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

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In the News
for the Week of 6-23-09

Highlights

  • Colonography predicts adenomas in high-risk, asymptomatic patients
  • Starting salaries rise for some while experienced doctors migrate to low-tax states

Test yourself

  • MKSAP quiz: chest pain in a pregnant woman

Oncology

  • Stroke risk higher for Hodgkin's lymphoma survivors

Dementia

  • Donepezil may slow Alzheimer's progression for depressed patients

Cardiology

  • Triple antiplatelet therapy superior to dual therapy after PCI in certain patients

FDA update

  • Zicam cold products associated with anosmia
  • Leukotriene inhibitors linked to neuropsychiatric events
  • Stolen Levemir insulin reappears in marketplace
  • Stamina-Rx recalled due to benzamidenafil
  • After analysis, FDA determines cefepime is safe

CMS update

  • CMS alerts providers to fax scam
  • Last chance to view your 2007 PQRI feedback reports

From ACP Internist

  • Your Thoughts Exactly: survey on internists and social media

From ACP Hospitalist

  • Glucose goals, Internal Medicine wrap-up and MKSAP in ACP Hospitalist

Cartoon caption contest

  • Vote for your favorite entry

Physician editor: Darren Taichman, ACP Member


Highlights

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Colonography predicts adenomas in high-risk, asymptomatic patients

Computed tomographic colonography has comparable outcomes to colonoscopy in asymptomatic patients at increased risk for colorectal cancer.

Colonography had a negative predictive value of 96.3% among patients with one of three risk factors for colon cancer. Among patients with a positive fecal occult blood test (FOBT), the negative predictive value was 84.9%.

European researchers wanted to assess colonography's accuracy using unblinded colonoscopy as the reference standard. They conducted a multicenter, cross-sectional study of people with a family history of advanced neoplasia in first-degree relatives, a personal history of colorectal adenomas, or positive FOBTs. They reported results in the June 17 Journal of the American Medical Association.

Each participant underwent colonography followed three hours later by colonoscopy advanced to the cecum. The endoscopist was initially blinded to the CT colonography results. At the end of each bowel segment evaluation, results for that segment were disclosed. If a polyp measuring 6 mm or larger was detected by colonography but not colonoscopy, the segment was reexamined to resolve the discrepancy.

Included in the final analysis were 937 patients: 373 in the family-history group, 343 with a personal history of adenomas and 221 with positive FOBTs. Colonography identified 151 of 177 patients with advanced neoplasia 6 mm or larger (sensitivity, 85.3% [95% CI, 79.0% to 90.0%]) and correctly classified results as negative for 667 of 760 participants without lesions (specificity, 87.8% [95% CI, 85.2% to 90.0%]). Positive and negative predictive values were 61.9% (95% CI, 55.4% to 68.0%) and 96.3% (95% CI, 94.6% to 97.5%), respectively. A significantly lower negative predictive value was found for the FOBT-positive group (84.9% [95% CI, 76.2% to 91.3%]; P< 0.001).

Results do not support using CT colonography as a first-line strategy in FOBT-positive patients. Despite several caveats, researchers added that "The high accuracy of CT colonography for cancer in our study is a valid argument for its use in FOBT-positive patients who refuse colonoscopy."

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Starting salaries rise for some while experienced doctors migrate to low-tax states

Physicians joining hospital-department practices had among the highest starting salaries in 2008 while new physicians specializing in emergency medicine, infectious disease and hematology/oncology saw their median salaries increase, according to the Medical Group Management Association's most recent salary survey.

The Physician Placement Starting Salary Survey, based on 2008 data, reported that anesthesiologists, noninvasive cardiologists, emergency medicine specialists and neurologists had the biggest increases in starting salaries. The survey also revealed that experienced physicians are migrating to Florida and Texas while those just out of residency tend to favor North Carolina and Illinois. Virginia and Florida reported the largest increase in placements between 2006 and 2008.

Florida and Texas both have no state income tax, which can boost a physician's income significantly and may contribute to the allure of those states, said an MGMA news release.

The survey found little difference in signing bonuses offered to residents one year out of residency or fellowship versus more experienced physicians. Primary care physicians, cardiologists and surgeons were offered similar signing incentives regardless of their years in practice.

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Test yourself

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MKSAP quiz: chest pain in a pregnant woman

A 22-year-old woman who is 16 weeks pregnant is evaluated for a 2-hour history of severe anterior chest pain radiating to her mid-back. She is a tall, thin woman with a pectus abnormality of her chest and long, thin fingers. Her blood pressure is 140/80 mm Hg, her pulse is 94/min and regular, and her respiratory rate is 24/min. Her chest wall is diffusely mildly tender to palpation. Her lungs are clear to auscultation. Cardiac auscultation shows a normal S1, a physiologically split S2, and a grade 2/6 diastolic decrescendo murmur at the left sternal border. There is no peripheral edema. Her electrocardiogram shows only nonspecific ST-T changes. Oxygen saturation by pulse oximetry on room air is 99%. Her D-dimer level is mildly elevated.

Which is the most likely cause of her chest pain?

A) Pulmonary embolus
B) Acute myocardial infarction
C) Aortic dissection
D) Costochondritis
E) Pericarditis

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

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Oncology

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Stroke risk higher for Hodgkin's lymphoma survivors

Patients who have received radiation therapy as a treatment for Hodgkin's lymphoma have a substantially higher than average stroke risk, according to a new study.

Researchers in the Netherlands performed a retrospective cohort study among 2,201 people who had been treated for Hodgkin's lymphoma between 1965 and 1995. All patients had been treated before age 51 and survived for at least five years after treatment. The study compared rates of clinically verified stroke and transient ischemic attack (TIA) in these patients with rates in the general population. The research was published online by the Journal of the National Cancer Institute.

During the median 17-year follow-up, 96 patients developed stroke and/or TIA. Compared to the general population, Hodgkin's lymphoma patients had more than double the risk of stroke, and their risk for TIA was triple the normal risk. In the 30 years after treatment, the patients' cumulative incidence for either event was 7%. Having received radiation to the neck and mediastinum was an independent risk factor, but chemotherapy was not.

Based on the results, study authors recommended that physicians incorporate risk-reduction strategies, such as hypertension treatment and lifestyle changes, into their treatment of young survivors of Hodgkin's lymphoma. The study also found that hypertension, diabetes and high cholesterol were associated with increased stroke risk.

The author of the accompanying editorial went further in his recommendations. Given the new evidence and existing knowledge about the risks of radiation, physicians should not choose radiation therapy as a primary treatment for Hodgkin's disease, he said. The benefits of the therapy are unclear, and it's unknown whether lowering the dose of radiation also lowers the risk of late side effects. Chemotherapy is an effective alternative with a proven safety record, the editorial concluded.

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Dementia

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Donepezil may slow Alzheimer's progression for depressed patients

Depression may increase the risk of developing Alzheimer's disease for those with mild cognitive impairment, but donepezil (Aricept) can help slow the progression of dementia for this population, a new study found.

The randomized, double-blind trial assigned 756 patients age 55 to 91 years with amnestic mild cognitive impairment to receive donepezil, vitamin E or placebo. Depressive symptoms at baseline were determined via the Beck Depression Inventory (BDI), and patients were followed for three years or until the progression to possible or probable Alzheimer's. The results were reported in the June 16 online issue of Neurology.

Each point higher on the baseline BDI was associated with a 3% higher risk of progression to Alzheimer's (P=0.03). Among the depressed patients, the proportion that progressed to Alzheimer's was lower for those taking donepezil (11%) than for the combined vitamin E and placebo groups (25%) at 1.7 years (P=0.023). At 2.2 years, 14% of depressed patients in the donepezil group had progressed to dementia compared to 29% in the combination group. At 2.7 years, 18% of depressed donepezil patients had progressed to Alzheimer's compared to 32% in the combined group—a difference that didn't quite reach statistical significance (P=0.07). For non-depressed patients, donepezil had little effect on dementia compared to vitamin E or placebo.

Donepezil appears to modify the higher risk of Alzheimer's disease that comes with depression in patients with amnestic mild cognitive impairment, the authors concluded. The study is limited, however, in that it involves a predominately Caucasian sample, which restricts the generalizability of results, they said.

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Cardiology

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Triple antiplatelet therapy superior to dual therapy after PCI in certain patients

Therapy with three antiplatelet agents is superior to dual therapy in patients with acute ST-segment elevation myocardial infarction (STEMI) after percutaneous coronary intervention (PCI) with drug-eluting stents, a new study reports.

Researchers performed a retrospective study to determine whether cilostazol added to aspirin and clopidogrel was associated with improved outcomes after PCI with drug-eluting stents in patients with acute STEMI. A total of 4,203 patients were studied, 2,569 in the dual-therapy group and 1,634 in the triple-therapy group. All patients received aspirin and clopidogrel for at least six months according to existing guidelines, while patients in the triple-therapy group also received cilostazol for at least a month. Results were published online June 15 in Circulation.

At eight months, patients receiving triple therapy had a lower incidence of cardiac death (adjusted odds ratio [OR], 0.52 [95% CI, 0.32 to 0.84]; P=0.007), total death (adjusted OR, 0.60 [95% CI, 0.41 to 0.89]; P=0.010), and total major adverse cardiac events (adjusted OR, 0.74 [95% CI, 0.58 to 0.95]; P=0.019) compared with the dual-therapy group, as well as a lower incidence of in-hospital mortality (2.2% vs. 3.4%; P=0.022). Triple therapy was associated with the improved outcomes particularly in patients with diabetes, patients older than 65, and women. Rates of major bleeding events were similar between the two groups.

The authors acknowledged the study's lack of randomization and lack of information on adverse reactions to cilostazol, but concluded that triple therapy was safe and associated with improved outcomes in the study population. They called for a randomized, controlled trial to confirm their findings.

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FDA update

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Zicam cold products associated with anosmia

Zicam Cold Remedy Nasal Gel, Zicam Cold Remedy Nasal Swabs, and Zicam Cold Remedy Swabs, Kids Size have all been linked with long-lasting or permanent anosmia, the FDA said in an advisory.

While the over-the-counter products were discontinued, consumers may still have them in their homes. Since 1999, the FDA has received more than 130 reports of anosmia associated with the use of Zicam zinc-containing intranasal products. Some people have lost their sense of smell with the first dose, while for others anosmia occurred after several doses. The products should be thrown away, the FDA said.

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Leukotriene inhibitors linked to neuropsychiatric events

Neuropsychiatric events have been reported in some patients taking montelukast (Singulair), zafirlukast (Accolate), and zileuton (Zyflo and Zyflo CR), the FDA said in a notice.

The FDA is requesting that manufacturers of the drugs include a precaution in their labeling about the reported events, which have included agitation, aggression, anxiousness, dream abnormalities and hallucinations, depression, insomnia, irritability, restlessness, suicidal thinking and behavior (including suicide), and tremor. Physicians should discontinue the medications in patients who report these side effects, the FDA said.

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Stolen Levemir insulin reappears in marketplace

Stolen vials of long-acting Levemir insulin (generic: insulin detemir) have reappeared and are being sold in the U.S. market, the FDA said in a news release.

About 129,000 vials were stolen and may not have been stored or handled properly, and thus may not be safe to use. At least one patient has suffered an adverse event due to poor glucose control after using a stolen vial. Patients should not use Levemir with the affected lot numbers of XZF0036, XZF0037 and XZF0038.

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Stamina-Rx recalled due to benzamidenafil

Erectile dysfunction supplement Stamina-Rx is being recalled by its manufacturer because an FDA analysis found that a sample contained benzamidenafil, the FDA said in a notice.

Benzamidenafil, which isn't FDA-approved, may interact with nitrates found in some prescription drugs, such as nitroglycerin, and may lower blood pressure to dangerous levels. The affected lot number is 08141578, but all lots are being recalled as a precaution.

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After analysis, FDA determines cefepime is safe

After a study review and meta-analysis, the FDA has determined there isn't a higher mortality risk with cefepime (Maxipime), said a safety alert.

The analysis was triggered by an article in the May 2007 Lancet Infectious Diseases that suggested a higher rate of death in patients treated with cefepime, as compared to patients treated with similar drugs. The injectable antibiotic is approved to treat a variety of infections due to susceptible strains of microorganisms, and remains appropriate for those uses, the FDA said.

The FDA will continue to review the safety of cefepime using hospital drug utilization data, and will report results from its ongoing analysis in about a year, the agency said.

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CMS update

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CMS alerts providers to fax scam

The Centers for Medicare and Medicaid Services (CMS) alerted providers to a scam involving faxes to physician offices. Someone posing as the Medicare carrier or Medicare Administrative Contractor (MAC) sends a fax to a physician office asking them to complete a questionnaire with updated account information within 48 hours in order to avoid a gap in Medicare payments.

Physician offices should be on the lookout for this type of request and check with contractors before providing any information. The fax may have the CMS and contractor logo on it. Providers should only send information to their Medicare contractors using the addresses found on the CMS Web site. Click the “Medicare Fee-for-Service Contact Information” link to find the address for the Medicare contractor in your state.

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Last chance to view 2007 PQRI feedback reports

Last week the Centers for Medicare and Medicaid Services (CMS) announced that the feedback reports for the 2007 Physician Quality Reporting Initiative (PQRI) program will no longer be available on the agency's Web site after June 30.

The feedback reports are being archived to make room for the new feedback reports from the 2008 PQRI and for the 2007 reports that are being re-run. Sign in online to view 2007 PQRI feedback.

CMS is re-running the 2007 reports because of several technical issues that were found in the original data analysis. Some eligible professionals who participated in the 2007 version of the program but did not qualify for the incentive payment may find that under the new analysis they will now qualify. The new reports will be available in October. Only the providers who had not previously qualified but do qualify under the re-run will receive a new report. Physicians who qualify for the bonus under the re-run will receive payment in addition to a new report.

More information is available on the College’s Web site.

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From ACP Internist

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Your Thoughts Exactly: survey on internists and social media

Everyone is buzzing about social media, but is it relevant to how internists practice medicine? Some physicians are using social media and multimedia tools to interact with their patients. Others are using it for career advancement, or just to express their thoughts about the practice of medicine today. Take our one-minute survey about how you are applying social media to your personal and professional lives.

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From ACP Hospitalist

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Glucose goals, Internal Medicine wrap-up and MKSAP in ACP Hospitalist

The next issue of ACP Hospitalist is live online, including articles on the following:

  • Experts debate new glucose goals for the ICU. NICE-SUGAR investigators find that intensive control increased mortality among more than 6,000 ICU patients, leading to a change in glucose management practices for hospitalists.
  • Wrapping up Internal Medicine 2009's hospitalist track. Hospital-acquired infections, delirium, and debunking the gospel of heparin for strokes.
  • Test yourself with MKSAP. If you enjoy the MKSAP questions and critiques in ACP InternistWeekly, find more questions to test your knowledge of infectious diseases.

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Cartoon caption contest

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Vote for your favorite entry

ACP InternistWeekly's cartoon caption contest continues. ACP staff has selected three finalists for the latest contest and is now asking readers to vote for their favorite caption to determine the winner.

Go online to view the cartoon and pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting continues through June 29, with the winner announced in the June 30 issue.

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MKSAP Answer and Critique

The correct answer is C) Aortic dissection. This question is available to MKSAP subscribers in Cardiovascular Medicine: Item 90.

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.

Aortic dissection should be considered in the differential diagnosis of chest pain in pregnancy.

There are several possible causes of acute severe chest pain in a pregnant woman. However, in this patient with musculoskeletal findings suggestive of Marfan syndrome, severe chest pain that radiates to her back, a new diastolic murmur, and a nonspecific electrocardiogram, the possibility of aortic dissection should be high on the differential diagnosis. Women with Marfan syndrome are at an increased risk of aortic dissection during pregnancy. Even in women without Marfan syndrome, the aortic root dilates by a few millimeters and the compliance of the arterial wall increases during pregnancy, most likely in response to hormonal changes. The increased risk of dissection in Marfan patients is due to the combination of these normal changes in the vessel wall, abnormal connective tissue microfibrils due to the fibrillin defect, and the increased aortic mechanical stress due to the higher output of pregnancy.

There is an increased risk of deep venous thrombosis and pulmonary embolism in pregnancy, but this patient has no evidence of leg swelling. D-dimer levels may be elevated during normal pregnancy and thus are less specific for the diagnosis of pulmonary embolism during pregnancy. Acute myocardial infarction due to spontaneous coronary artery dissection may occur during pregnancy even in the absence of atherosclerosis, but typical electrocardiographic changes would be present. Costochondritis is a diagnosis of exclusion and is associated with localized chest wall tenderness over the costochondral joints. Pericarditis is not associated with pregnancy per se, but could occur in a pregnant woman. The diagnosis of pericarditis is based on typical symptoms, a pericardial rub, and ST elevation on electrocardiogram, none of which are present in this case.

Key Points

  • Women with Marfan syndrome are at increased risk of aortic dissection during pregnancy.

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 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?

Find the answer

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