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

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ACP InternistWeekly



In the News for the Week of August 5, 2014




Highlights

Screen for apnea in patients with daytime sleepiness, guideline says

Doctors should assess the risk factors for and the symptoms of obstructive sleep apnea (OSA) in patients with unexplained daytime sleepiness, according to an ACP clinical practice guideline that appears in the Aug. 5 Annals of Internal Medicine. More...

Physical therapy and corticosteroid injections offer equal relief from shoulder pain and disability

Both physical therapy and subacromial corticosteroid injections provide significant improvement in pain and function for patients with unilateral shoulder impingement syndrome, according to a study in the Aug. 5 Annals of Internal Medicine. More...


Test yourself

MKSAP Quiz: evaluation for health insurance

A 21-year-old man is evaluated during a medical examination for health insurance. The patient is a weight lifter. He has no medical problems and takes no medications or illicit drugs. Following a physical exam, electrocardiogram, and echocardiogram, what is the most likely diagnosis? More...


Cardiology

Guideline on diagnosing, managing ischemic heart disease updated

A guideline on diagnosis and management of stable ischemic heart disease was updated last week by a collaboration of cardiology organizations. More...

Studies raise questions about decisions to implant, replace ICDs

Two new research letters raise questions about the decision-making process for implanting new implantable cardioverter-defibrillators (ICDs), as well as replacing existing ICDs. More...


Perioperative medicine

New guidelines on perioperative evaluation and management

Cardiology experts released new guidelines on perioperative care of patients undergoing noncardiac surgery last week. More...


Judicial update

ACP disagrees with Florida court decision preventing physicians from asking about guns

ACP strongly disagrees with the July 25 Florida court decision upholding a state law that bars doctors from asking patients about gun ownership, according to a press release. More...


Primary care shortage

IOM reforms need bigger role for primary care, ACP says

ACP has reviewed the Institute of Medicine's (IOM) recent efforts to revise the governance and financing of graduate medical education (GME). More...


From the College

ACP and Cleveland Clinic Journal of Medicine collaborate on Smart Testing series

ACP and Cleveland Clinical Journal of Medicine have collaborated to create a new series, Smart Testing, to help physicians provide high-value care by presenting clinical scenarios in which diagnostic tests are commonly ordered in the absence of supporting data. More...

Apply now for ACP's 2015 Washington internship

Applications are now being accepted for the College's Health Policy Internship for Resident/Fellow and Medical Student Members. Spend a month in Washington learning about health policy and advocating for internal medicine. More...


Cartoon caption contest

Put words in our mouth

ACP InternistWeekly wants readers to create captions for our new cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service. More...


Physician editor: Philip Masters, MD, FACP



Highlights


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Screen for apnea in patients with daytime sleepiness, guideline says

Doctors should assess the risk factors for and the symptoms of obstructive sleep apnea (OSA) in patients with unexplained daytime sleepiness, according to an ACP clinical practice guideline that appears in the Aug. 5 Annals of Internal Medicine.

annals.jpg

The guideline recommends a sleep study for patients with unexplained daytime sleepiness (weak recommendation, low-quality evidence). To diagnose OSA in symptomatic patients, physicians should use full-night, attended, in-laboratory polysomnography (PSG). In patients without serious comorbidities for whom PSG is not available, a home-based portable monitor can be used as an alternative (weak recommendation, moderate-quality evidence).

Sleep study monitoring methods are classified by type. Type I monitoring is standard, attended, in-laboratory PSG; the other types are available for portable use. Type II monitors are portable comprehensive PSG with a minimum of 7 channels, including electroencephalogram, electrooculogram, electrocardiogram or heart rate, respiratory rate, respiratory effort and airflow, and oxygen saturation monitoring. Type III monitors have a minimum of 4 channels, including ventilation and airflow, heart rate, electrocardiogram or heart rate, and oxygen saturation. Type IV monitors have 1 or 2 channels, usually airflow and oxygen saturation.

The guideline writers found low-quality evidence showing that type II monitors may identify apnea-hypopnea index (AHI) scores that may suggest OSA. No study directly compared different portable monitors with each other, although current evidence supports greater diagnostic accuracy with type III monitors than type IV monitors. Most studies excluded patients with comorbid conditions, including chronic lung disease, congestive heart failure, or neurologic disorders, making the utility of portable monitors for diagnosing OSA in these patients uncertain. Also, compared with PSG, type II, III, and IV monitors had a wide range of difference in AHI estimates.

Type IV monitors cannot differentiate between obstructive apneas, where airflow is disrupted because of airway obstruction, and central apneas, which are caused by a temporary failure of the brain to regulate breathing. Continuous positive airway pressure (CPAP) may be contraindicated in patients with central sleep apnea. Patients with cardiac, respiratory, or neurologic disease may be at the greatest risk for central sleep apnea, and the American Academy of Sleep Medicine does not recommend the use of portable monitors for diagnosis in these patients.

Low-quality evidence indicated that the Berlin Questionnaire may be used to screen for OSA. However, questionnaires include subjective questions about sleepiness. Not all patients, even those with severe OSA, report sleepiness, which may limit applicability to the general population.

There was not enough evidence to determine the effectiveness of phased testing (screening tests or battery followed by a full test) for the diagnosis of OSA or the utility of preoperative screening for OSA to improve postsurgical outcomes.

A randomized trial showed that CPAP treatment did not reduce mortality or coronary heart disease events in patients with OSA who did not have daytime sleepiness. Although CPAP seems to reduce blood pressure in patients with symptomatic OSA, its effect on blood pressure in adults with OSA who do not have daytime sleepiness is less well established.


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Physical therapy and corticosteroid injections offer equal relief from shoulder pain and disability

Both physical therapy and subacromial corticosteroid injections provide significant improvement in pain and function for patients with unilateral shoulder impingement syndrome, according to a study in the Aug. 5 Annals of Internal Medicine.

annals.jpg

Researchers randomly assigned 104 patients between the ages of 18 and 65 in a U.S. military hospital-based outpatient clinic to receive either as many as 3 total injections of subacromial injections of triamcinolone acetonide, 40 mg, at least 1 month apart during the 1-year period or 6 sessions of physical therapy over a 3-week period. Patients were treated for shoulder conditions such as rotator cuff tendinosis and shoulder bursitis. Physical therapy was matched to individual impairments and included a combination of joint and soft-tissue mobilizations; manual stretches; contract-relax techniques; and reinforcing exercises directed to the shoulder girdle or thoracic or cervical spine. Home exercises were prescribed to reinforce clinical interventions.

In the study, both groups experienced about a 50% improvement in Shoulder Pain and Disability Index scores maintained through 1 year, and the mean difference between groups was not significant (1.5%; 95% CI, −6.3% to 9.4%). Both groups showed improvements in Global Rating of Change scale and pain rating scores, and between-group differences were not significant for the Global Rating of Change scale (0; 95% CI, −2 to 1) and pain rating (0.4; 95% CI, −0.5 to 1.2).

During 1-year follow-up, patients receiving injections visited their primary care clinician more often (60% vs. 37%; risk ratio [RR], 0.64; 95% CI, 0.43 to 0.95), required additional steroid injections (38% vs. 20%; RR, 0.77; 95% CI, 0.59 to 0.99), and needed more physical therapy (19% vs. 9%). The authors concluded that patients in both groups experienced significant improvement in pain and function, but the physical therapy patients used less shoulder-related health care resources than the injections group.

An editorial noted, "Results of this trial and others suggest no long-term differences in clinical outcomes for patients with shoulder pain regardless of clinical intervention, setting, or diagnosis. In choosing a management plan, clinicians should consider patient preference, availability of practitioners, and other health care use. If a patient prefers a more active or self-management approach, manual physical therapy, exercise, and referral to a physiotherapist should be discussed. If the patient prefers a corticosteroid injection, its effectiveness, safety profile, and potential for additional health care should be discussed."



Test yourself


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MKSAP Quiz: evaluation for health insurance

A 21-year-old man is evaluated during a medical examination for health insurance. The patient is a weight lifter. He has no medical problems and takes no medications or illicit drugs.

On physical examination, blood pressure is 128/73 mm Hg, pulse rate is 56/min, and respiration rate is 16/min; BMI is 30. Increased skeletal muscle mass is noted. There is no jugular venous distention. Carotid upstrokes are brisk. There is a grade 2/6 early systolic murmur along the left lower sternal border that is accentuated by a Valsalva maneuver and decreases with a hand-grip maneuver. An S4 gallop is also noted. Electrocardiogram shows sinus bradycardia and left ventricular hypertrophy by voltage. Echocardiogram shows left ventricular hypertrophy with marked septal hypertrophy and an associated 46 mm Hg outflow tract obstruction, small left ventricular cavity size, normal systolic function with an ejection fraction of 65%, marked left atrial enlargement, and reduced early diastolic filling.

Which of the following is the most likely diagnosis?

A: Dilated cardiomyopathy
B: Hypertensive cardiomyopathy
C: Hypertrophic cardiomyopathy
D: Restrictive cardiomyopathy

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


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Cardiology


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Guideline on diagnosing, managing ischemic heart disease updated

A guideline on diagnosis and management of stable ischemic heart disease was updated last week by a collaboration of cardiology organizations.

The new update of the 2012 guideline, which was led by an American College of Cardiology/American Heart Association task force, added recommendations about the role of coronary angiography to diagnose coronary artery disease (CAD) in patients with suspected stable ischemic heart disease (SIHD), particularly those who are candidates for revascularization or in whom the results of angiography are likely to result in important changes to therapy.

The update also changed recommendations on chelation therapy, from not recommending chelation (based on Level C evidence) to stating that the usefulness of chelation in reducing cardiovascular events is uncertain (based on Level B evidence). The guideline writers reviewed the current evidence on chelation for the update and concluded that the therapy's usefulness was "highly questionable."

The update also included a review of recommendations regarding enhanced external counterpulsation (EECP), in response to comments received after publication of the 2012 guideline. After re-examining the literature, the update writers made no changes to the existing recommendation that EECP may be considered for the relief of refractory angina in patients with SIHD.

Finally, the update changed some recommendations on revascularization. A heart team approach is now recommended for patients with diabetes and complex multivessel CAD. A recommendation about use of coronary artery bypass grafting (CABG) in preference to percutaneous coronary intervention was revised and strengthened to specify that CABG is generally preferred in patients with diabetes and multivessel CAD if revascularization is likely to improve survival and the patient is a good candidate for surgery.

In addition to the ACC and AHA, the guideline was issued by the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions and Society of Thoracic Surgeons. It was published July 28 by the Journal of the American College of Cardiology, and Circulation.


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Studies raise questions about decisions to implant, replace ICDs

Two new research letters raise questions about the decision-making process for implanting new implantable cardioverter-defibrillators (ICDs), as well as replacing existing ICDs.

The first letter describes a retrospective cohort study of data from 33 Alzheimer disease centers (ADC) from September 2005 through September 2011. Researchers evaluated information on 16,245 patients who had had a baseline ADC visit and at least 1 follow-up visit during the study period. At baseline, 32.9% of patients had dementia, 21.3% had mild cognitive impairment (MCI), and 45.8% patients had no cognitive impairment. Over the study period, rates of incident (new) cardiac device implantation were 6.5 per 1,000 person-years for those with dementia, 4.7 per 1,000 for those with MCI, and 4.0 per 1,000 for those without cognitive impairment (P=0.001).

An adjusted model showed that patients who had dementia on the visit before an assessment for a new pacemaker were 1.6 times more likely to receive a pacemaker compared to those without cognitive impairment (P=0.02); the same trend held true in a model for consecutive visits (P<0.01). A separate model found patients whose Clinical Dementia Rating Scale score was 3 (severe dementia) were 2.9 times more likely to receive a pacemaker than those with a Clinical Dementia Rating Scale score of 0 (no cognitive impairment) (P=0.02). The findings run counter to conventional wisdom that patients who are cognitively disabled generally are treated less aggressively, the researchers wrote. More research needs to examine the decision-making process for cardiac devices in the cognitively disabled population, they added.

The second letter describes a study in which researchers surveyed consecutive patients who underwent ICD replacement at a single institution between 2009 and 2012 about their decisions to undergo replacement. Of the 106 responses, 51.9% of patients said they were unaware that ICD generator replacement was not mandatory. Twenty-seven percent of those patients said that, if given the option, they would have considered not replacing the ICD. There were no demographic or clinical differences between those who might have considered non-replacement and those who would not. Eighty-three percent of all 106 patients said it was "important" or "very important" to them to talk about the risks and benefits of ICDs before making a decision to continue with the therapy.

Many patients overestimated the life-saving benefits of ICD generator change and underestimated the risks; in particular, patients weren't aware of the risk of pocket infection, the researchers noted. "A thoughtful review of the way ICD replacement is approached is warranted," the researchers concluded, in order to elicit true preferences from informed patients and incorporate them into decision making.

Both research letters were published online July 28 by JAMA Internal Medicine.



Perioperative medicine


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New guidelines on perioperative evaluation and management

Cardiology experts released new guidelines on perioperative care of patients undergoing noncardiac surgery last week.

The updated guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) include recommendations on risk factors and timing to consider before surgery, preoperative tests, perioperative medication management, and postoperative surveillance for myocardial infarction.

The guideline writers separately commissioned a systematic review on which to base their perioperative beta-blocker recommendations. They concluded that beta-blockers should be continued in patients who have been on the drugs chronically and that it may be reasonable to begin them before surgery for patients with intermediate- or high-risk myocardial ischemia or 3 or more Revised Cardiac Risk Index risk factors. Initiation of therapy, however, should be far enough in advance to assess safety and tolerability, definitely not the day of surgery, and preferably more than 1 day before.

Other drugs addressed under the perioperative therapy recommendations include statins, alpha-2 agonists, angiotensin-converting enzyme inhibitors, and antiplatelet agents (including a treatment algorithm for patients with coronary stents). The guidelines also include a new algorithm to guide preoperative testing, addressing such methods as 12-lead electrocardiography, assessment of left ventricular function, coronary angiography, and stress testing.

Finally, the guidelines conclude with advice on surveillance for perioperative myocardial infarction, recommending troponin measurement and electrocardiography if a patient has signs or symptoms suggestive of myocardial ischemia or infarction. However, the usefulness of these tools in high-risk patients with no signs or symptoms is uncertain, and routine postoperative screening is not useful, the guideline concluded.

The 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery was published by the Journal of the American College of Cardiology and Circulation on Aug. 1.

The June issue of ACP Internist offered guidance on perioperative medication management.



Judicial update


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ACP disagrees with Florida court decision preventing physicians from asking about guns

ACP strongly disagrees with the July 25 Florida court decision upholding a state law that bars doctors from asking patients about gun ownership, according to a press release.

The ruling in the case, which included the Florida ACP chapter as a plaintiff, overturned a decision by a lower court that had struck the law down 2 years ago. The ruling said that there is no First Amendment protection for doctors providing their best medical advice to their patients.

"At the very least, this ruling is destructive to the patient-physician relationship," said ACP President David A. Fleming, MD, MA, FACP. "Many doctors ask about gun ownership as a normal part of screening patients, including it on a long list of health questions about drug and alcohol use, smoking, exercise, and eating habits."

The panel of the 11th U.S. Circuit Court of Appeals last week described the law as a "legitimate regulation" of professional conduct that simply codified good medical care. The court stated that physicians can continue to ask patients about firearms until the case is reviewed by the entire 11th Circuit.

This legislation could limit physicians from asking their patients about firearm ownership and prevent the discussion of firearms' safe storage and handling, ACP said. Firearms education of both adults and children has been shown to decrease the likelihood of unintentional injury or death. The presence of improperly stored firearms in the home can present a health danger to patients and others.

Earlier this year, ACP issued a position paper with 9 recommendations on firearms-related injuries and death that included preserving the rights of doctors to counsel their patients on preventing deaths and injuries from firearms.

"ACP believes this issue is much bigger than guns," Dr. Fleming concluded. "We believe it addresses whether the government or any other body should be allowed to tell physicians what they can and can't discuss with their patients, consistent with evidence-based standards of care."



Primary care shortage


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IOM reforms need bigger role for primary care, ACP says

ACP has reviewed the Institute of Medicine's (IOM) recent efforts to revise the governance and financing of graduate medical education (GME).

While the College agrees that the nation's investment in GME should be used to train physicians with the right numbers, mix, and distribution of specialties and practice location and skills needed to meet the nation's health care workforce needs, it is also concerned that IOM did not make recommendations that address the nation's looming physician workforce crisis.

The College supports strategic increases in the number of Medicare-funded GME positions in primary care and other specialties facing shortages, including many internal medicine subspecialties, as noted in a recent press release. But ACP is particularly concerned that the IOM stated that it "did not find credible evidence" to support claims that the nation is facing a looming physician shortage, particularly in primary care specialties. Paradoxically, the IOM suggested that "GME funds might be used to finance new incentives for choosing a primary care career," even as it questioned whether a primary care shortage exists. Although the College agrees with the IOM that more research is needed to guide physician workforce policies and that incentives, including payment reform, are needed to encourage careers in primary care, it believes there is credible evidence of a real and growing shortage of primary care physicians for adults, warranting immediate action.

Highly credible analyses conclude that the nation will need 44,000 to 46,000 additional primary care physicians by 2025. This figure does not take into account the increasing demand for primary care services, as an estimated 25 million uninsured Americans will obtain coverage through the reforms in the Affordable Care Act. There is also solid evidence that access to primary care is associated with better outcomes and lower cost of care.

ACP will be reviewing the IOM report in greater detail, offering suggestions in the spirit of building upon the many imaginative reforms recommended in the report. The College will also continue to advocate for policies to ensure an adequate supply of physicians to meet the nation's health care needs, including strategic increases in the number of Medicare-funded GME positions in primary care and other specialties facing shortages.



From the College


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ACP and Cleveland Clinic Journal of Medicine collaborate on Smart Testing series

ACP and Cleveland Clinical Journal of Medicine have collaborated to create a new series, Smart Testing, to help physicians provide high-value care by presenting clinical scenarios in which diagnostic tests are commonly ordered in the absence of supporting data.

The articles use evidence-based recommendations to clarify when testing is appropriate.

Patrick Alguire, MD, FACP, senior vice president for medical education at ACP, wrote an introduction to the series and ACP staff contributed other articles. An article on avoiding malpractice litigation while providing evidence-based care is the latest offering in the Smart Testing series, which is part of ACP's High Value Care initiative.


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Apply now for ACP's 2015 Washington internship

Applications are now being accepted for the College's Health Policy Internship for Resident/Fellow and Medical Student Members. Spend a month in Washington learning about health policy and advocating for internal medicine.

The internship represents an opportunity for 1 Resident/Fellow Member and 1 Medical Student Member to develop legislative knowledge and advocacy skills through working directly with the College's Washington staff. The program lasts for 4 weeks starting on April 27 and ending with ACP's 2015 Leadership Day. The deadline to apply is Oct. 20.



Cartoon caption contest


.
Put words in our mouth

ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

acpi-20140805-cartoon.jpg

E-mail all entries to acpinternist@acponline.org. ACP staff will choose finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.


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MKSAP Answer and Critique



The correct answer is C: Hypertrophic cardiomyopathy. This item is available to MKSAP 16 subscribers as item 51 in the Cardiovascular Medicine section. More information is available online.

The most likely diagnosis is hypertrophic cardiomyopathy. The cardiac examination is consistent with a dynamic left ventricular outflow tract obstruction, whereby the systolic murmur is accentuated during maneuvers that decrease preload (Valsalva maneuver) but attenuated by increasing afterload (hand-grip maneuver). Echocardiographic findings confirm left ventricular outflow tract obstruction and asymmetric septal hypertrophy consistent with hypertrophic cardiomyopathy.

The echocardiographic features in hypertrophic cardiomyopathy are diverse and include left ventricular hypertrophy, which may disproportionately involve the septal, anterior, lateral, or apical walls or may be concentric (particularly if marked). Dynamic left ventricular outflow tract or mid-cavity obstruction is a feature of hypertrophic cardiomyopathy, but it is not always seen nor is it a necessary finding to confirm the diagnosis. Additional echocardiographic features include a small left ventricular cavity size and significant left atrial enlargement. Although patients with hypertrophic cardiomyopathy may present with symptoms such as dyspnea, chest pain, or dizziness, many are asymptomatic.

This patient is a weight lifter, a known cause of concentric left ventricular hypertrophy (athlete's heart). Echocardiography is often useful in differentiating left ventricular hypertrophy associated with hypertrophic cardiomyopathy from that of athlete's heart. Marked hypertrophy with a small left ventricular cavity is typical of hypertrophic cardiomyopathy, whereas the cavity is often enlarged in athlete's heart. In addition, marked left atrial enlargement and diastolic dysfunction are not typical features of athlete's heart.

Dilated cardiomyopathy is easily excluded on the basis of echocardiography, which does not show an enlarged left ventricle with systolic dysfunction (ejection fraction <40%), as would be expected for this diagnosis.

Left ventricular hypertrophy, left atrial enlargement, and impaired early diastolic filling seen on the echocardiogram in this patient could be potentially explained by a hypertensive cardiomyopathy. However, a long-standing history of hypertension would need to be present. In addition, hypertensive cardiomyopathy cannot explain the patient's systolic murmur that increases in intensity with a Valsalva maneuver.

Restrictive cardiomyopathy could explain left ventricular hypertrophy. However, an accentuated rate of early diastolic filling (restrictive filling) is characteristic of this entity, and not impaired early filling, as is present in this patient. Lack of this pattern of filling virtually excludes restrictive cardiomyopathy.

Key Point

  • Hypertrophic cardiomyopathy is characterized by a dynamic left ventricular outflow tract obstruction evidenced by a systolic murmur that is accentuated during maneuvers that decrease preload (Valsalva maneuver) but attenuated by increasing afterload (hand-grip maneuver).

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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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