E FFECTIVE P HYSICIAN : N EW A STHMA G UIDELINES

,

PAGE

19

VO L . 4 0 , N O. 2 3

Internal Medicine News
www.eclinicalpsychia tr ynews.com www.inter nalmedicinenews.com T he Leading Inde p endent Ne wspaper for the Inter nist—Since 1968

DECEMBER 1, 2007

INSIDE

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

Fenofibrate Curbed Retinopathy in Diabetic Patients
Need for laser therapy was cut by 37%.
BY MITCHEL L. ZOLER

Early Signs of Parkinson’s
Preclinical brain changes can be seen on SPECT images.
PAGE 13

Philadelphia Bureau

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

Family History

Medical Home Set To Move Forward
BY KERRI WACHTER

Genetics column looks at new applications for family health history.
PAGE 28

Senior Writer

W A S H I N G T O N — Medical home advocates hope a new set of metrics will help primary care physicians move closer to implementing 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 importantly, 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 Academy 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 practices 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 Academy of Pediatrics. Not everyone is clear on what exactly a medical home is, noted Dr. James King, president of the American Academy of Family Physicians. “A lot of people [are] starting to use the phrase See Medical Home page 5

O R L A N D O — Treatment with fenofibrate led to a substantial drop in the need for laser treatments for retinopathy in a controlled trial of nearly 10,000 patients with type 2 diabetes. Physicians should “consider using fenofibrate on all patients with diabetes, even patients already on a statin and at their target lipid levels, to further reduce their risk and microvascular complications,” Dr. Anthony C. Keech said at an industry-sponsored press briefing during the annual scientific sessions of the American 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 significant effect on retinopathy. Patients treated with fenofibrate also had less progression of albuminuria, and fewer amputations, Dr. Keech and his associates reported. “The results were very clearcut. It’s very hard to make a coherent argument not to use fenofibrate” in patients with diabetes, said Dr. Keech, professor of See Fenofibrate page 20

Toe Tips
Clinical pearls for the diagnosis and treatment of onychomycosis.
PAGE 26

Oral Purgatives Linked With Acute Kidney Injury
BY ROBERT FINN

San Francisco Bureau

VITAL SIGNS
Average Workweeks in Selected Primary Care Specialties Were Similar in 2006
Internal medicine: pediatric (n = 76) Internal medicine: general (n = 3,368) Pediatric: hospitalist (n = 62) Family practice (without OB) (n = 4,634) Pediatric: general (n = 2,390) Pediatric: infectious disease (n = 14) 38.7 hours 37.0 hours 36.6 hours
E LSEVIER G LOBAL M EDICAL N EWS

S A N F R A N C I S C O — Acute kidney injury may not be as rare a consequence of oral sodium phosphate bowel purgatives as previously thought, researchers said at the annual meeting of the American Society of Nephrology. In a retrospective study of nearly 10,000 patients, those given oral sodium phosphate purgatives prior to colonoscopy had 2.35 times the chance of developing 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 colleagues at the Walter Reed Army Medical Center, Washington. The study involved 6,432 patients who received oral sodium phosphate and 3,367 who received polyethylene glycol as outpatients 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

36.6 hours 35.7 hours 33.1 hours

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

6

News

INTERNAL MEDICINE NEWS • December 1, 2007

Nephropathy Risk Quantified
Purgatives from page 1

date. The investigators noted in their poster presentation that they excluded patients 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 sodium 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 multivariate analysis as being independently associated 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 accompanied by a greater risk of acute kidney injury than were these other risk factors. Patients who developed acute kidney injury typically did not return to baseline levels of renal function. Their mean preprocedure 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, described his earlier study of acute phosphate

, Im getting

aggressive
with prehypertension, naturally .

nephropathy. The pathophysiology appears to involve obstructive calcium phosphate crystalluria and intratubular nephrocalcinosis. 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 creatinine to a mean of 2.4 mg/dL, and 4 of the 17 reached 2.0 mg/dL, but none returned 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 individuals at increased risk include those with advanced age and decreased intravascular volume, and people taking certain medications including ACE inhibitors, angiotensin II receptor blockers, and possibly NSAIDs. Dr. Markowitz said that other probable risk factors are inadequate hydration, excess phosphate dosing, a short interval between oral sodium phosphate doses, and fasting prior to the procedure to decrease the risk of aspiration during sedation. Other possible risk factors are female gender and small body habitus. Several professional societies—including the American Society of Colon and Rectal Surgeons—have added such warnings to their consensus documents on bowel preparation. This increased awareness will likely lead to a decline in acute phosphate nephropathy, 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, clinicians are increasingly recommending better hydration, to provide at least 72 ounces before, during, and after the use of oral sodium phosphate purgatives. ■

EDITORIAL A DV I S O RY B OA R D
Introducing ameal bp™ – the new dietary supplement containing the naturally derived active ingredient AmealPeptide®, clinically shown to maintain healthier blood pressure in prehypertensive patients.* AmealPeptide® is a naturally occurring ACE inhibitor derived from enzymatically hydrolized casein (milk proteins). Fourteen double-blind, placebo-controlled studies have shown a clinically significant lowering of both systolic and diastolic blood pressure Stratified analysis of 8 clinical studies by start value of blood pressure (Post-hoc analysis, 606 subjects from 8 studies) with AmealPeptide®. It has also been shown to be safe and well-tolerated.
Systolic blood pressure (mmHg)
10 0 -10 *** -20 *** -30 *** *** ** ** ~160 159~150 149~140 139~130

Diastolic blood pressure (mmHg)
~100 99~95 94~90 89~85

ameal bp™ is available online or at major drugstores in easy-to-swallow capsules and chewable tablets. Start prehypertensive patients on ameal bpTM when you start them on a diet and exercise program. Visit www.amealbp.com for more information.

**

AmealPeptide Placebo

®

Significant difference from placebo (t-test): **P<0.01, ***P<0.001.

Reference: 1. Data on file. Post-hoc analysis adapted from AmealPeptide® clinical studies.

*This statement has not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.
ameal bp™ and AmealPeptide® are trademarks of Calpis Co., Ltd. ©2007 Calpis Co., Ltd. A02

Helps maintain healthy blood pressure*

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. MICHAEL MELEWICZ, 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.