome during 24 weeks of treatment compared with placebo, according to a study.

Researchers randomly assigned 120 patients with primary Sjögren syndrome from 15 university hospitals in France: 56 received hydroxychloroquine (400 mg per day) and 64 received placebo for 24 weeks. Both groups received hydroxychloroquine between weeks 24 and 48.

Results appeared in the July 16 Journal of the American Medical Association.

At 24 weeks, the proportion of patients meeting the primary end point (defined as a 30% or greater reduction in 2 of 3 scores evaluating dryness, pain, and fatigue) was 17.9% (10 of 56) in the hydroxychloroquine group and 17.2% (11 of 64) in the placebo group (odds ratio, 1.01; 95% CI, 0.37 to 2.78; P=0.98). Looking at the symptoms individually, the researchers also failed to find clinically significant differences between the treatment and placebo groups, although pain appeared to be nonsignificantly improved by hydroxychloroquine.

Hydroxychloroquine had no efficacy in the subgroups of patients with anti-SSA autoantibodies, high immunoglobulin G levels, or systemic involvement. During the first 24 weeks, there were 2 serious adverse events in the hydroxychloroquine group and 3 in the placebo group. In the last 24 weeks, there were 3 serious adverse events in the hydroxychloroquine group and 4 in the placebo group.

The trial extends the negative results of the only previous controlled crossover trial of the treatment, which included 19 patients and suggested that previous open trials overestimated the therapeutic efficacy of hydroxychloroquine, the authors wrote.

"The absence of superiority of 6 months of hydroxychloroquine over placebo was consistent whatever the clinical variable evaluated," they wrote. "We observed no difference with the 2 treatments in objective features of dryness, disease-related discomfort, or quality of life assessed by validated questionnaires."



Infection control


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Hand hygiene recommendations released

Several professional societies, including the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America, recently released recommendations on preventing health care-associated infections through hand hygiene.

The recommendations were sponsored by SHEA and aimed to provide practical advice based on updated scientific evidence and to help health care facilities implement programs to improve hand hygiene adherence. Recommendations on basic practices for hand hygiene at all acute care hospitals included the following:

  • Routine hand hygiene with alcohol-based hand rubs (AHRBs) should involve a product with at least 62% alcohol.
  • Antimicrobial or nonantimicrobial soap should be available/accessible in all patient care areas for routine hand hygiene.
  • Clinicians should be involved in choosing products for hand hygiene to improve adherence.
  • Unit- or institution-specific barriers to hand hygiene should be assessed with clinicians to identify locally relevant interventions.
  • Hand hygiene adherence should be measured by direct observation, product volume, or automated monitoring.
  • Preferential use of soap and water should be considered during norovirus outbreaks by clinicians caring for patients with known or suspected infection, in addition to contact precautions.
  • Hot water should not be used for hand washing because of skin irritation.
  • AHBRs should not be used when hands are visibly soiled.
  • Triclosan-containing soaps should not be used.

The recommendations also included sections on recommended strategies for hand hygiene improvement, performance measures, and implementation strategies. The full text was published July 16 by Infection Control and Hospital Epidemiology and is available online.



Education


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ACP to host first national conference in India in September 2014

The American College of Physicians will host its first national conference in New Delhi, India, Sept. 5-6 at the Le Méridien 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 one U.S. and one Indian speaker per session. A presession focusing on gerontology issues will be held on Sept. 4 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 conference website.



High-value care


.
Article cites ACP and other groups for efforts to promote high-value care

According to an article published in the July 16 Journal of the American Medical Association (JAMA), professional organizations like ACP are the groups best positioned to engage physicians in qualitative efforts to improve the value of health care.

The article's authors note that implementation of the Affordable Care Act has laid some of the groundwork for reversing the trend of spiraling health care costs, but the current fee-for-service system does little to discourage overtreatment and wasteful practices. According to the authors, groups like ACP, the American College of Cardiology, the American Academy of Family Physicians, and the American Board of Internal Medicine can accelerate movement toward high-value care delivery because they are long recognized as "stewards of quality in medicine," are trusted by physicians, and have the depth of knowledge to develop resources targeted to their specialties.

The article cites resources available to clinicians through ACP's High Value Care platform, including clinical guidelines, public policy recommendations, and curricula for medical educators and students.



From the College


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Call for spring 2015 Board of Governors resolutions

The deadline for submitting new resolutions to be heard at the spring 2015 Board of Governors meeting is Sept. 24. Initiating a resolution provides ACP members an opportunity to focus attention at the ACP national level on a particular issue or topic that concerns them. When drafting a resolution, don't forget to consider how well it fits within ACP's Mission and Goals. In addition, be sure to use the College's 2014-2015 Priority Initiatives to guide you when proposing a resolution topic. Members must submit resolutions to their Governor and/or chapter council. A resolution becomes a resolution of the chapter once the chapter council approves it.

In accordance with the ACP Board of Governors Resolutions Process, resolutions should clearly distinguish the action requested within its resolved clause(s) as either a policy resolve ("Resolved that ACP policy…"), or a directive, which requests action/study on an issue ("Resolved that the Board of Regents…"). If more than one action is proposed, each should have its own resolved clause. Please contact your Governor if you have any questions regarding the resolution format.

The Board of Governors votes on new resolutions which are then presented to the Board of Regents for action. Members are encouraged to use the Electronic Resolutions System (ERS) to research the status of past resolutions before proposing a new resolution. Visit your chapter website and link to the ERS under the "Advocacy" heading.



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-20140722-cartoon.jpg

"So, darling, what ales you?"

This issue's winning cartoon caption was submitted by Keith A. Lascalea, MD, ACP Member. Thanks to all who voted! The winning entry captured 67% of the votes.

The runners-up were:

"I always like to let my alcohol breathe a little bit before I drink it."

"I really like this approach to introducing your new IPA to our group."


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MKSAP Answer and Critique



The correct answer is A: Cobalamin deficiency. This item is available to MKSAP 16 subscribers as item 64 in the Hematology and Oncology section. More information is available online.

The most likely diagnosis is cobalamin (vitamin B12) deficiency. Patients with vitamin B12 deficiency have elevated homocysteine and methylmalonic acid levels, whereas patients with folate deficiency have only an elevated homocysteine level. In addition, an elevated methylmalonic acid level is more sensitive and specific for diagnosing vitamin B12 deficiency than a low serum vitamin B12 level because serum vitamin B12 levels do not adequately assess tissue vitamin B12 stores, especially in patients with vitamin B12 levels in the low-normal range. Consequently, homocysteine and methylmalonic acid should be measured in patients with suspected vitamin B12 deficiency. Similarly, red blood cell folate can be low in patients with folate or vitamin B12 deficiency. Because folate supplementation can correct the anemia of vitamin B12 deficiency but not the progression of neurologic defects, vitamin B12 deficiency must be excluded before supplemental folate is administered to a patient with macrocytic anemia and a low red cell folate level.

Patients with vitamin B12 deficiency have elevated homocysteine and methylmalonic acid levels, whereas patients with folate deficiency have only an elevated homocysteine level. Therefore, this patient does not have folate or combined folate-cobalamin deficiency.

Patients with transcobalamin II deficiency have normal serum vitamin B12 levels because transcobalamin II is the primary transporter protein for vitamin B12 entry into cells. Deficiency of transcobalamin II is quite rare and typically presents in childhood as a megaloblastic anemia with normal vitamin B12 and red cell folate levels.

Key Point

  • An elevated serum methylmalonic acid level is more sensitive and specific for diagnosing cobalamin (vitamin B12) deficiency than a low serum vitamin B12 level.

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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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