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S HERI M ATTES /E LSEVIER G LOBAL M EDICAL N EWS

E LSEVIER G LOBAL M EDICAL N EWS

EFFECTIVE PHYSICIAN: NEW ASTHMA GUIDELINES, PAGE 19

P HYSICIAN : N EW A STHMA G UIDELINES , PAGE 19 Internal Medicine News www.inter

Internal Medicine News

www.inter nalmedicinenews.com

www.eclinicalpsychiatrynews.com

D ECEMBER 1, 2007
D ECEMBER 1, 2007

VO L .

40, N O.

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The Leading Independent Newspaper for the Internist—Since 1968

Leading Independent Newspaper for the Internist—Since 1968 Improved reimbursement is “a very urgent issue,” said

Improved reimbursement is “a very urgent issue,” said Dr. David C. Dale, president of the American College of Physicians.

Medical Home Set To Move Forward

BY KERRI WACHTER

Senior Writer

WASHINGTON — Medical home advocates hope a new set of metrics will help primary care physicians move closer to imple- menting this model of care. The metrics assess how patient centered an office-based practice is and how well the practice’s care delivery system works. Scores on the tool correlate with enhanced clinical performance and lead to voluntary designation as a patient-centered medical home, according to Dr. Greg Pawlson, executive vice president of the National Committee for Quality Assurance (NCQA). Having a set of metrics is “a very important step on the way

to

a series of large-scale pilot

demonstration projects,” Dr. Pawlson said at a press briefing to

unveil the tool. “Most impor- tantly, it provides a road map for where a practice needs to go from where it is now to where it needs to be as a patient-centered medical home,” he said. The American College of Physicians, the American Acade- my of Family Physicians, the American Academy of Pediatrics, and the American Osteopathic Association worked with NCQA on the development of Physician Practice Connections. These four primary care groups have en-

dorsed the tool as a way for prac- tices to qualify as medical homes in pilot demonstration projects slated to begin as early as 2008. “I think of medical home as the standard of care for primary care. That’s the type of care that we all want to provide,” said Dr. Vera F. Tait, associate executive director of the American Acade- my of Pediatrics. Not everyone is clear on what exactly a medical home is, not- ed Dr. James King, president of the American Academy of Fam- ily Physicians. “A lot of people [are] starting to use the phrase

I I N N S S I I D D E E Early Signs of

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I I N N S S I I D D E E
I I N N S S I I D D E E Early Signs of Parkinson’s
I I N N S S I I D D E E Early Signs of Parkinson’s
Early Signs of Parkinson’s

Early Signs of Parkinson’s

Preclinical brain changes can be seen on SPECT images.

Preclinical brain changes can be seen on SPECT images.

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13

Family History

Family History

Genetics column looks at new applications for family health history.

Genetics column looks at new applications for family health history.

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28

looks at new applications for family health history. PAGE 28 Toe Tips Clinical pearls for the
looks at new applications for family health history. PAGE 28 Toe Tips Clinical pearls for the

Toe Tips

Toe Tips

Clinical pearls for the diagnosis and treatment of onychomycosis.

Clinical pearls for the diagnosis and treatment of onychomycosis.

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26

See Medical Home page 5

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Average Workweeks in Selected Primary Care Specialties Were Similar in 2006

Internal medicine: pediatric

(n

= 76)

38.7 hours

Internal medicine: general

(n

= 3,368)

37.0

hours

 

Pediatric: hospitalist

(n

= 62)

36.6

hours

Family practice (without OB)

(n

= 4,634)

36.6

hours

Pediatric: general

(n

= 2,390)

35.7 hours

Pediatric: infectious disease

(n

= 14)

33.1 hours

 

Note: Mean hours that clinician is involved in direct patient care. Source: Medical Group Management Association

Fenofibrate Curbed Retinopathy in Diabetic Patients

Need for laser therapy was cut by 37%.

BY MITCHEL L. ZOLER

Philadelphia Bureau

O RLANDO — Treatment with fenofibrate led to a substantial drop in the need for laser treat- ments for retinopathy in a con- trolled trial of nearly 10,000 pa- tients with type 2 diabetes. Physicians should “consider us- ing fenofibrate on all patients with diabetes, even patients al- ready on a statin and at their tar- get lipid levels, to further reduce their risk and microvascular com- plications,” Dr. Anthony C. Keech said at an industry-sponsored press briefing during the annual scientific sessions of the Ameri- can Heart Association. “Having a new tool to deal

with [diabetic retinopathy] is very exciting. It’s exciting to use it to treat patients, and it opens a whole new area of research,” commented Dr. Virgil Brown, professor of internal medicine at Emory University, Atlanta. The benefits of fenofibrate for microvascular disease of diabetes appeared to extend beyond its sig- nificant effect on retinopathy. Pa- tients treated with fenofibrate also had less progression of albumin- uria, and fewer amputations, Dr. Keech and his associates reported. “The results were very clear- cut. It’s very hard to make a co- herent argument not to use fenofibrate” in patients with dia- betes, said Dr. Keech, professor of

See Fenofibrate page 20

Oral Purgatives Linked With Acute Kidney Injury

BY ROBERT FINN

San Francisco Bureau

kidney injury may not be as rare a consequence of oral sodium phosphate bowel purgatives as previously thought, researchers

Acute

S A N

F RANCISCO

said at the annual meeting of the American Society of Nephrology.

In

a

retrospective

study

of

nearly 10,000 patients, those giv- en oral sodium phosphate purga- tives prior to colonoscopy had 2.35 times the chance of devel- oping acute kidney injury as did those given polyethylene glycol purgatives. This result was ob-

tained after adjustment for many potential confounders, and was based on a definition of acute kidney injury as a 50% increase in serum creatinine, said Col. Frank P. Hearst, MC, USA, and his col- leagues at the Walter Reed Army Medical Center, Washington. The study involved 6,432 pa- tients who received oral sodium phosphate and 3,367 who re- ceived polyethylene glycol as out- patients prior to colonoscopy. All patients were at least 50 years old, and all had serum creatinine measurements within 365 days before and after the procedure

See Purgatives page 6

6

News

I NTERNAL

M EDICINE

N EWS

December 1, 2007

Nephropathy Risk Quantified

Purgatives from page 1

date. The investigators noted in their poster presentation that they excluded pa- tients who used purgatives for reasons other than screening colonoscopy, as well as those who had end-stage renal disease. The unadjusted absolute risk of acute kidney injury was 1.31% with oral sodium phosphate and 0.92% with polyethylene glycol, for a 0.39% increase in absolute risk. After adjustment for confounders, the relative risk associated with oral sodi- um phosphate was 2.35. One case of acute

kidney injury would be expected to occur for every 81 patients given oral sodium phosphate instead of polyethylene glycol. With use of a more stringent criterion for acute kidney injury—a doubling in the serum creatinine level—the adjusted relative risk associated with oral sodium phosphate purgatives was 3.81, and the number needed to harm was 288. Other factors emerged in the multivari- ate analysis as being independently asso- ciated with acute kidney injury: heart fail-

ure (relative risk 2.03), contrast exposure (relative risk 1.70), and age (relative risk 1.06 per year). The use of oral sodium phosphate purgatives was thus accompa- nied by a greater risk of acute kidney in- jury than were these other risk factors. Patients who developed acute kidney in- jury typically did not return to baseline lev- els of renal function. Their mean prepro- cedure creatinine level was 0.98 mg/dL. This rose to a mean of 1.78 mg/dL after the procedure. An average of 280 days later, the mean values had declined to 1.38 mg/dL. In a separate talk, Dr. Glen S. Markowitz of Columbia University, New York, de- scribed his earlier study of acute phosphate

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nephropathy. The pathophysiology ap- pears to involve obstructive calcium phos- phate crystalluria and intratubular nephro- calcinosis. Of 7,349 nontransplant renal biopsies, 31 revealed nephrocalcinosis; at least 21 of those were associated with the use of oral sodium phosphate purgatives. Patients with nephrocalcinosis had a mean baseline serum creatinine of 1.0 mg/dL, which had increased to 3.9 mg/dL at presentation. After a mean follow-up of

17 months, 4 of the 21 patients developed

end-stage renal disease. Of the remaining

17 patients, 16 had a decline in serum cre-

atinine to a mean of 2.4 mg/dL, and 4 of the 17 reached 2.0 mg/dL, but none re- turned to baseline levels. In response to this report and others, the Food and Drug Administration in May 2006 issued a warning on acute phosphate nephropathy associated with oral sodium phosphate purgatives, stating that individ- uals at increased risk include those with ad- vanced age and decreased intravascular vol- ume, and people taking certain medications including ACE inhibitors, angiotensin II re- ceptor blockers, and possibly NSAIDs. Dr. Markowitz said that other probable risk factors are inadequate hydration, ex- cess phosphate dosing, a short interval be- tween oral sodium phosphate doses, and fasting prior to the procedure to decrease the risk of aspiration during sedation. Other possible risk factors are female gen- der and small body habitus. Several professional societies—includ- ing the American Society of Colon and Rectal Surgeons—have added such warn- ings to their consensus documents on bowel preparation. This increased awareness will likely lead to a decline in acute phosphate nephropa- thy, Dr. Markowitz said. Clinicians will be more careful in selecting purgatives for each patient. Several manufacturers of bowel preparations have decreased their phosphate content by 16%-20%. Also, clin- icians are increasingly recommending bet- ter hydration, to provide at least 72 ounces before, during, and after the use of oral sodium phosphate purgatives.

E DITORIAL A DVISORY B OARD

ROY D. ALTMAN, M.D., California JON O. EBBERT, M.D., Minnesota FAITH T. FITZGERALD, M.D., California WILLIAM E. GOLDEN, M.D., Arkansas SIDNEY GOLDSTEIN, M.D., Michigan ROBERT H. HOPKINS, M.D., Arkansas HOLLY J. KRAMER, M.D., Illinois

J. LEONARD LICHTENFELD, M.D., Georgia

DIANE E. MEIER, M.D., New York

F. M ICHAEL M ELEWICZ , M.D., California

ALAN R. NELSON, M.D., Washington, D.C.

JOHN R. NELSON, M.D., Washington

BARBARA L. SCHUSTER, M.D., Ohio

DONNA E. SWEET, M.D., Kansas ERIC G. TANGALOS, M.D., Minnesota PETER G. TUTEUR, M.D., Missouri JOHN H. VASSALL II, M.D., Washington JOHN J. WHYTE, M.D., Washington, D.C. ROWEN K. ZETTERMAN, M.D., Nebraska

Technical Consultant:

GILMAN D. GRAVE, M.D.