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

Advertisement

ACP Internist® Weekly



In the News for the Week of August 12, 2014




Highlights

Digoxin may be associated with higher death risk in newly diagnosed afib patients

In a challenge to existing guidelines, a new study has found digoxin is associated with an elevated risk of death in patients with newly diagnosed atrial fibrillation. More...

Rifamycin-containing regimens appear effective, well tolerated for preventing latent TB reactivation

At least 3 months of therapy with rifamycin-containing regimens was reasonably well tolerated, efficacious, and possibly better than isoniazid (INH) monotherapy for preventing patients with latent tuberculosis (TB) infection from developing active cases in countries with a low TB incidence, a meta-analysis concluded. More...


Test yourself

MKSAP Quiz: 3-month history of intermittent itching

A 59-year-old man is evaluated for a 3-month history of intermittent itching on the forearms. He describes the itch as deep, with a burning or tingling sensation. Scratching helps somewhat, but over-the-counter topical corticosteroids have not helped. Cooling the skin soothes the itch. He did not notice a rash until he started scratching. The itch gets worse after being in the sun, but sun exposure does not cause redness or a rash. Following a physical exam, what is the most likely diagnosis? More...


Substance abuse disorders

Screening, brief intervention in primary care appear ineffective for reducing drug use

Screening and brief intervention targeting drug use do not appear to be effective in primary care, according to the findings of 2 recent studies. More...


Autoimmune disease

Lupus patient readmission rates are high and vary considerably by hospital, region, study finds

Approximately 1 in 6 hospitalized patients with systemic lupus erythematosus (SLE) were readmitted to the hospital within 30 days, according to a new study. More...


From the College

Available now: ACP Smart Medicine module on Ebola and Marburg viruses

In response to the recent outbreak of the Ebola virus, ACP Smart Medicine's module on Ebola and Marburg viruses is being offered free to all members of the health care community and the public at large. More...

ACP and Osmosis collaborate to improve medical student knowledge and self-assessment

ACP has collaborated with Osmosis to make educational content from its Medical Knowledge Self-Assessment Program (MKSAP) for Students available on the Osmosis Med platform. More...


From ACP Hospitalist

The August ACP Hospitalist is online

The latest issue of ACP Hospitalist is online. 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


.
Digoxin may be associated with higher death risk in newly diagnosed afib patients

In a challenge to existing guidelines, a new study has found digoxin is associated with an elevated risk of death in patients with newly diagnosed atrial fibrillation.

For their retrospective cohort study, researchers used data from 122,465 patients with newly diagnosed nonvalvular atrial fibrillation who were treated in the Veterans Affairs health care system between Oct. 1, 2003, and Sept. 30, 2008. All patients had at least 1 outpatient visit within 90 days of the index diagnosis. Researchers compared patients who started taking digoxin during the 90-day window with those who didn't and evaluated time to death. The average age for all patients was 72 years, and 98.4% of patients were men. Results were published online August 11 by the Journal of the American College of Cardiology.

About 23% of patients (n=28,679) received digoxin, and cumulative death rates were higher for these patients than for untreated patients (95 vs. 67 per 1,000 person-years; hazard ratio [HR], 1.37; P<0.001). Fewer than 25% of those given digoxin had been diagnosed with heart failure. Digoxin use was still associated with greater mortality after multivariate analysis (HR, 1.26; P<0.001) and propensity matching (HR, 1.21; P<0.001). The elevated mortality risk with digoxin was independent of age, sex, kidney function, heart failure, drug adherence, or concomitant use of warfarin, amiodarone, or beta-blockers.

Study limitations include that patients were primarily men and that heart failure severity—which could be a source of confounding—was unmeasured. Also, the use of all-cause rather than specific mortality might have stymied insight into how drug exposure could have led to death, the researchers noted. Still, the results present a challenge to some current guidelines that recommend digoxin as an adjunct to rate-control monotherapy, the authors concluded.

An editorialist noted the study had several strengths, including a very large sample size, a contemporary time frame for observation, and patients from many different U.S. centers. However, he noted, the results must be interpreted cautiously since treatment choices aren't random and are usually made on the basis of factors that can't be measured in observational analysis. "It seems likely that digoxin is selectively used in higher-risk patients, and that these and possibly other unmeasured factors could mediate the reported relationship between digoxin and mortality," he wrote. The upshot, he concluded, was that digoxin should be used selectively and carefully with atrial fibrillation patients and that dosing should be conservative, especially in elderly patients.


.
Rifamycin-containing regimens appear effective, well tolerated for preventing latent TB reactivation

At least 3 months of therapy with rifamycin-containing regimens was reasonably well tolerated, efficacious, and possibly better than isoniazid (INH) monotherapy for preventing patients with latent tuberculosis (TB) infection from developing active cases in countries with a low TB incidence, a meta-analysis concluded.

annals.jpg

Researchers did a meta-analysis of 53 trials to address the benefits and harms of 15 regimens aimed at preventing active TB in patients with latent infections. Treatments considered to be clinically similar were grouped for analysis: all isoniazid (INH)-rifampicin (RMP) regimens, INH regimens 3 to 4 months in duration, INH regimens 12 months or more in duration, INH-RMP regimens 3 to 4 months in duration, all RMP-pyrazinamide (PZA) regimens, and all RMP-INH-PZA regimens. Results appeared online first Aug. 12 in Annals of Internal Medicine.

The researchers concluded that regimens of INH only for 6 or 12 to 72 months, RMP only, RMP-INH for 3 to 4 months, RMP-INH-PZA, and RMP-PZA were efficacious for preventing active TB. Odds ratios (ORs) and 95% credible intervals (95% CrI) were calculated for all 15 regimens versus placebo. Compared with placebo, the odds ratios for active infection were:

  • INH for 6 months (OR, 0.64; 95% CrI, 0.48 to 0.83),
  • INH for 12 months or longer (OR, 0.52; 95% CrI, 0.41 to 0.66)
  • RMP for 3 to 4 months (OR, 0.41; 95% CrI, 0.18 to 0.86),
  • Rifapentine (RPT)-INH (OR, 0.61; 95% CrI, 0.29 to 1.22), and
  • RMP-INH (OR, 0.52; 95% CrI, 0.34 to 0.79).

Because currently recommended regimens are efficacious when studied in various settings and patient populations, the focus of clinical decision making shifts to considering potential adverse events (AEs) and interactions for each patient, the authors suggested. They added that global elimination of TB depends on shorter, effective, and well-tolerated regimens for latent infections.

"The long half-life of RPT is a key factor in making weekly INH-RPT noninferior to the current standard of care," they wrote. "Even shorter regimens may be feasible with other anti-TB drugs that also have a long half-life, such as bedaquiline, assuming its AE profile is similar to existing TB drugs."

An accompanying editorial said the study provides clear evidence that it is time to move away from INH as a primary therapy for latent TB and toward rifamycin-containing regimens that work better, are safer, and have shorter treatment durations.

"Surely, it is time to get a move on—away from INH as our primary therapy and toward regimens containing rifamycin," the editorial states. "The advantages are considerable for patients who would benefit from greater safety and better protection against TB and TB programs in which shorter duration should result in reduced workload and potentially lower costs."



Test yourself


.
MKSAP Quiz: 3-month history of intermittent itching

A 59-year-old man is evaluated for a 3-month history of intermittent itching on the forearms. He describes the itch as deep, with a burning or tingling sensation. Scratching helps somewhat, but over-the-counter topical corticosteroids have not helped. Cooling the skin soothes the itch. He did not notice a rash until he started scratching. The itch gets worse after being in the sun, but sun exposure does not cause redness or a rash.

mksap.gif

On physical examination, the patient shows evidence of chronic sun damage on sun-exposed skin, including hyperpigmentation and solar lentigines. A few excoriations are present on the forearms, but no significant dermatitis is observed. The patient's sensation on the arms and forearms is normal. Deep tendon reflexes are normal in the biceps, triceps, and brachioradialis.

Which of the following is the most likely diagnosis?

A: Brachioradial pruritus
B: Polymorphous light eruption
C: Prurigo nodularis
D: Solar urticaria

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


.

Substance abuse disorders


.
Screening, brief intervention in primary care appear ineffective for reducing drug use

Screening and brief intervention targeting drug use do not appear to be effective in primary care, according to the findings of 2 recent studies.

In the first study, researchers performed a randomized clinical trial in 7 safety-net primary clinics to examine whether a brief intervention compared with enhanced usual care would reduce drug use. Patients who reported any problem drug use in the past 90 days were randomly assigned to receive brief motivational interviewing, a handout and list of resources for substance abuse, and an attempted 10-minute telephone booster within 2 weeks, or to enhanced usual care, which included the handout and resources list.

The study's primary outcomes were self-reported days of problem drug use in the past 30 days and composite score on the Addiction Severity Index-Lite (ASI) Drug Use scale. Admission to substance abuse treatment; ASI medical, psychiatric, social, and legal composite scores; ED and inpatient hospital admissions; arrests; death; and HIV risk behavior were secondary outcomes. The study appeared in the Aug. 6 Journal of the American Medical Association (JAMA).

A total of 868 patients were randomly assigned to a study group between April 2009 and September 2012. Four hundred thirty-five were assigned to the brief intervention group, and 433 were assigned to the enhanced usual care group. Mean days of use of the most common problem drug (11.87 days vs. 9.84 days) and mean composite ASI Drug Use score (0.10 vs. 0.09) did not differ significantly 3 months after the intervention in the brief intervention versus enhanced usual care groups. This finding persisted in the 12 months postintervention for the 2 main outcome measures and for the secondary outcomes.

The second study, which appeared in the same issue of JAMA, examined the efficacy of screening and 2 brief counseling interventions for decreasing unhealthy drug use, which was defined as any illicit drug use or prescription drug misuse. A brief negotiated interview (a 10- to 15-minute structured interview by health educators) and an adapted motivational interview (a 30- to 45-minute intervention based on motivational interviewing and including a 20- to 30-minute booster conducted by counselors) were compared with no intervention in a 3-group randomized, clinical trial performed at a primary care practice based at an urban hospital. All participants received a resources list regardless of study group assignment. The study's primary outcome was days of use of the self-identified main drug in the past 30 days at 6 months. Other self-reported drug use measures, hair testing of drug use, and health care utilization were among the secondary outcomes.

A total of 529 patients enrolled in the study, but 1 withdrew before randomization. Of the 528 randomized, 177 were assigned to motivational interviewing, 174 were assigned to the brief negotiated interview, and 177 were assigned to no intervention. Sixty-three participants reported a main drug of marijuana at baseline, 19% reported cocaine, and 17% reported opioids. Ninety-eight percent of participants completed follow-up at 6 months.

At 6 months, the mean adjusted days using the main reported drug were 12 in the no intervention group, 11 in the brief negotiated interview group, and 12 in the motivational interviewing group. The incidence rate ratios in the 2 intervention groups were 0.97 (95% CI, 0.77 to 1.22) and 1.05 (95% CI, 0.84 to 1.32), respectively (P=0.81 for both comparisons with no intervention). Neither intervention appeared to have significant effects on any other outcomes, and no effects were seen in analyses stratified by main drug or by severity of drug use.

The authors of both studies concluded that the methods they examined did not appear to reduce drug use in their study populations. Both groups of study authors called for caution in promoting widespread use of such interventions to attempt to curb unhealthy drug use in primary care settings.

The authors of an accompanying editorial pointed out the studies' strengths (including random assignment, high rates of follow-up, and low attrition) and limitations (including no analysis of alcohol or tobacco as the primary drug and no measurement of same-day alcohol/drug or drug/drug use). The editorialists said that although the 2 studies don't directly support drug screening, brief intervention, and treatment referral in primary care, researchers should continue to develop and test new interventions that may be effective. This is especially important for adolescents and young adults, the editorialists said, who may be more likely to begin combined use of drugs, tobacco, and alcohol rather than a single substance. "If brief interventions are insufficient, then easily accessible treatment services with long-term follow-up may be needed, as will development of efficient primary care referral approaches to address risky substance use and related physical and mental comorbidities," the editorialists concluded.



Autoimmune disease


.
Lupus patient readmission rates are high and vary considerably by hospital, region, study finds

Approximately 1 in 6 hospitalized patients with systemic lupus erythematosus (SLE) were readmitted to the hospital within 30 days, according to a new study.

Researchers used hospital discharge databases from 5 states to study all-cause readmissions in patients with SLE that occurred between 2008 and 2009. Each hospitalization was evaluated as a possible index event leading to a readmission. The researchers adjusted for hospital case-mix and accounted for within-patient and within-hospital clustering of hospitalizations. Factors associated with 30-day readmission rates were also examined. The study results were published online Aug. 11 by Arthritis & Rheumatology.

A total of 55,936 hospitalizations in 31,903 patients with SLE were analyzed. Of these hospitalizations, 9,244 (16.5%) led to a readmission within 30 days in 4,916 patients. Age was inversely related to readmission risk in adjusted analyses. Black and Hispanic patients were more likely to be readmitted than white patients, and patients insured by Medicare and Medicaid were more likely to be readmitted than those with private insurance. Rural patients were less likely to be readmitted. An association with readmission was also seen in patients with lupus nephritis, serositis, and thrombocytopenia. After adjustment for case-mix and patient-level clustering, a significant variation in readmission rates was seen between hospitals. Geographic variation was also noted.

The authors noted that their study included data from only 5 states and therefore their results may not apply to all U.S. patients with SLE. They also acknowledged that they used administrative data and that some of the states in the study did not specify planned or acute readmission. However, they concluded that 30-day readmission rates appear to be notable in patients with SLE and that sociodemographic characteristics such as ethnicity and insurance type were important readmission predictors. They also said the association between younger age and readmission could be due to greater severity of SLE in younger patients.

"Taken together, our findings regarding both risk factors and variability in 30-day readmissions suggest that readmissions may be an important outcome measure in SLE," the authors wrote. Their findings provide data on both demographic and clinical risk factors that may be helpful to physicians in ambulatory care and hospital settings, they noted. "Although our study does not address the reasons for variation in readmission rates between hospitals and states, the presence of unexplained variation after careful risk adjustment suggests that there is room for quality improvement," they wrote. "Further work to identify care processes that can reduce readmission rates for this complex disease is needed."



From the College


.
Available now: ACP Smart Medicine module on Ebola and Marburg viruses

In response to the recent outbreak of the Ebola virus, ACP Smart Medicine's module on Ebola and Marburg viruses is being offered free to all members of the health care community and the public at large. The Ebola module is designed to help physicians treat patients who present with fever and nonspecific symptoms and who traveled to rural sub-Saharan Africa or had possible occupational exposure.

ACP Smart Medicine is a Web-based clinical decision support tool developed specifically for internal medicine physicians and contains 500 modules that provide guidance and information on a broad range of diseases and conditions. The Ebola module and other disease-related modules include helpful glossaries for clinical terms and acronyms and provide evidence-based recommendations concerning prevention, screening, diagnosis, therapy, consultation, patient education, and follow-up.


.
ACP and Osmosis collaborate to improve medical student knowledge and self-assessment

ACP has collaborated with Osmosis to make educational content from its Medical Knowledge Self-Assessment Program (MKSAP) for Students available on the Osmosis Med platform.

MKSAP for Students 5 Digital–Enhanced with Internal Medicine Essentials contains more than 450 patient-centered self-assessment questions and answers formatted as clinical vignettes that resemble the types of questions students encounter on the examination at the end of the clerkship and on the USMLE licensing examination.

The Osmosis Med mobile app, available for iOS or Android devices, provides push notifications with questions filled with images, videos, mnemonics, and reference material. Osmosis feeds can be customized based on curriculum, exam schedules, and course documents and allow users to go head-to-head with classmates by playing the "Osmose with Your Friends" game.

More details and ordering information are online.



From ACP Hospitalist


.
The August ACP Hospitalist is online

The latest issue of ACP Hospitalist is online. Top stories include the following:

Times are changing for hospitalists. Health care reform is bringing changes to payment mechanisms, patient volume, and the job market for hospitalists. Experts say hospital medicine doctors already possess many valuable skills for the new landscape, but it's wise to refine those abilities and to highlight your worth on the job.

Admitting patients for alcohol detox. Every hospitalist has experienced being called to the emergency department to decide whether or not to admit a patient for alcohol detoxification. Protocols can help in making this decision, though developing them can present challenges.

Rebuilding after disaster. A 2011 tornado that destroyed St. John's Regional Medical Center in Joplin, Mo., led to an opportunity to create a new and better Mercy Hospital Joplin. Safety, convenience, aesthetics, the patient experience—and much more—were considered in the redesign of the hospital, which opens this fall.



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.

acpi-20140812-cartoon.jpg

"Mr. Smith, I asked you to change into a gown."

"I'm afraid I have to recommend a circus-ision."

"I don't know, doc. I just feel funny all over."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting ends on Monday, Aug. 18, with the winner announced in the Aug. 19 issue.


.


MKSAP Answer and Critique



The correct answer is A: Brachioradial pruritus. This item is available to MKSAP 16 subscribers as item 44 in the Dermatology section. More information is available online.

This patient has brachioradial pruritus, a form of neuropathic itch that has been linked to abnormalities in the cervical spine. Inflammation or irritation of the appropriate cervical nerves causes recurrent and persistent itching in the upper extremities, usually on the forearms, but also, in some patients, around the neck, shoulders, and upper arms. A similar type of neuropathic itch occurs on the mid, medial back, called notalgia paresthetica. Evaluation of the spine may reveal evidence of osteoarthritis or other structural abnormalities; however, in the absence of gross neurologic deficits, surgery is unlikely to be of any benefit in managing this type of itch, so aggressive radiologic evaluation is generally not recommended.

Brachioradial pruritus is an "itch without a rash." The itch usually has a deep, crawling, or tingling sensation. There are no primary skin findings, although the skin may be excoriated and even become lichenified and hyperpigmented from repeated scratching. A response to application of ice or cold packs is very characteristic and helps clinically confirm the diagnosis. A skin biopsy is nondiagnostic.

Because this is not a histamine-mediated itch, antihistamines and corticosteroids are usually unsuccessful in treating the itch. Topical analgesics, such as pramoxine, offer short-term relief. More prolonged relief may be gained with use of gabapentin or pregabalin in some patients.

Polymorphous light eruption (PMLE) is another skin condition in which patients develop skin lesions after exposure to sunlight. A variety of skin lesions may be seen in PMLE, including urticarial wheals, papules, plaques, and vesicles. PMLE usually develops early in the spring, with the first few exposures to sunlight, and can be triggered by intense exposures. Skin lesions, rather than mere itch, are necessary for the diagnosis.

Prurigo nodularis is commonly known as "picker's nodules." This condition can develop in itchy skin (from whatever cause) and consists of thickened, lichenified, excoriated papules and nodules in skin that has been repeatedly scratched.

Solar urticaria is another rare condition in which exposure to ultraviolet light causes hives. It can be difficult to distinguish from PMLE.

Key Point

  • Brachioradial pruritus is characterized by a deep, crawling, or tingling sensation on the forearms, shoulders, and upper back; however, there are no visible skin findings.

Click here to return to the rest of ACP InternistWeekly.

Top




About ACP InternistWeekly

ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.

To add your e-mail address to your member record and to begin receiving ACP InternistWeekly, please click here.

Copyright © by American College of Physicians.

Test yourself

A 72-year-old woman is evaluated during a routine examination. She has very severe COPD with multiple exacerbations. She has dyspnea at all times with decreased exercise capacity. She does not have cough or any change in baseline sputum production. She is adherent to her medication regimen, and she completed pulmonary rehabilitation 1 year ago. She quit smoking 1 year ago. Her medications are a budesonide/formoterol inhaler, tiotropium, and an albuterol inhaler as needed. Following a physical and pulmonary exam, what is the most appropriate next step in management?

Find the answer

New Leadership Webinars

New Leadership Webinars

The ACP Leadership Academy is offering FREE webinars covering the core tenets of leadership, leadership in hospital medicine, finance, and more.

Join ACP Today!

Join ACP Today!

ACP membership connects you with like-minded colleagues and provides access to a variety of clinical resources, practice tools, and ways to earn MOC and CME.