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

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In the News
for the Week of 6-2-09

Highlights

Test yourself

  • MKSAP quiz: smoking-cessation management

Women's health

  • Inflammation may be marker for breast cancer recurrence
  • Brief breaks in hormone therapy don't reduce mammogram recalls
  • Cognition declines in perimenopause, but rebounds later, study finds

FDA update

  • Working group recommends steps to prevent acetaminophen overdose

From Annals of Internal Medicine

From ACP Internist

  • Latest issue is online and coming to your mailbox

From ACP Hospitalist

From the College

  • Primary care bill introduced during ACP’s Leadership Day

From the blogs

  • News from Digestive Disease Week
  • KevinMd features regular column from ACP
  • Doctors discuss the consequences of misleading medical news
  • Watch out, bad doctors

Cartoon caption contest

Physician editor: Darren Taichman, ACP Member


Highlights

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Antidepressants help with pain and depression

Patients who had both pain and depression benefitted from a combination of antidepressant therapy and pain self-management instruction, according to a recent study.

The randomized controlled trial included 250 patients from community and Veterans Affairs clinics in Indianapolis. Half the patients were assigned to 12 weeks of optimized antidepressant therapy, followed by six sessions of a pain self-management program and continuation of antidepressants for six months. The rest received usual care. The study was published in the May 27 Journal of the American Medical Association.

At one year, significantly more of the intervention patients had a 50% or greater reduction in depression severity; only 40.7% had major depression compared with 68.5% in the control group. The intervention group was also more than twice as likely to have a clinically significant reduction or global improvement in pain. Overall, 32 of the intervention patients met the primary outcome of the study (improvement in both depression and pain) while only 10 of the usual care group did.

Study authors offered some theories about why the treatment was effective. Patients in the intervention group took antidepressants longer than the usual care group and were more likely to switch or add medications during the study. It's possible that reductions in pain improved patients' moods, or that the lifting of depression made pain less troublesome, or that both problems were directly affected by treatment, the researchers speculated.

Because both depression and pain have significant societal costs, interventions such as this one may prove cost-effective and have important implications for treatment, the authors concluded.

ACP Internist offered a supplement on screening, diagnosing and treating clinical depression.

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Statins after first stroke reduce recurrent attacks

Prescribing statins upon hospital discharge to patients after their first acute stroke lowers the 10-year recurrence risk and improves survival, researchers reported.

Researchers conducted a retrospective, observational study of hospitalization and death records in 794 consecutive, first-ever acute ischemic stroke patients from the Athenian Stroke Registry in Greece since January 1997 for whom there was 10-year follow-up information. Statins included fluvastatin 40-80 mg/day, pravastatin 20-40 mg/day, simvastatin 10-40 mg/day and atorvastatin 10-40 mg/day. They reported their results in Neurology.

The recurrence rate was 16.3% among stroke patients not receiving a statin post-discharge compared with 7.5% among those who received one (P=0.002). Only statins post-discharge were a significant independent predictor of stroke recurrence (adjusted hazard ratio [HR], 0.65; 95% confidence interval [CI] 0.39 to 0.97; P<0.01). Patients prescribed a statin had significantly lower mortality (adjusted HR, 0.43; 95% CI 0.29 to 0.61; P<0.01).

Researchers commented that the study, although retrospective and thus unable to firmly establish statin use as the cause of the reduced recurrence rate, examined a drug class effect for a 10-year period in which post-stroke statins were not commonly prescribed in Greece. "Our findings support the need for statin treatment in the secondary prevention of stroke and the need for more studies in the future, including lipid lowering treatment modalities standardized to a particular drug or to a particular dosage regimen," they said.

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Test yourself

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MKSAP Quiz: smoking-cessation management

A 55-year-old man is evaluated for cough, scant clear-to-yellow sputum, and malaise of 3 days' duration. He has not had fever, chills, wheezing, or pleuritic chest pain, or recent contact with anyone who has been ill. He has a 40-pack-year smoking history and has had similar symptoms three times in the past 6 months, feeling well in the intervals between episodes.

On physical examination, temperature is 37.2° C (99.0° F), and pulse rate, respiration rate, and blood pressure are normal. The cardiopulmonary examination is normal, including clear lungs on auscultation with no signs of consolidation.

Which of the following is the most appropriate initial smoking-cessation management step during this visit?

A) Recommend nicotine gum
B) Provide a clear, personalized message to the patient
C) Refer the patient to a behavioral-modification program
D) Prescribe bupropion

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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Inflammation may be marker for breast cancer recurrence

Elevated levels of C-reactive protein (CRP) and serum amyloid A (SAA) in breast cancer patients may be predictors of earlier death or recurrence, according to the results of a recent study.

Using data from the National Cancer Institute's Health, Eating, Activity and Lifestyle (HEAL) study, researchers studied the relationship between circulating markers of inflammation and breast cancer survival. CRP and SAA levels were measured in 734 disease-free breast cancer survivors approximately 31 months after diagnosis and tested for association with disease-free survival (approximately four years follow-up) and overall survival (approximately seven years follow-up). Researchers found that elevated SAA and CRP were associated with reduced overall survival regardless of age, tumor stage, race, body mass index or self-reported history of cardiovascular events. The article was published online May 26 in the Journal of Clinical Oncology.

Researchers noted that inflammation is associated with modifiable risk factors, such as obesity, inactivity and cardiovascular disease. "Investigating the effect that reductions in these markers, through medications or lifestyle changes, can have on breast cancer recurrence and survival will be an important next step," said Robert Croyle, PhD, director of NCI’s division of cancer control and population sciences, in a National Institutes of Health news release.

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Brief breaks in hormone therapy don't reduce mammogram recalls

Women who stopped taking hormone therapy for brief periods before they had a mammogram were not less likely to be recalled for repeat testing than women on continuous therapy, according to a recent study.

In the study, published in the latest issue of Annals of Internal Medicine, researchers looked at 1,704 women between the ages of 45 and 80 who were on hormone replacement therapy and were due for an upcoming mammogram. Before their mammograms, women were randomly assigned no hormone therapy for one month, no hormone therapy for two months, or continued therapy.

The women then had mammograms and answered questions about menopause symptoms. Recall rates were 12.3%, 9.8% and 11.3%, respectively. Menopausal symptoms increased in the groups that stopped therapy.

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Cognition declines in perimenopause, but rebounds later, study finds

Women may suffer cognitive decline in perimenopause but regain their abilities when they reach menopause, and hormones can help or hurt cognition depending on when treatment is initiated, a study concluded.

In the Study of Women's Health Across the Nation, researchers assessed processing speed, verbal memory and working memory in 2,362 women over four years. With repeated testing, premenopausal and postmenopausal women scored higher on processing and verbal memory, but the scores of perimenopausal women did not improve over time. In addition, researchers found that while prior hormone users scored 4%-6% higher in all areas than other women, hormone use was associated with better cognition in premenopausal women but poorer performance in postmenopausal women. The study was published in the May 26 issue of Neurology.

The researchers concluded that women in perimenopause may experience a decline in their ability to learn compared with premenopause, but they regain that ability when they reach menopause. They added that their findings suggest that menopause transition-related cognitive problems may be temporary and that timing plays a significant role in when to introduce hormone treatment.

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FDA update

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Working group recommends steps to prevent acetaminophen overdose

An FDA working group has made a series of recommendations to prevent accidental overdose of acetaminophen leading to liver damage. An FDA advisory committee will meet to consider the group's report later this month.

The group recommended steps to improve labeling, limit maximum daily dosages and limit tablet strengths, among other suggestions. Specific
recommendations include:

  • Add warnings to label that taking more than the recommended amount may cause severe liver injury, that products should not be used with other products containing acetaminophen, and for people with liver disease or alcohol users;
  • Limit the maximum adult daily dose to 3,250 mg; lower for patients who drink three or more alcoholic drinks every day;
  • Limit the tablet strength for immediate-release formulations to a maximum of 325 mg and the single adult dose to a maximum of 650 mg;
  • Limit pediatric liquid formulation to one mid-strength concentration (compared to multiple dose strengths available now); and
  • Eliminate combination products.

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From Annals of Internal Medicine

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Look for these studies in the latest issue of Annals
  • Computer-assisted screening for domestic violence: Researchers randomly assigned 300 women in a busy urban clinic to either a computerized survey or usual care. Women in the intervention group completed a survey on a touch screen before their physician visit. The reports were then attached to the women’s medical charts. The women also received a computer-generated recommendation sheet about their reported health risks that included information on appropriate community agencies. Researchers found this method was effective, time-efficient and acceptable to patients. Read about domestic violence interventions and red flags in ACP Internist.
  • Scoring system for asymptomatic risk for diabetes: Using data from a prospective cohort study of 12,729 adults between the ages of 45 and 64, researchers developed and tested scoring systems that identify adults with a high 10-year incidence of diabetes. The basic system included age, weight, and waist circumference, hypertension, smoking, and family history of diabetes. The enhanced system also included blood tests. The researchers suggest that the low-cost basic approach could be used to identify asymptomatic adults who may need more thorough examination, including blood tests.

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From ACP Internist

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Latest issue is online and coming to your mailbox
Convocation at Internal Medicine 2009

The next issue of ACP Internist is online and coming to your mailbox. In June we digest the best of the Internal Medicine 2009's scientific sessions, including essential dermatology, the latest thinking on breast cancer prevention and screening, common drug interactions, and a music video correcting popular misconceptions about vaccination. Also, ACP members lobby their members of Congress to save primary care at Leadership Day 2009.

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From ACP Hospitalist

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Suggest a colleague as a Top Hospitalist

ACP Hospitalist is seeking candidates for our second annual Top Hospitalists issue. We're looking for the hospitalists who made notable contributions to the field in 2009, whether through cost savings, improved work flow, patient safety, leadership, mentorship or quality improvement.

Do you know a colleague who might qualify? Fill out our form and tell us who and why. All recommendations must be received by July 13, 2009, when our editorial advisory board will pick the winners. Top Hospitalists will be profiled in our November 2009 issue.

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From the College

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Primary care bill introduced during ACP’s Leadership Day

Rep. Allyson Schwartz (D-PA) recently announced the Preserving Patient Access to Primary Care Act of 2009 (H.R. 2350), a proposal to address the critical shortage of primary care physicians and other providers in the U.S.

Leadership Day launches push for primary care

At a press conference in Washington during ACP Services’ annual Leadership Day on May 20, Rep. Schwartz said, “Primary care is at the core of America’s health care system, and without a sufficient number of doctors, nurses and others providing primary care, Americans face long wait times to see their doctors and health care providers, as well as other obstacles to quality care. The bill outlines a series of different measures designed to help support the field of primary care.”

“It is critical that comprehensive reforms to halt the crisis in access to primary care be included in any legislation to expand health insurance coverage,” ACP President Joseph W. Stubbs, FACP, said. “Providing everyone with affordable coverage is essential, but coverage alone doesn’t guarantee access if there aren’t enough primary care physicians to take care of patients.”

Look for more coverage of the new legislation and other news about ACP Services’ Leadership Day in this Friday’s issue of the ACP Advocate and in the July issue of ACP Internist. View photos of ACP delegations visiting Congress, the press conference with Rep. Schwartz and other Leadership Day Activities online.

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From the blogs

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News from Digestive Disease Week

Digestive Disease Week is underway in Chicago this week, and our correspondent Paula Katz will be dispatching news from the meeting via ACP Internist's blog. Look for the latest research on tools to detect colorectal cancer and Crohn's disease, among other highlights.

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KevinMd features regular column from ACP

KevinMd.com, one of the Web's most influential medical blogs, will include monthly guest columns by Steven Weinberger, FACP, ACP's Deputy Executive Vice President and Senior Vice President for Medical Education and Publishing. The column will address a variety of internal medicine-related issues. The first column, "A Practice Model for Increasing the Appeal of General Internal Medicine" is online.

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Doctors discuss the consequences of misleading medical news

Doctors have to spend a lot of time correcting patients' misimpressions of medical research based on mainstream media reporting, readers told ACP Internist in their own words. Find out what your peers had to say on ACP Internist's blog.

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Watch out, bad doctors

ACP Hospitalist's blog reports that the interest group Public Citizen is launching a new campaign to get hospitals to step up their reporting of physician wrongdoing. While hospitals are required to submit the names of any physicians who have lost their admitting privileges for more than 30 days, there have been very few reports; more than half of hospitals have never submitted a single name.

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Cartoon caption contest

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And the winner is …

ACP InternistWeekly has compiled the results from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

This issue's winning cartoon caption was submitted by Michael B. Rudolph, ACP Member. He will receive a $50 gift certificate good toward any ACP product, program or service. In extraordinarily close voting (the caption won by 4 votes), readers cast 211 ballots online to choose the winning entry. Thanks to all who voted!


"The house of bricks concept was great until I herniated a disc."

The winning entry captured 35.5% of the votes.

The runners up were:
"We culled a quarter-million farmers, but I still ended up sick!"
"Honestly, doc, I'm getting a little tired of the lunchtime rush to see the pig in a blanket."

ACP Internist's cartoon caption contest continues next week.

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MKSAP Answer and Critique

The correct answer is B) Provide a clear, personalized message to the patient. This item is available online to MKSAP subscribers in the Foundations of Internal Medicine section: Item 13.

ACP's Medical Knowledge Self-Assessment Program (MKSAP) allows you to:

  • Update your knowledge in all areas of internal medicine
  • Prepare for ABIM certification or recertification
  • Support your clinical decisions in practice
  • Assess your medical knowledge with 1,200 multiple-choice questions

To order the latest edition of MKSAP, go online.

This patient's recurrent upper respiratory tract symptoms and cigarette-smoking history necessitate a smoking-cessation intervention consisting of a clear, personalized message provided by the physician during this visit. Brief interventions lasting as little as 1 to 3 minutes have been shown to result in an increase in number of patients who quit and abstain from cigarette smoking at 1 year. Clinicians can use the 5As model (Ask, Advise, Assess, Assist, and Arrange) to frame such an intervention, providing a message that:

  1. summarizes the clinical findings,
  2. expresses a concern that these recurrent symptoms relate to cigarette smoking,
  3. strongly recommends smoking cessation, and
  4. offers support in achieving this goal.

Although nicotine replacement therapy, bupropion, and behavioral therapy are appropriate adjunct interventions for smoking cessation, using these approaches would be premature before first determining the patient's readiness for behavioral change and outlining a more comprehensive plan for smoking cessation.

Key Points

  • Brief interventions are associated with a significant increase in the number of patients who quit and abstain from smoking at 1 year.
  • Advising a patient to stop smoking through a clear personalized message is an important component of a brief intervention.

Click here to return to the rest of ACP InternistWeekly.

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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 2009 by the American College of Physicians.

Test yourself

A 48-year-old man is evaluated during a follow-up visit for urinary frequency. He reports no hesitancy, urgency, dysuria, or change in urine color. He has not experienced fevers, chills, sweats, nausea, vomiting, diarrhea, or other gastrointestinal symptoms. He feels thirsty very often; drinking water and using lemon drops seem to help. He has a 33-pack-year history of smoking. He has hypertension, chronic kidney disease, and bipolar disorder. Medications are amlodipine, lisinopril, and lithium. He has tried other agents in place of lithium for his bipolar disorder, but none has controlled his symptoms as well as lithium. What is the most appropriate treatment intervention for this patient?

Find the answer

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