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Internal Medicine 2007 Key Messages You’ll Want to Take Home

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					Internal Medicine 2007: Key Messages
      You‟ll Want to Take Home


Moderator:
 Marie T. Brown, MD, FACP
Panelists:
 Virginia U. Collier, MD, FACP
 Karen McDonough, MD, ACP Member
 Katayoun K. Mostafaie, MD, ACP Member
Virginia U. Collier, MD, FACP
Hugh R. Sharp, Jr. Chair of Medicine
Christiana Care Health System
Newark, DE
Professor of Medicine
Jefferson Medical College
               Disclosure


 Stock Options/Holdings
  Celgene, Pfizer, Merck, Schering Plough,
  Abbott, Johnson and Johnson, Medtronic,
  McKesson, Amgen
                  Hematology


 Treatment of iron deficiency
   • “Iron dextran is no longer the parenteral
     treatment of choice. In fact, its use is difficult to
     justify.”
   • Black box warnings with iron dextran; ferric
     gluconate and iron sucrose now available and
     have excellent safety profiles vs. iron dextran
               Hematology
   Oral Iron Tolerance Test

    •   Underutilized test

    •  Helpful in distinguishing between non
    compliance and malabsorption in patients
    with iron deficiency anemia who are not
    responsive to oral iron.
         Oral Iron Tolerance Test


 1. Give two tablets of ferrous sulfate on an
  empty stomach or with orange/lemon juice.
 2. Measure serum iron at baseline (0‟ time)
  and at 30, 60, 90, and 120 minutes.
 3. Serum iron should increase by at least
  100 mcg/dl within this time period.
 4. If not, suspect malabsorption of iron (i.e.
  occult celiac disease) .
 Role of Hepcidin in the Anemia of Chronic
              Disease (ACD)
 25 amino acid peptide now thought to be
  the most important regulator of iron
  homeostasis
 In experimental animals causes a dose
  dependent fall in serum iron by decreasing
  absorption of iron and preventing the
  release of iron from macrophages.
 Plays a key role in the ineffective iron
  reutilization caused by inflammation and
  seen in the anemia of chronic disease
 Future therapies for ACD may be directed
  towards inhibiting or blocking the actions
  of hepcidin.
                  Neurology
 The role of carotid artery stenting (CAS) (vs
  carotid endarterectomy) in the treatment of
  carotid artery stenosis remains unclear.
   • Several head to head randomized trials,
     including the recent EVA-3S trial, have been
     terminated early because of significantly worse
     outcomes with CAS.
   • Consider CAS only in patients with
     symptomatic, severe (>70%) internal carotid
     artery stenosis who are high risk for surgery or
     who refuse surgery.
   • Send to high volume centers with experienced
     interventional physicians.
    Neurology: Treatment of Acute
        Hemorrhagic Stroke



 Breaking News: Recombinant factor VIIa
  does not appear to be beneficial in the
  treatment of acute hemorrhagic stroke
  (phase III trial completed)
       Neurology: Bell‟s Palsy


 Bilateral 7th nerve palsy: think Guillaume
  Barre
 Recurrent 7th nerve palsy: think Lyme
  disease in the appropriate settings
 70% of untreated Bell‟s palsy patients have
  a complete recovery
 When given within the first 1-2 weeks of
  onset, a one week course of steroids plus
  antivirals (ie acyclovir or valacyclovir) may
  increase the % of patients with complete
  recovery.
  Cardiology: Age Related Vascular
              Changes


 Because arteries become non-
  compressible with increasing age, carotid
  pulses remain easily palpable, even in the
  low flow states produced by severe aortic
  stenosis.
 Physical examination cannot reliably
  assess the severity of valvular lesions.
 Exercise and weight control are the only
  modalities which have been proven to
  blunt age related changes in the
  cardiovascular system.
   Cardiology : Rx of Blood Pressure
                After 80


 No available data to guide the treatment of
  elevated blood pressure in patients > 80.
   • Lower it. (24 – 47% risk reduction for stroke)
   • Correct target unknown. “Every Hg mm counts”.
          - Diastolic target < 90 mm Hg
          - Individualized systolic target
   • May need 2-3 drugs, but “start low, go slow”
   • No data which show that aldosterone
     antagonists are beneficial. Risk of
     hyperkalemia.
  Cardiology: Rx of Acute MI after 80


 Treat with thrombolytic therapy
   • Relative contraindications include HBP, recent
     CVA, h/o prior bleeds, predicted lifespan < 1 year
   • Must be given within 12 hours from onset of
     symptoms
   • Use lower dose
 No benefit of primary angioplasty over
  thrombolysis and possible disadvantages.
 Shock is the only compelling indication for
  PCI.
Cardiology: Coronary Multidetector CT

 Useful in the assessment of obstructive
  coronary artery disease in stable
  symptomatic patients.
 Higher radiation doses prohibit its use as a
  screening tool for asymptomatic patients.
 Limitations:
   • Failure rate (visualization of coronary arteries)
     as high as 15%
   • Need short term beta blockers and radiocontrast
   • High dose of ionizing radiation
    Cardiology: ACE Inhibitor Alert


 In a cohort of 29,507 infants studied for
  exposure to antihypertensive drugs,
  infants with only first trimester exposure to
  ACE inhibitors had an increased risk for
  major congenital malformations (risk ratio
  2.71).
 Exposure to ACE inhibitors during the first
  trimester (as well as during the second and
  third trimesters) cannot be considered safe
  and should be avoided.
 Infectious Disease: CA-MRSA vs HA-
                MRSA
Microbiology
 Different DNA fingerprint (USA300/USA400)
 Carries Panton-Valentine leukicidin (PVL)
  gene, which confers increased virulence
Epidemiology
 Younger, otherwise healthy patients,
  skin/soft tissue infections
 Athletic teams, jails, IVDU
    Infectious Disease: Community
            Acquired MRSA

 In the EMERGEncy ID NET (2006) study of
  ED patients, 60% of culture + pts with soft
  tissue infections were + for MRSA with
  clonal type USA300 (CA- MRSA)

 CA-MRSA is now an important cause of
  nosocomial infections in the hospital (app
  20% in some studies).
    Infectious Disease: Community
            Acquired-MRSA


 Influenza and PVL+ CA-MRSA: a toxic
  combination.
 Of 15 cases of CA-MRSA necrotizing
  pneumonia during 2003-4 influenza season,
  there were 4 deaths.
 CAP treatment during times of high
  influenza activity should include coverage
  for CA-MRSA!
    Infectious Disease: Vancomycin
           Resistant S. Aureus



 To date only 6 cases have been reported in
  the U.S. since 2002.
 Hepatobiliary and Pancreatic Disease


 Autoimmune cholangiopancreatitis
  • Should be considered in the diagnosis of
    obstructive jaundice of uncertain etiology
  • a/w other autoimmune diseases (PSC, Sjogren‟s,
    RA)
  • Elevated IgG type 4 (>135 mg/dL)
  • CT: “sausage shaped pancreas”
  • Pancreatogram: very thin pancreatic duct
  • Path: lymphoplasmacytic sclerosing pancreatitis
  • Rx: Prednisone
Hepatobiliary and Pancreatic Disease


 Use less invasive tests to diagnose
  obstructive jaundice: MRCP, CT (Multi-
  detector CT) and/or Endoscopic Ultrasound
 Save ERCP for therapy (even healthy
  patients have a 4/100 chance of severe
  complications and a 1 in 100 chance of
  dying from ERCP)
   • ERCP: biliary sphincterotomy, removal of
     stones
                  Rheumatology

 Anti-CCP (cyclic citrullinated peptide)
   • More specific than rheumatoid factor for
     rheumatoid arthritis
   • Useful in:
      - Seronegative rheumatoid arthritis
      - Patients with arthritis and Hepatis C or
        suspected polymyalgia rheumatica (in whom
        rheumatoid factor may be falsely positive). If
        anti-CCP positive, think RA.
   • Correlates with worse prognosis. If anti-CCP
     positive, consider more aggressive treatment at
     onset.
                Rheumatology


 Pts with RA (and SLE) have a significantly
  increased risk for atherosclerosis and
  CAD.
 No evidence based guidelines to direct
  therapy.
   • Consider RA as a coronary heart disease risk
     factor.
   • Use diabetic guidelines re lipid lowering.
   • Target LDL level < 100 mg/dL.
       Oncology: Targeted Therapy for
                  Cancer

 Imatinib in CML: best example of targeted therapy
   •   Inhibits causative tyrosine kinase, encoded by the
       bcr-ab gene
   •   5 yr f/u of prospective randomized phase III trial vs
       interferon alpha and cytarabine; overall survival rate
       of pts on imatinib was 89% (previously median
       survival was 4 years).
   •   Of patients who have a cytogenetic response at 12
       mos, 97% in complete remission after 60 mos.

 Many novel cancer treatments are currently under
  development. In your cancer patients, inquire at
  specialized cancer centers about the possibility of
  approved targeted therapies or clinical trials for
  other novel agents.
   Oncology: CT Screening for Lung
               Cancer


 Annual spiral CT scanning can detect small
  lung cancers while they are curable.
 Questions still exist about whether the
  study offers sufficiently powerful support
  to justify the expense of screening large
  numbers of at risk patients.
 Prospective randomized trials are under
  way to address the role of spiral CT in lung
  cancer screening. The time is “not yet
  right” for broad application of this method.
                 Nephrology


 Patients with advanced kidney disease may benefit
  from ACE inhibition.
 The safe use of benazepril confers a protective and
  survival advantage in patients with nondiabetic
  advanced (stage 4 – GFR 15 to 29 ) renal disease.
 Compared to placebo, benazepril lowered the risk
  for disease progression (including proteinuria) and
  death, independent of its effect on blood pressure
  control.
 Monitor GFR, serum K+, start with low dose.
  ENT: Acute bacterial rhinosinusitis


 Up to 87% of patients with viral-mediated
  colds have abnormalities on sinus CT
  scans.
 In acute sinusitis, imaging studies are
  more effective as negative predictors: 90%
  accuracy in ruling out disease.
 Sinus CT indicated for recurrent acute
  sinusitis despite appropriate medical
  therapy.
Speakers and References
                  Hematology


 Iron:Too Little,Too Much. John W. Adamson, MD
 Anemia: A Case Based Approach. Ernest Beutler,
  MD
References:
Bailie GR, Clark JA, Lane CE et al. Hypersensitivity
  reactions and deaths assoicated with intravenous
  iron preparations. Nephrol Dial Transplant, 2005.
Fleming RE, Bacon BR. Orchestration of Iron
   Homeostasis. N Engl J Med 2005;352:1741-44.
                 Neurology


 Neurology for the Non-Neurologist. S.
  Hariharan, MD
References
Mas J, Chatellier G, Beyssen B et al.
  Endarterectomy versus stenting in patients
  with symptomatic severe carotid artery
  stenosis. N Engl J Med 2006;355:1660–71.
Gilden D. Bell‟s palsy. N Engl J Med
  2004;351:1323-31.
                Cardiology


 Cardiovascular Disease After 80 Years of
  Age. Janice B. Schwartz, MD
 Update in Cardiology. Robert L. Frye, MD
 Multiple Small Feedings of the Mind:
  Cardiology. Noel Bairey Merz, MD.
References
MRC The study on cognition and prognosis
 in the elderly (SCOPE): principal results of
 a randomized double blind intervention
 trial. J Hyperten 2003;21:875-86.
                   Cardiology

Hoffman U, Naguerney JT, Moselewski F et al.
  Coronary multidetector computed tomography in
  the assessment of patients with acute chest pain.
  Circulation 2006;114:2251-60.
Cooper WD, Hernandez-Diaz S, Patrick G et al. Major
  congenital malformations after first trimester
  exposure to ACE inhibitors. N Eng J Med
  2006;354:2443-51.
Budoff MJ, Ackenbach S, Blumenthal RS et al.
  Assessment of coronary artery disease by cardiac
  computed tomography: a scientific statement from
  the American Heart Association. Circulation
  2006;114:1761-91.
             Infectious Disease

 Staphylococcus Aureus Infections: What‟s
  New? Daniel J. Diekema MD
References
Moran GJ, Krishnadson A, Gorwitz R et al.
 Methicillin resistant S. aureus infections
 among patients in the emergency
 department. N Eng J Med 2006;355:666-74.
Seybold U et al. Emergence of community
  associated methicillin resistant
  Staphylococcus aureus. Clin Infect Dis
  2006;42:647-656.
Hepatobiliary and pancreatic disease


 Hepatobiliary and pancreatic disease: a
  case based approach. Thomas J. Savides,
  MD.
References
Humano H, Kawa S, Horiuchi A et al. High
  serum IgG4 concentrations in patients with
  sclerosing pancreatitis. N Engl J Med
  2001;345:147-8.
                  Rheumatology
 Multiple Small Feedings of the Mind: Rheumatology.
  Brian Mandell, MD, PhD.
References
Avouac J, Gossec L, Dougados M. Diagnosis and
  predictive value of anti-cyclic citrullinated protein
  antibodies in rheumatoid arthritis: a systematic
  review. Ann Rheum Dis 2006;65:845-51.
Giles JT, Post W, Blumenthal RS et al. Therapy insight:
   managing cardiovascular risk in patients with
   rheumatoid arthritis. Nature Clin Practice
   2006;2:320-9.
Ouyyimmi AA. Inflamed joints and stiff arteries. Is
  rheumatoid arthritis a cardiovascular risk factor?
  Circulation 2006;114:1157- 9.
                 Oncology

 Update in Oncology. Lowell E. Schipper,
  MD
References
Druker BJ, Guilhot F, O‟Brien SG et al. Five
  year follow-up of imatinib for chronic
  myeloid leukemia. N Engl J Med
  2006;355:2408-17.
International Early Lung Cancer Action
   Program Investigators. Survival of patients
   with stage I lung cancer detected on CT
   screening. N Engl J Med 2006;355:1763-71.
                Nephrology


 Statins in Chronic Renal Disease. Vito M.
  Campese, MD
 Update in Nephrology. Stanley Goldfarb,
  MD
References
Hou FF, Zhang X, Zhang GH et al. Efficacy
  and safety of benazepril for advanced
  chronic renal insufficiency. N Engl J Med
  2006;354:131-40.
                     ENT

 ENT: Diagnosis and Treatment of Common
  Problems. Daniel G. Deschler, MD
References
Varonen H, Savolainen S, Kunnamo I et al.
  Acute rhinosinusitis in primary care: a
  comparison of symptoms, signs,
  ultrasound and radiography. Rhinology
  2003;41:37-43.
Snow V, Motter-Pilson CM, Hickner JM.
  Principles of appropriate antibiotic use for
  acute rhinosinusitis. Ann Int Med
  2001;134:495-497.
    Karen A. McDonough, MD

      Assistant Professor of Medicine
University of Washington School of Medicine
 Disclosure of Financial Relationships




 Dr. McDonough has no relationships with any proprietary
entity producing health care goods or services consumed by
                   or used on patients.
Cerebrovascular Disease & Stroke
Karen C. Johnston MD, MSc

Managing Symptomatic Carotid Stenosis
Cina CS The Cochrane Collaboration 2006. www.thecochranelibrary.com


≥ 70%      Endarterectomy + best medical tx.
50-69% Best medical tx. and consider CEA, but
       benefit may be small, especially for
       women and for retinal ischemia.
< 50%      Best medical tx.

   How do recent studies of carotid
        stenting change these
          recommendations?
Studies of Stents vs. CEA

 SAPPHIRE study NEJM 2004;351:1493
   • In patients believed to be at high risk of surgery,
     stenting NOT inferior to CEA.

 Eva 3S study NEJM 2006;355:1660
   • In symptomatic ≥ 60% stenosis, stents inferior to
     CEA: higher rates of nonfatal stroke at 1 and 6
     months

 SPACE study Lancet 2006;368:1239
   • In symptomatic ≥ 50% stenosis, stents inferior to
     CEA.

 CREST study: large, ongoing US study
  likely to provide definitive data
TAKE HOME:


 Carotid endarterectomy remains the
  standard of care
 Carotid stenting could be considered for
  patients at high surgical risk
Antiplatelet Stroke Prophylaxis:
3 Excellent First Line Choices


 ASA 81-325 mg/day (3¢)
   • Still considered first line by many

 Clopidogrel 75 mg/day ($3.50)
   • As good and may be slightly better than ASA for risk
     reduction in stroke patients

 ASA 25 mg / Dipyridamole 200 mg bid ($1.60)
Antiplatelet Stroke Prophylaxis: What
to Choose in Special Cases

 Patients with peripheral vascular disease:
  Clopidogrel
 Patients with true ASA allergy: Clopidogrel
 Financially limited patients: ASA
 Patients with gastric ulcer (healed): ASA +
  PPI
   • Lower rate of recurrent ulcers than clopidogrel
     alone (NEJM 2005;352:238)
Are two antiplatelet agents better than
one?
         TAKE HOME: NO
 MATCH, 2004: Clopidogrel + ASA vs.
  clopidogrel alone in stroke patients
 CHARISMA, 2006: Clopidogrel + ASA vs.
  ASA alone in MI, stroke, PAD patients
 No reduction in stroke, MI, or CV death with
  combination therapy
 Increase in bleeding with combination
  therapy
 Combination reserved for patients with
  acute coronary syndromes, cardiac stents,
  and by extension, cerebral vascular stents
Clinical Pearls: Gastroenterology
Mark Larson MD
 52 y.o. man considering THR. Remote alcohol
  abuse, CT shows cirrhosis and splenomegaly.
  No history of encephalopathy or GI bleed. INR
  1.8, Cr 1.4, bili 3.1. Normal Hgb, WBC, plts 97.
 Risk can be estimated with MELD score,
  calculated from INR, Cr, bilirubin (range 6-40).
 Retrospective study of 772 patients with
  cirrhosis having abdominal, orthopedic, and
  cardiac surgery showed the best predictors of
  outcome were MELD, age, and ASA class.
 This patient‟s MELD is 21 – his 30 day
  mortality is estimated at 53%.
               Teh SH. Gastroenterology 2007, epub Jan 25.
 Calculators


 TAKE HOME MESSAGE: Risk of perioperative
  mortality in patients with cirrhosis is best
  calculated with MELD score - and may be MUCH
  higher than you think.


 MELD: www.unos.org/resources/MELDcalculator
 Perioperative risk: http://www.mayoclinic.org/gi-
  rst/mayomodel15.html
Best Practices in the Critically Ill Patient
Gregory A. Schmidt MD

Fluid Management:
 Early goal directed therapy in sepsis
   • 1st 6 hours in the ED
   • Standard therapy: fluid and pressors to achieve
     standard goals (CVP 8-12, MAP > 65, U0 0.5 mL/kg/hr)
   • Early goal directed therapy: Fluid, pressors, blood
     and inotropes administered to achieve Scv02 of
     >70% in addition to standard goals
   • Significantly decreased mortality (31% vs. 47%) with
     early goal directed therapy.
                                     NEJM 2001; 345:1368
But what do you do when they are in
the ICU?
 Later fluid management in ALI/ARDS

 2 strategies for fluid and diuretic
  management:
   • conservative (CVP < 4, PCWP < 8)

   • liberal (CVP 10-14, PCWP 14-18)

 Conservative strategy reduced duration of
  ventilation and ICU stay WITHOUT ill effect
  on other organs (including kidneys)

 Patients also randomized to PA catheter vs
  central line only – no benefit to PA catheter

                                 NEJM 2006;354:2564
Clinical Pearl:


 Tidal volumes for lung protective
  ventilation (6 ml/kg) should be based on
  ideal rather than actual body weight.
 Example: Female, 5‟7”, weighs 110 kg.
 IBW 62 kg.
 Vt based on actual weight: 660 cc.
 Vt based on IBW: 370 cc.
Breaking news: As yet unpublished
study to watch for

 Corticus Trial
   • Hydrocortisone in sepsis - 50 mg q 6 x 5 days then
     tapered off over a week
   • Primary endpoint: mortality in ACTH non-
     responders
   • Results negative
Update in HIV
Constance A. Benson, MD, FACP
 40,000 new HIV cases per year in the US
 40% of new cases result from contact with
  an acutely infected patient.
 90+% of patients have symptoms with
  seroconversion: fever, pharyngitis, LAN, rash
 Diagnosis: HIV RNA > 5000 copies/mL.
 Role of ART in acute infection remains
  uncertain:
   • One study has shown improved viral load and
     CD4 at 2 y when ART begun within 2 weeks of
     illness and continued for ~1.5 y.
   • 2 RCT‟s underway
Prevention of HIV
 Circumcision
  • 3 studies show RR of seroconversion ~ 0.5 in
    circumcised men

 Pre-exposure prophylaxis
  • Drug taken daily to prevent infection – multiple
    studies underway in Africa and Asia
  • Unanswered ?s: Is it safe and does it work?
  • Practice in some communities has outpaced
    available evidence
  • Consider counseling high risk patients that this is
    NOT a good idea
Nonoccupational Postexposure
Prophylaxis




                     MMWR 2005;54:1-20
Non-occupational post-exposure
prophylaxis

2005 CDC recommendations:
 Within 72 hrs of exposure to HIV + source
   • 3 drug ART (adjusted according to source pt
     regimen/viral load if possible) for 28 days

 Case by case determination
   • Unknown HIV status of source

 Not recommended for
   • Patients seen later than 72 hours
   • Negligible risk exposure (intact skin, tears, etc)

                                   MMWR 2005;54:1-20
Primary Care of the Transplant Patient
Keith Superdock, MD, FACP

 Never stop immunosuppressive drugs
  without the involvement of a transplant
  physician
 BUT there are lots of ways to mess up a
  patients immunosuppressive medications
  without actually stopping them
 Cyclosporine, sirolimus, and tacrolimus
   • Have narrow therapeutic windows, especially
     early after transplant
   •   Are all metabolized by cytochrome P450 3A4
CYP 3A4 Inducers – decrease levels of
cyclosporine, tacrolimus, sirolimus

 Rifampin
 Nafcillin
 Phenytoin
 Carbamazepine
 St. John‟s wort
 Among many others
CYP 3A4 Inhibitors – increase
transplant drug levels

 Azoles – including clotrimazole troches
 Clarithromycin, erythromycin
 Isoniazid
 Diltiazem
 Verapamil
 Nicardipine
 Protease inhibitors
 Grapefruit juice
TAKE HOME POINT:

 For patients on cyclosporine, tacrolimus or
  sirolimus, don‟t start OR stop any drug
  without checking its impact on CYP 3A4.
Physiologic interactions



 Afferent arteriole        Efferent arteriole


  Cyclosporine,
tacrolimus constrict   ACE, ARB dilate

NSAIDs constrict
Issues with Immunosuppression


 Vaccines
  • OK EXCEPT live attenuated virus vaccines
  • Zoster vaccine, oral polio, intranasal flu.

 Cancer screening
  • Should include all age appropriate screening
                    PLUS
  • A yearly complete skin exam
Breaking News in Adult Vaccines:
Three New Vaccines Approved in 2006
Drs. Fryhofer, Hopkins and Poland

 Human Papilloma Virus vaccine
 Pertussis – Tdap
 Zoster vaccine
Human Papilloma Virus Vaccine
 Quadrivalent – serotypes 6, 11, 16, 18
 6 & 11 cause > 90% of genital warts
 16 & 18 cause 70% of cervical cancer
 95-100% protective against neoplasms
  caused by these serotypes IF given prior to
  infection
 Still protects against other serotypes if
  given after infection
 FDA approved for girls and women 9-26
 3 doses over 6 months, vaccine cost $360.
Pertussis Background:

 Reported incidence 8.8/100,000 BUT 100
  fold higher in areas with active surveillance
 Childhood vaccination rates high, but
  immunity wanes over time.
 Significant morbidity in adults, who often
  lack „classic‟ whoop and posttussive
  emesis
 Most fatalities in infants
 Recent healthcare associated outbreaks
 Disease transmitted to 90% of nonimmune
  household contacts
Recommendations for Tdap:
 Single dose to replace a dose of Td in
  adults age 19-64
   • Routine booster
   • Wound prophylaxis

 May be given < 10 years since last tetanus
  vaccine
 Women are encouraged to receive Tdap
  prior to pregnancy; if not, they should be
  vaccinated immediately post-partum
 Special emphasis on:
   • Adults with contact with infants
   •   Healthcare personnel
Herpes zoster vaccine:

 Incidence: 11 cases/1000 people > 60
 Lifetime risk of 50% in those living to 85
 Up to one third develop post-herpetic
  neuralgia (PHN)
 Live attenuated virus vaccine with much
  higher potency than childhood varicella
  vaccine
 Vaccine efficacy:
   • 51% reduction in zoster – slightly lower age > 70
   • 66% reduction in PHN – no difference age > 70
Zoster vaccine indicated for:
 Age > 60
 Contraindications:
   • Immunosuppression: drugs, disease, radiation
   • Pregnancy
   • Active TB
   • Anaphylaxis to neomycin or porcine gelatin

 Prior shingles not a contraindication
  according to expert opinion – but wait at
  least 12 months
 Can be given to HIV+ IF varicella serology
  CONFIRMS prior exposure and CD4 > 200
  Katayoun K. Mostafaie, MD

     Assistant Professor of Medicine
David Geffen School of Medicine at UCLA
     Harbor-UCLA Medical Center
                      Disclosure



  Dr. Mostafaie has no relationships with any proprietary
entity producing health care goods or services consumed by
                    or used on patients.
Noninvasive Testing for Coronary Artery Disease
 Michael S. Lauer, MD, FACC

 Prognosis >> Diagnosis
 Symptomatic patients >> asymptomatic
 Intermediate or high risk for CAD vs. low risk for CAD
 Exercise >> pharmacological

 Imaging : abnl ECG or prior revascularization

 Exercise Echo = Nuclear
 EBCT
    • Possible screening value in intermediate risk
    • No outcomes data demonstrating benefit
 CT angiography
    • Role unclear, poor resolution and radiation exposure
    • ? Combine with PET for “ultimate imaging”
Valvular Heart Disease: Essentials for
the Internist
Catherine M. Otto, MD, FACC



 Surgery is the primary treatment modality
  for valvular heart disease
 Indications for surgery:
   • Aortic stenosis: AVR at symptom onset
   • Aortic regurgitation: AVR for symptoms or early
     LV dysfunction (ESD≥ 55 mm, EF≤50%)
   • Mitral stenosis: valvuloplasty for symptoms,
     Afib or ↑PAP. MVR if valvuloplasty not feasible
   • Mitral regurgitation: MV repair for symptoms or
     early LV dysfunction (ESD ≥40 mm, EF≤60%)
Urology for the Internist
Lisa Granville, MD, FACP
   Urinary Incontinence
            Drugs                       Dietary
            Restricted Mobility         Retention of feces
            Infection                   Inflammation
            Polyuria                    Psychological
     •    Urge >> stress
     •    Treatment:
                    -   Behavioral (voiding diary, pelvic floor exercises)
                    -   Pharmacological (anticholinergics)
                    -   Surgical
   Erectile dysfunction
     •    Eliminate reversible causes (meds, alcohol, smoking)
     •    Optimal treatment needs integrated approach
     •    Stepwise treatment approach: PDE-5 Inhibitors, vacuum-constriction device,
          intraurethral therapy, penile injection therapy and penile prosthesis
   BPH
     •    Microscopic vs. macroscopic vs. clinical findings
     •    Men >80 : 90% histologic, 81% clinical symptoms, 10% urinary retention
     •    BPH vs. lower urinary tract symptoms
Osteoporosis and Other Metabolic Bone
Disease
Clifford J. Rosen, MD


 Bone quality and quantity
 On the horizon: new 10 year fx estimate
 Biggest risk for fracture is a previous osteoporotic
  fracture
 Bisphosphonate treatment may become intermittent
 Human Parathyroid Hormone: bone quantity as well as
  quality, safe, expensive, tx for 18-24 mon and then switch
  to bisphosphonates
 Combination therapy has not been shown to further
  reduce fracture risk
 Rosiglitazone may be detrimental to bone
 Vibration platforms-low mechanical signals that
  strengthen long bones when used 10 min per day: 3 NIH
  funded RCT
The Metabolic Syndrome, Dyslipidemia and
Cardiovascular Disease
Robert A. Kreisberg, MD, MACP



 ATP III definition of metabolic syndrome:
   • ↑TG, ↑ BS, ↑ BP, ↑Abd obesity, ↓HDL
   • Clinically applicable
   • Predictor of cardiovascular disease. ? Better
     than Framingham risk score

 5% of pts have nl BMI
 CRP not useful in clinical decision making
 Lifestyle modification: cheaper and most
  useful in long run as compared to drugs
Evidence-Based Approach to the
Perioperative Evaluation
Darrell W. Harrington, MD


 H&P assessment is still the most important
  preoperative tool.
The ACC/AHA guideline is a sensitive tool to
  decide who does not require additional
  testing or interventions.
 Patients with an RCRI score of < 2 do not
  routinely require additional diagnostic
  testing or preoperative interventions
Evidence-Based Approach to the Perioperative
Evaluation
Darrell W. Harrington, MD


   Evidence-Based View of Use of Perioperative B-blockers

   1. Strongly support use in patients with independent
      indications or positive stress test undergoing major
      vascular surgery.
   2. Start as early as possible prior to surgery (days or
      weeks)
   3. Make sure that adequate sympatholysis is achieved
      (HR < 65-70).
   4. Beneficial in patients with RCRI > 3
   5. Question utility in patients with RCRI < 2. Therefore,
      potential harm may outweigh benefits
   6. Beta-blockers are not a substitute for a vigilant and
      complete preoperative evaluation
Update/Perioperative Medicine
S.L. Cohn, MD and G. W. Smetana, MD


 Preoperative PCI:
   • Surgery soon after PTCA &PCI is unsafe
   • PTCA is no safer than stents
   • Major CV event rates are high among
     pts S/P PCI within one year prior to non-
     cardiac surgery
   • PCI ≠ risk reduction strategy
     preoperatively
Cirrhosis and Its Complications: Role of the
Generalist
Norton J. Greenberger, MD, MACP


 Evidence based tx of ascites:
   • Bed rest
   • Na restriction (4.0 gm salt diet)
   • Water restriction (2.0L/day)
   • Diuretics

 Failure to respond:
   • High salt diet, excessive fluid intake (1 pint
     ice=800 cc)
   • Consider either metolazone or HCTZ, lasix drip,
     paracentesis+ IV albumin + lasix drip
Cirrhosis and Its Complications: Role of the
Generalist
Norton J. Greenberger, MD, MACP


 Hepatic Encephalopathy
   • Bedside diagnosis (fetor hepaticus, asterixis, mental
     status changes)
   • No need to order an ammonia level
   • Fitness to drive a car can be impaired in patients with
     minimal hepatic encephalopathy
Cirrhosis and Its Complications: Role of the
Generalist
Norton J. Greenberger, MD, MACP


 Spontaneous bacterial peritonitis
   • In one series only 59% c/o abd pain
   • Hospital acquired SBP has a worse outcome
   • Rate of recurrence as high as 70% in one year
     without prophylaxis
   • Cirrhotic GIB need prophylaxis for SBP

 Varices
   • Cirrhotics need to be screened with EGD
   • Beta blockers indicated for large varices
   • Avoid lifting >20 lbs and straining
IBS: Evidence- Based Approach
Philip Schoenfeld, MD

 Diagnostic tests not indicated in most pts with IBS
  (in the absence of danger signs)
 Sometimes diagnostic tests are done to reassure
  patients
 r/o celiac sprue in a diarrhea predominant
  Caucasian patient
 Treatment (evidence-based):
   • Antispasmotics (Bentyl, Levsin)
   • Fiber
   • Laxatives
   • Antibiotics and probiotics (bifido bacterium infantis
     marketed as Align, not Activa)
IBS: Evidence- Based Approach
Philip Schoenfeld, MD


 Tegaserod: off the market while FDA
  investigates ↑in cardiovascular events
 IBS-D:
   • TCA+ loperamide → antibiotics →probiotics

 IBS-C:
   • No FDA-approved tx with benefit
   • Miralax + Levsin

 When all fails →SSRI to target brain pain
  centers
Peripheral Arterial Disease, Chronic Venous
Disease
Geno J. Merli, MD, FACP

 PAD: polyvascular dz, 3/5 have atherosclerosis in
  other vascular territories
 5 year CV M&M in pts with IC: 20% (MI/stroke)→
  aggressive tx
 HOPE trial (ramipril 10 mg): 25% RR in CV events
  (symptomatic)
 Ramipril improved pain free walking distance
 Heart Protection Study (simvastatin 20 mg,
  atorvastatin 10 mg): 24% RR in CV events
 METEOR trial: Rosuvastatin reduced rate of
  progression of max carotid intima-media thickness
 Ciloztazol: effective claudication tx, avoid in HF
Peripheral Arterial Disease, Chronic Venous
Disease
Geno J. Merli, MD, FACP


 Chronic venous insufficiency:
   • Post thrombotic syndrome (PTS) is a disabling
     dz
   • 50% of PTS can be prevented with compression
     stocking
   • Prevention of DVT is very important
      - After 8 years, 30% of DVT pts have PTS
   • Attempt to classify degree of venous dz
What to Do About the Pain of OA:
Sally W. Pullman-Mooar, FACR, FACP



 Examine the patient standing
 Re-evaluate acetaminophen as the 1st line:
   • Inc risk of newly dx HTN after ingestion of 4000 mg/d
     of APAP 6-7 days/wk over four years

 Alternative medicine
   • Glucosamine/Chondroitin (3 months)
   • Avocado oil (European studies, hip OA)

 Life style modification
   • weight loss
   • exercise: ↑ function + ↓ pain
Contraception in Women with Medical Problems:
R.Powrie, MD, FRCP, FACP



   Pregnancy should be planned
   Consider compliance and efficacy when
    recommending non- hormonal methods
   Depo Provera®, progestin only pills and IUD if can‟t
    take combination OC (COC)
Contraception in Women with Medical Problems:
R.Powrie, MD, FRCP, FACP
 Avoid combination oral contraceptives in :
   • Hx or current VTE, thrombophilia
   • Major surgery with immobilization
   • Uncontrolled hyperlipidemia
   • CAD or stroke
   • Age>35 and smoker
   • Valvular heart disease complicated by P-HTN, or
     afib
   • Congenital heart disease
   • Diabetes with end organ damage
   • Active hepato-biliary disease/cirrhosis/liver
     tumors
Pregnant and Nursing Patients:
K. A. Rosene-Montella, MD, FACP
L. Larson, MD and M. A. Miller, MD


 Fetal well being is dependent on maternal
  well being
 Medications are justifiable rather than safe
 According to FDA classification: only 6
  drugs are category A
 Withholding tx or diagnostic test may be
  harmful
 Preconception counseling is key
 Pregnancy acts as a stress test
Pregnant and Nursing Patients:
K. A. Rosene-Montella, MD, FACP
L. Larson, MD and M. A. Miller, MD


 VTE
   • 90% of DVT occur in left leg during pregnancy

 Diabetes
   • Hyperglycemia is a teratogen
   • Gestational DM carries a 30%-50% risk of type 2 Dm
     within 7-10 years

 HTN
   • Chronic HTN→ higher risk of preeclampsia
   • Preeclampsia is a risk factor for future CV events
   • Meds of choice: Methyldopa and labetolol
   • Meds to avoid: ACE inhibitors and ARB
Obesity: What Really Works and Who to Treat
Ken Fujioka, MD


 Diet:
   •   5%-10% weight loss →metabolic adjustment
   •   Fit the diet to the patient
   •   Eat breakfast!
 Exercise:
   •   Prevents loss of muscle during wt loss
   •   10,000 steps per day or 5 hrs/week
 Drugs associated with wt gain:
   •   Beta blockers: costs 100 cal/day
   •   TZD
   •   antipsychotic
 Thyroid hormone for wt loss: bone and muscle loss
            Internal Medicine 2007


 Clinical Pearls           Slide Shows

 Clinical Skills           Updates

 Meet the Professor        Doctor‟s Dilemma

 Multiple Small            Grand Rounds: The
  Feedings of the Mind       Professor in Action

 Practitioners‟ Morning    Exciting Research
  Report                     Advances

 Thieves‟ Market:          The Great Debates (new)
  Fascinating Cases         Intermission
                             Trivia/History of Medicine
                             (new)
  Internal Medicine 2008 and Beyond


 Internal Medicine 2008 Washington, D.C.
 Internal Medicine 2009 Philadelphia, PA

				
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