Today, at the Alabama Academy of Family Physicians, we'll be discussing:

• Mammograms
• Contraception
• Hormone Replacement
• Ovarian Cancer

The handout can be found here: https://files.me.com/jbwaits/7nvw8f

Please check back and I'll load links to some of the key articles and websites discussed.

Patients are asking about Coenzyme Q10

... from the Cleve Clin J Med. 2010 Jul;77(7):435-42.

Coenzyme Q10: A therapy for hypertension and statin-induced myalgia?

"In some clinical trials, coenzyme Q10 supplements significantly lowered diastolic and systolic blood pressure.

"Statins may lower coenzyme Q10 serum levels, and some investigators have evaluated the relationship between coenzyme Q10 deficiency and statin-related myalgia, but more evidence is needed to support the use of coenzyme Q10 supplements to prevent or treat myalgia.

"Coenzyme Q10 supplementation appears to be relatively safe. Most clinical trials have not reported significant side effects that necessitated stopping therapy. Gastrointestinal effects include abdominal discomfort, nausea, vomiting, diarrhea, and anorexia. Allergic rash and headache have also been reported.

"A typical daily dose of coenzyme Q10 for treating hypertension is 120 to 200 mg, usually given orally in two divided doses.

"For statin-induced myopathy, 100 to 200 mg orally daily has been used.
Coenzyme Q10 is given in divided doses to enhance its absorption and to minimize gastrointestinal effects. Taking it with a fatty meal may also increase its absorption."

(Journal Club follow-up from 4/26/2011)

Regarding the follow-up of patients treated with Amiodarone (Cordarone)... from AFP 2003

• Baseline CXR and PFT w/DLCO... then as symptoms present (CXR and PFTs)
• Baseline LFTs and TSH... then q6 months
• Baseline Digoxin and INR if appropriate... then as symptoms present

Blue Cross Blue Shield of Alabama - ALL Kids Update, February 2011

ALL Kids benefits now include coverage for four annual office visits for patients with an obesity diagnosis, International Classification of Diseases – Ninth Revision (ICD-9) diagnosis code V85.54. This is for pediatric patients with a body mass index greater than or equal to weight at the 95th percentile for their age.

In addition, patients with this diagnosis are allowed two annual nutritional counseling visits (Physicians’“Common Procedure Terminology” codes 97802 and 97803) with an eligible provider. These counseling visits are defined as 15-minute face-to-face assessments with the patient for medical nutritional therapy.

Fidaxomicin (also known as OPT-80 and PAR-101) is the first in a new class of narrow spectrum macrocyclic antibiotic drugs. The NEJM is reporting that:

"The rates of clinical cure after treatment with fidaxomicin were noninferior to those after treatment with vancomycin. Fidaxomicin was associated with a significantly lower rate of recurrence of C. difficile infection associated with non-North American Pulsed Field type 1 strains." Louie TJ, et al. Fidaxomicin versus Vancomycin for Clostridium difficile Infection. N Engl J Med. 2011 Feb 2. [Epub ahead of print]

References as promised after last week's Board Review Series... sorry for the delay... so, check out the recent consensus statement and the supporting articles, whose titles say it all... let's all stop using SSI alone... jbwMD

AACE/ADA Consensus Statement: American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control

"the persistent overuse of what has been branded as sliding scale insulin (SSI) for management of hyperglycemia. The term "correction insulin," which refers to the use of additional short- or rapid-acting insulin in conjunction with scheduled insulin doses to treat blood glucose levels above desired targets, is preferred. Prolonged therapy with SSI as the sole regimen is ineffective in the majority of patients (and potentially dangerous in those with type I diabetes)."

Glycemic control and sliding scale insulin use in medical inpatients with diabetes mellitus. Queale WS, Seidler AJ, Brancati FL. Arch Intern Med. 1997 Mar 10;157(5):545-52.

"Suboptimal glycemic control is common in medical inpatients with diabetes mellitus. The risk of suboptimal control is associated with selected demographic and clinical characteristics, which can be ascertained at hospital admission. Although sliding scale insulin regimens are prescribed for the majority of inpatients with diabetes, they appear to provide no benefit; in fact, when used without a standing dose of intermediate-acting insulin, they are associated with an increased rate of hyperglycemic episodes."

The rationale and management of hyperglycemia for in-patients with cardiovascular disease: time for change. Trence DL, Kelly JL, Hirsch IB. J Clin Endocrinol Metab. 2003 Jun;88(6):2430-7.

... contains nice examples of order sets for Insulin Infusions and Basal Bolus Insulin Orders.

Eliminating inpatient sliding-scale insulin: a reeducation project with medical house staff. Baldwin D, Villanueva G, McNutt R, Bhatnagar S. Diabetes Care. 2005 May;28(5):1008-11.

"Medical history, blood glucose, and HbA1c testing can effectively identify patients with inpatient hyperglycemia. Using direct ward-based teaching and a widely disseminated pocket set of guidelines, house officers can be taught to effectively and safely manage inpatient hyperglycemia without the use of SSI."

Sliding scale insulin use: myth or insanity? Umpierrez GE, Palacio A, Smiley D. Am J Med. 2007 Jul;120(7):563-7.

"Inpatient hyperglycemia in people with or without diabetes is associated with an increased risk of complications and mortality, a longer hospital stay, a higher admission rate to the intensive care unit, and higher hospitalization costs. Despite increasing evidence that supports intensive glycemic control in hospitalized patients, blood glucose control continues to be challenging, and sliding scale insulin coverage, a practice associated with limited therapeutic success, continues to be the most frequent insulin regimen in hospitalized patients. Sliding scale insulin has been in use for more than 80 years without much evidence to support its use as the standard of care. Several studies have revealed evidence of poor glycemic control and deleterious effects in sliding scale insulin use. To understand its wide use and acceptance, we reviewed the origin, advantages, and disadvantages of sliding scale insulin in the inpatient setting.

Sliding scale insulin--time to stop sliding. Hirsch IB. JAMA. 2009 Jan 14;301(2):213-4.

"In most teaching hospitals in the United States, primary care first-year residents and medical students learn about sliding scale insulin (SSI), usually from a senior resident. The more experienced resident explains how to prescribe regular insulin every 4 to 6 hours without any scheduled basal or mealtime (prandial) insulin. For the typical patient who is too sick to eat, this results in a roller coaster effect on blood glucose variability due to poor matching of insulin with individual blood glucose patterns. Unfortunately, for the patient who is able to eat, insulin scheduled to be administered based on a bedside capillary glucose measurement is actually administered long after the meal is consumed. Although there are often challenges with hospital logistics in terms of timing of insulin administration in relation to actual food intake, the SSI orders typically do not mention the relationship of the insulin injection as it pertains to a meal, even though at one time, the resident was taught that regular insulin is mealtime insulin. Even worse, SSI, as used here, does not account for the basic principles of insulin therapy.

"Medical professionals do not use sliding scale penicillin for fever or sliding scale oxygen for pulmonary edema. It is time to discontinue amusement park diabetes therapy so that decades from now clinicians are still not trying to abolish an illogical treatment. Perhaps next July or the following summer, when the senior resident is explaining to the intern hyperglycemia management for a newly admitted patient with pneumonia, the discussion will revolve around basal insulin, prandial insulin, and correction-dose insulin based on a protocol that all hyperglycemic patients receive throughout the entire health care system."

Fascinating article, illustrating the dilemma facing primary care physicians attempting to provide true preventive care to our patients... jbwMD

Comparison Between US Preventive Services Task Force Recommendations and Medicare Coverage

Lenard I. Lesser, MD1, Alex H. Krist, MD, MPH2, Douglas B. Kamerow, MD, MPH3 and Andrew W. Bazemore, MD, MPH4

http://www.annfammed.org/cgi/content/full/9/1/44

The study was setup like this...

"We undertook an analysis to assess a healthy senior American’s access to USPSTF-recommended preventive services if he or she were solely insured through Medicare, before the implementation of the new health insurance law."

The Results were as follows...

• The USPSTF recommended 15 preventive interventions for adults aged 65 years and older. Medicare reimbursed fully for the preventive coordination and the preventive service for 1 (7%) preventive service (screening for abdominal aortic aneurysm).
• The preventive coordination and associated screening need to be performed only once and is covered in conjunction with the WMV.
• For most preventive services (60%), Medicare reimbursed fully for the service or test, but only partially for the coordination of obtaining that service.
• For 4 services (27%) Medicare reimbursed clinicians partially for both the preventive coordination and the actual service. Finally, for 1 service (7%), breast cancer genetic testing,
• Medicare reimbursed fully for the coordination and assessment (as part of risk assessment in the WMV), but not for the test or service itself (intensive counseling by a trained genetic counselor).
• Most coverage for preventive coordination was included as part of the WMV. Although preventive tests were often covered beyond this visit, the risk assessment, coordination, and motivation of the patient were not.
• The USPSTF recommends against 16 preventive services that would apply to Medicare beneficiaries (excluding sexually transmitted infections and immunizations against hepatitis B and C). Medicare reimbursed clinicians for 7 (44%) of these services.
• USPSTF recommendations differed based on age and frequently included ages to stop screening. Medicare, by comparison, covered services for prevention for all beneficiaries regardless of age (eg, colon, cervical, and prostate cancer screening).
• The USPSTF and Medicare both recommend and covered, respectively, preventive services only for certain at-risk populations, yet there are several examples for which the 2 organizations define the at-risk population differently.

A portion of the discussion went like this...

"Our analysis shows that Medicare covered many USPSTF recommended preventive services. A substantial disconnect was evident, however, especially in 2 areas: coordination of care, and coverage of nonrecommended services.

"Congress first tried to increase coverage of preventive coordination in 2005, when it authorized the WMV, or Initial Preventive Physical Examination, which is the first time Medicare could specifically pay clinicians to coordinate prevention. In 2008, Congress tried to fix one of the problems with the WMV—that seniors could get a WMV only during the first 6 months of enrolling—by expanding the window to 1 year.

"Despite its intent, 3 realities undermined the WMV’s contributions to optimal preventive care: (1) only 6% of persons get their WMV6; (2) all USPSTF-recommended services applicable to adults for the rest of their lives cannot reasonably be covered in a single visit at the age of 65 years17; and (3), to be effective, many preventive services require periodic repetition beyond a single visit. The reasons for the low uptake of the WMV are unclear, but possible reasons are logistical issues and patients not being aware of the benefit.

"Although the new health care reform law provides new initiatives to improve the delivery of preventive services, it is now up to Medicare to align itself with the USPSTF recommendations and usher in an era of improved quality of care through effective prevention. Congress should simultaneously increase support for research on the delivery and effectiveness of preventive services."