LETTERS
Annals of Internal Medicine COMMENTS AND RESPONSES
Jonathan P. Wanderer, MD, MPhil Jesse M. Ehrenfeld, MD, MPH Vanderbilt University Nashville, Tennessee
Long-Term Opioid Therapy for Chronic Pain
Disclosures: Authors have disclosed no conflicts of interest. Forms
TO THE EDITOR: Opioid prescribing has undoubtedly in-
can be viewed at www.acponline.org/authors/icmje/ConflictOf InterestForms.do?msNum=L15-0196.
creased over the past several decades. As Chou and colleagues' review (1) details, improving risk mitigation strategies for negative outcomes from long-term opioid use is likely warranted. The authors highlight an absence of adequate scientific evidence on long-term opioid therapy and note that this paucity of data is in “striking contrast” to the widespread use of opioids. Although Chou and colleagues describe the consequences of current opioid prescribing patterns, they do not address what is driving this practice. In the late 1990s, the Joint Commission made wellintended recommendations that pain be better recognized (2). The American Pain Society subsequently developed a Pain Care Bill of Rights and promoted pain as a “fifth vital sign.” Other organizations followed suit, including the U.S. Department of Veterans Affairs, which published the Pain as the 5th Vital Sign Toolkit in 2000, further justifying the use of opioids for pain not related to cancer. The opioid boom began. With this modern culture of opioid prescribing, we have seen an incongruity between physician treatment goals and the patient perceptions of pain management (3). These situations inevitably result in patient–provider conflict. Face-to-face requests for opioids by patients often contradict many practice guidelines suggesting nonpharmacologic or nonopioid alternatives for pain. Most patients do not have formal medical training and are largely unaware of what constitutes “quality” medical care or of adverse medication effects. In the world of pain management, patient satisfaction surveys may lead to unintended consequences. Government programs now look to patient satisfaction as a surrogate for health care quality. For example, Medicare reimbursements partially rely on this metric as part of the Centers for Medicare & Medicaid Services Hospital Inpatient Value-Based Purchasing program (4). Not only are physician salaries subject to adjustment based on these data, but promotions may be delayed or jobs terminated as a result. Overworked physicians with very little time are therefore heavily incentivized to meet their patients' expectations by prescribing opioids (5). Pain is a vital sign, after all. Although Chou and colleagues make many salient suggestions for reducing harms of long-term opioid therapy, we may never be fully successful in curbing these risks without addressing the causes of opioid prescribing. Concerns about patient demand, patient satisfaction, and quality measures serve to further complicate this subject and deserve attention as our government moves to alter reimbursement without considering clinical reality. Michael Lubrano, MD, MPH New York University School of Medicine New York, New York
References 1. Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015;162:276-86. [PMID: 25581257] doi:10.7326/M14 -2559 2. The Joint Commission. Pain Assessment and Management: An Organizational Approach. Oakbrook Terrace, IL: The Joint Commission; 2000. 3. Frantsve LM, Kerns RD. Patient-provider interactions in the management of chronic pain: current findings within the context of shared medical decision making. Pain Med. 2007;8:25-35. [PMID: 17244101] 4. Centers for Medicare & Medicaid Services (CMS), HHS. Medicare program; Hospital Inpatient Value-Based Purchasing program. Final rule. Fed Regist. 2011;76:26490-547. [PMID: 21548401] 5. Zgierska A, Miller M, Rabago D. Patient satisfaction, prescription drug abuse, and potential unintended consequences. JAMA. 2012;307:1377-8. [PMID: 22474199] doi:10.1001/jama.2012.419
TO THE EDITOR: I read Chou and colleagues' review (1) with interest. Prescriptions of narcotic medications for chronic pain have increased dramatically over the past 3 decades. This trend has been accompanied by greatly increased levels of prescription narcotic overdose, abuse, addiction, and diversion. It is commonly blamed on irresponsible prescribing. An unintended consequence of this blame is that many younger physicians refuse to prescribe narcotics for persons with chronic pain. Not for anyone, not for any pain. The result is that pain is the only treatable condition that I can think of that many physicians deliberately do not treat. Chou and colleagues' review perpetuates the negative image of narcotic prescriptions for chronic pain. The authors reviewed 4209 English-language articles and found no study of the long-term outcomes related to pain, function, or quality of life. Not one. Their review is then given over entirely to a discussion of risks. However, risk alone is never the basis for the decision of a physician or patient—that basis is always the balance of risk versus benefit. Omitting discussion of benefit from a review on the effectiveness and risks of therapy is, at a minimum, curious. This review has other curious problems. It speaks of overdose deaths as if all deaths were the same. Some arguably happen from miscalculation in pursuit of a better high, some during pursuit of better pain control. It does not mention the tragic deaths of children who sample parents' medicines with lethal results. It does not recognize that some overdose deaths are suicides. Chronic pain can cause patients to lose jobs, self-sufficiency, family, all of their belongings, and hope. Suicide in patients with chronic pain is not surprising. Chou and colleagues do not discuss diverted narcotics, originally prescribed for pain, becoming gateway drugs for heroin. This review states that increased use of erectile dysfunction drugs in narcotic-treated patients may indicate opioidinduced sexual dysfunction. Another hypothesis is that pain © 2015 American College of Physicians 147
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LETTERS impairs sexual appetite. Treatment of that pain can allow sexual activity to rebound, uncovering the problem of erectile dysfunction. The authors also discuss the increased risk for myocardial infarction in narcotic-treated persons. Is the narcotic the cause? Or do the changes in activity and diet, forced by pain, increase this risk? And so on. This review might have closed by pointing out the similarities between narcotics and alcohol. Most persons who use alcohol, and most persons who are prescribed narcotics, use them responsibly. A few do not. Those few attract all of the attention. Many older physicians, myself included, still prescribe narcotics for our patients who have substantial chronic pain. Benefits do outweigh acknowledged risks. We believe that it is the right thing to do.
long-term therapy with opioids— drugs prescribed for medical purposes. While downplaying the harms of opioids, Dr. Retan at the same time curiously notes additional harms related to diversion and sampling of opioids by family members and friends and critiques our review for not addressing them. To clarify, as we have explained previously, our review focused on benefits and harms in persons prescribed opioids. However, we are unaware of any study that has attempted to estimate the harms related to diversion and sampling of opioids from persons prescribed these agents versus those not prescribed them or evaluated dose-dependent effects on such outcomes.
J. Walden Retan, MD The Pain Clinic, Cooper Green/Mercy Health Services Birmingham, Alabama
Disclosures: Disclosures can be viewed at www.acponline.org /authors/icmje/ConflictOfInterestForms.do?msNum=M14-2559.
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOf InterestForms.do?msNum=L15-0197. Reference 1. Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015;162:276-86. [PMID: 25581257] doi:10.7326/M142559
IN RESPONSE: We agree with Dr. Lubrano and colleagues that effectively managing the risks of prescribing long-term opioid therapy will not be based just on evidence about benefits and harms (the subject of our review) but will also require that clinicians and policymakers understand and address policy and factors related to the physician–patient interaction that may drive less appropriate prescribing practices (1). As Dr. Retan notes, we identified no studies meeting predefined inclusion criteria on the effectiveness of long-term opioid therapy for chronic pain. He does not describe any studies that we overlooked. Therefore, it is unclear what evidence he believes we should have included to discuss longterm benefits. For mortality and overdose-related events, studies generally could not exclude cases due to intentional suicide attempts; however, the authors controlled for psychological diagnoses and psychiatric medication use (2, 3). For these and other harms, we described limitations of the evidence, including the inability to completely address potential confounders and (in the case of endocrine-related adverse events) the reliance on a surrogate outcome (use of medications for erectile dysfunction and testosterone replacement) (4). We described the associations as reported in the studies and did not speculate on the underlying causes of myocardial infarction or other harms. High levels of scrutiny for opioid prescribing are warranted on the basis of the substantial increases in opioidrelated deaths and prescription opioid abuse (5). We disagree with Dr. Retan that it is appropriate to equate consumption of alcohol—a substance used recreationally—with 148 Annals of Internal Medicine • Vol. 163 No. 2 • 21 July 2015
Roger Chou, MD Oregon Health & Science University Portland, Oregon
References 1. Reuben DB, Alvanzo AA, Ashikaga T, Bogat GA, Callahan CM, Ruffing V, et al. National Institutes of Health Pathways to Prevention Workshop: the role of opioids in the treatment of chronic pain. Ann Intern Med. 2015;162:295300. [PMID: 25581341] doi:10.7326/M14-2775 2. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152:85-92. [PMID: 20083827] doi:10.7326/0003-4819 -152-2-201001190-00006 3. Gomes T, Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011;171:686-91. [PMID: 21482846] doi:10.1001/archinternmed.2011 .117 4. Deyo RA, Smith DH, Johnson ES, Tillotson CJ, Donovan M, Yang X, et al. Prescription opioids for back pain and use of medications for erectile dysfunction. Spine (Phila Pa 1976). 2013;38:909-15. [PMID: 23459134] doi:10.1097 /BRS.0b013e3182830482 5. Okie S. A flood of opioids, a rising tide of deaths. N Engl J Med. 2010;363: 1981-5. [PMID: 21083382] doi:10.1056/NEJMp1011512
Pressure Ulcer Prevention and Management TO THE EDITOR: Black (1) provides a useful perspective on the current state of scientific inquiry among nurses in the treatment and prevention of pressure ulcers. The field of wound care is stymied by a lack of research funding, making it difficult to move out of its “infancy,” and could benefit from additional investment in methodical research to support evidence-based practices. The National Institute of Nursing Research (NINR) is the primary institute of the National Institutes of Health to fund research related to pressure ulcer prevention given that it is a nursing issue. The NINR Strategic Plan, last updated in 2011, prioritizes research on the use of “technology for better wound care” (2). Qaseem and colleagues' guideline recommends the use of new bed technologies in wound care but also notes the importance of risk stratification with a predictively valid instrument, such as the Braden scale, despite “weak” evidence (3). The NINR should update its strategic plan to emphasize the importance of synergizing these instruments with new technologies and improving validity. www.annals.org
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LETTERS Funding to support research in wound care is scarce. The NINR has the smallest annual budget of all the National Institutes of Health at $136 million (4). Commercial industry could do more to supplement wound care research. Of the 10 leading manufacturers of products for evidence-based practices (for example, underpads, dressings, beds, and creams), only 3 are affiliated with foundations to support wound care research (5). In contrast, the pharmaceutical industry seems more involved, considering that 11 of the 12 leading pharmaceutical manufacturers according to the Fortune 500 belong to the Pharmaceutical Research and Manufacturers of America Foundation. Ultimately, the field of wound care has an opportunity to move quickly beyond reliance on costly clinical trials and time-consuming descriptive studies with the evolution of electronic health records. These tools provide accessibility to data that can be used to develop population-specific, predictive algorithms of patient risk and strategically implement evidence-based practices in the hospital or home health setting. William V. Padula, PhD, MS University of Chicago Chicago, Illinois Heidi M. Wald, MD, MSPH University of Colorado Aurora, Colorado David O. Meltzer, MD, PhD University of Chicago Chicago, Illinois Disclosures: Disclosures can be viewed at www.acponline.org /authors/icmje/ConflictOfInterestForms.do?msNum=L15-0232.
References 1. Black J. Pressure ulcer prevention and management: a dire need for good science [Editorial]. Ann Intern Med. 2015;162:387-8. [PMID: 25732284] doi:10 .7326/M15-0190 2. The National Institute of Nursing Research. NINR Strategic Plan. 2011. Accessed at www.ninr.nih.gov/sites/www.ninr.nih.gov/files/ninr-strategic-plan -2011.pdf on 18 March 2015. 3. Qaseem A, Mir TP, Starkey M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015;162:359-69. [PMID: 25732278] doi:10.7326 /M14-1567 4. National Institutes of Health. Office of Budget. 2015. Accessed at http: //officeofbudget.od.nih.gov on 18 March 2015. 5. PR Newswire. The top 20 companies in the advanced wound care market 2013-2023. 30 September 2013. Accessed at www.prnewswire.com/news -releases/the-top-20-companies-in-the-advanced-wound-care-market-2013-2023 -225784351.html on 18 March 2015.
IN RESPONSE: The annual number of cases of pressure ulcers
in the United States is difficult to discern because reporting varies. The National Pressure Ulcer Advisory Panel estimates that 4% to 7% of hospitalized patients develop these ulcers. The estimated incidence is higher in long-term care and recently increased to 14% in this setting (1). These numbers www.annals.org
likely constitute more than 400 000 cases yearly. Although this large number emphasizes the importance of pressure ulcers, it also nearly equals the total number of new cases of breast cancer (232 000) and lung cancer (221 000) combined (2). Given the growing number of elderly persons, the shortage of nurses, and increasingly fragmented care, these numbers will not likely decrease. Yet, as Dr. Padula and colleagues point out, the research money to study pressure ulcers is sorely lacking and there are no national foundations dedicated to this issue or public efforts to raise funds for it as there are for cancer. Sadly, public awareness of pressure ulcers often occurs at the bedside and in courtrooms, where they are labeled as medical errors or never-events. Now that the Centers for Medicare & Medicaid Services has made hospital-acquired pressure ulcers a quality measure, more hospitals are tracking these wounds. However, that work only occurs within a facility, with little to no externalization or published research. Tracking pressure ulcers through the Centers for Disease Control and Prevention would aid in the appreciation of the magnitude of the problem and drive money into the adequately powered studies of how to reduce the risk for these wounds, prevent them, quickly heal them, and maintain these efforts over time (3). Joyce Black, PhD, RN, CWCN University of Nebraska Medical Center Omaha, Nebraska Disclosures: Disclosures can be viewed at www.acponline.org /authors/icmje/ConflictOfInterestForms.do?msNum=M15-0190. References 1. Pieper B, ed. Pressure Ulcers: Prevalence, Incidence and Implications for the Future. Washington, DC: National Pressure Ulcer Advisory Panel; 2012. 2. American Cancer Society. Cancer Facts & Figure 2015. 2015. Accessed at www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures2015 on 11 June 2015. 3. Padula WV, Mishra MK, Makic MB, Sullivan PW. Improving the quality of pressure ulcer care with prevention: a cost-effectiveness analysis. Med Care. 2011;49:385-92. [PMID: 21368685] doi:10.1097/MLR.0b013e31820292b3
Tuberculosis Incidence in Immigrants and Refugees TO THE EDITOR: Liu and colleagues (1) attribute the recent
decline in tuberculosis (TB) cases among newly arrived, foreign-born persons in the United States to the increase in smear-negative/culture-positive cases diagnosed overseas among immigrants and refugees, as a result of the Centers for Disease Control and Prevention's implementation of the culture-based algorithm. This observation seems plausible until one considers that many foreign-born persons, including visitors, students, temporary workers, and unauthorized aliens, are not screened before admittance to the United States (2). In fact, immigrants and refugees constitute only approximately one third of the estimated 1.3 million foreignborn persons who enter the United States yearly for a longterm stay (3). The authors did not provide specific data about the number of reported TB cases in immigrants and refugees Annals of Internal Medicine • Vol. 163 No. 2 • 21 July 2015 149
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LETTERS and therefore cannot exclude with certainty the possibility that changes unrelated to overseas screening may have caused the observed decrease in the incidence of TB in newly arrived, foreign-born persons between 2007 and 2012. In recent years, TB control in foreign-born persons in the United States has garnered increased attention. For example, unlike earlier versions, the 2005 guideline for TB control designated foreign-born persons who have resided in the United States for fewer than 5 years as a particularly high-risk group (4). As a consequence, several notable efforts at targeted screening and treatment of latent infection in foreign-born persons are under way (5). Perhaps as a result of this enhanced focus, more newly arrived, foreign-born persons may have received treatment for latent infection between 2007 and 2012 than between 2002 and 2006. Furthermore, between 2007 and 2012, the authors found that 4032 cases of TB were diagnosed overseas by the culture-based algorithm, of which 2195 were smear-negative/ culture-positive and 480 were diagnosed clinically (1). However, the authors do not provide similar data for the old smear-based algorithm, preventing the panel physicians overseas from evaluating the effect of the new algorithm on the number of clinically diagnosed cases of TB. Thus, it is possible that, before the culture-based screeing, there were more clinically diagnosed TB cases than the 480 reported for the period 2007–2012. If so, this study would have overestimated the actual effect of culture-based screening in identifying cases of TB overseas. In summary, the absence of data distinguishing new TB cases among immigrants and refugees from those found in other foreign-born persons and lack of details on the old smear-based algorithm make interpretation of the results less straightforward. These factors thus dampen the authors' optimistic claims about the effect of the new culture-based screening on the incidence of TB among foreign-born persons in the United States. Azariyas A. Challa, MD, PhD University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOf InterestForms.do?msNum=L15-0263.
References 1. Liu Y, Posey DL, Cetron MS, Painter JA. Effect of a culture-based screening algorithm on tuberculosis incidence in immigrants and refugees bound for the United States: a population-based cross-sectional study. Ann Intern Med. 2015;162:420-8. [PMID: 25775314] doi:10.7326/M14-2082 2. Cain KP, Haley CA, Armstrong LR, Garman KN, Wells CD, Iademarco MF, et al. Tuberculosis among foreign-born persons in the United States: achieving tuberculosis elimination. Am J Respir Crit Care Med. 2007;175:75-9. [PMID: 17038659] 3. Grieco EM, Acosta YD, de la Cruz GP, Gambino C, Gryn T, Larsen LJ, et al. The Foreign-Born Population in the United States: 2010. American Community Survey Reports ACS-19. Washington, DC: U.S. Census Bureau; 2012. 4. Taylor Z, Nolan CM, Blumberg HM; American Thoracic Society. Controlling tuberculosis in the United States. Recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America. MMWR Recomm Rep. 2005;54:1-81. [PMID: 16267499] 150 Annals of Internal Medicine • Vol. 163 No. 2 • 21 July 2015
5. Cain KP, Garman KN, Laserson KF, Ferrousier-Davis OP, Miranda AG, Wells CD, et al. Moving toward tuberculosis elimination: implementation of statewide targeted tuberculin testing in Tennessee. Am J Respir Crit Care Med. 2012;186:273-9. [PMID: 22561962] doi:10.1164/rccm.201111-2076OC
IN RESPONSE: Dr. Challa suggests several limitations of the data in our analysis, raising doubts about the effect of a newly implemented, overseas, culture-based TB screening algorithm on reducing the importation of this condition to the United States. We discussed some of these limitations in our article but have reached a different conclusion. Newly arrived nonimmigrant visitors contribute to the TB burden in the United States (1). The mean annual admission of nonimmigrant visitors between 2007 and 2012 decreased by 8.5% compared with that between 2002 and 2006. However, during the same period, the mean annual number of reported TB cases among foreign-born persons within 1 year of arrival decreased by 24.7%. This discrepancy indicates that the decrease in admissions of nonimmigrant visitors alone could not account for the overall decline of TB cases in the newly arrived, foreign-born population. Dr. Challa suggests that more foreign-born persons were likely to have received treatment for latent TB infection between 2007 and 2012, causing the decline of TB among newly arrived, foreign-born persons. This assumption is not consistent with the results of previous studies. For example, within 1 year of arrival in the United States, only 5.8% of TB cases were likely due to reactivation of latent infection (2). Therefore, identifying and treating latent TB infection is unlikely to explain much of the observed decline in TB cases among foreign-born persons within 1 year of arrival. Dr. Challa indicates that our analysis may not have adequately accounted for clinically diagnosed cases in the old algorithm and suggests that clinical assessment alone might have identified most smear-negative/culture-positive cases. We have found no studies to support this assumption and do not believe that panel physicians could diagnose such large numbers of applicants with smear-negative/culture-positive TB without Mycobacterium tuberculosis culture screening. During the follow-up evaluation after arrival, active TB was diagnosed in 1.8% of persons with class B1 TB identified by the culture-based algorithm but in 3.5% of persons with class B1 or B2 TB identified by the smear-based algorithm. These results were consistent with those of other studies (3, 4), suggesting that the culture-based algorithm is more effective. Despite limitations, we believe that our data indicate that implementation of the culture-based algorithm substantially prevents the importation of TB to the United States.
Yecai Liu, MS Drew L. Posey, MD, MPH Martin S. Cetron, MD John A. Painter, DVM, MS Centers for Disease Control and Prevention Atlanta, Georgia Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOf InterestForms.do?msNum=M14-2082. www.annals.org
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LETTERS References 1. Liu Y, Painter JA, Posey DL, Cain KP, Weinberg MS, Maloney SA, et al. Estimating the impact of newly arrived foreign-born persons on tuberculosis in
4. Hoffman JR, Igarashi E. Influence of electrocardiographic findings on admission decisions in patients with acute chest pain. Am J Med. 1985;79:699-707. [PMID: 4073107]
the United States. PLoS One. 2012;7:e32158. [PMID: 22384165] doi:10.1371 /journal.pone.0032158 2. Walter ND, Painter J, Parker M, Lowenthal P, Flood J, Fu Y, et al; Tuberculosis Epidemiologic Studies Consortium. Persistent latent tuberculosis reactivation risk in United States immigrants. Am J Respir Crit Care Med. 2014;189: 88-95. [PMID: 24308495] doi:10.1164/rccm.201308-1480OC 3. Lowenthal P, Westenhouse J, Moore M, Posey DL, Watt JP, Flood J. Reduced importation of tuberculosis after the implementation of an enhanced pre-immigration screening protocol. Int J Tuberc Lung Dis. 2011;15:761-6. [PMID: 21575295] doi:10.5588/ijtld.10.0370 4. Oeltmann JE, Varma JK, Ortega L, Liu Y, O’Rourke T, Cano M, et al. Multidrug-resistant tuberculosis outbreak among US-bound Hmong refugees, Thailand, 2005. Emerg Infect Dis. 2008;14:1715-21. [PMID: 18976554] doi:10 .3201/eid1411.071629
Cardiac Screening TO THE EDITOR: Chou's guideline (1) on cardiac screening recommends that asymptomatic adults not have resting electrocardiography (ECG). I find that this recommendation, in many instances, goes against the standard of care. Obtaining ECGs for screening is standard for athletes, who, by definition, are asymptomatic. The European Community (2) continues to find this intervention cost-effective. To argue against screening ECGs, Chou cites 2 articles showing their limited usefulness. Rubenstein and Greenfield (3) found that “the routine ECG has little value as a baseline.” However, they state that 5% of patients were grouped into a class in which ECGs could be useful. A total of 5% of patients seems pretty important to me. Hoffman and Igarashi (4) recommend against routinely ordering ECGs in patients with chest pain. This conclusion today is consistent with medical malpractice. I agree that stress testing is overused but believe that extending the argument to resting ECGs is an unwanted stretch.
Paul Zimmermann, MD South Carolina Heart Center Camden, South Carolina Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOf InterestForms.do?msNum=L15-0260.
References 1. Chou R; High Value Care Task Force of the American College of Physicians. Cardiac screening with electrocardiography, stress echocardiography, or myocardial perfusion imaging: advice for high-value care from the American College of Physicians. Ann Intern Med. 2015;162:438-47. [PMID: 25775317] doi: 10.7326/M14-1225 2. Myerburg RJ, Vetter VL. Electrocardiograms should be included in preparticipation screening of athletes. Circulation. 2007;116:2616-26. [PMID: 18040041] 3. Rubenstein LZ, Greenfield S. The baseline ECG in the evaluation of acute cardiac complaints. JAMA. 1980;244:2536-9. [PMID: 7431589] www.annals.org
IN RESPONSE: As we described in the Methods section, our guideline on cardiac screening explicitly excluded preparticipation evaluation of athletes. Thus, the articles on screening of athletes that Dr. Zimmermann cited are not relevant. To clarify, Rubenstein and Greenfield (1) found that, in patients with chest pain who present to the emergency department, 5% (11 of 236) might have avoided an admission if a baseline ECG had been available. However, this percentage is a maximal estimate, because 9 of the 11 patients did not have a baseline ECG. In addition, how many admissions would have actually been avoided is unknown. Further, the authors found no cases in which an inappropriate discharge was avoided because a baseline ECG was available. Hoffman and Igarashi (2) found that baseline ECGs were not helpful in admission decisions in any of 84 patients presenting to the emergency department with acute chest pain. Their findings on the usefulness of ECGs for evaluation of acute chest pain are not relevant to our guideline, which only addresses screening of asymptomatic persons. Nonetheless, suggesting that Hoffman and Igarashi's study recommends against appropriate use of ECGs in this setting is misleading. Rather, they state that ECGs may not be necessary in patients with chest pain that is unlikely to be due to cardiac ischemia based on history and examination (for example, chest pain that is obviously musculoskeletal or due to esophageal reflux disease or that with atypical features in a young adult).
Roger Chou, MD Oregon Health & Science University Portland, Oregon Disclosures: Disclosures can be viewed at www.acponline.org /authors/icmje/ConflictOfInterestForms.do?msNum=M14-1225. References 1. Rubenstein LZ, Greenfield S. The baseline ECG in the evaluation of acute cardiac complaints. JAMA. 1980;244:2536-9. [PMID: 7431589] 2. Hoffman JR, Igarashi E. Influence of electrocardiographic findings on admission decisions in patients with acute chest pain. Am J Med. 1985;79:699-707. [PMID: 4073107]
Acute Myocardial Infarction TO THE EDITOR: High-sensitivity troponin assays are proving to be a costly problem facing internists in hospital medicine practice and such payers as Medicare. High-sensitivity troponin assays, when used in proper clinical context, are useful and increase the accuracy of diagnosing myocardial infarction (MI). Shroff (1) correctly highlights the higher mortality associated with and lack of evidence-based treatment options for type 2 MI or elevated troponin levels without treatable intracoronary lesions or obstruction. There is no sound empirical evidence to support risk stratification based on troponin assays or their routine use to rule out or rule in MI when patients present to the emergency department with noncardiac sympAnnals of Internal Medicine • Vol. 163 No. 2 • 21 July 2015 151
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LETTERS toms. However, troponin assays are routinely ordered in the emergency department without proper clinical rationale for most abdominal, thoracic, and neurologic symptoms. The admitting internist, while treating an unrelated noncardiac condition, is left to deal with the aftermath of abnormal troponin levels. This circumstance starts an unnecessary cascade of cardiology consultation and further testing, prolongs hospitalization, and complicates management of the patient. This diagnostic quest to nowhere does not end with cardiology consultation alone. Most recently, the “third universal definition of MI” defined diagnosis of this condition by the presence of at least 1 troponin level greater than the 99th percentile and one of the following factors: symptoms of ischemia, ST-segment changes, a pathological Q wave, imaging evidence of loss of viable myocardium or a new regional wall motion abnormality, or identification of an intracoronary thrombus on angiography or autopsy (2). The cardiologist who is consulted to solve the problem faces a conundrum. Symptoms are unreliable to rule out or rule in MI (3), and normal or equivocal results on electrocardiography do not help to narrow the differential diagnosis, either. Notwithstanding the sound clinical judgment that determines that MI is unlikely in a specific clinical setting, a cardiologist is forced to order invasive or noninvasive work because most patients admitted to hospitals usually have some cardiovascular risk factors. The internal medicine, cardiovascular, and emergency medicine sections of hospitals should develop a collaborative protocol for judiciously ordering troponin assays. Unless acute MI is in the differential diagnosis, these assays should be ordered in consultation with a cardiologist. Since the advent of high-sensitivity assays, troponin has become the new D-dimer for the heart. Sukhchain Singh, MD Ingalls Memorial Hospital Harvey, Illinois Amandeep Singh, MD Sanford Medical Center Thief River Falls, Minnesota Sandeep Khosla, MD Mount Sinai Hospital Medical Center and Rosalind Franklin University of Medicine and Science Chicago, Illinois Disclosures: Disclosures can be viewed at www.acponline.org /authors/icmje/ConflictOfInterestForms.do?msNum=L15-0277.
2. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al; Joint ESC/ACCF/AHA/WHF Task Force for Universal Definition of Myocardial Infarction. Third universal definition of myocardial infarction. J Am Coll Cardiol. 2012;60:1581-98. [PMID: 22958960] doi:10.1016/j.jacc.2012.08.001 3. Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, Holmes DR Jr, et al; ACC/AHA Task Force Members. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:e344-426. [PMID: 25249585] doi:10.1161/CIR.0000000000000134
IN RESPONSE: Whereas my article explored the ramifications
of a unique diagnostic code for type 2 MI, Dr. Singh and colleagues focus on indiscriminate use of troponin assays for noncardiac symptoms. As they point out, an uncritical and unscrutinized pattern of troponin measurement can lead to an unintended cascade of downstream testing that can be medically unnecessary, expensive, time-consuming, and potentially anxiety-provoking for the patient and therefore should be discouraged and avoided. Most cardiologists would agree that the management of a patient with an elevated troponin level obtained out of the clinical context for which troponin measurement was fundamentally designed (that is, detection of acute MI) is exceedingly problematic clinically. It therefore bears emphasis that the experts who proposed the universal definition of MI recommend that the terminology “MI” be used only in a clinical setting consistent with myocardial ischemia (1). Therefore, by extrapolation, measuring troponin levels only in clinical settings where myocardial ischemia is suspected would be most appropriate. Cardiac troponin levels are undoubtedly valuable in determining long-term prognosis in several clinical scenarios, but, so far, the literature has not successfully defined how to inculcate information about long-term prognosis into the immediate management of patients. The onus is on clinicians to recognize the context in which requesting troponin measurement is appropriate; certainly, “protocol-driven” reflexive checks should be strongly discouraged. It behooves us as clinicians to ensure that indiscriminate use of troponin levels is discouraged in our respective settings and as educators to ensure that we edify our trainees well in this regard. Gautam R. Shroff, MB, BS Hennepin County Medical Center and University of Minnesota Minneapolis, Minnesota Disclosures: The author has disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOf InterestForms.do?msNum=M14-2259. Reference
References 1. Shroff GR. Acute myocardial infarction: what's in a name? Ann Intern Med. 2015;162:448-9. [PMID: 25775318] doi:10.7326/M14-2259
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1. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al; Joint ESC/ACCF/AHA/WHF Task Force for Universal Definition of Myocardial Infarction. Third universal definition of myocardial infarction. J Am Coll Cardiol. 2012;60:1581-98. [PMID: 22958960] doi:10.1016/j.jacc.2012.08.001
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Annals of Internal Medicine COMMENTS AND RESPONSES
Jonathan P. Wanderer, MD, MPhil Jesse M. Ehrenfeld, MD, MPH Vanderbilt University Nashville, Tennessee
Long-Term Opioid Therapy for Chronic Pain
Disclosures: Authors have disclosed no conflicts of interest. Forms
TO THE EDITOR: Opioid prescribing has undoubtedly in-
can be viewed at www.acponline.org/authors/icmje/ConflictOf InterestForms.do?msNum=L15-0196.
creased over the past several decades. As Chou and colleagues' review (1) details, improving risk mitigation strategies for negative outcomes from long-term opioid use is likely warranted. The authors highlight an absence of adequate scientific evidence on long-term opioid therapy and note that this paucity of data is in “striking contrast” to the widespread use of opioids. Although Chou and colleagues describe the consequences of current opioid prescribing patterns, they do not address what is driving this practice. In the late 1990s, the Joint Commission made wellintended recommendations that pain be better recognized (2). The American Pain Society subsequently developed a Pain Care Bill of Rights and promoted pain as a “fifth vital sign.” Other organizations followed suit, including the U.S. Department of Veterans Affairs, which published the Pain as the 5th Vital Sign Toolkit in 2000, further justifying the use of opioids for pain not related to cancer. The opioid boom began. With this modern culture of opioid prescribing, we have seen an incongruity between physician treatment goals and the patient perceptions of pain management (3). These situations inevitably result in patient–provider conflict. Face-to-face requests for opioids by patients often contradict many practice guidelines suggesting nonpharmacologic or nonopioid alternatives for pain. Most patients do not have formal medical training and are largely unaware of what constitutes “quality” medical care or of adverse medication effects. In the world of pain management, patient satisfaction surveys may lead to unintended consequences. Government programs now look to patient satisfaction as a surrogate for health care quality. For example, Medicare reimbursements partially rely on this metric as part of the Centers for Medicare & Medicaid Services Hospital Inpatient Value-Based Purchasing program (4). Not only are physician salaries subject to adjustment based on these data, but promotions may be delayed or jobs terminated as a result. Overworked physicians with very little time are therefore heavily incentivized to meet their patients' expectations by prescribing opioids (5). Pain is a vital sign, after all. Although Chou and colleagues make many salient suggestions for reducing harms of long-term opioid therapy, we may never be fully successful in curbing these risks without addressing the causes of opioid prescribing. Concerns about patient demand, patient satisfaction, and quality measures serve to further complicate this subject and deserve attention as our government moves to alter reimbursement without considering clinical reality. Michael Lubrano, MD, MPH New York University School of Medicine New York, New York
References 1. Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015;162:276-86. [PMID: 25581257] doi:10.7326/M14 -2559 2. The Joint Commission. Pain Assessment and Management: An Organizational Approach. Oakbrook Terrace, IL: The Joint Commission; 2000. 3. Frantsve LM, Kerns RD. Patient-provider interactions in the management of chronic pain: current findings within the context of shared medical decision making. Pain Med. 2007;8:25-35. [PMID: 17244101] 4. Centers for Medicare & Medicaid Services (CMS), HHS. Medicare program; Hospital Inpatient Value-Based Purchasing program. Final rule. Fed Regist. 2011;76:26490-547. [PMID: 21548401] 5. Zgierska A, Miller M, Rabago D. Patient satisfaction, prescription drug abuse, and potential unintended consequences. JAMA. 2012;307:1377-8. [PMID: 22474199] doi:10.1001/jama.2012.419
TO THE EDITOR: I read Chou and colleagues' review (1) with interest. Prescriptions of narcotic medications for chronic pain have increased dramatically over the past 3 decades. This trend has been accompanied by greatly increased levels of prescription narcotic overdose, abuse, addiction, and diversion. It is commonly blamed on irresponsible prescribing. An unintended consequence of this blame is that many younger physicians refuse to prescribe narcotics for persons with chronic pain. Not for anyone, not for any pain. The result is that pain is the only treatable condition that I can think of that many physicians deliberately do not treat. Chou and colleagues' review perpetuates the negative image of narcotic prescriptions for chronic pain. The authors reviewed 4209 English-language articles and found no study of the long-term outcomes related to pain, function, or quality of life. Not one. Their review is then given over entirely to a discussion of risks. However, risk alone is never the basis for the decision of a physician or patient—that basis is always the balance of risk versus benefit. Omitting discussion of benefit from a review on the effectiveness and risks of therapy is, at a minimum, curious. This review has other curious problems. It speaks of overdose deaths as if all deaths were the same. Some arguably happen from miscalculation in pursuit of a better high, some during pursuit of better pain control. It does not mention the tragic deaths of children who sample parents' medicines with lethal results. It does not recognize that some overdose deaths are suicides. Chronic pain can cause patients to lose jobs, self-sufficiency, family, all of their belongings, and hope. Suicide in patients with chronic pain is not surprising. Chou and colleagues do not discuss diverted narcotics, originally prescribed for pain, becoming gateway drugs for heroin. This review states that increased use of erectile dysfunction drugs in narcotic-treated patients may indicate opioidinduced sexual dysfunction. Another hypothesis is that pain © 2015 American College of Physicians 147
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LETTERS impairs sexual appetite. Treatment of that pain can allow sexual activity to rebound, uncovering the problem of erectile dysfunction. The authors also discuss the increased risk for myocardial infarction in narcotic-treated persons. Is the narcotic the cause? Or do the changes in activity and diet, forced by pain, increase this risk? And so on. This review might have closed by pointing out the similarities between narcotics and alcohol. Most persons who use alcohol, and most persons who are prescribed narcotics, use them responsibly. A few do not. Those few attract all of the attention. Many older physicians, myself included, still prescribe narcotics for our patients who have substantial chronic pain. Benefits do outweigh acknowledged risks. We believe that it is the right thing to do.
long-term therapy with opioids— drugs prescribed for medical purposes. While downplaying the harms of opioids, Dr. Retan at the same time curiously notes additional harms related to diversion and sampling of opioids by family members and friends and critiques our review for not addressing them. To clarify, as we have explained previously, our review focused on benefits and harms in persons prescribed opioids. However, we are unaware of any study that has attempted to estimate the harms related to diversion and sampling of opioids from persons prescribed these agents versus those not prescribed them or evaluated dose-dependent effects on such outcomes.
J. Walden Retan, MD The Pain Clinic, Cooper Green/Mercy Health Services Birmingham, Alabama
Disclosures: Disclosures can be viewed at www.acponline.org /authors/icmje/ConflictOfInterestForms.do?msNum=M14-2559.
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOf InterestForms.do?msNum=L15-0197. Reference 1. Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015;162:276-86. [PMID: 25581257] doi:10.7326/M142559
IN RESPONSE: We agree with Dr. Lubrano and colleagues that effectively managing the risks of prescribing long-term opioid therapy will not be based just on evidence about benefits and harms (the subject of our review) but will also require that clinicians and policymakers understand and address policy and factors related to the physician–patient interaction that may drive less appropriate prescribing practices (1). As Dr. Retan notes, we identified no studies meeting predefined inclusion criteria on the effectiveness of long-term opioid therapy for chronic pain. He does not describe any studies that we overlooked. Therefore, it is unclear what evidence he believes we should have included to discuss longterm benefits. For mortality and overdose-related events, studies generally could not exclude cases due to intentional suicide attempts; however, the authors controlled for psychological diagnoses and psychiatric medication use (2, 3). For these and other harms, we described limitations of the evidence, including the inability to completely address potential confounders and (in the case of endocrine-related adverse events) the reliance on a surrogate outcome (use of medications for erectile dysfunction and testosterone replacement) (4). We described the associations as reported in the studies and did not speculate on the underlying causes of myocardial infarction or other harms. High levels of scrutiny for opioid prescribing are warranted on the basis of the substantial increases in opioidrelated deaths and prescription opioid abuse (5). We disagree with Dr. Retan that it is appropriate to equate consumption of alcohol—a substance used recreationally—with 148 Annals of Internal Medicine • Vol. 163 No. 2 • 21 July 2015
Roger Chou, MD Oregon Health & Science University Portland, Oregon
References 1. Reuben DB, Alvanzo AA, Ashikaga T, Bogat GA, Callahan CM, Ruffing V, et al. National Institutes of Health Pathways to Prevention Workshop: the role of opioids in the treatment of chronic pain. Ann Intern Med. 2015;162:295300. [PMID: 25581341] doi:10.7326/M14-2775 2. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152:85-92. [PMID: 20083827] doi:10.7326/0003-4819 -152-2-201001190-00006 3. Gomes T, Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011;171:686-91. [PMID: 21482846] doi:10.1001/archinternmed.2011 .117 4. Deyo RA, Smith DH, Johnson ES, Tillotson CJ, Donovan M, Yang X, et al. Prescription opioids for back pain and use of medications for erectile dysfunction. Spine (Phila Pa 1976). 2013;38:909-15. [PMID: 23459134] doi:10.1097 /BRS.0b013e3182830482 5. Okie S. A flood of opioids, a rising tide of deaths. N Engl J Med. 2010;363: 1981-5. [PMID: 21083382] doi:10.1056/NEJMp1011512
Pressure Ulcer Prevention and Management TO THE EDITOR: Black (1) provides a useful perspective on the current state of scientific inquiry among nurses in the treatment and prevention of pressure ulcers. The field of wound care is stymied by a lack of research funding, making it difficult to move out of its “infancy,” and could benefit from additional investment in methodical research to support evidence-based practices. The National Institute of Nursing Research (NINR) is the primary institute of the National Institutes of Health to fund research related to pressure ulcer prevention given that it is a nursing issue. The NINR Strategic Plan, last updated in 2011, prioritizes research on the use of “technology for better wound care” (2). Qaseem and colleagues' guideline recommends the use of new bed technologies in wound care but also notes the importance of risk stratification with a predictively valid instrument, such as the Braden scale, despite “weak” evidence (3). The NINR should update its strategic plan to emphasize the importance of synergizing these instruments with new technologies and improving validity. www.annals.org
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LETTERS Funding to support research in wound care is scarce. The NINR has the smallest annual budget of all the National Institutes of Health at $136 million (4). Commercial industry could do more to supplement wound care research. Of the 10 leading manufacturers of products for evidence-based practices (for example, underpads, dressings, beds, and creams), only 3 are affiliated with foundations to support wound care research (5). In contrast, the pharmaceutical industry seems more involved, considering that 11 of the 12 leading pharmaceutical manufacturers according to the Fortune 500 belong to the Pharmaceutical Research and Manufacturers of America Foundation. Ultimately, the field of wound care has an opportunity to move quickly beyond reliance on costly clinical trials and time-consuming descriptive studies with the evolution of electronic health records. These tools provide accessibility to data that can be used to develop population-specific, predictive algorithms of patient risk and strategically implement evidence-based practices in the hospital or home health setting. William V. Padula, PhD, MS University of Chicago Chicago, Illinois Heidi M. Wald, MD, MSPH University of Colorado Aurora, Colorado David O. Meltzer, MD, PhD University of Chicago Chicago, Illinois Disclosures: Disclosures can be viewed at www.acponline.org /authors/icmje/ConflictOfInterestForms.do?msNum=L15-0232.
References 1. Black J. Pressure ulcer prevention and management: a dire need for good science [Editorial]. Ann Intern Med. 2015;162:387-8. [PMID: 25732284] doi:10 .7326/M15-0190 2. The National Institute of Nursing Research. NINR Strategic Plan. 2011. Accessed at www.ninr.nih.gov/sites/www.ninr.nih.gov/files/ninr-strategic-plan -2011.pdf on 18 March 2015. 3. Qaseem A, Mir TP, Starkey M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015;162:359-69. [PMID: 25732278] doi:10.7326 /M14-1567 4. National Institutes of Health. Office of Budget. 2015. Accessed at http: //officeofbudget.od.nih.gov on 18 March 2015. 5. PR Newswire. The top 20 companies in the advanced wound care market 2013-2023. 30 September 2013. Accessed at www.prnewswire.com/news -releases/the-top-20-companies-in-the-advanced-wound-care-market-2013-2023 -225784351.html on 18 March 2015.
IN RESPONSE: The annual number of cases of pressure ulcers
in the United States is difficult to discern because reporting varies. The National Pressure Ulcer Advisory Panel estimates that 4% to 7% of hospitalized patients develop these ulcers. The estimated incidence is higher in long-term care and recently increased to 14% in this setting (1). These numbers www.annals.org
likely constitute more than 400 000 cases yearly. Although this large number emphasizes the importance of pressure ulcers, it also nearly equals the total number of new cases of breast cancer (232 000) and lung cancer (221 000) combined (2). Given the growing number of elderly persons, the shortage of nurses, and increasingly fragmented care, these numbers will not likely decrease. Yet, as Dr. Padula and colleagues point out, the research money to study pressure ulcers is sorely lacking and there are no national foundations dedicated to this issue or public efforts to raise funds for it as there are for cancer. Sadly, public awareness of pressure ulcers often occurs at the bedside and in courtrooms, where they are labeled as medical errors or never-events. Now that the Centers for Medicare & Medicaid Services has made hospital-acquired pressure ulcers a quality measure, more hospitals are tracking these wounds. However, that work only occurs within a facility, with little to no externalization or published research. Tracking pressure ulcers through the Centers for Disease Control and Prevention would aid in the appreciation of the magnitude of the problem and drive money into the adequately powered studies of how to reduce the risk for these wounds, prevent them, quickly heal them, and maintain these efforts over time (3). Joyce Black, PhD, RN, CWCN University of Nebraska Medical Center Omaha, Nebraska Disclosures: Disclosures can be viewed at www.acponline.org /authors/icmje/ConflictOfInterestForms.do?msNum=M15-0190. References 1. Pieper B, ed. Pressure Ulcers: Prevalence, Incidence and Implications for the Future. Washington, DC: National Pressure Ulcer Advisory Panel; 2012. 2. American Cancer Society. Cancer Facts & Figure 2015. 2015. Accessed at www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures2015 on 11 June 2015. 3. Padula WV, Mishra MK, Makic MB, Sullivan PW. Improving the quality of pressure ulcer care with prevention: a cost-effectiveness analysis. Med Care. 2011;49:385-92. [PMID: 21368685] doi:10.1097/MLR.0b013e31820292b3
Tuberculosis Incidence in Immigrants and Refugees TO THE EDITOR: Liu and colleagues (1) attribute the recent
decline in tuberculosis (TB) cases among newly arrived, foreign-born persons in the United States to the increase in smear-negative/culture-positive cases diagnosed overseas among immigrants and refugees, as a result of the Centers for Disease Control and Prevention's implementation of the culture-based algorithm. This observation seems plausible until one considers that many foreign-born persons, including visitors, students, temporary workers, and unauthorized aliens, are not screened before admittance to the United States (2). In fact, immigrants and refugees constitute only approximately one third of the estimated 1.3 million foreignborn persons who enter the United States yearly for a longterm stay (3). The authors did not provide specific data about the number of reported TB cases in immigrants and refugees Annals of Internal Medicine • Vol. 163 No. 2 • 21 July 2015 149
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LETTERS and therefore cannot exclude with certainty the possibility that changes unrelated to overseas screening may have caused the observed decrease in the incidence of TB in newly arrived, foreign-born persons between 2007 and 2012. In recent years, TB control in foreign-born persons in the United States has garnered increased attention. For example, unlike earlier versions, the 2005 guideline for TB control designated foreign-born persons who have resided in the United States for fewer than 5 years as a particularly high-risk group (4). As a consequence, several notable efforts at targeted screening and treatment of latent infection in foreign-born persons are under way (5). Perhaps as a result of this enhanced focus, more newly arrived, foreign-born persons may have received treatment for latent infection between 2007 and 2012 than between 2002 and 2006. Furthermore, between 2007 and 2012, the authors found that 4032 cases of TB were diagnosed overseas by the culture-based algorithm, of which 2195 were smear-negative/ culture-positive and 480 were diagnosed clinically (1). However, the authors do not provide similar data for the old smear-based algorithm, preventing the panel physicians overseas from evaluating the effect of the new algorithm on the number of clinically diagnosed cases of TB. Thus, it is possible that, before the culture-based screeing, there were more clinically diagnosed TB cases than the 480 reported for the period 2007–2012. If so, this study would have overestimated the actual effect of culture-based screening in identifying cases of TB overseas. In summary, the absence of data distinguishing new TB cases among immigrants and refugees from those found in other foreign-born persons and lack of details on the old smear-based algorithm make interpretation of the results less straightforward. These factors thus dampen the authors' optimistic claims about the effect of the new culture-based screening on the incidence of TB among foreign-born persons in the United States. Azariyas A. Challa, MD, PhD University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOf InterestForms.do?msNum=L15-0263.
References 1. Liu Y, Posey DL, Cetron MS, Painter JA. Effect of a culture-based screening algorithm on tuberculosis incidence in immigrants and refugees bound for the United States: a population-based cross-sectional study. Ann Intern Med. 2015;162:420-8. [PMID: 25775314] doi:10.7326/M14-2082 2. Cain KP, Haley CA, Armstrong LR, Garman KN, Wells CD, Iademarco MF, et al. Tuberculosis among foreign-born persons in the United States: achieving tuberculosis elimination. Am J Respir Crit Care Med. 2007;175:75-9. [PMID: 17038659] 3. Grieco EM, Acosta YD, de la Cruz GP, Gambino C, Gryn T, Larsen LJ, et al. The Foreign-Born Population in the United States: 2010. American Community Survey Reports ACS-19. Washington, DC: U.S. Census Bureau; 2012. 4. Taylor Z, Nolan CM, Blumberg HM; American Thoracic Society. Controlling tuberculosis in the United States. Recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America. MMWR Recomm Rep. 2005;54:1-81. [PMID: 16267499] 150 Annals of Internal Medicine • Vol. 163 No. 2 • 21 July 2015
5. Cain KP, Garman KN, Laserson KF, Ferrousier-Davis OP, Miranda AG, Wells CD, et al. Moving toward tuberculosis elimination: implementation of statewide targeted tuberculin testing in Tennessee. Am J Respir Crit Care Med. 2012;186:273-9. [PMID: 22561962] doi:10.1164/rccm.201111-2076OC
IN RESPONSE: Dr. Challa suggests several limitations of the data in our analysis, raising doubts about the effect of a newly implemented, overseas, culture-based TB screening algorithm on reducing the importation of this condition to the United States. We discussed some of these limitations in our article but have reached a different conclusion. Newly arrived nonimmigrant visitors contribute to the TB burden in the United States (1). The mean annual admission of nonimmigrant visitors between 2007 and 2012 decreased by 8.5% compared with that between 2002 and 2006. However, during the same period, the mean annual number of reported TB cases among foreign-born persons within 1 year of arrival decreased by 24.7%. This discrepancy indicates that the decrease in admissions of nonimmigrant visitors alone could not account for the overall decline of TB cases in the newly arrived, foreign-born population. Dr. Challa suggests that more foreign-born persons were likely to have received treatment for latent TB infection between 2007 and 2012, causing the decline of TB among newly arrived, foreign-born persons. This assumption is not consistent with the results of previous studies. For example, within 1 year of arrival in the United States, only 5.8% of TB cases were likely due to reactivation of latent infection (2). Therefore, identifying and treating latent TB infection is unlikely to explain much of the observed decline in TB cases among foreign-born persons within 1 year of arrival. Dr. Challa indicates that our analysis may not have adequately accounted for clinically diagnosed cases in the old algorithm and suggests that clinical assessment alone might have identified most smear-negative/culture-positive cases. We have found no studies to support this assumption and do not believe that panel physicians could diagnose such large numbers of applicants with smear-negative/culture-positive TB without Mycobacterium tuberculosis culture screening. During the follow-up evaluation after arrival, active TB was diagnosed in 1.8% of persons with class B1 TB identified by the culture-based algorithm but in 3.5% of persons with class B1 or B2 TB identified by the smear-based algorithm. These results were consistent with those of other studies (3, 4), suggesting that the culture-based algorithm is more effective. Despite limitations, we believe that our data indicate that implementation of the culture-based algorithm substantially prevents the importation of TB to the United States.
Yecai Liu, MS Drew L. Posey, MD, MPH Martin S. Cetron, MD John A. Painter, DVM, MS Centers for Disease Control and Prevention Atlanta, Georgia Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOf InterestForms.do?msNum=M14-2082. www.annals.org
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LETTERS References 1. Liu Y, Painter JA, Posey DL, Cain KP, Weinberg MS, Maloney SA, et al. Estimating the impact of newly arrived foreign-born persons on tuberculosis in
4. Hoffman JR, Igarashi E. Influence of electrocardiographic findings on admission decisions in patients with acute chest pain. Am J Med. 1985;79:699-707. [PMID: 4073107]
the United States. PLoS One. 2012;7:e32158. [PMID: 22384165] doi:10.1371 /journal.pone.0032158 2. Walter ND, Painter J, Parker M, Lowenthal P, Flood J, Fu Y, et al; Tuberculosis Epidemiologic Studies Consortium. Persistent latent tuberculosis reactivation risk in United States immigrants. Am J Respir Crit Care Med. 2014;189: 88-95. [PMID: 24308495] doi:10.1164/rccm.201308-1480OC 3. Lowenthal P, Westenhouse J, Moore M, Posey DL, Watt JP, Flood J. Reduced importation of tuberculosis after the implementation of an enhanced pre-immigration screening protocol. Int J Tuberc Lung Dis. 2011;15:761-6. [PMID: 21575295] doi:10.5588/ijtld.10.0370 4. Oeltmann JE, Varma JK, Ortega L, Liu Y, O’Rourke T, Cano M, et al. Multidrug-resistant tuberculosis outbreak among US-bound Hmong refugees, Thailand, 2005. Emerg Infect Dis. 2008;14:1715-21. [PMID: 18976554] doi:10 .3201/eid1411.071629
Cardiac Screening TO THE EDITOR: Chou's guideline (1) on cardiac screening recommends that asymptomatic adults not have resting electrocardiography (ECG). I find that this recommendation, in many instances, goes against the standard of care. Obtaining ECGs for screening is standard for athletes, who, by definition, are asymptomatic. The European Community (2) continues to find this intervention cost-effective. To argue against screening ECGs, Chou cites 2 articles showing their limited usefulness. Rubenstein and Greenfield (3) found that “the routine ECG has little value as a baseline.” However, they state that 5% of patients were grouped into a class in which ECGs could be useful. A total of 5% of patients seems pretty important to me. Hoffman and Igarashi (4) recommend against routinely ordering ECGs in patients with chest pain. This conclusion today is consistent with medical malpractice. I agree that stress testing is overused but believe that extending the argument to resting ECGs is an unwanted stretch.
Paul Zimmermann, MD South Carolina Heart Center Camden, South Carolina Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOf InterestForms.do?msNum=L15-0260.
References 1. Chou R; High Value Care Task Force of the American College of Physicians. Cardiac screening with electrocardiography, stress echocardiography, or myocardial perfusion imaging: advice for high-value care from the American College of Physicians. Ann Intern Med. 2015;162:438-47. [PMID: 25775317] doi: 10.7326/M14-1225 2. Myerburg RJ, Vetter VL. Electrocardiograms should be included in preparticipation screening of athletes. Circulation. 2007;116:2616-26. [PMID: 18040041] 3. Rubenstein LZ, Greenfield S. The baseline ECG in the evaluation of acute cardiac complaints. JAMA. 1980;244:2536-9. [PMID: 7431589] www.annals.org
IN RESPONSE: As we described in the Methods section, our guideline on cardiac screening explicitly excluded preparticipation evaluation of athletes. Thus, the articles on screening of athletes that Dr. Zimmermann cited are not relevant. To clarify, Rubenstein and Greenfield (1) found that, in patients with chest pain who present to the emergency department, 5% (11 of 236) might have avoided an admission if a baseline ECG had been available. However, this percentage is a maximal estimate, because 9 of the 11 patients did not have a baseline ECG. In addition, how many admissions would have actually been avoided is unknown. Further, the authors found no cases in which an inappropriate discharge was avoided because a baseline ECG was available. Hoffman and Igarashi (2) found that baseline ECGs were not helpful in admission decisions in any of 84 patients presenting to the emergency department with acute chest pain. Their findings on the usefulness of ECGs for evaluation of acute chest pain are not relevant to our guideline, which only addresses screening of asymptomatic persons. Nonetheless, suggesting that Hoffman and Igarashi's study recommends against appropriate use of ECGs in this setting is misleading. Rather, they state that ECGs may not be necessary in patients with chest pain that is unlikely to be due to cardiac ischemia based on history and examination (for example, chest pain that is obviously musculoskeletal or due to esophageal reflux disease or that with atypical features in a young adult).
Roger Chou, MD Oregon Health & Science University Portland, Oregon Disclosures: Disclosures can be viewed at www.acponline.org /authors/icmje/ConflictOfInterestForms.do?msNum=M14-1225. References 1. Rubenstein LZ, Greenfield S. The baseline ECG in the evaluation of acute cardiac complaints. JAMA. 1980;244:2536-9. [PMID: 7431589] 2. Hoffman JR, Igarashi E. Influence of electrocardiographic findings on admission decisions in patients with acute chest pain. Am J Med. 1985;79:699-707. [PMID: 4073107]
Acute Myocardial Infarction TO THE EDITOR: High-sensitivity troponin assays are proving to be a costly problem facing internists in hospital medicine practice and such payers as Medicare. High-sensitivity troponin assays, when used in proper clinical context, are useful and increase the accuracy of diagnosing myocardial infarction (MI). Shroff (1) correctly highlights the higher mortality associated with and lack of evidence-based treatment options for type 2 MI or elevated troponin levels without treatable intracoronary lesions or obstruction. There is no sound empirical evidence to support risk stratification based on troponin assays or their routine use to rule out or rule in MI when patients present to the emergency department with noncardiac sympAnnals of Internal Medicine • Vol. 163 No. 2 • 21 July 2015 151
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LETTERS toms. However, troponin assays are routinely ordered in the emergency department without proper clinical rationale for most abdominal, thoracic, and neurologic symptoms. The admitting internist, while treating an unrelated noncardiac condition, is left to deal with the aftermath of abnormal troponin levels. This circumstance starts an unnecessary cascade of cardiology consultation and further testing, prolongs hospitalization, and complicates management of the patient. This diagnostic quest to nowhere does not end with cardiology consultation alone. Most recently, the “third universal definition of MI” defined diagnosis of this condition by the presence of at least 1 troponin level greater than the 99th percentile and one of the following factors: symptoms of ischemia, ST-segment changes, a pathological Q wave, imaging evidence of loss of viable myocardium or a new regional wall motion abnormality, or identification of an intracoronary thrombus on angiography or autopsy (2). The cardiologist who is consulted to solve the problem faces a conundrum. Symptoms are unreliable to rule out or rule in MI (3), and normal or equivocal results on electrocardiography do not help to narrow the differential diagnosis, either. Notwithstanding the sound clinical judgment that determines that MI is unlikely in a specific clinical setting, a cardiologist is forced to order invasive or noninvasive work because most patients admitted to hospitals usually have some cardiovascular risk factors. The internal medicine, cardiovascular, and emergency medicine sections of hospitals should develop a collaborative protocol for judiciously ordering troponin assays. Unless acute MI is in the differential diagnosis, these assays should be ordered in consultation with a cardiologist. Since the advent of high-sensitivity assays, troponin has become the new D-dimer for the heart. Sukhchain Singh, MD Ingalls Memorial Hospital Harvey, Illinois Amandeep Singh, MD Sanford Medical Center Thief River Falls, Minnesota Sandeep Khosla, MD Mount Sinai Hospital Medical Center and Rosalind Franklin University of Medicine and Science Chicago, Illinois Disclosures: Disclosures can be viewed at www.acponline.org /authors/icmje/ConflictOfInterestForms.do?msNum=L15-0277.
2. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al; Joint ESC/ACCF/AHA/WHF Task Force for Universal Definition of Myocardial Infarction. Third universal definition of myocardial infarction. J Am Coll Cardiol. 2012;60:1581-98. [PMID: 22958960] doi:10.1016/j.jacc.2012.08.001 3. Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, Holmes DR Jr, et al; ACC/AHA Task Force Members. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:e344-426. [PMID: 25249585] doi:10.1161/CIR.0000000000000134
IN RESPONSE: Whereas my article explored the ramifications
of a unique diagnostic code for type 2 MI, Dr. Singh and colleagues focus on indiscriminate use of troponin assays for noncardiac symptoms. As they point out, an uncritical and unscrutinized pattern of troponin measurement can lead to an unintended cascade of downstream testing that can be medically unnecessary, expensive, time-consuming, and potentially anxiety-provoking for the patient and therefore should be discouraged and avoided. Most cardiologists would agree that the management of a patient with an elevated troponin level obtained out of the clinical context for which troponin measurement was fundamentally designed (that is, detection of acute MI) is exceedingly problematic clinically. It therefore bears emphasis that the experts who proposed the universal definition of MI recommend that the terminology “MI” be used only in a clinical setting consistent with myocardial ischemia (1). Therefore, by extrapolation, measuring troponin levels only in clinical settings where myocardial ischemia is suspected would be most appropriate. Cardiac troponin levels are undoubtedly valuable in determining long-term prognosis in several clinical scenarios, but, so far, the literature has not successfully defined how to inculcate information about long-term prognosis into the immediate management of patients. The onus is on clinicians to recognize the context in which requesting troponin measurement is appropriate; certainly, “protocol-driven” reflexive checks should be strongly discouraged. It behooves us as clinicians to ensure that indiscriminate use of troponin levels is discouraged in our respective settings and as educators to ensure that we edify our trainees well in this regard. Gautam R. Shroff, MB, BS Hennepin County Medical Center and University of Minnesota Minneapolis, Minnesota Disclosures: The author has disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOf InterestForms.do?msNum=M14-2259. Reference
References 1. Shroff GR. Acute myocardial infarction: what's in a name? Ann Intern Med. 2015;162:448-9. [PMID: 25775318] doi:10.7326/M14-2259
152 Annals of Internal Medicine • Vol. 163 No. 2 • 21 July 2015
1. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al; Joint ESC/ACCF/AHA/WHF Task Force for Universal Definition of Myocardial Infarction. Third universal definition of myocardial infarction. J Am Coll Cardiol. 2012;60:1581-98. [PMID: 22958960] doi:10.1016/j.jacc.2012.08.001
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