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American College of Physicians: Internal Medicine — Doctors for Adults ®

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Daily 4-22-10

Internal Medicine 2010 News reports breaking news and events live each day from Internal Medicine 2010 and the American College of Physicians.

Highlights

  • Anti-coagulation risks are known, but manageable
  • Keynote speaker to address equity and global health

Breaking news from Internal Medicine 2010

  • Follow live updates all week long at Internal Medicine 2010
  • Annals updates the year’s most important studies
  • Annals launches informational video for authors at Internal Medicine
  • Attend Internal Medicine 2010 sessions without leaving home

For attendees

  • Update to cover do’s and don’ts in hospital medicine
  • Research on sepsis, influenza highlights of Update in Critical Care
  • First Canadian Internal Medicine meeting includes Canadian history of medicine

Cartoon caption contest

  • Vote for your favorite entry

Highlights

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Anti-coagulation risks are known, but manageable

Clopidogrel (Plavix) is one of the best-selling drugs in the U.S., but its risks and limitations have been highlighted recently by both FDA warnings and new research. During Wednesday’s precourse on “Cardiology for the Internist,” speakers at Internal Medicine 2010 discussed some of the problems that the popular drug is posing for internists coordinating care with specialist physicians.

The risks of mixing clopidogrel with proton-pump inhibitors (PPIs) have become fairly well-known in the past year or so, and have discouraged clinicians from overusing the latter, but sometimes there’s a real need to use both drugs, noted David L. Fischman, FACP, associate professor of medicine at Thomas Jefferson University in Philadelphia. In those cases, it may be safest to go with pantoprazole (Protonix), he advised.

The advantage of pantoprazole is that it has less effect on liver enzyme CYP2C19, which metabolizes clopidogrel. The differences in patients’ capacities to metabolize the drug became big news in March when the FDA added a boxed warning to the clopidogrel label, advising that some patients metabolize the drug poorly and that genetic tests are available to determine which patients these are.

“You can do a test,” acknowledged Dr. Fischman. But, he added, “Most insurance companies don’t cover this.” The test, which runs about $500, is obscure enough that even the Mayo Clinic doesn’t offer it, according to Steven L. Kopecky, FACP, who also spoke during the precourse and is a professor of cardiology at Mayo in Minnesota. There is one simpler test to identify some higher-risk patients—ethnicity. About 14% of people of Chinese origin metabolize the drug poorly, compared to 1% or 2% in other races, Dr. Kopecky noted.

As for what to do once you’ve found the patients, he wasn’t too keen on one of the FDA’s possible solutions, a higher-dose regimen of a 600-mg loading dose followed by 150 mg once daily. The agency noted that the dose hasn’t been tested in a trial and Dr. Kopecky doesn’t plan to be the first. “None of us at Mayo feel comfortable doing that,” he said.

The warning also mentioned alternate antiplatelet medications, and one of those, prasugrel (Effient), does appear to have some potential advantages over clopidogrel, Dr. Fischman said. It poses less risk of interaction and has greater antiplatelet effect, but it’s got disadvantages, too. “The downside is higher incidence of bleeding,” Dr. Fischman said.

The bleeding risk posed by clopidogrel and other drugs is likely to be a particular concern to surgeons and anyone else who plans to cut your antiplatelet-taking patients open, the experts noted. “It comes up every day: Can this patient come off their Plavix?” described Dr. Fischman.

If the patient is taking the drug because they’ve received a bare-metal stent and it’s been at least a month, then it’s OK to halt it for surgery. But if the patient got a drug-eluting stent less than a year before, internists need to take a hard line because recommendations call for continuing antiplatelet therapy for a year in order to prevent late stent thrombosis.

“We’re trying to change the mentality of eye surgeons, dentists,” said Dr. Fischman. At the very least, patients should stay on their aspirin if not clopidogrel. And, if there’s any way to know before the stent goes in that the patient is going to require surgery within a year, opt for the bare-metal version. “You get your crystal ball out in the cath lab,” joked speaker Howard H. Weitz, FACP, a clinical associate professor of medicine at Jefferson.

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Keynote speaker to address equity and global health

This year's keynote speaker will be James Orbinski, OC, OOnt, MSC, humanitarian activist and associate professor at the University of Toronto, who will address equity and global health at this year's opening ceremony on Thursday, April 22, 9:30-10:30 a.m., Hall A.

James Orbinski, OC, OOnt, MSC Dr. Orbinski believes in humanitarianism, citizenship and actively engaging and shaping the world in which we live so that it is more humane, fair and just.

After extensive field experience with Médecins Sans Frontières/Doctors Without Borders, Dr. Orbinski was elected international president from 1998 to 2001. He launched the organization’s Access to Essential Medicines Campaign in 1999, and in that same year accepted the Nobel Peace Prize awarded to the organization for its pioneering approach to medical humanitarianism, and most especially for its approach to witnessing.

Dr. Orbinski worked as MSF's head of mission in Goma, Zaire, in 1996-1997 during the refugee crisis. He was MSF's head of mission in Kigali during the Rwandan genocide of 1994 and MSF's medical coordinator in Jalalabad, Afghanistan, in the winter of 1994. He was MSF's medical coordinator in Baidoa, Somalia, during the civil war and famine of 1992-1993. Dr. Orbinski's first MSF mission was in Peru in 1992.

As international president of MSF, Dr. Orbinski represented the organization in numerous humanitarian emergencies and on critical humanitarian issues in the Sudan, Kosovo, Russia, Cambodia, South Africa, India, and Thailand, among others. He has also represented MSF at the UN Security Council, in many national parliaments, the WHO, and the UNHCR.

Dr. Orbinski received his medical degree from McMaster University in 1990. He completed a master’s degree in international relations at the University of Toronto in 1998. He has received many honorary doctorates and awards, including the Meritorious Service Cross, Canada's highest civilian award.

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Breaking news from Internal Medicine 2010

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Follow live updates all week long from Internal Medicine 2010

Follow our blogs for session updates and special events at ACP Internist and ACP Hospitalist.

Follow our Twitter feeds at ACP Internist and ACP Hospitalist. If you're tweeting from the meeting, use the hashtag #IM10.

Facebook and LinkedIn fans can follow our news as well.

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Annals updates the year’s most important studies

Annals of Internal Medicine published several articles summarizing some of the most important studies of 2009 to coincide with Internal Medicine 2010. Updates in cardiology, gastroenterology, hematology and oncology, pulmonary/critical care medicine and nephrology can be accessed online at www.annals.org.

Studies highlighted in the updates were chosen for novelty, quality and potential impact on clinical practice. Updates in each subspecialty include articles on a variety of relevant topic areas. Highlights include:

Cardiology
Nine cardiology articles that had significant clinical implications for areas such as antithrombotic therapy and management of multivessel coronary artery disease.

Gastroenterology and Hepatology
Eleven articles cover esophageal disorders, proton pump inhibitor therapy, liver disease, acute pancreatitis, pelvic floor disorders and bowel disorders.

Hematology and Oncology
Seven articles address prominent advances in breast cancer and prostate cancer.

Pulmonary/Critical Care Medicine
Trials provide insight into the management of patients with chronic obstructive lung disease, pneumonia and asthma.

Nephrology
Key trials could have implications for internists and other professionals who care for patients with chronic kidney disease. The studies also present new information in lupus, nephritis and end-stage renal disease.

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Annals launches informational video for authors at Internal Medicine

A new informational video for authors aims to debunk some of the existing myths about submitting research to Annals of Internal Medicine, including author interviews that highlight the process and benefits associated with getting published in Annals.

Annals of Internal Medicine has earned a reputation for being a difficult journal to get into,” said Christine Laine, FACP, MPH. “While our review process is rigorous and thorough, authors may be surprised to learn that our editors and our processes are actually very author-friendly. We hope this video will enlighten internists and encourage them to submit their research to the journal.”

The Annals Author Information Video is on display in the Annals section of the ACP booth. The video also can be viewed online at www.annals.org.

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Attend Internal Medicine 2010 sessions without leaving home

eCollege ACP’s eCollege allows you to attend Internal Medicine 2010 sessions from your home, your office, your car, or on-the-go, all while maintaining the quality of education you have come to value and expect from ACP. Courses are available in a variety of formats so you can choose the method that is best for you. What’s more, many eCollege products offer CME credit, making it easier than ever to get the credits you need. Visit www.iplaybackacp.com for a complete list of courses and topics and to order eCollege products.

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For attendees

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Update to cover do’s and don’ts in hospital medicine

Hospitalists spend a lot of time reading and hearing about what they should do in their practice. But when Joseph Li, ACP Member, began planning for today's Update in Hospital Medicine, 8:15-9:15 a.m. in the North Auditorium, he found several new studies highlighting things that it’s important for hospitalists not to do.

The session will be structured as case presentations. “It’s easier to talk about something as if it’s real life,” said Dr. Li, who is director of hospital medicine at Beth Israel Deaconess Medical Center in Boston. “I’ll present a case and then I’ll ask a question, with multiple potential answers.”

To help attendees select the correct answer, he’ll review some of the most significant topical research that came out in 2009. Session participants will get a chance to ensure that their hospital practice is in accordance with the newest research, and that they’re up-to-date on the latest in study-title acronyms.

One of the best acronyms, and most significant studies, to come out of last year was the NICE-SUGAR trial, which compared intensive and conventional glucose control in intensive care patients and was published in the March 26, 2009 New England Journal of Medicine. “The issue of glycemic control in hospitalized patients has been a controversial topic and something that’s been discussed frequently in the past five to 10 years,” said Dr. Li.

Thanks to the trial, that discussion has evolved into a consensus that it may be best not to intensively control glucose. “They essentially found that intensive glucose control increased mortality among adults in the ICU,” Dr. Li explained.

Vertebroplasty was another treatment that physicians in the hospital had been using for some time, without clear evidence for or against it. Then, last August, two studies in the New England Journal of Medicine, one nicknamed INVEST, put the procedure to the randomized test. A group of patients with osteoporotic vertebral fractures received either actual vertebroplasty or a sham procedure in two studies. The researchers then compared outcomes in patients who had gotten the procedure and those who hadn’t.

“This is a procedure that’s been popularized and frequently done for patients with this issue, and what they found was that there were no significant differences in pain or disability between the groups,” said Dr. Li. “It appears that patients would have done just as well if we had not done the procedure.”

Another popular habit among hospitalists—until recently—had been the prescription of acid-suppressive medications. “There is a perceived thought that these drugs have little or no side effects,” said Dr. Li.

That’s not the case, according to a study published in the Journal of the American Medical Association in May, which Dr. Li will review during the update. At a large teaching hospital, use of acid-suppressive medications, especially proton-pump inhibitors, was associated with increased odds of developing hospital-acquired pneumonia.

“The previous concern was that perhaps we might have been wasting some money, but really there weren’t any significant side effects. But there is some concern that by doing this, we are actually increasing the risk for hospital-acquired pneumonia,” Dr. Li noted.

The pro-intervention study on Dr. Li’s agenda suggests a method for reducing the risk of hospital-acquired infections. “A lot [of attention] has been focused on quality of care in the hospital, and prevention of infection in hospitalized patients. There are a number of strategies to prevent infection,” he said.

One successful strategy was revealed in the Jan. 1, 2009 New England Journal of Medicine. The trial evaluated the effectiveness of decontamination of the digestive tract and oral pharynx in intensive care patients. “I don’t think this study has a catchy name,” warned Dr. Li. But it did have a positive result. “Both measures were associated with reduced mortality, to a similar extent, so it appears that both of these measures do reduce mortality in ICU patients.”

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Research on sepsis, influenza highlights of Update in Critical Care

New research on sepsis and influenza will take center stage at today's Update in Critical Care, 7-8 a.m. in the North Auditorium

Henry Masur, MACP, and Anthony Suffredini, FACP, will co-moderate the session, which will also look at studies on intensive glucose control, sedation vacations, and infection in patients with venous catheters.

Dr. Suffredini, associate chief of the critical care medicine department and medical director of the critical care therapy and respiratory care section at the National Institutes of Health in Bethesda, Md., will kick things off by examining the NICE-SUGAR trial (N Engl J Med. 2009;360:1283-1297), which looked at the effects of intensive glucose control in critically ill patients. The study found that intensive glucose targets were associated with higher rates of hypoglycemia and fatal events. "The purported benefits were not there," Dr. Suffredini said. "In critically ill patients, the risks of intensive glucose control greatly exceed the benefits."

In more positive news, a randomized trial of critically ill adults receiving mechanical ventilation (The Lancet. 2009;373:1874-1882) found that those who were awakened daily from sedation and received physical and occupational therapy had better functional status at discharge than those who remained sedated. "Perhaps we don't have to think that it's impossible to get a patient mobilized while on mechanical ventilation," Dr. Suffredini said. "If you choose your patients well and have a good team of nurses and therapists, you can intervene and have an important effect on outcomes."

Dr. Suffredini will also look at a study on the use of low-dose corticosteroids in septic shock (JAMA. 2009;301;2362-2375). Researchers performed a meta-analysis of 20 trials to determine what dose and duration of corticosteroids would be most effective in this population. The trial indicated that high doses of steroids for short periods of time, such as one to two days, did not benefit patients but caused no harm in the aggregate, Dr. Suffredini said. A potential survival benefit was seen, however, with long-term corticosteroid therapy at low doses. Dr. Suffredini noted that rates of complications associated with steroids were not as high as expected, but also pointed out that these variables were not examined systematically. While the meta-analysis suggests there is a beneficial effect from the adjunctive use of low doses of steroids in sepsis, he said, "the definitive trial has not yet been done."

Dr. Masur, chief of the critical care medicine department at the National Institutes of Health, will present data from an article on critically ill patients with H1N1 in Canada (JAMA. 2009;302-1872-1879). Although the 2009 H1N1 outbreak was generally considered mild, the JAMA article is of interest because it allows experts to extrapolate the potential resources needed for a future, more severe epidemic, he said. "Even if the epidemic strain of influenza is not generally highly virulent, if the size of the infected population is large enough, the small fraction of patients with severe disease could overtax our hospitals and intensive care units," Dr. Masur noted. "Each jurisdiction and each medical care facility must plan for surge capacity since we know that a highly virulent epidemic will eventually occur."

Another study that Dr. Masur plans to cover addressed the use of chlorhexidine-impregnated sponges for venous catheters (JAMA. 2009;301:1231-1241). Researchers examined differences in infection rates when catheter sites were treated with chlorhexidine-impregnated sponges versus standard dressings, and when dressings were changed every three versus every seven days. Chlorhexidine sponges decreased the infection rate, and less frequent dressing changes were not inferior to more frequent changes.

One of the study's take-home points is that new techniques to combat infection should continue to be developed, Dr. Masur said. He noted, however, that the researchers used povidone-iodine to prepare the skin before catheter insertion rather than chlorhexidine, which is now more common in the U.S., and that it's not clear whether both preparing the skin and using a chlorhexidine sponge are necessary to effectively fight infection. "If your [infection] rate is already close to zero, the incremental benefit of adding this impregnated sponge may be impossible to discern," Dr. Masur said.

Dr. Masur will also cover a study on sepsis, specifically the effects of failure to correctly choose initial antibiotics to combat septic shock (Chest. 2009;136:1237-1248). Researchers performed a retrospective chart review to examine how inappropriate initial therapy affected outcomes. They found that the first regimen tried had no effect against the causative organism about 20% of the time, and that mortality rates were much lower in patients who received appropriate initial therapy than in those who did not (approximately 10% vs. 52%).

The study supports the idea that physicians working in ICUs need to choose broader-spectrum drugs than they would in the outpatient setting, Dr. Masur said. Physicians should make sure that they understand the patient, as well as the likely causes of the potential infection, and then choose antibiotics that cover those possibilities broadly, he noted. "With a life-threatening infection," he said, "you can't afford to guess wrong."

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First Canadian Internal Medicine meeting includes Canadian history of medicine

When in Canada, learn about Canadians. That may not be exactly how the old saying goes, but it is the theme of this year’s History of Medicine sessions.

Canadian historians will lecture about some of Canada’s medical heroes, beginning on Friday afternoon with one of the greatest—Sir William Osler. Medical historian Michael Bliss will speak about Osler, and then, in a separate session on Saturday afternoon, Sir Frederick Banting, whom Mr. Bliss has studied extensively. “He wrote two award-winning books on the discovery of insulin for diabetes and Banting, who was the discoverer of insulin,” said session organizer T. Jock Murray, MACP.

The lectures should provide new information even for meeting attendees who are familiar with the legendary physicians’ work, according to Dr. Murray. “Those are names that the average physician knows. But what we’re going to talk about is something about their lives and how they came to make great discoveries.”

Tommy Douglas, who will be profiled by historian Jacalyn Duffin on Friday, is well-known to Canadians, if not Americans. It is an opportune time for U.S. internists to learn about him, noted Dr. Murray. “Tommy Douglas was the individual who single-handedly initiated the Canadian health care system, which is of interest in the U.S. right now.” In perhaps an indicator of how Canadians feel about their health care system, Dr. Douglas was recently voted the most outstanding Canadian of the 20th century.

Even Canadians may be unfamiliar with the final physician to be discussed on Friday: Norman Bethune. “He’s a Canadian physician who went to China with Mao on the Great March. In China, every schoolchild knows about Norman Bethune,” said Dr. Murray. In a talk subtitled “Maverick Surgeon and the Hero of China,” the Right Honorable Adrienne Clarkson will offer insights from the book she recently wrote about Dr. Bethune.

“Adrienne Clarkson had a career in journalism on television and then became governor general of Canada,” said Dr. Murray. “It’s an amazing thing to get the governor general to give one of the talks at the ACP.” (The governor general is appointed by the Queen of England to carry out the monarch's constitutional and ceremonial duties in Canada.)

Attendees will learn about Dr. Bethune’s controversial activities and long-standing popularity in China. “There’s a poem written by Mao about Bethune that’s recited and memorized by every Chinese schoolchild. Here you have a person who has become known to billions of people in China, but not so well-known in the rest of the world,” Dr. Murray said.

On Saturday, Ms. Duffin will speak about James Langstaff, a 19th-century physician whom almost no one in the world has ever heard of. “Rather than talking about a great hero of medicine, she’s going to talk about the day-to-day life of a physician, who goes about doing medicine the way it’s supposed to be done. She wrote a book from the remarkable records of a practitioner who lived in the country and took care of his people for his career,” described Dr. Murray.

Finally, Dr. Murray will close out this year’s history of medicine symposia—the twelfth that he’s organized—with a talk about Wilder Penfield, a pioneer of neurosurgery.

History of Medicine I
Friday, 2:15-3:45 p.m.
Room 717
Sir William Osler: High Priest of Medicine
Politics and Pulpits: Tommy Douglas and the Foundation of Canadian Health Care
Norman Bethune: Maverick Surgeon and the Hero of China

History of Medicine II
Saturday, 2:15-3:45 p.m.
Room 717
Sir Frederick Banting: Troubled Nobel Laureate
Fed Me; Fed My Horse: Innovation and Survival in 19th Century Practice
Wilder Penfield: The Brain Revealed

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Cartoon caption contest

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Vote for your favorite entry

ACP InternistWeekly's cartoon caption contest continues. Readers can vote for their favorite caption to determine the winner.

“I guess we’ve got some bad news for each other. Do you want yours first?”
“You drug reps will do just about anything to get my attention.”
“OK, OK, I admit it. I should have called hospice sooner.”

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting continues through May 3, with the winner announced in the May 4 issue of ACP InternistWeekly.


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