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

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ACP Internist® Weekly



In the News for the Week of August 26, 2014




Highlights

Large numbers of elderly patients with low life expectancy still receiving unnecessary cancer screens

A substantial proportion of patients with limited life expectancy are receiving prostate, breast, cervical, and colorectal cancer screenings that are unlikely to benefit them, a recent study found. More...

USPSTF recommends intensive behavioral counseling for overweight, obese adults with additional CVD risk factors

The U.S. Preventive Services Task Force (USPSTF) announced an update and refinement of its 2003 recommendation on dietary counseling for adults with risk factors for cardiovascular disease (CVD). More...


Test yourself

MKSAP Quiz: 8-month history of crampy abdominal pain, loose bowel movements

A 42-year-old woman is evaluated for an 8-month history of crampy abdominal pain and three loose bowel movements per day. The pain is relieved by a bowel movement. There are no nocturnal bowel movements, and there is no blood or dark tarry material in the stool. She has not had fever, night sweats, or weight loss. She has a history of Hashimoto disease and is treated with levothyroxine. Following a physical exam, rectal exam, and lab tests, what is the most appropriate next step in management? More...


Smoking cessation

Phone and medication intervention increased smoking cessation after hospital discharge

A post-discharge intervention increased smoking cessation among recently hospitalized adults who wanted to quit, a recent study found. More...


Cardiology

Clarithromycin may be associated with increased risk for cardiac death

Clarithromycin may be associated with increased risk for cardiac death, although the absolute risk appears small, according to a new study. More...


CMS update

Deadline to review data on industry payments extended to Sept. 8

Physicians and teaching hospitals now have until Sept. 8, 2014 to register, preview, and dispute data submitted by industry as part of CMS's Open Payments Preview and Dispute period. More...

Editorial note: ACP InternistWeekly will not be published next week due to the Labor Day holiday. The cartoon caption contest will resume in the Sept. 9 edition.


Physician editor: Daisy Smith, MD, FACP



Highlights


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Large numbers of elderly patients with low life expectancy still receiving unnecessary cancer screens

A substantial proportion of patients with limited life expectancy are receiving prostate, breast, cervical, and colorectal cancer screenings that are unlikely to benefit them, a recent study found.

Rates of self-reported cancer screening were gathered from 27,404 participants age 65 and over in the National Health Interview Survey, conducted annually from 2000 through 2010. Participants were grouped by their risk for mortality within 9 years: low (<25%), intermediate (25-49%), high (50-74%) and very high (≥75%). Results were published by JAMA Internal Medicine on Aug. 18.

Participants with increased mortality risk were less likely to be screened, but still 31% to 55% of the participants with very high mortality risk had been recently screened for at least 1 of the studied cancers (prostate, breast, cervical, and colorectal). Prostate screening was the most common at 55% of men. Excessive cervical screening was also common; of women who had had a hysterectomy for benign reasons, 34% to 56% had a Pap test within the past 3 years.

Screening was common even among participants with less than 5 years of life expectancy. Rates of prostate and cervical cancer screening decreased over the study period, but not significantly more in the lower life-expectancy groups than the higher ones. The results show that a substantial proportion of the U.S. population with limited life expectancy receive cancer screens that are unlikely to benefit them, the study authors concluded.

There is increasing recognition that life expectancy, rather than just age, is important to determining the appropriateness of screening, the authors said, citing ACP's recommendation that prostate cancer screening decisions be based in part on a patient's general health and life expectancy. However, life expectancy is difficult to calculate and to communicate to patients. Defensive medicine may also contribute to the overuse of screening, the authors speculated. They called for development of simple and reliable ways to assess life expectancy and education for physicians and patients to reduce these unnecessary screens, thereby decreasing wasteful spending and harms to patients.

An accompanying editorial noted that cancer screening has recently been "losing its luster" and suggested that, in addition to better life expectancy assessment, restrictions on Medicare payments for screening and quality measures that address overscreening could help to make cancer prevention/screening efforts more evidence based and patient centered.


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USPSTF recommends intensive behavioral counseling for overweight, obese adults with additional CVD risk factors

The U.S. Preventive Services Task Force (USPSTF) announced an update and refinement of its 2003 recommendation on dietary counseling for adults with risk factors for cardiovascular disease (CVD).

The USPSTF based its current recommendation on a systematic review of the literature, which looked at the benefits and harms of lifestyle counseling interventions in adults with CVD risk factors. The review included literature published from January 2001 to October 2013, a total of 74 trials. Most of the interventions studied in the trials were intensive combined counseling on healthful diet and physical activity involving multiple contacts over extended time periods (average, 5 to 16 contacts over 9 to 12 months). In all but 2 of the included trials, patients' average body mass index exceeded 25 kg/m2.

annals.jpg

The review found that at 12 to 24 months, intensive lifestyle counseling in patients who were selected for counseling because of risk factors had decreased total cholesterol levels, low-density lipoprotein cholesterol levels, systolic blood pressure, diastolic blood pressure, fasting glucose levels, diabetes incidence, and weight. The trials included in the review did not have many data available on patient health outcomes, harms, or longer-term follow-up, but the authors concluded that intensive behavioral counseling on diet and physical activity consistently improved several important intermediate health outcomes for up to 2 years.

As a result, the USPSTF recommends that clinicians offer intensive behavioral counseling interventions to promote a healthful diet and physical activity to adults who are overweight or obese and have additional factors for CVD, or refer this group to such interventions. This differs slightly from the USPSTF's 2003 recommendation, which recommended intensive behavioral dietary counseling for adult patients with known CVD risk factors. The recommendation applies to adults 18 years of age or older in primary care settings who are overweight or obese and have such additional CVD risk factors as hypertension, dyslipidemia, impaired fasting glucose, or the metabolic syndrome. It is a grade B recommendation, meaning that there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

Both the recommendation and the systematic review were published online Aug. 26 by Annals of Internal Medicine.



Test yourself


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MKSAP Quiz: 8-month history of crampy abdominal pain, loose bowel movements

A 42-year-old woman is evaluated for an 8-month history of crampy abdominal pain and three loose bowel movements per day. The pain is relieved by a bowel movement. There are no nocturnal bowel movements, and there is no blood or dark tarry material in the stool. She has not had fever, night sweats, or weight loss. She has a history of Hashimoto disease and is treated with levothyroxine.

mksap.gif

On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 128/84 mm Hg, pulse rate is 64/min, and respiration rate is 16/min; BMI is 23. No rash is noted. There is mild diffuse abdominal tenderness without peritoneal signs and no abdominal masses. Rectal examination is normal. Complete blood count and thyroid-stimulating hormone level are normal.

Which of the following is the most appropriate next step in management?

A: Breath test for bacterial overgrowth
B: Colonoscopy with random biopsies
C: Stool culture
D: Tissue transglutaminase antibody testing

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


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Smoking cessation


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Phone and medication intervention increased smoking cessation after hospital discharge

A post-discharge intervention increased smoking cessation among recently hospitalized adults who wanted to quit, a recent study found.

Researchers randomized 397 hospitalized daily smokers who wanted to quit to either standard care (recommendations from an inpatient smoking counselor) or an intervention that included 90 days of free smoking cessation medication and automated interactive voice-response telephone calls. The mean age of participants was 53 years, 81% were non-Hispanic whites, and the study was conducted from August 2010 to November 2012 at Massachusetts General Hospital. Results were published in the Aug. 20 Journal of the American Medical Association.

At 6-month follow-up, patients in the intervention group had significantly higher rates of biochemically confirmed 7-day tobacco abstinence: 26% vs. 15% (relative risk, 1.71 [95% CI, 1.14 to 2.56]; P=0.009; number needed to treat, 9.4). The smokers who received the intervention were also significantly more likely to be using counseling and/or pharmacotherapy at 1, 3 and 6 months after discharge. Using multiple imputation for missing outcomes, the researchers calculated a relative risk for 7-day abstinence of 1.55 in the intervention group compared to the usual care group (95% CI, 1.03 to 2.21; P=0.04).

The study was limited by 19% of participants being lost to follow-up and 22% of those who reported not smoking not providing a saliva sample, the researchers noted. Additionally, the effects of the medication and the phone calls cannot be separated, and the results may apply only to smokers who plan to quit after hospital discharge.

Still, the findings suggest that such an intervention could provide high-value care at relatively low cost and help hospitals meet the Joint Commission's tobacco cessation hospital quality standard. Before widespread implementation, the results need replication, which the study authors are currently attempting in a multisite trial, they said.



Cardiology


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Clarithromycin may be associated with increased risk for cardiac death

Clarithromycin may be associated with increased risk for cardiac death, although the absolute risk appears small, according to a new study.

Researchers in Denmark performed a nationwide cohort study using registry data to examine whether clarithromycin and roxithromycin were associated with cardiac death risk. (Both drugs are macrolide antibiotics, but only clarithromycin is available in the United States.) The study's main outcome measure was risk of cardiac death associated with each drug in comparison with penicillin V, which has no known relation to cardiac risk. The authors also conducted subgroup analyses by sex, age, risk score, and concomitant therapy with drugs that inhibit the cytochrome P450 3A enzyme and could therefore affect the way the body metabolizes macrolides. The study results were published online Aug. 19 by The BMJ.

A total of 5,104,594 treatment courses were included in the study, involving Danish adults from 40 to 74 years of age who were treated between 1997 and 2011. There were 160,297 courses of clarithromycin, 588,988 courses of roxithromycin, and 4,355,309 courses of penicillin V.

Overall, 285 patients died of cardiac causes, 18 during clarithromycin use, 32 during roxithromycin use, and 235 during penicillin use. The incidence rates for each drug were 5.3 per 1,000 person-years for clarithromycin, 2.5 per 1,000 person-years for roxithromycin, and 2.5 per 1,000 person-years for penicillin V. Adjusted rate ratios for clarithromycin and roxithromycin were 1.76 (95% CI, 1.08 to 2.85) and 1.04 (95% CI, 0.72 to 1.51), respectively. The association between clarithromycin and cardiac risk was stronger in women than in men (adjusted rate ratios, 2.83 [95% CI, 1.50 to 5.36] and 1.09 [95% CI, 0.51 to 2.35], respectively; P=0.07 for homogeneity). The adjusted absolute risk difference was 37 cardiac deaths (95% CI, 4 to 90) per 1 million treatment courses for clarithromycin and 2 cardiac deaths (95% CI, −14 to 25) per 1 million treatment courses with roxithromycin compared with penicillin V.

The authors acknowledged that they had no data on patients' lifestyle factors that would affect cardiac risk, such as body mass index and smoking status, as well as no information about the reasons why the drugs may have been prescribed, among other limitations. They also stressed that the clinical implications of their findings for individual patients are uncertain and that the absolute risk in their study was small.

"On the other hand, clarithromycin is one of the more commonly used antibiotics in many countries and many millions of people are prescribed this drug each year; thus, the total number of excess (potentially avoidable) cardiac deaths may not be negligible," the authors wrote. "These factors need to be considered when assessing the overall benefit/risk profile of macrolides (clarithromycin specifically), an important area for future work by, for example, regulatory agencies and other public health officials."



CMS update


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Deadline to review data on industry payments extended to Sept. 8

Physicians and teaching hospitals now have until Sept. 8, 2014 to register, preview, and dispute data submitted by industry as part of CMS's Open Payments Preview and Dispute period.

After resolving problems with the program's website, CMS extended the deadline an additional 12 days in order to give more time for review. Data on industry payments will still be publicly posted starting on Sept. 30. Ability to review and dispute reports will continue past the Sept. 8 deadline, but will only be corrected on the public site on a limited schedule.

Instructions on registering to view the data are available from CMS and help is also available by email, or by phone at 1-855-326-8366. ACP also offers information about the Open Payments program and how it affects you.


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MKSAP Answer and Critique



The correct answer is D: Tissue transglutaminase antibody testing. This item is available to MKSAP 16 subscribers as item 10 in the Gastroenterology & Hepatology section. More information is available online.

This patient should undergo tissue transglutaminase antibody testing. The American College of Gastroenterology recommends routine serologic testing for celiac disease in patients who present with symptoms of diarrhea-predominant or mixed irritable bowel syndrome (IBS). Additionally, there is a well-established association between comorbid autoimmune disorders and celiac disease, especially type 1 diabetes mellitus and autoimmune thyroid disease.

Although some evidence suggests a role of small-bowel bacterial overgrowth in the pathogenesis of IBS, evidence is insufficient to warrant testing for this condition with a breath test.

Approximately 2% of patients with features of diarrhea-predominant IBS are found to have microscopic colitis. A history of nocturnal or large-volume diarrhea or a stool osmotic gap less than 50 mOsm/kg (50 mmol/kg) would make a compelling case for microscopic colitis. In the absence of these features, a colonoscopy and random biopsies might be indicated, but the yield is low.

In patients who meet clinical criteria for IBS without alarm features, routine testing with stool culture is unlikely to result in an alternative diagnosis. Similarly, other laboratory tests such as the erythrocyte sedimentation rate and thyroid-stimulating hormone have a low yield. Patients who should be considered for colonoscopy and additional evaluation with blood and urine studies include those older than 50 years or those with a short history of symptoms, documented weight loss, nocturnal symptoms, family history of colon cancer or rectal bleeding, and recent antibiotic use.

Key Point

  • The American College of Gastroenterology recommends routine serologic testing for celiac disease in patients with symptoms of diarrhea-predominant or mixed irritable bowel syndrome.

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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?

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