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


ACP HospitalistWeekly 7-21-10


  • Use MRI, not CT, to diagnose ischemic stroke, new guideline says
  • Physicians don’t always report impaired or incompetent colleagues

Adverse medication events

  • New score helps assess risk of adverse drug reactions in elderly patients


  • Albumin-creatinine ratio in morning urine most predictive

Electronic health records

FDA news

Cartoon caption contest

Physician editor: A. Scott Keller, FACP


Use MRI, not CT, to diagnose ischemic stroke, new guideline says

A new guideline says physicians should use a diffusion MRI scan to diagnose ischemic stroke within 12 hours of a first symptom, instead of a non-contrast CT scan.

The American Academy of Neurology guidelines committee systematically analyzed literature from 1966 to January 2008 on the use of diffusion and perfusion MRI to diagnose stroke. Their other recommendations include:

  • Baseline diffusion MRI volume should be considered useful in predicting baseline clinical stroke severity and final lesion volume in anterior-circulation stroke syndromes (Level B evidence).
  • Baseline diffusion MRI volume may be considered not useful in predicting baseline National Institutes of Health Stroke Scale (NIHSS) score in posterior-circulation stroke syndromes (Level C).
  • Baseline diffusion MRI volume may be considered useful in predicting clinical outcome as measured by the NIHSS and Barthel Index (Level C).
  • Baseline perfusion MRI volume may be considered useful in predicting baseline clinical stroke severity (Level C).
  • There is insufficient evidence to support or refute the value of perfusion MRI in diagnosing acute ischemic stroke (Level U).

The recommendation to use diffusion MRI within 12 hours of a first symptom is based on Level A evidence. The true sensitivity of diffusion MRI for diagnosing ischemic stroke is "probably closer to 80%-90% in a general sample of patients presenting for emergency evaluation of possible stroke," the guidelines said. False-negative diffusion MRI in ischemic stroke may be due to small strokes, brainstem location and the earliest times from onset, they said. Guidelines were published in the July 13 issue of Neurology.

CT can still be used if an MRI isn't immediately available, and a person needs an emergency injection of intravenous thrombolytic therapy to break up a blood clot, said Peter Schellinger, MD, lead author of the guidelines and researcher at the Johannes Wesling Clinical Center in Minden, Germany, in a press release. "MRI can be added later if more information is needed," he said. "Otherwise MRI should be used first."


Physicians don’t always report impaired or incompetent colleagues

Most physicians agree they have an ethical obligation to report impaired or incompetent colleagues, but many don't always do so, according to a new study.

Researchers performed a survey of 2,938 physicians practicing in the fields of anesthesiology, cardiology, family practice, general surgery, internal medicine, pediatrics and psychiatry. Nearly two thousand (n=1,891) physicians responded (64.4%). Respondents were asked whether they agreed or disagreed that physicians should always report impaired or incompetent colleagues. They were also asked whether they were prepared to deal with such colleagues and whether they had been aware of and subsequently reported an impaired or incompetent colleague in the past three years. Those who reported knowing of an impaired or incompetent colleague were asked if they had ever not reported unprofessional behavior for certain reasons, such as believing someone else was handling the problem or that the physician in question would be too harshly disciplined as a result of the reporting. The survey results appear in the July 14 Journal of the American Medical Association.

Overall, 1,120 physicians (64% of the respondents) agreed that the tenets of their profession obligated them to report impaired or incompetent colleagues. Still, only 69% (n=1,208) were prepared to deal with impaired colleagues and 64% (n=1,126) were prepared to deal with incompetent colleagues. Of the 309 physicians (17%) who personally knew an incompetent colleague, 67% (n=204) said that they had reported him or her. Physicians who were underrepresented minorities, who did not graduate from a U.S. medical school and who lived in an area where malpractice claim numbers were high were less likely to report, while those working in hospitals or medical schools rather than group or small practices were more likely to report. Physicians were most likely to cite a belief that "someone else was taking care of the problem" as the reason for failing to report. Other common reasons included believing that reporting would have no effect and fearing that it would lead to retribution.

The study results may have been affected by nonresponse bias, and physicians may have been wrong about their colleagues' job performance. However, the authors concluded that based on their survey results, self-regulation does not guarantee accurate reporting of impaired or incompetent physicians. External regulation by such bodies as professional societies should be strengthened, they suggested, and reporting systems must guarantee reporting physicians’ anonymity and provide feedback once the reported problem is addressed.

The author of an accompanying editorial pointed out that the study results could be viewed more positively, since most physicians did agree that they had an obligation to report impaired or incompetent colleagues. He also noted that "today there are multiple complementary methods, developed by the profession, to monitor competence and detect impairment," such as clinical performance measurement, CME requirements, and maintenance of certification programs. The editorialist agreed that some physicians do not report colleagues when they should, and that the existing reporting system should be improved. However, he wrote, the current study "is also a reminder that physicians are always seeking to perfect the complex web of interactive processes used for quality assurance in medicine."


Adverse medication events

New score helps assess risk of adverse drug reactions in elderly patients

A new risk score can help identify patients age 65 and older who are at increased risk of an adverse drug reaction, a study found.

In developing their score, Italian researchers tested the GerontoNet ADR (Adverse Drug Reaction) Risk Score on 5,936 patients admitted to community and academic hospitals during survey periods in 1993, 1995 and 1997. The patients were at least age 65 years and received at least one medication during their hospital stay; the mean number of medications taken was 6.3. Of the 5,936 patients, 6.5% (n=383) had an ADR during the hospital stay. Ninety percent of those who had an ADR had only one, 7.8% had two ADRs, and 2.1% had three or more ADRs. Cardiovascular and arrhythmic complications were the most frequent ADRs (25.3% of all ADRs; n=97); then gastrointestinal complications (18%; n=69); then neurologic and neuropsychiatric complications (17.8%; n=68), electrolytic complications (13.1%; n=50), and dermatologic/allergic complications (11.7%; n=45). The strongest predictors for developing ADRs were the number of concurrently used drugs and a history of an ADR, followed by heart failure, liver disease, presence of four or more medical conditions and renal failure. These variables were used to compute the risk score.

The researchers then conducted a validation study on 483 adults admitted to four geriatric and internal medicine wards between September and December 2008. The patients, age 65 years and older, were followed until discharge, and used an average of 11 medications during their stay. An ADR was observed in 11.6% (n=56) of patients. Except for heart failure, all the variables in the risk score were associated with an increased rate of ADRs. An ADR was observed in 28% of patients with a risk score of 8 or more; 11.5% of patients with a score of 6-7; 7.0% of patients with a score of 4-5; 4.2% of patients with a score of 2-3 and 4.5% of patients with a score of 0-1. The area under curve (AUC), which assesses the ability of the risk score to predict ADRs in this sample, was 0.70 (95% CI, 0.63 to 0.78). Results were published in the July 12 Archives of Internal Medicine.

Study limitations include that data on preventability of ADRs wasn't collected, and that the findings can't be extrapolated to younger persons, the researchers noted. Also, the data used to develop the score was collected between 1993 and 1997; since then, older adult patients have gotten more medically complex. Still, the risk score is a simple, efficient and practical method to identify patients at increased risk of an ADR, the researchers said. ADR incidence in older patients hasn't decreased in the last decade, suggesting a problem with identifying those at risk; the score can help with that, after further validation in different populations and settings, they said.



Albumin-creatinine ratio in morning urine most predictive

Using a first morning urine sample to measure albumin-creatinine ratio in patients with type 2 diabetes and renal disease offers the best predictor of renal events, according to a new study.

Researchers used data from the industry-funded RENAAL (Reduction In Endpoints in Non Insulin Dependent Diabetes Mellitus with the Angiotensin-II Antagonist Losartan) study to compare methods of measuring proteinuria in patients with type 2 diabetes and kidney disease. The four methods tested were urinary protein excretion from a 24-hour urine collection, urinary albumin excretion from a 24-hour urine collection, urinary albumin concentration from a first morning urine sample and albumin-creatinine ratio from a first morning urine sample. The study's primary outcome measure was time to doubling of serum creatinine concentration or time to end-stage renal disease. The results were published early online July 15 by the Journal of the American Society of Nephrology.

Seven hundred one patients with type 2 diabetes and nephropathy collected both a first morning urine sample and a 24-hour urine sample. Of these, 202 (28.8%) had a doubled serum creatinine concentration or developed end-stage renal disease during follow-up. Hazard ratios for renal outcome risk per SD increment in each measure were 3.16 (95% CI, 2.60 to 3.86) for urinary albumin excretion, 3.02 (95% CI, 2.53 to 3.62) for urinary protein excretion, 3.23 (95% CI, 2.67 to 3.91) for urinary albumin concentration and 4.36 (95% CI, 3.50 to 5.45) for albumin-creatinine ratio. The albumin-creatinine ratio had a significantly higher area under the receiver-operating curve than the other measures.

The authors cautioned that their results are not generalizable to patients without diabetes and nephropathy, but concluded that measuring albumin-creatinine ratio in first morning urine is the best way to predict progression of renal disease in this population. An accompanying editorial concurred, stating, “Given data from this study and the considerable patient effort required for a 24-hour urine collection, we agree with the authors that the first morning [albumin-creatinine ratio] is in general the logical choice for quantifying proteinuria in clinical practice.”


Electronic health records

CMS defines meaningful use, ACP responds

Last week, the Centers for Medicare & Medicaid Services (CMS) issued final rules defining meaningful use of electronic health records, which physician practices and hospitals must meet in order to qualify for Medicare and Medicaid incentive payments.

Two companion final rules were announced. One regulation, issued by CMS, defines the minimum requirements that providers must meet through their use of certified EHR technology in order to qualify for the payments. The rule includes modifications that address concerns raised by stakeholders, according to a CMS press release. For example, as originally proposed the rule called on eligible professionals to meet 25 requirements (23 for hospitals) in their use of EHRs, but the final rule divides the requirements into a core group of requirements that must be met, plus an additional menu of procedures from which providers may choose. A summary overview of the requirements and a discussion of the rule by CMS leaders were published online by the New England Journal of Medicine.

The other rule, issued by the Office of the National Coordinator for Health Information Technology (ONC), identifies the standards and certification criteria for EHR technology, so providers may be assured that the systems they adopt are capable of performing the required functions.

ACP Executive Vice President and Chief Executive Officer John Tooker, MACP, responded to the rules’ release in a letter sent on Thursday to the administrators of CMS and ONC. Overall, ACP is pleased with the administration’s responses to the core issues regarding meaningful use and is supportive of the direction in which the rules move the health IT community. However, the College does have some remaining concerns, which College representatives intend to review with CMS and ONC.

Dr. Tooker said the rules are encouraging and lead ACP to believe that the remaining issues about which the College has concerns can be addressed through continued dialogue, clarification, and collaboration on future rule-making.


FDA news

FDA panel divided on rosiglitazone

A panel that advises the FDA was divided last week in a vote on whether rosiglitazone (Avandia) should be removed from the market.

The panel has 33 members, 12 of whom voted that rosiglitazone should be withdrawn. Ten members voted that sale of the drug should be restricted and its warnings strengthened, while seven favored only strengthening the warnings and three voted for no changes, according the July 14 New York Times.

After reviewing large amounts of data, the advisory panel also found that there was sufficient evidence to be concerned that rosiglitazone increases the risk of heart attacks and strokes but insufficient evidence that it increases the risk of death, reported the July 15 Washington Post. The panel also recommended that the FDA approve a large head-to-head trial against pioglitazone (Actos).


Coumadin samples recalled

Some sample packs of Coumadin (warfarin) have been recalled by the manufacturer because the active ingredient may be below or above therapeutic levels.

The voluntary recall by Bristol-Myers Squibb affects three lots of physician sample blister packs of Coumadin 1 mg tablets and five lots of Coumadin 1 mg tablet hospital unit dose (HUD) blister packs. The following lot numbers are being recalled: Physician Sample Blister Packs: Lot# 9A48931A, 9A48931B, 9A48931C, expiration January 2012; HUD Blister Pack: Lot# 8F34006B, 8K44272A, 8K46168A, 9F44437A and 9K58012B with expiration dates between June 2011 and November 2012.

According to a press release from the manufacturer, the recall is a precautionary measure based upon the company’s determination that some of the tablets, over time, may not meet specifications for isopropanol, which is used to maintain the active ingredient in a crystalline state.


Cartoon caption contest

Put words in our mouth

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E-mail all entries to 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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